Cost, Payment, and Delivery Reform – Page 4 – The National Academy for State Health Policy

Serving Children and Youth with Special Health Care Needs in Medicaid Managed Care: Targeted Contract Language

AHRQ Launches Initiative to Improve Heart Health in States with High Rates of Heart Disease and Stroke

March 9, 2020/in Policy Blogs Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Staff

The Agency for Healthcare Research and Quality’s (AHRQ) has announced the launch of a new initiative that will invest up to $18 million over three years to help primary care practices prevent heart disease and stroke.

Through this new funding opportunity, the agency is expanding its commitment to ensuring that primary care practices have the support they need to put patient-centered evidence into practice. Building off AHRQ’s EvidenceNOW initiative, this effort focuses on building improvement capacity in states with the highest rates of preventable heart attacks and strokes.

Grantees will form state-based cooperatives that bring together existing state-based organizations to align their efforts to engage primary care practices.

Through these cooperatives, the grantees will build a learning network of primary care practices across their states. The cooperatives and networks will ensure that the latest primary care relevant findings and resources are delivered to primary care professionals to improve the health of their patients and practices. All cooperatives will also conduct a multi-component quality improvement project with at least 50 primary care practices to improve the heart health of their patients. Applicants will also propose evaluation and sustainability plans.

A technical assistance conference call for interested teams will take place at 3 p.m. (ET) Tuesday, March 17, 2020. To register, send an email to Robert.Mcnellis@AHRQ.hhs.gov. Letters of intent are due April 10, 2020 and applications are due May 22, 2020.

Snapshot of 12 States’ Hospital Financial Transparency Laws

March 9, 2020/in Policy Charts Cost, Payment, and Delivery Reform, Health System Costs, Hospital/Health System Oversight, Quality and Measurement Health System Costs /by Johanna Butler, Maureen Hensley-Quinn and Deborah Fournier

State Strategies to Promote Children’s Preventive Services

March 6, 2020/in Policy Charts, Maps Children/Youth with Special Health Care Needs, CHIP, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, Healthy Child Development, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Value-Based Purchasing /by NASHP Writers

How the President’s Proposed FFY 2021 Budget Would Impact Critical State Health Programs

February 20, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, HIV/AIDS, Housing and Health, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Safety Net Providers and Rural Health /by NASHP Staff

The President’s budget request for federal fiscal year (FFY) 2021 proposes a 10 percent reduction in the Department of Health and Human Services’ (HHS) budget. A signature piece of the budget features the President’s Health Reform Vision, which includes $844 billion in cuts over 10 years to implement the Administration’s efforts to provide “better care at lower costs.”

While the proposed budget is subject to Congressional review and expected to change, it is important for states to consider how the Administration’s priorities could affect public health programs. The following highlights some of the key budget proposals that impact state health programs.

Prescription Drugs

Increases oversight of the 340B Program. The proposal gives explicit oversight authority to the Health Resources and Services Administration (HRSA) with the goal of creating enforceable standards for participation and ensuring 340B benefits low-income and uninsured patients. Part of the increased funding for oversight ($34 million) will come from a new user fee on covered entities based on 340B sales.

Bipartisan drug pricing proposals. The budget includes an allowance of $135 billion in savings for bipartisan Congressional drug pricing proposals. The Administration specifically supports efforts to improve the Medicare Part D benefit by establishing an out-of-pocket maximum and lowering out-of-pocket costs for seniors, as well as reforms to US Food and Drug Administration (FDA) approval and regulatory measures to bring lower-cost generics and biosimilars to market.

Health Insurance Markets

Encourages expansion of coverage in the small-group market through Multiple Employer Welfare Arrangements (MEWAs). Provides additional funding to the Employee Benefits Security Administration to encourage adoption of policies to boost insurance coverage for small businesses. Specifically, the budget suggests promotion of MEWAs – an arrangement made when multiple employers coordinate to offer benefits to their employees – for example, association health plans are a type of MEWA. State regulation of MEWAs varies, though largely they are exempt from many requirements imposed on other health plans, including consumer protections codified under the Affordable Care Act (ACA). This investment follows prior action taken by this Administration to promote association health plans.

Medicaid

Reductions in overall program funding. Proposes to cut $920 billion over 10 years from Medicaid.

Eligibility and Enrollment

Requires work and community engagement initiatives. To receive Medicaid benefits, the budget proposes requiring all able-bodied, working-age, Medicaid-eligible individuals to find employment, participate in job training, or volunteer. It estimates this will generate $152.4 billion in savings over 10 years.

Gives states the ability to change certain program elements and eligibility determination processes. Proposes to allow states to implement certain changes to Medicaid benefits and cost sharing, including making non-emergency medical transportation optional and allowing states to use state plan authority rather than a waiver to increase copayments for nonemergency use of emergency departments. Proposes to permit states to apply asset tests for individuals who are financially eligible for the program through the Modified Adjusted Gross Income (MAGI) standard. States would also be permitted to conduct eligibility redeterminations for MAGI-eligible individuals more frequently, to align with the soon-to-be released proposed rule on Medicaid eligibility determination processes.

Requires documentation of immigration status prior to receipt of Medicaid. Proposes that before they receive Medicaid coverage, individuals must provide evidence of citizenship or satisfactory immigration status. While states will still be allowed to provide coverage during a reasonable opportunity period, they will not be able to receive federal match for these individuals during this time. This is estimated to save $2.6 billion over 10 years.
Reduces maximum allowable home equity for Medicaid eligibility. Eliminates states’ ability to set a higher home equity limit for individuals seeking long-term care coverage through Medicaid, which is estimated to save $34.3 billion over 10 years.

Payments and Financing

Changes the ACA’s financing for the expansion population. Indicates that it will end the “…financial bias that currently favors able-bodied working adults over the truly vulnerable.” While no specific details were provided about how precisely this would be accomplished, language in the budget brief references allowing states with expansion populations to elect a block grant or per capita cap to finance their coverage. No details were provided as to whether the existing federal match rate for expansion adults would be reduced, to what base rate that reduction would be, or when this change would be enacted by Congress.
Reduces the federal match rate for Medicaid-eligible workers. Reduces the federal match rate for Medicaid-eligible workers from 75 percent to 50 percent by FFY 2024.

