New York

Current Updates (as of 8/3/2021)

Medicare-Medicaid Integration

On June 7, 2021, the Centers for Medicare & Medicaid Services (CMS) and the New York State Department of Health (NYSDOH) released a Three-Way Contract Amendment and Summary of Contract Changes for the state’s Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) demonstration. The updated contract states a new end date for the demonstration, December 31, 2023. The contract amendment also includes the following changes:

  • Allows for Qualified Intellectual Disabilities Professionals (QIDPs) to serve as a Care Manager and conduct Comprehensive Service Planning Assessments (CSPAs)
  • Increases the target medical loss ratio (MLR) in Demonstrations Years 5-7
  • Applies an additional 1 percent withhold to the Medicare Parts A and B rate component of the Quality Withhold Measures for Demonstration Years 5-7
  • Extends the parameters on the administrative cost limit for Demonstration Year 1 to Demonstration Years 2-3
  • Includes a new Appendix J which allows dually eligible participants to change enrollment on a monthly basis

(Source: Summary of Changes; 6-7-2021, Three-Way Contract Amendment; 6-7-2021)

On July 7, 2021, CMS released a combined second and third evaluation report for the New York Fully Integrated Duals Advantage (FIDA) demonstration. The demonstration began on January 1, 2015 and ended on December 31, 2019. The report provides an overview of the implementation of the FIDA demonstration and results from the second and third rounds of evaluation. Findings are from the demonstration period between 2017 to 2019 and fall into categories including: integration of Medicare and Medicaid, eligibility and enrollment, care coordination, beneficiary experience, and quality of care. The report also describes the planning activities during the demonstration final year to transition duals to Medicare Advantage Plus plans in early 2020.

(Source: NY FIDA Combined Second and Third Evaluation Report; 7-7-2021)

Past Updates

New York Flag

Managed LTSS Program

New York’s Medicaid Redesign Team Proposal #90 and 2011 state budget legislation require the state to transition certain community-based Medicaid LTC service recipients into Managed Long-Term Care Plans (MLTCPs) or Care Coordination Models (CCMs).  New York operates three models of MLTCP:  the Program of All-Inclusive Care for the Elderly (PACE); Medicaid Advantage Plus (MAP); and partially capitated MLTCPs.  All models provide community-based LTC services; nursing home care; and many ancillary services.  In 2012, CMS approved the state to proceed with auto-assignment into partially capitated MLTCPs for Medicaid members in New York City.  (Source: State Medicaid Update, September 2012; State Managed Long Term Care/Care Coordination Model website)

In December 2013, New York’s mandatory Medicaid managed LTC program began in four upstate counties. The state plans to implement mandatory managed LTC for Medicaid beneficiaries requiring more than 120 days of community-based LTC in every county in the state by the end of 2014. (Source: MLTSS Network Weekly Roundup, link no longer available, 1/23/2014; HMA Weekly Roundup, 12/4/2013)

The state has released its RFQ for the behavioral health carve-in, which is scheduled for New York City on January 1, 2015, and for the rest of the state on July 1, 2015. The RFQ lays out requirements for becoming a Health and Recovery Plan (HARP), a managed care program that will be offered to individuals with SMI or substance use disorder. (Source: HMA Weekly Roundup, 3/26/2014)

New York has delayed transitioning nursing home populations into managed LTC until at least June 1, 2014, while the state negotiates with CMS to resolve details in the managed care program roll-out. (Source: HMA Weekly Roundup, 4/30/2014)

The state’s Office for People with Developmental Disabilities (OPWDD) and the Department of Health are working with CMS on an agreement called the People First Waiver, a §1915 (b)(c) HCBS waiver. This agreement will renew the OPWDD §1915(c) Comprehensive HCBS Medicaid Waiver for People with DD and will also be the vehicle OPWDD uses to authorize the creation of a managed care delivery system for individuals with disabilities. The managed care delivery system will allow individuals to enroll on a voluntary basis in a Developmental Disability Individual Support and Care Coordination Organization (DISCO). Originally planned for October 2014, the state now expects that DISCOs will begin providing service in October 2015. (Source: HMA Weekly Roundup, 7/2/2014)

On July 15, 2014, the New York Legal Assistance Group filed a class action lawsuit against the state’s MLTSS program. The lawsuit accuses the state commissioners of the Department of Health and the Office of Temporary and Disability Assistance of allowing companies to quietly reduce or terminate Medicaid home care services to chronically ill and disabled people whose needs for services have not changed, without proper notice, the chance to appeal or even an explanation, protections required by law. (Source: New York Times website, 7/15/2014)

The state released a new timeline for transitioning to mandatory managed LTC; the new timeline extends the transition period through February 2015.  (Source:  State Managed LTC website)
Updated 2014-2015 MLTC Transition Timeline

As of September 2014, the state has delayed transitioning nursing home populations into managed LTC; the nursing home benefit carve-in is now scheduled for January 2015.  (Source:  HMA Weekly Roundup, 9/24/2014) 

On September 19, 2014, the state announced an updated timeline for the transition of behavioral health services to managed care.  The revised implementation dates are as follows:  April 1, 2015 for adults in in New York City; and October 1, 2015 for adults in the rest of the state.  (Source:  State Department of Health website)
Letter from New York Medicaid Director (9/19/2014)

As of October 2014, as part of the state’s implementation of mandatory managed long-term care for Medicaid beneficiaries requiring more than 120 days of community-based long-term care, the state is implementing a Conflict-Free Evaluation and Enrollment Center (CFEEC).  The state has partnered with Maximus to provide all activities related to the CFEEC, including initial evaluations to determine if a consumer is eligible for community-based long-term care for more than 120 days.  (Source:  State Department of Health website; HMA Weekly Roundup, 10/1/2014)
CFEEC FAQs (9/29/2014)

On December 11, 2014, the Medicaid Managed Care Advisory Review Panel (MMCARP) provided an update on the state’s Medicaid Managed Care (MMC) programs:  (1) The nursing home transition is still set for January 1, 2015; and (2) The Behavioral Health transition is still set for April 1, 2015, despite pending approval from CMS on the state’s Behavioral Health 1115 Amendment.  (Source:  HMA Weekly Roundup, 12/17/2014)

