1115 WAIVER Utah Department of Health Division of Medicaid and Health Financing 1Chacon

 The primary goal of Utah’s reform is to significantly reduce the rate at which Utah Medicaid expenditures are increasing each year.  To align incentives in such a way that the delivery patterns move away from billable events and focus more on patient outcomes and quality of care. 2Chacon

 Utah has a 1915(b) Freedom of Choice, Waiver, Utah Choices of Health Care Delivery Program which has been in place since  Current waiver requires enrollees to make a plan choice in the four most populous counties of the state or be assigned to a plan.  Pharmacy, mental health services, transportation and dental are carve outs. 3Chacon

 Requires submission of a waiver proposal to CMS by July 1,  Grant’s preferential funding consideration when expenditures are less that appropriated funding or historical expenditures. 4Chacon

 Allows the residual amount to be deposited in a new “Medicaid Growth Reduction and Budget Stabilization Account.”  Requires the State to implement the waiver within the fiscal year following approval by CMS. 5Chacon

 Accountable Care Organization Model  Risk Adjusted, Capitated Payments  Funding and Special Considerations  Budget Management Strategy 6Chacon

 Out of Network Payment Limitations  ACO Scope of Benefits, Pharmacy  Quality of Care Standards  Individual Accountability and Responsibility 7Chacon

 Client Incentives  Premium Subsidy Option  Prioritizing Services- Oregon Model  State’s four most populous counties: Salt Lake, Davis, Utah and Weber. Chacon8

 Psychotropic medications  Mental health services  Substance abuse services  Emergency and non-emergency Transportation  Dental  Long term care services 9Chacon

 Less than 3 months eligibility  Retroactive eligibility  Medicaid Spend down Cases  Utah State Hospital and Utah Developmental Center Residents  Primary Care Network Program  H.O.M.E. Program Chacon10

 More Detail on Medical Home Model  Emphasis on prevention may overshadow chronic disease management  Concerns regarding coordinated case management services for disabled populations  Cost sharing Chacon11

 Objections to premium assistance options for State plan populations  Prioritized service list and concerns regarding rationing of care- Oregon Model Chacon12

 Utah is meeting with CMS on a weekly basis  Goal- Approval from CMS no later than December 31, 2011  Implementation- July 1, 2012 Chacon13