Prohibits Medicaid payments to public providers in excess of costs. Proposes to limit Medicaid reimbursement for health care providers operated by a governmental entity to no more than the actual cost of providing services to Medicaid beneficiaries.
Increases transparency of Medicaid financing and supplemental payments. Supports the finalization of a recently proposed rule that would require more data on states’ financing of Medicaid supplemental payments.
Gives the Centers for Medicare & Medicaid Services (CMS) increased ability to recoup Medicaid improper payments and recover Medicaid and Children’s Health Insurance Program (CHIP) overpayments. Permits CMS to issue disallowances for payments made due to noncompliance with provider screening and enrollment requirements and collect overpayments made to states for ineligible or misclassified Medicaid beneficiaries.
Continues Medicaid Disproportionate Share Hospital (DSH) reductions. Current law reduces Medicaid DSH allotments between FFY 2020 and FFY 2025. The budget proposes to continue DSH allotment reductions through FFY 2030 and estimates this will save $32.4 billion over 10 years.

Modifies Institutions for Mental Diseases (IMD) payment exclusions. Allows states that meet certain criteria and requirements to receive federal Medicaid reimbursement for covered services provided to adults with serious mental illness living in IMDs, which is estimated to cost $5.4 billion over 10 years. Also, if a group foster home is considered a qualified residential treatment program (QRTP) and qualifies as an IMD, these QRTPs would be exempted from the IMD payment exclusion.

Other Proposed Medicaid Changes

Eliminates Money Follows the Person (MFP) evaluation and reduces financing for the program, which provides funding to states to help transition people to home and community-based settings from institutions.

Creates new MFP state plan option. Provides states the ability to establish an MFP program with an enhanced federal match for the first five years of services if they spend less than 50 percent of their long-term service and supports funding on home- and community-based services in the previous year.
Extends Medicaid managed care waivers. Permits states to grandfather managed care authorities in waivers and demonstration programs if a waiver has been renewed once before and there are no substantive changes.

Proposals Affecting Individuals Dually Eligible for Medicare and Medicaid

Coordinates review of Dual Eligible Special Needs Plans marketing materials. Allows for joint state and CMS review of marketing materials for Dual Eligible Special Needs Plans.

Revisits Part D special enrollment period for dually eligible individuals. Clarifies the special enrollment period (SEP) for Medicare Part D to allow CMS to apply the same annual election process for all eligible individuals, but maintains the ability for dually eligible beneficiaries to opt into integrated care programs or to change plans following auto-assignment.

Children’s Health Insurance Program

Creates a shortfall fund to replace Child Enrollment Contingency Fund. Calls for creation of a shortfall fund containing unused annual appropriations that could be distributed to states that need additional CHIP funding. This fund serves to replace the Child Enrollment Contingency Fund as of FFY 2022; the Performance Bonus fund would also be eliminated that year.
Aligns Medicaid and CHIP policies on suspending and reinstating coverage for enrollees under age 21 who are incarcerated and released from custody. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act contains a policy requiring states to suspend coverage for youth under age 21 enrolled in Medicaid who are incarcerated instead of terminating coverage. The budget proposes extending this requirement to CHIP programs with the goal of providing access to health coverage upon release.

Children’s Health

Increase in Maternal and Child Health Services (MCH) Block Grant funding to offset reduction in other HRSA-funded programs to support children. Proposes a $60 million increase over FFY 2020 levels for the Title V MCH Block Grant, however this increase is combined with $97 million in reductions in other HRSA-funded programs for children, including: Sickle Cell Disease Treatment Demonstration, Autism and Other Developmental Disabilities, Heritable Disorders in Newborns and Children, and Emergency Medical Services for Children. This assumes states will fund the types of activities these programs previously funded through their MCH Block Grant programs.
Continue funding and disseminating research into neonatal abstinence syndrome. Proposes $2.25 million to continue the Centers for Disease Control and Prevention’s (CDC) work to investigate neonatal abstinence syndrome and share findings to improve care and outcomes for children and families.
Maintains Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Maintains MIECHV program at current levels.
Level funding proposed for Children’s Mental Health Services grants. The budget proposes $150 million to the Substance Abuse and Mental Health Services Administration (SAMHSA) – consistent with FFY2019 funding – for Children’s Mental Health Services for state, tribes, and communities through competitive grant awards that promote collaboration between juvenile justice, child welfare, and education systems. Up to 10 percent of these funds are proposed for a new demonstration initiative that will target those at risk for developing serious mental illnesses.

Maternal Health

The overall budget proposes $116 million for the President’s Improving Maternal Health in America Initiative. The initiative focuses on health outcomes for all women of reproductive age by improving prevention and treatment, healthy pregnancies and births by prioritizing quality improvement, health futures by optimizing post-partum health, and improved data and bolster research to inform interventions.

Promotes state innovations to improve maternal health outcomes. Expands the State Maternal Health Innovation Grant Programby $30 million, the Alliance for Innovation on Maternal Health (AIM) by $10 million, and the Rural Maternity and Obstetrics Management Strategies (RMOMS) program by $10 million. There is a $50 million increase ($80 million total for FY 2021) to HRSA to improve the overall quality of maternal health services.
Advances state efforts to combat maternal mortality and morbidity. The proposed budget invests $24 million in the CDC to expand maternal mortality review committees to all 50 states and DC.

Women’s Health

Allows states to provide postpartum coverage for pregnant women with substance use disorders (SUDs). Proposes to make it easier for states to offer pregnant women diagnosed with SUD full Medicaid benefits for one year postpartum, which would cost $205 million over 10 years.
Maintains funding for family planning and health related services. Provides $286 million for the Title X family planning program but prohibits certain entities that provide abortion services from using the funding.

