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  4. The Path to Transformation: Illinois 1115 Waiver Proposal

The Path to Transformation: Illinois 1115 Waiver Proposal 

 

Table of Contents

  1. Description of Proposed Program
  2. Demonstration Eligibility and Enrollment
  3. Benefits
  4. Service Delivery Models
  5. Cost Sharing
  6. Public Notice and Input
  7. Approach to Budget Neutrality
  8. Approach to Evaluation
  9. Waiver and Expenditure Authority Requests
  10. Appendices

Description of Proposed Program

Background and Overview

Illinois’ Medicaid and All Kids programs have undergone tremendous change in recent years as the state implements improvements to enhance access and quality for beneficiaries while also controlling costs. As Illinois prepares to implement a major Medicaid expansion that will extend eligibility by 2017 to an estimated 500,000 individuals, through a combination of “newly eligible” adults and “already eligible” clients, the state is seeking additional flexibility in our Medicaid program to incentivize delivery system and payment innovation, increase access to community based options, and positively impact social determinants of health that are driving up health care costs.

The State of Illinois Department of Healthcare and Family Services, in cooperation with the Department of Children and Family Services, the Department on Aging, the Department of Human Services and the Department of Public Health, is seeking a five-year Medicaid and Children’s Health Insurance Program (CHIP) Section 1115 research and demonstration waiver that encompasses all services and eligible populations served under a single demonstration authority, with broad flexibility to manage the programs more efficiently and to align and coordinate programs around the triple aim rather than around traditional silos. We recognize that for our clients who live in poverty, social, cultural, environmental, economic and other factors are major causes of rates of illness and health disparities. Under this Path to Transformation waiver, Illinois Medicaid will reposition itself to directly tackle these multiple, challenging causes of ill health associated with poverty, with a renewed emphasis on the social determinants of health throughout all of our programs, services, policies and reform initiatives.

Through the Path to Transformation waiver, Illinois seeks to become a national leader in Medicaid payment and delivery system innovation, transforming from a fee-for-service system to an advanced system of care where patient outcomes and provider payments are aligned. Illinois, like many states, needs investment from the federal government to make the fundamental changes that are needed now in order to achieve the triple aim of better health, improved care delivery systems and lower costs. In order to make the changes outlined in this proposed waiver, Illinois is seeking substantial flexibility and additional federal investment in innovative strategies designed to increase access to care and incentivize the development of comprehensive, integrated delivery systems capable of taking responsibility for the health of a defined population.

Illinois’ Path to Transformation waiver represents the next critical step in reform efforts undertaken by the state in recent years, including the Governor’s Health Care Reform Implementation Council; the development of a statewide, comprehensive State Health Care Innovation Plan (Alliance for Health); a large-scale expansion of managed care across Medicaid eligibility groups; multiple coordinated efforts to improve access to home and community based services; the development of a statewide, secure electronic transport network for sharing clinical and administrative data among health care providers in Illinois and bordering states (ILHIE); and a major public health initiative to implement activities throughout Illinois that focus on tobacco-free living, active living and healthy eating, and fostering healthy and safe physical environments. Each of these reform efforts directly informed the content of this Section 1115 waiver proposal.

Illinois Health Care Reform Implementation Council

On July 29, 2010, Governor Pat Quinn signed Executive Order #10-12 to create the Illinois Health Care Reform Implementation Council, an inter-agency subcabinet that has been charting Illinois' multi-dimensional path toward ACA implementation. The Council continues to meet regularly and has issued recommendations to help guide the state in: establishing a health insurance exchange (also known as a Marketplace) and other pro-consumer reforms; reforming Medicaid; assuring high quality care; identifying federal grants and other non-governmental funding sources; fostering the widespread adoption of electronic medical records; and strengthening Illinois’ health care work force.

Expansion of managed care

Illinois is among the last of the major states with an unsustainable fee-for-service Medicaid system. Consequently, service delivery is often fragmented and uncoordinated. This is rapidly changing, however. Pursuant to P.A. 96-1501 (“Medicaid Reform”), signed into law in January 2011, Illinois must enroll at least 50% of its Medicaid clients into some form of risk-based coordinated care by January 1, 2015. Under Medicaid Reform, care coordination is defined broadly to include both traditional managed care organizations as well as provider-organized delivery systems that include risk-based payment methodologies.

HFS currently manages two capitated Medicaid managed care programs and an early expansion waiver program for individuals residing in Cook County, which was extended through March 31, 2014. The first is a voluntary program for children and parents (with enrollment of approximately 247,000) in 18 counties.1 The second program, known as the “Integrated Care Program” (ICP), is a mandatory program for non-dual seniors and persons with disabilities (SPDs). The program began in 2010 for individuals residing in the Chicago suburbs and collar counties surrounding Chicago and has an enrollment of approximately 39,500.2 Four additional regions were recently added to the ICP and are not reflected in this enrollment figure. Long-term services and supports (LTSS) were added to the ICP a year ago, making Illinois one of just a handful of states with an integrated managed acute and long-term care program. In early 2013, the State, in collaboration with the Cook County Board and the Cook County Health and Hospitals System (CCHHS) received an 1115 waiver to early-enroll approximately 115,000 individuals who will become eligible for Medicaid services in 2014. Under the “CountyCare” program, “newly eligible” are served by a provider network that includes both CCHHS and contracted network providers through a unique public-private partnership.

A third capitated program is just starting through the Medicare-Medicaid Alignment Initiative for dually eligible beneficiaries. Joint capitation rates will be paid by the State and federal governments to eight plans in two large regions of the state starting in February 2014.

1Illinois Department of Healthcare and Family Services, enrollment as of August 2013

2Illinois Department of Healthcare and Family Services, enrollment as of August 2013

Illinois Medicaid Managed Care Programs

Program Covered Population Geography Current/Projected Enrollment Launch Date
ICP Non-Dual Eligible (Medicaid-only) Seniors and Persons with Disabilities Greater Chicago; Rockford; Quad Cities; Central Illinois; Metro East 144,000 Varies by Region. Suburban Chicago in 2011, remaining non-Chicago regions in late 2013, City of Chicago in early 2014
County Care New ACA Adults Cook County 115,000 October 2013
MMAI Dual Eligibles Greather Chicago; Central Illinois 111,000 March 1, 2014 (voluntary; June 1, 2014 (opt-out)
CCEs Complex Adults, Complex Children CEE Specific TBD CCE Specific
ACEs Family Health Plan, New ACA Adults ACE Specific TBD July 1, 2014
Voluntary TANF Family Health Plan Adams, Brown, Cook, DeKalb, Henderson, Henry, Jackson, Kane, Knox, Lee, Livingston, Madison, McHenry, McLean, Mercer, Peoria, Perry, Pike, Randolph, Rock Island, Scott, St. Clair, Tazewell, Warren, Washington, Williamson, Winnebago, Woodford 254,000 1980s

In order to provide options for care coordination services, Illinois has recently implemented innovative, alternate models of care in addition to the traditional managed care organizations. The alternative models of care – “care coordination entities” (CCEs) and “accountable care entities” (ACEs) – are organized and managed by hospitals, physician groups, Federally Qualified Health Centers, or social service organizations and are required to provide a full continuum of services, including behavioral health. CCEs were created under Medicaid Reform to provide an organized system of care for the most complex and vulnerable individuals, including the severely mentally ill, homeless, complex children and other high-cost, high-need groups.

ACEs were created by statute in the spring of 2013 and were informed by the early experience of preparing CCEs to become operational, as well as the findings and recommendations from the Alliance planning process on the structure and components of integrated delivery systems. Whereas CCEs are primarily focused on highly targeted sub-populations (e.g., homeless) and, therefore, will have fairly small enrollment, ACEs are focused on the full Family Health Plan and newly eligible populations. Both CCEs and ACEs are paid a PMPM care coordination fee, with fee-for-service reimbursement and shared savings potential initially; ACEs are required (and CCEs are encouraged) to begin moving to a risk-based arrangement after 18 months.

Development of a comprehensive State Health Care Innovation Plan

On February 21, 2013, Illinois was awarded a State Innovation Model grant from the federal Department of Health and Human Services Innovation Center. This funding supported an intensive six-month planning process designed to build upon the delivery and payment system reforms already underway in the state to develop a comprehensive, multi-payer State Health Care Innovation Plan (SHCIP). The planning process was led by a broad stakeholder group – the Alliance for Health (“Alliance”) – comprised of representatives from providers, health plans, state agencies, social service organizations and other entities. Stakeholders participated in an intensive consensus building process toward the development of the SCHIP.

The SHCIP outlined a vision for health system transformation built upon the premise that the major contribution to better health and lower costs will be achieved when people live in healthy, safe communities with appropriate resources, including access to high-quality health care delivery systems in which provider teams help patients achieve physical, mental and emotional wellbeing. To achieve this vision, the Alliance for Health Innovation Plan was organized around five major transformation objectives that support the Triple Aim:

Collectively, these transformation drivers will support the establishment of an integrated care model standard for health care delivery; provide incentives and tools to assist both medical and non-medical providers in advancing along a continuum toward becoming comprehensive, community-based integrated delivery systems that provide patient-centered individual care; and improve the health status of populations. Many of the innovations of the Alliance Plan related to Medicaid are reflected in this Path to Transformation waiver. On January 16, 2014, Governor Quinn signed an executive order creating the Governor’s Office of Health Innovation and Transformation (OHIT), to lead implementation of the recommendations of the Alliance Plan, including leadership on implementation of this proposed 1115 waiver.

Improving access to community-based long-term services and supports

In Illinois, home and community-based services in Home and Community Based Services (HCBS) waivers, currently approved under Section 1915(c) of the Social Security Act, are compartmentalized under nine separate waivers managed by the Department of Healthcare and Family Services through agreements with two other departments and numerous divisions within departments. The current waivers are for adults with developmental disabilities; children and young adults with developmental disabilities; elderly; medically fragile/technology dependent children; persons with brain injury; persons with disabilities; persons with HIV or AIDS; supportive living facilities; and a support waiver for children and young adults with developmental disabilities.

These separate waivers provide services based on an individual’s primary disability rather than identification of service needs across disability. Illinois intends to create a new approach to these programs, building on projects already underway to coordinate care for Seniors and Persons with Disabilities (SPD), intended to break through the silos that do not effectively address the holistic needs of clients with multiple disabilities and conditions.

Under the Path to Transformation waiver, Illinois intends to continue this work by developing a comprehensive program of long term supports and services for seniors and people with disabilities to enable them to achieve and maintain their highest level of independent functioning while living in the most community-integrated residential setting possible, based on their needs. Under the proposed 1115 waiver program changes will improve access, choice, and integration of services to individuals, incentivizing providers to partner with the state to innovate, coordinate and participate in new care models, and ensuring appropriate credentialing, certification/licensure of those who provide services to clients. In order to ensure that children, youth, and adults in community settings receive the effective behavioral health services and support, at the appropriate level of intensity based on their needs, Illinois will offer LTSS that follow the principles and values of systems of care to children with SED/youth and adults with serious mental illness.

Illinois is also currently implementing consent decrees related to three Olmstead-related class action lawsuits, by helping residents of nursing homes and other institutions to transition to the community. We have learned through the early implementation of these consent decrees, as well as implementation of the Money Follows the Person Program, that existing community infrastructure needs to be strengthened through the addition of community-based services that will enable individuals to remain in their own community post-transition and avoid re-institutionalization. In addition, the State recently received funding under the Balancing Incentive Program (BIP) and plans to use the enhanced matching funds through that program to achieve additional expansion of capacity in the community.

Implementation of Community Transformation Grant

In 2011, Illinois received a Community Transformation Grant (CTG) from the CDC for $24M over a five-year period. The CTG, named We Choose Health, focuses on four main areas: tobacco-free lifestyles, active living and healthy eating; high-impact quality clinical and other preventive services, and creation of healthy and safe physical environments. We Choose Health seeks to improve the level of health equity in communities through a combination of locally targeted and statewide initiatives. Statewide initiatives include healthy child care (an initiative to implement the Nutrition and Physical Activity Self Assessment for Child Care through the Child Resource and Referral Network) and Healthy Hearts (an initiative to support providers’ prevention efforts by integrating data exchange and analysis tools).

Health Information Exchange

The Illinois Health Information Exchange (ILHIE) is a statewide, secure electronic transport network for sharing clinical and administrative data among health care providers in Illinois and bordering states. The exchange is designed as a secure environment to improve the health of the people of Illinois through better and more informed decision-making enabled by the quick exchange of, and access to patient information such as medical records, labs, immunizations and prescriptions at the point of care. The Illinois Health Information Exchange Authority (ILHIE Authority) was established to provide a governance structure for the network, which currently serves more than 3,500 health care providers throughout the state and connects more than 120 hospitals for electronic public health reporting.

Waiver Goals

The goals of the Path to Transformation waiver are to:

  1. Support linkages between health care delivery systems and services that directly impact key social determinants of health, including housing and early intervention home visitation services.
  2. Create incentives to drive development of integrated delivery systems that are built around patient-centered health homes; have a network of providers including primary care, specialists, hospitals, long-term, and behavioral health, as dictated by the populations they serve; and can incentivize a system of care that creates value and ensures that savings are shared with individual health care.
  3. Promote efficient health care delivery through optimization of existing managed care models, including traditional risk-based managed care, ACEs and CCEs.
  4. Enhance the ability of the health care system to engage in population management, by leveraging public health resources and encouraging linkages between public health and health care delivery systems.
  5. Strengthen the state’s health care workforce to ensure it is prepared to meet the needs of Medicaid beneficiaries.
  6. Develop a comprehensive program of long term supports and services for older adults and people with disabilities to enable people to achieve their highest level of independent functioning and live in the most community integrated residential settings possible, based on their needs. This will rationalize service arrays and choices so that beneficiaries will remain as independent as possible, and based on needs defined by a functional/medical needs tool, rather than based on disability or condition, which is currently the basis for Illinois’ nine existing 1915(c) waivers. This will include thoughtful review and adjustments to current institutional eligibility thresholds, allowing HCBS waiver services to be provided to individuals who meet specific program eligibility criteria that may be less stringent than the institutional threshold. Illinois hypothesizes that providing the appropriate home and community-based services at the critical point in the client’s arc of need, may result in prolonging the client’s independence in the community, and reducing need for more intense level of services.
  7. Increase flexibility and choice of long-term supports for adults and children and support development and expansion of choice within tiered levels of community based options based on need.
  8. Institute a provider assessment on HCBS waiver providers, including, but not limited to, residential habilitation providers (CILAs) and supportive living facilities, to create greater access to home and community based residential services.
  9. Reduce Prioritization of Unmet Need for Services (PUNS) wait-list maintained for access to services for individuals with a developmental disability.
  10. Promote and foster greater community-integrated, competitive employment opportunities moving the system away from facility-based sheltered work programs;
  11. Enhance access to community-based behavioral health and substance abuse services and encourage integration of these services with physical health care services;

Demonstration Eligibility and Enrollment

Illinois proposes to include all mandatory and optional eligibility groups approved for Medicaid or CHIP coverage per the Illinois Title XIX Medicaid or Title XXI CHIP state plans. (State Plan changes related to eligibility requirements for groups affected by the ACA are not yet finalized.) Note that Illinois generally refers to AABD related groups as Seniors and Persons with Disabilities or SPDs.

Groups for whom coverage includes comprehensive benefits that will be included under the waiver:

  1. Children from birth through age 18
  2. Parents and other caretaker relatives
  3. Pregnant women full benefits
  4. Persons eligible for Transitional Medical Assistance
  5. CHIP Unborn Children
  6. CHIP Postpartum Care Health Services Initiative
  7. Aged, Blind and Disabled Persons in 209(b) states
  8. Disabled Adult Children
  9. Aged, Blind and Disabled Individuals Financially Eligible for SSI Cash Assistance
  10. Persons with Disabilities eligible for Medicaid under Title 1619 (a) or (b)
  11. HCBS waiver enrollees eligible under institutional rules
  12. Aged, Blind or Disabled Poverty Level Group
  13. Aged, Blind or Disabled individuals receiving only optional state supplements in 209(b) or certain SSI criteria states
  14. Persons with disabilities who work per the Ticket to Work and Work Incentives Improvement Act (TWWIIA Basic Group)
  15. Medically Needy Aged, Blind or Disabled persons, pregnant women and children
  16. Persons who need treatment for breast or cervical cancer or related conditions
  17. New group: ACA Adults
  18. New group: Former Foster Children
  19. Refugees
  20. TANF recipients if not covered under one of the preceding groups

Groups for whom coverage includes partial benefits that will be included under the waiver:

Benefits

All eligible demonstration enrollees will have access to all Illinois Medicaid State Plan benefits as approved by CMS. The proposed demonstration includes enhanced behavioral health state plan benefits for children and adults. Services will be sufficient in amount, duration and scope to reasonably achieve their purpose. An explicit objective of the demonstration is the provision of Long Term Services and Supports (LTSS) to eligible enrollees, in a restructured consolidation of nine (9) preexisting 1915(c) Home and Community Based waivers. The nine HCBS waivers are listed below.

1915 (c) Waiver Population Operating Agency/Division
Adults with Developmental Disabilities Department of Human Services— Developmental Disabilities (DDD)
Children and Young Adults with Developmental Disabilities-Support Department of Human Services— Developmental Disabilities (DDD)
Children and Young Adults with Developmental Disabilities-Residential Waiver Department of Human Services— Developmental Disabilities (DDD)
Children that are Medically Fragile/Technology Dependent (MFTD) Care managed by the University of Illinois at Chicago 
Persons with Brain Injury (TBI) Department of Human Services— Rehabilitation Services (DRS)
Persons who are Elderly Department on Aging
Persons with HIV/AIDS Department of Human Services— Rehabilitation Services (DRS)
Persons with Physical Disabilities Department of Human Services— Rehabilitative Services (DRS)
Supportive Living HCBS Waiver Department of Healthcare and Family Services

The following LTSS will be available. The specific services, and level of intensity will be based on the individual’s functional and medical needs as identified by a standardized tool and process:

Service definitions are included in Appendix A.

Service Delivery Models

To achieve the goals outlined above, Illinois has designed the Pathway to Transformation around four primary focus areas, or “pathways”:

Pathway 1: Transform the Health Care Delivery System

As described above, Illinois is in the midst of a rapid and significant shift from a largely fee-for-service model to a variety of risk-based managed care models including both traditional MCOs as well as new, provider-driven models. All of the entities will establish integrated delivery systems centered on Patient-Centered Health Homes. They will develop multi-disciplinary teams, robust care coordination capabilities, and a high level of integration among primary care, hospital and behavioral health providers. They will be linked by connective technology for tracking clients and timely transmission of patient clinical data among provider partners. The providers within the network will manage care transitions and deliver care in the most appropriate settings.

These new models of integrated service delivery will also demonstrate how Medicaid can reduce the rate of growth to sustainable levels by piloting payment reforms, including financial incentives that reflect value-based purchasing policies and Illinois’ requirements for risk-based payments in care coordination systems. These payment reforms will incorporate multi-payer strategies developed through the Illinois State Innovation Model Design initiative. While CCEs and ACEs will contract directly with the state, they will also have the ability to contract with traditional MCOs and MCCNs, driving higher levels of integration and accountability throughout the Medicaid program. These new models will enable people covered by Medicaid to remain with their providers if they shift from Medicaid to subsidized coverage under the Illinois Marketplace. With tens of thousands of people newly eligible for Medicaid likely to shift between Medicaid and Marketplace coverage as wages and hours change it becomes even more important for the state’s providers to care for people in their community regardless of the payer. Given the importance of these new models to system redesign efforts, Illinois will invest in their design, start-up, and implementation, including:

One of the cornerstones of the State Health Care Innovation Plan is the creation of a new Innovation and Transformation Resource Center (ITRC) within the newly created Governor’s Office of Health Innovation and Transformation (OHIT) that will, among other functions, serve as a technical assistance “hub” for health system transformation. This may include, for example, technical assistance designed to:

Under the Path to Transformation, Illinois will invest $40 million annually Medicaid administrative dollars to support the creation and ongoing operations of the ITRC, which will be a critical element in the state’s plan to drive delivery system transformation.

