Washington

Current Updates (as of 8/3/2021)

Past Updates

State Demonstration to Integrate Care for Dual Eligible Individuals

(Managed Fee-For-Service Model & Capitated Model)

HealthPath Washington (formerly Pathways to Health), Washington State’s Medicare & Medicaid Integration Project, proposes to realign and integrate care through three strategies: 1. Health Homes (managed fee-for-service financial model); 2. Full Financial Integration Capitation (three-way capitation financial model); and 3. Modernized and Consolidated Service Delivery with Shared Outcomes and Aligned Financial Incentives (capitation and fee-for-service). The project’s target population is full benefit Medicare-Medicaid enrollees of all ages.

Strategy 1: Health Homes (Managed Fee-For-Service Model) Approved (10/25/2012)

On October 25, 2012, CMS approved the first strategy in the state’s Financial Alignment demonstration proposal. According to the Memorandum of Understanding, the state would implement this Managed Fee-for-Service Financial Alignment Demonstration on April 1, 2013. The Washington Health Care Authority Department of Social and Health Services later said the state will introduce Health Homes on July 1, 2013. (Source: Financial Alignment Demonstrations for Dual Eligible Beneficiaries Compared: California, Illinois, Massachusetts, Ohio, and Washington, Kaiser Commission on Medicaid and the Uninsured, May 2013; Washington Health Care Authority website)

Under the demonstration, eligible Medicare-Medicaid enrollees elect to receive health home services from Health Home Care Coordinators, supplemented by multidisciplinary teams that coordinate across disciplines, including primary, acute, prescription drugs, behavioral health, and long-term services and supports (LTSS). Health home services include: comprehensive care management; care coordination and health promotion; comprehensive transitional care; individual and family supports; referral to community and social support services; and the use of a web-based clinical decision support tool (PRISM) and other health information technology to improve communication and coordination of services. The geographic area for this Demonstration encompasses all counties in the state, with the exception of any counties in which the state receives approval from CMS to implement a capitated Financial Alignment Demonstration (Strategy 2). At this time, the exceptions include King, Snohomish, and Whatcom counties. If the state no longer seeks to implement a capitated model in any of the three counties, Washington may expand this Demonstration to those additional counties beginning by November 1, 2013, at the latest. (Source: Memorandum of Understanding)
Memorandum of Understanding (10/24/2012)
Addendum to Demonstration Proposal
Washington Managed FFS Model Final Demonstration Agreement (6/28/13)

Strategy 2: Full Integration Capitation (Three Way Contract between Health Plan/State/CMS)
MOU Signed (11/25/2013)

HealthPath Washington is Strategy 2 Financial Alignment Demonstration; this strategy will use a full-risk managed care model of health delivery that coordinates Medicare and Medicaid medical services, behavioral health services, and long-term services and supports. The Demonstration will be available to adults and children of King County and Snohomish County who are eligible for both Medicare and Medicaid, and for whom the state has a responsibility for payment of cost sharing obligations under the Washington State Plan.

Beneficiaries may not be concurrently enrolled in the Demonstration and a Medicare Advantage Plan, the Program of All-inclusive Care for the Elderly (PACE), or a Medicare Hospice Program. Beneficiaries may participate in and are eligible for enrollment in the Demonstration if they voluntarily dis-enroll from their existing programs. Beneficiaries who are on the Medicaid Fee-for-Service delivery system and the Medicare Fee-for-Service delivery system and are receiving Medicare ESRD benefits may also voluntarily enroll in the Demonstration.

At a future date, subject to additional discussions with CMS and other interested parties, Washington may also include beneficiaries receiving developmental disabilities §1915(c) home and community-based waiver services. If this population is included, the Medicare-Medicaid Integrated (MMI) Plans (managed care plans) will be responsible for services specified in the negotiated 3-way contract.

