Expensive [state Medicaid director or other official],
On behalf of [Organization(s)], we urge you to undertake the suggestions under for implementing Medicaid work necessities to reduce hurt and protect steady entry to important [Medicaid or state program name] companies for older adults, individuals with disabilities and power well being situations, caregivers, and others. We additionally ask that you simply share these suggestions and considerations with federal officers as they finalize steerage for implementation.
[Add info about organization(s)]
As [aging and disability] advocates, we’re involved that work necessities create administrative limitations that can result in improper terminations and disrupted entry to essential healthcare. These burdens disproportionately influence older adults and other people with disabilities who’ve a tougher time discovering work and sustaining employment attributable to useful limitations, altering work or caregiving duties, and fluctuating well being. For instance, the overwhelming majority of older adults ages 50-64 enrolled in Medicaid growth who’re retired or not working (86%) report having a well being situation that stops them from working.1 Though the statutorily required exemptions for people who find themselves “medically frail” and for household caregivers are supposed to guard these populations, in apply such exemptions regularly fail to achieve or work for the individuals they have been meant to guard partially attributable to complicated paperwork, slender interpretations, and reliance on automated information checks that fail to completely seize people who find themselves eligible.
We have now offered suggestions and additional concerns for implementing exemptions to reduce disruptions in protection and entry to look after older adults, individuals with disabilities, and household caregivers attributable to work necessities.
Routinely exclude individuals with Medicare and other people eligible by means of the aged and disabled pathways from work necessities.
The state should make sure that people who’re categorically excluded from work necessities beneath the regulation are robotically and completely exempted, together with individuals age 65 and older, individuals dually enrolled in Medicare and Medicaid, and other people of any age eligible by means of incapacity and different necessary pathways. The state ought to make the most of present information to determine these present enrollees with out subjecting them to extra paperwork and guarantee its eligibility programs are set to robotically display screen out new candidates. We urge the state to take steps to reduce confusion and clearly talk to new candidates whether or not or not they’re topic to work necessities, notably if they’re filling out paper purposes.
Don’t impose extra restrictions on exemptions not required by the statute.
The state ought to decide eligibility for the medically frail and household caregiver exemptions based mostly on a person’s reported medical situations, diagnoses, useful impairments, or caregiving duties, and never require proof of unemployment or lack of ability to work. Proof of latest or present employment shouldn’t be thought-about in figuring out exemption eligibility, as many individuals who qualify as medically frail or household caregivers may be employed. Making certain they’ve the exemption in place will assist shield them from protection loss ought to their employment standing change, which is especially widespread for individuals with disabilities, critical well being situations, and caregiving duties.
Beneath the medically frail exemption, the statute requires the state to exempt many classes of people effectively past Social Safety incapacity requirements, together with individuals with a bodily, mental or developmental incapacity that considerably impairs a number of actions of each day residing, a substance use dysfunction, a disabling psychological dysfunction, or a critical or complicated medical situation. Due to this fact, the state should not restrict the medically frail exemption to Social Safety incapacity or equally strict requirements and guarantee its eligibility standards are inclusive of individuals described within the statute.
H.R. 1 makes use of the RAISE Household Caregivers Act definition to outline caregivers as “an grownup member of the family or different particular person who has a major relationship with, and who gives a broad vary of help to, a person with a power or different well being situation, incapacity, or useful limitation.” All such household caregivers, together with caregivers for older adults and others who might not determine as disabled, have to be exempted. The state should not impose restrictions like requiring the individual being cared for to have a recognized incapacity, or be a dependent of or associated to the caregiver. Nor ought to the state require caregivers to be offering a minimal variety of weekly or month-to-month caregiving hours.
Actual world software [insert your own example or customize this one]: Robin, age 49, is a caregiver for her father who has a number of well being situations and lives by himself in the home Robin grew up in. Robin lives about 20 miles away and visits her father a number of days per week to assist him with groceries, meal preparation, and to take him to docs’ appointments. Not too long ago, after her father fell and broke his leg, Robin made the tough choice to transition to half time on the retail retailer the place she works in order that she will be able to spend extra time serving to her father. Robin misplaced her well being protection and is making use of for Medicaid.
Right here, Robin meets the RAISE Act definition for the caregiver exemption and the state ought to approve her Medicaid software based mostly on her self-attestation that she is a caregiver. The state shouldn’t require her to submit any documentation of her caregiving duties when she applies for or renews Medicaid protection.
Make the most of self-attestation and ex parte verification to reduce administrative burden and procedural churn.
