New York Medicaid, SCHIP, & Federal Authority

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Section 1115 Waiver – In 1997, the Centers for Medicare and Medicaid Services (CMS) approved New York’s section 1115 Medicaid demonstration, the Partnership Plan, in which Medicaid beneficiaries began receiving benefits through  mandatory managed care.  In 2001, CMS approved New York’s Family Health Plus (FHPlus) amendment. FHPlus expanded health insurance to childless adults with incomes up to 100 percent of the federal poverty level (FPL) and expanded coverage to parents with incomes up to 150 percent of the FPL.  Prior to 2001, these populations were covered in the state’s Safety Net program.  FHPlus is delivered via managed care organizations and has a less comprehensive benefit package than traditional Medicaid.  In 2002, the waiver was amended to include a family planning demonstration which expands family planning services to individuals with net incomes at or below 200 percent of the FPL.  In 2007, New York further amended the waiver to include a premium assistance program in FHPlus. If an FHPlus enrollee has access to employer-sponsored health insurance, such coverage must be evaluated to determine if it is cost effective for the State to pay the employee’s share of the health insurance program as opposed to Medicaid.  Such analysis must include the cost provided to FHPlus enrollees of the wrap-around services.

Section 1115 Waiver – In 2006, New York was approved for a new Section 1115 Medicaid demonstration, the Federal-State Health Reform Partnership (FSHRP).  Under this demonstration, New York is undertaking significant reforms to promote the efficient operation of its healthcare system by reducing excess capacity in acute care hospitals, shifting emphasis in long-term health care to community settings, investing in health IT, and reorienting the healthcare system to a value-based outpatient and primary care driven system which rewards quality.  The federal government will provide federal financial participation for designated state-funded health programs which serve low-income and uninsured individuals, not otherwise eligible for federal matching funds. After incurring expenditures, the state may draw down federal match only as it is ready to expend state funds on the specified health reform initiatives.  Once the state meets required milestones, the federal government will provide up to $300 million per year to allow the state to invest in the agreed upon healthcare reforms.  Failure to meet a milestone will result in cessation of federal matching funds.  New York is required to generate $3 billion in gross Medicaid savings over the 5-year demonstration period. Additionally, the FSHRP demonstration transfers the authority from the Partnership Plan demonstration to enroll adults with disabilities, children with disabilities, and older adults in managed care.