1115 medicaid waivers health management associates
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1115 Medicaid Waivers Health Management Associates. February 10, 2010. 1115 Waivers. Waivers at a glance Comparison of California to Massachusetts and New York Opportunities and challenges. California’s 1115 Waiver. Currently a hospital waiver with $180 million a year in coverage - PowerPoint PPT PresentationTRANSCRIPT
February 10, 2010
1115 WaiversWaivers at a glanceComparison of California to Massachusetts and New York
Opportunities and challenges
Medicaid 1115 Waivers
California’s 1115 Waiver Currently a hospital waiver with $180 million
a year in coverage Provides vital funding for the safety net Expires September 2010 Necessitates a negotiation and
renewal/extension
Medicaid 1115 Waivers
Waiver Basics Medicaid rules highly prescriptive Authorized by section 1115 of the Social Security
Act Great flexibility provided by a 1115 Waiver Can make changes to a small portion of program –
or at the other end of the spectrum, a state’s entire Medicaid program can be placed under a waiver
Some provisions are not waiveable under any circumstances
Waivers have been a key element of health reform in many states
Medicaid 1115 Waivers
Costs Not Otherwise Matchable One of the most powerful provisions in section 1115
allows the Secretary of HHS to grant approval of costs not otherwise matchable or CNOM
The most common use of CNOM is for coverage of nondisabled childless adults because there is no other legal mechanism to extend Medicaid eligibility to these individuals
State and local program spending can also be approved as a CNOM
The “catch” is that there has to be budget neutrality “room” for CNOM expenditures, as they can only be counted on the “with waiver” side of the equation
Medicaid 1115 Waivers
Budget Neutrality Budget neutrality – which is not a legal or regulatory
matter – prevents the federal government from spending more than would/could be the case in the absence of the waiver
Budget neutrality is negotiated between the state and federal government
Key elements of the negotiation are the: “With waiver” cost projections “Without waiver” theoretical baseline cost (and what can
be counted is negotiable) The inflation factor by which the “without waiver”
baseline can grow Budget neutrality can be calculated in the aggregate,
on a per capita basis, or a combination of the two
Medicaid 1115 Waivers
Sources of Savings States have found savings from a number of
sources Managed care Redirection of DSH Pooling of UPL or other funds Other savings
Medicaid 1115 Waivers
Ca., Mass and NY ComparedCHCF Published Paper Comparing 3 states’
waiversWaivers are similar in many waysMass demonstrates how a state can use a
waiver to expand coverage for the uninsuredN.Y. demonstrates how state can reorient
spending from institutional care and use savings for coverage and programs in the state
http://www.chcf.org/documents/policy/Medicaid1115Waiver.pdf
Medicaid 1115 Waivers
Medicaid SpendingAll 3 states have similar FMAP ratesN.Y covers 27%, Mass. 19%, and Ca. 29% of
populationNew York and Massachusetts has among the
highest per enrollee spending in the nation ($9,656 and $8,300, respectively, in 2006)
California spends less per enrollee than almost any other state ($4,528).
Easier for high cost states to reduce their per enrollee spending and use savings
California has already achieved significant Medicaid savings.
Medicaid 1115 Waivers
Federal Safety Net SupportA second disadvantage for CaliforniaFederal government’s indigent care per resident
contribution is three times higher in Massachusetts and almost twice as high in New York as it is in CaliforniaMass $164, N.Y. $96, Ca. $50
A larger portion of Ca’s population is uninsured.Mass 7.9, N.Y. 13.6 Ca. 18.6
175% DSH cap makes it costly to redirect DSH funds to coverage
Medicaid 1115 Waivers
Managed CareMassachusetts and New York expanded Medicaid
managed care through 1115 waiversAllowed to reinvest the federal share of savings
to cover uninsured or for other programsCa. expanded managed care during the same
periodExpansions were not done under an 1115 waiver,
so California gets no credit for these savings. As of June 2007, 60% of Medicaid beneficiaries
in Mass. were enrolled in managed care, 62% in N. Y. and 51% in California.
Medicaid 1115 Waivers
OpportunitiesWaiver provides opportunity for increased federal
funding forHospitalsCovering the uninsuredCoverage initiativesState
The larger the waiver the more funding opportunityOpportunity to improve Medi-Cal program and
improve integration and delivery of careCa. has been successful in past in improving
programs and obtaining significant federal funding from waivers .
Medicaid 1115 Waivers
Issues and Challenges for California Ca. federal baseline funding is insufficient to
achieve sufficient federal funds to meet all needs
Ca. will need to receive credit for savings already achieved through managed care and other changes
Baseline will also need to be increased to reflect changes such as a hospital fee.
The federal flexibility needed to recapture savings – in effect – to treat California like other states – would come at a cost to the federal government
Medicaid 1115 Waivers
Challenges State general fund crisis makes it difficult to
invest in the improvements needed For more than 25 years, CA has endured
significant pressures on the state budget Created a reimbursement system that
encourages the delivery of inpatient hospital care
Low physician and primary care rates Severely compromise CA’s ability to create
health delivery system reform in lower cost more coordinated care settings
Medicaid 1115 Waivers
Challenges FMAP cannot be waived All new federal funds must have a match from non-
federal government funds The federal government would expect significant
reforms and improvements in Medi-Cal and possibly increased coverage in exchange for budget neutrality flexibility
Federal government may want to require DSH and other support to indigent care be shifted to coverage Required in Mass. Mass. has 3 times the funding per resident as Ca.
Medicaid 1115 Waivers
Conclusion1115 Waiver provides an opportunity for
CaliforniaFederal government has significant flexibility
in waiver approvals-no federal rulesCan be approved without federal legislationWaivers are state specific-while other states
look at precedence-it can be tailored to state. Historically 1115 waivers have provided
California with significant additional funding.
Medicaid 1115 Waivers