Medicaid Waivers

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Medicaid Waivers. Joan Alker Co-Executive Director Annual Conference July 19, 2012. Section 1115 Waivers. Permit states to use federal program funds (e.g., Medicaid & CHIP) in ways not otherwise permitted Law says they must be “ experimental, pilot, or demonstration project(s) ” - PowerPoint PPT Presentation

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Medicaid WaiversJoan AlkerCo-Executive DirectorAnnual ConferenceJuly 19, 2012

Section 1115 Waivers2Permit states to use federal program funds (e.g., Medicaid & CHIP) in ways not otherwise permittedLaw says they must be experimental, pilot, or demonstration project(s)that promote the objectives of the programBroadest waiver authorityWhy are they important for kids?3They can change the way Medicaid is financed;They can change the way services are delivered;States sometimes requests limits to EPSDT or increases in cost-sharing.Enforcing Budget Neutrality4Budget neutrality is longstanding federal policy to ensure feds dont spend moreIn general, section 1115 waivers rely on per capita caps to enforce budget neutralityState claims match for all people covered by the waiver butCannot claim more than amount permitted by the capPer person amount is agreed as part of the waiver (usually based on historical costs with a trend rate)What is a Global Cap?5Global caps have been used in Vermont, Rhode Island, and Pharmacy Plus waivers during Bush yearsWaiver sets overall cap on federal funding (not on a per person basis)Similar in nature to a block grantWhat are some recent trends?6Move to managed care for more vulnerable populations;New cost-sharing and/or premiums (CA, FL, UT, WI) that have been turned down for kidsLimits around the edges on EPSDT(19 and 20 yr olds approved in some states, Oregon list of services, other proposals rejected)1915 WaiversSection 1915(b) Managed CareWaivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit peoples choice of providers.

1915(c) Home and Community-Based Services Waivers: States can apply for waivers to provide long-term care services in home and community settings rather than institutional settings.

Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneously implement two types of waivers to provide a continuum of services to the elderly and people with disabilities, as long as all Federal requirements for both programs are met.7What flexibility exists already in Medicaid?Significant delivery system reform possibleNorth Carolina PCCM model didnt need a waiverMost Medicaid beneficiaries can be required to enroll in managed care without a waiver as long as consumer protections are observed as in HealthWaveDual eligibles, children on SSI or in foster care require an 1115 or 1915 waiver

8I cant figure out how to make the 3rd bullet (most medicaid beneficiaries ..) a diamond bullet89Waiver Process: How Does it Work and What is Required?

Waiver Process10Closed negotiations between state and federal governmentAt federal level, Secretary of HHS makes the decisionCenters for Medicare and Medicaid Services (CMS) staffs the process for the SecretaryOffice of Management and Budget (OMB) is typically deeply involved in negotiating financing termsNot unusual for members of Congress to weigh in, but no formal process for their involvementWhat are the Opportunities for Public Input?11Widespread concern about the lack of transparency in the process leads to a provision in the Affordable Care Act requiring new rulesThese rules were just issued on Feb. 22, 2012 and became effective April 22nd, 2012State and federal governments must have a 30 day public notice and comment process

Waiver Pressure Points12CMS National OfficeOffice of the Secretary of HHSWhite House/OMBCongressional delegationState legislatorsState agency/Executive branch