As of January 2015, the behavioral health carve-in (using Health and Recovery Plans or HARPs) has been delayed an additional 3 months.  The state anticipates CMS approval by March 2015, and expects Medicaid managed care plans in New York City to begin managing the full behavioral health benefit on July 1, 2015, with the rest of the state following in approximately 6 months.  HARPs will rely on passive enrollment with an opt-out.  Individuals enrolled in Medicaid managed care who have been identified as HARP-eligible will be passively enrolled in the HARP that is operated by the managed care plan in which they are enrolled, and they will be informed of their ability to opt-out.  (Source:  HMA Weekly Roundup, 1/14/2015)

Effective February 1, 2015, managed care plans began covering the full range of Nursing Home (NH) services to current managed care enrollees new to NH care.  Effective February 1, 2015, in New York City, all eligible beneficiaries age 21 and over in need of long term placement in a nursing facility will be required to join a Medicaid Managed Care Plan (MMCP) or a Managed Long-Term Care Plan (MLTCP).  On April 1, 2015, the counties of Nassau, Suffolk, and Westchester will be phased in; the rest of the State is scheduled to transition in July 2015 for both dual and non-dual eligible populations.  All current long term placed beneficiaries in a Medicaid certified skilled nursing facility (NH) prior to February 1, 2015 for Phase 1; April 1, 2015 for Phase 2; and July 1, 2015 for the upstate phase-in will remain in fee-for-service (FFS) Medicaid and will not be required to enroll in a managed care plan.  No individual will be required to change nursing homes resulting from this transition; however, new placements will be based upon the MMCP’s or MLTC’s contractual arrangements and the needs of the individual.  Effective October 1, 2015, voluntary enrollment into managed care will become available to individuals residing in NHs who are in FFS Medicaid.  (Source:  NY DOH Medicaid Update Vol. 31, 1/2015)

As of February 2015, the behavioral health carve-in has been delayed several times; however, CMS has committed to work with the state to achieve waiver approval by the end of March.  Outstanding issues include compliance with the HCBS settings rule; conflict-free care management; and payment rates for services, benefits, and premiums. Implementation is scheduled for July 2015 in New York City and approximately six months later throughout the rest of the state.  (Source:  HMA Weekly Roundup, 2/18/2015)

As of April 1, 2015, the behavioral health carve-in is scheduled to begin in New York City on July 1, 2015.  The state expects that CMS will approve the terms and conditions for the carve-in imminently.  (Source:  HMA Weekly Roundup, 4/1/2015)

On April 24, 2015, the state released an updated timeline for its adult and children’s behavioral health Medicaid managed care transition. The adult behavioral health transition will begin in New York City on October 1, 2015, with passive enrollment for individuals eligible to enroll in a Health and Recovery Plan (HARP). HCBS will become available as part of the HARP benefit in January 2016. (Source: HMA Roundup, 4/29/2015)
Behavioral Health Managed Care Transition Timeline (Updated 4/24/2015)

The New York Department of Health (DOH) has announced intentions to eliminate its 1915(c) HCBS waivers for Traumatic Brain Injury (TBI) and the Nursing Home Transition and Diversion (NHTD) programs. Program participants will either be enrolled into a mainstream managed care plan, or a managed long-term care plan, with a target implementation date of January 1, 2018. According to a draft transition plan from DOH, benefits will be coordinated with the Community First Choice Option, a program that allows for enhanced state plan HCBS services and an increased federal medical assistance percentage (FMAP). DOH will be accepting public input on the draft plan through August 24, 2016. (Source: Draft Plan; HMA Weekly Roundup 6/15/2016)  

On November 23, 2016, Politico New York reported that the state’s largest MLTSS health plan, GuildNet, will cease enrollment of Medicaid beneficiaries in Nassau, Suffolk, and Westchester counties, due to claims of insignificant reimbursement. GuildNet will continue to operate in the New York City market, which makes up the majority of its enrollees. (Source: Politico New York 11/23/2016; HMA Weekly Roundup)

The New York Department of Health (DOH) released a draft demonstration evaluation for the state’s section 1115 waiver, which it will submit to CMS by January 31, 2017. The proposed evaluation will encompass the entire demonstration, and will include a focus on the following areas:

  • Managed long-term care (MLTC);
  • Mainstream Medicaid Managed Care Program (MMMC);
  • Medicaid beneficiaries transitioned from institutional settings to community-based care;
  • Temporary Assistance to Needy Families;
  • Twelve month continuous eligibility period; and
  • Express lanes eligibility.

The MLTC program will be evaluated along the following parameters:

  • Improved care coordination for the Medicaid program’s highest risk and highest cost populations;
  • Improved patient safety and quality of care;
  • Reduced preventable hospital admissions; and
  • Improved consumer satisfaction. (Source: Draft Evaluation 12/2016)

The State of New York’s executive budget proposal contains a few changes relevant to managed long-term care (MLTC) in the state. Under the proposed budget, new entrants into MLTC health plans would need to meet nursing facility level of care (LOC). This is in contrast to the current standard, which is over 120 days of community-based long-term care. The budget also incorporates an $18 million dollar reduction in nursing home rates. (Source: Budget Proposal 1/2017; HMA Weekly Roundup 1/25/2017) 

The Home Care Association of New York (HCA) is out with a report on the fiinancial status of New York's home care providers, which makes extensive reference to the state’s Managed Long-Term Care (MLTC) program. The report argues that, due to insufficient reimbursement rates from the state, 61 percent of participating MLTC health plans were in the negative in terms of premium incomes in 2015, and 72 percent of Certified Home Health Agencies (CHHAs) and Long Term Home Health Care Programs (LTCHHCPs) had negative margins in 2014.  The report also notes that underpayment can lead to delays in service provision, and is also compounded by the impact of minimum wage standards, such as changes to the Fair Labor Standards Act (FLSA). However, the state discussed, at a recent Medicaid Managed Care Advisory Review Panel meeting, how it intends to increase reimbursement for home care agencies to account for changes in the minimum wage, and is also convening a workgroup on minimum wage oversight and education. (Source: HCA Report 2/2017; HMA Weekly Roundup 2/22/2017; HMA Weekly Roundup 3/1/2017)

New York is launching a Managed Long Term Care (MLTC) Workforce Investment Program as a part of the state’s Section 1115 waiver. The program aims to enhance the state’s LTSS workforce and help prepare it for the increased focus on home and community based services versus institutional care. The state hosted a webinar on May 25, 2017, to launch of the program. New York can allocate up to $245 million through 2020 in support of initiatives to retain and recruit long-term care workers. (Source: Webinar Link 5/25/2017)

