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​Medicaid Coverage for Former Foster Care Youth from a Different State and Substance Use Disorder Section 1115 Demonstration

The Department of Human Services (Department) is making available for public review and comment the proposed renewal application for extension of the Section 1115 Medicaid Demonstration (Demonstration) titled Medicaid Coverage for Former Foster Care Youth from a Different State and SUD Demonstration (Project Number: 11-W-003083/3).  The effective dates of the current approved Demonstration are October 1, 2017 through September 30, 2022.  The extension requested will be for an additional 5 years through September 30, 2027. 

Description of the Demonstration

This section 1115(a) Demonstration enables the Commonwealth to provide Medicaid coverage to out‑of‑state former foster care youth (FFCY) under age 26 years who were in foster care under the responsibility of another state or tribe in such other state when they turned 18 (or such higher age as the state has elected for termination of federal foster care assistance under title IV‑E of the Social Security Act [the Act]), were enrolled in Medicaid at that time, and are now applying for Medicaid in the Commonwealth.

The objectives of the FFCY Demonstration component are to increase and strengthen overall coverage of FFCY and improve health outcomes for this population.

Through the substance use disorder (SUD)/opioid use disorder (OUD) amendment effective July 1, 2018, the Commonwealth intends to maintain critical access to OUD and other SUD services and continue delivery system improvements for these services to provide more coordinated and comprehensive SUD/OUD treatment for Medicaid beneficiaries. This Demonstration component will provide the Commonwealth with authority to provide high quality, clinically appropriate SUD treatment services in residential and inpatient treatment settings that qualify as an Institution for Mental Disease (IMD). The Demonstration will also build on the Commonwealth's existing efforts to improve models of care focused on supporting individuals in the community and home, outside of institutions, and strengthen a continuum of SUD services based on the American Society of Addiction Medicine (ASAM) criteria.

The Commonwealth will test whether the SUD section 1115 Demonstration amendment is likely to assist in promoting the objectives of Medicaid by achieving the following results:

1.     Increased rates of identification, initiation, and engagement in treatment.

2.     Increased adherence to and retention in treatment.

3.     Reductions in overdose deaths, particularly those due to opioids.

4.     Reduced utilization of emergency department (ED) and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate through improved access to other continuum of care services.

5.     Fewer readmissions to the same or higher level of care (LOC) where the readmission is preventable or medically inappropriate.

6.     Improved access to care for physical health (PH) conditions among beneficiaries.

Impacts of the Demonstration

The Demonstration will not affect the health care delivery system and cost sharing (premiums, co-payments, and deductibles) required of individuals under the Demonstration. Under the Demonstration, the only change in eligibility is the FFCY coverage outlined above, expanding eligibility for out‑of‑state former foster care youth under age 26 years who were in foster care under the responsibility of another state or tribe in such other state when they turned 18. There are fewer than 50 FFCY on the Demonstration. Please see table below for the number of eligible individuals and aggregate expenditures for the FFCY component of the Demonstration:

Demonstration Year Out of state FFCY eligible under the demonstration per yearTotal aggregate expenditures
FFY201839$       151,438.76
FFY201942$       160,969.11
FFY202028$       117,651.04
FFY202142$       177,930.85

The only change in benefit coverage is that, under Managed Care, Medicaid now reimburses for services provided to individuals 21-64 years of age in Institutions for Mental Diseases (IMDs) that provide SUD treatment and services.

In the first year of the Demonstration, the Commonwealth provided coverage for 7,500 residents of IMDS.  That number dropped to about 6,809 residents of IMD by the end of the third year as the ASAM placement criteria and complete continuum of care was implemented. An estimate of the enrollment and aggregate expenditures in the SUD portion of the Demonstration extension is included below:

With-Waiver Total ExpendituresDemonstration Years (DY)         Total
 Actual DY1Actual DY2Actual DY3Projection DY4Projection DY5Projection DY6Projection DY7Projection DY8Projection DY9Projection DY10 
Total$56,532,821 $58,381,714 $58,115,475 $84,905,390 $91,205,379 $97,972,818 $105,242,401 $113,051,387 $121,439,800 $32,612,658 $811,020,666
Eligibles under the Demonstration            7,544     7,297 6,809          7,547           7,736           7,929             8,128             8,331             8,539           2,188  

