Thank you to everyone who attended NAMD’s Annual Fall Meeting last week in Crystal City, Virginia! Due to a record number of registrations, it was our best attended, and most highly engaging, meeting yet. We’d like to especially thank all of our speakers who leveraged their incredible expertise to make the breakouts and plenaries as insightful and informative as they were constructive and forward-thinking.
A shout-out, also, to our sponsors and the staff of ARB, our vendor! We couldn’t have pulled this off without you.
CMS Approves Iowa’s 1115 Waiver on Medicaid Retroactive Eligibility
At the end of October, the Centers for Medicare & Medicaid Services (CMS) approved Iowa’s request to amend its Medicaid section 1115 demonstration, “Iowa Health and Wellness Plan.” The amendment includes a waiver of the three-month retroactive eligibility period, which will apply to all Iowa Medicaid beneficiaries, except for pregnant women (and during the 60-day period beginning on the last day of the pregnancy) and infants under one year of age. Beneficiaries will continue to receive Medicaid coverage effective the first day of the month in which their Medicaid application was filed, or as otherwise allowed by the state plan. Additionally, the three-month retroactive eligibility waiver will only apply to new applications or new beneficiaries who join an existing household, for applications filed or requested on or after November 1, 2017.
CMS released a long-awaited Medicaid Director letter on Section 1115 waivers for substance use disorders (SUD). The letter outlines CMS’s updated thinking around these waivers, which provide a pathway for Medicaid to cover the continuum of care for addiction, including inpatient care in institutions for mental disease (IMD).
Unlike the old guidance, which required states to meet certain milestones prior to waiver approval, CMS will allow states to achieve those milestones over the life of the demonstration. While the guidance reduces the expectations for initial waiver approval, it appears to outline significant new reporting and evaluation requirements for states that receive a SUD 1115 waiver, including:
Regularly reporting on their progress towards the six milestones in the demonstration;
Reporting on a core set of measures in this demonstration model, as well as additional measures specific to a particular state’s demonstration parameters;
Conducting a robust independent interim and final evaluation; and
Subjecting states to a $5 million deferral for each instance where the state fails to submit an acceptable and timely evaluation design or other required reports.
CMS Bulletin Addresses Directed Payments in Managed Care
CMS released an Informational Bulletin last week on the use of directed payment approaches in Medicaid managed care. The guidance provides additional detail on the types of directed payment approaches that CMS will approve in managed care, the use of multi-year approvals, and payment arrangements are not subject to CMS review and approval. Key takeaways from the guidance include:
States’ evaluation plan for their directed payment approach must reflect the size and complexity of the directed payment arrangement. The evaluation plan must include performance criteria to assess whether the directed payment is meeting its goals; baseline data for those performance criteria; and performance improvement targets.
For value-based or delivery system reform directed payments, provider participation must be available using the same terms of performance for a class of providers and use a common set of performance measures across all payers and providers in the initiative. States also can’t set the amount or frequency of expenditures or recoup unspent funds that were allocated to the MCOs for those payment arrangements.
CMS will consider multi-year directed payment arrangements (as opposed to single year arrangements) when the state: has described the payment arrangement as a multi-year effort; has developed a plan for a multi-year arrangement, including a multi-year evaluation and the multi-year impact on the state’s quality goals; and will not be making changes to the payment methodology for all years of the multi-year payment arrangement.
Certain payment arrangements are not subject to the directed payment requirements, including: a general provider reimbursement increase, as long as the state is not mandating a specific payment methodology or amounts; or a general requirement for MCOs to use value-based purchasing or alternative payment arrangements when the state does not mandate a specific payment methodology.
On November 2, the Centers for Medicare and Medicaid Services (CMS) issued a final rule outlining the second year of the Quality Payment Program (QPP), created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The pre-publication version of the rule is available on the Federal Register here, with the official version scheduled for publication on November 16. A fact sheet and executive summary are also available.
The final rule includes several modifications to Other Payer Advanced Alternative Payment Models (APMs) in the QPP which may be of interest to Medicaid Directors, including:
Adding a revenue-based 8% nominal amount risk standard for APM entities whose payment arrangements are defined expressly in revenue terms;
Finalizing the payer initiation of the APM determination process, with 2019 eligible payers including Medicaid, Medicare Advantage plans; and
An extended timeline for introducing gradual risk requirements under the Medical Home model, starting at 2.5% in 2018 and reaching 5% in 2021 and after.
