Bill Text: NY S04973 | 2019-2020 | General Assembly | Introduced
Bill Title: Directs the commissioner of health to evaluate existing needs assessment tools and develop additional professionally and statistically valid assessment tools to be used to assist in determining the amount, nature and manner of services and care needs of individuals receiving medical assistance and care.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2020-01-08 - REFERRED TO HEALTH [S04973 Detail]
Download: New_York-2019-S04973-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 4973 2019-2020 Regular Sessions IN SENATE April 3, 2019 ___________ Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed to the Committee on Health AN ACT to amend the social services law and the public health law, in relation to needs assessment and rate adequacy for medicaid The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 365-a of the social services law is amended by 2 adding a new subdivision 10 to read as follows: 3 10. For any determination of the amount, nature and manner of provid- 4 ing assistance under this article for which an assessment tool is used, 5 the department, in consultation with the independent actuary, represen- 6 tatives of medical assistance recipients, representatives of the managed 7 care programs, representatives of long term care providers and other 8 interested parties, shall evaluate existing assessment tools and develop 9 additional professionally and statistically valid assessment tools to be 10 used to assist in determining the amount, nature and manner of services 11 and care needs of individuals which shall involve consideration of vari- 12 ables including but not limited to physical and behavioral functioning; 13 activities of daily living and instrumental activities of daily living; 14 family, social or geographic determinants of health; primary or second- 15 ary diagnoses of cognitive impairment or mental illness; and other 16 appropriate conditions or factors. 17 § 2. Paragraphs (c) of subdivision 18 of section 364-j of the social 18 services law, as added by sections 40-c and 55 of part B of chapter 57 19 of the laws of 2015, are amended to read as follows: 20 (c) (i) In setting such reimbursement methodologies, the department 21 shall consider costs borne by the managed care program to ensure actuar- 22 ially sound and adequate rates of payment to ensure quality of care for 23 its enrollees and shall comply with all applicable federal and state 24 laws and regulations, including, but not limited to, those relating to 25 wages, labor, and actuarial soundness. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD04193-01-9S. 4973 2 1 [(c)] (ii) The department [of health] shall require the independent 2 actuary selected pursuant to paragraph (b) of this subdivision to 3 provide a complete actuarial memorandum, along with all actuarial 4 assumptions made and all other data, materials and methodologies used in 5 the development of rates, to managed care providers thirty days prior to 6 submission of such rates to the centers for medicare and medicaid 7 services for approval. Managed care providers may request additional 8 review of the actuarial soundness of the rate setting process and/or 9 methodology. 10 (iii) In fulfilling the requirements of this paragraph, the department 11 shall establish separate rate cells or risk adjustments to reflect the 12 costs of care for specific high-need enrollees in managed care provid- 13 ers. The commissioner shall make any necessary amendments to the state 14 plan for medical assistance under section three hundred sixty-three-a of 15 this title, and submit any applications for waivers of the federal 16 social security act, as may be necessary to ensure federal financial 17 participation. As used in this subparagraph and subparagraph (iv) of 18 this paragraph, "managed care provider" shall mean a managed care 19 provider operating on a full capitation basis or a managed long term 20 care plan operating under section forty-four hundred three-f of the 21 public health law; and "long term care entity" shall mean a home care 22 services agency under article thirty-six of the public health law, a 23 fiscal intermediary in the consumer directed personal assistance 24 program, other long term care provider authorized under a home and 25 community based waiver administered by the department or the office for 26 people with developmental disabilities. The high-need rate cells or 27 risk adjustments established in accordance with this subparagraph shall 28 be consistent with subdivision ten of section three hundred sixty-five-a 29 of this title and include, but shall not be limited to: 30 (A) individuals enrolled with a managed care provider, who remain in 31 the community and who daily receive live-in twenty-four hour personal 32 care or home health services or twelve hours or more of personal care, 33 home health services or home and community support services; 34 (B) such other individuals who, based on the assessment of their care 35 needs, their diagnosis or other factors, are determined to present espe- 36 cially high needs related to factors that would influence the delivery 37 (including but not limited to home location) or their use of services, 38 as may be identified by the department. 