Medicaid Council Reports on MACPAC Commissioners’ May Public Meeting
May 31, 2013 03:17 PM
On May 16-17, the National Council on Medicaid Home Care’s director of policy, Michelle Martin, attended the May public meeting of the MACPAC commissioners. The meeting included a robust discussion of waivers, from both the federal and state perspectives, as well as an update on MACPAC’s gathering of Medicaid data, known as MACStats.
Cindy Mann, CMS Deputy Administrator/Director was the first presenter on the “Medicaid Waivers: Federal Perspectives” panel. Ms. Mann discussed waivers, generally, as well as some greater detail on how many active waivers exist and their purpose (65 active 1115 waivers, 57 active 1915(b) waivers, and 320 active 1915(c) waivers). The commissioners expressed concern over waivers, essentially questioning whether waivers need to continue, since many waivers have become long-standing programs, or if amendments should be made to state plans to accommodate the waivers.
Ms. Mann explained that the waivers are so popular because they are very flexible, allow for creating change in a way that seems significant, and let the states test new ideas. Whether waivers are, in fact, allowing for innovation instead of a clever work-around is a concern and Ms. Mann indicated that CMS is moving toward making the waiver process more streamlined and transparent at the same time as aggressively moving toward a focus on quality and better evaluation of waivers.
Following Ms. Mann’s presentation, Katherine Iritani, Director of Health Care Issues at the U.S. Government Accountability Office (GAO) presented on GAO reviews of Medicaid demonstration waivers - 1115 waivers. Ms. Iritani’s presentation focused on the scope and methods of GAO’s reviews of waivers and the findings of the GAO studies. First, the requirement for budget neutrality was discussed, with spending limits calculated, according to HHS policy, from the spending base and growth rates.
Ms. Iritani presented a few of the GAO general findings:
Lack of public input and transparency
Inconsistent with the Secretary’s authority under 1115
Insufficient assurance that waivers will not raise federal costs
In terms of the findings as to budget neutrality, GAO has found that HHS’s basis for approving state demonstrations’ spending limits as budget neutral has not always been clear and negotiations with the states and the rational for approved spending limits has not always been documented. GAO has found that HHS has not always ensured that approved demonstrations maintain the fiscal integrity of the program.
In response to these findings, GAO has suggested that Congress consider requiring increased attention to fiscal responsibility in the approval of section 1115 demonstrations.
Following Ms. Iritani’s presentation, the Commissioners engaged the panelists in a question and answer session where the overall theme was one of respecting the policy and statutory origins of the Medicaid program. Meaning, instead of having a Medicaid program that seems to run entirely by waiver, CMS has taken the comments from GAO and the states into consideration and is working to get Medicaid back to its origins as a flexible statute and filling in with waivers.
Maintaining flexibility and encouraging innovation at the same time as keeping some level of uniformity while keeping costs under control is a significant task and one that CMS is taking very seriously.
The panel on Medicaid waivers from the state perspective included three speakers:
Valerie J. Harr, Director, Division of Medical Assistance and Health Services, State of New Jersey
Thomas J. Betlach, Director, Arizona Health Care Cost Containment System
Robin E. Cooper, Director of Technical Assistance, National Association of State Directors of Developmental Disabilities Services
To start the session, Valerie J. Harr described New Jersey’s waiver experience. In 2010, New Jersey had two 1115 waivers that meant unmanaged, uncoordinated long term care services, lack of coordination between physical and behavioral health providers, lack of services for high acuity ID/DD and addiction services populations, and complex and varied federal reporting requirements. In February 2011, New Jersey’s Governor, Chris Christie, called for Medicaid reform in his budget address.
Through a series of program review meetings, stakeholder meetings, legislative hearings, discussion with CMS, and many other meetings, New Jersey developed and implemented a Comprehensive Medicaid Waiver that encompasses eight, previously uncoordinated, waiver programs and maintains significant flexibility for the state. In developing the Comprehensive Waiver, New Jersey saw moving to managed long-term services and supports as the area with the most opportunity since the waiver would simplify the provision of a greater number of services to a wider population.
The Comprehensive Medicaid Waiver allowed for administrative simplification and created a way for New Jersey to pay for care that could not be provided under the Medicaid program, which meant a higher level of care for a broader group of people. The waiver approval process and operational processes proved challenging for New Jersey, but nothing that could not be overcome, especially given the benefits that come from the waiver. Ms. Harr concluded her presentation by indicating a hope that waivers will continue, perhaps in a simplified version as the application process was very lengthy and expensive.
The next panelist, Thomas Betlach, provided a unique perspective on the waiver program. He described Arizona’s 30-year history with waivers and how Arizona has used 1115 waivers to expand the Medicaid program into new populations and to expand the level of care offered to populations already included in the Medicaid program. Arizona expanded the Medicaid program to include long-term services and support and SNF services in 1988 and 1990. When the state of Arizona faced debilitating funding issues during the recession, the Arizona Health Care Cost Containment System (AHCCCS) responded by preserving the core care offered through the program—meaning preservation of the plans and providers as well as keeping the highest number of services available to the largest number of people.
