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Appendix 1: Federal Waiver Evaluation Design

Federal Section 1115 Waiver Evaluation Plan
Domain Research Questions
Medicaid-supported Enrollment in Qualified Health Plans (QHPs) How do states supporting QHP enrollment for newly eligible beneficiaries compare to Medicaid expansion states in terms of access and health outcomes? Are beneficiaries enrolled in QHPs able to access care at similar or better rates, compared to beneficiaries enrolled in Medicaid?
Does provider participation improve under premium assistance?
What is the unmet need for medical care?
Is there continuity of coverage between Medicaid and Marketplace coverage?
How do states supporting QHP enrollment compare to Medicaid expansion states in terms of total spending, especially given premium variability over time with QHPs? How do premium assistance states compare to Medicaid expansion states in terms of per beneficiary spending on direct medical services and capitation payments?
How do premium assistance states compare in terms of states’ administrative costs?
How do states supporting QHP enrollment compare to Medicaid expansion states in terms of take-up rates? Does the take-up rate among likely eligible individuals suggest that premium assistance (i.e., enrollment in QHPs) is more attractive to beneficiaries than traditional Medicaid?
Are there patterns in the timing of Medicaid beneficiary enrollment that may be related to the Marketplace open enrollment period, even though Medicaid beneficiaries are not subject to open enrollment periods?
Beneficiary Engagement/Premium Incentive Structures and Other Financial Contributions To what extent do requirements for premiums act as a disincentive to enrollment? How does requirement to make premium payments to complete enrollment, as compared to following an initial period of enrollment, affect take-up of coverage?
How do the premium amounts affect take-up of coverage?
What effects do premiums appear to have on continuity of coverage? Do incentive programs that require premiums affect continuity of coverage?
What is the effect of premium enforceability rules, such as required time lapses (or “lock-out” periods) before reenrollment?
Beneficiary Engagement/Premium Incentive Structures What strategies are states using to educate beneficiaries about preferred healthy behaviors? What strategies are states using to explain incentives and disincentives? Which are perceived to be effective?
Conditional on qualitative information suggesting successful education strategies, or on survey or focus group data from state evaluations that explores beneficiary understanding, what is the effect of mode, content, and/or timing of education?
To what extent can program incentives encourage Medicaid enrollees to actively participate in their care without impairing access to needed care? To what extent can program incentives encourage Medicaid enrollees to actively participate in their care?
Do program incentives impair access to needed care?
Do incentives for wellness behaviors work? Which behavior incentives yield the greatest relative gains in preventive care?
Which behavior incentives yield the greatest relative gains in management and care of chronic conditions?
Which behavior incentives yield the greatest reductions in dis-incentivized care (i.e., non-emergent ED visits)?
What are the administrative costs to states and managed care companies of implementing incentive programs? What administrative costs do states with healthy behavior incentive programs incur to establish and maintain these programs? To what extent are costs borne by the state versus contracted health plans?
Link to Evaluation Design https://www.medicaid.gov/medicaid-chip-program-information/by-topics/waivers/1115/downloads/evaluation-design.pdf (Tables III.4, III.5, and III.6)

