CMS Guidance Authorizes Medicaid Demonstration Applications That Cap Federal Funding: Implications for States

The Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Director Letter on January 30, 2020 inviting states to apply for Section 1115 demonstration projects that would impose caps on federal Medicaid funding for the adult expansion and some other adult populations in exchange for new programmatic flexibility. Referred to as “Healthy Adult Opportunity” by CMS, these demonstrations would allow states to choose between two types of capped funding arrangements: a per capita cap or an aggregate cap (i.e., a block grant). In this SHVS issue brief, our colleagues at Manatt Health review the key features of the proposed capped funding demonstrations and highlight the considerations for states.

State Investments in Supportive Housing

While Medicaid typically does not pay for housing (room and board), it does pay for some clinical and non-clinical services that can help people obtain and maintain their housing. New federal authorities to cover housing-related services have motivated states to think more broadly about the Medicaid populations who could benefit from access to housing-related services and the types of services that can promote housing stability. State Investments in Supportive Housing provides an overview of the federal authorities under which states are able to cover nonclinical housing-related services for high-need Medicaid enrollees. The issue brief also details how states are using these authorities to invest in supportive housing for diverse high-need Medicaid populations.

Implementing the ASAM Criteria for SUD Treatment through Medicaid Managed Care

As the opioid epidemic continues, Medicaid programs are applying for SUD Section 1115 Demonstration waivers (SUD waiver) to expand Medicaid-funded treatment options. Some states with approved SUD waivers have formally implemented the American Society for Addiction Medicine (ASAM) Criteria to promote consistency in client placement for SUD treatment. The ASAM Criteria is a clinically driven multidimensional client assessment model that emphasizes treatment outcomes, client-specific lengths of service, and a team-based approach to care. This issue brief draws from the experiences of states that were among the first to implement their SUD waivers to profile how the ASAM Criteria is used within the context of managed care and utilization review, and the challenges and best practices associated with its use.

How States Can Use Measurement as a Foundation for Tackling Health Disparities in Medicaid Managed Care

Many people in America face segregation, social exclusion, encounters with prejudice, and unequal access and treatment by the health care system, all of which can impact health. Medicaid programs serve a disproportionate share of populations that are negatively impacted by health disparities. This new State Health and Value Strategies (SHVS) issue brief provides examples from a handful of states that have begun the work of identifying, evaluating, and reducing health disparities within their Medicaid managed care programs. Additionally, it offers an approach for other states interested in measuring disparities in health care quality in Medicaid managed care as a step towards achieving health equity, such that all Medicaid managed care enrollees have a fair and just opportunity to be as healthy as possible.

Addressing Social Factors That Affect Health: Emerging Trends and Leading Edge Practices in Medicaid

Medicaid programs are increasingly considering how best to address social factors, such as housing, healthy food, and economic security, that can affect health and medical expenditures. Often referred to as social determinants of health (SDOH), these factors are significant drivers of population health outcomes. While states historically have had some experience tackling such issues for specialized, high-need populations, they are now confronting whether, and how, Medicaid should address SDOH for a broader population of Medicaid enrollees in order to achieve better health outcomes. This issue brief explores the “next generation” practices that states are deploying to address social factors using Medicaid 1115 waivers and managed care contracts, as well as the specific steps states can take to implement these practices.

Leveraging Multi-Payer Claims Databases for Value

All payer claims databases (APCDs) and multi-payer claims databases are a source of information that, when used effectively, can provide insight into how states’ health care systems are functioning and facilitate data-driven decision-making. This issue brief looks at the progress states and community organizations have made in using their APCDs and other multi-payer claims databases for various strategic purposes, and offers considerations for states that are seeking to optimize their own claims databases to achieve health care system performance improvement goals. The State Health Policy Highlight, Achieving Transparency and Value Using Multi-Payer Claims Databases, provides an overview of how states are leveraging their claims databases and reviews the lessons experienced states and community organizations have to offer other states seeking to optimize their own databases.

State Reinsurance Programs: Design, Funding, and 1332 Waiver Considerations for States

Faced with a fluid federal regulatory environment, many states continue to encounter challenges in stabilizing their individual health insurance markets, including large premium increases and declining insurer participation. One solution to continued market instability is a state-based reinsurance program similar to the federal program that reduced premiums by more than 10 percent per year from 2014 to 2016. The brief provides a roadmap of policy, program design, and financing considerations for states that are contemplating development of a state-based reinsurance program under 1332 waiver authority.

State Health Policy Highlights: Service Integration and Joint Accountability Across State Agencies and Programs

Health status is largely influenced by factors outside the health care delivery system, particularly for low-income populations. State efforts to improve health and reduce health disparities through the lens of medical care alone will miss opportunities for individuals, particularly the most vulnerable and their communities. As more states focus broadly on population health goals, they seek to employ and coordinate a variety of health and other resources on targeted efforts. This State Health Policy Highlight profiles three State Health and Value Strategies (SHVS) issue briefs that provide states with practical approaches to improve individual and population health and create joint accountability across health care and other sectors.

State Health Policy Highlights: Addressing Social Determinants of Health

There is an extensive body of evidence that shows social determinants of health (SDOH) play a powerful role in shaping health and health outcomes. State policymakers are increasingly focused on SDOH because of the influence they have on health, health care outcomes and Medicaid spending. As state Medicaid agencies consider addressing SDOH, there are a range of models they can employ. State Health and Value Strategies (SHVS) has published resources and hosted webinars with information for state health officials on approaches to addressing SDOH. This State Health Policy Highlight profiles two issue briefs and a webinar produced by SHVS on the topic of how state Medicaid programs can address SDOH.

Safeguarding Financial Stability of Provider Risk-Bearing Organizations

An increasingly common feature of health care payment models is the transfer of financial risk from payers to providers for health care services delivered to a defined population of patients. In these “value-based payment” models, providers accept financial responsibility should spending for most, or all, services for an attributed patient population exceed targeted levels. This financial liability is often shared with payers, and maximum risk exposure is typically capped. This issue brief explores options for states as they consider oversight of risk-bearing organizations, with a focus on states that have elected to act to protect against provider insolvency.

State Health and Value Strategies hosted a companion webinar, Safeguarding Financial Stability of Provider Risk-Bearing Organizations, based on the issue brief that provided an overview of options for states as they consider oversight of risk-bearing organizations (RBOs) as well as a deeper dive on the Massachusetts approach.