The following information is intended to provide a summary of the proposed 1115 Medicaid Waiver Demonstration and what we know so far. If you have any additional questions about the waiver proposal or CCN’s preparation for the waiver, please contact Amy Gecan, Director of Business Development and Strategy for Care Compass Network at AGecan@carecompassnetwork.org.
How it All Began
Back in 2014, NYS announced a new demonstration program under its 1115 Medicaid Waiver. While the waiver has afforded NYS flexibility to redesign and implement innovative changes to improve statewide Medicaid programs since 1997, the Delivery System Reform Incentive Payment (DSRIP) program aimed at specific and measurable systemic improvements that have a positive and lasting effect on the most vulnerable populations. The overarching goals of the DSRIP program were to reduce avoidable hospital use by 25%, reduce total Medicaid costs, and improve the health and well-being of the Medicaid population.
After extensive planning and rallying within the community, 11 projects standing to have the greatest impact were selected from the DSRIP program. Care Compass Network joined the DSRIP program in 2015 and became 1 of 25 Performing Provider Systems (PPS) in New York State working on the Medicaid program. With a core program value of value-based care and measurable impact, each PPS drew down available payments based on the metrics from each project that was selected and distributed these to the community based on project-related deliverables and testing innovative programs aimed at delivery system reform. In March 2020, the 5-year DSRIP program concluded with NYS ranking CCN and its partners as one of the top 3 PPSs of New York State based on overall improvement to project metrics.
The Journey Isn’t Over
In late August 2021, NYS submitted a new 1115 Medicaid Waiver Demonstration proposal to the Centers for Medicaid and Medicare Services (CMS) proposing an investment of over $13.5 billion over a 5-year period to continue to advance Medicaid reform and value-based payment (VBP) contracting in New York State that began with DSRIP. There is a significant focus on health equity as the pandemic highlighted the vast health disparities among people of color and other marginalized groups. We’ve highlighted several of the key goals and concepts from NYS’s proposal.
Key Goals and Concepts of the 1115 Medicaid Waiver Demonstration Proposal
Throughout the DSRIP program, the state had focused on advancing value-based payment approaches. The state remains focused on VBP and proposed investing nearly 50% of the $13B program towards the maturation of VBP in NYS. One big difference between the original DSRIP program and the new 1115 Medicaid Waiver Demonstration is the emphasis placed on health equity along with the creation of two new roles; the Health Equity Regional Organizations (HEROs) and the Social Determinants of Health Networks (SDHNs).
What are HEROs and SDHNs and what do they do?
HEROs will be developed by region and will be tasked with addressing health equity in their region as these needs differ by community and within those communities. The HEROs will be the central entity that will convene and collaborate with key regional stakeholders and act as the catalyst for addressing and closing the gap in health disparities in the community While HEROs will play a central role in planning and coordination, the state recognizes the critical need to integrate CBOs and social service providers with health care systems, which will be the role of the SDHNs. This role will take a comprehensive approach to addressing the Social Determinant of Health needs of the region by supporting the integration of CBOs, helping them incorporate IT infrastructure, and developing a set of standards for social care data exchange.
What are the key goals of the 1115 Medicaid Waiver Demonstration?
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.
- Establish and invest in regional planning through HEROs
- Establish and invest in the performance of SDHNs
- Advance VBP models that focus on reducing health disparities and increase health and social care systems
- Build capacity and training to achieve goals for health equity
- Ensure adequate access for criminal justice-involved populations
Goal 2: Developing and strengthening supportive housing services and alternatives for the homeless and long-term institutional populations
- Investment in supportive housing services and other alternatives for the homeless and long-term institutional populations
Goal 3: Redesign and strengthen system capabilities to improve quality, advance health equity, and address workforce shortages
- Establish a funding pool to allow financially distressed hospitals and nursing homes to participate in VBP engagements
- Development of a diverse and well-trained workforce
Goal 4: Creating statewide digital health and telehealth infrastructure
- Build and invest equitably in digital and telehealth infrastructure to expand access to care to underserved areas
What’s Next?
- October 20 and ongoing: CMS will review the 1115 Medicaid Waiver Demonstration proposal
There is no defined timeline in which CMS has to respond to the proposal. However, there are indications that CMS will view New York’s 1115 waiver proposal favorably. On September 28th, CMS announced approval of two state 1115 demonstration waiver proposals: the Massachusetts proposal for a $2B investment and the Oregon proposal for an investment of $1B. These are the first two 1115 demonstration waivers approved by CMS in 2022.
At this time there is a lot of uncertainty around what will be included in the 1115 Medicaid Waiver Demonstration and the total investment associated, and CCN will continue to focus on its current strategy which aligns with the current proposal but will not dedicate specific planning efforts until CMS weighs in. CCN is currently prepared to apply for both the HERO and SDHN roles for as we await feedback from CMS. As information is shared, Care Compass will continue to update partners.
In the meantime, if you have any questions, please feel free to reach out to Amy Gecan the Director of Business Development and Strategy at AGecan@carecompassnetwork.org.
Other Insights and Information on the Medicaid Proposal:
Helgerson Solutions Group https://www.hsg.global/insights
MS Hall and Associates: https://mshallandassociates.com/stories/
NYS DOH 1115 Medicaid Demonstration Waiver proposal: https://www.medicaid.gov/medicaid/section-1115-demonstrations/downloads/ny-medicaid-rdsgn-team-pa-09152022.pdf