Appendix 2: State Waiver Evaluation Design Plans

Arkansas
# Goals Hypotheses*
1 HCIP beneficiaries will have equal or better access to health care compared with what they would have otherwise had in the Medicaid fee-for-service system over time. Premium Assistance beneficiaries will have equal or better access to care, including primary care and specialty physician networks and services.
Premium Assistance beneficiaries will have lower non emergent use of emergency room services.
Premium Assistance beneficiaries will have lower rates of potentially preventable emergency department and hospital admissions.
Premium Assistance beneficiaries who are young adults eligible for EPSDT benefits will have at least as satisfactory and appropriate access to these benefits.
Premium Assistance beneficiaries will have appropriate access to non-emergency transportation.
2 HCIP beneficiaries will have equal or better care and outcomes compared with what they would have otherwise had in the Medicaid fee-for-service system over time. Premium Assistance beneficiaries will have equal or better access to preventive care services.
Premium Assistance beneficiaries will report equal or better experience in the care provided.
Premium Assistance beneficiaries will have lower non-emergent use of emergency room services.
Premium Assistance beneficiaries will have lower rates of potentially preventable emergency department and hospital admissions.
3 HCIP beneficiaries will have better continuity of care compared with what they would have otherwise had in the Medicaid fee-for-service system over time. Premium Assistance beneficiaries will have fewer gaps in insurance coverage.
Premium Assistance beneficiaries will maintain continuous access to the same health plans, and will maintain continuous access to providers.
Maintenance of continuous access to the same providers.
4 Services provided to HCIP beneficiaries will prove to be cost effective. Premium Assistance beneficiaries, including those who become eligible for Exchange Marketplace coverage, will have fewer gaps in plan enrollment, improved continuity of care, and resultant lower administrative costs
Premium Assistance will reduce overall premium costs in the Exchange Marketplace and will increase quality of care.
The cost for covering Premium Assistance beneficiaries will be comparable to what the costs would have been for covering the same expansion group in Arkansas Medicaid fee-for-service in accordance with STC 68 on determining cost effectiveness and other requirements in the evaluation design as approved by CMS.
Link to Evaluation Design https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ar/Health-Care-Independence-Program-Private-Option/ar-private-option-demo-waiver-proposed-eval-02202014.pdf
* Research questions of interest identified in the development and approval process for the HCIP waiver include those examining the goals of improving access, improving care and outcomes, reducing churning, and lowering costs. The final waiver design collapses some of these hypotheses and identifies measures to assess the four main goals.
Indiana
# Goals Hypotheses
1 Reduce the number of uninsured low income Indiana residents and increase access to health care services. HIP will reduce the number of uninsured Indiana residents with income under 138% FPL over the course of the demonstration.
HIP will increase access to quality health care services among the target population.
POWER account contributions for individuals in the HIP Plus plan are affordable and do not create a barrier to health care access.

  • Few individuals will experience the lockout period because the policy will deter nonpayment of POWER account contributions policy for HIP Plus beneficiaries.
Presumptive eligibility and fast-track prepayments will provide the necessary coverage so as not to have gaps in health care coverage.
Waiver of non-emergency transportation to the non-pregnant and non-medically frail population does not pose a barrier to accessing care.
2 Promote value-based decision making and personal health responsibility. HIP policies will encourage member compliance with required contributions and provide incentives to actively manage POWER account funds, including:

  • HIP policies surrounding rollover and preventive care will encourage beneficiaries’ compliance with required contributions and provide incentives to actively manage POWER account funds.
HIP Plus members will exhibit more cost-conscious healthcare consumption behavior than: a) HIP Basic members; and b) traditional Hoosier Healthwise members in the areas of primary, specialty, and pharmacy service utilization without harming beneficiary health.
HIP’s (i) graduated copayments required for non-emergency use of the emergency department (ED), (ii) ED prior authorization process, and (iii) efforts to expand access to other urgent care settings will together effectively deter inappropriate ED utilization without harming beneficiary health.

