Common use of PROGRAM DESCRIPTION AND OBJECTIVES Clause in Contracts

PROGRAM DESCRIPTION AND OBJECTIVES. The State‟s goal in implementing the Partnership Plan section 1115(a) Demonstration is to improve access to health services and outcomes for low-income New Yorkers by: • improving access to health care for the Medicaid population; • improving the quality of health services delivered; • expanding access to family planning services; and • expanding coverage to additional low-income New Yorkers with resources generated through managed care efficiencies. The demonstration is designed to use a managed care delivery system to deliver benefits to Medicaid recipients, create efficiencies in the Medicaid program and enable the extension of coverage to certain individuals who would otherwise be without health insurance. It was approved in 1997 to enroll most Medicaid recipients into managed care organizations (Medicaid managed care program). As part of the Demonstration‟s renewal in 2006, authority to require the disabled and aged populations to enroll in mandatory managed care was transferred to a new demonstration, the Federal-State Health Reform Partnership (F-SHRP). In 2001, the Family Health Plus (FHPlus) program was implemented as an amendment to the Demonstration, providing comprehensive health coverage to low-income uninsured adults, with and without dependent children, who have income greater than Medicaid State plan eligibility standards. FHPlus was further amended in 2007 to implement an employer-sponsored health insurance (ESHI) component. Individuals eligible for FHPlus who have access to cost-effective ESHI are required to enroll in that coverage, with FHPlus providing any wrap-around services necessary to ensure that enrollees get all FHPlus benefits. During this extension period, the State will expand Family Health Plus eligibility for low-income adults with children. In 2002, the Demonstration was expanded to incorporate a family planning benefit under which family planning and family planning-related services are provided to women losing Medicaid eligibility and certain other adults of childbearing age (family planning expansion program). In 2010, the Home and Community-Based Services Expansion Program (HCBS expansion program) was added to the Demonstration. It provides cost-effective home and community-based services to certain adults with significant medical needs as an alternative to institutional care in a nursing facility. The benefits and program structure mirrors those of existing 1915(c) waiver programs, and strives to provide quality services for individuals in the community, ensure the well-being and safety of the participants and to increase opportunities for self-advocacy and self-reliance. As part of this extension, the State is authorized to develop and implement two new initiatives designed to improve the quality of care rendered to Partnership Plan recipients. The first, the Hospital- Medical Home (H-MH) project, will provide funding and performance incentives to hospital teaching programs in order to improve the coordination, continuity, and quality of care for individuals receiving primary care in outpatient hospital settings. By the end of the demonstration extension period, the hospital teaching programs which receive grants under the H-MH project will have received certification by the National Committee for Quality Assurance as a patient-centered medical home and implemented additional improvements in patient safety and quality outcomes. The second initiative is intended to reduce the rate of preventable readmissions within the Medicaid population, with the related longer-term goal of developing reimbursement policies that provide incentives to help people stay out of the hospital. Under the Potentially Preventable Readmissions (PPR) project, the State will provide funding, on a competitive basis, to hospitals and/or collaborations of hospitals and other providers for the purpose of developing and implementing strategies to reduce the rate of PPRs for the Medicaid population. Projects will target readmissions related to both medical and behavioral health conditions. Finally, CMS will provide funding for the State‟s program to address clinic uncompensated care through its Indigent Care Pool. Prior to this extension period, the State has funded (with State dollars only) this program which provides formula-based grants to voluntary, non-profit and publicly- sponsored Diagnostic and Treatment Centers (D&TCs) for services delivered to the uninsured throughout the State.

