Medicaid 201: An Overview  of State Plan Amendments & Waivers

Date: March 2021

Pages: 19

Authors:

• Kelli DePriest, PhD, RN
• Soha Vaziri
• Karlyn Tunnell
• Caroline Adams

 Medicaid is the largest health insurance program in the United States, covering more than 76 million individuals. Federal Medicaid requirements set broad standards for the benefits and populations states must cover, but modifications through state plan amendments and waivers allow individual states to adjust the Medicaid program to fit their residents’ needs.  State plan amendments and waivers address different aspects of the Medicaid program and therefore have unique requirements and approval processes. This issue brief outlines these two mechanisms for changing payment and delivery system models in state Medicaid programs and presents descriptions and notable uses for five types of Medicaid waivers.  

The project period for the grants is July 1, 2021 to June 30, 2023

The Advancing Health Literacy to Enhance Equitable Community Responses to COVID-19 seeks to demonstrate the effectiveness of local government implementation of evidence-based health literacy strategies that are culturally appropriate to enhance COVID-19 testing, contact tracing and/or other mitigation measures (e.g., public health prevention practices and vaccination) in racial and ethnic minority populations and other socially vulnerable populations, including racial and ethnic minority rural communities.

OMH expects the awardee projects to demonstrate the effectiveness of working with local community-based organizations to develop health literacy plans to increase the availability, acceptability, and use of COVID-19 public health information and services by racial and ethnic minority populations. Recipients are also expected to leverage local data to identify racial and ethnic minority populations at the highest risk for health disparities and low health literacy, as well as populations not currently reached through existing public health campaigns.

California Grantees City State Awards

• Alameda County Health Care Services San Leandro CA $1,994,565
• City of Chula Vista Chula Vista, CA $4,000,000 
• City of Fresno,  Fresno CA  $4,000,000
• City of Santa Ana Santa Ana, CA    $4,000,000
• Fresno County Department of Public Health Fresno, CA $3,000,000
• Monterey County Health Department Salinas, CA   $3,952,43

Total  for all USA $250,000,000 

 The Financing Community Health Programs for Scale and Sustainability  course series presents an in-depth exploration of the financing value chain needed to understand resource needs as well as to mobilize resources for community health. The series aims to engage learners with insights from stakeholders within Ministries of Health (MOH), Ministries of Finance (MOF), global health institutions, private sector organizations, and academia, supported by examples demonstrating how different financing approaches have been implemented in practice. 

By the end of this series, learners will be able to:

• Know the definition and core functions of health financing
• Have an in-depth understanding of the financing pathway needed to mobilize resources for community health, including, but not limited to: costing community health programs, developing investment cases, mapping key stakeholders, and growing funding options.

A successful course series will equip learners with the resources and tools needed to actualize the financing pathway for their contexts. This will ensure that community health programs are successfully launched, adequately resourced, and financially sustained. 

Course 1: Political prioritization [Self-paced]

Course 2: Costing [Self-paced]

Course 3: Resource mapping and gap analysis [Self-paced]

Course 4: Making the case [Self-paced]

Course 5: Sources of funding [Self-paced]

Course 6: Investment planning and creating systems for sustainable financing [Self-paced]

Course 7: Public financial management [Self-paced] 

 The governor's May Budget Revision 

Summary: May Budget 2021 revision 

Chapter: Health and Human Services  (page 85 )

" Community Health Workers—The May Revision includes $16.3 million ($6.2 million General Fund), increasing to $201 million ($76 million General Fund) by 2026-27, to add community health workers to the class of health workers who are able to provide benefits and services to Medi-Cal beneficiaries, effective January 1, 2022. "

http://www.ebudget.ca.gov/2021-22/pdf/Revised/BudgetSummary/HealthandHumanServices.pdf

HRSA-21-140 - Local Community-Based Workforce to  Increase COVID-19 Vaccine Access

https://grants.hrsa.gov/2010/Web2External/Interface/FundingCycle/ExternalView.aspx?fCycleID=582201c2-b90f-42bc-bdf0-4bd549ab17e1

Estimated Award Amount: $1,000,000.

Number of Awards Offered:  Approximately 121 nationally

Application Due Date: June 9, 2021

Period of performance: July 1, 2021-June 30, 2022 (12 months)

 NACCHO  - Scaling up COVID-19 Prevention and Mitigation Strategies with Refugee, Immigrant, and Migrant Populations (RIM)

https://www.naccho.org/blog/articles/funding-opportunity-scaling-up-covid-19-prevention-and-mitigation-strategies-with-refugee-immigrant-and-migrant-communities-funding-opportunity

Funding Amount:

• Tier 1: up to $175,000 to implement at least one primary prevention strategy
• Tier 2: up to $250,000 to implement an additional primary or secondary prevention strategy

Number of Awards offered:  Approximately 20 nationally

Application Due Date: June 11. 2021 at 11:59 PM PT.

