Washington State: CMS approves waiver to provide continuous Medicaid eligibility through age 6...with an odd catch

via the Centers for Medicare & Medicaid Services:

CMS Approves of State of Washington Medicaid Section 1115 Demonstration

April 14: CMS approved an amendment to the State of Washington's Medicaid section 1115(a) demonstration, titled “Medicaid Transformation Project." Approval of this demonstration amendment includes several improvements, like historic continuous eligibility for Medicaid children from the point they become eligible until they reach age six, regardless of income fluctuations or changes that would affect eligibility. The demonstration also expands the definition of transportation so eligible program participants can gain access to benefits, including community services and activities based on their service plan.

So far, so good; that's a pretty big deal, especially as we're in the middle of the Medicaid Unwinding process nationally.

However, there's a rather curious provision at the end of the announcement:

...The amendment is effective upon approval and will expire along with the demonstration on June 30, 2023.

Wait, what?? A Medicaid waiver that's only approved for 11 weeks?? What's up with that?

The only thing which makes sense to me is that this is a way for the state of Washington to ensure no coverage gap for families who get lost in the Unwinding redetermination shuffle--basically giving some extra coverage breathing room for them to work out any paperwork/administrative headaches.

Here's the the approval letter, but I'm not sure I see anything which provides any further insight as to the brief authorization. Even for a test run that seems like an absurdly short time window:

The Centers for Medicare & Medicaid Services (CMS) is approving an amendment to the section 1115(a) demonstration titled, “Medicaid Transformation Project” (MTP) (Project Number 11-W00304/0) (the “demonstration”), in accordance with section 1115(a) of the Social Security Act. Approval of this demonstration amendment will enable the state to change the definition of longterm services and supports (LTSS) transportation, revise the value-based payment (VBP) adoption targets for 2021 and 2022, and implement continuous eligibility for a defined group of children. This amendment is effective as of the date of this approval through June 30, 2023, upon which date, unless extended or otherwise amended, all authorities granted to operate this demonstration will expire.

CMS’s approval of this section 1115(a) demonstration, as amended, is subject to the limitations specified in the attached waiver and expenditure authorities, Special Terms and Conditions (STCs), and any supplemental attachments defining the nature, character, and extent of federal involvement in this project. The state may deviate from the Medicaid state plan requirements only to the extent those requirements have been specifically listed as waived or not applicable to expenditures under the demonstration.

Extent and Scope of Demonstration

Washington is expanding its definition of transportation for individuals who receive the Medicaid Alternative Care (MAC) and Tailored Supports for Older Adults (TSOA) LTSS benefit packages. The definition is changed to allow transportation in accordance with the participant’s service plan. Consistent with the definition of non-medical transportation under 1915(c) waivers, this service is offered in order to enable participants to gain access to community services, activities, and resources, as defined by the service plan.

Washington’s Delivery System Reform Incentive Payment (DSRIP) Program includes aggressive alternative payment model (APM) adoption goals for its state procurement of healthcare services, as well as financial incentives for Accountable Communities of Health (ACHs) and Medicaid managed care organizations (MCOs) to improve their VBP contracting levels. The state has established VBP contracting goals consistent with the Health Care Payment Learning & Action Network (HCP-LAN) APM Framework. Through this demonstration amendment, the 2021 and 2022 VBP adoption targets are adjusted from 90 percent to 85 percent. Washington has not distributed DSRIP incentive payments for the 2021 and 2022 performance years. Washington requests this adjustment in light of the effects of the COVID-19 pandemic on the state’s capacity to advance additional risk-based contractual arrangements.

With this approval, the state is able to provide continuous eligibility for Medicaid children from the time of initial eligibility determination until they reach age six, regardless of changes in circumstances that would otherwise cause a loss of eligibility. CMS is authorizing this continuous eligibility with the aim to support consistent coverage and continuity of care by keeping beneficiaries enrolled until they reach age six, regardless of income fluctuations or other changes that otherwise would affect eligibility (except for death or ceasing to be a resident of the state). The continuous eligibility policy is likely to assist in promoting the objectives of Medicaid as it is expected to minimize coverage gaps and to help maintain continuity of access to program benefits for young children, and thereby help improve health outcomes. Continuous coverage is also an important aspect of reducing the rate of uninsured and underinsured individuals.