On May 25, 2017, the New York Department of Health (DOH) held a webinar for stakeholders interested in learning more about the state Workforce Investment Program for the long-term care sector workforce. The initiative is funded via the state’s section 1115 waiver and there is up to $245 million available until March 2020. The Workforce Investment Program will mandate long-term care (MLTC) health plans to contract with designated workforce training centers in order to:

  • Invest in innovative initiatives; 
  • Target workers toward underserved communities; 
  • Develop new trainings and retraining strategies; and
  • Enhance opportunities for home and community-based care, as well as respite; 

The workforce training centers, which will be known as Long-Term Care Workforce Investment Organizations (LTC WIOs), will be selected on a competitive basis and will be broken down on the same regional basis as the MLTC program: Central Region; Hudson Valley Region; Long Island Region; North End Region; North East Region; New York City Region, and; Western Region. On June 30, 2017, DOH released a draft of the application criteria for LTC WIOs. (Source: DOH 6/26/2017; DOH 6/30/2017) 

On September 22, 2017, the New York Department of Health (DOH) established standards for managed long-term care (LTC) plans that are transitioning due to a planned closure, a service area reduction, or a merger or acquisition. Effective immediately, managed LTC plans must submit a formal request to DOH to withdraw from the market or take other similar actions. LTC plans must also provide notices to all plan members; members will have 60 days to select a new plan before being auto-assigned to a new one. These new standards come as New York has seen a number of plans exit its Medicaid managed care market. (Source: DOH 9/22/2017)

The New York Department of Health (DOH) recently released its Medicaid Global Spending Cap Report, which runs through August 2017. New York’s global spending cap increased from $18.6 billion in FY17 to $19.5 billion in FY18, a growth of 5.2 percent. Areas of growth include price and utilization increases. Specifically:

  • Increases for mainstream Medicaid managed care totaling $411 million, and managed long-term care (MLTC) rates equaling $101 million;
  • Utilization increases included annualization of FY17 new enrollees, and new enrollment for FY18 that included 8,100 nursing home (NH) and 13,000 community-based eligibles.

MLTC enrollment continues to grow in New York—driven by mandatory enrollment, and the expansion into NH eligibles. In March 2017, New York had 201,610 enrollees in MLTC, but it projects that by March 2018 it will have nearly 224,000. (Source: Medicaid Global Spending Cap Report 8/2017)

New York released its value-based payment (VBP) reporting requirements, which details the quality measures for MCOs participating in the state’s Medicaid VBP initiative. There are five different VBP arrangements that are available under the program, including one for MLTC. The set of measures are based on an analysis of their validity and reliability, and classified under either pay for reporting (P4R) or pay for performance (P4P). The vast majority of the measures address clinical outcomes, with only 4 addressing quality of life or service satisfaction (Source: MLTC VBP Measure Set 11/2017)

In the most recent budget cycle, the Governor and both houses of the New York legislature have agreed to the following programmatic changes to the state’s managed long-term care (MLTC) program: 

  • Disenrolling Medicaid beneficiaries that become permanent residents of a nursing facility, which will be defined as three months or longer; and
  • Establishing a new rate cell specifically for high need/high cost individuals in need of HCBS. (Source: HMA Weekly Roundup 3/21/2018)


The Quarterly Medicaid Managed Care Advisory Review Panel was held on February 21, 2019. Three managed long-term care plans, Partners Health Plan, Hamaspik Choice, and iCircle Care, are interested in expanding into broader Medicaid managed care to participate in New York’s upcoming Specialized I/DD plan, if their 1115 waiver is approved by CMS. (Source: New York Health Access, 3-4-2019; HMA Weekly Roundup, 2-27-2019)

On March 25, 2021, the New York Department of Health submitted an amendment request for the New York Medicaid Redesign Team 1115 demonstration waiver. The state is seeking to change the federally required 60-month transfer of assets lookback for community based long-term care services (CBLTCS) to 30 months. CBLTCS are available through managed long-term care (MLTC) and Medicaid managed care (MMC). This initiative would impact the following services: • Adult day health care • Assisted living program (ALP) • Certified home health agency (CHHA) services • Personal care services • Consumer directed personal assistance program • Limited licensed home care services • Private duty nursing services • Managed long-term care in the community

(Source: New York Medicaid Redesign Team Waiver Amendment Request; 3-25-2021)

On November 10, 2020 the New York Department of Health submitted an amendment request for the New York Medicaid Redesign Team 1115 waiver. This amendment would modify the eligibility criteria for MLTC plans by requiring assessed individuals to need assistance with at least two activities of daily living (ADL). The amendment would also allow dually eligible individuals who are not assessed to need CBLTCS (well duals) and are enrolled in a D-SNP to remain or enroll in a Mainstream Medicaid Managed Care Plan (MMMC).

(Source: New York Medicaid Redesign Team Waiver Amendment Request; 11-10-2020)

On December 19, 2019, the New York Medicaid Managed Care Advisory Review Panel announced that CMS approved two changes to the state’s Managed Long Term Care (MLTC) program. These changes included removing nursing home coverage from the MLTC benefit, which would disenroll an individual from MLTC if they reside in a nursing home for more than three months; and a new lock-in policy for MLTC members that allowed enrollees to transfer to another Medicaid managed care plan during a 90-day window at the beginning of a 12-month period.

