April 13, 2022
Dear MRT Listserv Subscriber,
In compliance with 42 CFR 431.408(a)(1), the New York State Department of Health is pleased to announce that it will conduct two virtual public hearings, to provide an overview of the State’s proposed 1115 waiver amendment request, “Strategic Health Equity Reform Payment Arrangements: Making Targeted, Evidence-Based Investments to Address the Health Disparities Exacerbated by the COVID-19 Pandemic” (SHERPA), and allow members of the public to provide comments. This notice further serves to open the 30-day public comment period which will close on May 13, 2022. In addition to this 30-day comment period where the public will be afforded the opportunity to provide written comments, the Department of Health will be hosting two virtual public hearings during which the public may provide oral comments. Any updates related to the public hearings will be sent via the MRT ListServ.
The two virtual public hearings will be held as follows:
- First Public Hearing
- Thursday, April 28, 2022, 1:00 pm – 4:00 pm
- Pre-registration is required for anyone wishing to provide oral comment using this link: https://meetny.webex.com/meetny/onstage/g.php?MTID=e440388fd1bde4d353e94606bd0945ccc
- Individuals who wish to provide comment will need to register with an “SP” in front of their name (ex: SP Jane Doe) and must email 1115waivers@health.ny.gov no later than Wednesday, April 27, 2022, at 4pm to confirm registration.
- Individuals will speak in the order of registration. We kindly request that all comments be limited to five minutes per presenter to ensure that all public comments may be heard.
- Second Public Hearing
- Tuesday, May 3, 2022, 1:00 pm – 4:00 pm
- Pre-registration is required for anyone wishing to provide oral comment using this link: https://meetny.webex.com/meetny/onstage/g.php?MTID=eb8826e2d40e98858a9cc9d11aa1a3a18
- Individuals who wish to provide comment will need to register with an “SP” in front of their name (ex: SP Jane Doe) and must email 1115waivers@health.ny.gov no later than Monday, May 2, 2022, at 4pm to confirm registration.
- Individuals will speak in the order of registration. We kindly request that all comments be limited to five minutes per presenter to ensure that all public comments may be heard.
Prior to finalizing the proposed MRT 1115 waiver amendment Strategic Health Equity Reform Payment Arrangements application, the Department of Health will consider all written and verbal comments received. These comments will be summarized and addressed in the final version that is submitted to CMS.
A draft of the proposed amendment request is available at: https://health.ny.gov/health_care/medicaid/redesign/2022/docs/2022-04_1115_waiver_draft_amendment.pdf. For individuals with limited online access and require special accommodation to access paper copies, please call (518) 473-0868.
Amendment Proposal Summary and Objectives
The New York State Department of Health (the State) requests $13.5 billion over five (5) years to fund a new 1115 Waiver amendment that addresses the inextricably linked health disparities and systemic health care delivery issues that have been both highlighted and intensified by the COVID-19 pandemic. If approved, this 1115 Waiver amendment would utilize an array of multi-faceted and linked initiatives in order to change the way the Medicaid program integrates and pay for social care and health care in New York State (NYS). It would also lay the groundwork for reducing long standing racial, disability-related, and socioeconomic health disparities, increase health equity though measurable improvement of clinical quality and outcomes, and keep the overall Medicaid program expenditures budget neutral to the federal government.
To achieve this overall goal of fully integrating social care and health care into the fabric of the NYS Medicaid program, while recognizing the complexity of addressing varying levels of social care needs impacting the Medicaid population, this waiver proposal is structured around four subsidiary goals:
- Building a more resilient, flexible, and integrated delivery system that reduces health disparities, promotes health equity, and supports the delivery of social care;
- Developing and strengthening supportive housing services and alternatives for the homeless and long-term institutional populations;
- Redesigning and strengthening system capabilities to improve quality, advance health equity, and address workforce shortages; and
- Creating statewide digital health and telehealth infrastructure.
