Bill Text: CT SB00814 | 2015 | General Assembly | Comm Sub

Connecticut Senate Bill 814 (Prior Session Legislation)

Bill Title: An Act Concerning State Accountable Care Organizations.

Spectrum: Committee Bill

Status: (Introduced - Dead) 2015-06-02 - Senate Recommitted to Public Health [SB00814 Detail]

Download: Connecticut-2015-SB00814-Comm_Sub.html

General Assembly		*Substitute Bill No. 814*
*January Session, 2015*		_____SB00814PH____033115____

AN ACT CONCERNING STATE ACCOUNTABLE CARE ORGANIZATIONS.

Be it enacted by the Senate and House of Representatives in General Assembly convened:

Section 1. (NEW) (Effective October 1, 2015) For purposes of this section and sections 2 to 6, inclusive, of this act:

(1) "Accountable care organization" or "ACO" means an organization of clinically integrated health care providers certified by the Commissioner of Public Health in accordance with the provisions of section 2 of this act;

(2) "ACO participant" means a health care provider that is one of the health care providers that comprise the ACO;

(3) "Certificate of authority" means a certificate of authority issued by the Commissioner of Public Health in accordance with section 2 of this act;

(4) "Health care provider" means a person or entity licensed or certified pursuant to chapters 370, 372, 373, 375, 378 and 379 of the general statutes or licensed or certified pursuant to chapter 368d or 384d of the general statutes; and may also include, to the extent provided in regulations adopted by the Commissioner of Public Health under section 3 of this act, any other person or entity that provides technical assistance, information systems and services, care coordination and other services to health care providers and patients participating in an ACO;

(5) "Primary care" means the medical fields of family medicine, general pediatrics, primary care, internal medicine, primary care obstetrics or primary care gynecology, without regard to board certification, provided by a health care provider acting within the health care provider's scope of practice; and

(6) "Health insurance carrier" means any insurer, health care center, hospital service corporation, medical service corporation or other entity delivering, issuing for delivery, renewing, amending or continuing any individual or group health insurance policy in this state providing coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469 of the general statutes and may also include any entity identified in regulations adopted by the commissioner pursuant to section 3 of this act, including, but not limited to, an entity such as a pharmacy benefits manager, fiscal administrator, or administrative services provider that participates in the administration of a health insurance system.

Sec. 2. (NEW) (Effective October 1, 2015) (a) The Commissioner of Public Health shall establish a voluntary program within the Department of Public Health to promote the use of ACOs to deliver health care services for the purpose of improving the quality, value, coordination and accountability of services provided to patients in the state.

(b) The commissioner may issue a certificate of authority to an entity that meets conditions for ACO certification as set forth in regulations adopted by the commissioner pursuant to section 3 of this act.

(c) The commissioner may limit, suspend or terminate a certificate of authority if an ACO is not operating in accordance with the provisions of sections 1 to 6, inclusive, of this act.

(d) The commissioner may seek federal approvals and waivers to implement the provisions of sections 1 to 6, inclusive, of this act, including, but not limited to, those approvals or waivers necessary to obtain federal financial participation.

(e) Not later than January 1, 2016, and annually thereafter, the Commissioner of Public Health shall report, in accordance with the provisions of section 11-4a of the general statutes, to the joint standing committee of the General Assembly having cognizance of matters relating to public health concerning the program established pursuant to this section. Such report shall include recommendations as to (1) whether such program shall be continued, and (2) if it is recommended that the program be continued, any modifications to such program.

Sec. 3. (NEW) (Effective October 1, 2015) (a) The Commissioner of Public Health, in consultation with the Attorney General, health care providers, health insurance carriers, advocates representing patients and any other person the commissioner deems appropriate, shall adopt regulations, in accordance with the provisions of chapter 54 of the general statutes, to establish criteria for certificates of authority, quality standards for ACOs, reporting requirements and other matters deemed to be appropriate and necessary in the operation and evaluation of ACOs under sections 1 to 6, inclusive, of this act. Such regulations shall be consistent, to the extent practicable, with regulations adopted by the federal Centers for Medicare and Medicaid services for accountable care organizations under the Medicare program.

(b) (1) Regulations adopted by the commissioner pursuant to this section shall allow independent practice associations to obtain a certificate of authority and may otherwise promote and support the participation of independent community health care providers and community hospitals in ACOs by means, including, but not limited to, (A) creating an expedited or streamlined process for ACOs formed by, or that include a significant number of such health care providers or hospitals, to obtain a certificate of authority, and (B) providing technical and administrative assistance to such ACOs during and after issuance of a certificate of authority.

(2) To the extent that it is consistent with the provisions of sections 1 to 6, inclusive, of this act, the commissioner may adopt regulations to allow an ACO certified or accredited by an independent organization, including, but not limited to, URAC, to obtain a certificate of authority.