(Source: HMA Newsletter; 1-8-2020)

Medicaid §1115 Demonstration Waivers

In 1997, CMS approved the state’s first §1115 Demonstration Waiver, known as the Partnership Plan Medicaid §1115 Demonstration. The Partnership Plan consists of four program components: the Medicaid Managed Care Program, which provides Medicaid State Plan benefits through comprehensive MCOs to most Medicaid recipients; the Family Health Plus Program, which provides limited benefits with imposed cost-sharing for adults who meet income eligibility; the Family Planning Benefit Program, which serves individuals not otherwise eligible for Medicaid who are in need of family planning services and meet specified income eligibility, and women who lose Medicaid eligibility 60-days postpartum; and the HCBS Expansion Program, which expands three §1915(c) waiver programs by eliminating the financial eligibility barrier for receiving care at home. (Source: State Website on Partnership Plan Waiver; Partnership Plan Fact Sheet)

In April 2005, CMS approved the state’s second §1115 Demonstration Waiver, known as the Federal-State Health Reform Partnership (F-SHRP) Medicaid §1115 Demonstration, effective September 2006. The F-SHRP supported a health reform program to modernize the state’s acute and long-term care infrastructure; increase primary and ambulatory care capacity; and invest in health information technology. The F-SHRP also permitted mandatory managed care enrollment for Medicaid eligible aged, blind and disabled individuals statewide; and children, caretaker relatives, and pregnant women in selected counties. (Source:; State Website on Federal-State Health Reform Partnership; Fact Sheet on F-SHRP, link no longer available)

In March 2014, CMS approved the state’s November 2013 request to move authority for Medicaid eligibles receiving services under the F-SHRP Demonstration to the Partnership Plan under the state’s F-SHRP §1115 Demonstration Phase Out Plan, when the F-SHRP Demonstration expired in March 2014. (Source: Medicaid Waiver website, link no longer available)
F-SHRP Phase-Out Plan and Letter to CMS (11/27/2013)
CMS Approval Letter for F-SHRP Phase-Out (3/31/2014)

On April 14, 2014, CMS approved the state’s Medicaid Redesign Team (MRT) Waiver, which the state submitted in August 2012 as an amendment to its §1115 Partnership Plan Demonstration Waiver. The waiver includes three funding elements: a $500 million allocation for the Interim Access Assurance Fund to assure financially stressed hospitals have adequate funding until DSRIP funding becomes available in 2015; a $6.42 billion Delivery System Reform Incentive Payment (DSRIP) program; and $1.08 billion for other Medicaid Redesign Team activities, including Health Home support, investments in the LTC workforce, and funding for enhanced behavioral health services (1915(i) services) as part of the new Health and Recovery Plans for individuals with SMI. New York’s DSRIP program under the state’s MRT Waiver is significantly different from other state Medicaid DSRIP programs because it requires statewide accountability. The state must meet state-wide performance goals or be subject to funding reductions. Further, if CMS reduces DSRIP, the state must reduce funds in an equal distribution across all DSRIP projects. This is designed to move New York’s managed care program from a volume-based fee-for-service payment system to a value-based payment system. (Source: State Medicaid website; HMA Weekly Roundup, 1/29/2014; HMA Weekly Roundup, 4/16/2014)
MRT Waiver Application (8/6/2012)
MRT Multi-Year Action Plan
MRT Waiver Amendment Update Presentation (4/2014)
CMS Approval Letter with Special Terms and Conditions (4/14/2014)
Public Comments on Special Terms and Conditions (5/14/2014)

On June 13, 2014, the state published a Draft Revised Medicaid Managed Care Program Quality Strategy for public comment as part of the Special Terms and Conditions of its §1115 Demonstration Waiver; comments are due by July 13, 2014. The revised Quality Strategy encompasses the state’s traditional managed care plans, as well as recent improvements to the state’s Medicaid program, including approval of the new MRT Waiver. (Source: State Medicaid Managed Care website)
Draft Quality Strategy for the New York State Medicaid Managed Care Program 2014 (6/13/14)

In July 2014, the New York Department of Health posted the DSRIP Design Grant applications it received from over 50 emerging Performing Provider Systems to receive money to plan and design their DSRIP applications. The state will announce design grant awards on August 1, 2014. (Source: HMA Weekly Roundup, 7/9/2014)
DSRIP Project Design Grant Applications (7/2014)

On July 14, 2014, the state posted a Draft DSRIP Evaluation Plan for public comment. The state plans to submit its draft evaluation plan to CMS on August 14, 2014, and begin the procurement process for an independent evaluator in November 2014. (Source: State Department of Health website)
Draft DSRIP Evaluation Plan (7/14/2014)

On August 1, 2014, the state held a DSRIP update webinar, noting CMS and the state agreed to create a new project as a result of public comments about the state’s Draft DSRIP Evaluation Plan. The new project will focus on increasing patient and community activation related to health care, paired with increased resources to help uninsured (UI), non-utilizing (NU), and low utilizing (LU) populations gain access to and utilize benefits associated with DSRIP PPS projects, particularly primary and preventative services. (Source: State Department of Health website) DSRIP Update PowerPoint (8/1/2014)

On August 6, 2014, the state announced its funding awards to emerging Performing Provider Systems to develop comprehensive DSRIP project plans. (Source: State Department of Health website)
DSRIP Project Design Grant Final Award Allocation (8/8/2014)

The New York Department of Health, in partnership with Salient, developed DSRIP dashboards to generate data and analysis to assist with planning, community needs assessment, and application development for the DSRIP initiative. The dashboards present Medicaid utilization and enrollment data made available by the state DOH. The data will be updated monthly to present the most current information for service, beginning with data from 2011 through present. (Source: State DSRIP Dashboards website; HMA Weekly Roundup, 8/13/2014)

The New York State Department of Health posted Draft DSRIP PPS Plan Application materials for public review and comment; comments may be submitted via email through October 29, 2014.  (Source:  State DSRIP Program website
Draft DSRIP Project Plan Application

The New York State Department of Health and the Dormitory Authority of the State of New York announced the availability of funds under the Capital Restructuring Financing Program (CRFP), a state grant program with awards totaling up to $1.2 billion over seven years to support capital projects to strengthen and improve infrastructure, promote integrated health systems, and support increased primary care capacity.  The grant program is meant to complement awards granted by the DSRIP Program.  The Department of Health will accept public comments about the CRFP through November 1, 2014.  (Source:  State DSRIP Program website)
Capital Restructuring Financing Program Information Sheet

The New York State Department of Health posted the DSRIP PPS Lead & PPS Financial Stability Test on the state’s DSRIP website for completion by potential PPS Lead organizations.  Potential PPS Lead organizations must complete the Test document and the Test Excel Tool and submit completed application documents by November 7, 2014 to be eligible to serve as a PPS Lead organization.  (Source:  State DSRIP Program website)

The New York State Department of Health posted a Draft DSRIP Measure Specification and Reporting Manual for public review and comment; comments may be submitted via email through November 10, 2014.  The manual includes information about DSRIP project measure requirements, reporting mechanisms, and PPS reporting requirements.  The manual also includes information about performance goals and methods for establishing improvement targets.  (Source:  Community Health Care Association of NY State, 10/2014)  
Draft DSRIP Measure Specification and Reporting Manual

