Public Health Law Series Webinar. Medicaid 1115 Waivers: How are they Transforming the Health System?

Transcription

1 Public Health Law Series Webinar Medicaid 1115 Waivers: How are they Transforming the Health System?

2 How to Use Webex Audio: If you can hear us through your computer, you do not need to use your phone. Just adjust your computer speakers as needed. Support: If you need technical assistance, call Webex Technical Support at Submitting Questions: All participants are muted. Type a question into the Q & A panel for our panelists to answer. Submit your questions at any time during webinar. Recording: This webinar is being recorded. If you arrive late, miss details or would like to share it, we will send you a link to this recording after the session has ended. Public Health Law Series Webinar: Medicaid 1115 Waivers 2

3 Public Health Law Series Webinar A series focused on providing substantive knowledge on important issues in public health law o May qualify for CLE credits, details will be sent after the webinar Webinar series partners include: o American Society of Law, Medicine & Ethics o Network for Public Health Law o Public Health Law Research Program Public Health Law Series Webinar: Medicaid 1115 Waivers 3

4 Intersection of Law, Policy and Prevention October 16 & 17 Atlanta, GA Attend to learn how law can be used to address some of today s most critical public health issues. Get more info and register at: phlc2014.org Public Health Law Series Webinar: 4

5 Public Health Law Series Webinar Medicaid 1115 Waivers: How are they Transforming the Health System?

6 Moderator Introduction Akshara Menon, J.D., M.P.H. Senior Legal Analyst/ORISE Fellow, Public Health Law Program, Office for State, Tribal, Local, and Territorial Support, Centers for Disease Control and Prevention J.D. from Emory University School of Law, M.P.H. in Health Policy and Administration from Yale School of Public Health Research interests/areas of expertise: Prescription Drug Overdose, Anti-Viral Distribution, Electronic Health Information and Health System Transformation Public Health Law Series Webinar: Medicaid 1115 Waivers 6

7 Panel Introduction Sarah Somers, J.D., M.P.H., Managing Attorney, Network for Public Health Law Southeastern Region, National Health Law Program J.D. from University of Michigan, M.P.H. from University of North Carolina School of Health Policy and Management, B.A. from Wellesley College Research interests/areas of expertise: Issues related to Patient Protection and Affordable Care Act; Medicaid; the Americans with Disabilities Act; and other publicly-funded health care programs Specializes in litigation and litigation support, expertise in Medicaid and disability issues Public Health Law Series Webinar: Medicaid 1115 Waivers 7

8 Panel Introduction Ardas Khalsa, M.S.W. Director of Healthcare Transformation Waiver Operations with the Medicaid CHIP Division, Texas Health and Human Service Commission M.S.W., University of Texas at Austin, B.S., Berry College Research interests/areas of expertise: Implements the Delivery System Reform Incentive Payment Program Extensive experience at the local level, focusing on behavioral health systems of care, literacy education, and social services Public Health Law Series Webinar: Medicaid 1115 Waivers 8

9 Panel Introduction Suzanne Bierman, J.D., M.P.H., Director, Continuity of Care and Coordination of Coverage Division of Medical Services Arkansas Medicaid J.D., from the University of Arkansas Little Rock School of Law, M.P.H., from University of Arkansas Medical Science Fay W. Boozman College of Public Health, B.A. from Hendrix College Research interests/areas of expertise: Coordinating DMS efforts in the implementation of the Health Care Independence Program and promoting coordination of coverage for Medicaid recipients Policy analysis, public health Public Health Law Series Webinar: Medicaid 1115 Waivers 9

10 Public Health Law Series Webinar Medicaid 1115 Waivers: How are they Transforming the Health System? Medicaid 1115 Demonstrations: The Basic Rules Sarah Somers, Managing Attorney Network for Public Health Law Southeastern Region National Health Law Program June 19, 2014

11 Medicaid Basics States are required to have an approved state Medicaid plan Must meet specific statutory requirements Eligibility and coverage of services Statewideness Choice of willing provider Limits on cost sharing 42 U.S.C. 1396a (Section 1902) A state plan for medical assistance must... provide Public Health Law Series Webinar: Medicaid 1115 Waivers 11

12 Section 1115 Research and Demonstration Projects Experimental, pilot, or demonstration Likely to assist in promoting the objectives of the Medicaid Act States may waive compliance with section 1902 Public Health Law Series Webinar: Medicaid 1115 Waivers 12