Prevention and Public Health

Substance use disorder and the opioid epidemic

Increases grant funds to states for SUD prevention, treatment, and recovery:Adds $85 million over the FY20 budget for State Opioid Response (SOR) grants, bringing the total to $1.6 billion, and includes language to emphasize opportunities to expand activities to address methamphetamine and other stimulants. This increase, however, is coupled with decreases or total elimination of other SUD-related grants, which may lead to states re-aligning their existing activities into this grant.
Reduces substance use prevention funding to states:Strategic Prevention Framework (SPF) grants to states have been reduced by over $109 million, eliminating all by SPF prescription drug funds, which were maintained at $10 million. This appears to assume that state prevention activities can be picked up in the increased SOR grant funds.
Eliminates Medication-Assisted Treatment for Prescription Drug and Opioid Addiction (MAT-PDOA) grantsas part of the Targeted Capacity for Expansion (TEC) program that is designed to fill gaps in treatment capacity for communities. This $89 million reduction appears to assume that these treatment activities can be picked up in the increased SOR funding. Other funding within the program for peer-to-peer grants and special projects will be maintained at $11.2 million.
Eliminates $30 million in federal funding for Screening, Brief Intervention, and Referral to Treatment (SBIRT)program grants, shifting payment for these services to states and third-party payers.
Maintains funding for the Recovery Community Services Programs (RCSP)that will continue and enhance efforts to develop recovery networks and collaboration with peer organizations.
Maintains level funding to states through the Substance Abuse Prevention and Treatment Block Grantat a total of $1.9 billion.
Maintains level funding of $8.7 million for Opioid Treatment Programs (OTP) that provide methadone– funding also supports training and technical assistance for providers.
Continues grants to nonprofitComprehensive Opioid Recovery Centers: Maintains $2 million in grants to nonprofit SUD treatment organizations as part of a four-year project that provides a continuum of treatment services.
Supports State and Tribal Youth Implementation grants: Maintains nearly $30 million to fund 11 new grants and continue 35 existing grants that support states and tribes to address gaps in SUD treatment for youth and caregivers.
Maintains level funding for justice-involved populations with SUD: Provides $89 million for 54 new and 92 existing drug courts and also supports 11 new and five existing Offender Reentry Program grants.
Maintains Building Communities of Recovery programswith $8 million for 20 new and eight continuing grants that support recovery services.
Maintains level funding to prevent and reverse overdoses:
- Provides a continued $41 million in funding to the First Responder Training program through $41.0 million in grants to states, localities, and tribes for purchasing and training of overdose-reversal drugs.
- Provides a continued $12 million through grants to states to purchase and distribute naloxone kits and provide overdose reversal training.
Funding for Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act activities
- $5 million to fund hospitals and emergency departments for alternative pain management treatments intended to decrease opioid prescribing;
- $4 million to train emerging prescribers via 117 grants to medical schools and teaching hospitals to develop curricula to educate students on MAT and providing SUD treatment;
- $4 million to implement post-overdose bridges to SUD treatment; and
- $4.5 million project to 15 select states, to provide an enhanced FMAP (80 percent) for five of those states for some SUD services.
Supports a tool that warns about emerging issues:Adds $10 million for the Drug Abuse Warning Network (DAWN), a surveillance system that can warn about emerging SUD and behavioral health crises.
Increase of $18 million, for a total of $25 million, for the Assertive Community Treatment for Individuals with Serious Mental Illness program to help 33 communities establish, maintain, or expand efforts to engage patients with serious mental illness through emergency and inpatient settings.
$25 million for Assisted Outpatient Treatment to expand SAMHSA’s existing grant program. The program has achieved favorable outcomes in reductions in hospitalization, emergency department visits, and substance use, and increases in mental health functioning.
$35 million increase, including a new 5 percent set-aside, in all states and territories to build crisis systems for individuals in mental health crisis. States will continue to spend at least 10 percent of the funds on early interventions for those experiencing a first episode of psychosis.
$225 million ($25 million increase) for certified community behavioral healthcenters –clinics certified by SAMHSA and funded through a prospective payment model, similar to federally qualified health centers (FQHC).

Provides direct support for rural communities to address SUD needs:Maintains level funding for the Rural Communities Opioid Response Program (RCORP), providing a total of $110 million in grant funds to communities to address prevention, treatment, and recovery while building infrastructure and capacity. Adds new pilot programs to address the unique and emerging needs of rural communities responding to the opioid and SUD crises.
Supports infectious disease prevention and surveillance in high-risk regions:Increases existing funding by $48 million for activities that reduce the transmission of infectious disease and the incidence of potentially fatal cardiac and skin infections as a consequence of the opioid epidemic.
Maintains $475 million and builds on existing support for data capacity in states and other jurisdictions: Through Opioid Abuse and Overdose Prevention funding, CDC will continue to support states in tracking both fatal and non-fatal drug overdoses and prescribing patterns.
Shifts Drug-Free Communities funding to CDC: Moves $100 million from the Office of National Drug Control Policy (ONDCP) that was previously administered by SAMHSA as prevention grants, into the CDC budget.
Proposes a $350 million block grant program for states to address chronic disease priorities, including tobacco control and prevention, nutrition and physical activity, heart disease and stroke, diabetes, and arthritis.

Chronic disease prevention and management

Supports training for behavioral health workforce:Maintains $139 million within Behavioral Health Workforce Development (BHWD) Programs that train professionals in under-served communities (including at health centers) and supports an addiction medicine fellowship.
Expanded support for the Ending the HIV Epidemic initiative:
- $137 million (an increase of $87 million) for HIV prevention services in FQHCs, including pre-exposure prophylaxis (PrEP), outreach efforts, and care coordination in approximately 500 community health centers.
- Additional $95 million allocated for the Ryan White HIV/AIDS program.
Cuts CDC’s total discretionary budget authority by $1.289 billion, compared to 2020 funding levels.Program-level cuts would be $175 million. Other changes include:
- A cut of $427 million for chronic disease prevention and health;
- An increase of $40 million for influenza monitoring and prevention; and
- The creation of the America’s Health Block Grant as a means of reforming state-based chronic disease programs.
Proposes a new user fee on e-cigarettes. The budgetcontains $812 million in user fees to support FDA’s anti-tobacco programs, which includes a new $100 million fee to be collected from e-cigarette manufacturers. It also proposes to move the FDA’s Center for Tobacco Products to a newly created agency within HHS.

