Archive for the ‘Medicaid’ Category

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Making Medicaid Enrollment Easier — for People and for States

Wednesday, May 29th, 2013

Advocates, stakeholders, federal and state governments are busy planning strategies for enrolling millions of newly eligible people into health coverage in 2014. But last week, CMS quietly released guidance that could lighten the load on everyone.

The May 17 guidance lays out five state policy options. If elected, these options will increase the number of new eligibles who enroll in coverage on day one and remain covered throughout the year, while also easing the administrative burden of processing these applications.

The guidance allows states to enroll adults who we already know are eligible based on:

  • • Supplemental Nutrition Assistance Program (SNAP) eligibility. Most households who qualify for SNAP have incomes that will also qualify them for Medicaid . The recent guidance empowers states to take advantage of their SNAP data by enrolling adults on that program straight into Medicaid, without requiring a new application. This option expires at the end of 2015.
  • • Children’s income eligibility. States have a rich database of hundreds of thousands of potentially-eligible parents—those whose children are currently enrolled in Medicaid or CHIP . The guidance would allow states to enroll parents who are deemed eligible based on their children’s income eligibility, without requiring a new application. This option is also time-limited.

For both of these options, the process is not quite as seamless as enrolling the identified adults straight into coverage. States still need a signature (which can be written, electronic, oral or telephone-based) from the eligible adults and to verify some non-income eligibility criteria such as citizenship status. The guidance lays out several options for states to get this missing information as simply and expediently as possible.

The guidance also allows states to guarantee adults 12 months of coverage regardless of income fluctuations. Low-income households often experience small fluctuations in income that put them just above and below the Medicaid-eligibility level. To help states reduce the churn and administrative costs associated with these income changes, the guidance allows them to offer 12-month continuous eligibility to adults. 32 states already offer continuous eligibility to children in Medicaid or CHIP, but this is the first time that option has been available to adults.

Finally, the guidance includes two policy options aimed at easing the administrative burden on states from adopting a new income-counting methodology (Modified Adjusted Gross Income, or MAGI.)

The key to all these options is that they are just that: options. States must submit waivers to take advantage of them. Our work over the next few months is to encourage states to adopt these common-sense strategies for connecting families to the coverage they need.

– Katherine Howitt, Senior Policy Analyst

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Help for Improving Long-Term Services

Tuesday, May 28th, 2013

After a long gestation, the federal government this week birthed new guidance designed to help managed care for Medicaid long-term services and supports (MLTSS) grow up into a more consumer-friendly, homey program. This is good news for the hundreds of thousands of people nationwide with mental and physical disabilities who depend on these services to help them live full lives.

Among the great new requirements are that states set up independent advocates or ombudsman for consumers in these programs, establish a state-level stakeholder advisory group and require managed care organizations to establish member advisory committees. In addition, states must provide independent counseling to consumers about their enrollment choices, and give them time to choose a managed care plan before they are automatically assigned. States must also use payment mechanisms that promote the home and community-based care that consumers prefer over nursing home care.

The guidance document from the Center for Medicaid & CHIP Services sets out 10 elements that federal regulators will use as they decide whether to approve new or revised LTSS programs in the states. The recommendations apply to LTSS programs designed using waivers of federal rules, called 1115 or 1915(b) waivers.

The Center summarized the elements in a four-page document. The elements are: Adequate Planning, Stakeholder Engagement, Enhanced Provision of Home and Community Based Services, Alignment of Payment Structures and Goals, Support for Beneficiaries, Person-Centered Processes, Comprehensive Integrated Service Package, Qualified Providers, Participant Protections and Quality.

If these sound vaguely familiar, it might be because we identified promising practices in these areas in a paper last fall, which the Center cites as a reference.

The guidance doesn’t go as far as we’d like in some areas – for example, the ombudsman isn’t required to collect examples of systemic problems and recommend improvements to MLTSS. Also, the guidance doesn’t set specific standards to prevent disruption of care to consumers whose current providers are not in their new managed care plan. And requirements for transparency of managed care records are limited.