CMS Bulletins Outline Process Improvements for SPAs, 1915 Waivers, 1115 Demonstrations
On November 6, the Centers for Medicare and Medicaid Services (CMS) published two informational bulletins describing a series of process improvements to the approval and renewal processes for state plan amendments (SPAs), section 1915 waivers, and section 1115 demonstrations. The steps outlined in these documents broadly reflect CMS’s discussions with NAMD and states in the NAMD Spring Meeting in Austin, and in subsequent workgroup convenings. More detailed analysis of each bulletin is below.
SPA and Waiver Process Improvements: This bulletin provides a brief background of CMS’s statutory obligations to review SPA and 1915 waivers and provides statistics of its median SPA and waiver processing times in 2016. It also describes a series of short-term strategies to improve processing times, including holding a call with states within 15 days of SPA/waiver submission, creating a set of toolkits to facilitate complete submissions, expanding the use of the MACPro electronic submission platform, and reducing the current amount of SPAs on approval backlog. The bulletin also describes CMS’s vision for gradually eliminating the same-page review issue as MACPro expands. It concludes with a commitment to continue the dialogue with states to identify longer-term process improvement strategies.
1115 Demonstration Waiver Streamlining: This bulletin outlines CMS’s strategies for reducing burden, increasing efficiency, and promoting transparency within the 1115 demonstration approval process. CMS identifies specific steps it will take within these three areas:
Reducing Burden: CMS will streamline the 1115 template to prioritize only the information necessary to ensure adequate federal evaluation of the proposal; will work with states to develop timelines for the approval process; and prioritize policy agreement in the Standard Terms and Conditions negotiation process, leaving technical/operational issues to post-approval conversations.
Increasing Efficiency: CMS will expedite the approval of waivers elements which substantially replicate existing approved waivers; approve waiver elements with routine, successful, non-complex sections for 10-year demonstration periods; will revise the fast-track renewal process to allow more waivers to fall under its purview; and will separate complex elements of waiver demonstrations from non-complex elements to allow the latter to be approved in a timelier manner.
Promoting Transparency: CMS will develop a transparency review checklist to ensure submissions meet all appropriate requirements; share with states a list of open or unresolved issues during the approval process, when necessary; develop demonstration-specific timelines with states; coordinate approval activities across CMS, including demonstration-related SPA or waiver approvals and reporting requirements; and providing technical assistance and standard STCs regarding budget neutrality.
CMS also describes its expectations for 1115 demonstration monitoring and evaluation in the bulletin. Notably, CMS intends to combine the fourth quarter demonstration report with the annual report to reduce overall reporting burden, and to reduce the frequency of reports for demonstrations meeting identified criteria.
CMS Issues Guidance on CHIP Funding Shortfall Procedures
On November 9, the Centers for Medicare and Medicaid Services (CMS) published an informational bulletin outlining program options and financing information for states facing a federal funding shortfall in their Children’s Health Insurance Programs (CHIP). The bulletin:
Describes options for states to transition current CHIP enrollees to alternative coverage sources and the operational activities associated with these changes;
Reviews CHIP maintenance of effort requirements for CHIP-funded Medicaid expansion programs;
Describes SPAs needed to effectuate any changes;
Provides details around available FY 2018 CHIP funding, comprised of unused FY 2017 CHIP allotments (reduced by 1/3 per federal statute) and unused allotments from previous fiscal years; and
Outlines the CMS process for providing redistribution funding and applying the statutorily required 1/3 reduction to the FY 2017 CHIP allotment carry-overs.
The President’s Commission on Combating Drug Addiction and the Opioid Crisis Report
Last week, the President’s Commission on Combatting Drug Addiction and the Opioid Crisis released a report laying out 56 recommendations on how policymakers should combat the epidemic. The recommendations address cross-agency collaboration, media campaigning, prescribing standards, prescription drug monitoring programs, sentencing, treatment, and funding.
The report comes on the heels of President Trump’s declaration last week that the opioid epidemic constituted a public health emergency, but critics have reported that the emergency fund dedicated to public health crises only has about $57,000 remaining after recent natural disasters. The head of the Opioids Commission, New Jersey Governor Chris Christie, predicted that the President will take the lead in requesting more funding, specifying that the request is likely to be for “billions of dollars.”
