A lawsuit challenging Indiana's Medicaid work requirements policy was filed in federal court, putting the controversial policy supported by the Trump administration before the court for the fifth time.
The National Health Law Program filed the lawsuit Sept. 23 in the U.S. District Court for the District of Columbia. Much like the previous lawsuits, the court document claims the U.S. Department of Health and Human Services does not have the authority to approve the policy and that work requirements harm Medicaid recipients.
"Congress has defined the scope of [HHS Secretary Alex Azar's] power to waive portions of the Medicaid Act, and that scope is limited," Jane Perkins, legal director for the National Health Law Program, said in a Sept. 23 statement. "This approval will not promote coverage, but it will result in significant coverage losses, and that is the administration's goal — to weaken the Medicaid program and cull people whom it deems unworthy from it."
The lawsuit is filed against the federal government, not against the state of Indiana, according to the organization. Indiana Legal Services joined the National Health Law Program on the lawsuit, according to the statement.
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Medicaid is the dual state and federally run health insurance program for people with low incomes, a wide population including children and the elderly. Work requirements mandate that individuals work or participate in community engagement activities like school or volunteering for a set number of hours every month in order to keep their Medicaid eligibility.
The policy has been accompanied by criticism as it has led to more than 18,000 people losing Medicaid coverage in Arkansas in 2018 and put as many as 17,000 people at risk of losing coverage in New Hampshire.
Seema Verma, administrator for the Centers for Medicare and Medicaid Services, continues to defend work requirements as a way to help people gain employment.
The National Health Law Program has also challenged policies in Arkansas, New Hampshire and Kentucky, with Kentucky's case going to court twice. Each challenge has gone before District Judge James Boasberg, and Boasberg has struck down work requirements all four times.

Mara Youdelman, managing attorney for the National Health Law Program's Washington, D.C., office, said Sept. 25 at a national Medicaid conference that the organization expects the Indiana case to go before Boasberg as well.
Youdelman stressed that the organization believes HHS has gone past its authority to approve this policy through a section 1115 waiver, a system that allows states to request to implement experimental or pilot Medicaid policies or programs.
Section 1115 waivers can be used to enact broad changes; however, they must also uphold the principles of the Medicaid program, including expanding benefits or eligibility. Boasberg has highlighted in his decisions that work requirements violate those principles, pointing to the coverage losses in Arkansas.
Youdelman spoke at the America's Health Insurance Plans' 2019 National Conference on Medicaid in Washington, D.C.
Verma defended CMS' review of the waivers Aug. 15, telling reporters that states need flexibility and freedom from the federal government to operate their Medicaid programs effectively, which includes trying new Medicaid policies like work requirements.
Structure of Indiana's program
Indiana's work requirements took effect Jan.1 and penalties can be issued beginning Dec. 31, according to the lawsuit.
The state structured its program to be phased in over time and did not have an hours-based requirement for the first six months. Currently, Medicaid recipients are required to work 20 hours each month. The requirement increases to 40 hours per month on Oct. 1; 60 hours per month Jan. 1, 2020; and 80 hours per month July 1, 2020, according to Indiana's Family and Social Services Administration.
Recipients are at risk of losing coverage if they do not meet the hours-based requirement for four months in a calendar year. If someone fails to meet the state's requirement when the state conducts year-end reviews, they lose eligibility at the beginning of the next calendar year, according to the lawsuit. People can regain coverage in several ways, including proving that they have fulfilled the monthly hours requirement.
Indiana exempts certain populations from the requirements, including women who are pregnant, people over the age of 60, students and people who are medically frail, according to the state's Family and Social Services Administration.
The lawsuit comes weeks before appeals trials for Kentucky and Arkansas are set to begin. The federal government is appealing Boasberg's decisions in the U.S. Court of Appeals for the District of Columbia Circuit; oral arguments are scheduled for Oct. 11. If the appeals court's rulings are then challenged, the cases could go before the U.S. Supreme Court.
Stephanie Bates, deputy commissioner for the Commonwealth of Kentucky Cabinet for Health and Family Services, said at the Sept. 25 conference that having to shut down its community engagement program twice has been frustrating. Despite the two court rulings, Bates was confident that the state will eventually implement the policy.

