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CMS Administrator Seema Verma is worried about a “subsidy cliff” in states that have not expanded Medicaid but are seeking to implement Medicaid work requirements.

The cliff impacts those who earn too much to qualify for Medicaid, but not enough to receive government subsidies. Verma is worried that if states without expanded Medicaid programs require recipients to get jobs, the added income will push them into this grey zone, leaving them without coverage.

Verma is not entirely against work requirements, though, saying, “I want to be careful about this. [States] need to come up with a plan to address this issue. We’re dealing with some very complex issues. We’re dealing with a vulnerable population, so we want to be careful.”

CMS has approved work requirements in Arkansas, Indiana, and Kentucky – all Medicaid expansion states. Non-expansion states Kansas, Maine, Mississippi, Utah, and Wisconsin currently have pending work requirements applications. According to Modern Healthcare, Tennessee and Virginia are also planning to submit such requests.

Verma has not ruled out approving these waivers for non-expansion states, but instead cautions that they need to find a “bridge to self-sufficiency.” The HHS did release a legal filing after more than 40 public health scholars joined a lawsuit challenging Kentucky’s work requirements. In this filing, the HHS and the Trump administration viewed work requirements primarily as an option for adults in expansion states.

“Community-engagement initiatives would make little sense for vulnerable low-income individuals likely to need medical assistance,” HHS said.

32 States and Washington, D.C. have expanded Medicaid under the ACA, and CMS has approved work requirements Arkansas, Indiana, and Kentucky. An additional 8 states are pending CMS approval to implement work requirements:

Arizona – expanded Medicaid

  • Kansas – not expanded Medicaid
  • Maine – not yet expanded Medicaid, though voters in the state last year approved a ballot initiative direct the state to do so
  • Mississippi – not expanded Medicaid
  • New Hampshire – expanded Medicaid
  • Utah – not yet expanded Medicaid, though state officials have requested CMS’ permission to implement a partial Medicaid expansion;
  • Wisconsin – not expanded Medicaid
  • North Carolina – dependent on state legislation



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