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Medicaid Waiver

Medicaid Waiver

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Published by: larrymmcbride on Jul 25, 2012
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07/25/2012

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Medicaid 1115 Waiver | DSRIP | UC Summary

• Medicaid 1115 Waiver is a 5 year redesign program and states use waivers for the following purposes: expand coverage, change delivery systems, alter benefits and cost sharing, modify provider payments and extend coverage during an emergency Private hospital UPL (Upper Payment Limit) programs which help to fund underserved population initiatives is being replaced by the Medicaid 1115 Waiver o Waiver is a new methodology of UPL and creates Regional Healthcare Partnerships UPL Dollars are divided into: o UC (Uncompensated Care) pool: costs of care provided to individuals who have no funds or third party coverage for services provided by the hospital or other providers.  UC Dollars will be fixed at some time o DSRIP (Delivery System Reform Incentive Payments): support coordinated care and quality improvements through the regional healthcare partnerships to transform care delivery systems  DSRIP dollars are “at risk” and are pending achievement of metrics and milestones of projects o The breakdown of % of UC v. DSRIP dollars will change over the next 5 years with fixed UC dollars decreasing to 50% of total dollars DSRIP Project Categories: o Category 1: Infrastructure Development: lays foundation for delivery system transformation o Category 2: Program innovation and design o Category 3: Quality improvement o Category 4: Population focused improvements IGT (Intergovernmental Transfers)- are dollars that are transferred between governmental entities to: academic medical centers (such as UT Southwestern), public health agencies (HHS), etc. are “matched” dollars from the government Regional Healthcare Partnerships (RHP): Regions developed throughout the State to deliver care and provide increased access to care for low-income Texans under the 1115 Transformation waiver. Each RHP must develop plans for the allocation of DSRIP funding. These plans must be submitted to the State and CMS for approval and shall include estimated IGT funding available by year to support UC and DSRIP payments. o Anchoring entity (anchor): The single IGT entity in an RHP serving as the primary contact to HHSC responsible for providing opportunities for public input to the development of RHP plans and coordinating discussion and review of proposed RHP plans prior to plan submission to the State. o RHP 9 includes Dallas and Kaufman counties and is anchored by Parkland o RHP 18 includes Denton, Collin, Rockwall and Grayson counties and is anchored by Collin County Due dates: o September 1 => Anchor must submit RHP plans to HHSC o October 31 => Final RHP plans are due to CMS

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IGT Parkland or Collin gets a set amount of $ based on matched IGT funding Money is divided into UC and DSRIP

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UC Medicaid cap dependent Level of funding based off of: o Level of IGT in federal match o Hospital’s % of total patient participants in UC pool

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DSRIP At risk payments dependent on meeting metrics and milestones to improve care (disbursed every 6 months) Contingent upon approved projects that meet categories in regulations Value in meeting milestones that are approved and payments made accordingly

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