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, 2012.
STATE OF NEW YORK
________________________________________________________________________
6676
2009-2010 Regular Sessions
IN ASSEMBLY
March 11, 2009
___________
Introduced by M. of A. SCHIMMINGER, CHRISTENSEN, SCHROEDER, DelMONTE --
Multi-Sponsored by -- M. of A. LAVINE, MAGEE, REILLY -- read once and
referred 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
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03966-01-9
A. 6676 2
1 management of the enrollees condition. The enhanced services component
2 shall encourage enrollees to engage in approved health activities by
3 including the flexibility for health spending accounts. Plans shall be
4 encouraged to establish customized benefit packages targeted to specific
5 special needs populations that shall foster enrollee choice and enable
6 enrollees to access health care services they need. The packages may
7 vary the amount, duration and scope of some traditional medicaid
8 services, provided the mandatory medicaid services are included, the
9 benefits are actuarially equivalent to the value of traditional medicaid
10 services, and they pass a sufficiency test to ensure the package is
11 sufficient to meet the medical needs of the target population. These
12 benefit packages shall be prior approved by the commissioner. Partic-
13 ipation shall be mandatory in demonstration areas for all medicaid popu-
14 lations not specifically excluded by the commissioner of health. Those
15 not required to participate shall be provided the option to voluntarily
16 participate in the demonstration waiver;
17 (ii) A choice of managed care provider which shall rest with the indi-
18 vidual recipient, provided failure to choose shall result in an automat-
19 ic assignment. After a limited open enrollment period, recipients may be
20 locked in a capitated managed care network for twelve months. A recipi-
21 ent shall be allowed to select another capitated managed care network
22 after twelve months of enrollment. However, nothing shall prevent a
23 medicaid recipient from changing primary care providers within the capi-
24 tated managed care network during the twelve month period;
25 (iii) An opt-out provision whereby medicaid recipients shall be able
26 to use their medicaid premium to purchase health care coverage through
27 an employer sponsored health insurance plan instead of through a medi-
28 caid certified plan;
29 (iv) An enhanced benefit package under which medicaid recipients will
30 receive financial incentives as a reward for healthier behavior. Funds
31 shall be deposited into a special health savings account and available
32 to the individual to offset health care related costs such as over the
33 counter medicines, vitamins or other expenses not covered under their
34 plan or to retain for use in purchasing employer provided insurance;
35 (v) A mechanism to require capitated managed care plans to reimburse
36 qualified emergency service providers, including ambulance services and
37 emergency medical services, provided the demonstration shall include a
38 provision for continuing fee-for-service payments for emergency services
39 for individuals who are subsequently determined to be eligible for medi-
40 caid;
41 (vi) A choice counseling system to assist recipients in selecting a
42 capitated managed care plan that best meets their needs, including
43 information on benefits provided, cost sharing and other contract infor-
44 mation. The commissioner of health shall prohibit plans, their employees
45 or contractees from recruiting recipients, seeking enrollment through
46 inducements, or prejudicing recipients against other capitated plans;
47 (vii) A system to monitor the provisions of health care services in
48 the pilot program, including utilization and quality of care to ensure
49 access to medically necessary services;
50 (viii) A grievance resolution process for medicaid recipients enrolled
51 in the pilot program including an expedited review if the life of a
52 medicaid recipient is in imminent and emergent jeopardy;
53 (ix) A grievance resolution process for health care providers employed
54 by or contracted with a capitated managed care network under the demon-
55 stration waiver to settle disputes; and
A. 6676 3
1 (x) A technical advisory panel convened by the commissioner of health
2 to advise the agency in the areas of risk-adjusted-rate setting, benefit
3 design including the actuarial equivalence and sufficiency standards to
4 be used, choice counseling and any other aspects of the demonstration
5 identified by the commissioner of health. The panel shall include, but
6 shall not be limited to, representatives from the state's health plans,
7 representatives from provider-sponsored networks, a medicaid consumer
8 representative, and a representative from the state insurance depart-
9 ment.
10 c. The demonstration waiver shall be implemented in no less than three
11 geographic areas of the state to be determined by the commissioner of
12 health.
13 d. The department of health shall comprehensively evaluate the
14 programs created in this subdivision and continue such evaluation for
15 twenty-four months after the pilot programs have enrolled medicaid
16 recipients and provided health care services. The evaluation shall
17 include assessments of the level of consumer education, choice and
18 access to services, coordination of care, quality of care by each eligi-
19 bility category and managed care plan in each pilot site and any cost
20 savings. The evaluation shall describe administrative or legal barriers
21 to the implementation and operation of each pilot program and include
22 recommendations regarding statewide expansion of the managed care pilot
23 programs. The department of health shall submit an evaluation report to
24 the governor, the temporary president of the senate and the speaker of
25 the assembly by December thirty-first, two thousand twelve.
26 e. Upon completion of the evaluation conducted under paragraph d of
27 this subdivision, the commissioner of health may request statewide
28 expansion of the demonstration projects. Statewide expansion into addi-
29 tional areas shall be contingent upon review and approval by the legis-
30 lature.
31 f. This waiver authority is contingent upon federal approval and
32 federal financial participation (FFP) for:
33 (i) those medicaid benefits and eligibility categories participating
34 in the waiver, including the lock-in provisions;
35 (ii) the employer sponsored insurance option with cost sharing;
36 (iii) any enhanced benefit expenditures, including the ability to
37 disburse health savings account funds to former medicaid recipients who
38 accrued funds while on medicaid; and
39 (iv) any other federal approvals or federal financial participation
40 contingencies that the commissioner of health may deem necessary.
41 § 2. This act shall take effect immediately; provided, however, that
42 the department of health shall submit the medicaid reform demonstration
43 waiver pursuant to the provisions of subdivision 6-b of section 366 of
44 the social services law, as added by section one of this act, within six
45 months of the effective date of this act.
