Introduction
The “One Big Beautiful Bill Act” (BBB) creates a requirement for states to establish Medicaid community engagement requirements for certain individuals. The community engagement requirements are targeted toward “able-bodied” enrollees ages 19-64; there is a list of qualifying activities, including 80 hours per month of employment, community services, or workforce training, or enrollment in an educational program at least part-time. BBB also contains a list of mandatory and optional exemptions, including those enrolled in or entitled to Medicare Part A or B; individuals with a short-term hardship; a parent, guardian, caretaker relative, or family caregiver of a dependent child 13 years of age and under or a disabled individual; medically frail individuals; and individuals in SUD treatment. States have until December 31, 2026 to comply with the new requirements, with the option to enact changes earlier if approved by CMS.
History of Work Requirements in Indiana
Gateway to Work was Indiana’s work and community engagement requirement for the Healthy Indiana Plan (HIP), the state’s 1115 demonstration project providing coverage for its Affordable Care Act Medicaid expansion population. Gateway to Work started in 2015 as a voluntary program to connect HIP enrollees to available employment, work search and job training programs. In 2017, Indiana applied for an amendment to its 1115 to make participation in Gateway to Work mandatory, creating a work and community engagement requirement for HIP members. CMS approved this amendment, and design and implementation occurred over a two-year period. The program launched in 2019 with a phase-in over several months; Indiana was in the final weeks leading to enforcement of the new requirements when a federal lawsuit halted the Gateway to Work program in late 2019.
Indiana’s Previous Vision for Gateway to Work
Gateway to Work was envisioned as a way to connect individuals to resources for community participation. The design focused on two goals:
- For individuals who met the requirements or qualified for an exemption, create a streamlined process that placed as little burden on the individual as possible. Ideally, these individuals would feel little to no impact of the program’s implementation.
- For individuals who did not appear to meet the requirements, create paths to connect them to resources for employment, education, volunteerism, or community supports in order to meet the program requirements without loss of coverage.
Success was defined as connections to resources that led to improved support, not loss of coverage. In the months leading up to implementation, emphasis was placed on taking all steps possible to verify participation, support individuals and their unique circumstances, and minimize loss of coverage wherever possible, with the goal of zero persons losing coverage as a result of the program.
Barriers to Implementation
Creating a streamlined, efficient program that focuses on connections to resources and minimizes loss of coverage required overcoming a myriad of barriers and complexities, including:
- Defining the details of “Who, What, When, How” of the program: Who does it apply to, What are they required to do, When must they complete activities, and How will they submit information
- Creating sustainable data pathways and reporting portals to efficiently verify compliance or exemptions
- Establishing legal pathways to overcome privacy and security concerns across programs with varying requirements (i.e. HIPAA, FERPA, Workforce, Social Security, SNAP/TANF, SUD treatment)
- Providing clear and concise communication to the public and stakeholders
- Creating a comprehensive and robust network of resources to refer individuals who need assistance getting into compliance with the requirements, particularly in rural area
What’s Next?
- BBB requires all states to implement a community engagement requirement similar to the Gateway to Work program no later than December 31, 2026- giving states approximately 18 months to design and create this new program.
- BBB provides defined parameters regarding several requirements, but leaves many within the state’s discretion. States will need to be purposeful and thoughtful about how to design and implement this program to ensure the health and well-being of their constituents while minimizing disruption to business processes and operational realities.
- Notably, efforts to create data exchanges, reporting portals, and tools like real-time dashboards must begin as soon as possible in order to be in place by the compliance deadline.
- Successful education and outreach may take several months, both for informing the public and creating important connections to local community resources for referrals.
- States can design a program that defines success as connections to resources and minimal loss of coverage- coverage loss rates should be an indicator of barriers that need to be overcome systemically.
Conclusion
States are facing a short timeline to design a process that, for many states, does not align with the current strategic vision for its Medicaid program. The Delineate team has unique expertise and insight to assist states grappling with these changes from both a policy and data perspective. Download the full report here.
