This report covers the responses House Human Services received for their RFI on Charges #2.2-2.5, relating to 1115 waivers, Texas Targeted Opioid Responses Grant, CMS proposed Medicaid Fiscal Accountability Rule, and the Health Texas Women Section 1115 Demonstration Waiver. The RFI for this charge can be found here and a complete list of responses can be found here.
The HillCo report below is a summary of information intended to give you an overview and highlight of the various topics included in the responses. This report does not cover the entirety of each response but aims to provide an overview of the testimony submitted.
Texas Health and Human Services Commission
The next phase of the 1115 Healthcare Transformation and Quality Improvement Program Waiver
- 1115 contains two funding pools (UC and DSRIP) and enables managed care directed payment programs that provide funding to hospitals and nursing homes
- UC helps offset uncompensated costs from other providers
- DSRIP provides incentive payments to encourage providers to improve outcomes and particularly benefits the Medicaid, uninsured, low income population
- Draft DSRIP transition plan should sustain healthcare transformation and advance value-based payments; HHSC considering options to support this program
- 1115 waiver created $8 billion dollars of savings; created budget neutrality room for UC and DSRIP pools
- Expects CMS changes to decrease the size of the budget; will only allow states to roll over savings from the most recent 5 years
- Currently considering whether or not to submit a request for an extension of the waiver
Texas Targeted Opioid Response Program
- SAMHSA has increased funds each year to Texas in State Opioid Response
- SAMHSA also awarded two discretionary grants in 2016 and 2017:
- Texas Strategic Framework for Prescription Drugs: to raise awareness about drug abuse through activities in targeted communities
- Texas First Responders: to reduce opioid overdose mortality rates and coordinate care for survivors
- Does not predict an impact on its program despite decreased funding from SAMHSA this year
- Summarizes key deliverables of this program
- Medicaid Fiscal Accountability Rule: CMS decided to withdraw this rule from regulatory agenda
Healthy Texas Women Section 1115 Demonstration Waiver
- Offers free women’s health and family services to low income, eligible women; in favor of testing, preventative treatment, and education; does not promote elective abortions
- Federal approval did not change client benefits or provider requirements
- HTW services are now provided through general revenue funds
- Now using MAGI methodologies; Special Supplemental Nutrition Program for Women, Infants, and Children and the SNAP are no longer automatically eligible for HTW
- Change in method of finances with this plan increases GR savings
Healthy Texas Women Plus
- Developed comprehensive postpartum plan to address major issues leading to maternal morbidity: postpartum depression, artery disorders, substance abuse
- Will seek an amendment to the 1115 waiver to receive funding under these programs; with CMS approval, they will receive federal matching funds
- Made changes to HTW by allowing: telemedicine, COVID-19 testing, extended eligibility to all states to receive enhanced Medicaid
Children’s Defense Fund of Texas
- Recommends Texas expands Medicaid programs to address patients who were dependent on 1115 waiver
- Because the government covers 90% of Medicaid expansion costs, it places less burden on state hospitals to pay for uncompensated care
- Medicaid facilitate primary care and preventative health services, which ultimately function as cost saving mechanisms
- Consistent coverage via Medicaid reduces maternal mortality and morbidity
- Medicaid reduces racial disparities
Children’s Hospital Association of Texas
- The state should maximize federal Medicaid funding through existing federal flexibilities
- The state address costs driver and quality of care issues; should overall partner with children’s hospitals to transform care
- The CMS proposed Medicaid Fiscal Accountability Rule would have detrimental impacts on safety net hospitals; Medicaid is the primary payer in Texas for children
- Forecasted DSRIP payments until 2023; realized savings in annual budgets to extend funding further
- Legislation should establish local health departments as a provider-type recognized by MCOs
- Would allow health departments to be reimbursed for Medicaid services
- Similar proposal found in last sessions’ SB 2021; committee approved of
- Overviews Austin DISRIP programs, including: Maternal Infant Outreach, The Community Diabetes Initiative, Immunizations, Permanent Supportive Housing
- Legislature should maintain levels of funding for Healthy Texas Women
- Stakeholders are concerned that eligible women will no longer be automatically enrolled
- Recommends improving the administrative renewal process; in lieu of auto-enrollment
- Recommends implementing post enrollment verification in addition to the renewal process
- Recommends negotiating with CMS to achieve adjunctive eligibility
- Should have greater communication with HHSC about the HTW Plus eligibility system
- Urges legislators to monitor SB 750 next session to ensure effective implementation
- Supports HTW Plus programs; does not want detraction of funds from Healthy Texas Women and Family Planning Program
- 1115 funding is essential; recommends that FQHC are at the table during discussion of 1115 renewal
Meadows Mental Health Policy Institute