The capitated demonstration is currently scheduled to begin with opt-in enrollment commencing on October 1, 2014 and passive enrollment starting in January 2015. (Source: Washington State Health Care Authority Request For Application (RFA) NO. 2013-003, revised April 17, 2013, CMS Washington State Financial Alignment Initiative Website, July 2014)
HealthPath Washington project website
HealthPath Washington Medicaid Health Homes Website
HealthPath Washington Medicaid Health Homes Presentation, link no longer available (6/21/2012)

In November 2013, CMS and the state signed a Memorandum of Understanding for the state’s capitated model demonstration proposal. (Source: CMS Demonstration Approvals website; Kaiser Family Foundation Duals Demonstration Proposal Status Map, March 2014; NSCLC Dual Eligible State Profiles website, March 2014)
Memorandum of Understanding (11/25/2013)
Washington Capitation Readiness Review Tool (12/27/2013)
Washington Health Care Innovation Plan, link no longer available (12/2013)

In mid-September, 2014, the state announced it is delaying implementation of the HealthPathWashington program until July 2015 due to bidder dropout.  (Source:  Business Examiner website,  9/18/2014)

On February 3, 2015, the state announced that it was not moving forward with its capitated financial demonstration in King and Snohomish Counties (covering Seattle and Everett, Washington) after the withdrawal of one of its two participating health plans, Community Health Plan of Washington. CMS has required that dual eligible individuals have a choice of at least two health plans, so with one plan, Washington could not move forward.   (Source: Washington Health Care Authority Press Release, 2/2015​)

On January 22, 2016, Modern Healthcare reported on Washington's Health Home Program, which is a managed fee-for-service initiative that aims to better integrte care for dually eligible individuals, or those jointly eligible for Medicare and Medicaid. Health homes in the state act as a focal point for coordinating acute, behavioral, primary care and long-term services and supports (LTSS) for beneficiaries. Over the period of July 2013-December 2104 the initiative accrued over $21 million in savings to the Medicare program, which are detailed in a report from RTI International, the evaluator for the CMS coordinated care demonstrations. A follow-up report will be conduncted by RTI International on the potential savings achieved for the state's Medicaid program.  (Source: RTI Report 1/4/2016; Modern Healthcare 1/22/2016)

On March 29, 2016, the Washington State Hospital Association noted the State House and Senate’s compromise on a supplemental budget that invests in a number of health care priorities. Included in the budget are $3.9 million in state and $4 million federal funds to expand the state’s Health Homes program for high-risk individuals that are jointly eligible for Medicare and Medicaid. (Source: WA State Hosp. Assoc. 3/29/2016)  

On July 13, 2017, RTI International released a report produced for CMS on Washington State’s managed fee-for-service dual eligible financial alignment demonstration. The report contains substantial data on the first demonstration period of the program, from July 1, 2013, through December 31, 2014, and preliminary data on the second demonstration period, which ran January 1 through December 31, 2015. The authors note that this report only contains estimated savings to the Medicare program due to insufficient Medicaid data at this time. The report estimates a total of $34.9 million in savings for demonstration period one, and $32.1 million for demonstration period two, for a total savings to Medicare of $67 million. (Source: RTI Report 7/13/2017)

CMS recently published a report summarizing the final Medicare Parts A & B savings estimates from the Washington health home managed fee-for-service (MFFS) demonstration. The report includes final analysis from 2015 and a preliminary analysis of savings for 2016. The Washington Health Home MFFS demonstration leverages Medicaid health homes, established under Section 2703 of the Affordable Care Act, to integrate care for full-benefit MedicareMedicaid beneficiaries. This demonstration aims to improve service quality and integration while reducing costs of care for high-risk, high-cost dually eligible beneficiaries.

In 2015, Washington demonstrated a final gross Medicare savings of $30 million. The preliminary gross Medicare savings for 2016 are $42 million.

Sources: Full Analysis of Washington’s Demonstration (11-16-2018); CMS Blog Post (11-16- 2018).

