Preparing for Major Medicaid Expansion in New York with 1115 Waiver Amendment

The Centers for Medicare & Medicaid Services (CMS) recently approved the New York Health Equity Reform (NYHER) waiver amendment, signaling a significant milestone after almost three years of design and negotiation. With an allocation of approximately $7.5 billion over 3 years, NYHER aims to transform New York State's Medicaid Program, focusing on health equity and reducing disparities for over 7.6 million beneficiaries.

1. Payment Structure for HRSN

The approved waiver includes $500 million for social care networks (SCNs) and more than $3 billion for health-related social needs (HRSN) services. These services cover housing, nutrition, respite care, and transportation, targeting individuals facing adverse social conditions. While Level 1 HRSN services will be available to all Medicaid enrollees, Level 2 services require eligibility screening and standardized assessments.

Next Steps

Organizations should confirm potential roles as HRSN service providers. Organizations will likely include physician practices, hospitals and health systems, community-based organizations
Building partnerships with SCNs is crucial for effective service delivery.

2. Hospital Global Budget Program and Safety Net Hospital Funding

NYHER allocates $2.2 billion to hospitals participating in a Hospital Global Budget program, focusing on private not-for-profit hospitals in specific New York counties with a Medicaid and uninsured payor mix of at least 45%. Eligible hospitals must commit to participating in the initiative, set to launch around April 1, 2027.

Next Steps

Eligible hospitals should assess qualifications and consider executing a Letter of Intent.
Become familiar with “AHEAD” (States Advancing All-Payer Health Equity Approaches and Development), CMMI’s new multi-payor model which will include global budgets for hospitals in participating states.

3. Workforce Initiatives and Funding

$694 million is dedicated to workforce initiatives, aiming to enhance access to care in Medicaid. This includes student loan repayment for qualified providers and career pathway trainings (CPT). CPT focuses on addressing workforce shortages in healthcare staffing and supporting the delivery of HRSN services.

Next Steps

Healthcare organizations should assess staff eligibility for workforce funding opportunities.
Stay informed about implementation details and timelines for these initiatives.

NYHER also introduces Health Equity Regional Organizations (HEROs) with funding of up to $125 million through March 2027. These entities play a crucial role in reducing health disparities, conducting regional needs assessments, and developing statewide health equity plans.

What's Not Included?

The final waiver excludes certain components discussed in the initial Concept Paper, such as specific funding for Primary Care Medical Home (PCMH), coverage for individuals released from incarceration, the Serious Mental Illness (SMI) component, and continuous Medicaid eligibility for children ages 0-6. However, some elements may be pursued through separate State-Directed Payments or subsequent amendments

Stay connected with Canton for the latest updates

The CMS-approved NYHER waiver marks a transformative step for New York's Medicaid Program. Stakeholders, including healthcare organizations and providers, should carefully evaluate their eligibility and consider proactive steps to engage with the key initiatives outlined in the waiver. Ongoing updates and analysis will be crucial as more information becomes available. You can subscribe to our newsletter below for the latest news and updates.