State Flexibility Through Waivers NASHP Annual State Health Policy Conference October 5, 2011

1. State Flexibility Through WaiversNASHP Annual State Health Policy ConferenceOctober 5, 2011 Jenny Hamilton, MSG Project Manager, Washington State Health Care Authority

2. The “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?) Hamilton

3. Transitional Bridge1115 Demonstration Waiver(Approved for Implementation 1/1/11) Hamilton

4. Purpose 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 2014 Hamilton

5. Key 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 Hamilton

6. Key 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 Hamilton

7. Lessons 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 Hamilton 7

8. Health Innovation for Washington (HIW) (Request submitted 4/29/11; discussion continues) Hamilton

9. Purpose of HIW • Flexibility • Value based benefit & payment reforms • Delivery system reforms • Consumer engagement • Prevention & wellness • Administrative simplification • Technical assistance • Financial support Hamilton

10. Where 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 Hamilton

11. Lessons 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… Hamilton

12. Additional 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 Hamilton