1115 Medicaid Waiver Programs Section1115 of the Social Security Act allows CMS the authority to approve state demonstration projects that improve care, increase efficiency, and reduce costs related to their state s Medicaid program. ACA CMS DSRIP SNCP DSTI RHP Triple Aim Affordable Care Act Centers for Medicare and Medicaid Delivery System Reform Incentive pool Safety Net Care Pool Delivery System Transformation Initiatives Regional Health Care Partners A framework developed by the Institute for Healthcare Improvement for optimizing health system performance In recent years, a new trend in Section 1115 waivers has evolved in which states and providers are developing innovative approaches to incentivize fundamental delivery system reform in line with the Triple Aim. Safety net hospital systems in California, Massachusetts, and Texas are leading the way in achieving these goals under their current Section 1115 waivers. The states have established targeted programs that provide incentive payments to safety net hospitals and health systems that have agreed to undertake intensive delivery system reform. The participating hospitals are required to develop detailed and highly specific plans for such reform and identify progressive milestones that must be met to receive funding. In all three states the incentive programs under the waivers demonstrate the importance of coordinated, but tailored, solutions to build transformation. California The central element of California s waiver is the DSRIP which supports both the state s public hospital systems and some of the University of California hospitals. Each hospital has, on average, 15 concurrent projects, ranging from implementing and utilizing disease management registries to expanding medical homes and detecting and managing sepsis. Massachusetts The Massachusetts waiver, MassHealth, was implemented in 1997 and has developed over time through amendments and renewals. Under the waiver, Massachusetts receives federal support in the form of a SNCP which provides matching funds to help cover uncompensated hospital costs. The SNCP also funds Commonwealth Care, a free or low-cost managed care health insurance program. Their current waiver request supports delivery system changes, DSTI s. Texas The Texas waiver provides for significant expansion of the number of Medicaid beneficiaries required to enroll in managed care and establishes two funding pools. One will assist providers with uncompensated care costs and another that will fund a DSRIP to promote system transformation with the following projects:

Infrastructure Development, expanding Primary care capacity Behavioral health care capacity Specialty care capacity Clinical & administrative reporting systems that support quality improvement Primary care workforce training Reporting & health information technology and capabilities Program Innovation and Redesign Redesigning primary care Redesigning behavioral health care Increasing specialty care access/redesign referral process Adopting medical homes Expanding chronic care management model Implementing/expanding care transition programs Implementing real-time hospital acquired infections system Population-focused Improvements Potentially preventable admissions 30-day readmissions Potentially preventable complications Patient-centered health care including patient satisfaction and medication management Emergency department More recently, New York has submitted its waiver renewal with several new programs and enhancements of previous programs. New York New York wants to fundamentally reform the way care is provided to the Medicaid population and the remaining uninsured in public hospitals (n=27). Waiver funding will be specifically used to plug existing gaps in public hospital systems related to the continued need for additional care management and targeted primary care capacity for the Medicaid population and the uninsured. New York State hopes to design and implement a program to provide pre-emergency Medicaid services to both uninsured and Medicaid members with access to: 1) Culturally appropriate care management; 2) Improved discharge planning for higher need patients; and 3) Primary care expansion through integrated Patient Centered Medical Homes with co-located behavioral health. To achieve this, New York has requested the federal government allow the state to reinvest over a five-year period up to $10 billion of the $17.1 billion in federal savings generated by Medicaid reforms. Specific programs: Primary Care Expansion ($1.2B) Provide technical assistance Financial & business planning Support regional adoption of universal EHR Support training & technical assistance to improve quality (monitoring) Behavioral health integration

