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.
                                                                   LBD11336-01-1

        A. 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.
feedback