33,000 West Virginia residents

An initial analysis by the West Virginia Department of Human Services showed that about 33,000 state Medicaid recipients are not currently meeting federal work or volunteer requirements taking effect in January, and are not automatically exempted from them, lawmakers were told Wednesday. 

That number could change and is likely a conservative estimate, according to a presentation from Christy Donohue, state commissioner of the Bureau for Medical Services. 

The study does not take into account a June interim final rule by the federal Centers for Medicare and Medicaid Services that narrowed an exemption for the “medically frail,” Donohue said.

Donohue said the department is on target to implement federal work requirements on Jan. 1, 2027, as required under President Donald Trump’s One Big Beautiful Bill Act. 

The work requirements are expected to make the Medicaid enrollment decline. Donohue said the impact on enrollment won’t start until March because the state is looking at two months of a person’s work or volunteer history to determine eligibility.

The new requirements are for the expansion population of Medicaid recipients. The expanded Medicaid program is available to people who make up to138% of the federal poverty line, or about $45,540 for a family of four. 

At the time of the analysis, the state had around 156,000 expanded Medicaid recipients, she said. 

With some exceptions, people on expanded Medicaid ages 19 through 64 will be required to work, train or volunteer at least 80 hours per month in order to remain eligible for the health care program. 

Individuals that participate in drug addiction, alcohol treatment or rehabilitation programs are excluded from this requirement, Donohue told the members of the Legislative Oversight Committee on Health and Human Resources Accountability. 

Based on the DoHS analysis, about 119,000 of the state’s Medicaid members will be automatically excluded from the requirements, she said. Another 4,460 Medicaid recipients currently meet the requirements, according to state estimates.

The June interim final rule defined “medical frailty” more strictly than what states had anticipated, according to health policy research group KFF.

The law itself specifies the medically frail exemption includes those who are blind or disabled; have a physical, intellectual or developmental disability that limits their ability to perform one or more activities of daily living, have a substance use disorder, have a “disabling” mental disorder; or have a “serious or complex” medical condition, according to KFF.

The new rule requires states to also consider whether the person’s condition negatively impacts their ability to meet the work requirements, KFF reported. 

The rule also allows in kind or unpaid hours to count toward the requirement, such as when a Medicaid recipient is a property manager and receives free or reduced rent as compensation, she said. 

“Prior to the IFR, it was limited to not-for-profit,” she said. “Now it’s open to other agencies that can calculate or that can count towards community service.”

Donohue said the agency is working closely with other states to come up with a way to determine if a person is medically frail. 

“Louisiana has been working with (the Centers for Medicare and Medicaid Services) very closely, and they have come up with a model that goes into a little more data mining and looking at diagnosis codes and looking more into the member’s prescriptions, so that we are not putting the ownership back on the member,” she said. “We’re able to gather all the data, hopefully through our claims information, prescriptions, also our (managed care organizations), in trying to make sure that we are utilizing every option available before we ask the member to actually provide this information.”

Sen. Brian Helton, R-Fayette, co-chair of the committee, said the state’s workforce participation rate is a top priority. He questioned the requirements as they relate to substance use disorder. West Virginia has long had one of the highest drug overdose rates in the country. 

Donohue clarified that people with substance use disorder who have been in recovery five or more years are not exempt from the community requirements. 

Helton questioned whether a Medicaid recipient person undergoing suboxone treatment for less than five years might be required to meet the work requirements if they’re stable.

Donohue replied that they’d have to drill down on the data and ask for more information. “I don’t know from a claims perspective.” she said. I don’t think there’s a definition for stable. I could be wrong.”

Helton said most West Virginians want to know that people are “doing their fair share. And they’re out here working when they can.”

“I think five years for us to pay through Medicaid (for drug treatment) and not require anyone to work is a really long time, and I don’t think people find that acceptable,” he said. “So if that’s something we can look into. I think it would be huge. Because again, we found out yesterday we’re still two and a half times give or take a few points the national average on overdose rate, and we’re still last in workforce participation. It’s not even close. So this is a significant issue of waste, fraud and abuse, and it’s a significant issue of improving workforce, and it’s a significant issue of bringing accountability back to these programs.”

Donohue said allowing a person five years for drug treatment before work is required is a federal rule.

“As much as I would love to make a change, I cannot do that,” she said.