Public Notice for Proposed Substance Use Disorder Serious Mental Illness and Serious Emotional Disturbance Treatment and Recovery Access Section 1115(a) Research and Demonstration Waiver Extension Request

Notice is hereby given that, as part of its ongoing efforts to maintain and improve access to behavioral health services in the State, the NH Department of Health and Human Services (DHHS) is applying for an extension to its Section 1115(a) Research and Demonstration Waiver from the Centers for Medicare and Medicaid Services (CMS) for a period of an additional five years. This extension would enable DHHS to claim federal reimbursement for payment of services provided to Medicaid beneficiaries as follows:

• Beneficiaries under age 65 who are otherwise eligible and primarily receiving treatment and withdrawal management services for substance use disorder (SUD) who are short-term residents in facilities that meet the definition of an institution for mental diseases (IMD);
• Beneficiaries ages 21-64 who are otherwise eligible and primarily receiving short-term inpatient psychiatric treatment or short-term residential mental health treatment for serious mental illness (SMI) in an IMD; and
• Beneficiaries who are otherwise eligible and receiving SUD, SMI or Serious Emotional Disturbance (SED) treatment while an inmate of a public institution within NHDOC’s system of state prisons, for a tailored package of care coordination services to be provided during the period 45 days prior to release (Tailored Medicaid Services to Support Successful Community Reentry or “Community Reentry”).

There are no proposed changes to the delivery system; the demonstration will continue to apply across managed care and fee for service systems.

Overview of New Community Reentry Program

As part of this extension submission, the State is requesting approval from CMS for a change to the demonstration to authorize federal Medicaid matching funds for the provision of a tailored set of benefits targeting those incarcerated in NH Department of Corrections (NHDOC) custody in state prisons with behavioral health (BH) disorders (SUD, OUD, SMI, or SED) transitioning to community release. The targeted services primarily involve care coordination: (i) MCO enrollment, (2) peer recovery supports or counseling and (iii) new prescribing provider appointments with identified community BH providers (i.e. one telehealth or in-person intake appointment and one or two peer support or counseling sessions). These connection points are critical to building stronger transitional bridges to the community in the 45-day period prior to release from incarceration.

Demonstration Hypotheses and Evaluation Approach 

The approved goals of the SUD component of the demonstration are:

• Increased rates of identification, initiation, and engagement in treatment; 
• Increased adherence to, and retention in, treatment; 
• Reduced overdose deaths, particularly those due to opioids; 
• Reduced utilization of emergency department and inpatient hospital settings for treatment where the utilization is preventable or medically inappropriate, through improved access to other continuum of care services; 
• Reduced readmissions to the same or higher level of care, where the readmission is preventable or medically inappropriate; and 
• Improved access to care for physical health conditions among beneficiaries.

The approved goals of the SMI component of the demonstration are:

• Reduce utilization and lengths of stay in emergency departments among Medicaid beneficiaries with SMI/SED while awaiting mental health treatment in specialized settings; 
• Reduce preventable readmissions to acute care hospitals and residential settings; 
• Improve availability of crisis stabilization services, including services made available through call centers and mobile crisis units, intensive outpatient services, as well as services provided during acute short-term stays in residential crisis stabilization programs, psychiatric hospitals, and residential treatment settings throughout the state; 
• Improve access to community-based services to address the chronic mental health care needs of beneficiaries with SMI/SED, including through increased integration of primary and behavioral health care; and 
• Improve care coordination, especially continuity of care in the community following episodes of acute care in hospitals and residential treatment facilities.

The proposed Community Reentry portion of the demonstration is designed to test the following hypothesis: by providing a tailored Medicaid benefit 45 days prior to release, re-integration rates will increase and recidivism will be reduced among Medicaid beneficiaries who receive the pre-release transitional services. The demonstration is focused on the NHDOC system of state prisons and represents a preliminary opportunity to trial this intervention within the relatively standardized system of NHDOC to evaluate the opportunity for future statewide deployment in more varied settings. The proposed goals for Community Reentry are:

• Increase time in community following release from incarceration by enhancing care coordination pre-release; 
• Reduce parole violations related to SUD and SMI/SED by effectively connecting formerly incarcerated members with community-based providers; 
• Reduce recidivism, especially for SUD-related offenses; 
• Reduce utilization of IMD services by formerly incarcerated members; and 
• Reduce utilization of emergency department and inpatient hospital settings for SUD and SMI/SED treatment where the utilization is preventable or medically inappropriate, through improved access to other continuum of care services.

New Hampshire’s request to extend the demonstration period will allow the State to continue pursuing all of the above goals, and will allow the State to continue testing all associated hypotheses.

Waiver and Expenditure Authorities

Specifically, New Hampshire is requesting that:

• CMS waive §1905(a)(31)(A) and §1905(a)(31)(B) of the Social Security Act as amended, 42 CFR §438.6(e), 42 CFR §435.1010, and 42 CFR §441.11(c)(2) and (5).and any other related federal regulations; and
• Expenditure authority be applied to individuals who meet the criteria above who are either covered as Medicaid fee-for-service or enrolled in Medicaid managed care.