Delivery System Reform Incentive Payments (DSRIP) to Transform Public Providers

Illinois is home to two large public health and hospital systems – the University of Illinois Hospital and Health System (UI Health) and Cook County Health and Hospitals System (CCHHS). These systems play a vital role in the state’s health care delivery system, including the provision of trauma and burn services, transplant services, and sub-specialty care. CCHHS is a major safety net provider for the underserved of Cook County and is one of the largest and most comprehensive public health and hospital systems in the country. UI Health includes a 495-bed tertiary hospital with nationally recognized transplant programs, an outpatient facility, and 19 neighborhood clinics serving communities throughout the near west, south and southwest sides of Chicago. As the only State government acute care hospital and health system, UI Health is also positioned to leverage its own strengths to improve care and lower costs for patients statewide. Both of these public systems were active participants in the Illinois Alliance for Health and are committed to the transformation outlined in the State Health Care Innovation Plan.

Illinois will continue to rely on its public providers throughout the implementation of the ACA. However, the state also recognizes that large public providers face numerous unique barriers to transformation that extend beyond those faced by other providers. These include legal and political barriers that can inhibit integration with other providers, cost-based reimbursement methodologies that may not have always incentivized efficiency, and multiple layers of oversight that can slow the pace of change. For these reasons, Illinois proposes to invest $200 million annually during the waiver period for a Delivery System Reform Incentive Program (DSRIP) to create strong incentives for transformation within these vital providers. DSRIP funds will be contingent on public systems meeting aggressive milestones with respect to integrated care delivery and improved patient outcomes.

Brief descriptions of proposed DSRIP projects are outlined below. Please see Appendix B for a more detailed description. Specific project parameters, milestones, timelines and payment schedules will be negotiated individually with CMS.

Cook County Health and Hospital System

In late 2012, CCHHS launched a Medicaid managed care plan under an “early expansion” 1115 Waiver. Named “CountyCare,” this plan met with a very high level of demand for coverage by low income, uninsured eligible adults. Over 127,000 applicants sought this coverage in less than a year’s time and 115,000 are projected to enroll, making CountyCare one of the country’s landmark Medicaid expansion success stories. Now, with health reform implementation rapidly evolving, CCHHS is poised to bring administrative efficiency to the challenge of providing direct services, while also serving as a health plan, a payer (i.e., purchaser of services), and a population health management entity with a public health department within its scope. Termed the “4Ps Strategy,” the CCHHS vision will be implemented in these four domains—provider, plan, payer, and population health manager.

CCHHS proposes to pursue delivery system transformation within this 4Ps construct. With federal support, CCHHS will be able to pursue innovative transformative initiatives aimed at supporting the triple aim through significant changes in its service delivery model, targeted workforce development initiatives, and initiatives that address key social determinants of health.

University of Illinois Hospital and Health Sciences System

The proposed 1115 waiver, in coordination with the Illinois Alliance for Health Innovations Plan, includes objectives that would directly benefit with the alignment of existing and expandable resources of the University of Illinois. The University of Illinois is providing two critical functions to the Illinois Medicaid program - that of a large medical provider rendering some of the most complex services to the Medicaid population, as well as that of an academic center and educator of medical professionals. The medical school alone graduates more physicians than any other medical school in the nation.   

Illinois proposes to use DSRIP funding to help transform the University’s health care delivery system and integrate its teaching and academic resources to implement these statewide objectives. While the University will affect all of the innovation objects, targeted DSRIP funding will provide a significant impact on the following:

Illinois is initially proposing four categories of DSRIP initiatives through the University of Illinois to address the transformation drivers, as well as a joint DSRIP category between UI and Cook County. One of the four UI categories would focus on transforming the University’s own direct medical care delivery system by integrating these existing assets into the state Medicaid agency’s transformation plan. The other categories would focus on assisting the state Medicaid agency in its efforts to transform the entire state Medicaid system.  Details further describing each category are provided in Appendix B.

University DSRIP Proposals and Their Relation to Delivery System Reform

Innovations Driver Objective Provider Delivery Transformation Statewide Delivery Transformation
Category 1
Specialty Care Access
Category 2
Telemedicine
Category 3
Continuing Education
Category 4
Medical Education*
Integrated health care delivery / payment reforms X      
Additional support / services for those with special needs X      
Ensuring an adequate workforce   X X X
Leadership to promote / improve health care systems X X X X

The University’s medical education initiatives under DSRIP as a government owned provider will be coordinated with other workforce initiatives under CNOM. See Appendix D for detailed descriptions.

Cook County and UI Joint DSRIP Initiatives

The public resources invested in healthcare by the University and Cook County are enormous. The two health systems together are by far, the largest providers of Medicaid care and services in the state. While the Cook County Health and Hospital System relies on its own tax based revenue for operating the health system, the University’s health system is partially funded by the state Medicaid program, partially funded by the state GRF, and partially funded by the revenue from Medicare and other commercial health plan revenue. Given the public investment of both systems, and their overlapping service networks, collaboration between the two should be enhanced. Currently, the new CountyCare program (early option Medicaid) is well on its way to providing healthcare to an estimated 100,000 newly covered Medicaid clients but it is already clear that some specialty care services will have to be expanded to meet the healthcare needs of this group of individuals. Considering the large public expense on the two systems, proximity to each other, and overlapping service areas, it is essential that the University and Cook County implement joint collaborations in order to meet the specialty care needs of the county. DSRIP funding will be used to establish and maintain such services in order to improve coordination, efficiency, and outcomes between these two public provider networks.

Hospital/Health System Transformation

Much of healthcare reform is focused on reducing hospital admissions/readmissions and the use of emergency rooms for primary care, which will positively impact health outcomes and the quality of care but may also negatively impact some hospitals' revenue. The Path to Transformation waiver will invest in hospitals that are committed to transitioning to a modern service delivery model through the creation of two new programs:

Health System Integration and Transformation Performance Program

Under this proposal, Illinois would establish a Health System Integration and Transformation Performance Program to allow participating hospitals and health systems to earn incentive payments by meeting specific performance objectives. The performance objective would be designed to advance health system transformation, drive integration of services across the full continuum (including behavioral health, substance abuse treatment, community-based care and long-term care), reduce costs, and improve patient safety. The Illinois Department of Healthcare and Family Services will appoint an advisory committee to review and recommend three to five performance standards based on potential return on investment, impact on quality of care, and other factors. The advisory committee will include representatives from hospitals, accountable care entities (ACEs), as well as experts in health care performance/outcomes measurement and evaluation. A sample of performance metrics to be considered by the advisory committee includes, but is not limited to, the following: 

The State proposes to invest $100 million annually in the Health System Integration and Transformation Performance Program. Funds will be divided into two pools: one for designated Critical Access Hospitals and hospitals that meet the state’s criteria for “safety net hospitals”3 and one for hospitals that do not meet these criteria. This will ensure that those providers that need the greatest amount of support to achieve quality and integration objectives have an opportunity to participate.  While these payments will be within allowable actuarial soundness limits, the State proposes to make these payments directly to providers to support delivery system transformation across multiple payment models.

3 See 305 ILCS 5/5-5e.1

Hospital Access Assurance Program

Illinois hospitals are key players in the State’s safety net system for Medicaid and the uninsured. While the 2014 Medicaid coverage expansion will help to mitigate uncompensated care costs, safety net providers will continue to incur significant amounts of unreimbursed costs related to Medicaid and the uninsured. The State’s Path to Transformation waiver proposes to recognize this by establishing a hospital Access Assurance Program, which will help preserve the safety net system and provide financial stability as hospitals implement transformative reforms under the waiver.

The State of Illinois’ disproportionate share hospital (DSH) allotment is largely paid only to certain publicly owned hospitals. As a result, private hospitals in Illinois are not able to access the DSH funds necessary to subsidize the actual uncompensated care costs relative to the inpatient and outpatient hospital services provided to Medicaid and uninsured individuals. The assessment-funded Medicaid UPL supplemental hospital payment program is a critical alternative to subsidizing the unreimbursed cost of furnishing hospital services to Medicaid (and the uninsured indirectly). The Access Assurance Program will help to ensure access to care for critical hospital services provided to the State’s most vulnerable populations as the state moves forward with its planned expansion of Medicaid managed care. Payments under the Access Assurance pool would initially be made using the methodologies currently outlined in the approved State Medicaid plan, as modified by any approved changes resulting from the state’s rate reform efforts. However, the State will implement a payment methodology during the waiver period that transitions access assurance payments to a methodology that is based on uncompensated care costs.

Institution Transition Fund

As Illinois works to rebalance the array of long-term care options for Medicaid beneficiaries, the state recognizes the importance of appropriate supports and incentives for institutional providers to reduce excess capacity or convert facilities to currently needed uses. In some cases, institutions may desire to close, downsize or repurpose their space but are unable to do so due to existing debt service requirements. To address this issue, Illinois will create an Institution Transition Fund, funded at $25 million annually, which would allow eligible facilities to receive additional Medicaid reimbursement if they close their facility or convert it to alternative uses.

The amount of additional reimbursement available to each eligible facility under this section will be determined by taking into consideration multiple factors, including, but not limited to:

  1. The location of the facility.
  2. The number of beds proposed to be closed or converted.
  3. The current and historical census of the facility.
  4. The financial condition of the facility operator.
  5. The quality of care provided by the facility operator.
  6. The proposed time frame for closing or converting the facility.
  7. The availability of other facilities and services to meet the needs of residents.
  8. The economic impact of the closure on the surrounding community,

In order to receive additional reimbursement available under this section, providers will be required to comply with Health Facilities and Services Review Board requirements and submit a plan to the Departments of Healthcare and Family Services and Public Health that fully describes the proposed plan to close or convert the institution. The plan must include an assessment of community needs and how such needs will be met if the closure/conversion proceeds.

Children with Medical Complexity

Illinois is home to several health systems and hospitals that play a major role in the provision of inpatient and outpatient pediatric Medicaid services. Several of these institutions are working to develop integrated systems of care for children with medical complexity. Under The Path to Transformation, Illinois is requesting that CMS allow the State of Illinois an option to implement (without an amendment to the waiver) at any future point in time during the five year term of the waiver, a program of integrated delivery system networks to support services to children with medical complexity. If the State elected to propose the creation of pediatric networks and request that CMS review such proposed networks for federal designation, and CMS approved such networks, then Illinois and CMS would jointly develop and approve quality metrics and shared savings/risk methodologies that are consistent with CMS' guidance.

Pathway 2: Build Capacity of the Health Care System for Population Health Management

By 2017, Illinois expects that an additional 500,000 Medicaid clients will be enrolled under the Affordable Care Act, a combination of "newly eligible" adults and "already eligible" clients under pre-ACA Medicaid rules. In addition, another 500,000+ people will purchase private health insurance in the Health Insurance Marketplace. The health status of these currently uninsured populations is varied — many of the formerly uninsured will be young, relatively healthy adults, while others will have pent-up demand for health care.

The new community needs assessment mandate offers opportunities for the state and local health departments to collaborate with local hospitals and community health centers to share data and analyses and assure that as much attention as possible is directed to fulfilling the identified needs. Providing health coverage to more people also requires a focus on front-end strategies to deflect individuals from costlier back-end care. The Path to Transformation waiver will leverage resources by investing in incentives that drive integration of public health services, with the goal to lower costs of traditional medical services

Population health considers the health outcomes of an entire population, focusing on the vulnerable to reduce health disparities. Population health addresses the social determinants of health, which are social, economic, environmental and behavioral factors (such as: lack of access to fresh fruits and vegetables, unemployment and violence) and are interdependent with medical care. Public health, with a focus on population health, has historically collaborated with the healthcare delivery system to provide science and data expertise, education, prevention, promotion of healthy lifestyles, and community-based health services. Thus, population health strengthens and enhances healthcare delivery systems by improving the health of patients presenting for care, informing care priorities, and supporting healthy communities. Illinois is committed to building linkages between public health and health care delivery systems and expanding the capacity of the health care system to manage the health of a defined population.

Integrate Public Health and Health Care Delivery

To incentivize integration of public health and traditional health care delivery toward achieving better overall population health outcomes, Illinois will create a bonus pool, funded at $10 million annually, for health plans that agree to use the funds to develop population health interventions in conjunction with public health entities, including newly created Regional Public Health Hubs.

Recognizing that additional public health resources and improved integration are necessary to catalyze the efforts of isolated health systems and local communities, the Illinois Alliance for Health recommended the creation of Regional Public Health Hubs (Regional Hubs). The Regional Hub will serve as a “nexus” between the Illinois Department of Public Health (IDPH), local health departments (LHDs), communities, and the health plans and providers serving the region. The Regional Hubs will align and coordinate the multiple community needs assessments performed in the same regions. Through technical assistance and the opportunity to promote regional collaboration, the Regional Hubs can ensure that the best available data is used to inform the health assessments. In addition, the Regional Hubs will promote the use of evidence-based assessment tools such as those recently released by the CDC. The Regional Hub will facilitate the cooperative selection of core health priority areas and selection of appropriate metrics using evidence-based tools. Factors such as health disparities, the impact of social determinants of health, availability of evidence-based interventions, and balanced outcomes will inform the prioritization process.

An important feature of the Regional Hubs will be to assist local communities to link community interventions and to provide technical assistance in selecting evidence-based interventions such as those endorsed by the Community Preventive Services Task Force. The Regional Hubs will afford anti-trust protection for hospitals and health systems, traditional marketplace competitors, to come together to collaborate on community health interventions. In addition, many locally-sponsored community health interventions are multi-faceted and too diffuse to have an observable impact on population health indices. By reinforcing and aligning multiple projects, the Regional Hubs can amplify local efforts and aggregate results. In addition to promoting the development of coordinated community health interventions, the Regional Hubs will work with LHDs and IDSs to promote policy, systems, and environmental changes that improve health. This may include interventions that address key social determinants of health, including crime/public safety, access to healthy foods, and environmental factors.

Expand Maternal-Child Home Visit Programs

Illinois proposes to utilize Medicaid administrative match to support the expansion of maternal-child home visitation models coordinated by the Departments of Public Health and Human Services, including the family case management, the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHVP), and the Nurse-Family Partnership program. This $10 million annual investment will allow the state to increase the number of families receiving these services by 50%. These programs summarized below have a strong track record and extensive evidence base for improving social and health outcomes, and reducing future health care costs. For example, evidence from the NFP studies indicate that, on average, enrolling 1,000 low-income families in NFP will result in: 4

4 Ibid

This expansion of maternal-child home visit programs will be coordinated with existing integrated delivery systems, including risk-based managed care models.

Pathway 3:   21st Century Health Care Workforce 

Illinois recognizes that transformation of the health care delivery system will also require concomitant transformation of the health care workforce. Over the last year, the state has engaged in an intensive planning process to develop specific workforce goals and strategies. As part of this process, the Governor directed the Illinois Department of Public Health (IDPH) Director to lead a Health Care Workforce Workgroup under the Health Care Reform Implementation Council. The Workgroup assessed the jobs needed to achieve the goals of health care reform and meet the health needs of Illinois’ growing, increasingly diverse and aging population. The Workgroup also assessed the existing health care workforce landscape and developed an analysis of gaps that need to be filled both for current needs and the impending demand created by expansion of health coverage through the ACA. In addition to IDPH, the Workgroup includes the Governor’s Office, departments of Commerce and Economic Opportunity, Healthcare and Family Services, Aging, Financial and Professional Regulation, Employment Securities, Veteran’s Affairs, Human Services and Children and Family Services with support from the University of Illinois at Chicago School of Medicine, Health and Medicine Policy Research Group and participation from external stakeholders as needed.

The state also recently reconstituted Health Care Taskforce under the Illinois Workforce Investment Board (IWIB). The IWIB is appointed by the Governor and charged with the task of reviewing the progress of the state’s workforce planning efforts. It facilitates workforce development services and programs in such a way that together the government and the private sector can meet the workforce needs of Illinois employers and workers. Finally, utilizing the resources provided by CMMI, the Illinois Alliance for Health applied for and subsequently received support for a half-day retreat for technical assistance on health care workforce planning. Members of the Health Care Workforce Workgroup attended this meeting.

Merging the findings and recommendations from each of these efforts, Illinois is committed to implementing a health care workforce development strategy that will:

  1. create new and sustainable health care worker roles, and ensure that all health care workers are paid a living wage;
  2. enable medical professionals work at the top of their training and education;
  3. create capacity to serve underserved communities; and
  4. promote team-based care within integrated delivery systems.

Current Health Care Workforce and Projected Need

Illinois ranks near the middle among states on the total number of active physicians and active primary care physicians per 100,000 population. However, the supply of providers does not match the demand in certain high-need areas of the state and for some populations. For example, only 64.9% of Illinois physicians reported that they were accepting new Medicaid patients in 2011, compared to a national median of 76.4%.5 Similarly, 28.5% of Illinois residents live in an area that has been designated as a primary care Health Professional Shortage Area (HPSA), compared to a national median of 18.6%.6 Even in areas where supply is currently sufficient, concerns exist about capacity for an expanded insured population when Marketplace and expanded Medicaid coverage begin in 2014. Indeed, State of Illinois Industry Employment Projections show that Illinois will need more than 100,000 new workers in the health care field by 2020.7

In addition, Illinois falls well below the national median in its use of non-physician providers. Illinois has 20.2 physician assistants and 35.3 nurse practitioners per 100,000 people, compared the national median of 33.5 and 62.1, respectively. While it is not possible to rapidly increase the pipeline of physicians, the State can and must invest in training and retraining the types of providers that are needed within the Medicaid program. Similarly, we must invest in a workforce that includes healthcare professionals who can provide and/or assist with primary and preventative healthcare for our clients.

Illinois proposes to invest in training and preparing the kinds of healthcare providers that will be vital to the future of the State’s Medicaid program, including community health care workers, in-home specialized personal attendants, care coordinators, nurses of all specialties, physician assistants/nurse practitioners and physicians to work on primary care provider teams to assure that overall health improvement goals are achieved in addition to providing appropriate clinical care. Education in healthcare across the lifespan and disabilities is essential for our workforce to be prepared for the rapid growth of aging adults and people with disabilities. This workforce training will be implemented in cooperation with state universities, community colleges and other certification programs. Illinois requests that the following be treated as Designated State Health Programs under the 1115 waiver.

5 NCHS analysis of NAMCS Electronic Medical Records Supplement from Decker, S. “In 2011 Nearly 1/3 of Physicians Said They Would Not Accept New Medicaid Patients, But Rising Fees May Help.” Health Affairs, 31, no. 8, 2012. Accessed through the Benchmark State Profile Report for Illinois provided by CMMI.

6 HPSA information from the Health Resources and Services Administration (HRSA); population data from ACS. Accessed through the Benchmark State Profile Report for Illinois provided by CMMI.