On January 1, 2015, transportation services (emergency and non-emergency) will be carved-out of the managed care benefit package for all managed care enrollees in seven additional upstate counties in Western New York:  Allegany; Cattaraugus; Chautauqua; Erie; Genesee; Niagara; and Wyoming.  (Source:  NY Department of Health website)

The New York Community Trust awarded a $75,000 grant to the New York Integrated Network for Persons with Intellectual and Developmental Disabilities (NYIN).  NYIN is a Brooklyn-based nonprofit planning a managed care network for Medicaid beneficiaries with I/DD; NYIN will use the grant to create a DD integrated support and care coordination organization, a network of agencies providing a full range of coordinated health and social services under a risk-based capitation arrangement.  (Source:  HMA Weekly Roundup, 11/5/2014)

The New York State Department of Health (DOH) posted DSRIP Vital Access Provider (VAP) Exception Appeals for public review and comment; comments may be submitted via email through December 3, 2014.   The DOH is currently reviewing the VAP Exceptions and making recommendations for inclusion in the DSRIP safety net process.  Approval of these exception appeals is contingent upon obtaining approval from CMS.  (Source:  State DSRIP Program website)

On December 4, 2014, New York Department of Health (DOH) published Frequently Asked Questions about its MRT Waiver Amendment Delivery System Reform Incentive Payment (DSRIP) Plan.  DOH also published an updated DSRIP Timeline.  (Source:  NY DSRIP website, 12/2014) 
FAQ:  MRT Waiver Amendment DSRIP Plan (12/4/2014) 
DSRIP Timeline (12/4/2014)

On December 11, 2014, New York DOH and the Center for Health Care Strategies (CHCS) presented a webinar that included an overview of the state’s DSRIP model and details on the plan’s financing structure, project domains, measurement approach, and evaluation criteria.  (Source:  NY DSRIP website, 12/2014) 
NY’s DSRIP Program:  A Model for Reforming the Medicaid Delivery System PowerPoint Slides (12/11/2014)

New York DOH has extended the due date for its Capital Restructuring Financing Program (CRFP) Request for Applications from the current deadline of December 22, 2014 to February 20, 2015.  The CRFP will provide $1.2 billion in funding to eligible facilities that can demonstrate that a capital project will assist in meeting the goals of DSRIP.  (Source:  NY DOH website, 12/2014)

On December 24, 2014, CMS approved the 2014 Quality Strategy for the New York State Medicaid Managed Care Program.  The 2014 Quality Strategy delineates the updated and expanded goals of the state’s Medicaid managed care program and the actions taken by New York DOH to ensure the quality of care delivered to Medicaid managed care enrollees.  (Source:  NY DOH website, 2/2014)
2014 Quality Strategy for the NYS Medicaid Managed Care Program

On December 31, 2014, CMS granted a temporary extension to New York’s §1115 demonstration waiver, the Partnership Plan, effective through March 31, 2015.  The waiver was originally scheduled to expire at the end of 2014.  (Source:  NY DOH 1115 Waiver website)
CMS Temporary Extension Approval Letter (12/31/2014)

The New York State Department of Health has posted a presentation on its DSRIP website about shared savings and value-based payments.  (Source:  NY DOH DSRIP website; HMA Weekly Roundup, 1/21/2015)
DSRIP, Shared Savings, and the Path Toward Value-Based Payment Slides

On March 25, 2015, the New York Department of Health announced it is extending the deadline to submit DSRIP Implementation Plans to May 1, due to the postponement of the final valuation until after the State Legislature approves the budget.  (Source:  New York MRT Updates List Serv, 3/25/2015)

On April 10, 2015, the New York Department of Health released an updated MRT Waiver/DSRIP Year 1 Timeline.  (Source:  New York MRT Updates List Serv, 4/10/2015)
MRT Waiver/DSRIP Key Dates Year 1 (Updated 4/10/2015)

State Demonstration to Integrate Care for Dual Eligible Individuals

The state initially proposed to integrate care for dual eligibles through two models: a Capitated Financial Alignment Model and a Managed Fee-for-Service Model. However, the state withdrew its Managed Fee-for-Service model. (Source: Withdrawal Letter, 3/21/2013)

On August 23, 2013, the state and CMS signed an MOU for the Capitated Financial Alignment Model, known as Fully-Integrated Duals Advantage (FIDA). Built off the state’s Medicaid Advantage Plus program, the FIDA program will cover full dual eligibles age 21 or older who require 120 or more days of LTSS. Full dual eligibles age 21 or older who are receiving services through the Office of Persons with Developmental Disabilities (OPWDD) system will be served under FIDA OPWDD statewide. (Source: CMS Press Release, 8/26/2013; State Dual Eligibles website)
Memorandum of Understanding
Three-Way Contract for Demonstration (7/3/2014)

The state will establish FIDA plans in eight downstate counties. Voluntary enrollment for community-based and nursing home populations begins October 1, 2014; and passive enrollment for both populations begins January 1, 2015. The state intends to have final three-way contracts signed by July 2014. (Source: HMA Weekly Roundup, 1/15/2014; HMA Weekly Roundup, 1/22/2014; MLTSS Network Weekly Roundup, link no longer available 2/20/2014; State Duals Demonstration website)

On July 2, 2014, the state and CMS announced the FIDA enrollment start date will be postponed until January 1, 2015, to give plans three additional months to complete readiness review activities and fix plan deficiencies before FIDA begins. (Source: State Duals Demonstration website)

As of November 19, 2014, New York has completed contracts with 22 managed long-term care plans to participate in the Fully Integrated Duals Advantage demonstration program (FIDA).  A total of $14.6 billion in contracts was awarded, covering the period from October 2014 through December 2017.  Large contracts were awarded to VNS Choice ($2.37 billion); GuildNet ($1.8 billion); Elderplan ($1.4 billion); and Managed Health ($1.4 billion).  (Source:  HMA Weekly Roundup, 11/19/2014) 

On December 11, 2014, the Medicaid Managed Care Advisory Review Panel (MMCARP) provided an update on the state’s Fully-Integrated Duals Advantage (FIDA) program:  (1) Region 1 opt-in enrollment will begin January 1, 2015, and passive enrollment will begin April 1, 2015; (2) Region 2 opt-in enrollment will begin April 1, 2015, and passive enrollment will begin July 1, 2015; and (3) The earliest FIDA passive enrollment for nursing homes will begin in August 2015.  (Source:  HMA Weekly Roundup, 12/17/2014)

