Bill Text: NY A06676 | 2009-2010 | General Assembly | Introduced
Bill Title: Authorizes the commissioner of health to apply for a medicaid reform demonstration waiver; creates an initiative to provide for a more efficient and effective medicaid services delivery system; sets forth a managed care pilot program and requires reporting to the governor, temporary president of the senate and speaker of the assembly by December 31, 2012.
Spectrum: Moderate Partisan Bill (Democrat 8-1)
Status: (Introduced - Dead) 2010-01-06 - referred to health [A06676 Detail]
Download: New_York-2009-A06676-Introduced.html
S T A T E O F N E W Y O R K ________________________________________________________________________ 6676 2009-2010 Regular Sessions I N A S S E M B L Y March 11, 2009 ___________ Introduced by M. of A. SCHIMMINGER, CHRISTENSEN, SCHROEDER, DelMONTE -- Multi-Sponsored by -- M. of A. LAVINE, MAGEE, REILLY -- read once and referred to the Committee on Health AN ACT to amend the social services law, in relation to authorizing the commissioner of health to apply for a medicaid reform demonstration waiver THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Section 366 of the social services law is amended by adding 2 a new subdivision 6-b to read as follows: 3 6-B. A. THE COMMISSIONER OF HEALTH SHALL APPLY FOR A MEDICAID REFORM 4 DEMONSTRATION WAIVER PURSUANT TO SECTION ELEVEN HUNDRED FIFTEEN OF THE 5 FEDERAL SOCIAL SECURITY ACT IN ORDER TO CREATE AN INITIATIVE TO PROVIDE 6 FOR A MORE EFFICIENT AND EFFECTIVE MEDICAID SERVICES DELIVERY SYSTEM IN 7 NEW YORK THAT EMPOWERS MEDICAID PATIENTS, BRIDGES PUBLIC AND PRIVATE 8 COVERAGE, IMPROVES PATIENT OUTCOMES AND STABILIZES PROGRAM COSTS. 9 B. THE DEMONSTRATION WAIVER SHALL INCLUDE, BUT SHALL NOT BE LIMITED 10 TO, THE FOLLOWING COMPONENTS: 11 (I) A RISK ADJUSTED CAPITATED MANAGED CARE PILOT PROGRAM FOR RECIPI- 12 ENTS CURRENTLY SERVED IN MEDICAID-FEE-FOR SERVICE OR MEDICAID MANAGED 13 CARE THAT PROVIDES BENEFIT PLANS THAT MORE CLOSELY RESEMBLE PRIVATE 14 PLANS YET ARE ACTUARIALLY EQUIVALENT TO THE CURRENT MEDICAID BENEFIT 15 PACKAGE. RISK ADJUSTED CAPITATION RATES SHALL BE SEPARATED INTO THREE 16 COMPONENTS TO COVER COMPREHENSIVE CARE, CATASTROPHIC CARE AND ENHANCED 17 SERVICES AND MAY PHASE-IN FINANCIAL RISK FOR APPROVED PROVIDERS. HEALTH 18 PLANS SHALL PROVIDE COMPREHENSIVE CARE WHICH SHALL COVER ALL EXPENSES 19 UNTIL A PREDETERMINED THRESHOLD OF EXPENSES IS REACHED AT WHICH TIME THE 20 CATASTROPHIC COMPONENT SHALL TAKE OVER. HEALTH PLANS MAY CHOOSE TO 21 ASSUME THE CATASTROPHIC RISK FOR TARGET POPULATIONS THEY SERVE. THE 22 CATASTROPHIC COMPONENT SHALL ENCOURAGE PROVIDER NETWORKS TO IDENTIFY 23 RECIPIENTS WITH UNDIAGNOSED CHRONIC ILLNESS AND ENSURE PROPER DISEASE EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD03966-01-9 A. 6676 2 1 MANAGEMENT OF THE ENROLLEES CONDITION. THE ENHANCED SERVICES COMPONENT 2 SHALL ENCOURAGE ENROLLEES TO ENGAGE IN APPROVED HEALTH ACTIVITIES BY 3 INCLUDING THE FLEXIBILITY FOR HEALTH SPENDING ACCOUNTS. PLANS SHALL BE 4 ENCOURAGED TO ESTABLISH CUSTOMIZED BENEFIT PACKAGES TARGETED TO SPECIFIC 5 SPECIAL NEEDS POPULATIONS THAT SHALL FOSTER ENROLLEE CHOICE AND ENABLE 6 ENROLLEES