PROGRAM DESCRIPTION AND OBJECTIVES. The State‟s state‟s goal in implementing the Partnership Plan section 1115(a) Demonstration is to improve access to health services and outcomes for low-income New Yorkers by: • improving Improving access to health care for the Medicaid population; • improving Improving the quality of health services delivered; • expanding Expanding access to family planning services; and • expanding Expanding coverage with resources generated through managed care efficiencies to additional low-income New Yorkers with resources generated through managed care efficienciesYorkers. The demonstration Demonstration is designed to use a managed care delivery system to deliver benefits to Medicaid recipients, create efficiencies in the Medicaid program program, and enable the extension of coverage to certain individuals who would otherwise be without health insurance. It was approved in 1997 to enroll most Medicaid recipients into managed care organizations (MCOs) (Medicaid managed care program). As part of the Demonstration‟s renewal in 2006, authority to require the disabled and aged populations to enroll in mandatory managed care was transferred to a new demonstration, the Federal-State Health Reform Partnership (F-SHRP). In 2001, the Family Health Plus (FHPlus) program was implemented as an amendment to the Demonstration, providing comprehensive health coverage to low-income uninsured adults, with and without dependent children, who have income greater than Medicaid State state plan eligibility standards. FHPlus was further amended in 2007 to implement an employer-sponsored health insurance (ESHI) component. Individuals eligible for FHPlus who have access to cost-effective ESHI are required to enroll in that coverage, with FHPlus providing any wrap-around services necessary to ensure that enrollees get all FHPlus benefits. During this extension period, the State state will expand Family Health Plus eligibility for low-income adults with children. In 2002, the Demonstration was expanded to incorporate a family planning benefit under which family planning and family planning-related services are provided to women losing Medicaid eligibility and to certain other adults of childbearing age (family planning expansion program). In 2010, the Home and Community-Based Services Expansion Program (HCBS expansion program) was added to the Demonstration. It provides cost-effective home and community-based services to certain adults with significant medical needs as an alternative to institutional care in a nursing facility. The benefits and program structure mirrors those of existing section 1915(c) waiver programs, and strives to provide quality services for individuals in the community, ensure the well-being and safety of the participants participants, and to increase opportunities for self-advocacy and self-reliance. As part of this the 2011 extension, the State state is authorized to develop and implement two new initiatives designed to improve the quality of care rendered to Partnership Plan recipients. The first, the Hospital- Medical Home (H-MH) project, will provide funding and performance incentives to hospital teaching programs in order to improve the coordination, continuity, and quality of care for individuals receiving primary care in outpatient hospital settings. By the end of the demonstration extension period, the hospital teaching programs which receive grants under the H-MH project will have received certification by the National Committee for Quality Assurance as a patient-centered medical home homes and implemented additional improvements in patient safety and quality outcomes. The second initiative is intended to reduce the rate of preventable readmissions within the Medicaid population, with the related longer-term goal of developing reimbursement policies that provide incentives to help people stay out of the hospital. Under the Potentially Preventable Readmissions (PPR) project, the State state will provide funding, on a competitive basis, to hospitals and/or collaborations of hospitals and other providers for the purpose of developing and implementing strategies to reduce the rate of PPRs for the Medicaid population. Projects will target readmissions related to both medical and behavioral health conditions. Finally, CMS will provide funding for the State‟s state‟s program to address clinic uncompensated care through its Indigent Care Pool. Prior to this extension period, the State state has funded (with State state dollars only) this program which provides formula-based grants to voluntary, non-profit profit, and publicly- sponsored Diagnostic and Treatment Centers (D&TCs) for services delivered to the uninsured throughout the Statestate. In 2012, New York added to the Demonstration an initiative to improve service delivery and coordination of long-term care services and supports for individuals through a managed care model. Under the Managed Long-Term Care (MLTC) program, eligible individuals in need of more than 120 days of community-based long-term care are enrolled with managed care providers to receive long- term services and supports as well as other ancillary services. Other covered services are available on a fee-for-service basis to the extent that New York has not exercised its option to include the individual in the Mainstream Medicaid Managed Care Program (MMMC). Enrollment in MLTC may be phased in geographically and by group. The state‟s goals specific to managed long-term care (MLTC) are as follows: Expanding access to managed long term care for Medicaid enrollees who are in need of long term services and supports (LTSS); Improving patient safety and quality of care for enrollees in MLTC plans; Reduce preventable inpatient and nursing home admissions; and Improve satisfaction, safety and quality of life.

