Medicaid work requirements: Why transparency is needed in Ohio’s eligibility waiver

Now that the federal government has approved the Ohio Department of Medicaid’s Group VIII Work Requirement and Community Engagement Section 1115 Demonstration Waiver, Governor Mike DeWine’s administration should do everything it can to ensure it is meeting its obligations for data transparency, legally, and as a matter of public interest. Such a significant potential cut in Medicaid, would affect hundreds of thousands of Ohioans, and hundreds of millions in taxpayer dollars. Ohioans should be equipped with the knowledge and insights needed to ensure this experimental program is having the intended effect of connecting more low-income individuals to meaningful employment opportunities.

Seventeen states have sought federal approval for work mandates in Medicaid and nearly half have no plan to track the impact of these experimental policies, falling short of federal rules regarding transparency and public reporting. States that have sought these waivers, and the current federal administration overseeing them, have been criticized by policy and legal experts, nationally, for disregarding the rules around them.

The state should create and develop a robust monthly report that documents key health and financial metrics associated with implementation on the state, local and beneficiary levels.

The Center for Community Solutions is asking the state to ensure that there is a process of regularly reporting meaningful data so that everyone, regardless of their position on the issue, can evaluate the effectiveness of this new mandate.

The following represents our recommendations on what should be included as a part of the waiver:

Broad Design Element

  1. Work With Independent Researchers

It is important that the public have trust in the research and analysis conducted on its behalf and financed with taxpayer dollars. To accomplish this, the Ohio Department of Medicaid should contract with independent entities to carry out some of the essential research elements of the waiver.

For example, Michigan’s Department of Medicaid contracts with the University of Michigan’s Institute for Healthcare Policy & Innovation (UMIHPI) to develop some of the analysis required in their waiver’s terms and conditions. Specifically, UMIHPI conducts a beneficiary survey documenting the experience of individuals enrolled in the program. Ohio, which has a tradition of independent evaluation in Medicaid, should build on its legacy of transparency and identify external experts to assist in cultivating the public’s trust regarding the waiver’s implementation through timely and apparent data-based reporting. 

2. Regularly Report on Hypotheses Being Tested

In the state’s application, three hypotheses are being tested, including:

a. Group VIII population will have improved health outcomes as a result of complying with the Work and Community Engagement Requirement.

b. Supporting and encouraging member community engagement will result in transition to employer-based coverage.

c. Employment requirements will result in broader sustained employment over time.

Hypotheses b and c will be measured through surveys. These should be independently conducted. However, the state should also consider partnering with the Ohio Development Services Agency to measure key employment statistics, particularly in the healthcare services, given the Medicaid expansion’s causal relationship to financial stability for this sector. The state should also consider the effect disenrollment has on employer-sponsored insurance premiums, as there is a relationship between lower employer insurance premiums and the presence of Medicaid expansion as a source of coverage.

Ohio’s Medicaid expansion has been successful in creating economic opportunity for its enrollees

3. Iterative, Transparent Monthly Reports

Regular, iterative measurement and analysis is the hallmark of quality improvement. The state should create and develop a robust monthly report that documents key health and financial metrics, both inside and outside of government, associated with implementation on the state, local and beneficiary levels. Recommendations are described in detail in subsequent sections.

4. Develop a Centralized, Web-Based Location for all Waiver Materials

All related reports, state and federal documents, consumer information and associated forms and templates should be clearly organized, simply labeled, easily discoverable and readily available on a single page within the Ohio Department of Medicaid’s website. As a part of the functionality of the page, individuals should be able to sign up to an electronic, email-based listserv where major announcements or releases of information associated with the waiver will be made available as is the case with most policy activities of the state department and General Assembly.

The state should also include information for beneficiaries who may be affected by the waiver, including resources to connect to the Ohio Integrated Eligibility System, any engagement activity reporting responsibility structure and/or portals, contact information for county Job and Family Service case managers and appeals process information.