GAO Report finds that CMS Fell Short Tracking Medicare Beneficiaries at Risk of Opioid Abuse
A new report released by the GAO last week finds that CMS failed to identify hundreds of thousands of seniors using prescription painkillers who are risk of becoming addicted to the pills. CMS has delegated monitoring of these seniors to private organizations, all of which follow CMS monitoring criteria. While these criteria identify beneficiaries at the greatest risk of harm from opioid use, the report finds that they do not capture comprehensive data. In turn, the report recommends three actions for CMS to improve oversight:
Gather information over time on the number of beneficiaries at risk of harm from opioids, including those who receive high opioid morphine equivalent doses regardless of the number of pharmacies or providers, as part of assessing progress over time in reaching the agency’s goals related to reducing opioid use;
Require its contractor, National Benefit Integrity Medicare Drug Integrity Contractor, to identify and conduct analyses on providers who prescribe high amounts of opioids separately from providers who prescribe high amounts of any Schedule II drug; and
Require plan sponsors to report to CMS on investigations and other actions taken related to providers who prescribe high amounts of opioids.
Administrator Verma Outlines Vision for Medicaid, Announces Historic Steps Taken to Improve the Program at NAMD’s Fall Meeting
Last week at NAMD’s Fall Meeting, CMS Administrator Seema Verma discussed her vision for the future of Medicaid and unveiled new CMS policies that encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability. “Our vision for the future of Medicaid is to reset the federal-state relationship and restore the partnership, while at the same time modernizing the program to deliver better outcomes for the people we serve,” said Administrator Verma. “We need to ensure that we are building a Medicaid program that is sound and solvent to help all beneficiaries reach their highest potential.”
Verma emphasized her commitment to “turn the page in the Medicaid program” by giving states more freedom to design innovative programs that achieve positive results for the people they serve and pledged to remove impediments that get in the way of states achieving this goal. In doing so, she announced several new policies involving website content on 1115 demonstrations; strategies to improve 1115 demonstration, state plan amendments, and 1915 waiver processes; and Medicaid Scorecards, intended will provide greater transparency and accountability of the Medicaid program by tracking and publishing state and federal Medicaid outcomes.
In 2011, the Office of Management and Budget offered a waiver of OMB Circular A-87 cost allocation rules to support the integration of eligibility systems between health and human services programs, such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). This waiver allowed States that wish to build integrated systems to do so without having to allocate the costs of developing shared eligibility services to human services programs (more information can be found here). In 2015, a three-year extension of the A-87 waiver authority was offered through December 2018, enabling states to fund the initial development costs needed to retire their legacy eligibility determination systems and integrate their functionalities into improved systems.
As a reminder, states will need to incur costs for goods and services furnished no later than December 31, 2018 to make use of this exception (essentially, if an amount has been obligated by December 31, 2018, but the good or service has not yet been furnished by that date, then such expenditure must be cost allocated at the normal cost allocation). States should consider the financial impact this will have on their state budgets, and amend their Public Assistance Cost Allocation Plan as appropriate to properly allocate costs to all the other benefitting non-Medicaid federal programs.
House Passes CHIP Reauthorization Package; Senate Continues Offset Negotiations
On November 3, the House passed its CHIP reauthorization package, the CHAMPIONING HEALTHY KIDS Act, on a vote of 242 – 174. The package would:
Reauthorize CHIP for five years, with a gradual reduction of the CHIP enhanced FMAP and retaining maintenance of effort for beneficiaries below 300% FPL;
Funds FQHCs for an additional two years;
Extends several public health programs for two years;
Boosts Medicaid funding for Puerto Rico and the U.S. Virgin Islands by over $1 billion to support disaster relief;
Postpones FY 2018 and 2019 Medicaid disproportionate share hospital (DSH) reductions; and
Offsets the above by revising Medicaid third-party liability obligations; allowing states to disenroll lottery winners from Medicaid; increasing Medicare premiums for beneficiaries earning above $500,000 a year; and drawing down funds from the ACA’s Prevention and Public Health Fund.
The vote was partisan due to Democratic concern over the offsets, an unusual departure from the strong bipartisan support for CHIP that has characterized the program since its creation in 1997. Focus now turns to the Senate, which continues to negotiate its own offsets – with little indication of when such a package may be expected.
