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Federal waivers allow states to test new ways to deliver and pay for health care services. Changes to the state’s Medicaid program often require waivers approved by the federal Centers for Medicare & Medicaid Services (CMS) to continue receiving federal Medicaid funding. The following are waivers that the Minnesota Department of Human Services (DHS) has applied for or received.
DHS submitted a substance use disorder (SUD) section 1115 demonstration waiver application March 15, 2018, for CMS review and approval. This demonstration project is an important component of the state’s larger effort to address the opioid crisis as well as transform the health care delivery system for Medicaid recipients who need substance use disorder treatment and services.
DHS held an initial 30-day public comment period on the waiver request through March 13, 2018. All written comments received during the public comment period were included in the March 15, 2018, waiver application. In addition, DHS held public hearings to provide stakeholders and other interested persons the opportunity to comment on the waiver request:
On March 28, 2018, CMS requested that DHS publish a new request for public comment to clarify certain elements of the waiver proposal. The description below includes these clarifications about the project’s financing, goals and objectives. The proposal itself remains unchanged.
DHS resubmitted the waiver request titled "Minnesota SUD System Reform” (PDF) following this second 30-day comment period.
State law directs DHS to seek federal waiver authority to receive Medicaid matching funds for residential programs that have been determined as Institutions for Mental Disease (IMDs) to ensure continued access to this level of care for individuals with the most intensive treatment needs. Accordingly, the state proposes a five-year demonstration project that will test the impact of evidence-based provider referral arrangements and practices on health outcomes for Medicaid enrollees with substance use conditions.
Under this new demonstration, provider referral networks will be designed to provide Medicaid enrollees access to each of the levels of care for SUD treatment, as well as community mental health services. Consistent with guidance from CMS to state Medicaid directors, the levels of care will be modeled after the levels of care recommended by the American Society of Addiction Medicine for treating addictive, substance-related and co-occurring conditions.
Providers seeking to participate in this demonstration will verify to the department that they have, or will have, established the necessary partnerships or referral arrangements with other SUD providers to provide all levels of care for enrollees during the waiver period. In place of the state’s existing process for assessment and placement under Rule 25, participating providers will be required to assess and record their Medicaid patients’ treatment needs based on an evidence-based assessment tool called the ASAM Six Dimensions of Multidimensional Assessment. All providers participating in this demonstration will also be required to apply at least three of the four evidence-based practices that were recently identified as cost effective by the Minnesota Management and Budget agency when applied to adults receiving SUD treatment.
The state intends to implement the first phase of the demonstration with interested SUD providers July 1, 2018. In the second year of the waiver, the state proposes to integrate community mental health services into the demonstration by permitting each of the state’s six Certified Community Behavioral Health Clinics to apply to participate in the project.
The proposed SUD reform waiver demonstration is designed to support the following goals and objectives:
This demonstration will build on the state’s efforts to transform its SUD delivery system to improve access to appropriate treatment and greater integration of SUD services with the broader health care system, including community mental health providers with the inclusion of the Certified Community Behavioral Health Clinic model. Over time, the state expects that these referral networks or partnerships that follow ASAM criteria will lead to better health outcomes for Medicaid enrollees, including those in need of the most intensive services in residential settings.
Minnesota currently uses fee-for-service and managed care systems as specified under its state plan for delivering SUD services, both of which currently operate statewide. The only difference in the demonstration project will be for enrollees receiving assessments and services for treatment through the federal model for the Certified Community Behavioral Health Clinics program. The state intends to maintain the cost-based payment model currently permitted by federal law for the Certified Community Behavioral Health Clinics model.
The state will use the same standards and methodologies to determine Medicaid eligibility for all populations in the demonstration project as used in the state plan. The state expects that all enrollees affected under the demonstration would be otherwise eligible for Medicaid, and that any enrollees eligible and enrolled in Medicaid seeking or receiving services from a participating provider would be included in this demonstration’s population.
Other than the differences described below, the benefits for Medicaid enrollees participating in this demonstration will be the same as those for all other enrollees under the Medicaid state plan. The benefits provided under the demonstration will differ from those provided under the state plan in two ways:
The cost-sharing requirements under this demonstration will not differ from those provided under the Medicaid state plan.