13 Examples of 1115 Demonstrations Delivering services through mandatory managed care (AZ, HI, TN) Extending coverage to childless adults (e.g. AZ, DE, ME, OR, VT) Imposing enhanced cost sharing (AZ, OR) Topics/Waivers/Waivers.html?filterBy=1115#waivers Public Health Law Series Webinar: Medicaid 1115 Waivers 13

14 Medicaid Expansion ACA added option requiring states to cover childless adults through Medicaid, with 100% federal match Supreme Court ruling means that expansion is optional ALTERNATIVE: 1115 Expansion Demonstrations Public Health Law Series Webinar: Medicaid 1115 Waivers 14

15 Medicaid Expansion Demonstrations Receives full federal match Assistance to pay premiums for private insurance (some demonstrations) Full Medicaid protections/wraparound Approved plans in AR, IA, MI Pending/Under development in PA, IN, NH Public Health Law Series Webinar: Medicaid 1115 Waivers 15

16 What is affected by waiver? E.g. Limits on premiums and cost sharing Requirement to cover non-emergent transportation Benefit packages Public Health Law Series Webinar: Medicaid 1115 Waivers 16

17 Limits on authority per HHS No partial expansion Full Medicaid protections (particularly for lowest income) Must provide choice of two plans Time limited Public Health Law Series Webinar: Medicaid 1115 Waivers 17

18 Texas Healthcare Transformation and Quality Improvement Program 1115 Waiver Ardas Khalsa Director, Healthcare Transformation Waiver June 19, 2014

19 Transformation Waiver Overview Five-Year Medicaid 1115 Demonstration Waiver ( ) Allows expansion of managed care while protecting hospital supplemental payments under a new methodology Incentivize delivery system improvements and improve access and system coordination Establishes Regional Healthcare Partnerships (RHPs) anchored by public hospitals or another public entity in coordination with local stakeholders. 19

20 UC and DSRIP Under the waiver, historic Upper Payment Limit (UPL) funds and new funds are distributed to hospitals and other providers through two pools Uncompensated Care (UC) Pool ($17.6 billion) Replaces UPL Costs for care provided to individuals who have no third party coverage for hospital and other services Delivery System Reform Incentive Payments (DSRIP) Pool ($11.4 billion) New program to support coordinated care and quality improvements through RHPs Transform delivery systems to improve care for individuals (including access, quality, and health outcomes), improve health for the population, and lower costs through efficiencies and improvements DSRIP providers include hospitals, physician groups, community mental health centers, and local health departments. 20

21 UC and DSRIP UC & DSRIP Pool Funding Distribution (All Funds) Page 21

22 Regional Healthcare Partnerships Beginning October 1, 2012, to participate in DSRIP and UC, hospitals and other providers must participate in a Regional Healthcare Partnership (RHP). In May 2012, HHSC established 20 RHPs: Each RHP is anchored by a public hospital or other public entity. Each RHP submitted an RHP Plan by December 31, 2012, that outlined priority community needs and DSRIP projects to improve regional health care delivery. 22

23 20 RHPs 23

24 How Texas DSRIP is Different from other States The RHP concept is unique to Texas. Intergovernmental transfers (IGT) from governmental entities largely local public hospital districts are the non-federal share for DSRIP payments (at the FMAP rate about 40 percent non-federal share), including for private hospitals. There are 300 DSRIP performing providers 224 hospitals (public and private), 18 physician groups, 38 community mental health centers, and 20 local health departments. 24

25 RHP Plans: Two Key DSRIP Protocols Along with the approved waiver, two protocols serve as the basis for RHP Plan development and DSRIP funding. Program Funding and Mechanics (PFM) Protocol Initially approved by CMS on August 31, 2012 Amended four times, most recently in May 2014 Includes project, funding allocation and reporting requirements for projects. RHP Planning Protocol (DSRIP Menu) Initially approved by CMS in September 2012 Amended in May 2014 for technical clean up and to update the outcomes measures so there are measures appropriate for all projects and provider types. 25

26 RHP Plans: RHP Planning Protocol The RHP Planning protocol outlines the menu of projects eligible for DSRIP funds. RHPs were able to select their projects from the menu as long as they met minimum requirements and the projects address priority community needs. Category 1 Infrastructure Development - Lays the foundation for the delivery system through investments in people, places, processes and technology. Pay for performance. Category 2 Program Innovation and Redesign - Pilots, tests and replicates innovative care models. Pay for performance. Category 3 Quality Improvements - Healthcare delivery outcomes improvement targets tied to Category 1 and 2 projects. Pay for outcomes. Category 4 Population-Based Improvements - Requires hospitals in all RHPs to report on the same measures. Pay for reporting. 26

