PUBLIC INFORMATION & COMMUNICATIONS

Request for Comments

The Human Services Department (HSD), Medical Assistance Division (MAD), invites comments from the public about changes to the Centennial Care 2.0 program that are being considered as part of an amendment that is proposed to be effective July 1, 2019. Comments will be accepted until 5:00pm MST on Monday, April 15, 2019. Read below to learn more about the Centennial Care 2.0 waiver amendment.

HSD will hold two public hearings in different regions of the state to receive comments about the draft amendment to the waiver. Please see below for the locations and times of the hearings.

All comments will be reviewed and evaluated to inform additional modifications prior to submission of the final waiver amendment application to CMS.

Public Hearings

Las Cruces – Wednesday, April 10, 2019

Santa Fe – Monday, April 15, 2019

About Centennial Care 2.0

The New Mexico Human Services Department (HSD) is proposing improvements to the Centennial Care 2.0 program and is seeking input from stakeholders throughout New Mexico for consideration before submitting a final waiver amendment to the federal Centers for Medicare and Medicaid Services (CMS).

HSD has released a draft Section 1115 Demonstration Waiver amendment application for Centennial Care 2.0.  The draft amendment outlines HSD’s modifications to improve the program.  The draft amendment can be reviewed by clicking here. HSD is seeking federal authority to amend the 1115 Centennial Care 2.0 Waiver (Project Number 11W-00285/6) to make the following changes:

1. Removal of Co-payments for Centennial Care Members

As currently approved, the Centennial Care 2.0 waiver would allow co-payments of $8 for non-emergency use of the hospital Emergency Department (ED) and $8 for non-preferred prescription drugs for most Centennial Care members. HSD does not intend to implement these co-payments and seeks to remove this authority from the waiver.

2. Removal of Premiums for Members of the Adult Expansion Group

The current Centennial Care 2.0 waiver requires HSD to implement monthly premiums of $10 for members of the Adult Expansion Group who have income above 100% of the Federal Poverty Level (FPL), effective July 1, 2019. HSD does not intend to implement premiums and seeks to remove the requirement to implement them from the waiver.

3. Reinstatement of Retroactive Eligibility 

The current Centennial Care 2.0 waiver includes a phase-out of the three-month retroactive Medicaid coverage period for non-pregnant adults covered under Centennial Care. In calendar year 2019, the retroactive period is limited to one month. In calendar year 2020, the waiver requires the HSD to eliminate retroactive coverage for this population completely.

HSD does not intend to proceed with eliminating retroactive coverage in 2020 and seeks federal approval to reinstate the full retroactive coverage period for all affected individuals as quickly as possible. HSD’s proposed effective date for reinstating retroactive coverage is July 1, 2019.

4. Community Benefit Services

Centennial Care expanded the availability of Community Benefit (CB) services to individuals who qualify for full Medicaid coverage and meet a Nursing Facility Level of Care (NF LOC) by eliminating the requirement for a waiver allocation in order to access the full suite of CB services. HSD has continued to provide access to CB for certain members who do not meet standard Medicaid financial eligibility by establishing 4,289 slots in the Centennial Care waiver. Current allocation efforts by HSD are keeping up with attrition; however, HSD anticipates that the need for additional slots will increase. HSD is proposing to increase the number of slots by 1,500 through the waiver amendment.

5. Home Visiting Pilot

The Centennial Care 2.0 home visiting pilot program focuses on pre-natal care, post-partum care, and early childhood development in state-designated counties. HSD is proposing to remove the restriction on the number of counties in which the home visiting project can be implemented, as well as the number of potential members who can be served by home visiting services. Additional counties providing home visiting services will be designated by HSD throughout the term of the waiver.

The public will have opportunities to provide feedback to HSD about the changes outlined in the draft application during two public hearings in April 2019, or by submitting written comments.  After the hearings, HSD will develop its final waiver amendment application for submission to CMS in April 2019.

Centennial Care Approvals.