7 State of Illinois Industry Employment Projections(Long-Term): 2010-2020

Workforce Development and Training

To promote improved access and quality of care for Medicaid beneficiaries in the State by supporting the development of the health care workforce and to increase the rate of Medicaid participation among Illinois providers, the State is requesting that certain health workforce training programs and related supports that significantly impact the Medicaid program be treated as Designated State Health Programs (Appendix C). These programs train much of the provider workforce that serves the Medicaid population and, like other components of the health care system, must make immediate investments in curriculum development and residency program design to prepare future providers for a system built off of team-based care within integrated delivery systems. Please see Appendix D for examples of workforce training programs that may be targeted for expansion under the Path to Transformation waiver.

Illinois is also committed to training non-provider members of the health care workforce that play a critical role in outreach, access and direct care for vulnerable populations. This includes, but is not limited to, Community Health Workers and direct care workers. Within the care team, these workers often have the most frequent contact with the individual and their family. Team-based care requires that they be fully engaged with and integrated into the care team in order to optimize their role in serving vulnerable populations statewide.

Under the Path to Transformation, Illinois will invest at least $50 million annually to develop and expand educational opportunities through the universities, community colleges and other education partners to address multiple workforce needs and establish curricula and competency testing standards, including front-line workers and primary care professionals that meet the needs of the state Medicaid program. These priorities will be established by the Office of Health Innovation and Transformation and payments distributed by the Department of Healthcare and Family Services.

Health Care Workforce Loan Repayment

To supplement the workforce training efforts described above, Illinois will commit to funding a loan repayment program at $10 million annually, and seeks designation of this investment as a Designated State Health Program. The state has currently authorized loan repayment programs for family medicine, nursing, allied health professions, dental, and psychiatry, but many of these programs were subject to budget cuts during the economic downturn have not been funded since 2009. By July 1, 2015, the state will establish a loan repayment assistance to providers and other health care workers who commit to serving Medicaid populations in rural or other underserved areas (as designated by the Secretary or using state-developed criteria approved by the Secretary). The state is currently reviewing the existing loan repayment programs and will modify them as needed to ensure alignment with health care workforce needs and based on available funds. This will include adding additional professions (e.g., social workers and other mental health and substance use disorder professionals, community health workers, direct care workers) that qualify for loan repayment and ensuring that all loan repayment programs are contingent on the recipient practicing in an underserved area.

In addition to funding the state loan repayment program, Illinois will establish a bonus payment pool for hospitals that are designated as Critical Access Hospitals or classified by the state as a “safety net hospital” that establish their own loan repayment programs. Many of these safety net hospitals struggle to maintain a stable and adequate work force to serve the Medicaid population, often investing substantial resources in training staff that leave for other opportunities after they are trained. This program would incentivize hospitals and health systems to create their own loan repayment programs to attract and stabilize their workforce. Hospitals can customize their loan repayment programs based on their specific workforce needs and the workforce profile of the communities they serve.

Graduate Medical Education

Illinois is currently one of a handful of states that does not have a Medicaid Graduate Medical Education program. In order to align the provider workforce with the needs and goals of the state, we propose to develop a Graduate Medical Education (GME) pilot program with the following goals:

Consistent with the approach taken by at least 10 other state Medicaid programs,8 Illinois’ Medicaid GME program will be designed to address state workforce goals through payments for performance on specific GME program metrics. Proposed program parameters are outlined below.  

The program would incentivize GME programs in Illinois to address state workforce goals through two mechanisms. First, the state will invest $10 million annually in a program that mirrors the current Department of Health and Human Services/HRSA’s Teaching Health Center Graduate Medical Education Program (THC) program in the state of Illinois. During its brief existence, this program, funded by the Affordable Care Act (ACA) in 2010, has been effective in supporting the training of primary care providers committed to working in underserved areas. Indeed, despite uncertain federal funding, nearly half of the trainees in THCGME programs have gone on to practice in related safety net care settings.9 Illinois is currently home to just one THC. This program just launched its first fully-trained cohort of eight Family Physicians, all of whom took positions in Community Health Centers. The Illinois program requires applicants to be bilingual and received more than 860 applications for the eight positions available this year. During their three years of training, these residents take on progressive responsibility (under faculty supervision) to provide ambulatory care to panels of patients, most of whom are Medicaid recipients.

8 AAMC, Medicaid Direct and Indirect Graduate Medical Education Payments: A 50-State Survey, April, 2010.

9 Phillips RL, Petterson S, Bazemore A. Do Residents Who Train in Safety Net Settings Return for Practice? Academic Medicine. 9000;Publish Ahead of Print:10.1097/ACM.0000000000000025

At the expiration of federal statutory funding for the THC program in 2015, the state would provide continued funding of the current THC supported GME program(s). Other GME programs in Illinois would be encouraged to seek state funding under the same criteria currently operative for the THC program. Illinois HFS would oversee the administration of this program, including the development of performance metrics to ensure that programs generate primary care practitioners that serve in underserved areas in order to continue receiving funding.

Second, the state will invest $26 million annually in incentive-based payments for performance on specific metrics achieved by current Illinois GME programs in designated medical specialties. A number of primary care and primary care-related specialties will be included that have been recognized in Illinois, as well as nationally, as sources of physicians that are in high demand in medically underserved areas. Designated GME programs must be accredited by either the Accreditation Council on Graduate Medical Education (ACGME), the American Osteopathic Association (AOA) or the Commission on Accreditation of the American Dental Association (ADA). These programs include the primary care programs Family Medicine, Internal Medicine, Pediatrics and Internal Medicine-Pediatrics. Other designated programs include Obstetrics and Gynecology, Psychiatry, General Surgery, General Dentistry, Pediatric Dentistry and Geriatrics. Programs that are dual accredited by the ACGME and AOA are only eligible for a single yearly payment. Eligible residency programs must have been in existence for two years before application for funds. New programs must meet the two year requirement.

The performance criteria for incentive payments will evolve over the first five years of the program to allow programs time to align training with the proposed incentives and to demonstrate desired physician workforce outcomes.

Years One and Two:
Years Three and Four:

In years 5 and beyond, the criteria for payment will shift to a heavier emphasis on graduate placement and a smaller emphasis on residency training locations. Specific parameters for years 5 and beyond will be developed as the program progresses.

Training of the state’s future physician workforce cannot be done at the expense of ensuring access to care, however. Therefore, Illinois requests that payments made under its Medicaid GME program be exempt from federal upper payment limit requirements, as defined in 42 CFR 447 and be paid directly by the state to qualified teaching hospitals and federally qualified health centers.

Workforce Planning and Evaluation

To ensure that the state’s workforce development programs continue to align with the projected workforce needs of the Medicaid program, Illinois will coordinate all workforce development programs under the Innovation and Transformation Resource Center. The ITRC will take a comprehensive approach to evaluating future workforce needs by collecting and analyzing data and developing data-driven projections. This may include:

This work will inform any future changes to the state loan repayment program, Medicaid GME program, Teaching Health Center GME program, and other investments in health care workforce training.

Pathway 4: LTSS Infrastructure, Choice, and Coordination

Providing the right care, in the right setting, at the right time is critical to ensuring individuals can safely remain in the home and community and realize their highest level of independent functioning and quality of life. In order to achieve this goal, we will ensure that an adequate array and supply of long term services and supports (LTSS) are available, and level of care thresholds are appropriate to offer eligible participants a non-biased choice of service settings.

Illinois will leverage the actions underway in implementing consent decrees related to three Olmstead-related class action lawsuits, by helping residents of nursing homes and other institutions transition to the community. Early work on these consent decrees, as well as the Money Follows the Person (MFP) Program, has revealed that the existing community infrastructure needs to be strengthened to enable individuals to achieve their highest level of independent functioning and live in the most community integrated setting possible.

Illinois will expand home and community-based service options, especially for those with complex health and behavioral health needs and ensure that services are based on individual needs and not arbitrarily limited based on a particular disability. Currently, persons with serious mental illness (SMI) and substance use disorders (SUD) are not served through a waiver; however, these populations will be included in this 1115 Waiver.

Illinois will also develop a comprehensive health homes program under Section 2703 of the Affordable Care Act for individuals with complex health needs, including HIV/AIDs. Under the Path to Transformation waiver, we are requesting 90/10 federal match for this program.

Moving from a Disability-Based to Needs-Based System

In Illinois, LTSS in Home and Community Based Services (HCBS) waivers, currently approved under Section 1915(c) of the Social Security Act, are compartmentalized under nine separate waivers, three departments and numerous divisions within departments for portions of day to day operations.

The nine waivers are very traditional service arrays tied to a specific age, physical, developmental or behavioral disability rather than identification of essential services needed to help avoid unwanted placement in a facility. The current waiver structure impedes the ability of healthcare providers and community organizations to forge new relationships and service delivery models that encourage and incent coordination and cooperative care for clients. Therefore, Illinois will consolidate its nine 1915(c) waivers under the umbrella of this 1115 demonstration, eliminating barriers to needed services, enhancing transparency, implementing common service definitions, provider qualifications and reimbursement schedules and simplifying the claims payment process for both fee for service and for managed care encounter data. For example, some LTSS service providers submit service claims to multiple departments or agencies. The transformation claims process will allow claims to be submitted directly to the Medicaid agency or its designee. The State heard from many providers that this planned change is a welcome simplification.

Illinois intends to continue its transformation of long term care services and supports by building on the work underway through the Balancing Incentive Plan, Money Follows the Person, Olmstead-related consent decrees, and other initiatives. This waiver will enable the state to develop a long term supports and services plan for all people with disabilities who qualify for state assistance to help them live as independently and in the most community integrated setting as possible. A broad array of service and support options will help care managers develop person-centered plans around the needs of each individual. This will improve on the current waiver-specific service structure where individuals care plans are limited to those specifically available under that specific waiver. Evidence suggests that the state will achieve higher levels of efficiency by assuring access to the right service at the right time. This increased efficiency will lead to lower costs as care plans will be more carefully targeted to needs.

Consolidating nine existing 1915c waiver programs into one LTSS program moves beyond the need to access waivers by disability or condition supports and improves access, choice, and integration of services to individuals, encourages providers to partner with the state and each other to develop and implement innovative care models that address waiver participants’ health needs and outcomes in a way that achieves improved or stabilized health in the participants’ chosen settings. It will build on existing programs, enhance community based options, and take a meaningful step forward to support long term sustainability of community based options by providing an opportunity for health plans and individual service providers to partner in new ways to improve services and health outcomes for HCBS clients. This approach reflects the State’s vision, as well as recognizes federal direction for home and community based waiver programs. Waiver participants whose needs change or who “age out” of one of the nine stand alone waivers will be able to transition seamlessly without having to terminate and reapply, or make decisions based purely on what is available in a specific waiver, but will be able to construct a service plan truly based on their identified needs.

As part of this initiative, the state will begin to address the significant number of individuals with developmental disabilities who are on a waiting list for waiver services by creating additional waiver slots for those individuals. The vision infuses additional dollars into the program to support the array of services that waiver participants will be able to access. $60M has been identified to care for people currently on the PUNS waitlist, and $150M to expand access to services for specific populations, e.g., older adults, whose service package and average spending under the current waiver is very limited. 

Though Illinois firmly believes that this is the right approach, the state lacks the financial resources to implement these changes without the funding that is included in the Path to Transformation waiver. The system reforms, improved service availability and delivery encompassed by the waiver consolidation are critical to the state’s ability to maintain momentum.   

Approval of funding will allow the state to move forward with the administrative and programmatic changes required.  The attached service definitions represent an initial step in the process.  The state will embark on the technical and programmatic implementation following established CMS procedures, so that timing mirrors the agreement of final Special Terms and Conditions.

The Path to Transformation waiver will assist the State in developing and implementing, across disabilities and across agencies, a universal assessment tool, a consolidated waiver structure, and enhanced LTSS capacity. The State recently received funding under the Balancing Incentive Program (BIP) and plans to use the enhanced matching funds through that program to achieve additional expansion of capacity in the community. The 1115 demonstration will provide the flexibility needed to deliver appropriate and essential LTSS in a coordinated fashion through managed care entities and their provider networks. In addition, the state is in the process of developing an integrated web-based universal assessment tool (UAT) for SPD populations that will support efforts to tie services to the needs of the beneficiary. Specifically, Illinois seeks to accomplish the following through Pathway 4 the Path to Transformation:

Administrative Simplification

Universal Assessment

Illinois’ current functional eligibility process for accessing community-based LTSS is the completion of a level of care determination for each of the HCBS Waivers or an assessment for Medicaid Rehabilitation Option services. Under the present service delivery system, individuals requiring LTSS who have complex needs, including co-occurring behavioral health needs, are not necessarily assessed in a holistic fashion nor are all of the LTSS options presented. The table below includes specific information about current functional eligibility requirements of Illinois’ Medicaid LTSS programs.

 

LTSS Program Functional Eligibility Tool
Alcohol and Substance Abuse DSM4/ASAM
Children and Young Adults with Developmental Disabilities -Residential Waiver Inventory for Client and Agency Planning (ICAP)
Children and Young Adults with Developmental Disabilities -Support Waiver Inventory for Client and Agency Planning (ICAP)
Children that are Medically Fragile/ Technology Dependent Waiver Illinois MFTD Level of Care (LOC) instrument
Community Care Program (CCP) Comprehensive Community Assessment
Developmentally Disabled Adult Waiver Inventory for Client and Agency Planning (ICAP)
Persons with Brain Injury Waiver Determination of Need (DON)
Persons who are Elderly Waiver Determination of Need (DON)
Persons with HIV or AIDS Waiver Determination of Need (DON)
Persons with Physical Disabilities Waiver Determination of Need (DON)
Rule 132 – Mental Health Community Services LOCUS – ACT/CST & residential programs
Supported Living Facilities Waiver Determination of Need (DON)

There are a variety of tools used, depending on the population or if someone is accessing services under the Medicaid Rehab Option or for substance use disorder (SUD) services.

Through the Balancing Incentive Program, the state is enhancing its current standardized assessment tools and developing a uniform, person centered tool that can be used consistently across the State to determine an individual’s needs for support services, medical care, transportation, and other services. The tool will be phased in for adults and children. The State has contracted with a national consultant and convened a workgroup of state agencies to develop policy and processes around the adoption of a new universal assessment tool (UAT). Once finalized, the UAT will be used to replace the current Determination of Need (DON) assessment tool that has been used since 1983 to determine the functional level of care for institutional and home and community-based long term care services for the elderly and individuals with physical disabilities. The UAT will also replace other LTSS assessments and/or incorporate existing LTSS assessments into the UAT. A stakeholder process will be employed to review the draft tool.

In general, the UAT instrument/process will:

By implementing this new tool and accompanying policy and processes, the State intends to streamline consumer intake and service eligibility across all populations and reduce administrative burden and cost through improved system performance and efficiency. As previously noted, in the varying operational and oversight structures of the nine HCBS waivers, there is a lack of standardization concerning service eligibility rules, assessment tools, service definitions, service packages, and rate development. This lack of uniformity across the system leads to inequities in the manner in which different target populations experience the service delivery system. To address these issues, Illinois will design a system that relies on a UAT that identifies the beneficiary’s unique constellation of needs. The information gathered via the UAT will then be used to identify a service tier that coincides with the beneficiary’s identified needs. This data will be available in a standardized format across multiple agencies and programs to facilitate better continuity and consistency in services provided. Following a person-centered planning process, the beneficiary/family will use the information from the UAT and the service tier, to develop a plan of services for the individual.

Common service definitions, provider qualifications and reimbursement rates

Consolidating nine waivers under the 1115 waiver authority will result in numerous efficiencies for the State of Illinois. The administration and operation of a single waiver, for example, will cut down on redundant administrative activities related to provider enrollment and monitoring, waiver amendments and renewals, records management, reporting, financial tracking, quality assurance, and other functions that will benefit waiver participants and service providers as well as the State.

As part of the LTSS process, the State will develop a common set of service definitions and provider qualifications for each of the waiver services that will be available to eligible waiver recipients. The service definitions included in Appendix A are incorporated from the current HCBS waivers, with some modifications based on stakeholder input, but will be made more consistent through ongoing stakeholder involvement. As noted above, persons with SMI and SUD are not served through a waiver; however, these populations will be included in this 1115 Waiver and specific service definitions and provider qualifications unique to this population will be developed.

These changes will reduce and/or eliminate the service-level variability and disparity that exists across populations and assist waiver providers in delivering the right service to the right person at the right time. This includes children and youth who meet eligibility for behavioral health services. See Appendix A for the complete listing of consolidated home and community based service definitions under the Path to Transformation waiver.

Streamlining monitoring, paperwork, and other reporting requirements

A comprehensive LTSS program under the 1115 waiver authority will result in numerous efficiencies for the State of Illinois. The administration and operation of a single waiver, for example, will cut down on redundant administrative activities related to provider enrollment and monitoring, waiver amendments and renewals, records management, reporting, financial tracking, and other functions that will benefit waiver participants and service providers as well as the State.

Increased Access to Community-Based Services

Expanded Service Array

Under the current system, each of the nine HCBS waivers has its own discrete set of services. Access to an expanded array of community-based services will enable individuals to remain in their community, avoid or delay institutionalization, assist them with transitioning back to the community, and avoid or delay re-institutionalization. The Path to Transformation waiver will provide eligible Medicaid waiver recipients access to a broader array of community-based LTSS options. Individual waiver recipients will be able to access these services based on their needs, as determined by the UAT and person-centered care planning process. Emphasis will be placed on service planning and quality oversight of case management to ensure there is appropriate use and utilization of available services.

Eligible waiver recipients will be assigned a service level tier based on their functional ability and support needs as determined by the UAT. Through the Universal Assessment Tool (UAT) the state will develop an institutional diversion process to emphasize Home and Community Based Services to determine when an individual on an institutional placement track may be more appropriately served with HCBS. Each tier will be assigned a budgetary range that increases with the functional need. The same array of services will be available to eligible individuals in all tiers regardless of disability. See Appendix A for the complete listing of consolidated home and community based service definitions. We believe the expanded array of services and resource allocation process will increase flexibility and improve satisfaction for individuals receiving services.

Reduce Waitlist for Individuals with Developmental Disabilities

Illinois is committed to reducing the Developmental Disabilities waitlist through a phased approach over the next five (5) years. The Prioritization of Unmet Need for Services (PUNS) lists 22,000 people waiting for Adult DD services. Other data sources indicate that approximately 35% of those individuals are already receiving either DD waiver services or LTSS services on another waiver. The Department estimates instituting a clean-up of the waitlist would potentially reduce the waitlist by another 15%. While these are estimates, the data indicates that through administrative efforts alone the waitlist could be significantly reduced.

In order to further reduce the waitlist and move individuals into services, Illinois will utilize a variety of mechanisms which may include:

HFS will work with DDD to develop a strategy and implementation plan for achieving this reduction over time.

Quality Incentives and Outcomes

Illinois is seeking to adopt outcome-based reimbursement strategies to ensure that waiver recipients are not only receiving the right service at the right time, but that high quality services and support are being provided by qualified providers. This quality incentive program will be developed in conjunction with stakeholders, including waiver recipients, families, providers, state staff and other advocacy groups. While an incentive program will eventually be rolled out for all waiver populations, the State has opted to initially focus on outcomes for the ID/DD population. The State has identified areas for systems-level improvement and will target incentive payments to increase:

The stakeholder group will develop a series of objectives and performance measures with benchmarks aimed at moving the system towards the State’s goals. New and expanded quality incentive payments will be developed and implemented through a continuous quality improvement process. Areas for improvement will be constantly evaluated through quality improvement activities that:

Waiver Consolidation: Integration of Behavioral Health              

Illinois’ current efforts to improve access to LTSS services and care coordination has produced data confirming that consumers transitioning from institutional care to the community often have very complex needs. Nearly half (42%) of MFP participants have five (5) or more major medical and behavioral health co-morbidities. These chronic health conditions include diabetes, heart disease, and COPD, and serious mental illnesses (SMI) (MFP 2011 End of Year Report, University of Illinois at Chicago). In addition, research has shown that the increased morbidity and mortality of persons with serious mental illness (SMI) are largely due to preventable conditions, highlighting the need to better integrate services targeting these illnesses as well as services for substance use disorders for individuals receiving HCBS. 

