Most Medicaid beneficiaries who would be included in community engagement (CE) programs in Kentucky already meet activity requirements or qualify for a medical frailty exemption for the program, according to a study published in JAMA Network Open.

In this cross-sectional study, researchers used administrative data for all Medicaid beneficiaries in Kentucky as of February 2018 (n=1,390,286) and randomly surveyed 9396 beneficiaries between May 5, 2018, and September 8, 2018, to estimate the number and characteristics of those who would have to meet CE requirements. Variables included age, sex, race/ethnicity, geographic location, pregnancy status, healthcare utilization, health outcomes, socioeconomic status, and concomitant enrollment in Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP).

Of the entire population of Medicaid beneficiaries in Kentucky, a large subset was already obliged to meet work requirements for the SNAP and TANF programs (n=101,502), thus exempting them from the Medicaid CE requirements. Those exposed to Kentucky’s Helping to Engage and Achieve Long-Term Health (HEALTH) program would likely have been included in CE hour and reporting requirements (n=132,790; 95% CI, 129,132-136,449).

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Of this group, 25,422 may have been eligible for a medical frailty exemption. The remaining beneficiaries were engaged in activities that met CE requirements (n=58,943; 95% CI, 55,687-62,196) but would be required to report hours or could qualify for an exemption from monthly reporting if they informed the state of ≥30 hours of work per week. Excluding all of these beneficiaries, researchers estimated that 14.7% of the population exposed to the Kentucky HEALTH program during the study period did not meet CE requirements (n=48,427; 95% CI, 45,281-51,574).

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The limitations of this study include its reliance on data from a large, original, population-based survey potentially prone to bias from social desirability and differences between responders and nonresponders; inherent difficulty in assessing and identifying disability and medical frailty; possible differences between Medicaid populations in Kentucky and other states, limiting its generalizability; and estimates that do not account for exposure to other elements of the demonstration waiver.

The researchers suggested that because most Medicaid beneficiaries who would be included in CE programs already maintain insurance or qualify for an exemption, CE program outcomes will need to depend on states’ processes to address administrative and socioeconomic barriers to participating in and reporting CE activities and identifying medical frailty.


Venkataramani AS, Bair EF, Dixon E, et al. Assessment of Medicaid beneficiaries included in community engagement requirements in Kentucky. JAMA Netw Open. 2019;2(7):e197209