F-SHRP Waiver DD Transformation Amendment - April 2013


NUMBER:        11-W-00234/2

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

AWARDEE:      New York State Department of Health

Under the authority of section 1115(a)(2) of the Social Security Act (the Act), expenditures made by New York for the items identified below, which are not otherwise included as expenditures under section 1903 shall, for the period beginning April 1, 2013 through March 31, 2014, be regarded as expenditures under the State´s title XIX plan.

The following expenditure authorities shall enable New York to implement the approved Special Terms and Conditions (STCs) for the Federal-State Health Reform Partnership Medicaid Section 1115 Demonstration. The expenditure authorities authorize New York to claim federal funding as medical assistance for the following demonstration costs.

  1. Twelve-Month Continuous Eligibility Period. Expenditures for health-care related costs for individuals specified in Table 4 of paragraph 16(c) of the STCs for continued benefits during any periods within a twelve-month eligibility period when these individuals would be found ineligible if subject to redetermination.
  2. Dual-Eligible Appeals. Expenditures for capitation payments provided to managed care organizations (MCOs) which restrict enrollees´ right to pursue a Medicaid grievance, as designated under section 1903(m)(2)(A)(xi) and section 1932(b)(4). MCOs participating in the Partnership Plan will be permitted to restrict a Medicare/Medicaid dual eligible who has voluntarily enrolled in an MCO from pursuing a Medicaid grievance procedure with an MCO, to the extent that the individual has already pursued a Medicare appeal for the same issue.
  3. Medicaid Eligibility Quality Control. Expenditures that would have been disallowed under section 1903(u) of the Act based on Medicaid Eligibility Quality Control (MEQC) findings as long as the State is operating the alternative MEQC program as specified in STC 17.
  4. Facilitated Enrollment Services. Expenditures for enrollment assistance services provided by organizations that do not meet the requirements of section 1903(b)(4) of the Act, as interpreted by section 438.810(b)(1) and (2). Inasmuch as these services may be rendered by MCOs and therefore included in the MCOs´ capitation payments, no expenditures other than these payments may be submitted for FFP.
  5. Designated State Health Programs Funding. Expenditures for designated state health programs which provide health care services to low-income or uninsured New Yorkers in an amount not to exceed the amount of monies the State expends over the demonstration period on the health system reform activities described in STC 37, except that in no case may expenditures exceed the amount that results in $1.5 billion in federal funding between the period of October 1, 2006 and March 31, 2014.
  6. Demonstration-Eligible Community Long Term Services and Supports Population. Expenditures for health-care related costs for individuals moved from institutional nursing facility settings to community settings for long term services and supports who would not otherwise be eligible based on income, but whose income does not exceed a more liberal income standard, and who receive services through the managed long term care program under this Demonstration.

Demonstration Approval Period: April 1, 2011 through March 31, 2014
Amended August 2012