Programs Addressing Social Determinants of Health

Some components of the HHS and Department of Housing and Urban Development (HUD) budgets could affect states’ abilities to address health through housing and other social determinants of health initiatives.

Cuts HUD funding by $8.6 billion — a 15.2 percent decrease from the 2020 enacted budget.
Proposes changes to federal investment in rental assistance.The budget request would increase rental assistance to $41.3 billion, which would maintain services for all currently enrolled HUD-assisted households. Uniform work requirements would be placed on “work-able” households.
Adds funds to the Rental Assistance Demonstration program, which supports transitioning public housing to housing voucher and project-based rental assistance units.
Increases funding for lead-safe healthy homesby $69 million to $240 million.
Supports reductions to existing programs:
- Cuts $80 million from Housing Opportunities for People with AIDS, and
- Would eliminate the Community Development Block Grant.
Proposes policy and financial changes for safety net programs.The budget cuts $15.3 billion from the Supplemental Nutrition Assistance Program (SNAP) and cuts approximately $1.1 billion from the Temporary Assistance for Needy Families (TANF) block grant. Would apply consistent work requirements for federally funded public assistance programs, including SNAP, Medicaid, and TANF.

Long-term services and support

Cuts family caregiver services by $35 million, which provides grants to states and territories to fund various supports that help family caregivers care for older adults in their homes.
Cuts state councils on developmental disabilities by $22 million, which are charged with identifying the most pressing needs of people with developmental disabilities.
Reduces National Institute on Disability, Independent Living, and Rehabilitation Research by $21.6 million.
Cuts state health insurance assistance programs by $16 million, which are state programs that receive federal funding to provide free, local health coverage counseling to people with Medicare.

Health Care Infrastructure and IT

Supports rural health care infrastructure. Authorizes up to $2.5 billion for loans to assist communities with developing or improving public services in rural areas, including rural health clinics. Allows critical access hospitals to voluntarily convert to rural stand-alone emergency hospitals, which would enable those facilities to draw in Medicare payments at emergency department rates without the additional burden of maintaining in-patient beds.
Promotes price transparency and health IT interoperability. Finances several agencies to enable implementation of policies related to the President’s Executive Order to encourage price transparency. This includes $51 million to the Office of the National Coordinator for Health Information Technology for efforts to advance interoperability, electronic information sharing, and to align patient health and cost information.

Other Programs

Enforces conscience protection laws. Makes permanent the Weldon Amendment, which prohibits government agencies — including state agencies that receive federal money — from discriminating against entities or individuals who refuse to provide or refer for abortions. Expands the authority of the Office of Civil Rights enforce the Weldon Amendment.

Other proposals addressed in the Administration’s budget include:

Access to better care at lower costs;
Personalized care;
Protection for pre-existing conditions;
Policies to encourage choice and affordability of coverage; and
Policies to address surprise medical bills.

Governors Tackle Health Care Costs, Coverage, and Quality in their State of the State Addresses

February 18, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Expansion, Population Health, Prescription Drug Pricing, Safety Net Providers and Rural Health, Social Determinants of Health, State Insurance Marketplaces, State Rx Legislative Action, Work Requirements /by Sarah Lanford and Anita Cardwell

In their 2020 state of the state speeches, governors identified new health policy initiatives on a wide range of issues. As of mid-February, 42 governors had delivered speeches or outlined key budget priorities, and all addressed health issues – most commonly strategies to tackle health care costs and behavioral health issues. Below are highlights of the key health themes that governors raised.

Behavioral Health Issues

Mental health and/or substance use disorder issues were the most frequently mentioned by governors, with 33 commenting on these topics. Governors often cited efforts to increase access to behavioral health care services and initiatives to redesign and better coordinate care systems across agencies and providers.

The speeches recognized the significant challenges of addressing the needs of individuals with mental health issues. Gov. Kim Reynolds of Iowa asked legislators to provide sufficient funding to support the state’s strengthened mental health systems for adults and children. Others focused on children’s behavioral health with four governors specifically identifying the need to ensure that schools have an adequate number of mental health professionals. Others called for comprehensive insurance coverage and better integration of behavioral and physical health care that focus on the “whole child.”

View an interactive chart to discover how 42 governors’ addressed health care in their 2020 state of the state addresses.

Gov. Tony Evers of Wisconsin proposed specifically targeting the mental health needs of farmers by creating a new program that will help them access one-on-one counseling and connect them to peer support initiatives. In Colorado, Gov. Jared Polis highlighted a task force, created in 2019, that is assessing the state’s behavioral health system and developing recommendations for reforms. Another theme, raised by at least five governors, is the importance of better addressing the behavioral health needs of justice-involved individuals either prior to incarceration or as they transition back into community settings.

Combating the opioid epidemic continues to be a top priority, with 19 governors commenting on progress made in addressing the crisis. Gov. Brad Little of Idaho praised his state’s prescription drug monitoring program and noted a proposal to provide $30 million to help physicians and pharmacists identify and prevent opioid abuse. Multiple governors cited a number of successful strategies used to reduce overdose deaths, including increasing access to naloxone and outpatient treatment, medication-assisted treatment, and other targeted, data-driven and evidence-based efforts. Kentucky’s governor, Andy Beshear, pledged that any dollar received from the state’s ongoing lawsuit against opioid manufacturers and distributors would be used to end the epidemic.

Curbing Health Care Costs

Twenty-one governors addressed health care affordability. California Gov. Gavin Newsom and New Jersey Gov. Phil Murphy proposed creating offices within their executive branches dedicated to reducing consumers’ health care costs and increasing price transparency. Gov. Eric Holcomb of Indiana is proposing the establishment of an all-payer claims database to increase cost transparency and improve information about hospital pricing and insurance reimbursement.

