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1115 Waivers: A Bridge to 2014 for People Living with HIV Prepared by: Center for Health Law and Policy Innovation, of Harvard Law School & the Treatment.

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Presentation on theme: "1115 Waivers: A Bridge to 2014 for People Living with HIV Prepared by: Center for Health Law and Policy Innovation, of Harvard Law School & the Treatment."— Presentation transcript:

1 1115 Waivers: A Bridge to 2014 for People Living with HIV Prepared by: Center for Health Law and Policy Innovation, of Harvard Law School & the Treatment Access Expansion Project July 2011

2 Presentation Outline Part 1: Background on 1115 Waivers and How They Can Help Your State Part 2: Centers for Medicare and Medicaid (CMS) Guidance Part 3: Next Steps

3 1115 Waivers and the National HIV/AIDS Strategy The Federal Implementation Plan calls on Centers for Medicare and Medicaid Services (CMS) to: “promote and support the development and expedient review of Medicaid 1115 waivers to allow States to expand their Medicaid programs to cover pre-disabled people living with HIV.” 3

4 Part 1 What Is an 1115 Waiver and How Will It Help My State?

5 1115 Waiver = A “Demonstration Project” to Expand Coverage E.g., categories of eligibility E.g., benefits package E.g., statewideness States have flexibility in designing Medicaid programs, but have to follow federal laws “experimental, pilot, or demonstration project[s] which,” in her judgment, are “likely to assist in promoting the objectives of [the Act]” Section 1115 of Social Security Act says that Secretary of HHS can waive federal requirements Federal Costs w/ Waiver ≤ Federal Costs w/out Waiver Traditionally, successful waivers must demonstrate “budget neutrality” Federal share (FMAP) varies by state and is based on per capita income Federal & state governments share coverage costs Must be re-approved after a five-year period 1115 waivers are time- limited

6 Examples of 1115 Waivers to Expand Medicaid Coverage Examples of 1115 Waivers Response to public health emergency Expansion to childless adults Cost-effective early intervention to people living with HIV

7 How Will an 1115 Waiver Help My State? Waiting lists for ADAP have grown to over 8,000 individuals nationwide Ryan White care, treatment and service demands far outpace current funding The majority of ADAP beneficiaries in every state would be eligible for Medicaid through a waiver A Waiver Will Help Address the AIDS Drug Assistance Program (ADAP) Crisis

8 How Will an 1115 Waiver Help My State? Because Medicaid is funded jointly by the federal government and states, moving people from ADAP to Medicaid means matching federal $$ A Waiver Will Allow States to Leverage Federal Matching Funds State Response1115 State/Federal Response $28 million out of state budget to address ADAP crisis $28 million from state would leverage $51.3 million in federal matching funds (at 64.71% FMAP) with an 1115 waiver Example: North Carolina

9 How Will an 1115 Waiver Help My State? Reduces transmission rates Reduces costly hospitalizations and other costs of late intervention Reduces expenditures by disproportionate share hospitals Reduces Social Security disability costs Increases productivity and employment A Waiver Will Provide Cost- Effective Early Intervention

10 How Will an 1115 Waiver Help My State? In 2014, most people up to 133% FPL will be eligible for Medicaid Incremental expansion allows for a smooth transition to full Medicaid expansion Phases-in integration of providers and consumers Provides opportunity to effectively integrate Ryan White model of care 1115 Waiver Is a Test Run for the 2014 Medicaid Expansion

11 YearEnrolled State CostFederal Cost Total Cost (including rebates) FY022301$ 699,700$ 7,816,675 $ 9,716,375 FY032716$ 1,011,873$ 8,491,468 $ 10,703,342 FY044399$ 4,635,821$ 9,352,017 $ 15,887,838 FY054738$ 4,216,175$ 11,591,967 $ 17,708,142 FY064668$ 4,216,175$ 7,427,022 $ 13,543,197 FY075141$ 1,958,523$ 10,726,583 $ 14,585,106 FY085601$ 1,958,523$ 11,733,010 $ 15,591,533 FY095882$ 1,958,523$ 12,640,882 $ 16,099,405 Massachusetts ADAP: How Many Are Covered and at What Cost?

