Bill Text: NY S03973 | 2015-2016 | General Assembly | Introduced

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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, 2019.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2016-01-21 - PRINT NUMBER 3973A [S03973 Detail]

Download: New_York-2015-S03973-Introduced.html

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                           S T A T E   O F   N E W   Y O R K
       ________________________________________________________________________
                                         3973
                              2015-2016 Regular Sessions
                                   I N  S E N A T E
                                   February 25, 2015
                                      ___________
       Introduced  by  Sen.  RANZENHOFER -- read twice and ordered printed, and
         when printed to be committed 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
   24  MANAGEMENT OF THE ENROLLEE'S CONDITION. THE ENHANCED SERVICES  COMPONENT
        EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                             [ ] is old law to be omitted.
                                                                  LBD09434-01-5
       S. 3973                             2
    1  SHALL  ENCOURAGE  ENROLLEES  TO  ENGAGE IN APPROVED HEALTH ACTIVITIES BY
    2  INCLUDING THE FLEXIBILITY FOR HEALTH SPENDING ACCOUNTS.  PLANS SHALL  BE
    3  ENCOURAGED TO ESTABLISH CUSTOMIZED BENEFIT PACKAGES TARGETED TO SPECIFIC
    4  SPECIAL  NEEDS  POPULATIONS THAT SHALL FOSTER ENROLLEE CHOICE AND ENABLE
    5  ENROLLEES TO ACCESS HEALTH CARE SERVICES THEY  NEED.  THE  PACKAGES  MAY
    6  VARY  THE  AMOUNT,  DURATION  AND  SCOPE  OF  SOME  TRADITIONAL MEDICAID
    7  SERVICES, PROVIDED THE MANDATORY MEDICAID  SERVICES  ARE  INCLUDED,  THE
    8  BENEFITS ARE ACTUARIALLY EQUIVALENT TO THE VALUE OF TRADITIONAL MEDICAID
    9  SERVICES,  AND  THEY  PASS  A  SUFFICIENCY TEST TO ENSURE THE PACKAGE IS
   10  SUFFICIENT TO MEET THE MEDICAL NEEDS OF  THE  TARGET  POPULATION.  THESE
   11  BENEFIT  PACKAGES SHALL BE PRIOR APPROVED BY THE COMMISSIONER OF HEALTH.
   12  PARTICIPATION SHALL BE MANDATORY IN DEMONSTRATION AREAS FOR ALL MEDICAID
   13  POPULATIONS NOT SPECIFICALLY EXCLUDED BY  THE  COMMISSIONER  OF  HEALTH.
   14  THOSE NOT REQUIRED TO PARTICIPATE SHALL BE PROVIDED THE OPTION TO VOLUN-
   15  TARILY PARTICIPATE IN THE DEMONSTRATION WAIVER;
   16    (II) A CHOICE OF MANAGED CARE PROVIDER WHICH SHALL REST WITH THE INDI-
   17  VIDUAL RECIPIENT, PROVIDED FAILURE TO CHOOSE SHALL RESULT IN AN AUTOMAT-
   18  IC ASSIGNMENT. AFTER A LIMITED OPEN ENROLLMENT PERIOD, RECIPIENTS MAY BE
   19  LOCKED  IN A CAPITATED MANAGED CARE NETWORK FOR TWELVE MONTHS. A RECIPI-
   20  ENT SHALL BE ALLOWED TO SELECT ANOTHER CAPITATED  MANAGED  CARE  NETWORK