To cut back administrative limitations for each Medicaid enrollees and the state, self‑attestation must be accepted as verification for medically frail and caregiver exemptions. The statute permits self-attestation and [name of your Medicaid program] already makes use of self-attestation with out extra verification for caretaker relative eligibility [add other eligibility categories that your state accepts self-attestation for].2
Actual world software [insert your own example or customize this one]: Marsha, 56, is making use of for Medicaid. She has diabetes and arthritis which considerably restrict her mobility and have compelled her to go weeks with out working. Marsha qualifies for a medically frail exemption since one in every of her actions of each day residing are restricted. She doesn’t personal a automobile or have entry to public transportation, and, being uninsured, she doesn’t have a main care supplier. Final time she ran out of insulin, she ended up within the emergency room.
In Marsha’s case, self-attestation can be essentially the most accessible and environment friendly methodology for verifying she is eligible for the medically frail exemption. If the state required medical or different documentation of her situation, then Marsha can be in an not possible place the place she can’t entry Medicaid with out first getting well being care from a supplier to confirm she is medically frail. Marsha must both pay out-of-pocket to get documentation or doubtlessly go to the emergency room. This creates costly and burdensome delays for each Marsha and the state.
We additionally urge the state to scale back administrative burden by robotically renewing exemptions, together with these based mostly on incapacity, useful impairment, or a power situation that’s unlikely to vary over time. Equally, the caregiver exemption must be robotically renewed for so long as the caregiving relationship lasts.
H.R. 1 requires states to make use of an ex parte course of to confirm exemption eligibility and keep away from requesting people to supply for added data every time potential. The state ought to maximize such information‑pushed verification by linking and cross‑checking present state sources to determine individuals who qualify for the medically frail exemption, similar to [Medicaid claims, Managed Care Organization (MCO) records, long-term services and supports and other disability and aging services data, and behavioral health records]. Equally, the state might be able to use present information to exempt some caregivers, similar to these being paid beneath Medicaid Dwelling- and Group- Primarily based Providers (HCBS) applications. Ex parte information that confirms a person meets a statutory exemption must be utilized robotically with out requiring the applicant or enrollee to supply extra documentation confirming their exemption standing. Importantly, even when maximizing these information sources, the state should settle for self‑attestation since most household caregivers aren’t recognized in present information sources and many individuals who qualify for the medically frail exemption, like Marsha, can’t simply doc their situation, particularly with out Medicaid.
Guarantee accessibility, due course of, and operational safeguards.
Given the intensive and complicated nature of those work necessities, it’s important for the state to supply clear and accessible data to candidates and enrollees. This contains plain‑language, accessible notices in a number of codecs and languages explaining the reporting necessities, exemptions, and details about requesting lodging. It’s particularly essential that the state take a look at purposes and any know-how and embody older adults among the many testers.
Medicaid enrollees also needs to have accessible choices, similar to a well-staffed hotline, to achieve educated and educated workers to ask questions or get extra data. The state also needs to be express about enrollees’ proper to attraction antagonistic choices, together with a possibility to briefly proceed protection pending attraction and a possibility for a listening to. This contains offering clear deadlines for requesting appeals and for company choices, and guarantee beneficiaries obtain well timed discover of these deadlines. Beneficiaries also needs to be supplied help, together with assist finishing varieties, requesting continuations, and acquiring illustration or advocacy help.
[Additional topics to raise if relevant to the state (e.g., utilizing Beneficiary Advisory Committees and other stakeholder engagement opportunities; data sharing responsibilities, role of MCOs and third-party contractors, privacy concerns and proper use of data, etc.)]
Conclusion
We respect your cautious consideration of those suggestions and urge the state to undertake these insurance policies and practices to guard entry to care whereas implementing work necessities. Establishing clear exemption guidelines and processes in step with Congress’s intent to exempt individuals with critical and complicated well being situations and household caregivers for older adults, prioritizing self‑attestation and ex parte renewals, and offering strong due course of rights will scale back wrongful terminations and assist protect well being and independence for older adults, individuals with disabilities, and their caregivers.
[Add request for meeting and/or individual contact info]
- Tavares, J. and Cohen, M., What are Socio-Demographic Traits of Medicaid Growth Inhabitants in comparison with Non-Growth Medicaid Inhabitants age 50 to 64? Analytic Temporary, LeadingAge LTSS Heart @UMass Boston (April 2025), https://www.ltsscenter.org/wp-content/uploads/2025/04/Variations-between-Growth-and-Non-Growth-Medicaid-Beneficiaries-April-2025.pdf.
- See Medicaid eligibility verification plans by state: https://www.medicaid.gov/medicaid/eligibility/medicaidchip-eligibility-verification-plans.
