Letter to Assistant Secretary for MassHealth Regarding Section 1115 Demonstration Waiver Amendment Request

Submitted by email to 1115WaiverComments@mass.gov

Re: MassHealth Section 1115 Demonstration Waiver Amendment Request

Dear Assistant Secretary Levine,

On behalf of the undersigned organizations and individuals, thank you for the opportunity to submit comments on MassHealth’s proposed Section 1115 Demonstration waiver amendment released on August 2, 2023. We strongly support the waiver amendment, which will promote health equity, improve continuity of care, increase investments in health-related social needs (HRSNs) and expand MassHealth and ConnectorCare coverage to previously excluded populations. More detailed comments about each provision within the 1115 waiver amendment proposal are outlined below.

1. Preserve CommonHealth Members’ Ability to Enroll in One Care Plans
   We strongly support MassHealth’s proposal to continue to allow CommonHealth members to have the opportunity to enroll into a One Care plan. The One Care program is crucial to many people enrolled in both MassHealth and Medicare. The integrated care model that the One Care health plans adhere to encourages individuals to be in the driver’s seat when it comes to their care decisions. This person-centered care model has benefited thousands of dual eligible enrollees. We applaud MassHealth for ensuring that CommonHealth members will continue to have this integrated care option when One Care transitions from a Duals Demonstration plan to a Medicare Advantage Fully Integrated Dual Eligible Special Needs Plan. We suggest one addition to the request to mirror the language for enrollees at or over age 65: “MassHealth CommonHealth members who were enrolled in One Care under age 65, who are disenrolled due to a lapse or downgrade in their MassHealth eligibility for a period of 12 months or less, may be reinstated to their One Care plan.” This will help ensure comparable continuity of coverage and care for One Care members between 21-64 years old, who may have a lapse or downgrade in coverage due to a variety of factors, including administrative churn during the eligibility redeterminations process.

2. Expand Health Connector Subsidies to Additional Individuals
   We strongly support the request for additional expenditure authority to support the pilot expansion of ConnectorCare, the state’s subsidized program for uninsured individuals without access to employer-sponsored insurance. ConnectorCare is one of the key reasons that Massachusetts has the lowest uninsurance rate in the nation.

   Despite high levels of coverage in Massachusetts, 41% of residents struggled to afford health care during the past year. Black and Hispanic/Latinx individuals are more likely to face challenges affording care, and the disparities are most acute for those with incomes over the current 300% of the federal poverty level (FPL) eligibility threshold for ConnectorCare. Many of our organizations hear regularly from consumers with incomes just above 300% FPL whose only health coverage options have high deductibles and co-pays in addition to steep premiums, too often putting care out of reach. This issue is more important than ever. As MassHealth resumes the eligibility redeterminations process, individuals and families no longer eligible for MassHealth will need affordable health coverage options.

   The two-year pilot program expanding ConnectorCare to individuals and families with incomes between 300% to 500% FPL, recently signed into law through the FY2024 state budget, will bring immense relief to between 50,000 and 70,000 residents and help maintain or strengthen the state’s insurance coverage rate. Massachusetts already has expenditure authority for the current ConnectorCare program. The request for a federal match for the expanded program is essential to the state’s ability to provide affordable health coverage and maintain continuity of coverage.

3. Increase the Income Limit for Medicare Savings Program (MSP) Benefits for Members on MassHealth Standard to the State Statutory Limit
   We strongly support the expansion of the three Medicare Savings Programs (MSPs), as required under the state’s FY2023 budget. MSPs are important benefits for low-income elderly and disabled Medicare beneficiaries. Seniors already face challenges with the rising costs of living. Unaffordable health care only adds to this burden. Increasing the income and removing the asset test for assistance provides much needed relief. Allowing members who qualify for MassHealth Standard at higher income levels, as long as their income falls below the updated income limits for the MSPs, to benefit from both coverage and cost assistance will make health care more affordable for thousands of Massachusetts seniors.

4. Remove the Waiver of Three Months Retroactive Eligibility
   We strongly support MassHealth’s proposal to provide all eligible members with three months of retroactive coverage, in line with the federal Medicaid statute. This provision builds on the recently approved 1115 waiver extension authority to reinstate 3 months of retroactive coverage for children under 19 and pregnant individuals, and the longstanding practice for members ages 65 and older. Retroactive coverage can help prevent medical debt for low-income individuals and families. The 2021 Massachusetts Health Insurance Survey shows that 15% of families income eligible for MassHealth reported problems paying medical bills and 38% having been contacted by collection agencies about unpaid medical bills. Medical debt can affect people’s credit, add challenges to meeting basic needs, and cause people to delay or avoid needed care. Inadequate retroactive coverage has also required health care providers to absorb financial losses. Removing the waiver of 3 months of retroactive coverage will help mitigate enrollee medical debt, promote continuity of care and squarely align with both the word and intent of federal Medicaid law.

5. Provide 12 Months Continuous Eligibility for Adults and 24 Months Continuous Eligibility for Members Experiencing Homelessness Who Are 65 and Over
   We applaud MassHealth for identifying additional ways to ensure continuous coverage and reduce churn for enrollees. This waiver amendment builds on recent implementation of 12 months of postpartum coverage, 12 months of continuous eligibility for individuals (including youth) transitioning from correctional facilities and 24 months of continuous eligibility for individuals experiencing homelessness. We also stand ready to work with MassHealth to ensure successful implementation of 12 months continuous eligibility for children under 19 beginning in January 2024, as required by the federal Consolidated Appropriations Act of 2023. We strongly support MassHealth’s proposed expansion of 12 months continuous eligibility to adults and equitable application of 24 months continuous eligibility for members experiencing homelessness to those 65 and older. These provisions will help to address coverage gaps many of the most underserved individuals and families in the Commonwealth face. Recently released data show that over 25% of MassHealth members lost coverage at any point during 2018. Continuous coverage policies reduce churn for members who lose and gain eligibility over a short period of time due to administrative challenges or income volatility, promotes continuity of coverage and access to care and provides a stable foundation for MassHealth’s delivery system reforms.

