Understanding New Yorks 1115 Waiver Amendment

Background

The federal Medicaid program allows states to apply for waivers that let them test innovative approaches to delivering health care while staying within overall budget constraints. Section 1115 of the Social Security Act provides the statutory authority for these demonstration waivers. New York has used this authority for several years to implement the NY State Medicaid Redesign Initiative (NY Medicaid Redesign), a set of reforms aimed at improving health outcomes, containing costs, and increasing system efficiency.

In 2022, the Centers for Medicare & Medicaid Services (CMS) approved a renewal of New Yorks 1115 waiver, and the state subsequently introduced an amendment that expands several core components of the program. The amendment, commonly referred to as the 1115 Waiver Amendment, was enacted by the New York State Legislature in 2024 and became effective July 1, 2024.

Key Provisions of the Amendment

The amendment builds on the original waiver and can be grouped into four major pillars:

• ValueBased Payments (VBP): New payment models that tie a larger portion of provider reimbursement to quality and cost metrics.
• Integrated Care Expansion: Greater support for medicallegal partnerships, behavioral health integration, and communitybased services.
• Benefit Redesign: Introduction of new optional benefits, such as nonemergency medical transportation (NEMT) in rural areas and expanded oral health services.
• Data Transparency & Accountability: Enhanced reporting requirements and the creation of a publicly available performance dashboard.

1. ValueBased Payments

Under the amendment, about 30% of the Medicaid feeforservice (FFS) budget will be transitioned to valuebased contracts by 2026. The models include:

• Accountable Care Organizations (ACOs) with shared savings.
• Episodebased bundled payments for highcost procedures (e.g., joint replacement, cardiac surgery).
• PayforPerformance (P4P) adjustments for primary care providers based on preventive care metrics.

2. Integrated Care Expansion

The amendment directs $150million annually toward integrating behavioral health into primary care clinics and funding community health workers (CHWs) in highneed zip codes. It also creates a grant program for medicallegal partnerships to address social determinants of health.

3. Benefit Redesign

New optional benefits are offered to eligible enrollees:

• Expanded dental services for adults up to age 64.
• Comprehensive vision coverage.
• NEMT for those living more than 15miles from their primary care provider.

4. Data Transparency & Accountability

A statewide Medicaid performance dashboard will be launched in Q42024. The dashboard displays:

• Cost per enrollee trends.
• Quality scores by provider type.
• Utilization of optional benefits.

Impact on Providers

Provider organizations should be aware of several practical implications:

• Contract Negotiations: Many health systems will need to renegotiate Medicaid contracts to incorporate VBP terms.
• Reporting Requirements: Enhanced data submission (quality metrics, cost reports) will be required quarterly.
• Investment in Infrastructure: Integration of electronic health records (EHR) with state reporting platforms is essential for bundled payments.
• Opportunities for Grants: CHW and medicallegal partnership grants are competitive but can offset staffing costs.

Dental and vision provider groups will also see increased patient volumes as the optional benefits become widely adopted. Early adopters are encouraged to register with the Department of Healths Benefit Expansion Portal by August15,2024.

Impact on Beneficiaries

For Medicaid enrollees, the amendment promises:

• Better coordination of physical and mental health services.
• Reduced travel barriers through expanded NEMT coverage.
• Improved oral health outcomes thanks to broader dental benefits.
• Greater transparency about the quality of their providers.

Eligibility for the new optional benefits is based on a needsassessment tool that considers geographic location, chronic condition burden, and income level. Beneficiaries will receive a personalized benefits statement in the mail each year.

Implementation Timeline

Further Resources

For detailed guidance, visit the official New York State Department of Health pages or contact the Medicaid Waiver Help Desk.

• NY Department of Health 1115 Waiver
• CMS Section 1115 Waiver Overview
• NY Medicaid Redesign Initiative
• Waiver Help Desk (email)