Bill Text: NY A07903 | 2021-2022 | General Assembly | Introduced
Bill Title: Establishes a state-level program of all-inclusive care for the elderly for persons 55 years of age or older, qualifying for nursing home levels of care who wish to remain in their community; makes a technical correction to the social services law.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2022-01-05 - referred to health [A07903 Detail]
Download: New_York-2021-A07903-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 7903 2021-2022 Regular Sessions IN ASSEMBLY May 28, 2021 ___________ Introduced by M. of A. GOTTFRIED -- read once and referred to the Committee on Health AN ACT to amend the public health law, in relation to establishing a state-level program of all-inclusive care for the elderly; to amend the social services law, in relation to making technical corrections to such law; and repealing certain provisions of the social services law relating thereto The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Legislative findings and intent. The legislature finds that 2 the Program of All-Inclusive Care for the Elderly ("PACE") is a feder- 3 ally recognized model of comprehensive care for persons 55 years of age 4 or older, qualifying for nursing home levels of care who wish to remain 5 in their community (see, Sections 1894 and 1934 to Title XVIII of the 6 Social Security Act; 42 CFR 460). The PACE program includes both Medi- 7 caid and Medicare covered benefits. Federal preemption of state laws 8 with respect to PACE has inhibited the ability of state agencies - 9 particularly the New York State Department of Health ("DOH") - to regu- 10 late PACE plans similarly to other public and commercial health plans. 11 The legislature further finds that: Research has demonstrated that 12 PACE has delivered marked improvements for enrollees in the programs 13 nationwide including, but not limited to reduced hospitalizations and 14 readmissions; reduced reliance on emergency medical services; improved 15 quality of life; and higher satisfaction with the totality of their 16 care. In conjunction with these improvements, the implementation of PACE 17 in New York has realized significant savings to the state's Medicaid 18 program compared to costs that would have been incurred under fee-for- 19 service. As neither a fee-for-service model nor a managed long-term care 20 plan, PACE represents a unique approach to care and coverage for those 21 with long-term care needs. PACE organizations are currently required to 22 be licensed and are regulated under multiple provisions of state and EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD11336-01-1A. 7903 2 1 federal law. Uniformity of regulation of PACE organizations promotes 2 both efficiency for organizations and for the state. 3 For all the foregoing reasons, it is the intent of the legislature 4 through this act to provide a more efficient and uniform structure to 5 promote the prudent development of PACE organizations in the state, to 6 promote better health outcomes for New Yorkers enrolled in such 7 programs, and to realize administrative efficiencies through these 8 programs. It is the intent of the legislature to recognize PACE organ- 9 izations as integrated providers of care and to that end, nothing in 10 this article is intended to construe PACE organizations as a managed 11 care organization as defined by article 44 of the public health law. 12 § 2. The public health law is amended by adding a new article 29-EE to 13 read as follows: 14 ARTICLE 29-EE 15 PROGRAMS OF ALL-INCLUSIVE 16 CARE FOR THE ELDERLY 17 Section 2999-s. Definitions. 18 2999-t. PACE program establishment. 19 2999-u. Criteria for program eligibility and licensure. 20 2999-v. Eligibility and enrollment. 21 2999-w. Included program benefits. 22 2999-x. Reimbursement. 23 2999-y. Severability. 24 § 2999-s. Definitions. For the purposes of this article, the following 25 terms shall have the following meanings: 26 1. "PACE organization" means a PACE provider, as defined in 42 U.S.C. 27 §1395eee and established in accordance with federal public law 105-33, 28 subtitle I of title IV of the Balanced Budget Act of 1997. 29 2. "Program of all-inclusive care for the elderly" or "PACE program" 30 means the federally recognized model of comprehensive care that provides 31 Medicaid and Medicare covered services to eligible individuals, and 32 shall include those programs defined as "operating demonstrations" by 33 section forty-four hundred three-f of this chapter. 