But the guidance lays a foundation on which to build. Advocates can use it to press states to do better for the many people eligible for Medicaid who need help with daily activities, personal care, chores and other services. In addition, the Center says they are open to refining the guidance as they and states develop more experience with managed care for LTSS. We’ll take them at their word on that, and offer a more detailed analysis on how the guidance can be strengthened in the coming weeks and months.

- Alice Dembner,  Project Director

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Engaging Veterans in the Medicaid Expansion

Friday, May 24th, 2013

At Community Catalyst, we believe everyone should have a say in the decisions that affect their health. Many governors are now making decisions that affect the health of thousands of veterans and their families.

According to a report published by the Urban Institute, 1.3 million veterans of our armed forces currently do not have health insurance coverage. Under the Affordable Care Act’s (ACA) Medicaid expansion, more than 40 percent of these uninsured nonelderly veterans would gain health coverage. Being covered by Medicaid would not preclude veterans from using the U.S. Department of Veterans Affairs (VA) system if they qualify, and would allow them to gain access to greater health care choices at a lower cost.

However, more than half of all poor uninsured veterans (with incomes below 100 percent of the federal poverty level), are in states that may opt out of the Medicaid expansion. Because many states with large populations of veterans currently oppose expanding Medicaid, it’s a critical time to raise awareness among veterans who may qualify for Medicaid. In states such as Florida that are not committed to expanding Medicaid, and where military presence is particularly high, there are more than 40,000 uninsured veterans who will qualify if the program is expanded. Similarly, Georgia, Michigan, North Carolina, Ohio, and Texas are all on the fence about expanding Medicaid, yet they have high numbers of uninsured veterans who stand to gain coverage under the option.

To help advocates engage the veteran community and encourage them to be a voice for supporting the Medicaid expansion, we’ve gathered resources in our fact sheet, Engaging Veterans in Medicaid Expansion Campaigns. It includes a summary of information that can be helpful to health care advocates as they engage veterans—and those who work with veterans—in building a meaningful and powerful campaign narrative that prioritizes access to the quality, affordable health care they deserve.

For many veterans, this is a time of transition – away from military life and back into a civilian one. Let’s honor our veterans by ensuring access to health insurance is just one more way to ease that transition.

– Jeanelle Roman, National Urban Fellow

 

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New Polling Shows Strong Support for Expanding Medicaid in the Deep South

Wednesday, May 22nd, 2013

This week advocates in the South received yet another good reason to push for expanding Medicaid in their states. A new poll from the Joint Center for Political and Economic Studies found that residents in five of the most conservative states in the nation strongly support expanding Medicaid and implementing the core pieces of the Affordable Care Act. Residents in the deep Southern states of Alabama, Georgia, Louisiana, Mississippi, and South Carolina not only support expansion overall, but the support spans across racial lines.  This evidence of strong support among the very people they serve should be a clarion call for Southern state lawmakers to expand Medicaid.

The Joint Center conducted a poll of 2,500 Southern residents between March and April of this year to examine how the public in conservative states view key parts of the Affordable Care Act generally and the Medicaid expansion specifically. Among the findings:

  • • 62 percent support Medicaid expansion
  • • 75 percent support the creation of health insurance Exchanges
  • • Nearly 69 percent support financial help (premium subsidies) for low-income individuals
  • • Expansion draws support across all ethnic groups

There are nearly 15 million uninsured people in the South – the highest number and proportion of any region of the country. Expanding state Medicaid programs will provide insurance coverage to 7 million people, greatly improving the health and productivity of Southern residents. This dramatic increase in health care coverage through Medicaid will also address health disparities in reducing death and disease among nonelderly adults, racial and ethnic minorities, and residents of low-income areas. With the federal government covering the full cost of expansion for the first three years, expanding Medicaid will also be a great economic benefit to states. This should be a no brainer for the South.

But even with these clear cut health and economic benefits, nine Southern governors stand in opposition to accepting federal funding for expansion – with only, Arkansas, Kentucky, and Florida in favor. And even in Southern states with a supportive governor, challenges remain, especially when it comes to persuading state legislators.

