DC Legislative Update and Policy Discussion _______________ Session # 9 Camille Dobson, MPA

1. DC Legislative Update and Policy Discussion • _______________ • Session # 9 • Camille Dobson, MPA • Deputy Executive Director, NASUAD

2. Learning Objective(s) Participants will gain knowledge in: • Current waiver activities for work requirements • The implications on Medicaid eligibility of HHS proposed rules addressing public charge and Federal poverty level • Key elements of Medicaid managed care rule

3. Disclosure and Conflict of Interest Declaration I declare that neither I nor any member of my family have a financial arrangement or affiliation with any corporate organization offering financial support or grant monies for this continuing dental education program, nor do I have a financial interest in any commercial product(s) or service(s) I will discuss in the presentation.

4. Who is NASUAD? • Membership association for state aging and disabilities LTSS directors • Purpose is to provide leadership, technical assistance, and policy support to State LTSS systems

5. “Work” Requirements – Current Status • In January 2018, CMS issued new guidance for state Medicaid waiver proposals that would impose work requirements in Medicaid as a condition of eligibility. • Those subject to the requirements must either work, do community service or be in school/job training (although requirements vary by state) • Earliest approvals were targeted at ‘expansion’ (ie. low income adult) populations • More recent approvals have permitted requirements for ‘traditional’ adults – parents of Medicaid-eligible children and disabled and elderly adults • Most waivers have exceptions built in for pregnant women and adults with a disability

6. “Work” Requirements – Current Status • Current status of state demonstrations: • 9 have been approved by CMS: • 6 are pending with CMS: #Have been stayed by Federal courts and cannot be implemented * Not implemented by state at this time

7. HHS New Rules Affecting Medicaid Eligibility • “Public Charge” Rule • Currently the Department of Homeland Security decides 1) whether lawful immigrants in the United States can get a “green card”; and 2) whether those seeking lawful entry to the United States can be admitted and rejoin family based on whether: • more than half of an individual’s income comes from cash assistance (TANF, SSI or state GA programs) OR • the individual gets Medicaid long-term care benefits • If either of these tests are met, the individual is considered a ‘public charge’ and may not be permitted to remain/admitted to the US

8. HHS New Rules Affecting Medicaid Eligibility “Public Charge” Rule The September 2018, revised definition released by Dept. of Homeland Security would • take into account whether a lawful immigrant has received, or are judged likely to receive in the future, any benefits tied to need. • That could include Medicaid, CHIP, Medicare Part D subsidies, SNAP, or Section 8 housing vouchers • No longer would use half of income but receipt (or likely receipt) of any such assistance ‘count’ against the immigrant • Establish income levels that would be weighed against or in favor of applicants. For example, if a person earns less 125% of the Federal poverty level ($31,000 for a family of four), this would be considered a negative factor in assessing whether the lawful immigrant is a ‘public charge’

9. HHS Proposed New Rules Affecting Medicaid Eligibility Change in Federal Poverty Level calculation • The official poverty measure compares cash income, before taxes, against a threshold that is set at three times the cost of a minimum food diet in 1963 • That amount (currently $25,750 for a family of four) is increased annually by the Consumer Price Index - Urban • Proposed change – seeking comment on using other indexes including the ‘regular’ CPI or or the Personal Consumption Expenditures Price Index (PCEPI). Both have typically increased more slowly than the CPI-U. • Medicaid implications: Over time, eligibility levels for programs that use the FPL to determine eligibility such as Medicaid, CHIP, Head Start, the national school lunch program, SNAP, and the Low-Income Home Energy Assistance Program would increase more slowly.

10. Medicaid Managed Care • Predominant delivery system for children and pregnant women (70% Medicaid; 73% CHIP)

11. Medicaid Managed Care Rule – 2016 Changes • Managed care regulations (both Medicaid and CHIP) updated by Obama Administration in 2016 – first time since initial implementation in 2001 • Purpose: • alignment with other insurers; • encourage delivery system reform; • improve payment and accountability improvements; • establish more rigorous beneficiary protections • modernize requirements and improve quality

12. Medicaid Managed Care Rule – 2016 Changes • New beneficiary protections: * • Better information in enrollment materials, including provider directories • State must operate website for consumers • Taglines and alternative formats required on all materials • Require health risk assessment within 90 days of enrollment

13. Medicaid Managed Care Rule – 2016 Changes • Mandatory network adequacy standards * • States have to set time and distance standards for: • Primary care (including pediatric); • specialty care (including pediatric); • OB/GYN; • Behavioral health; • Hospital; • Pharmacy; and • Pediatric dental

14. Medicaid Managed Care Rule – 2016 Changes • More stringent rules for MCO payments and imposing medical-loss ratio of 85% • Align grievance and appeals timeframes with Medicare Advantage • Applied FFS program integrity provisions to managed care delivery systems – e.g. requirement provider enrollment with State * • Quality * • Establish new Quality Rating System for MCOs • Require all MCOs to be accredited • Allows CHIP to use EQROs for quality oversight

15. Medicaid Managed Care Rule – 2018 Changes • Trump Administration proposed changes in November 2018; awaiting finalization in 2019 • Changes focused on 3 major areas: • Payment – more flexibility in setting MCO capitation rates • Beneficiary protections – removed requirement for taglines and frequent provider directories (quarterly rather than monthly) • Network adequacy – removed time and distance standard requirement completely as well as specific types of providers they are subject to; returns to 2001 version

16. Questions

17. References • https://www.kff.org/medicaid/issue-brief/medicaid-waiver-tracker-approved-and-pending-section-1115-waivers-by-state/ • https://www.federalregister.gov/documents/2018/10/10/2018-21106/inadmissibility-on-public-charge-grounds • https://www.federalregister.gov/documents/2019/05/07/2019-09106/request-for-comment-on-the-consumer-inflation-measures-produced-by-federal-statistical-agencies • https://www.medicaid.gov/medicaid/managed-care/enrollment/index.html • https://www.medicaid.gov/medicaid/managed-care/guidance/index.html • https://www.medicaid.gov/chip/managed-care/index.html

18. Camille Dobson Camille Infussi Dobson is the Deputy Executive Director at NASUAD. In that role, she provides executive leadership and policy guidance to state aging & disabilities agencies, focused on managed LTSS and quality measurement. She is the co-author of three reports from the MLTSS Institute on MLTSS issues, including managed care programs for individuals with intellectual/developmental disabilities. She previously worked for 10 years at CMS, focusing on Medicaid policy, and culminating in a promotion to Senior Policy Advisor for Medicaid managed care. In that role, she was the primary author of CMS’ 2013 guidance to States laying out key elements for MLTSS programs, which has since been translated into the new CMS Medicaid managed care rule. Before joining CMS, she spent twelve years working for two Maryland Medicaid MCOs focused on regulatory compliance and quality improvement.

19. Contact Information Camille Dobson Deputy Executive Director National Association of States United for Aging and Disabilities 241 18th St. S, Ste. 403 Arlington, VA 22202 202/499-5947 cdobson@nasuad.org

20. DC Legislative Update • Medicare: Senate Bill 22 • A Dental Benefit in Medicare • _______________ • Session # 9 • Senator Ben Cardin • United States Senate — Maryland