News & Info for Members of the NYS Council – 1/29/24

January 29, 2024

Important article in Sunday’s (1/28) NY Times:

Helgerson Solutions Group write up re:  NY’s new 1115 waiver (linked below) 

Please note:  As we discussed several weeks ago during a NYS Council Member Support and Public Policy call, if the BH services we had proposed to be carved out of MMC were to be returned to FFS (carved out), this would NOT result in the individuals we serve being ineligible for Level 2 services (as described in the Waiver).  Remember:  The proposal to carve out is about returning a discrete set of outpatient BH services to a FFS reimbursement model.  The carve out proposal does not carve out people from the state’s MMC Program – just a group of outpatient BH services.  As such, the individuals we serve would indeed be eligible for Level 2 HRSN services.

PoliticoPro article on the Medicaid rate increases discussed in New York’s new 1115 Waiver. 

Please note:  We sent info to all members re: the elements of this provision a few weeks ago.  It is attached again, for your convenience. 

How the Biden administration forced states to raise Medicaid rates

New York will spend an additional $200 million over three years on rate increases, according to the federal waiver approval it received last week.


The Biden administration has for the past two years been quietly requiring states to pay doctors and hospitals more for treating patients with Medicaid.

The Centers for Medicare and Medicaid Services has in six states mandated an increase in Medicaid rates for regular doctor’s visits and other kinds of bread-and-butter care. It’s part of a deal to allow the states access to billions in federal money to pay for services that fall outside of the traditional health care realm, such as housing, transportation and nutrition support.

CMS is using these requests, known as waivers, as leverage to boost Medicaid rates and attempt to address a long-standing disparity with Medicare rates.

It’s part of what the Biden administration has pitched as an “all of Medicaid” approach targeted at improving health care coverage, access and quality — especially for people of color, who make up the majority of program enrollees. And it demonstrates how federal health officials are tangibly delivering on their health equity goals.

“It sends a signal to states about making sure their Medicaid programs are running right,” said Cindy Mann, a partner at Manatt Health and former director of the Center for Medicaid and CHIP Services under the Obama administration. “It also sends a message that access to services is a real priority for the administration and that when they have new regulations in place, they will be paying close attention to whether states meet the new access standards.”

The insurance program, which covers roughly 88 million low-income adults and children, typically pays, on average, 30 percent below Medicare, and doctors and hospital executives have long lamented its low rates. Many refuse to take Medicaid, leading to access issues. Medicaid rates are set by perennially cash-strapped states, giving the federal government little power to directly address the issue.

New York will spend an additional $200 million over three years on rate increases, according to the federal waiver approval it received last week. Arizona, California, Massachusetts, Oregon and Washington state have reached similar agreements with federal officials.

Spokespeople for New York and Washington state’s Medicaid agencies said CMS’ requirement meshes with their own priorities on primary, behavioral and obstetric care. The four other states and CMS did not respond to requests for comment from POLITICO.

CMS is requiring the states to raise reimbursement rates for primary care, behavioral health and obstetrics by at least 2 percentage points if their current rates are less than 80 percent of what Medicare pays. The rate increases apply both to the traditional Medicaid program, known as fee-for-service, as well as managed care, where insurers are paid by the state to provide services to enrollees.

The requirements only apply to states that have proposed spending $50 million or 0.5 percent of their total Medicaid spending on health-related social needs, according to CMS.

CMS’ request has prompted some states to go further. California’s most recent budget allocated nearly $240 million to provider rate increases for its Medicaid program, Medi-Cal, for the current fiscal year and proposed $580 million annually moving forward to boost primary, behavioral health and maternity care rates to at least 87.5 percent of Medicare rates.

The boost aims to “strengthen Medi-Cal’s foundation by providing long-term certainty for provider rate increases to drive greater Medi-Cal provider participation especially in underserved areas and in primary and preventive care and advance equity in the Medi-Cal Program,” the state Health and Human Services Agency said in a budget summary.

The bid to raise rates is one of several steps the administration is taking to address gaps in health equity. CMS has also installed new requirements for insurers and doctors to screen for certain social risks, such as food insecurity or lack of transportation.

Medicare Advantage plans will become eligible for bonuses based on how well they close equity gaps starting in 2027.