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A07910 Summary:

BILL NOA07910
 
SAME ASNo Same As
 
SPONSORGottfried
 
COSPNSRSayegh
 
MLTSPNSR
 
Amd §364-j, Soc Serv L
 
Requires notice and additional review for managed care providers of the methodologies and fee schedules and other materials used for determining medicaid reimbursement rates.
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A07910 Actions:

BILL NOA07910
 
05/28/2021referred to health
01/05/2022referred to health
01/25/2022reported referred to ways and means
05/09/2022reported referred to rules
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A07910 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A7910
 
SPONSOR: Gottfried
  TITLE OF BILL: An act to amend the social services law, in relation to determination and approval of reimbursement rates for managed care providers under medicaid   PURPOSE OR GENERAL IDEA OF BILL: To increase transparency and promptness in the annual capitated rate development process for Medicaid managed care plans and allow the plans to preview and request actuarial review of the rates.   SUMMARY OF SPECIFIC PROVISIONS: The bill amends Social Services Law § 364- j(18)(c) and (e), to add more detail to the existing disclosure required of the Department of Health (DOH) to plans before submitting rates to the Center for Medicare and Medicaid Services (CMS) for approval. Additional disclosures would include the actuarial certif- ication letters and correspondence between the state and CMS related to the rates, and other information and methodologies that DOH had consid- ered but did not use in the development of the proposed rates. The plans would then be able to spot errors in the department's assump- tions and request an actuarial-soundness review of the rates at least ten days prior to DOH's submission to CMS. If DOH grants the review, DOH does not submit the rates to CMS until the review is completed. If DOH declines the review, DOH provides a written explanation to the plans giving clear reasons why the request is denied.   JUSTIFICATION: Most of the Medicaid program functions through managed care plans, either the mainstream plans or the long-term care plans. The plans receive a capitated rate, per member per month, that is expected by state and federal law to be actuarially sound - sufficient to cover the full risk of medical care for the patient population served by the plan, and the administrative costs to negotiate all the provider contracts and benefit delivery. Downstream providers complain that they are manipu- lated at the mercy of the plans. Plans complain that they are manipu- lated at the mercy of the Medicaid program. This bill aims for course correction at the most upstream point, the capitated rate itself. The existing rate disclosure requirement is missing key information and DOH has consistently been late informing the plans of their rates. For example, the draft April 2020 rates were initially shared with plans in late October 2020, more than six months after their effective date. As of December, they continued to be revised and were not yet submitted to CMS by the new year. Nonetheless plans continued to assume risk and deliver services, not certain of their reimbursement rates. This bill requires DOH to notify MMC plans of anticipated rates prior to the effective date of the rates so that plans can effectively manage busi- ness operations, member services and provider payments. DOH has been using rates that are at the bottom of the actuarially acceptable rate range. Current law allows plans to request an actuari- al-soundness review of proposed rates but does not require a DOH response. This bill will provide plans with the certainty they need. Either their request will be reviewed before CMS submission, or it will not and if not, they will be told why.   PRIOR LEGISLATIVE HISTORY: New bill   FISCAL IMPLICATIONS: None   EFFECTIVE DATE: Immediately
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A07910 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          7910
 
                               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 social services law, in  relation  to  determination
          and  approval  of reimbursement rates for managed care providers under
          medicaid
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  Paragraph  (c)  of subdivision 18 of section 364-j of the
     2  social services law, as added by section 55 of part B of chapter  57  of
     3  the laws of 2015, is amended to read as follows:
     4    (c)  The  department [of health] shall require the independent actuary
     5  selected pursuant to paragraph (b) of  this  subdivision  to  provide  a
     6  complete actuarial memorandum, along with all actuarial assumptions made
     7  and  all other data, materials and methodologies used in the development
     8  of rates, to managed care providers thirty days prior to  submission  of
     9  such  rates  to  the  centers  for  medicare  and  medicaid services for
    10  approval. The actuarial memorandum  shall  include  (i)  any  additional
    11  materials  submitted  to  the centers for medicare and medicaid services
    12  including  actuarial  certification  letters,  (ii)  any  correspondence
    13  between  the  state  and  the centers for medicare and medicaid services
    14  related to the rates, (iii)  other  data,  materials  and  methodologies
    15  considered  but  not  used  by  the department in the development of the
    16  rates, and (iv) any information required to be disclosed to managed care
    17  providers or the  public  under  federal  rules.  The  department  shall
    18  require  the independent actuary to separately identify and present in a
    19  collective group the required material under  each  applicable  subpara-
    20  graph  (i)  through  (iv)  of this paragraph. Managed care providers may
    21  request that the department and its independent  actuary  conduct  addi-
    22  tional  review  of  the  actuarial soundness of the rate setting process
    23  and/or methodology.  Prior to submission of rates  to  the  centers  for
    24  medicare  and  medicaid  services  for  approval,  the  department shall
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD11482-01-1

        A. 7910                             2
 
     1  respond to any request from managed care providers for additional review
     2  of the actuarial soundness of the rate setting process  or  methodology,
     3  and  in  such  response  the department shall either: (1) agree to addi-
     4  tional  review  and  delay  submission  of the rates for approval to the
     5  centers for medicare and medicaid services until the department's review
     6  is complete and shared with managed care providers, or (2)  decline  the
     7  requested  additional  review,  stating in writing clear reasons why the
     8  request is denied.
     9    § 2. Subdivision 18 of section 364-j of the  social  services  law  is
    10  amended by adding a new paragraph (f) to read as follows:
    11    (f)  The  department shall notify managed care providers of reimburse-
    12  ment rates prior to the effective date of such rates.
    13    § 3. This act shall take effect immediately; provided that the  amend-
    14  ments  to  section 364-j of the social services law made by sections one
    15  and two of this act shall not affect the  repeal  of  such  section  and
    16  shall expire and be deemed repealed therewith.
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