Regulatory Waiver

Millennium Collaborative Care Waiver Request Form

The state considers new regulatory waiver requests on a quarterly basis. Partners cannot request waivers themselves; all requests must be submitted through the PPS. Use this form to request a new waiver (submit one form per waiver requested).

What you should know about requesting waivers for DSRIP:

  • If a waiver is approved for Millennium Collaborative Care, it can only be used by Millennium partners. If another PPS in New York State receives a waiver, it only applies to partners in that PPS.
  • Waivers granted for DSRIP are only expected to last for the duration of DSRIP.
  • If granted, waivers cover all patients, not just Medicaid.

Before requesting a waiver, please do your research to assess whether a waiver is necessary and/or possible. Many requests have been denied either because no waiver is necessary or the request refers to a Federal regulation which the state has no authority to waive.

Email completed requests to .

Millennium will review and evaluate all requests before submitting them to the state, and may follow up to request additional information or clarification.

1Regulation

Identify the regulation you would like waived. Please include specific citation; e.g., 10 NYCRR § 600.9(c). Important: Research the regulation to provide the exact citation. If you are requesting waiver of more than one regulation, you must fill out a separate form for each regulation.

Citation:

2DSRIP Project

Identify the project(s) for which the regulatory waiver is being requested:

☐2.a.i. IDS
☐2.b.iii ED Care Triage
☐2.b.vii INTERACT
☐2.b.viii Hospital/Home Care
☐2.d.i. Patient Activation Measures (PAM)
☐3.a.i. Behavioral Health Integration (models 1 & 2)
☐3.a.ii. Community Crisis Stabilization
☐3.b.i. Cardiovascular Disease Management
☐3.f.i. Maternal & Child Health
☐4.a.i. Mental, Emotional, and Behavioral Wellbeing
☐4.d.i. Reduce Premature Births

For each project selected, describe the components of the project that are relevant to the request for waiver of the regulation.

Project:
Components:

3Reasons for Request

Explain why you are requesting this waiver.

This waiver would facilitate implementation of project ___ because . . .
This regulation impedes our ability to implement project ___ because . . .

4Alternatives

Identify any alternativesyou considered prior to requesting regulatory relief.

5Patient Safety

5.1Risk to Patient Safety

Provide information to support why the cited regulatory provision does not pertain to patient safety and why a waiver of the regulation(s) would not risk patient safety.

5.2Conditions

Include any conditions that could be imposed to ensure that there is no risk to patient safety. For example, conditions could include submission of policies and procedures designed to mitigate the risk to persons or providers affected by the waiver, training of appropriate staff on the policies and procedures, monitoring of implementation to ensure adherence to the policies and procedures, or evaluation of the effectiveness of the policies and procedures in mitigating risk. Be specific (for example, the specific type of training or policy).

Waiver request form in Word.docx1

Millennium Collaborative Care