The voices of their constituents should serve as a powerful motivator for policymakers who say they are representing the will of the people. The case for expanding Medicaid is clear. And advocates in the South will add this strong evidence of support to their efforts to mobilize and engage key constituencies. State policymakers have a responsibility to not just speak into their own megaphones but to listen to the voices in the crowd. These poll findings clearly show that the will of the people is to expand Medicaid in states across the Deep South.

Ongoing debates during the 2013 legislative sessions showed signs that even within the most conservative states expanding Medicaid was not completely off the table. Statements from Governor Bentley (AL) that Medicaid will not be expanded “as it exists under the current structure,” suggest that expansion remains possible. In addition, a number of governors and legislators are considering alternative models such as Arkansas’ premium assistance model to expand Medicaid.

As these poll results show, and to borrow from Mark Twain, reports of the demise of Medicaid expansion in the South have been greatly exaggerated. For economic, political, and moral reasons, expanding Medicaid is a top priority for advocates in the Southern states. At Community Catalyst, we will continue to lift up and promote all the reasons why Southern states should move forward with expanding Medicaid and implementing the Affordable Care Act. Advocates will discuss their Medicaid expansion campaign strategies at the 6th Annual Southern Health Partners convening in Atlanta, Georgia this July. There is no doubt the findings of this report will be an integral part of the conversation.

– Dara Taylor, Project Director
Southern Health Partners

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New Study Builds Case for Expanding Medicaid

Friday, May 3rd, 2013

A new study in the New England Journal of Medicine confirms what consumer health advocates have known for decades: Medicaid is essential for keeping low-income households on stable financial footing. This should come as no surprise, since protecting families from unexpected and devastating medical costs is exactly what health insurance is meant to do. The study also proves that Medicaid coverage significantly improves beneficiaries’ mental health.

But opponents of Medicaid have distorted the study’s results; they claim it supports their agenda to block millions of low-income, uninsured families from accessing this vital coverage program. Their arguments are misinformed at best. The new study only strengthens the case for expanding Medicaid.

What the study tells us: Medicaid Works!

The researchers looked at the health and finances of low-income, uninsured Oregon residents who were given the opportunity to enroll in Medicaid through a one-time lottery, and compared it to their peers who remained uninsured.

The study shows that Medicaid virtually eliminated all catastrophic medical expenditures (medical expenses exceeding 30 percent of household income) for its beneficiaries. It also indicates that people with Medicaid coverage are significantly less likely to face any medical debt, borrow money to pay bills, or skip payments.

These results are extremely promising, especially in light of the fact that medical bills currently prompt more than 60 percent of U.S. bankruptcies. If we want to reduce the drag bankruptcies create on our economy and the ruin they leave behind in our communities, providing low-income families with Medicaid coverage is a good place to start.

The study also found that Medicaid is a powerful tool in combating mental illness. Medicaid beneficiaries in the study were 30 percent less likely to suffer from depression than those who remained uninsured. Given that suicide takes more lives in the US than any other form of injury and that depression accounts for more than $83 billion in the US between lost productivity and medical expenses, the impact of Medicaid on depression deserves attention and celebration.

File Under: Non sequitur

Instead of celebrating, opponents of Medicaid are arguing this study makes the case for withholding Medicaid coverage from millions of low-income, uninsured families. They base this on the study’s failure to detect statistically significant improvements in a handful chronic disease measures — blood pressure, cholesterol, or hemoglobin levels — in those with Medicaid compared to those without coverage.

That’s like saying because your blood pressure didn’t go down, we are going to prevent you from getting coverage for cancer treatment or a pap smear.

It’s certainly true that the U.S. health care system needs to be better at managing chronic conditions. We routinely lag behind other industrialized nations on measures of chronic care management, such as following medical guidelines for treating hypertension and diabetes. Plus, this study only looks at the impact of two years of coverage; significant improvements in these persistent chronic illnesses may take much longer to materialize.

