DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-26-12 Baltimore,Maryland 21244-1850
CENTER FOR MEDICAID CHIP SERVICES
OCT 3 0 2014
John Polanowicz Secretary
Executive Office of Health and Human Services One Ashburton Place
11th Floor
Boston, MA 02108
Dear Secretary Polanowicz:
This letter is to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved your request to extend Massachusetts' section 1115 demonstration project, entitled MassHealth (Project Number 11-W-00030/1). The new extension period is approved for the period starting with the date of this approval letter through June 30, 2019.
During this extension period, the Commonwealth will continue to sustain and improve its ability to provide affordable coverage and access to health care by continuing and expanding existing demonstration programs to advance children's and adults' health care coverage. The Commonwealth will conduct programs to maintain affordability of coverage, such as the Medicare Cost Sharing Assistance program, that will assist in covering all or part of the cost of Medicare premiums, deductibles, and coinsurance for certain demonstration populations. The demonstration also provides authority for the Commonwealth to continue to utilize the streamlined redetermination process to renew Medicaid enrollments for families who are enrolled in Supplemental Nutrition Assistance Program (SNAP). This streamlined process will be extended to renew enrollments in MassHealth for certain other individuals, including certain nonpregnant childless adults and parents who are receiving SNAP benefits.
This approval will allow for the Delivery System Transformation Initiatives (DSTI) and Infrastructure and Capacity Building Expenditure authorities under the Safety Net Care Pool (SNCP) to continue, with increased funding, for the first three years of the renewal period with changes aimed to improve health care outcomes, data collection, and levels of behavioral health integration. During that time, the Commonwealth and CMS will collaborate to reach agreement on a redesigned SNCP structure for the 4th and 5th year of this demonstration renewal [Demonstration Years (DYs) 21 and 22]. The redesign process will be informed by the SNCP Financing and subsequent Sustainability and Delivery System Transformation reports, which will provide a detailed analysis of the payments under the SNCP. These reports will also recommend a strategic platform for payments effective July 1, 2017 that sustainably support
delivery of care to low-income populations and align with system-wide transformation. Using these reports as a resource, the Commonwealth and CMS will work collaboratively and with input from affected stakeholders, inclusive of a defined working process with the DSTI hospitals and public hospital, to reach an agreement on a redesigned SNCP and work towards any necessary demonstration amendments by June 30, 2017.
Ifan amendment to the demonstration for restructured SNCP provider payments for DYs 21 and 22 is not approved, Massachusetts will resume making Disproportionate Share Hospital (DSH) payments in accordance with an approved State plan pursuant to section 1902(a)(13)(A)(iv) of the Social Security Act.
CMS also approved the federal support for Designated State Health Programs (DSHP) with the agreement that DSHP funding (not including Health Connector subsidies) would phase down over the first three years of the renewal, and would not be available in the last two years of this renewal period. Health Connector subsidies shall continue for all five years of this renewal period.
CMS acknowledges and supports the Commonwealth's commitment to promote and adopt alternative payment methodologies and will continue working with the Commonwealth related to its request to develop a Primary Care Payment Reform Initiative (PCPRI) and an Accountable Care Organization (ACO) payment model. The Commonwealth has contract amendments pending approval with CMS for PCPRI. While CMS and the Commonwealth were not able to finalize the requests related to these efforts concurrently with this demonstration renewal, CMS and the Commonwealth have agreed to a timetable with a goal of approval in 2015. By March 2, 2015, the Commonwealth shall submit to CMS an actuarial analysis for the proposed shared savings methodology. CMS's approval of the PCPRI and/or ACO proposal by the target approval period, or thereafter, is subject to receipt and review of the proposals.
While CMS has approved the premium assistance portion of the Health Connector subsidies through DY 22, as indicated over the course of our discussions, CMS is unable to approve state subsidies to offset cost sharing in the Marketplace, and CMS has not approved and did not incorporate into the section 1115 demonstration the Commonwealth's requests to remove the provider sub-cap under the Safety Net Care Pool (SNCP). Also, indicated over the course of our discussions, CMS does not have the authority to approve Federal Financial Participation for lawfully present immigrants who do not meet the five-year waiting period; therefore, we are not
. able to approve the Commonwealth's proposal to expand the Health Connector Subsidies to this population.
