Jim’s Notebook: Exempting Hospice Patients from Medicaid Work Requirements
Last week was a rough one, and I was glad to have a half restful weekend. I needed that.
I want to talk today about Medicaid work requirements. In a nutshell, beginning Jan. 1, 2027, non-disabled adults ages 19 to 64 enrolled in Medicaid through expansion programs must complete at least 80 hours per month of work, education or community service. The requirement includes exemptions for caregivers and individuals with certain health conditions. You can find more details in this Hospice News piece that went out in our newsletter on Monday.
When the U.S. Centers for Medicare and Medicaid Services (CMS) gift wrapped this little present from the Trump administration to sick and struggling families, they may have made at least one little oversight – hospice and palliative care patients are not on the list of exemptions.
Now, one could argue that those patients would be covered under the exemption for people who are blind, have a certified physical, intellectual, or developmental disability affecting activities of daily living or have a serious/complex medical condition. But vague or ambiguous elements in regulatory language can cause serious problems and create a slew of unanswered questions.
For example, who exactly qualifies for this exemption? What conditions are considered “serious or complex?” How are CMS, state agencies or Medicaid Managed Care Organizations going to identify those patients and ensure they implement any exceptions to this rule?
Without clarification, this could potentially lead to claims denials, delays in care or even expulsion from the Medicaid program for the most vulnerable patients. It also puts the providers who care for them at some degree of financial risk.
Policies for hospice eligibility within Medicaid also vary among the states, with some requiring prior authorizations like Alaska, Nevada, Mississippi and others. Will patients be denied these authorizations because they did not meet work requirements?
I wasn’t able to find national data on how many patients receive hospice coverage via Medicaid. Medicare covers the vast majority. Also, many of those patients are dual eligible for both programs. However, a contingent of patients, regardless of how large or small, do get their hospice coverage via Medicaid, and they should be protected. All patients should be protected.
CMS needs to specifically add hospice and palliative care patients to its list of exemptions. They should also issue at the very least some type of subregulatory guidance on how to address, verify or report exemptions for medically complex, seriously ill and frail patients, including defining those terms in this context.