May 25, 2010

State Flexibility for Medicaid Benefit Packages

Proposed Rule
Summary

Score: 16 / 60

Key materials
Additional details
Agency
Department of Health and Human Services
Regulatory Identification Number
0938-AO48
Agency Name
Department of Health and Human Services
Rule Publication Date
02/22/2008

RULE SUMMARY

This proposed rule would implement provisions of section 6044 of the Deficit Reduction Act of 2005, Pub.
L. 109–171, which amends the Social Security Act by adding a new section 1937 related to the coverage of medical assistance under approved State plans. Under this new section, states have increased flexibility under an approved state plan to define the scope of covered medical assistance by offering coverage of benchmark or benchmark-equivalent benefit packages to certain Medicaid recipients.

METHODOLOGY

There are twelve criteria within our evaluation within three broad categories: Openness, Analysis and Use. For each criterion, the evaluators assign a score ranging from 0 (no useful content) to 5 (comprehensive analysis with potential best practices). Thus, each analysis has the opportunity to earn between 0 and 60 points.

Criterion Score

Openness

1. How easily were the RIA , the proposed rule, and any supplementary materials found online?
A link to the proposed rule containing the RIA is five clicks from the home page. Click on "regulations" (intuitive). The rest is unintuitive: click on "other regulations," expand the "detail" list, click on "CMS regulations," and then click on "quarterly provider updates - regulations" and select the update list from the period covering the date of the regulation. It can also be found on regulations.gov using the RIN and keyword search.
4/5
2. How verifiable are the data used in the analysis?
The RIA mentions data from three sources; however, it is nearly impossible for a private citizen to verify these.
1/5
3. How verifiable are the models and assumptions used in the analysis?
The analysis clearly makes assumptions about the extent to which states would adopt alternative health plans and the effect on costs, but no support is given for these assumptions. It is impossible to verify the assumptions made because of the brief discussion.
1/5
4. Was the analysis comprehensible to an informed layperson?
The analysis is reasonably clearly written. The main barrier to understanding is that the assumptions appear to be pulled from thin air. Thus, it is hard to understand how the analysis arrived at the results.
3/5

Analysis

5. How well does the analysis identify the desired outcomes and demonstrate that the regulation will achieve them?
1/5
Does the analysis clearly identify ultimate outcomes that affect citizens’ quality of life?
Several types of outcomes are mentioned: cost savings, coverage more tailored to recipients' actual needs, and coverage that makes it easier for families to transition to private coverage.
4/5
Does the analysis identify how these outcomes are to be measured?
The analysis identifies only the cost savings, in dollars.
2/5
Does the analysis provide a coherent and testable theory showing how the regulation will produce the desired outcomes?
It does not explain why states would choose to offer different types of plans, though cost savings might be a big motivation.
0/5
Does the analysis present credible empirical support for the theory?
The analysis does not address this topic.
0/5
Does the analysis adequately assess uncertainty about the outcomes?
The analysis acknowledges uncertainties but does not try to estimate them or provide a range of estimates.
1/5
6. How well does the analysis identify and demonstrate the existence of a market failure or other systemic problem the regulation is supposed to solve?
1/5
Does the analysis identify a market failure or other systemic problem?
There is some discussion in the rule of how restrictions under previous law made it difficult for states to offer innovative coverage.
2/5
Does the analysis outline a coherent and testable theory that explains why the problem (associated with the outcome above) is systemic rather than anecdotal?
The analysis simply says, "The law changed."
0/5
Does the analysis present credible empirical support for the theory?
There is no real discussion of how many states used the older waiver process or what benefits flowed from that.
0/5
Does the analysis adequately assess uncertainty about the existence or size of the problem?
The analysis does not address this topic.
0/5
7. How well does the analysis assess the effectiveness of alternative approaches?
1/5
Does the analysis enumerate other alternatives to address the problem?
The analysis mentions two more restrictive options as hypothetical possibilities and presents some reasons for dismissing them, but no real analysis was done.
1/5
Is the range of alternatives considered narrow (e.g., some exemptions to a regulation) or broad (e.g., performance-based regulation vs. command and control, market mechanisms, nonbinding guidance, information disclosure, addressing any government failures that caused the original problem)?
The range is narrow—other options involved more requirements or less flexibility than the option chosen.
1/5
Does the analysis evaluate how alternative approaches would affect the amount of the outcome achieved?
The analysis rejects hypothetical options that would have imposed more requirement on states or limited their flexibility. It asserts the options would be more costly or burdensome to states, but did not measure this.
1/5
Does the analysis adequately address the baseline? That is, what the state of the world is likely to be in the absence of federal intervention not just now but in the future?
There is some kind of baseline employed in the analysis, but derivation of the baseline is not really clear.
1/5
8. How well does the analysis assess costs and benefits?
1/5
Does the analysis identify and quantify incremental costs of all alternatives considered?
Cost (savings) of only one option was considered, and the analysis was not well-documented.
1/5
Does the analysis identify all expenditures likely to arise as a result of the regulation?
Expenditure savings are estimated but not well documented.
1/5
Does the analysis identify how the regulation would likely affect the prices of goods and services?
The analysis does not address this topic.
0/5
Does the analysis examine costs that stem from changes in human behavior as consumers and producers respond to the regulation?
The analysis assumes various levels of state response but does not give much justification.
1/5
If costs are uncertain, does the analysis present a range of estimates and/or perform a sensitivity analysis?
Uncertainty is acknowledged due to unpredictability of state responses, but the analysis offers no estimates reflecting uncertainty.
1/5
Does the analysis identify the alternative that maximizes net benefits?
Reasons for rejecting hypothetical alternatives appear to reflect concern about net benefits.
1/5
Does the analysis identify the cost-effectiveness of each alternative considered?
See above.
1/5
Does the analysis identify all parties who would bear costs and assess the incidence of costs?
The analysis assesses both federal and state cost savings.
2/5
Does the analysis identify all parties who would receive benefits and assess the incidence of benefits?
The analysis does not address this topic.
0/5

Use

9. Does the proposed rule or the RIA present evidence that the agency used the analysis?
The explicit purpose was to implement changes in law, some of which had already been written into HHS guidance.
1/5
10. Did the agency maximize net benefits or explain why it chose another alternative?
There is no discussion of net benefits. Hypothetical alternatives do not appear to have been seriously considered, since they are presented as hypothetical. Assertion that all changes were required by legislation might be interpreted as an assertion that the agency had no responsibility for discussing net benefits.
1/5
11. Does the proposed rule establish measures and goals that can be used to track the regulation's results in the future?
The analysis does not address this topic.
0/5
12. Did the agency indicate what data it will use to assess the regulation's performance in the future and establish provisions for doing so?
It discusses cost data only.
1/5
 
Total 16 / 60