Arizona was able to make modifications to the system to keep it running through the creativity allowed by the waiver process. Now that the state’s budget has recovered, Arizona is back to developing programs that will serve in-need populations through waivers.
On October 1, 2013, Maricopa County will begin an integration waiver strategy aimed at providing fully integrated care (Medicaid Behavioral Health, Medicaid Physical Health, Medicare D-SNP, and Housing/Employment) to members living with serious mental illness. Over Arizona’s 30 years of Medicaid innovation through the use of 1115 waivers, the state has found great value as well as opportunity for growth and continued improvement.
The final speaker on waivers, Robin Cooper, provided insight to home and community based services (HCBS). She began by explaining that HCBS means different kinds of care to the different populations receiving the care. Ms. Cooper went on to explain why the HCBS waivers are so popular—namely, the waivers create an opportunity to develop a set of benefits that serve the needs of specific populations and the ability to cap the waiver—either by number of people enrolled in the waiver or by individual benefit—which allows for budgetary certainty. There are also levels of care and cost neutrality difficulties that come up through the use of the 1915(c) waiver, as well as quality management requirements that differ from other HCBS waivers.
Ms. Cooper spent some time describing 1915(i) State Plan Home and Community-Based Services, which offers great flexibility and benefits to populations that are often left un-covered, otherwise. The caveat to the 1915(i) is that it is an optional benefit under Medicaid – and is therefore an entitlement - and cannot be capped which creates some difficulty.
Ms. Cooper concluded with the belief that somewhere between 1915(c) waivers and the 1915(i) program lies the perfect world offering the best in terms of flexibility and allowing for budgetary certainty. HCBS waivers may have reached a point that requires overarching authority, perhaps a State plan amendment that allows for continuing the benefits received through HCBS waivers but limits the pitfalls.
In response to the presentations, the Commissioners questioned whether the innovations occurring through waivers need to continue through the waiver process. In cases where a program has proven to be successful, would it make better sense to create policy around the waiver instead of requiring every state to apply for a waiver that allows for the same benefits? Is a fundamental re-thinking of waivers necessary—one that allows more variation through statute, creating a path to permanency, instead of individual waivers that have to be renewed every five years.
The panelists agreed that a simpler process would be ideal but brought up concerns about evaluation of programs that are deemed suitable for permanency which lead to a discussion on quality evaluation in waiver programs. It was clear that there is more work to be done in terms of identifying the appropriate quality metrics for tracking and gathering the related data. Work is going on at the state level and with various collaboratives to discuss oversight and find ways to evaluate managed long-term care, and long term care in general, in ways that are useful going forward.
The remaining sessions that were attended had no focus on long-term services and supports but, instead, looked at Express Lane Eligibility and MACPAC June Report Chapter Updates that focused on Maternity Eligibility and Coverage in the Medicaid and CHIP Programs, with accompanying data tables. While this topic is not directly on point for the Medicaid Council’s work, the session proved useful because of the discussion on the data limitation in Medicaid.
The commissioners noted that 2009 data, which is the most current information available, is too old to provide an accurate picture of cost and usage in 2014. The speakers during the session, Amy Bernstein, Senior Advisor, and April Grady, Director of Data Development and Analysis, explained that the states record and report data differently, and the reporting back to CMS is often incomplete. A number of Medicaid data pitfalls were brought into the light, leading the commissioners to feel that a closer look at the data question will be necessary.
There is likely to be a chapter on Medicaid data improvement in a future MACPAC report. While the work of the Commission will not result in an immediate change in data gathering, the fact that the lack of data available is coming to light is very important. Many big statements are made about Medicaid—such as Medicaid spending being the largest part of a state’s budget—based on incomplete, and sometimes inaccurate, data. These big statements can lead to broad misunderstanding of the Medicaid program and policy changes that are detrimental to the populations served by Medicaid.
Gathering data in Medicaid will always be difficult given that the program is different in each state but the acknowledgment and desire of the Commissioners to move toward an evaluation of the lack of Medicaid data could lead to vast improvements and better understanding of how and where money is spent in the Medicaid program. This is important to the Medicaid Council because improved data would allow for more accurate measurement of the value and growth of home care in Medicaid.
All in all, attendance at the MACPAC meetings has proven useful. It is important for the Medicaid Council to stay informed of the Commissioners’ views of the issues most important to the Medicaid home care space. This most recent meeting was especially helpful as it covered some key issues. While the Commissioners expressed some concern that waivers can reduce the consistency and uniformity in state Medicaid programs, and that some waivers are better suited as State plan amendments, waivers enjoy widespread support because of the flexibility they offer, and are here to stay.
Medicaid data has been of recent concern to the Medicaid Council and we are pleased to see the focus on the need to strengthen Medicaid’s data collection efforts. Improved data is key to strengthening and improving Medicaid policies.