Waiver Design and Management

PCG helps states to obtain waivers and to design, develop, and implement innovative programs that will improve access, continuity, and quality of care, improve consumer satisfaction, and maintain compliance with Centers for Medicare and Medicaid Services (CMS) requirements for cost-effectiveness and budget neutrality.

 

CMS Requirements

State Medicaid agencies are faced with laws, regulations, and policy guidelines governing the individuals and families they may enroll in the program, the services they may cover, and the reimbursement methods they may use. States must obtain waivers from CMS if they wish to expand enrollment beyond optional groups allowed under the state Medicaid plan, to restrict recipient choice among qualified provider organizations, to offer enhanced services to groups with unique needs, or to offer different benefits in different geographic areas within the state.

 

PCG Solutions

PCG helps states with waiver programs such as:

• Home and community-based services tailored to the needs of the frail elderly and physically disabled persons at risk of nursing home placement, individuals with developmental disabilities requiring the level of care provided in ICFs/MR, and other individuals at risk of institutional care, such as medically fragile children and individuals with AIDS;
• Waivers of recipient free choice to permit mandatory enrollment in high quality, cost-effective delivery systems, such as HMOs and capitated behavioral health plans;
• Programs that utilize community-based primary care practitioners to offer regular preventive care and to manage the delivery of inpatient and specialty care when needed;
• Demonstration projects offering unique eligibility, coverage, and reimbursement incentives and strategies on a statewide basis, or in regional pilot programs.

PCG Expertise

PCG’s consulting knowledge and experience is grounded in a thorough understanding of:

• Key provisions of federal Medicaid law, such as sections 1115, 1915(b), and 1915(c) of the Social Security Act;
• Waiver program regulations such as 42 CFR 431.55 and 441.300-.365;
• CMS State Medicaid Manual and policy issuances;
• CMS waiver templates such as the Independence Plus templates;
• CMS research and demonstration waiver priorities;
• Exemplary practices pioneered by states in all regions of the US since the 1980’s.

PCG consultants have extensive experience with CMS waiver requirements and provide clients with unmatched waiver program
services, including but not limited to:

• Identifying waiver types and models that will best achieve state objectives;
• Identifying all requirements that must be waived and the rationale for each waiver;
• Defining key elements of the waiver program including eligibility standards, plans of care, services to be offered, provider types, appropriate licensure and certification standards, quality assurance and quality improvement strategies, level of care documentation, methods of reimbursement, audits, and annual reporting on utilization, costs, and impact of the waiver;
• Estimating the cost and impact of the waiver program in future years, including projected caseloads, utilization of waiver and non-waiver services by enrollees, and projected average per capita costs.

Attachments:

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