12 YearFull PayCo-PayPremiums FY02 $ 7,947,832 $ 648,030 $ 1,120,512 FY03 $ 7,961,862 $ 963,205 $ 1,778,272 FY04 $11,174,879 $ 1,553,758 $ 3,159,200 FY05 $ 9,756,201 $ 1,839,807 $ 6,112,132 FY06 $ 4,634,683 $ 1,893,206 $ 7,015,306 FY07 $ 4,147,713 $ 2,071,118 $ 8,366,273 FY08 $ 4,184,279 $ 2,083,431 $ 9,323,821 FY09 $ 4,695,780 $ 2,567,789 $ 8,835,835 Massachusetts ADAP: Expenditures by Category

13 IncomeEnrolledPercentage < 100% FPL271152% 100 - 200% FPL125124% 200 - 300% FPL61812% 300 - 400% FPL4028% > 400% FPL2495% 13 Massachusetts ADAP: Eligibility (Sept. 2009)

14 FY09 $16,591,488 FY10 $18,078,571 (1,233 enrolled) FY11 $18,801,714 In addition, MA provides approximately $30M per year in funding to MA DPH to support a broad range of testing, care, treatment and prevention initiatives. Massachusetts Medicaid HIV Expansion Line Item Budget Allocation

15 Key Mass. Outcomes 38% decrease in HIV incidence compared to 8% national increase (2005-08) AIDS diagnosis rate of 6.5 per 100K compared to 11.2 per 100K nationally (2008) 42% decrease in AIDS deaths compared to 24% decrease nationally (2002- 08) Adjusted death rate of 2% compared to 3.7% nationally (2008) Total viral suppression rate of 65% compared to 49% nationally (2006)

16 Estimated Cost Saving Associated with HIV Investments Estimated lifetime medical costs of over $300K per person and over $1.2B saved Estimated 4,085 cases averted Between 1999 and 2008…

17 Part 2 CMS Guidance: What Is It and How Will it Help My State?

18 What is CMS Doing to “Promote and Support” 1115 Waivers? Guidance on several health care reform opportunities to expand access to care for people living with HIV and AIDS 1115 waiver to cover pre-disabled people living with HIV and AIDS Medicaid Health Home program for Medicaid enrollees with chronic conditions (including HIV and AIDS) 1915 Home and Community Based Care waivers “Money Follows the Person” program to Help People Living with HIV and AIDS transition from institutions to the community State Medicaid Director Letter

19 How Will the CMS Guidance Help States Put Together Successful Applications? The health care reform law permits states to immediately cover most individuals up to 133% of the federal poverty level rather than wait until 2014 For the purposes of the waiver, covering pre-disabled people living with HIV is a way for a state to expand Medicaid early for this population Waiver Population = “Pass Through” Creative Ways to Demonstrate “Budget Neutrality”

20 How Will the CMS Guidance Help States Put Together Successful Applications? Providing early intervention to an individual living with HIV through the waiver is less costly than waiting for that person to become disabled Early intervention reduces costly hospitalizations and other costs associated with disease progression Cost Avoidance Factors in the number of AIDS cases averted due to expanded Medicaid coverage Simplified Cost Avoidance Creative Ways to Demonstrate “Budget Neutrality”

21 How Will the CMS Guidance Help States Put Together Successful Applications? States divert DSH funds to pay for uninsured individuals living with HIV/AIDS Disproportionate Share Hospital (DSH) Diversion E.g., implementation of a managed care service delivery model or a pharmacy discount program such as 340B “Unique Programmatic Savings” Creative Ways to Demonstrate “Budget Neutrality”

22 1115 Waiver Is Still a Heavy Lift in Most States Still need to allocate scarce state $$ to draw the federal match Difficult political environment for Medicaid State Medicaid offices are understaffed and underfunded

23 Part 3 Next Steps

24 What You Can Do… Meet with your state Medicaid office, Governor’s office and state legislators Make sure you know what the application process is in your state (some states require legislative approval to apply for a waiver) Start talking with state officials about the 1115 waiver Commission a study to analyze costs and benefits of implementing a waiver Commit Medicaid office to consider applying Support introduction of a resolution in your state legislature, if needed Contact Barbara Edwards, Director, Disabled and Elderly Health Program Group, or Vikki Wachino, Director, Children and Adults Health Program Group at (410) 786-5647 Use CMS as a resource

25 Treatment Access Expansion Project  Taepusa.org Contact: Amy Killelea, akillelea@law.harvard.edu Dose of Change  Doseofchange.org CMS, State Medicaid Director Letter  https://www.cms.gov/SMDL/SMD/ 25 For More Information


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