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Medicaid Section 1115 Waiver Overview. Michelle Apodaca, J.D . Stacy E. Wilson, J.D. April 20, 2012. Why A Waiver?. Upper Payment Limit Program - $2.7 billion/year Eliminated due to statewide expansion of managed care Need to save supplemental funding to hospitals. Why This Waiver?. - PowerPoint PPT Presentation
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Michelle Apodaca, J.D.Stacy E. Wilson, J.D.April 20, 2012
Medicaid Section 1115 Waiver Overview
Why A Waiver?
Upper Payment Limit Program - $2.7 billion/year
Eliminated due to statewide expansion of managed care
Need to save supplemental funding to hospitals
2
Why This Waiver?
3
California received a waiver as a pathway to health reform
HHSC negotiated a waiver that both saves UPL payments and incentivizes change and improvement to healthcare delivery system
What Does This Waiver Do?
Brings the opportunity for more money ($29 billion over 5 years vs. $14 billion under UPL)
Budget neutral to the federal government
Creates two funding pools– Uncompensated Care Pool– Delivery System Reform
Incentive Payment Pool4
Overview
5
Waiver Pool
Hospitals eligible for funding must
commit to investing in
system transformation
Uncompensated Care Pool
Delivery System Reform Incentive
Pool
Pays hospitals for cost of care not compensated by Medicaid directly or through DSH
Pays hospitals for achieving metrics that move toward the triple aim
Inpatient
Outpatient
Physician
Pharmacy
Clinic
Category 1 – Infrastructure Development
Category 2 – Program Innovation & Redesign
Category 3 – Quality Improvements
Category 4 – Population Focused Improvements
Hospitals must participate in a
regional healthcare
partnership to receive funds from
either pool
Regional Partnerships
19 regions proposed based on UPL affiliations and feedback
Each region will have– Anchor– Funding public
entities– Participating hospitals
6
RHP Participants
Duties– Anchors
Administrative functions Interface between RHP
and HHSC Do not dictate how
transferring entities spend their money
– Transferring entities Fund waiver payments Help select DSRIP
projects 7
Participating Hospitals
Be an RHP member
Work on incentive projects
Provide expense alleviation for public entity to create IGT capacity
8
Uncompensated Care Pool
Uncompensated Care– Supplements hospitals
for Medicaid underpayment and uninsured
– Additional categories of costs can be claimed Physicians Clinics Pharmacies
9
DSRIP Pool
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Project categories– Infrastructure Development
• Enhance access to care– Program Innovation &
Redesign• Medical homes
– Quality Improvements• Preventable readmissions
– Population-Focused Improvement• Diabetes, preventive care
RHP Plans
11
Draft template released by HHSC– RHP Organization– Executive Overview– Community Needs
Assessment– Stakeholder Engagement– Incentive Projects– Allocation of Funds– Affiliation Agreements
Public input into plan
12
State Fiscal Year 2012 – transition payments based on prior UPL payments
March 2012 – HHSC submitted UC Tool to CMS April – HHSC has distributed DSRIP draft project menu May 1 – RHPs to submit RHP areas and participants to
HHSC August 31 – HHSC to submit RHP areas and participants and
DSRIP project menu to CMS Sept. 1 - RHPs to submit plans to HHSC October 31 – HHSC to submit final RHP Plans to CMS
OpportunitiesScorecard on Local Health System Performance
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Challenges
Aggressive timeline Many vital pieces still
under development IGT capacity - sufficient
local dollars to access available federal funds
Politics Balance between
structure and flexibility
15
Resources
HHSC website: http://www.hhsc.state.tx.us/1115-waiver.shtml
THA website: http://www.tha.org/waiver Harris County Hospital District’s waiver
website: http://www.1115waiver.com
Stacy E. Wilson - 465-1027; [email protected]
Michelle Apodaca – 465-1506; [email protected]
