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Public Notice: Comprehensive Preconception Care Model Waiver

The South Carolina Department of Health and Human Services (SCDHHS) will submit a Section 1115 Demonstration Waiver application to the Centers for Medicare and Medicaid Services (CMS) to adopt a preconception care (PCC) model for family planning, pursuant to Title XIX of the Social Security Act Medical Assistance Program (Medicaid). The waiver application is available for public review and comment at https://msp.scdhhs.gov/pcc.

This second public notice incorporates initial feedback received and highlights, among other goals, the PCC Waiver application’s compliance with South Carolina Executive Order No. 2017-15. SCDHHS intends to implement the requirements of the waiver on the first day of the quarter following 90 days after CMS approval. SCDHHS proposes a waiver period of five years. This notice provides details about the waiver submission and serves to open the 30-day public comment period, which closes Aug. 22, 2018, at 5 p.m.

Wavier Proposal Description
To continue efforts to improve the health and well-being of mothers, infants and children enrolled in the Medicaid program, SCDHHS intends to amend and enhance its family planning benefit to encompass a broader scope of preconception care in a manner that aligns with clinical evidence and nationally accepted treatment guidelines. This effort represents a shift from the traditional model of focus on contraception and care during the prenatal period to a model that includes and ensures the delivery of high quality care during the preconception period.

The primary focus of this demonstration waiver is to offer more comprehensive coordination of preconception care coverage to existing Medicaid beneficiaries, creating a more complete and coordinated health care delivery model. The proposed demonstration waiver employs a more robust and focused care model (e.g., the PCC model) to ensure the coordination of family planning and reproductive health care with primary care services and chronic disease management for both full- and limited-benefit Medicaid beneficiaries. To achieve this enhanced level of coordination, SCDHHS intends to implement a series of policies to ensure the delivery of integrated care that addresses overall health care needs.

To adopt a comprehensive PCC model, SCDHHS proposes the following:

  • The enhancement of the benefit available to individuals enrolled in the optional family planning eligibility group to include: (1) additional primary care outpatient services; (2) a limited pharmacy benefit, focused on drugs that treat chronic disease known to affect reproductive health and birth outcomes; and (3) substance use disorder (SUD) treatment services.
  • Leveraging a focused network of providers for the provision of family planning benefits. Specific requirements for providers who participate in this network will include the ability to screen for and treat the entire scope of PCC, including regularly managing diabetes, hypertension, heart disease, depression and substance use disorder. To effectively ensure that qualified providers participate in the delivery of preconception care, this application requests waiver of Section 1902(a)(23) of Title XIX of the Act.

SCDHHS seeks to implement a more comprehensive set of provider qualifications to ensure that those providers engaged in the delivery of the PCC model are able to adequately care for the overall health needs of the Medicaid members they serve. These provider qualifications will also ensure that SCDHHS conforms to the requirements set forth in South Carolina Executive Order No. 2017-15 by limiting participation in the Medicaid provider network for those providers who engage in the provision of elective abortions.

 Hypothesis and Evaluation
SCDHHS hypothesizes that adopting the PCC model and steering utilization of family planning and related services toward providers who routinely and expertly provide the full spectrum of care inherent to that model will improve the health outcomes of the population using family planning and related services.  Improvements in outcomes will be assessed using the conditions described above, along with additional aggregate measures of health status. South Carolina intends to test this hypothesis by using Medicaid claims data and assessing comparisons of neonatal intensive care unit (NICU) rate trends, and Neonatal Abstinence Syndrome (NAS) rate trends before and after implementation of the demonstration.

Although the consequences of poor birth outcomes are far reaching, and SCDHHS expects diversity of health improvements along with improved prenatal health, the analysis presented as part of the Demonstration rational focuses on three common measures of birth outcomes: gestational age at birth, perinatal neonatal intensive care unit (NICU) involvement and prevalence of NAS. These measures of birth outcomes will serve as the basis for evaluating the success of the Demonstration.

In conducting the evaluation for this demonstration, SCDHHS will contract with an independent external evaluator to ensure a critical and thorough assessment of program outcomes that is consistent with accepted research practice.

