October 5, 2022
Please find the two below Public Notices in today’s State Register by NYSDOH related to the IMD Transformation Demonstration Program. FYI
We first sent you notice of the two public hearings (discussed below) yesterday.
PUBLIC NOTICE
Department of Health
IMD Transformation Demonstration Program
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, IMD Transformation Demonstration
Program, during which the public may provide oral comments. This
notice further serves to open the 30-day public comment period which
will close on November 4, 2022. During this 30-day comment period,
the public will be afforded the opportunity to provide written
comments. Any updates related to the public hearings will be sent via
the New York State Office of Mental Health and the Office of Addiction Services and
Supports listservs.
New York State (NYS) is requesting approval from the Centers for
Medicare and Medicaid Services (CMS) for an amendment to its
Medicaid Redesign 1115 Demonstration to authorize federal Medicaid
matching funds for reimbursement to Institutions for Mental Diseases
(IMD) for inpatient, residential, and other services provided to
Medicaid enrolled individuals with behavioral health diagnoses
including serious mental illness (SMI), serious emotional disturbance
(SED), and substance use disorder (SUD). This demonstration will allow the state to
promote improved access to community-based
behavioral health services and aid in the state’s efforts to continue to
transform the behavioral health service system.
As a continuation of the transition of Medicaid Behavioral Health
Services from primarily fee-for-service to a managed care environment this demonstration will:
transform the role of some state psychiatric inpatient facilities and substance use disorder residential
treatment facilities; improve care transitions and access to community based treatment and support services; and improve health and
behavioral health outcomes in individuals with chronic and/or serious
mental illnesses by transforming sone selected (pilot site) state-run
psychiatric hospitals, facilities, and campuses from long-term care
institutions to community-based enhanced service delivery systems.
The IMD demonstration project will include the use of crisis services,
respite, step down and short-term residential services, intensive community support services, crisis diversion centers, coordinated specialty
care for first episode psychosis, a full continuum of care for individuals with substance use disorder, and integrated community
participation with a time-limited inpatient service capacity focused on expert
intermediate care treatment.
The primary goals will be transformation with a focus on:
D Reduction of inpatient and transitional residential lengths of stays.
D Community integration and maintenance with a focus on recovery.
D Overall reduced costs of care.
The waiver eligible cohort will include individuals from all Stateoperated adult, non-forensic facilities or residing in
residential addiction treatment programs, discharged within 30 days on average.
Principles, interventions, techniques, and tools, as described throughout the proposal, offer the potential to impact length of stay for adults
age 21 and older.
New York State aspires to grow the waiver population during the
waiver period. As inpatient assessment, stabilization, and treatment
are optimized, NYS will be able to increase the total number of
individuals discharged within 30 days or less.
NYS plans to make system changes allowing for waiver-eligible
patients to remain covered by Medicaid during their inpatient stay,
preventing coverage gaps. Also as part of this demonstration, NYS is
requesting authorization of Medicaid coverage for a targeted set of inreach services up to 30 days prior to discharge
including care management, clinical consultations, peer services, and pharmaceutical management. These in-reach services would be made available to
individuals who do not fall into the 30-day average length of stay
cohort outlined in this waiver.
The two virtual public hearing/public forum meetings will be held
on the following dates:
October 26th and 31st.
The full public notice and draft of the proposed IMD Transformation Demonstration 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 518-473-5569.
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: Department of Health, Office of Health Insurance Programs, Waiver Management Unit, 99
Washington Ave., 12th Fl., Suite 1208, Albany, NY 12210
All comments must be postmarked or emailed by 30 days of the
date of this notice.
PUBLIC NOTICE
Department of Health
IMD Transformation Demonstration Program
In compliance with 42 CFR 431.408(a)(1), this notice serves to
open the 30-day public comment period which will close on November
4, 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 on
October 26th and 31st, 2022, during which the public may provide
oral comments. Any updates related to the public hearings will be sent
via the New York State Office of Mental Health and the Office of Addiction Services and Supports listservs.
