Section 1115 of the Social Security Act provides the Secretary of Health and Human Services with the unique ability to approve demonstration projects (and establish pools for this purpose) that help further the goals of Medicaid programs. Demonstration projects are used to give states additional flexibility to design and improve their own programs in order to better serve Medicaid populations. Typically, states will seek Section 1115 waivers to offer Medicaid services that address overcoming barriers to care and make changes to Medicaid eligibility and benefits. Section 1115, which requires these demonstrations to be budget neutral, provides states with federal Medicaid matching funds for costs that would not otherwise be eligible for federal match, among other requirements.
On March 30, 2023, the Centers for Medicaid and Medicare Services approved New Jersey’s FamilyCare’s Comprehensive Section 1115 Demonstration renewal application. The renewal expands, amends and implements various projects and programs relating to Housing, Behavioral and Physical Health, and Worker Training that will enhance health care coverage, access and services to New Jersey FamilyCare members, which include Medicaid and CHIP beneficiaries.
The Section 1115 Demonstration project provides New Jersey with federal authority to expand parts of the NJ FamilyCare program, and will include several new programs, for example:
- Creation of an incentive based-payment program for Medicaid behavioral health providers to implement health information technology (“HIT“) functionality to support integrated and high quality care;
- Formation of an Autism Adjunct Services Pilot that will support and provide children living with autism rehabilitative and therapeutic services, such as aquatic, recreational and music therapies;
- Establishment of a Community Health Worker Pilot that will focus on overcoming health disparities within local communities by providing care coordination services and directly providing preventive or related services; and
- A new multifaceted, integrated housing strategy for Medicaid beneficiaries that incorporates coverage for additional targeted services, and coordination across state and community resources involved in the provision of health and housing services, including, enhancements to the Managed Long Term Services and Supports program.
The state may claim up to $6 million in allowable expenditures for five years as payments to incentivize HIT use. Statewide expenditures for the Community Health Worker Pilot are limited to $5 million per year. This pilot program will be administered by Managed Care Organizations (“MCOs”). MCOs must submit a proposal to the state in order to participate, which must include at least the population of targeted individuals, a description of the intervention, implementation timeline, quality improvement milestones, expected impacts, the control or comparison group for determining the evaluation of impact, identification of how the intervention could be scaled more broadly and budget of expenses. In addition, each pilot initiative must be evaluated by the state’s demonstration evaluator.
The demonstration includes additional programs that benefit FamilyCare members and providers, and enhancements to existing programs.
The renewal is effective as of April 1, 2023 through June 30, 2028 and is subject to limitations and other special terms and conditions.
Should you have any questions regarding the above, please contact the authors, or your regular Garfunkel Wild contact or email us at [email protected].