Requests Not Being Approved at this Time

CMS and Washington are continuing discussions of the state’s pending request related to implementing a new presumptive eligibility (PE) process for a defined group of individuals. Washington requested to extend a PE process to individuals who are being discharged from acute care hospitals or psychiatric hospitals, or diverted from these facilities, and need to access home and community-based services (HCBS) under Medicaid state plan and 1915(c) waiver authorities. Under this proposal, the state or qualified entity will determine that the individual appears to meet functional and financial eligibility requirements. CMS is generally supportive of efforts to facilitate access to covered services in the most appropriate and least restrictive setting, and will continue to work with the state on this proposal.

Monitoring and Evaluation

Consistent with CMS requirements for all section 1115 demonstrations, and as outlined in the STCs, the state will be required to conduct comprehensive monitoring and evaluation of the demonstration amendment. The demonstration’s monitoring activities must support tracking the state’s progress toward meeting the applicable program-specific goals. Specifically, with this amendment, the state must undertake standardized reporting on categories of metrics including, but not limited to: beneficiary enrollment, quality of care, and health outcomes. For example, to monitor the continuous eligibility policy, the state must track and report enrollment and renewal metrics, utilization of preventative services (including vaccinations), and avoidable inpatient hospitalizations and nonemergent use of emergency departments.

With respect to the demonstration evaluation requirements, Washington will submit a revised Evaluation Design to include the amendment components to assess whether the demonstration amendment components are effective in producing the desired outcomes. For example, for the continuous eligibility policy, the state should assess how the continuous eligibility policy affects coverage, enrollment and churn (i.e., temporary loss of coverage in which beneficiaries are disenrolled but then re-enroll within 12 months) as well as population-specific appropriate measures of service utilization and health outcomes. The state must also evaluate how changing the definition of transportation for beneficiaries who receive the MAC and TSOA LTSS benefit packages enables participants to gain access to community services, activities, and resources.

Furthermore, to the best extent feasible, the state must collect data to support analyses stratified by key subpopulations of interest (e.g., by sex, age, race/ethnicity, primary language, disability status, sexual orientation and gender identity, and geography). Such stratified data analyses will provide a fuller understanding of existing disparities in access to and quality of care and health outcomes and help inform how the demonstration’s various policies might support reducing such disparities. Given that the new components of the demonstration have a limited period of implementation during the current approval period for the state’s demonstration, the evaluation design will accommodate as comprehensive an assessment of the demonstration’s progress as feasible within this time period.

Consideration of Public Comments

Washington provided public notice for this amendment submission in accordance with the processes described in the September 27, 1994 Federal Register notice (59 FR 49249) as generally acceptable methods of state public notice for demonstration amendments. CMS generally considers a state to have provided acceptable public notice for a demonstration amendment if the state follows one or more (if the state desires) of the processes described in the 1994 Federal Register notice.

The state conducted a 30-day public notice and comment period on the draft amendment proposal from November 12, 2020 to December 13, 2020. The state held two public hearings on the amendment proposal.

The federal comment period was open from April 1, 2021 through April 30, 2021. CMS received three comments. One comment expressed support for the PE and transportation components of the amendment. One commenter suggested modifications to the demonstration to support the needs of American Indian/Alaska Native (AI/AN) people, but they are not related to the amendment requests. The remaining comment was not related to the MTP demonstration.

The continuous eligibility for Medicaid children proposal was included in Washington’s extension application submitted on July 15, 2022. In accordance with federal requirements for section 1115 demonstration extension applications, Washington completed its state level public comment period from May 12, 2022 to June 13, 2022. The state held three public hearings on the extension proposal.

The federal comment period for the extension application was open August 1, 2022 through August 31, 2022. No comments were received related to continuous eligibility for children during the federal comment period.

After carefully reviewing the state’s requests of the public comments submitted during the federal comment period and the information received from the state, CMS has concluded that the demonstration, as amended, is likely to advance the objectives of Medicaid. This demonstration, as amended, will promote stable health care coverage for Medicaid beneficiaries.