• Michigan and other states received 389 pages of guidance just more than a month ago for new Medicaid requirements
• But a lot remains unknown, among other things: Who is ‘medically frail’ and therefore exempt from work requirements?
• Implementing the changes will be a heavy lift for local advocates and the state, which has budgeted for more than 400 new workers to implement the guidance

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ROYAL OAK — With less than six months to go before seismic changes in Medicaid, including new work requirements, nearly 700,000 Michiganders still have few answers about keeping their coverage.

And the places they’d normally turn — community based organizations and the Michigan Department of Health & Human Services — aren’t yet much help.

Meanwhile, the state is hiring at least 421 new staff to help implement the changes.

“Every day people are like: ‘How do I get a job? Do I have to get a job? Do I have to go back to school? What do I need to do to make sure I don’t lose my Medicaid?’” said Meredith Buhalis, a program manager at Ypsilanti-based Washtenaw Health Project, a health program for low-income residents.

Right now, she doesn’t have a lot of answers.

Leaders at several Michigan’s community organizations told Bridge Michigan they’re scrambling with less than six months to go. Lengthy federal guidance released June 1 left crucial, unanswered questions, they said.

Related:

• New federal rules for Medicaid: Here’s what’s changing in Michigan
• Michigan Medicaid rolls drop 5%, prompting fears of surge in uninsured
• Michiganders soon to face stricter Medicaid rules. What to know

Buhalis and other advocates in community organizations, in fact, say they’re not even sure who will be subject to the new requirements, even as the state starts mailing general information to beneficiaries this month.

“Everybody wants to get going. We’re on pins and needles waiting to launch this,” said Lindsay Calcatera, who oversees communications and government relations at Easterseals MORC, which serves adults and children with disabilities and mental health issues.

“We just don’t have a lot of answers,” she said.

People enrolled in traditional Medicaid aren’t subject to the new federal work requirements, but those requirements do apply to people enrolled in the Healthy Michigan Plan. That plan covers people who are relatively healthy and whose family income is up to 138% of the federal poverty level. Beginning Jan. 1, the state must begin collecting extra documentation from the first cohort of the nearly 700,000 Michiganders in the Healthy Michigan Plan.

Unless they’re considered “medically frail,” adult recipients without young children and without disabilities generally must either be working, in school or some job training, or volunteer in their communities at least 80 hours a week.

The requirements are the result of a mainly Republican effort to trim Medicaid spending by billions of dollars and crack down on what they said was fraud and abuse in the system. The changes were finalized with the passage of the “One Big, Beautiful Bill.” 

Medicaid is funded using state and federal dollars, The federal government reimburses the state for the lion’s share of the cost. Michigan could lose as much as $635 million in revenue a year under the changes, according to a report late last year by the state health department. 

But those efforts may sweep up people like Emily Katz, who said she thrives — working as a Meijer cashier and volunteering as a cook at the Dreams Unlimited Clubhouse — because of Medicaid. 

In addition to paying for her medication, Medicaid pays for Katz to receive services at Dreams Unlimited, a mental health rehabilitation program. 

When Bridge visited Katz on a recent morning, she was mixing hummus for lunch at the clubhouse — focused, at least at that moment, on measurements and mixing methods rather than the changes ahead.

Will Katz be one of those caught up in the work requirements?

It’s unclear.

Will she lose access to her medications that keep her out of the hospital? 

Also unclear.

Will this clubhouse — whose lifeline is the Medicaid reimbursements from Katz and others — survive the upcoming cuts and confusion?

She shakes her head quickly, as if to ward off the thought. 

“It’s hard to know what to worry about most,” she said.

A search for answers

The state awaits clarification, too, communicating with the US Centers for Medicaid & Medicare Services, said Meghan Groen, who leads the state’s nearly $28 billion Medicaid program at the Michigan Department of Health and Human Services.

The US Centers for Medicare and Medicaid Services issued a lengthy guidance document June 1, outlining for states how to implement “community engagement” or Medicaid work requirements.

To the surprise of many, it established a two-part test for exempting residents who are “medically frail or otherwise” having “a special medical need.” 

Allowing exemptions “based solely on diagnosis or condition would risk sweeping in individuals whose conditions do not significantly impair their functional capacity,” according to the June 1 guidance.

It left it up to the states to partially refine the details — not an easy task.

While some in substance use recovery are able to work; others are not, said Calcatera at Easterseals MORC, which operates the clubhouse.

Some people with cancer may be able to work; but what happens when “chemo wipes you out for a week or two and you’re fighting for your life?” she said.

“Not only do you have to prove that you have this condition, you have to prove — at least for the month they choose to look — you have to prove why that condition prevented you from work,” said Calcatera.

And who will help determine frailty — doctors, the state, some yet undetermined board? 

“Is that a letter from a therapist? Something else? We don’t know,” she said.

Katz, 44, seems to fall into a gray area. 

After all, she spent months in the hospital when her mental health spun out of control. She struggles at times to stay at her cash register, fighting panic attacks as she suspects some customers are annoyed with her, but equally convinced they are not.

For months now, she has been able to maintain work as a cashier, not only because of her medications, but also because of the support she receives from Easterseals — and the confidence built here at the clubhouse.

“When I first started here, I didn’t feel that comfortable in the kitchen,” Katz said. “Now I can cook a meal by myself for like 15, 20 people.”

But if Katz doesn’t meet her paperwork obligations — if she misses a deadline or files the wrong documents, for example — she’ll lose Medicaid coverage. And if she loses access to her medications and treatment. She fears her mental health will spin out of control.

And isn’t that the exact opposite of what was intended by work requirements? said Calcatera.

Like filing taxes twice a year

Complicating matters further, the state will be required to do twice-yearly eligibility checks, doubling the current rate of reviews.

“It will be like having to file taxes twice a year, and right now, we have no direction on how to help with that,” said Brent Wirth, president and CEO of Easterseals MORC.

The job training, life skills-building and camaraderie they provide here at this low-slung building with walls crowded with pictures and awards depend on Medicaid reimbursements by people like Katz.

If the clients lose Medicaid; the clubhouse loses its budget.

Funding fallout

For every beneficiary that loses Medicaid, their providers must trim budgets — whether the Clubhouse, a small doctor’s office, a private therapist or a large health care system.

Precisely how many Michiganders will lose coverage is uncertain. Estimates have ranged from 150,000 to 500,000, according to a May report by the Michigan-based Citizens Research Council, a not-for-profit public affairs research organization.

But even if it’s the lower end of those estimates, the state health department’s Groen said, “it will be a lot of uncompensated care, right? And if you’re a provider, you have to account for that in your budget and what you’ll be able to do.”

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