1915c Stakeholder Update for Comment

Children´s Medicaid System Transformation Update:
Overview of Draft 1915(c) Children´s Waiver Amendment

August 27, 2018

Today´s Agenda

Review of Current Status

  • On June 21, 2018, CMS advised the State it should use a concurrent 1915(c) and 1115 waiver to implement the Children´s Medicaid Redesign
  • On June 28, 2018, the State submitted to CMS a conceptual road map and timeline for implementing the concurrent waivers
  • Consistent with that timeline, on August 7, 2018, the State submitted a draft 1915(c) Children´s Waiver to CMS and posted the draft for public comment (focus of today´s discussion)
  • On August 23, 2018, the State has also submitted to CMS draft "Standards Terms and Conditions" for implementing amendments to the concurrent the 1115 Waiver
  • CMS is now reviewing draft documents
Draft, Preliminary Timeline Subject CMS Conceptual Agreement and Timely Approvals* Preliminary Draft Date*
Implement three of Six New State Plan Services* (Other Licensed Practitioner, Psychosocial Rehabilitation, Community Psychiatric Treatment and Supports) January 1, 2019
Transition to Health Home Begins January 1, 2019
1915(c) Children´s Consolidated Waiver, new array of HCBS in Managed Care, remove exemption and exclusion for 1915(c) Consolidated Waiver children from Managed Care** April 1, 2019
Implement Family Peer Supports State Plan Service July 1, 2019
Three–year phase in of Level of Care (LOC) July 1, 2019
Behavioral Health Benefits to Managed Care July 1, 2019
Foster Care Population to Managed Care July 1, 2019
Implement Remaining New State Plan Services – Youth Peer Support and Training and Crisis Intervention January 1, 2020
* Children and Family Treatment and Support Services
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Draft 1915(c) Children´s Waiver Posted for Stakeholder Review and Comment

  • The draft 1915(c) Children´s Waiver has been posted for stakeholder review and comment
  • Comments are due September 23, 2018, and can be submitted to BH.transition@health.ny.gov. Please indicate "1915(c) Children´s Waiver Comments" in the subject of the email
    • To help expedite review of comments and formal submission of 1915(c) Children´s Waiver Amendment, State would appreciate receiving comments as early as possible
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Achieving the Children´s Medicaid Redesign

  • Per direction of CMS the elements of the Children´s Design will be achieved under a different authority, i.e., the concurrent implementation of a 1915(c) Waiver and 1115 Waiver amendments
  • As proposed to CMS and subject to their approval, the concurrent waivers achieve all the elements of the Children´s Design
  • Some of the elements are achieved under the 1915(c) children´s waiver (e.g., combining aligned HCBS under a single 1915(c) waiver) and under the 1115 (e.g., authorizing the aligned HCBS to be included in Managed Care benefit package)
  • See webpage that provides summary of which authority, the 1915(c) or 1115, will achieve which element of the design
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High Level Overview of Draft 1915(c) Children´s Waiver

Structure of the Draft 1915(c) Children Waiver Sections

  • The structure of the 1915(c) is required by CMS (i.e., it is like an "application" that includes a specific set of requests for information) and includes the following Appendices (i.e., sections of the Waiver)
  • The structure follows the existing structure of the current six 1915(c) waivers for children (3 B2H, OMH SED, 2 CAH) that are being consolidated under the 1915(c) Children´s Waiver
    • Opening Section: Information and Purpose of Amendment, Summary of Appendices, State Assurances
    • Appendix A: Waiver Administration and Operation
    • Appendix B: Participant Access and Eligibility
    • Appendix C: Participant Services
    • Appendix D: Participant–Centered Planning and Service Delivery
    • Appendix F: Participant Rights
    • Appendix G: Participant Safeguards
    • Appendix H: Systems Improvement
    • Appendix I: Financial Accountability
    • Appendix J: Cost–Neutrality Demonstration
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Appendices A & B

A: Waiver Administration & Operation
  • Includes proposed effective date of April 1, 2019, consistent with proposed timeline reflected on slide three
  • Includes proposed HCBS Level of Care criteria and combines all six HCBS children´s waivers into a single authority
  • Establishes concurrent operation with 1115 MRT waiver
  • Establishes authority of Single State Medicaid Agency (oversight and monitoring will be done in collaboration with State Partners)
B: Participant Access and Eligibility
  • Establishes target groups for waiver, as well as specific target criteria for Serious Emotional Disturbances (SED), Medically Fragile LOC Population, Developmental Disability LOC Population who are Medically Fragile, and Developmental Disability LOC in or formerly in Foster Care
  • Establishes limitations on the number of participants served at any point in time and outlines the expansion of the number of participants over time (Capacity will be managed under Statewide list) – establishes the State will not apply an individual cost limit
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Appendix C

