Medicaid work requirement waiver: Comparing the draft versus final submission

At The Center for Community Solutions, we have advocated for the least harmful language to be iterated throughout the mandated Section 1115 Work Requirement Demonstration. Ohio’s Section 1115 work requirement waiver was established to align Medicaid enrollment with work. The waiver was developed by the Ohio Department of Medicaid in response to legislative mandates from the 135^th Ohio General Assembly and guided by federal Centers for Medicare & Medicaid Services (CMS) policy. Under the waiver, eligible adults must work at least 20 hours per week or participate in qualifying activities for exemption from the requirement.

So, how does the 2024 initial draft differ from the final submission? Let’s take a look:

The first draft laid out the legislative mandate and stated its main goals: promoting economic stability, encouraging financial independence, and improving health outcomes. In contrast, the final submission incorporated feedback from stakeholders, transforming it from a technical document into one that genuinely addresses public concerns.

Initial Draft:

• Introduces the legislative mandate (House Bill 33 and ORC section 5166.37) and the proposal’s key goals of promoting economic stability, financial independence, and improved health outcomes.

Final Submission:

• This draft reflects revisions in response to stakeholder feedback, showing an evolution from a primarily technical submission to one that shows responsiveness to public concerns. 

Section I: Program description

The initial draft was very detailed and methodical, laying everything out in clear, structured sections. Then, after gathering input from various stakeholders, the final submission emerged more streamlined and reflective of public comments. Here’s how the two versions differ:

Initial Draft:

• Demonstration Overview: Describes the legislative background (House Bill 33, ORC section 5166.37) and outlines the five eligibility criteria (age, employment, school/training enrollment, addiction treatment participation, or intensive health care needs/serious mental illness).
• Emphasizes the dual aim of promoting economic stability and enhancing health outcomes. The waiver seeks to identify and support individuals already engaged in work or capable of engagement.
• Presents preliminary evaluation metrics (e.g., tracking health service use, employment status changes) with statistical projections for enrollment and cost impacts. Statistics stay unchanged, with figures such as 766,296 individuals enrolled in Calendar Year (CY) 2025 and a projected average monthly enrollment that declines slightly once the waiver is implemented.

Final Submission:

• Reiterates the legislative basis and eligibility criteria in almost identical terms. However, the language is slightly streamlined, and there is an explicit note that the waiver will use available data to identify individuals meeting the pre-enrollment criteria.
• Maintains the original goals but adds clarity on the mechanism by stating that the waiver “only applies to members who say they can benefit from job training or work.” This refined phrasing underscores the demonstration’s selective application.
• Remains consistent with the 2024 version in terms of statistics and evaluation methodology.
• The 2025 submission also clearly outlines the use of claims data, wage data from OhioBenefits, and surveys, but it incorporates minor language changes to reflect lessons learned during the first implementation phase. There is emphasis on using robust data systems for evaluation.

Section II: Demonstration eligibility

While both the initial draft and the final submission offer the same information about eligibility criteria and data verification, the final submission offers a more streamlined approach to expectations, making it easier for readers to understand how the process will work.

Initial Draft:

• Specifies that only those already enrolled in Group VIII will be assessed for the additional work and engagement requirements.
• First, verifying eligibility through Ohio Benefits data, and if necessary, employing a third-party data vendor.
• Contains detailed statistical tables with projected enrollments. For example, it expects that approximately 61,826 enrollees will lose Medicaid eligibility once the waiver takes effect. The narrative explains that the waiver’s effect will be gradual, with disenrollment lagging in the first year.

Final Submission:

• The language is nearly identical in the eligibility criteria section; however, the presentation is more detailed with an expanded table (displaying distinct member counts by age, gender, and enrollment type).
• Reinforces the same process of verifying eligibility with OhioBenefits and a third-party vendor. The description in the 2025 version has been updated to better explain the process by which members confirm or dispute the data provided by the state.
• The projections remain unchanged. What is added is further contextual explanation of how the waiver will affect enrollment, emphasizing the lag in disenrollment and the use of standard eligibility renewal dates to conduct reviews. This section in the 2025 submission is more polished and offers clearer guidance on how data will be handled.

