1. Medicaid Transformation Project Demonstration
On behalf of the HCA and DSHS, thanks for letting us be here with you today to talk about the demonstration.

2. Healthier Washington
It’s important to remember the larger initiative that this demonstration sits under, Healthier Washington. Essentially, Healthier Washington encompasses all the work happening at HCA and around the state that is transforming the health system to reward high-quality care, focus on whole-person health, and empower local communities to tackle their local health needs.

3. Effective through December 31, 2021
How we got here
State Innovation Model design grant
February 2013
Governor Request legislation
2014
State Innovation Model testing grant
December 2014
MTP concept paper
May 2015
MTP application
August 2015
MTP approved
January 2017
Effective through December 31, 2021

4. Legislation supporting transformation
Washington enacted legislation furthering delivery system reform:
HB 2572 (2014): Value-based purchasing reform; increasing transparency; empowering communities, standardized performance measures
SB 6312 (2014): Whole-person integrated managed care by 2020
2ESHB 2376 / Subsections 213 (1)(d-g) (2016): Appropriation for Medicaid transformation demonstration waiver initiatives
HB 2572: Transforming the Health Care Delivery System
Increase value-based contracting, alternative quality contracting, and other payment incentives that promote quality, efficiency, cost savings, and health improvement for Medicaid and public employee purchasing.
Develop and implement a process for designating communities of health
SB 6312: Fully integrated Medicaid managed care
By January 1, 2020, the community behavioral health program must be fully integrated in a managed care health system that provides mental health, chemical dependency, and medical care services
Medicaid managed health care contracts shall include process to incentivize integration of behavioral health services in the primary care setting.
Incentive payments to counties which elect to become early adopters by April 1, 2016
2376: Appropriation for Medicaid Transformation Demonstration Waiver Initiatives
Initiative 1: Transformation through accountable communities of health
Initiative 2: Tailored support for older adults and Medicaid alternative care
Initiative 3: Foundational Community Supports

5. Special Terms and Conditions (STCs)
The contract between the state and the Centers for Medicare and Medicaid Services (CMS)
Enables Washington to operate this demonstration
The information contained in the STCs outlines the conditions and limitations of the demonstration
We have agreed upon Special Terms and Conditions with the Centers for Medicare & Medicaid Services. The Special Terms and Conditions set the “rules of the road” over the course of the five-year demonstration.

6. Medicaid Transformation demonstration

7. Who Medicaid serves Apple Health covers 1.9 million individuals
600,000 newly eligible adults under Medicaid expansion
Populations served include children, pregnant women, disabled adults, elderly persons, and former foster care adults

8. People served in your region Better Health Together
32% of region covered by Medicaid
186,531 individuals
56% Adults
44% children
66,183 are newly eligible adults
33% with identified mental illness need
12% with identified substance use disorder treatment need
61% well-child visits (ages 3-6)
This is the kind of information that will help the ACHs set priorities in their regions. HCA is committed to making data available to regions to help them make decisions about the projects they want to take on.

9. Medicaid in your region North Sound Accountable Community of Health

10. Medicaid transformation goals
Over the five-year demonstration, Washington will:
Integrate physical and behavioral health purchasing and service delivery
Convert 90% of Medicaid provider payments to reward outcomes
Support provider capacity to adopt new payment and care models
Implement population health strategies that improve health equity
Provide targeted services that address the needs of our aging populations and address the key determinants of health
Goals over the next five years all focus on moving from a volume-based health system to a value-based health system. This includes addressing social determinants of health, incentivizing providers to deliver quality over quantity, and rewarding better health outcomes.

