Summary of New York 1115 Medicaid Redesign Team (MRT) Waiver Amendment

Office for People with Developmental Disabilities

August 31, 2017

• Summary is also available in Portable Document Format (PDF)

New York´s amendment to its current 1115 MRT Waiver will create a model of care that integrates the delivery of care and enables qualified Specialized Intellectual and Developmental Disabilities (I/DD) plans (SIPs) throughout the State to meet the needs of individuals with Intellectual and Developmental Disabilities (I/DD). This amendment, to be effective January 1, 2018, requires approval from the Centers for Medicare & Medicaid Services (CMS).

The goal to integrate the delivery of care for individuals with intellectual and developmental disabilities, referred to as the I/DD population, and will begin with the enrollment into Health Homes in 2018. Consistent with the approved 1115 waiver, all individuals utilizing I/DD Targeted HCBS services will have a person–centered Life Plan. Concurrently with the submission of this waiver amendment, the State will also be submitting a State Plan Amendment (SPA) to expand the Health Home eligibility criteria to include I/DD conditions.

The transition of the I/DD population to managed care will initially occur on a voluntary enrollment basis with the establishment of SIPs. These plans–which will initially be formed by experienced I/DD providers (called SIPs – Provider Led [SIPs–PL]), or which will later be offered as a separate line of business by Mainstream Medicaid Managed care (MMMC) plans (called Specialized I/DD plans–Mainstream [SIPs–M])–will receive a capitated payment for all covered State Plan services and an additional non–risk payment for I/DD residential services and I/DD Targeted Home and Community–Based Services (HCBS).

In addition, MMMC plans not offering a SIP–M will be required to comply with basic I/DD requirements for any I/DD population choosing to remain in MMMC following mandatory enrollment. This population includes those individuals already enrolled in managed care and those whose families are already in MMMC and newly entering Office for People with Developmental Disabilities (OPWDD) HCBS services under this 1115 waiver.

This 1115 MRT Waiver Amendment reflects an anticipated timeline for implementation that begins January 1, 2018 and runs through January 1, 2024. Depending on the timeframes for acquiring any necessary approvals, these dates may be modified accordingly. The provisions of the 1115 MRT waiver amendment are part of a package of reform and redesign initiatives, including the submission of a concurrent amendment to the current State Plan for Health Homes to incorporate I/DD–specific criteria. Members receiving I/DD Targeted HCBS services will receive Health Home care management. OPWDD will also end date the current Comprehensive 1915(c) waiver to close out the waiver.

The timely and collective implementation and approval of the 1115 MRT Waiver amendment and State Plan Amendment is necessary to ensure that all persons in New York receive comparable services under the 1115 MRT Demonstration Waiver. Because these services permit the delivery of Health Home services consistent with CMS guidance, the approval of the State Plan Amendment is linked to the approval of this 1115 MRT Waiver amendment and ensuring that comprehensive coordination of physical health and behavioral health within Health Homes as well as appropriate utilization review of services. The Health Home program, which will begin enrolling persons with I/DD on July 1, 2018, is also an integral part of the implementation of the overall MRT Redesign Plan.

Medicaid Service Changes →

• Enrolling persons with I/DD in Health Homes
• Transitioning Targeted I/DD HCBS to Demonstration
• Offering CFCO service for eligible Family of One children
• Including previously excluded services in plans

Specialized I/DD Plans (SIPs) →

• Allowing voluntary enrollment in SIPs–PL
• Offering non–risk Targeted I/DD HCBS and residential services in SIPs initially
• Including previously exempted/excluded populations
• Mandating dual eligibles with I/DD to enroll in SIPs

Mainstream Medicaid Managed Care →

• Allowing mainstream plans to offer SIPs–M for mandatory populations
• Requiring mainstream plans not offering a SIP–M to comply with basic I/DD requirements

In addition, the amendment will:

• Include populations under the 1115 MRT Demonstration Waiver that were previously exempted or excluded including:
  • Working individuals with disabilities who buy into Medicaid – TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act
  • Working individuals with disabilities who buy into Medicaid–TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act
  • Optional State supplement recipients
  • Other specified groups (including statutory/regulatory reference to reflect the additional groups in the State Plan that may receive services under this waiver)
  • Individuals who qualify under 1902(a)(10)(A)(i)(II)(bb)(Qualified Severely Impaired)
  • Disabled Adult Children (DAC) beneficiaries who are eligible under 1634(c) of the Act
  • Dual eligibles receiving OPWDD services¹

Table 1 reflects the delivery system that will be utilized in the 1115 MRT Demonstration Waiver for each eligibility group that participates in the Demonstration, as well as the appropriate authority authorizing the delivery system.

Table 1: Delivery system

Delivery System Chart Eligibility Group	Delivery System	Authority
Individuals with I/DD not otherwise excluded or exempt from MMMC I/DD	MMMC or Specialized I/DD managed care plan – MCO. Health Home Care Management or the State Independent Entity if the individual declines Health Home care management.	1115 MRT Demonstration and State Plan
Individuals with I/DD excluded or exempt from MMMC, including those receiving I/DD residential services and I/DD Targeted HCBS	FFS and Health Home care management, or care management by State Independent Entity if the individual declines Health Home care management.	1115 MRT Demonstration and State Plan

The initial enrollment under the demonstration will be FFS with a voluntary phase–in to SIPs–PL followed by a phase–in of mandatory enrollment in SIPs or remaining in MMMC. The exemption and exclusion of I/DD individuals from managed care currently in the 1115 MRT Demonstration waiver will be eliminated:

• Individuals who are exempt or excluded from MMMC enrollment will be included in the Demonstration in the FFS Medicaid delivery system until the point they will transition to a SIP.
• Dually eligible individuals not participating in the I/DD FIDA Demonstration and receiving I/DD Targeted HCBS will be included in the Demonstration in the FFS Medicaid delivery system until the point they will transition to a SIP.
• Dually eligible individuals participating in FIDA will remain in the FIDA plans for the duration of the FIDA Demonstration.