6. Include Short-Term Post Hospitalization Housing (STPHH) as an allowable Health-Related Social Needs (HRSN) Service
   We strongly support the inclusion of Short-Term Post Hospitalization Housing as an allowable HRSN service. Supportive housing for those experiencing homelessness provides a safe and stable place for members to continue their recuperation after discharge from hospital and inpatient treatment settings. The model, which includes integrated clinical services, has been shown to reduce lengths of hospital stays and improve clinical outcomes. It also has the potential to reduce health disparities, and to improve hospital wait times by providing an appropriate and supportive setting for those who no longer need an inpatient level of care.

7. Increase the Expenditure Authority for the Social Service Organization Integration Fund
   We strongly support the increased expenditure authority for the Social Service Organization (SSO) Integration fund. MassHealth’s commitment to addressing HRSNs, particularly through the current Flexible Services Program, which connects certain members to housing and nutrition related supports, has been a crucial forward-thinking feature of the state’s 1115 waiver programs. The new HRSN Program structure under development will solidify, expand, and integrate these supports into overall MassHealth programing. Doing so will require SSOs that partner with Accountable Care Organizations (ACOs) to provide the HRSN supports to evolve and enhance some of their capabilities. In particular, the updated HRSN program will likely require new referral platforms and billing mechanisms. This technical infrastructure will be challenging for many SSOs, many of which already face resource and capacity constraints. It would be a loss for the state and for MassHealth members if SSOs that provide culturally competent and locally rooted supports were unable to participate in the program because of these constraints.

   The increased expenditure authority for the SSO Integration Fund would address this challenge by making sure SSOs have the financial resources they need to upgrade their infrastructure and capacity to successfully participate in the HRSN program. The proposed fund is essential to maintaining and expanding the incredible partnerships between community based SSOs and ACOs in a way that will maintain and grow the HRSN supports MassHealth members need.

8. Provide Pre-Release MassHealth Services to Individuals in Certain Public Institutions
   We strongly support MassHealth’s amended proposal to provide pre-release services to MassHealth eligible individuals in carceral settings. This proposal makes a powerful case for the value of pre-release services to strengthen access to community resources that address the health care and HRSN of this population, improve health outcomes, address racial health inequities, and reduce emergency department visits and inpatient hospital admissions for returning individuals. We appreciate that MassHealth is committed to extending services as broadly as possible in light of the April 2023 guidance from the Centers for Medicare and Medicaid Services (CMS) and the 1115 waivers CMS has already approved for California and Washington.

   However, there are many important decisions that will be made in developing the final proposal, negotiating the terms of approval from CMS, finalizing an implementation and reinvestment plan, implementing pre-release services in the facilities operated by Department of Corrections, the fourteen county sheriffs, and the Department of Youth Services, and monitoring and evaluating the outcomes. We strongly urge MassHealth to enlarge the interagency Coordinating Council with which it has been working since 2021 to include a broader group of stakeholders, particularly those with lived experience. The CMS guidance relies on recommendations from the federal advisory committee that included not just representatives of the jail and prison systems, but also managed care organizations, health care providers and Medicaid beneficiaries. CMS strongly encourages states to engage individuals with lived experience who were formerly incarcerated in both the design and implementation of demonstration proposals. California convened a robust advisory group including reentry service providers, managed care plans, people with lived experience and community-based organizations. We urge MassHealth to bring community into the planning for the transition from incarceration to community-based settings.

We appreciate MassHealth’s leadership in prioritizing health equity and access to care for the most underserved individuals and families in the Commonwealth. Our organizations look forward to partnering with you to successfully implement the provisions outlined in the proposed 1115 waiver amendment. Please do not hesitate to reach out to Suzanne Curry at Health Care For All at scurry@hcfama.org with any questions or to discuss this comment letter further.

Sincerely,

1199 SEIU - Massachusetts
AccessHealth MA
Association for Behavioral Healthcare
Boston Center for Independent Living
The Brookline Center for Community Mental Health
Center for Health Law and Policy Innovation of Harvard Law School
Center for Innovation in Social Work & Health, BU School of Social Work
Community Teamwork
Disability Law Center
Disability Policy Consortium
Easterseals Massachusetts
The Greater Boston Food Bank
Greater Boston Legal Services
Health Care For All
Health Law Advocates
Joint Committee for Children’s Health Care in Everett
Justice Center of Southeast Massachusetts
The Latino Health Insurance Program, Inc.
MA Chapter of the American Academy of Pediatrics
Massachusetts Association of Community Health Workers
Massachusetts Association for Infant Mental Health
Massachusetts Association for Mental Health
Massachusetts Law Reform Institute
Massachusetts Medical Society
Massachusetts Public Health Association
Massachusetts Senior Action Council
Mass. Health & Hospital Association
Mass Home Care Association
John McDonough, Harvard T.H. Chan School of Public Health
MLPB
Northeast Independent Living Program, Inc.
Parent/Professional Advocacy League, Inc.
Project Bread
Public Health Institute of Western MA
Rosenfeld & Rafik, P.C.
Vinfen

View a PDF version of this letter here.