Alabama appears to be following other states in considering a work requirement for some adult Medicaid recipients, according to state Medicaid officials and Gov. Kay Ivey.

President Donald Trump’s administration released guidance last week for states wanting to test “a work requirement” for adult Medicaid recipients. It would be the first requirement in the history of the program, though states have historically sought federal waivers to test new ideas.

On Jan. 11, the Centers for Medicare and Medicaid Services [CMS] asked states to begin testing programs that weigh factors like jobs, skills training, job-searching or education when determining who qualifies for Medicaid — a sharp contrast from Obama-era policies that gave states the option to expand their programs with no additional requirements.

Following the new guidance from CMS, 10 mostly Republican states submitted proposals for federal waivers that, if approved, would essentially allow them to deny coverage to “able-bodied” recipients who are unemployed. Alabama wasn’t among them at the time.

Medicaid currently covers about one in every five Americans, though Alabama’s ratio is closer to one in every four. This year, the Alabama Legislature appropriated more than $800 million for the program including a $105 million supplement from the state’s oil spill settlement with BP.

Earlier this month, Alabama Medicaid Commissioner Stephanie Azar put in a budget request for $757 million to fund the state’s program through 2019. She told lawmakers a significant carry over from last year caused by drops in the price of prescriptions led to the more modest request.

Alabama Gov. Kay Ivey recently extended grant funding to 122 “high-quality” pre-k locations throughout the state.

However, after her recommended budget was introduced in the Senate for the first time Tuesday, Ivey gave the indication that some of those anticipated savings could be the result of plans implementing a work requirement and increase copays for Alabama Medicaid recipients.

“Improving Medicaid delivery and controlling costs is central to my budget; that is why I instructed Commissioner Stephanie Azar in October 2017 to begin working on implementing work requirements and increased copays for Medicaid recipients,” Ivey said. “That process has been ongoing, and I look forward to the future implementation of those policies.”

Ivey went on to say the changes are “aimed at continuing to increase efficiency and decrease costs related to Medicaid, all in an effort to be good stewards of taxpayer dollars.”

Alabama’s Medicaid costs took up one-third of the current General Fund budget, and the program is routinely the most expensive item lawmakers have to fund.

Despite that, a recent report from the Medicaid and CHIP Payment and Access Commission found Alabama already runs the leanest program of any state based on the average medical benefit received by its enrollees.

While Ivey’s comments indicate those policy changes are moving forward, there’s still not a lot that’s concrete about what they’ll look like with regards to how many and which Alabamians will have to work for their Medicaid benefits.

Robin Rawls, communications director for Alabama’s Medicaid Agency, told Lagniappe Tuesday afternoon that work requirements in Alabama could be as simple as an “incentive to encourage people to move into the workforce,” though she said there’s no official proposal yet.

“We’re in the process developing the concept and working toward a time when we can develop a document to submit to CMS for review,” Rawls said. “It is important to know that, as we move in that direction, there will be multiple opportunities for public comment on the proposal.”

Currently, more than half of Alabama’s 1,050,117 Medicaid-eligible patients are children living beneath the federal poverty line and of the 126,000 eligible patients in Mobile County in 2016, 58 percent were under the age of 19.

However, the Trump administration made clear that any waiver requiring Medicaid recipients to work would not apply to children, the elderly, or pregnant women enrolled in the program. In a press release on Tuesday, Azar also said her staff has been working to ensure “[Medicaid] recipients continue to receive an adequate level of care” during the transition.

“Last week, during my testimony to the General Fund Budget Committee, I illustrated how the work requirements and the copay increases will benefit the Alabama Medicaid Agency,” she said. “Thanks to the improved economy and continued efforts to seek efficiency and decrease cost in the program, Medicaid is requesting less money than expected. We are certainly moving in the right direction to take care of the Alabamians that depend on our services.”