1. #HA2016 HEALTH ACTION 2016 1332 State Innovation Waivers Cheryl Fish-Parcham HEALTH ACTION 2016 1332 State Innovation Waivers Cheryl Fish-Parcham

2. #HA2016 Agenda What are 1332 Waivers? How did they come about? An overview of 1332 Waivers What can states change under 1332 waivers? Key elements of 1332 Waiver What are the consumer protections (“guardrails”) that must remain in place as states make changes? Guardrails of a 1332 Waiver Can 1332 waivers be coordinated with Medicaid 1115 waivers and what does that look like? Mega-Waivers Latest and most detailed information on how 1332 waiver applications will be reviewed and approved. December, 2015 Guidance We'll hear from advocates Where are the states?

3. #HA2016 Waiver for State Innovation Created by Section 1332 of the Affordable Care Act (42 U.S.C. § 18052) Allows states to request waivers of certain Marketplace rules, and divert federal funding from premium credits and cost sharing assistance to implement changes in insurance or health care delivery systems Section 1332 authority begins January 1, 2017; States can now request waivers from HHS and Treasury for innovations effective in 2017 or later. Also known as “Wyden Waivers”

4. #HA2016 What are waivable areas? Individual Mandate Employer Mandate Premium credits, cost- sharing reductions, benefits QHP requirements, Exchanges

5. #HA2016 What can’t be waived? © RWJ/Manatt Health Solutions

6. #HA2016 What are the statutory guardrails? © RWJ/Manatt Health Solutions

7. #HA2016 LATEST GUIDANCE FROM HHS AND TREASURY

8. #HA2016 Guidance Issued December 12, 2015

9. Certain changes a state may seek under a 1332 waiver are not feasible through healthcare.gov at this time. –Federal platform will not support different rules for different states The IRS cannot administer different rules in different states –But state might be able to waive a tax provision and administer a different tax #HA2016 Additional “operational” considerations

10. Amount state's residents would have gotten in premium credits and cost sharing #HA2016 How much $ is passed through to states?

11. States must pass legislation to have authority to pursue a 1332 waiver. Guidance says: at least a 30 day comment period on a proposed waiver at the state level, and another comment period at federal level. #HA2016 What public input is required?

12. #HA2016 Mega-Waivers

13. The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under titles XVIII, XIX, and XXI of the Social Security Act, and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions. 42 USC § 18052(a)(5) #HA2016 Coordinated 1115 and 1332 waivers

14. The assessment (of whether the 1332 waiver should be approved) would not take into account changes to Medicaid and CHIP that require separate federal approval, such as changes in coverage or Federal Medicaid or CHIP spending that would result from a proposed Section 1115 demonstration, regardless of whether the Section 1115 demonstration proposal is submitted as a part of a coordinated waiver application. Savings accrued under either proposed or current Section 1115 Medicaid or CHIP demonstrations are not factored into the assessment of whether a proposed state waiver meets the deficit neutrality requirement. December 12, 2015 Guidance #HA2016 Coordinated 1115 and 1332 waivers

15. CMS 1332 waiver resource hub: https://www.cms.gov/CCIIO/Programs- and-Initiatives/State-Innovation- Waivers/Section_1332_state_Innovation_Waivers-.htmlhttps://www.cms.gov/CCIIO/Programs- and-Initiatives/State-Innovation- Waivers/Section_1332_state_Innovation_Waivers-.html Families USA: http://familiesusa.org/product/whats-new-federal-guidance- about-1332-state-innovation-waivers and http://familiesusa.org/product/how-could-1332-waiver-affect-medicaid-and- chiphttp://familiesusa.org/product/whats-new-federal-guidance- about-1332-state-innovation-waivers http://familiesusa.org/product/how-could-1332-waiver-affect-medicaid-and- chip State Health Reform Network: search “1332” on statenetwork.org; various presentations available by Mannatt Health Solutions. Understanding the Affordable Care Act’s State Innovation (“1332”) Waivers, Center on Budget and Policy Priorities: http://www.cbpp.org/research/understanding-the-affordable-care-acts-state- innovation-1332-waivers http://www.cbpp.org/research/understanding-the-affordable-care-acts-state- innovation-1332-waivers Innovation Waivers, The Commonwealth Fund www.commonwealthfund.org/publications/issue-briefs/2015/apr/innovation- waivers-and-health-reform www.commonwealthfund.org/publications/issue-briefs/2015/apr/innovation- waivers-and-health-reform #HA2016 Resources

16. #HA2016