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Healthy Indiana Plan 2.0

Vonnie Baranko, of NorthShore Health Centers in Portage, helps a patient sign up for Healthy Indiana Plan coverage in February 2016. Certain Hoosiers with that Medicaid plan will have to meet work requirements beginning this year.

New work requirements for certain Indiana residents on Medicaid officially went into effect Jan. 1. However, those people don't have to start working until July 1 and can't lose their coverage until 2020.

Confused yet? The Times has the answers to your questions on Indiana's Gateway to Work program:

1. How did this happen?

In January 2017, the Indiana Family and Social Services Administration asked the federal government to approve changes to its Medicaid program, requiring that certain members work part time or lose their coverage.

The Trump administration had signaled it would allow states to be more flexible with the design of their Medicaid programs, which typically provided health coverage to poor and disabled Americans without conditions.

Under President Obama, the feds already had enabled Indiana to make one of the more radical changes to Medicaid ever: charging beneficiaries monthly premiums and copays. Essentially, Indiana agreed to the Affordable Care Act's Medicaid expansion in exchange for charging money to the new enrollees.

That extended health coverage to hundreds of thousands of previously uninsured Hoosiers. However, some bureaucratic complexities and initial glitches actually caused some of those people to get kicked off their insurance.

In January 2018, the U.S. Department of Health and Human Services approved Indiana's work requirements.

2. What is the point?

"Healthy, fulfilling lives require not just health coverage, and health care, but also a sense of purpose, often obtained through work," HHS Secretary Alex Azar said at a ceremony in Indianapolis announcing the approval. "It recognizes that Medicaid can become a pathway out of poverty, paving the way for better, long-term health for all enrollees."

In its application to the federal government, FSSA said research shows that "employed individuals are both physically and mentally healthier, as well as more financially stable, as compared to unemployed individuals."

FSSA cited a Robert Wood Johnson Foundation report that linked unemployment to an increased risk of high blood pressure, stress-related illnesses like heart disease and depression.

However, that paper also cited the importance to health of good-paying jobs, workplace safety, anti-discrimination policies and paid sick leave. Critics of the work requirements contend that people need to be healthy in order to work, train or look for a job.

3. Who does this apply to?

This program is only for people on HIP, not for residents with traditional Medicaid, Hoosier Healthwise (for children) and Hoosier Care Connect (for people who are elderly, blind or have disabilities). 

Many HIP members, however, will be eligible to get exemptions from the requirement to work. They include caregivers, students, pregnant women, residents age 60 and up, the homeless, and people with a substance abuse disorder or who are considered "medically frail."

The state previously estimated that the work requirements apply to less than 30 percent of HIP's more than 400,000 members.

4. What are the requirements? When do they start?

Ultimately, eligible Medicaid beneficiaries will have to work 80 hours a month.

But they aren't required to work at all until July 1, and at that time will only need to be employed 20 hours a month.

The requirement increases to 40 hours on Oct. 1, and 60 on Jan. 1, 2020, with the permanent 80-hour rule beginning June 30, 2020.

However, people only have to work eight months out of the year (meaning four of the last six months of 2018; those months can technically be done anytime this year).

Those who don't meet the requirements will have their insurance taken away Jan. 1, for a minimum of a month, until they start meeting the provisions.

FSSA Director Jennifer Walthall said at a state Senate hearing Wednesday that her agency will be diligent in reminding members to meet the requirements or helping them move into other kinds of insurance if they are suspended.

"What our plan is, and what our goal is, and I have stated publicly many times, is that we will not lose a single individual’s health care coverage because of this program," she said.

4. Are there alternatives to work?

Yes. Quite a few, in fact.

Hoosiers in Gateway for Work can meet their hourly requirements with such activities as looking for a job, volunteering, internships, apprenticeships, taking care of grandchildren, studying for a GED, vocational education or homeschooling their kids.

Even "helping a neighbor and helping your community" count, according to FSSA. "Illegal activities" and going to doctor appointments, however, don't.

4. Have other states done this?

Arkansas rolled out the nation's first Medicaid work requirement program in June 2018. Critics have panned the initiative for causing nearly 17,000 residents to lose coverage, while supporters say the more than 4,000 people who gained employment shows that it's a success.

Kentucky was supposed to be first, but a federal judge blocked that state's plan. He disagreed with HHS' stand that the work requirement fits with Medicaid's objective of improving health and well-being; he said Congress passed Medicaid to cover the cost of health care services for the needy.

5. How do people show that they're exempt or working?

People who are exempt are supposed to contact their health plan (Anthem, CareSource, MDWise or MHS), who then will let FSSA know. Those who already work won't have to do anything new. People who don't will have to report their hours of work or other activities, by the end of the calendar year, by calling their health plan or visiting an online portal at fssabenefits.in.gov (documentation is not required).

Opponents of these types of programs said it's generally the reporting that causes people to lose coverage. Many Medicaid recipients lack internet access or a mailing address, or have a mental illness.

"Every state work requirement has the unintended consequences of taking coverage away from people who are already working or should be exempt," Judy Solomon, senior fellow at the Center on Budget and Policy Priorities, said during a conference call with reporters Wednesday. "What we've learned in Arkansas is that the reporting itself is even more of a barrier than we expected."

She did, however, predict that the slower rollout of Indiana's program would cause less coverage loss than in Arkansas or New Hampshire, whose work requirements start in March.

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Health Reporter

Giles is the health reporter for The Times, covering the business of health care as well as consumer and public health. He previously wrote about health for the Lawrence (Kansas) Journal-World. He is a graduate of Northern Illinois University.