Public comments reveal concerns over Alaska 1115 Waiver

The federal public comment period for Alaska’s 1115 waiver closed over the weekend. While the comments submitted generally express support for the waiver, the majority also raise significant concerns with the waiver’s current form.

Concerns Previously Raised, Not Addressed

Alaska State Hospital and Nursing Home Association commented that it had already raised several concerns during the waiver development process, but that these concerns have not yet been heard.

“While we support the concept of the waiver, we have some concerns. We articulated these concerns during the stakeholder process that led to the waiver development however, no modifications in the application have been made, so we are resubmitting the same comments during the federal public comment process. Please find our concerns outlined in the attached document.”

ASHNHA outlines four main concerns with the waiver in its comments.

  1. The waiver is founded on the assumption that cost-neutrality can be achieved through reductions in acute services. We are concerned that this is not an accurate premise.
  2. The waiver does not fully address the integration of primary care and behavioral health.
  3. The state is making a significant shift from managing programs and grants to managing a contract with an Administrative Services Organization. These are very different skill sets and we are concerned about the state’s ability to effectively manage the contract.
  4. We also have questions about how reimbursement methodologies would change under an ASO contract.

The Alaska Behavioral Health Association criticized the lack of details available in the draft application:

“The application begins to fall short at the more detailed level. As was mentioned in our previous comment, the plan itself focuses largely on what it is that is hoped to be achieved and lacks critical details on how it might be achieved. Questions to this effect that have been put to the Department have been met with responses such as “This level of detail will be addressed through the waiver implementation plan.”

Administrative Services Organization (ASO)

Multiple Alaska Native organizations submitted near identical comments. For example, The Alaska Native Tribal Health Consortium says in its comments:

“While the Tribes articulated these concerns during the consultative process, it did not address the most critical tribal issues posed by the waiver, so we are resubmitting these comments during the federal public comment process. ANTHC is concerned that unless these changes are made in the waiver itself or in Standard Terms and Conditions, the ATHS and the AN/AIs it serves will not be able to take advantage of the services authorized under this demonstration waiver”

ANTHC, along with other AN/AI groups, raise multiple concerns, but the “most significant issue” is the Administrative Service Organization. ANTHC echoes ASHNHA’s concern over the state’s ability to manage the ASO contract.

ANTHC argues that Alaska Natives and American Indians must be exempt from mandatory enrollment in an ASO, while also ensuring that the ASO meets their managed care requirements should they choose to enroll. ANTHC is also concerns that the ASO “will impose additional service authorization and other administrative burdens” that prevents providers from seeing patients.

Eligibility Requirements

The Rural Alaska Community Action Program’s comments requested that housing services be included in the waiver and raised concerns over the current eligibility requirements. RulAL CAP requests that the eligibility criteria be expanded to include the federal definitions of physical disability and chronic homelessness.

Providence Health & Services also raised concerns over the eligibility requirements for Group 2: Transitional Age Youth and Adults with Acute Mental Health Needs. Currently, the eligibility criteria require a DSM-5 mental disorder and the utilization of three or more acute intensive services in the prior year.

Providence has three concerns with the proposed eligibility criteria:

  1. That it will actually encourage, rather than discourage, inappropriate use of intensive or emergency settings by transitional youth and adults during the period leading up to their becoming eligible for coverage, when those same individuals in many cases should be receiving their diagnosis and associated care in sub-acute care settings;
  2. That it will impede and delay access to behavioral health care for patients with severe mental health issues until they are experiencing a mental health crisis;
  3. That it is likely to result in severely mentally ill individuals never becoming eligible for coverage if they are not willing or able to travel to a location in which hospital and ED services are available on a repeated basis over the course of a year (a significant concern for most of Alaska, not limited to the villages).

Providence believes that “the criteria is inconsistent with federal requirements and past CMS guidance” and “the Group 2 utilization criteria is not consistent with state law.”

Treatment Options

The American Society of Addiction Medicine submitted comments that raised some concerns over specific language related to substance abuse treatment options included in the waiver.

“ASAM urges CMS to revise the recently issued state Medicaid director letter to clarify that Section 1115 demonstration applications should cover all FDA-approved agonist and antagonist medications for opioid use disorder (OUD) treatment. Treatment modalities work differently for each patient and these decisions should be made by doctors and their patients.”

ASAM also expressed concerns about the implications of preferred addiction treatment options and ensuring that payment for the new services reflect the time and expenses needed to provide SUD care.

The Mat-Su Health Foundation raised concerns over the proposed caps on the length of long-term residential services and the need to expand early intervention options, especially for children and adolescents.

“The shortening of long-term residential services is probably not in the best interest of building a complete continuum of care as some patients with SUD/MH problems will continue to require longer term residential treatment. This places tremendous emphasis on providing peer support and seeing to a person’s social needs in the community which may not be as well coordinated or funded in all areas of Alaska. Capping residential lengths of stay should only be done with respect to the other non-clinical conditions in a patient’s life that effect the clinical progress made while in treatment. Capping should also be contingent on the existence of the build-out of the outpatient supports in the region the individual lives in to support them when they are released after a shorter stay.”