This is hardly a reason to block millions of low-income families from gaining health coverage they need and deserve. We have no evidence that people with private insurance or Medicare fare any better than Medicaid beneficiaries on these measures, yet no one is suggesting we should all drop our health insurance.

Getting people covered is the first step in creating an effective health care system that works for everyone, but it is not the only step. The ACA contains numerous initiatives to improve the quality of health care.

File under: extremely relevant

Meanwhile, dozens of states are still trying to decide whether or not to take up the option to extend Medicaid coverage to millions of low-income, uninsured adults. This study confirms Medicaid can give beneficiaries peace of mind that they won’t go bankrupt when they experience that unexpected illness, and make staggering improvements in their mental health. It adds to the growing list of reasons why this decision should be a no-brainer for all 50 states.

–Katherine Howitt, Senior Policy Analyst

 

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The Morning After

Tuesday, March 12th, 2013

OK. Sequestration has happened. That means funding cuts for community health centers, public health and medical research. Medicare provider payments will be shaved by two percent while Medicaid and CHIP are exempt. VA health benefits are also exempt, but the Indian Health Service is not. Though, like Medicare provider payments, cuts are limited to two percent.

Sequestration is not only bad health policy, it is also bad economic policy since it will shrink the economy and could push us back into a recession. 

On the other hand, being against sequestration is not enough because bad as it is, it could be worse. Not only are many programs for low-income people protected, but cuts are balanced between military and domestic spending. We are actually better off if the alternative is a bad deal – e.g. cuts greatly exceed revenue, military spending is spared, social spending is hit hard, and health care cuts fall heavily on beneficiaries rather than on weeding out waste, inefficiency and low-value spending.

For the most part, we have yet to feel the effects of sequestration and won’t right away. Unlike a government shutdown, sequestration is more like a slow drip than a sudden convulsion. But the pain will be real. The questions for advocates is what do we have to do now? Can we roll back the cuts? Can we continue to protect Medicare and Medicaid benefits? To answer those questions, we need to understand how we got here and why.

The blame game

Of course, both sides blame the other. House and Senate Republican leaders have lambasted the President for not offering an alternative (even though he did, just not one they like), while for weeks leading up to the deadline, President Obama traveled the country and took to the airwaves trumpeting the ill effects of sequestration and calling on Congressional Republicans to replace the automatic cuts with a more balanced approach that includes new revenue.

Who is responsible for sequestration, and at this point does it matter? The answer is both Congressional Republicans and the President are responsible, and yes, it does matter.

Congressional Republicans are fundamentally responsible for sequestration.

The overwhelming preference of Republicans to resist taxes at all costs and demand cuts in Medicare, Medicaid, Social Security and other federal programs, (the opposite of the preferences of the American people by the way) is the core cause of sequestration. As long as “no new revenue” remains the Republican Party mantra, then sequestration will remain in force, for better and for worse. For worse because it means there is little chance of restoring cuts in the short run. For better because it also means there is little willingness to consider Medicare or Medicaid cuts within the Democratic caucus.

What about the Democrats?

Most of the blame lies with Congressional Republicans. However, President Obama also shares the blame—and not for the dopey reason that Bob Woodward says (Obama brought up the sequester idea first)—but because there are many things the administration did or didn’t do over the past several years that helped bring us to where we are today. The highlights include: embracing the politics of austerity even during a time of economic weakness; negotiating with Republicans over the debt ceiling; and, most recently, decoupling the debate about the expiring Bush tax cuts from sequestration decisions and the debt ceiling, thereby giving away most of his leverage.

As to why it matters, it’s important to remember the President remains committed to a “grand bargain” of spending reductions and tax increases. While most of the President’s policy proposals are progressive, some are decidedly not—including reductions in Medicare, Medicaid and Social Security benefits. Not only that, but some of his best policy proposals—reducing Medicare overpayments for prescription drugs—face tough sledding in Congress not only from Republicans, but also from Democrats.

