More on 1115 Waiver Plans

July 14, 2021

The NYS Council continues to provide important information to our members regarding the state’s plan to seek a new 1115 waiver from CMS.  We began writing to members and sharing slides from various presentations on this topic on June 15, and we have sent several updates since then. 

On Monday morning I had another opportunity to listen to Brett Friedman discuss the evolving model for New York’s next waiver demonstration program.  Brett was speaking to a group of grassroots advocates and care recipients who advocate for the protection and enhancement of services for Medicaid beneficiaries.  As such, there was a little more meat on the bone related to the development of Social Determinant of Health networks, how NY plans to assess the needs of special populations who could benefit from targeted interventions, and how upfront investment dollars will be prioritized.

Yesterday afternoon we posted the slides Brett used during the presentation on our website.  My notes that accompany the slides are below.  

Go to and click on the first link in the box called “Medicaid Redesign” to view the slides.

PLEASE remember this information is evolving and subject to change:

DoH is preparing to submit a Concept Paper to CMS that provides information regarding the 1115 waiver demonstration program the state is developing. This is the first in a series of steps NYS needs to take prior to submission of a waiver application.  The Concept Paper will tell CMS what NY wants to do, and CMS will tell NYS if it should go ahead and make a formal application based on the Concept Paper and subsequent discussions.  At this point nothing is in stone and any part of the plan being discussed currently is subject to change based on the conversations NYS will have with CMS throughout the summer and into the fall. 

New York will apply for another 5 year 1115 Waiver Demonstration Program.  No hard numbers yet but Brett assumes the request to CMS will be somewhere in the range of $12-$17B.  The actual amount will depend on a Budget Neutrality Rebasing exercise NYS needs to go through (a technical exercise that could result in savings that can be reinvested in our proposed demo.)  

About the Model
The envisioned model includes development of and funding for Social Determinants of Health (SDH) networks, as well as limited funds for the activities of new regional entities called HEROs (Health Equity Regional Organizations).  The HERO is not a PPS but more of a coordinating body, a collaborative entity (includes MCOs) that will receive a limited amount of funding to engage in planning efforts that include gathering of information and data that helps to identify the health and social health needs of a target
population of Medicaid beneficiaries within that region of the state.  HEROs will use an innovative social care model to conduct social care assessments utilizing a trained network of assessors (Brett used the example of a Visiting Nurse service).  

HEROs will focus on implementing solutions that will connect HERO member data systems, and collection of missing data that would help identify what care recipients in the region need, etc.  Brett made clear that this is not another waiver where (as was the case with DSRIP) there is a list of projects regional networks can choose from that may/may not be relevant to the actual needs of the target population. There will be one and only one HERO per region.  Some regional HEROs may (geographically) overlap with another but (unlike DSRIP) there is no attribution tied to the HERO.  Ultimately the HERO will decide on the intervention for a target population.  MCOs are part of the
HERO, and ultimately, they will be incentivized to create a VBP contract with the HERO to implement the intervention.  The contract and the intervention will first need to be approved by the state.  

Upfront Investments of Waiver Dollars
Biggest investment of waiver funds will go to the VBP Incentives Pool.  Next biggest investment will be for development of Supported Housing (NY’s waiver will ask for the ability to provide tenant assistance.)  Third on the list (from largest investment to smallest) is investments is Social Determinants of Health networks (approx. $1B), followed by funds to train and support the healthcare workforce and safety net.  Next comes investments to fund activities of the HEROs and finally, investments in telehealth/ technology.   FYI, Brett commented that the only truly sustainable way for the state to fund social determinant of health interventions is through VBP arrangements and running these funds (for SDH) through MCOs will
create the federal match we need to adequately fund these services.   

Investments to Advance Value Based Payment Arrangements
VBP can be viewed as the vehicle through which the state can incentivize the correct interventions to change health outcomes.  State will use incentives not penalties (as was the case with DSRIP) to develop a robust statewide VBP Program.  Waiver will encourage alternative payment models that incentivize whole person care such as global pre-paid payment models, targeted sub-population contracts, episodic arrangements, etc.  Brett stated that previous VBP models were not effective in addressing person-centered care, or in meeting the needs of special pops.  HEROs will ultimately create a menu of qualified VBP arrangements that match the needs of targeted pops in the region, and they will receive additional dollars to support these arrangements meaning that ultimately CBOS will get upfront payments and won’t have
to rely on possible shared savings to implement an intervention.  

Funds Flow to MCOS
Brett discussed two different pathways for funds flow to MCOs:

  • via risk adjusted premiums based on social needs of members.  In this case the social care assessment (discussed above) 
  • additional premiums specifically to fund approved VBP arrangement