Form 1 State medicaid Agency Groups

Evaluating the Impact of 1115 Medicaid Waivers

on Ryan White HIV/AIDS Program and Its Clients and Providers

Discussion Guide

State Medicaid Agency Staff

Step 1: Welcome and Introduce Participants

Convene the group (if applicable), welcome everyone, and ask participants and JSI staff to introduce themselves.

Step 2: Read Introductory Script (below)

“Thank you for joining us today for this discussion. Before we begin, I have some important information that I need to share with you. I will then answer any questions you have, and then we will start the discussion.

“The US Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau has asked John Snow, Inc. to study the implementation of 1115 Medicaid waivers that have expanded Medicaid eligibility for people living with HIV/AIDS (PLWH). These waivers are part of Section 1115 of the Social Security Act that allows states to develop, test, and implement new approaches to providing Medicaid coverage outside of federal program rules, leading up to full implementation of the Affordable Care Act.

“The purpose of our discussion today is to learn more about the waiver in place here in [SAY STATE, or COUNTY NAME]. The case study is not an evaluation of your program/agency, but a study to learn more about the waivers in practice. The goal is to understand how Medicaid expansion and the 1115 Medicaid waivers will affect the Ryan White HIV/AIDS Program (hereafter, Ryan White Program) as well as PLWH, and how the waivers have prepared states for implementation of the Affordable Care Act.

“Specifically, we hope to learn more about your experience with the waiver process, from application to implementation, and practice. We would like to hear about any notable successes or challenges [SAY STATE, CITY, or COUNTY NAME] had as well as anything that you think could have been done differently. We will be holding similar discussion groups with Medicaid and Ryan White Program staff in a total of eight states that have implemented these waivers.

“Participation in this study, including taking part in today’s discussion, is completely voluntary and will not affect your relationship with any federal funder. Any information that you share with us today will not be attributed to you by name. However, the final report will include the names of all individuals who participated in this study, and may include examples of the waivers’ impact in specific locations.

“As facilitator, I have a series of questions that I want to cover with you. A similar set of questions will be asked in each discussion group with Medicaid and Ryan White Program staff. These questions are the same at each of the eight sites we will be visiting across the country. Please note that for any question in which we refer to the 1115 Medicaid waiver, we are primarily interested in how it relates to PLWH and Ryan White Programs, not in the overall waiver or broader populations affected.

“It is possible that during our conversation, we will cover many of the questions without prompting; in other cases, we may need to ask you more pointed questions or probes. We encourage you to share your thoughts and opinions openly and freely, but we also ask that you be respectful of the other participants’ opinions and time. At no time should you feel you have to answer a question.

“We will be taking notes and recording this discussion to help ensure that we gather all of the information you share with us. The recording will only be used by staff to ensure that our notes are accurate and compete. We are not recording your names.

“We anticipate that our discussion will last no longer than two hours. If you feel uncomfortable or decide you no longer want to participate, you may leave at any time.

“The results of this discussion and others held at here in [SAY STATE, CITY, or COUNTY NAME] will be used to develop individual case studies for each jurisdiction. All case studies will then be analyzed as a group. A final report will be prepared that identifies key themes across the sites, unique challenges and successes, and any lessons learned that could affect the Affordable Care Act implementation as well as help to understand how Medicaid expansion will affect RWHAP and PLWH in the future.

“Before we begin, are there any questions about what I’ve said, why we’re here, or what we are going to do?”

Step 3: Answer Questions from Participants

Step 4: Obtain Consent to Record

“Does anyone have any objections to us recording the conversation? If not, I’ll turn on the digital recorder.”

Step 5: Turn on the Recorder

Step 6: Confirm Consent to Participate

“Based on what you’ve heard so far, I want to confirm that each of you consents to participate in today’s discussion. Please say “YES” if you understand and wish to participate.”

Step 7: Begin Discussion with Questions on the Next Page

Note: Questions in italics may be part of pre-interview data collection process. If not, begin with Question #1.

Discussion Questions

1. What eligibility categories enabled adults with HIV to enroll in Medicaid prior to the waiver?

2. What services are covered by Medicaid under the state plan across eligibility categories?

2.1. Are there any differences in coverage across eligibility or programs?

2.2. How do the services covered now under the waiver differ from the state plan services covered?

3. Explain any other financing or coverage differences between the state plan services and waiver services such as cost-sharing (co-pays, deductibles) or service limitations (dollar or visit limits).

4. Is the waiver program administered by capitated health plans or entities that accept global payment (i.e., managed care)? If yes, please describe.

5. Are there any differences in access to specific health care providers or plans for people who receive services under the waiver as compared to those who receive state plan services (e.g. are services provided by different health plans, different provider networks within the plans, or different fee-for-service providers if plans are not involved)?

6. Has the State received feedback as to whether these changes are perceived as introducing limitations or improvements? If so, what are the key limitations or improvements noted?

7. How is/was outreach to expansion populations conducted, specifically to people living with HIV?

8. How many PLWH were enrolled in Medicaid pre- and post-implementation of the 1115 waiver?

9. In developing this waiver (and implementing other major Medicaid changes) how did the Medicaid office involve other agency and state program stakeholders (e.g., state HIV/AIDS office)? What, if any, interaction was there with Part A, B, C grantees in design and implementation?

10. How familiar are you with the Ryan White Program-funded services in your state?

11. What HIV quality measures and performance standards are incorporated into the state’s fee-for-service quality measures and Medicaid managed care contract requirements?

12. How is your state evaluating the impact of the waiver program?

13. Has your state made plans to either continue the waiver or to expand Medicaid under the new ACA eligibility group in 2014?

14. What would you do differently if you were to implement an 1115 waiver initiative in your state again?

15. What recommendations would you give to other states planning to implement a waiver?

16. Thinking about the 1115 waiver initiative in your state, please reflect on the successes and challenges.

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DISCUSSION GUIDE: MEDICAID PROGRAM STAFF

DRAFT, OMB No. 0915-xxxx