The greatest danger for Medicare and Medicaid beneficiaries comes if Republicans ever soften in their opposition to new revenue. In that case, the President’s desire for a grand bargain coupled with the reluctance of many Democrats to confront the powerful interest groups who profit from waste and inefficiency in health care could lead to much deeper benefit cuts than the relatively modest, but still troubling changes currently backed by the White House.

Now what?

The next round in the game of serial fiscal chicken is passage of a new Continuing Resolution, which must be in place by end of March or we will face government shut down. While there will certainly be some skirmishes, government shutdown seems pretty unlikely. At the same time, it is also very unlikely sequestration cuts generate enough heat to create deal that includes revenue. That means the status quo continues at least until the next fiscal face off when the debt limit has to be raised again this summer.

A three part agenda for advocates

As the deficit wars drag on through the summer, people who want to protect Medicare and Medicaid benefits have to keep up the pressure on Congress and the White House for a three-part agenda:

  • First, new revenue must be part of any additional debt reduction strategy.
  • Second, budget savings must not be tilted in favor of military spending and against domestic needs.
  • Third, any savings that are obtained from federal health programs should come from reducing overpayments to drug companies, insurers and providers and improving public health, not from cutting benefits. (You can read about Community Catalyst’s recommendations for achieving health care related budget savings without hurting Medicare and Medicaid beneficiaries here.)

Recent initiatives, such as the letter sent by more than 100 members of Congress opposing any cuts in benefits are a good start and advocates should recognize these efforts by thanking their members of Congress. But it’s only a beginning. We’ve bungee-jumped off the fiscal cliff and it is a long climb back to the top.

– Michael Miller, Director of Strategic Policy

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Improving Medicaid: Federal help to expand home care

Wednesday, February 27th, 2013

Is your state still stowing in nursing homes people who could live at home with adequate help ? Is the state spending millions of Medicaid dollars on institutional long-term care when they could get federal funds to expand the less expensive community services, such as personal care and homemaker services, people want and need?

You can find out in a new entry to Community Catalyst’s Medicaid Report Card that shows which states are leading and which are lagging on providing home and community-based services to seniors and people with disabilities. The entry also explains the federal Balancing Incentive Program and how it can help states save money in Medicaid while improving care for the millions of people who depend on it.

Our newly updated Medicaid Report Card also includes other policies affecting primary care, prescription drugs and hospital stays that are smart ways to make Medicaid more efficient without cutting needed services. For each policy, we provide a concise summary of the evidence for cost savings and quality improvement, and name which states have and have not adopted it.

But back to the innovative program from the Affordable Care Act (Section 10202) to enhance community-based long-term services and supports. The Balancing Incentive Program increases federal matching funds by millions of dollars to pay for new or expanded home- or community-based services, including upfront costs. Texas, which is participating, will get as much as $277 million, while Maryland will get up to $106 million. States must meet certain obligations in return. Some states that have already done the right thing are reporting big savings plus increased consumer satisfaction and well-being. You can read more in our Medicaid Report Card, and find links to all the details.

If this sounds like a good deal for your state, don’t delay! The program sunsets in 2015 or when the $3 billion allotted runs out.

– Alice Dembner, project director

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The Insider: Health care and the fiscal debate: Where are we now and where are we going?

Thursday, December 13th, 2012

As the final days of 2012 slip away, little time remains for Congress and the President to strike a deal on tax rates and spending levels. If there is no deal, a host of tax cuts enacted under both Presidents Bush and Obama will expire (along with a number of other measures that protect the unemployed and stimulate economic growth), and the automatic spending cuts that were created by the Budget Control Act will go into effect. (Other year-end issues that must be addressed include preventing a significant reduction in Medicare reimbursement to physicians and reauthorizing several health coverage programs such as the “Medicare Savings Initiative,” which provides assistance to low-income Medicare beneficiaries.)

Observers are seeing the closed door negotiations between President Obama and Speaker of the House John Boehner as a sign the two are coming closer to an agreement (although Mr. Boehner’s statement on the House floor on Tuesday may have thrown cold water on that. That may or may not be a good thing: a bad deal is not better than no deal. The President has indicated that he is willing to give substantial ground on Medicare and Medicaid spending if Republicans accept higher tax rates for the wealthiest Americans. Some observers anticipate a deal that would allow some increase in tax rates for the top 2 percent of earners along with capping deductions in exchange for an increase in the Medicare eligibility age. However, this is unlikely unless Republicans also give some ground on raising the debt ceiling.