On January 7, 2015, CMS posted the Evaluation Design Plan for New York’s duals demonstration.  (Source:  CMS website)
New York Evaluation Design Plan (1/7/2015)

On March 5, 2015, Capital New York reported the state is temporarily delaying the second phase of implementation for its Fully Integrated Duals Advantage (FIDA) demonstration due to network deficiencies; opt-in enrollment in Region 2 (Suffolk and Westchester Counties) was initially scheduled to begin April 1, 2015.  The state began opt-in enrollment in Region 1 (New York City and Nassau Counties) on January 1, 2015.  (Source:  Capital New York, 3/5/2015)

As of May 1, 2015, New York’s FIDA program enrollment is 7,215; roughly 45,000 individuals have opted out of the program. (Source: HMA Roundup, 5/20/2015)
On April 28, 2015, New York DOH announced significant adjustments to Fully Integrated Duals Advantage (FIDA) and Managed Long Term Care (MLTC) payments. DOH estimates a 4.5 to 5.6 percent increase in FIDA rates to bring them in line with MLTC rates. DOH is coordinating with CMS to implement these adjustments for FY 2015-2016. (Source: Leading Age New York, 5/2015)

On June 8, 2015, the New York Department of Health (DOH) announced plans to expand its duals demonstration to the state’s I/DD population. The new initiative will be known as the Fully Integrated Duals Advantage (FIDA-IDD) and will focus on individuals receiving LTSS and I/DD services. (Source: NYS DOH, 6/8/2015)

New York has officially applied to CMS for an extension of its dual eligible demonstration, Fully Integrated Duals Advantage, or FIDA, for two more years. Despite lower than expected enrollment, New York hopes to see increased numbers through additional educational and outreach strategies. Enrollment in the demonstration witnessed a marginal decline from August to September, from 7,676 to 7,280, even with the passive enrollment of 1,020 new enrollees. In September, the New York Department of Health and CMS jointly hosted events illuminating positive experiences and best practices from the demonstration. (, link no longer available 8/24/2015; HMA Roundup 9/23/2015) 

On October 21, 2015, Modern Healthcare reported that CMS will assist New York’s dual eligible demonstration in reaching out to providers in an attempt to increase enrollment. Beneficiaries in the program are allowed to change plans every month, which has destabilized the continuity of the demonstration. Other state dual eligible demonstrations have needed mid-course corrections to ensure success. (Source: ModernHealthcare 10/21/2015)

On November 5, 2015, CMS and New York announced a second initiative to coordinate care for dual eligible individuals with intellectual and developmental disabilities. The program, Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD), will work alongside with New York’s original duals demonstration, Fully Integrated Duals Advantage (FIDA). An estimated 20,000 dual eligibles with IDD will be eligible to participate. The demonstration will be a capitated program, will only serve the downstate region of New York—New York City, Long Island, Rockland and Westchester Counties—and will not passively enroll beneficiaries as FIDA did. Opt-in enrollment will begin no earlier than April 1, 2016. (Source: 11/5/2015)

CMS has announced shared risk adjustment rates for New York's FIDA dual eligible demonstration. Manhattan and the Bronx will see Medicare rate increases of 5.7 percent, while other areas participating in FIDA will see increases as high as 10.5 percent. The increases are retroactively effective as of January 1, 2016. (Source: HMA Weekly Roundup 2/17/2016)

New York has launched a new web page specifically devoted to providing information regarding the state's dual eligible demonstration, Fully Integrated Duals Advantage (FIDA). As of January 2016, New York has 109,000 FIDA-eligible beneficiaries, of which 6,290 have enrolled in the program, and 61,362 have opted out. (Source: FIDA Webpage 

New York’s dual eligible demonstration for individuals 21 and older that receive long-term care and developmental disability services, FIDA-IDD, officially commenced enrollment in March, with services beginning as early as April 1, 2016. Individuals residing in Rockland, Westchester, Long island and NYC counties are eligible for the demonstration. Individuals can choose to enroll or opt-out at any time. (Source: HMA Roundup 3/9/2016)

New York’s demonstration to integrate care for dual eligibles, Fully Integrated Duals Advantage (FIDA), has been extended until December 2019. FIDA is set to expand into Region 2—which encompasses Suffolk and Westchester Counties—in March 2017. Enrollment in Region 2 is voluntary and will not include passive enrollment. New York also plans to launch a new stakeholder engagement process that will review FIDA. (Source: HMA Weekly Roundup 3/1/2017)

Five health plans participating in New York’s dual eligible demonstration, Fully Integrated Duals Advantage (FIDA), announced they will be dropping out of the program. The fives plans are: Aetna, Guildnet (only closing in Nassau County), Fidelis, ICS, and North Shore. The closures will affect Nassau County and NYC, and 534 FIDA members. (Source: NY Health Access 1/11/2018; HMA Weekly Roundup 1/10/2018)

On January 1, 2018, the New York Department of Health re-executed its three-way contract with CMS and health plan participants for the FIDA, the state’s dual eligible financial alignment demonstration. Some of the changes in the newly executed contract include:

  • Formally extended the demonstration through December 31, 2019;
  • Revised to update language to comply with Medicaid managed care regulations;
  • Amended provider credentialing requirements; and
  • Added new detail on member enrollment/disenrollment. (Source: Summary of Changes 1/1/2018)

The New York Department of Health (DOH) and the Office of People with Developmental Disabilities (OPWDD) have released new FIDA-Intellectual and Developmental Disabilities (FIDA-IDD) demonstration policy that details how assessments, person-centered service planning, and care management will be conducted under FIDA-IDD program. FIDA-IDD is the state’s second financial alignment demonstration for individuals eligible for both Medicare and Medicaid, with FIDA-IDD focusing specifically on the IDD population.  As a part of the FIDA-IDD demonstration, the Interdisciplinary Team (IDT) is responsible for coverage determinations, as well as services planning and care management.  (IDT Policy 1/1/2018)