The current, multiple waivers have led to care that is fragmented with potential gaps in needed care. While individuals gain access to necessary LTSS, identification and referral to needed mental health and substance use disorder (SUD) services can be inconsistent. When referrals do occur, minimal coordination exists across the mental health and SUD providers and HCBS Waiver providers. Additionally, individuals with some of the most complex needs are left to navigate the healthcare and human service delivery systems without the assistance of a care coordinator to help them in addressing/managing all of their needs. Therefore Illinois proposes to ensure co-occurring mental health and/or substance use disorders are identified (consistent with BIP and the recently developed Illinois Mental Health Services Five Year Strategic Plan) and needed services available to Medicaid eligible individuals with qualifying needs for both state plan and waiver services. In addition, Illinois will develop health homes for individuals with SMI as well as persons with SMI and a co-occurring chronic health condition(s), including SUDs. It is believed that health homes will address the current lack of a whole health approach to care and the necessary care coordination across multiple providers to improve health outcomes for persons with complex health care needs.

Behavioral Health Expansion and Integration   

The Path to Transformation waiver will allow Illinois to reinvest resources to rebuild and maintain a robust continuum of community based mental health and substance use disorder services better integrated within the larger and broader health care system. By 2015, it is expected that 60% of Illinois Medicaid clients will have selected or will be assigned to one of the managed care models in managed care regions. All of these entities are required to integrate behavioral health services within their networks. In order to achieve this goal, Illinois Medicaid managed care entities as well as those providers outside of managed care regions will be required to:

Furthermore, as they become integrated delivery systems (IDSs), these managed care entities will have the ability to employ team-based care practices, accept and disburse payments and financial incentives to providers within their system, and provide performance reports and counseling to individual doctors and practices. Because IDSs will be held accountable for the health outcomes of individual patients within their networks, as well as for their overall patient population, it will be important for all behavioral health services and the populations accessing them to be well integrated into these systems. The initiatives outlined below will support the overarching goals for IDSs to improve quality through management of care and care transitions and thereby reduce costs and be provided incentives to ensure the right care at the right time in the most appropriate setting.

Health Homes for Adults with SMI

Illinois will work together with physical health and behavioral health stakeholders to develop a health home program for adults with SMI, including those with co-occurring chronic health conditions. Understanding that a small number of individuals account for a large portion of the health care costs, we will utilize data to support the target population for these efforts with an initial focus on reduction of emergency room and inpatient utilization, as well as ensuring access to primary care, including routine screenings of the physical health conditions that have led to increased morbidity and mortality in the SMI population. Care coordination will focus heavily on care transitions, especially those individuals being discharged from institutional settings into the community. While case management of mental health needs has been a longstanding service, enhanced whole health care coordination will require significant planning, service redesign and workforce development as part of the state’s implementation. Also of importance will be the development and use of health information technology (HIT) for mental health and substance use disorder  programs, to make necessary seamless exchange of clinical data possible across behavioral health, primary care, and hospital providers.   Illinois plans to formalize its health home program through a formal submission under the health home provision authorized by Section 2703 of the Affordable Care Act. To accelerate the development of health homes, we will offer technical assistance services through the new state Innovation and Transformation Resource Center (ITRC; see Pathway 1 for additional information).

Improved Access and Outcomes through Improved Utilization Management

Illinois plans to engage behavioral health stakeholders, including consumers and their families, to redesign the behavioral health system. This process will include a review of existing programs for their efficacy and evidence base and the addition of services through state plan amendments. As part of the Path to Transformation planning process, Illinois engaged internal and external stakeholders to begin this process. Gaps in services and subsequent new service recommendations are already in progress and included within this submission; others, such as State Plan access for certain services, are also envisioned.  Emphases on services that support social as well as physical integration within the community are being prioritized. Efforts to discharge individuals as part of the Williams and Colbert Consent Decrees have highlighted the need for improved home-based supports for those with the highest need. In order to offer new services within the continuum, a system redesign will occur to create improved efficiency within the current system to support the addition of services and the anticipated increase in individuals newly eligible under the Medicaid expansion.

In an effort to transition a large number of individuals from nursing facilities to more community integrated settings, the Illinois General Assembly included in Senate Bill 26 (PA  98-0104), along with Medicaid expansion, the creation of Specialized Mental Health Rehabilitation Facilities (SMHRFs). These facilities will specialize in the treatment of serious mental illness and often co-occurring substance use disorders. SMHRFs’ four levels of care encompass crisis intervention, acute stabilization, intermittent stays and long term services and supports within a residential setting. As Illinois plans for and implements a more robust community based system to support individuals with high needs it will be essential to maintain access to the SMHRF services during this transition to more community based services. Illinois requests that SMHRF services be treated as costs not otherwise matchable for the five years of the waiver period. This will create funding for increased access to community-based services that support discharge to more independent living arrangements. Specifically increased access will be achieved through expanded:

  • Assertive Community Treatment (ACT) teams and Community Support Teams (CST) to support individuals at high risk for or transitioning from institutional care and/or correctional settings,
  • community-based Medicaid Rehabilitation Option (MRO) services and expansion of services to treat substance use disorders, and System of Care (SOC) for youth.
Timely Access and Identification of Behavioral Health Needs

Illinois proposes to provide an expanded continuum of services through a state plan amendment to meet the needs of children and adults. Evidence supports that prevention and early intervention can bend the cost curve on health care spending. A robust health care system identifies emerging illnesses and when appropriately treated can decrease the long term costs of treatment. Therefore Illinois proposes to implement a series of prevention and early intervention programs that include Screening, Brief Intervention, and Treatment (SBIRT), as well as including access to services and supports that prevent or limit residential placements for children with both mental health and/or substance use disorder needs. State agencies will develop strategies that incorporate Medicaid 1115 funding along with other existing federal funding streams, such as SAMHSA SAPT and MHBG funding, to create a robust proactive system of health care. We will reinvest savings to support enhanced skills training and assistance, peer support services, and assistance with non-medical needs associated with long term disability and soon to be eliminated learned dependency on institutional settings. Expansion of substance use disorder services will also include peer recovery supports and case management for those with high needs. Illinois will work with our stakeholders to prioritize access to the most vulnerable and at risk populations including those leaving the criminal justice system who are living with mental health and/or substance use disorders and individuals and families with socioeconomic challenges associated with poverty.

Stable Living Through Supportive Housing

The ACA offers a paradigm shift to assist low-income adults, with complex health and behavioral health needs, who will have access to health coverage under Medicaid for the first time, by reason of income -- even if they do not qualify for Medicaid as a permanently disabled person. It is possible to aid in recovery of these adults by offering the essential healthcare services and supports.

A recovery-oriented model must consider the healthcare value of providing supportive housing and employment for these vulnerable populations in Illinois. Not only can supportive housing prevent individuals from unnecessarily living in costlier institutional settings, but a growing body of research suggests that stable and affordable housing may help individuals living with chronic diseases and behavioral health conditions maintain their treatment regimens and achieve better health outcomes at a lower cost.10 For example:

Through the Path to Transformation waiver Illinois seeks to expand access to supportive housing by incentivizing the health care delivery system to invest in and build linkages with providers of housing and supportive housing services.

10 See also Culhane, et al., Public Service Reductions Associated with Supportive Housing, Housing Policy Debates, Volume 13, Issue 1, 2002, pages 107-163; and Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011.  

11 Sadowski LS, Kee RA, Vander Weele TJ & Buchanan D. (May 2009). Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults. The Journal of the American Medical Association.

12 Larimer, Mary E Ph.D. et al. (2009, April 1) Health Care and Public Service Use and Costs Before and After Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems. Journal of the American Medical Association (Vol. 301, No. 13) 1349-1357.

13 Corporation for Supportive Housing (2012, October 10) “Frequent Users Programs Seeing Positive Early Results in Los Angeles” Retrieved from http://www.csh.org/news/frequent-users-programs-seeing-early-results-in-los-angeles (Accessed October 31, 2012) & Los Angeles Frequent Users Systems Engagement (FUSE) Program Retrieved from http://www.csh.org/csh-solutions/community-work/systems-change/local-systems-change-work/los-angeles-fuse (Accessed October 31, 2012).  

An estimated 80% of individuals diagnosed with serious mental illness and high overall health care costs do not have access to stable housing. Many of these individuals are in need of temporary rental assistance until they qualify for SSI. An SSI application can take up to two years to be approved. With a SOAR application (SSI Outreach, Access and Recovery), SSI typically is approved within six months. Under the incentive pool program described below, plans and providers could utilize incentive payments to pay for transitional rental assistance, completion of SOAR applications, or make capital investments in housing for patients. These incentives are aimed at individuals with severe mental illness (SMI) and/or substance use disorders (SUD), including, but not limited to those who are homeless. As summarized above, there is a significant body of research to show that getting these individuals into stable housing can have a large, positive impact on health care outcomes and costs. In addition, the provisions are also aimed at individuals who could be cared for in the community, but – due to lack of stable housing --  are unable to be in the community and, therefore, reside in a more costly, more restrictive institutional setting.

Incentivize Managed Care Entities to Invest in Stable Housing

Illinois will incentivize Medicaid health plans, ACEs, and CCEs who are at risk financially to invest in housing and housing supports for their patients by establishing an incentive-based bonus pool. Plans will be eligible for payments from the pool if they demonstrate beneficiaries diagnosed with serious mental illness (SMI) and/or substance use disorders (SUDs) attributed to them that are maintained in stable housing for an extended period of time.  

Build Linkages Between Behavioral Health Providers and Supportive Housing

In regions of the state that do not have a significant Medicaid managed care presence, the State also proposes to establish an incentive-based pool for community behavioral health (both mental health and substance use disorder) providers to support the maintenance of at-risk populations in stable housing. Providers will be eligible for payments from the pool if they demonstrate meaningful improvements in the number of beneficiaries diagnosed with serious mental illness (SMI) and/or substance use disorders (SUDs) attributed to them that are maintained in stable housing for an extended period of time.

Cost Sharing

No changes to cost sharing is being proposed.

Public Notice and Input

Prior to submission of this waiver application, Illinois had an extensive process for public input and dialogue. Our public notice and input process was consistent with the requirements outlined in 42 CFR Part 431 Subpart G. It should also be noted that many of the provisions included in this proposal grew out of the ongoing health reform dialogue in the state (including numerous opportunities for public input) as outlined in Section I of this proposal, including the Alliance for Health and the Governor’s Health Reform Implementation Council.

Public Website

The State developed a website for the Path to Transformation waiver, which is accessible on the state’s health reform page. The web page includes a copy of the waiver concept paper, waiver drafts, slide decks from stakeholder meetings, attendance lists from stakeholder meetings, and instructions (with links) on how to submit comments on the concept paper and waiver drafts.

A copy of the waiver concept paper was posted on the state’s website on November 7 and also distributed via e-mail to dozens of stakeholders. The State received written comments from 94 organizations and individual stakeholders on the concept paper. Comments were grouped by topic and summarized for review by state staff and consultants.

A draft of the waiver proposal was posted on the state’s website in January and also distributed via e-mail to stakeholders. The State received written comments from 85 organizations and individuals on the draft waiver proposal. Comments were grouped by topic and summarized for review by state staff and consultants.

Stakeholder Meetings

The state held three large group stakeholder meetings to discuss waiver concepts and solicit input from stakeholders. Each stakeholder meeting was held more than once, and in-person, phone and video options were provided to maximize accessibility. The dates and primary topics of the wiaver stakeholder meetings are listed below:

Date Event
October 18:  Waiver kick-off meeting; waiver goals and timeline
November 14 (two sessions):     Consolidation of 1915(c) waivers; under 1115; concept paper discussion
January 9/10 (two sessions):      Consolidation of 1915(c) waivers; under 1115; discussion of draft waiver
   

In addition to the large group stakeholder meetings, state staff and our consultants met individually with dozens of stakeholder groups and advocates, including, but not limited to the following. Please see Appendix E for a complete list of stakeholder meetings.

Finally, our waiver consultant team met regularly with all interested state agencies, including the Medicaid agency (Department of Healthcare and Family Services) and the agencies with responsibility for the current 1915(c) (Department on Aging, Department of Human Services). Cross-agency briefings on the waiver were held on

Legislative Briefings and Hearing

Key legislative staff members were briefed on the waiver on multiple occasions by the governor’s office and agency leadership. In addition, several legislative hearings on the waiver were held, including:

Public Notice of Waiver Application 

A public notice of the waiver application was published in the Illinois Register on February 7, 2014, allowing for a 30-day comment period. The waiver application was also posted on the state’s website for public comment. Additional public stakeholder meetings were held on February 14 (Springfield) and February 20 (Chicago), in compliance with federal regulations. More than 70 individuals and organizations provided written comments during this public notice period. While many of the comments were beyond the scope of the waiver or were already addressed in the waiver, additional refinements were made to the waiver based on public comments. In addition, many helpful comments were received and will be catalogued to inform the waiver implementation process and future discussions with CMS regarding the waiver. There were several recurring themes in the comments received, which are summarized below:

Pathways 1 and 2

Pathway 3

Pathway 4

Approach to Budget Neutrality

Illinois understands that it must demonstrate budget neutrality for the Path to Transformation Demonstration, which means that Illinois may not receive more federal dollars under the Demonstration than it would have received without it. When submitting a Section 1115 waiver, states are required to include an initial showing that the Demonstration is expected to be budget neutral. This is the state’s best estimate of cost and caseload at the time it submits its request. The test for budget neutrality will be applied according to the terms and conditions for the Demonstration that have been agreed to by the state and CMS, and will be measured periodically throughout the course of the Demonstration approval period and will finally be measured at the conclusion of the Demonstration. Appendix F contains all budget neutrality calculations.

It is important to note that the state is requesting match on designated state health programs. There is a full understanding that these requests have been based on actual expenditures and appropriations in a year prior to Medicaid expansion. The state realizes that federal financial participation in these programs will be based on actual expenditures in the waiver years.

One of the critical programs the state is seeking match on expenditures related to Institutions of Mental Disease. These are critical funds the state needs to be able to begin the process of moving people to less restrictive lower cost settings. Until services in the community are funded and available the state must continue to fund safe places for people to live and receive treatment. There is not the ability to double fund during the transition without financial involvement from their federal partner.

Approach to Evaluation

The Path to Transformation waiver touches every part of the Illinois Medicaid program. As a result, the evaluation design will be complex. At a minimum, the scope of the evaluation will include measuring program objectives, identifying lessons learned, determining cost savings, and measuring quality improvements and clinical outcomes.

The State’s evaluation design will also assess key program objectives such as:

It is the state’s hypothesis that successful restructure and expansion of LTCSS, transformation of the current delivery systems, emphasis on population health, and workforce development will result in improved access, capacity, and appropriate utilization.

Evaluation activities of performance will include the impact of the waiver implementation on  the following:

As in the program design phase, stakeholder engagement in the program evaluation design will be critical. Through informal feedback and formal processes such as advisory groups and recipient satisfaction surveys, stakeholders will provide input on evaluation design elements including program evaluation questions, data sources and program impact.

The State will submit to CMS a specific design plan that includes the outcome measures, data sources and sampling methodology. Illinois is also agreeable to other approaches to the evaluation of the Path to Transformation through discussions with CMS.

To support the evaluation, the State will solicit outside funding from foundations, CMS, or other federal agencies.

Waiver and Expenditure Authority Requests

Title XIX Waiver Requests

The following waivers of Title XIX of the Social Security Act are requested to enable Illinois to implement the Path to Transformation Section 1115 Demonstration.

Reasonable Promptness, Section 1902(a)(8), 42 CFR 435.911 and 435.930 and Comparability, Section 1902(a)(10)(B), 42 CFR 440.240

To be consistent with existing HCBS waiver authority (section 1915(c)), Illinois is requesting these waivers to the extent necessary to operate a waitlist for HCBS. The State will take into account current demand and utilization rates and will work to eliminate waitlists as capacity expands sufficient to meet the long term care needs of participants.

Amount, Duration, Scope of Services and Comparability, Section 1902(a)(10)(B), 42 CFR 440.240 and 440.230

To the extent necessary to enable the State to offer differences in HCBS to individuals who are Medicaid eligible and who meet level of care.

To the extent necessary to enable the State to offer certain HCBS (homemaker, personal assistant, adult day health, emergency home response service) to individuals enrolled in the Community Care Program and are not Medicaid eligible, have income at or below 100 percent of FPL but who meet level of care.

To the extent necessary to allow the State to place service cost maximums on HCBS.

To permit managed care entities to provide additional or different benefits to participants that may not be available to other eligible individuals.

Freedom of Choice, Section 1902(a)(23), 42 CFR 431.51

To the extent necessary for the State to require participants to receive benefits through managed care entities.

Upper Payment Limits for Hospitals, Section 1902(a)(30)(A)

To the extent necessary to permit the State to rely on its hospital inpatient and outpatient services upper payment limit calculations for 2013 for the duration of the waiver with one exception: The State will calculate separate UPLs for inpatient and outpatient services that take into account the newly eligible population beginning in 2014 and in subsequent years.

Efficiency, economy, quality of care, Section 1902(a)(30)(A)

To the extent necessary to allow direct payments from the state to providers in areas of the state where managed care has been implemented in order to permit non-managed care providers to receive quality incentive payments for integrating physical and behavioral health and payments for the Hospital Access Assurance Program.

Limits on Payments to Other Providers, 42 CFR 438.60

To enable the state to make payments directly to qualified providers under the Health System Integration and Transformation Performance Program. While these payments will be within allowable actuarial soundness limits, the State proposes to make these payments directly to providers to support delivery system transformation across multiple payment models.

Classes of health care services and providers for Provider Taxes, 42 CFR 433.56

To allow for a provider assessment fee to be imposed on HCBS providers including, but not limited to residential habilitation providers (CILAs) and supportive living facilities, to support rate increases and to provide an additional financial incentive toward deinstitutionalization.

Expenditure Authority Waiver Requests

Under  the authority of Section 1115(a)(2) of the Social Security Act, expenditures made by the State for the items identified below, which are not otherwise included as expenditures under Section 1903 shall, for the period of this demonstration, be regarded as expenditures under the Medicaid State Plan:

  1. Expenditures made by the State to permit coverage of certain home and community-based services (homemaker, personal assistant, adult day health, emergency home response service) to people who meet the eligibility criteria of the Community Care Program and have income at or below 100 percent of FPL.
  2. Expenditure authority to allow assessment of a health care related tax under Section 1903(w) on the following class of providers: assisted living and residential rehabilitation providers rendering home and community based services to individuals with intellectual disabilities.
  3. Expenditure authority under contracts with managed care entities (Section 1903(m) and 42 CFR 438.6) for the following
    1. To allow alternative provider payment methodologies for reimbursement on the basis of outcomes and quality, including payment structures that incentivize prevention, person-centered care, comprehensive coordination, and maintenance of stable housing.
    2. To permit flexibility to provide services that may not always traditionally be reimbursed as a Medicaid State plan service but help keep people living in the community.
    3. To allow incentive payments for stable housing and public health infrastructure in excess of 105 percent of the approved capitation payments.
    4. To allow the State to make GME payments directly to qualified teaching hospitals and federally qualified health centers.
  4. Expenditures made by the State to permit coverage for home and community based services with detailed person-centered plans of care (POCs) are developed. The state intends to develop standard POCs approved by the Medicaid agency that will allow almost immediate entry into services upon a finding of eligibility. A more robust person-centered plan will be developed on a rapid timeline. This approach is intended to mitigate institutional bias and provide equal opportunity for beneficiaries to elect HCBS.