The requested changes will impact the currently approved waiver authorities, expenditure authorities and Special Terms and Conditions (STCs) for the period between January 1, 2019 and December 31, 2023. Please note that the STCs for Centennial Care 2.0 are currently being modified by CMS for technical corrections identified by HSD. Due to the status of the technical corrections, actual references to STC language are not reflected in this document; however, STC language will be made available upon request.

I. Program Description, Goals, and Objectives

The state’s goals for the Centennial Care 2.0 demonstration include providing the most effective and efficient health care possible for eligible New Mexicans, as well as continuing the healthcare delivery reforms of Centennial Care. Specifically, the state will further the following goals:

• Assure that Medicaid members in the program receive the right amount of care, delivered at the right time, and in the right setting;
• Ensure that the care and services being provided are measured in terms of their quality and not solely by quantity;
• Slow the growth rate of costs or “bend the cost curve” over time without inappropriate reductions in benefits, eligibility or provider rates; and streamline and modernize the Medicaid program in the state.

Today, Centennial Care 2.0 features an integrated, comprehensive Medicaid delivery system in which a member’s Managed Care Organization (MCO) is responsible for coordinating his/her full array of services, including acute care (including pharmacy), behavioral health services, institutional services and home and community-based services (HCBS).

The waiver amendment provides the opportunity for the state to continue advancing successful initiatives under the demonstration while continuing to implement new, targeted initiatives to address specific gaps in care and improve healthcare outcomes for Centennial Care members. Key initiatives under the Centennial Care 2.0 program include:

• Refine care coordination to better meet the needs of high-cost, high-need members, especially during transitions in their setting of care;
• Continue to expand access to long-term services and supports (LTSS) and maintain the progress achieved through rebalancing efforts to serve more members in their homes and communities;
• Improve the integration of behavioral and physical health services, with greater emphasis on other social factors that impact population health;
• Expand payment reform through value-based purchasing arrangements to achieve improved quality and better health outcomes;
• Continue the Safety Net Care Pool and time-limited Hospital Quality Improvement Initiative; and
• Further simplify administrative complexities and implement refinements in program and benefit design.

As part of the demonstration extension, the state will continue to expand access to LTSS through the Community Benefit (CB) that includes both the personal care and HCBS benefits, and by allowing eligible members who meet a NF LOC to access the CB without the need for a waiver slot. Individuals who are not otherwise Medicaid eligible and meet the criteria for the 217-like group will be able to access the CB if a slot is available. As is the case today, managed care enrollment will be required for all members who meet NF level of care or who are dually eligible.

II. Proposed Health Care Delivery System and Eligibility Requirements, Benefit Coverage, and Cost-Sharing

A.​ Delivery System & Eligibility Requirements

Centennial Care 2.0 provides a comprehensive benefit package to eligible populations through an integrated managed care model that includes a number of innovations. The following are descriptions of the current eligible populations and covered benefits:

Table 1: Eligibility Groups Covered in Centennial Care

Population Group	Populations
TANF and Related	Newborns, infants, and children Children’s Health Insurance Program (CHIP) Foster children Adopted children Pregnant women Low-income parent(s)/caretaker(s) and families Breast and Cervical Cancer Refugees Transitional Medical Assistance
Supplemental Security Income (SSI) Medicaid	Aged, blind and disabled Working disabled
SSI Dual Eligible	Aged, blind and disabled Working disabled
Medicaid Expansion	Adults between 19-64 years-old up to 133% of Modified Adjusted Gross Income (MAGI)

The following populations are excluded from Centennial Care:

• Qualified Medicare Beneficiaries;
• Specified Low-Income Medicare Beneficiaries;
• Qualified Individuals;
• Qualified Disabled Working Individuals;
• Non-citizens only eligible for emergency medical services;
• Program of All-Inclusive Care for the Elderly;
• Individuals residing in Intermediate Care Facilities for Individuals with an Intellectual Disability;
• Medically Fragile 1915(c) waiver participants for HCBS;
• Developmentally Disabled 1915(c) waiver participants for HCBS;
• Individuals eligible for family planning services only; and
• Mi Via 1915(c) waiver participants for HCBS.

