Proposal: revamping HR1 rules for Medicaid Community Engagement

[harrisj]

Hello,

While I appreciate there has been some initial work related to HR1 compliance (see the is_medicaid_eligible variable for instance), I think it has a few issues in its implementation that I would like to correct:

• It seems like it's applying Medicaid work requirements to all when they really just apply to people in the Medicaid expansion population. Is there a definition to tell if a user is in_medicaid_expansion population?
• Grouping compliance into separate major buckets for exemptions, hardships (temp. exemptions for things like disasters, etc.) as well as compliance might be useful. Eligibility is then rolling up those specific categories
• CMS' current interpretation of the rule is that lookback period for an application is the 6 months immediately before the month of the current application date, but that the state can use any single month in that lookback to show compliance (meaning we should test each individual month)
• States actually have the option of picking 1-3 months to validate for CE. We expect most states will pick one, but it's something to have to support.

Here is a non-complete list of the different type of variables at play (more to fill in later), with a check of implementation progress for an associated PR

• Exemptions
  • Pregnant
  • Under 19 or over 65
  • Taking care of a child 13 or younger
  • Taking care of a person with a disability
  • Veteran with a disability rating of 100 (see Reworking HR1 Medicaid Rules #7752 )
  • Is pregnant
  • Blind
  • Deaf
  • Disabling mental health condition (to be defined)
  • Medically frail (to be defined)
  • Has a substance use disorder and/or is in treatment
  • Disabled under SSA definition
  • American Indian or California Indian or receiving services from the IHS
  • Has been incarcerated in the past 3 months
• Compliance
  • Income
    • Earned more than $580 (80xfederal minimum wage) in a
    • Earned more than $580x3 in a single quarter (if it fits in prior 6 months)
  • Worked more than 80 hours in a month (combined from work, volunteering or job training)
  • Enrolled half or full-time in an educational institution
• Hardship
  • County of residence unemployment the min of (1.5x national avg or 8%).
  • County of residence was declared a federal disaster site
  • Having to travel outside of county long distances to receive medical care

Possible challenges:

• Is identifying if someone is in the Medicaid expansion group straightforward > 1 PFL but <= 1.38x PFL? or does it vary depending on the state and the person's Medicaid category?
• Medicaid uses a 6-month period and a 3-month period for some checks. Is that easy enough to support as periods?
• when should we attempt to compute a variable based on underlying data vs. just accepting a boolean to indicate a determination has been made? It seems like if there are parameters we'd want to simulate chnages for, it might make sense to use them internally.
• harships use county-level data that needs to be updated monthly. Is this something the system can do?

What do you all think? Does this make sense to do here? Should the work be structured as one big PRs or multiple PRs?

[PavelMakarchuk]

@harrisj Thank you for filing this issue. We will take a look!

For future issues, one thing that would be incredibly helpful are the primary sources which we can use to double check and verify.

Based on he initial issue scope I believe this can encoded in one big PR. We will get back to you on specifics around the possible challenges questions shortly.

[harrisj]

Thank you. The main primary sources I have for now are:

• HR 1 text
• Code for America Work Requirements Tookit
• CMCS Informational Bulletin 2025-12-08

[harrisj]

One question for each of the exemptions is how granular to send the data in for it. For instance, in the case of the veteran disability exemption, the system could take a single boolean has_total_veteran_disability or it can do a calculation based on the disability rating ("total" == 100). I chose the latter because it might be useful if we wanted to simulate changes to the disability rating threshold and see the effects (unlikely, but hey)

[PavelMakarchuk]

One question for each of the exemptions is how granular to send the data in for it. For instance, in the case of the veteran disability exemption, the system could take a single boolean has_total_veteran_disability or it can do a calculation based on the disability rating ("total" == 100). I chose the latter because it might be useful if we wanted to simulate changes to the disability rating threshold and see the effects (unlikely, but hey)

I believe for now having a check for is_veteran & is_disabled those are derived from the data.

The individual rating categories are harder to get good data on.

[harrisj]

Unfortunately, is_disabled is too broad for the legislation. It specifically calls for a VA total disability rating (ie, a rating of 100). It's challenging because there are some parts of the law and policy that do seem general (for instance, using the Social Security definition of disabled elsewhere), but then it also has its own specific criteria in places.