  • The graduated copayment structure for non-emergency use of the emergency department will decrease inappropriate ED utilization without harming beneficiary health.
  • The prior authorization process for hospital emergency department use and efforts to expand access to other urgent care settings will decrease inappropriate ED utilization without harming beneficiary health.
3 Promote disease prevention and health promotion to achieve better health outcomes. HIP will effectively promote member use of preventive, primary, and chronic disease management care to achieve improved health outcomes.
4 Promote private market coverage and family coverage options to reduce network and provider fragmentation within families. HIP’s defined contribution premium assistance program (HIP Link) will increase the proportion of Indiana residents under 138% FPL covered by employer-sponsored insurance (ESI).
HIP’s ESI premium assistance option for family coverage will increase the number of low income families in which the parents and children have access to the same provider network.
5 Provide HIP members with opportunities to seek job training and stable employment to reduce dependence on public assistance. Referrals to Department of Workforce Development (DWD) employment resources at the time of application will increase member employment rates over the course of the demonstration.
6 Assure state fiscal responsibility and efficient management of the program. HIP will remain budget-neutral for both the federal and state governments.
Link to Evaluation Design https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-draft-eval-design-10292015.pdf
Iowa – Wellness Plan
# Goals Hypotheses
1 What are the effects of the Wellness Plan on member access to care? Wellness Plan members will have equal or greater access to primary care and specialty services.
Wellness Plan members will have equal or greater access to preventive care services.
Wellness Plan members will have equal or greater access to mental and behavioral health services.
Wellness Plan members will have equal or greater access to care, resulting in equal or lower use of emergency department services for non-emergent care.
Wellness Plan members without a non-emergency transportation benefit will have equal or lower barriers to care resulting from lack of transportation.
Wellness Plan members ages 19-20 years will have equal or greater access to EPSDT services.
2 What are the effects of the Wellness plan on member insurance coverage gaps and insurance service when their eligibility status changes (churning)? Wellness Plan members will experience equal or less churning.
Wellness Plan members will maintain continuous access to a regular source of care when their eligibility status changes.
3 What are the effects of the Wellness Plan on member quality of care? Wellness Plan members will have equal or better quality of care.
Wellness Plan members will have equal or lower rates of hospital admissions.
Wellness Plan members will report equal or greater satisfaction with the care provided.
4 What are the effects of the Wellness Plan on the costs of providing care? The cost for covering Wellness Plan members will be comparable to the predicted costs for covering the same expansion group in the Medicaid State Plan.
5 What are the effects of the premium incentive and copayment disincentive programs on Wellness Plan enrollees? The premium incentive for the Wellness Plan enrollees will not impact the ability to receive health care.
The copayment for inappropriate emergency department (ED) use for the Wellness Plan enrollees will not pose an access to care barrier.
In year two and beyond, the utilization of an annual exam will be higher than in the first year of the program.
In year two and beyond, the utilization of smoking cessation services will be higher than in the first year of the program.
6 What is the adequacy of the provider network for Wellness Plan enrollees as compared to those in the Iowa Medicaid State Plan? Iowa Wellness Plan members will have the same access to an adequate provider network as members in the Medicaid State Plan.
Link to Evaluation Design http://dhs.iowa.gov/sites/default/files/WellnessPlanEvaluationDesignApproval.pdf
Iowa – Healthy Behaviors Plan
# Goals Hypotheses
1 Which activities do members complete? The proportion of Wellness Plan (WP) and Marketplace Choice(MPC) members who complete a wellness exam is greater than the proportion of Medicaid State Plan (MSP) or IowaCare members.
The proportion of WP/MPC members who complete a Health Risk Assessment is greater than 50%.
The proportion of WP/MPC members who are eligible to participate and complete at least one behavior incentive is greater than 50%.
Members (WP/MPC) are most likely to complete the behaviors that require the least amount of effort.
Members (WP/MPC) will be least likely to complete incentivized behaviors requiring sustained enrollee participation.
Members (WP/MPC) will be most likely to complete incentivized behaviors with the largest real or perceived value.
2 What personal characteristics are predictive of completing at least one behavior incentive, and the number (or extent) of behavior incentives completed? Members (WP/MPC) who have heard of the program from their health care provider are more likely to complete at least 1 behavior.
Members (WP/MPC) who are young, white, female, and/or live in metro areas are more likely to complete at least 1 behavior.
Members (WP/MPC) with poorer health status are less likely to complete the behaviors when compared to members with better health status.
Members who do not pay a contribution (WP members less than 50% FPL) are less likely to complete behaviors compared to those who pay a contribution.
Members (WP/MPC) receiving care at federally qualified health centers, rural health clinics, and public hospitals will be more likely to participate in the incentive programs than members receiving care in other settings.
3 Is engaging in behavior incentives associated with health outcomes? The program will improve WP/MPC members’ access to health care.
Health outcomes of WP/MPC members will be positively impacted by completing the healthy behaviors.
4 What are the effects of the program on health care providers? Providers use the information from the Health Risk Assessment.
Providers are encouraging patients to participate in the behavior incentive program.
Providers are receiving their additional reimbursement.
Providers are more likely to use the HRA with Wellness Plan members compared to Marketplace Choice Plan members
The HRA changes communication between the provider and patient.
The HRA changes provider treatment plans.
There are barriers to providers using the HRA information.
5 What are the effects of HBI on Medicaid costs? The costs of the program do not exceed the savings.
6 What are the implications of disenrollment? Disenrolled members do not understand the disenrollment process.
Disenrolled members do not understand premiums.
Disenrolled members do not understand the HBI program.
Disenrolled members find it difficult to meet their health needs.
Disenrolled members are unable to re-enroll due to administration issues.
7 What are members’ knowledge and perceptions of the HBI program? Members (WP/MPC) will value incentives offered to complete healthy behaviors.
Members (WP/MPC) will be most willing to complete behaviors that have lower costs/barriers compared to those with higher benefits and relevance.
Members (WP/MPC) with a greater sense of locus of control will be more willing to participate.
Members (WP/MPC) understand the logistics (for example – payment, payment options, requirements of the program, …) of the HBI program.
Members (WP/MPC) understand the purpose of HBI and how it is supposed to influence their behavior.
Members (WP/MPC) do not report difficulties paying premiums related to payment form accepted by IME.
8 What are the experiences of ACOs related to the Health Behavior Incentives Program? ACOs experience barriers to reaching targets for wellness exams and HRA.
ACOs promote the HBI program.
ACOS experience advantages and successes from the HBI program.
Link to Evaluation Design http://dhs.iowa.gov/sites/default/files/HealthyBehaviorsEvalDesignApproval_042015.pdf
Iowa – Dental Wellness Plan
# Goals Hypotheses
1 What are the effects of DWP on member access to care? DWP members will have equal or greater access to dental care.
DWP members will be more likely to receive preventive dental care.
DWP members will have equal or greater access to care, resulting in equal or lower use of emergency department services for non-traumatic dental care.
DWP members will have equal or greater access to dental EPSDT services.
High risk populations in the Dental Wellness Plan will be more likely to receive preventive dental care.
2 What are the effects of the DWP on member quality of care? DWP members will have equal or better quality of care.
DWP members will report equal or greater satisfaction with the care provided.
DWP members will be equally or more likely to return for a second recall exam within 6-12 months.
3 What are the effects of the DWP on costs of dental care as compared to traditional Medicaid adult dental coverage? The cost for providing dental care to DWP members will be comparable to the

