Senate Republicans fume over Medicaid work requirement time frame

Virginia’s Department of Medical Assistance Services has completed a draft of the state’s Medicaid work requirement proposal, which is now open for public comment before it goes to the federal government for approval.

But when they were briefed on the work requirement during a meeting Thursday, Republican members of the Senate Finance Committee gnashed their teeth after finding out that work requirement might not actually be implemented for another two years.

The General Assembly directed the Department of Medical Assistance Services, which manages Virginia’s Medicaid program, to create a work requirement for Medicaid members when it voted to expand the program earlier this year.

Since then, the department has been operating on two tracks toward implementation: One to actually expand Medicaid to an estimated 400,000 additional members by January, and the other to prepare a waiver, which the federal government must approve before the state can create a work requirement for Medicaid members.

Senate Finance Committee members grilled Medicaid director Dr. Jennifer Lee Thursday on when the work requirement would start in Virginia, and made a show of their frustration when she couldn’t give an exact answer.

“When do you expect that the work requirement would be implemented in Virginia?” Sen. Tommy Norment, R-James City, asked.

“I would say as soon as we receive approval” Lee started, but Norment cut her off.

“That’s an amorphous answer,” he said. “What is your best estimate, at this point, when the work component will be implemented in Virginia?”

“I wish I had a crystal ball, senator,” Lee said.

“I wish you had an answer,” Norment retorted.

Lee explained that the work requirement depends entirely on federal approval. If Virginia had begun imposing work requirements earlier, the state would be violating federal laws and regulations.

She said her department is working with a consultant to advise them on the experiences of other states, some of which worked on their waivers for two years.

She estimated it could take a year for the federal government to approve the waiver — thought it could also happen as early as this spring, she added — and from there it could take another year to actually get the program up and running. That means, if the department submits the waiver by early November, as it expects to, the work requirements might not actually be implemented until late 2020 or early 2021.

“These are new services and programs and requirements that we will have to create on both the Medicaid side and also with the social services programs,” she said. “We want to make sure that we are standing up this program responsibly and correctly.”

Sen. Ryan McDougle, R-Hanover, said that, during discussions earlier this year of adding a work requirement, he never expected the process to take that long.

“If it comes a year later, in 2021, you’ve got to be kidding me,” he said. “That, to me, would violate everything I’ve ever heard from beginning to end. And I know you need to get it right, but there’s getting it right and then there’s also slow walking because of, maybe, a policy difference.”

In the budget it passed earlier this year, the General Assembly gave the Department of Medical Assistance Services 150 days to complete the waiver and submit it for approval. That includes 30 days for public comment, which begins today. The department has been working on the waiver over the summer and will submit it by Nov. 4, Lee said.

Virginia is calling its work requirement program the “Training, Education, Employment and Opportunity Program.” It will require able-bodied adults to work, go to school or be part of a community engagement program as a condition of Medicaid enrollment.

But there are plenty of exemptions to the requirement: people with disabilities, pregnant women, people over 65 and those who have a serious mental illness, are victims of domestic violence or are former foster care kids under the age of 26, among others.

A February Joint Legislative Audit and Review Commission report estimated that about 32 percent of the Medicaid expansion population would be subject to the requirements.

Those who aren’t exempt and don’t comply with the requirements for three months out of a 12-month period — and they don’t have to be consecutive months — will lose their coverage and can gain it again by qualifying for an exemption or showing that they meet the work requirements for at least one month.

The program also implements $5 to $10 premiums and co-payments, specifically for non-emergency use of the emergency department, for adults with incomes between 100 and 138 percent of the federal poverty level, which is between about $12,000 and $16,000 a year for an individual.

The draft waiver goes into details of the work requirement program — including what activities fill the requirements, how many hours the Medicaid member must work every week and what exemptions are available — but it does not delve into how the program will actually be implemented, such as how members will report their qualifying activities.

In a Joint Subcommittee on Health and Human Resources Oversight meeting Wednesday, Lee said the draft waiver outlines “the design features of the program and less on the actual mechanics, which I think is where we still have to, frankly, iron out a lot of those details. And we will need contract support to do a lot of this. It is new, it is complicated, a lot of the systems will have to be built for the first time.”