New York’s Demonstration Year 2 (2016) for the NY Fully Integrated Duals Advantage (FIDA) included seventeen of the twenty-one plans from Year 1 (2015).  All Financial Alignment Demonstrations include a provision to ‘withhold’ a portion of the Medicare-Medicaid Plans’ capitation rate that can be recaptured if the MMPs meet quality measures.  The average percent of performance measures met was 77%.  Only one plan met less than 67% of the performance measures. Five plans met 100%. In 2016, the average percent of quality withholds “received” dropped to 82% compared to 93% in 2015. Six plans received 100% of withheld funds. Additionally, New York reported on another demonstration which provided services for people with Intellectual and Developmental Disabilities (I/DD) in FIDA-IDD Demonstration Year 1 (2016). This demonstration’s sole MMP, Partners Health Plan, Inc., met 100% of its performance measures and received 100% of the quality withhold. (Source: NY FIDA Medicare-Medicaid Year 1, Year 2, NY FIDA-IDD-Calendar Year 2016, 6-19-2018)

On December 17th, the New York State Department of Health held a stakeholder update regarding its Medicare-Medicaid Coordination activities, with an emphasis on the state’s Fully Integrated Duals Advantage (FIDA) program. Notable information from this update includes:

  • FIDA enrollment was estimated at 3,800 in October 2018, down from a peak of 8,900 individuals enrolled;
  • Four FIDA plans will leave the market after the end of 2018, leaving six plans in operation during 2019;
  • The FIDA demonstration will end on December 31, 2019, except for the intellectual/developmental FIDA, which will end on December 31, 2020;
  • New York is exploring using default enrollment to promote integration between Medicare and Medicaid once FIDA ends.

Source: New York Stakeholder Update Presentation (12-17-2018).

Medicare Medicaid Integration

New York’s Fully Integrated Duals Advantage (FIDA) demonstration is set to end at the end of 2019. The six FIDA plans have a Medicaid Advantage Plus (MAP) plan aligned with D-SNPs in the same service areas. FIDA members will be able to join a MAP plan, which the state is seeking to enhance to resemble FIDA plans. The Department of Health is looking to integrate the grievance and appeals processes, aligned and default enrollment processes, and integrated marketing materials and models from FIDA plans in the MAP plans. (Source: Providing Integrated Care for New York's Dual-Eligible Members, 2-28-2019)

The New York State Department of Health (NYSDOH) published the phase-out plan for the Fully Integrated Dual Advantage (FIDA) demonstration on June 24, 2019. Current FIDA plans offer a Medicaid Advantage Plus (MAP) plan aligned with a D-SNP. NYSDOH is working with CMS to transition the 2,706 demonstration participants into MAP plans and D-SNPs. NYSDOH plans to passively enroll individuals from FIDA plans into a MAP-participating D-SNP plan with the approval of CMS. Passive enrollments are expected to begin January 1, 2020. Medicaid plans are expected to accept the transfer enrollment of demonstration participants that select or are automatically assigned to a plan to ensure continuity of care, effective October 2019.

(Source: FIDA Demonstration Phase-Out Plan, 6-24-2019)

CMS released the results of quality withhold analyses of both of New York’s  Financial Alignment Initiative (FAI) programs:  the  Fully Integrated Duals Advantage (FIDA) demonstration , and Fully Integrated Duals Advantage for Individuals with Intellectual and Developmental Disabilities (FIDA-IDD) demonstration  A percentage of both state Medicaid and federal Medicare capitation rates are withheld from the Medicare -Medicaid Plans (MMPs to ensure quality for dually eligible individuals. MMPs can earn the withheld funds back if Federal, CMS Core, and state-specific quality withhold performance measures were met.

New York’s FIDA MMPs met 91 percent of overall quality withhold measures, 81 percent of federal quality withhold measures, 96 percent of New York-specific measures, and 100 percent of alternative measures for the third demonstration year (CY 2017). Alternative measures are used in quality withhold analysis when an MMP is unable to report at least three quality withhold measures for a given demonstration year.

New York’s FIDA-IDD MMPs met 100 percent of overall, federal, and state quality withhold measures for calendar years 2016 and 2017.

(Sources: New York FIDA Medicare-Medicaid Plan Quality Withhold Analysis Results; 8-14-2019, New York FIDA-IDD Medicare-Medicaid Plan; 8-14-2019)

CMS released the first evaluation report for the New York Fully Integrated Duals Advantage (FIDA) Program. The report provides an overview of the implementation of the FIDA demonstration and results from the first round of evaluation. Findings are from the demonstration period between January 1, 2015 and December 31, 2015. Areas evaluated include: eligibility and enrollment, care coordination, beneficiary experience, financing and payment, and service utilization. Data for the evaluation comes from key informant interviews, focus groups, results from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, Medicare claims data, and other sources.

(Source: FAI New York Fully Integrated Duals; 9-24-2019).


Balancing Incentive Program

In March 2013, CMS awarded New York an estimated $598.7 million in enhanced Medicaid funds (a 2% enhanced FMAP rate). (Source: BIP Award Letter, 3/15/2013)
BIP Structural Change Work Plan, link no longer available (12/20/2013)
BIP Work Plan Update (1/9/2014)
Request for BIP Funding Grant Applications, link no longer available (3/21/2014)

Section 1915(k) Community First Choice Option

The state’s Community First Choice Options Development and Implementation Council has been holding meetings to discuss the state’s proposed application/implementation of the option. (Source: State CFCO website)

As of September 2014, New York is still in the process of developing a CFC application. (Source: Conversations with state officials)

As of November 2014, the state has officially submitted a Section 1915(k) Community First Choice Option SPA to CMS for approval.  (Source:  Kaiser Community First Choice website, 10/2014)

On October 23, 2015, New York received approval for its Community First Choice option (CFCO) 1915(k) to provide home and community-based attendant services and support with a July 1, 2015 effective date (Medicaid policy allows for retroactive approval of state plan changes). The CFCO provides a 6 percentage Federal Medical Assistance Percentage (FMAP) increase for any expenditures on these HCBS services, which New York plans on using to pursue its Olmstead initiatives. New York’s program includes a number of services and supports, including congregate meals, home health, and consumer-directed personal care. (Source: SPA Approval Letter 10/23/2015) 

The New York Department of Health (DOH) announced that New York will begin implementation of the Community First Choice Option (CFCO) on April 1, 2017, for both the fee-for-service (FFS) and Medicaid managed care populations. The CFCO, which required an amendment to the State’s Medicaid Plan, was first approved by CMS on July 1, 2015. New York CFCO State Plan services and supports include:

  • Assistive technology beyond the scope of Durable Medical Equipment;
  • ADL and IADL skill acquisition, maintenance, and enhancement;
  • Community Transitional Services;
  • Moving Assistance;
  • Environmental Modifications;
  • Vehicle Modifications;
  • Non-Emergent Transportation; and
  • Congregate and/or Home Delivered Meals.