Finally, the temporary DSHP authorities for the orderly closeout and transition of the Commonwealth Care premium assistance program; and the temporary (FFS) state operated coverage for individuals who were not able to receive a full eligibility determination for MassHealth or Marketplace coverage will end on February 28, 2015. Enrollment in Medicaid and the Marketplace is expected to replace enrollment into temporary coverage on November 15, 2014. The Commonwealth assures that no federal funds will be claimed for state transition program expenditures for individuals whose enrollment in other coverage options has become effective or whose income is ultimately found to be higher than 400 percent of the federal
poverty level (FPL) and are not eligible for MassHealth coverage during the period the expenditure authorities were in effect.
The CMS approval of the extension of the MassHealth demonstration is conditioned upon continued compliance with the enclosed set of Special Terms and Conditions (STCs) defining the nature, character, and extent of anticipated federal involvement in the project. The state may deviate from the Medicaid state plan requirements only to the extent those requirements have been waived or specifically listed as not applicable to the expenditure authorities.
This award letter is also subject to our receipt of your written acceptance of the ·award, including the waiver and expenditures authorities and STCs, within 30 days of the date of this letter. Your project officer is Ms. Elizabeth Matthews, who may be reached at (410) 786-5433 and through e mail at . Communications regarding program matters and official correspondence concerning the demonstration should be submitted to Ms. Matthews at the following address:
Centers for Medicare Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16
7500 Security Boulevard
Baltimore, MD 21244-1850
Official communications regarding program matters should be sent simultaneously
Ms. Matthews and to Mr. Richard McOreal, Associate Regional Administrator in our Boston Regional Office. Mr. McOreal's contact information is as follows:
Centers for Medicare & Medicaid Services JFK Federal Building
Room 2325
Boston, MA 02203
Telephone: (617) 565-1226
E-mail:
Ifyou have questions regarding this approval, please contact Eliot Fishman, Director of the Children and Adults Health Programs Group in the Center for Medicaid CHIP Services at (410) 786-5647.
CMS looks forward to continuing work with your staff on future developments within your demonstration.
Sincerely,
....-
Cindy Mann Director
cc: Richard McGreal, Associate Regional Administrator, Region I Julie McCarthy, Region I
CENTERS FOR MEDICARE & MEDICAID SERVICES WAIVER LIST
NUMBER: 11-W-00030/1
TITLE: MassHealth Medicaid Section 1115 Demonstration AWARDEE: Massachusetts Executive Office of Health and Human Services
(EOHHS)
All requirements of the Medicaid program expressed in law, regulation and policy statement, not expressly waived in this list, shall apply to the demonstration project beginning the date of the approval letter, through June 30, 2019, unless otherwise specified. In addition, these waivers may only be implemented consistent with the approved Special Terms and Conditions (STCs).
All previously approved waivers for this demonstration are superseded those set forth below for the state’s expenditures relating to dates of service during this demonstration extension.
Under the authority of section 1115(a)(1) of the Social Security Act (the Act), the following waivers of state plan requirements contained in section 1902 of the Act are granted in order to enable the Commonwealth of Massachusetts (State/Commonwealth) to carry out the MassHealth Medicaid section 1115 demonstration.
1. Statewide Operation Section 1902(a)(1)
To enable Massachusetts to provide managed care plans or certain types of managed care plans, only in certain geographical areas of the Commonwealth
2. Comparability/Amount, Duration, and Scope Section 1902(a)(10)(B)
To enable the Commonwealth to provide benefits that vary from those specified in the State plan, as specified in Table B of STC 37, and which may not be available to any categorically needy individuals under the Medicaid state plan, or to any individuals in a statutory eligibility group.
3. Eligibility Procedures and Standards Section 1902(a)(10)(A),
Section 1902(a)(10)(C)(i)-(iii), and Section 1902(a)(17)
To enable Massachusetts to use streamlined eligibility procedures including determining and redetermining eligibility based on gross income levels and streamlined redeterminations for children, parents, caretaker relatives, and childless adults.
4. Annual Redeterminations Section 1902(a)(17)
To the extent necessary to enable the Commonwealth not to perform required redeterminations of eligibility between October - December 2013 and January - December 2014.
