This week, our In Focus section reviews the new guidelines issued by the Centers for Medicare & Medicaid Services (CMS) on expediting the approval process for Medicaid waivers and state plan amendments (SPAs) and improving quality, accessibility, outcomes, and transparency. The guidelines, titled Section 1115 Demonstration Process Improvements and State Plan Amendment and 1915 Waiver Process Improvements to Improve Transparency and Efficiency and Reduce Burden were released on November 6, 2017.
1115 Waivers
CMS is seeking to improve the 1115 Medicaid demonstration waiver process to facilitate expedited approval of demonstrations. Under the Trump administration, which promised increased flexibility to states, states have submitted applications to expand Medicaid, many including work requirements, premiums, and other conditions. However, most of the waivers have not been acted on, while others have been left to expire or have been withdrawn. Currently, there are 38 submitted 1115 waivers pending CMS approval. To expedite the waiver process, CMS will employ the following strategies:
Reduce Burden
- Streamline and simplify the Demonstration Application
- Work with states to develop a timeline for the approval process
- Standardize approved Special Terms and Conditions (STC) language across similar demos, focusing on specific milestones, performance metrics, benchmarks, and anticipated outcomes
Increase Efficiency
- Develop parameters for expedited approval of demonstrations similar to those approved in other states
- Provide technical assistance to states
- Approve the extension of routine, successful, non-complex section 1115(a) waiver
- Offer virtual working meetings with states to review and clarify STC language
- Support states to use fast track process through a streamlined review process for demonstration extension requests in timeframes similar to Medicaid section 1915 waivers or State Plan Amendments with an abbreviated application template
- Remove the requirement that states must have had at least one full extension cycle without substantial program changes
Promote Transparency
- Offer technical assistance to states considering changes to their Medicaid programs
- Share a working list of open issues with states during demonstration review process
- Work with states to determine whether waivers may be available instead of or in combination with section 1115
- Help states identify any other federal funding sources
- Clarify expectations and provide guidance on policy and methodology for demonstrating budget neutrality
- Standardize budget neutrality STCs
Monitoring and Evaluation
- Improve and standardize measurement sets to facilitate state data development, collection, and reporting capacity
- Strengthen state evaluation designs
- Implement a State Technical Advisory Group (TAG) of experts to advice CMS on monitoring and evaluation processes
- Reduce the number of monitoring reports for all demonstrations by combining the fourth quarterly reports with annual reports
- Generate general evaluation design and evaluation report guidance for all section 1115 demonstrations
State Plan Amendments and 1915 Waivers
State plan amendments (SPAs) describe how a state administers its Medicaid and CHIP programs, including details such as eligible individuals, services, methodologies for provider reimbursement, and administrative activities. As with the 1115 waivers, CMS currently has a backlog of 350 SPAs and 1915 waivers due to unanswered requests for additional information (RAIs). The average pending time of SPAs is two years. CMS conducted an extensive review of SPA standard operating procedures to better understand the factors impacting the processing time and identify areas for increased consistency and enhanced efficiency. CMS will implement the following strategies for SPA and 1915 waiver process improvements:
- Contact states within 15 days of receipt of each new SPA or section 1915 waiver submission to discuss the intent of the submission and any critical timelines
- Provide states with an SPA and 1915 waiver toolkit consisting of preprints, templates, checklists and other guidance
- Reduce the current backlog by providing states a comprehensive list of their SPAs and work to resolve the amendments
- Expand MACPro, a web-based system for the submission, review, and disposition of SPAs, to additional SPA authorities
- Review the proposed changes and provisions as soon as an SPA is submitted
- Develop other short and long-term strategies in the future