After some adjustments, federal government takes over Virginia’s Medicaid work requirement application

Virginia’s Medicaid work requirement application is finally out of the state’s hands and into the federal government’s after months of work and a last-minute delay from some state Republicans.

The Department of Medical Assistance Services submitted its Section 1115 waiver — which allows states to make changes to their Medicaid programs — to the U.S. Centers for Medicare & Medicaid Services Nov. 20, more than two weeks after the department was required to do so under the state’s budget.

The delay, Del. Chris Jones, R-Suffolk, said during a Joint Subcommittee for Health and Human Resources Oversight meeting Monday, was due to some state Republicans, including himself and Sen. Emmett Hanger, R-Augusta, wanting “extra time to review” the application.

One of the hangups was the slew of exemptions that Virginia included in its application so that those who cannot work due to a disability or some other extenuating circumstance do not lose coverage under the work requirement rule.

DMAS tweaked the waiver application in response to the Republicans’ concerns and the thousands of public comments it received. Over 1,800 public comments were submitted to the department, the vast majority of which cited concerns about the work requirements.

Only four expressed some kind of support for the work requirement program or the waiver in general.

Some of the changes include listing self-employment as a qualifying activity; stipulating that the new employment supports meant to help Medicaid members get jobs will still be available even if they qualify for an exemption; and clarifying that not all standard exemptions are permanent.

It also states that Virginia will institute a “no wrong door” policy for Medicaid members to report their exemptions or that they are complying with the requirements.

In Arkansas, where one of the first work requirement programs is up and running, thousands of members have lost coverage, sometimes simply because they do not have internet access in order to report that they are complying with the program.

“We don’t have perfect broadband access in every area of the commonwealth,” Dr. Jennifer Lee, the DMAS director, told the subcommittee during Monday’s meeting, adding that DMAS is working on other avenues through which members can report, such as through the Department of Social Services.

But very little about implementation has been decided at this point, Lee cautioned. The federal government will likely provide some directions, and “this is still early on in the process,” she said.

There is no set time frame for when the federal government must approve the waiver, nor how long implementation will take.

Are there enough doctors? 

As the state has worked over the past several months to expand its Medicaid program, looming large over the conversation is whether there are enough medical providers to cover the newly eligible population.

Lee said Monday that a third-party organization contracted by DMAS confirmed that the networks of its six health plans are adequate for the expanded population.

But access still varies in different areas. Some parts of the state are considered health-professional shortage areas, a federal designation that means everyone in the area, including those with private coverage, have difficulty finding providers who can meet their primary care needs.

For Medicaid members, it’s likely even more difficult, Lee said.

About 63 percent of physicians in the state participate in Medicaid, and only about 71 percent of those are accepting new patients, according to estimates Lee presented to the subcommittee.

“We do think there are more challenges for Medicaid enrollees seeking primary care access because there are few who are accepting Medicaid patients,” she said.

Virginia’s Medicaid program’s reimbursement for adult preventive and primary care services is about 66 percent of the market rate.

Lee said DMAS has sent a survey to all primary care providers in the state to see what would increase their likelihood of accepting Medicaid patients. The likely answer, Jones pointed out, is reimbursement.

DMAS has submitted a budget request to increase reimbursement rates for primary care providers, but Lee said the specifics of what that rate should be are still under discussion.