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

May 8, 2017

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

To seek authorization from the Centers for Medicare & Medicaid Services (CMS) effective January 1, 2018, New York has drafted an amendment to its current 1115 MRT Waiver to create a children´s model of care that:

  • Enables qualified managed care organizations (MCOs) throughout the State to comprehensively meet the needs of children and youth under 21 years with behavioral health (BH) and home– and community–based services (HCBS) needs, including HCBS for medically fragile children, children with a BH diagnosis and children in foster care (FC) with these needs that will transition to managed care including FC children with developmental disabilities.
  • Ensures there is equitable access to the MCO and HCBS benefit packages driven by need and acuity.
  • Ensures that children, including those with co–morbid conditions, receive care according to their assessed needs not in the system in which they receive care.
  • The draft MRT Waiver Amendment for Children reflects an anticipated timeline for implementation that begins July 1, 2018 and runs through July 1, 2020. Depending on the timeframes for acquiring any necessary approvals, these dates may be modified accordingly. The provisions of the draft 1115 MRT Waiver are part of a package of children´s reform and redesign initiatives which includes two separately proposed State Plan Amendments (SPAs) to implement six new State plan services, and collectively constitutes the MRT Children´s Redesign Plan. A seventh State Plan amendment, which is related to the transition of the foster care population included in the MRT Children´s Redesign Plan, will also be submitted at a later date.

The timely and collective implementation and approval of the State Plans and Demonstration amendment is necessary to ensure that all children in New York receive comparable services under the Demonstration. Because these services permit the delivery of community evidence– based practices consistent with CMS guidance, the approval of the State Plan Amendments is linked to the approval of this Demonstration amendment and ensuring that comprehensive coordination of physical health and behavioral health within Health Homes as well as appropriate utilization review over these new services within FFS and managed care occurs. The Health Home program, which began enrolling children on December 8, 2016, is also an integral part of the implementation of the overall MRT children´s Redesign Plan.

Medicaid Service Changes

  • Children enrolled in Health Homes
  • New Addiction Services
  • New Children´s State Plan Services
  • Residential Supports and Services

Mainstream Medicaid Managed Care

  • Including previously exempted and excluded populations
  • Including previously excluded services
  • Population Phase–in (Current eligible children, LON/FC Children)

Mainstream Medicaid Managed Care

  • Transition HCBS to demonstration
  • Single HCBS benefit package
  • Health Home care management for HCBS
  • Include new HCBS populations

In addition, the amendment will:

  • Transition the six New York children´s Section 1915(c) HCBS waivers to the 1115 Demonstration authority. Care management will be provided by Health Home for children, which was launched on December 8, 2016. Provide children´s HCBS through Medicaid managed care for children who are eligible. For children who are exempt or excluded from Medicaid managed care, children will continue to receive Medicaid services including HCBS through the Fee–for–Service (FFS) delivery system under the Demonstration (see Table 1).
  • Streamline children´s HCBS into a new benefit array and administration to have more consistent eligibility processes and benefits across all populations.
    • Provide Health Home care management for children eligible for HCBS.
    • Offer a single HCBS benefit package to all children meeting institutional Level of Care (LOC) functional criteria including offering State Plan Community First Choice Option (CFCO) services to children not eligible under the State Plan but who otherwise meet CFCO eligibility criteria.
  • Include in the Demonstration, medically needy children under age 21 (42 CFR 435.308) with income at or below the monthly income standard or spenddown if they are eligible for HCBS.
  • Expand HCBS to children at risk of institutionalization but not meeting institutional LOC functional criteria. These at–risk Level of Need (LON) HCBS do not include State Plan CFCO services.
  • Expand Medicaid eligibility for children with waived parental income and resources meeting at–risk HCBS LON targeting criteria, risk factors, and functional status to offer an HCBS benefit package identical to the HCBS package for other at–risk LON children under the Demonstration.

Table 1 reflects the delivery system that will be utilized in the Demonstration 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
Children not otherwise excluded from Mainstream Medicaid Managed Care (MMMC) or HIV Special Needs Plans (SNPs) including children in FC and/or receiving HCBS Managed care – Health Home Care Management or the MCO if decline Health Home care management. Note: HCBS Non–Medical Transportation (NMT) will be provided by the State´s transportation broker. 1115 Demonstration and State Plan
Children with HCBS exempted or excluded from MMMC or HIV SNPs FFS and Health Home care management or care management by State Independent Entity if Health Home care management is declined. Note: HCBS NMT will be provided by the State´s transportation broker. 1115 Demonstration and State Plan

Table 2 reflects the comprehensive benefit packages for children enrolled in the Demonstration and receiving CFCO resulting from the amendment, as well as already covered under the State Plan.