This extension will further the objectives of Title XIX of the Social Security Act by increasing access to and strengthening providers and provider networks available to serve Medicaid populations in the state. This will be accomplished by enhancing substance use disorder and mental health treatment supports and by reinforcing the comprehensive, integrated continuum of behavioral health treatments and care for residents of New Hampshire.

Aside from Community Reentry, the state is not requesting any changes to the demonstration scope as approved in the Special Terms and Conditions dated June 2, 2022. The complete version of the Substance Use Disorder Serious Mental Illness Serious Emotional Disturbance Treatment and Recovery Access Section 1115(a) Research and Demonstration Waiver Extension Request is available for public review on the Medicaid Waivers & Demonstrations web page.

CMS guidance regarding opportunities to design innovative service delivery systems to support adults and children with substance use disorder can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf. Similar guidance regarding opportunities to support adults and children with serious mental illness and serious emotional disturbance can be found at: https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf.

Enrollment and Expenditure Projections

Below are the projected enrollment and expenditures for each year of the demonstration extension by component of the demonstration.

Cost sharing will not be part of this demonstration. There will be no changes other than those described above. 

Opportunities to Provide Feedback

The 30-day public comment period for the Substance Use Disorder Serious Mental Illness Serious Emotional Disturbance Treatment and Recovery Access Section 1115(a) Research and Demonstration Waiver Extension Request is from Monday, August 8, 2022 until Tuesday, September 6, 2022 at 5:00 pm (Eastern). All comments must be received by 5:00 pm (Eastern) on Tuesday, September 6, 2022.

Public Hearings

DHHS will host two public hearings during the public comment period:

Wednesday, August 10, 2022 – Manchester
5:30 - 7:00 pm

Manchester Public Library Auditorium
405 Pine Street
Manchester, NH 03104

Join Zoom Meeting
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Meeting ID: 886 5218 7407
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Thursday, August 18, 2022 – Littleton
5:00 - 6:30 pm

Littleton Regional Healthcare
600 St. Johnsbury Road
Littleton, NH 03561

Note: Attendee best entrance will be at the Medical Office Building. See map for more details. Masks are required upon entrance and for the duration of stay inside the facility.

Join Zoom Meeting
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Meeting ID: 849 0426 6940
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If accommodations are needed for communication access such as interpreters, CART (captioning), assistive listening devices, or other auxiliary aids and/or services, please contact Carolyn Richards at Carolyn.S.Richards@dhhs.nh.gov or (603) 271-9439 no later than three business days before the hearing. Every effort will be made to accommodate needs identified with advance notice.

Medical Care Advisory Committee Meeting

Comments will also be considered at the Monday, August 8, 2022 Medical Care Advisory Committee (MCAC) meeting, from 10:00 a.m. – 12:00 p.m. All MCAC meetings are open to the public. The MCAC meeting location is:

Fred H. Brown Building Auditorium
129 Pleasant Street
Concord, NH 03301

Join Zoom Meeting
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Meeting ID: 696 002 9379
Passcode: 454733
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Ways to Submit Comments

DHHS would like to hear your comments about the extension request. After hearing the public's ideas and comments about the proposed changes, DHHS will make final decisions about what changes to make to the Substance Use Disorder Serious Mental Illness Serious Emotional Disturbance Treatment and Recovery Access Section 1115(a) Research and Demonstration Waiver Extension Request and then submit to CMS for final approval. The summary of comments will be posted for public viewing on the Medicaid Waivers & Demonstrations web page, along with the extension request when it is submitted to CMS.

There are several ways to give your comments to DHHS:

• Attend either of the two public hearings or MCAC meeting held at the dates / locations noted above. At these events, you can give verbal or written comments to DHHS representatives. Additional information about providing comments is noted below.
• Email comments to SUD-SMI.1115.Extension@dhhs.nh.gov.
• Mail written comments to:
  Carolyn Richards
  NH Department of Health and Human Services
  Attn: SUD-SMI-SED-TRA Demonstration Extension
  129 Pleasant Street
  Concord, NH 03301

When mailing or emailing please specify “SUD-SMI-SED-TRA Demonstration Extension” as the subject.

Additional Information

Requests for a hard copy of the document should be submitted by mail to:
Carolyn Richards
NH Department of Health and Human Services
Attn: SUD-SMI-SED-TRA Demonstration Extension
129 Pleasant Street
Concord, NH 03301

A hard copy of the Substance Use Disorder Serious Mental Illness Serious Emotional Disturbance Treatment and Recovery Access Section 1115(a) Research and Demonstration Waiver Extension Request can also be picked up at DHHS, which is located at:

NH Department of Health and Human Services 
Fred H. Brown Building Reception
129 Pleasant Street
Concord, NH 03301

All information regarding the proposed extension request can be found on the DHHS Medicaid web page at under "Helpful Resources". DHHS will update this website throughout the public comment and application process.