Medicaid Expansion


Virginia authorized several major changes to its Medicaid program in 2018, including expanding coverage to additional adults living in poverty. Other program reforms include adding a work and community engagement requirement, health and wellness incentives, and employment and housing support for high need populations. These three reforms became known as the COMPASS (Creating Opportunities for Medicaid Participants to Achieve Self-Sufficiency) waiver. The General Assembly directed JLARC to review several aspects of Medicaid expansion implementation:

      • access to health care services for new Medicaid members;
      • accuracy and timeliness of eligibility determinations;
      • Medicaid enrollment and spending following expansion; and
      • state and local readiness to implement the COMPASS waiver.


Medicaid is a joint federal and state program that provides health insurance and long-term care to low-income families, individuals 65 and older, and individuals with disabilities. States have the option to include all adults with low incomes in Medicaid (regardless of whether they are a parent) through the federal Patient Protection and Affordable Care Act. Until recently, Virginia’s Medicaid program did not cover low-income adults who were not parents, but Virginia authorized Medicaid expansion in 2018 to cover this population, with enrollment beginning on January 1, 2019. More than 300,000 individuals enrolled in Medicaid expansion through the first eight months.


Enrollment and Spending (FY20)
Virginia spent $13.7 billion on Medicaid benefits in FY20, $558 million lower than expected. Lower spending was driven by reduced spending on non-emergency services during the COVID-19 pandemic, which more than offset a higher-than-expected increase in enrollment. In addition, children and non-disabled adults, who are less expensive to cover, made up a large pecentage of new enrollees.

Access to Services
Managed care organizations (MCOs), which are responsible for developing adequate networks of providers, generally have a sufficient number of the most commonly used providers located across the state. However, it is unclear if Medicaid expansion members are able to get necessary appointments with these providers in a timely manner. The Department of Medical Assistance Services (DMAS) requires managed care organizations to ensure members can get appointments, but does not collect data to measure whether or not it is occurring.

Eligibility Determination
Virginia’s policies and systems are adequate to accurately determine eligibility for the Medicaid expansion population. The strategies deployed to manage the significantly increased eligibility determination workload during the first few months of expansion were effective at enabling most applications and renewals to be completed on time.

Enrollment and Spending (FY19)
Medicaid enrollment and spending were lower than expected at the beginning of Medicaid expansion, however enrollment is catching up to projections. In the first six months of FY19, actual Medicaid expansion spending was $867 million, which was 21 percent lower than the $1.1 billion projected. The lower spending amount was caused primarily by lower-than-expected enrollment (14 percent) at the beginning of Medicaid expansion. Spending in the base Medicaid program slowed during FY19 because of Medicaid expansion, growing 1.8 percent in FY19. However, annual spending for the base Medicaid program is projected to outpace historical trends in the future, increasing an estimated 6.6 percent in FY21–FY22.

COMPASS Readiness
Virginia is in the process of obtaining federal approval to carry out three Medicaid reforms, as directed through the 2018 Appropriation Act. These reforms (known as the COMPASS waiver) would each apply to a subset of the Medicaid population and include a work and community engagement requirement, premiums and copays, and employment and housing support. As of December 2019, Virginia had not received federal approval for any of these initiatives, placing initial implementation in 2021 at the earliest. The Department of Medical Assistance Services conducted some planning work during 2019 for the initiatives, but significant work would remain to operationalize those plans if the initiatives are ultimately approved.



Executive action

  • DMAS should develop and implement a methodology to measure whether Medicaid members are able to schedule appointments in a timely manner.