C: Participant Services
  • All services in current six 1915(c) waivers for children are authorized in the proposed 1915(c) Children´s Waiver or the State Plan.
  • Appendix C of the proposed 1915(c) Children´s Waiver includes service descriptions for the new aligned HCBS, including:
    • Caregiver/Family Supports and Services.
    • Respite.
    • Prevocational Services.
    • Supported Employment.
    • Community Self–Advocacy Training and Support.
    • Non–Medical Transportation.
    • Adaptive and Assistive Equipment.
    • Accessibility Modifications.
    • Palliative Care – Expressive Therapy
    • Palliative Care – Pain and Symptom Management
    • Palliative Care – Bereavement Service
    • Palliative Care – Massage Therapy
    • Community Habilitation
    • Day Habilitation
  • Includes new and separate definitions for "Community Habilitation" and "Day Habilitation" services. This will ensure that:
    • There is continuity of care for habilitation services that are provided today (i.e., under B2H),
    • There are clear definitions for the services of Community Habilitation and Day Habilitation services and services are described in a manner that meets CMS requirements for a 1915(c) Waiver submission
    • Service descriptions align with the implementation of Community First Choice Option State Plan services, that will include "Community Habilitation"
  • A Webinar was held on August 21, 2018, for providers that were designated under Children´s HCBS designation process as a "habilitation" provider to provide information and guidance on how their designations will be updated to reflect the two new service definitions.
  • Includes provider qualifications for each HCBS services
  • Provides children receiving HCBS will be enrolled in and receive care management from the Health Home program authorized under the existing Health Home State Plan, provides alternative for children that may opt out of Health Home (i.e., independent entity)
  • Specifies that criminal background checks and Statewide Central Register checks are required (also reflects new 2018 statute for HCBS and Health Home care managers)
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Appendix D

D: Participant–Centered Planning and Service Delivery
  • Assigns responsibility for Service Plan Development
    • Health Home Care Manager, Independent Entity for children opting out of Health Home
  • Establishes the Health Home will comply with Conflict Free Case Management Standards
  • Describes the Service Plan Development Process
    • Eligibility Evaluation/Assessment
    • Plan of Care Development
    • Plan of Care Update
    • Case Records Maintenance
  • Service Plan (POC) Implementation and Monitoring
    • Monitoring Safeguard: Entities and/or individuals that have responsibility to monitor service plan implementation and participant health and welfare may not provide other direct waiver services to the participant

Appendices F & G

F: Participant Rights
  • Establishes an applicant/participant´s right to a Fair Hearing
  • Indicates that the State operates an additional dispute resolution process, including external appeal by an independent reviewer
  • Describes the State operated grievance/complaint system
G: Participant Safeguards
  • Describes the response to Critical Events or Incidents
    • Most children will be monitored and served by MCOs, who are required to train clinical staff on reporting and monitoring requirements within 30 days of hiring
    • For FFS children, the HHCM/IEIE will be responsible for this process
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Appendix H

H: Systems Improvement
  • Describes the Quality Improvement Strategy in effect during the waiver
  • Established Interagency Monitoring Team (IMT)
  • The IMT is chaired by NYSDOH staff with representation from State children´s licensing, certification, designation and service agencies (OMH, OASAS, OCFS and OPWDD) will collect the reports outlined in the waiver application with review at least quarterly.
  • An interagency agreement (under development) will outline oversight roles of IMT partners.
  • NYSDOH and the IMT committee holds the primary responsibility for monitoring and assessing the effectiveness of system and programmatic design changes to determine if the desired effect has been achieved
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Appendices I & J

I: Financial Accountability
  • Statewide audits are conducted by the Office of the State Comptroller (OSC), the Office of the Attorney General (AG), the Department of Health, and the Office of the Medicaid Inspector General
  • For fiscal report beginning April 1, 2019, and thereafter, Non–State operated fee–for–service providers are required to file an annual fiscal report to the State within 120 days (150 with a requested extension) following the end of the provider´s fiscal reporting period
J: Cost Neutrality
  • Demonstrates the Waiver is Cost Neutral
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Next Steps

  • State will review and incorporate Stakeholder feedback and formally submit 1915(c) Waiver to CMS – anticipated date October 1, 2018
  • To keep process moving, State and CMS will continue to work on draft documents
  • The State will send periodic email updates on the status of implementation, upcoming trainings, and other helpful information to be responsive to stakeholders
    • These will be distributed through the MRT Listserv, Children´s Managed Care Listserv, Health Home Listserv, and to MMCP contacts
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Questions and Discussion

Updates, Resources, Training Schedule and Questions

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