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Illinois Medicaid 1115 Waiver February 19, 2014

Illinois Medicaid 1115 Waiver February 19, 2014. What is a Medicaid 1115 Waiver?. Section 1115 of the Social Security Act. Allows states to apply for program flexibility from the Centers for Medicare & Medicaid Services to test new approaches to financing & delivering Medicaid

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Illinois Medicaid 1115 Waiver February 19, 2014

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  1. Illinois Medicaid 1115 WaiverFebruary 19, 2014

  2. What is a Medicaid 1115 Waiver? Section 1115 of the Social Security Act • Allows states to apply for program flexibility from the Centers for Medicare & Medicaid Services to test new approaches to financing & delivering Medicaid • Provides incentives to providers to develop new models of care • Lasts five years, but can be renewed/amended • Must be budget neutral, leading to overall savings Our State’s Waiver Application • Called the Path to Transformation Waiver • Includes all services in the Illinois Medicaid program for better coordination • Covers all Medicaid-eligible populations

  3. Four Pathways to Transformation Goals: Better Health Outcomes Lower Costs Pathway 1 Pathway 2 Pathway 4 Pathway 3 • State Draft • Waiver • Application Population Health Home- & Community-Based Supports Delivery System Transformation Workforce

  4. Waiver Goals • Support linkages between health care delivery systems and services that directly impact key social determinants of health • Create incentives to drive development of integrated delivery systems • Promote efficient health care delivery through optimization of existing managed care models • Enhance ability of the health care system to engage in population management • Strengthen the state’s health care workforce to meet needs of Medicaid beneficiaries • (Goals continued on next page)

  5. Waiver Goals (continued) • Consolidate Illinois’ nine existing 1915(c) waivers under a single 1115 waiver • Increase flexibility and choice of long-term supports for adults and children • Institute a provider assessment on residential habilitation providers • Reduce prioritization of unmet need for services wait list • Promote and foster greater community-integrated, competitive employment opportunities

  6. 1st Pathway: Delivery System Transformation • Waiver promotes care coordination & integrated delivery system development • Provides Coordinated Care Entities & Accountable Care Entities with analytics, data collection & other activities related to managing a population • Hospital performance & integration pool tied to hospital & health system performance measures • Public hospitals will have separate pool for specific projects Delivery System Transformation

  7. 2nd Pathway: Population Health • Focuses on developing regional public health hubs • Premium add-on payment to health plans for developing population health interventions • Fund regional public health hubs to provide technical assistance in addressing health disparities, social determinants of health, and evidence-based interventions, including those endorsed by the Community Preventive Services Task Force Population Health

  8. 3rd Pathway: Workforce • Increase Physician Supply • Provide incentives for training physicians (primary care & high-need specialties) in community settings, treating underserved patients • Expand loan repayment programs, including incentive funding for hospital-sponsored loan repayment programs • Community Health Workers Training • In-home personal attendants, nurses & other providers to work on primary care provider teams • Establish and certify community health workers Workforce

  9. 4th Pathway: Home & Community-Based Supports • Consolidation of nine existing home- & community-support waivers • Behavioral health expansion & integration • Increase funding & uniformity in benefits • Base benefits on beneficiary needs, increase choice for beneficiaries, and expand community-based options • Children & Young Adults with Developmental Disabilities • Children who are technologically dependent • Medically Fragile • Individuals with HIV or AIDS • Elderly Home- & Community-Based Supports

  10. Opportunities and Challenges Challenges Opportunities • Many needs • Limited funding • Negotiatons with CMS will determine final funding allocations • A Waiver Provides: • A possible option to preserve hospital assessment program • New funding for: • Hospital quality and transformation initiatives • Primary care physician development in underserved areas • Behavioral health programs • Maternal child visits and medical home development • Loan repayment for physicians through safety-net hospitals • Strengthening of: • Community-based options • Public health resources - +

  11. Why is the Waiver an Option for Preserving Assessment Funding? • Upper Payment Limit (UPL) Conundrum • Under Federal law, states can’t make direct payments to hospitals that exceed the upper payment limit • Includes hospital assessment payment • UPL = Estimate of what would be paid under Medicare principles for persons in the Medicaid Fee-for-Service system • 50% coordinated care mandate by 1/1/2015 Capitation Assessment UPL

  12. What is the Access Assurance Pool? • Option to replace current assessment (or UPL) payments • Maintain current assessment payment distribution method “as is” for transition period (e.g. 1st two years of the waiver) • Then, Access Assurance (AA) payments based on a hospital’s unreimbursed costs for Medicaid and uninsured patients • Can include hospital and other services (e.g. Dr., Rx) • Goal: AA payments to replace, as closely as possible, the current Assessment payments for each hospital

  13. How is a Waiver Financed? • Costs Not Otherwise Matchable (CNOM) • One of the most powerful provisions in Section 1115 allows CMS to grant approval of Costs Not Otherwise Matchable or CNOM • Includes services not normally qualifying as Medicaid expenditures • Must be budget neutral • Must reinvest freed-up state funds back into the Medicaid program

  14. Budget Neutrality Under 1115 Waiver CNOM counts toward budget neutrality gap

  15. Hospital-Specific Waiver Payments

  16. Transforming Illinois Health Care Illinois hospitals have the infrastructure to bring together a wide range of providers

  17. 11/5/13 Concept paper finalized The Waiver Process 6-12 mos. State negotiates with CMS 10/18/13 Stakeholder kick-off meeting 1/8/14 Draft waiver posted for comment 2/10/14 Final waiver with comments posted 1/22/14 Waiver comments due 3/12/14 Waiver submitted to CMS 10/18 – 12/13/13 Stakeholder meetings 12/18/13 Legislative hearing

  18. For More Information @ Patrick Gallagher Group Vice President, Health Delivery & Payment Systems (630) 276-5496pgallagher@ihastaff.org State of Illinois 1115 Waiver Web Page http://www2.illinois.gov/gov/healthcarereform/Pages/1115Waiver.aspx

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