39 (iv) Any contract for services under this title by a managed care 40 provider with a long term care entity shall ensure that resources made 41 available by the payer under such contract will support the recruitment, 42 hiring, training and retention of a qualified workforce capable of 43 providing quality care, including compliance with all applicable federal 44 and state laws and regulations, including, but not limited to, those 45 relating to wages and labor. A managed care provider with a long term 46 care entity shall report its method of compliance with this subdivision 47 to the department as a component of cost reports required under section 48 forty-four hundred three-f of the public health law. 49 (v) A long term care entity that contracts with a managed care provid- 50 er shall annually submit written certification to the department as a 51 component of cost reports required under section thirty-six hundred 52 twelve of the public health law and sections three hundred sixty-five-a 53 and three hundred sixty-seven-q of this title, as applicable, as to how 54 it applied the amounts paid in compliance with this subdivision to 55 support the recruitment, hiring, training and retention of a qualifiedS. 4973 3 1 workforce capable of providing quality care and consistent with section 2 three hundred sixty-five-a of this title. 3 § 3. Subparagraph (ii) of paragraph (a) and paragraph (g) of subdivi- 4 sion 7 and subdivision 8 of section 4403-f of the public health law, 5 subparagraph (ii) of paragraph (a) of subdivision 7 as amended by 6 section 43 of part C of chapter 60 of the laws of 2014, paragraph (g) of 7 subdivision 7 as amended by section 41-b of part H of chapter 59 of the 8 laws of 2011, subparagraph (i) of paragraph (g) of subdivision 7 as 9 amended by section 1 of part GGG of chapter 59 of the laws of 2017, 10 subparagraph (iii) of paragraph (g) of subdivision 7 as amended by 11 section 54 of part A of chapter 56 of the laws of 2013 and subdivision 8 12 as amended by section 21 of part B of chapter 59 of the laws of 2016, 13 are amended to read as follows: 14 (ii) Notwithstanding any inconsistent provision of the social services 15 law to the contrary, the commissioner shall, pursuant to regulation, 16 determine whether and the extent to which the applicable provisions of 17 the social services law or regulations relating to approvals and author- 18 izations of, and utilization limitations on, health and long term care 19 services reimbursed pursuant to title XIX of the federal social security 20 act, including, but not limited to, fiscal assessment requirements, are 21 inconsistent with the flexibility necessary for the efficient adminis- 22 tration of managed long term care plans and such regulations shall 23 provide that such provisions shall not be applicable to enrollees or 24 managed long term care plans, provided that such determinations are 25 consistent with applicable federal law and regulation, and subject to 26 the provisions of [subdivision] subdivisions eight and ten of section 27 three hundred sixty-five-a and paragraph (c) of subdivision eighteen of 28 section three hundred sixty-four-j of the social services law. 29 (g) (i) Managed long term care plans and demonstrations may enroll 30 eligible persons in the plan or demonstration upon the completion of a 31 comprehensive assessment [that shall include, but not be limited to, an32evaluation of the medical, social, cognitive, and environmental needs] 33 of each prospective enrollee in such program consistent with section 34 three hundred sixty-five-a of the social services law. This assessment 35 shall also serve as the basis for the development and provision of an 36 appropriate plan of care for the enrollee. Upon approval of federal 37 waivers pursuant to paragraph (b) of this subdivision which require 38 medical assistance recipients who require community-based long term care 39 services to enroll in a plan, and upon approval of the commissioner, a 40 plan may enroll an applicant who is currently receiving home and commu- 41 nity-based services and complete the comprehensive assessment within 42 thirty days of enrollment provided that the plan continues to cover 43 transitional care until such time as the assessment is completed. 