Following are the state’s estimates of the expected increase in annual enrollment and expenditures under the demonstration. Please note that more than 80 percent of the increase in Medicaid enrollee months shown below represents months of eligibility already covered in Medicaid at 100 percent state expense.
| Demonstration year 1 | Demonstration year 2 | Demonstration year 3 | Demonstration year 4 | Demonstration year 5 | |
| Fee-for-service IMD resident months | 4,178 | 4,333 | 4,493 | 4,660 | 4,832 |
| Managed care IMD residential months | 14,443 | 14,624 | 14,807 | 14,992 | 15,179 |
| State-funded IMD resident months become added Medicaid enrollee months | 18,622 | 18,957 | 19,300 | 19,651 | 20,011 |
| New withdrawal management service adds withdrawal management enrollee months | 3,443 | 3,570 | 3,702 | 3,839 | 3,982 |
| Total added Medicaid enrollee months | 22,065 | 22,527 | 23,003 | 23,491 | 23,993 |
| Total added Medicaid average enrollees (months/12) | 1,839 | 1,877 | 1,917 | 1,958 | 1,999 |
| Demonstration year 1 | Demonstration year 2 | Demonstration year 3 | Demonstration year 4 | Demonstration year 5 | |
| Costs for fee-for-service IMD resident months | $22,027,628 | $23,528,060 | $25,133,833 | $26,844,242 | $28,675,813 |
| Costs for managed care IMD resident months | $11,395,051 | $11,883,636 | $12,393,168 | $12,924,525 | $13,478,614 |
| State-funded IMD costs become added Medicaid costs | $33,425,293 | $35,414,363 | $37,526,555 | $39,769,742 | $42,152,282 |
| New withdrawal management service costs | $18,152,494 | $19,388,866 | $20,709,427 | $22,119,942 | $23,626,551 |
| Total added Medicaid costs | $51,575,173 | $54,800,562 | $58,236,428 | $61,888,709 | $65,780,978 |
Under the demonstration the state will receive federal matching funds for withdrawal management services and SUD services provided to Medicaid beneficiaries in participating IMDs.
Through this demonstration, the state will test the impact of ASAM-based referral networks on enrollee access to services. The state will also evaluate the impact over time of the application of ASAM recommendations on quality of care and health outcomes. After the first year of the demonstration, the state will also assess the impact of integrating community mental health care providers into an ASAM-based provider referral network with SUD providers and other health care professionals as needed. Refer to Attachment B1 of the waiver application for the evaluation plan, including questions, metrics and data for testing its hypotheses related to SUD outcomes.
Under the authority of section 1115 of the Social Security Act, the state is requesting the following waiver and spending authorities in order to implement the SUD system reform demonstration:
CMS held a federal comment period following DHS’ submission of the SUD system reform waiver request. At that time, comments were to be submitted directly to CMS by going to www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html and entering Minnesota in the search box.
On Feb. 11, 2016, CMS approved Minnesota’s request to renew the PMAP+ waiver through Dec. 31, 2020.
The PMAP+ waiver special terms and conditions require the state to provide updates to CMS on the program’s implementation. We submit reports quarterly and annually. Reports from prior demonstration years have been archived and can be made available by request via dhs.waiver.comments@state.mn.us.
The MFPP was implemented beginning July 1, 2006, as a federal waiver demonstration project approved by CMS. The MFPP waiver gave Minnesota the authority to receive federal matching funds for family planning services delivered to men and women, ages 15 to 50, who have family incomes at or below 200 percent of the federal poverty level and who are not enrolled in Medical Assistance or MinnesotaCare. The 2014 Minnesota Legislature directed DHS to seek federal authority to operate the MFPP under the Medicaid state plan. Effective Jan. 1, 2017, the program was converted to state plan authority under the Family Planning State Plan Option.
Under the Family Planning State Plan Option, the following MFPP benefits and other criteria will remain unchanged:
Please see Bulletin #16-21-13 (PDF) for more information regarding changes to certain eligibility rules for the MFPP under the Family Planning State Plan Option.
In October 2013, CMS approved Minnesota’s Reform 2020 section 1115 demonstration project through June 30, 2018.
The five-year demonstration provides federal support for the Alternative Care program, which provides supports to help seniors at risk of nursing home placement to stay in their homes. The Reform 2020 demonstration waiver will also provide access to expanded self-directed options under the Community First Services and Supports (CFSS) program for people who would not otherwise be eligible for these services. Implementation of this part of the demonstration is contingent upon federal approval of additional state plan and waiver authority.
On July 10, 2017, DHS submitted a request to CMS to renew the Reform 2020 Section 1115 waiver. The current waiver expires June 30, 2018. The renewal request seeks to continue the current waiver for another three-year period, through June 30, 2021.
Reform 2020 Renewal Application (PDF)
A 30-day public comment period from May 22, 2017, to June 21, 2017, was held by DHS to provide the public the opportunity to weigh in on the proposed waiver renewal.
