Loren Anthes, MBA
Public Policy Fellow
The Center for Community Solutions
Medicaid Policy Center


August 23, 2019

The Center for Community Solutions (Community Solutions) seeks to improve health, social and economic conditions through applied demographic research, nonpartisan policy analysis, advocacy and communication. As a part of this work, Community Solutions established the Center for Medicaid Policy (CMP), which seeks to promote sound, cost-effective policy in Ohio’s Medicaid program. The following represents Community Solutions’ public comment regarding Ohio’s Group VIII Work Requirement and Community Engagement 1115 Demonstration Waiver Evaluation Design.


The Centers for Medicare and Medicaid Services (CMS) has explicit standards regarding the monitoring metrics associated with 1115 demonstration Waivers. According to the state’s current draft of the evaluation, the following metrics are absent and should be included:

Metric NumberCategoryMetric Name
AD_5EnrollmentNew enrollees
AD_6EnrollmentReenrollments or reinstatements for beneficiaries not using defined pathways after disenrollment or suspension of benefits for noncompliance.
AD_15RenewalBeneficiaries due for renewal.
AD_18RenewalBeneficiaries determined ineligible for the demonstration at renewal, transferred to CHIP.
AD_20RenewalBeneficiaries who had pending/uncompleted renewals and were still enrolled.
AD_23Cost sharing limitBeneficiaries who reached 5% limit.
AD_29Access to CarePrimary care provider availability.
AD_30Access to CarePrimary care provider active participation.
AD_31Access to CareSpecialist provider availability.
AD_32Access to CareSpecialist provider active participation.


While the evaluation design has been released, the required implementation plan and monitoring protocol have not. Those should be made available upon submission of the evaluation design to allow for a comprehensive scope of work.

Additionally, while there will be data that is collected, collated and reviewed on regular intervals, there appears to be no way for the public to gain access to those materials. In Arkansas, for example, the state issued regular reports that highlighted key pieces of data relevant for the Waiver. Ohio should produce something similar where data and operational information is made available as soon as possible. Importantly, as noted in the evaluation, the state may have to adjust its modeling based on changes in the population being studied. Any such changes should be explicitly identified in reporting with an explanation on the effects in regards to statistical relevance. Last, while the state has some information on rates relative to coverage and churn, these rates should be expressed in terms of volume.


The state included metric “AD_45” which will outline the “cost of contracts or contract amendments and staff time equivalents required to administer demonstration policies, including premium collection, health behavior incentives, premium assistance and/or community engagement.” This information should unambiguously include county-level costs and make apparent those costs borne by counties versus the Ohio Department of Medicaid. Alongside these costs should be an attestation by the contracted actuary indicating if the Waiver meets the standard of budget neutrality and, if the standard is being met, if the reasons confirm or disconfirm the hypotheses being tested.

Additionally, the state should include information on how the Waiver is impacting per member per month (PMPM) costs both within and outside of Group VIII, including information on the impact of the Waiver in rate cell construction for managed care entities. If it is found that the changes in PMPM affect the overall growth target rate established by the Joint Medicaid Oversight Committee (JMOC), the Ohio Department of Medicaid should notify JMOC and suspend Waiver enforcement for beneficiaries until the committee reviews the causes for the cost increase.

Community Solutions appreciates the opportunity to comment on this important aspect of Ohio’s Community Engagement Waiver and hopes the Ohio Department of Medicaid considers its comments before submission to CMS.

Loren Anthes
The Center for Community Solutions, Public Policy Fellow
The Center for Medicaid Policy