In addition to the above, Illinois has identified a number of State-funded programs for which it is seeking federal matching payments under demonstration authority. These “Designated State Health Programs” include programs that contribute directly to the ability of the Medicaid program to control costs, maintain beneficiaries in the least restrictive settings, and maintain beneficiary access to needed services. Securing federal support for these programs will allow the state to make the investments in services and infrastructure outlined in this waiver proposal. These investments are critical at this time as the State seeks to incentivize delivery system and payment innovation, increase access to community based options, and positively impact social determinants of health that are driving up health care costs.

A list of identified programs is included as Appendix C. These programs are vital for the success of health system transformation, spanning mental health, public health, community services, and child health services. Currently, state funds support these services and programs to meet health needs that Medicaid, as it is currently structured, does not.

Illinois’ request is patterned after similar approved requests in other states (e.g., California, Oregon and Massachusetts), and Illinois hopes to be given the same opportunity. Approval of this request will allow Illinois to move forward with our mutual reform goals without eroding services that are vital for transformation.

The proposed DSHPs include:

Please see Appendix C for a complete list of proposed Designated State Health Programs.

Appendices

Appendix A: 1115 Waiver HCBS Service Definitions Draft

Homemaker

Services consisting of general household activities (meal preparation and routine household care) and personal care provided by a trained homecare assistant. Homemakers shall meet such standards of education and training as are established by the State for the provision of these activities.

Specific components of in-home services may include the following:

Adult Day Health Services

Adult Day Service is the direct care and supervision of adults aged 60 or over, in a community-based setting for the purpose of providing personal attention; and promoting social, physical and emotional well-being in a structured setting. Required service components include:

Home Health Aide

Home Health Aide (HHA) services are part of the treatment plan outlined by the attending physician. Services will include the use of simple procedures as an extension of therapeutic services; ambulation and exercise; personal care; household services essential to healthcare at home; assistance with medications that are ordinarily self-administered; and reporting changes in a participant’s condition and needs to the registered nurse or appropriate therapist.

The provided services are as defined in 42 CFR 440.70, with the exception that limitations on the amount, duration, and scope of such services imposed by the State's approved Medicaid state plan shall not be applicable.

The services are provided by an individual that meets Illinois standards for a Certified Nursing Assistant (CNA) through completion of an approved course. The CNA must provide a copy of the certificate of completion or be listed on the Illinois Department of Public Health Registry website.

Services provided are in addition to any services provided through the State Plan. The amount, duration, and scope of services are based on identified needs.

Personal Assistant

Personal Assistants will provide assistance with eating, bathing, personal hygiene, and other activities of daily living in the home and at work (if applicable). These services may include assistance with preparation of meals, but does not include the cost of the meals themselves. When specified in the plan of care, this service may also include housekeeping chores, such as bed making, dusting, vacuuming, which are incidental to the care furnished or which are essential to the health and welfare of the consumer rather than the consumer's family. Personal care providers meet state standards for this service. Personal care will only be provided when it has been determined by the case manager that the consumer has the ability to supervise the personal care provider.

State laws, regulations and policies referenced in the specification are readily available to CMS upon request through the Medicaid agency or the operating agency (if applicable).

Personal Support Services

Personal Support services teach adaptive skills to assist the participant to reach goals related to activities of daily living, and are provided on a short-term basis because of the absence, incapacity or need for relief of those persons who normally provide care (typically referred to as respite).

Supports are typically provided in such areas as eating, bathing, dressing, personal hygiene, community integration, meal preparation (excluding the cost of the meals), transportation and other activities of daily living.

Supports may be provided to assist the participant to perform such tasks as light housework, laundry, grocery shopping, using the telephone, and medication management, which are essential to the health and welfare of the participant, rather than for the participant’s family. Supports may be provided to develop skills in money management or skills necessary to self-advocate, exercise civil rights and exercise control and responsibility over other support services. Such assistance also may include the supervision of participants as provided in the support plan.

Personal Support may function as an extension of behavioral and therapy services. Extension of services means activities by the Personal Support worker that assist the participant to implement a behavioral, occupational therapy, physical therapy, or speech therapy plan to the extent permitted by state law and as prescribed in the individual service plan. Implementation activities include assistance with exercise routines, range of motion, reading the therapist’s directions, helping the participant remember and follow the steps of the plan or hands-on assistance. It does not include the actual service the professional therapist provides.

Personal Support is not intended to include professional services, home cleaning services, or other community services used by the general public. Personal Support may be provided in the participant's home and may include supports necessary to participate in other community activities outside the home. The need for Personal Support and the scope of the needed services must be documented in the participant centered service plan.

Personal Support will not be duplicative of other services in the Waiver, i.e., Residential Habilitation, Developmental Training, etc., since the scope of Personal Support services are already included in those services.

Personal Support services are included in the participant’s monthly cost limit. For participants still enrolled in school, Personal Support services may not be delivered during the typical school day relative to the age of the participant or during times when educational services are being provided.

Community-Based Day Habilitation

Community-based day habilitation includes

Services are furnished four or more hours per day on a regularly scheduled basis as specified in the participant’s service plan. Meals provided as part of these services shall not constitute a "full nutritional regimen" (three meals per day).

Community-based day habilitation services focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the service plan.

In addition, Community-based day habilitation services may serve to reinforce skills or lessons taught in other settings.

Community-based day habilitation also includes

Community-based day habilitation also enhances a participant's ability to engage in productive work activities through a focus on such habilitative goals as compliance, attendance, and task completion. Community-based day habilitation may also include training and supports designed to maintain skills and functioning and to prevent or slow regression.

Activities may consist of

Community-based day habilitation includes transportation between the residence and other community locations where Community-based day habilitation occurs. Transportation is provided and billed as an integral part of Community-based day habilitation. The cost of transportation is included in the rate paid to providers of Community-based day habilitation services. Training and assistance in transportation is provided as needed.

Community settings are defined as non-residential, integrated settings that are primarily out in the community where services are not rendered within the same building(s) alongside other non-integrated participants.

Facility-Based Day Habilitation

Assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills that takes place outside of the Participant’s home in an approved facility that support learning and assistance outside of the Participant’s home. Activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, personal choice and are intended to build relationships and natural supports.

Services are furnished four or more hours per day on a regularly scheduled basis as specified in the participant’s service plan. Meals provided as part of these services shall not constitute a "full nutritional regimen" (three meals per day).

Facility-based day habilitation services focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational, or speech therapies in the service plan.
In addition, Facility-based day habilitation services may serve to reinforce skills or lessons taught in other settings.
Facility-based day habilitation also includes a range of adaptive skills in the areas of motor development, attention span, safety, problem solving, quantitative skills, and capacity for individual living. Facility-based day habilitation also enhances a participant's ability to engage in productive work activities through a focus on such habilitative goals as compliance, attendance, and task completion. Facility-based day habilitation may also include training and supports designed to maintain skills and functioning and to prevent or slow regression.
Facility-based day habilitation includes the reduction of maladaptive behaviors through positive behavioral supports and other methods.

Facility-based day habilitation does not include the following:

Residential Habilitation

Residential Habilitation means individually tailored supports that assist with the acquisition, retention, or improvement in skills related to living in the community. These supports include case management, adaptive skill development, assistance with activities of daily living, community inclusion, transportation, adult educational supports, social and leisure skill development, that assist the participant to reside in the most integrated setting appropriate to his/her needs.

Residential Habilitation also includes personal care and protective oversight and supervision. Payment is not made for the cost of room and board. Included in the cost not covered are building maintenance, upkeep and improvement (other than such costs for modification or adaptations to a facility required to assure the health and safety of residents, or to meet the requirements of the applicable life safety code). Residential Habilitation includes the reduction of maladaptive behaviors through positive behavioral supports and other methods. Payment is not made, directly or indirectly, to members of the participant's immediate family. Transportation provided as a component part of Residential Habilitation is included in the rate paid to providers of Residential Habilitation services.

In addition, Residential Habilitation may include necessary nursing assessment, direction and monitoring by a registered professional nurse, and support services and assistance by a registered professional nurse or a licensed practical nurse to ensure the participant’s health and welfare. These include monitoring of health status, medication monitoring, and administration of injections or suctioning. It also includes administration and/or oversight of the administration of oral and topical medications consistent with the Illinois Nursing and Advanced Practice Nursing Act (225 ILSC 65) and the Mental Health and Developmental Disabilities Administrative Act.

Nursing services are considered an integral part of Residential Habilitation services. Meeting the routine nursing needs of participants receiving 24-hour residential services is the responsibility of the residential service provider who must employ or contract with a professional nurse to perform their professional duties including the oversight and training of direct support staff. Nursing supports are part-time and limited; 24-hour nursing supports, similar to those provided in a nursing facility (NF) or Intermediate Care Facility for individuals with Developmental Disabilities (ICF/DD), are not available to participants in the Waiver. These services are in addition to any Medicaid State Plan nursing services for which the participant may qualify.

Residential Habilitation services are available to participants who require this intensity of service based on their identified needs. Factors involved in the assessment of the need for this service include the urgency of the situation (e.g., the unexpected loss of a caregiver) and the individual’s health and welfare concerns (e.g., an abusive or neglectful situation). To ensure criteria are fairly applied to all initial applicants and to those whose circumstances may change once they are enrolled in the Waiver, the Operating Agency staff convenes an internal committee to review each request from a statewide perspective.

Residential Habilitation sites are limited in size, depending on the licensure standards for the setting. Community Individual Living Arrangements (CILA) and Community Living Facilities are limited to no more than four individuals. Current settings as of 1/1/14, of 8 to 16 individuals will be eligible for funding subject to an approved plan for moving to four person settings.

This service will not be duplicative of other services in the Waiver. For example, non-medical transportation is an integral component of Residential Habilitation services.

Service Facilitation

Service Facilitation includes services that assist participants in gaining access to needed Waiver and other State plan services, as well as medical, social, educational and other services, regardless of the funding source for the services. The Service Facilitator assists the participant and guardian, if one has been appointed, in designing an array of habilitation and support services to meet the participant’s needs.

The Service Facilitator assists the participant and guardian (if applicable) to convene a service planning team, or may convene the team as directed by the participant or guardian (if applicable). The team consists of the participant, guardian (if applicable), family members and/or other individuals important to the participant, Service Facilitator, Individual Service and Support Advocate (ISSA), as well as any other professionals and service providers needed. Based on assessment information and discussions among members of the service planning team, the Service Facilitator develops/updates the participant-centered support plan at least annually or more often if needed.

The Service Facilitator assists the participant and guardian in choosing services and service providers as needed.
The Service Facilitator is responsible for ongoing monitoring of the provision of services included in the participant’s service plan and for ensuring participant health and welfare. The Service Facilitator is responsible for ensuring the completion of Service Agreements between the participant and service providers and monitoring the expenditure of funds according to the individual budget, service plan and Service Agreements. The Service Facilitator also assists the participant in determining whether individual providers of services, such as Personal Support, Non-Medical Transportation and Behavior Intervention and Treatment, are competent to provide the specific services the participant is receiving.

Service Facilitation is only available to participants who are self-directing their waiver services. This service will not be duplicative of other services in the waiver. For example, case management/care coordination services are a component of residential services. This service is included in the participant’s monthly cost limit. The individual service plan (ISP) and Service Agreement must set aside two hours per month to allow for routine required administrative activities.

Temporary Assistance (Emergency Support)

Temporary Assistance services (formerly called Crisis Services) are provided on an emergency temporary basis because of the absence or incapacity of the persons who normally provide unpaid care. Absence or incapacity of the primary caregiver(s) must be due to a temporary cause, such as hospitalization, illness, injury, or other emergency situation. Temporary Assistance services are not available for caregiver absences for vacations, educational or employment-related reasons, or other non-emergency reasons.

Temporary Assistance services include:

Medically Supervised Day Care

This service offers the necessary technological support and nursing care provided in a licensed medical day care setting as a developmentally appropriate adjunct to full time care in the home. Medically supervised day care serves to normalize the child’s environment and provide an opportunity for interaction with other children who have similar medical needs.

Such services are to be an alternative to otherwise necessary private duty nursing services in the home and are to include required safe and supervised transport between the home and day care center, while school age children may utilize day care facilities, HFS provides no reimbursement for education services nor is it part of the rate methodology for day care facilities. For purposes of this waiver, authorization of day care services requires: a prescription by the physician managing medical care; a request by the child’s parent(s) and/or legal guardian; the use of a facility licensed by the State to provide day care services and assurances of staffing ratios that are at least one licensed staff nurse for each three children.

Maximum of 12 hours per day, five days per week, based on identified need and service maximums.

Home Accessibility Modifications

Those physical adaptations to the private residence of the participant or the participant’s family, required by the participant's support plan, that are necessary to ensure the health, welfare and safety of the participant or that enable the participant to function with greater independence in the home. Such adaptations include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or the installation of specialized electric and plumbing systems that are necessary to accommodate the adaptive equipment that are necessary for the welfare of the participant.

Excluded are those adaptations or improvements to the home that are of general utility, such as carpeting, roof repair, central air conditioning, and are not of direct remedial benefit to the participant. Adaptations that add to the total square footage of the home are excluded from this benefit. Seasonal items such as swimming pools and related equipment are excluded. All services shall be provided in accordance with applicable State or local building codes.
This service is not included in the participant’s monthly cost limit/individual budget.

There is a $15,000 maximum per participant per five-year period for any combination of Adaptive Equipment/Assistive Technology, Home and Vehicle Modifications.

Within the five-year maximum, there is also a $5,000 maximum per address for permanent home modifications for rented homes. This service is subject to prior approval by the Operating Agency.

Vehicle Modifications

Vehicle Modifications are adaptations or alterations to an automobile or van that is the participant’s primary means of transportation in order to accommodate the special needs of the participant. Vehicle adaptations are specified by the service plan as necessary to enable the participant to integrate more fully into the community and to ensure the health, welfare and safety of the participant. The vehicle that is adapted must be owned by the participant, a family member with whom the participant lives or has consistent and on-going contact, or a nonrelative who provides primary long-term support to the participant and is not a paid provider of such services.

This service will not be duplicative of other services in the waiver. For example, vehicle modifications are within the transportation component of Residential Habilitation and Developmental Training services.

The following are specifically excluded:

  1. Adaptations or improvements to the vehicle that are of general utility, and are not of direct remedial benefit to the participant;
  2. Purchase or lease of a vehicle; and
  3. Regularly scheduled upkeep and maintenance of a vehicle.

For participants who choose home-based supports, this service is not included in the participant’s monthly cost limit. There is a $15,000 maximum per participant per five-year period for any combination of adaptive equipment, assistive technology, home modifications, and vehicle modifications.

This service requires prior approval by the Operating Agency.

Specialized Medical Equipment and Supplies

This service is the provision of equipment or supplies needed to maintain a participant in the home and the coverage of operational and maintenance costs of equipment, not otherwise available through the State Plan or through other third party liability.

Medical supplies, equipment and appliances are provided only on the prescription of the primary care physician as specified in the plan of care. Since each home care waiver case addresses a unique set of needs, provision of an all-inclusive list is not possible. Therefore, the State assures that these services will only be provided to meet the medical, health and safety needs of the participant. These will be limited in scope to the minimum necessary to meet the participant’s needs and will be utilized in accordance with manufacturer’s suggested standards.

This service differs from that offered under the State Plan in that it includes operational and maintenance costs for equipment. (Maintenance costs are incurred only for Department leased or owned equipment not otherwise available under the State Plan.)

Assistive Technology/Adaptive Equipment

Assistive technology device means an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of participants. Assistive technology service means a service that directly assists a participant in the selection, acquisition, or use of an assistive technology device. Assistive technology includes --

  1. the evaluation of the assistive technology needs of a participant, including a functional evaluation of the impact of the provision of appropriate assistive technology and appropriate services to the participant in the customary environment of the participant;
  2. services consisting of purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices for participants;
  3. services consisting of selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices;
  4. coordination and use of necessary therapies, interventions, or services with assistive technology devices, such as therapies, interventions, or services associated with other services in the support plan;
  5. training or technical assistance for the participant, or, where appropriate, the family members, guardians, advocates, or authorized representatives of the participant; and
  6. training or technical assistance for professionals or other persons who provide services to, employ, or are otherwise substantially involved in the major life functions of participants.

Items reimbursed with Waiver funds do not include any assistive technology furnished by the school program or by the Medicaid State Plan and exclude those items that are not of direct remedial benefit to the participant. All items shall meet applicable standards of manufacture, design and installation. All purchased items shall be the property of the participant or the participant’s family.

Home Delivered Meals

Prepared food brought to the client’s residence that may consist of a heated luncheon meal, a dinner meal, or both which can be refrigerated and eaten later. This service is designed primarily for a client who cannot prepare his/her own meals but is able to feed him/herself. This service will be provided as described in the service plan and will not duplicate those services provided by personal care services or homemaker provider.

Respite

Respite services provide relief for unpaid family or primary care givers, who are currently meeting all service needs of the customer. Services are limited to personal assistant, homemaker, nurse, adult day care, and provided to a consumer to provide his or her activities of daily living during the periods of time it is necessary for the family or primary care giver to be absent. FFP will not be claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence. It may be provided in the waiver participant’s home; or in  an appropriate care setting for the waiver participant, based on identified needs. Residential respite is limited to no more than 14 consecutive days and must be within the service cost maximum. The amount, duration, and scope of services are based on need and the service cost maximum.

Emergency Home Response Service

Emergency home response service (EHRS) is defined as a 24-hour emergency communication link to assistance outside the participant's home for participants based on health and safety needs and mobility limitations. This service is provided by a two-way voice communication system consisting of a base unit and an activation device worn by the participant that will automatically link the participant to a professionally staffed support center. The support center assesses the situation and directs an appropriate response whenever this system is engaged by a participant. The purpose of providing EHRS is to improve the independence and safety of participants in their own homes in accordance with the authorized plan of care, and thereby help reduce the need for nursing home care. Services cover both initial one time installation and monthly rental costs. The amount, duration and scope of services is based on need and the service cost maximum

Prevocational Services

Prevocational services not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or Section 602(16) and (17) of the Individuals with Disabilities Education Act (20 U.S.C. 1401 (16 and 17). Services are aimed at preparing an individual for paid or unpaid employment, but are not job-task oriented. Services include teaching such concepts as compliance, attendance, task completion, problem solving and safety. Prevocational Services are provided to persons expected to be able to join the general work force or participate in a transitional sheltered workshop within one year (excluding supported employment programs). When compensated, individuals are paid at less than 50 percent of the minimum wage. Activities in this service are not primarily directed at teaching specific job skills, but at underlying habilitative goals, such as span and motor skills. All prevocational services will be reflected in the individual’s plan of care as directed to habilitative, rather than explicit employment objectives. Documentation will be maintained in the file of each individual receiving this service that: The service is not otherwise available under a program funded under the Rehabilitation Act of 1973, or P.L. 94-142. The amount, duration, and scope of services is based on need and service cost maximum level as approved by the OA.