Table 2: Benefit Package Chart

Eligibility Group Benefit Package
Children not meeting HCBS targeting, risk factors and functional criteria All State Plan and Demonstration (Outpatient/residential Addiction, Crisis Intervention, and LBHP) services
Children meeting HCBS targeting, risk factors, and functional criteria for institutional LOC All State Plan services including CFCO services – Note: Family of One institutional LOC children will receive CFCO services under the Demonstration, 1115 HCBS children´s services (see Table 3) and Demonstration (Outpatient/residential addiction, crisis intervention, and LBHP) services
Children meeting HCBS targeting, risk factors and at–risk LON functional criteria All State Plan services (not eligible for CFCO services), 1115 HCBS children´s services (see Table 3) and Demonstration (Outpatient/residential addiction, crisis intervention, and LBHP) services

The State Plan behavioral health benefits listed below are a comprehensive list of behavioral health services in the MMMC and HIV SNP plans for children under age 21 who are not otherwise exempted or excluded from managed care enrollment. Children exempted or excluded from MMMC and HIV SNP will receive the State Plan and HCBS benefits via the FFS delivery system.

Table 3: Services from Attachment A of the Current 1115 MRT Waiver Standard Terms and Conditions

For individuals 21 and older Now also applicable to Children/Youth under age 21
State Plan Inpatient and Outpatient Behavioral Health Services in MMMCs for individuals 21 and older, excluding rehabilitation services for residents of community residences X
Clinic: Medically supervised outpatient withdrawal X
Clinic: Office of Alcoholism and Substance Abuse Services (OASAS) outpatient and opioid treatment program (OTP) services X
Rehabilitation: OASAS outpatient rehabilitation programs X
Clinic: Licensed clinic services (OMH services) X
Outpatient Hospital: Comprehensive psychiatric emergency program including Extended Observation Bed (EOB) X
Clinic: Continuing day treatment X (minimum age is 18 for medical necessity)
Clinic: Partial hospitalization X
Rehabilitation: Personalized Recovery Oriented Services X (minimum age is 18 for medical necessity)
Rehabilitation: Intensive Psychiatric Rehabilitation Treatment X
Rehabilitation: Assertive Community Treatment X (minimum age is 18 for medical necessity)
Targeted Case Management (being phased out) including Intensive case management/supportive case management X
Inpatient Hospital: Medically Managed detoxification (hospital based) X
Inpatient Hospital: Medically supervised inpatient detoxification X
Inpatient hospital: Inpatient treatment X
Inpatient Hospital: Inpatient psychiatric services X
Rehabilitation: Services for residents of community residences Note: these services are currently excluded from the BH integration. Will be phased into MMMC via contract amendments at a later date. X

Child Specific Behavioral Health services

The State Plan behavioral health benefits below are currently excluded from the BH integration and will be phased into MMMC plan via contract amendments at a later date for Children/Youth under age 21:

  • Children´s Day Treatment.
  • RTFs.
  • Inpatient and Outpatient BH Services in OMH operated facilities.
  • Residential Rehabilitation Services for Youth (RRSYs).
  • Teaching Family Home.

Table 4 reflects the CFCO, HCBS, and State Plan/Demonstration service packages included under the 1115 MRT Waiver amendment for children. The far–right column lists services newly created under the Demonstration and State Plan for children in the MRT initiative.

