Like we were saying…
On the heels of Health and Human Services Secretary Tom Price’s letter to Governors inviting them to apply for Section 1332 waivers (a sort of ACA DIY provision - read more about it here), newly installed CMS Director Seema Verma and Secretary Price sent out another letter assuring Governors that, as far as the Medicaid program goes, things will be different.
Different is good. Governors and State Medicaid Directors are chock full of horror stories about the years that get dedicated to approval of changes to their programs even when they are proven improvements. Previous administrations and especially the Obama administration, had placed a much higher priority on changes to the Medicare program often to the detriment of modernization and improvements to Medicaid. Members of Congress have even pointed out that less than 5 percent of CMCS officials have experience in a state Medicaid program, suggesting perhaps they talent isn't quite what it should be.
Here are our conclusions about the latest letter:
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The waiver process will be faster and easier. CMS is considering fast track approval of waiver and demonstration project extension. Currently, waivers and demonstrations have a shelf life of five years. Approvals for extensions often take a year or more, even when changes are minimal or non-existent.
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Managed care regulations, some of which treat the whole idea as innovative and experimental, will get a shave and a haircut. The intent is to make adoption of Medicaid managed care programs easier.
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Work requirements for low-income adult beneficiaries will no longer be verboten at CMS. Indiana attempted to include a work requirement in its Medicaid expansion but was shot down by a long standing aversion at CMS to such requirements.
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Alternative benefit designs that include HSAs and cost-sharing will be encouraged.
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Programs that seek to integrate a state Medicaid program with ESI will also be encouraged. Governor Bill Haslam’s Insure Tennessee which ultimately was approved by CMS under the Obama administration but shot down by his legislature is one model for this approach.
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Back end “bridge” programs that allow families where some members are Medicaid eligible and others that have access to the individual market or ESI to all be enrolled in the same plan. Tennessee and Washington State proposed programs in the past that ultimately were not approved by CMS.
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An end to requirements to provide non-emergency transportation without cost-sharing
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Limitations on presumptive eligibility and retrospective coverage that discourage continuous coverage
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Delay in implementation of January 2014 rule on home and community-based services.
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Fast track approval of mental health and substance abuse program waivers including, we expect, an end to IMD exclusion.
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Programs that shift resources away from expansion population and toward other traditional category of beneficiary like aged, blind and disabled.
Each state will react differently to this guidance and on varying time lines. Texas, Florida and Tennessee are all working on waivers, having been granted temporary extensions, and could shift their focus to more innovative ideas sooner rather than later. It will take more time for things to play out in other states.
As we noted in our quick take on the Indiana Plan, Medicaid programs under a Trump administration are going to be less friendly toward paying for care in hospitals as they turn their attention to better mental health and substance abuse treatment, primary care and other services that bring more health care bang for the buck.
Call with questions. Hours after being sworn in, Seema Verma is already making things interesting.
Emily Evans
Managing Director
Health Policy
@HedgeyeEEvans
