F-SHRP Waiver September 2006

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NUMBER:        11-W-00234/2

TITLE:              Federal-State Health Reform Partnership Medicaid Section 1115 Demonstration

AWARDEE:      New York State Department of Health

All requirements of the Medicaid program expressed in law, regulation, and policy statement, not expressly waived in this list, shall apply to the Demonstration project beginning October 1, 2006, through September 30, 2011.

The following waivers shall enable New York to implement the approved Special Terms and Conditions (STCs) for the Federal-State Health Reform Partnership Plan Medicaid Section 1115 Demonstration.

1. Statewideness                                               Section 1902(a)(1)

  • To permit the exclusion of some counties in New York from participation in the mandatory managed care program.

2. Access to State Fair Hearing                       Section 1902(a)(3)

  • To relieve the State from the requirement to hold a duplicative Medicaid fair hearing on the same issue that is subject to a Medicare appeal for an individual dually eligible for Medicare and Medicaid who is voluntarily enrolled in a managed care organization (MCO).

3. Medicaid Eligibility and Quality Control     Section Section1902(a)(4)(A)

  • To enable New York to employ a Medicaid Eligibility and Quality Control System which varies from that required by law and regulation. New York is required to receive annual approval from CMS for its alternative MEQC program.

4. Freedom of Choice                                         Section 1902(a)(23)

  • To enable New York to restrict freedom-of-choice of provider for eligible beneficiaries enrolled in the mandatory managed care program under this demonstration.

5. Third Party Liability                                         Section 1902(a)(25)

  • To enable New York to delegate responsibility for pursuing third party liability to MCOs participating in the mandatory managed care program. New York will reduce all capitation rates by an actuarially appropriate amount, based on historic MCO-reported third-party liability collections, to reflect the average amount of funds that are expected to be recovered from third parties.

Demonstration Approval Period: October 1, 2006 through September 30, 2011