For the last decade, through its current 1115 waiver, NYS has engaged in efforts to redesign Medicaid using managed care and its recently ended DSRIP program. DSRIP had an overall goal of reducing avoidable hospitalizations by 25 percent and achieving savings while transforming the health system to use VBP. NYS achieved many of its goals with DSRIP, including a 26 percent reduction in Potentially Preventable Admissions (PPAs) and an 18 percent reduction in Potentially Preventable Readmissions (PPRs) through Measurement Year 5; facilitated a significant increase in Patient Centered Medical Home (PCMH) certification; made major progress in integrating physical and behavioral health care; and improved care transitions that directly reduced readmissions. The DSRIP program also incorporated a Value-Based Payment Roadmap, which achieved its goals of at least 80% of the value of all Medicaid managed care contracts in shared savings (Level 1) or higher VBP arrangements, and 35% of contract value in upside and downside risk (Levels 2 and 3) arrangements. As a result of all these initiatives and others in the State’s current 1115 waiver, as well as other Medicaid redesign initiatives, NYS Medicaid spending per beneficiary in 2019 was less than in 2011.
With this waiver demonstration proposal, NYS is incorporating lessons learned from its DSRIP experience, the experience of forming and collaborating with PPSs, the feedback received from stakeholders and the public throughout the demonstration, and insights uncovered during the subsequent DSRIP evaluation process. The State has identified several key practices that will be again leveraged to accomplish the health equity and system transformation goals listed in this amendment with some adjustments in implementation in response to the challenges, nuance, and opportunities experienced during previous efforts, and that recognize addition need as highlighted by COVID-19.
The following chart outlines the specific goals NYS hopes to achieve through this waiver and the objectives of each goal.
Goal |
Objective(s) |
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Investments in supportive housing services, with a focus on the homeless and long-term institutional populations
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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
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Eligibility, Benefits, and Cost Sharing Changes
Beneficiaries would experience no reduction in available services, how they receive and access services, how services are delivered, or their expected cost sharing responsibilities. Under New York’s current 1115 waiver demonstration, cost sharing is required only for pharmacy- and durable medical equipment-related costs. NYS seeks approval from CMS to provide a targeted set of Medicaid services for incarcerated individuals 30 days prior to release, including in-reach care management and discharge planning, clinical consultant services, peer services, medication management plan development and delivery of certain high priority medications to ensure active Medicaid status upon release and to assist with the successful transition to community life. While this work may be conducted post-release, the chances of finding and engaging a previously incarcerated individual is significantly more difficult post-release and greatly reduces the chance of stabilization. Early results from other pilots across the nation show significant improvements in stabilization and outcomes when a pre-release model is used. These changes paired with coordinated field-based services that SDHNs through new VBP funding models could stabilize and support this population and reduce recidivism and adverse health outcomes. Individuals eligible for this program are those who are incarcerated in state facilities with two or more chronic physical/behavioral health conditions, a serious mental illness, HIV, or an opioid use disorder.
Enrollment and Fiscal Projections
We anticipate no change in estimated annual enrollment to result from the programs detailed in this application with the exception of the provision for Criminal Justice-involved populations. This component of the amendment is estimated to result in an added enrollment of approximately 92,000 members annually based on DOCCS discharge information by condition for individuals with chronic conditions, SMI, or HIV/AIDS, compiled in 2019. Current average annual enrollment is 4.8 million.
The expected increase the annual average demonstration cost of $40 billion by $2.7 billion to $42.7 billion annually.
Hypotheses and Evaluation
The State will evaluate this amendment in alignment with all CMS requirements. An evaluation design will be developed that will evaluate the hypotheses identified below and will include the methodology, measures, and data sources that will be used to assess the impact of the amendment. This evaluation design will be in addition to the current approved evaluation design. Included in the chart below are the hypotheses by goal and examples of measures and data sources. These hypotheses, measures, and data sources are subject to change and may be further clarified based on input from CMS and stakeholders.