11. 5 years from now Current system Transformed System
Fragmented care delivery
Disjointed care transitions
Disengaged clients
Capacity limits
Impoverishment
Inconsistent measurement
Volume-based payment
Transformed System
Integrated, whole-person care
Coordinated care
Activated clients
Access to appropriate services
Timely supports
Standardized measurement
Value-based payment
The long-term vision of the demonstration is that we have a system that works best for those who are served by it.
Current system:
Fragmented clinical and financial approaches to care delivery
Disjointed care transitions
Disengaged clients
Capacity limits in critical service areas
Individuals impoverish themselves to access needed LTSS
Inconsistent measurement of delivery system performance
Volume-based payment
Transformed system:
Integrated systems that deliver whole person care
Coordinated care transitions
Activated clients
Optimal access to appropriate services
Timely supports delay or diver need for Medicaid LTSS
Standardized performance measurement with accountability for improved health outcomes
Value-based payment

12. Elements of the demonstration
The demonstration has 3 key initiatives:
Transformation through Accountable Communities of Health
Long-term Services and Supports
Foundational Community Supports and Services
We want to take some time to explain in more detail the three major elements of this demonstration.

13. Delivery System Reform Program

14. A regional approach ACHs play a critical role:
Coordinate and oversee regional projects aimed at improving care for Medicaid beneficiaries.
Apply for transformation projects, and incentive payments, on behalf of partnering providers within the region.
Solicit community feedback in development of Project Plan applications.
Decide on distribution of incentive funds to providers for achievement of defined milestones.
ACHs play a critical role in overseeing transformation projects in their communities. They are responsible for managing and coordinating partnering providers, those traditional and nontraditional providers that have made a commitment to these projects in order to move the needle in health transformation. ACHs, as the conveners in their communities, help determine how these projects will be carried out.
-ACHs are responsible for managing and coordinating partnering providers.

15. The Project Toolkit Care Continuum Community Priorities
Financial Sustainability through Value-Based Payment
Workforce
Systems for Population Health Management
Care Continuum
Community Priorities
Domain 1: Health Systems and Community Capacity Building
Financial sustainability through value-based payment
Systems for population health management
Domain 2: Care Delivery Redesign
Bi-directional integration of care and
primary care transformation
Community-based care coordination
Transitional care
Diversion interventions
Domain 3: Prevention and Health Promotion
Addressing the opioid use public health crisis
Maternal and child health
Access to oral health services
Chronic disease prevention and control
There are three domains – Domain 1 is the foundational layer for each of the project areas. They’re the elements that should be considered when planning projects.
Within Domain 2, Bi-directional integration of care is required.
Within Domain 3, addressing the opioid use public health crisis is required.
There are a total of 4 required projects – 2 already identified, and 2 determined by regions

16. Resources and relationships
Domains and Projects should not be implemented in isolation from one another.
Projects will be highly interrelated and interdependent
Transformation projects must:
Be based on community-specific needs for the Medicaid population
Avoid redundancy and duplication
Regional projects will be assessed based on achievement of defined milestones and metrics.
ACHs don’t have to start from square one.
-Leverage existing resources, optimize existing beneficiary-provider relationships
-While if you look at the toolkit, it might be easy to think of projects as its own initiative siloed off from others, but they are not meant to be separate. Need to identify links to other community priorities, working together.
-Where is there the opportunity to make the most progress?
-Focus on areas where there is work to be done.

17. Project milestones
Project planning progress milestones – “Pay for Planning”
Initial planning activities and partnerships that establish foundational structure and capacity for transformation project goals
Project implementation planning – “Pay for Reporting”
Action steps taken by participating providers specified in the project’s initial planning activities
Scale and Sustain – “Pay for Outcomes”
Demonstrable progress towards project outcomes made by participating providers due to the implementation of the project plan
Three categories of milestones can trigger incentive payments under a transformation project

18. Independent assessor
State-contracted vendor
Will serve as independent assessor for delivery system reform activities under the demonstration
The state will develop the tool that the vendor will use in evaluating project plans.
Cannot have an affiliation with Accountable Communities of Health or their partnering providers
Independent assessor responsibilities
Reviewing Accountable Communities of Health Project Plan applications
Providing recommendations to state regarding approval, denial, or recommended changes to ACH Project Plans
Assessing project performance throughout the demonstration
The independent assessor is not the same state-contracted vendor as the financial executor

19. What to expect in Year One
Protocol development
ACH certification process
Phase 1
Phase 2
ACH project plan development and submission
Independent assessor review/approval of project plans
State procurements for vendors
It will be a busy next five years.
Currently we’re in protocol development – all of the elements that HCA will provide to CMS within the next 60 to 120 days.

