Wisconsin Waiver Adds Medicaid Work Requirements, Drug Screens
On Wednesday, the Centers for Medicare and Medicaid Services (CMS) approved Wisconsin’s request to enact a series of restrictions that would limit Medicaid eligibility and restrict enrollees’ use of Medicaid benefits. The newly-approved Section 1115 waiver will require certain adult beneficiaries to work 80 hours per month to maintain health coverage, institute premiums and subject applicants to drug use screening questions. This decision is the latest in a series of work requirement approvals, however, Wisconsin is the first non-Medicaid expansion state to receive permission from CMS to impose work requirements.
The waiver includes the following key provisions:
- Work Requirements: The waiver allows Wisconsin to require 80 hours per month of work activities on non-pregnant, non-disabled, non-elderly childless adults ages 19 through 49 whose incomes are up to 100 percent of the federal poverty line (FPL). Activities that meet the requirements include employment, job training, and community service. Unless they qualify for an exemption, beneficiaries subject to the requirements who have not met the criteria for 48 aggregate months will be disenrolled from Medicaid and locked out of the program for six months unless found eligible for another reason. Some exemptions include a mental or physical inability to work, being a primary caregiver, current participation in an alcohol or drug rehabilitation program, or enrollment in an educational institution. Having a substance use disorder does not quality as an exemption.
- Premiums and Copayments: Wisconsin is permitted to charge $8 monthly premiums on childless adults with incomes between 50 and 100 percent of the FPL. Individuals who fail to pay could be locked out of coverage for six months. Additionally, individuals who use the emergency room (ER) for non-emergency visits will be required to make $8 co-payments.
- Drug Screening Questions: Although CMS turned down the state’s bid to drug test all Medicaid applicants, it will allow the state to ask Medicaid applicants if they have used drugs in the past or if they are in recovery from addiction through a health risk assessment (described below).
- Health Risk Assessments — The state will be permitted to require beneficiaries to complete a health risk assessment (HRA). The results of the HRA will be used to determine premiums for that population, and beneficiaries may be charged more for behaviors such as tobacco use, drug use, alcohol use, unhealthy diet and exercise habits and not wearing seatbelts.
- SUD Treatment: While many provisions of Wisconsin’s waiver will harm Medicaid enrollees, one positive component of the waiver is a program to expand short-term substance use disorder (SUD) residential treatment. The state was granted a waiver of the Institutes of Mental Disease (IMD) rule to expand the number of facilities eligible to receive Medicaid payment for short-term residential substance use disorder treatment.
The National Council has serious concerns about the impact this waiver will have on Wisconsinites with behavioral health conditions. The National Council is strongly opposed to work requirements as they deny care to individuals with mental illness or SUDs who cannot qualify for a specific exemption or meet the administrative burden of reporting their work hours. Moreover, the use of health risk assessments, including questions about prior drug use, will actively discourage individuals with SUDs from applying for Medicaid. Should individuals with a history of substance use apply regardless, they could be subject to discriminatory practices such as higher premiums.
It is important to note that the 2018 midterm elections could have a significant impact on the implementation of this waiver if current Wisconsin Governor Scott Walker (R) loses his bid for re-election on Nov. 6th. A new governor could choose to not implement the waiver or only implement parts of the waiver.