Estimated Period of Performance: 12 months (July 2021 – July 2022) 

NACCHO Website: 

State Strategies to Promote Team-Based Primary Care Through Medicaid Managed Care

Cassie Barrett, BSN, RN* and Matthew Ralls, MPH, Center for Health Care Strategies

April 1, 2021

Supporting team-based care is an important way for states to advance the delivery of high-quality, comprehensive, and equitable primary care. Team-based care improves health outcomes for patients by enabling primary care practices to offer care that better addresses patients’ unique combinations of medical, behavioral health, and social needs, among others. And a recent Health Affairs article found that care teams outperformed solo providers at managing care for patients with chronic conditions. By employing staff with diverse skillsets who can collaborate, communicate, and work at the top of their licenses (where applicable), practices are better equipped to provide high-quality and efficient patient-centered care. For example, approaches that use care team members who share similar life experiences as the patient, such as peer providers and community health workers (CHWs), are effective at improving outcomes, promoting health equity, and generating return on investment.

Strengthening Primary Care through Medicaid Managed Care

This blog post is part of learning series from the Center for Health Care Strategies, Strengthening Primary Care through Medicaid Managed Care. It will examine the tools and levers that states can use to advance comprehensive primary care strategies and equitably improve the health of Medicaid enrollees through webinars, resources, and blog posts. This series is made possible by The Commonwealth Fund.

Action Plan for Supporting Team-Based Care through Managed Care

1. Establish the Roles of Primary Care Providers and Managed Care Organizations

State Medicaid agencies seeking to encourage team-based care in a managed care program must determine the role that managed care organizations (MCOs) will play in supporting and promoting the model. This will depend on many factors, including: (1) the capacity and sophistication of provider organizations to manage team-based care efforts; (2) familiarity of both MCOs and providers with care delivery models such as patient-centered medical homes (PCMHs) or multi-disciplinary care management; and (3) the presence of other care coordination entities like accountable care organizations to manage the effort. Because MCOs or primary care practices can take ownership of common responsibilities, like care management, it is important that these responsibilities are clearly delineated between the entities to prevent duplication of duties or efforts.

2. Identify Whether to Use a Standardized or Flexible Approach

States promoting team-based care will have to consider how prescriptive to be in directing MCOs or provider organizations managing this work. States can take a prescriptive approach, requiring MCOs to use specific care models selected by the state, thus ensuring enrollees have access to related care and services. For example, a state may wish to connect enrollees with CHWs, and a prescriptive approach can require MCOs and providers to incorporate them into their respective care teams. Alternately, states can set general guidelines that allow MCOs the flexibility to choose and customize program models that may better reflect the needs of their providers and patient populations. Once a strategy is selected, states can use managed care contracts or the MCO procurement process to encourage, incent, or require MCOs or providers to contract with care team members to provide services. For example, Minnesota’s MCO request for proposals asks potential MCOs to describe their plan to use “non-traditional health care services (such as doulas, community EMTs, community paramedics, community health workers, etc.) to provide culturally competent care and/or improve health outcomes.”  

Michigan’s managed care contract is more prescriptive, requiring MCOs to support the design and implementation of CHW interventions.

While more directive policies and programs will create uniform standards, they may also require more state resources to design, implement, and oversee. Similarly, state-defined standards for PCMH programs, staff training, and certifications would also require more state involvement, rather than adopting existing external models or allowing MCOs flexibility to use their own approaches. States can also attempt to reduce administrative burden — on themselves and other stakeholders — by aligning team-based care models with other initiatives.

3. Determine How to Compensate Providers for Team-Based Care

New reimbursement pathways are critical for supporting the adoption of team-based primary care teams. Examples include increased reimbursement rates for practices recognized as PCMHs, as well as additional or enhanced per member per month (PMPM) payments for care coordination and other team-based care activities a state or MCO wants to prioritize. Oregon uses the latter approach, requiring its Coordinated Care Organizations to provide supplemental PMPM payments to the state’s Patient-Centered Primary Care Home clinics to support the development of infrastructure and operations.

States can also create billing codes for team-based care activities. For example, Washington State created new billing codes for primary care teams to use the collaborative care model to address the behavioral health needs of patients; while Minnesota’s medical assistance program uses billing codes that cover care coordination and patient education services provided by certified CHWs.

