California is the first state in the country to have received approval from CMS to revamp the way it provides treatment for substance use disorders to Medicaid recipients. Under a CMS drug waiver, the state will expand inpatient care, case management, recovery and added medication services. Beginning in 2016, drug treatment centers will be able to get reimbursed for providing a much wider range of services to Californians enrolled in Medicaid than previously.

In other news, four key pieces of legislation were signed into law last month in California that protect patients from unfair out-of-pocket costs. Considered by advocates to be some of the strongest consumer protection measures in the nation, they will help prevent out-of-network bills due to inaccurate provider directories, huge cost-sharing for specialty drugs, double deductibles in family plans, as well as extend protections against “junk insurance” to those covered by large employers. Health Access California, California Pan-Ethnic Network and Consumers Union campaigned for these protections, and Health Access summarizes each issue here, with links to the statutes and fact sheets.  


An often invisible conflict that sits at the heart of reducing health care spending became visible in Baltimore when the state’s Health Services Cost Review Commission (HSCRC), which sets payment rates for all hospitals in Maryland, agreed to a compromise on a program to provide decent jobs to Baltimore residents. Led by Johns Hopkins Hospital, many advocates in Baltimore lobbied the HSCRC to raise payments to hospitals by more than $40 million so they could create up to 1,000 new hospital jobs for residents in Baltimore’s struggling neighborhoods. However, the HSCRC, which is tasked with keeping health care costs under control, agreed to a much smaller increase with concomitantly smaller job growth.


Massachusetts Attorney General Maura Healey has appointed Donald Berwick, a pediatrician, former CMS Administrator and longtime consumer and health care advocate, to the state’s Health Policy Commission (HPC). The 11-member HPC was created in 2012 to monitor health care industry mergers in the state and track costs. The HPC’s membership includes health care experts, state officials and business and labor leaders.

 In other news, MassHealth, the state’s Medicaid program, hosted a public meeting on Dec. 7 on the dual eligible demonstration project. Key highlights from the meeting:

  • The state will conduct auto-assignment in 2016 for Tufts Health plan only
  • The rate methodology changes announced in September will be incorporated in the three way contract by end of 2015
  • The One Care program is meeting some of the expected outcomes, such as increased access to community-based long-term services and supports 


The Michigan Ombudsman program for the MI Health Link dual eligible demonstration project went live on Dec. 1. The ombudsman program is a collaboration between the Michigan Elder Justice Initiative (MEJI) and the Counsel and Advocacy Law Line. MEJI is a partner in the Voices for Better Health project, as well.

The Michigan Department of Health and Human Services released the latest monthly enrollment dashboard for MI Health Link  as of December 2015.

New York

The New York State Department of Health has issued long-anticipated course corrections to New York’s dual-eligible demonstration project in an effort to increase enrollment and gain more support from providers. The changes include eliminating passive enrollment, delaying the implementation of the demonstration in Westchester and Suffolk counties until after mid-2016, altering rules around the Interdisciplinary Care Team and increasing flexibility in the marketing guidelines for plans.

Advocates in New York state, led by the Center for Independence of the Disabled, New York (CID-NY), have done groundbreaking work advocating for people with disabilities in the design of the state’s dual-eligible demonstration and the implementation of managed long-term care in New York. They have made many of the materials they’ve developed available to other advocates, including a report on 18 months of their work between 2014 and 2015, a guide for care managers and a presentation on lessons learned from their efforts. CID-NY is a steering committee member of the Coalition to Protect the Rights of New York’s Dually Eligible.

Rhode Island

The working group for health care innovation, a group of stakeholders appointed by Governor Gina M. Raimondo, has released its final report, which lays out a set of recommendations to help improve the state’s health care system and address high costs while maintaining quality of care. The proposals in this report represent a starting point for achieving the governor’s ambitious goal to drive reform across the entire health care system. This report offers four broad recommendations with specific targets, deliverables and metrics:

  • Recommendation 1: Create an Office of Health Policy to set statewide health policy goals and oversee effective implementation
  • Recommendation 2: Hold the system accountable for cost and quality, and increase transparency through a spending target
  • Recommendation 3: Expand the state’s health care analytic capabilities to drive improved quality at sustainable costs
  • Recommendation 4: Align policies around alternative payment models, population health, health information technology and other priorities


Earlier this month, the Virginia Department of Medical Assistance Services (DMAS) posted its Section 1115 demonstration waiver for stakeholder review and a public comment period which runs through January 6, 2016. This waiver seeks approval from the Centers for Medicare & Medicaid Services (CMS) to implement two initiatives: (1) a mandatory Medicaid managed long-term services and supports (MLTSS) program; and (2) a Delivery System Reform Incentive Payment (DSRIP) program. The MLTSS program is expected to enroll approximately 130,000 Virginians receiving LTSS benefits, including enrollees in three of the state’s existing 1915(c) home and community based services (HCBS) waivers. The state will select managed care plans to provide a fully integrated care model that includes physical, behavioral, substance use, and LTSS benefits. The program will operate statewide. Among those expected to be enrolled are over 60,000 dual eligible beneficiaries who enrolled or opted out of Commonwealth Coordinated Care (CCC), the state’s dual eligible demonstration. The CCC is slated to end at the end of 2017.

The DSRIP would create provider collaborations, Virginia Integrated Partners (VIPs), which would provide patient-centered care and explore alternative payment models.  Each VIP will have a coordinating health system, which provides administrative support, oversees contracting relationships, and provides management leadership. VIPs will select from a menu of DSRIP projects, including: (1) System Transformation Projects; (2) Financial Incentive Alignment Projects; and (3) Clinical Improvement Transformation Projects.

If approved by CMS, the 1115 demonstration will operate for a 5-year period beginning January 2017.