Connecticut Gov. Ted Lamont is proposing to curb the state’s annual health care cost increases to reduce the outsized impact of medical expenses on residents. Prior to his state of the state speech, Lamont signed an executive order establishing health care cost growth benchmarks and a primary care spending target.

New York’s Gov. Andrew Cuomo proposed expanding the state’s out-of-network surprise medical billing law to require hospitals and emergency room doctors to participate in the independent dispute resolution process to resolve surprise balance bills. Additionally, five other governors urged lawmakers to pass legislation to address surprise billing.

Two governors highlighted money-saving programs that could be expanded to larger populations. Gov. Ron DeSantis in Florida noted a patient savings plan for state employees that increases price transparency that has reportedly saved the state millions of dollars, and he argued that making a similar plan available throughout the state could result in similar savings for more individuals. Polis spotlighted a community purchasing alliance in a Colorado county that pools individuals and employers together and uses their combined purchasing power to negotiate prices with hospitals and doctors directly to save money. He wants to replicate the purchasing alliance model in other parts of his state.

Polis and other governors also recognized reinsurance programs that have reduced premium costs on their exchanges by about 20 percent. Virginia’s governor, Ralph Northam, asked state lawmakers to create a similar program.

Medicaid Reforms and Expansion

This year, 13 governors addressed Medicaid and/or Medicaid expansion. Eight governors commented on recent program improvements, the growth of overall program costs, or cost savings achieved through program reforms. Gov. Charlie Baker of Massachusetts commented that his state “cleaned up” the MassHealth program while achieving the state’s goal to limit increases in total health care expenditures. In New York, Cuomo said the state’s $6 billion financial deficit is primarily due to Medicaid costs and noted that the state will need to restructure financing arrangements with local governments. Gov. Jim Justice in West Virginia proposed creating a Medicaid Families First Reserve Fund of $150 million to ensure services are available to those most in need. In his speech, the Gov. Tony Evers of Wisconsin praised policymakers for extending access to care in rural areas by ensuring that Medicaid covered telehealth services.

Six governors spoke about the value of implementing Medicaid expansion in their states. Idaho’s governor, Brad Little, said that his proposed budget funds a full year of Medicaid expansion with a net-zero impact on the general fund by using the state’s Millennium Fund and county contributions to cover the state’s share. Both Gov. Laura Kelly in Kansas and Evers in Wisconsin advocated for passage of Medicaid expansion bills. Evers noted expansion would bring $1.6 billion in new federal investment to the state’s health care system and Kelly highlighted evidence that expanding Medicaid coverage reduces mortality rates, improves infant and maternal health, helps address opioid abuse, and strengthens rural hospitals.

Health Care Coverage and Access

Nineteen governors mentioned their efforts to ensure that individuals have health care coverage and access to care. They often mentioned state initiatives and proposals to increase coverage options, ensure protections for pre-existing conditions, and broaden access to services. Three governors proposed codifying certain Affordable Care Act (ACA) protections in state law.

Bill Lee, Tennessee’s governor, mentioned the state’s Health Care Modernization Task Force is looking for ways to provide access to high-quality, affordable health care plans, and spoke of plans to increase funding for rural health clinics to improve access to dental care and make investments in the health care safety net. Newsom highlighted plans to strengthen coverage both through Medi-Cal and Covered California. Polis in Colorado explained how the state’s public option proposal will help to both reduce costs and provide greater choices for consumers. Three governors lauded their state-based exchanges’ successes, while Murphy of New Jersey shared plans to establish a state-based exchange. Similarly, Govs. Janet Mills of Maine and Northam of Virginia noted legislation to establish state-based marketplaces to better meet the needs of their residents and address increasing premiums and decreasing enrollment.

In Oklahoma, Gov. Kevin Stitt shared plans to use the Trump Administration’s Healthy Adult Opportunity Medicaid demonstration to expand coverage through a block grant for certain adult populations. The plan – SoonerCare 2.0 – would include work or community engagement requirements and premiums while also providing treatment for substance use disorders.

Prescription Drug Costs

Twelve governors addressed rising drug costs – an increase from last year when seven governors spoke about the topic. The most comprehensive proposal came from California’s governor, whose budget proposes:

Expanding the state’s authority to consider drug prices in other countries when negotiating for state supplemental rebates;
Leveraging the purchasing power of the Medicaid program to negotiate rebates on behalf of targeted populations outside the program; and
Increasing the state’s purchasing program by expanding partnerships with local pharmaceutical purchasers.

The governor’s budget also includes a single market for drug pricing that would combine state purchasing power and create the state’s own generic drug label through partnerships with generic drug manufacturers.

Michigan Gov. Gretchen Whitmer, Polis of Colorado, and New Hampshire Gov. Chris Sununu all supported drug pricing transparency. Illinois Gov. J.B. Pritzker noted his state capped out-of-pocket insulin costs at $100 for a 30-day supply, and three other governors urged lawmakers to pass similar legislation.

Polis and DeSantis of Florida also mentioned their states’ efforts to implement wholesale drug importation programs, while Cuomo, Sununu, and Gov. Lujan Grisham of New Mexico urged their lawmakers to enact a similar program. In addition to a wholesale drug importation program, Cuomo also wants to grant the New York Department of Financial Services additional enforcement authority over spikes in drug costs and to register and regulate pharmacy benefit managers.

Health Care Workforce

Ten governors raised the issue of the health care workforce, with most proposing ways to address provider shortages. Four governors highlighted plans to invest state general funds or to create loan repayment and scholarship programs to help attract providers to underserved areas. To help develop and sustain rural practices, Alabama Gov. Kay Ivey recommended creating a pilot program to incentivize primary care physicians and nurse practitioners to establish services in medically underserved areas and asked legislators to support other rural health initiatives to increase care access. Gov. Kim Reynolds of Iowa shared plans to increase the state’s capacity to provide obstetric services through a fellowship and tele-mentoring program that will train family practice physicians to specialize in this type of care. Mills of Maine noted that the state is providing $75 million over two years to nursing homes, in part to help fulfill their workforce needs. In Washington State, Gov. Jay Inslee highlighted the state’s multi-employer, multi-union health care apprenticeship program.

