Reprinted from HEALTH PLAN WEEK, the most reliable source of
objective business, financial and regulatory news of the health insurance
industry.
By Carina Belles, Editor of AIS’s Medicare
and Medicaid Market Data (MMM)
October 23, 2017 Volume 27 Issue 37
Several states have submitted new or amended
1115 Demonstration Waiver requests that would allow them to implement
alternative models of Medicaid delivery to improve member outcomes (and
therefore cut costs) by integrating primary care, behavioral health services
and long-term care. Other states are seeking conservative reforms such as
limited eligibility, benefit designs that mirror employer-sponsored coverage
and work requirements. Here’s a look at reforms in the works among states with
notable 1115 demonstration waivers recently approved or still pending.
(1) Alabama’s Medicaid
waiver would establish Regional Care Organizations (RCOs) to act as managed
care entities with a localized focus on care management. The waiver was
approved Feb. 9, 2016. The RCOs were set to launch Oct. 1, 2017, with the goal
of becoming capitated full-risk managed care plans. However, citing uncertain
funding sources beyond 2018, the state decided not to go forward with the
program, and is working to design a new initiative more in line with Trump
administration guidelines. Blue Cross Blue Shield of Alabama and Alabama
Community Care Inc., a regional network of hospital and provider groups, were
set to participate.
(2) Arkansas’ Arkansas
Works program offers subsidized premiums on private health insuranceprovided by a
participating employer or purchased on the state exchange to the state’s
Medicaid eligibles with annual incomes of up to 138% of the federal poverty
level (FPL). Depending on the member’s household income, the state may pay all
or most of the monthly premium. The proposal, which has been pending since June
30, 2017, would limit eligibility to those living at 100% of the FPL or lower;
eliminate subsidized premiums for employer-sponsored health plans; and
implement work requirements for all members aged 19-49.
(3) Illinois created a
strategy to integrate behavioral health into its Medicaid delivery system by offering
several new benefits to all Medicaid recipients, including assistance with
housing and employment searches, transitional services for incarcerated
individuals, residential treatment programs for mental illness and substance
abuse and in-home services for families of children with mental health needs.
The proposal has been pending since Oct. 20, 2016.
(4) Indiana seeks to
modify its Medicaid expansion program, the Healthy Indiana Plan (HIP) 2.0, with
several new requirements, under an application that has been pending since July
20, 2017. It would make the voluntary Gateway to Work program a requirement for
all able-bodied adults receiving benefits through HIP who are not working or in
school at least 20 hours per week. The program also would require HIP
beneficiaries at 22% or greater of the FPL to pay 2% of their monthly income to
a Personal Wellness and Responsibility (POWER) account, similar to a Health
Savings Account.
(5) Kentucky is seeking
approval for a five-year demonstration project, Kentucky HEALTH.
Its application has been pending since Sept. 8, 2016, with modifications
proposed July 3, 2017. The demonstration would seek to cut down on costs and
improve health outcomes by encouraging its nondisabled adult population to
become more accountable for their care. The new requirements include work or
educational activities of at least 20 hours per week as a condition of
eligibility; disenrollment from the program if changes in employment or income
are not reported in a timely manner; and monthly member premiums implemented on
a sliding scale based on income.
(6) Maine intends to
revamp its Medicaid program, MaineCare, by expanding on the state’s previous
efforts to implement work requirements for nondisabled adults. Under the
proposed demonstration, potential Medicaid beneficiaries aged 19-24 would have
to work or pursue education at least 20 hours per week, perform community
service for at least 24 hours per month, demonstrate proof of job search or
participate in job readiness programs. They also would pay a monthly premium
based on income, starting at 50% of the FPL. The application has been pending
since Aug. 2, 2017.
(7) Massachusetts wants
to see its Medicaid program become more aligned with commercial insurance
markets, according to its waiver amendment request, which has been
pending since Sept. 8, 2017. By January 2019, the state hopes to have all
nondisabled adults with incomes over 100% of the FPL enrolled in Qualified
Health Plans (QHPs) through the state’s exchange. It also would create a
commercial-style closed formulary that allows the state to deny coverage of
select drugs, with at least one drug available per therapeutic class; exclude
drugs that have limited evidence of clinical value, such as newer brand-name
drugs; and pursue its own pharmacy network, with an emphasis on limiting
specialty pharmacies. These reforms were proposed in part to discourage
consumers from seeking out MassHealth coverage due to its open formulary.
(8) New Jersey will
maintain its current Medicaid managed care and CHIP program, FamilyCare, while improving
integration of managed long term services and supports and behavioral health
services for all Medicaid beneficiaries. The approved amendment extends the
original FamilyCare 1115 Waiver through June 30, 2022. Changes include expanded
benefits for members receiving long-term care services while living at home and
for children with intellectual and developmental disabilities.
(9) North Carolina
proposed to redesign its Medicaid program, shifting coverage
to managed care plans called Prepaid Health Plans (PHPs), which could include
commercial plans and provider-sponsored entities. PHPs will receive monthly
capitated payments from the state and contract directly with local providers.
The state aims to launch the program in 2019, according to its final proposal,
which the state released in August 2017. Approval is pending and no insurers
are set to participate yet.
(10) Wisconsin intends
to implement new restrictions on the childless adult population that became
eligible for Medicaid after expansion, as well as create health and employment
incentive programs. The application, pending since June 15, 2017, calls for
small monthly premiums for members at 50% or higher than the FPL; reduction in
premium payments by up to 50% if beneficiaries engage in approved healthy
behavior activities; use of a drug screening program as a condition of
eligibility; and a 48-month maximum eligibility period for enrollees who do not
meet certain employment rules.
https://aishealth.com/archive/nhpw102317-04?utm_source=Real%20Magnet&utm_medium=email&utm_campaign=119599867
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