Republicans really lack leverage on the tax rates, so giving in on the Medicare age is not something Obama needs to do—he can secure an increase in rates for the top 2 percent of earners without conceding anything. The real leverage point for Republicans is the debt ceiling, and it is unlikely the White House would make a major concession unpopular with its own supporters, only to have to turn around in a few weeks and negotiate entitlement spending all over again

Of course, only a very small number of people really know what is going on in the debt talks and they aren’t telling. But a straight-up swap of a tax increase for the top 2 percent for an age increase for Medicare beneficiaries is unlikely. (You heard it here first.)

Good news, bad news and no news from HHS

First the good news: The administration has indicated that it withdrawing its support for the idea of a Medicaid “blended rate” as a way to reduce federal health spending. A blended rate would shift costs onto states and undermine the chances of states taking up the now optional Medicaid expansion to 138 percent Federal Poverty Level (FPL).

At the same time, HHS has indicated that only a full expansion to 138 percent FPL will qualify for enhanced matching funds. Although advocates have been sweating this one, and Republican governors predictably complained, the Administration did not have much choice.

First, the decision is consistent with how the ACA is drafted. Perhaps weighing more heavily in the decision are the budget consequences of allowing a partial expansion. It would be impossible to allow “reluctant” states to expand only to 100 percent FPL while requiring more supportive states to go to 138 percent. The administration would have had to make that option available to everyone. Since all states would probably take advantage of the option, the net result would be an increase in federal health spending because the cost of federally financed Exchange credits is higher than the federal share of the Medicaid expansion.

The bad news: HHS announced it would release regulations or guidance on the Basic Health Plan (BHP) “eventually.” This essentially kills the hope BHP guidance would be available in time for states to make a reasonable determination on whether to use the BHP option prior to the 2014 launch of the ACA coverage expansion. This decision disadvantages a number of populations including legal immigrants with incomes below 138 percent FPL, who will have to get coverage in the higher cost Exchanges rather than through Medicaid; people in a number of states who have income between 138-200 percent FPL who have Medicaid now and are likely to see their benefits reduced and their costs go up when states switch them over to Exchange coverage; and low-income people in general who will face higher premiums and cost sharing than they otherwise might have. Of particular concern is that low-income people may be drawn to plans with no premiums but high out-of-pocket costs, leaving them with barriers to access and unaffordable bills even if they get coverage.

Community Catalyst is working with state partner organizations to develop policy alternatives that will help protect these populations.

Finally, the no news: No word yet on how CMS will revise the formula for distributing Disproportionate Share Hospital payments to states. The new formula will come out some time next year…

 – Michael Miller, Director of Strategic Policy

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Highlights from 2012 NEACH Children’s Health Care Summit

Monday, November 26th, 2012

On November 14, Community Catalyst’s New England Alliance for Children’s Health (NEACH) hosted its annual Children’s Health Care Summit in Worcester, Massachusetts. The summit covered topics such as consumer assistance programs, foster youth and the Affordable Care Act (ACA), and an assessment of the policy environment on the federal level.

Updates from the New England states highlighted accomplishments and challenges in the past year and opportunities for the upcoming year. ACA implementation was cited as an opportunity for advocacy in Massachusetts. Vermont and Rhode Island highlighted the importance of focusing on affordability of plans in the ACA Exchanges. The shift in the political climate may mean changes in the viability of Medicaid expansion particularly in Maine and New Hampshire. Connecticut advocates highlighted their successful efforts to maintain coverage and benefits for children, parents and pregnant women in the state’s Medicaid program – HUSKY. Budget deficits were cited by most of the states as a challenge for the coming year.