TO ACCESS HEALTH CARE SERVICES THEY NEED. THE PACKAGES MAY 7 VARY THE AMOUNT, DURATION AND SCOPE OF SOME TRADITIONAL MEDICAID 8 SERVICES, PROVIDED THE MANDATORY MEDICAID SERVICES ARE INCLUDED, THE 9 BENEFITS ARE ACTUARIALLY EQUIVALENT TO THE VALUE OF TRADITIONAL MEDICAID 10 SERVICES, AND THEY PASS A SUFFICIENCY TEST TO ENSURE THE PACKAGE IS 11 SUFFICIENT TO MEET THE MEDICAL NEEDS OF THE TARGET POPULATION. THESE 12 BENEFIT PACKAGES SHALL BE PRIOR APPROVED BY THE COMMISSIONER. PARTIC- 13 IPATION SHALL BE MANDATORY IN DEMONSTRATION AREAS FOR ALL MEDICAID POPU- 14 LATIONS NOT SPECIFICALLY EXCLUDED BY THE COMMISSIONER OF HEALTH. THOSE 15 NOT REQUIRED TO PARTICIPATE SHALL BE PROVIDED THE OPTION TO VOLUNTARILY 16 PARTICIPATE IN THE DEMONSTRATION WAIVER; 17 (II) A CHOICE OF MANAGED CARE PROVIDER WHICH SHALL REST WITH THE INDI- 18 VIDUAL RECIPIENT, PROVIDED FAILURE TO CHOOSE SHALL RESULT IN AN AUTOMAT- 19 IC ASSIGNMENT. AFTER A LIMITED OPEN ENROLLMENT PERIOD, RECIPIENTS MAY BE 20 LOCKED IN A CAPITATED MANAGED CARE NETWORK FOR TWELVE MONTHS. A RECIPI- 21 ENT SHALL BE ALLOWED TO SELECT ANOTHER CAPITATED MANAGED CARE NETWORK 22 AFTER TWELVE MONTHS OF ENROLLMENT. HOWEVER, NOTHING SHALL PREVENT A 23 MEDICAID RECIPIENT FROM CHANGING PRIMARY CARE PROVIDERS WITHIN THE CAPI- 24 TATED MANAGED CARE NETWORK DURING THE TWELVE MONTH PERIOD; 25 (III) AN OPT-OUT PROVISION WHEREBY MEDICAID RECIPIENTS SHALL BE ABLE 26 TO USE THEIR MEDICAID PREMIUM TO PURCHASE HEALTH CARE COVERAGE THROUGH 27 AN EMPLOYER SPONSORED HEALTH INSURANCE PLAN INSTEAD OF THROUGH A MEDI- 28 CAID CERTIFIED PLAN; 29 (IV) AN ENHANCED BENEFIT PACKAGE UNDER WHICH MEDICAID RECIPIENTS WILL 30 RECEIVE FINANCIAL INCENTIVES AS A REWARD FOR HEALTHIER BEHAVIOR. FUNDS 31 SHALL BE DEPOSITED INTO A SPECIAL HEALTH SAVINGS ACCOUNT AND AVAILABLE 32 TO THE INDIVIDUAL TO OFFSET HEALTH CARE RELATED COSTS SUCH AS OVER THE 33 COUNTER MEDICINES, VITAMINS OR OTHER EXPENSES NOT COVERED UNDER THEIR 34 PLAN OR TO RETAIN FOR USE IN PURCHASING EMPLOYER PROVIDED INSURANCE; 35 (V) A MECHANISM TO REQUIRE CAPITATED MANAGED CARE PLANS TO REIMBURSE 36 QUALIFIED EMERGENCY SERVICE PROVIDERS, INCLUDING AMBULANCE SERVICES AND 37 EMERGENCY MEDICAL SERVICES, PROVIDED THE DEMONSTRATION SHALL INCLUDE A 38 PROVISION FOR CONTINUING FEE-FOR-SERVICE PAYMENTS FOR EMERGENCY SERVICES 39 FOR INDIVIDUALS WHO ARE SUBSEQUENTLY DETERMINED TO BE ELIGIBLE FOR MEDI- 40 CAID; 41 (VI) A CHOICE COUNSELING SYSTEM TO ASSIST RECIPIENTS IN SELECTING A 42 CAPITATED MANAGED CARE PLAN THAT BEST MEETS THEIR NEEDS, INCLUDING 43 INFORMATION ON BENEFITS PROVIDED, COST SHARING AND OTHER CONTRACT INFOR- 44 MATION. THE COMMISSIONER OF HEALTH SHALL PROHIBIT PLANS, THEIR EMPLOYEES 45 OR CONTRACTEES FROM RECRUITING RECIPIENTS, SEEKING ENROLLMENT THROUGH 46 INDUCEMENTS, OR PREJUDICING RECIPIENTS AGAINST OTHER CAPITATED PLANS; 47 (VII) A SYSTEM TO MONITOR THE PROVISIONS OF HEALTH CARE SERVICES IN 48 THE PILOT PROGRAM, INCLUDING UTILIZATION AND QUALITY OF CARE TO ENSURE 49 ACCESS TO MEDICALLY NECESSARY SERVICES; 50 (VIII) A GRIEVANCE RESOLUTION PROCESS FOR MEDICAID RECIPIENTS ENROLLED 51 IN THE PILOT PROGRAM INCLUDING AN EXPEDITED REVIEW IF THE LIFE OF A 52 MEDICAID RECIPIENT