- DSRIP reduction will adversely affect people with Serious Mental Illnesses; 40 percent of funding for people with mental illness comes through DSRIP
- Additional taxpayer expenses will be incurred if this level of funding cannot continue
- Recommends building on Star Plus managed care framework and establishing Certified Community Behavioral Health Clinics
- Promotes access to care for SMI Target Population under Star Plus Managed Care Program; create a target population of SMI adults who are eligible
- Recommends establishing an Integrated Capacity Building Initiative: will expand access to primary, mental health, and SUD services as well as provide access to social determinants
- CMHCs will continue match to draw local funds
Methodist Healthcare Ministries
- Recommend that uninsured population is addressed after 1115 expires
- Healthcare providers, particularly rural ones, will lose significant amounts of money from this transition
- State leadership should not support HHSC’s Proposed Termination of Crucial HTW Policies such as Auto-Enrollment, Adjunctive Eligibility, and the Simplified Application Form
- Recommend HHSC consider providing technical training and assistance to HTW providers as they make the transition to MAGI
- Supports continuation of reimbursement for healthcare providers to subsidize application process with regards to HTW
- Recommends women have 90 days rather than 40 to submit proof of eligibility by implementing post verification enrollment
National Association of Social Workers
- Recommends the next steps listed in HHSC Behavioral Health Workforce Workgroup report to improve the mental health and substance use workforce across the state” be considered in the interim report
- Recommends extension of postpartum Medicaid coverage from 2 to 12 months
- HTW needs sufficient resources to provide mental health and substance abuse services
- Suggests raising rates on substance use disorder providers and bolster programs financially that work with maternal populations
- Urge a one-year extension of the DSRIP program; will not be a cost to GR but will ensure public health
- Recommend seeking CMS flexibility to keep $2.49 million available in DSRIP funding
- Hesitance to go to and reopen clinical facilities both decreases the revenues and impacts health of patients
- Because of COVID-19, state does not have facilities to implement a brand-new program; do not have enough information on the virus to make an informed strategy for the future
- Suggest they use available budget neutrality to support an integrated, local care system for Texans
- Could pilot value-based integrated coverage programs that partner with community-based organizations
- Texas should maximize federal funds to insure more Texans
- Lack of adequate insurance contributes to racial health disparities
- Medicaid will save the state general revenue, take pressure off property tax, reboot the economy, and help rural hospitals
- importance of Medicaid for essential workers
- Medicaid directly correlates to children’s insurance rate and facilitates the benefits that preventative care provides
- Medicaid has been successful in other states and is supported by Texans
Texas Alliance of Boys and Girls Clubs
- “Positive Action” program aims to prevent vulnerable child population from doing drugs; uses education, prevention, and intervention to address the opioid crisis
Texas Association of Community Health Centers
- Recommends examining and investing in primary care innovation models such as federally qualified health centers
- Recommends flexible practice to allow value-based payments and alternative payment models
- Should be greater data sharing between state, providers, and health plans
- Enabling services at FQHCs can reduce access to care barriers and address social determinants of health to increase utilization of primary and preventive care
- Recommends Trauma Informed Care for Medicaid populations; addresses events such as homelessness and school shootings through prevention and early treatment
- Recommends conducting a study on how to address social determinants of health in MEDICAID and CHIP programs
- Recommends Texas ensures continuation of funding for programs funded through the 1115 waiver and DSRIP
- Should draw down “millions in federal funds” to expand Medicaid to the uninsured/low-income
- Recommends monitoring HTW Plus to ensure proper implementation
- Due to 5% COVID-19 related budget cuts, concerned about revised plan to reduce enrollment and eligibility workers; will lead to delays in enrolling pregnant women/other HTW applicants
Texas Association of Health Plans
- Need to transition to managed care
- Opposes the loss of Medicaid eligibility for mothers 60 days after birth
- Requests that HTW Plus and all HTW programs be implemented with managed care rather than a fee for service charge
- Recommends implementation of care coordinators to provide education, advocacy, and connection with providers for patients
- Recommends addressing social determinants of health and examining the “whole person “in regard to their level of access to food, education, housing
Texas Conservative Coalition Research Institute
- Recommends preserving the 1115 waiver rather than expanding Medicaid; it allows expanded access to care while rewarding positive outcomes and not enrolling the uninsured in an entitlement program
- Recommends that lawmakers define priorities for any new directed payment models: projects should have measurable outcomes rather than “number of patients served” target
- Recommends lawmakers focus on projects that support Medicaid enrollees and the indigent; highlights that the waiver has paid billions unpacifically, even to those not in need
