Category Archives: Waivers

How the Medicaid expansion will be treated under a block-grant financing framework

One of the most pressing issues before the 115th Congress and newly inaugurated President Trump will be to determine how the Medicaid expansion population will fit into a broader reform package for the Medicaid program as a whole.  Many state governors in expansion states have expressed concern that the long-standing Republican proposal of block-granting Medicaid will leave them exposed to unsustainable financial pressures.

President Trump’s nominee for HHS Secretary,… More

Medicaid Directors: Trump Administration Should Formally Include States in Development of Medicaid Regulations

Introduction

Over the course of the last several blog posts, we’ve discussed how the Medicaid program could potentially be transformed under the incoming Trump Administration.  We also described the central role that state-led demonstration waivers would play in defining the parameters of this transformation.  Now, the association for State Medicaid directors is weighing in on precisely this issue.  The National Association of State Medicaid Directors (NAMD)recently published a document laying out the group’s priorities for the Medicaid program in the first 100 days of the incoming Trump Administration. … More

CMS Announces new Medicare-Medicaid ACO Model

Currently, nearly 10 million Americans are dually-eligible for both Medicare and Medicaid. These “dual eligibles” are low-income seniors and individuals with disabilities who are separately eligible for and receive coverage under both the Medicare and Medicaid programs.  In general, Medicare acts as the primary payer for dual-eligibles, while Medicaid provides “wrap-around” coverage for these individuals, helping with some out-of-pocket costs (such as premiums, copayments and deductibles) and offering coverage for services not otherwise covered by Medicare (vision,… More

Looking Forward: Pay for Success in the Medicaid Program

As we noted here last month, Medicaid is a 1960s-era health insurance plan operating in a 21st century world.  As Medicare and commercial payers have started taking steps to move away from payment by volume to paying for value, it’s important to recognize that the same innovation needs to occur in Medicaid.  In fact, one could argue that this innovation is even more critical in Medicaid.

Why? … More

Medicaid Waivers in Conservative States Hold Hints for What is to Come for Drug Manufacturers

Introduction

The nomination of Seema Verma by President-Elect Trump for the position of CMS Administrator sends a clear signal that the Trump Administration considers Medicaid one of its top healthcare reform priorities.  Seema Verma is the the “architect” of the Healthy Indiana Plan 2.0” waiver (HIP 2.0), a consumer-driven Medicaid expansion demonstration approved by the Obama Administration under a Section 1115 waiver.  Most recently, Verma was also involved in designing Kentucky’s proposed “Kentucky HEALTH” (“HEALTH”) Section 1115 waiver,… More

Medicaid under a Trump Administration: Rethinking the Medicaid Program

Last week, we wrote about the importance of the Medicaid program, especially given its size as, by far, the largest health insurance plan in the United States.  We noted that Medicaid covers 71 million people (this number increased dramatically after the Affordable Care Act was enacted in 2010).  We said that “Medicaid is important for all of us” – whether you are a program beneficiary, a taxpayer who helps pay for it,… More

Medicaid under a Trump Administration: What the Next Four Years Might Look Like

Dear readers: this post is going to be a bit different from our regular posts, in that we are going to try to refrain from getting too far in the weeds, and avoid too much legalese. Why? Because the results of the November election will likely have major implications not only for the Medicaid program itself, but for the millions of individuals it serves. We are fortunate to have a platform here and it is our hope that,… More

CMS and Massachusetts Advance Delivery System Reform with Approval of New 1115 Waiver

On November 4, 2016, the Centers for Medicare & Medicaid Services (“CMS”) sent word to the Massachusetts Executive Office of Health and Human Services (EOHHS, referred to here as “MassHealth”) that it approved a major amendment to Massachusetts’ section 1115 demonstration project through June 30, 2017.  At the same time, CMS also approved an extension of this same demonstration through June 30, 2022. Approval of Massachusetts’ waiver amendment comes after nearly a year of negotiations and may ultimately result in the transition of the vast majority of MassHealth enrollees into newly-formed Accountable Care Organizations (“ACOs”) operating under one three models,… More

Everything you have ever wanted to know about Medicaid waivers

We frequently read about state Medicaid programs receiving or being granted “waivers” by CMS, but what does that mean exactly?  What is a “waiver”?  What is the history of Medicaid waivers?  How does the process work?  We hope to answer these questions in this blog post.

The Legal Standard

A “waiver” refers to authority that the Secretary of Health and Human Services possesses under section 1115 of the Social Security Act:

“(a)  In the case of any experimental,… More