New Attacks on Medicaid: Drastic Cuts, Work Requirements and Lifetime Caps

By Susan Goodman, JD 

This memo applies to all people with disabilities who are receiving services from the Maryland Developmental Disabilities Administration (DDA).  These services are funded by the state and the Medicaid Home and Community Based Services (HCBS) program that funds most community-living and employment supports for adults with disabilities and many children in the United States and is administered by the Center for Medicare and Medicaid Services (CMS) through the U.S. Department of Health and Human Services (HHS). 

  • States are starting to use the Medicaid waiver process to limit employment services which would cause great harm to people who are working or in programs that provide work preparation skills. 
  • Some states are asking to impose lifetime caps on Medicaid spending 
  • The President’s budget is assuming Medicaid cuts and caps to balance the budget 

As 2018 starts, the attacks on the Medicaid waiver Home and Community Based Services continue in earnest with no end in sight.  Families and people with disabilities will need to be vigilant as this has the potential to severely limit services for all people with disabilities and will affect our sons and daughter’s future.   

Will they have jobs and other services to be able to live as independently as possible or will those vital supports be eliminated? 

The state of Maryland to date has provided support people with disabilities need and promoted independence and productivity.  However, we cannot rely on the fact that our State has always been here for us.  In the current political climate, with the threats of cuts in Medicaid (DDA funding in Maryland) and in Congress all states are at risk.  

President’s Budget 

With the release of the president’s budget last week, attacks on Medicaid Home and Community-Based services have been revealed.  In part, this is happening because the final tax bill, the Tax Cuts and Jobs Act, passed in December 2017.  This bill  reduces revenue by over $1.4 trillion and members of Congress have said will be paid for, in part, with cuts to Medicaid, Medicare and other important programs.  These potential cuts are often referred to as “entitlement reform.” 

Even though attempts to repeal the Affordable Care Act and impose drastic cuts and cap Medicaid were defeated three times last year, the President’s budget (sent to the Senate and the House of Representatives) again calls for drastic cuts in Medicaid funding.  The Graham-Cassidy -Heller-Johnson bill, which was defeated last September and would convert all Medicaid HCBS funding to per capita caps and block grants is proposed in this budget.  This would decimate the Home and Community-Based Services program.  

The language in “Fiscal Year 2019 “EFFICIENT, EFFECTIVE, ACCOUNTABLE: AN AMERICAN BUDGET” states as follows:   

“The Budget supports a two-part approach to repealing and replacing Obamacare, starting with enactment of legislation (modeled closely after the Graham-Cassidy-Heller-Johnson GCHJ) bill as soon as possible, followed by enactment of additional reforms to help set Government healthcare spending on a sustainable fiscal path.” 

This transmittal of this budget to the House of Representatives and Senate is only the first step in the budget process. Although the President’s budget is usually not passed by Congress, we are in a new political climate.  The House of Representatives and Senate are working on their respective budgets. 

Administration Can Cut Medicaid Home and Community-Based Services without Congress 

On  January 2018, the CMS issued guidance to states in a State Medicaid Director Letterstating that it would support state efforts to design work requirements (referred to as “community engagement”) in Medicaid as a condition to eligibility for Medicaid health services and community supports.   

The guidance describes the potential scope of requirements that could be approved and presents the case for how these policies promote the objectives of the Medicaid program.  This action reverses previous Democratic and Republican Administrations, which had not approved such waiver requests on the basis that such provisions would not further the program’s purposes of promoting health coverage and access.  This allows states to impose new restrictions on Medicaid HCBS spending through the Medicaid waiver process – by applying to CMS.   

CMS has already approved work requirement waivers in Kentucky and Indiana, and nearly a dozen other states have already submitted similar requests. Medicaid work requirement proposals would generally require beneficiaries to participate in approved activities, such as employment, job search, or job training programs, for a certain number of hours per week, and certify this participation, to receive health coverage.   

The guidance permits states to target only people who are “eligible on a basis other than disability.” This means that Medicaid recipients who qualify for the program who are also receiving Supplemental Security Income (SSI), which is solely for people in poverty or significantly disabled, would not be subject to these work requirements.  However, there are no clear parameters on who would be too disabled to work.   

While many people with Down syndrome and other disabilities do take the SSI pathway into the Medicaid program, many qualify for Medicaid through other pathways. Many adults are disabled but not certified “disabled” by SSI so would still be subject to these work requirements. While it purports to use SSI or SSDI standard in determining who is too disabled to work, 57% of non-elderly people with disabilities are not on SSI or SSDI. 

The work requirements will also negatively impact many low-income caregivers who are Medicaid recipients. The data shows that people want to work, and many are already working. See here for an issue brief outlining how these Medicaid work requirements may affect adults with disabilities: 

Although CMS states that it is only imposing a “work” requirement, it recently denied Indiana’s request to use Medicaid funding to help participants meet their work requirement by providing them skills assessment, training and assistance with searching for a job.  (   

In addition to work requirements, at least five states have asked CMS to approve proposals that would put a cap on how long beneficiaries of Medicaid can receive coverage. These proposals, which have not yet been approved, look very different from each other.  

For example, Arizona and Utah are seeking a five-year limit on Medicaid coverage, but Utah’s restrictions would only apply to childless adults. In Arizona, time limits would only apply to periods in which Medicaid recipients do not meet work requirements. Maine has put forth a proposal that would impose limits on coverage to three months in any 36-month period, but these limits would only apply if the recipients aren’t meeting the program’s work requirements. In Kansas, Utah and Wisconsin, the proposed time limits would apply even to those people who do meet the work requirements.   

Imposing these new requirements would mean that any of the federal waivers mean that thousands of people will lose vital coverage.  For more information about the proposed time limits, see here: 

Susan Goodman is the parent of an adult son with autism.  She retired as Director of Policy and Advocacy for National Down Syndrome Congress in December.  

This article was adapted for use for Marylanders from an article written for the National Down Syndrome Congress Policy and Advocacy Newsline. 

For further information, contact Susan Goodman at 

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  • We are concerned because attacks on Medicaid program are being carried out by the current Administration allowing restrictions on services that Medicaid funding can be used 
  • My son or daughter relies on this funding through DDA to live and receive the support services he or she needs for a quality life. 
  • Attacks by the Administration through the Center on Medicaid and Medicare Services (CMS) are being carried out in Kentucky, Indiana and are on the wish-list of several other states 
  • The Administration sent their budget to Congress proposing to save money cutting Medicaid funding by imposing per capita caps and cuts  
  • States can fight many of these actions by not imposing these new restrictions through the Medicaid waiver program.