Although the demonstration is budget neutral overall, the Commonwealth is requesting that the eligibility group for the SSI Dual Eligibles be split into two populations with the same trend rate because that eligibility group has exceeded its originally approved without waiver costs. The State's actuary, Mercer, has analyzed the underlying casemix relative to the original data used to calculate the Without Waiver PMPMs. We have concluded that if the SSI Dual Eligible eligibility group were split into two populations using the original data and trend rates, the eligibility group would be within the approved Without Waiver costs. The new split (SSI Dual_NFCE and SSI Dual_NFI) split the SSI Dual data between the Nursing Facility Clinically Eligible (NFCE) and Nursing Facility Ineligible (NFI) populations. The impact of this change is reflected above in the projected expenditures of the demonstration.  Because budget neutrality for this demonstration is on a pass through, hypothetical basis, there is no impact expected to the overall budget neutrality of the demonstration.

Hypothesis and Evaluation: FFCY

In the FFCY Modified Evaluation Design submitted by Pennsylvania to CMS on June 26, 2018, the following goals for the Demonstration were identified:

Goal 1: Ensure access to Medicaid services for former foster care individuals between the ages of 18 years and 26 years who previously resided in another state.

Evaluation Questions

1.    Does the Demonstration provide continuous health insurance coverage?

A.    Hypothesis: Beneficiaries will be continuously enrolled for 12 months.

B.    Measure: Number of beneficiaries continuously enrolled.

2.    How did beneficiaries utilize health services?

C.   Hypothesis: Beneficiaries will access health services.

D.   Measure: Number of beneficiaries who had an ambulatory care visit.

E.    Measure: Number of beneficiaries who had an Emergency Department (ED) visit.

F.    Measure: Number of beneficiaries who had an inpatient visit.

G.   Measure: Number of beneficiaries who had a behavioral health (BH) encounter.

The Demonstration was found to provide continuous health insurance for 12 months for approximately 40% of the 38 youth enrolled in the program each year. This resulted in access to health care for all 38 of the enrollees. Annually, 69% of youth received at least one ambulatory care visit. Overtime, the number of youth with at least one an ED visit fluctuated from 26% to 43% with the average number of youth with an ED visit at 36% annually. The number of youth with an inpatient visit was on average 5% annually (ranging from 0% to 11%). The number of youth with a BH encounter was on average 21% annually.

Goal 2: Improve or maintain health outcomes for the target population.

Evaluation Questions
  1. What do health outcomes look like for beneficiaries?

A.    Measure: Number of beneficiaries with appropriate follow‑up care for hospitalizations.

B.    Measure: Number of beneficiaries with appropriate medication management for asthma.

C.   Measure: Number of beneficiaries on persistent medication with annual monitoring.

D.   Measure: Number of beneficiaries with an annual preventive visit.

E.    Measure: Number of beneficiaries eligible with a cervical cancer screening.

The Demonstration was found to improve or maintain health outcomes for the target population. For example, on average, there was appropriate follow-up after hospitalization 43% of the time for the target population. Sixty-seven percent of the population with asthma had appropriate medication management for asthma in Demonstration Year 1 (DY1) increasing to 100% of the population with asthma in DY2–DY4. Sixty-seven percent of the populations on persistent medication had appropriate medication monitoring year DY1 increasing to 100% of the population on persistent medication having appropriate monitoring in DY4. Twenty-one percent of the population had an annual preventive visit in each of the DYs. Eighteen percent of the beneficiaries eligible to have a cervical cancer screening received a screening.

