NYS Releases Additional Information on its "DSRIP 2.0" Medicaid Waiver Proposal - What You Need to Know
Post Written by Kalin Scott, Chief Innovation Officer
Will we see January 1, 2023 start date for a proposed $13.52B Medicaid initiative in New York? That’s the question on the minds of health care stakeholders in New York as the state’s Medicaid program released an updated timeline on its waiver amendment ask.
As a reminder, the state is looking for this investment to invest in its stated goals of promoting health equity across its Medicaid program (I’ve outlined more detail in this recent blog post.) While this program is not DSRIP 2.0, it is the long-awaited follow-up to New York’s successful DSRIP program.
In public hearings held in the first weeks of May, the state outlined a timeline (below) to move from concept to implementation.
New York State Medicaid’s Proposed Timeline for Waiver Amendment Activities & Implementation:
April 13: Public notice published & comment period begins
April 13: Tribal comment period begins
May 3: Public hearing #1
May 10: Public hearing #2
May 20: Public comment period ends (written comment due)
July 1: Target date to incorporate public comments, finalize amendment
July 25: Target date for New York State to send updated formal waiver amendment submission to CMS
July 30 – August 29: Federal public comment period
Summer 2022: Potential start for negotiations between New York and CMS
January 1, 2023: Target Implementation Date
(Source: slides presented by NYS DOH at May 3 & May 10 Public Hearings)
States must follow a federally-required public engagement process before submitting a formal amendment to the Centers for Medicare and Medicaid Services (CMS) for approval. New York began this process in early April with the release of its draft waiver amendment submission.
With the completion of two public hearings (held virtually due to COVID-19 precautions), and the nearing end date of the state public comment period, the next focus for the state will be to incorporate public comment into its draft document and finalize and formally submit the amendment to CMS.
Can stakeholders still provide comment on New York’s proposal?
Yes. The state is taking written public comment through May 20. The state has pledged to review and incorporate public comment into its formal waiver amendment, which will be updated and is targeted to be submitted by July 1.
After the state’s formal waiver amendment submission, CMS will review the state documents for completeness, and if the agency determines the submission is complete, a 30-day federal public comment period will begin. CMS will outline how stakeholders can submit written comment directly to the agency. The CMS website posts all state 1115 waivers, and when the federal public comment period is open, a form to submit comments is made available along with the state’s submission. Typically, the state will also send out a notification to stakeholders through its listserv when the federal comment period begins.
How likely is it that New York will meet its target implementation date of January 2023?
It’s possible – but unlikely. The submission of a waiver amendment doesn’t guarantee anything; CMS may or may not choose to prioritize waiver amendment discussions and negotiations with the state, which will affect the timeline. Typically, CMS won’t formally negotiate with states until the end of the federal public comment period (which is proposed to end on August 29, according to the state’s projections.) While the state references Summer 2022 as a ‘potential start’ for negotiations, it’s up to CMS to begin negotiations, and it’s uncertain as to whether that will happen or not.
Even if CMS jumps into negotiations, a waiver amendment request of this size and scope will take significant resources on the state and federal sides and will likely push the timeline well into 2023.
How likely is it that the state will receive its full funding ask of $13.52B?
It’s not at all likely. In August 2021, the state released a concept paper proposing a $17B investment for this approach. State Medicaid staff revealed earlier this year that feedback from CMS led the state to scale back its ask to the current $13.52B number. If CMS agrees to consider the request and negotiates an agreement with the state, it’s much more likely we’ll see an investment about half the size (or less) of the current ask.
CMS invested $8B into New York through the MRT Waiver Amendment, the vehicle for the state’s Delivery System Reform Incentive Payment (DSRIP) program that ran from 2014-2020. Historically, states that have been approved for DSRIP or other similar investments have received much smaller investments for subsequent delivery system reform requests.
What makes me qualified to make that prediction?
I’ve lived through this process before! As a principal negotiator on a small team of state Medicaid staff, I remember the good, the bad, and the ugly that led us to the historic $8B investment for delivery system reform through the MRT Waiver Amendment. We worked with CMS for two years to reach agreement.
New York’s original ask, in May 2012, was $10B to support 13 grant-like programs to support Medicaid providers and stakeholders. Our final agreement, reached in April 2014, was a comprehensive DSRIP program, driven by performance-based payments, and supported by accompanying program investments in workforce, health homes and home and community-based services.
We had commitment from our CMS colleagues to focus on our request, and it still took months from an agreed-upon ‘path forward’ to get to an agreement in principle – a one-page document committed to an $8B federal investment. After reaching that important milestone, it took two solid months of daily meetings with large teams from New York and CMS to finalize the program and receive formal approval.
It takes an incredible amount of commitment and effort from teams on both sides to reach agreement, and that requires a lot of time. The New York team has been committed to this ask since the Fall of 2020, when it released a DSRIP 2.0 request that was not acted upon by CMS under the Trump administration. The state’s approach has evolved aligned with the realities of the COVID-19 pandemic and new priorities of CMS under the Biden administration. It’s also important to understand that what we see today in the current proposal is likely to change significantly – not just the timeline or dollar amount – the programs themselves will be subject to intensely detailed negotiations and will likely look very different if a future agreement is reached between the state and CMS.
It takes tremendous commitment and effort to design and create program requests of this magnitude – the New York team appears to be strongly committed to devoting resources, incorporating stakeholder feedback and prioritizing this request, which will hopefully help lead to an agreement in the future.
What’s included in the state’s waiver request?
On April 13, 2022, New York Medicaid released its formal request to the federal government for a $13.52 billion investment in continued delivery system reform. The request reinforced the state’s total commitment to payment reform: $7 billion dollars - more than 52% of the requested funding - would be invested in advancing value-based payment (VBP) models in Medicaid. $910M over the five-year period would flow to yet-to-be-created Health Equity Regional Organizations (HEROs) and Social Determinants of Health Networks (SDHNs.)
This long-awaited draft 1115 Medicaid waiver amendment is the follow-up to the state’s successful DSRIP program. The state outlines a detailed request for five years of funding, totaling $13.52 billion which would fund providers and communities through Medicaid to promote health equity, address the social care needs of Medicaid members, build on the success of DSRIP, and expand advanced models of VBP.
We last saw the state’s official position on this approach in August 2021 with its very similar concept paper outlining a proposed investment of $17B and proposed strategies to accomplish many of these same goals.
I wrote a blog post earlier this year outlining more details of the request and what it all means. You can read it here.
Is this program DSRIP 2.0?
No. The state previously submitted what was referred to as a ‘DSRIP 2.0’ request - a waiver request to restructure and continue DSRIP programs and funding - in November 2019, which was not acted upon by CMS under the Trump administration. This request does not continue funding for DSRIP programs, but it does build on the success of DSRIP initiatives.
How can you stay informed?
The state has a listserv for announcements related to the Medicaid program and 1115 Waiver – you’ll want to sign up for that to make sure you get the latest updates. And stay tuned here – we’ll have more in the coming weeks.
And get in touch – what do you think about the state’s request and public engagement to date? What’s your prediction on if and how much the state will receive, and when that will happen? Are there any other questions or reactions you’d like to share? I’d love to hear from you – you can find me at the contact info below.
About the Author: Kalin Scott is the Chief Innovation Officer at Helgerson Solutions Group. Follow her on Twitter and connect with her on LinkedIn.