Goals and Objectives
SCDHHS anticipates by adopting the PCC model and steering utilization of family planning and related services toward providers who routinely and expertly provide the full spectrum of care, the model will improve the health outcomes of the population using family planning and related services. To evaluate the degree to which this transition in health care delivery models improves outcomes, SCDHHS anticipates the use of the following evaluation parameters:

  • Rate of NICU Admissions, with NICU defined as nursery level III or IV (revenue codes 0173 and 0174
  • Rate of delivery with a gestational age less than 37 weeks, using the estimation of gestation as indicated on the birth certificate
  • Rate of children born with a diagnosis of NAS, as indicated on the Medicaid claim

Eligibility
SCDHHS does not intend to make any changes to the standards or methodologies used to determine Medicaid eligibility as a result of this waiver; the standards and methodologies currently articulated in the state plan will continue to govern eligibility determination. This application does not propose an expansion of the Medicaid population or require any modifications to eligibility procedures.

As family planning services are a mandatory benefit for all Medicaid members, the number of individuals potentially impacted by the delivery system changes, as described in Section 4 of the application, and would extend to the entire Medicaid population. As of March 31, 2018, current membership includes 1,060,000 full benefit and approximately 170,000 family planning members. Of that population, 95,000 full-benefit and 36,000 limited-benefit members accessed family planning services during calendar year 2017.

Medicaid members who are currently eligible for family planning benefits will remain the same, and SCDHHS estimates enrollment trends will remain consistent based on historical experience. As such, SCDHHS anticipates that the overall population eligible for services for which provider qualifications are addressed in the application will total 1.2 million individuals annually throughout the initial five-year demonstration period. SCDHHS emphasizes that the enrollment estimates represent neither an increase or decrease annual enrollment, but are rather a continuation of the current enrollment trends, extrapolated from historical data.

A detailed listing of the eligibility groups that qualify for family planning benefits, and therefore who may be impacted by the additional provider qualifications is below.

Mandatory Categorically Needy

 



Eligibility Group Name


Citations


Waiver Impact


Low Income Families


1931


No eligibility impact


Transitional Medical Assistance


408(a)(11)(A)

1931(c)(2)

1925

1902(a)(52)


No eligibility impact


Extended Medicaid due to Child or Spousal Support Collections


408(a)(11)(B)

42 CFR 435.115

1931(c)(1)


No eligibility impact


Children with Title IV-E Adoption Assistance, Foster Care or Guardianship Care


1902(a)(10)(A)(i)(I)

473(b)(3)

42 CFR 435.145


No eligibility impact


Qualified Pregnant Women and Children


42 CFR 435.116 - old

1902(a)(10)(A)(i)(III)

1905(n)


No eligibility impact


Mandatory Poverty Level Related Pregnant Women


1902(a)(10)(A)(i)(IV)

1902(l)(1)(A)


No eligibility impact


Mandatory Poverty Level Related Infants


1902(a)(10)(A)(i)(IV)

1902(l)(1)(B)


No eligibility impact


Mandatory Poverty Level Related Children Aged 1-5


1902(a)(10)(A)(i)(VI)

1902(l)(1)(C)


No eligibility impact


Mandatory Poverty Level Related Children Aged 6-18


1902(a)(10)(A)(i)(VII)

1902(l)(1)(D)


No eligibility impact


Deemed Newborns


1902(e)(4)

42 CFR 435.117


No eligibility impact


Individuals Receiving SSI


1902(a)(10)(A)(i)(II)(aa)

42 CFR 435.120


No eligibility impact


Aged, Blind and Disabled Individuals in 209(b) States


1902(f)

42 CFR 435.121


No eligibility impact


Individuals Receiving Mandatory State Supplements


42 CFR 435.130


No eligibility impact


Individuals Who Are Essential Spouses


42 CFR 435.131

1905(a)


No eligibility impact


Institutionalized Individuals Continuously Eligible Since 1973


42 CFR 435.132


No eligibility impact


Blind or Disabled Individuals Eligible in 1973


42 CFR 435.133


No eligibility impact


Individuals Who Lost Eligibility for SSI/SSP Due to an Increase in OASDI Benefits in 1972