44 (ii) The assessment shall be completed by a representative of the 45 managed long term care plan or demonstration, in consultation with the 46 prospective enrollee's health care practitioner as necessary. The 47 commissioner shall prescribe the forms on which the assessment shall be 48 made. 49 (iii) The enrollment application shall be submitted by the managed 50 long term care plan or demonstration to the entity designated by the 51 department prior to the commencement of services under the managed long 52 term care plan or demonstration. Enrollments conducted by a plan or 53 demonstration shall be subject to review and audit by the department or 54 a contractor selected pursuant to paragraph (d) of this subdivision. 55 (iv) Continued enrollment in a managed long term care plan or demon- 56 stration paid for by government funds shall be based upon a comprehen-S. 4973 4 1 sive assessment [of the medical, social and environmental needs] of the 2 recipient of the services consistent with section three hundred sixty- 3 five-a of this social services law. Such assessment shall be performed 4 at least every six months by the managed long term care plan serving the 5 enrollee. The commissioner shall prescribe the forms on which the 6 assessment will be made. 7 8. Payment rates for managed long term care plan enrollees eligible 8 for medical assistance. The commissioner shall establish payment rates 9 for services provided to enrollees eligible under title XIX of the 10 federal social security act. Such payment rates shall be subject to 11 approval by the director of the division of the budget and shall reflect 12 savings to both state and local governments when compared to costs which 13 would be incurred by such program if enrollees were to receive compara- 14 ble health and long term care services on a fee-for-service basis in the 15 geographic region in which such services are proposed to be provided. 16 Payment rates shall be risk-adjusted to take into account the character- 17 istics of enrollees, or proposed enrollees, including, but not limited 18 to: frailty, disability level, health and functional status, age, 19 gender, the nature of services provided to such enrollees, and other 20 factors as determined by the commissioner. The risk adjusted premiums 21 may also be combined with disincentives or requirements designed to 22 mitigate any incentives to obtain higher payment categories. In setting 23 such payment rates, the commissioner shall consider costs borne by the 24 managed care program to ensure actuarially sound and adequate rates of 25 payment to ensure quality of care and shall comply with all applicable 26 laws and regulations, state and federal, including [regulations as to], 27 but not limited to, those relating to wages, labor and actuarial sound- 28 ness [for medicaid managed care]. 29 § 4. Subparagraph (i) of paragraph (g) of subdivision 7 of section 30 4403-f of the public health law, as added by section 65-c of part A of 31 chapter 57 of the laws of 2006 and such paragraph as relettered by 32 section 20 of part C of chapter 58 of the laws of 2007, is amended to 33 read as follows: 34 (i) Managed long term care plans and demonstrations may enroll eligi- 35 ble persons in the plan or demonstration upon the completion of a 36 comprehensive assessment [that shall include, but not be limited to, an37evaluation of the medical, social and environmental needs] of each 38 prospective enrollee in such program consistent with section three 39 hundred sixty-five-a of the social services law. This assessment shall 40 also serve as the basis for the development and provision of an appro- 41 priate plan of care for the prospective enrollee. 42 § 5. This act shall take effect immediately; provided that sections 43 two and three of this act shall take effect April 1, 2020; and provided, 44 further that: 45 a. the amendments to section 364-j of the social services law made by 46 section two of this act shall not affect the repeal of such section and 47 shall be deemed repealed therewith; 48 b. the amendments to section 4403-f of the public health law made by 49 section three of this act shall not affect the repeal of such section 50 and shall be deemed repealed therewith; and 51 c. the amendments to subparagraph (i) of paragraph (g) of subdivision 52 7 of section 4403-f of the public health law made by section three of 53 this act shall not affect the expiration and reversion of such subpara- 54 graph, pursuant to subdivision (i) of section 111 of part H of chapter 55 59 of the laws of 2011, as amended, when upon such date the provisions 56 of section four of this act shall take effect.