B. Benefit Coverage

Centennial Care 2.0 provides a comprehensive package of services that includes behavioral health, physical health, and long-term care services and supports (LTSS). Members meeting a Nursing Facility Level of Care (NF LOC) are able to access LTSS through Community Benefit (CB) services (i.e., home- and community-based services) without a waiver slot. The CB is available through Agency-Based Community Benefit (ABCB) services (services provided by a provider agency) and Self-Directed Community Benefit (SDCB) services (services that a participant can control and direct).

As outlined in the draft amendment waiver application, the state has proposed some additional refinements to benefits and eligibility, including:

• Reinstatement of three-month retroactive eligibility period for most Centennial Care 2.0 members;
• Expanding the Centennial Home Visiting (CHV) program that focuses on prenatal care, post-partum care and early childhood development in collaboration with CYFD and the New Mexico Department of Health; and
• Expanding the availability of Community Benefit (CB) services for certain members who do not meet standard Medicaid financial eligibility by establishing an additional 1,500 slots through the waiver amendment.

C. Cost-Sharing – Co-Payments & Premiums

The Centennial Care 2.0 waiver amendment proposal removes premium requirements (monthly payments) for individuals in the Adult Expansion Group who have income above 100% of the federal poverty level (FPL). The waiver amendment also removes all co-payments for Centennial Care members.

Additional details may be found in the proposed waiver amendment application.

III. Budget Neutrality

A. Budget Neutrality Overview

The proposed waiver amendment proposals will have a minimal impact to the budget neutrality.

B. CHIP Allotment Neutrality

The amendment proposals will not impact allotment neutrality.

C. Budget Neutrality Summary

The federal share of the combined Medicaid expenditures for the populations included in this demonstration, excluding those covered under the Title XXI Allotment Neutrality, will not exceed what the federal share of Medicaid expenditures would have been without the demonstration.

The federal share of the combined Medicaid expenditures for the populations included in this demonstration, excluding those covered under the Title XXI Allotment Neutrality, will not exceed what the federal share of Medicaid expenditures would have been without the demonstration.

HSD makes the following assumptions regarding budget neutrality:

• HSD proposes a per capita budget neutrality model for the populations covered under the demonstration, outlines the per capita limit by Medicaid Eligibility Group (MEG) and proposes an aggregate cap, trended annually for uncompensated care and Hospital Quality Improvement Incentive expenditures;
• State administrative costs are not subject to the budget neutrality calculations;
• The projected savings is the difference between the without and with waiver projections;
• Nothing in this demonstration application precludes HSD from applying for enhanced Medicaid funding as CMS issues new opportunities or policies; and
• The budget neutrality agreement is in terms of total computable so that HSD is adversely affected by future changes to federal medical assistance percentages.

Current Approved Without Waiver and With Waiver Projected Medicaid Expenditures (Toal Computable)

IV. Hypothesis and Evaluation Parameters of the Demonstration

HSD will maintain the original hypotheses and evaluation design plan of Centennial Care 2.0 but will remove metrics associated with the implementation and administration of premiums and co-payments. The table below describes the hypotheses of Centennial Care 2.0 and how HSD will evaluate the impact.