Other Health-Related Issues

Most governors mentioned other health-related accomplishments and proposals. These included reducing tobacco and vaping use among youth, family and medical leave, and maternal health. Governors in seven states expressed concerns about the rate of tobacco use by youth. California’s Newsom supports a tax of $2 per 40 milligrams of nicotine in vaping products that will go into effect in 2021, while New York and Rhode Island governors applauded lawmakers for banning flavored e-cigarette products last year.

Five governors praised their states’ paid family and medical leave policies, and others expressed support for implementing these types of initiatives. Sununu of New Hampshire urged legislators to pass a bill to establish a voluntary paid family leave program, Lee of Tennessee proposed 12 weeks of paid family leave to eligible state employees, and Gov. Phil Scott of Vermont indicated he would soon be introducing a voluntary paid family leave plan. Gov. Lujan Grisham of New Mexico highlighted her proposed Senior Dignity Fund to provide seniors and their caregivers with support.

Four governors expressed support for maternal health programs. Whitmer of Michigan plans to expand access to home visiting programs, particularly for women of color, and Virginia’s Northam urged lawmakers to pass a health equity budget that would give new mothers access to care for a year after their baby is born. Lee of Tennessee proposed expanded prenatal and postpartum coverage, including a pilot program to extend postpartum coverage to 12 months for mothers covered by Medicaid.

Many governors also mentioned the importance of social determinants of health and public health initiatives. Next week, the National Academy for State Health Policy (NASHP) will release a chart and blog that highlight how governors plan to address health-related social and economic factors in 2020, including education, housing, jobs, and the environment, among other topics.

Given the wide range of health initiatives proposed by governors, it is clear states will continue to pursue innovative health policies and programs in 2020. NASHP will track many of these proposals as they take shape.

How Governors Addressed Health Care in their 2020 State of the State Addresses

February 13, 2020/in Policy Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Prescription Drug Pricing, Social Determinants of Health, State Insurance Marketplaces, State Rx Legislative Action, Work Requirements /by Sarah Lanford and Anita Cardwell

NASHP Joins Lewin Group to Provide Integrated Care for Kids Model Support

February 10, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Karen VanLandeghem

The Centers for Medicare & Medicaid Services (CMS) has awarded the Lewin Group and its partners, which includes the National Academy for State Health Policy (NASHP), a seven-year contract to support implementation and monitoring for CMS’ Integrated Care for Kids (InCK) Model.

Launched in January 2020, this model is part of CMS’s strategy to fight the opioid crisis and address its impact on vulnerable Medicaid and the Children’s Health Insurance Program (CHIP)-covered children and their caregivers. The InCK Model aims to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable payment models to coordinate physical and behavioral health care with services to address health-related needs. InCK funding will provide Connecticut, Illinois (2 awards), New Jersey, New York, North Carolina, Ohio, and Oregon with the flexibility to design interventions for their local communities that align health care delivery with child welfare support, educational systems, housing and nutrition services, mobile crisis response services, maternal and child health systems, and other relevant service systems. By bringing together medical, behavioral, and community-based services, InCK strives to reduce fragmentation in service delivery and expand access to care for children and youth.

The Lewin Group, NASHP, and the other team members will support implementation of the InCK Model through technical assistance, program monitoring, measuring awardees’ progress on critical program milestones and outcomes measures, data collection and analysis, and critical feedback loops to support awardees’ work toward their goals.

“The Lewin Group is excited to contribute to this innovative approach that breaks new ground in the delivery of child- and family-centered care and the development of pediatric alternative payment models. We look forward to working with CMS to positively impact of the health of the next generation,” said Lisa Alecxih, Lewin Chief Capabilities Officer.

“NASHP is delighted to partner with the Lewin Group to support this innovative CMS InCK model,” said Trish Riley, NASHP’s executive director. “We bring to this work our decades of expertise in state health care delivery system design, cross-sector partnerships, payment reform, and the unique needs of children and their families.”

The Lewin Group is an established leader in health care and human services policy research, analytics and consulting at the federal and state level.

CMS Requests Input to Better Coordinate Care for Children with Complex Conditions from Out-of-State Providers

February 10, 2020/in Policy Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, EPSDT, Health Equity, Health System Costs, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Social Determinants of Health /by Kate Honsberger

The Centers for Medicare & Medicaid Services (CMS) recently released a request for information (RFI) for input from states, providers, health systems, and families to better coordinate care from out-of-state providers for children with complex health conditions enrolled in Medicaid. The deadline to submit comments is March 23, 2020.

States have long addressed issues of access to care, provider availability, service delivery system design, and public insurance reimbursement for children with medical complexity (CMC). This RFI addresses considerations for CMC who may require specialized treatment or therapy that is not offered by in-state providers and therefore need services in other states, complicating the ability of states to coordinate and deliver care effectively.

Coordinating care for enrollees from out-of-state providers can also present an administrative burden for state officials who are required to screen and enroll these providers in their Medicaid programs in order to provide payment for services. This RFI is part of a requirement from the Medicaid Services Investment and Accountability Act of 2019 which calls for the secretary of the Department of Health and Human Services to issue guidance to states on this topic.

CMS is seeking input from states and stakeholders who have experience with specific aspects of coordinating care from out-of-state providers, including:

Sate initiatives that have promoted and/or improved the coordination of services and supports provided by out-of-state providers to children with CMC;
Administrative, fiscal, and regulatory barriers that states, providers, and enrollees and their families experience that prevent children with CMC from receiving care, such as community and social support services, from out-of-state providers in a timely fashion, as well as examples of successful approaches to reducing those barriers;
Measures that have been or can be employed by states, providers, health systems, and hospitals to reduce barriers to coordinating care for children with CMC when receiving care from out-of-state providers; and
Best practices for developing appropriate and reasonable contract terms and payment rates for out-of-state providers in both Medicaid fee-for-service and managed care systems.

