Bill
HB 5645
Imposes Medicaid work requirements, tightens eligibility verification, and expands data-sharing to curb improper payments and restrict benefits for certain non-citizens.
HB 5645 (2026) – West Virginia
Summary of Medicaid program integrity and work requirements
Purpose and intent
- Establish and enforce work requirements for Medicaid-eligible individuals (and broader public assistance integrity measures) and strengthen verification of income, identity, citizenship/alien status, and residency.
- Prohibit certain non-citizens from receiving SNAP and Medicaid benefits unless explicitly eligible under federal law.
- Expand data-sharing and reporting to improve ongoing eligibility determinations and prevent improper payments.
- Require legislative oversight for waivers, state plan amendments, and retroactive eligibility changes.
Key provisions and changes
1) Medicaid work requirements (Article 11, §9-11-2 to §9-11-9)
- Implementation deadline: December 31, 2026, the Bureau for Medical Services must implement work requirements for applicable individuals.
- Eligibility condition: An applicant for Medicaid must demonstrate compliance with work requirements for the three months immediately preceding the application month.
- Verification: Documentary evidence required; no self-attestation for initial eligibility. Ongoing quarterly verification between redeterminations; failure to verify would affect enrollment.
- Exemptions: Exemptions available only with verified documentation; no new exemptions beyond what federal law requires without legislative approval; exemptions cannot be granted based on managed care organization determinations.
- Exemption criteria: Medically frail or individuals with special needs require medical certification from a qualified health professional; exemptions cannot exceed federal scope.
- Enforcement: Disenroll Medicaid enrollees who fail to comply with work requirements.
- Reporting: Quarterly reports to Legislature and Governor on compliance, exemptions, and enrollment impact (in line with federal reporting requirements).
2) Eligibility verification and redetermination (Article 11, §9-11-5)
- Verification scope: No self-attestation for key factors (income, residency, identity, household composition, citizenship/immigration status) at enrollment.
- Data-driven redetermination: Quarterly checks with wage data, tax data, corrections/recidivism data, Social Security data, mortality data, address changes, and out-of-state EBTP activities; annual checks with broader revenue data; monthly checks with corrections and employment data; cross-state enrollment monitoring (monthly reporting to CMS national database by 2029).
- Residency and address changes: Monthly cross-checks and potential redetermination if residency changes are identified.
- Data-sharing: Authority to enter MOUs with relevant agencies and to contract with third parties for data.
- Reporting: Annual public reporting of key metrics and impacts.
- Effective timing: Data-sharing and cross-check implementations specified to begin by 2027 and 2029 for specific steps.
3) Citizenship/alien status and hospital reporting (Article 11, §9-11-6)
- Eligibility restrictions: Non-citizens must meet eligible alien status and verification via SAVE or documentary proof; real-time verification at enrollment and redetermination.
- Reporting obligations: Provide information on unlawfully present aliens to DHS and HHS; provide status details to the WV Secretary of State as applicable.
- Reasonable opportunity period: If verification cannot be completed, provide one opportunity period (per federal minimums) for documentation; provisional coverage during this period; denial/termination if documentation isn’t provided.
- Presumptive eligibility: Hospitals must collect and transmit citizenship/alien status data; hospitals must inform patients that status collection does not affect care; quarterly hospital reports on admissions by status category; annual state-level reporting on admissions, uncompensated care costs, and impact.
4) Retroactive Medicaid eligibility limits (§9-11-7)
- Caps retroactive coverage for expansion population to one month prior to completed application, and two months for non-expansion population.
- Annual reporting on applications and denials, with fiscal impact estimates.
- Effective date: January 1, 2027.
5) Annual reporting and waivers (§9-11-8)
- Annual reporting on waiver compliance and budget neutrality; public posting.
- Legislature must approve any new waivers or state plan amendments that expand coverage or increase state costs.
6) Miscellaneous
- Effective date: The act takes effect upon passage.
- Broad authority for rulemaking and implementation to align with federal requirements, subject to legislative oversight for major policy changes.
Who is affected
- Medicaid applicants and recipients (nonelderly adults, expansion and non-expansion groups as defined by federal standards).
- Individuals potentially subject to SNAP work requirements and related income/identity verification provisions (SNAP provisions are included in Articles 8 and 13, separate from the Medicaid provisions, but the bill’s scope intersects eligibility verification across programs).
- Hospitals, clinics, and other providers (for presumptive eligibility data collection and reporting).
- State agencies (Bureau for Medical Services, Department of Revenue, Workforce West Virginia, Vital Statistics, Corrections and Rehabilitation, HUD, SSA, USPS, SAVE program, and other federal data-sharing partners).
- State taxpayers and providers via anticipated changes in eligibility determinations and potential changes to uncompensated care costs.
Procedural and timeline notes
- 2026: Bill introduced; committee referral to Government Organization.
- 2026–2027: Implementation deadlines for work requirements (Dec 31, 2026) and several data-sharing milestones (by 2027 and 2029).
- Annual reporting obligations begin after initial implementation; ongoing quarterly and annual reporting to Legislature and Governor.
- Rulemaking: The Bureau may promulgate rules; requires legislative approval for waivers/state plan amendments affecting coverage.
Overall impact
- Aims to tighten eligibility verification, enforce work requirements for Medicaid, restrict benefits for certain non-citizens, and strengthen program integrity through enhanced data-sharing and interagency cooperation. Potentially reduces Medicaid spending and SNAP expenditures by reducing improper eligibility and noncompliance, while increasing administrative burdens on applicants and providers.
Compiled from official sources — confirm details with the bill’s official record.
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