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Medicaid 1115 Waiver | DSRIP | UC Summary

Medicaid 1115 Waiver is a 5 year redesign program and states use waivers for the following purposes: expandcoverage, change delivery systems, alter benefits and cost sharing, modify provider payments and extend

coverage during an emergency

Private hospital UPL (Upper Payment Limit) programs which help to fund underserved population initiatives isbeing replaced by the Medicaid 1115 Waiver

o Waiver is a new methodology of UPL and creates Regional Healthcare Partnerships UPL Dollars are divided into:

o UC (Uncompensated Care) pool: costs of care provided to individuals who have no funds or third partycoverage for services provided by the hospital or other providers.

UC Dollars will be fixed at some timeo DSRIP (Delivery System Reform Incentive Payments): support coordinated care and quality

improvements through the regional healthcare partnerships to transform care delivery systems

DSRIP dollars are at risk and are pending achievement of metrics and milestones of projectso The breakdown of % of UC v. DSRIP dollars will change over the next 5 years with fixed UC dollars

decreasing to 50% of total dollars

DSRIP Project Categories:o Category 1: Infrastructure Development: lays foundation for delivery system transformationo Category 2: Program innovation and designo Category 3: Quality improvemento Category 4: Population focused improvements

IGT (Intergovernmental Transfers)- are dollars that are transferred between governmental entities to: academicmedical centers (such as UT Southwestern), public health agencies (HHS), etc. are matched dollars from the

government Regional Healthcare Partnerships (RHP): Regions developed throughout the State to deliver care and provide

increased access to care for low-income Texans under the 1115 Transformation waiver. Each RHP must develop

plans for the allocation of DSRIP funding. These plans must be submitted to the State and CMS for approval and

shall include estimated IGT funding available by year to support UC and DSRIP payments.

o Anchoring entity (anchor): The single IGT entity in an RHP serving as the primary contact to HHSCresponsible for providing opportunities for public input to the development of RHP plans and

coordinating discussion and review of proposed RHP plans prior to plan submission to the State.

o RHP 9 includes Dallas and Kaufman counties and is anchored by Parklando RHP 18 includes Denton, Collin, Rockwall and Grayson counties and is anchored by Collin County

Due dates:o September 1 => Anchor must submit RHP plans to HHSCo October 31 => Final RHP plans are due to CMS

IGT

Parkland or Collin gets a set amount of $based on matched IGT funding

Money is divided into UC and DSRIP

UC

Medicaid cap dependent Level of funding based off of:

o Level of IGT in federal matcho Hospitals % of total patient

participants in UC pool

DSRIP

At risk payments dependent on meetingmetrics and milestones to improve care

(disbursed every 6 months)

Contingent upon approved projects thatmeet categories in regulations

Value in meeting milestones that areapproved and payments made

accordingly