State Releases Medicaid Global Waiver Application – Seeks Comments

July 23, 2015

July 24, 2015

To:                    Chief Executive Officers and Government Relations staff

From:               Chelene Whiteaker, Policy Director, WSHA
Claudia Sanders, Senior Vice President, WSHA
Ben Lindekugel, Executive Director, AWPHD

Staff Contact:   Chelene Whiteaker: or 206-216-2545

Subject:          State Releases Medicaid Global Waiver Application – Seeks Comments

This bulletin is intended to inform you of opportunities to provide public comment on the state’s work with the Centers for Medicare & Medicaid Services (CMS) to seek a global waiver for the transformation of Medicaid. The state is seeking $3 billion in federal funds to support transformation. The state plans to submit its application to CMS in September 2015.   WSHA and AWPHD want your comments and feedback on our draft letter to the state.

All hospitals and their communities will be impacted by a global waiver, if approved by CMS.

Understand the basics of the global waiver and connect with key partners in your community to help shape this program. Review WSHA’s comment letter to the state Health Care Authority (HCA) and provide suggestions to us.

The state HCA has identified a new opportunity with CMS to provide the state added flexibility in the delivery of non-traditional services for Medicaid and up-front funding to be used to support transformation. If the state is successful in getting federal approval for its waiver request, it is likely to have large implications for health care in our state. A waiver can provide additional federal funds for current and new programs undertaken by hospitals, counties, and public health agencies in care for vulnerable populations, such as those with behavioral health needs, the homeless, and others. Many opportunities will be directed through the newly forming Accountable Communities of Health (ACH).

Federal law allows CMS to waive certain Medicaid requirements on states for purposes of testing new methods of health care delivery and payment. Under this section of federal law, CMS has instituted a new program to grant states approval of Delivery System Reform Incentive Payment (DSRIP) initiatives.  DSRIP is not a grant program and participation must show additional federal investments will be balanced by savings to achieve budget neutrality. A number of states (Texas, California, New York, Kansas, and others) have taken advantage of this opportunity and are getting large infusions of new federal funds ($11 billion for California).  HCA believes it can get approval for a program in Washington State and take advantage of many of the cost cutting measures the state has already put in place over the last decade in order to show new investments are budget neutral.

In order to benefit from this program, the state still will need to come up with state-based funding to use for Medicaid match. While the state general fund can provide match, there are limited new dollars available at the state level. The HCA believes much of the matching dollars can be raised through arrangements with local public entities, including counties and public hospitals. For example, funds can be transferred from a public hospital to the federal government, matched, and returned to create a DSRIP pool which will fund delivery system reform initiatives.  The ACHs will have a major role in determining the local DSRIP initiatives. Hospitals, working through their ACH, can shape these discussions and participate in developing and providing the new services. AWPHD is in discussions with HCA on the opportunities this creates for its members as well as for other hospitals in the community. Another avenue for matching funds could come through the 1/10 of one percent sales tax for behavioral health services that many counties in the state have enacted.

HCA’s waiver application to CMS focuses on three major areas: (1) transformation through ACHs; (2) targeted long-term services and supports to individuals at risk of utilizing more intensive care; (3) targeted foundational community supports (population health activities). Specifically, the application makes significant changes to long term care and support services.  HCA states these changes will reduce expenditures as the population ages.  HCA proposes to define a new group of eligible individuals, those with functional issues, age 55 and older with incomes under 300 percent of the federal poverty level. For example, these newly eligibles would receive home based support services in order to keep them from needing nursing home care.

Next Steps

  1. Read the application HCA just released for the waiver.  The application is similar to the concept paper released earlier this summer.
  2. Participate or send a representative from your organization to the public meetings around the state during the first week of August. (See below for more details)
  3. Review WSHA’s draft comment letter  to the HCA on the waiver and let us know if you have additional comments or suggestions. Please send your suggestions to Chelene Whiteaker by Friday, August 14.

Opportunity to Provide Public Comment
Before submitting the application to CMS, HCA is seeking feedback through several public meetings. If you plan to attend, please RSVP to .

Monday, August 3
8:00 -10:00 a.m. Pierce College-Ft. Steilacoom, Lakewood
1:00 – 3:00 p.m.  Everett Community College, Everett

Tuesday, August 4
8:00 am – 10:00 a.m. Yakima Valley Community College, Yakima
2:00 – 4:00 p.m.  Columbia Basin College, Pasco

Wednesday, August 5
10:00 a.m. – noon Spokane Regional Health District, Spokane

Background and References 
Read WSHA’s bulletin on Healthier Washington (insert: for more information.


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