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    Original Investigation
    Health Policy
    July 17, 2019

    Assessment of Medicaid Beneficiaries Included in Community Engagement Requirements in Kentucky

    Author Affiliations
    • 1Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
    • 2Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 3Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 4Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
    • 5National Opinion Research Center (NORC) at the University of Chicago, Chicago, Illinois
    • 6National Opinion Research Center (NORC) at the University of Chicago, Bethesda, Maryland
    • 7Columbia Law School, New York, New York
    • 8Department of Population and Family Health, Mailman School of Public Heath, Columbia University, New York, New York
    JAMA Netw Open. 2019;2(7):e197209. doi:10.1001/jamanetworkopen.2019.7209
    Key Points español 中文 (chinese)

    Question  What proportion of Medicaid beneficiaries in Kentucky would be included in community engagement (CE) requirements to maintain insurance coverage in the state’s Medicaid demonstration waiver program?

    Findings  In this cross-sectional study, administrative records and survey data collected at the time of the originally intended demonstration waiver implementation date (July 2018) showed that more than 130 000 beneficiaries (40.2% of those included in the demonstration waiver) would likely be required to meet CE requirements. Of this group, approximately 48 000 (14.7% of individuals included in the overall waiver and 36.3% of individuals included in CE requirements) did not meet CE hours at baseline nor were likely to qualify for medical frailty and would have had to take on new activities to maintain benefits.

    Meaning  The findings suggest that most beneficiaries of Medicaid in Kentucky who were included in CE requirements likely already meet required hours or qualify for an exemption for the program.


    Importance  States are pursuing Section 1115 Medicaid demonstration waiver authority to apply community engagement (CE) requirements (eg, participation in work, volunteer activities, or training) to beneficiaries deemed able-bodied as a condition of coverage. Understanding the size and characteristics of the populations included in these requirements can help inform policy initiatives and anticipate effects.

    Objective  To estimate the number and characteristics of Kentucky Medicaid beneficiaries who would have to meet CE requirements.

    Design, Setting, and Participants  Cross-sectional study in which administrative records for the entire population of Medicaid beneficiaries in Kentucky as of February 2018 and original survey data, based on responses from 9396 Medicaid beneficiaries included in the waiver program, were analyzed.

    Exposures  Eligibility for Kentucky’s Medicaid demonstration waiver as of the originally planned implementation date (July 2018).

    Main Outcomes and Measures  Number of beneficiaries included in CE requirements, including those already meeting vs not meeting hour quotas and those who may qualify for medical frailty exemptions.

    Results  Among the 9396 individuals included in the Section 1115 waiver program who participated in the survey, the mean weighted (SD) age was 36.1 (11.9) years; a weighted 47.2% of respondents were female, and most beneficiaries (weighted percentage, 78.2%) were non-Hispanic white participants. We estimated that 132 790 (95% CI, 129 132-136 449) beneficiaries would have been required to meet CE requirements in July 2018, amounting to 40.2% of Medicaid beneficiaries included in the demonstration waiver. Of this group, 25 422 (95% CI, 23 135-27 710) beneficiaries may have qualified for a medical frailty exemption either by self-attestation (after confirmation by their Medicaid insurer) or by being identified as eligible by physicians or their insurer. Another 58 943 (95% CI, 55 687-62 196) beneficiaries likely would have met CE hour requirements and been required to report compliance. Ultimately, 48 427 (95% CI, 45 281-51 574) individuals would have had to add new activities to meet CE requirements, amounting to 14.7% of those included in the demonstration waiver as a whole and 36.3% of those included in the CE component of the waiver. Beneficiaries in the potentially medically frail group reported worse socioeconomic status, poorer health outcomes, and higher rates of hospital admission and emergency department use than those meeting CE requirements. Similarly, the group currently not meeting and not exempt from CE hour requirements reported worse socioeconomic status than those meeting the CE requirements, although magnitudes of the differences were smaller.

    Conclusions and Relevance  Findings suggest that most beneficiaries who would be included in CE programs either already meet activity requirements, which they will be required to proactively report, or may qualify for a medical frailty exemption. Consequently, the outcomes of CE programs will depend on states’ processes for addressing health-related, socioeconomic, and administrative barriers to participating in and reporting CE activities and identifying medical frailty.