CFCO services must be approved through a Person Centered Service Plan (PCSP). A number of these services have cost limitations. (Source: 11/10/2016)

New York has delayed implementation of the 1915(k) Community First Choice Option (CFCO) from July 2017 to January 2018. Both the Nursing Home Transition and Diversion and the Traumatic Brain Injury waivers will have their transitions to Medicaid managed care pushed back from January 2018 to April 2018. (Source: HMA Weekly Roundup 3/1/2017)

Health Homes

New York has 3 approved Health Home State Plan Amendments. The Health Homes target Medicaid enrollees with SMI; chronic medical conditions; or behavioral health conditions. (Source: CMS State Health Home Proposal Status website, 6/2014; CMS State Health Home SPA Matrix, 3/2014)
Approved State Plan Amendment (2/3/2012)

As of September 19, 2014, the state is in the process of drafting a fourth Health Home State Plan Amendment for Health Homes to Better Serve Children; and the state plans to submit its proposed SPA to CMS on November 1, 2014.  (Source:  State Health Homes website)
Revised Schedule for Health Homes to Better Serve Children (9/19/2014)
Draft Health Home Application to Serve Children (6/30/2014)

A new report, “Who’s Going to Care? Analysis and Recommendations for Building New York’s Care Coordination and Care Management Workforce,” discusses the challenges facing Medicaid Health Homes in New York. Specifically, the report discusses issues with hiring and retaining care management and care coordination personnel. Low salaries, heavy caseloads, and a lack of essential skills are noted as key drivers of these challenges. (Source:, link no longer avaialble 7/2015) 

On April 7, 2016 CMS approved New York’s State Plan Amendment (SPA) for pediatric health homes, with an implementation date of October 1, 2016. CMS also approved a rate structure that will be in place for two years and then reevaluated after that time. Health Homes will be responsible for providing six essential services: comprehensive care management; care coordination and health promotion; comprehensive transitional care; patient and family support; referral to community supports, and; use of Health Information Technology (HIT). (Source: HMA Weekly Roundup 4/13/2016)  

New York will require organizations participating in one of the states’ Medicaid Health Homes initiative to operate a Quality Management Program beginning on June 1, 2017, in the hopes that it will contribute to enhanced quality and oversight of that program. To be eligible for Health Home services in New York, Medicaid enrollees must have one of the following: two or more chronic conditions; or, one single qualifying condition, such as HIV/AIDs, Serious Mental Illness (SMI) for adults, or Serious Emotional Disturbance (SED) or complex trauma for children. (Source: HMA Weekly Roundup 5/10/2017; NY Dept. of Health 5/18/2017)

The New York Department of Health (DOH) and the New York State Office for People with Developmental Disabilities (OPWDD) are collaborating to expand the state’s Health Home Program to serve individuals with intellectual and/or developmental disabilities (I/DD). Health Homes designated for individuals with I/DD will be referred to as People First Care Coordination Organization Health Homes (CCO/HHs). This marks the initial step in a process to transition I/DD services into Medicaid managed care. Ultimately, the state envisions CCO/HHs will transition into specialized MCOs (I/DD MCOs) or contract with existing I/DD MCOs to provide Health Home and care management services to the I/DD population. The anticipated timeline the state has released is as follows:



Draft Health Home Application Released

June 30, 2017

Due Date to Submit Letter of Interest

August 4, 2017

Final Application Released

September 30, 2017

Application Due

November 30, 2017

Transition to CCO/HH for individuals with I/DD

July 2018

(Source: 7/28/2017)
On November 13, 2017, Politico published an article on some the successes and challenges of New York’s Medicaid Health Homes program. New York’s Health Homes program has reduced inpatient costs by 8 percent per month, and utilization has decreased by 6 percent. Enrollment, however, has lagged projections—it was estimated that as many as close to a million individuals would be eligible, but currently there are 163,000 enrolled in the program in 35 health homes across New York. The state aims to increase program effectiveness by submitting altered rates and new rules to align incentives across the program, which will have to be approved by CMS. (Source: Politico New York 11/13/2017)
The New York Office for People with Developmental Disabilities (OPWDD) released a draft waiver transition plan for HCBS, Health Home Care Management for Individuals with I/DD, and the Development of Specialized Managed Care. As a part of the Health Home model, New York has selected new Care Coordination Organizations (CCOs), made up of existing I/DD providers, to coordinate all services for I/DD individuals via an individualized Life Plan. The six CCOs selected are:
  • Advance Care Alliance;
  • Care Design NY;
  • LIFEPlan;; 
  • Person Centered Services; 
  • Prime Care Coordination;
  • Tri-County Care; 

The six CCOs will begin providing services on July 1, 2018. The state notes that the Health Home Care Management program does not constitute Medicaid managed care, but that managed care will be available statewide for individuals with I/DD at a later date.  (Source: Draft Transition Plan 2/21/2018)

On March 29, 2018, the New York legislature passed its final state fiscal year 2018-19 budget, which included a few changes to the state’s Medicaid Health Homes program. A few additional changes were not included in legislation but the state Medicaid agency agreed to address them via administrative processes. Items included in the budget: 

  • Providing inventive payments to health home beneficiaries that participated in wellness programs;
  • New incentives for health homes participants that avoided preventable emergency department use and hospitalizations. 

The item not included in the budget that the state agency will address is to create requirements for MCOs and health homes to enroll a targeted number of high-risk individuals into the program. (Source:  HMA Weekly Roundup 4/11/2018)

On May 1, 2018, the New York Citizens Budget Commission (CBC) released a new report entitled Options for Enhancing New York’s Health Home Initiative. Included in the report are the following suggested improvements for the state’s health home program:

  • Enhanced targeting of priority populations;
  • Increased focus on specialized health home organizations;
  • Better relationships between health homes and MCOs;
  • Alternative payment rates for health homes;
  • Consolidated development of marketing and training materials; and
  • New programs to support electronic health record interoperability between MCOs, health homes, and providers. (Source: CBC Site 5/1/2018)