Table 4 – Quality Goals and Evaluation

Section	Hypothesis	Methodology	Data Sources
Goal 1: Improve Member outcomes with refinements to care coordination
1.1	Enhancements to care coordination will result in decreases for avoidable emergency room visits and hospital readmissions.	Track and trend member utilization of avoidable emergency room visits and hospital readmissions and monitor MCO adherence to common chronic disease management and other social support services requirements for care coordination.	Claims data HEDIS reports MCO reporting
1.2	Birthing outcomes will improve with pregnant women participating in the home visiting pilot.	Track and trend low birthweight, pre-term birth, prenatal/post-partum visits and well child visits for members in pilot.	Claims data HEDIS reports MCO reporting
Goal 2: Increase Behavioral Health Integration
2.1	Member’s utilization of Health Homes will increase.	Track and trend the number of members participating in Health Homes.	Claims data MCO reporting
2.2	Treatment outcomes of members participating in Health Homes will improve.	Track and trend Health Homes’ treatment outcomes of common behavioral/physical health conditions and care coordination outcomes such as avoidable emergency room visits, hospital readmissions and follow up after hospitalization for mental illness.	Claims data HEDIS reports MCO reporting
Goal 3: Expand member access to Long Term Services and Supports
3.1	Allowing all Medicaid-eligible members who meet a nursing facility level of care to access the Community Benefit will maintain New Mexico’s accomplishments in rebalancing efforts.	Track and trend members accessing community benefits.	Claims data
3.2	Increasing caregiver respite hours will improve member outcomes and utilization.	Track and trend member utilization and member outcomes.	Claims data HEDIS reports
3.3	Automatic Nursing Facility Level of Care (NFLOC) approvals will achieve administrative simplification for HSD, the MCOs and members.	Track and trend automatic NFLOC approvals.	MCO reporting
Goal 4: Increase quality of care with Value Based Payment (VBP) arrangements.
4.1	Healthcare outcomes will improve for members served by providers that have VBP arrangements for the full delegation of care coordination.	Track and trend member utilization and common chronic disease management outcomes of providers with VBP arrangements that include full delegation of care coordination.	Claims data HEDIS reports MCO reporting
4.2	Implementing incremental minimum VBP requirements will support bending the cost curve of Medicaid program costs through alignment with Centennial Care 2.0 program goals of improving care coordination, focus on transitions of care.	Track and trend program expenditure.	Claims data HEDIS reports MCO reporting
Goal 5: Promoting Member Engagement and Responsibility
5.1	Members participating in the Centennial Rewards program will continue to have improved healthcare outcomes with decreases in higher-cost services, such as inpatient stays.	Track and trend member utilization of preventive services and rewards credits.	Claims data HEDIS reports MCO/Reward Program Contractor reporting
Goal 6: Improve administrative effectiveness and simplicity.
6.1	Members will have increased access to inpatient services at an Institution for Mental Disease (IMD).	Track and trend member utilization of IMDs.	Claims data
Goal 7: Improve Delivery System and Access to Services
7.1	Members will have increased access to CHWs and CHRs.	Track and trend member utilization.	MCO reporting
7.2	Members will have increased access to telehealth.	Track and trend member utilization.	Claims data
7.2	Members will have increased access to Patient Centers Medical Homes.	Track and trend member utilization.	MCO reporting

V. Waiver and Expenditure Authorities

A.   Title XIX Waiver Amendment Language/Removal/Elimination

1.	Reasonable Promptness and Medical Assistance		Section 1902(a)(8) and (10)
To the extent necessary to enable the state to begin benefit coverage on the first day of the month following receipt of the required premium by the premium due date for individuals in a Medicaid category of eligibility that requires premiums.   To the extent necessary to enable the state to prohibit initial enrollment for individuals who fail to pay required premiums.   To the extent necessary to enable the state to suspend coverage for individuals detailed in STC 60(a) who fail to pay required premiums until such time the premiums are paid in full or a hardship waiver, as detailed in STC 60(a)(1), is granted.
2.	Retroactive Eligibility	Sections 1902(a)(10) and (34) 42 CFR 435.915
To the extent necessary to enable the state to reduce, and then eliminate in demonstration year 7, coverage for the three-month period prior to the date that an application for medical assistance (and treatment as eligible for medical assistance) is made for specified eligibility groups, as described in STC 23. This waiver does not apply with respect to individuals eligible for Institutional Care (IC) categories of eligibility, pregnant women (including during the 60-day postpartum period beginning on the last day of the pregnancy), infants under age 1, or individuals under age 19.
3.	Premiums	Section 1902(a)(14) insofar as it incorporates Section 1916 and 1916A
To the extent necessary to enable the state to charge monthly premiums, as described in the STC 60(a).
3.	Comparability	Sections 1902(a)(17) and 1902(a)(10)(B)
To the extent necessary to enable the state to charge monthly premiums, as described in the STC 60(a).

B.   Expenditure Authority Requests

No language changes are required as part of the waiver amendment proposals.