By OPEN MINDS Circle
On September 8, 2022, the New York Department of Health (DOH) submitted a Medicaid waiver amendment to the Centers for Medicare & Medicaid Services (CMS). The state requested $13.5 billion over five years to fund the waiver, which includes two new provider organization types: Health Equity Regional Organizations (HEROs) and Social Determinants of Health Networks (SDHNs). It also funds value-based payment (VBP) initiatives.
Health Equity Regional Organizations
HEROs will build coalitions with managed care plans, local health departments, hospitals and health systems, community-based providers; providers of long-term services and supports (LTSS), including those who serve individuals with intellectual/developmental (I/DD) or physical disabilities, community-based organizations (CBOs) organized through SDHNs, Qualified Entities (QEs), consumer representatives, and other stakeholders. Each regional HERO would receive planning grants and data from a variety of sources and use these resources to develop a range of VBP models or other interventions to meet regional needs. For HEROs, the state requested $293 million over five years. Spending in the first year would be $32.5 million to factor in time for HERO procurement, and spending would be $65 million annually thereafter.
Social Determinants of Health Networks
SDHNs will function as independent practice associations composed of networks of CBOs in a given region. The SDHNs will organize delivery of social services and VBP arrangements to support them. The cost of the SDHN per region includes the initial infrastructure, staffing, coordination of CBOs, capacity building of CBOs, and contracting. For SDHNs, the state requested $833 million over five years. Accounting for the time it will take to procure the SDHNs, funding in the first year would be $92.5 million, and would be $185 million in each subsequent year. Funding will be distributed to the awarded lead SDHN entities in each designated region.
Value-Based Payment
The state proposed creating the coronavirus disease 2019 (COVID-19) Unwind Quality Restoration Pool that would be available to financially distressed safety net and critical access hospitals and nursing homes that have a high Medicaid payer mix. The VBP funds will flow through the state’s Medicaid managed care organizations to support advanced VBP arrangements with the facilities to facilitate post-pandemic quality improvement. The state requested $1.5 billion, with $1 billion for quality improvement and health equity-related initiatives, and $500 million for workforce training. The funds will be available to safety net and critical access hospitals and nursing homes for the following activities:
- Initiatives to improve quality and promote health equity through VBP arrangements that are consistent with the waiver amendment goals.
- Workforce training, developed in collaboration with workforce investment organizations, to support quality improvement initiatives, pandemic-related needs such as cross training of staff (consistent with their scope of practice) to enable cross-coverage between inpatient and ambulatory care settings and health equity work. The initiatives can also target recruitment and retention, strengthening career pathways for entry-level frontline worker, helping workers obtain certification and licensure, expanding the community health worker and related workforce, and standardizing occupations and job training.
- Interventions to support health equity and population health improvement goals. The hospital and nursing home proposals should align with priorities identified by the HEROs and SDHNs in their region to complement and align with the regional needs, health inequities, chosen target populations, and targeted interventions.
Starting January 1, 2023, the first waiver year, DOH intends to update its VBP Roadmap. The advanced VBP arrangements focused on health equity and social care will begin during the first waiver year. One of the state’s five waiver goals relies on VBP arrangements. The DOH believes that establishing the HEROs, SDHNs, and advanced VBP arrangements will result in universal screening for social needs which will increase referrals to CBOs. To measure progress, DOH will monitor health plan data for performance on a HEDIS quality measure related to social need screening and intervention.
Other Initiatives
The waiver included requests for additional funding streams. To ensure Medicaid access for criminal justice-involved populations, the state requested $748 million to provide additional in-reach Medicaid services. For the enhanced transitional housing initiative, the state requested $1.57 billion over five years to fund community transitional services, tenancy supports, and medical respite programs. To support the telehealth provisions, the state requested $300 million to create an Equitable Virtual Care Access Fund and invest in telehealth initiatives.
Implementation Timeline
Most provisions of the waiver amendment will begin immediately on January 1, 2023. The HEROs and SDHNs will require additional time for procurement and set up, and the advanced VBP arrangements informed by these entities.
- In Year One: the state will procure the regional HEROs and SDHNs. The VBP Roadmap will be updated, and advanced VBP arrangements focused on health equity and social care will launch. The HEROs will begin housing assessments. Pre-release services for the criminal-justice involved populations will begin. Transitional housing services begin. Workforce investments begin. Telehealth investments begin.
- In Year Two the SDHNs will contract with CBOs. Training to build CBO capacity will begin.
- By Year Three, all provisions of the waiver amendment will be operational. The evaluation will measure performance from Years 2-5.
For more information, contact: Jonah Bruno, Director of Communications, New York State Department of Health, Empire State Plaza, Corning Tower, Albany, New York 12237; Email: dohweb@health.ny.gov; Website: https://www.health.ny.gov/health_care/medicaid/redesign/medicaid_waiver_1115 (scroll to the Amendments section)