Coverage Expansion Timeline for Adults in Arkansas

On March 17, 2021, the Centers for Medicare and Medicaid Services (CMS) withdrew its approval of a work and community engagement requirement as a condition of eligibility for Arkansas’s Medicaid expansion program, Arkansas Works.

This came after CMS, under the direction of Biden administration, sent a letter in February notifying the state that it had “preliminarily determined that allowing work and other community engagement requirements to take effect in Arkansas would not promote the objectives of the Medicaid program” and that it would complete a review to determine whether to withdraw the approval.

The work and community engagement requirement had been halted by a federal judge’s order two years earlier, and the case had reached the U.S. Supreme Court. However, in a signal of the impending withdrawal of approval, the U.S. Supreme Court cancelled oral arguments at the request of the Biden administration on March 11.

Early in March, legislation was filed to replace Arkansas Works with Arkansas Health and Opportunity for Me (ARHOME). Notably, this legislation would remove the work and community engagement requirement as a condition of eligibility and instead would provide an incentive for enrollees to remain in a qualified health plan (QHP) by participating in “economic independence initiatives,” including work and community engagement. While the enrollees may not lose coverage, they could be transferred to the Medicaid fee-for-service program for non-participation.

This updated timeline notes significant events in the life of coverage expansion for adults in Arkansas, including its development, programmatic changes, and legislative history.

Key takeaways:

• In 2013, Arkansas opted to expand healthcare coverage to low-income adults earning up to 138% of the federal poverty level (FPL) through the Patient Protection and Affordable Care Act (ACA). Colloquially known as the “Private Option,” the Health Care Independence Program (HCIP) used federal funds allotted for Medicaid expansion under the ACA to purchase qualified health plans available in the Health Insurance Marketplace.
• During the life of the waiver, HCIP underwent modifications in response to legislative amendments to the enabling bill – the Health Care Independence Act – including the introduction of health independence accounts to incorporate personal responsibility and limitations on use of non-emergency transportation.
• Prior to expiration of HCIP on Dec. 31, 2016, Arkansas sought and received approval for a waiver extension to continue the premium assistance model, renamed “Arkansas Works.”
• The five-year waiver extension included requirements for premium payments for individuals earning between 101% and 138% of the FPL and an employer-sponsored health insurance premium assistance program.
• In 2017, additional modifications to Arkansas Works were legislatively enacted, notably a work and community engagement requirement as a condition of eligibility and an eligibility cap at 100% of the FPL. On March 5, 2018, Arkansas received approval to amend the waiver to allow modifications such as implementing a work and community engagement requirement for enrollees ages 19 to 49, with certain exemptions, and waiving the retroactive eligibility period from 90 days to 30 days.
• The work and community engagement requirement went into effect on June 1, 2018, for enrollees ages 30 to 49. By December 2018, over 18,000 enrollees had lost coverage due to non-compliance with the requirement.
• In March 2019, a D.C. district judge halted the work and community engagement requirement. Following signals that the incoming Biden administration was poised to withdraw approval of the work and community engagement requirement and a delay of oral arguments in the state’s case pending before the U.S. Supreme Court, the Centers for Medicare and Medicaid Services officially withdrew its approval of the waiver amendment on March 17, 2021.
• On March 1, 2021, legislation was filed to replace Arkansas Works with Arkansas Health and Opportunity for Me (ARHOME). One key modification proposed in the legislation is the removal of the work and community engagement requirement as a condition of eligibility. Instead, ARHOME enrollees would be incentivized to participate in “economic independence initiatives,” including work and community engagement, and could be transferred from their QHP coverage to the Medicaid fee-for-service program for non-participation.

