1. Health Care Reform in the
Commonwealth of Virginia
Hunter W. Jamerson
Macaulay & Burtch, P.C.
Richmond, VA

2. Overview of Presentation
Indoctrination into Virginia living
Medicaid program fundamentals
Breakdown of Virginia’s Medicaid Program
Virginia’s health reform initiative
Medicaid eligibility expansion debate
A review of other exemplar states
The path forward in Virginia
What should family physicians think?

3. Welcome to the Commonwealth
Red? Blue? Purple? Gerrymandered?
Outgoing governor, election on Tuesday
Very strong Hospital Association, Health Plan
Association, and medical societies
Heavy presence of Tea Party organizations and
Americans For Prosperity

4. 2013 Legislative Session
Budget stalemate over transportation and health care
reform
Enactment of 3-phase health care reform process
Creation of the Medicaid Innovation and Reform
Commission (“MIRC”)
6 House Members, 6 Senate members, 2 Cabinet
Secretaries
Majority of the members from each chamber must vote
to support eligibility expansion

5. Medicaid Program Fundamentals
Medicaid is a state program in the form of a state-federal
partnership
States operate Medicaid programs under federal law and
regulations that define the terms and conditions for a state
to receive federal matching funds
States are entitled to federal Medicaid matching funds on
all qualifying expenditures, as defined in:
Medicaid state plan, including
Any federally-approved waivers that
allow
expenditures that otherwise would
not qualify

6. State Decisions but Federal
Permission
State Medicaid programs are designed and administered
by state policy makers, within federal rules
Each state Medicaid program is unique
State programs vary based on state decisions on:
Eligibility, provider payment levels, benefits and limits on
benefits, cost sharing, delivery systems, use and types of
managed care, quality requirements, special initiatives and
innovations
Decisions reflect state priorities, fiscal realities, health care
systems, traditions and values

7. Virginia’s Medicaid Program
Frugality through cost controls, public-private
partnership, and innovation
Initiatives to improve care and control costs through
Virginia Medicaid; a few recent examples:
Statewide managed care
Development of a demonstration plan to integrate and
coordinate care for dual Medicaid – Medicare eligible
population
Development of initiative to coordinate behavioral health
services
Working toward managed long term services and supports

8. Virginia’s Medicaid Program Today
700,000 Medicaid members
80% in managed care, 20% in traditional FFS
Seven managed care plans (including 4 provider
sponsored plans)
All managed care plans are full-risk
Existing Medicaid program = 21% of Virginia’s annual
budget
Cost drivers: FFS, LTC, ABD, Foster Care and
Behavioral Health

9. Overview
Estimate Details
Key Assumptions
Population Estimate
Insurance Coverage of the Non-Elderly in Virginia 2009-2010
Individual
387,500
6%
Medicaid
680,400
10%
Other Public
369,200
5%
Uninsured
Employer
4,329,600
64%
Uninsured Adults
875,300
13%
Uninsured Children
154,700
2%
Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current
Population Survey (CPS: Annual Social and Economic Supplements).
10

10. Overview
Estimate Details
Key Assumptions
Population Estimate
Insurance Coverage of the Non-Elderly in Virginia 2009-2010
395,300*
480,000
0-139% FPL
> 139% FPL
Uninsured Adults
875,300
13%
Uninsured
104,700
Uninsured Children
154,700
50,000
0-200% FPL
> 200% FPL
*It is estimated that 195,000 adults fall between 0 – 100% FPL. Without a Medicaid expansion, these individuals
would not be eligible for Medicaid or federal subsidies through the Exchange.
Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2011 and 2012 Current
Population Survey (CPS: Annual Social and Economic Supplements).
11

11. Overview
Estimate Details
Key Assumptions
Population Estimate
As a result of the ACA, Virginia estimates
currently eligible children will enroll in
Medicaid (“woodwork”). If Virginia coo ses to expand Medicaid, an estimated
h
additional
currently eligible children would be expected to enroll in Medicaid and
newly-eligible
individuals would be likely to take up Medicaid coverage
Children - "Initial
Woodwork"
74,996
Children - Additional
Woodwork "Buzz
Factor"
7,500
TPL Adults
5,606
Disabled Adults
1,080
Caretaker Adults
66,204
Childless Adults
175,033
13

12. The Medicaid Expansion Debate
Concern that federal government might not live up to
its commitment for ongoing funding, due to its focus
on federal debt
Concern about local political backlash
Concern about access and lack of providers to serve
more Medicaid patients
Concern that current Medicaid program can be
improved and should be reformed first.

14. Virginia’s Health Care Reform
Initiative
Amendment to the 2013 Appropriations Bill handed
down by the Governor during Veto Session
Three-phase approach to reforming the existing
Medicaid Program
Many reforms will require CMS approval
Reforms must either be completed or have a plan in
place for completion prior to Virginia Medicaid
requesting permission to expand

17. Status of Phase 1 Reforms
Title
Access to
Veterans
Benefits
for
Medicaid
Recipients
SFY14-16 Total
Savings
Minimal at this
time
Behavioral
Health
Services
SFY14-16 Total
Savings
($133,960,168)
Progress
Timeline/Updates
•
Assisting veterans to obtain benefits and avoid
Medicaid expenditures when services are more
appropriately funded by the Federal Government.
•
To establish the program -DMAS, VDVS and VDSS
have together developed an MOU, interagency
data transfer and internal procedures to get the
program up and running.
•
Now transferring quarterly data match files with
federal government to link applicants with federal
services when available
•
December 2013: Implement strengthened
regulations to improve integrity and quality
•
December 2013: Implement new Behavioral
Health Services Administrator (Magellan)
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21. Status of Phase 3 Reforms
Title
Progress
Timeline/Target Date
All Inclusive
Coordinated Care
for LTC
Beneficiaries
(coordinated
delivery for all LTC
services)
July 2016
Statewide
MedicareMedicaid (Duals)
Coordinated
Care, including
children
July 2018
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22. Expansion Proposals in Other States
Ohio – Governor Kasich has proposed program expansion
driven by cost sharing for adults 100-133% of FPL
Michigan – Governor Snyder has proposed full expansion
through mandatory managed care enrollment and creation
of a Health Savings Fund
Indiana – Governor Pence has proposed an expansion of
the Healthy Indiana Plan to encompass the newly eligible
potential Medicaid population; driven by an HSA model

23. Expansion Proposals in Other States
Arizona – Mandatory managed care for entire
population; expansion tied to an 80% federal match
sunset clause
Iowa – Wellness Plan (ACO/PCMH model within
Medicaid) and Marketplace Choice Plan (Exchange
premium assistance)
Arkansas – Premium assistance through commercial
plans, cost sharing, HSAs

24. A Virginia Expansion Solution?

29. What Should Family Physicians Think?
How much of your practice is Medicaid?
What impedes you from taking more Medicaid
patients?
Does the existing program need overhaul before new
patients are added?
Is Medicaid Expansion a priority for you?

30. Sources
http://mirc.virginia.gov
http://hac.virginia.gov/MIRC/10-2113/102113_No5_Jones_MIRC.pdf
http://mirc.virginia.gov/documents/10-2113/102113_No7_Hazel_MIRC.pdf
http://mirc.virginia.gov/documents/08-1913/Health_Mgmt_Assoc.pdf
http://mirc.virginia.gov/documents/08-1913/Costs_of_Medicaid_Expansion.pdf

31. Questions?