Ohio’s Medicaid expansion has been successful in creating economic opportunity for its enrollees, with most members disenrolling due to an increase of income. While the state’s goal of creating a program that enables upward economic mobility and decreases cost is a laudable one, this waiver, based on experience in other states, may ultimately conflict with that stated goal. The only way to evaluate the effectiveness of this demonstration is for the Ohio Department of Medicaid to comprehensively and transparently evaluate its.

What’s Next?

The Next Six Months

  1. In accordance with federal law, Ohio needs to develop and publish a comprehensive implementation plan that is due within 90 days of federal approval, covering the key policies being tested. This plan should include:

a. Definitions and parameters, including identification of those items which will require rule development by the Ohio Department of Medicaid or any other agencies affected.

b. Outline of strategic approach to implementing policies, timelines associated with key milestones (see item 2a).

c. Strategy and tactics for notifying and communicating with enrollees, current or potential, about their responsibilities, reporting requirements, liabilities and options for appeal or redress regarding their eligibility.

d. Strategy and tactics for notifying and training eligibility coordination agencies, particularly the county Departments of Job and Family Services, about their responsibilities, reporting requirements and liabilities regarding the waiver.

2. In accordance with federal law, Ohio needs to develop and publish monitoring protocol within 150 days of federal approval

a. The state should commit to quarterly and annual reporting requirements in accordance with 42 CFR 431.428 including, but not limited to:
i. Any policy or administrative difficulties in the operation of the demonstration
1. County level data on average application processing time/caseload
2. Successful delivery of notification letters expressed as a rate
ii. Complaints identified by beneficiaries
1. Hotline/complaint line volume
2. Resolution rate and time-based data points (i.e. how long it took to resolve)
iii. Coverage levels
1. How coverage was attained (“no touch” volume vs. in-person case intervention)
2. Reason for disenrollment (higher income, new coverage, failure to comply and reason for non-compliance, met other qualifying requirement)
iv. Outcomes of care, quality of care, cost of care and access to care for demonstration populations
v. The existence or results of any audits, investigations or lawsuits that impact the demonstration
vi. The financial performance of the demonstration, including
1. Analysis expressed as PMPM and impact relative to Joint Medicaid Oversight Committee target rate
2. Costs of implementation on the county level
3. Budget neutrality
vii. The status of the evaluation and information regarding progress in achieving demonstration evaluation criteria
1. Employment status of individuals before and after implementation
2. The nature of employment (seasonal, industry type, if it was due to referral from state or associated agencies)
viii. Any State legislative developments that may impact the demonstration
ix. The results/impact of any demonstration programmatic area defined by CMS that is unique to the demonstration design or evaluation hypothesis
x. A summary of the annual post-award public forum, including all public comments received regarding the progress of the demonstration project
b. The state should use the Centers for Medicare and Medicaid (CMS) template organized by milestones and make that a public record released as milestones are either achieved or not achieved. If not achieved, the state should identify the consequences of failing to meet the milestone, including suspension or termination of the waiver.
c. Information should be expressed on a county-level to accommodate potential exemptions tied to Supplemental Nutrition Assistance Program regulations
d. Data should include basic demographic information on enrollees
e. Reporting should expressly describe how the Department is addressing any civil rights and/or equal protection issues

3. In accordance with federal law, Ohio needs to develop and publish an evaluation plan within 180 days after approval

a. With this long of a time frame, Ohio should establish a “baseline” from which to gauge the effectiveness of the waiver. Ohio, being in the unique position of rolling back expansion, has longitudinal data from which to draw and should establish measurements that comprehensively address earlier reporting and any data points which are tied to the hypotheses being tested in the approved application.

b. This evaluation should be comprehensive, including all the elements identified previously and explicitly state if the waiver achieved success relative to its hypotheses. This final evaluation, specifically in regards to success, should be conducted independently, with a multi-disciplinary team, and results should be made public. If it is determined the waiver was not successful in attaining its stated goals, the Ohio Department of Medicaid should immediately terminate its waiver.

On a Monthly Basis

  1. Create a monthly report that documents implementation tied to the milestones in the terms and conditions

a. Arkansas developed a reporting tool that was public available on the monthly progress of the waiver and should serve as a foundation for a similar product developed by the Ohio Department of Medicaid.