CMS Approves WA’s 1115 Waiver with Health-Related Social Needs & Justice-Involved Initiatives

Health Highlights

On June 30, 2023, the Centers for Medicare & Medicaid Services (CMS) approved Washington’s five-year Section 1115 demonstration renewal, the Medicaid Transformation Project 2.0 (MTP 2.0 or Demonstration). Through its renewed and expanded Apple Health Demonstration, Washington State seeks to advance the following goals:

  • Expand coverage and access to care, ensuring that people can get the care they need.
  • Advance whole-person primary, preventive and home- and community-based care.
  • Accelerate care delivery and payment innovation, focused on health-related social needs (HRSNs).

The Demonstration, which is effective from July 1, 2023, through June 30, 2028, builds on long-standing programs from Washington’s prior Medicaid Transformation Project demonstration and introduces new programs and innovations, including:

  • HRSN services. Washington joins a cadre of states—including New Jersey, Arizona, Massachusetts and Oregon—with federal authority and funding to cover HRSN services under CMS’ new HRSN policy framework. Washington will offer an array of evidence-based services across the Medicaid fee-for-service and managed care delivery systems. Covered services include nutrition supports such as medically tailored meals and nutrition counseling, housing supports including up to six months’ rent for qualifying individuals and case management services. Washington will be permitted to spend up to $1.5 billion over the five-year Demonstration on HRSN services and up to $270 million to fund infrastructure-building activities to support HRSN service capacity in the state.

    Washington plans to offer HRSN services under MTP 2.0 alongside a set of in lieu of services and supports (ILOS) for its managed care-enrolled populations. All Apple Health enrollees, regardless of the delivery system in which they are enrolled, will have access to an aligned array of HRSN services as a result of Washington’s reliance on both Demonstration and ILOS authorities.
  • Community Hubs and a Native Hub. To coordinate HRSN service delivery, Washington will develop new Community Hubs and a Native Hub that will provide case management, outreach and education services to individuals enrolled in Medicaid and support HRSN administration throughout the state. Community Hubs will be run by nine regional Accountable Communities of Health—entities in Washington that have closely partnered with the state and with communities to advance Medicaid transformation priorities to date, including through the original Medicaid Transformation Project demonstration. The Native Hub will, in parallel, offer services statewide in close coordination and engagement with Washington tribes.
  • Prerelease services for justice-involved individuals. Washington is the second state to receive CMS approval to operate a justice-involved initiative, which will provide a targeted set of Medicaid services to youth and adults in state prisons, county and city jails and youth correctional facilities up to 90 days before release. Earlier this year, CMS issued guidance on how states can design Section 1115 demonstrations to provide services to justice-involved individuals prior to release to support their reentry into the community, following approval of a first-in-the-nation program in California. Washington will test and evaluate the impact on health outcomes and coverage of providing prerelease services and will, alongside California, serve as a model for other states seeking to implement similar programs (14 states have justice-involved reentry demonstration requests pending before CMS).1
  • Contingency management services. Washington State will expand its successful contingency management services pilot through the Demonstration. Contingency management is an evidence-based treatment for substance use disorders that provides incentives to beneficiaries for nonuse of substances. CMS first approved coverage of contingency management in California’s Section 1115 demonstration in 2021 and is now approving a similar program in Washington.
  • Continuous postpartum and children’s coverage. Under the American Rescue Plan, Washington has taken up the option to provide 12 months of continuous coverage for postpartum individuals who were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) while pregnant. Under MTP 2.0, Washington will also provide 12 months of continuous coverage to postpartum individuals who were not enrolled in Medicaid or CHIP while pregnant (i.e., for individuals who enroll in Medicaid and CHIP during the postpartum period), with incomes of up to 193 percent of the federal poverty level. CMS declined to approve Washington’s proposal to provide postpartum coverage for undocumented people through the Demonstration; however, Washington plans to leverage state funding to provide postpartum coverage to individuals who are not U.S. citizens. Additionally, MTP 2.0 extends Washington’s approval from earlier this year for an additional five years to cover children in families with incomes below 215 percent of the federal poverty level until their 6th birthday.
  • Presumptive eligibility for home- and community-based supports (HCBS). To allow more timely access to HCBS, CMS is permitting Washington to implement a presumptive eligibility process whereby individuals who need access to HCBS under Medicaid State Plan and Section 1915(c) authorities may self-attest to meeting financial and functional eligibility requirements to begin receiving a limited set of services, pending a formal application decision.

In addition to these new initiatives, MTP 2.0 continues several programs previously implemented under Washington’s original Medicaid Transformation Project demonstration, such as long-term services and supports programs, including for individuals not yet eligible for Medicaid (with modest benefit and eligibility modifications from the prior waiver); the ability to offer treatment for substance use disorder and serious mental illness in institution for mental diseases (IMD) settings; and a housing and employment supports program.

CMS has not yet approved several of Washington’s demonstration proposals and has pended them for further discussion. These include expenditure authority for community-based projects to advance health equity, reentry services for those being discharged from state hospitals and IMDs and rental subsidies for targeted populations beyond the six-month time frame approved in this waiver. CMS also pended Washington’s request to leverage Designated State Health Programs (DSHP) funding to support new MTP 2.0 initiatives.

With the approval of MTP 2.0, Washington becomes one of the first states to pilot several new Medicaid innovations, from covering HRSN services and contingency management to implementing a justice-involved initiative and establishing “Hubs” for community-based care coordination. As Washington begins to implement the Demonstration, it will serve as a model for states looking to implement similar demonstration programs and integrate lessons learned from Washington.

1 The states are Arizona, Illinois, Kentucky, Massachusetts, Montana, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Utah, Vermont and West Virginia.



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