PROGRAM DESCRIPTION AND OBJECTIVES. The State‟s goal MassHealth demonstration is a statewide health reform effort encompassing multiple delivery systems, eligibility pathways, program types and benefit levels. The demonstration was initially implemented in implementing July 1997, and expanded Medicaid income eligibility for certain categorically eligible populations including pregnant women, parents or adult caretakers, infants, children and individuals with disabilities. Eligibility was also expanded to certain non- categorically eligible populations, including unemployed adults and non-disabled persons living with Human Immunodeficiency Virus (HIV). Finally, the demonstration also authorized the Insurance Partnership Plan section 1115(a) Demonstration is program which provides premium subsidies to improve access to health services both qualifying small employers and outcomes for their low-income New Yorkers by: • improving access to health care employees for the Medicaid population; • improving the quality purchase of private health services delivered; • expanding access to family planning services; and • expanding coverage to additional low-income New Yorkers with resources generated through managed care efficienciesinsurance. The demonstration is designed Commonwealth was able to use a support these expansions by requiring certain beneficiaries to enroll in managed care delivery system systems to deliver benefits generate savings. However, the Commonwealth’s preferred mechanism for achieving coverage has consistently been employer-sponsored insurance, whenever available and cost-effective. The implementation of mandatory managed care enrollment under MassHealth changed the way health care was delivered resulting in a new focus on primary care, rather than institutional care. In order to Medicaid recipientsaid this transition to managed care, create efficiencies the demonstration authorized financial support in the Medicaid program and enable the extension form of coverage to certain individuals who would otherwise be without health insurance. It was approved in 1997 to enroll most Medicaid recipients into supplemental payments for two managed care organizations (MCOs) operated by safety net hospital providers in the Commonwealth to ensure continued access to care for Medicaid managed enrollees. These payments ended in 2006. In the 2005 extension of the demonstration, CMS and the Commonwealth agreed to use federal and state Medicaid dollars to further expand coverage directly to the uninsured, funded in part by redirecting certain public funds that were dedicated to institutional reimbursement for uncompensated care programto coverage programs under an insurance-based model. This agreement led to the creation of the Safety Net Care Pool (SNCP). As part of This restructuring laid the Demonstration‟s renewal groundwork for health care reform in 2006Massachusetts, authority because the SNCP allowed the Commonwealth to require the disabled and aged populations to enroll in mandatory managed care was transferred to develop innovative Medicaid reform efforts by supporting a new demonstrationinsurance program. Massachusetts’ health care reform legislation passed in April 2006. On July 26, the Federal-State Health Reform Partnership (F-SHRP). In 2001, the Family Health Plus (FHPlus) program was implemented as 2006 CMS approved an amendment to the DemonstrationMassHealth demonstration to incorporate those health reform changes, providing comprehensive health which expanded coverage to childless adults, and used an insurance connector (Marketplace) and virtual gateway system to facilitate enrollment into the appropriate program . This amendment included: • the authority to establish the Commonwealth Care program under the SNCP to provide sliding scale premium subsidies for the purchase of commercial health plan coverage for uninsured persons at or below 300 percent of the FPL; • the development of payment methodologies for approved expenditures from the SNCP; • an expansion of employee income eligibility to 300 percent of the FPL under the Insurance Partnership; and • increased enrollment caps for MassHealth Essential and the HIV/Family Assistance Program. At this time there was also an eligibility expansion in the Commonwealth’s separate title XXI program for optional targeted low-income uninsured adultschildren between 200 percent and 300 percent of the FPL, with and without dependent children, who have income greater than Medicaid State plan eligibility standardswhich enabled parallel coverage for children in households where adults are covered by Commonwealth Care. FHPlus was further amended in 2007 This expansion ensured that coverage is equally available to implement an employer-sponsored health insurance (ESHI) component. Individuals eligible for FHPlus who have access to cost-effective ESHI are required to enroll in that coverage, with FHPlus providing any wrap-around services necessary to ensure that enrollees get all FHPlus benefits. During this extension period, the State will expand Family Health Plus eligibility for members of low-income adults with childrenfamilies. In 2002With the combination of previous expansions and the recent health reform efforts, the Demonstration was expanded to incorporate a family planning benefit under which family planning and family planning-related services are provided to women losing