20. Long-term Services and Supports

21. Unprecedented demand for LTSS
Projected Growth of Older Population in WA State as % of 2012 Population
Washington is a national leader in providing LTSS that help people remain in their homes and communities – but our population is aging.
We will continue to provide more intensive services to those who need them, but we must prepare for the “age wave” by testing new services that support unpaid family caregivers and provide targeted supports to people who may or may not qualify for Medicaid.

22. Caregiving: Impacts on family
In Washington State, approximately 80% of the care statewide is provided by family members and other unpaid caregivers
Unpaid caregiving has an economic impact on families:
Loss of earning potential
Decreased savings for retirement
Impacts on ability to provide for their own children’s needs
Increased health care costs due to stress and burden
If just one-fifth of unpaid caregivers stopped providing care, it would double the cost of long-term services and supports in Washington
The LTSS System of the Future Must:
Provide effective services for individuals before they spend down to Medicaid
Provide effective supports to unpaid family caregivers
Promote the right service at the right time and place
Have the capacity to meet the needs of a growing population
Strategically target LTSS Medicaid investments to slow the growth rate of public expenditures

23. Services designed to delay & divert need for more intensive interventions
Medicaid Alternative Care (MAC)
A new choice designed to support unpaid caregivers in continuing to provide quality care
Tailored Supports for Older Adults (TSOA)
A new eligibility group to support individuals who need Long-term Services and Supports and are at risk of spending down to impoverishment
Number of individuals served at full ramp up (based on model):
TSOA 4200
MAC 2800
Total population approximately 8000 clients
Benefits:
Caregiver Assistance Services: Services that take the place of those typically performed by unpaid caregiver.
Training and Education: Assist caregivers with gaining skills and knowledge to care for recipient.
Specialized Medical Equipment & Supplies: Goods and supplies needed by the care receiver.
Health maintenance & therapies: Clinical or therapeutic services for caregivers to remain in role or care receiver to remain at home.
Personal Assistance Services: Supports involving the labor of another person to help recipient (TSOA only).

24. Medicaid Alternative Care (MAC)
A new benefit package that will:
Provide support for unpaid family caregivers who support individuals eligible for Medicaid but not currently accessing Medicaid-funded LTSS
Provide necessary supports to unpaid caregivers to enable them to continue to provide high-quality care and focus on their own health and well-being
An alternative to traditional Long-term Services and Supports:
Unpaid family caregiver support to Medicaid-eligible individuals who choose it
No estate recovery
Earlier interventions decrease health impacts to caregivers and allow individuals to stay at home longer.
Financial supports decrease financial burden on the family.

25. Tailored Supports for Older Adults (TSOA)
A new eligibility group that will:
Provide a benefit package for individuals at risk of future Medicaid LTSS use
Help individuals and their families avoid or delay impoverishment and the future need for Medicaid-funded services while providing support to individuals and unpaid family caregivers
Offering help earlier:
Higher asset levels enable individuals to access services earlier without spending down to Medicaid levels ($53,100).
No estate recovery
Earlier interventions decrease health impacts to caregivers
Financial supports decrease financial burden on the family
TSOA offers a small personal care benefit to individuals without an unpaid caregiver who would not otherwise be eligible.

26. Implementation Currently we are engaged in:
Ramp up work including preparing eligibility, assessment, and payment systems
Financial WAC – Public comment March 2017
Development of client materials – April 2017
Program WAC – Public review May 2017
Implementation July 1, 2017

27. Foundational Community Supports (FCS)

28. Foundational Community Supports
What it is
Targeted Medicaid benefits that help eligible clients with complex health needs obtain and maintain housing and employment stability.
Supportive housing services
Supported employment services
What it isn’t
Ongoing payments for housing, rent, or room & board costs
Wages or wage enhancements for clients
Entitlement
Foundational Community Supports are not an entitlement; rather, support is targeted to those with the greatest and most immediate needs

29. Supportive housing Community Transition Services (NEW)
One-time supports for individuals transitioning out of institutions or at imminent risk of becoming institutionalized
Includes rental deposit, move-in costs, necessary furnishings and other necessary supports
Community Support Services
Housing assessment and development of a plan to address barriers
Assistance with applications, community resources, and outreach to landlords
Education, training, coaching, resolving disputes, and advocacy
Supportive housing services do not include funds for room and board or the development of housing.

