Tag Archives: block grants

Health Adult Opportunity 1115 waiver option considerations

On January 30, the Centers for Medicare and Medicaid Services (CMS) introduced guidance describing the new Healthy Adult Opportunity (HAO) 1115 waiver option. This option outlines conditions under which a state might convert open-ended matching funding for expansion adults into a block grant or per capita program.

The HAO offers states new flexibilities for their Medicaid programs in return for assuming the financial risk of block grants. State program directors face many complex considerations as they evaluate these options. While the HAO will clearly appeal to states that have previously considered requesting a block grant, the range of policy options made available under this initiative may bear considerations for states across the country.

In this paper, Milliman’s consultants discuss 10 key considerations for states evaluating the HAO.

What are the risks and considerations of Medicaid block grants?

In September 2019, the State of Tennessee, Division of Tenncare, released a draft version of Amendment 42 to its Section 1115 Demonstration Waiver, “Tenncare II Demonstration.” With the exception of pharmacy and certain waiver services, the vast majority of Tennessee’s Medicaid program services are funded under this Section 1115 Demonstration Waiver authority. Amendment 42 makes Tennessee the first state to take concrete steps to engage the Centers for Medicare and Medicaid Services in a proposed block grant funding methodology.

A block grant funding arrangement is attractive from a federal financing perspective because it establishes an authorized level of spending, creating an incentive for states to better control costs. States could also find this structure attractive because it includes a savings component if efficient management of the program produces costs below the authorized spending levels.

This paper by Milliman’s Jeremy Cunningham and Mat DeLillo discusses the risks and considerations of changing Medicaid’s funding formula to a general block grant structure.

Changes to actuarial soundness requirements may or may not accompany changes to Medicaid funding

Proposals to change federal funding for state Medicaid programs using block grants or per capita caps could affect federal actuarial soundness requirements for Medicaid managed care capitation rates. In this article, Milliman’s Michael Cook discusses the following three scenarios that could play out if changes to Medicaid funding happen.

• The continuation of federal actuarial soundness requirements under revised federal funding is a plausible scenario.
• The establishing of individual state requirements if federal requirements are eliminated.
• The continued development of actuarially sound capitation rates by individual states even in the absence of any soundness requirements.

Considerations for Medicaid reform proposals

Republican Medicaid reform proposals have thus far focused on converting federal funding from the current approach of proportional federal and state financing to either block grants or per capita caps. While these funding approaches may sound relatively straightforward, understanding the implications of such changes requires consideration of several factors.

In this paper, Milliman consultants break down the detailed considerations into two primary categories: initial benchmark development and annual growth rates. Defining the assumptions and methodologies used to establish benchmarks and growth rates is key to aligning service cost with funding under alternative federal financing for Medicaid. Without consideration of these concepts, the actual cost of Medicaid relative to the federal budget for Medicaid will begin to diverge, and the gap may become wider over time. As this theoretical funding gap emerges, states will be at increased risk for funding additional program cost.