SUD Evaluation Design

Evaluation questions and hypotheses to be addressed in the SUD portion of the evaluation were derived from and organized based on Driver Diagram. The overall aims of the project are to: 1) Reduce overdose deaths, particularly those due to opioids; 2) Reduce utilization of ED and inpatient hospital settings; and 3) Reduce readmissions to the same or higher LOC. To accomplish these goals, the demonstration includes several key activities (called primary drivers) including increasing access to care, ensuring high quality of care across the entire treatment continuum and increasing treatment program retention, and improving care transition across the continuum of SUD services. Six secondary drivers support the three primary drivers for this change. These secondary drivers become the milestones in the Commonwealth's implementation plan:

    1. Increase access to critical LOCs for OUD and other SUDs.
    2. Implement evidence-based, SUD-specific Patient Placement Criteria.
    3. Implement nationally recognized SUD-specific program standards to set provider qualifications for RTFs.
    4. Ensure sufficient provider capacity at critical LOCs including MAT for OUD.
    5. Implement comprehensive treatment and prevention strategies to address Opioid abuse and OUD.
    6. Improve care coordination and transitions between LOCs.

The evaluation of the Pennsylvania 1115 waiver utilizes a mixed-methods evaluation design with three main goals:

    1. Describe the progress made on specific waiver-supported activities (process/ implementation evaluation).
    2. Demonstrate change/accomplishments in each of the waiver milestones (short-term outcomes).
    3. Demonstrate progress in meeting the overall project goals/aims.

A combination of qualitative and quantitative approaches is used throughout the evaluation. Qualitative methods include key informant interviews with the Office of Mental Health and Substance Abuse Services (OMHSAS) and provider staff regarding waiver activities, document reviews of agreements, policy guides and manuals, and summaries of Consumer and Family Satisfaction Team (CFST) surveys conducted between 2019 and 2021. Quantitative methods include descriptive statistics showing change over time in both counts and rates for specific metrics and ITS analysis to assess the degree to which the timing of waiver interventions affect changes across specific outcome measures.

Qualitative analysis has been used to identify and describe the SUD delivery system and the changes/maintenance through the Demonstration for Medicaid enrollees in the eligible population. Each of the milestones are discussed and documented in this Interim Evaluation Report. We identify key elements that Pennsylvania intended to modify through the demonstration and measure the effects of those changes. Using a combination of case study methods, including document review, telephone interviews, surveys, and face-to-face meetings, we will have conducted a descriptive analysis of the key Pennsylvania demonstration features.

SUD Evaluation Hypotheses and Research Questions

Milestone 1: Improve access to critical LOCs for OUD and other SUDs for individuals in Medicaid managed care. Critical LOCs are defined as early intervention, outpatient services, IOP and PHP services, residential and inpatient services, WM, and MAT.
Hypothesis 1: The 1115 SUD Demonstration will increase access to the specified critical LOCs for individuals in Pennsylvania Medicaid managed care compared to prior to the waiver.
Research Question 1: Has access to critical LOCs as defined below improved in Medicaid managed care?
Analytic Approach: ITS; regression analysis for change over time after waiver implementation.
Research Question 2: Since the development of the 1115 SUD waiver, are more individuals receiving services at critical LOCs when compared to the numbers prior to the waiver onset?
Analytic Approach: ITS; regression analysis for change over time after waiver implementation.
Milestone 2: Use of Evidence-based, SUD-specific Patient Placement Criteria.
Hypothesis 2: The 1115 SUD Demonstration will lead to use of ASAM placement criteria by all providers by the end of the first year of the Demonstration project.
Research Question 1: Has the use of evidence-based SUD‑specific patient placement criteria (ASAM Criteria) been implemented across all LOCs for all patient populations?
Analytic Approach: Qualitative narrative analysis; counts.
Milestone 3: Use of Nationally recognized SUD-specific program standards to set provider qualifications for RTFs.
Hypothesis 4: The 1115 SUD Demonstration will establish ASAM Criteria and program standards to set provider qualifications for all Residential Facilities by January 2021.
Research Question 1: Has OMHSAS established ASAM Criteria and program standards to set provider qualifications for all Residential Facilities?
Analytic Approach: Qualitative narrative analysis; counts.
Milestone 4: Improve provider capacity at critical LOCs including MAT for OUD in Medicaid.
Hypothesis 3: The 1115 SUD Demonstration will increase provider capacity as defined below for SUD treatment at critical LOCs for individuals in Pennsylvania Medicaid managed care.
Research Question 1: Has the availability of providers in Medicaid accepting new patients including MAT improved under the Demonstration?
Analytic Approach: Qualitative narrative analysis; counts.
Milestone 5: Improvements in comprehensive treatment and prevention strategies to address opioid abuse and OUD for individuals in Medicaid managed care.