Tax Reform Progresses through House Committee, Senate Begins Markup This Week; CBO Reassessment of Individual Mandate Repeal Impact Complicates Potential Offsets
Congressional Republicans’ efforts to achieve comprehensive tax reform made progress last week as the House Committee on Ways and Means (W&M) advanced its package on a 24 – 16 party line vote, following four days of continuous mark-up. It is now expected to go to the House floor for a vote this week, where is prospects are generally favorable despite differences among the caucus. In the upper chamber, the Senate Finance Committee is set to begin its own markup this week, where a similarly lengthy exercise in voting down Democratic amendments is anticipated.
A complicating factor in the tax reform debate is a recently revised score of the individual mandate repeal from the Congressional Budget Office (CBO), released on November 8. The revised analysis, which reflects adjusted CBO models and projections after several years of data from the individual mandate in action, indicates that the mandate’s repeal would:
Reduce the deficit by $338 billion between 2018 and 2027;
Increase the number of uninsured by 4 million in 2019, up to 13 million in 2027;
Not impact the overall stability of the nongroup insurance markets in almost all areas of the country; and
Increase premiums by 10% in most years of the next decade.
The revised CBO projections indicate lower federal savings from the mandate’s repeal than previous projections, which may limit the utility of repeal as an offset for tax reform purposes. There is not yet an indication that either chamber intends to include repeal of the individual mandate as part of a tax reform package.
RECAP: E&C Analyzes APMs Under MACRA
On November 8, the House Energy and Commerce Subcommittee on Health (E&C) held a hearing titled “MACRA and Alternative Payment Models: Developing Options for Value-Based Care.” A recording of the hearing, full witness list, and submitted witness testimony is available on E&C’s website here.
The hearing focused primarily on the Medicare-oriented APMs that are being developed by the Physician Technical Advisory Committee (P-TAC) and other provider stakeholders. Subcommittee Chairman Michael Burgess (R-TX) and Ranking Member Gene Green (D-TX) each highlighted the importance of MACRA and its reauthorization, as well as the promise of APMs. The P-TAC witnesses described their role and functions, and noted that the lack of technical assistance resources, sufficient data sharing, and limited scale testing of models were barriers to APMs that merited additional consideration from Congress.
In the News
Maine Votes to Expand Medicaid
Last Tuesday, Maine voters approved a ballot measure to expand the state’s Medicaid program under the Affordable Care Act, in a rebuke to GOP Gov. Paul LePage, who repeatedly vetoed legislation to that effect. Maine will become the 32nd state to expand Medicaid, and the first one to do so by referendum. At least 80,000 additional Maine residents will become eligible for Medicaid as a result of the referendum.
Kaiser Health News: “Pain Doctors Soak up Profits by Screening Urine for Drugs”
Urine samples arriving to Comprehensive Pain Specialists (CPS) labs have become “liquid gold,” generating profits across the doctor-owned network of 54 clinics, the largest pain-treatment practice in the Southeast. Medicare paid the company at least $11 million for urine and related tests in 2014; a year later, Dr. Peter Kroll, one of the founders of CPS and its medical director, billed Medicare $1.8 million. Dr. Kroll said the costly tests are medically justified to monitor patients on pain pills against risks of addiction or even selling of pills on the black market, explaining “I have to know the medicine is safe and you’re taking it.”
In light of this information, Kaiser Health News, with assistance from researchers at the Mayo Clinic, analyzed available billing data from Medicare and private insurance billing nationwide, and found that spending on urine screens and related genetic tests quadrupled from 2011 to 2014 to an estimated $8.5 billion a year. However, there are virtually no national standards regarding who gets tested, for which drugs, and how often. According to many, the dearth of standardization has become problematic, enabling Medicare to spend tens of millions of dollars on tests to detect drugs that present minimal abuse danger for most patients – often to the benefit of providers. “We’re focused on the fact that many physicians are making more money on testing than treating patients,” said Jason Mehta, an assistant U.S. attorney in Jacksonville, Fla. “It is troubling to see providers test everyone for every class of drugs every time they come in.”
