Illinois medicaid 1115 waiver february 19 2014
1 / 18

Illinois Medicaid 1115 Waiver February 19, 2014 - PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

Illinois Medicaid 1115 Waiver February 19, 2014. What is a Medicaid 1115 Waiver?. Section 1115 of the Social Security Act. Allows states to apply for program flexibility from the Centers for Medicare & Medicaid Services to test new approaches to financing & delivering Medicaid

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Illinois Medicaid 1115 Waiver February 19, 2014

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Illinois Medicaid 1115 WaiverFebruary 19, 2014

What is a Medicaid 1115 Waiver?

Section 1115 of the Social Security Act

  • Allows states to apply for program flexibility from the Centers for Medicare & Medicaid Services to test new approaches to financing & delivering Medicaid

  • Provides incentives to providers to develop new models of care

  • Lasts five years, but can be renewed/amended

  • Must be budget neutral, leading to overall savings

Our State’s Waiver Application

  • Called the Path to Transformation Waiver

  • Includes all services in the Illinois Medicaid program for better coordination

  • Covers all Medicaid-eligible populations

Four Pathways to Transformation


Better Health Outcomes

Lower Costs

Pathway 1

Pathway 2

Pathway 4

Pathway 3

  • State Draft

  • Waiver

  • Application

Population Health

Home- & Community-Based Supports

Delivery System Transformation


Waiver Goals

  • Support linkages between health care delivery systems and services that directly impact key social determinants of health

  • Create incentives to drive development of integrated delivery systems

  • Promote efficient health care delivery through optimization of existing managed care models

  • Enhance ability of the health care system to engage in population management

  • Strengthen the state’s health care workforce to meet needs of Medicaid beneficiaries

  • (Goals continued on next page)

Waiver Goals (continued)

  • Consolidate Illinois’ nine existing 1915(c) waivers under a single 1115 waiver

  • Increase flexibility and choice of long-term supports for adults and children

  • Institute a provider assessment on residential habilitation providers

  • Reduce prioritization of unmet need for services wait list

  • Promote and foster greater community-integrated, competitive employment opportunities

1st Pathway: Delivery System Transformation

  • Waiver promotes care coordination & integrated delivery system development

  • Provides Coordinated Care Entities & Accountable Care Entities with analytics, data collection & other activities related to managing a population

  • Hospital performance & integration pool tied to hospital & health system performance measures

  • Public hospitals will have separate pool for specific projects

Delivery System Transformation

2nd Pathway: Population Health

  • Focuses on developing regional public health hubs

  • Premium add-on payment to health plans for developing population health interventions

  • Fund regional public health hubs to provide technical assistance in addressing health disparities, social determinants of health, and evidence-based interventions, including those endorsed by the Community Preventive Services Task Force

Population Health

3rd Pathway: Workforce

  • Increase Physician Supply

  • Provide incentives for training physicians (primary care & high-need specialties) in community settings, treating underserved patients

  • Expand loan repayment programs, including incentive funding for hospital-sponsored loan repayment programs

  • Community Health Workers Training

  • In-home personal attendants, nurses & other providers to work on primary care provider teams

  • Establish and certify community health workers


4th Pathway: Home & Community-Based Supports

  • Consolidation of nine existing home- & community-support waivers

  • Behavioral health expansion & integration

  • Increase funding & uniformity in benefits

  • Base benefits on beneficiary needs, increase choice for beneficiaries, and expand community-based options

    • Children & Young Adults with Developmental Disabilities

    • Children who are technologically dependent

    • Medically Fragile

    • Individuals with HIV or AIDS

    • Elderly

Home- & Community-Based Supports

Opportunities and Challenges



  • Many needs

  • Limited funding

  • Negotiatons with CMS will determine final funding allocations

  • A Waiver Provides:

  • A possible option to preserve hospital assessment program

  • New funding for:

    • Hospital quality and transformation initiatives

    • Primary care physician development in underserved areas

    • Behavioral health programs

    • Maternal child visits and medical home development

  • Loan repayment for physicians through safety-net hospitals

  • Strengthening of:

    • Community-based options

    • Public health resources



Why is the Waiver an Option for Preserving Assessment Funding?

  • Upper Payment Limit (UPL) Conundrum

  • Under Federal law, states can’t make direct payments to hospitals that exceed the upper payment limit

    • Includes hospital assessment payment

  • UPL = Estimate of what would be paid under Medicare principles for persons in the Medicaid Fee-for-Service system

  • 50% coordinated care mandate by 1/1/2015




What is the Access Assurance Pool?

  • Option to replace current assessment (or UPL) payments

  • Maintain current assessment payment distribution method “as is” for transition period (e.g. 1st two years of the waiver)

  • Then, Access Assurance (AA) payments based on a hospital’s unreimbursed costs for Medicaid and uninsured patients

    • Can include hospital and other services (e.g. Dr., Rx)

  • Goal: AA payments to replace, as closely as possible, the current Assessment payments for each hospital

How is a Waiver Financed?

  • Costs Not Otherwise Matchable (CNOM)

  • One of the most powerful provisions in Section 1115 allows CMS to grant approval of Costs Not Otherwise Matchable or CNOM

  • Includes services not normally qualifying as Medicaid expenditures

  • Must be budget neutral

  • Must reinvest freed-up state funds back into the Medicaid program

Budget Neutrality Under 1115 Waiver

CNOM counts toward budget neutrality gap

Hospital-Specific Waiver Payments

Transforming Illinois Health Care

Illinois hospitals have the infrastructure to bring together a wide range of providers


Concept paper finalized

The Waiver Process

6-12 mos.

State negotiates with CMS


Stakeholder kick-off meeting


Draft waiver posted for comment


Final waiver with comments posted


Waiver comments due


Waiver submitted to CMS

10/18 – 12/13/13

Stakeholder meetings


Legislative hearing

For More Information


Patrick Gallagher

Group Vice President, Health Delivery & Payment Systems


State of Illinois 1115 Waiver Web Page

  • Login