The Bazelon Center for Mental Health Law

DEPARTMENT OF HEALTH & HUMAN SERVICES
Health Care Financing Administration
Center for Medicaid and State Operations
Family and Children's Health Program Group
Division of Integrated Health Systems
7500 Security Boulevard
Baltimore, MD 21244-1850

Oct. 19, 2000

Mr. Robert T. Maruca
Director
New Mexico Human Services Department
Medical Assistance Division
Santa Fe, New Mexico 87504-2348

Dear Mr. Maruca:

I am pleased to inform you that the Health Care Financing Adminstration (HCFA) is approving New Mexico's request for a 2-year continuation of the physical health (non- behavioral health) portion of its section1915(b) waiver Medicaid managed care program, known as Salud!. At your request, today, we are considering the behavioral health portion of the renewal separate from the physical health portion of the renewal. We are unable to approve the behavioral health portion of your request. Specifically, the approval of the physical health program provides for a waiver of the following sections of the Act: 1902(a)(1) Statewideness, 1902(a)(10)(B) Comparability of Services, and 1902(a)(23) Freedom of Choice to permit New Mexico to continue to operate its managed care program.

This decision is based on evidence submitted to HCFA demonstrating that the State's physical health waiver program is consistent with the purpose of the Medicaid program and will continue to meet all statutory and regularoty requirements for assuring beneficiaries' access to care and quality of services, waiver cost-effectiveness for secton 1915(b) programs, and will not restrict family planning or emergency services. Approval of this request is also contingent upon New Mexico meeting the following terms and conditions and arranging for an independent evaluation of the overall waiver program with special emphais on these factors to be submitted 3 months prior to the end of the waiver period.

Because we are unable to approve the proposed behavioral health program, you have 90 days from the date of this letter to transition the behavioral health care and services from the waiver program to the fee-for service system. Within two weeks of the date of this letter, please provide us with your transition plan to transfer beneficiaries to the fee-for-service system. The transition plan should describe how beneficiaries will be informed about what to do, whom to call for clarificaton, and the amount of time beofre termination. The transition plan should also describe how continuity of care will be maintained. We will continue to monitor access to services during and after the State's transition of these services to a fee-for-service system.

Special Needs Children Terms and Conditions Applicable to All Waiver Renewals Nationally

1. The state will comprehensively identify, or require the MCOs to comprehensively identify, and forward data to the State regarding the number of children enrolled in the MCOs who are in category 1 of the BBA definition of Children with Special Health Care Needs (CSHCN)(SSI children). These SSI children may be identified through aid code analysis or, if necessary, through manual review. The State will submnit this data to HCFA on an annual basis.

2. With respect to quality of care, the State will conduct a study which will stratify its analyses such that outcomes for children in category 1 of the BBA definition of CSHCN enrolled in the MCOs are discussed and assessed. Or, the State may perform a quality study that focuses solely on children in category 1 of the FFA definition who are enrolled in the MCOs.

3. The State will review complaints and grievances and track those cases involving children identified in category 1 of the BBA definition of CSHCN enrolled in the MCOs. (A manual review is acceptable). On an annual basis, the State will report to HCFA the number of complaints and grievances for this group, and submit an analysis of type and number of complaints and grievances filed, and information regarding their resolution.

4. The State will submit to HCFA on an annual basis the number of children identified in category 1 of the BBA definition of CSHCN who voluntarily transfer from one MCO to another.

1. For the voluntary population, the State will have to account for selection bias in the cost effectiveness calculations in the next waiver renewal request. One method the State may use would be to track the per member per month (PMPM) costs of Native Americans who elect to enroll in Salud! versus the PMPM costs of those in traditional fee-for-service Medicaid and include that data in the cost effectiveness analysis for the lookback period. The State may also propose an alternative option that is approved by HCFA and the Office of Management and Budget.

Approval of this waiver request covers a period of 2 years, from October 22, 2000 through October 21, 2002. New Mexico may request that this authority be renewed and should submit its request for renewal 90 days in advance of the expiration date.

We appreciate the effort you and your staff have shown in serving the Medicaid beneficiaries in New Mexico. If you have any questions regarding regarding this letter, you may contact Calvin Cline, Associate Regional Administrator, Division of Medicaid and State Operations, HCFA's Dallas Regional Office at (214) 767-6305.

Sincerely,

Tim Westmoreland
Director

cc: Calvin Cline, Associate Regional Administrator
Dallas Regional Office