42 CFR 435.134


No eligibility impact


Individuals Who Would be Eligible for SSI/SSP but for OASDI COLA increases since April, 1977


1939(a)(5)(E)

42 CFR 435.135

Section 503 of P.L. 94-566


No eligibility impact


Disabled Widows and Widowers Ineligible for SSI due to Increase in OASDI


1634(b)

42 CFR 435.137


No eligibility impact


Disabled Widows and Widowers Ineligible for SSI due to Early Receipt of Social Security


42 CFR 435.138

1634(d)


No eligibility impact


Working Disabled under 1619(b)


1902(a)(10)(A)(i)(II) 1905(q)

1619(b)


No eligibility impact


Disabled Adult Children


1634(c)


No eligibility impact


Qualified Medicare Members


1902(a)(10)(E)(i)

1905(p)


No eligibility impact


Qualified Disabled and Working Individuals


1902(a)(10)(E)(ii)

1905(s)

1905(p)(3)(A)(i)


No eligibility impact


Specified Low Income Medicare Members


1902(a)(10)(E)(iii)

1905(p)(3)(A)(ii)


No eligibility impact


Qualifying Individuals


1902(a)(10)(E)(iv)

1905(p)(3)(A)(ii)


No eligibility impact


Children with Non-IV-E Adoption Assistance


1902(a)(10)(A)(ii)(VIII)

42 CFR 435.227


No eligibility impact


Independent Foster Care Adolescents


1902(a)(10)(A)(ii)(XVII)

1905(w)

42 CFR 435.226


No eligibility impact


Optional Targeted Low Income Children (M-CHIP)


1902(a)(10)(A)(ii)(XIV)

1905(u)(2)(B)

42 CFR 435.229 and 435.4


No eligibility impact


Children under 21 Not Receiving Cash


1902(a)(10)(A)(ii)(I) (IV)

1905(a)(i)

42 CFR 435.222


No eligibility impact


Families Who Would Qualify for Cash if Requirements Were More Broad


1902(a)(10)(A)(ii)(III)

42 CFR 435.223

1905(a)


No eligibility impact


Individuals Eligible for Cash except for Child Care Subsidy


1902(a)(10)(A)(ii)(II)

42 CFR 435.220


No eligibility impact


Optional Poverty Level Related Pregnant Women and Infants


1902(a)(10)(A)(ii)(IX)

1902(l)(2)


No eligibility impact


Presumptively Eligible Pregnant Women


1902(a)(47)

1920


No eligibility impact


Presumptively Eligible Children


1902(a)(47)

1920A

42 CFR 1100-1102


No eligibility impact


Individuals Electing COBRA Continuation Coverage


1902(a)(10)(F)

1902(u)(1)


No eligibility impact


Individuals Eligible for but not Receiving Cash


42 CFR 435.210

1902(a)(10)(A)(ii)(I)

1905(a)

1902(v)(1)


No eligibility impact


Individuals Eligible for Cash except for Institutionalization


1902(a)(10)(A)(ii)(IV)

42 CFR 435.211

1905(a)


No eligibility impact


Individuals in HMOs Guaranteed Eligibility


42 CFR 435.212

1902(e)(2)


No eligibility impact


Individuals Receiving Home and Community Based Services under Institutional Rules


42 CFR 435.217

1902(a)(10)(A)(ii)(VI)


No eligibility impact


Individuals Participating in a PACE Program under Institutional Rules


1934


No eligibility impact


Individuals Receiving Hospice Care


1902(a)(10)(A)(ii)(VII)

1905(o)


No eligibility impact


Optional State Supplement Recipients - 1634 States, and SSI Criteria States with 1616 Agreements


1902(a)(10)(A)(ii)(IV)

42 CFR 435.232


No eligibility impact


Optional State Supplement Recipients - 209(b) States, and SSI Criteria States without 1616 Agreements


42 CFR 435.234

1902(a)(10)(A)(ii)(XI)


No eligibility impact


Qualified Disabled Children under 19


1902(e)(3)


