Texas Well and Healthy

The following is PART 3 of a “Waiver Watch” series contributed by Anne Dunkelberg, Center for Public Policy Priorities.

Since my last Waiver Watch post:

  1. HHSC held a March meeting of their Executive Waiver Committee (EWC) working group for the Hospital waiver,
  2. The “Clinical Champion” working group has worked with HHSC to develop a draft menu of service/payment/delivery reforms, and
  3. The Legislature held a first hearing related to the other 1115, which we are calling the SB 7 waiver.

What follows are some high points, links, issues and questions that will need to be addressed:

1. The EWC Meeting:   

HHSC is meeting monthly with federal Medicaid officials at the Centers for Medicaid & Medicare Services (CMS).

Uncompensated Care: On March 1 HHSC sent a proposal to CMS for approval for how hospitals will be paid for uncompensated care and for the gap between Medicaid and Medicare payment rates—“the UC protocol”.  One challenge is figuring out how to cost out certain kinds of free care to the uninsured (doctors and pharmacy costs) that have not been part of the old “UPL” system that the waiver replaces.

Who Decides? It was re-emphasized that so-called “anchor” hospitals that serve as a central administrative hub for each Regional Healthcare Partnership (RHP) are not ‘Gatekeepers” who dole out the waiver funds or dictate the roles of other RHP partner hospitals and entities.

However, there was discussion that if there are more partners and activities looking for waiver funding than there are local public matching dollars available to fund those projects, that SOMEONE will have to decide how the funds will be allocated.  HHSC staff acknowledged that this was an important issue for them to establish some policy on, but again said that the anchor hospital should not be put in the position of making those calls.

2. “Clinical Champion” Work Group Puts Forth “DSRIP” Reform Menu:
Clinical experts from across the state are helping HHSC develop a menu of required and optional reform elements for hospitals and RHPs to work and choose from.  Hospitals asked HHSC to get a draft out for review as early as possible, because input from beyond the working group members will be essential.

Members stated that the DSRIP pool funds should not be use to replace any current funding (no “supplantation”), but should be reserved for NEW investments.

Challenge: how to make DSRIP standards ambitious enough for the big urban systems, but still flexible enough to allow for the more modest capacities of rural hospitals.

Which Dollars are OK? A set of Legal principles for Intergovernmental Transfers from the HHSC Counsel is being reviewed by HHSC commissioner and should be share “soon”.

Who Does What? If the County Hospital is in the RHP, and anti-obesity investments are being funded, does the county hire the contractor to build a walking trail, or does the hospital?

County MHMR Centers/Authorities:  There is great interest in whether and how these entities (which typically have public funds that might be available for match), will be partners in the RHPs.  HHSC has acknowledged that they need to clarify policy on this sooner rather than later.

Be sure to check here for HHSC updates:  http://www.hhsc.state.tx.us/1115-waiver.shtml

3. The SB7 Waiver:
The 2011 Legislature also authorized a different 1115 waiver (article 13 of SB 7, special session), directing HHSC to seek exemption from federal minimum Medicaid eligibility, benefits, and co-pay standards.  (Confused?  Refer to our Waiver Watch #1: What’s up with Medicaid Waivers? Why Should I Care, and How to Keep Up? )

SB 7 created a special House-Senate committee for this project, and their first hearing was on 2/29.  You can watch the whole thing here, or see a list of who testified, and also check out agency presentations made at this hearing by HHSC and DADS.

HHSC emphasized that federal Medicaid  law does place some limits on what can be “waived” in federal law; that is, exceptions are not allowed to some federal Medicaid standards.  Both agencies indicated state and federal interest in new pilots to merge Medicaid and Medicare care management for seniors and Texans with disabilities who are on both programs , that is the “dual eligibles.”

Agencies and lawmakers greatest interest seemed to be in program changes for seniors and Texans with disabilities.  Agency officials indicated that making changes to the non-elderly Medicaid program would be more realistic after 2014, assuming implementation of the Affordable Care Act (ACA- health reform), which will make many of  the parents of the 2.6 million Texas children in Medicaid eligible for coverage for the first time.

CPPP testimony focused on the need for Texas and the US to reform health care across the entire system, not just Medicaid, because xix costs have actually grown more slowly than Medicare or the private sector.  The graphic below shows how the US spends dramatically more than any other industrialized nation  per citizen – even though we leave millions without access to care and have poorer health indicators than average. What’s Next?  My next “Waiver Watch” post will update you on draft documents and proposed policies for the Hospital waiver that HHSC has made public.  Stay tuned!

Contributed by: Anne Dunkelberg, Center for Public Policy Priorities

Last week, I promised to come up with shorthand names to help us distinguish between the two different Medicaid 1115 waivers. To avoid wonky acronyms, I’ve decided to call the new waiver that the feds approved in December 2011—formally named, “Texas Healthcare Transformation and Quality Improvement Program”—the “Hospital Waiver.”