For a full list of requested information please review the RFI. CMS will review input from states and stakeholders and issue guidance by October 2020. The new guidance will include:

Best practices for using out-of-state providers to provide care to children with CMC;
Coordinating care provided by out-of-state providers to children with CMC, including services provided in emergency and non-emergency situations;
Reducing barriers that prevent children with CMC from receiving care from out-of-state providers in a timely fashion; and
Processes for screening and enrolling out-of-state providers, including efforts to streamline these processes or reduce the burden of these processes on out-of-state providers.

The National Academy for State Health Policy (NASHP) encourages states to submit relevant information to shape future guidance.

The RFI was posted on January 21, 2020 and comments are due March 23, 2020.

View the CMS RFI for instructions on how to submit comments. NASHP will share the release of any future CMS guidance on this topic as part of its ongoing work in the area of children with medical complexity.

To review NASHP resources related to children with medical complexity and children and youth with special health care needs, please visit its resource page.

Overview of the Centers for Medicare & Medicaid Services’ New Medicaid Block Grant Guidance

February 3, 2020/in Medicaid Managed Care Blogs, Featured News Home Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health System Costs, Medicaid Expansion, Program Design, Work Requirements /by Anita Cardwell

Introduction by Trish Riley, NASHP Executive Director

For decades, the proposal to convert the Medicaid program from an open-ended entitlement to capped funding as a “block grant” has been a fiercely argued policy, legal and ideological debate. Opponents contend that capped financing violates the foundation of Medicaid as an entitlement and would severely impair states’ abilities to address needs because there is no provision to adjust for medical and prescription drug cost increases nor to accommodate natural disasters or economic downturns that cause more people to need Medicaid’s protections.

Proponents argue that a block grant, much like the Children’s Health Insurance Program, provides more flexibility to states to design their programs and constrain cost growth. Here, the Trump Administration takes a new tact, using the Section 1115 waiver authority, to test the viability of a block grant concept on a subset of Medicaid enrollees.

The proposal does not address rising health care costs but does contain a “special circumstances adjustment” that could address unforeseen circumstances that are out of a state’s control. The guidance could encourage those states that have not expanded Medicaid eligibility to childless adults eligible under the ACA to do so. It could also allow states that have expanded eligibility to roll back current levels of coverage.

Because Section 1115 waivers are designed to test innovation in the Medicaid program, the Administration proposes a means to test the efficacy of a block grant, limiting its reach to a subset of Medicaid enrollees. NASHP’s Anita Cardwell walks us through what CMS’ new rules are proposing and notes that legal challenges are inevitable. Should the Administration succeed in approving these waivers, rigorous, independent evaluation will be critical for policymakers to assess its impact.

New guidance from the Centers for Medicare & Medicaid Services (CMS) would allow states to receive part of their federal Medicaid funding through a capped financing model. Through CMS’ Healthy Adult Opportunity (HAO) option, states would be able to seek approval through a Section 1115 waiver to accept a set amount of federal Medicaid funding for certain eligible adults.

While the option is limited to a specific portion of the Medicaid-eligible population, this is a significant change from Medicaid’s current structure in which the program operates as an open-ended entitlement and states receive federal matching payments based on their Medicaid program spending without a predetermined funding limit. The following describes some of the key elements of the HAO model.

Eligible Populations

The HAO model targets adults under age 65 who are not eligible for Medicaid due to:

Disability or need for long-term care services and supports,
Eligibility under a state plan designation.

States could use the model to cover adults who would be eligible through the Affordable Care Act’s (ACA) Medicaid expansion, but states will also be permitted to use the initiative to cover other groups of individuals. For example, states could use the HAO demonstration to provide coverage for:

Individuals with severe mental illness;
Those needing substance use disorder treatment; or
Individuals with HIV/AIDS.

States will also be allowed to set the income eligibility standard under the demonstration, and the guidance permits states to require an asset test for individuals seeking coverage under the HAO model. However, for states to receive the enhanced federal match available for the ACA Medicaid expansion population, states will need to have an income standard of at least 133 percent of the federal poverty level, will not be able to apply an asset test, and will not have the ability to cap enrollment. But the guidance does not explicitly indicate that enrollment cannot be capped if a state agrees to accept a lower match rate.

Financing Structure

States that pursue this new option will receive a capped amount of federal Medicaid funding for the populations covered under the HAO model. States’ spending would be matched by the federal government, but only up to a certain limit, and states would assume the risk for any expenditures for the demonstration population that exceed the defined amount. CMS is providing states with two financing options to select — an aggregate cap model or a per capita cap model.

States that cover new populations that they lack data for, such as the expansion population, will initially need to use the per capita cap model. CMS will calculate a per enrollee base amount for each eligibility group that is included in the demonstration using previous year expenditures, or if those are not available then it will be based on national and regional expenditures. CMS will trend the base amount for each group forward to the demonstration year, multiply each of these amounts by the number of enrollees for that year to account for changes in enrollment, and then total them to establish an overall per capita cap.

Under the aggregate cap model, CMS will determine a base year amount using prior expenditures based on the populations and services included in the demonstration, and will trend this amount forward to each demonstration year, but without consideration of enrollment changes. If a state would like to pursue the aggregate cap option for a population that has not been covered previously, they must first operate their HAO demonstration under the per capita cap model for at least two years. The guidance requires states using the aggregate cap model to annually spend at least 80 percent of their aggregate cap amount on health services.

Unlike the per capita cap model, states that use the aggregate cap approach that are able to keep costs below their annual cap and meet certain reporting and performance criteria may be eligible to reinvest a part of the savings into their Medicaid programs. These reinvestments must be determined to be likely to promote Medicaid program objectives and could include providing Medicaid services for groups not covered by the state plan, paying for services that are not in the state plan – such as pre-vocational services, initiatives to improve care quality and access, and allowable benefits and services designed to address certain social determinants of health.