(1) The governance, leadership and management structure of the ACO that reasonably and equitably represents the ACO's participants and the ACO's patients, including the manner in which clinical and administrative systems and clinical participation shall be managed;

(2) A description of the population proposed to be served by the ACO, that may include reference to a geographical area and patient characteristics;

(3) The character, competence, and fiscal responsibility and soundness of an ACO and its principals;

(4) Governance standards that address financial conflicts of interest and promote transparency;

(5) The adequacy of an ACO's network of participating health care providers, including primary care health care providers;

(6) Mechanisms by which an ACO is to provide, manage and coordinate quality health care for its patients including improving access to primary care services and, where practicable, elevating the services of primary care health care providers to meet patient-centered medical home standards, coordinating services for complex high-need patients, and providing access to health care providers that are not ACO participants;

(7) Mechanisms by which the ACO shall receive and distribute payments to its participating health care providers, that may include incentive payments, such as medical home payments, or mechanisms for combining payments received by participating health care providers from health insurance carriers and patients, provided any such payment mechanism shall not create an incentive to deny or limit medically necessary care;

(8) Mechanisms and criteria for accepting health care providers to participate in the ACO that are related to the needs of the patient population to be served and needs and purposes of the ACO, and preventing unreasonable discrimination;

(9) Mechanisms for quality assurance and grievance procedures for patients or health care providers where appropriate, and procedures for reviewing and appealing patient care decisions;

(10) Mechanisms that promote evidence-based health care, patient engagement, coordination of care, electronic health records, other enabling technologies and integrated, efficient and effective health care services;

(11) Performance standards for, and measures to assess, the quality and utilization of care provided by an ACO;

(12) Mechanisms to evaluate patient satisfaction regarding the patient's access to care and the quality and cost of care;

(13) Appropriate requirements for ACOs to promote compliance with the purposes of sections 1 to 6, inclusive, of this act;

(14) Posting on the Department of Public Health's Internet web site information about ACOs that would be useful to health care providers and patients, including similar metrics;

(15) Requirements for the submission of information and data by ACOs and their participating and affiliated health care providers as necessary for the evaluation of the success of ACOs;

(16) Protection of patient rights as appropriate;

(17) The impact of the establishment and operation of an ACO, including providing that it shall not diminish access to any health care service for the population served and in the area served; and

(18) Establishment of standards to promote the ability of an ACO to participate in applicable federal programs for ACOs.

(d) An ACO shall provide for meaningful participation in the composition and control of the ACO's governing body for ACO participants or their designated representatives.

(e) The ACO governing body shall include an administrative officer, medical director and not less than one representative of: (1) Medicaid or HUSKY plan recipients; and (2) other patients and consumers. Such representatives shall have no conflict of interest with the ACO and no immediate family member with a conflict of interest with the ACO.

(f) Not less than seventy-five per cent control of the ACO's governing body shall be held by ACO participants. Members of the ACO governing body shall have a fiduciary relationship with the ACO and shall be subject to conflict of interest requirements adopted by the ACO and set forth in regulations adopted by the commissioner. The ACO's finances, including dividends and other return on capital, debt structure, executive compensation, and ACO participant compensation, shall be arranged and conducted to maximize the achievement of the purposes of sections 1 to 6, inclusive, of this act.

(g) An ACO shall use its best efforts to include among the ACO participants, on reasonable terms and conditions, any federally-qualified health center that is willing to be an ACO participant and that serves the area and population served by the ACO.

(h) An ACO may focus its efforts on providing health care services to patients with one or more chronic conditions or special needs. However, an ACO shall not otherwise, on the basis of a person's medical or demographic characteristics, discriminate for or against or discourage or encourage any person with respect to enrolling or participating in the ACO.

(i) An ACO shall not, by incentives or otherwise, discourage a health care provider from providing, or an enrollee or patient from seeking, appropriate health care services.

(j) An ACO shall not discriminate against or disadvantage a patient or patient's representative for the exercise of patient autonomy.

(k) An ACO shall not limit or restrict patients' use of health care providers contracted or affiliated with the ACO. An ACO shall not require a patient to obtain the prior approval, from a primary care gatekeeper or otherwise, before utilizing the services of other providers. An ACO shall not make adverse determinations as defined in section 38a-591a of the general statutes.

(l) An ACO shall not prevent ACO participants from disclosing price information to patients, state agencies or the public and shall encourage ACO participants to provide patients with relevant price information to support informed value-based care decisions.

(m) An ACO shall provide care coordination for its participating patients, that includes, but need not be limited to, managing, referring, locating, coordinating, and monitoring health care services for the patient to ensure that all medically necessary health care services are made available to, and are effectively used by, the patient in a timely manner, consistent with patient autonomy and is not a requirement for prior authorization for health care services. Referral shall not be required for a patient to receive a health care service.