predicted costs for providing dental care to DWP members had they been enrolled in

Medicaid State Plan.

4 What are the effects of the earned benefit structure on DWP members? The earned benefit structure for DWP members will increase regular use of recall dental exams.
Over 50% of DWP members will earn access to Enhanced Benefits.
Over 50% of DWP members will earn access to Enhanced Plus Benefits.
In year two and beyond, the regular use of dental recall exams will be higher than in the first year of the program.
The earned benefit structure will not be seen as a barrier to care perceived as needed by DWP members.
5 What is the adequacy of the provider network for DWP members? DWP members will have better access to an adequate provider network than those in the Medicaid State Plan as reflected by travel distance and time, access to safety net providers, and provider acceptance of new patients.
6 What are provider attitudes towards the DWP? The earned benefit structure will not be perceived by DWP providers as a barrier to providing care.
Over 50% of DWP providers will remain in the plan for at least 3 years.
7 What are the effects of DWP member outreach and referral services? DWP member outreach services will address dentists’ concerns about missed appointments.
DWP member referral services will improve access to specialty care compared to members in the State Medicaid Plan.
DWP member outreach will improve members’ compliance with follow-up visits, including recall exams.
 Link to Evaluation Design http://dhs.iowa.gov/sites/default/files/DentalWellnessPlanEvaluationDesign_Sept2014.pdf
Michigan
# Goals Hypotheses
1 Uncompensated Care Analysis:

Uncompensated care in Michigan will decrease significantly.

Uncompensated care in Michigan will decrease significantly relative to the existing trend in Michigan.
Uncompensated care will decrease more by percentage for Michigan hospitals with baseline levels of uncompensated care that are above the average for the state than for hospitals with levels that are below the average for the state.
Uncompensated care will decrease more by percentage for Michigan hospitals in areas with above average baseline rates of uninsurance in the state than for hospitals with below state average levels
Uncompensated care in Michigan will decrease significantly relative to states that did not expand their Medicaid programs.
Trends in uncompensated care in Michigan will not differ significantly relative to other states that did expand their Medicaid programs.
2 Reduction in the Number of Uninsured:

The uninsured population in Michigan will decrease significantly.