Increase PC capacity & accessibility via capital investment Health Home Development Fund ($525M) Member engagement Workforce/staff training & retraining Clinical Connectivity (for community providers) Joint governance support New Care Models ($375M) Peer services Facilitate movement of difficult-to-place patients between hospitals & LTCs Expand home modification & assistive technology Patient navigation & transition assistance Intensive residential services for substance use disorder Support for new organizational structures Medical respite care for chronically homeless Expand Vital Access/Safety Net Program ($1B) Short-term funding (3 yrs) to achieve defined operational goals related to facility closures, mergers, integration or reconfiguration of services Public Hospital Innovation ($1.5B) Intensive care coordination/case management for uninsured & Medicaid patients Home care and acute transitional care management Identifying & enrolling super utilizers in medical homes Primary care expansion Medicaid Supportive Housing Expansion ($150M) Supportive housing capital expansion Supportive housing services program Long Term Transformation & Integration to Managed Care ($750M) Nursing home transition assuring access & choice Capital funding for assisted living programs increase capacity Quality improvement program HIT supporting delivery system integration Ombudsperson program Capital Stabilization for Safety Net Hospitals ($1.7B) Short term funding to under-capitalized public hospitals Technical assistance to safety net hospital boards Transitional capital Balance sheet restructuring (mergers, acquisitions) and development of alternate care models including FQHC s Hospital Transition ($520M) Integration program funding to hospitals for transition plans for development of future integrated delivery systems

Ensuring a Health Workforce ($500M) Health workforce retraining initiative Workforce development for patient centered medical homes & health homes Workforce development for long-term care Training the health workforce in culturally-competent patient centered care Interdisciplinary education and training Promote labor-management partnerships Building health care career ladders Recruitment and retention incentives for the underserved Expand Primary Care Service Corps Health workforce data repository Health workforce research Regional health workforce information centers Public Health Innovation ($395.3M) Implement preventative nurse home visits for maternity care Expand nurse home-based services for asthma patients Fund community-based providers to deliver diabetes prevention programs Lead poisoning prevention program Enhance water fluoridation via grants to water systems Provide short-term prevention project awards to hospitals implementing sepsis prevention projects Regional Health Planning ($25M) Implement regional health planning organizations Support regional health assessments including hospitals & develop strategies to address identified needs Waiver Evaluation and Program Implementation ($500M) Evaluation of ongoing (waiver) initiatives Evaluation of waiver amendment initiatives Waiver implementation assistance Consumer education to promote effective health service utilization Conclusion: All these waiver programs share the following key areas of focus: 1) integrated health care delivery including testing innovation and redesign by developing Primary Care Medical Homes, integrating behavioral health and physical health, and building an integrated primary care network; 2) expanded primary care capacity to provide preventive as well as chronic disease care; 3) improvement in health care quality; and 4) population-focused improvements and emphasis on preventive care, at-risk populations, and care coordination. Developing the waivers and demonstration projects takes intensive work and negotiation between providers, state Medicaid agencies, and CMS. Provider participation requires considerable up-front time, capital, and human resource investment. Considerable resources are required to manage the regional health care partnership collaboration.

Nevada In the Concept Paper submitted with Nevada s Medicaid 1115 Waiver application, the Department of Health and Human Services, Division of Healthcare Financing and Policy (DHCFP) requests CMS to provide the greatest degree of flexibility necessary in order to target programs at specific populations based on their medical needs through: innovative provider reimbursement and care delivery modes; cost-sharing and benefit design; increased use of medical/health homes, accountable care organizations and electronic health records. In particular, request CMS to waive requirements necessary to ensure mandatory enrollment of most Medicaid beneficiaries into managed care programs, especially the newly eligible. Those Medicaid beneficiaries who are fee-for-service (FFS) will eventually be enrolled into the Care Management Organization, Health Care Guidance Program. After more than 3 years of planning and review by CMS of the 1115 Waiver application, Nevada has launched its program, Health Care Guidance Program ( a Care Management Organization) on June 1 st, 2014. This program is designed to coordinate care for initially 41,500 Medicaid fee-for-service enrollees that could eventually expand to more than 80,000 members after the initial demonstration period is concluded and goals accomplished. Medicaid patients with the following conditions are eligible for the program: asthma, cerebrovascular disease, COPD, diabetes, end stage renal disease, heart disease, HIV/AIDs, mental health disorders, musculoskeletal system diseases, neoplasm/tumors, obesity, pregnancy, substance abuse disorder, and complex conditions/high utilizers. Services offered include: Individualized patient support Access to regional care team resources Counseling Appointment tracking & reminder calls Co-attendance at provider meetings Assistance with medication adherence After hours clinical support Support patient self-management skills and health outcomes The goals of the comprehensive care management program will be to: o Provide a degree of cost savings for the current Medicaid FFS population through improved care coordination o Develop a cost-effective, statewide infrastructure to promote the further development of medical homes/health homes