Editor's Note: This is the first in four-part series looking at Arkansas' work requirements for Medicaid. Part two will appear in Friday's edition.

Nannette Ruelle was kicked off her Arkansas Works health insurance in September and will be locked out until Jan. 1.

The 38-year-old Little Rock resident lost her coverage at the end of August due to Arkansas' new requirement that certain Medicaid beneficiaries report their work hours to the state. For months, she's been carefully rationing both her medications, allowing herself a Gabapentin only when the nerve pain becomes so bad she fears she won't be able to do her job. Ruelle works 25-35 hours a week at a chain restaurant in Little Rock, where she makes $9 an hour.

"It's some serious stuff. They're just playing around with people's lives, and I don't think it's fair," she said. "What if I wake up one morning and I can't even function because my feet are hurting and I have nothing left?"

Ruelle said she first recalled hearing about the requirement in May, when she was working a minimum-wage job at a different restaurant. The instructions on the notice she received from the state Department of Human Services were confusing, but she tried to do what the letter demanded.

"What happened was that I got my information and I tried to fax it to them. The fax wouldn't go through, so I tried calling them, and I never got an answer on the phone. I went up there and they were out of the office," she said.

When she got no reply after leaving voicemails and visiting her local DHS office, Ruelle said, she gave up. "I just quit trying, because you can only try so many times before it's like, 'OK, you're closing the door in my face.'"

Over the past three months, DHS has removed close to 17,000 people from Arkansas Works — the state's Medicaid-funded insurance program for low-income adults — for not reporting their work hours. The rule, which began for the first subset of beneficiaries in June, requires able-bodied adults under age 50 to report at least 80 hours of "work activities" each month. (In 2018, the requirement applied only to those ages 30-49, but it will begin including 19- to 29-year-olds in 2019.) Those who don't comply for any three months in a calendar year are kicked off Arkansas Works and locked out until the new year begins.

Ruelle's attempts to reach DHS were unsuccessful in part because the agency had until recently only allowed people to report their work hours through a website, rather than by fax, phone or mail. This online-only requirement was unlike any other reporting required by DHS.

DHS first sends Arkansas Works recipients who must meet the work requirement a letter directing them to access.arkansas.gov. That URL sent users to a general DHS landing page containing information about voter registration, not health insurance. This was a federal mandate, according to the governor's office. From the landing page, a beneficiary navigates a series of menus to reach a login page, where he or she is prompted to create a new account. (Doing so requires an active email address.) Then, the user must locate a unique "reference number" contained on the letter from DHS "to link an online account to the person's healthcare coverage." Only then can the beneficiary enter work hours.

Ruelle said she tried to follow this process but ran into problems there, too.

"You set up passwords and stuff, and the passwords won't work. ... It would tell you your user ID was invalid and then it would tell you your password's invalid," she said. "I tried to call them to help me go through all that stuff, and I couldn't ever get a response."

DHS spokeswoman Marci Manley said local offices have resources on hand to help beneficiaries report their hours.

Arkansas is the first state to implement a work requirement in its Medicaid program. Kentucky attempted to launch a similar rule earlier this year, but a federal judge in the District of Columbia sided with a group of plaintiffs and blocked the policy in June before it went into effect. A lawsuit challenging Arkansas's work requirement is now before the same judge, but a ruling isn't expected until 2019.

Gov. Asa Hutchinson has said the "common-sense" policy is saving taxpayers money and incentivizing Arkansas Works beneficiaries to move up the economic ladder. He's pointed to an unemployment rate near record lows as evidence jobs are available for anyone willing to work. Beneficiaries also get some credit for other activities, like school, volunteering or searching for jobs. The state Department of Workforce Services operates dozens of centers statewide that stand ready to help people find employment or training, Hutchinson adds.

The governor has also noted the broad exemptions built into the program. Anyone with a dependent child in the house, for example, is exempt from reporting, as are full-time students and certain people with high-end medical needs. DHS also automatically exempts people whose incomes were at least $680 per month when they first applied for Arkansas Works. The requirement applies only to the "Medicaid expansion" population under the Affordable Care Act, thus excluding anyone receiving federal disability payments (Supplemental Security Income, or SSI) and those in other "traditional" Medicaid categories.

To Ruelle, though, losing health coverage only makes it harder to participate in the workforce.

This reporting is made possible in part by a yearlong fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. It is published here courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan project dedicated to producing journalism that matters to Arkansans. Find out more at arknews.org.