Supported Employment

Supported Employment services consist of intensive, ongoing supports to participants who, because of their disabilities, need intensive ongoing supports to obtain and maintain an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. The outcome of the service is sustained paid employment at or above minimum wage in an integrated setting in the general workforce, in a job that meets personal and career goals. Supported Employment services are individualized and may include any combination of the following services:

Transportation will be provided between the participant's place of residence and the employment site or between habilitation sites (in cases where the participant receives waiver services in more than one place) as a component of Supported Employment services. The cost of this transportation is included in the rate paid to providers of Supported Employment services.

Documentation is maintained in the file of each participant receiving this service that the service is not available under a program funded under Section 110 of the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.). Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

  1. Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program.
  2. Payments that are passed through to users of supported employment programs.

Supported Employment does not include sheltered work or other similar types of vocational services furnished in specialized facilities. Medicaid funds may not be used to defray the expenses associated with starting up or operating a business.

Such assistance may include:

  1. aiding the participant to identify potential business opportunities;
  2. assistance in the development of a business plan, including potential sources of business financing and other assistance in developing and launching a business;
  3. identification of the supports that are necessary in order for the participant to operate the business; and
  4. the ongoing assistance, counseling and guidance once the business has been launched.

This service is included in the participant’s monthly cost limit. Supported Employment services are subject to prior approval by the Operating Agency.

The annual rate is spread over 1,100 hours for any combination of day programs.

Supported Living Facilities (Assisted Living)

Personal care and supportive services that are furnished to waiver participants who reside in a homelike, non-institutional setting that includes 24-hour on-site response capability to meet scheduled or unpredictable participant needs and to provide supervision, safety and security. Services also include social and recreational programming, and medication assistance. Additionally, medication administration, intermittent nursing services and periodic nursing evaluations are provided. Transportation for activities must be supplied, as well as arrangement for transportation to scheduled medical appointments. Additionally, Personal Emergency Response Systems (PERS) are required in participant apartments and facility common areas. The system is connected to a supportive living facility's emergency call system staffed by nursing and response personnel. Other services include:

Services that are provided by third parties must be coordinated with the supportive living provider.

Case management services are provided to assist participants in gaining access to needed waiver and other State Plan services, as well as medical, social, educational and other services, regardless of the funding source for the services to which access is gained.

Nursing and skilled therapy services are incidental rather than integral to the provision of assisted living
services. Payment is not made for 24-hour skilled care. Nursing services required in the Supportive Living
Program include:

  • assessments,
  • service plan development/approval and implementation,
  • health promotion or disease prevention counseling and teaching self-care,
  • medication set-up and medication administration.
  • The use of home health services are also allowed in supportive living facilities, as ordered by a physician, but is not a required service.
  • SLF staff are expected to coordinate care and services with home health care providers. This includes among other skilled services, wound care and physical and occupational therapy.
  • Supportive living facilities must assist participants with obtaining such services.

    Access to the larger community is achieved through scheduled activities and assistance with individual
    preferences with regard to community involvement. Activities in the larger community may include
    volunteer/charity opportunities, musical presentations, religious programs, sporting events, shopping, cultural destinations and outdoor activities, like fishing. Additionally, community members are invited to participate at the facility.

    All assisted living services are provided by employees of the supportive living facility. Staff members provide
    individualized participant services based on the comprehensive assessment and a participant's preferences as determined through the service planning process. All participants are entitled to receive all of the services provided by the Supportive Living Program. Participants and others of their choosing, such as a designated representative, are involved with the development of the service plan. Participants are able to identify which services they would like to receive and the frequency. The Medicaid agency monitors supportive living facilities to ensure that this individualization occurs and verifies that participant care needs are being met. This monitoring occurs during annual/bi-annual on-site certification reviews and complaint investigations.

Non Medical Transportation

Non-Medical Transportation is a service offered in order to enable waiver participants to gain access to waiver and other community services, activities and resources, as specified by the service plan. This service is offered in addition to medical transportation required under the Code of Federal Regulations (42 CFR §431.53) and transportation services under the Medicaid State Plan, defined in the Code of Federal Regulations at 42 CFR §440.170(a) (if applicable), and does not replace them. Transportation services under the Waiver are offered in accordance with the participant’s service plan. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge are utilized.

Excluded is transportation to and from covered Medicaid State Plan services. Also excluded is transportation to and from day habilitation program services.

For participants who choose home-based supports, this service is included in the participant’s monthly cost limit.

This service will not be duplicative of other services in the Waiver. For example, Non-Medical Transportation is an integral component of residential and day services.

No more than $500 of the participant's monthly cost limit may be used for Non-Medical Transportation services.

Training and Counseling for Unpaid Caregivers

Training and Counseling services are provided to individuals who provide unpaid support, training, companionship or supervision to participants. For purposes of this service, individual is defined as any person, family member, neighbor, friend, companion, or co-worker who provides uncompensated care, training, guidance, companionship or support to a Waiver participant. Training includes instruction about treatment regimens and other services included in the support plan, use of equipment specified in the service plan, and includes updates as necessary to safely maintain the participant at home. All training for individuals who provide unpaid support to the participant must be included in the participant’s individual service plan.

Training furnished to individuals who provide uncompensated care and support to the participant must be directly related to their role in supporting the participant in areas specified in the service plan. Counseling must be aimed at assisting the unpaid caregiver in understanding and meeting the needs of the participant.

This service also provides short-term, issue-specific family or individual counseling for the purpose of maintaining the participant in the home placement. This service is prescribed by a physician based upon his or her judgment that it is necessary to maintain the child in the home placement. This service must be provided by a licensed clinical social worker (LCSW), a licensed clinical psychologist (LCP), or an agency certified by the Department of Human Services, Division of Mental Health or Department of Children and Family Services to provide Medicaid Rehabilitation Option services. The service provider must accept HFS payment, as payment in full, and provide services in the home if the participant or participant's family is unable to access services outside the home.

This service will not be duplicative of other services in the Waiver. For example, the Adaptive Equipment/Assistive Technology service includes training for family members in the use and/or maintenance of the device, therefore, Training and Counseling could not cover this type of training.

This service may not be provided in order to train paid caregivers or school personnel.

Nursing

Service provided by an individual that meets Illinois licensure standards for a Certified Nursing Assistant (CNA) and provides services as defined in 42CFR 440.70, with the exception that limitations on the amount, duration, and scope of such services imposed by the State's approved Medicaid state plan shall not be applicable. Services provided in this waiver shall be in addition to any available under the state plan.

Services provided are in addition to any services provided through the State Plan. The amount, duration, and scope of services is based on assessment of need and the service cost maximum

Intermittent Nursing

Nursing services are provided within the scope of the State's Nurse Practice Act by registered nurses, licensed practical nurses, or vocational nurses licensed to practice in the state and are not otherwise covered through Early and Periodic Screening, Diagnostic, and Treatment (EPSDT).

The amount, duration, and scope of services is based on the assessment of need and the service cost maximum.
All waiver clinical services require a prescription from a physician. The duration and/or frequency of these services are dependent on continued authorization of the physician, and relevance to the customer’s service plan.

Services provided through the state plan are of a curative or rehabilitative nature and demonstrate progress toward short-term goals. State plan services are provided to facilitate and support the individual in transitioning from a more acute level of care, e.g., hospital, long term care facility, etc., to the home environment to prevent the necessity of a more acute level of care. Under the State plan, the first 60 days following discharge from a hospital or long term care facility do not require prior approval when services are initiated within 14 days of discharge. Services may be provided under the waiver when the individual does not meet eligibility requirements for the state plan service.

Skilled Nursing

Services listed in the participant-centered service plan that are within the scope of the State's Nurse Practice Act and are provided by a registered professional nurse, or licensed practical nurse under the supervision of a registered nurse, licensed to practice in the State.

These services are in addition to any Medicaid State Plan nursing services for which the participant may qualify.

This service will not be duplicative of other services in the Waiver. For example, nursing services beyond those covered in the State Plan, are a component of residential services.

For participants who choose home-based supports, this service is included in the participant’s monthly cost limit.

There is a State fiscal year combined maximum of 365 hours of service by a registered nurse and 365 hours of service by a licensed practical nurse.

Behavior Intervention and Treatment

Behavior Intervention and Treatment includes a variety of individualized, behaviorally-based treatment models consistent with best practice and research on effectiveness that are directly related to the participant’s therapeutic goals. Interventions include, but are not limited to: Applied Behavior Analysis, Relationship Development Intervention (RDI), and Floor Time. These services are designed to assist participants to develop or enhance skills with social value, lessen behavioral excesses and improve communication skills. Key elements are:

A behavior consultant assesses the participant, including analysis of the presenting behavior and its antecedents and consequences, and develops written behavior strategies based upon the participant’s individual needs. The strategies are a component of the participant-centered service plan and must be approved by the participant, guardian if one has been appointed, responsible QIDP/Service Facilitator, Individual Service and Support Advocate (ISSA) and the other members of the planning team. The behavior consultant monitors progress on at least a monthly basis and more frequently if needed to address issues with the participant’s outcomes. A progress report is prepared by the behavior consultant and sent to the service planning team at least every six months. This progress report is available to State staff upon request to evaluate the efficacy of the intervention and treatment.

The behavior consultant supervises implementation of the behavior plan. This includes training of the direct support staff and unpaid informal caregivers to ensure that they apply the interventions properly, understand the specific services and outcomes for the participant being served, and know the procedures for regularly reporting participant progress.

Services are provided by professionals working closely with the participant’s direct support staff and unpaid informal caregivers in the participant’s home and other natural environments. Direct support staff and unpaid informal caregivers of participants receiving Behavior Intervention and Treatment are vital members of the behavior team. They must be involved in the initial training session to initiate services, and must remain involved with the behavior consultant so that they are able to carry through and reinforce the behaviors being worked on. A client may receive an annual maximum of 66 hours of behavior intervention and treatment.

Behavioral Services

Psychotherapy is a treatment approach that focuses on a goal of ameliorating or reducing the symptoms of emotional, cognitive or behavioral disorder and promoting positive emotional, cognitive and behavioral development. Counseling is a treatment approach that uses relationship skills to promote the participant’s abilities to deal with daily living issues associated with their cognitive or behavioral problems using a variety of supportive and re-educative techniques.

For participants who choose home-based supports, this service is included in the participant’s monthly cost limit.

There is a State fiscal year maximum of 60 hours for any combination of psychotherapy and counseling services.

Cognitive Behavioral Therapies

Cognitive/Behavioral services are not covered in the Illinois State Plan. These services are specific to persons with brain injury and are initiated as a result of a clinical recommendation. The overall goal is to assist waiver participants in managing their behaviors, by decreasing maladaptive behaviors, and/or enhancing their cognitive functioning. The ultimate goal is to improve waiver participant’s capacity for independent living.

Cognitive/behavioral therapies are performed by individuals who are licensed to provide speech therapy or clinical counseling services. Qualified providers are listed below:

Counseling may be provided in either individual or group settings. Typically, this is for short-term periods, although some individuals may require more intensive, longer sessions. Depending on the theory followed by the practitioner, different approaches are used including counseling, psychotherapy, and behavior modification.
Behavioral modifications may also include social/environmental modifications.

Cognitive therapies are provided by a speech therapist. Cognitive therapies may include assisting with communication problems by having the person complete basic reading and vocalizing tasks, or by teaching alternative communication methods.

All waiver clinical services require a prescription from a physician. The duration and/or frequency of these services are dependent on continued authorization of the physician, and relevance to the service plan. The amount, duration, and scope of services is based on the assessment score and service cost maximum.

Extended State Plan Service (ESPS) HHA

Home Health Aide in the waiver is an extended State Plan version of the "Home Health Aide" service in the State Plan and on the HFS Fee Schedule for Home Health Nursing Agencies. Services provided through the State Plan are provided on a short-term or intermittent basis. These services are of a curative or rehabilitative nature and demonstrate progress toward short-term goals. State plan services are provided to facilitate and support the individual in transitioning from a more acute level of care, e.g., hospital, long term care facility, etc., to the home environment to prevent the necessity of a more acute level of care. Under the State plan the first 60 days following discharge from a hospital or long term care facility do not require prior approval when services are initiated within 14 days of discharge. Home Health Aides in the State Plan are paid per visit; rather than hourly. Visits are limited to two hours or less.

Home Health Aide services, under the waiver are paid hourly and may be provided when the individual does not meet the prior approval requirements for the State Plan services. The waiver services are in addition to any Medicaid State Plan Home Health Aide services for which the participant may qualify. Home Health Aide services through the waiver focuses on long term habilitative needs rather than short-term acute restorative needs.

Services are provided by an individual that meets Illinois standards for a Certified Nursing Assistant (CNA) and provides services as defined in 42CFR 440.70, with the exception that limitations on the amount, duration, and scope of such services imposed by the State's approved Medicaid state plan shall not be applicable.

Specific tasks follow:

Home Health Aide duties may include but are not limited to:

The amount, duration, and scope of services is based on the assessment conducted by the case manager/counselor and the service cost maximum.

All waiver clinical services require a prescription from a physician. The duration and/or frequency of these services are dependent on continued authorization of the physician, and relevance to the service plan. Participants receiving personal assistant or personal support services are not eligible for this service.

ESPS Physical Therapy

Physical Therapy services under the waiver differ in nature and scope from Physical Therapy services in the Medicaid State Plan. Waiver Physical Therapy focuses on the long-term therapeutic needs of the participant, rather than short-term acute restorative needs.

Restorative services are covered under the Medicaid State Plan.

For participants who choose home-based supports, this service is included in the participant’s monthly cost limit.

There is a State fiscal year maximum of 26 hours, unless additional documentation supports the need for additional hours (up to 52 hours). Services are subject to prior approval by the Operating Agency.

ESPS Occupational Therapy

Occupational Therapy in the waiver is an extended State Plan version of the Occupational Therapy service in the State Plan. Services provided through the State Plan are provided on a short-term or intermittent basis. Under the State Plan, adults are allowed 20 therapy visits, per year. Prior approval is required. For children there are no limits. State Plan services are of a curative or rehabilitative nature and demonstrate progress toward short-term goals. These services are provided to facilitate and support the individual in transitioning from a more acute level of care, e.g., hospital, long term care facility, etc., to the home environment to prevent the necessity of a more acute level of care. Services may be provided under the waiver when the individual does not meet eligibility requirements for the State Plan services.

Services are provided by a licensed occupational therapist that meets Illinois licensure standards. Waiver services are in addition to any Medicaid State Plan services for which the participant may qualify. Occupational therapy through the waiver focuses on long term habilitative needs rather than short-term acute restorative needs.

Specific tasks may include: instructing persons on techniques and equipment that can make daily living and working easier. The OT treats persons with injuries, illnesses, or disabilities, through the therapeutic use of everyday activities. They help develop, recover, and improve the skills needed for daily living. Duties include but are not limited to evaluating the person's condition and needs, establishing a treatment plan, determining the types of activities and specific goals to be reached, demonstrating exercises that can help relieve pain, evaluating a home or workplace, identifying how it can be better suited to the person's health needs, educating the family about how to accommodate and care for the person, recommending special equipment, such as wheelchairs and eating aids, instructing on how to use the equipment, assessing and recording activities and progress, and reporting information to physicians and other healthcare providers.

All waiver clinical services require a prescription from a physician. The duration and/or frequency of these services are dependent on continued authorization of the physician, and relevance to the customer's service plan.

The amount, duration, and scope of services is based on the assessment score and service cost maximum level.

ESPS Speech Therapy

A medically prescribed speech and/or language based service identified in the service plan that is used to evaluate and/or improve a customer's ability to communicate. The service is provided by a licensed speech therapist that meets Illinois licensure standards. Speech therapy through the waiver focuses on long-term habilitation needs rather than short-term acute restorative needs.

Services may be approved under the waiver if the individual is no longer eligible for therapies under the state plan, but continues to need long-term habilitative services.

All waiver clinical services require a prescription from a physician. The duration and/or frequency of these services are dependent on continued authorization of the physician, and relevance to the customer's service plan.

The amount, duration, and scope of services is based on the determination of need and the service cost maximum.

Services provided through the State plan are of a curative or rehabilitative nature and demonstrate progress toward short-term goals. State plan services are provided to facilitate and support the individual in transitioning from a more acute level of care, e.g., hospital, long-term care facility, etc., to the home environment to prevent the necessity of a more acute level of care. Under the State plan, the first 60 days following discharge from a hospital or long-term care facility do not require prior approval when services are initiated within 14 days of discharge. Services may be provided under the waiver when the individual does not meet eligibility requirements for the State plan services.

Child Group Home

Residential services for children, must meet residential facility certification requirements.

Appendix B: Additional Detail on DSRIP Projects

The following give potential examples from Cook County and University of Illinois health systems. Specific projects will be under the direction of HFS and focus on transformation of service delivery by these two public entities.

Cook County Health and Hospital System

In 2013, CCHHS embarked on an epic initiative to launch a Medicaid managed care plan under an 1115 Waiver authority. Launched early in 2013 as “CountyCare,” this plan met with a very high level of demand for coverage by low income, uninsured eligible adults. Over 127,000 applicants sought this coverage in less than a year’s time and over 70,000 were enrolled, making CountyCare one of the country’s landmark Medicaid expansion success stories.

Now, with health reform implementation rapidly evolving, CCHHS is poised to bring administrative efficiency to the challenge of providing direct services, while also serving as a health plan, a payer (i.e., purchaser of services), and a population health management entity with a public health department within its scope. Termed the “4Ps Strategy,” the CCHHS vision will be implemented in these four domains—provider, plan, payer, and population health manager.

CCHHS will pursue transformation within this 4Ps construct. With federal support, CCHHS will be able to pursue innovative transformative initiatives across several of these areas, as follows:

Lead a partnership directed at achieving the triple aim by increasing outpatient service availability and improving efficiency. CCHHS will consider partnership opportunities that better position the organization to implement the triple aims in line with our mission through consolidation with one or more partners of our clinical service delivery, teaching and research functions. Such a consolidation will afford CCHHS the opportunity to participate in bringing a full array of comprehensive services to the delivery of patient care, including highly specialized interventions, while reaching a larger target population in a cost effective manner. Through partnership and consolidation, CCHHS will aim to offer high quality graduate medical education and training in community health as well as in subspecialty care. Further, partnership and consolidation opportunity will be explored to increase research capacity and expand expertise to pursue investigations and studies in line with our mission.

Redirect resources to more appropriate locations for primary care, subspecialty consultation and diagnostics. To upgrade and expand subspecialty services beyond those offered on the Stroger Hospital Campus, CCHHS will reconfigure its delivery of ambulatory services to provide multispecialty adult consultation and diagnostic services in two or more community settings as well as in new, efficient space at or near its historic location. These “hubs” will provide primary and specialty care as well as preventive and group educational services, and will serve as a referral resource for local patients seeking specialty consultation. By placing adult subspecialty care in local community settings, CCHHS will be able to direct resources to areas that have been long neglected and provide and economic boost to the surrounding communities.

Collaborate with the University of Illinois College of Nursing to improve CCHHS workforce capacity and competency. Located adjacent to the CCHHC campus, the University of Illinois at Chicago offers a nationally ranked nursing curriculum with special expertise in advanced practice nursing, nursing leadership, and research. CCHHS will collaborate with this program to offer specialized nursing education and training tailored to meet the immediate needs of our inpatient and ambulatory settings. The program will help address a chronic CCHHS nursing shortage and primary care shortage. Further, the partnership will strengthen the internal nursing competency assessment processes to embrace new delivery models and address the needs of a changing patient population. Finally, this program will increase the number of CCHHS nurses prepared with leadership training who can in turn attend to the demands of change management in a rapidly changing environment.