34 3. "PACE center" means a diagnostic and treatment center established 35 under article twenty-eight of this chapter and operated by a PACE organ- 36 ization where primary care and other services are furnished to enrollees 37 of such program. 38 4. "PACE program agreement" shall have the same meaning as defined by 39 42 U.S.C. § 1395eee. 40 § 2999-t. PACE program establishment. 1. Notwithstanding any incon- 41 sistent provision of law to the contrary, the commissioner shall estab- 42 lish a state program of all-inclusive care for the elderly, to provide 43 community-based, risk-based, and capitated long-term care services as 44 optional services under the state's Medicaid state plan and any applica- 45 ble waivers, as well as under contracts entered into between the federal 46 centers for Medicare and Medicaid services, the department, and PACE 47 organizations. 48 2. The establishment of such a program shall not preclude the contin- 49 ued operation of existing approved PACE organizations at the time of 50 enactment of this article. The department may establish a process, if 51 deemed necessary, to assist the transition of such existing programs 52 through processes and requirements set forth pursuant to this article. 53 § 2999-u. Criteria for program eligibility and licensure. 1. Program 54 criteria. The requirements of the PACE program, as provided for pursuant 55 to 42 U.S.C. § 1395eee and 42 U.S.C. § 1396u-4 shall not be waived or 56 modified. New York state PACE organization requirements shall include:A. 7903 3 1 (a) The provision of a PACE center; and 2 (b) The adoption and implementation of an interdisciplinary team 3 approach to care management, care delivery, and care planning. 4 2. Contracting. The department may enter into contracts with public or 5 private organizations for implementation of the state's PACE program, 6 and may enter into additional contracts as necessary to implement such 7 program, or any other requirement deemed necessary to provide comprehen- 8 sive community-based, risk-based and capitated long-term care to eligi- 9 ble populations. Additionally: 10 (a) PACE organizations shall contract with the federal center for 11 Medicare and Medicaid services to enter into a PACE organization agree- 12 ment. 13 (b) PACE organizations licensed under this article shall be authorized 14 to act as fiscal intermediaries for their enrollees without entering 15 into additional contracts with the state to conduct such duties on 16 behalf of enrollees. 17 3. Licensure. In setting forth requirements to establish the state's 18 PACE program, the department shall provide for a unified licensure proc- 19 ess for PACE organizations that is inclusive of program requirements set 20 forth under articles forty-four, thirty-six, and twenty-eight of this 21 chapter, as well as pertinent regulatory requirements for PACE organiza- 22 tions in accordance with a regulatory approach which shall be estab- 23 lished by the department. For the purposes of subdivision one of section 24 sixty-five hundred twenty-seven of the education law, a PACE organiza- 25 tion shall be deemed to be a health maintenance organization as defined 26 by section forty-four hundred one of this chapter. 27 4. Operations and oversight. The department shall: 28 (a) Establish requirements for financial solvency for PACE organiza- 29 tions in compliance with those set forth in paragraph (c) of subdivision 30 one of section forty-four hundred three of this chapter, and shall 31 establish a contingent reserve requirement for PACE organizations which, 32 pursuant to regulations, may be different than other programs; 33 (b) Provide oversight of PACE organization operations in coordination 34 with the centers for Medicare and Medicaid services, including any rules 35 appropriate for the safe, efficient and orderly administration of the 36 program; and 37 (c) Develop a single process for PACE organizations to complete all 38 reports, audits, surveys, and other data or information collection 39 required by federal, state or local authorities. 40 § 2999-v. Eligibility and enrollment. 1. To be eligible for enrollment 41 in the PACE program, an individual must: 42 (a) (i) Be at least fifty-five years old; 43 (ii) Meet the state's eligibility criteria for nursing home level of 44 care; 45 (iii) Reside within the PACE program-approved service area; and 46 (iv) Be able to be maintained safely in the community-based setting at 47 the time of enrollment with the assistance of a PACE organization; or 48 (b) Be otherwise eligible for participation in a PACE demonstration or 49 specialty program authorized by the federal PACE Innovation Act and 50 approved by the centers for Medicare and Medicaid services. 