Comprehensive Preconception Care Model Waiver

PUBLIC NOTICE: 
SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES

PUBLIC Notice

SUBJECT:         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.

Waiver 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 dueto Child or Spousal Support Collections

408(a)(11)(B)

42 CFR 435.115

1931(c)(1)

No eligibility impact

Children with TitleIV-EAdoption Assistance, FosterCareor 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

MandatoryPovertyLevel Related Pregnant Women

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

1902(l)(1)(A)

No eligibility impact

MandatoryPovertyLevel RelatedInfants

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

1902(l)(1)(B)

No eligibility impact

MandatoryPovertyLevel Related Children Aged1-5

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

1902(l)(1)(C)

No eligibility impact

MandatoryPovertyLevel Related Children Aged6-18

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 ReceivingSSI

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

42 CFR 435.120

No eligibility impact

Aged, Blind andDisabledIndividuals in 209(b)States

1902(f)

42 CFR 435.121

No eligibility impact

Individuals ReceivingMandatoryState Supplements

42 CFR 435.130

No eligibility impact

Individuals Who AreEssential Spouses

42 CFR 435.131

1905(a)

No eligibility impact

InstitutionalizedIndividuals ContinuouslyEligibleSince1973

42 CFR 435.132

No eligibility impact

Blind orDisabledIndividuals Eligiblein 1973

42 CFR 435.133

No eligibility impact

Individuals WhoLost Eligibilityfor SSI/SSP Dueto anIncreasein OASDIBenefits in 1972

42 CFR 435.134

No eligibility impact

Individuals Who Would be Eligible for SSI/SSP but forOASDI COLA increases sinceApril, 1977

1939(a)(5)(E)

42 CFR 435.135

Section 503 ofP.L. 94-566

No eligibility impact

Disabled Widows and WidowersIneligibleforSSIduetoIncrease in OASDI

1634(b)

42 CFR 435.137

No eligibility impact

Disabled Widows and WidowersIneligibleforSSIduetoEarly Receipt of Social Security

42 CFR 435.138

1634(d)

No eligibility impact

WorkingDisabled under1619(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 DisabledandWorking Individuals

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

1905(s)

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

No eligibility impact

SpecifiedLowIncomeMedicareMembers

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

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

No eligibility impact

QualifyingIndividuals

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

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

No eligibility impact

Children with Non-IV-EAdoptionAssistance

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

42 CFR 435.227

No eligibility impact

IndependentFosterCare Adolescents

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

1905(w)

42 CFR 435.226

No eligibility impact

Optional TargetedLowIncome Children(M-CHIP)

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

1905(u)(2)(B)

42 CFR 435.229 and 435.4

No eligibility impact

Children under21 Not ReceivingCash

1902(a)(10)(A)(ii)(I)– (IV)

1905(a)(i)

42 CFR 435.222

No eligibility impact

Families Who Would QualifyforCash if Requirements Were MoreBroad

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

42 CFR 435.223

1905(a)

No eligibility impact

Individuals EligibleforCash except forChild CareSubsidy

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

42 CFR 435.220

No eligibility impact

Optional PovertyLevelRelated Pregnant Women andInfants

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

1902(l)(2)

No eligibility impact

PresumptivelyEligiblePregnant Women

1902(a)(47)

1920

No eligibility impact

PresumptivelyEligibleChildren

1902(a)(47)

1920A

42 CFR 1100-1102

No eligibility impact

Individuals ElectingCOBRA Continuation Coverage

1902(a)(10)(F)

1902(u)(1)

No eligibility impact

Individuals Eligibleforbut not ReceivingCash

42 CFR 435.210

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

1905(a)

1902(v)(1)

No eligibility impact

Individuals EligibleforCash except forInstitutionalization

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 ReceivingHome and CommunityBased Services underInstitutional Rules

42 CFR 435.217

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

No eligibility impact

Individuals Participatingin a PACE Program underInstitutional Rules

1934

No eligibility impact

Individuals ReceivingHospiceCare

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

1905(o)

No eligibility impact

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

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

42 CFR 435.232

No eligibility impact

Optional StateSupplement 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

InstitutionalizedIndividuals EligibleunderaSpecialIncomeLevel

42 CFR 435.236

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

1905(a)

No eligibility impact

PovertyLevelAged 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 orCervical Cancer

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

1902(aa)

No eligibility impact

PresumptivelyEligibleWomen with Breast or Cervical Cancer

1920B

1902(aa)

No eligibility impact

WorkIncentives EligibilityGroup

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 MedicalImprovements Group

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

No eligibility impact

FamilyOpportunityActChildren with Disabilities

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

1902(cc)

No eligibility impact

Individuals EligibleforFamilyPlanningServices

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

No eligibility impact

Individuals Eligiblefor Homeand Community-Based Services

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

1915(i)

No eligibility impact

Individuals EligibleforHomeand Community-Based Services - SpecialIncomeLevel

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

1915(i)

No eligibility impact

Individuals at or below 133%FPLAge19 through 64

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

earlyimplementation option

No eligibility impact

 

MedicallyNeedy

 

 

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.

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: 
  3. All Healthy Connections County Offices (See Attachment A)
  4. 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 at all  online at https://msp.scdhhs.gov/pcc/site-page/proposed-waiver.

Attachment A: Healthy Connections County Offices

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

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