The conversations at the summit were also shaped by policy developments on the federal level. Community Catalyst’s Director of External Affairs and Policy, Amy Rosenthal and Director of Strategic Policy, Michael Miller offered an informative and lively update on the election’s impact on ACA implementation, and what the current fiscal debate means for health programs. Their presentation stressed that Medicaid is very much on the table for deficit discussions and more than ever state advocates need sharing stories of what Medicaid means for families.

One exciting new component at this year’s summit was a discussion of how ACA implementation benefits foster youth. Community Catalyst’s Senior Policy Analyst, Kate Lewandowski underscored the key provisions for foster care children and youth under the ACA. Kate helped bring advocates up to speed on the new expansion of Medicaid coverage for former foster youth that begin January 2014. For more on that issue please check out our paper on Foster Youth and ACA.

Thank you to all our partners for making the 2012 NEACH Children’s Health Care Summit a success! We came away so energized and excited for a very productive 2013. For more information on the summit including links to the presentations, please visit our website.

 – Chiedza Mufunde, Graduate Intern
New England Alliance for Children’s Health 

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Washington State First to Receive Approval to Implement a Managed Fee-for-Service Duals Demonstration Program

Monday, November 19th, 2012

Last month, Washington became the second state to sign a Memorandum of Understanding (MOU) with the Centers for Medicare and Medicaid (CMS) to participate in a duals demonstration project. Washington is pursuing a managed-fee-for-service financial model unlike the Massachusetts MOU, which is working on a capitated financing model. The demonstration is expected to be implemented in all but two counties, where it will pursue the capitated financing model.

Under the MOU, Washington will build on its Medicaid Health Homes plan by targeting Medicare-Medicaid enrollees (dual eligibles) with chronic health conditions. The state will contract with a Health Home Lead Entity who will in turn subcontract with a Health Home Coordinated Care Organization (HCCO). The HCCO is paid to provide care coordination services that complement the existing fee-for-service system. Under this managed fee-for-service model Washington will be eligible to receive a payment based on its performance on beneficiary experience, quality and savings criteria.

The MOU provides state advocates with greater detail about how the demonstration will work in Washington. For other states pursuing a managed fee-for-service model it provides some insight into what they can expect in their MOU negotiations and final agreements.

The Washington demonstration has many positive features that have been reflected in the final MOU, such as:

  • • The state will be responsible for creating accessible and understandable outreach and education materials for enrollees.
  • • The state will have to require providers to demonstrate their compliance with the Americans with Disabilities Act (ADA) and require training for providers on accessibility, accommodations, independent living and recovery, and wellness philosophies
  • • CMS and Washington will hire an independent evaluator to compare a similar group of dual eligibles from a non-demonstration state to the enrollees in Washington’s demonstration group to see how effectively the demonstration is working to improve care and lower costs.

While the MOU reflects many of the consumer concerns, there are provisions that raise red flags for advocates and beneficiaries.

  • • The MOU was silent on how consumer engagement will work at both the state and delivery system levels. While the state has established a state-level Health Advisory Team (HAT), it remains unclear if the HAT is an effective vehicle for taking in consumer and advocates’ feedback. The MOU also states that the Health Home networks will be required to ensure beneficiary input and involvement, however it lacks sufficient details on how this will actually happen.
  • • For many advocates, the health home model as described in the MOU is confusing. Advocates have asked the state to simplify the model to ensure beneficiaries understand how the new delivery system will work and to be specific about model details to ensure transparency throughout the readiness review and contracting process.
  • • Many of the health home lead entities that will be chosen will be managed care organizations that may not have sufficient expertise to provide high level care coordination to dual eligibles.

The MOU is not the final contract; the state will be finalizing a Final Demonstration Agreement. In the meantime, advocates are posing many questions to the state to better understand the plan and are working together both on this MOU as well as the upcoming negotiations between the two counties, the state and CMS.

While there are positive aspects to the Washington MOU, advocates in other states must go beyond what is proposed here and set the bar even higher. The success of these demonstration projects will rest on ensuring the right implementation and oversight structures are in place for ongoing consumer input and transparency throughout these demonstration projects.

 – Leena Sharma, State Advocacy Manager

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