Community Engagement Section 1115 Demonstration Waiver Application
I. Overview
In accordance with federal law, specifically 42 C.F.R. Section 431.408, the South Carolina Department of Health and Human Services (SCDHHS) must notify the public of its intent to submit to the Centers for Medicare & Medicaid Services (CMS) an application for a section 1115 demonstration waiver project. SCDHHS must provide an appropriate public comment period before submitting to CMS a new section 1115 demonstration waiver application.
Public notice is hereby given that SCDHHS intends to submit an application for a new section 1115 demonstration waiver to CMS. The public can review the official waiver application online at https://msp.scdhhs.gov/cew/ and provide comments until Jan. 22, 2019.
In addition, all public comments will be communicated to CMS as part of the final waiver application.
II. Background
Section 1115 of the Social Security Act provides the Secretary of the United States Department of Health and Human Services (HHS) broad authority to authorize research and demonstration projects, which are experimental or pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statute. Flexibility under section 1115 is sufficiently broad to allow states to test substantially new ideas of policy merit. SCDHHS will submit a new section 1115 demonstration waiver application to CMS that will authorize SCDHHS to implement policies related to community engagement activities for beneficiaries who are enrolled in Medicaid in the Parent Caretaker Relative (PCR) and Transitional Medicaid Assistance (TMA) groups. Once approved, this waiver will allow SCDHHS to apply community engagement activities to qualified PCR and TMA Medicaid beneficiaries as a condition of maintaining an active eligibility status.
III. Project Goals
The goal of demonstration waiver is to improve the health and well-being of qualified PCR and TMA Medicaid beneficiaries by promoting participation in community engagement activities to assist them with obtaining employment and transitioning to other health insurance.
IV. Project Objectives
- To connect individuals with resources designed to assist them with employment training and other community engagement activities.
- To assist individuals moving from Medicaid to other health insurance.
- To reduce the number of individuals dependent on Medicaid.
V. Project Description
SCDHHS seeks to implement community engagement activities for non-disabled adults currently covered under traditional Medicaid, including low-income parents and caretaker relatives eligible under Section 1931 and individuals eligible for TMA. Community engagement activities will not be applicable to the following:
- Children enrolled in Medicaid or the Children's Health Insurance Program (CHIP);
- Pregnant women;
- Disabled individuals, including individuals who have a medical condition that would prevent them from participation in this project;
- Individuals over the age of 65;
Individuals receiving Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI)
- Individuals who are the primary caregiver of a child under the age of six or someone who is disabled;
- Individuals participating in a Medicaid covered treatment program for alcohol or substance abuse addiction, including opioid addiction;
- Individuals receiving treatment through Medicaid's Breast and Cervical Cancer Program;
- Individuals compliant with or exempt from the Supplemental Nutrition Assistance Program (SNAP) and the Temporary Assistance for Needy Families (TANF) requirements related to employment; and
- Individuals who are determined by SCDHHS to be exempt on a case specific basis.
Individuals can fulfill the workforce training activities in a variety of ways. The following list contains acceptable activities and may be amended as necessary depending on individual needs:
- Participation in an adult secondary education program through a public-school district or technical college. The Department is exploring the provision of support for activities not otherwise covered by other state- or federally-funded adult education programs, including the cost of GED testing.
- Full-time (as defined by the South Carolina Commission on Higher Education) participation in a degree- or certificate- seeking program in an accredited institution of higher education.
- Compliance with unemployment insurance (UI) work-search requirements (first 16 weeks of UI benefits).
- For dual Medicaid-SNAP/TANF beneficiaries, demonstrated compliance with SNAP community engagement standards.
- Full-time employment, or part-time employment for not less than 80 hours per month.
Individuals who qualify for community engagement activities and who fail to participate in one of the approved activities will have their Medicaid eligibility placed in a suspended status until the requirements are met.
VI. Delivery System Impact
The demonstration waiver will not change the current health care delivery system, benefit coverage or cost sharing for individuals participating in the waiver.
VII. Hypothesis and Evaluation Parameters
During the approved waiver period, SCDHHS will test the following hypotheses:
- Participation in community engagement opportunities will result in transitions to other health insurance.
- Participation in community engagement activities will result in an increase in the number of individuals entering the workforce.
A detailed evaluation design will be developed for review and approval by CMS. SCDHHS will use relevant data from the Medicaid program and its managed care organizations as well as information from other pertinent organizations and programs such as the Supplemental Nutrition Program (SNAP) and the Temporary Assistance for Needy Families (TANF). Data elements may include eligibility, enrollment, claims, payment, encounter/utilization, chart reviews and other administrative data. All evaluation reports will be made public and posted on the SCDHHS website.
VIII. Enrollment and Cost Effectiveness Analysis
Federal policy requires section 1115 waiver demonstrations be budget neutral to the federal government. This means that a demonstration should not cost the federal government more than what would have otherwise been spent absent the demonstration. Particulars, including methodologies, are subject to negotiation between SCDHHS and CMS.