No eligibility impact


Institutionalized Individuals Eligible under a Special Income Level


42 CFR 435.236

1902(a)(10)(A)(ii)(V)

1905(a)


No eligibility impact


Poverty Level Aged or Disabled


1902(a)(10)(A)(ii)(X)

1902(m)(1)


No eligibility impact


Individuals with Tuberculosis


1902(a)(10)(A)(ii)(XII)

1902(z)


No eligibility impact


Certain Women Needing Treatment for Breast or Cervical Cancer


1902(a)(10)(A)(ii)(XVIII)

1902(aa)


No eligibility impact


Presumptively Eligible Women with Breast or Cervical Cancer


1920B

1902(aa)


No eligibility impact


Work Incentives Eligibility Group


1902(a)(10)(A)(ii)(XIII)


No eligibility impact


Ticket to Work Basic Group


1902(a)(10)(A)(ii)(XV)


No eligibility impact


Ticket to Work Medical Improvements Group


1902(a)(10)(A)(ii)(XVI)


No eligibility impact


Family Opportunity Act Children with Disabilities


1902(a)(10)(A)(ii)(XIX)

1902(cc)


No eligibility impact


Individuals Eligible for Family Planning Services


1902(a)(10)(A)(ii)(XXI)


No eligibility impact


Individuals Eligible for Home and Community-Based Services


1902(a)(10)(A)(ii)(XXII)

1915(i)


No eligibility impact


Individuals Eligible for Home and Community-Based Services - Special Income Level


1902(a)(10)(A)(ii)(XXII)

1915(i)


No eligibility impact


Individuals at or below 133% FPL Age 19 through 64


1902(a)(10)(A)(i) (VIII)

early implementation option


No eligibility impact

 

Medically Needy




 

South Carolina Medicaid does not determine eligibility based on medical need.

 

Demonstration Benefits and Cost Sharing Requirements
SCDHHS proposes no change to the amount, duration, authorization requirements or cost sharing in benefits available to Medicaid members as a result of this demonstration application. SCDHHS does propose the addition of provider qualification requirements intended to ensure that family planning service providers are expert, proficient and routinely engaged in the delivery of full PCC model and are, therefore, able to adequately care for the overall health needs of the Medicaid members they serve. 



Benefit


Description of Amount, Duration and Scope


Reference


Family Planning Services

 


Additional provider specifications and qualifications


1905(a)(4)(C)

 


Family Planning Services for Limited Benefit Members


Additional provider specifications and qualifications


1902(a)(10)(G)

 

In transitioning to a system that encourages the PCC model, SCDHHS intends to also enhance the services provided through the limited-benefit family planning program. SCDHHS anticipates the provision of these enhancements through the authorities currently allowable in the coverage of family planning and family planning-related services for this population. SCDHHS will pursue the necessary amendments to the Medicaid State Plan, policy changes and other activities necessary to execute these benefit enhancements. Changes to the covered services provided through the limited-benefit family planning program are not, however, part of the application.

 
Delivery System and Payment Rates
Aside from the additional provider qualifications described in Section 4 of the application, the delivery system used to provide benefits in the context of this demonstration do not differ from those currently provided through the South Carolina State Plan.

SCDHHS will continue to use the current structure of delivery through fee-for-service and managed care organizations for the provision of preconception care. Guidelines regarding the enrollment in managed care will not deviate from those currently articulated in the state plan. This current structure provides for the provision of care for most full-benefit members through managed care organizations (MCOs) on a statewide basis. Members enrolled in the limited-benefit family planning program are excluded from participation in managed care, and these members are managed through the fee-for-service system. Provisions related to access requirements of MCOs will not change pursuant to this demonstration.

No deviation from current provider reimbursement rates or quality-based supplemental payments are anticipated as a result of this demonstration. While SCDHHS does not anticipate the need to adjust capitation rates as a result of this demonstration, as there is no underlying change to the scope, duration or reimbursement rates for available services, the impact of the demonstration will be considered through the current managed care contracting and rate setting processes.