5. Disproportionate Share Hospital (DSH) Section 1902(a)(13) insofar as it Requirements incorporates Section 1923
To exempt Massachusetts from making DSH payments to hospitals which qualify as a Disproportionate Share Hospital.in any fiscal year in which Massachusetts is authorized to make provider payments from the Safety Net Care Pool (the amount of any DSH payments must be prorated if necessary so that DSH payments will not exceed the percentage of the DSH allotment corresponding to the percentage of the federal fiscal year for which payment of DSH payments is required).
6. Financial Responsibility/Deeming Section 1902(a)(17)
To enable Massachusetts use family income and resources to determine an applicant’s eligibility even if that income and resources are not actually made available to the applicant, and to enable Massachusetts to deem income from any member of the family unit (including any Medicaid-eligible member) for purposes of determining income.
7. Freedom of Choice Section 1902(a)(23)(A)
To enable Massachusetts to restrict freedom of choice of provider for individuals in the Demonstration, as outlined in Table D, STC 46, including to require managed care enrollment for certain populations exempt from mandatory managed care under section 1932(a )(2), limiting primary care clinician plan (PCC) plan enrollees to a single Prepaid Insurance Health Plan (PIHP) for behavioral health services, limiting enrollees who are clients of the Departments of Children and Families and Children and Youth Services to a single PIHP for behavioral health services, unless such enrollees chose a managed care plan, requiring children with third party insurance to enroll into a single PIHP for behavioral health services; in addition to limiting the number of providers within any provider type as needed to support improved care integration for MassHealth enrollees, and limiting the number of providers who provide Anti-Hemophilia Factor drugs.
8. Direct Provider Reimbursement Section 1902(a)(32)
To enable Massachusetts to make premium assistance payments directly to individuals who are low-income employees, self-employed, or unemployed and eligible for continuation of coverage under federal law, in order to help those individuals access qualified employer-sponsored insurance (where available) or to purchase health insurance on their own, instead of to insurers or employers providing the health insurance coverage.
9. Retroactive Eligibility Section 1902(a)(34)
To enable the Commonwealth not to provide retroactive eligibility for up to 3 months prior to the date that the application for assistance is made and instead provide retroactive eligibility as outlined in Table D, STC 46.
10. Extended Eligibility Section 1902(a)(52)
To enable Massachusetts to not require families receiving Transitional Medical Assistance to report the information required by section 1925(b)(2)(B) absent a significant change in circumstances, and to not consider enrollment in a demonstration- only eligibility category or CHIP (title XXI) eligibility category in determining eligibility for Transitional Medical Assistance.
CENTERS FOR MEDICARE & MEDICAID SERVICES EXPENDITURE AUTHORITY
NUMBER: 11-W-00030/1
TITLE: MassHealth Medicaid Section 1115 Demonstration AWARDEE: Massachusetts Executive Office of Health and Human Services
Under the authority of section 1115(a)(2) of the Social Security Act (the Act), expenditures made by Massachusetts for the items identified below, which are not otherwise included as expenditures under section 1903 of the Act shall, for the period of this demonstration extension (date of the approval letter through June 30, 2019), unless otherwise specified, be regarded as expenditures under the State’s title XIX plan. All previously approved expenditure authorities for this demonstration are superseded by those set forth below for the state’s expenditures relating to dates of service during this demonstration extension.
The following expenditure authorities may only be implemented consistent with the approved Special Terms and Conditions (STCs) and shall enable the Commonwealth of Massachusetts (State/Commonwealth) to operate its MassHealth section 1115 Medicaid demonstration.
I. Demonstration Population Expenditures
1. CommonHealth Adults. Expenditures for health care-related costs for adults aged 19 through 64 who are totally and permanently disabled and not eligible for comprehensive coverage under the Massachusetts state plan, but who are:
a. Employed; or
b. Not employed and meet a one-time only deductible.
2. CommonHealth Children. Expenditures for health care-related costs for children from birth through age 18 who are totally and permanently disabled with incomes greater than 150 percent of the Federal poverty level (FPL) and who are not eligible for comprehensive coverage under the Massachusetts state plan .
3. Family Assistance [e-Family Assistance and e-HIV/FA]. Expenditures for health care- related costs for the following individuals:
a. Individuals who are HIV-positive, if they are age 64 or younger, are not institutionalized, with incomes above 133 through 200 percent of the FPL and are not otherwise eligible under the Massachusetts Medicaid state plan. These expenditures include the 90-day period between the time an individual submits an application and the time that the individual provides to the Commonwealth proof of his or her HIV-positive health status.