Develop a community health worker residency program and collaborate on other training programs to address workforce shortages. In collaboration of Malcolm X College of the City Colleges of Chicago, CCHHS will develop a residency program to train community health worker students in supervised direct practice community setting. This collaboration will strengthen the community health worker role by offering a team-based training experience in a delivery setting. Through community health worker residency program design and implementation, we intend to contribute a replicable training model as well as recommended practices for ongoing workplace supervision of this emerging role.  As part of this collaboration, CCHHS will participate as an advisor to the Malcolm X College curriculum development process for preparation of future community health workers. In addition, CCHHS will serve as a post-graduate employment setting for selected highly qualified Malcolm X health sciences graduates as needed within our system. Finally, through the CCHHS collaboration with Malcolm X College, we will also build workforce training programs specific to CCHHS needs.

Integrate behavioral health and primary care. Approaching their model of care through the PCMH lens, both CCHHS and its CountyCare network of contracted providers will implement a population screening measure that allows better identification of patients with mild to moderate depression and related behavioral health disorders (anxiety, grief, substance use). Using its leverage as a payer, CountyCare will promote screening and referral, using incentives and penalties to increase screening, early identification, care coordination and enrollment in treatment to address costly, prevalent mental health issues.

Address food insecurity – CCHHS would collaborate with local private non-profits to provide a comprehensive approach to food insecurity, with a particular focus on vulnerable adults. This comprehensive approach would include: a public health campaign on the relationship of food to health, vending of fresh food at CCHHS and other CountyCare contracted network provider sites through community partnerships, patient education regarding interaction of food with chronic illness and with medication, and specialized health professions training on food as an element of a planned approach to health care delivery, including for emerging professions such as community health workers.

University of Illinois Hospital and Health Sciences System

The below projects present ways that the only State hospital and health system can leverage its own strengths to improve care and lower costs for patients statewide. As a major provider of both primary and specialty care services to the Medicaid population, UI Health also intends to transform care within its own system in order to achieve the triple aim of improved quality of care, improved health outcomes, and reduced costs. By transitioning to new payment models, through both the development of a UI Health Medicaid care coordination network and partnership with entities that have other models (including the MCOs, MCCNs, CCEs, and ACEs described elsewhere in this application), the state’s healthcare system can lower its own costs at the same time as it improves healthcare outcomes for some of the most vulnerable patients in the state. Along with integrating the University’s providers, it will also align and expand its educational and academic resources to implement statewide objectives in order to address the following transformation needs:

Integrating University Medical Services Into Managed Care Delivery Systems

The University of Illinois Hospital and Health Sciences System is one of the largest Medicaid providers of inpatient and outpatient care in the state of Illinois. Given the University’s model of healthcare delivery under the auspices of the academic medical center model, the University’s obvious and dominant strength lies in the provision of healthcare services that specially target very complex medical conditions. While the University does provide primary care in its clinics and FQHC network, its ability to provide complex medical care continues to be a significant asset to the state Medicaid program. Under DSRIP, the University would not just continue to be a major specialty medical care provider, but it would expand its specialty care capacity to address the lack of access to specialty care which is well documented in many parts of the Chicago area, as well as across the state. Many of the University’s medical care services have been recognized as the center for excellence for such specialty services and include:  

These specialty services are essential to assuring that Medicaid clients maintain reasonable access. In many cases, the University is the preferred, and in some cases, the only provider of such specialty services to the Medicaid population.   

While the University is currently developing its own managed care network that will include both primary and specialty care services, the University’s medical and academic and research assets will continue to provide Illinois’s Medicaid program with the latest advancements in health care. The prevalence of this specialized care provides a unique opportunity to help transform the way in which complex medical care may be provided to the most medically complex clients.

DSRIP Projects – Category 1:  Expanding Local and Statewide Specialty Care and Laboratories of Healthcare Delivery Transformation

The medical expertise of specialty care for Medicaid clients already exists within the University’s various clinics and centers. Illinois proposes to establish delivery models for complex medical conditions that align the University’s social service assets to provide specialized care coordination and follow up, tailored to the specific medical needs and social circumstances of clients receiving specialty care. Such services may be provided to clients enrolled with managed health care plans, as well as those remaining under fee for service. While payments from the Medicaid agency or other plans are likely to be based on a fee for service or negotiated amount for the delivery of traditional medical service delivery, DSRIP funds will be used to fund the additional costs of condition specific social and care coordination enhancements, as well as any alternative clinical costs. The University will also utilize DSRIP funding to engage its academic and research expertise in the areas of finance and economics to develop potential global payment scenarios and assess long term cost savings of such approaches. The goal of such pilot projects is to develop specialized approaches for the most complex and costly Medicaid clients. As a public university with a mission to both create and disseminate knowledge, the details of effective and cost saving approaches will be reported to the Medicaid agency to aid in future policy development, as well as other commercial provider plans for potential replication. While such alternative specialty care delivery pilots can be developed for a wide range of complex medical conditions, initial projects should focus on those with Sickle Cell and those that are HIV positive.

Under this category, the University shall use DSRIP funding to;

State Delivery Transformation Initiatives

In addition to the University’s medical services, its academic resources will provide an integral component addressing current and growing need throughout the state. Aligning these resources will directly benefit other providers and provider networks and improve medical access throughout the state.

DSRIP Projects – Category 2 – Establish a Statewide Telemedicine Infrastructure

The Medicaid State Plan already allows for telemedicine as a billable service. However, there does not yet exist an effective statewide network of specialty services available for medical consultations. The University proposes to build on its experience in telemedicine to offer new services to patients in regions of Illinois where such services are not available. This includes capabilities in areas such as tele-psychiatry, as well as other areas in which access to needed specialty consultations often needs significant enhancement.

Under this category, the University shall use DSRIP funding to:

DSRIP Projects – Category 3 – Establish Continuing Education Resources for Medically Complex Conditions

The University proposes to expand its current capacity to provide remote learning through an interactive, multidisciplinary training site. Through the use of simulation, transformative innovations in healthcare innovations may be accessed by hospitals and practitioners throughout the state, with a specific focus on specialty care and expertise that may be lacking in some regions of the state.

Under this category, the University shall use DSRIP funding for purposes similar to those under Category 2 above.

DSRIP Projects – Category 4 – Medical Education

The University propose to use DSRIP funding for medical education costs not currently reimbursed in the Medicaid program and for the development of new medical education initiatives that are targeted at increasing the availability of medical professionals providing services in medically underserved urban and rural areas. New, targeted medical education initiatives will include the recruitment of students coming from medically underserved areas, as well as rotational training and experiences into such communities, thereby increasing the chances / likelihood of graduates establishing practices in such urban and rural areas. Specific proposals include addressing health professional shortages of; primary care physicians, nursing, pharmacists, social workers, dentists, applied health professions, and public health. 

Under this category, the University shall use DSRIP funding to cover the cost of medical education needed to address provider shortages, to the extent such costs are not already reimbursed under Medicaid or any other federal funding source. 

University DSRIP Proposals and Their Relation to Delivery System Reform
Innovations Driver Objective Provider Delivery Transformation Statewide Delivery Transformation
Category 1
Specialty Care Access
Category 2
Telemedicine
Category 3
Continuing Education
Category 4
Medical Education*
Integrated health care delivery / payment reforms X      
Additional support / services for those with special needs X      
Ensuring an adequate workforce   X X X
Leadership to promote / improve health care systems X X X X

Appendix C: Costs Not Otherwise Matchable/Designated State Health Programs

Department of Human Services DDD

Department of Human Services - DDD Annual $
DD FFS - Respite  (87D) (89D) (DD Billable Respite)  $ 7,101,500
DD FFS - DD Legacy Model Community Serv (DD Billable Residntial)  $ 1,165,200
DD FFS - Specialized Services (DD Billable Residntial)  $ 2,644,500
DD FFS - Child Care Institutions (CCI 19D) (DD Billable Residntial)  $ 4,495,300
DD Grant - Individual Service Coordination (DD Case Mgt.)  $ 4,970,000
DD Grant - Pas Bogard (Defined Pop Case Mgt.)  $ 1,210,300
DD Grant - ARC Lifespan (DD Service Outreach)  $ 376,100
DD Grant - Autism - The Hope School (Education and Referral)  $ 4,300,000
DD Grant - Best Buddies (Education and Awareness)  $ 500,000
DD Grant - Epilepsy (Education and Referral)  $ 2,075,400
DD Grant - Dental  (DD Dental not billed ind.)  $ 1,103,400
DD Grant - UIC Family Clinics  $ 1,789,900
DD Grant - Group Respite (DD Respite)  $ 973,000
Total Department of Human Services - DDD  $ 32,704,600

Department of Human Services - DMH

Department of Human Services - DMH Annual $
Juvenile Justice  $ 2,370,947
Psychiatrist Services in Mental Health Center  $ 26,921,471
Special Projects  $ 34,316,075
Specialized Direct Clinical Services  $ 618,432
Crisis Staffing  $ 12,467,473
Outreach  $ 580,081
Clinical Review  $ 628,200
Reintegration Residential Forensics  $ 577,474
Individual Care Grant  $ 19,627,870
Total Department of Human Services - DMH  $ 98,108,023

Department of Human Services - DASA

Department of Human Services - DASA Annual $
Addiction Treatment Services - Case Management  $ 819,000
Addiction Treatment Services - Early Intervention  $ 774,900
Addiction Treatment Services - Methadone  $ 3,570,000
Addiction Treatment Services - Childcare Residential Rehab Related  $ 217,560
Addiction Treatment Services - Recovery Coaching  $ 800,000
Addiction Treatment Services - Toxicology  $ 117,600
Total Department of Human Services - DASA  $ 6,299,060

Department of Healthcare and Family Services

Department of Healthcare and Family Services Annual $
LTC- IMD  $ 97,419,400
Limited Benefit Package - Hemophilia  $ 12,500,000
Limited Benefit Package - Renal Dialysis  $ 300,000
Limited Benefit Package - Sexual Assault Treatment  $ 300,000
Total Department of Healthcare and Family Services  $ 110,519,400

Department on Aging

Department on Aging Annual $
Community Care Program (Grants/Admin)  $ 305,846,641
CCP Demo:  Managed Community Care Program (MCCP)  $ 1,104,597
CCP Demo: Comprehensive Care in Residential Settings (CCRS)  $ 1,228,457
CCP Demo:  Senior Companion Services  $ 91,978
CCP Demo:  Money Management  $ 254,769
CCP Demo:  My Choices/ Cash and Counseling  $ 407,214
CCP Demo:  Money Follows the Person (MFP)  $ 53,834
Adult Protective Service  $ 19,259,700
Grandparents Raising Grandchildren Program  $ 300,000
For Grants to Senior Health Assistance Programs  $ 1,600,000
Planning and Service Grants to Area Agencies on Aging  $ 7,722,000
Distribution to 13 Area Agencies on Aging - Home Delivered Meals/Mobile Food Equip  $ 11,623,200
Total Department on Aging  $ 349,492,390

Department of Corrections/Department of Juvenile Justice

Department of Corrections/Department of Juvenile Justice Annual $
Parolee Resource - Substance Abuse & Mental Health Counseling  $ 7,000,000
Parolee Resource - Psychotropic drugs given upon release  $ 11,000
Aftercare Placements - Residential Placement of Youth  $ 3,000,000
Total Department of Corrections/Department of Juvenile Justice  $ 10,011,000

Department of Public Health

Department of Public Health Annual $
Health Promotion  $ 35,601,000
Women's Health  $ 4,036,400
Illinois Breast and Cervical Cancer (IBCCP)  $ 17,423,400
Public Health Laboratories  $ 27,906,800
Health Policy, Planning, and Statistics  $ 15,769,800
Total Illinois Department of Public Health  $ 100,737,400

Department of Children and Family Services

Department of Children and Family Services Annual $
Substitute Care - Foster Care & IGH  $ 111,587,700
Adoption & KinGAP  $ 25,219,610
Cash Assistance (Norman Cash Assistance)  $ 1,937,272
Children's Advocacy Centers  $ 3,360,300
Counseling  $ 19,164,040
Preservation  $ 3,133,329
Foster Care Initiative  $ 7,411,792
Day Care  $ 17,810,803
Psychological  $ 3,028,400
Total Department of Children and Family Services  $ 192,653,245

Department of Human Services - Family and Community Services (FCS)

Department of Human Services - Family and Community Services (FCS) Annual $
Healthy Families  $ 10,040,000
Parents Too Soon  $ 4,379,900
Homelessness Prevention  $ 1,000,000
Rape Victims/Prevention Act  $ 6,159,700
Domestic Violence Shelters  $ 18,635,067
Youth Programs  $ 8,800,000
IL Chicago Area Project  $ 5,645,376
Comprehensive Community Services  $ 11,046,400
Redeploy Illinois  $ 4,885,100
Homeless Youth Services  $ 3,598,100
Total Department of Human Services - Family and Community Services (FCS)  $ 74,189,643

State Workforce Training

State Workforce Training Annual $
University of Illinois (all campuses)  $ 90,000,000
Southern Illinois University - Carbondale  $ 49,090,613
Southern Illinois University - Edwardsville  $ 9,581,463
Governors State University  $ 3,367,848
State Loan Repayment Program  $ 10,000,000
New Workforce Training Programs  $ 50,000,000
Total State Workforce Training  $ 212,039,924

Poison Control

Poison Control Annual $
Poison Control  $ 4,000,000
Total Poison Control  $ 4,000,000

Local Government Sources

Local Government Sources Annual $
Local Government  $ 50,000,000
Total Local Government Sources  $ 50,000,000

Illinois State Board of Education

Illinois State Board of Education Annual $
Local Government  $ 42,000,000
Birth-To-Three Initiative  $ 42,000,000

Total Costs Not Otherwise Matchable $ 1,232,754,686

Appendix D: Examples of Workforce Training Programs Being Considered for Targeted Investment

As described in the waiver narrative, Illinois proposes to make targeted investment in workforce training programs that directly benefit the Medicaid program. Below are examples of programs that are being evaluated for potential expansion at public universities in the Illinois, including

Increasing Social Workers and Community Health Workers in Medically Underserved Areas

Increasing Primary Care Physicians and Placement in Medically Underserved Areas

 Increasing the Supply of Dental Services in Underserved Areas

Increasing the Supply of Nurses in Medically Underserved Areas

Increasing the Supply of Pharmacists in Medically Underserved Areas

Increasing the Supply of OT and PT in Medically Underserved Areas

Increasing Mental Health Services in Medically Underserved Areas

Increasing the Supply of Registered Dieticians and Their Placement in Medically Underserved Areas

Increasing the Availability of Public Health and Community Health Workers in Underserved Areas

Appendix E: 1115 Waiver Stakeholder Meetings

Appendix F -- Budget Neutrality Detail and Expenditure Plan

The Path to Transformation waiver is focused on increasing access to critical, community-based services and supporting the creation of integrated delivery systems that are incentivized to provide the right care at the right time in the right setting with the right provider. While many of the provisions proposed in the waiver will have large returns on investment over time in quality and cost, our financial analysis is focused on the areas where we expect to see a significant impact within the five-year waiver period. Specifically, the waiver:

We believe these and other provisions outlined in the waiver will bend the cost curve over the next five years and beyond and will allow Illinois to meet the aggressive budget neutrality goals we have set. We also anticipate that the benefits and savings from the waiver will be significant for the newly eligible population and have incorporated this estimated impact into our analysis.

Baseline Trends

To calculate baseline trends without innovations, Medicaid data files with dates of service occurring in years 2009, 2010, 2011, 2012 and 2013 were used. Additionally, we added the impact of state plan filed recently as well as the impact of the proposed additional 1915c waiver slots and waiver parity provisions (see page 40, “Moving from a Disability Based to a Need Based System”) for further discussion) to the overall trend rates and base year costs. These state plan amendments include the following:

All of these changes can be made without an 1115 waiver and, based on recent Consent Decrees and lawsuits filed, we believe would eventually happen. For this reason, we have added them to the base on both the without waiver and with waiver calculations. They partially replace drastic reductions made in 2012 and 2013 (see further discussion below) to balance the state budget. In some cases these additions are less than the amounts reduced and will continue to grow to meet the need. Additionally, the state’s experience with the newly eligible population through the County Care waiver in calendar year 2013 makes it clear that strengthening behavioral health services is critical for avoiding very expensive unnecessary emergency room utilization, inpatient hospitalizations, and institutionalization of the population. These changes will save the state and federal government significant monies over not just the life of the waiver, but many years beyond.

Specific Characteristics of Illinois Medicaid

The Illinois Medicaid program has relied on rate freezes and provider-funded payments to help control state spending. With the exception of some recent rate reductions (discussed below), most reimbursement rates to Medicaid providers have remained stagnant for 20 years. Given the state-initiated Medicaid reforms, as well as the new opportunities presented through the Affordable Care Act, it is clear that the old method of controlling spending through rate freezes and dependence on supplemental institutional payments does not contribute to an efficient health care delivery system. In fact, HCBS waiver providers and the behavioral health providers have been unable to meet the needs of their population due to a lack of funding, while the institutional providers have been able to prop up rates through a provider assessment. This has contributed to the inefficiency of the system.

Due to an unprecedented state budget crisis, Illinois enacted the Saving Medicaid Access and Resources Together (SMART) Act, which implemented $1.6 billion in savings through more than 60 specific program changes for dates of service beginning July 1, 2012. While these savings measures were well planned and required, they have had the unfortunate effect of further weakening both HCBS and behavioral health services. If we are unable to make the changes contemplated in this waiver, costs will rise more quickly and quality will suffer. It is important to note that Medicare spending on a per capita basis rose by 4.85% over the period (see CMMI report).

Anticipated Cost Savings from Waiver

Based on the current cost and utilization trends across those populations, the state estimates that Illinois and the federal government will realize cumulative savings in Medicaid/CHIP spending by the end of the waiver period as a result of implementing the innovations specified in the State Innovation Plan and in the waiver. While budget neutrality is calculated over a five-year period, it is important to note that we project large, ongoing savings well-beyond the waiver period attributable to the investments made in the early years of the waiver.

Impact of Innovations Through the State Innovation Plan and the Waiver

Illinois’ innovations are expected to result in quantifiable changes in utilization and cost savings on a per capita basis. The outcome measures we will use to quantify these changes are:

  1. reducing avoidable emergency room visits;
  2. reducing ambulatory sensitive inpatient admissions;
  3. reducing avoidable inpatient readmissions within 30 days of being discharged from a hospital for the same or related admission;
  4. reducing overall cost of medical care; and
  5. reducing spending on institutional services.
Reducing Avoidable Emergency Room Visits

Through the Alliance for Health innovations, and the clinical integration and payment reform innovations in particular, Illinois expects to reduce preventable emergency department (ED) room visits for the Medicaid and CHIP populations by 20% by the third year of the waiver. To determine the base of preventable ED visits per 10,000, Illinois used the New York University algorithm as a nationally recognized methodology for classifying ED data. These included the following classifications:

Data from CY2010 through CY2012 were reviewed based on the principal diagnosis code (ICD-9). In the case of uncertainty in assignment, visits were deliberately grouped into emergent/non-preventable classifications in order to avoid overstating the savings of innovations. Other visits that did not contain enough information were assigned as being unclassified.

