Below is the HillCo client report from the June 27 Executive Waiver Committee meeting.
The committee met to discuss aspects of the current 1115 Healthcare Transformation Waiver and the potential renewal or extension of the waiver.
Pam McDonald, Rate Analysis Director, HHSC

  • Hopeful that things will be much smoother for next demonstration year
  • Still hoping to do first 2014 DSH payment in September contingent on HHSC being able to adopt rules and being able to comply with Rider 86 payments
  • Shooting for October for an advanced UC payment for DY3; specific rules determine who can receive an advanced payment
  • CMS requires HHSC to reconcile UC payments to actual UC costs; first UC payment were for federal FY12; DY3 payments will be for federal FY14 but based on 2012 data; there are two reconciliations , one interim and one final; trying to eliminate the interim reconciliation; final reconciliation will be performed similar to the way the DSH audit is performed

Frank Genco, Senior Policy Advisor for Long Term Services and Supports, HHSC

  • HHSC is required by CMS to have an external quality review organization (EQRO); they perform 3 functions; validation of performance incentive projects (PIPs), validation of performance measures, review MCOs to determine compliance with managed care regulations
    • Institute for Child Health Policy is the EQRO
  • Most of the established measures are national measures, there are a few state measures
  • Potentially preventable events are being used for the pay for quality initiative
  • EQRO looks at PIPs and tries to find room for improvements
  • Each MCO has to do two PIPs per program
  • PIP topics are becoming more focused and HHSC has more direction for these
  • HHSC is going to extend them for two years on a case by case basis if they are being worked on legitimately
  • Quality Assessment and Performance Review Projects are designed by each MCO
  • Nursing facilities will have to have their own going forward
  • Up to 5% of MCOs capitation is at risk based on these measures
  • Moving increasingly away from process measures to more outcome measures
  • 3M software has specifications built in for illness severity; HHSC is adding specifications for other things such as patient income levels, area of the state they have patients in, etc.
  • MCO report cards rolled out for the first time this Spring
  • Report cards for DMOs will also be developed
  • There is a workgroup set up to develop quality indicators for nursing facilities
    • Available for public comment through July 24
  • Started a workgroup to develop performance measure for the portion of STAR+PLUS that does long term services and supports; they will look at coordination between providers and MCOs

Ardas Khalsa, Healthcare Transformation Waiver Operations Director, HHSC

  • Between four year and three year projects there are around 1,500 active DSRIP projects
  • There are five regions that do not have enough funds to fully fund all their three year projects
  • For DY3 metrics; approved over 90% of what was reported; IGT request have gone out and IGT transfers are due by July 9
  • Depending on IGT availability providers can receive over $690 million in funds for July
  • For mid-point assessments, if goals are already being achieved plan modifications need to be made for the last two years of the waiver
  • September 9-10 will be holding a summit to share what DSRIP participants have learned and to share experience for projects; will invite all DSRIP participants, legislature staff, HHSC staff and waiver committee members; all performing providers will be able to send at least one representative
  • Sent out a survey in the recent weeks; responses are due July 1; have a draft agenda already but will look at the survey to add additional missed items; using survey to get a sense of who has strong projects to present at the summit
  • Will start looking forward to waiver renewal at the summit as well; may be inviting CMS representatives to make remarks

Lisa Kirsch, Medicaid and CHIP Deputy Director, HHSC

  • April 1 marks the official midpoint of the 5 year waiver; must submit a renewal or extension request no later than September 30, 2015 to renew or extend the waiver (there may be more time if it is a renewal and not an extension); must include a demonstration summary and objectives and measures to determine how objectives are met
  • It would be rare that a waiver would not be renewed; Texas will need to renew the waiver to continue delivering care through STAR and STAR+PLUS models as well
  • The waiver was negotiated with the assumption that Texas would not be expanding Medicaid when it was a requirement; the Supreme Court decision that states did not have to expand coverage came after the initial waiver request so that may impact the extension or renewal
  • Given the complexity of the waiver a simple extension request may not be available
  • It is likely that there will be some things that CMS will ask HHSC to modify within the waiver
  • Must submit a transition plan by March 2015 regarding the UC and DSH pools
  • Will be holding public hearings and comment periods regarding the renewal
  • Once the plan is submitted to CMS they have public input opportunities as well
  • Executive Waiver Committee will be key in helping create the waiver extension request
  • Q: can existing projects be continued in the renewed waiver
    • Assuming pool sizes are the same, some projects are going to shake out; there may be money not tied to a project, one option would be to allow it for more projects or strategic projects; CMS has expressed interest in a performance bonus pool to try to get more out of projects instead of adding more projects
  • Want to work with stakeholders in determining how best to gather and display data to show success in DSRIP projects
  • Q: who is going to tie benefit linkage between managed care and the projects; concerned that MCOs are not linked in to the whole DSRIP side of things
    • There is work to be done in this area; with DSRIP now off the ground, HHSC is taking time to work with the managed care side to show where we are already aligned but will need to show CMS a plan for further alignment
  • Trying to work on how to support or improve data exchange
  • CMS has a huge emphasis on pay for performance for outcomes so that will continue through the renewed waiver
  • Considering narrowing the menu for projects and outcomes
  • Due to number and types of providers and projects in the waiver, valuation is difficult; need to consider that CMS may wish to change the valuation structure
  • Need to make a stronger case for the continued use of UC; CMS is tightening up on other states in this area; in some states CMS is doing one year UC extension but they are asking for increased reporting
  • HHSC is developing a managed care model for children with disabilities; need to consider that with the renewal
  • Next steps: will be sending out surveys to get input on the renewal, will be watching other states and how their renewal processes go, the summit will be a big part of the discussion of the renewal, want to have an outline ready by session to share with legislators

Next scheduled meeting is set for August 7.