The goals of this amendment are as follows:
- Building a more resilient, flexible, and integrated delivery system that reduces health disparities, promotes health equity, and supports the delivery of social care.
- Developing and strengthening supportive housing services and alternatives for the homeless and long-term institutional populations.
- Redesigning and strengthening system capabilities to improve quality, advance health equity, and address workforce shortages.
- Creating statewide digital health and telehealth infrastructure.
The proposed hypotheses for these goals, as well as examples of measures and data sources, are as follows:
Hypothesis |
Example Measures (Not Final) |
Data Sources |
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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 |
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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: |
Claims data |
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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: |
Claims data; Survey |
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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 |
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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; |
Health Plan Data |
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Goal 2: Developing and Strengthening Supportive Housing Services and Alternatives for the Homeless and Long-Term Institutional Population |
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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 |
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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 |
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Goal 3: Redesigning and Strengthening System Capabilities to Improve Quality, Advance Health Equity, and Address Workforce Shortages |
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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; |
Survey |
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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; |
Survey |
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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; |
Survey |
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Goal 4: Creating Statewide Digital Health and Telehealth Infrastructure |
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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 |
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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 |
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Targeted investments in digital/telehealth infrastructure increase telehealth utilization across communities of color. |
Rate of telehealth visits stratified by race and ethnicity |
Claims data |
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Targeted investments in digital/telehealth infrastructure will be associated with improved outcomes |
HEDIS Measures: |
Claims data |
Waiver and Expenditure Authorities
In addition to the waiver authorities already granted in the current 1115 waiver demonstration, the State is requesting the following waiver authorities necessary to implement the initiatives aimed at addressing health disparities and the social determinants of health as detailed in this amendment.
# |
Authority |
Waived |
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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)
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2 |
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Comparability Section 1902(a)(10) Section 1902(a)(17)
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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) |
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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)
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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) |
Expenditure Authority: New York is requesting expenditure authorities under Section 1115 to disburse funds for the initiatives detailed in this amendment. These include the authority to disburse funds for the creation and initial planning operations of HEROs and SDHNs; to utilize VBP funds in service of this amendment’s health equity goals; the expansion of supportive housing services; programming targeted at quality improvement, workforce, and health equity in financially distressed hospitals and nursing homes and workforce investments; digital health and telehealth infrastructure.
In addition, the State is requesting expenditure authority similar to that allowed for Designated State Health Program (DSHP) funding so that certain state and local health program expenditures are counted toward the State’s share of funding for this amendment.
# |
Program |
Authority |
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1 |
Demonstration-Eligible Populations |
Expenditures for healthcare related costs for the following populations that are not otherwise eligible under the Medicaid state plan.
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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. |
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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. |
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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]. |
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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]. |
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Designated State Health Programs Funding |
Expenditures for designated state health program. Program specifications and total funding amount to be negotiated with CMS. |
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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 |
Submission and Review of Public Comments
A draft of the proposed amendment request is available for review under the “MRT 1115 Waiver Amendments” tab at: https://www.health.ny.gov/health_care/medicaid/redesign/medicaid_waiver_1115.htm. For individuals with limited online access and require special accommodation to access paper copies, please call (518) 473-0868.
Prior to finalizing the proposed amendment application, the Department of Health will consider all written and verbal comments received. These comments will be summarized in the final submitted version. The Department will post a transcript of the public hearings on the following website: https://www.health.ny.gov/health_care/medicaid/redesign/medicaid_waiver_1115.htm.
Please direct all questions to 1115waivers@health.ny.gov.
Written comments will be accepted by email at 1115waivers@health.ny.gov or by mail at:
New York State Department of Health
Office of Health Insurance Programs
Waiver Management Unit
99 Washington Avenue
12th floor (Suite 1208)
Albany, NY 12210
All comments must be postmarked or emailed by 30 days of the date of this notice.
Thank you.
Medicaid Redesign Team Updates