- Recommends lawmakers gain more information on funding pools where all state and federal funds are being paid out
- Recommends the Human Resources Code which prohibits abortions remains intact
- Approves waiver that upholds HTW
Texas Council of Community Centers
- Commends the impact of DSRIP on programs/advancements for the mentally ill
- Viable DSRIP transition program includes: creation of a target population of uninsured with SMI, associated value-based payment program and access to CHBCS
- Requests one-year DSRIP extension; community centers provide vital care
- Deterrents to effective administration of the Medicaid Program include:
- Change to definition of “public funds” does not account for complexities of states’ delivery systems
- “Totality of circumstances” and net effect language is excessively vague
- Sunsetting of financial mechanisms after 3 years will create administrative burden and planning difficulties
Texas Healthcare and Bioscience Institute
- Supports Medicaid and the 1115 Transformation Waiver
- Supports 1115 waiver, particularly the flexibility and innovation associated with it
- Requests HHSC ask CMS to expand DSRP one more year, particularly in the wake of COVID-19
- Lists needs for the Texas Healthcare Safety Net:
- Ensuring access to care for the uninsured
- Building DSRIP successes into existing Medicaid managed care structures
- Preserving and maximizing federal payments for hospitals and other providers
- Rewarding collaboration and partnerships among local providers
- Recommends HHSC share budget neutrality calculations to determine impact of changes going forward
- Correlation between COVID-19 job loss and loss of job-paying health insurance
- Opposes CMS’ proposed Medicaid Fiscal Responsibility Rule; should not shift the rule for financing non-federal share of Medicaid payment
- Supports one-year expansion of 1115 Healthcare Transportation and Quality Improvement Waiver with an emphasis on DSRIP
- Waiver was built on hospital-centric care rather than community-centric community based accountable care organization
- Recommend a pilot of the ACO in at least one rural and one urban region
- Recommend ACO based on following values: to reduce health disparities, to leverage a primary care foundation, to promote collaboration with Medicaid managed care, to reward patient outcomes, to support information exchange
- Deterioration of Medicaid will harm all patients, not just beneficiaries; Texas must reduce uninsured population
- Recommends restructuring RHPs to emphasize local governance
- Should use federal dollars to create statewide healthcare coverage with emphasis on the following initiatives:
- Reduce premiums for those who have marketplace plans
- Provide 12-month postpartum care for women
- Extend Medicaid to uninsured working age adults
- Establish 12-month continuous care for children enrolled in Medicaid
- Need to ensure that HTW can still provide continuous care as it switches to a Medicaid Initiative
- Recommends state revisit elimination of HTW auto-enrollment, adjunctive eligibility for women applying to HTW, and simplified HTW application form
Texas Policy Evaluation Project
- Does not support new HTW eligibility and enrollment principles
- Recommends an improved the administrative renewal process
- Recommends implementation of post verification enrollment
- Recommends maintenance of funding for enrollment and eligibility staff
- Recommends negotiations with CMS for adjunctive eligibility
- HTW Plus is a beneficial program; if it does not get waiver approval, it would need to draw from GR which siphons money away from HTW itself
- Recommends that the Legislature vote to expand Medicaid; there are “vast” numbers of uninsured Texans
Texas Women’s Health Coalition
- Recommends HHSC not terminate the following crucial policies: auto enrollment, adjunctive eligibility, and simplified applications
- Should: improve the administrative renewal process, reestablish post enrollment verification, request a waiver amendment for adjunctive eligibility, and maintain a streamlined HTW application and funding
- Elimination of these policies will adversely affect cost savings for the state
- Highlights the need for provider network for HTW Plus services
- Texas Family Planning services provide vital but limited services; requests implementing the following services:
- Requests 12 months Medicaid coverage for mothers
- Requests drawing down Medicaid funds for low income Texans
- Requests exploring available revenue solutions rather than a 5 percent budget cut
- Requests protecting the family planning program
University of Texas Rio Grande Valley
- Supports the DSRIP program under 1115
- As the state considers transition, need a model that sustains initiatives for the Medicaid and uninsured population
Women’s and Men’s health Services of Coastal Bend
- Recommends HHSC not terminate the following: auto enrollment, adjunctive eligibility, and simplified applications
- Proposes improving the administrative renewal process, reestablishing post enrollment verification, requesting a waiver amendment for adjunctive eligibility, and maintaining a streamlined HTW application/funding
- Highlights the mental health initiatives under Waiver 1115
- Should renew 1115 Healthcare Transformation and Quality Improvement Waiver
- Recommends Texas expand Medicaid if waiver is retired
- Recommends higher education institution inform women about available health and family planning mechanisms through electronic notification