The two virtual public hearings will be held as follows:
- First Public Hearing
a. Wednesday October 26, 2022, 3:30 pm – 5:00 pm
b. Pre-registration is required for anyone wishing to attend the hearing using this link: https://meetny-events.webex.com/meetny-events/
j.php?RGID=ra4ca24a1a9e2e60ef935eb4172291e33. Individuals who
wish to provide oral comment will need to respond “yes” to the question in the Webinar registration.
c. 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.
d. All registrants will receive an automated email confirmation of
their registration. Those registered to speak will receive an additional
confirmation one week prior to the event. - Second Public Hearing
a. Monday October 31, 2022, 11:00 pm – 12:30 pm
b. Pre-registration is required for anyone wishing to attend the hearing using this link: https://meetny-events.webex.com/meetny-events/
j.php?RGID=r6a567861b36b3235b79c08dbce775a52. Individuals
who wish to provide oral comment will need to respond “yes” to the
question in the Webinar registration.
c. 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.
d. All registrants will receive an automated email confirmation of
their registration. Those registered to speak will receive an additional
confirmation one week prior to the event.
Prior to finalizing the proposed IMD Transformation Demonstration Program 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.
Amendment Proposal Summary and Objectives
New York State (NYS) is requesting approval from the Centers for
Medicare and Medicaid Services (CMS) for an amendment to its
Medicaid Redesign 1115 Demonstration to authorize federal Medicaid
matching funds for reimbursement to Institutions for Mental Diseases
(IMD) for inpatient, residential, and other services provided to
Medicaid enrolled individuals with behavioral health diagnoses
including serious mental illness (SMI), serious emotional disturbance
(SED), and substance use disorder (SUD). This demonstration will allow the state to promote improved access to community-based
behavioral health services and aid in the state’s efforts to continue to
transform the behavioral health service system.
As a continuation of the transition of Medicaid Behavioral Health
Services from primarily fee-for-service to a managed care environment this demonstration will: transform the role of some state psychiatric inpatient facilities and substance use disorder residential treatment facilities; improve care transitions and access to community based treatment and support services; and improve health and
behavioral health outcomes in individuals with chronic and/or serious
mental illnesses by transforming some selected (pilot site) state-run
psychiatric hospitals, facilities, and campuses from long-term care
institutions to community-based enhanced service delivery systems.
The IMD demonstration project will include the use of crisis services,
respite, step down and short-term residential services, intensive community support services, crisis diversion centers, coordinated specialty
care for first episode psychosis, a full continuum of care for individuals with substance use disorder, and integrated community participation with a time-limited inpatient service capacity focused on expert intermediate care treatment.
The primary goals will be transformation with a focus on:
D Reduction of inpatient and transitional residential lengths of stays.
D Community integration and maintenance with a focus on recovery.
D Overall reduced costs of care.
Also, as part of this demonstration, NYS is requesting authorization
of Medicaid coverage for a targeted set of in-reach services up to 30
days prior to discharge including care management, clinical consultations, peer services, and pharmaceutical management. These in-reach
services would be made available to individuals who do not fall into
the 30-day average length of stay cohort outlined in this waiver.
Eligibility, Benefits, and Cost-Sharing Changes
Eligibility
Medicaid eligibility requirements will not differ from the approved
Medicaid State Plan.
Cost-Sharing
Cost sharing requirements under the Demonstration will not differ
from the approved Medicaid State Plan.
SMI Benefits
New York State will be retrospectively identifying eligible patients
that will allow NYS to claim federal financial participation for
inpatient psychiatric and other non-duplicative services provided
while receiving inpatient services at State run psychiatric centers. It is
expected that approximately 450 individuals between the ages of 21
and 64 will meet the criteria for waiver participation annually.
Individuals will be excluded from the cohort in the event they are forensically involved or have been identified clinically as “long stay”
members.
NYS plans to make system changes allowing for waiver-eligible
patients to remain covered by Medicaid during their inpatient stay,
preventing coverage gaps.
SUD Benefits
The Demonstration will permit Medicaid recipients in New York
with SUD to receive high-quality, clinically-appropriate Medicaid
State Plan-approved SUD treatment services in outpatient and
community-based settings, as well as in residential and inpatient treatment settings that qualify as an IMD.
Enrollment and Fiscal Projections
Enrollment
Waiver demonstration eligibility will be determined by highly
skilled clinicians familiar with the community and its available resources and will include individuals discharged from all Stateoperated adult, non-forensic facilities or residing in residential addiction treatment programs, discharged within 30 days on average.
Fiscal
The total cost of this amendment is estimated to be $268.37 million
over five years, an average $53.67 million increase to the annual demonstration cost of $40 billion. The total estimated enrollment for this
demonstration is estimated to be an increase of 6,146 (in year five)
over the current average annual enrollment of 4.8 million.