Based on these results, 51.6% (sum of non-emergent and emergent/primary care treatable for 2012) was used as the percentage of ED visits that are considered to be potentially preventable. For Waiver Year 1, we have predicted a reduction of 6.66%, increasing to 13.33% by Waiver Year 2, and to 20% by Waiver Year 3. In subsequent waiver years, we expect to maintain that reduction. However, since it is assumed that the avoidable ED visits are more likely to be paid at a lower ED reimbursement rate, the value of each service is reduced by 10%. It is also assumed that in order to achieve these savings, the ED visits are likely to be replaced by physician services. Therefore, the savings realized from the reduced ED visits are offset by an equal increase in the number of professional services. The resulting applications of projected savings can be summarized as follows:

Waiver Year 1:

(Total ED Visits) x (6.66%) x 51.6%) = (Predicted # of reduced in ED visits)
(Reduced ED visits) x (ED Unit Cost) x (90%) = Gross Savings
(Gross Savings) – (cost of proportional increase in professional services) = (Net Savings)
Subsequent waiver years use the same approach, reaching 20% by Waiver Year 3.

Avoiding Ambulatory Sensitive Hospital Admissions

National PQI data indicates that 5.4% of all hospital admissions can be classified as ambulatory sensitive and potentially preventable. However, the rate in Illinois, as calculated by the Illinois Department of Public Health, is 6.8% which is a statistically significant increase. In addition, it is common for the uninsured to have a higher admission rate. If we assume 2.8 million current Medicaid clients to be at 5.4% and the addition of 350,000 newly eligible residents under the Affordable Care Act will have a rate of 9.9%, prorating the combined population during the first three years of the waiver results in a rate of 5.9%. This percentage is considered to be conservative, given that it is still well below the Illinois-specific estimate of 6.8% for all residents.

Using a base of 5.9% of all Illinois Medicaid admissions as ambulatory sensitive and potentially preventable, we anticipate that the innovations will gradually reduce these admissions by 20% by the end of Waiver Year 3 and maintained in Waiver Years 4 and 5. We assume that to achieve these savings, reductions in admissions are likely to be replaced with proportional increases in professional services, outpatient services, and pharmaceuticals. The resulting application of savings is similar to that of avoidable ED visits, but with the additional proportional offsetting increases in pharmaceuticals and outpatient services.

Avoiding Preventable Readmissions Within 30 days

Illinois is implementing 3M software to identify potentially preventable readmissions within 30 days of a discharge from the same or another hospital for an identical or related admission. The methodology identifies outliers within peer groups of similar diagnosis, with the exclusion of certain unavoidable readmissions such as cancer treatment and obstetrical care. Through this methodology we are projecting a gross savings of $30 million by Waiver Year 3 that will be maintained in Waiver Years 4 and 5. The savings will be implemented through rate reductions for hospitals that exceed peer group thresholds. However, it is also anticipated that these savings may be offset by some additional costs, such as improved care coordination and follow-up after discharge. To offset these costs, we estimate a total net savings of $20 million by Waiver Year 3. In years 4 and 5 we expect to have permanently reduced the growth rate for these services.

Reducing Total Cost of Care

We anticipate a reduction in the total cost of care on a per member per year basis by the conclusion of Waiver Year 5 as a result of implementing innovations. Additional savings will be realized through shifting the focus away from institutional care and a relative increase in spending on long-term support services.

Rebalancing to Increase Long Term Support Services

Independent of the specific Plan innovations, Illinois has made strides in rebalancing resources from institutional care to community settings. Historical trends from CY2010 through CY2012 show decreases in utilization per thousand for nursing homes, institutions for the developmentally disabled, and state operated mental health facilities. These decreases in institutional utilization are consistent across all populations groups. For the same time period, we see a dramatic increase in waiver services across each population group.

Unlike other innovations that can easily quantify the value of change on spending and utilization, we anticipate the shift toward long term support services to accelerate through the implementation of several changes. These include the dramatic increase in care coordination through the implementation of the integrated delivery systems contracting directly with the state, as in the CCE and ACE Medicaid options, traditional Medicaid capitation contracts with MCOs and MCCNs, and the Cook County County Care model. In addition, anticipated implementation of three new initiatives will affect the way in which long term care services are provided.

These include,

  1. a new rate methodology for nursing homes,
  2. development of a more objective and verifiable screening assessment prior to admission into a long-term care facility and
  3. expanded access to home and community-based services for individuals with qualifying LTSS needs and behavioral health services for adults with SMI or SUD and children with SED. With a new nursing home rate methodology based on Resource Utilization Groups, Illinois anticipates that rates for nursing home residents will increase when medical needs are high, and decrease for those with lower medical needs. This, coupled with a new screening tool prior to admission and increased availability of community resources, will have the combined effect of rewarding nursing facilities that accept the responsibilities of high-need residents, and expanding service options for those that are able to remain in the community over 7 years, Illinois projects reducing the number of people who would otherwise have been residing in nursing facilities significantly.

Financing/Budget Neutrality

By implementing the Path to Transformation, Illinois expects to achieve significant savings, including the following:

The with-waiver baseline also incorporates the following:

As described above, Illinois has taken significant action to address a looming Medicaid budget crisis. These actions were necessary to prevent collapse of the Medicaid program, but they are not sustainable. Illinois recognizes that it must invest now to ensure access for the uninsured population that will gain Medicaid or Exchange coverage beginning in 2014. We must also invest now to build a modern, integrated delivery system that can achieve better outcomes at less cost. Failing to make these investments now may result in short-term savings but longer-term costs in the form of high emergency department and inpatient admissions and poorer health outcomes and population health. To ensure that Illinois is able to make these investments, we are requesting to use a without-waiver trend that is reflective of the national rate of cost growth. Specifically, we are requesting a without-waiver trend rate of 4.85%

Illinois will maintain budget neutrality over the five-year life of the Path to Transformation Wavier, with per capita spending under the waiver not exceeding what the federal government would have spent without the waiver. We are not, however, proposing to establish a global cap on federal Medicaid expenditures for Illinois. In partnership with the federal government, and with the flexibility afforded by the Path to Transformation waiver, Illinois Medicaid will be transformed to a high quality healthcare delivery system, producing positive health outcomes for our Medicaid populations while reducing costs and creating a significant return on investment.

Path to Transformation Expenditure Plan

Pathway #1
Waiver Provision Funding Source Year1$ Year2$ Year3$ Year4$ Year5$
Technical Assistance/ITRC CNOM/Savings $40,000,000 $40,000,000 $40,000,000 $40,000,000 $40,000,000
DRSIP IGT $200,000,000 $200,000,000 $200,000,000 $200,000,000 $200,000,000
Access to Care Pool Self Financed $2,353,600,000 $2,353,600,000 $2,353,600,000 $2,353,600,000 $2,353,600,000
Quality and Transformation Pool CNOM/Savings $100,000,000 $100,000,000 $100,000,000 $100,000,000 $100,000,000
Institution Transition Fund CNOM/Savings $25,000,000 $25,000,000 $25,000,000 $25,000,000 $25,000,000
Pathway #2
Waiver Provision Funding Source Year1$ Year2$ Year3$ Year4$ Year5$
Public Health integration MCO Tax $10,000,000 $10,000,000 $10,000,000 $10,000,000 $10,000,000
Expand Maternal-Child Health Visits CNOM/Savings $10,000,000 $10,000,000 $10,000,000 $10,000,000 $10,000,000
Pathway #3
Waiver Provision Funding Source Year1$ Year2$ Year3$ Year4$ Year5$
Loan Repayment reinstatement and expansion CNOM/Savings $10,000,000 $10,000,000 $10,000,000 $10,000,000 $10,000,000
Safety Net Hospital Loan Repayment CNOM/Savings $20,000,000 $20,000,000 $20,000,000 $20,000,000 $20,000,000
Workforce training/Curriculum and Competency testing CNOM/Savings $25,000,000 $50,000,000 $50,000,000 $50,000,000 $50,000,000
Teaching Health Center CNOM/Savings $10,000,000 $10,000,000 $10,000,000 $10,000,000 $10,000,000
GME CNOM/Savings $26,000,000 $26,000,000 $26,000,000 $26,000,000 $26,000,000
Pathway #4
Waiver Provision Funding Source Year1$ Year2$ Year3$ Year4$ Year5$
Increase in service cost to bring parity to waivers CNOM/Savings $150,000,000 $150,000,000 $150,000,000 $150,000,000 $150,000,000
Addition of slots to IDD to reduce wait list CNOM/Savings $60,000,000 $70,000,000 $80,000,000 $90,000,000 $100,000,000
Expansion of behavioral Health Services; MRO expansion CNOM/Savings $140,000,000 $150,000,000 $160,000,000 $170,000,000 $180,000,000
Expansion of BH Services to include clinic option CNOM/Savings $40,000,000 $50,000,000 $60,000,000 $70,000,000 $80,000,000
Children's Mental Health Services CNOM/Savings $30,000,000 $30,000,000 $30,000,000 $30,000,000 $30,000,000
2703 Health homes for HIV/AIDs and other high-risk* Savings $50,000,000 $50,000,000 $50,000,000 $50,000,000 $50,000,000
Bonus for stable housing CNOM/Savings $60,000,000 $60,000,000 $60,000,000 $60,000,000 $60,000,000
Increased rate for residential habilitation providers Res Hab Fees $38,400,000 $38,400,000 $38,400,000 $38,400,000 $38,400,000
Bonuses for ACT/CST team start ups CNOM/Savings $9,000,000 $9,000,000 $9,000,000 $9,000,000 $9,000,000

Other

Waiver Provision Funding Source Year1$ Year2$ Year3$ Year4$ Year5$
Administrative costs for waiver implementation (HFS, DHS, DOA) CNOM/Savings $15,000,000 $15,000,000 $15,000,000 $15,000,000 $15,000,000

*90/10 FMAP rate

 

5 Years of Historic Data

Specify time Period and Eligibility Group Depicted:
Children & Adults SFY2009 SFY2010 SFY2011 SFY2012 SFY2013 5-Years
Total Expenditures $5,502,435,518 $5,904,275,188 $6,127,578,654 $6,175,090,070 $6,116,535,772 $29,825,915,201
Eligible Member Months 23,973,805 25,757,264 26,978,323 27,835,586 27,724,340  
PMPM Cost $229.52 $229.23 $227.13 $221.84 $220.62  
Trend Rates Annual Change
Trend Rates SFY2009 SFY2010 SFY2011 SFY2012 SFY2013 5-Years
Total Expenditures   7.30% 3.78% 0.78% -0.95% 2.68%
Eligible Member Months   7.44% 4.74% 3.18% -0.40% 3.70%
PMPM Cost   -0.13% -0.92% -2.33% -0.55% -0.98%
Aged, Blind & Disabled
Aged, Blind & Disabled HY1 HY2 HY3 HY4 HY5 5-Years
Total Expenditures $6,694,594,168 $7,074,178,369 $7,436,143,259 $7,574,382,525 $7,221,731,153 $36,001,029,474
Eligible Member Months 4,985,138 5,169,967 5,436,013 5,668,532 5,733,367  
PMPM Cost $1,342.91 $1,368.32 $1,367.94 $1,336.22 $1,259.60  
Trend Rates Annual Change
Trend Rates SFY2009 SFY2010 SFY2011 SFY2012 SFY2013 5-Years
Total Expenditures   5.67% 5.12% 1.86% -4.66% 1.91%
Eligible Member Months   3.71% 5.15% 4.28% 1.14% 3.56%
PMPM Cost   1.89% -0.03% -2.32% -5.73% -1.59%

Demonstration Without Waiver (WOW) Budget Projection: Coverage Costs for Populations

Children & Adults Pop Type: Medicaid
Eligibility Group Trend Rate 1 Months of Aging Base Year DY00 Trend Rate 2 DY01 DY02 DY03 DY04 DY05 Total WOW
Eligible Member Months 3.7%   27,724,340 3.7% 28,750,141 29,813,896 30,917,010 32,060,939 33,247,194  
PMPM Cost 4.95% 18 $236.86 4.9% $248.35 $260.39 $273.02 $286.26 $300.14  
Total Expenditure         $7,140,097,413 $7,763,240,323 $8,440,962,050, $9,177,764,482 $9,978,812,821 $42,500,877,088
Aged, Blind & Disabled Pop Type: Medicaid
Eligibility Group Trend Rate 1 Months of Aging Base Year DY00 Trend Rate 2 DY01 DY02 DY03 DY04 DY05 Total WOW
Eligible Member Months 3.56% 0 5,733,367 3.6% 5,937,475 6,148,849 6,367,748 6,594,440 6,829,202  
PMPM Cost 4.85% 18 $1,352.33 4.9% $1,417.92 $1,486.69 $1,558.79 $1,634.39    
Total Expenditure         $8,418,864,361 $9,141,432,276 $9,925,981,895 $10,777,886,895 $11,702,930,094 $49,967,095,0127
New Spend in Base Year Pop Type: Medicaid
Eligibility Group Trend Rate 1 Months of Aging Base Year DY00 Trend Rate 2 DY01 DY02 DY03 DY04 DY05 Total WOW
Eligible Member Months 0.0% 0 1 0.0% 1 1 1 1    
PMPM Cost 0.0% 0 $1.00 4.9% $1,511,400,000.00 $1,585,458,600.00 $1,663,146,071.40 $1,744,640,228.90    
Total Expenditure         $1,511,400,000 $1,585,458,600 $1,663,146,071 $1,744,640,229 $1,830,127,600 $8,334,772,500
Existing Adults ACA Pop Type: Medicaid
Eligibility Group Trend Rate 1 Months of Aging Base Year DY00 Trend Rate 2 DY01 DY02 DY03 DY04 DY05 Total WOW
Eligible Member Months     2,011,200 0.0% 2,011,200 2,011,200 2,011,200 2,011,200 2,011,200  
PMPM Cost     $882.35 4.9% $925.15 $970.02 $1,017.06 $1,066.39 $1,118.11  
Total Expenditure     $1,774,588,235   $1,860,655,765 $1,950,897,569 $2,045,516,101 $2,144,723,632 $2,248,742,728 $10,25,535,796
New Eligibles Pop Type: Expansion
Eligibility Group Trend Rate 1 Months of Aging Base Year DY00 Trend Rate 2 DY01 DY02 DY03 DY04 DY05 Total WOW
Eligible Member Months     4,104,000 0.0% 4,104,000 4,104,000 4,104,000 4,104,000 4,104,000  
PMPM Cost     $882.35 4.9% $925.15 $970.01 $1,017.06 $1,066.39 $1,118.11  
Total Expenditure     $3,621,164,400   $3,796,790,873 $3,980,935,231 $4,174,010,589 $4,376,450,103 $4,588,707,933 $20,916,894,730

Demonstration with Waiver (WW) Budget Projection: Coverage Costs for Populations

Children & Adults Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months 27,724,340 3.7% 28,750,141 29,813,896 30,917,010 32,060,939 33,247,194  
PMPM Cost $236.86 3.4% $244.79 $252.99 $261.47 $270.23 $279.28  
Total Expenditure     $7,037,746,913 $7,542,617,494 $8,083,970,585 $8,663,827,625 $9,285,276,353 $40,613,338,970
Aged, Blind & Disabled Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months 5,733,367 3.6% 5,937,475 6,148,849 6,367,748 6,594,440 6,829,202  
PMPM Cost $1,352.33 3.4% $1,397.63 $1,444.45 $1,492.84 $1,542.85 $1,594.54  
Total Expenditure     $8,298,392,996 $8,881,704,895 $9,506,028,915 $10,174,231,480 $10,889,435,566 $47,749,793,852
Additional Spending Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months 1 0.0% 1 1 1 1 1  
PMPM Cost $1.00 3.4% $1,511,400,000.00 $1,562,031,900.00 $1,614,359,968.65 $1,668,441,027.60 $1,724,333,802.02  
Total Expenditure     $1,511,400,000 $1,562,031,900 $1,614,359,969 $1,668,441,028 $1,724,333,802 $8,080,566,698
CNOM Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months     1 1 1 1 1  
PMPM Cost   0.00% $805,000,000.00 $885,000,000.00 $915,000,000.00 $945,000,000.00 $975,000,000.00  
Total Expenditure     $805,000,000 $885,000,000 $915,000,000 $945,000,000 $975,000,000 $4,525,000,000
DSRIP Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months     1 1 1 1 1  
PMPM Cost     $200,000,000.00 $200,000,000.00 $200,000,000.00 $200,000,000.00 $200,000,000.00  
Total Expenditure     $200,000,000 $200,000,000 $200,000,000 $200,000,000 $200,000,000 $1,000,000,000
Existing Adults ACA Pop Type: Medicaid
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months 2,011,200 0.0% 2,011,200 2,011,200 2,011,200 2,011,200 2,011,200  
PMPM Cost $882.35 3.35% $911.91 $942.46 $974.03 $1,006.66 $1,040.38  
Total Expenditure     $1,834,030,828 $1,895,470,860 $1,958,969,134 $2,024,594,600 $2,092,418,519 $9,805,483,942
New Eligibles Pop Type: Expansion
Eligibility Group DY00 Demo Trend Rate DY01 DY02 DY03 DY04 DY05 Total WW
Eligible Member Months 4,104,000 0.0% 4,104,000 4,104,000 4,104,000 4,104,000 4,104,000  
PMPM Cost $882.35 3.35% $911.91 $942.46 $974.03 $1,006.66 $1,040.38  
Total Expenditure     $3,742,473,407 $3,867,846,267 $3,997,419,116 $4,131,332,657 $4,269,732,301 $20,008,803,748

 

Budget Neutrality Summary

Without-Waiver Total Expendtures
Medicaid Populations
  DY01 DY02 DY03 DY04 DY05 Total
Children & Adults $7,140,097,413 $7,763,240,323 $8,440,962,050 $9,177,764,482 $9,978,812,821 $42,500,877,088
Agenda, Blind & Disabled $8,418,864,361 $9,141,432,276 $9,925,981,895 $10,777,886,501 $11,702,930,094 $49,967,095,127
New Spend in Base Year $1,511,400,000 $1,585,458,600 $1,663,146,071 $1,744,640,229 $1,830,127,600 $8,334,772,500
DSH Allotment Diverted $ - $ - $ - $ - $ - $ -
Other WOW Categories
Existing Adults ACA $1,860,655,765 $1,950,897,569 $2,045,516,101 $2,144,723,632 $2,248,742,728 $10,250,535,796
New Eligibles $3,796,790,873 $3,980,935,231 $4,174,010,589 4,376,450,103 $4,588,707,933 $20,916,894,730
Total $22,727,808,412 $24,421,963,998 $26,249,616,707 $28,221,464,947 $30,349,321,176 $131,970,175,241
With-Waiver Total Expendtures
Medicaid Populations
  DY01 DY02 DY03 DY04 DY05 Total
Children & Adults $7,037,746,913 $7,542,617,494 $8,083,870,585 $8,663,827,625 $9,285,276,353 $40,613,338,970
Agend, Blind & Disabled $8,298,392,996 $8,881,704,895 $9,506,028,915 $10,174,231,480 $10,889,435,566 $47,749,793,852
Additional Spending $1,511,400,000 $1,562,031,900 $1,614,359,969 $1,668,441,028 $1,724,333,802 $8,080,566,698
Expansion Populations
Existing Adults ACA $1,834,030,828 $1,895,470,860 $1,958,969,134 $2,024,594,600 $2,092,418,519 $9,805,483,942
New Eligibles $3,752,473,407 $3,867,846,267 $3,997,419,116 $4,131,332,657 $4,269,732,301 $20,008,803,748
Excess Spending From Hypothetical
Other WW Categories
CNOM $805,000,000 $885,000,000 $915,000,000 $945,000,000 $975,000,000 $4,525,000,000
DSRIP $200,000,000 $200,000,000 $200,000,000 $200,000,000 $200,000,000 $1,000,000,000
Total $23,429,044,114 $24,834,671,416 $26,275,647,720 $27,807,427,390 $29,436,196,541 $131,782,987,210
Variance $(701,235,732) $(412,707,418) $(26,031,012) $414,037,558 $913,124,635 $187,188,031