Bill Text: NJ A5873 | 2020-2021 | Regular Session | Introduced
Bill Title: Requires Medicaid and NJ FamilyCare managed care organizations to offer patient-centered medical home model or other alternative payment model to primary care providers.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2021-06-14 - Introduced, Referred to Assembly Budget Committee [A5873 Detail]
Download: New_Jersey-2020-A5873-Introduced.html
Sponsored by:
Assemblywoman ELIANA PINTOR MARIN
District 29 (Essex)
SYNOPSIS
Requires Medicaid and NJ FamilyCare managed care organizations to offer patient-centered medical home model or other alternative payment model to primary care providers.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning patient-centered medical homes and supplementing Title 30 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in this act:
"Alternative payment model" means a payment approach that gives providers financial incentives to deliver high-quality and cost-efficient care and may apply to a specific clinical condition, care episode, or population.
"Department" means the Department of Human Services.
"Division" means the Division of Medical Assistance and Health Services in the Department of Human Services.
"Managed care organization" means a Medicaid managed care organization, as that term is defined pursuant to 42 U.S.C. s.1396b(m)(1)(A).
"Patient-centered medical home model" means a type of alternative payment model that supports a clinical model of team-based health care, led by a health care provider, to provide comprehensive, person-centered, and continuous medical care to patients in order to achieve maximal health outcomes.
"Primary care provider" means a licensed medical doctor, doctor of osteopathy, or a licensed medical practitioner who, within the scope of practice and in accordance with State certification or licensure requirements, standards, and practices, is responsible for maintaining continuity of patient care and providing all required primary care services to enrollees, including periodic examinations, preventive health care and counseling, immunizations, diagnosis, and treatment of illness or injury, coordination of overall medical care, record maintenance, and initiation of referrals to specialty providers. A primary care provider shall include general or family practitioners, pediatricians, internists, and shall include specialist physicians, physician assistants, certified nurse midwives, certified nurse practitioners, or clinical nurse specialists, provided that the practitioner carries out all primary care provider responsibilities in accordance with licensure requirements.
2. A managed care organization that provides benefits to persons who are eligible for Medicaid under P.L.1968, c.413 (C.30:4D-1 et seq.) or NJ FamilyCare under P.L.2005, c.156 (C.30:4J-8 et al.) shall offer a patient-centered medical home model to primary care providers in the managed care organization's network. The division, in its sole discretion, may waive the requirements of this section if a managed care organization can demonstrate that the managed care organization offers an alternative payment model to primary care providers that is not a patient-centered medical home model but that similarly incentivizes high quality, efficient, and holistic care.
3. a. A managed care organization shall submit annually to the division a description of the managed care organization's patient-centered medical home model or, if waived by the division to offer a patient-centered medical home model, the other alternative payment model offered to primary care providers, which description shall include, but not be limited to:
(1) the basic financial structure of the model, which shall include incentive or population management payments which may be available to providers participating in the model;
(2) whether participating providers are required to obtain any certifications to participate in the model;
(3) quality or other performance metrics which affect provider payment under the alternative payment model;
(4) the requirements for a provider to be eligible to participate in the model, including but not limited to the number of unique patients seen by a provider or past quality performance;
(5) whether the model qualifies as an "Other Payer Advanced APM" as defined in 42 CFR 414.1305;
(6) a list of all providers participating in the model; and
(7) the number of enrollees provided services by providers participating in the model, listed by county.
b. The managed care organization shall make the description required pursuant to subsection a. of this section available to the public on the managed care organization's Internet website, after division approval. The division may also post such descriptions on its Internet website.
c. The division may, in its discretion, establish a standardized format for managed care organizations to use in providing the description required pursuant to subsection a. of this section.
d. The division may, in its discretion, extend the requirements of subsection a. of this section to any other alternative payment models, which are targeted toward non-primary care provider categories, offered by a managed care organization that contracts to provide benefits to persons eligible for Medicaid or NJ FamilyCare.
4. a. Notwithstanding the provisions of the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) or any other law to the contrary, the division shall establish standardized quality metrics for patient-centered medical home models and other alternative payment models offered to primary care providers in accordance with this section.
b. The division shall develop, through a public stakeholder process, standardized quality metrics for patient-centered medical home models and other alternative payment models offered to primary care providers and request public comment on such standardized quality metrics.
c Following the public comment period, and periodically thereafter, the division shall identify a list of standardized quality metrics and shall mandate that managed care organizations utilize only those standardized quality metrics when determining or calculating payments to providers under the managed care organization's patient-centered medical home model or other alternative payment offered to primary care providers. To the extent practicable, the standardized quality metrics shall promote alignment with other non-Medicaid payers.
d. Nothing in this act shall be construed as precluding the division from imposing additional requirements on managed care organizations that relate to patient-center medical home models or other alternative payment models offered to primary care providers.
