Medicaid Not Jumping at TMA’s 1115 Waiver Ideas

State Medicaid officials offered a lukewarm response to TMA's recommendations to increase physician involvement in Medicaid transformation plans, boost physicians' Medicaid payment rates, and design a privately based plan to cover more uninsured, low-income Texas adults.

Texas' five-year 1115 Medicaid Transformation Waiver will expire Sept. 30, 2016, unless the federal government grants a renewal or extension. Texas received a waiver in 2011 to allow it to expand Medicaid managed care statewide, to establish a new uncompensated care pool for safety net hospitals and health professionals, and to establish and fund innovative projects to improve availability and quality of services to Medicaid and uninsured Texans. Federal and state funds sustain the waiver, with primary funding coming from large hospital districts.

In his July 16, 2015, letter to the Health and Human Services Commission (HHSC), TMA President Tom Garcia, MD, said TMA "absolutely supports renewal" of Texas' 1115 waiver but with more physician involvement and a solid plan to recruit more physicians to the Medicaid program. The letter pointed out that the U.S. Centers for Medicare & Medicaid Services (CMS) told states it will be more likely to approve waiver renewals if states take steps to improve coverage of uninsured, low-income residents and to pay physicians enough to "promote provider participation and access."

On Aug. 11, 2015, HHSC Chief Deputy Executive Commissioner Charles Smith said the agency "appreciate[s] TMA's initial support of the waiver renewal despite the concerns you raise in your letter." Mr. Smith said HHSC is aware of CMS' preference for coverage expansion and better pay for physicians but said neither is likely to happen in Texas any time soon.

Of TMA's request that HHSC "design a pragmatic, private health insurance initiative to extend coverage to the 1 million Texans earning too much for Medicaid but too little to qualify for federal health insurance subsidies," Mr. Smith wrote, "At this time, Texas opted not to proceed with a Medicaid coverage expansion; therefore, HHSC does not plan to include a request for coverage expansion in the extension request."

And in response to Dr. Garcia's call for "competitive Medicaid physician payments to attract and retain physicians within Medicaid," Mr. Smith said the agency "must operate within the parameters of its budget in setting provider rates. Given our rate constraints, HHSC is working to increase physician participation in Medicaid by reducing administrative burdens both in fee for service and managed care."

He was more positive in answering TMA's request that HHSC establish an ongoing physician advisory council composed of privately practicing physicians as well as their academic and hospital-affiliated peers to actively assist in the development, implementation, and evaluation of new or renewed health care delivery projects under the 1115 waiver. Mr. Smith said TMA representatives currently serve on two waiver advisory committees, and "HHSC would be glad to add more privately practicing physicians" to the committee that provides clinical and quality input on the program.

Finally, Dr. Garcia asked that HHSC require each regional health care partnership (RHP) to establish a physician advisory committee composed of county medical society physician representatives and practicing community and academic physicians (to the extent the latter practice within the region) to ensure that physicians are actively involved with the RHP in designing, implementing, and evaluating projects. Each committee would be required to convey its recommendations not only to its RHP but also to HHSC and the general public to ensure greater transparency. Mr. Smith said "further involvement of community doctors would strengthen" the 1115 projects, and HHSC will consider that request later this year.

For more information about the 1115 Medicaid Transformation Waiver, visit the HHSC website or see the article in the upcoming October issue of Texas Medicine magazine.

Action, Sept. 1, 2015

Last Updated On

May 13, 2016