MassHealth Medicaid eligibility and certain other adults of childbearing age (family planning expansion program). In 2010, the Home and Community-Based Services Expansion Program (HCBS expansion program) was added to the Demonstration. It provides cost-effective home and community-based services to certain adults with significant medical needs as an alternative to institutional care in a nursing facility. The benefits and program structure mirrors those of existing 1915(c) waiver programs, and strives to provide quality services for individuals in the community, ensure the well-being and safety of the participants and to increase opportunities for self-advocacy and self-reliance. As part of this extension, the State is authorized to develop and implement two new initiatives designed to improve the quality of care rendered to Partnership Plan recipients. The first, the Hospital- Medical Home (H-MH) project, will provide funding and performance incentives to hospital teaching programs in order to improve the coordination, continuity, and quality of care for individuals receiving primary care in outpatient hospital settings. By the end of the section 1115 demonstration extension period, the hospital teaching programs which receive grants under the H-MH project will have received certification by the National Committee for Quality Assurance as a patient-centered medical home and implemented additional improvements in patient safety and quality outcomes. The second initiative is intended to reduce the rate of preventable readmissions within the Medicaid population, with the related longer-term goal of developing reimbursement policies that provide incentives to help people stay out of the hospital. Under the Potentially Preventable Readmissions (PPR) project, the State will provide funding, on a competitive basis, to hospitals and/or collaborations of hospitals and other providers for the purpose of developing and implementing strategies to reduce the rate of PPRs for the Medicaid population. Projects will target readmissions related to both medical and behavioral health conditions. Finally, CMS will provide funding for the State‟s program to address clinic uncompensated care through its Indigent Care Pool. Prior to this extension period, the State has funded (with State dollars only) this program which provides formula-based grants to voluntary, non-profit and publicly- sponsored Diagnostic and Treatment Centers (D&TCs) for services delivered to the uninsured throughout the State.now covers approximately

PROGRAM DESCRIPTION AND OBJECTIVES. The State‟s goal in implementing the Partnership Plan section 1115(a) MassHealth Demonstration is a statewide health reform effort encompassing multiple delivery systems, eligibility pathways, program types and benefit levels. The Demonstration was initially implemented in July 1997, and expanded Medicaid income eligibility for certain categorically eligible populations including pregnant women, parents or adult caretakers, infants, children and individuals with disabilities. Eligibility was also expanded to improve access certain non- categorically eligible populations, including unemployed adults and non-disabled persons with HIV disease. Finally, the Demonstration also authorized the Insurance Partnership program which provides premium subsidies to health services both qualifying small employers and outcomes for their low-income New Yorkers by: • improving access to health care employees for the Medicaid population; • improving the quality purchase of private health services delivered; • expanding access to family planning services; and • expanding coverage to additional low-income New Yorkers with resources generated through managed care efficienciesinsurance. The demonstration is designed Commonwealth was able to use a support these expansions by requiring certain beneficiaries to enroll in managed care delivery system systems to deliver benefits generate savings. However, the Commonwealth’s preferred mechanism for achieving coverage Demonstration Approval Period: December 22, 2008 through June 30, 2011 1 has consistently been employer-sponsored insurance, whenever available and cost-effective. The implementation of mandatory managed care enrollment under MassHealth changed the way health care was delivered resulting in a new focus on primary care, rather than institutional care. In order to Medicaid recipientsaid this transition to managed care, create efficiencies the Demonstration authorized financial support in the Medicaid program and enable the extension form of coverage to certain individuals who would otherwise be without health insurance. It was approved in 1997 to enroll most Medicaid recipients into supplemental payments for two managed care organizations (MCOs) operated by safety net hospital providers in the Commonwealth to ensure continued access to care for Medicaid managed enrollees. These payments ended in 2006. In the 2005 extension of the Demonstration, CMS and the Commonwealth agreed to use Federal and State Medicaid dollars to further expand coverage directly to the uninsured, funded in part by redirecting certain public funds that were dedicated to institutional reimbursement for uncompensated care programto coverage programs under an insurance-based model. This agreement led to the creation of the Safety Net Care Pool (SNCP). As part of This restructuring laid