Organizations from across the Southern Tier submitted questions regarding the New York State Health Equity Reform (NYSHER) to Care Compass. We compiled those questions and provided answers below.
NYS Department of Health recently posted all of the questions submitted from across the state. Those questions and answer can be downloaded here. For additional information and past NYSHER Waiver Town Hall recordings regarding the waiver, visit our On-Demand Resources and News section. Plus, here are links to download the CMS Approval Letter (plus CCNÂ Table of Contents for the Waiver Document):Â https://www.medicaid.gov/sites/default/files/2024-01/ny-medicaid-rdsgn-team-appvl-01092024.pdf
General Application Questions
Q. As a CBO entity, can you join more than one social care network?
A. Absolutely! If your organization spans multiple regions, it is likely that you will participate with more than one Social Care Network (SCN). We are working on a strategy to support organizations working with multiple SCNs to make the process easier wherever possible.
Q. Do you anticipate any competition for the SCN for that region?
A. We support competition and anticipate that there may be more than one applicant for the Southern Tier region.
Q. What do we know about health equity in this waiver?
A. The Health Equity Regional Organization (HERO) was created to set the baseline for how we are performing by region in addressing health disparities among marginalized populations – Specifically, those that qualify for these enhanced services because they are the most marginalized groups. The services and the fee schedules are anticipated to be rolled out in a way that advances health equity and the system has to transform in order for that to be achieved. Presently, there is no RFA published for the HERO role and so more details will be forthcoming.
Most importantly, health equity is the foundation of the entire NYSHER waiver and will be a core driver for all activities supported by the SCN.
Q. What would be the role for hospitals and healthcare providers in administering the Health Related Social Needs (HRSN) Screening and Social Care Navigation? Would these services be reimbursable through the SCN?
A. Hospitals and healthcare providers are eligible to be reimbursed for screening, navigation, and case management under the NYSHER waiver.
Q. Are there eligibility requirements for CBOs to participate?
A. These have been defined by NYS and can be found on pages 19-20 in the NYSHER Social Care Networks RFA for specific details. It is expected that an eligible CBO:
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- Provides navigation or at least one of the enhanced HRSN services.
- Maintains a coverage area that includes zip codes within the SCN region.
- Holds not-for-profit status with an active EIN (for profit entities will only be considered when there is not a non-profit that can cover the service for part of the region).
- Designates contacts to engage and be trained on the SCN data and IT platform and validate the accuracy of CBO information on routine intervals.
- Demonstrates cultural and linguistic competency.
- Committed to accepting referrals and providing services and collaborating with the SCN and other stakeholders to coordinate the delivery of HRSN services.
- Can assess or project potential capacity constraints and estimate need (if any) for capacity building funding from the SCN.
Q. You mentioned that this eventually would be phased into a risk-based kind of model. Is there still going to be pots of funding to fund the risk? Is Medicaid going to become a Value Based payor out of all this or do you have any indication of where this transitions to after the three years are up?
A. We do not know how to answer this in full. What the state is aspiring for is very lofty in terms of being able to achieve risk-based contracts for social care services in three years but the exciting part is that the NYS DOH desires to eventually include the class of social care services as part of the overall cost of health care moving forward for the Medicaid population. That is huge process if we can make inroads around that point during the waiver period because that means that we are one step closer to looking at individuals holistically as opposed to in silos and really getting to the root of the challenges that are causing these health disparities. This would be a huge process if we were able to operate in that way without risk. There has not been a lot of discussion about the vision for how risk is introduced, but we would not be looking to put our CBO members at risk of not being successful in that environment.
Q. What should we be asking ourselves as an organization to know or determine if this is something that we should pursue?
A. The most important preparation CBO can do is to 1.) understand if your organization desires to provide any of the HRSN services defined in the waiver and if yes, 2.) identify the actual cost for your organization to provide those services, on a per unit of service basis, so that when the fee schedule is defined, you can determine if the payment for those services will cover your expenses.
Q. Is there additional information about payment for these enhanced services?
A. The fee schedule is determined by the state and has not been released. The lead SCN will be receiving the PMPM from the MCO’s and organizations will be paid through the social care network lead entity.
Q. How will these services overlap or work with existing services, like OPWDD?
A. For OPWDD, you would be a referral agent and a recipient for referrals for individuals who are not yet connected with those services. The way we are reading the NYSHER waiver right now, it looks very similar to how the Care Coordination Organizations (CCOs) are structured. We are envisioning a cooperative collaborative approach to delivering services for specific subsets of population identified in this waiver. There is reference to person-centered planning which, as those who have worked with OPWDD know, is at the core of their service model.
Q. How are high risk individuals determined?
A. NYS DOH determined high risk based on 11 qualifying conditions for individuals who will be eligible for enhanced HRSN services. The below determination was provided in the Social Care Network RFA that was released by the state.
