Goal

Objective(s)

1. Building a more resilient, flexible and integrated delivery system that reduces health disparities, promotes health equity, and supports the delivery of social care

1. Investments in regional planning through Health Equity Regional Organizations (HEROs)
2. Investments in Social Determinant of Health Networks (SDHNs)
3. Investments in Advanced VBP Models that fund the coordination and delivery of social care via an equitable, integrated health and social care delivery system
4. Capacity building and training to achieve health equity goals
5. Ensuring access for criminal justice-involved populations

1. Developing and strengthening supportive housing services and alternatives for the homeless and long-term institutional populations

Investments in supportive housing services, with a focus on the homeless and long-term institutional populations

1. Redesigning and strengthening system capabilities to improve quality, advance health equity, and address workforce shortages

1. Creation of a COVID-19 Unwind Quality Restoration Pool for financially distressed hospitals and nursing homes
2. Investments to expand workforce capacity and develop a strong, representative and well-trained workforce 

1. Creating statewide digital health and telehealth infrastructure

Ensure that the consumer-driven wave is available equitably by building digital and telehealth infrastructure and care models to significantly expand access to care, both in underserved areas, such as rural and other communities without convenient access to primary or specialty care, and for underserved needs, such as behavioral health and the management of chronic diseases

Hypothesis

Example Measures (Not Final)

Data Sources

Goal 1: Building a More Resilient, Flexible and Integrated Delivery System that Reduces Health Disparities, Promotes Health Equity, and Supports the Delivery of Social Care 

Establishment of the HEROs, SDHNs, and advanced targeted VBP arrangements will be associated with a decrease in health disparities across the demonstration.

HEDIS Quality Measure:
Hemoglobin A1c Control for Patients with Diabetes

Claims data

Establishment of the HEROs, SDHNs, and advanced targeted VBP arrangements will promote greater integration between physical health, behavioral health, and social care needs. 

HEDIS Quality Measure:
Screening for Clinical Depression and Follow-up Plan

Claims data; Survey

Establishment of the HEROs, SDHNs, and advanced targeted VBP arrangement will result in the implementation of universal screening for social needs will result in increased referrals over the period of the amendment.

Number of referrals

Statewide social needs referral and data platform

The number of advanced targeted VBP arrangements, and the number of members and dollars covered in such arrangements will increase over the period of the amendment.

Number of advanced targeted VBP arrangements;
Number of members in advanced targeted VBP arrangements;
Number of dollars in advanced targeted VBP arrangements

Health Plan Data

Goal 2: Developing and Strengthening Supportive Housing Services and Alternatives for the Homeless and Long-Term Institutional Population 

Establishment of a regional network of SDHNs will increase referrals to Enhanced Supportive Housing Initiative services.

Number of referrals

Statewide social needs referral and data platform

The regional approach by the SDHNs of referring members to Enhanced Supportive Housing Initiative services for the homeless and long-term institutional population will result in permanent housing. 

Rate of formerly homeless in permanent housing

Statewide social needs referral and data platform

Goal 3: Redesigning and Strengthening System Capabilities to Improve Quality, Advance Health Equity, and Address Workforce Shortages

Investments in financially-distressed hospitals and nursing homes will increase quality improvement initiatives, workforce training, pandemic-related needs, and health equity-related work over the life of the amendment.  

Number of quality improvement initiatives;
Number of workforce trainings

Survey

Investment in Workforce Investment Organizations (WIOs) to retain existing healthcare staff and recruit new staff will reduce workforce shortages and turnover. 

Number of new staff;
Staff turnover rate

Survey

Investment in healthcare workforce training will result in an increased number of community health workers, care navigators, and peer support workers.  

Number of community health workers;
Number of care navigators;
Number of peer support workers

Survey

Goal 4: Creating Statewide Digital Health and Telehealth Infrastructure

Targeted investments in digital/telehealth infrastructure will increase telehealth utilization for underserved areas (e.g., rural, other communities without convenient access to primary or specialty care). 

Rate of telehealth visits

Claims data

Targeted investments in digital/telehealth infrastructure will increase telehealth utilization in populations with underserved needs (e.g., behavioral health, management of chronic disease). 

Rate of behavioral health telehealth visits

Claims data

Targeted investments in digital/telehealth infrastructure increase telehealth utilization across communities of color. 

Rate of telehealth visits stratified by race and ethnicity

Claims data

Targeted investments in digital/telehealth infrastructure will be associated with improved outcomes

HEDIS Measures:
Follow-up after Hospitalization for Mental Illness Hemoglobin A1c Control for Patients with Diabetes

Claims data

1

To permit New York to geographically phase in the Managed Long Term Care (MLTC) program and the Health and Recovery Plans (HARP) and to phase in Behavioral Health (BH) Home and Community Based Services (HCBS) into HIV Special Needs Plans (HIV SNP).