IS IN IMMINENT AND EMERGENT JEOPARDY; 53 (IX) A GRIEVANCE RESOLUTION PROCESS FOR HEALTH CARE PROVIDERS EMPLOYED 54 BY OR CONTRACTED WITH A CAPITATED MANAGED CARE NETWORK UNDER THE DEMON- 55 STRATION WAIVER TO SETTLE DISPUTES; AND A. 6676 3 1 (X) A TECHNICAL ADVISORY PANEL CONVENED BY THE COMMISSIONER OF HEALTH 2 TO ADVISE THE AGENCY IN THE AREAS OF RISK-ADJUSTED-RATE SETTING, BENEFIT 3 DESIGN INCLUDING THE ACTUARIAL EQUIVALENCE AND SUFFICIENCY STANDARDS TO 4 BE USED, CHOICE COUNSELING AND ANY OTHER ASPECTS OF THE DEMONSTRATION 5 IDENTIFIED BY THE COMMISSIONER OF HEALTH. THE PANEL SHALL INCLUDE, BUT 6 SHALL NOT BE LIMITED TO, REPRESENTATIVES FROM THE STATE'S HEALTH PLANS, 7 REPRESENTATIVES FROM PROVIDER-SPONSORED NETWORKS, A MEDICAID CONSUMER 8 REPRESENTATIVE, AND A REPRESENTATIVE FROM THE STATE INSURANCE DEPART- 9 MENT. 10 C. THE DEMONSTRATION WAIVER SHALL BE IMPLEMENTED IN NO LESS THAN THREE 11 GEOGRAPHIC AREAS OF THE STATE TO BE DETERMINED BY THE COMMISSIONER OF 12 HEALTH. 13 D. THE DEPARTMENT OF HEALTH SHALL COMPREHENSIVELY EVALUATE THE 14 PROGRAMS CREATED IN THIS SUBDIVISION AND CONTINUE SUCH EVALUATION FOR 15 TWENTY-FOUR MONTHS AFTER THE PILOT PROGRAMS HAVE ENROLLED MEDICAID 16 RECIPIENTS AND PROVIDED HEALTH CARE SERVICES. THE EVALUATION SHALL 17 INCLUDE ASSESSMENTS OF THE LEVEL OF CONSUMER EDUCATION, CHOICE AND 18 ACCESS TO SERVICES, COORDINATION OF CARE, QUALITY OF CARE BY EACH ELIGI- 19 BILITY CATEGORY AND MANAGED CARE PLAN IN EACH PILOT SITE AND ANY COST 20 SAVINGS. THE EVALUATION SHALL DESCRIBE ADMINISTRATIVE OR LEGAL BARRIERS 21 TO THE IMPLEMENTATION AND OPERATION OF EACH PILOT PROGRAM AND INCLUDE 22 RECOMMENDATIONS REGARDING STATEWIDE EXPANSION OF THE MANAGED CARE PILOT 23 PROGRAMS. THE DEPARTMENT OF HEALTH SHALL SUBMIT AN EVALUATION REPORT TO 24 THE GOVERNOR, THE TEMPORARY PRESIDENT OF THE SENATE AND THE SPEAKER OF 25 THE ASSEMBLY BY DECEMBER THIRTY-FIRST, TWO THOUSAND TWELVE. 26 E. UPON COMPLETION OF THE EVALUATION CONDUCTED UNDER PARAGRAPH D OF 27 THIS SUBDIVISION, THE COMMISSIONER OF HEALTH MAY REQUEST STATEWIDE 28 EXPANSION OF THE DEMONSTRATION PROJECTS. STATEWIDE EXPANSION INTO ADDI- 29 TIONAL AREAS SHALL BE CONTINGENT UPON REVIEW AND APPROVAL BY THE LEGIS- 30 LATURE. 31 F. THIS WAIVER AUTHORITY IS CONTINGENT UPON FEDERAL APPROVAL AND 32 FEDERAL FINANCIAL PARTICIPATION (FFP) FOR: 33 (I) THOSE MEDICAID BENEFITS AND ELIGIBILITY CATEGORIES PARTICIPATING 34 IN THE WAIVER, INCLUDING THE LOCK-IN PROVISIONS; 35 (II) THE EMPLOYER SPONSORED INSURANCE OPTION WITH COST SHARING; 36 (III) ANY ENHANCED BENEFIT EXPENDITURES, INCLUDING THE ABILITY TO 37 DISBURSE HEALTH SAVINGS ACCOUNT FUNDS TO FORMER MEDICAID RECIPIENTS WHO 38 ACCRUED FUNDS WHILE ON MEDICAID; AND 39 (IV) ANY OTHER FEDERAL APPROVALS OR FEDERAL FINANCIAL PARTICIPATION 40 CONTINGENCIES THAT THE COMMISSIONER OF HEALTH MAY DEEM NECESSARY. 41 S 2. This act shall take effect immediately; provided, however, that 42 the department of health shall submit the medicaid reform demonstration 43 waiver pursuant to the provisions of subdivision 6-b of section 366 of 44 the social services law, as added by section one of this act, within six 45 months of the effective date of this act.