In some cases, states could use the shared savings to support existing state-funded programs, such as a statewide tobacco cessation program. CMS also notes that states can use any annual savings to offset expenditures that exceed the cap for the subsequent three demonstration years. Also, while the guidance indicates that CMS will make changes to the base amount or annual caps to “adjust for state flexibilities that could significantly affect enrollment to ensure that states do not achieve savings from disenrolling individuals,” it does not provide further details about how this type of adjustment would be implemented.

Benefit Package

Rather than the traditional Medicaid benefit package, states that opt to pursue the HAO initiative will be able to structure a benefit package that aligns with private market coverage, although they will need to include at a minimum the benefits in the Essential Health Benefit (EHB) package. This means that states will not be required to provide services such as non-emergency medical transportation (NEMT) and coverage of early and periodic screening, diagnostic and treatment services (EPSDT) for individuals ages 19 to 20 included in an HAO demonstration. However, states could opt to provide these services, along with others, in addition to EHBs.

Prescription Drugs and Medicaid Drug Rebate Program

To address prescription drug costs, the HAO option will permit states to have a closed drug formulary that aligns with formularies provided through exchange coverage in the commercial health insurance market. The guidance stipulates that states provide coverage of certain drugs for individuals with HIV or behavioral health conditions.

However, although states would be allowed to omit coverage of certain prescription drugs, states would still be able to receive rebates through the Medicaid Drug Rebate Program. States could also make arrangements with manufacturers for supplemental rebates by including the manufacturers’ drugs on the state formulary.

Other Key Elements of the HAO Model

In its guidance, CMS indicates that it is “offering flexibilities currently available to states in a comprehensive suite of pre-packaged waiver authorities.” CMS notes that although its intent is to provide states with a “menu” of program design options, each demonstration will be approved on a case-by-case basis. States will be able to implement program elements to the populations covered by the demonstration, such as:

Charging higher premiums and cost-sharing requirements not allowed under traditional Medicaid for most individuals in the HAO model (individuals’ aggregate out-of-pocket costs could not be more than 5 percent of income, measured on a monthly or quarterly basis), and suspending enrollment for nonpayment;
Including conditions on eligibility, such as work requirements;
Choosing to waive retroactive coverage and hospital presumptive eligibility requirements; and
Conducting eligibility renewals before the standard 12-month renewal period to align with the open enrollment period of exchanges.

States operating under an HAO demonstration will also be allowed to implement certain changes without additional federal approval, unless the change has the potential to “substantially” impact enrollment. These could include programmatic changes to benefits, premiums, and copayments, or certain administrative modifications, such as changes in provider payment rates.

States that already have an approved 1115 waiver to cover populations that would be eligible for coverage through the HAO model would be permitted to transition those waivers into HAO demonstrations – for example, a state with an existing waiver to provide coverage to the Medicaid expansion population group.

Delivery Systems, Payment Models, and Managed Care

States seeking to participate in the HAO demonstration will be encouraged to implement payment and delivery system reforms to “improve the effectiveness of coverage, improve health outcomes and reduce the cost of care.” To align with Medicare and commercial payers, CMS suggests that states consider incorporating arrangements and strategies like ones established through the Center for Medicare & Medicaid Innovation (CMMI) that have demonstrated promising outcomes.

States will generally be allowed to use any mix of fee-for-service and managed care delivery systems, and as long as certain guidelines are met states will have the ability to modify these arrangements during the demonstration. If states are serving the HAO demonstration population through managed care, they will generally have to comply with specified statutory requirements related to beneficiary protections and decision making, access to services, and assessing program administration and delivery system quality. But states will be allowed to suggest their own strategies for ensuring network adequacy, access to care, and availability of services, and will also not have to request prior federal approval of managed care rates.

Monitoring and Evaluation

States participating in the HAO demonstration will be required to have a written strategy to evaluate care access and quality, and the health outcomes of enrollees, using measures from the CMS Adult Core Set. CMS is also expecting HAO demonstration states to report on certain performance measures related to enrollment, retention, access to care, and financial management on a quarterly basis. Also, participating states are expected to have an independent assessor provide suggestions for changes that could be made during the demonstration period.

Legal challenges are expected because, as noted by many analysts and highlighted in a recent letter from some House Democrats, there are questions about whether CMS has the ability to use the 1115 authority to change Medicaid’s financing in this way. The HAO demonstration model may also be challenged on the grounds that it does not promote the overall objectives of the Medicaid program.

States considering the model will need to carefully weigh the potential implications, because choosing to accept limits on federal Medicaid funding — even for only a portion of the program’s eligible individuals — introduces financial risk for states. For example, state Medicaid program spending regularly fluctuates as economic shifts occur, new treatments become available, or states experience public health emergencies or natural disasters. While the guidance does contain a “special circumstances adjustment” that would allow states to propose updates to address these types of situations, this would require states to undertake additional negotiations with CMS.

The HAO model could be appealing to the 14 states that have not implemented Medicaid expansion because it would provide them with greater flexibility to manage their Medicaid program benefits and impose certain enrollee requirements. If these states do pursue the HAO initiative to expand Medicaid, while more individuals would gain health coverage and it would meet EHB standards, the coverage provided would be less robust than that provided to traditional Medicaid expansion enrollees and individuals would likely face other enrollment restrictions. One of the 14 non-expansion states that has expressed interest in this approach is Oklahoma, whose governor announced his intention to pursue the concept to expand Medicaid with the inclusion of work requirements and premiums. However, his proposal could be in conflict with Oklahoma voters’ views, if they pass an initiative on the ballot this year to implement traditional Medicaid expansion. Another state, Tennessee, already has a proposal pending with CMS that requests to implement a “modified block grant” model that would allow for federal funding increases if enrollment rises, along with requests for certain program flexibilities. However, Tennessee’s plan differs from the recent guidance as it does not propose to implement the ACA’s Medicaid expansion, and instead would apply the block grant funding model to enrollees who are low-income parents, children, and individuals with disabilities.

The governor of Alaska – a state that has already implemented expansion – has indicated interest in seeking a block grant financing model and commissioned a study on the issue, so there may be interest in the HAO demonstration among policymakers there.

NASHP will continue to track and report on state activity related to the HAO model in the coming months.