You should read this letter from Virginia Gov. Bob McDonnell which lays out a litany of questions from the states to U.S. HHS Sec. Kathleen Sebelius on exchange implementation and Medicaid. There are seventeen questions about exchanges, and another thirteen about Medicaid, and a healthy skepticism about the workability of the current plan:
“We also believe that it is unlikely that the federal government will have fully functional exchanges in place by the fall of 2013 in order for millions of Americans to be able to purchase coverage beginning January 2014. We respectfully request the Administration provide the detailed work plan that demonstrates these deadlines will be met. If they cannot be met, the responsible course would be for HHS to level with us and the American people.”
Virginia had estimated that it would cost the state $2.2 billion to expand Medicaid back in 2010, but McDonnell says they’re working on an updated estimate. The 13 questions are below the fold:
1.) When can we expect to receive updated guidance on Medicaid expansion and related topics?
2.) Is there a deadline for letting the federal government know if a state will be participating in the Medicaid expansion? How does that relate to the exchange declaration deadline? The two programs are currently scheduled to be implemented simultaneously in January 2014.
3.) Will states that expand Medicaid coverage up to a level below 138% of the federal poverty level (FPL), for example up to 100% of FPL, still receive the enhanced federal medical assistance percentage (FMAP) available for “newly covered” populations?
4.) Will states be allowed to phase in Medicaid coverage up to 138% of FPL (or 100% FPL) years after 2013 and still receive the enhanced FMAP?
5.) Does the MOE requirement apply to the expansion population or does it apply only to the current Medicaid population? If a state accepts the expansion, but the federal match goes away, can we drop out of the expansion program? Will you waive the MOE under your 1115 waiver authority? What will be the penalties for failure to comply with MOE requirements? Since the MOE was a direct result of the expansion funding, if a state chooses not to expand is the MOE no longer effective?
6.) Regarding the two year increase in Medicaid reimbursement for primary care codes, are you going to extend it? If so, how are you going to pay for it? Congressional Republicans have expressed opposition to any funded for PPACA.
7.) Will states still be required to convert their income counting methodology to MAGI for purposes of determining eligibility regardless of whether they expand to the optional adult group? If so, how do states link the categorical eligibility criteria to the MAGI? How will the federal exchanges utilize the state’s criteria?
8.) If a state expanded Medicaid through a waiver prior to enactment of the PPACA, but then chooses not to expand coverage further, are they still eligible for the 75% to 90% enhanced FMAP for the previously expanded population?
9.) Will the federal government support options for the Medicaid expansion population that encourage personal responsibility – cost sharing or accountability provisions, the use of high deductible plans such as Health Savings Accounts, and other options at the state’s choice?
10.) What specific plans and timeline do you have for enacting the reforms and flexibility options for Medicaid that you spoke of in 2009? When can states give further input on the needed reforms?
11.) You have stated that you will not deport undocumented aliens who have not committed a crime. You have also said that these undocumented aliens will be exempt from the individual mandate. How will the state be reimbursed for medical services given to these individuals?
12.) Will CMS approve global waivers with an aggregate allotment, state flexibility, and accountability if states are willing to initiate a portion of the expansion?
13.) The Disproportionate Share allotments will be reduced every year with a methodology based in the reduction in the number of uninsured. One, when will HHS issue the regulations and methodology for this reduction? Two, for a state that does not see a decrease in its uninsured population will the remaining state absorb the full reduction? In addition, can a state implement a new DSH Diversion program as part of the optional expansion? Can a state implement new DSH Diversion programs for services to the uninsured/uncompensated care services?
The press is already framing this as McDonnell, who’s the chair of the Republican Governors Association, expressing willingness to implement. But I don’t believe that was his goal here and probably stems from a lack of understanding of the issues – which is fine, giving how surprising this decision was even for experts. But this is all leading up to what’s likely going to be a hash-it-out meeting of the NGA in Williamsburg this weekend.