The uninsured population in Michigan will decrease significantly relative to the existing trend within Michigan.
The uninsured population in Michigan will decrease more by percentage for subgroups with higher than average baseline rates of uninsurance in the state than for subgroups with lower than state average baseline rates.
The uninsured population in Michigan will decrease significantly relative to states that did not expand their Medicaid programs.
The uninsured population in Michigan will decrease to a similar degree relative to states that did expand their Medicaid programs.
Reduction in the Number of Uninsured:

Medicaid coverage in Michigan will increase significantly.

The Medicaid population in Michigan will increase significantly relative to the existing trend in Michigan.
The Medicaid population in Michigan will increase significantly more by percentage for subgroups with rates of uninsurance higher than state average baseline than for subgroups with baseline rate lower than the state average.
The Medicaid population in Michigan will increase significantly relative to states that did not expand their Medicaid programs.
The Medicaid population in Michigan will increase to a similar degree relative to states that did expand their Medicaid programs.
3 Impact on Healthy Behaviors and Health Outcomes:

Emergency Department Utilization

Emergency department utilization among the Healthy Michigan beneficiaries will decrease from the Year 1 baseline.
Healthy Michigan Plan beneficiaries who make regular primary care visits (at least once per year) will have lower adjusted rates of emergency department utilization compared to beneficiaries who do not have primary care visits.
Healthy Michigan Plan beneficiaries who agree to address at least one behavior change will have lower adjusted rates of emergency department utilization compared to beneficiaries who do not agree to address behavior change.
Impact on Healthy Behaviors and Health Outcomes:

Healthy Behaviors

Receipt of preventive health services among the Healthy Michigan Plan population will increase from the Year 1 baseline.
Healthy Michigan Plan beneficiaries who make regular primary care visits (at least once per year) will have higher rates of general preventive services compared to beneficiaries who do not have primary care visits.
Healthy Michigan Plan beneficiaries who complete an annual health risk assessment will have higher rates of preventive services compared to beneficiaries who do not complete a health risk assessment.
Healthy Michigan Plan beneficiaries who agree to address at least one behavior change will demonstrate improvement in self-reported health status compared to beneficiaries who do not agree to address behavior change.
Healthy Michigan Plan beneficiaries who receive incentives for healthy behaviors will have higher rates of preventive services compared to beneficiaries who do not receive such incentives.
Impact on Healthy Behaviors and Health Outcomes:

Hospital Admissions

Adjusted hospital admission rates for Healthy Michigan Plan beneficiaries will decrease from the Year 1 baseline.
Healthy Michigan Plan beneficiaries who make regular primary care visits (at least once per year) will have lower adjusted rates of hospital admissions compared to beneficiaries who do not have primary care visits.
Healthy Michigan Plan beneficiaries who agree to address at least one behavior change will have lower adjusted rates of hospital admission compared to beneficiaries who do not agree to address behavior change.
4 Participant Beneficiary Views of the Healthy Michigan Plan Describe Healthy Michigan Plan enrollees’ consumer behaviors and health insurance literacy, including knowledge and understanding about the Healthy Michigan Plan, their health plan, benefit coverage, and cost-sharing aspects of their plan.
Describe Healthy Michigan Plan enrollees’ self-reported changes in health status, health behaviors (including medication use), and facilitators and barriers to healthy behaviors (e.g. knowledge about health and health risks, engaged participation in care), and strategies that facilitate or challenge improvements in health behaviors.
Understand enrollee decisions about when, where and how to seek care, including decisions about emergency department utilization.
Describe primary care practitioners’ experiences with Healthy Michigan Plan beneficiaries, practice approaches and innovation adopted or planned in response to the Healthy Michigan Plan, and future plans regarding care of Healthy Michigan Plan patients.
5 Impact of Contribution Requirements & MI Health Accounts Cost-sharing implemented through the MI Health Account framework will be associated with beneficiaries making more efficient use of health care services, as measured by total costs of care over time relative to their initial year of enrollment, and relative to trends in the Healthy Michigan Plan’s population below 100% of the Federal Poverty Level that face similar service-specific cost-sharing requirements but not additional contributions towards the cost of their care.
Cost-sharing implemented through the MI Health Account framework will be associated with beneficiaries making more effective use of health care services relative to their initial year of enrollment, as indicated by a change in the mix of services from low-value (e.g., non-urgent emergency department visits, low priority office visits) to higher-value categories (e.g., emergency-only emergency department visits, high priority office visits), and relative to trends in the Healthy Michigan Plan’s population below 100% of the Federal Poverty Level that face similar service-specific cost-sharing requirements but not additional contributions towards the cost of their care. Several questions on the Healthy Michigan Voices Survey also address this hypothesis.
Cost-sharing and contributions implemented through the MI Health Account framework will not be associated with beneficiaries dropping their coverage through the Healthy Michigan Plan.
Exemptions from cost-sharing for specified services for chronic illnesses and rewards implemented through the MI Health Account framework for completing a health risk assessment with a primary care provider and agreeing to behavior changes will be associated with beneficiaries increasing their healthy behaviors and their engagement with healthcare decision-making relative to their initial year of enrollment. Several questions on the Healthy Michigan Voices Survey also address this hypothesis.
This increase in healthy behaviors and engagement will be associated with an improvement in enrollees’ health status over time, as measured by changes in elements of their health risk assessments and changes in receipt of recommended preventive care (e.g., flu shots, cancer screening) and adherence to prescribed medications for chronic disease (e.g., asthma controller medications).
Link to Evaluation Design http://www.michigan.gov/documents/mdhhs/
Healthy_Michigan_Plan_2nd_Waiver_STCs_12_17_15_508663_7.pdf
(Attachment B)
New Hampshire
# Goals Hypotheses
1 Continuity of coverage:

For individuals whose incomes fluctuate, the Demonstration will permit continuity of health plans and provider networks.

Premium assistance beneficiaries will have equal or fewer gaps in insurance coverage.
Premium assistance beneficiaries will maintain continuous access to the same health plans, and will maintain continuous access to providers.
2 Plan Variety:

The Demonstration could also encourage Medicaid Care Management carriers to offer QHPs in the Marketplace in order to retain Medicaid market share, and could encourage QHP carriers to seek Medicaid managed care contracts

Premium assistance beneficiaries, including those who become eligible for Exchange Marketplace coverage, will have equal or fewer gaps in plan enrollment, equal or improved continuity of care, and resultant equal or lower administrative costs.
The Demonstration could lead to an increase in plan variety by encouraging Medicaid Care Management carriers to offer QHPs in the Marketplace in order to retain Medicaid market share, and encouraging QHP carriers to seek Medicaid managed care contracts
3 Cost-effective Coverage:

The premium assistance approach will increase QHP enrollment and may result in greater economies of scale and competition among QHPs.

Premium assistance beneficiaries will have equal or lower non-emergent use of emergency room services.
Premium assistance beneficiaries will have equal or lower rates of potentially preventable emergency department and hospital admissions.
The cost for covering premium assistance beneficiaries will be comparable to what the costs would have been for covering the same expansion group in New Hampshire Medicaid in accordance with STC #69 on determining cost-effectiveness and other requirements in the evaluation design as approved by CMS.
4 Uniform Provider Access:

The State will evaluate access to primary, specialty, and behavioral health care services for beneficiaries in the Demonstration to determine if it is comparable to the access afforded to the general population in New Hampshire

Premium assistance beneficiaries will have equal or better access to care, including primary care and specialty physician networks and services.
Premium assistance beneficiaries will have equal or better access to preventive care services.
Premium assistance beneficiaries will report equal or better satisfaction in the care provided.
Premium assistance beneficiaries who are young adults eligible for EPSDT benefits will have at least as satisfactory and appropriate access to these benefits.
Premium assistance beneficiaries will have appropriate access to non-emergency transportation.
Link to Evaluation https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/nh/health-protection-program/nh-health-protection-program-premium-assistance-draft-eval-design-03042015.pdf
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