References

1. 1. Arkansas Center for Health Improvement. (2016, June 16). Arkansas Health Care Independence Program (“Private Option”) Section 1115 Demonstration Waiver Interim Report. Retrieved from http://achi.net/wp-content/uploads/2018/10/Arkansas-Health-Care-Independence-Program-Section-1115-Demonstration-Waiver-Interim-Report-June-2016.pdf.
   2. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2016, Dec. 8). Demonstration approval [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.
   3. AR Act 6, 2017, 91st General Assembly 1st Special. (2017, May 4). Retrieved from https://www.arkleg.state.ar.us/Acts/Document?type=pdf&act=6&ddBienniumSession=2017%2F2017S1.
   4. AR SB 410, 2021, 93rd General Assembly. (2021, March 1). Retrieved from https://www.arkleg.state.ar.us/Bills/FTPDocument?path=%2FBills%2F2021R%2FPublic%2FSB410.pdf.
   5. AR Act 1498, 2013, 89th General Assembly. (2013, April 23). Retrieved from http://www.arkleg.state.ar.us/assembly/2013/2013R/Acts/Act1498.pdf.
   6. State of Arkansas Governor’s Office. (2013, Aug. 2). [Letter]. Retrieved from http://humanservices.arkansas.gov/dms/Documents/Final%201115%20Waiver%20Materials%20for%20Submission.pdf.
   7. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2013, Sept. 27). Demonstration approval [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-app-ltr-09272013.pdf.
   8. Kaiser Family Foundation. Marketplace average benchmark premiums, 2014-2021. Retrieved from https://www.kff.org/health-reform/state-indicator/marketplace-aver.
   9. Kaiser Family Foundation. Number of Issuers Participating in the Individual Health Insurance Marketplaces, 2014-2021. Retrieved from https://www.kff.org/other/state-indicator/number-of-issuers-participating-in-the-individual-health-insurance-marketplace/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
   10. 10. AR Act 257, 2014, 89th General Assembly Fiscal. (2014, March 7). Retrieved from http://www.arkleg.state.ar.us/assembly/2013/2014F/Acts/Act257.pdf.
   11. AR Act 283, 2014, 89th General Assembly Fiscal. (2014, March 13). Retrieved from http://www.arkleg.state.ar.us/assembly/2013/2014F/Acts/Act283.pdf.
   12. AR Act 276, 2014, 89th General Assembly Fiscal. (2014, March 13). Retrieved from http://www.arkleg.state.ar.us/assembly/2013/2014F/Acts/Act276.pdf.
   13. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2014, March 24). Evaluation design approval [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-eval-design-appvl-ltr-03242014.pdf.
   14. Arkansas Health Connector Division and Arkansas Insurance Department. (2014, June 5). Plan Management Frequently Asked Questions. Retrieved from https://static.ark.org/eeuploads/hbe/PM_FAQ_Purchasing_Guidelines.pdf.
   15. Arkansas Department of Human Services. (2014, Dec. 31). Demonstration approval [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-demo-appvl-12312014.pdf.
   16. Arkansas Department of Human Services. (2016, May 23). Arkansas Health Independence Accounts Assurance of Compliance. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-assrnc-cmplnce-rpt-05232016.pdf.
   17. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2015, Jan. 30). State plan amendment approval [Letter]. Retrieved from https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/AR/AR-15-0001.pdf.
   18. AR Act 46, 2015, 90th General Assembly. (2015, Feb. 12). Retrieved from http://www.arkleg.state.ar.us/assembly/2015/2015R/Acts/Act46.pdf.
   19. Arkansas Department of Human Services and Arkansas Insurance Department. (2015, March 5). Plan Management Frequently Asked Questions. Retrieved from https://static.ark.org/eeuploads/hbe/FAQs-3-13-15.pdf.
   20. The Secretary of Health and Human Services. (2015, June 15). [Letter]. Retrieved from https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/Final-Signed-Letters-SBM-AR.pdf.
   21. Arkansas Department of Human Services. (2015, July 14). Technical corrections request [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-tech-crrctns-req-07142015.pdf.
   22. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2015, Aug. 14). CMS approval letter. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-appvl-ltr-08142015.pdf.
   23. Arkansas Center for Health Improvement. (2016, May). Arkansas Works Act of 2016. Retrieved from http://achi.net/wp-content/uploads/2018/01/Arkansas-Works-Act-of-2016-Fact-Sheet.pdf.
   24. Department of Health and Human Services, Centers for Medicare and Medicaid Services. [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-application-07072016.pdf.
   25. Arkansas Department of Human Services. (2017, March 8). Arkansas Private Option 1115 Demonstration Waiver Quarterly Report. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-works-qtrly-rpt-apr-jun-2016.pdf.
   26. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2016, Dec. 8). [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-ca.pdf.
   27. State of Arkansas Governor’s Office. (2017, June 30). [Letter]. Retrieved from https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/ar-works-pa2.pdf.
   28. Supreme Court of the United States. (2020, July 6). Arkansas, Petitioner v. Charles Gresham, et al., No. 20‒38. Retrieved from https://www.supremecourt.gov/docket/docketfiles/html/public/20-38.html.
   29. Arkansas Department of Human Services. Monthly Enrollment and Expenditure Report, Calendar Year 2020. Retrieved from https://humanservices.arkansas.gov/wp-content/uploads/Monthly-Enrollment-and-Expenditure-Report_DECEMBER-2020.pdf.
   30. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2021, March 17). [Letter]. Retrieved from https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-works-ca2.pdf.
   31. Arkansas Department of Human Services. (2021, July 19). Application-Arkansas Health and Opportunity for Me (ARHOME). Retrieved from https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-arhome-pa.pdf
   32. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2021, December 21). Demonstration Approval. Retrieved from https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-arhome-ca.pdf
   33. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2021, November 1). Demonstration Amendment Approval. Retrieved from https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ar-arhome-ca-11012022.pdf