CMS Letter of Completeness

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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-25-26
Baltimore, Maryland 21244-1850
State Demonstrations Group

October 25, 2023

Amir Bassiri
Medicaid Director, Deputy Commissioner
New York Department of Health
Empire State Plaza, Corning Tower, Room 1466
Albany, NY 12237

Dear Deputy Commissioner Bassiri:

The Centers for Medicare & Medicaid Services (CMS) approved the Evaluation Design for New York's Reasonable Opportunity Period COVID-19 Public Health Emergency (PHE) amendment to the section 1115 demonstration entitled, "New York Medicaid Redesign Team" (Project No: 11- W00114/2). We sincerely appreciate the state's commitment to efficiently meeting the requirement for an Evaluation Design as was stipulated in the approval letter for this amendment dated October 28, 2022, especially under these extraordinary circumstances.

In accordance with 42 CFR 431.424(c), the approved Evaluation Design may now be posted to the state's Medicaid website within 30 days. CMS will also post the approved Evaluation Design on Medicaid.gov.

Consistent with the approved Evaluation Design, the draft Final Report will be due to CMS 18 months after the expiration of the amendment approval period.

We sincerely appreciate the state's commitment to evaluating the Reasonable Opportunity Period COVID-19 PHE amendment under these extraordinary circumstances. We look forward to our continued partnership on the New York Medicaid Redesign Team section 1115 demonstration. If you have any questions, please contact your CMS demonstration team.

Sincerely,

Danielle Daly Director
Division of Demonstration Monitoring and Evaluation

cc: Melvina Harrison, State Monitoring Lead, CMS Medicaid and CHIP Operations Group

Prepared for New York State Department of Health by the Public Consulting Group
July 7, 2023

Public Consulting Group

BACKGROUND

The Centers for Medicare & Medicaid Services (CMS) developed a new section 1115(a)(2) demonstration opportunity to allow states to extend the Reasonable Opportunity Period (ROP) during the transition out of the COVID-19 Public Health Emergency (PHE) and during the unwinding period for individuals who declared to U.S. citizenship at the time of Medicaid application. New York's demonstration application submitted on June 8, 2022 was approved in October 2022, and this amendment will test, in the context of the COVID-19 PHE unwinding period, how the expenditure authority to provide coverage beyond the statutorily limited 90-day ROP for individuals who have declared U.S. citizenship, but for whom that status has not been verified, will support state's management of workload during the unwinding period in a manner that promotes continuity of coverage and reduces barriers to care, in line with the objectives of the Medicaid program.

Specifically, the state will extend the 90-day reasonable opportunity period for individuals who have had Medicaid benefits maintained during the PHE, in compliance with the continuous enrollment provision of the Families First Coronavirus Response Act (FFCRA), without a full eligibility determination and whose eligibility rests on verification of their U.S. citizenship.

During the demonstration, the state will continue to make a good faith effort to verify and if needed following a determination of eligibility, provide a 90-day reasonable opportunity period for individuals to furnish documentation of their U.S citizenship throughout the unwinding period. This approach will also facilitate an orderly redetermination process by allowing the state time to review a volume of up to approximately 59,000 documents more evenly over a 12-month period, rather than attempting to undertake this activity in the months following the end of the PHE declaration.

The above flexibility is expected to support the state's efforts to maintain beneficiary access to care, and to facilitate meeting any alternative or additional objectives specified by the state in its requests for the demonstration authority.

DEMONSTRATION GOALS

The purpose of the demonstration is to furnish medical assistance in a manner intended to protect, to the greatest extent possible, the health, safety, and welfare of individuals and providers who may be affected by COVID-19.

The specific goals are:

  1. To maintain beneficiary access to care during the unwinding period
  2. To facilitate the management of the workload to conduct redeterminations during the unwind period

The target population for this demonstration is current title XIX State plan beneficiaries who have had Medicaid benefits maintained during the PHE, in compliance with the continuous enrollment provision of the Families First Coronavirus Response Act (FFCRA), without a full eligibility determination and whose eligibility rests on verification of their U.S. citizenship.

EVALUATION QUESTIONS AND HYPOTHESES

Research Question 1: Did the demonstration support beneficiary access to care during the unwinding period?

Hypothesis 1a: The demonstration will minimize inappropriate terminations of coverage during the unwinding period.

Measure: Percent of Medicaid members who are terminated due to failure to supply documentation of citizenship within 90 days.

Hypothesis 1b: The demonstration will promote accurate determinations of eligibility.

Measure: Percent of Medicaid members eligible for extended ROP who are verified as US citizens.

Research Question 2: Did the demonstration facilitate the management of the workload to conduct redeterminations during the unwind period?

Hypothesis 2a: The demonstration will promote a manageable distribution of redeterminations.

Measure: Number of postponed redeterminations completed each month across the 12 months following the end of the PHE.

Hypothesis 2b: The demonstration will improve member experience for renewals during the unwind period.

Measure: The ease with which individuals can get through to customer service (e.g., calls answered, call center wait time, or average call handling time).

METHODOLOGY

Data sources

Aggregated enrollment and eligibility data will be obtained from the Welfare Management System from local districts and the NY State of Health The Official Health Plan Marketplace (NYSOH).

Qualitative data will be obtained through document review of implementation reports and other artifacts, and key informant interviews with implementing agency staff. These data will be used to add context and to build a narrative documenting challenges and successes in implementation.

Analysis

Because the ROP extension is a time-limited policy tied to the PHE and unwinding period, the demonstration will be treated as a single intervention. Comparisons will focus on subgroups within the member population, rather than across time.

Quantitative data will be analyzed using standard methods for rates, proportions, frequencies, and measures of central tendency (e.g., mean, median, mode). Results will be stratified by age, sex, race/ethnicity, preferred language, and region. Hypothesis tests such as t-tests, chi-squared, and Fisher's exact test will be used to compare subgroups. For each factor, the largest group will serve as the reference. The null hypothesis will be no difference among subgroups.

Qualitative data will be analyzed thematically, using qualitative coding of transcripts and documents. Themes will be derived prospectively from the research questions and added empirically as they emerge from the data.

METHODOLOGICAL LIMITATIONS

  1. Data Availability The main data source will be enrollment and eligibility data generated during the unwinding and redetermination process. Some metrics may not be available for both local districts and NYSOH. Individual level data will not be available, limiting the analyses that can be performed. Quasi-experimental methods are not feasible, but the IE will be able to compare subgroups as described, and report on any differences in ROP outcomes among demographic groups. Qualitative analysis will provide narrative context to support findings regarding the demonstration's success in accomplishing its goals.
  2. Lack of comparison group The ROP demonstration covers a historically unique time period, where care delivery and utilization were disrupted, and an unprecedented backlog of redeterminations developed, making comparisons to previous time periods inappropriate. Comparisons will be made among subgroups of NY Medicaid members, but with the caveat that the differential impact of the PHE is likely to drive observed differences, particularly by age, race/ethnicity, and region. Rather than treat this as confounding, the IE will seek to interpret findings carefully, and provide insight on how the PHE impact influenced members' outcomes during redetermination, in support of the states' health equity goals.

TIMELINE

Milestone/Deliverable Date
ROP demonstration begins March 1, 2023
ROP demonstration ends June 30, 2024
Data collection and analysis January 1, 2024 - June 30, 2025
ROP Evaluation Report due December 31, 2025