Hypothesis 5: The 1115 SUD Demonstration will improve outcomes for individuals in Pennsylvania Medicaid managed care under the following measures:

          • Alcohol or other drug (AOD) Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET).
          • Use of opioids at high dosage.
          • Use of opioids from multiple providers.
          • Concurrent use of opioids and benzodiazepines.
          • Continuity of pharmacotherapy for OUD.
          • Follow-up after discharge from the ED for MH or alcohol or other drug dependence.
          • Rate of overdose deaths in the Commonwealth.
          • Access to preventive/ambulatory health services for adult Medicaid managed care beneficiaries with SUD.
Research Question 1: Will improvements in treatment and prevention strategies in Medicaid managed care improve outcomes of individuals with an SUD in Medicaid managed care as demonstrated by: more effective initiation of treatment, decrease use of opioid at high dosages, reduce use of multiple opioids from multiple providers, reduce concurrent use of opioids and benzodiazepines, improve continuity of pharmacotherapy for OUD, decreased overdose deaths and access to preventive/ambulatory services?
Analytic Approach: ITS; regression analysis for change over time after waiver implementation.
Milestone 6: Improved care coordination and transition between LOCs for individuals in Medicaid managed care.
Hypothesis 6: The 1115 SUD Demonstration will improve follow-up after discharge from EDs and decrease re-admissions for individuals in Pennsylvania Medicaid managed care with SUD.

Research Question 1: Has the Demonstration impacted access to care for individuals with SUD in Medicaid managed care by linking beneficiaries with community‑based services and supports following stays in residential and inpatient treatment facilities and reducing re-admission rates for treatment?

          • Follow-up after discharge from the ED for MH or AOD dependence; Follow‑up after discharge from the ED for MH within seven days or 30 days: beneficiaries with an outpatient visit, IOP visit or PHP with a MH practitioner within seven days or 30 days after an ED visit with a principal diagnosis of mental illness/ED visits with a principal diagnosis of mental illness.
          • Follow-up after discharge from the ED for AOD dependence within seven days or 30 days: beneficiaries with an outpatient visit, IOP visit or PHP with a MH practitioner within seven days or 30 days after an ED visit with a principal diagnosis of AOD dependence/ED visits with a principal diagnosis of AOD.
Analytic Approach: ITS; regression analysis for change over time after waiver implementation.

The evaluation design also includes the following CMS-required measures of cost:

  • Total Medicaid SUD spending in Medicaid managed care during the measurement period.
  • Total Medicaid SUD spending on residential treatment within IMDs in Medicaid managed care during the measurement period.
  • Costs by source of care for high-cost individuals with SUD in Medicaid managed care during the measurement period.

Summary of SUD findings: The findings reported here are consistent with a Demonstration that is still in the midst of implementation efforts. Somewhat sharp increases in diagnosis and more gradual increases in access to some levels of SUD care reflect full implementation of ASAM Criteria for assessing treatment needs and making appropriate placements. However, it is hard to explain a very high single month jump of individuals diagnosed during the first implementation month. More gradual increases observed over time after implementation, however, are consistent with early implementation of the ASAM assessment criteria. It is also important to note that the original intent of the waiver was to maintain access to key SUD services that would have been eliminated due to CMS rule changes. Original research hypotheses only anticipated small changes across the entire array of services.

An important theme in discussing Demonstration implementation with key stakeholders is that change takes time. DDAP may have underestimated how disruptive providers viewed the changes. However, initial concerns are beginning to lessen with greater communication, technical assistance and allowing more time for alignment activities.

