Key Questions Remaining in Medicaid Work Requirements: Education
HR 1 established new Medicaid work requirements that will take effect January 1. To implement this significant change, the law requires the Trump administration to release an interim final rule by June 1. Congress also exempted this rulemaking from the Administrative Procedure Act, meaning the rule does not need to go out for public comment.
As we await the interim final rule, we will be examining the key questions that remain for implementation. Today's newsletter focuses on how CMS will count time spent in education toward the new community engagement requirements.
The Statute
HR 1 generally requires adults in the Medicaid expansion to meet "community engagement" requirements. While these are commonly called work requirements, there are several ways to satisfy the standard and maintain coverage. The statute lists:
Working at least 80 hours per month
Volunteering for at least 80 hours per month
Participating in a work program for at least 80 hours per month
Enrolling in an educational program at least half-time
Any combination of the activities listed above totaling at least 80 hours per month
This raises an important question: if an individual can combine educational enrollment with work, volunteering, or a work program to meet the community engagement requirement, what counts as an "hour" of education?
Half-Time Students
Enrollment in school at least half-time should, on its own, be sufficient to meet the requirement. CMS has not yet defined what "half-time" means, but let's presume it tracks the definition used by the educational institution. Even if a student enrolled half-time is also working, which is common, the educational enrollment alone should satisfy the requirement; the individual should not need to separately document work hours.
Less-Than-Half-Time Students
For students enrolled less than half-time, the picture is less clear. Congress explicitly created the possibility of combining activities to qualify, but CMS has not yet offered any public guidance on how to count partial educational enrollment toward the 80-hour threshold.
If half-time enrollment is treated as the equivalent of working or volunteering for 80 hours per month, as the statute implies, then enrollment below half-time should convert proportionally to a corresponding number of hours. For example, a student enrolled at one-quarter of what their school considers full-time should have that count as 20 hours, leaving 60 hours of work, volunteering, or work program participation required to maintain coverage.
The Academic Calendar Problem
For all students, it is also unclear how CMS will handle the academic calendar. The statute assesses whether an individual has met the requirement on a month-by-month basis, but academic calendars rarely align neatly with the calendar month.
Consider a full-time student who graduates in the middle of June. If they apply for Medicaid in July and their state looks back at the prior month, have they met the requirement, even though they were only in school half the month? Likewise, how will CMS treat summers for full-time students whose institutions do not offer summer classes?
We will be looking for answers to these questions in the interim final rule CMS is expected to release by June 1.
Outstanding Questions
Defining "half-time": Will CMS defer to the educational institution's definition, or develop its own? Will it be measured in credit hours or some other metric?
Year-round coverage: Does full-time enrollment during the academic year provide continuous coverage through the summer?
Partial months: How will CMS treat months in which an academic institution offers classes for only part of the month?