51 2. Notwithstanding any law or regulation to the contrary, if federal 52 law or regulation sets forth broader eligibility or enrollment require- 53 ments than those set forth under subdivision one of this section, eligi- 54 bility for the PACE program shall conform to such federal requirements. 55 3. Enrollment and participation by individuals in the PACE program 56 shall be voluntary.A. 7903 4 1 § 2999-w. Included program benefits. Enrollees in the PACE program 2 shall be provided a benefit package by their PACE organization, regard- 3 less of source of payment, that includes: 4 (a) All Medicare-covered items and services; 5 (b) All Medicaid-covered items and services, as specified in the 6 state's Medicaid plan and in section three hundred sixty-four-j of the 7 social services law; and 8 (c) Other such services as determined necessary by the interdiscipli- 9 nary team to improve and maintain the participant's overall health 10 status. 11 § 2999-x. Reimbursement. The department shall develop and implement, 12 in conformance with applicable federal requirements, a methodology for 13 establishing rates of payment for costs of benefits provided by PACE 14 organizations to its Medicaid eligible PACE program enrollees. 15 1. Methodology. To the extent required by federal law, such rate meth- 16 odologies for PACE organizations shall result in a payment amount no 17 greater than the amount that would otherwise have been paid for compara- 18 ble services provided pursuant to the state plan if the participants 19 were not enrolled in the PACE program. PACE program rates shall be set 20 in compliance with relevant centers for Medicare and Medicaid services 21 rate setting rules and guidance. 22 2. Transparency. The department shall provide, or shall require any 23 independent actuary used to review PACE program reimbursement rates to 24 provide, to PACE organizations the documents and information regarding 25 PACE program reimbursement rates submitted to the centers for Medicare 26 and Medicaid services in a form and time frame consistent with the 27 requirements for the department to provide or cause to be provided docu- 28 ments and information to Medicaid managed care providers under paragraph 29 (c) of subdivision eighteen of section three hundred sixty-four-j of the 30 social services law. 31 § 2999-y. Severability. If any provision of this article, or any 32 application of any provision of this article, is held to be invalid, or 33 to violate or be inconsistent with any federal law or regulation, such 34 violation or inconsistency shall not affect the validity or effective- 35 ness of any other provision of this article, or of any other application 36 of any provision of this article, which can be given effect without such 37 provision or application; and to such end, the provisions and applica- 38 tions of this article shall be severable. 39 § 3. Paragraph (c) of subdivision 18 of section 364-j of the social 40 services law, as added by section 55 of part B of chapter 57 of the laws 41 of 2015, is REPEALED. 42 § 4. Paragraph (c) of subdivision 18 of section 364-j of the social 43 services law, as added by section 40-c of part B of chapter 57 of the 44 laws of 2015, is amended to read as follows: 45 (c) In setting such reimbursement methodologies, the department shall 46 consider costs borne by the managed care program to ensure actuarially 47 sound and adequate rates of payment to ensure quality of care. The 48 department shall require the independent actuary selected pursuant to 49 paragraph (b) of this subdivision to provide a complete actuarial memo- 50 randum, along with all actuarial assumptions made and all other data, 51 materials and methodologies used in the development of rates, to managed 52 care providers thirty days prior to submission of such rates to the 53 centers for Medicare and Medicaid services for approval. Managed care 54 providers may request additional review of the actuarial soundness of 55 the rate setting process and/or methodology.A. 7903 5 1 § 5. This act shall take effect January 1, 2022, provided, however, 2 that the amendments made to section 364-j of the social services law 3 made by sections 3 and 4 of this act shall not affect the repeal of such 4 section and shall be deemed repealed therewith. Effective immediately, 5 the addition, amendment and/or repeal of any rule or regulation neces- 6 sary for the implementation of this act on its effective date are 7 authorized to be made and completed on or before such effective date.
