Recommendations to improve our 1115 Behavioral Health Transformation Waiver:
What’s an 1115 waiver?
Recently, the state proposed an ambitious plan to transform the Medicaid behavioral health system in Illinois. As part of its plan, the state proposes to use an 1115 waiver which would allow certain federal rules to be used so that federal funds could be used in ways that are otherwise not allowed. The catch is that the state must keep all efforts budget neutral for the federal government meaning that services provided have to be equal to what the feds would have spent within the state without the waiver.
The state plans to use both the 1115 waiver and state plan amendments to realize its transformation plan
As a reminder, Medicaid is paid for jointly by both federal and state funding. Illinois has proposed several things within this waiver, some of which will be allowed through the waiver, and others that will be included in state plan amendments. State Plan amendments are used to change program policies, benefits, or operational approaches of the Medicaid State Plan for Illinois. 1115 waivers and state plan amendments both change the way that Medicaid is delivered, but there is a significant difference between the two. The 1115 waiver is a demonstration that will last five years and allow the state to try new ideas within Medicaid that are not necessarily permanent, and can target certain populations. By contrast, the state plan amendment codifies (into law) Medicaid services that apply across the State. The 1115 waiver and state plan amendments will be used together to transform the Medicaid Behavioral Health delivery system.
Expanded benefits and new initiatives
The long-term vision for Illinois’ behavioral health system as articulated in the Behavioral Health Transformation 1115 waiver draft deserves applause. It includes a commitment to addressing social determinants of health, and expanding the Medicaid benefit package for people with serious mental illness and substance use disorders.
Expanded benefits proposed in the draft waiver include supported employment services and pre-tenancy supportive housing services, and new initiatives such as loan forgiveness and training for providers, integrated behavioral health homes, and expanded use of telemedicine. There’s even more, if you would like to read the draft yourself.
Recommendations for the transformation of the behavioral health system in Illinois
With any great system transformation, we need to contend with the realities of the short term. In order to implement many of the benefits and initiatives proposed in this waiver, we need to address systemic capacity, clarify roles of payers and providers, as well as improve infrastructure and accountability.
Invest in Mental Health Workforce and Infrastructure
Illinois would be wise to use the waiver to make much needed strategic investments in workforce and infrastructure in the short and long term. In order to enhance access to services and reduce unnecessary expenditures, prioritizing the assessment and diagnosis of mental illness and substance use disorders outside of the Emergency Department, the most expensive entry point to the health system, is paramount. Assessment and diagnosis should happen in community and outpatient settings. Because eligibility for services proposed in the waiver is closely tied to diagnoses, Illinois’ workforce challenges must be adequately addressed. Without much needed workforce improvements, the work simply can’t be done, and Illinois will fail to take full advantage of services promised through the proposed waiver.
Further, while the services are critical to proposed cost savings, Illinois needs enough providers, who are paid enough to cover their costs. This is not the current reality. Illinois needs rate reform for behavioral health providers, as well as reform to allow providers to work at the top of their license. Loan forgiveness and training, as described in the 1115 waiver draft, by themselves, are simply not enough. Though the waiver does reference expanding telehealth, which will likely help increase access to care, adequate rates are still needed to pay a provider on the other end of the screen.
The state should incorporate Medicaid infrastructure dollars to allow providers to keep pace, build capacity to bill, contract, and hire to provide services. We need to make sure that providers are sufficiently armed to do what is expected and best within their roles by investing in the infrastructure of the behavioral health system.
Clarify Roles of Providers and Payers
The waiver as drafted needs greater clarity on the roles of Managed Care Organizations vs. the roles of providers. As currently crafted, it appears the State is outsourcing a good deal of responsibility to MCOs and that Managed Care Organizations will be expected to implement service delivery. But the problem is that MCOs are payers, not providers. When the waiver addresses implementation of health homes and subsequent creation of a state plan amendment, providers and other stakeholders must be at the forefront of designing them. We don’t call our MCO when we need care, we call our doctor because that’s where the expertise lies.
Establish an Illinois Behavioral Health Transformation Team
In line with providing greater clarity of roles, the State needs to remain accountable for service delivery. The State should establish an Illinois Behavioral Health Transformation Team, comprised of stakeholders representing providers, advocates, and consumers, to provide guidance on the implementation of the waiver. With our state at a crossroads, operating with limited resources, taking advantage of the time and expertise of smart, dedicated, caring providers, advocates, and consumers, can help to shape the long-term transformation envisioned within this demonstration waiver. Advocates and others stand ready to help.
This waiver proposal contains several promising elements, but more is needed. The State must have a commitment to:
- Increase capacity in the short term with Medicaid infrastructure investments and rate reform
- Clarify roles - to make sure the right people are doing what they are best suited to do
- Create responsive mechanisms for accountability
Without this, all the good ideas within this proposal will lack the critical support necessary to transform our behavioral health system for the better.
Associate Director, Strategic Health Initiatives
Health & Disability Advocates