   21  AFTER  TWELVE  MONTHS  OF  ENROLLMENT.  HOWEVER, NOTHING SHALL PREVENT A
   22  MEDICAID RECIPIENT FROM CHANGING PRIMARY CARE PROVIDERS WITHIN THE CAPI-
   23  TATED MANAGED CARE NETWORK DURING THE TWELVE MONTH PERIOD;
   24    (III) AN OPT-OUT PROVISION WHEREBY MEDICAID RECIPIENTS SHALL  BE  ABLE
   25  TO  USE  THEIR MEDICAID PREMIUM TO PURCHASE HEALTH CARE COVERAGE THROUGH
   26  AN EMPLOYER SPONSORED HEALTH INSURANCE PLAN INSTEAD OF THROUGH  A  MEDI-
   27  CAID CERTIFIED PLAN;
   28    (IV)  AN ENHANCED BENEFIT PACKAGE UNDER WHICH MEDICAID RECIPIENTS WILL
   29  RECEIVE FINANCIAL INCENTIVES AS A REWARD FOR HEALTHIER  BEHAVIOR.  FUNDS
   30  SHALL  BE  DEPOSITED INTO A SPECIAL HEALTH SAVINGS ACCOUNT AND AVAILABLE
   31  TO THE INDIVIDUAL TO OFFSET HEALTH CARE RELATED COSTS SUCH AS  OVER  THE
   32  COUNTER  MEDICINES,  VITAMINS  OR OTHER EXPENSES NOT COVERED UNDER THEIR
   33  PLAN OR TO RETAIN FOR USE IN PURCHASING EMPLOYER PROVIDED INSURANCE;
   34    (V) A MECHANISM TO REQUIRE CAPITATED MANAGED CARE PLANS  TO  REIMBURSE
   35  QUALIFIED  EMERGENCY SERVICE PROVIDERS, INCLUDING AMBULANCE SERVICES AND
   36  EMERGENCY MEDICAL SERVICES, PROVIDED THE DEMONSTRATION SHALL  INCLUDE  A
   37  PROVISION FOR CONTINUING FEE-FOR-SERVICE PAYMENTS FOR EMERGENCY SERVICES
   38  FOR INDIVIDUALS WHO ARE SUBSEQUENTLY DETERMINED TO BE ELIGIBLE FOR MEDI-
   39  CAID;
   40    (VI)  A  CHOICE  COUNSELING SYSTEM TO ASSIST RECIPIENTS IN SELECTING A
   41  CAPITATED MANAGED CARE PLAN  THAT  BEST  MEETS  THEIR  NEEDS,  INCLUDING
   42  INFORMATION ON BENEFITS PROVIDED, COST SHARING AND OTHER CONTRACT INFOR-
   43  MATION. THE COMMISSIONER OF HEALTH SHALL PROHIBIT PLANS, THEIR EMPLOYEES
   44  OR  CONTRACTEES  FROM  RECRUITING RECIPIENTS, SEEKING ENROLLMENT THROUGH
   45  INDUCEMENTS, OR PREJUDICING RECIPIENTS AGAINST OTHER CAPITATED PLANS;
   46    (VII) A SYSTEM TO MONITOR THE PROVISIONS OF HEALTH  CARE  SERVICES  IN
   47  THE  PILOT  PROGRAM, INCLUDING UTILIZATION AND QUALITY OF CARE TO ENSURE
   48  ACCESS TO MEDICALLY NECESSARY SERVICES;
   49    (VIII) A GRIEVANCE RESOLUTION PROCESS FOR MEDICAID RECIPIENTS ENROLLED
   50  IN THE PILOT PROGRAM INCLUDING AN EXPEDITED REVIEW  IF  THE  LIFE  OF  A
   51  MEDICAID RECIPIENT IS IN IMMINENT AND EMERGENT JEOPARDY;
   52    (IX) A GRIEVANCE RESOLUTION PROCESS FOR HEALTH CARE PROVIDERS EMPLOYED
   53  BY  OR CONTRACTED WITH A CAPITATED MANAGED CARE NETWORK UNDER THE DEMON-
   54  STRATION WAIVER TO SETTLE DISPUTES; AND
   55    (X) A TECHNICAL ADVISORY PANEL CONVENED BY THE COMMISSIONER OF  HEALTH
   56  TO ADVISE THE AGENCY IN THE AREAS OF RISK-ADJUSTED-RATE SETTING, BENEFIT
       S. 3973                             3
    1  DESIGN  INCLUDING THE ACTUARIAL EQUIVALENCE AND SUFFICIENCY STANDARDS TO
    2  BE USED, CHOICE COUNSELING AND ANY OTHER ASPECTS  OF  THE  DEMONSTRATION
    3  IDENTIFIED  BY  THE COMMISSIONER OF HEALTH. THE PANEL SHALL INCLUDE, BUT
