Transforming Illinois Health Care

Illinois Medicaid 1115 Waiver

Transforming Illinois Health Care

State’s Vision to Achieve Triple Aim Transform Illinois’ Medicaid program and health care

delivery system

Transition from fee for service system to an integrated,

patient-centered delivery model

Strengthen community based & primary care infrastructure

Empower providers to manage care and incentivize quality

and improved patient outcomes

Transforming Illinois Health Care

Illinois hospitals have the infrastructure to bring together a

wide range of providers

Accountable Care Entities

Unique to Illinois

Established by IL law in 2013

Provider owned and operated

A group of doctors and hospitals; not an insurance company

Doctors and hospitals within an ACE are connected to easily share information

Responsible for all care provided

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What is a Medicaid 1115 Waiver?

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Allows states to apply for program flexibility from the Centers for Medicare & Medicaid Services to test new approaches to financing & delivering Medicaid

Provides incentives to providers to develop new models of care Lasts five years, but can be renewed/amended Must be budget neutral, leading to overall savings

Our State’s Waiver Application

Called the Path to Transformation Waiver

Four Pathways to Transformation

State

Waiver

Application

6Pathway 4Pathway 1 Pathway 2 Pathway 3

Goals:

Better Health Outcomes Lower Costs

Delivery System

Transformation

Population Health

Workforce

Home- & Community-

Based Supports

1st Pathway: Delivery System TransformationWaiver promotes care coordination & integrated delivery system development

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Hospital performance & integration pool

Institution transition pool

Access Assurance Pool

Innovation and transformation resource center

Public hospital pool

Delivery System

Transformation

2nd Pathway: Population Health

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Fund regional public health collaboratives

Expansion of maternal-child home visitation program

Population Health

3rd Pathway: Workforce

Strengthen the state’s health care workforce Provide incentives for training

physicians

Funding for loan repayment programs

Safety Net and Critical Access Hospital loan program

Establish training and certify community health workers

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Workforce

4th Pathway: Home & Community-Based Supports

Consolidation of nine existing home- & community-support waivers

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Home- & Community-

Based Supports

Increase funding & uniformity in benefits

Increase capacity of care provided in the community

Behavioral health expansion & integration

Challenges

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Many needs Limited fundingNegotiatons with CMS will determine final funding allocations.

Incentive pools, workforce, behavioral health home, transformation resource center, and public health integration provisions are critical for hospitals and continued transformation.

Waiver often has general descriptions of proposals. Will need provider input when finalizing details.

Incentive funding provisions need to have realistic expectations.

How is a Waiver Financed?

Costs Not Otherwise Matchable (CNOM) One of the most powerful provisions in Section

1115 allows CMS to grant approval of Costs Not Otherwise Matchable or CNOM

Includes services not normally qualifying as Medicaid expenditures

Must be budget neutral

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Budget Neutrality Under 1115 Waiver

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CNOM counts toward budget neutrality gap

Waiver Examples Aligned With Hospital Transformation Efforts

1115 Waiver Payments and Initiatives

Integration & Incentive Pool

Institution Transition Pool

GME funding

Loan forgiveness

Community-Based Training and certification

Behavioral health homes

Integration with public health

Enhanced home and community supports

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What does Waiver Mean for Providers?

Financial & Technical Assistance to transform care models

Incentives for quality improvement, transformation and integration activities

Increased capacity for behavioral health referrals

Funding to recruit, train and retain qualified health care workforce

Better crisis, referral and discharge services

Model Test Grant- CMMI

$100 million- four years

Six integrated delivery systems

Public and private payer participation

Align quality metrics across plans

Linkages with community supports via public health

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How is state receiving input?

Alliance for Health Alliance Steering Committee

• All major stakeholders

Five workgroups

• Integrated Delivery System Reform

• Public Health Integration

• Workforce

• Data and Technology

• Services and Supports

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Conclusion

Waiver and Model Test are consistent with IHA goals

Key hospital provisions are critical to achieving waiver goals

Funding needs to reach providers

State can set criteria and standards

Rural health and health literacy needs can be enhanced

Waiver provides up-front investment for transformation

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