Sec. 4. (NEW) (Effective October 1, 2015) (a) Subject to regulations adopted by the Commissioner of Public Health pursuant to section 3 of this act, an ACO may: (1) Enter into arrangements with one or more health insurance carriers to establish payment methodologies for health care services for the health insurance carrier's enrollees provided by the ACO or for which the ACO is responsible, such as full or partial capitation or other arrangements. Such arrangements may include provision for the ACO to receive and distribute payments to the ACO's participating health care providers, including incentive payments and payments for health care services from health insurance carriers and patients; and (2) include mechanisms for combining payments received by participating health care providers from health insurance carriers and patients.

(b) Notwithstanding any provision of the general statutes, the Commissioner of Public Health may, in consultation with the Attorney General, authorize a health insurance carrier to participate in payment methodologies with an ACO under this subsection, provided the payment methodology is consistent with the purposes of sections 1 to 6, inclusive, of this act.

(c) An ACO may contract with a health insurance carrier to serve as all or part of the health insurance carrier's provider network or care coordination agent, provided the ACO shall be subject to all provisions of title 38a of the general statutes that are applicable to the provider network of the health insurance carrier.

(d) The provision of health care services directly or indirectly by an ACO through health care providers shall not be considered the practice of a profession by the ACO under title 20 of the general statutes.

Sec. 5. (NEW) (Effective October 1, 2015) (a) The Commissioner of Public Health, in regulations adopted pursuant to section 3 of this act, shall permit and encourage cooperative, collaborative and integrative arrangements among health insurance carriers and health care providers who might otherwise be competitors. To the extent that it is necessary to accomplish the purposes of sections 1 to 6, inclusive, of this act, competition may be supplanted and the state may provide state action immunity under state and federal antitrust laws to health insurance carriers and health care providers.

(b) The commissioner shall engage in state supervision to promote state action immunity under state and federal antitrust laws and may inspect, require or request additional documentation and take other actions under sections 1 to 6, inclusive, of this act to verify and ensure that the provisions of sections 1 to 6, inclusive, of this act are implemented in accordance with their intent and purpose.

(c) With respect to the planning, implementation and operation of ACOs, the commissioner shall, by regulation, specify safe harbors that exempt ACOs from the application of arrangements and agreements in restraint of trade, fee-splitting arrangements and health care provider referrals.

(d) The commissioner may seek federal grants, approvals and waivers to implement the provisions of sections 1 to 6, inclusive, of this act, including federal financial participation under public health coverage. The commissioner shall provide copies of applications and other documents, including drafts, submitted to the federal government seeking such federal grants, approvals and waivers to the joint standing committee of the General Assembly having cognizance of matters relating to public health simultaneously with the submission of such documents to the federal government.

(e) The commissioner may directly, or by contract with nonprofit organizations, provide: (1) Consumer assistance to patients served by an ACO as to matters relating to ACOs; (2) technical and other assistance to health care providers participating in an ACO as to matters relating to the ACO; (3) assistance to ACOs to promote their formation and improve their operation; and (4) information sharing and other assistance among ACOs to improve the operation of ACOs.

Sec. 6. (NEW) (Effective October 1, 2015) Notwithstanding any provision of sections 1 to 5, inclusive, of this act, each ACO operating in the state shall submit to the Commissioner of Public Health: (1) Its articles of incorporation and bylaws; (2) annual financial reports as requested by the commissioner; (3) a description of (A) the standards used by the ACO to determine which hospitals and health care providers are permitted to participate in the ACO, (B) the process for hospitals and health care providers to apply to participate in the ACO, and (C) any related appeal or grievance procedures.


This act shall take effect as follows and shall amend the following sections:
Section 1	October 1, 2015	New section
Sec. 2	October 1, 2015	New section
Sec. 3	October 1, 2015	New section
Sec. 4	October 1, 2015	New section
Sec. 5	October 1, 2015	New section
Sec. 6	October 1, 2015	New section

Statement of Legislative Commissioners:

In Section 3(a), the word "shall" was moved to be immediately before "adopt", for clarity; in Section 3(c)(13), "this article" was changed to "sections 1 to 6, inclusive, of this act", for accuracy; in Section 3(c)(14), "department's" was changed to "Department of Public Health's", for clarity; in Sections 3(h) and (k), "may not" was changed to "shall not" for internal consistency; in Section 3(l), "participants" was changed to "ACO participants" for conformity with the defined term; in Section 3(m), "member" was changed to "patient" for consistency; in Section 5(a), "this section and sections 1 to 6" was changed to "sections 1 to 6" for internal consistency, and "health care insurers" was changed to "health insurance carriers" for conformity with the defined term.

Joint Favorable Subst. -LCO