The SUD 1115 Demonstration has been a key tool in Governor Wolf's Administration's campaign to address SUDs. Throughout the 15 SUD PHEs, the Commonwealth has utilized multiple interventions to address all aspects of OUD. OMHSAS has found DDAP and its SCAs to be good partners in implementing the 1115 Demonstration.

Based on the Commonwealth's experience with the 1115 SUD Demonstration to this point the following lessons have been learned and will be described: 1) placement criteria matters, 2) the pandemic disrupted service patterns, and 3) change management disrupted service patterns before improving access to care. The Commonwealth has two closely related recommendations at this time: 1) a measured approach to change may create less provider abrasion and 2) acceptance of change takes time.

List and Programmatic Description of Waiver and Expenditure Authorities

Waiver Authority Requested

The Commonwealth requests an extension of the waiver authority granted in the original Demonstration. The Commonwealth did not need to request any expenditure authority to provide Medicaid coverage under the new adult group. The Commonwealth submitted an eligibility State Plan Amendment (SPA) under S50 to cover the group for youth above 133 percent Federal Poverty Limit (FPL) and requests waivers of sections 1902(a)(8) and 1902(a)(10) to limit this State Plan group coverage to FFCY who were in Medicaid and foster care in a different state. The eligibility SPA under S50 was approved on September 29, 2017 with an effective date of October 1, 2017. This waiver authority does not apply to the SUD component of the Demonstration:

    • Provision of Medical Assistance Section 1902(a)(8) and 1902(a)(10) — To the extent necessary to permit the Commonwealth of Pennsylvania to limit the provision of medical assistance (MA) (and treatment as eligible) for individuals described in the eligibility group under section 1902(a)(10)(A)(ii)(XX) of the Act and the Medicaid State Plan to only FFCY who are under 26 years of age, were in foster care under the responsibility of another state or tribe on the date of attaining 18 years of age (or such higher age as the state has elected), and who were enrolled in Medicaid on that date.

Expenditure Authority Requested

The Commonwealth requests a renewal of the expenditure authority granted in the original Demonstration:

    • Residential and Inpatient Treatment Services for Individuals with SUD. Expenditures for otherwise covered services furnished to otherwise eligible individuals enrolled in managed care who are primarily receiving treatment and withdrawal management (WM) services for SUD who are short‑term residents in facilities that meet the definition of an IMD as described in the Special Terms and Conditions #28 of the approved Demonstration.

Public Hearing Schedule

The Department will conduct two virtual public hearings to receive comments from the public regarding the proposed Demonstration renewal application.  These meetings will be held as follows:

The Department will also present updates on the Demonstration renewal application at the Medical Assistance Advisory Committee (MAAC) meeting on January 27, 2022. You can register for the MAAC meeting at the link below:

 https://attendee.gotowebinar.com/register/1192383395911684111

Public Comment Process

The 30-day public comment period will begin on January 15, 2022, and was originally slated to end on February 15, 2022. The Commonwealth will be extending the public comment period and it will now end on March 10, 2022, so the public can see the clarifications made to this page. Persons who wish to speak at one of the public hearings to provide comments on the proposed Demonstration renewal application should schedule a time by calling (717)705-8154  or emailing  chtshudy@pa.gov.  Individuals may also send a written request to Mr. Charles Tshudy, Bureau of Policy, Planning and Program Development, Office of Mental Health and Substance Abuse Services, 11th Floor, Commonwealth Tower, 303 Walnut Street, Harrisburg, PA 17101 during the comment period.

Even if you are not planning to speak at the hearing to provide comments, but are attending, please email your name, organization, email, and phone number to chtshudy@pa.gov so we have your contact information for our records. 

Individuals may also submit written comments at any of the public hearings or by email to chtshudy@pa.gov or by mail to Mr. Charles Tshudy at the address mentioned above. The Department will consider all comments received by February 15, 2022, in developing the final Demonstration renewal application.

Persons with a disability who require auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).