New York’s 1115 waiver: First, a little background

New York state has a long history of being at the forefront of Medicaid programming, so it’s no surprise that the latest 1115 Waiver amendment, the New York Health Equity Reform (NYHER) waiver, is making some big moves to move the state ahead (no pun intended - if you know, you know!) in using evidence-based practices to advance the health of New York’s Medicaid recipients. But what is striking about this waiver is the feeling that everything that was old is now new again.

Having started my career in healthcare at the dawn of the Affordable Care Act, it was only natural that I jumped headfirst into the world of Health Homes, a comprehensive care management program that used population health stratification tools to identify the highest need New York Medicaid members facing severe mental illnesses, substance use disorders and HIV/AIDs, all services that were once siloed by their respective agencies.

Many of the care managers who started their careers in specialized programs were now expected to provide a generalized approach – covering all health and social care needs regardless of the diagnoses. While it wasn’t without challenges, it was an important step in the right direction for New York’s health outcomes.

In comes the NYHER waiver, a multi-program waiver which not only expanded the delivery of social care services to the entire New York Medicaid population but also broke out these services separately from other care management services available to New York Medicaid members. The $7.5 billion waiver has a goal of advancing health equity, reducing health disparities and supporting the delivery of social care services through its three parts:

1. Social care networks (SCNs) that provide social care navigation and service referrals to
   New York’s Medicaid members. 
2. A population health initiative that incorporates Centers for Medicare & Medicaid Services’ (CMS) models and an organization dedicated to supporting and assessing the social care service needs across the state. 
3. Workforce development efforts to support those providing an array of healthcare services to these members.

SCNs, the most similar to the Health Home Program, have four key operational pieces:

1. Build out a governing body that will understand the region and its unique health equity needs. 
2. Submit fee-for-service claims and receive payments from New York and ensure network partners are paid for services rendered. 
3. Build a regionally appropriate network that includes managed care organizations
   (MCOs) and community-based organizations (CBOs).
4. Implement an IT platform that can manage social care referrals and health related social
   need (HRSN) data sharing. 

With that established, there is some value in understanding the role of the MCOs and CBOs in completing this work. While SCNs are the middleman, MCOs are integral in determining eligibility, and CBOs are integral in finding members and providing services. This structure bears a striking resemblance to that of the Health Home program, but I think that could be a strength here once operational. With each key player focusing on a role they are familiar with and (should be) well versed in, it should set the program up for success.

Unlike the Health Home program, which had eligibility requirements, all Medicaid recipients will be eligible for HRSN screening and needed services. This is an important difference and speaks to a gap that currently exists within the Health Home program, which only provides service to the highest need Medicaid members. That said, this waiver also establishes a higher level of services (Level 2) for recipients who may be considered higher risk and, therefore, may have more health-related social needs, and the MCOs will be responsible for identifying these members.

This waiver also promises to work towards a value-based payment model for which the MCOs will be key players.

CBOs will be required to complete HRSN assessments for just about any New York Medicaid recipient that walks through their door, and it will be interesting to see how that plays out long term. Care managers already deal with large caseloads, which can often lead to sacrificing connection with those with fewer needs to support than those at higher risk. However, parsing out those whose primary need surrounding social care, rather than health care, may offer relief to some care managers who care to focus more on medical needs.

With that said, I remain optimistic that the program will provide some benefit to a healthy portion of Medicaid recipients in New York.

In the second part of our series, we’ll explore a variety of the waiver’s initiatives. Stay tuned into Inside Angle for more!

Lauren Schultz is a lead consultant, regulatory and payer solutions, at Solventum.