CMS held a federal comment period following DHS’ submission of the Reform 2020 renewal request. At that time, comments were to be submitted directly to CMS by going to www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/index.html and entering Minnesota in the search box.
The Reform 2020 waiver special terms and conditions require the state to provide updates on the program’s implementation to CMS. Reports are submitted on a quarterly and annual basis. Reports from prior demonstration years have been archived and can be made available by request via dhs.waiver.comments@state.mn.us.
A 30-day comment period on the revised Indian Health Board of Minneapolis (IHB), section 1115 Medicaid waiver application, began on April 17. The IHB waiver application was initially submitted to the Centers for Medicare & Medicaid Services (CMS) on Jan. 13, 2017. Key changes can be found on page 5 of the application, which has been revised to include information on the research hypothesis and evaluation parameters related to the demonstration’s proposed goals. DHS plans to submit the revised request in May of 2017.
Comments received will be posted on the DHS website. To ask for a paper copy of the waiver request, please contact Elizabeth Bonnell at 651-431-2836. Written comments may be submitted to dhs.waiver.comments@state.mn.us or by mail to the address below. DHS would like to provide copies of comments received in a format that is accessible for people with disabilities. Therefore, we request comments be submitted in Microsoft Word documents or incorporated within the email text. If you would like to provide a signed copy of the comment letter, you may submit a second copy in Adobe PDF format or mail it to the address below. Comments must be received by May 16, 2017.
Revised IHB Waiver Application (PDF)
Attachment D: Evaluation Plan (PDF)
Marie Zimmerman
Medicaid Director
Minnesota Department of Human Services
P.O. Box 64983
St. Paul, Minnesota 55164-0983
CMS will hold a federal comment period following DHS’ submission of the IHB waiver request. At that time you may submit comments directly to CMS by going to http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Waivers.html and entering Minnesota in the search box.
The 2016 Minnesota State Legislature directed DHS to seek federal waiver authority to allow tribal organizations to receive the Indian Health Services encounter rate for Medicaid services provided to American Indian and Alaskan Native populations. Only organizations that are dually certified as Urban Indian Health Programs and Federally Qualified Health organizations qualify. The Legislature also asked DHS to seek authority for the state to be eligible for 100 percent federal financial participation for such services. (See Minn. Stat. § 256B.0625, specifically subdivisions 30 and 34.)
On Jan. 13, 2017 DHS submitted the Indian Health Board of Minneapolis Section 1115 waiver request to the Centers for Medicare & Medicaid Services (CMS). Currently, the Indian Health Board of Minneapolis (IHB) is the only entity eligible under this waiver authority, should it be granted by CMS. As a demonstration project under section 1115 of the Social Security Act, DHS plans to test new ways to help urban American Indians served by the IHB to access quality health care. This approach includes the use of an abbreviated application process for American Indians eligible for Medicaid and targeting additional funding for the IHB into enhanced care coordination and application assistance for this population.
The MSC+ waiver allows Minnesota to require seniors to enroll in managed care to receive Medicaid services. This includes people who are dually eligible for both Medicaid and Medicare and who have not opted to enroll in Minnesota Senior Health Options (MSHO). The waiver operates in combination with Minnesota’s existing Elderly Waiver to enable the integration of community-based long-term care services into the managed care service delivery system.
The CCDTF is the fee-for-service payment mechanism for substance use treatment services in Minnesota. The CCDTF is accessed through an enrollee’s county or tribe of residence. Each county and tribe is responsible for:
The waiver allows recipients to be directed to a provider designated by the locality.
CCDTF waiver renewal request and CMS approval letter (PDF).
The Case Management waiver allows Minnesota to continue to limit case management providers for the home and community-based waivers to counties and tribes under contract with DHS or their subcontractors. The waiver applies only to enrollees whose waiver services are covered fee-for-service and who receive services under one of the following Section 1915(c) home and community-based waiver programs:
The current Case Management waiver expires March 31, 2022.
Case Management waiver renewal request and CMS approval letter (PDF)
This is a free email subscription service that allows you to receive one-way email notification when new information is available about Medicaid waivers, such as the Reform 2020 waiver, the Prepaid Medical Assistance Plus (PMAP+) waiver, the Minnesota Senior Care Plus waiver and new waiver applications. Subscribers will receive emails when DHS is seeking public comment on items that will be submitted for federal approval, when requests for federal authority are submitted to the federal government, and when waiver requests have been approved or denied.
Information on Minnesota's federal Medicaid waivers also is available on the CMS website at https://www.medicaid.gov/medicaid/section-1115-demo/demonstration-and-waiver-list/waivers_faceted.html (enter Minnesota in the search box).