Throughout the 1980s and 1990s, the nation’s hospital chains worked to get bigger and bigger, as for-profit companies like HCA and Tenet snapped up local hospitals and opened clinics in one town after another while big academic medical centers like Partners Healthcare scooped up smaller rivals. As a result of this consolidation, a handful of hospital chains today dominate American health care, with brands like Tenet and Catholic Health Initiatives and the Mayo Clinic “competing for patients the way Panera and Chipotle and the Olive Garden compete for diners.” Yet, as Politico explores, this McDonaldization of American hospitals has hit a wall. In the past year, two of the nation’s three largest for-profit hospital systems, Tenet and Community Health Systems, began selling off dozens of their hospitals while entertaining bids to break up their entire companies; meanwhile, prominent not-for-profit chains like Partners Healthcare are reporting nine-digit losses, and the Mayo Clinic is pulling back from some rural locations in the Midwest. In a new article, Politico discusses these shifts in the context of the policy changes under the Affordable Care Act, hospital profit lines, and new incentives targeting value-based care. Importantly, the article considers whether big hospital “chains” will be superseded by smaller, nimbler competitors, arguing that such a change will come eventually (but not soon) given the dilatoriness of payment reform: “A decade after policymakers began pushing hospitals to adopt alternative payment models,” writes Politico, “those models still represent less than 30 percent of payments to the average health care provider.”
Washington Post: “Rural America’s Disappearing Maternity Care”
Increasingly, rural women lack access to maternity services, jeopardizing their health and that of their newborns at a time when U.S. maternal mortality is rising. A recent study in Health Affairs shows that more than half of rural counties lack obstetric services, and that the least populated and most remote communities have been hit hardest. In many states, according to the study, Medicaid contributes to these “maternity deserts”: While Medicaid pays for more than half of the births at rural hospitals, rural communities in states where Medicaid covers only the poorest pregnant women are less likely to have in-county obstetric services, compared with states with more generous eligibility criteria. The study recommends that to help women in rural communities, states should consider addressing housing and transportation needs of rural residents who give birth far from home. Alaska, for example, finances homes where rural pregnant women can stay as their due dates approach; the state also funds travel by pregnant women to medical hubs and clinical teams to accompany high-risk cases.
NBER Explores Medicaid Financing Reform Potential Impacts on State Budgets
Recently, the National Bureau of Economic Research (NBER) published a working paper titled “Implications of Medicaid Financing Reform for State Government Budgets.” The paper analyzes Medicaid financing formula changes, how these changes redirect federal dollars between the states, how these reforms may impact state budgets during recessions, and how the reforms may influence state Medicaid coverage decisions.
ACAP Report Examines Housing Availability for Low Income, Disabled Seniors
Recently, the Association for Community Affiliated Plans (ACAP) published a report titled “Bridging the Health and Housing Gap: Transitioning Medicaid Recipients from Institutions to the Community in the Context of Housing Shortages and Affordability.” The report briefly reviews federal health and housing policies, noting the barriers created that seniors with clinically-driven housing insecurity must navigate. It then reviews a series of initiatives that ACAP members are undertaking to address housing as a social determinant for this vulnerable population, with examples from California, Ohio, and North Carolina.
Urban Institute, How Have Providers Responded to the Increased Demand for Health Care Under the Affordable Care Act?
To understand how health care providers met the increased demand for services under the Affordable Care Act (ACA), researchers from the Urban Institute conducted interviews with health care stakeholders in five communities that saw some of the largest percent increases in the number of insured people after the ACA’s coverage expansions took effect: Detroit, Michigan; Lexington, Kentucky; Sacramento, California; Spokane, Washington; and Morgantown and nearby northeastern counties in West Virginia (which we refer to collectively as West Virginia). These interviews showed that as the demand for health care services increased, providers responded by expanding their staff, including hiring more advanced practice clinicians (such as nurse practitioners) and care coordinators; opening new or expanding existing health care sites; and/or extending their office hours. The number of urgent care and retail clinics also grew.
Despite these changes, gaps in provider capacity persist. Respondents reported that health professional shortages that predated the ACA-including significant shortages of primary care professionals in some communities-were exacerbated by increased demand from newly insured patients. The most significant unmet health care needs were in the areas of behavioral health (especially treatment for opioid use disorder), adult dental care, and specialty services.
Integrated Care Resource Center Brief Highlights VBP in Nursing Facilities
The Integrated Care Resource Center (ICRC) released a new issue brief that examines value-based payment (VBP) approaches in nursing facilities. The brief describes how these VBP approaches link financial rewards for nursing homes to measures of quality, and explores examples of states and managed care plans that are currently using such approaches. It also discusses ways that integrating VBP incentives across payers can support care delivery improvements for individuals dually eligible for Medicare and Medicaid.
