Medicaid waiver makes money available for housing, nutrition

$67b agreement also supports primary care, behavioral health

THE FEDERAL GOVERNMENT on Wednesday approved a five-year, $67 billion agreement with the state of Massachusetts that will govern how the state administers its Medicaid program.  

Gov. Charlie Baker said the so-called 1115 waiver is the primary way in which Massachusetts has historically been able to implement new, innovative programs within MassHealth, including paving the way for universal coverage. The latest agreement includes initiatives aimed at addressing social issues that affect health, like housing and nutrition, while also putting additional money into areas like primary care, behavioral health, and workforce training.  

“It includes many important features that will make a really big difference for people in Massachusetts going forward,” Baker said on a press call Wednesday with administrators from the Centers for Medicare & Medicaid Services. 

The last state Medicaid waiver was approved in 2017. The new one goes into effect October 1 and will last through December 2027. The full waiver approval runs for 394 pages. While waivers are typically approved after drawn-out negotiations between state and federal officials, Massachusetts may have had a leg up in getting this one passed: Massachusetts’ former Medicaid director Dan Tsai left state government in 2021 to accept an appointment by the Biden administration as deputy administrator for the Center for Medicaid and Medicaid Services.  

Tsai said the new initiatives in Massachusetts, as well as a waiver that was approved Wednesday in Oregon, are about “thinking about the whole person when it comes to care.” 

Tsai touted as “groundbreaking” provisions implemented by both states that will let a certain population of Medicaid recipients maintain continuous coverage for more than a year without having to renew their coverage. Typically, people must renew their Medicaid insurance coverage annually and have their eligibility reconfirmed. (That has been suspended during the COVID public health emergency.)  

Tsai said many people lose coverage at the renewal date not because they are ineligible but because they don’t get the notification letter or do not take steps to renew their coverage. The Massachusetts waiver will let people who are homeless maintain continuous coverage for 24 months without having to renew their coverage. 

“It’s a pretty big deal to be expanding continuous eligibility beyond 12 months,” Tsai said on the call. 

MassHealth members recently released from correctional facilities will get 12 months of continuous coverage without having to prove that they remain eligible.  

Another new approval included in the waiver will let the state use MassHealth money to incorporate social supports into the services it provides MassHealth recipients. Social supports could include food assistance and medically tailored meals or various types of housing support. The benefits will be tailored to certain vulnerable populations, including post-partum women 12 months after giving birth, children, and pregnant women. Money can also be used for transition support for individuals on MassHealth who are released from incarceration. 

CMS Administrator Chiquita Brooks-LaSure said the approval will let Massachusetts partner with community-based providers “to address the root social causes of health concerns, like lack of access to nutritious food and housing insecurity.” Brooks-LaSure said the Biden administration is supporting these initiatives as a way to take a “whole person approach” toward health care, acknowledging that social factors like nutrition and housing play a major role in keeping people healthy.  

The approval, signed by Brooks-LaSure, explains the reasons to expand MassHealth to cover things like housing and nutrition: “housing instability or inadequate nutrition may impede an individual’s ability to enroll in coverage and access needed health care. Such circumstances may create physical, social ,or emotional conditions that are counterproductive to the otherwise positive effects of the health care services an individual does receive, including through Medicaid.” 

Another major piece of the waiver is the authorization of $43 million over five years for loan repayment and residency training programs for behavioral health clinicians who will serve Medicaid patients. Baker said one of the biggest reasons people have trouble getting mental health appointments today is a lack of clinicians in the field – which comes back to a lack of funding for clinicians.  

One of the biggest challenges we have in behavioral health is we haven’t funded it adequately for a long time,” Baker said. The waiver provides money for the Baker administration’s behavioral health roadmap, a plan that the state is currently implementing to increase the availability of behavioral health care services. 

There will be $115 million a year going into primary care, which Baker said will help the state expand the delivery system for primary care through a system that rewards team-based, high-value health care.  

There will be programs focused on improving the quality of care and ensuring equity within primary care delivery. A $2 billion, five-year initiative will hold private hospital systems accountable for reducing disparities in health care quality and access, including in maternal health. 

The waiver expands a Medicare Savings Program, which lowers the out-of-pocket cost for prescription drugs for people eligible for both Medicare and Medicaid. It will become easier to enroll in MassHealth for adults with disabilities and pregnant individuals and children. 

It also includes a new version of an assessment on hospitals, which the Baker administration, Legislature, and state hospitals had previously agreed upon, that is expected to yield federal matching funds and result in an annual $600 million windfall for hospitals, primarily those that serve low-income patients. The assessment is basically a tax that hits hardest on wealthier hospitals, where the money raised is matched by the federal government, then returned to hospitals, with a focus on community hospitals that care for poorer patients. 

Tim Foley, executive vice president of the healthcare workers union 1199SEIU, praised the agreement for the new assessment system and the additional money for housing support and equity programs. “These essential reforms ensure that the MassHealth 1115 waiver helps reduce health disparities and addresses social determinants of health,” Foley said in a statement.  

The announcement that the US government was approving the waivers for Massachusetts and Oregon was timed to coincide with President Biden’s conference on hunger, and administration officials played up the fact that the waivers will let both states provide nutrition support using health care money. 

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Shira Schoenberg

Reporter, CommonWealth

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

About Shira Schoenberg

Shira Schoenberg is a reporter at CommonWealth magazine. Shira previously worked for more than seven years at the Springfield Republican/MassLive.com where she covered state politics and elections, covering topics as diverse as the launch of the legal marijuana industry, problems with the state's foster care system and the elections of U.S. Sen. Elizabeth Warren and Gov. Charlie Baker. Shira won the Massachusetts Bar Association's 2018 award for Excellence in Legal Journalism and has had several stories win awards from the New England Newspaper and Press Association. Shira covered the 2012 New Hampshire presidential primary for the Boston Globe. Before that, she worked for the Concord (N.H.) Monitor, where she wrote about state government, City Hall and Barack Obama's 2008 New Hampshire primary campaign. Shira holds a master's degree from Columbia University's Graduate School of Journalism.

“This is an historic moment in our nation’s fight to end hunger and improve health equity, particularly in states like Oregon and Massachusetts,” said HHS Secretary Xavier Becerra in a statement. “Groundbreaking action in each state will ensure children and youth remain connected to health care, and that we double down on tackling social needs impacting health, such as nutrition.”  

House Ways and Means chairman Richard Neal, a Springfield Democrat, said in a statement that the waiver will let providers “continue to reimagine and improve care, particularly in the behavioral health area” and will help providers “address the short and long-term physical and mental health impacts of the COVID pandemic and the health inequities it unearthed.”