2018 Session

Budget Amendments - SB30 (Member Request)

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Chief Patron: Hanger
Medicaid Coverage of Low-Income Adults

Item 303 #38s

Item 303 #38s

First Year - FY2019 Second Year - FY2020
Health and Human Resources
Department of Medical Assistance Services FY2019 ($64,353,926) FY2020 $0 GF
FY2019 $359,572,959 FY2020 $0 NGF

Page 257, line 34, strike "$10,983,034,643" and insert "$11,278,253,676".

Page 269, strike lines 50 through 57.

Page 270, strike line 1, and insert:

"4.a. The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance under Title XIX of the Social Security Act, and any waivers thereof, to implement coverage for newly eligible individuals pursuant to 42 U.S.C. § 1396d(y)(1)[2010] of the Patient Protection and Affordable Care Act.

The coverage shall incorporate the following elements:

(i) Incorporation of the GAP Program Waiver into the Medicaid state plan by (1) covering individuals aged 19 and 20; (2) covering individuals with substance use disorders; (3) covering in-patient services; and (3) using managed care organizations to deliver and manage all GAP services.
(ii) Special provisions for individuals with mental illness including substance use disorders. Such provisions shall include same day access at Community Services Boards, and collaboration with courts and jails to (1) divert offenders into treatment rather than incarceration; (2) provide access to immediate coverage and treatment for those who have been incarcerated upon their release; and (3) utilize supportive housing.
(iii) Increased personal responsibility by establishing a schedule of co-payments that include incentives for primary care and appropriate treatment of chronic conditions and to discourage non-emergency use of emergency rooms.
(iv) Services that are closely aligned to commercial insurance.
(v) Incentives for preventive services, an initial primary care visit, wellness activities, healthy behaviors and job readiness.
(vi) Incentives to encourage employment for individuals who are unemployed, not attending school as full time students, not receiving Unemployment Compensation or Social Security Disability benefits and not caring for dependent family members under 12 months of age or a disabled family members of any age.
(vii) Options to pay premiums for available employer-based coverage.
(viii) Protections for Virginia in the event the federal financial participation is reduced below 90 percent.
(ix) Payments to health plans and providers that are conditioned on quality care measures and support patient-centered medical homes.
(x) Strengthened efforts to prevent, detect and punish fraud and abuse.

b. Each of the elements of the coverage expansion shall be evaluated by the department on an ongoing basis to measure program integrity, cost-effectiveness a value of services provided, and success in moving enrollees into higher paying employment and to self-sufficiency.

c. The department shall implement the provisions in paragraph SS.4.a. of this item by July 1, 2018.  The department shall have authority to implement these coverage provisions prior to completion of any regulatory process in order to effect such changes.

d. The Secretary of Health and Human Resources shall convene a work group composed of such interested stakeholders as he shall deem appropriate together with at least two members of the House of Delegates and at least two members of the Senate to develop recommendations for an application for a waiver , pursuant to § 1115 of the Social Security Act, 42 U.S.C. § 1315, to allow the Commonwealth to (i) institute a work requirement for all able-bodied adult recipients of medical assistance services; (ii) provide for periodic verification of household income of an individual subject to the work requirement and for redetermination of the individual's eligibility for medical assistance services; (iii) impose certain requirements related to cost sharing for recipients of medical assistance services, including requirements for premiums, copayments, and coinsurance; (iv) provide incentives that encourage healthy behaviors; (v) waive retroactive eligibility for certain recipients of medical assistance; and (vi) provide premium subsidies to allow individuals described in 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII) whose household incomes exceed 100 percent of the federal poverty level to enroll in private insurance through the federal health insurance exchange. Upon adoption of the final recommendations by the work group, the Secretary shall prepare an application for such waiver in accordance with such recommendations and shall submit the application to the Centers for Medicare and Medicaid Services for approval. The Secretary shall report on the work of the workgroup and status of such waiver application to the Chairmen of the House Committee on Appropriations and Senate Finance Committee by December 1, 2018.

e.  The provisions in paragraph SS.4.a. of this item shall expire on June 30, 2020, unless the waiver described in paragraph SS.4.d. of this item has been approved by the Centers for Medicare and Medicaid Services and implemented by the Secretary of Health and Human Resources."


(This amendment increases Medicaid coverage to low-income adults under the State Plan for Medical Assistance with certain parameters in order to improve access to and realign the availability of community-based mental health services, address Virginia's opioid crises and provide basic medical services for the uninsured, by July 1, 2018. It also creates a workgroup to develop recommendations for an 1115 waiver that will supersede the State Plan amendment. If the 1115 waiver is not implemented by July 1, 2020, then the coverage expansion under the State Plan expires. The impact of increasing Medicaid coverage is already included in the introduced budget, however since this amendment moves the effective date up by three months, there are higher general fund savings and federal spending in the first year.)