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Illinois' Medicaid 1115 Waiver Stakeholder Update

Health & Medicine Policy Research Group (HMPRG)
February 11, 2014
Health and Medicine has been responsible for reviewing and summarizing the public comments on the draft of Illinois’ 1115 waiver application. The stakeholder engagement process was extraordinary in the State’s history, with over 450 individuals and organizations registering to attend stakeholder meetings.  Both Health Management Associates and the State used the summaries of input from stakeholders to craft the new waiver application, which is available here.
As stakeholders across Illinois prepare for the next steps in the 1115 waiver process, here are some highlights from the public comments on the draft waiver application:
  • Eighty-five organizations submitted 949 comments or recommendations
  • Disability rights advocates and service providers submitted the most comments at 209, followed by health policy advocates with 99, housing organizations with 87, and aging advocates and providers with 81.
  • Of the four pathways in the draft 1115 waiver application, Home and Community-based Services was the pathway with the most comments.
  • Health and Medicine used 50 broad categories to organize the comments. The top 5 categories of comments were:
    • Governance and Financing of the Waiver
    • Care Coordination
    • Waiver Process
    • Housing
    • Specific Reimbursement Recommendations
Overall, stakeholder comments offered suggestions for improving the waiver application so that it matches ongoing health reforms that the State has been working to implement, ensuring that it takes into account the care and support happening in clinics, community organizations, and within communities, and also asking for further assurance of protections for the different consumers and constituencies who advocates and providers serve.  Many comments expressed general support for the waiver and requested that stakeholders continue to be engaged beyond the application process for both the negotiation and implementation phases of the waiver.

Many stakeholders commenting on care coordination highlighted how their current activities could contribute to the overall waiver goal of coordinated health care and social services. Of course many also included recommendations for reimbursing for those activities, and still more requested more detail about how the waiver contemplates changes to existing delivery and payment systems.

The ambitious changes the waiver proposes for Illinois’ long-term services and supports system stimulated intense commentary. The 1115 waiver would consolidate nine 1915(c) waivers that Illinois currently uses to provide home and community-based services under a single streamlined assessment, service planning and rate setting system. Amidst the understandable anxiety from advocates and providers alike, stakeholders offered suggestions for common service definitions, consumer protections, training for LTSS workers, and expanding community services for people with serious mental illness and people with substance use disorders, to name just a few topics.

The possibility of new funding pools for hospitals to expand services and implement delivery system reforms piqued stakeholders’ interest as well. Several offered recommendations for performance metrics and visions for integrated delivery models the incentive pools could support. Others expressed unease about interfering with existing hospital financing mechanisms and concern about the exclusion of some providers, especially downstate and rural hospitals. Some comments also expressed concerns with the Universal Assessment Tool’s (UAT) development and implementation, the desire for more details, and requests for assurance that stakeholders will be deeply involved in producing, testing, and modifying the UAT.

The public comments also reflected a passionate interest in the 1115 waiver’s housing proposal. Several stakeholders offered thoughtful arguments on the relationship between housing and health outcomes, and many also recommended additions and improvements to the draft waiver application’s plan for incentivizing housing supports through Medicaid, including calls for funding wraparound services and integrated housing for people with disabilities.

Emphasizing the connection between the health care workforce and the overall goals of the waiver, many comments suggested specific additions to the loan repayment and GME proposals while also highlighting the need for a linguistically and culturally competent workforce that includes people with disabilities and people who have been justice-involved and further, that all workers are paid a living wage.

There were hundreds of comments on many, many diverse topics, reflecting the wide interest and varied expertise of Illinois’ health care providers, consumers, and advocates. Be sure to take a look at the new waiver application to see what’s changed and please stay involved as Illinois negotiates with the Center for Medicare and Medicaid Services and moves toward implementation.

Many of the comments have not been included by HMA and the State in the final draft of the Waiver Application, whether because they are not matters that need to be waived by the CMS, are implementation issues, or if for some other reason, they did not fit into the application; however, these comments will be helpful to advocates and the state as negotiations with CMS proceed and as the state moves to implement the final agreement between the State and CMS. It is a rare and valuable opportunity to have a large portion of the State’s many committed health advocates and constituencies provide such engaged input for improving a large program, such as Medicaid.  Health and Medicine is committed to ensuring that the comments that were generated through the stakeholder engagement process are further analyzed and those that may have not been included in the waiver are taken into consideration for further improving Medicaid at the State level. 

The 1115 waiver has been described as a request to the Federal Government to waive certain requirements and provide financial flexibility to improve Medicaid in Illinois.  The necessary counterpart to the waiver application is continued stakeholder engagement within the State, both to implement the waiver itself and to make reforms to further ensure access to care, increase care quality, and improve the health of Illinoisans. Health and Medicine plans to share more details of the comments moving forward so that all of us can learn from other organizations’ priorities and develop more robust planning, programming, and advocacy agendas. We thank the advocates and constituents who have been involved thus far and are excited to continue to engage people regarding improving Medicaid in Illinois.