State Flexibility Through WaiversState Flexibility Through Waivers

NASHP Annual State Health Policy NASHP Annual State Health Policy ConferenceConferenceOctober 5, 2011October 5, 2011

Jenny Hamilton, MSGProject Manager, Washington State Health Care Authority

The “Why” and “What” for WA StateThe “Why” and “What” for WA State

• Budget shortfalls – state-funded programs in jeopardy

• Health system status quo unsustainable• Governor’s 4% challenge• 2014 potentially 400-500K new Medicaid enrollees

• Federal partnerships requested for:– Transitional Bridge (1115 Demonstration waiver)– Health Innovation for Washington (innovation / waiver?)

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Transitional BridgeTransitional Bridge1115 Demonstration Waiver1115 Demonstration Waiver

(Approved for Implementation 1/1/11)(Approved for Implementation 1/1/11)

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Purpose of Transitional Bridge WaiverPurpose of Transitional Bridge Waiver

• ACA early Medicaid expansion allowed for hypothetical populations

• Waiver essential to sustain coverage in state-funded programs:

– Basic Health – Medical Care Services (Disability Lifeline)– Medical Care Services (Alcohol and Drug Addiction

Treatment and Support Act – ADATSA)

• Waiver populations eligible for Medicaid in 20144Hamilton

Key Waiver InnovationsKey Waiver Innovations

• Used TANF methodology - countable income of 133% FPL captures Basic Health up to 200% FPL

• No maintenance of effort required• Sustained critical program cost-sharing &

reimbursement approaches• Flexible enrollment caps & waiting lists approved• Emergency suspension or termination• Dynamic approach – milestones established

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Key CMS RestrictionsKey CMS Restrictions

• Individuals eligible for Medicaid must transfer• American Indian/Alaska Native requirements– Basic Health cost-sharing exemption– Differential payment needed for health plans– Indian Health providers = full Medicaid payment– Retroactive supplemental payments by 12/31/13

(100% match) CHALLENGE = verification of status

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Lessons LearnedLessons Learned

• Conceptual design period identified major issues before formal application

• “Transparent” conversation critical• Words matter (e.g., dynamic transition, bridge)• Devil is in the detail – be clear on waiver needs• Tribes/Stakeholders can be allies – engage them early• Waiver approval timed to give Legislature leverage to

sustain programs• Commercial managed care contracts very different from

Medicaid contracts

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Health Innovation for Washington (HIW) Health Innovation for Washington (HIW)

(Request submitted 4/29/11;(Request submitted 4/29/11; discussion continues) discussion continues)

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Purpose of HIWPurpose of HIW

• Flexibility– Value based benefit & payment reforms– Delivery system reforms– Consumer engagement– Prevention & wellness– Administrative simplification

• Technical assistance• Financial support

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Where We Are TodayWhere We Are Today

• Progress underway– Health homes & dual eligibles planning grants

• On hold until federal ACA guidance available– Broader use of “essential benefits”– MAGI eligibility determination across Medicaid

• Discussion /technical assistance continues– Flexibility for MCO payment restructure– Prescription drug formulary / cost sharing– FQHC/RHC payment redesign – Centers of experience

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Lessons LearnedLessons Learned

• Flexibility may be available without waiver• Innovation funneled through grants; otherwise

1115 waivers seem the main vehicle• Medicaid State Technical Assistance Teams are

valuable resource• Value of other states’ experience • More to come…

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Additional ResourcesAdditional Resources

• Transitional Bridge Waiver Documents: http://www.wacommunitycheckup.org/

• Governor Gregoire’s health reform site: http://www.governor.wa.gov/news/news-view.asp?pressRelease=1469&newsType=1

• Health Innovation for Washington: http://www.governor.wa.gov/priorities/healthcare/default.asp

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