Section 1115 Demonstrations

1
Section 1115 Demonstrations

• Ryan White CARE Act Training and Technical
  Assistance
• Grantees Meeting
• August 28-31, 2006

2
The Social Security Act

• Social Security Act authorizes multiple waiver
  and demonstration authorities to allow states
  flexibility in operating Medicaid programs
  including the new Deficit Reduction Act of 2005.
• Each authority has a distinct purpose, and
  requirements.

3
Types of Authority

• Section 1915(b) Managed Care/ Freedom of Choice
  waivers
• Section 1915(c) Home and Community-Based Services
  Waivers
• Section 1115 Research and Demonstration Projects

4
Section 1115 Demonstration

• This section of the SSA provides the Secretary of
  Health and Human Services broad authority to
  approve projects that test policy innovations
  likely to further the objectives of the Medicaid
  Program.

5
Flexibility

• The flexibility allows states to test
  substantially new ideas of policy and merit.
• May demonstrate and evaluate a policy or approach
  that has not been demonstrated on a widespread
  basis.

6
Some State Initiatives

• Expand eligibility to individuals not otherwise
  eligible
• Childless Adults
• Provide services that are not typically covered
• Methadone Clinic Services
• Innovative Service Delivery Systems
• State Run Managed Care Organization

7
Types of Authority Requested

• Section 1115(a)(1)
• Allows the Secretary to waive provisions of
  section 1902 to operate demonstration programs
• Example -- 1902(a)(1) Statewideness

8
Types of Authority Requested

• Section 1115(a)(2)
• Allows the Secretary to provide federal financial
  participation for costs that otherwise cannot be
  matched under section 1903
• Example Expenditures for the employee share of
  authorized employer-sponsored insurance

9
Demonstration Time Frame

• Section 1115(a)
• Generally 5 years
• Section 1115(e)
• Renewal Request
• 3 years as specified in statute
• Section 1115(f)
• Renewal Request
• 3 years as specified in statute

10
Application Process

• There is no standardized format to apply for a
  section 1115 demonstration
• The application must be submitted by the single
  state Medicaid agency
• Promote the objectives of the Medicaid Program
• Be budget neutral over the life of the
  demonstration

11
Application Process

• Things CMS should see in an application
• Environment
• Administration
• Eligibility
• Benefits and Coverage
• Delivery System
• Access
• Quality
• Budget Neutrality/Financing Issues
• Systems Support
• Implementation Time Frames
• Evaluation and Reporting

12
Review Process

• Proposals are subject to review by the federal
  review team
• Additional information is usually required during
  the review process
• There is no specific time frame to approve, deny,
  or request additional information, except in the
  case of extensions

13
Florida Concept to Implementation

• PowerPoint Presentation of concept to CMS
• CMS provided initial knee-jerk reaction
• FL went back to the drawing board
• Interaction and technical assistance with the
  State went on for over a year

14
Why Request an 1115

• In SFY 2004-05 Florida spent over 14.9B to
  provide Medicaid services to 2.093M residents and
  equated to over 25 of the entire state budget
• Without any action Medicaid expenses could
  account for 59 of the States budget by the year
  2015
• Dissatisfied Customers

15
How did CMS Review?

• What CMS looked for
• Innovation
• Promote Objectives of the Medicaid Program
• Budget Neutrality/ Financing Issues
• Administration's Goals
• Personal Responsibility
• Promotes Market Place Competition
• Employer Sponsored Insurance
• Reduce the Rate of Uninsured
• Public Notice

16
Approval

• CMS approved the Florida Medicaid Reform section
  1115 demonstration on October 19, 2005.