27 DSRIP Proposed Projects As of May 1, 2014, there were 1,277 approved and active 4-year DSRIP projects. More than 200 additional proposed 3-year projects received initial federal approval in May Common project types: Expand access to primary care Expand access to specialty care Behavioral health interventions to prevent unnecessary use of services in certain settings (e.g. emergency department, jail) Programs to help targeted patients navigate the healthcare system 27

28 DSRIP Projects and Public Health DSRIP Menu project options: Evidence-based Health Promotion Programs examples include Chronic Disease Prevention and Education (such as diabetes) Prenatal and Postnatal programs to improve birth and postnatal outcomes Interdisciplinary teams to promote preventive health and health literacy Fall prevention and safety for low income older adults. Evidence-based Disease Prevention Programs examples include Obesity prevention in children through nutrition and physical activity Screening programs and awareness education for colorectal cancer, mammography Expand HIV and STD screenings focused on high risk populations Promote and provide preventive immunizations to low-income adults. 28

29 DSRIP Timeline Most 4-year projects received approval by September Demonstration Years (DYs) 2-3 (October 2012-September 2014) - Start-up activities, including developing project infrastructure Project planning Hiring and training of providers and other staff Expansion of space, hours DY 3 - This year, all projects must select outcomes and submit outcome baseline data. Many projects will begin to report on the number of additional patients served due to the project. For local health departments, outcomes measurement can also include activities such as regional exchange of public health surveillance data DY 4-5 (October 2014-September 2016) Projects will earn funds by serving additional patients, showing improvements in outcomes, and continuous quality improvement. 29

30 How DSRIP Funds are Earned DSRIP funds must be earned based on achievement of projectspecific metrics each year. Payments are at the Medicaid matching rate - about 60% federal funds and 40% non-federal funds (intergovernmental transfers, largely from local public entities). As of January 2014, DSRIP participants had earned over $2.1 billion all funds for achievement through September For demonstration years 3-5 (October 2013-September 2016), providers have two opportunities to report achievement each year (April and October) to earn DSRIP funds. For April 2014 reporting, payments will be made in July

31 DSRIP Projects Measuring Success Most DSRIP projects have completed their start-up phase, and have successfully reported achievement of initial project activities. Projects have begun reporting their direct patient impact and establish benchmarks for project outcomes. Providers report twice a year on project metrics and milestones completed to earn DSRIP payments. In the final two years of the waiver, providers will report improvement in outcome measures related to each project. HHSC will conduct a mid-point assessment this year to evaluate the progress of the projects so far, and to determine if they require any modifications or technical assistance to be successful. This assessment will include a review each project s impact on those served and particularly Medicaid and uninsured individuals, and how the project could be strengthened. 31

32 DSRIP Projects Measuring Success Groups of providers and other DSRIP participants are meeting across the state to work collaboratively to identify best practices, share ways to improve projects, and promote continuous quality improvement. These learning collaboratives are underway in many regions, and a statewide learning collaborative summit for all RHPs will be held September 9-10, Common topics for the regional learning collaboratives: Behavioral healthcare, including integrated behavioral/primary healthcare Care transitions and patient navigation Chronic care and disease management Reducing unnecessary emergency room use, potentially preventable readmissions Primary care/access 32

33 Summary DSRIP provides a major opportunity to improve how health care is delivered in Texas, especially for Medicaid and low-income uninsured patients. The RHP structure provides a new avenue for increased regional cooperation and learning. Many DSRIP projects are underway and HHSC expects a significant amount of DSRIP funds will be paid in July to further DSRIP progress. DSRIP success will help contribute to waiver extension beyond September 30,

34 Waiver Website Find background materials and updates: 34

35 Public Health Law Series Webinar Medicaid 1115 Waivers: How are they Transforming the Health System? Arkansas Health Care Independence Program (Private Option) Suzanne Bierman Director, Coordination of Coverage & Continuity of Care Division of Medical Services, Arkansas Department of Human Services

36 Background on Section 1115 Waivers States have the flexibility to design programs to test policy innovations, including testing innovative delivery systems Section 1115 of the Social Security Act permits the Department of Health and Human Services to waive requirements of the federal Medicaid law Demonstration projects under Section 1115 must be budget neutral, i.e. the Demonstration may not cost more than the Medicaid program would without the Demonstration Waivers are generally approved for 3-5 years States must provide public process for notice and comment on proposed waiver application Public Health Law Series Webinar: Medicaid 1115 Waivers 36

