Illinois Medicaid Changes Highlight Challenges in Determining Work Exemptions

Starting January 1, 2027, adults in the Illinois Medicaid expansion program must prove they worked 80 hours in the past month or show they are too ill to work. This requirement raises concerns about accurately assessing who is truly unwell and unable to work.

Understanding the New Requirement

States, including Illinois, will rely heavily on billing codes to decide if patients are too sick to meet work requirements. For example, a woman in between an abnormal mammogram and a confirmed diagnosis may seem healthy based on codes, but her doctors might disagree. This highlights the challenge states face in accurately identifying those who need exemptions.

Exemption Challenges

The exemption for people classified as “medically frail” is supposed to protect those whose conditions prevent them from working. However, detecting these individuals is difficult. In Illinois, like many states, claims data will play a key role. While effective for ongoing chemotherapy patients, this data misses those awaiting diagnosis or post-treatment monitoring.

Error Potential in the System

An abnormal mammogram doesn’t immediately translate to a cancer diagnosis in the system. Between initial screenings and confirmation via a pathology report, a patient undergoes more tests and procedures, yet may not qualify for an exemption. If Medicaid renewal occurs during this period, she could be miscategorized, significantly impacting her access to care.

Furthermore, Illinois’s Medicaid covers breast and cervical cancer treatment separately. However, those already eligible under the expansion aren’t easily transitioned to receive this specific coverage, despite a confirmed diagnosis. They remain subject to work requirements during treatment, illustrating systemic challenges.

Lessons from Other States

Arkansas offers insight into possible outcomes. During its 2018 work requirement, about 18,000 individuals lost Medicaid in the first seven months. Employment rates didn’t rise, and many lost coverage because they couldn’t handle the reporting process, not because they were jobless. By early 2019, few had regained coverage.

Solutions for Better Implementation

Though federal law is settled, states have flexibility in execution. Illinois doesn’t need to alter federal policy to safeguard patients. Instead, they can adjust administrative practices to lessen the burden on those awaiting or undergoing treatment.

• Protect patients with abnormal screening results immediately.
• Add grace periods to capture lag in billing claims.
• Accept documentation from community clinics for non-billing patients.
• Continue covering survivors under monitoring.

Conclusion

The Centers for Medicare and Medicaid Services anticipate 2.3 million losing Medicaid in the first year. While federal laws remain unchanged, state officials will soon decide on criteria for exemptions and required documentation. As cancer doesn’t pause for billing processes, timely and thoughtful state decisions are crucial.

Written by Akshaya Sahasra Ganji, a health policy researcher focusing on women’s health and related policies.