Additionally, states can consider providing MCOs with value-based payment (VBP) incentives to drive the adoption of team-based care among primary care practices through incentive or penalty arrangements. States that wish to be directive can require MCOs to meet targets or metrics related to team-based care initiatives, such as member enrollment in PCMHs or number of enrollees served by certain types of care team members. For example, New Mexico requires that at least three percent of enrollees are served by CHWs or Community Health Representatives. States can also incorporate team-based care elements into MCO care management requirements or within performance improvement projects, VBP initiatives, or Section 1115 demonstration projects or pilot programs.

Takeaways and An Opportunity to Learn More

States looking to promote team-based care can facilitate this effort in a way that not only achieves their goal of delivering optimal care for patients, but also supports MCOs, primary care practices, and care team members. To employ team-based care as an enhancement to primary care, states can explore what configuration and funding methods will enable and incentivize MCOs and providers to do so effectively and efficiently.

*Cassie Barrett is an intern at the Center for Health Care Strategies

Community Health Workers for COVID Response and Resilient Communities (CCR) CDC-RFA-DP21-2109.
 

 The Coronavirus Aid, Relief, and Economic Security (“CARES”) Act of 2020 allocated funds to the Centers for Disease Control and Prevention (CDC) to states, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes. CDC announces the availability of funds to achieve the goal of the CARES Act in preventing COVID-19 and protecting the American people from related public health impacts.

This Notice of Funding Opportunity (NOFO) supports this work through training and deployment of community health workers (CHWs) to response efforts and by building and strengthening community resilience to fight COVID-19 through addressing existing health disparities. Program strategies include integrating CHWs into organizations and care teams and strengthening relevant CHW knowledge, roles, and skills to prepare them to successfully engage with existing state and/or local public health-led actions to manage COVID-19 among priority populations.

Related Information

Full funding information: 

Opening date: March 25, 2021

Closing date: May 24, 2021

Understanding Eligibility
Understanding Strategies

Questions? 

Email nccdphp_chw@cdc.gov.

Priority populations are those with increased prevalence of COVID-19 and are disproportionately impacted by long-standing health disparities related to sociodemographic characteristics, geographic regions, and economic strata. Examples include, racial and ethnic minority groups, persons who are economically disadvantaged, justice-involved, experiencing homelessness, or have certain underlying medical conditions that increase COVID-19 risk.

The purpose of this NOFO, DP21-2110 (CCR-ETA), is to conduct a national evaluation of and provide training and TA to strengthen capacity of recipients and their partners funded under DP21-2109 (CCR) to address disparities in access to COVID-19 related services.

This NOFO has two components:

• Component 1 (C1), conduct a national evaluation of DP21-2109 (CCR)
• Component 2 (C2), deliver training and TA to DP21-2109 (CCR) recipients

Applicants may only apply for one component.

Please also see the related Notice of Funding Opportunity, Community Health Workers for COVID Response and Resilient Communities (CCR) CDC-RFA-DP21-2109.

California Advancing and Innovating Medi-Cal (CalAIM) Demonstration 30-Day Public Comment and Public Hearings

The Department of Health Care Services (DHCS) has begun a 30-day public comment period for the CalAIM Section 1115 demonstration (or waiver), starting on April 6 and ending on May 6. This email provides background information, links to public comment materials, and information on how to provide feedback during the public comment period.

Background

DHCS is seeking federal approval to implement key provisions of the CalAIM initiative. CalAIM will move California’s whole person care approach—first authorized by the Medi-Cal 2020 Section 1115 demonstration—to a statewide level, with a clear focus on improving health and reducing health disparities and inequities. The broader multiyear system, program, and payment reforms included in CalAIM will allow California to take a population health, person-centered approach to providing services, with the goal of improving health outcomes for Medi-Cal and other low-income populations in the state.

The CalAIM Section 1115 demonstration proposal seeks to amend and renew the Medi-Cal 2020 Section 1115 demonstration, approved by the Centers for Medicare & Medicaid Services (CMS) in December 2015 and ending on December 31, 2021. DHCS also plans to seek an amendment and renewal to expand the existing Specialty Mental Health Services (SMHS) Section 1915(b) waiver and consolidate Medi-Cal managed care, dental managed care, SMHS, and the Drug Medi-Cal Organized Delivery System (DMC-ODS) under a single 1915(b) waiver. Federal regulations require California to seek public comments on the Section 1115 demonstration prior to CMS submission.