 
Implementation
The nature of this demonstration, involving no modification in Medicaid eligibility and limited changes to available benefits, allows for a relatively straightforward implementation. Considering this, SCDHHS intends to implement the provisions of this demonstration to be effective the beginning of the quarter following 90 days after CMS approval. Implementation will be statewide and will not require a phase-in approach.

Providers who will be subject to the qualification requirements set forth in Section 4 of the application will be notified in advance of the implementation date. SCDHHS will also notify any Medicaid member who has received services from an impacted provider at least 30 days before implementation.

Coordination with MCOs throughout the application process will facilitate a seamless transition of the requirements into the managed care delivery system. The necessary contact amendments will be incorporated into the managed care contractual agreement in anticipation of the demonstration’s implementation.

 
Enrollment, Financing and Budget Neutrality
As this demonstration contemplates neither a change in the underlying Medicaid population, nor a change in the breadth of covered services, the cost of delivering care is not anticipated to deviate from historical trends as a result of this demonstration. As the benefits of the PCC model are realized through improvements in health outcomes, with resulting moderate and long-term health care savings, SCDHHS anticipates this demonstration to result in meaningful overall cost savings. SCDHHS expects no change in enrollment and no significant change in short-term care expenditures as a result of this waiver.

Given no anticipated change in expenditures resulting from this demonstration, SCDHHS modeled the following expenditure estimates based on historical trends. Anticipated expenditures for family planning services are expected to total an average of $35 million annually for the five-year initial duration of the waiver. An accounting of expenditures, by state fiscal year, is included below. SCDHHS emphasizes that these expenditures do not represent an increase or decrease in expenditures, but are rather a continuation of the current family planning expenditure trends, extrapolated from historical data.
 




 


FY 2019


FY 2020


FY 2021


FY 2022


FY 2023


Limited Benefit


$6,287,000


$6,104,000


$5,920,000


$5,737,000


$5,554,000


Full

Benefit


$26,944,000


$28,178,000


$29,412,000


$30,646,000


$31,880,000


Total Expenditures


$33,231,000


$34,282,000


$35,332,000


$36,383,000


$37,434,000

 

Proposed Waivers and Expenditure Authorities
To effectively ensure that qualified providers participate in the delivery of preconception care, this demonstration requires waiver of Section 1902(a)(23) of Title XIX of the Act. In adopting the preconception care model, SCDHHS proposes to leverage a focused network of providers for the provision of family planning benefits. Specific requirements for providers who participate in this network will include the ability to treat the entire scope of care, including regularly managing diabetes, hypertension, heart disease and depression. Providers must also either provide direct care for substance use disorder or have established relationships with treatment centers to facilitate referral.

As this application does not seek to expand South Carolina Medicaid’s scope of benefits or eligibility population, the authorities for expenditures described in this application exist through 1905(a) of Title XIX of the Act, as approved in South Carolina’s current Medicaid State Plan.

Communication and Public Comments
SCDHHS wants to hear from the public about the proposed PCC model waiver program to serve Medicaid beneficiaries during their reproductive years. A copy of this notice and the Transitioning to Preconception Care draft waiver application are available at the following locations:

  1. Electronic Access: scdhhs.gov (under “PCC Waiver” section)
  2. Hardcopies:
    a.      All Healthy Connections County Offices (See Attachment A)
    b.      SCDHHS lobby at 1801 Main Street, Columbia, S.C.

In addition to the 30-day public comment period, the public was able to provide verbal comments directly to SCDHHS during three public hearings held across the state (May 22 in Greenville, June 1 in Columbia and June 4 in Charleston). A live webinar also took place Thursday, May 24. If you have a comment, please submit it by 5 p.m. Aug. 22, 2018:

  1. Online:  https://msp.scdhhs.gov/pcc/
  2. Email:     PCCWaiver@scdhhs.gov
  3. Mail:      South Carolina Department of Health and Human Services
                   ATTN: PCC Waiver
                   Post Office Box 8206, Columbia, SC 29202-8206

This is the full public notice set forth in 42 CFR 431.408(a)(1)(i) and 431.412(a). The complete application is available online at https://msp.scdhhs.gov/pcc/site-page/proposed-waiver.

 

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