Hypotheses and Evaluation
New York will conduct a multi-method, comprehensive statewide
evaluation using an independent evaluator to document the impact of
the IMD Waiver on health care service delivery, quality, health
outcomes, and cost effectiveness. In addition, program components
that posed particular successes or challenges for implementation and
outcomes for this population will also be examined.
SMI Evaluation
NYS will evaluate this IMD Waiver amendment in alignment with
all CMS requirements. An evaluation design will be developed to test
the hypotheses identified below and will include the methodology,
measures, and data sources to support the expected impact of the
amendment. Additionally, it is expected that the current evaluation
plan will be folded into the current approved 1115 Waiver evaluation
design.
GOAL 1: Improving Access to Health Care for the Medicaid population
Hypotheses Example Measures
(Not Final)
Data Sources
Goal 1a: Improve access to specialized inpatient mental health services,
reduce utilization and lengths of stay in EDs among IMD Waiver eligible
adults
Admissions for IMD
Medicaid beneficiaries
to State Psychiatric
Inpatient IMD Units
will increase over time
Monthly IMD admission numbers and proportions
MHARS (State
Psychiatric EHR)
Medicaid Claims
Lengths of stay for
IMD eligible Medicaid
beneficiaries admitted
to IMD Psychiatric
Hospitals will decrease
over time
Average Length of
Stay
MHARS (State
Psychiatric EHR)
Psychiatric ED visits
will decrease for individuals admitted to an
IMD psychiatric hospital
Average psychiatric
ED visits in year following IMD discharge
Medicaid Claims
Goal 1b: Increase availability of Crisis Stabilization Centers
Utilization of crisis
stabilization centers
will increase as the
number of crisis service providers increase
Utilization of crisis
services over time
Number of crisis programs
Medicaid Claims
CONCERTS
(OMH Licensing
database)
Goal 1c: Improve access to community based and integrated primary and
behavioral health care services
Individuals discharged
from an IMD psychiatric hospital will be
more likely to access
specialty mental health
services (e.g. ACT,
PROS) than IMDeligible individuals
discharged from a nonIMD psychiatric bed
Proportion of individuals with specialty mental health services in
the year following discharge
Medicaid Claims
Individuals discharged
from an IMD psychiatric hospital will be
more likely to access
Home and Community Based Services
(HCBS) than IMDeligible individuals
discharged from a nonIMD psychiatric bed
Proportion of individuals with HCBS services in the year following discharge
Medicaid Claims
Access to the targeted
in-reach and person centered community based services will be
available to all vulnerable groups, including
tribal communities,
cultural (racial/ethnic),
and socio-economic
disadvantaged communities
Proportion of individuals with access to the
recovery hub and other
targeted services,
stratified by vulnerable
groups
MHARS (State
Psychiatric EHR)
GOAL 2: Improve Quality of Care
Hypotheses Example Measures
(Not Final)
Data Sources
Goal 2a: Improve Quality of care, and recovery in the community following episodes of acute psychiatric inpatient care
Hypotheses Example Measures
(Not Final)
Data Sources
Individuals discharged
from an IMD psychiatric hospital will be
more likely to have
higher rates of quality
metrics for health
monitoring and prevention than IMDeligible individuals
discharged from a nonIMD psychiatric bed
State run HEDIS Measures, including multiple health and behavioral health measures
Medicaid Claims
Goal 2b: Reduce preventable readmissions to acute care hospitals among
individuals discharged from IMD units
Individuals discharged
from an IMD psychiatric hospital will be less
likely than individuals
with an inpatient stay
at a non-IMD psychiatric hospital in the same
period of observation
Potentially Preventable
Psychiatric Hospital
Readmission rate –
State run 3M measure
Medicaid Claims
SUD Evaluation
The demonstration will evaluate whether the New York Medicaid
SUD treatment system is more effective through a provision of a
complete coordinated continuum of care using LOCADTR placement
criteria and standards, including SUD residential treatment services.
The delivery system reforms are particularly important to address the
needs of the Medicaid expansion population, which has historically
been underserved.
GOAL 1: Improve quality of care and population health outcomes
for Medicaid enrollees with SUD
Hypotheses Example Measures
(Not Final)
Data Sources
The Demonstration
will decrease hospital
admissions among
Medicaid enrollees
with at least one SUD
treatment visit.
Annual inpatient stays
year over year
Medicaid Data
Warehouse
Enrollees who receive
residential SUD services will have lower
hospital readmission
rates compared to a
matched cohort of
members who did not
receive residential
SUD services.