LTSS Program

On July 23, 2015, the State of Washington announced it is seeking a Section 1115 Waiver to reform its Medicaid program, known as Apple Health. Initiative 2 of the program adds two additional limited benefits packages that aim to target LTSS services to those most at risk of using intensive care. The first package is called Medicaid Alternative Care (MAC), and is targeted toward family caregivers. The second is Tailored Supports for Older Adults (TSOA), which adds a new eligibility category in addition to being a limited benefits package for those individuals most at risk of having to use Medicaid LTSS but do not, at that moment, meet the Medicaid financial eligibility levels. Washington’s proposal adds to a short, but growing, list of states that are interested in providing more limited HCBS to the pre-nursing home level of care population in order to prevent more costly LTSS in the future. (Source: WA.gov, 7/23/2015) 

On January 9, 2017, the Washington State Health Care Authority (HCA) announced it has received official approval of its section 1115 waiver application from CMS. The waiver, which has been detailed in previous editions of the State Medicaid Integration Tracker©, includes $1.1 billion in DSRIP funding, the implementation of Accountable Communities of Health, and a number of changes to broaden HCBS services for older adults and persons with disabilities aimed to prevent or delay institutionalization. (Source: WA.gov 1/9/2017)

CMS released a third evaluation report of Washington’s Managed Fee-for-Service Financial Alignment Initiative (FAI), which uses a health home model. The evaluation describes how the program is implemented and changes made to the program’s structure, beneficiary experience with the health homes, and cost savings. Highlights from the evaluations include: the program decreased beneficiaries’ use of institutional care; participants in the program self-reported an improvement in their health and/or quality of life in the past 3 years; and 87 percent of respondents to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey were satisfied or very satisfied with care coordination.

(Source:  FAI Washington Health Home MFFS Demonstration Third Evaluation Report; 9-24-2019)

CMS recently published a report summarizing the final Medicare savings estimates from the Washington’s Managed Fee-for-Service Financial Alignment Initiative (FAI), which uses a health home model. The report includes final analysis from 2016 and a preliminary analysis of savings for 2017.

In 2016, Washington demonstrated a final gross Medicare savings of $38.8 million. The preliminary gross Medicare savings for 2016 are $46.5 million.

(Source:  Washington Health Homes MFFS Medicare Savings Report; 9-24-2019)

Section 1915(i) HCBS State Plan Option (Withdrawn)

Washington submitted a proposed §1915(i) HCBS State Plan Amendment to CMS; however, the state later withdrew its proposed SPA. (Source: Kaiser HCBS State Plan Option website, 5/2014)

Section 1915(k) Community First Choice Option

In Engrossed Substitute House Bill 2746 and Substitute Senate Bill 6387, the 2014 Washington State Legislature directed the Department of Social and Health Services (DSHS) to seek stakeholder input on program and system design for CFCO.  The CFCO entitlement program is intended to refinance personal care services offered through state plan and waiver programs.  DSHS intends to fully implement CFCO no later than August 30, 2015.  (Source:  State CFCO website)

On March 18, 2015, the state officially submitted a Section 1915(k) Community First Choice Option SPA to CMS for approval.  (Source:  Kaiser Community First Choice website, 3/2015; State ALTSA website)

Health Homes

Effective July 1, 2013, CMS approved the state’s first Health Home State Plan Amendment. The Health Home will target Medicaid recipients in 37 of 39 counties who have select chronic conditions and at greater risk for costly and poorly coordinated health care services. The state plans a second strategic approach for the remaining two counties; which the state will begin in 2014. (Source: Health Homes News Release, link no longer available 6/28/2013)
State Website on Health Homes
Health Homes Updated Fact Sheet, link no longer available (6/8/2013)
Washington Health Home State Plan Amendment, link no longer available (Effective 7/1/2013)

In December 2013, CMS approved the state’s second Health Home State Plan Amendment, effective October 1, 2013. The Health Home will target Medicaid recipients with two or more chronic conditions; one chronic condition and the risk of developing another; or one serious and persistent mental health condition. (Source: CMS Health Home Proposal Status website, 2/2014; Medicaid.gov website)
CMS Approval Letter (12/11/2013)
Approved Health Home State Plan Amendment (Effective 10/1/2013)