Public Comment Materials

All public comment materials can be found on the CalAIM 1115 Demonstration & 1915(b) Waiver webpage; DHCS will update this page throughout the public comment period and application process. The following materials are posted on the webpage:

• Public Notice
• Abbreviated Public Notice
• Proposed CalAIM Section 1115 Demonstration Amendment and Renewal Application
• Proposed CalAIM Section 1915(b) Waiver Overview

Opportunities to Comment

Stakeholders may submit public comments via mail, electronic mail, and/or during two upcoming public hearing webinars (scheduled for April 26 and May 3). 

Written Comments

Comments will be accepted via U.S. mail or electronic mail.

Written comments may be sent to the following address; please indicate “CalAIM Section 1115 & 1915(b) Waivers” in the written message:

Department of Health Care Services

Director’s Office

Attn: Angeli Lee and Amanda Font

P.O. Box 997413, MS 0000

Sacramento, California 95899-7413

Email comments may be submitted to CalAIMWaiver@dhcs.ca.gov. Please indicate “CalAIM Section 1115 & 1915(b) Waivers” in the subject line of the email message.

To be assured consideration prior to our submission of the CalAIM Section 1115 demonstration application and Section 1915(b) waiver application to CMS, comments must be received no later than 11:59 p.m. PT (Pacific Time) Thursday, May 6, 2021. Please note that comments will continue to be accepted after May 6, 2021, but DHCS may not be able to consider those comments prior to our submission of CalAIM waiver applications to CMS.

Public Hearings

DHCS will host the following public hearings to encourage and solicit stakeholder comments. The public hearings will be held electronically to promote social distancing and mitigate the spread of COVID-19. The meetings will have online video streaming and telephonic conference capabilities to ensure statewide accessibility.

Monday, April 26 – First Public Hearing

• 1 – 2:30 p.m. PT
• Register for Zoom conference link: https://manatt.zoom.us/webinar/register/WN_csWzNuSFQiiY46ZinTufLg
  • Please register in advance to receive your unique login details and link to add the hearing to your calendar
• Call-in information (669) 900-6833 or (888) 788 0099 (Toll Free)
  • Webinar ID: 944 4865 1547
  • Passcode: 042621
  • Callers do not need an email address to use the phone option and do not need to register in advance

Monday, May 3 – Second Public Hearing

• 2 – 3:30 p.m. PT
• Register for Zoom conference: https://manatt.zoom.us/webinar/register/WN_dj9UAypdQ76aOtCXafuhSA
  • Please register in advance to receive your unique login details and link to add to calendar
• Call-in information (669) 900-6833 or (888) 788 0099 (Toll Free)
  • Webinar ID: 994 3157 8945
  • Passcode: 050321
  • Callers do not need an email address to use the phone option and do not need to register in advance

For individuals with disabilities, DHCS will provide assistive devices, including sign-language interpretation, real-time captioning, note takers, reading or writing assistance, and conversion of training or meeting materials into Braille, large print, audiocassette, or computer disk. To request these services or copies in an alternate format, please call or write:

Department of Health Care Services

Director’s Office

P. O. Box 997413, MS 0000, Sacramento, CA 95899-7413

(916) 440-7400

Email: CalAIMWaiver@dhcs.ca.gov 

Please note that the range of assistive services available may be limited if requests are received less than ten working days prior to the meeting or event.

 The Department of Health Care Services (DHCS) is providing this update of significant developments regarding DHCS programs, including guidance related to the COVID-19 public health emergency (PHE).

On March 23, the Centers for Medicare & Medicaid Services (CMS) approved DHCS’ request for a temporary extension of the Medi-Cal Specialty Mental Health Services (SMHS) 1915(b) waiver program through December 31, 2021. This nine-month extension allows DHCS time to develop and obtain approval for the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and to align with the proposed one-year extension of the 1115 waiver (Medi-Cal 2020). The CalAIM initiative includes transitioning the Medi-Cal SMHS 1915(b) and 1115 waivers into a single comprehensive section 1915(b) waiver, with a proposed effective date of January 1, 2022. DHCS will continue to work with CMS during the extension period.

On March 26, CMS approved State Plan Amendment (SPA) 21-0016 to add Medicaid Disaster Relief to implement temporary policies under section 1135 during the PHE. As approved in the SPA, DHCS will increase the fee-for-service payment rate for durable medical equipment (DME), specifically oxygen and respiratory equipment, equivalent to 100 percent of the Medicare rate. The payment increase will be effective for dates of service on or after March 1, 2020, so DME providers can continue providing necessary equipment during the COVID-19 PHE