30. Supported employment Individual Placement and Support (IPS) model
Principles of supported employment:
Open to anyone who wants to work
Focus on competitive employment
Rapid job search
Client preferences guide decisions
Individualized long-term supports
Integrated with treatment
Benefits counseling included

31. What’s new? – Third Party Administrator
Single administrative entity for supportive housing & supported employment
What is a Third Party Administrator (TPA)?
A single, statewide entity responsible for contracting with providers and authorizing and distributing service payments
What does it mean?
Services will no longer be administered by multiple systems
Services and target populations remain the same
There are a few notable, but positive, changes in the FCS program since approval, notably that supportive housing and supported employment are to be framed as Home and Community Based services (or HCBS), which are typically allowable under different Medicaid authorities, including 1915c waivers and 1915i state plan amendments. This still gives us the authority we need to provide the services, plus it allows for the Community Transition Services mentioned earlier.
In addition, we have decided to change our administrative approach to a single administrative entity, or Third Party Administrator, for both supportive housing and supported employment benefits. We believe this will streamline funds flow and administration, as well as better support the transition to a sustainable model by the end of the demonstration.

32. Initiative 3: Medicaid funds flow – previous model
HCA
MCOs
SH/SE – Physical Health Conditions
BHA
BHOs
SH/SE – Behavioral Health Conditions
ALTSA
HCS/AAAs
SH/SE - LTSS
Tribes
SH/SE – Tribal Members
Program oversight
Payer
Some of you may be familiar with this slide. This represents the previous model that we are no longer pursuing
Provider 32

33. Initiative 3: Medicaid funds flow – current model
HCA – DBHR – ALTSA
TPA
SH/SE – CBOs
SH/SE – Health care providers
SH/SE – Comm. BH agencies
SH/SE – LTSS providers
SH/SE – Tribal providers
Program Oversight
Benefits administrator
This funds flow model represents the current approach. It remains a joint effort across HCA, DBHR and ALTSA, with a single TPA administering the benefits. HCA will hold the contract with the TPA, while DBHR and ALTSA will lead network development and provider support.
Provider 33

34. Foundational Community Supports Next steps
Foundational Community Supports protocol
Protocol must be approved before services can be provided
TPA
Procurement will begin shortly
State rules
Will be sent out for external review soon
Webinar: March 10 at 10 a.m.
Register online at

35. What’s Next?

36. Implementation timeline
This snapshot of implementation includes both state and ACH responsibilities.
State Responsibilities include:
Protocol development defined by STCs
Fund flow/Incentive Payment methodology
Finalize Project Toolkit
Project Plan Application Template
Procure necessary vendors
Develop “How to Guides”
Strategic support for ACHs to guide project plan development
Finalize benefit specifications for initiatives 2 and 3
ACH Responsibilities include:
Completion of certification process/criteria
Developing project plan application
Authentic community/consumer engagement
Adoption of tribal engagement protocol

37. Learn more at www.hca.wa.gov/hw
Communications Library features:
Demonstration video
Fact sheets
Timeline
Presentation slide deck
How to prepare: Engage, Inform, Communicate
We recognize that you have questions and you have your own stakeholders to communicate with. To meet this need, we have prepared a Communications Library. You can access the library right now by visiting our website hca.wa.gov/hw
From our website you can download our video, fact sheets, the timeline and more. This is designed to be your direct line to resources to help you with engagement.

38. Send questions to: medicaidtransformation@hca.wa.gov
Join the Healthier Washington Feedback Network. Sign up at: hca.wa.gov/hw
Send questions to:
Thank you for participating today. Please join our feedback network to stay in-the-know about Healthier Washington. 38