To ensure budget neutrality for each fiscal year of this new section 1115 demonstration waiver, SCDHHS will continue to use a per-member per-month (PMPM) methodology specific to the PCR and TMA adult populations with income under 100 percent of the federal poverty level (FPL). The demonstration will measure the financial impact to the program independent of enrollment fluctuations.
In establishing the baseline PMPM, historic enrollment and expenditure experience related to PCR and TMA adults (both in managed care and fee-for-service) were evaluated. To predict future costs, adjustments to reflect enrollment trends based on community engagement activities were predicted based on information related to work requirements for SNAP and TANF.
Table 1: Historical Information
| Count | Member Months | PMPM | |
|---|---|---|---|
| 2014 | 114,330 | 940,876 | $369.39 |
| 2015 | 154,982 | 1,418,989 | $346.57 |
| 2016 | 196,393 | 1,713,032 | $336.45 |
| 2017 | 207,186 | 1,949,467 | $319.50 |
| 2018 | 209,244 | 1,949,467 | $327.39 |
The following table illustrates the state's enrollment projections by total member months, updated to reflect the proposed modifications to the program. The table also demonstrates the state's budget projections based on enrollment fluctuations during the five-year period.
Without Waiver
| DY1-2019 | DY1-2020 | DY1-2021 | DY1-2022 | DY1-2023 | |
| Estimated Number of Member Months | 2,256,006 | 2,610,746 | 3,021,266 | 3,496,337 | 4,046,110 |
| PMPM | $317.17 | $307.27 | $297.68 | $288.38 | $279.38 |
| WOW Total Costs | $715,538,946.08 | $802,201,773.90 | $899,360,809.89 | $1,008,287,307.10 | $1,130,406,487.02 |
With Waiver
| DY1-2019 | DY2-2020 | DY3-2021 | DY4-2022 | Dy5-2023 | |
| Estimated Number of Member Months | 1,001,528 | 1,167,572 | 1,361,014 | 1,586,355 | 1,848,834 |
| Non-Primary Caregiver,Non-Elderly, Non Working Member Months | 280,428 | 326,920 | 381,084 | 444,179 | 517,673 |
| Member Months Remaining Noncompliant with Community Engagement Requirements | 19,630 | 22,884 | 26,676 | 31,093 | 36,237 |
| WW Medicaid Member Months (Removed) | (19,630) | (22,884) | (26,676) | (31,093) | (36,237) |
| PMPM | $317.17 | $307.27 | $297.68 | $288.38 | $279.38 |
| Removed Medicaid Enrollment Cost (Savings) | ($6,226,040.77) | ($7,031,676.19) | ($7,940,790.94) | ($8,966,594.06) | ($10,123,971.78) |
| (Savings) | ($6,226,040.77) | ($7,031,676.19) | ($7,940,790.94) | ($8,966,594.06) | ($10,123,971.78) |
| WW Total Costs | $709,312,905.31 | $795,170,097.71 | $891,420,018.94 | $999,320,713.05 | $1,120,282,515.24 |
During the five-year demonstration period, PMPM for South Carolina Medicaid is expected to decrease by $37.79. In addition, the anticipated number of enrollees is expected to decrease by approximately 11,377 individuals over the course of the demonstration period. Member months will fluctuate based on individuals remaining in the program or exiting the program.
IX. Specific Waiver and Expenditure Authorities
Title XIX Waiver Requests
1. Eligibility Section 1902(a)(10)(A)
To the extent necessary, to enable SCDHHS to make compliance with community engagement activities a condition of active eligibility status for the population identified in Section II of this notice.
X. Review of Documents and Submission of Comments
Location of Demonstration Application for Public Comment and Review
Copies of the demonstration application may be requested in writing from:
South Carolina Department of Health and Human Services
ATTN: Community Engagement Waiver
Post office Box 8206
Columbia, S.C. 29202-8206
A copy of the demonstration can be downloaded and printed from https://msp.scdhhs.gov/cew/or may be requested at CEWaiver@scdhhs.gov .
Copies are also available at all Healthy Connections County Offices (see Attachment A) and the SCDHHS lobby, located at 1801 Main Street, Columbia, SC.
Public Hearings
The first public hearing on this proposed demonstration request is scheduled for Monday, Dec. 10, 2018, from 11 a.m.-noon at:
LRADAC Education & Training Center
2711 Colonial Dr.
Columbia, SC 29203
The second public hearing on this proposed demonstration request is scheduled for Tuesday, Dec. 11, 2018, from 11 a.m.-noon at:
Charleston Public Library
68 Calhoun Street
Charleston, SC 29401
The third public hearing on this proposed demonstration request is scheduled for Thursday, Dec. 13, 2018, from 11 a.m.-noon at:
Greenville Health System Auditorium
701 Grove Road
Greenville, SC 29605
The SCDHHS will also hold a webinar Wednesday, Dec. 12, at 3 p.m. Information on registering for the webinar is available at https://msp.scdhhs.gov/cew/. Instructions will be provided to participants when they complete the registration process.