the Demonstration‟s renewal groundwork for health care reform in 2006Massachusetts, authority because the SNCP allowed the Commonwealth to require the disabled and aged populations to enroll in mandatory managed care was transferred to develop innovative Medicaid reform efforts by supporting a new demonstrationinsurance program. Massachusetts’ health care reform legislation passed in April 2006. On July 26, the Federal-State Health Reform Partnership (F-SHRP). In 2001, the Family Health Plus (FHPlus) program was implemented as 2006 CMS approved an amendment to the Demonstration, providing comprehensive MassHealth Demonstration to incorporate those health reform changes. This amendment included: • the authority to establish the Commonwealth Care program under the SNCP to provide sliding scale premium subsidies for the purchase of commercial health plan coverage for uninsured persons at or below 300 percent of FPL; • the development of payment methodologies for approved expenditures from the SNCP; • an expansion of employee income eligibility to 300 percent of FPL under the Insurance Partnership; and • increased enrollment caps for MassHealth Essential and the HIV/Family Assistance Program. At this time there was also an eligibility expansion in the Commonwealth’s separate title XXI program for optional targeted low-income uninsured adultschildren between 200 percent and 300 percent FPL, with which enabled parallel coverage for children in households where adults are covered by Commonwealth Care. This expansion ensured that coverage is equally available to all members of low-income families. With the combination of previous expansions and without dependent childrenthe recent health reform efforts, who have MassHealth now covers more than 1 million low-income greater than Medicaid State plan eligibility standardspersons. FHPlus was further amended in 2007 to implement an employer-sponsored health insurance (ESHI) component. Individuals eligible for FHPlus who have access to cost-effective ESHI are required to enroll in that coverage, with FHPlus providing any wrap-around services necessary to ensure that enrollees get all FHPlus benefits. During For this extension period, the State will expand Family Health Plus eligibility for low-income adults with children. In 2002, Commonwealth’s goals under the Demonstration was expanded continue to incorporate a family planning benefit under which family planning and family planningbe: • Achieving near-related services are provided universal health care coverage for all citizens of the Commonwealth • Continuing the redirection of spending from uncompensated care to women losing Medicaid eligibility and certain other adults of childbearing age (family planning expansion program). In 2010, the Home and Community-Based Services Expansion Program (HCBS expansion program) was added to the Demonstration. It provides insurance coverage • Demonstrating successful cost-effective home and community-based services to certain adults with significant medical needs as an alternative to institutional care in a nursing facility. The benefits and program structure mirrors those containment by reducing the rate of existing 1915(c) waiver programs, and strives to provide quality services for individuals spending growth in the community, ensure the well-being Medicaid budget for eligible populations • Increasing access to and safety of the participants and to increase opportunities for self-advocacy and self-reliance. As part of this extension, the State is authorized to develop and implement two new initiatives designed to improve improving the quality of care rendered to Partnership Plan recipients. The firstfor Demonstration enrollees Demonstration Approval Period: December 22, the Hospital- Medical Home (H-MH) project2008 through June 30, will provide funding and performance incentives to hospital teaching programs in order to improve the coordination, continuity, and quality of care for individuals receiving primary care in outpatient hospital settings. By the end of the demonstration extension period, the hospital teaching programs which receive grants under the H-MH project will have received certification by the National Committee for Quality Assurance as a patient-centered medical home and implemented additional improvements in patient safety and quality outcomes. The second initiative is intended to reduce the rate of preventable readmissions within the Medicaid population, with the related longer-term goal of developing reimbursement policies that provide incentives to help people stay out of the hospital. Under the Potentially Preventable Readmissions (PPR) project, the State will provide funding, on a competitive basis, to hospitals and/or collaborations of hospitals and other providers for the purpose of developing and implementing strategies to reduce the rate of PPRs for the Medicaid population. Projects will target readmissions related to both medical and behavioral health conditions. Finally, CMS will provide funding for the State‟s program to address clinic uncompensated care through its Indigent Care Pool. Prior to this extension period, the State has funded (with State dollars only) this program which provides formula-based grants to voluntary, non-profit and publicly- sponsored Diagnostic and Treatment Centers (D&TCs) for services delivered to the uninsured throughout the State.2011 2