HHS did not immediately respond to inquiries about Scott’s request for a meeting or what HHS would do if Florida did not start paying Medicaid doctors at the new rates, but HHS spokeswoman Erin Shields Britt issued a brief general statement: “Under the law, the federal government is increasing the rate primary care physicians are paid in Medicaid to improve care … and boost quality for beneficiaries,” noting that the feds are paying all costs for the increase.

About the exchanges, Britt said HHS “will work with any state to set up an exchange at any time. Consumers in all 50 states will have access to an exchange come January of 2014.”

Neither HHS nor AHCA responded to questions about how much money might come to Florida doctors under the proposal.

Timothy J. Stapleton, executive vice president of the Florida Medical Association, said the pay increase was long overdue. “We believe that increasing Medicaid physician payment rates will improve access, lead to healthier Floridians and save money in the long-term by ensuring that fewer patients seek treatment in costly settings like hospital emergency rooms.”

Matt Salo, executive director of the National Association of Medicaid Directors, said the U.S. Supreme Court ruling last spring on the healthcare act allowed states to opt out of the provision for expanding Medicaid to more patients but determined that all other provisions of the law — including increased doctors pay — were lawful.

Salo noted that the federal law only requires Washington to pay for the Medicaid payment increases for two years. “That is going to create a difficult situation for states,” he said . States will need to lobby Washington to get the pay extended. If the efforts fail, the states would have to pick up the increased cost or doctors’ rates would have to be slashed — choices that states would hate to deal with, Salo said.

Shortly after the election, Sen. Don Gaetz, R-Destin, the incoming Senate president, said he supports paying Medicaid primary care doctors more and fought for such legislation at the last session, but lost. Gaetz said he feared approving increased federal funding for Florida programs that might end, leaving legislators with unpleasant choices.

Paradise, of the Kaiser Foundation, said the reform act has a two-year limit because Congress wanted to see what effects the pay increases had. The law requires states to collect data to see if the added pay brought more doctors into Medicaid and whether that increased patients’ access to care.

The governor’s offer for discussions with HHS mentioned an additional point of tension between the state and federal governments: Florida’s request for a federal waiver to allow the state to carry out a huge reform of Medicaid that would include putting recipients throughout the state in managed care plans.

“We appreciate all the work your staff has done on the current Medicaid waiver request,” Scott wrote to Sebelius at HHS, “and look forward to your approval.”

Paradise noted that the Affordable Care Act includes a clause that requires even Medicaid managed care plans, which often set their own fee schedules, to pay primary care doctors at Medicare rates.