Table 2 reflects the proposed implementation schedule.

Table 2: Phase–in schedule

Phase	Timing	Description
Phase 1	1/1/2018	I/DD Targeted HCBS, I/DD residential services and I/DD populations are moved under the Demonstration
Phase 2	July 2018	I/DD populations receiving I/DD Targeted HCBS and eligible I/DD residential services will transition to Health Homes. Early adopter SIPs–PL may begin voluntary enrollment in late 2018.
Phase 3	2019	Downstate2 –Voluntary Enrollment in SIPs–PL
	2020	Rest of State–Voluntary Enrollment in SIPs–PL
Phase 4	2021	Downstate–Mandatory Enrollment in plans
	2022	Rest of State–Mandatory Enrollment in plans
	2023	Downstate–Capitated at–risk I/DD residential services and risk contracting for I/DD Targeted HCBS
	2024	Rest of State–Capitated at–risk I/DD residential services and risk contracting for I/DD Targeted HCBS

Table 3 reflects the comprehensive benefits for persons enrolled in the Demonstration and receiving CFCO resulting from the amendment, as well as already covered under the State Plan.

Table 3: Benefit Package Chart

Eligibility Group	Benefit Package
Individuals not meeting HCBS targeting criteria and institutional LOC.	All State Plan services. Individuals in MMMC plans including all SIPs will receive Demonstration services (licensed behavioral health practitioner, crisis intervention, and outpatient and residential addiction).
Individuals meeting HCBS targeting criteria and institutional LOC.	All State Plan services including CFCO services; Targeted I/DD HCBS Individuals in MMMC, including all SIPs, will receive Demonstration services (licensed behavioral health practitioner, crisis intervention, and outpatient and residential addiction services).

Persons exempted or excluded from MMMC and HIV SNP will receive the State Plan and HCBS benefits via the FFS delivery system. Individuals in MMMC plans prior to the MMMC plans offering I/DD services will continue to receive their I/DD Targeted HCBS or other services that have not transitioned to managed care through FFS until the MMMC plan contracts are modified.

New York will provide IDD Targeted HCBS to individuals meeting the targeting criteria and institutional LOC if medically necessary and listed on the individual´s person–centered HCBS Plan of Care (Life Plan), including:

• Habilitation
  • Residential
  • Day
  • Community
  • Prevocational (site–based and community)
  • Supported Employment
  • Pathway to Employment
• Respite
• Adaptive Devices – Assistive Tech (CFCO)
• Environmental Modifications
• HCBS care management
• Family Education and Training
• Services to Support Self Direction
• Fiscal Intermediary
• Support Brokerage
• Individual Directed Goods and Services
• Community Transition Services (CFCO)
• Live–in Caregiver
• Intensive Behavioral Support
• Vehicle Modification (CFCO) (Pending CMS approval–Amendment 1)

Individuals meeting institutional LOC criteria, who also meet CFCO eligibility and who are eligible for Medicaid under community eligibility rules, will be eligible for CFCO services under the State

Plan. Individuals eligible for Medicaid under Family of One institutional rules, who also meet CFCO eligibility, will be eligible for CFCO services under the 1115 Demonstration:³

• Assistive Technology
• Community Transitional Services
• Durable Medical Equipment/Medical Supplies
• Environmental Modification
• Community Habilitation
• Supervision and/or Cueing
• Home Delivered/Congregate Meals
• Home Health Care (Aide)
• Homemaker/Housekeeper
• Moving Assistance
• Personal Care/Consumer Directed Personal Assistance Program
• Personal Emergency Response
• Transportation – Non–Emergency, Medical
• Transportation – Non–Emergency, Social
• Vehicle Modification

See Table 4 below for the current I/DD waiver, ICF and other I/DD populations enrollment in Federal Fiscal Year (FFY) 2015.

Table 4: Current Enrollment in Federal Fiscal Year (FFY) 2015 (in Member Months)

Population	Approximate Current Individuals	FFY 2014/2015 Member Months
OPWDD Comprehensive waiver (#NY–0238)	75,483	880,086
OPWDD ICF Residents	6,700	80,400
Other I/DD	26,300	315,600
Total	108,483	1,276,086

These counts include approximately 20,000 individuals already in MMMC. It is not anticipated that an unserved population exists and will become Medicaid eligible under the Optional Population in this amendment.

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^{1 With the discontinuation of the 1915(c) Comprehensive waiver (#NY.0238), the 1115 MRT Demonstration Waiver will become the HCBS authority for the I/DD Fully Integrated Duals Advantage (FIDA) Demonstration. Any reference to Dual Eligibles in this 1115 MRT Waiver Amendment includes the I/DD FIDA Demonstration participants and their costs. I/DD FIDA Plans may have a separate line of business to offer a SIP–PL under this 1115 MRT Demonstration. 1
2 For ease of reading the regional phase–in schedule is referred to using Downstate and Rest of State in this application. Other regions may be phased in when access is assured. 2
3 Each individual eligible for HCBS under both CFCO and I/DD Targeted HCBS will have limits to each service being the greater of either benefit not the sum of the two benefits together. 3}