The CMS has taken steps to bring more transparency and ease administrative hurdles to the review and approval process of Medicaid demonstration waivers.
The agency's oversight over 1115 waivers was the subject of two recent Capitol Hill hearings, and numerous Government Accountability Office reports dating back to the 1990s. A primary criticism has been there is no process in place to quickly renew waivers that have been up and running for years.
The CMS says implementation of a “fast track" federal review process for Section 1115 (PDF) will address this.
“We have also heard your feedback about the waiver renewal process for existing demonstrations,” HHS Secretary Sylvia Mathews Burwell said at the National Governors Association Summer Meeting in West Virginia this past weekend.
“This (fast-track process) will streamline the extension process and reduce the administrative burden on states and the federal government,” Burwell said.
Demonstrations that qualify for this fast-track process include ones that are established, meaning that they have had at least one full extension cycle without substantial program changes.
The demonstrations must comply with reporting deliverables and possess positive monitoring and evaluation results that show the objectives of the demonstration and the Medicaid/CHIP program have been achieved, the notice says. The state also can't propose any major or complex changes.
The new fast-track process involves states using a streamlined extension application template.
The CMS will notify the state of whether its extension request meets the criteria for expedited review within 15 days of receiving the application. If one is granted, it will be offered a five-year extension, versus the traditional three-year period, to reduce the number of times a state must apply for waiver renewals.
The CMS will aim to get a decision back to the state roughly within 90 days. That's the time frame it usually takes the CMS to respond to an amendment to a state Medicaid plan, unless the agency has substantive questions, which can delay a decision for a few more weeks. The tightened turnaround is notable as some states now reportedly wait for more than a year for a decision on their waiver applications.
To support the fast-track pathway, the CMS created a new unit dedicated to reviewing 1115 waivers and has increased staffing, the agency says in the notice.
The CMS, however, does not appear to be addressing another leading criticism of the 1115 waiver program, which is ensuring waivers are budget-neutral. That term means the CMS is spending the same amount of money on a state that it would have spent without a waiver.
The GAO has claimed there are numerous cases in which states overspent by billions.
For example, in 2013 and 2014, five demonstrations reviewed by the agency spent $33 billion more than what documentation would have supported.
The agency also released a bulletin Monday that outlines a new plan for states to use 1115 waivers to address substance use disorders.
That initiative bulletin released Monday (PDF) aims to help states implement innovative treatment approaches, including developing effective care-coordination models to better connect those with substance use disorders to providers.