Thousands of Allegheny County residents could lose Medicaid coverage under new rules requiring more frequent paperwork and proof that they work, volunteer or study.
The One Big Beautiful Bill Act, also known as HR1, requires people to recertify twice a year instead of once and meet an 80-hour monthly work, volunteer or study requirement.
Public Source spoke with Jessica Ruffin, chief equity officer of the Allegheny County Department of Human Services, about efforts to help residents understand the changes.
This interview has been edited for length and clarity.
Q: Who are the people that are supposed to be enrolled in these Medicaid programs? And what are the changes in store for them?
A: The group that’s impacted by these HR1 changes is what we would call the Medicaid expansion group. And there’s not an easy way to describe this group to be honest with you. There were specific income requirements, age requirements, age of children and things like that. There’s a whole formula involved. And so in Allegheny County we’re estimating 10,000 are at risk of losing their benefits coverage as soon as Jan. 1 because of the additional requirements. (The estimate was provided by the state.)
If you are enrolled in one of these plans you may be affected
- UMPC For You
- Highmark Wholecare
- AmericaHealth Caritas
- Geisinger Health Plan
- Jefferson Health Plans Everwell
So the long and short of it is that they want people to be showing that they’re working or engaging in some sort of community or service activities in order to retain their benefits. And so there’s a lot of paperwork requirements. And quite honestly, we’re still waiting for guidance from the federal government on what that actually means and who would be exempt from this.
Because we’re still awaiting the guidance, our baseline message is, you could be impacted. Make sure that your address is updated not just on the state COMPASS website, but also with the United States Postal Service, so you’re getting the information directly from the state about what you would need to do in order to maintain your benefits.
Q: On the state’s website, there are some descriptions of who is supposed to be exempt. What don’t we know that we still need guidance about?
A: We’re still waiting for some guidance around folks with medical frailty and to see if that would exempt them from these work requirements. We’re also awaiting guidance on how people report that they are exempt. Do they need to go to the doctor and get a doctor’s note? Who do I turn that doctor’s note in to? A lot of this is because we’re still awaiting guidance from the feds.
The state has been a really good partner in this, making sure that as they get information, they’re sharing information, sharing resources, sharing drafts of the letters that are being sent to people. So people know that it’s not junk mail, that this is something that they need to pay attention to. And when we’re tabling and going out in the community, we have that letter right on the table so that people can say, “Hey, I got that.”
Q: Have the letters already gone out? And is the information going to be more general, like what you would find on your website? Or is it going to be more specifically tailored to their situation?
A: So there are multiple versions of letters that are going out right now. Keep in mind there are different communities that are going to be impacted by this at different times. So, our non-citizen neighbors are actually going to be impacted as early as Oct. 1 when they can lose their coverage if they can’t show that they are lawful citizens or on a pathway to citizenship. We’re still trying to get a little bit of clarity around what that means.
From Pennsylvania DHS’ FAQ
- Going to school at least part time meets the full work requirement.
- When attending less than half time, hours can be combined with other activities to meet the 80-hour requirement.
- Each school determines whether their students are enrolled full time, part time or less than part time.
- Applicants and recipients may also meet the requirement based on their household’s monthly income if it is at least $580 each month.
- Seasonal workers may also meet work requirements based on their household’s average monthly income.
And so the letters that they received were very general, just saying, hey, you are in the Medicaid expansion group. In order for you to maintain your coverage, you need to make sure that you upload your Green Card if you have one or any other accompanying documentation to the Compass app or take it into the county assistance office, so that we can have it on file so that you can maintain your coverage. So that was the first round of letters that went out earlier in the summer.
The second round of letters that have just started to go out are for the folks that will be impacted effective Jan. 1. It’s just acknowledging that you’re in the Medicaid expansion group, that you’re going to be subject to additional work requirements and what to do about that.
We’re still waiting for guidance around what do community activities mean, training programs and things like that. We don’t know if folks participating in an English language learning class would qualify.
Q: Let’s say that I receive one of those letters. I’ve been pointed out as someone who potentially could lose coverage if I don’t start working, doing volunteer activities or classes. But I think I might be exempt or I’m wondering if what I’m already doing right now would qualify as work. What should I do?