5. The division shall specify a format and methodology through which managed care organizations shall submit patient-level data and provider-level data on participation and performance in a patient-centered medical home model or other alternative payment model in order to facilitate the division's evaluation of the performance of such patient-centered medical home models and alternative payment models offered to primary care providers.
6. The Commissioner of Human Services and the Commissioner of Banking and Insurance may jointly waive any provision of P.L.1999, c.409 (C.17:48H-1 et seq.) to the extent necessary to support provider participation in Medicaid patient-care medical home models or any other Medicaid alternative payment models. Such waivers shall be granted, in writing, by both commissioners and shall only be issued if the Commissioner of Human Services and the Commissioner of Banking and Insurance jointly determine, in their sole discretion, that any risk of adverse consequences to the public are minimal.
7. The Commissioner of Human Services shall apply for such waivers, federal approvals, or state plan amendments as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid expenditures under the federal Medicaid program.
8. This act shall take effect one year following the date of enactment provided that approval of any waivers, federal approvals, or state plan amendments has been received prior to that date, otherwise the effective date of this act is delayed until such approvals are received. The Commissioner of Human Services may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.
STATEMENT
This bill requires Medicaid and NJ FamilyCare beneficiaries managed care organizations to offer patient-centered medical home models or other alternative payment models to primary care providers. As defined under the bill, a "patient-centered medical home model" means a type of alternative payment model that supports a clinical model of team-based health care, led by a health care provider, to provide comprehensive, person-centered, and continuous medical care to patients in order to achieve maximal health outcomes. An "alternative payment model" means a payment approach that gives providers financial incentives to deliver high-quality and cost-efficient care and may apply to a specific clinical condition, care episode, or population.
Under the bill, a managed care organization that provides benefits to persons who are eligible for Medicaid under P.L.1968, c.413 (C.30:4D-1 et seq.) or NJ FamilyCare under P.L.2005, c.156 (C.30:4J-8 et al.) is to offer a patient-centered medical home model to primary care providers in the managed care organization's network. The Division of Medical Assistance and Health Services in the Department of Human Services (division), in its sole discretion, may waive this requirement if a managed care organization can demonstrate that the managed care organization offers an alternative payment model to primary care providers that is not a patient-centered medical home model but that similarly incentivizes high quality, efficient, and holistic care.
The bill provides that a managed care organization is to submit annually to the division a description of the managed care organization's patient-centered medical home model or, if waived by the division to offer a patient-centered medical home model, the other alternative payment model offered to primary care providers, which description is to include, but not be limited to: 1) the basic financial structure of the model, which is to include incentive or population management payments which may be available to providers participating in the model; 2) whether participating providers are required to obtain any certifications to participate in the model; 3) quality or other performance metrics which affect provider payment under the model; 4) the requirements for a provider to be eligible to participate in the model, including but not limited to the number of unique patients seen by a provider or past quality performance; 5) whether the model qualifies as an "Other Payer Advanced APM" as defined in 42 CFR 414.1305; 6) a list of all providers participating in the model; and 7) the number of enrollees provided services by providers participating in the model, listed by county.
Under the bill, the division is to establish standardized quality metrics for patient-centered medical home models and other alternative payment models offered to primary care providers. The division is to develop, through a public stakeholder process, standardized quality metrics for patient-centered medical home models and other alternative payment models offered to primary care providers and request public comment on such standardized quality metrics. Following the public comment period, and periodically thereafter, the division is to identify a list of standardized quality metrics and is to mandate that managed care organizations utilize only those standardized quality metrics when determining or calculating payments to providers under the managed care organization's patient-centered medical home model or other alternative payment offered to primary care providers. To the extent practicable, the standardized quality metrics are to promote alignment with other non-Medicaid payers.
The bill provides that the division is to specify a format and methodology through which managed care organizations are to submit patient-level and provider-level data on participation and performance in a patient-centered medical home model or other alternative payment model in order to facilitate the division's evaluation of the performance of such patient-centered medical home models and alternative payment models offered to primary care providers.