Table 4: Service Packages

Service CFCO1 for LOC Children Children´s 1115 HCBS2 Services for LOC and LON Children New SP/Demonstration3 Services
Caregiver/Family supports and services   X  
Community self–advocacy training and support   X  
Adaptive and assistive equipment Assistive Technology only X  
Community Psychiatric Support and Treatment.     New SP
Community transitional services X    
Crisis intervention     New SP4 /1115 Demonstration
Customized goods and services (and Financial Management Services for the pilot)   X  
Durable medical equipment/medical supplies X   SP
Environmental modification (Accessibility Modifications) X X  
Family Peer Support Services.     New SP
Habilitation Community only X  
Health Home   X  
Home–delivered/congregate meals X    
Home health care (aide) X   SP
Home modifications exceeding the limits in CFC (Accessibility Modifications)   X  
Homemaker/housekeeper X    
Home visits by medical personnel     SP
Moving assistance X    
Other licensed practitioner/licensed behavioral health practitioner     New SP/1115 Demonstration
Outpatient and residential addiction services     New SP/1115 Demonstration
Palliative Care including: family palliative care education (training); bereavement therapy; pain and symptom management; expressive therapy (art, music, and play); and massage therapy   X  
Personal care/Consumer Directed Personal Assistance program – can include regularly–scheduled relief care X   SP
Personal emergency response X    
Prevocational services   X  
Psychosocial Rehabilitative Supports     New SP
Rehabilitative services     New SP
Residential Supports and Services (i.e., FC residual)     New SP
Respite   X  
Substance use disorder outpatient and residential     New SP/1115
Supervision and/or cueing X    
Supported employment   X  
Transportation (Non–medical including social) Social only X  
Transportation (Non–emergency, medical) X   SP
Vehicle modification (Accessibility Modifications) X X  
Youth Peer Support and Training     New SP

Table 5: Current Children´s HCBS Waivers with Following Enrollment in Calendar Year (CY) 2014 (in Member Months)

Waiver CY2014 Member Months CY2014 Estimated Children*
OMH SED 1915(c) waiver (NY.0296) 20,266 2,027
B2H SED 1915(c) waiver (NY.0469) 34,054 3,405
CAH I/II 1915(c) waiver (NY.4125) 15,194 1,519
OPWDD CAH 1915(c) waiver (NY.40176) 4,548 459
B2H Medically Fragile 1915(c) waiver (NY.0471) 1,511 151
B2H DD 1915(c) waiver (NY.0470) 6,095 610
Total 81,668 8,167

* Assumes 10 months Average Length of Stay

Table 6: Projected Number of Unduplicated LON Member Months to be Served Annually (Specify for year one–five)5

Annual Period From To Projected Number of Community Eligible LON Member Months Estimated Number of Community Eligible LON Children* Projected Number of Family of One LON Member Months Estimated Number of Family of One LON Children*
Year 1/DY 19 4/1/2017 3/31/2018        
Year 1/DY 20 4/1/2018 3/31/2019 36,918 3,692 483 48
Year 2/DY 21 4/1/2019 3/31/2020 97,476 9,748 9,660 966
Year 3/DY 22 4/1/2020 3/31/2021 110,604 11,060 19,344 1,934
Year 4/DY 23 4/1/2021 3/31/2022 131,220 13,122 36,744 3,674

* Assuming 10–month Average Length of Stay

Table 7: Current Children's HCBS Waivers in CY2014 compared to future enrollment projected for DY23 (April 1, 2021 – March 31, 2022)

HCBS Population Children´s Member Months Served in HCBS Waivers Prior to Demonstration in CY2014 Estimated Children Served in HCBS Waivers Prior to Demonstration* Children´s Member Months Proposed to be Eligible for HCBS under Demonstration in DY23 Estimated Children Proposed Eligible for HCBS in DY23
Medicaid Children meeting LOC under Community Eligibility rules 65,064 6,506 147,869 14,787
Medicaid Children meeting LOC under Family of One rules 16,605 1,661 18,363 1,836
Medicaid Children meeting at–risk HCBS LON under Community Eligibility rules N/A N/A 131,220 13,122
New Medicaid Children meeting at–risk HCBS LON under Family of One rules N/A N/A 36,744 3,674
Total 81,668 8,167 334,196 33,420

* Assumes Average Length of Stay of 10 month


1. CFCO services are for children meeting LOC and CFCO criteria under the State Plan and Demonstration.  1
2. Children´s 1115 HCBS services are for children meeting LOC and LON under the Demonstration.  2
3. Demonstration services are for children in Managed Care.  3
4. SP services are State Plan services for all children with "New SP" denoting new State Plan services being added to the New York State Plan concurrent with the Demonstration amendment.  4
5. Note: This chart and the budget neutrality estimates with this submission reflect originally proposed implementation dates of various aspects of this demonstration and range between October 1, 2017, and January 1, 2020. The State is in the process of updating the budget neutrality estimates and this chart to reflect the updated proposed effective date of this amendment of January 1, 2018 through January 1, 2020, subject to the CMS approval, through the end of the Demonstration, consistent with the remaining demonstration years of the current renewal.  5