The Division of Medical Assistance (DMA) manages health care services for the most vulnerable North Carolina residents. With a budget of nearly $14 billion, DMA serves about 2 million low-income parents, children, seniors, and people with disabilities through the NC Medicaid and NC Health Choice for Children programs.
The North Carolina Division of Medical Assistance is seeking a Chief Medical Officer (CMO). This position functions as a key member of the Division Executive Team, providing input into policy decisions and medical leadership to all Medicaid sections and initiatives, with the goal of promoting the delivery of high quality services within a sustainable budget. The position will also have management responsibilities. The CMO will interact on a regular basis with Pre-Paid Health Plans (PHP) and Local Management Entities/Managed Care Organizations (LME/MCO) medical directors and clinical and non-clinical staff in other state agencies including the Division of Public Health, Division of Mental Health, Intellectual & Developmental Disabilities, and Substance Abuse, and others as needed. Other key responsibilities include analysis of proposed legislation and testimony at legislative committee meetings, input on state-related payment reform, leadership on Social Determinants, and serving as a liaison to the healthcare provider community.
The Missouri Department of Social Services (DSS) is seeking a MO HealthNet Finance Director as part of the senior leadership team. This position offers the unique opportunity to be an integral part of developing and sustaining innovative financial systems to support the state’s Medicaid program for low-income Missourians.
This position is responsible for MO HealthNet Budget forecasting, development and expenditure control and financial reporting; institutional reimbursement; rate setting; financial services and payment models.
The successful candidate will be a hands-on leader capable of building and leading a team of dedicated financial staff. This position, located in Jefferson City, Missouri, reports to the department’s Chief Financial Officer and takes daily direction from the MO HealthNet Division Director. For additional information about our department, visit http://dss.mo.gov/.
The Oregon Health Authority is looking for a passionate leader who is eager to influence and advance health system transformation in Oregon, to join the innovative team as the State Medicaid Director.
This key position is a catalyst in building strong collaborative relationships with public health, behavioral and oral health champions throughout the state. The State Medicaid Director provides overall leadership and direction for strategic program development, health policy and program implementations for the Oregon Health Plan, with an enrollment of over one million individuals.
Oregon invites you to view additional details about this opportunity in this electronic brochure.
Iowa Posting for Medicaid Director
Iowa Department of Human Services seeks a professional to lead the Iowa Medicaid Enterprise (IME). IME is a health care payor that provides comprehensive health care benefits to over 600,000 Iowans annually and has annual expenditures in excess of $ 5.6 billion. This key critical position serves on the Department’s executive management team.
The Medicaid Director is the primary architect of the strategy that establishes IME’s goals for optimal health outcomes and financial performance. This position defines program objectives and performance measures to ensure goals are attained. The role requires a superior knowledge of the insurance industry’s healthcare payment systems and CMS regulations, in order to integrate federal mandates into compliant state policy. This pivotal role provides vision and direction for IME staffs and contractors to implement strategies focused on effective delivery results. The Director must be an effective communicator to craft initiative messages and continually collaborate with a broad and diverse group of stakeholders inclusive of consumers, provider associations, legislators and CMS.
Nebraska Posting for Policy and Communications Deputy Director
The Nebraska Department of Health and Human Services (DHHS) has an exciting opportunity for a Policy and Communications Deputy Director to join our team within the Division of Developmental Disabilities. The Deputy Director will be responsible for overall policy formulation for the Division. Successful candidates will have policy development experience, strong interpersonal skills, and share in our mission of “helping people live better lives.”
The Deputy Director will be responsible for all the administration and management of planning, coordinating, and implementing the overall policy formulation for the Division of Developmental Disabilities with delegated authority to provide communication for the Division; interacting with stakeholders on behalf of the Division Director to promote system reform and transparency; monitoring and communicating Division objectives, activities, and potential areas of concern regarding policy or precedent as well as proposed remedies to the Director and other members of the leadership team; and play a key role in efforts of internal reorganization, management of the state’s newly redesigned Medicaid home and community-based waiver programs for people to lead healthy, independent, and active lives in communities throughout Nebraska.