Both the first draft and the final submission remain congruent in terms of benefits.

Section III: Benefits and cost sharing requirements

Both the first draft and the final submission remain congruent in terms of benefits. Though the final draft displays an evolution in terms of programming, both drafts display the same message that the waiver will not change the benefits you get. The initial draft offers a detailed explanation, while the final submission is more streamlined, driving home the message that the changes are strictly about eligibility.

Initial Draft:

• States that the waiver does not propose changes to Ohio’s Alternative Benefit Plan (ABP) or introduce new cost-sharing measures. According to the Ohio Department of Medicaid, “The Affordable Care Act (ACA) mandated that expansion states, such as Ohio, must have an ABP for the adult expansion population, also known as Group VIII (because it is defined in Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act). The ABP is a separate state plan from the traditional Medicaid state plan, although in Ohio, the benefits in the ABP mirror the traditional Medicaid state plan with just a few exceptions to assure mental health parity, also mandated by the ACA.”

Final Submission:

• The language mimics the 2024 draft in this section. It reaffirms that beneficiaries will continue to receive the same benefits without new cost-sharing requirements, ensuring continuity in coverage.
• The consistency between both submissions in this area underscores that the waiver is focused solely on eligibility modifications, not on altering the benefits package.

Section IV: Delivery system and payment rates for services

In the initial draft, the focus is on making it clear that only the eligibility processes are affected, while those who are still eligible will continue receiving their care coverage. The first draft emphasizes that there’s no impact on how services are delivered or on existing payment rates. In the final submission, the same assurance is maintained in that the waiver will not disrupt Medicaid service delivery. There are no substantial changes in substance between the drafts.

Initial Draft:

• This section explains that the waiver only affects eligibility processes. Individuals who remain eligible continue to receive coverage through their managed care plans.
• The section is brief, affirming that there is no impact on the delivery system or the existing payment rates.

Final Submission:

• This section holds the same assurances as the 2024 draft, that the waiver does not disrupt the current delivery of Medicaid services.
• The language in the 2025 version is slightly streamlined for clarity, but no substantive changes are made.

Section V: Implementation of demonstration

While the core timeline and overall process remain the same, the final submission refines the evaluation process and communication strategies ensuring that both new applicants and existing members clearly understand how the waiver will be applied. The final submission keeps that January 1, 2026, start date, though it mentions that the date is a placeholder subject to negotiations. The final submission also adds more depth in a few key areas. It gives clearer guidance on how those already enrolled before this date will be evaluated, emphasizing that while the process will mirror the standard Medicaid renewal protocols, there will be more verification steps involved. The final submission also details how communication will be handled.

Initial Draft:

• Outlines that the waiver will be implemented statewide beginning January 1, 2026.
• Describes that new applicants will be informed of their eligibility status at the point of application, while current enrollees will be assessed at their next renewal.
• The process mirrors regular eligibility reviews with the addition of verifying the new Group VIII criteria.

Final Submission:

• Reiterates the January 1, 2026, implementation date (noting that it is a placeholder subject to negotiations).
• Offers more detailed guidance on how individuals enrolled prior to this date will be evaluated. The narrative emphasizes that the process will mirror standard Medicaid renewal protocols but with more verification steps.
• The 2025 version adds clarity about communication ensuring that both new applicants and existing members understand how the waiver will be applied.

Section VI: Demonstration financing and budget neutrality

The first draft of the Demonstration Financing and Budget Neutrality section focuses heavily on laying out the technical details. It provided a thorough explanation of the budget methodologies recommended by CMS, both the Standard and Hypothetical Methods. It also broke down budget neutrality projections into separate analyses for Managed Care and Fee-For-Service (FFS), using detailed tables to show projected member months, Per Member Per Month (PMPM) costs, and total expenditures. The draft also accounted for cost adjustments due to trends, including the impact of the Public Health Emergency (PHE) unwinding.

The final submission keeps all the core elements intact, including the methodologies, statistical tables, and cost trend adjustments. However, the key difference is in how the information is presented.