Monthly readmissions
year over year
Medicaid Data
Warehouse
Enrollees with a crisis
visit for SUD will have
improved rates of initiation and engagement
of alcohol and other
drug use treatment
(IET)
IET measure HEDIS Medicaid Data
Warehouse
Enrollees will have
fewer opioid-related
overdose deaths.
Year over year opioid
deaths
DOH overdose database
GOAL 2: Increase enrollee access to and use of appropriate SUD
treatment services based on LOCADTR criteria
NYS Register/October 5, 2022 Miscellaneous Notices/Hearings
93
Hypotheses Example Measures
(Not Final)
Data Sources
The Demonstration
will increase the supply of the critical
LOCs for Medicaid
enrollees.
Number of admissions
to OASAS residential
levels of care year over
year
Medicaid Data
Warehouse
The Demonstration
will increase the use of
residential and MAT
for Opioid and alcohol
for Medicaid enrollees.
Number of prescriptions for opioid and
alcohol medications to
individuals who have a
Medicaid claim to residential services year
over year
Medicaid Data
Warehouse
Fewer overrides for
services not available
and clinical justification for residential services
Year over year overrides
LOCADTR
GOAL 3: Improve care coordination and care transitions for
Medicaid enrollees with SUD
Hypotheses Example Measures
(Not Final)
Data Sources
The Demonstration
will increase the rate of
Medicaid enrollees
with SUD-related conditions who are also
receiving primary/
ambulatory care.
The number of
monthly primary/
ambulatory care claims
per enrollee with SUDrelated conditions
Medicaid Data
Warehouse
The Demonstration
will improve follow-up
after discharge from
ED
HEDIS Follow-up ED
visit
Medicaid Data
Warehouse
Enrollees with SUD
will have increased
treatment engagement
as measured by treatment duration (CET)
QARR Continued Engagement to Treatment
measure.
Medicaid Data Warehouse
Medicaid IMD providers will demonstrate
consistency in program
design and discharge
planning policies.
Review of IMD program and discharge
policies and procedures
OASAS Site Review
Increase Number of
Medicaid enrollees
with SUD who are
enrolled in Health
Home
Year over year Medicaid Data
Warehouse
GOAL 4: Maintain or reduce Medicaid cost of individuals with
SUD
Hypotheses Example Measures
(Not Final)
Data Sources
The Demonstration
will be budget neutral
to the Federal
government.
Annual total cost of
care for individuals
with SUD
Medicaid Data
Warehouse
Hypotheses Example Measures
(Not Final)
Data Sources
Total Medicaid SUD
spending during the
measurement period
will remain constant
after adjustment for the
new residential services and any other
new SUD treatment
services including care
coordination developed under this
Demonstration.
Medicaid SUD-related
claims
Medicaid Data
Warehouse
Total Medicaid SUD
spending on residential
treatment within IMDs
during the measurement period will remain constant after
adjustment for the new
residential services and
any other new SUD
treatment services including care coordination developed under
this Demonstration.
Medicaid IMD residential treatment
claims
Medicaid Data
Warehouse
Costs by source of care
for individuals with
SUD incurring high
Medicaid expenses
during the measurement period will remain constant after
adjustment for the new
residential services and
any other new SUD
treatment services including care coordination developed under
this Demonstration.
Medicaid claims by
source of care
Medicaid Data
Warehouse
Waiver and Expenditure Authorities
Waiver Authority
There are no waiver authorities expected to be needed for this
amendment.
Expenditure Authority
New York is requesting expenditure authority under Section 1115 to
claim as medical assistance the following services that are not
otherwise coverable under Medicaid:
Residential and Inpatient Treatment for Individuals with Substance
Use Disorder (SUD), Serious Mental Illness (SMI), or Severe Emotional Disturbance (SED). Expenditures for otherwise covered
Medicaid services furnished to otherwise eligible individuals who are
primarily receiving treatment and withdrawal management services
for substance use disorder (SUD) or a serious mental illness (SMI) or
severe emotional disturbance (SED) who are short-term residents in
facilities that meet the definition of an institution for mental diseases
(IMD).
Submission and Review of Public Comments
The full public notice and draft of the proposed IMD Transformation Demonstration 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 518-473-5569.
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
Miscellaneous Notices/Hearings NYS Register/October 5, 2022
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: Department of Health, Office of Health Insurance Programs, Waiver Management Unit, 99
Washington Ave., 12th Fl., Suite 1208, Albany, NY 12210
All comments must be postmarked or emailed by 30 days of the
date of this notice.