Now, the OTHER 1115 waiver:

• was authorized in article 13 of Senate Bill 7 of the 82nd special session of the Texas legislature;
• directs Texas Medicaid to seek exemption from federal minimum Medicaid eligibility, benefits, and co-pay standards;
• at present, is only a concept, but has a newly-named Legislative Oversight committee with a first public hearing set for Wednesday February 29!

I will be calling this the “SB 7 waiver.”  This avoids calling it anything that indicates either opposition (like “block grant waiver”) OR support (like “reform waiver”).  At least for now, that seems the reasonable thing to do.

Consumer Eyes on the Hospital Waiver

As I reported last week, Texas HHSC asked staff of the CPPP to act as a consumer representative in their working group of mostly hospital representatives that meets monthly. Here are some newsworthy notes from the February 2 meeting:

  • Stanley Stewart, who some people may know from his successful oversight of the TIERS roll-out and the rescue of the HHSC eligibility system after its 2006-2009 melt-down, has been designated the project implementation director for the hospital 1115. Waiver policy development leads will still be Maureen Milligan and Bill Rago, under Texas Medicaid Director & Deputy Executive Commissioner Billy Millwee.
  • Timelines: HHSC wants to send a “menu” of reform project choices for Regional Health Partnerships (RHPs) to pick from to federal Medicaid authorities at the end of August 2012, and a list of the RHPs (what counties, which hospitals) by the end of October 2012.
  • HHSC has a group of “clinical champions” advising them on SERVICE/QUALITY/SAFETY/PAYMENT reform ideas and benchmarks that may go into the menu of options.
  • An important discussion seemed to clarify that the “anchor” hospitals – the ones that have local tax dollars to contribute to the waiver funding pool – will NOT be in the role of auditing or “policing” services by and payments to the partner hospitals. It is not yet clear who WILL audit to ensure partner hospitals really meet their goals.
  • Another discussion considered whether a private-for-profit hospital could participate and ONLY do Medicaid care and free care to the uninsured; that is NOT participate in the health delivery reforms. HHSC indicated that policy was not defined, but that clearly the anchor hospitals would have to agree.
  • HHSC said they will provide an option to sign up for email alerts when there is Hospital 1115 waiver news, but as of 2/20/2012 this does not appear to have been added to the HHSC web site. You can check here for HHSC updates.
  • Read a quick CPPP analysis of the waiver and key concerns here (page 4).

The Take-Away: Communities around Texas are holding stakeholder meetings about their ideas for their local Regional Health Partnership.

On behalf of the CPPP, I will be sending a recommendation to HHSC that all local RHP planning meeting announcements be shared with HHSC and posted at the HHSC website. If you or your organization agrees, you may wish to make a similar comment.

Contributed by: Anne Dunkelberg, Center for Public Policy Priorities

In December, federal Medicaid officials approved a Texas request for a Medicaid waiver officially named “Texas Healthcare Transformation and Quality Improvement Program.”  This waiver lets Texas Medicaid expand HMO-style care to more Texans without losing large federal payments to hospitals.  In return for keeping those federal dollars, Texas will re-purpose them into a fund to help pay hospitals for care for the uninsured, and help launch health reforms that move away from paying hospitals simply for volume of care, and toward payment that depends on better outcomes and safety, and more cost-effective care.

You can find all the official state and federal documents here and here.  Read the Center for Public Policy Priorities analysis of the waiver and key concerns here (page 10).

Consumer Eyes and Ears for this Waiver.  Texas HHSC (that’s Health and Human Services Commission for all non-wonks) has a working group of mostly hospital representatives meeting monthly, and CPPP was asked to send a staff member as a sort of informal consumer representative.  We will update fellow consumers on key information and issues from these meetings through regular emails and blog posts in the months to come.  Check back for a report on the 2/2/2012 meeting in the next few days.

BUT, another 1115 Waiver May be On the Way.  The 2011 Legislature also authorized a different 1115 waiver (article 13 of SB 7, special session), directing HHSC to seek exemption from federal minimum Medicaid eligibility, benefits, and co-pay standards.

Read CPPP analysis of this second proposed waiver and key concerns here (page 12).  See also testimony on HB 13.


A legislative oversight committee required in the SB 7 was just named and a hearing has just been posted for 9:00 AM, Wednesday, February 29, 2012.  See the Agenda and the Schedule.

Joint Committee on Oversight of Medicaid Reform Waiver (C885):

Sen. Jane Nelson

Rep. Garnet Coleman
Rep. Brandon Creighton
Sen. Bob Deuell
Rep. Lois W. Kolkhorst
Sen. Dan Patrick
Sen. Royce West
Rep. John Zerwas

Texans who care about kids health and the health care safety net in general will need to stay tuned for opportunities to get involved in this committee’s work and not-yet-known process Texas HHSC will take to develop a second 1115 waiver proposal. Meanwhile, we promise to come up with shorthand names to help us keep these two different waivers apart—by next week!

Contributed by: Anne Dunkelberg, Center for Public Policy Priorities