Initial Draft:

• Provides a detailed description of the methodologies recommended by CMS, both the Standard and Hypothetical Methods.
• Breaks down the budget neutrality projections with separate analyses for Managed Care and Fee-For-Service (FFS) segments, including detailed tables showing projected member months, Per Member Per Month (PMPM) costs, and total expenditures.
• The section contains technical details about adjustments for trends, including cost changes following the Public Health Emergency (PHE) unwinding.

Final Submission:

• Retains the same structure and statistical tables as the 2024 submission. The technical details, including definitions, the derivation of PMPM costs, and the expected cost trends stay unchanged.
• The 2025 submission, however, clarifies the presentation of the data. For instance, it includes an updated table for the net change in expenditures when comparing “with waiver” (WW) and “without waiver” (WOW) scenarios, ensuring that reviewers can clearly see the impact on budget neutrality.
• The language is polished further, reducing potential confusion for CMS reviewers while maintaining identical numerical data.

Section VII: List of proposed waivers and expenditure authorities

In the initial draft, the focus was on clearly outlining the key waiver components and the expenditure authorities needed to implement the eligibility changes. It covered essential areas such as comparability of eligibility requirements, provision of medical assistance, the use of a third-party vendor, and renewal procedures based on available data. While the final submission reflects responsiveness to feedback and helps streamline the document.

Initial Draft:

• Lists the key waiver components and expenditure authorities needed to implement the eligibility changes.
• Covers comparability of eligibility requirements, provision of medical assistance, authority to use a third-party vendor, and procedures for renewal based on available data.
• The content is clear and concise, linking the waiver components to statutory requirements.

Final Submission:

• Contains a similar list of proposed waivers and expenditure authorities.
• In addition to the items in the 2024 submission, the 2025 version notes that an earlier reference to Appendix A was removed to avoid duplication, showing responsiveness to earlier feedback.
• The list is still comprehensive and methodically presented, ensuring that all statutory bases are clearly addressed.

Section VIII: Public comment period

The original draft had stricter income thresholds compared to work-related benefits. However, after receiving public input during the public comment period, the language evolved. Instead of relying heavily on metrics like households at 30% of the Federal Poverty Level, language evolved to be more inclusive of varied realities amongst families. There is now a broader sense of inclusivity. Now, smaller amounts of earned income are considered a sign of self-sufficiency. Families now have a wider income threshold that encompasses a variety of work situations.

Initial Draft:

• This section is relatively brief. It states that the public comment period begins on December 17, 2024, and that a summary of comments will be added after the period concludes.

Final Submission:

• Represents the most significant evolution from the earlier submission.
• Contains extensive details about the public comment process, including:
  
  • Methods of Notification include web postings, electronic mailing, physical mail, courier/drop off, and public hearings.
  • Quantitative Feedback is summarized. The comments are described (e.g., 6.7% in support, 90.1% opposed, 3.2% neutral/unrelated).
  • There is a detailed Question and Answer section: There is a comprehensive section responding to questions and recommendations. This includes clarifications on eligibility definitions, the administrative process, exemptions, and predicted impacts on various populations.
  • The 2025 submission shows that the waiver has been subject to a rigorous public review, and the responses show that while feedback was considered, the fundamental approach stays unchanged.
  • This section not only documents stakeholder concerns but also explains the state’s rationale for keeping specific eligibility criteria and implementation strategies.

Both the first draft and final submissions share the same foundations of eligibility criteria, and overarching goals, namely, to support economic stability and improve health outcomes among Group VIII Medicaid enrollees. The 2024 draft is more straightforward in its presentation, serving as an initial submission that lays out the framework of the waiver application. While the 2025 submission keeps all the original numerical data and core proposals, it shows a significant evolution in structure and detail. It streamlines the format, clarifies procedures, and, most notably, includes an extensive section on public comments that addresses stakeholder input and clarifies many administrative and operational questions.

The changes to the 2025 final submission reflect an evolution of the waiver application process and a commitment to transparency and responsiveness.

The changes to the 2025 final submission reflect an evolution of the waiver application process and a commitment to transparency and responsiveness, ensuring that the state’s proposal is both robust and well understood by federal reviewers and the public alike. Most notably, the 2025 submission reflects language that is inclusive of the voices of advocates. So, keep advocating.

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