37 Arkansas Private Option Waiver Approval Timeline Feb. 22 Mar. 13 Apr. 1 Apr. 17 Apr. 23 June 24 July 2, 8, 9 Aug. 6 Aug. 8 Sept. 27 Oct. 1 Jan. 1, 2014 Governor Beebe meets with Secretary Sebelius Secretary Sebelius expresses support for Arkansas framework Governor Beebe signs Private Option authorizing legislation Statewide public hearings on Waiver CMS notifies Arkansas submission is complete and releases for public comment Open Enrollment began Arkansas releases Private Option framework General Assembly passes Private Option authorizing legislation Arkansas releases draft of Private Option Waiver for public comment Private Option Waiver submitted to CMS CMS approves Private Option Waiver Up to an estimated 250,000 Arkansans became eligible for coverage under Private Option

38 Arkansas Health Care Independence Program The Health Care Independence Act of 2013 calls on the Arkansas Department of Human Services to reform the Medicaid Program to: Maximize the available service options; Promote accountability, personal responsibility, and transparency; Encourage and reward healthy outcomes and responsible choices; and Promote efficiencies that will deliver value to the taxpayers

39 The Private Option Offers Significant Benefits 39 Individuals may remain with the same plan and providers as their income shifts More than 35 percent of adults with incomes below 200% FPL will experience a change in eligibility within six months The size of the Marketplace will double, with the addition of 200,000 + Private Option enrollees Enrollees will be fully integrated into the Marketplace The enrollment of Private Option enrollees into Qualified Health Plans (QHPs) will facilitate payment and delivery system reform

40 Private Option Eligible Individuals in Childless adults between ages with incomes at or below 138% FPL Parents ages with incomes between 17% and 138% FPL Who are not on Medicare Who are not disabled Who have not been determined to be more effectively covered under the standard Medicaid program, such as an individual who is medically frail or other individuals for whom coverage through the Health Insurance Marketplace is determined to be impractical, overly complex or would undermine continuity or effectiveness of care FEDERAL MEDICALLY FRAIL DEFINITION IS THE STARTING POINT A disabling mental disorder Serious and complex medical conditions Physical, intellectual or developmental disability that significantly impairs their ability to perform one or more activities of daily living A disability determination

41 Private Option Benefits 41 QHP benefit package, including 10 Essential Health Benefits (EHBs) Additional Medicaid-specific benefits through fee-for-service Medicaid, not QHPs: Non-emergency transportation Dental and vision services for 19 & 20 year olds Private Option enrollees will access all benefits through one insurance card Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services, and chronic disease management Pediatric services, including oral and vision care

42 Cost Sharing in the Private Option in 2014: 42 Private Option eligible individuals are permitted to shop among and enroll in QHPs offered at the Silver metal level in the Marketplace Arkansas designed a standardized cost sharing structure for all high-value Silver plans in the Marketplace, regardless of whether the individual is eligible for the Private Option or tax credits (above 138% FPL to 150% FPL) Individuals with incomes below 100% FPL are exempt from cost sharing (and enroll in the 100% AV QHP) Individuals with incomes above 100% FPL are subject to cost sharing and enroll in the high-value Silver QHP with standardized cost sharing All cost sharing is consistent with both Medicaid and Marketplace requirements.

43 Private Option Today 43 As of May 31, 187,123 Arkansans had been determined eligible for coverage in the Private Option This represents approximately 75% of expected Private Option enrollees. Four issuers are offering QHPs in the Arkansas Marketplace. Ambetter of Arkansas Arkansas Blue Cross Blue Shield Blue Cross Blue Shield, a multi-state plan QualChoice Health Insurance of Arkansas Private Option coverage became effective on January 1, 2014.

44 Private Option 2015 Initiatives 44

45 Private Option Initiatives for The Arkansas Division of Medical Services will submit and seek federal approval for the following revisions to the Private Option: Designing a limited state-designed non-emergency transportation program Implementing cost-sharing for Private Option adults with incomes above 50% of FPL Developing a model for Private Option enrollees to utilize flexible Independence Accounts

46 Q&A Please type your questions in the Q&A panel. Public Health Law Series Webinar: Expanding Medical Marijuana Laws 46

47 Upcoming Webinars Thank you for attending. Please join us for our upcoming webinar: Taking on Tobacco Regulation: An Overview of New York City s Tobacco Control Laws Presented by the Network for Public Health Law and New York State Bar Association Public Health Committee Friday, June 27 at 3 p.m. (ET) networkforphl.org/webinars Public Health Law Series Webinar: 47