The rule does not do a good job explaining who does not have to follow work requirements. This is bad for people who get health care through Medicaid. This is bad for states trying to follow the rule. This resource will explain it as much as possible. But, the rule itself is confusing. That is part of why the rule is so bad.
Mandatory Exceptions
If a person gets health care through a program like Medicaid expansion, they probably have to follow work requirements. But there are some cases where this is not true. These cases are called mandatory exceptions. Mandatory exceptions are rules that mean some groups of people do not have to follow work requirements.
Below are some examples of mandatory exceptions. If something below is true about someone, that person probably does not have to follow work requirements.
The person was younger than 19 years old during the month they were told they could get health care from a program like Medicaid expansion.
The person gets health care through Medicare Part A or Part B.
Medicare Part A and Part B are ways to get health care through Medicare. Medicare is a type of health care that the government can give to people. Medicare is different from Medicaid. If a person gets health care from Medicare Part A or Part B, they do not need to follow work requirements.
The person is part of a mandatory eligibility group for Medicaid.
A mandatory eligibility group is a group of people a state has to give Medicaid to.
Children who live with families that do not make a lot of money are a mandatory eligibility group.
Pregnant people who do not make a lot of money are a mandatory eligibility group.
People who are part of a mandatory eligibility group do not need to follow work requirements to keep getting health care through Medicaid.
People who have been to prison or jail in the past three months.
Not everyone who has been in prison or jail recently has a mandatory exception. It matters when a person is allowed to get Medicaid. People with a mandatory exemption get Medicaid at a certain time. That time has to be within three months of leaving jail or prison.
Here is an example: Melanie lives in Maine. The Maine Medicaid agency tells Melanie that she is allowed to get Medicaid on May 15th. The month she can get Medicaid is May. If Melanie was in prison or jail three months before May 1st, she does not have to follow work requirements. Melanie was in jail until April 21st. That is less than three months before May 1st. Melanie does not have to follow work requirements.
Specified Excluded Individuals
There are other people who do not have to follow Medicaid work requirements. The rule calls these people Specified Excluded Individuals (SEI).
We talk about what might make someone a Specified Excluded Individual below. A person might be a Specified Excluded Individual if something below is true about the person. If the person is a Specified Excluded Individual, they don’t have to follow work requirements.
People who are “medically frail”.
Medically frail means people who have a certain kind of disability that makes them not able to work. The definition of medically frail in the rule is very confusing. We made another resource to explain it.
You can read the resource here.
People who are a parent, guardian, caretaker relative, or family caregiver of a child with disabilities.
The child also needs to be 13 or younger. This group of specified excluded individuals uses a different meaning of disability than other parts of the rule. This group uses a better meaning of disability. We wish the whole rule used this meaning. Different meanings of disability in the same rule will confuse people.
The rule says a parent is someone that state law says is the mother or father of a child. Different states have different laws about who is a mother or father.
The rule says a guardian is an adult who makes important choices for a child or a disabled person who can not make choices alone. A person is only a legal guardian if a judge says so.
The rule says a caretaker relative is a parent or another adult family member who takes care of a child. A caretaker relative has to live with the child they take care of.
The rule says a family caregiver is an adult who takes care of a child or disabled person. A family caregiver can be related to the child or disabled person. But a family caregiver does not have to be related to the child or disabled person. A person has to spend a lot of time with a child or disabled person to count as a family caregiver. A person has to help the child or disabled person in a lot of different ways to count as a family caregiver.
People who are an American Indian, Alaska Native, or California Indian.
These are the names the US government uses for different groups of Indigenous peoples. Indigenous peoples are people with ancestors who lived in a place before other people took control of the place. American Indians, Alaska Natives, and California Indians are people with ancestors who lived on this land before it became the United States.
There are two ways Indigenous people can be a SEI. One way is to be part of a tribe that is on the government’s list of tribes. The other way is if a person is allowed to get health care from the Indian Health Service. The Indian Health Service is a part of the government that gives health care to indigenous people.
People who are pregnant.
People who get health care through Medicaid right after having a baby.
Different states give people this health care for different amounts of time. Some states only give health care for 60 days. That is the shortest amount of time a state can give health care to people who were pregnant through Medicaid. The longest amount of time is one year.
People who are 25 years old or younger and used to be in foster care.
Foster care is when children live with adults who are not their parents for a short time. Children live in foster care while their parents get the help they need to take care of the children. Some children move between many different foster homes while their parents get help.
Veterans that the Department of Veterans Affairs says have a “total disability”.
A veteran is someone who worked in the U.S. military.
The Department of Veterans Affairs helps veterans get health care and other services. The Department of Veterans Affairs is called “the VA” for short.
If someone gets a disability from getting hurt while they work for the military, the person can tell the VA. The VA will give the person a disability rating. A higher disability rating means someone can get more help from the VA.
The highest disability rating is called “total disability”. If the VA tells a person they have a “total disability”, that person probably will not have to follow work requirements.
People who live in a jail or prison.
Some people who get help from TANF.
TANF is another government program for people who do not have a lot of money. People can get money from TANF. People can get help paying for childcare through TANF. People can get job training through TANF. TANF is short for Temporary Assistance for Needy Families.
TANF also has work requirements. TANF work requirements are different from Medicaid work requirements. If a person is following TANF work requirements to get help from TANF, the person is a SEI.
Some people who live with a person who can get SNAP.
SNAP helps people get food when they do not have enough money for food. SNAP is short for Supplemental Nutrition Assistance Program. SNAP is also called food stamps.
SNAP also has work requirements. SNAP work requirements are different from Medicaid work requirements. Some people who get SNAP are exempt from SNAP work requirements.
Exempt means the government says the person does not have to follow the SNAP work requirements. If a person lives with someone who is exempt, the person is not a SEI. If a person lives with someone who is not exempt, the person is a SEI.
People who are getting help to stop using drugs or alcohol in a way that hurts their body or brain.
The person has to be getting help from a program that the government says is okay.
You can talk to your State Medicaid Agency to find out if you are a SEI.