A: I’m going to give you the answer that we hate the most: It depends. We are strongly recommending that folks reach out to our partners at places like the Pennsylvania Health Access Network or Just Harvest that we’ve been working with pretty regularly that have a better handle on what’s happening.
We at DHS unfortunately do not administer the benefits programs and so we just try to put them in the hands of the people that have additional guidance and support and can look at clients’ cases a little bit more holistically.
Q: With a lot of work and diligence on getting the word out, is the goal to shrink that number as small as possible? Is it possible that nobody loses coverage if everybody figures out their requirements, does what’s required of them and submits the paperwork?
A: That’s the ideal situation. But is it theoretically possible that everyone who has coverage can continue it? I mean, if I’m being honest, I don’t think that it’s possible that everyone’s going to be able to maintain their coverage just due to the requirements.
The administrative burden of having to submit paperwork with the new HR1 rules means they will have to re-certify every six months. And if they don’t do that and they lose coverage, they still have to wait another six months before they’re able to apply again. So, I really don’t think that we’re living in a world where even with our best efforts we are able to save everyone.
This requires really strong partnerships with everyone from the larger healthcare providers and our community federally qualified healthcare centers (FQHCs). It really is an all-hands-on-deck situation because the loss of those dollars coming into the region and into our healthcare system can really have an impact.
Q: What are you hearing from health care providers about the people who might lose coverage, and how are they preparing?
A: A lot of folks are in planning mode and just trying to brace for impact. This is going to be a huge hit for a lot of folks. When you think about our FQHCs, 20% to 30% of the population that they work with are Medicaid eligible. And a majority of those folks could also be in this Medicaid expansion group. It’s significant.
We know a little bit more about the providers supporting non-citizens right now just because that deadline is coming up on us. And a lot of it is just that people are afraid. Even if they do have Green Cards or things like that, they’re still afraid to submit them out of fear of what could happen to them.
When we’re looking at our actual healthcare providers like the FQHCs and our larger medical systems, they’re just afraid that people aren’t going to continue to be proactive in seeking care. And then if they need to, they go to the emergency room. Which is going to be catastrophic because they don’t have insurance and they don’t necessarily have a pathway to insurance. And so we have to think about what that potential uncompensated care is going to look like.
Q: Do you have any sense of whether there’s sufficient resources to successfully get the word out?
A: I honestly don’t know if there is an amount of money that could fix this. Right now we’re trying to plan around a moving target. So if we can get a little bit more clarity around who is actually going to be impacted and and being very clear about that, that would be amazing.
Q: You brought up a group of people you referred to as the medically frail. They’re not so incapacitated they would definitely be exempt. Are there any other groups where it’s not clear whether they’ll be exempt?
A: We are looking to see how they’re going to treat people that are experiencing homelessness or recently exiting homelessness. There are some categories of older adults that we’re really trying to make sure that they are able to maintain their connection. We do have a population of folks, not huge but significant, that receive both Medicare and Medicaid, depending on their symptoms. And so just trying to track what the impact is going to be on their treatment.
And when we talk about the medically frail, that is a really large category because in some cases, depending on a diagnosis, it might be episodic. So it might be that they’re medically frail because they need a new kidney. So once they have that, they could be fine. And so, would they still have to participate in the work requirements knowing that they’re sick now, but they’ll be better later? Versus someone that has something that’s a little bit more long term like cancer that they have to engage in longer-term treatment for?
Q: Are we going to have like a whole army of medically frail people volunteering at the local library and the food bank? Or taking jobs at Walmart as greeters?
A: Honestly I’m not sure. I do think that there are probably people that could work, could be enrolled in school, could be doing service, those types of things, that will start to do that, which appears to be the spirit behind these changes.
However, there are some folks where that would be challenging to do so for whatever reason. And so I don’t know that we would see a huge kind of social shift or impact here. But I do think that we’re going to see some changes.
Oliver Morrison is the health and environment reporter at Pittsburgh’s Public Source and can be reached at oliver@publicsource.org.
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