Statewideness

Section 1902(a)(1)

2

1. To enable New York to apply a more liberal income standard for individuals who are deinstitutionalized and receive HCBS through the managed long term care program than for other individuals receiving community-based long term care.
2. To the extent necessary to permit New York to waive cost sharing for non-drug benefit cost sharing imposed under the Medicaid state plan for beneficiaries enrolled in the Mainstream Medicaid Managed Care Plan (MMMC) – including Health and Recovery Plans (HARP) and HIV SNPs – and who are not otherwise exempt from cost sharing in §447.56(a)(1).
3. Family of One Non-1915 Children, or “Fo1 Children” – To allow the state to target eligibility to, and impose a participation capacity limit on, medically needy children under age 21 who are otherwise described in 42 CFR §435.308 of the regulations who: 1) receive Health Home Comprehensive Care Management under the state plan in replacement of the case management services such individuals formerly received through participation in New York’s NY #.4125 1915(c) waiver and who no longer participate in such waiver due to the elimination of the case management services, but who continue to meet the targeting criteria, risk factors, and clinical eligibility standard for such waiver; and 2) receive HCBS 1915(c) services who meet the risk factors, targeting criteria, and clinical eligibility standard for the above-identified 1915(c) waiver.  Individuals who meet either targeting classification will have excluded from their financial eligibility determination the income and resources of third parties whose income and resources could otherwise be deemed available under 42 CFR §435.602(a)(2)(i).  Such individuals will also have their income and resources compared to the medically needy income level (MNIL) and resource standard for a single individual, as described in New York’s state Medicaid plan.
4. To provide targeted services to individuals who are incarcerated up to 30 days prior to their release into the community, to the extent that such individuals are eligible to enroll in MMMC, HARP or HIV SNPs.  .

Comparability

Section 1902(a)(10)

Section 1902(a)(17)

3

To enable New York to provide behavioral health (BH) HCBS services and the Adult Rehabilitation Services named Community Oriented Recovery and Empowerment (CORE) Services, whether furnished as a state plan benefit or as a demonstration benefit to targeted populations that may not be consistent with the targeting authorized under the approved state plan, in amount, duration and scope that exceeds those available to eligible individuals not in those targeted populations.

Amount, Duration & Scope

Section 1902(a)(10)(B)

4

To the extent necessary to enable New York to require beneficiaries, including those individuals who are incarcerated up to 30 days prior to their release, to enroll in managed care plans, including the Mainstream Medicaid Managed Care (MMMC), and MLTC (excluding individuals designated as “Long-Term Nursing Home Stays”) and HARPs programs in order to obtain benefits offered by those plans. Beneficiaries shall retain freedom of choice of family planning providers.

Freedom of Choice

Section 1902(a)(23)(A)

5

To enable the state to limit the number of medically needy Fo1 Children not otherwise enrolled in the Children’s 1915(c) waiver.

Reasonable Promptness

Section 1902(a)(8)

1

Demonstration-Eligible Populations

Expenditures for healthcare related costs for the following populations that are not otherwise eligible under the Medicaid state plan.

1. Demonstration Population 2 (TANF Adult). Temporary Assistance for Needy Families (TANF) Recipients. Expenditures for health care related costs for low- income adults enrolled in TANF. These individuals are exempt from receiving a MAGI determination in accordance with §1902(e)(14)(D)(i)(I) of the Act.
2. Demonstration Population 9 (HCBS Expansion). Individuals who are not otherwise eligible, are receiving HCBS, and who are determined to be medically needy based on New York’s medically needy income level, after application of community spouse and spousal impoverishment eligibility and post-eligibility rules consistent with section 1924 of the Act.
3. Demonstration Population 10 (Institution to Community). Expenditures for health care related costs for individuals moved from institutional nursing facility settings to community settings for long term services and supports who would not otherwise be eligible based on income, but whose income does not exceed the income standard described in STC 4(c) of section IV, and who receive services through the managed long term care program under the demonstration.
4. Included in Demonstration Population 12 [Family of One (Fo1) Children]- Medically needy children Fo1 Demonstration children under age 21 with a waiver of 1902(a)(10)(C)(i)(III) who meet the targeting criteria, risk factors, and clinical eligibility standard for #NY.4125 waiver including intermediate care facilities (ICF), nursing facilities (NF), or Hospital Level of Care (LOC) who are not otherwise enrolled in the Children’s 1915(c).

2

Twelve-Month Continuous Eligibility Period

Expenditures for health care related costs for individuals who have been determined eligible under groups specified in Table 1 of STC 3 in Section IV for continued benefits during any periods within a twelve month eligibility period when these individuals would be found ineligible if subject to redetermination. This authority includes providing continuous coverage for the Adult Group determined financially eligible using Modified Adjusted Gross Income (MAGI) based eligibility methods. For expenditures related to the Adult Group, specifically, the state shall make a downward adjustment of 2.6 percent in claimed expenditures for federal matching at the enhanced federal matching rate and will instead claim those expenditures at the regular matching rate.

3

Facilitated Enrollment Services

Expenditures for enrollment assistance services provided by managed care organizations (MCO), the costs for which are included in the claimed MCO capitation rates.

4

Demonstration Services for Behavioral Health Provided under Mainstream Medicaid Managed Care (MMMC)

Expenditures for provision of residential addiction services, crisis intervention and licensed behavioral health practitioner services to MMMC enrollees only and are not provided under the state plan [Demonstration Services 9].

5

Targeted Behavioral Health (BH) HCBS and CORE Services

Expenditures for the provision of BH HCBS and CORE Services under Health and Recovery Plans (HARP) and HIV Special Needs Plans (SNP) that are not otherwise available under the approved state plan [Demonstration Services 8].

Designated State Health Programs Funding

Expenditures for designated state health program. Program specifications and total funding amount to be negotiated with CMS.

Health Equity Regional Organizations (HEROs), Social Determinants of Health Networks (SDHN), and Value Based Payment Incentive Pools

Expenditures for incentive payments and planning grant payments for the HERO, SDHN, and VBP programs