Additional Published COVID-19 PHE Guidance

• SPA 20-0040 - CMS-Approved State Plan Amendment
• CMS Fourth Approval of Additional 1135 Waivers
• Appendix K for 1915c Waivers: Consolidated Extension
• Appendix K Approval Letter: Consolidated Extension
• PACE Policy Letter 21-01 - Vaccine Administration
• HCBA Waiver PL 21-001 - Vaccine Administration
• APL 20-022 (Revised): COVID-19 Vaccine Administration
• COVID-19 Vaccine Guidance for Behavioral Health Providers - Frequently Asked Questions
• SPA 21-0020 - Request for COVID-19 Vaccine Reimbursements in FQHCs and RHCs
• MEDIL I 21-04 - Additional and Updated Frequently Asked Questions Due to the COVID-19 Public Health Emergency
• APL 20-004 (Revised): Emergency Guidance for Medi-Cal Managed Care Health Plans in Response to COVID-19

Additional updates will be posted to the DHCS COVID-19 Response page.

Thank you,

Department of Health Care Services

www.dhcs.ca.gov

 NCFH Grant Announcement
New Funding Opportunity

National Center for Farmworker Health (NCFH) is now accepting applications for grants up to $100,000 to facilitate vaccine access and to continue COVID-19 prevention and mitigation efforts for farmworker families!  Grants will be awarded on a rolling basis with an expected project period beginning as early as 4/16/21 through 9/29/21. 

Please see NCFH's website for the request for proposals and grant application forms or contact Paige Menking with any further questions – menking@ncfh.org
_________________
Nos da mucho gusto anunciar una nueva oportunidad para becas – ¡proporcionaremos $1.2 millón para facilitar acceso a las vacunas y continuar los esfuerzos de prevención y mitigación de COVID-19 para familias trabajadores agrícolas! Becas empezarán a darse a partir del 16 de abril y esperamos el periodo del proyecto empezar tan pronto como 16/4/21 y terminar 29/9/21. 

Por favor, visita la página web de NCFH para el requisito de propósitos y los formularios de aplicaciones, o contacte a Paige Menking con preguntas – menking@ncfh.org 

This live event occurred on Tuesday, May 23, 2017. 

RECORDING  To access a copy of the recording

NEW!  Community Health Worker & Promotora Trainings!

CPCA is offering this multi-part training program to introduce health centers and regional associations to a new workforce; community health workers (CHWs) and Promotoras who can be integrated into a clinic to help provide a more holistic approach when caring for patients.

Many clinics are considering using CHWs to improve the quality of care to their patients. One of the biggest obstacles is obtaining funding to help with the costs of training CHWs, and in some instances, paying the wages of CHWs. 

Representatives from the United States Department of Agriculture's (USDA) Food and Nutrition Service (FNS), who administers the SNAP Employment and Training (SNAP E&T) program nationwide will review available 50-50 reimbursement program. Through the states, the program is seeking to develop partnerships with local organizations (community based organizations, clinics, and community colleges) to train SNAP (Food stamp) participants in an array of jobs, like CHWs and Promotoras.

The SNAP E&T program offers 50 percent reimbursement grants (50-50 funds) where the federal government will reimburse 50 percet of the costs of the training program for SNAP participants when non-federal funds (state, county, health center, etc.) are used. This training program can be defined broadly to include tuition, fees, books, uniforms, and suportive services such as transprotation, child care, and case management. Retention costs for up to 90 days can also be covered. Also, federal funding, through the SNAP Ed program, could be available to help pay for the slararies of SNAP recipients, with prior approval by the state and/or county, if the CHW is providing eligible nutrition education,.

Join us for this 60-minute session where we will also have a health center explain how they were able to access grant funds to help support their CHW/Promotora programs, as well as CPCA's Chief Medical Officer provide an overview of the Whole Person Care Pilot Program and learn how funds can be used to expand a clinics workforce.  Participants will learn best practices on how to partner with state entities and private entities to access funds if they wish to integrate CHWs/Promotoras into their workforce. 

Click the link below to view a description and register for part 3 in this series:
May 30 - Data Collection and Evaluation for CHW/Promotora Programs

LEARNING OBJECTIVES

• Understand the available funding for CHW/Promotora programs, including the 50-50 fund program and other grants available.
• Gain an understanding on how to build a successful partnership with states, counties, and if applicable, private entities in order to access funding.
• Learn how funds from the Whole Person Care pilot program can be used to hire CHWs/Promotoras. 

SPEAKER

• Community Clinic/Health Center - TBD
• Brian Soloman, Senior Analyst, USDA Food & Nutrition Service (FNS)
• Mike Witte, MD, Vice President and Chief Medical Officer, California Primary Care Association

(pdf of 2015/2016 awardees )

Phone: (916) 326-3723
Email: Trisha.Duchaine@oshpd.ca.gov

Phone: (916) 326-3706
Email: Liz.Martin@oshpd.ca.gov