    4  SHALL  NOT BE LIMITED TO, REPRESENTATIVES FROM THE STATE'S HEALTH PLANS,
    5  REPRESENTATIVES FROM PROVIDER-SPONSORED NETWORKS,  A  MEDICAID  CONSUMER
    6  REPRESENTATIVE, AND A REPRESENTATIVE FROM THE STATE DEPARTMENT OF FINAN-
    7  CIAL SERVICES.
    8    C. THE DEMONSTRATION WAIVER SHALL BE IMPLEMENTED IN NO LESS THAN THREE
    9  GEOGRAPHIC  AREAS  OF  THE STATE TO BE DETERMINED BY THE COMMISSIONER OF
   10  HEALTH.
   11    D.  THE  DEPARTMENT  OF  HEALTH  SHALL  COMPREHENSIVELY  EVALUATE  THE
   12  PROGRAMS  CREATED  IN  THIS SUBDIVISION AND CONTINUE SUCH EVALUATION FOR
   13  TWENTY-FOUR MONTHS AFTER  THE  PILOT  PROGRAMS  HAVE  ENROLLED  MEDICAID
   14  RECIPIENTS  AND  PROVIDED  HEALTH  CARE  SERVICES.  THE EVALUATION SHALL
   15  INCLUDE ASSESSMENTS OF THE  LEVEL  OF  CONSUMER  EDUCATION,  CHOICE  AND
   16  ACCESS TO SERVICES, COORDINATION OF CARE, QUALITY OF CARE BY EACH ELIGI-
   17  BILITY  CATEGORY  AND  MANAGED CARE PLAN IN EACH PILOT SITE AND ANY COST
   18  SAVINGS.  THE EVALUATION SHALL DESCRIBE ADMINISTRATIVE OR LEGAL BARRIERS
   19  TO THE IMPLEMENTATION AND OPERATION OF EACH PILOT  PROGRAM  AND  INCLUDE
   20  RECOMMENDATIONS  REGARDING STATEWIDE EXPANSION OF THE MANAGED CARE PILOT
   21  PROGRAMS. THE DEPARTMENT OF HEALTH SHALL SUBMIT AN EVALUATION REPORT  TO
   22  THE  GOVERNOR,  THE TEMPORARY PRESIDENT OF THE SENATE AND THE SPEAKER OF
   23  THE ASSEMBLY BY DECEMBER THIRTY-FIRST, TWO THOUSAND EIGHTEEN.
   24    E. UPON COMPLETION OF THE EVALUATION CONDUCTED UNDER  PARAGRAPH  D  OF
   25  THIS  SUBDIVISION,  THE  COMMISSIONER  OF  HEALTH  MAY REQUEST STATEWIDE
   26  EXPANSION OF THE DEMONSTRATION PROJECTS. STATEWIDE EXPANSION INTO  ADDI-
   27  TIONAL  AREAS SHALL BE CONTINGENT UPON REVIEW AND APPROVAL BY THE LEGIS-
   28  LATURE.
   29    F. THIS WAIVER AUTHORITY  IS  CONTINGENT  UPON  FEDERAL  APPROVAL  AND
   30  FEDERAL FINANCIAL PARTICIPATION (FFP) FOR:
   31    (I)  THOSE  MEDICAID BENEFITS AND ELIGIBILITY CATEGORIES PARTICIPATING
   32  IN THE WAIVER, INCLUDING THE LOCK-IN PROVISIONS;
   33    (II) THE EMPLOYER SPONSORED INSURANCE OPTION WITH COST SHARING;
   34    (III) ANY ENHANCED BENEFIT  EXPENDITURES,  INCLUDING  THE  ABILITY  TO
   35  DISBURSE  HEALTH SAVINGS ACCOUNT FUNDS TO FORMER MEDICAID RECIPIENTS WHO
   36  ACCRUED FUNDS WHILE ON MEDICAID; AND
   37    (IV) ANY OTHER FEDERAL APPROVALS OR  FEDERAL  FINANCIAL  PARTICIPATION
   38  CONTINGENCIES THAT THE COMMISSIONER OF HEALTH MAY DEEM NECESSARY.
   39    S  2.  This act shall take effect immediately; provided, however, that
   40  the department of health shall submit the medicaid reform  demonstration
   41  waiver  pursuant  to the provisions of subdivision 6-b of section 366 of
   42  the social services law, as added by section one of this act, within six
   43  months of the effective date of this act.