article: This case is one of several federal cases challenging the Trump Administration’s ongoing attempts to reduce Medicaid eligibility under the Affordable Care Act (ACA). The case arose from federal and state efforts to limit the ACA’s Medicaid expansion. Medicaid, established under Title XIX of the Social Security Act, requires states to cover all individuals of a mandatory covered population group and prohibits states from imposing additional eligibility requirements. However, Section 1115 of the Social Security Act allows DHHS to waive certain federal Medicaid requirements when necessary to allow a state to carry out an experimental project that is likely to promote the Act’s objectives. In 2010, the ACA expanded Medicaid coverage to include adults with household incomes less than 133% of the federal poverty level (FPL). Michigan passed legislation authorizing the Medicaid expansion but sought a waiver under Section 1115 to require new enrollees to pay premiums and copayments that could be reduced by the individual’s engagement in certain “healthy behaviors.” For enrollees with incomes above the FPL, the monthly premium was set at two percent of the individual’s income. DHHS granted the waiver application, effective through December 31, 2018, but specified that no individual may lose or be denied Medicaid eligibility for failure to pay premiums or copayments. In January 2018, DHHS issued a letter to state Medicaid directors announcing its intention to approve Medicaid waiver applications containing work requirements. This action was consistent with President Trump's January 20, 2017 executive order instructing federal agencies to scale back the ACA “[t]o the maximum extent permitted by law." In response, Michigan submitted a Section 1115 waiver application that would add mandatory work requirements. The work requirements consisted of 80 hours of specified work or work-related activities per month and mandatory monthly reporting of work activities, with the loss of coverage for enrollees who do not report the required hours for three months in a 12-month period. The application also included mandatory healthy behaviors and heightened, mandatory premiums for enrollees with incomes above the FPL who received coverage for 48 cumulative months. Failure to pay a premium within 60 days after the invoice date would result in termination of coverage. Enrollees in the same subgroup also had to complete a health risk assessment or specified healthy behaviors in the 12 months before their annual redetermination to remain eligible. DHHS approved these three HMP waivers, effective January 1, 2019 through December 31, 2023, and granted Michigan permission to implement the measures starting January 1, 2020. The work requirements went into effect on January 1, 2020. The state deferred the implementation of the healthy behavior requirements and new premium requirements until October 1, 2020. The plaintiffs, all members of Michigan’s Medicaid program, filed this class-action lawsuit on November 22, 2019 in the U.S. District Court for the District of Columbia against the U.S. Department of Health and Human Services (DHHS). The plaintiffs challenged amendments to the Healthy Michigan Plan (HMP), including work requirements that would result in the loss of health coverage for 61,000 to 183,000 individuals. Represented by the National Health Law Program, the Center for Civil Justice, and the Michigan Poverty Law Program, the plaintiffs requested an injunction against the defendants’ implementation of Michigan’s amended HMP eligibility requirements and declaratory relief. Specifically, the plaintiffs argued that the defendants failed to undergo the required rule-making process in issuing a new policy on Medicaid waivers and acted outside the scope of their waiver authority under Section 1115 of the Social Security Act in approving Michigan’s application that imposed additional Medicaid eligibility requirements. According to the plaintiffs, these actions violated the Administrative Procedure Act (5 U.S.C. § 551 <i>et seq.</i>), the Social Security Act, and the Take Care Clause in Article II, Section 3 of the U.S. Constitution. The plaintiffs sued on their behalf and on behalf of all Michigan residents enrolled in the HMP on or after January 1, 2019. On February 19, 2020 the Michigan Department of Health and Human Services (MDHHS) filed an unopposed motion to intervene, which was granted the next day. On February 25, 2020, MDHHS filed a motion for partial summary judgment solely on the issue of whether the federal approval of the work and community-engagement requirements in the HMP section 1115 demonstration project was lawful. In light of the D.C. Circuit Court’s decision in <i>Gresham v. Azar</i>, striking down the work requirements of the Arkansas Medicaid program under the Section 115 waiver, Judge Boasberg granted MDHHS’s motion for partial summary judgment. The December 21, 2018 approval of the work and community engagement requirements in the Healthy Michigan Plan Amended Demonstration Extension Application by the defendant, Secretary Azar, was vacated. Michigan could not enforce the Medicaid work or community engagement requirements that went into effect on January 1, 2020. On April 2, 2020, MDHHS filed a motion to stay in light of the COVID-19 pandemic. The same day, the court granted the motion and the case is stayed until the earlier of 1) the end of the COVID-19 public health emergency, or 2) 45 days before the date Michigan begins to implement the premiums that are conditions of continued Medicaid eligibility or the healthy behavior requirements that are conditions of continued Medicaid eligibility. As of June 2020, the Medicaid work and community engagement requirements cannot be enforced. The plaintiffs challenged the payment of premium and cost sharing, community engagement, and healthy behavior components of the HMP. The plaintiffs did not specifically challenge the rest of the waiver, but the complaint asked the court to permanently enjoin the entire HMP. When the case resumes, the court will need to decide on the appropriate remedy, whether to disband the entire HMP, or to only vacate some or all of the specifically challenged portions. <b>Background</b> Medicaid beneficiaries in four other states have filed similar suits challenging the Administration's use of Section 1115 waiver authority. See <a href="https://www.clearinghouse.net/detail.php?id=16440"><i>Stewart v. Azar</i></a> (Kentucky), <a href="https://www.clearinghouse.net/detail.php?id=17162"><i>Gresham v. Azar</i></a> (Arkansas), <i>Philbrick v. Azar</i> (New Hampshire), and <i>Rose v. Azar</i> (Indiana). In <i>Stewart v. Azar</i>, the court struck down Kentucky's waiver, which included work requirements, on the basis that the agency failed to sufficiently consider the impact of the proposed project on Medicaid coverage. Similarly, in <i>Gresham v. Azar</i>, the court found that the agency failed to adequately consider how the imposition of work requirements in Arkansas's program would lead to loss of coverage for a substantial number of beneficiaries including the needy, a core group under Medicaid.
summary: This is one of a series of cases challenging the Trump Administration's decision to allow states to impose eligibility requirements on Medicaid beneficiaries. A group of Michigan Medicaid beneficiaries sued the U.S. Department of Health and Human Services to block its decision to allow Michigan to impose work requirements and payment obligations on them. The plaintiffs claimed that DHHS' actions violated the Administrative Procedure Act, the Social Security Act, and the Constitution. The Michigan Department of Health and Human Services intervened, and filed a motion for partial summary judgment on federal approval of the work and community-engagement requirements of the Healthy Michigan Plan. The court granted this motion, declaring federal approval of these provisions unlawful. Michigan cannot enforce the Medicaid work and community engagement requirements. As of May 2020, due to COVID-19, the case is stayed.