Medicaid “community engagement” and eligibility requirements may have profound impact on people with progressive vision loss and low vision
In a response letter to an Interim Final Rule (IFR) issued on June 1 by the Centers for Medicare and Medicaid Services (CMS), Prevent Blindness has expressed profound concern over the structure of Medicaid community engagement requirements (a.k.a., work requirements) mandated by the 2025 H.R. 1, the “One Big Beautiful Bill Act”, (OBBBA) and the potential impacts expected for people with vision loss, visual impairment, low vision, and blindness as well as their communities.
Under the OBBBA, adults aged 19 to 64 years who apply for or renew coverage under the Affordable Care Act’s expanded Medicaid program must report at least 80 hours per month of employment or work, education, or community service per month or as having monthly income over 80 times the federal minimum wage (or be a seasonal worker and have an average monthly income over past six months that is at least minimum wage times 80 hours) before they can receive health care coverage under Medicaid. These new rules are estimated to affect up to 20 million people in 43 states and the District of Columbia, and states must implement these new requirements no later than January 2027. While Congress required CMS to issue an IFR by June 1 outlining the policy and operational components of these new work requirements, CMS is not obligated to respond to stakeholder comments, recommendations, or input. As such, the policies outlined in the IFR are slated to take effect immediately after the comment period closes.
Specifically, Prevent Blindness has significant concern over the agency’s narrow definition of “medically frail” that will be used to determine an individual’s eligibility for coverage acquired through state-expanded Medicaid coverage plans. Individuals who have vision loss that meets the legal definition of blindness under the Social Security Act would be exempt from work requirements and would not have to report work hours or community engagement to receive or keep their health care coverage. As drafted in the IFR, however, it is unclear whether people with decreased functional vision loss that is significant enough to potentially preclude them from activities necessary to work or attend school, like driving, but is not severe enough to meet the clinical threshold of blindness would be deemed ineligible to receive health care coverage. Theoretically, states could expand the criteria for exemption; however, due to the lack of clarity outlined in the IFR from CMS, two people living in different states with the same degenerative eye condition may get different determinations of eligibility based on the state they live in and how states apply exemption criteria to functional disabilities rather than a diagnosis of vision loss. In many cases, a diagnosis may not be enough and may require documentation of functional impact to meet requirements for coverage, but states may not have systems established to make these determinations.
Prevent Blindness also shares alarm echoed across the patient community, including the National Health Council, about the effect of work requirements on caregivers who may need health care coverage while caring for a loved one, the administrative burden on the patients with respect to attestation, reporting, and eligibility, and the potentially crippling timeline for states to comply with requirements as well as the impacts on patients.
“People who face vision loss, eye disease, visual impairment, low vision, and blindness already face significant barriers acquiring the full spectrum of health care to meet their needs and optimize their quality of life,” said Jeff Todd, President and CEO of Prevent Blindness. “We implore CMS to ensure that the right steps are taken to protect patients’ access to the Medicaid program and to take steps to mitigate potentially harmful impacts and unintended consequences.”
For information on these changes, and to read the letter, please visit Understanding Insurance Benefits for Eye Care or please contact [email protected].
