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COA submitted a comment letter on the federal rules implementing Medicaid work requirements, urging reconsideration of the restrictive definition of medical frailty, allowance of broader exclusions, an extension of self-attestation, and more.
Colorado Access (COA) submitted official comments to the Centers for Medicare & Medicaid (CMS) on its interim final rule (IFR) regarding operational guidelines and implementation rules of community engagement, or “work,” requirements for the Medicaid expansion population as established by H.R. 1. In our comment letter, we urged CMS to reissue this rule and emphasized the significant risk of coverage loss due to the IFR’s administrative burden. The rules went into effect on July 31, the same day as the comments were due.
The One Big Beautiful Bill Act (H.R. 1), signed into law last July, included a $1 trillion reduction in federal health care spending over the next decade – the largest cut to health care in history – primarily targeting Medicaid and the Affordable Care Act (ACA) Marketplace. The provisions make significant changes to Medicaid, including eligibility criteria, how individuals maintain eligibility, and how the program is financed.
Established by H.R. 1, work requirements will be imposed on the Medicaid expansion members, broadly defined as adults ages 19-64 who earn up to 133% of the federal poverty level. The law included a list of populations that will be exempt from complying with these new requirements, including, but not limited to, children 18 and under, adults 65 and older, pregnant and postpartum individuals, caregivers, and individuals who already comply with SNAP or Colorado’s Temporary Assistance for Needy Families (TANF) work requirements. However, H.R. 1 did not include specifics on how states will need to verify compliance or exemptions for work requirements, nor definitions of specific conditions such as “medically frail.”
The IFR provided details to states about how to operationalize this new condition of eligibility, including the process for individuals to comply with the new requirements, what happens when reliable data is not available, what circumstances self-attestation is allowed, and the role of managed care organizations (MCOs) as a key communicator to members. In some cases, the IFR went beyond the statute’s plain language, as in the case of medical frailty and the use of good faith waivers.
We also highlighted in our letter the challenges for our members, providers, community members, and us, as a health plan. Specifically, we asked CMS to make several changes:
- Eliminate the work-impairment requirement of the medically frail exemption
- The IFR restricts the definition of medically frail and adds language that a condition must “significantly impair” an individual’s ability to comply with work requirements. This additional language is unnecessary and suggests state Medicaid agencies and providers will need to make this determination, which is inappropriate and unfair.
- Allow categorical exclusions based on certain diagnoses
- The IFR explicitly does not allow states to exempt individuals based on certain diagnoses. Still, we asked CMS to reconsider certain conditions such as cancer, HIV/AIDs, specific behavioral health conditions, and other chronic conditions. While the rule allows for self-attestation, this approach does not account for individuals with serious illnesses, lifelong conditions, or complex needs, whose stable coverage is critical to their health.
- Allow self-attestation in perpetuity
- While we appreciate that states can accept self-attestation during the first year of implementation, we requested that CMS extend this form of verification as long as H.R. 1 is in effect or at least two to three years after initial implementation. Self-attestation will be key, especially in cases where documentation does not reasonably exist for exemptions. Extending self-attestation would reduce confusion, give members time to adjust, and allow states to communicate more effectively.
- Clarify the role of managed care plans
- The IFR identifies managed care plans like COA as key implementation partners, allowing plans to undertake specific activities such as educating and outreaching members. However, the IFR greatly underestimates the burden on plans and the costs of these additional activities and, specifically, does not allow them to be included in the development of capitation rates. We asked that CMS closely monitor actuarial soundness to reflect additional responsibilities and member acuity. Additionally, we requested that CMS require states to share relevant data with plans so we can proactively reach out to members amid these changes.
Our feedback is grounded in our mission to partner with communities and empower people through access to quality, equitable, and affordable care. As these changes take effect, COA will continue advocating to protect Medicaid, reduce unnecessary administrative hurdles, and keep members enrolled.