If a member is enrolled in Medicaid Managed Care, screens positive for an unmet HRSN and meets one of the following criteria:
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- Medicaid High Utilizer (defined by Emergency Department, Inpatient, or Medicaid spend or transitioning from an institutional setting).
- Individuals enrolled in a designated Health Home which currently includes HIV/AIDS, Serious Mental Illness, Sickle Cell Disease, Serious Emotional Disturbance or Complex Trauma (children only), or those with two or more chronic conditions (e.g., diabetes and chronic obstructive pulmonary disease).
- Pregnant Persons/up to 12 months Postpartum.
- Post-Release Criminal Justice-Involved Population with serious chronic conditions, SUD, or chronic Hepatitis-C.
- Juvenile justice involved, foster care youth, and those under kinship care.
- Children under the age of 6.
- Children under the age of 18 with one or more chronic condition.
- Substance Use Disorder.
- Intellectual or Developmental Disability (I/DD).
- Serious Mental Illness.
Q. Do fresh produce and non-perishable groceries have to be medically tailored or approved by a registered dietitian? I am not reading it, but I want to verify. Also, are frozen and refrigerated foods other than produce included here (such as lean meats, low fat dairy products)?
A. The medically tailored and dietician requirements are not specified with the pantry stocking service description as provided in the NYSHER waiver approval document. However, there will be a SCN Program Manual provided at some point that may indicate additional requirements and definitions for services.
Questions about Regional Definitions
Q. Will CCN be doing two applications so Chemung, Schuyler and Steuben can be included? Does that mean partnering opportunities will be impacted moving forward if CCN becomes a SCN and these counties are not included?
A. We will be applying to be the Social Care Network (SCN) lead for the Southern Tier region. We are developing a strategy to continue to support the four counties that were removed from the historical Southern Tier region from the previous DSRIP waiver and will provide updates as this develops.
Q. I am in the Finger Lakes Region, and we were reorganized from being a CCN location from the 1115 Waiver and my biggest question when it comes to the IT structure, is this specifically for partners in the CCN region? Is there opportunity for us to collaborate?
A. Yes, this is for all of our original DSRIP partners across our 9-county region that we are already working with as part of the Open Network and this will support all of our current members in the Open Network.
Q. I have been wondering what the CCN Board decided about the counties that were not included in the region (including Steuben, Cortland, Schuyler and Chemung)?
A. We are developing an approach to advocate to continue to serve these counties. The Board of Directors has not finalized an approach yet, but we are likely to make some form of request to get the counties back.
Questions about Care Compass’ Approach
Q. Will you be reaching out early to get the invoicing process up and running?
A. If we are selected as the SCN for the Southern Tier region, we will do everything within our ability to expedite implementation of required infrastructure to support a successful approach to the NYSHER waiver activities.
Q. What do you see as the relationship between CCS IPA and the waiver. Especially if a CBO is already doing the paperwork to get up and running under CCS IPA will that paperwork.
A. One of the goals of the waiver is to build a regional social care network to provide screening, navigation, and Health Related Social Needs (HRSN) services to an eligible population which is aligned with the purpose and intent of Care Compass Supporting IPA (CCS IPA). While CCS IPA does not meet the minimum requirements to apply to be the SCN lead for the waiver, Care Compass Collaborative (CCC) does and will apply to be the SCN lead in the southern tier region. Given CCC is the sponsoring entity of CCS IPA, we will be able to use the work that has been occurring over the last several months with CCS IPA to help manage the SCN. Even if CCC is not selected to be the lead SCN for the Southern Tier, we will continue to work collectively to integrate and strengthen clinical and social care interventions and services, thereby minimizing the health and social inequities to promote access, connection, inclusion, and the well-being of our community.
Q. Is CCN planning on applying for the waiver? It seems right in line with your goals.
A. Yes, we will be applying to serve as the Social Care Network for the Southern Tier region.
Q. For the SCN application, will you need to form partnerships with CBOs during the application, or will you be doing that during contract development if awarded the contract?
A. No. However, we have distributed letters of intent for organizations that wish to participate in the SCN, should we be awarded the role. These letters of intent will be non-binding.
Q. Do you see CCN having a decisive process in rationing the resources that you have? Will CCN be the one to say we don’t want to spend too much in this area? How will that work?
A. For Health Related Social Needs, there is $3.2B allocated across the state so in our estimation, that approximates to about 60 million dollars. Funding for the Southern Tier region as its currently defined over 3 years for delivery of those services. We have not had any planning on how to strategically coordinate services. One service line doesn’t dominate above another service line. It seems like we will be given a budget and a spending strategy relative to that budget.
Q. Who will be vetting the IT Platform Solution RFI applicants? Will partners be part of that process?
A. RFI’s submitted in response to the Care Compass Network IT Platform Solution request will be reviewed by committees that will consist of both member organizations, IT Committee Members, and CCN staff.