Additional opportunities to learn about the application will be available in early January.
Submitting Public Comments
SCDHHS wants to hear from the public about the proposed section 1115 demonstration waiver to improve the health of Medicaid beneficiaries through community engagement. Public comments must be received by 5 p.m. Jan. 22, 2019:
1. Website: https://msp.scdhhs.gov/cew
2. Email: CEWaiver@scdhhs.gov
3. Mail: South Carolina Department of Health and Human Services
Attn: Community Engagement Waiver
P.O. Box 8206
Columbia, SC 29202
| SCDHHS COUNTY OFFICE | ADDRESS |
| Abbeville | 909 W. Greenwood Street, Suite 1, Abbeville, SC 29620 |
| Aiken | 1410 Park Ave, Aiken, SC 29801 |
| Allendale | 521 Barnwell Road, Allendale, SC 29810 |
| Anderson | 224 McGee Road, Anderson, SC 29625 |
| Bamberg | 374 Log Branch Road, Bamberg, SC 29003 |
| Barnwell | 10913 Ellenton Street, Barnwell, SC 29812 |
| Beaufort | 1905 Duke Street, Beaufort, SC 29901 |
| Berkeley | 2 Belt Drive, Moncks Corner, SC 29461 |
| Calhoun | 2831 Old Belleville Road, St. Matthews, SC 29135 |
| Charleston | 3366 Rivers Avenue, North Charleston, SC 29405 |
| Cherokee | 1231 N. Limestone Street, Suite C, Gaffney, SC 29340 |
| Chester | 115 Reedy Street, Chester, SC 29706 |
| Chesterfield | 203 Commerce Avenue, Chesterfield, SC 29709 |
| Clarendon | 236 Commerce St., Manning, SC 29102 |
| Colleton | 215 South Lemacks Street, Walterboro, SC 29488 |
| Darlington | 300 Russell Street, Room 145, Darlington, SC 29532 |
| 404 S. Fourth Street, Suite 301, Hartsville, SC | |
| Dillon | 1213 Highway 34 West, Dillon, SC 29536 |
| Dorchester | 216 Orangeburg Road, Summerville, SC 29483 |
| Edgefield | 120 W.A. Reel Drive, Edgefield, SC 29824 |
| Fairfield | 1136 Kincaid Bridge Road, Winnsboro, SC 29180 |
| Florence | 2685 South Irby Street, Box I, Florence, SC 29505 |
| 345 South Ron McNair Blvd., Lake City, SC 29560 | |
| Georgetown | 330 Dozier Street, Georgetown, SC 29440 |
| Greenville | 301 University Ridge, Suite 6700, Greenville, SC 29601 |
| Greenwood | 1118 Phoenix Street, Greenwood, SC 29646 |
| Hampton | 102 Ginn Altman Avenue, Hampton, SC 29924 |
| Horry | 1201 Creel Street, Conway, SC 29526 |
| Jasper | 10908 North Jacob Smart Blvd., Ridgeland, SC 29936 |
| Kershaw | 110 East Dekalb Street, Camden, SC 29020 |
| Lancaster | 1599 Pageland Hwy, Lancaster, SC 29720 |
| Laurens | 93 Human Services Drive, Clinton, SC 29325 |
| Lee | 820 Brown Street, Bishopville, SC 29010 |
| Lexington | 605 West Main Street, Lexington, SC 29072 |
| Marion | 137 Airport Court, Suite J, Mullins, SC 29574 |
| Marlboro | 1 Ag Street, Bennettsville, SC 29512 |
| McCormick | 215 North Mine St/Hwy 28 North, McCormick, SC 29835 |
| Newberry | 2107 Wilson Road, Newberry, SC 29108 |
| Oconee | 223 B Kenneth Street, Walhalla, SC 29691 |
| Orangeburg | 2570 St Matthews Road, Orangeburg, SC 29116 |
| Pickens | 212 McDaniel Avenue, Pickens, SC 29671 |
| Richland | 3220 Two Notch Road, Columbia, SC 29204 |
| Saluda | 613 Newberry Highway, Saluda, SC 29138 |
| Spartanburg | 1000 N. Pine Street, #23, Spartanburg, SC 29303 |
| Sumter | 105 N. Magnolia Street, 3rd Floor, Sumter SC |
| Union | 200 South Mountain Street, Union, SC 29379 |
| Williamsburg | 121 Hampton Avenue, Kingstree, SC 29556 |
| York | 454 S. Anderson Road, Suite 11, Rock Hill, SC 29730 |
Community Engagement
Section 1115 Demonstration Waiver Application