S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 5986--A

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                              March 9, 2015
                               ___________

Introduced  by  M. of A. SCHIMMINGER, LAVINE, MAGEE, GIGLIO -- read once
  and referred to the Committee on Health -- recommitted to the  Commit-
  tee  on Health in accordance with Assembly Rule 3, sec. 2 -- committee
  discharged, bill amended, ordered reprinted as amended and recommitted
  to said committee

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:

  Section 1. Section 366 of the social services law is amended by adding
a new subdivision 6-b to read as follows:
  6-B.  A.  THE COMMISSIONER OF HEALTH SHALL APPLY FOR A MEDICAID REFORM
DEMONSTRATION WAIVER PURSUANT TO SECTION ELEVEN HUNDRED FIFTEEN  OF  THE
FEDERAL  SOCIAL SECURITY ACT IN ORDER TO CREATE AN INITIATIVE TO PROVIDE
FOR A MORE EFFICIENT AND EFFECTIVE MEDICAID SERVICES DELIVERY SYSTEM  IN
NEW  YORK  THAT  EMPOWERS  MEDICAID PATIENTS, BRIDGES PUBLIC AND PRIVATE
COVERAGE, IMPROVES PATIENT OUTCOMES AND STABILIZES PROGRAM COSTS.
  B. THE DEMONSTRATION WAIVER SHALL INCLUDE, BUT SHALL  NOT  BE  LIMITED
TO, THE FOLLOWING COMPONENTS:
  (I)  A  RISK ADJUSTED CAPITATED MANAGED CARE PILOT PROGRAM FOR RECIPI-
ENTS CURRENTLY SERVED IN MEDICAID-FEE-FOR SERVICE  OR  MEDICAID  MANAGED
CARE  THAT  PROVIDES  BENEFIT  PLANS  THAT MORE CLOSELY RESEMBLE PRIVATE
PLANS YET ARE ACTUARIALLY EQUIVALENT TO  THE  CURRENT  MEDICAID  BENEFIT
PACKAGE.  RISK  ADJUSTED  CAPITATION RATES SHALL BE SEPARATED INTO THREE
COMPONENTS TO COVER COMPREHENSIVE CARE, CATASTROPHIC CARE  AND  ENHANCED
SERVICES AND MAY PHASE IN FINANCIAL RISK FOR APPROVED PROVIDERS.  HEALTH
PLANS  SHALL  PROVIDE  COMPREHENSIVE CARE WHICH SHALL COVER ALL EXPENSES
UNTIL A PREDETERMINED THRESHOLD OF EXPENSES IS REACHED AT WHICH TIME THE
CATASTROPHIC COMPONENT SHALL TAKE  OVER.  HEALTH  PLANS  MAY  CHOOSE  TO
ASSUME  THE  CATASTROPHIC  RISK  FOR  TARGET POPULATIONS THEY SERVE. THE

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD09434-03-6
              

A. 5986--A                          2

CATASTROPHIC COMPONENT SHALL ENCOURAGE  PROVIDER  NETWORKS  TO  IDENTIFY
RECIPIENTS  WITH  UNDIAGNOSED  CHRONIC ILLNESS AND ENSURE PROPER DISEASE
MANAGEMENT OF THE ENROLLEE'S CONDITION. THE ENHANCED SERVICES  COMPONENT
SHALL  ENCOURAGE  ENROLLEES  TO  ENGAGE IN APPROVED HEALTH ACTIVITIES BY
INCLUDING THE FLEXIBILITY FOR HEALTH SPENDING ACCOUNTS.  PLANS SHALL  BE
ENCOURAGED TO ESTABLISH CUSTOMIZED BENEFIT PACKAGES TARGETED TO SPECIFIC
SPECIAL  NEEDS  POPULATIONS THAT SHALL FOSTER ENROLLEE CHOICE AND ENABLE
ENROLLEES TO ACCESS HEALTH CARE SERVICES THEY  NEED.  THE  PACKAGES  MAY
VARY  THE  AMOUNT,  DURATION  AND  SCOPE  OF  SOME  TRADITIONAL MEDICAID
SERVICES, PROVIDED THE MANDATORY MEDICAID  SERVICES  ARE  INCLUDED,  THE
BENEFITS ARE ACTUARIALLY EQUIVALENT TO THE VALUE OF TRADITIONAL MEDICAID
SERVICES,  AND  THEY  PASS  A  SUFFICIENCY TEST TO ENSURE THE PACKAGE IS
SUFFICIENT TO MEET THE MEDICAL NEEDS OF  THE  TARGET  POPULATION.  THESE
BENEFIT  PACKAGES SHALL BE PRIOR APPROVED BY THE COMMISSIONER OF HEALTH.
PARTICIPATION SHALL BE MANDATORY IN DEMONSTRATION AREAS FOR ALL MEDICAID
POPULATIONS NOT SPECIFICALLY EXCLUDED BY  THE  COMMISSIONER  OF  HEALTH.
THOSE NOT REQUIRED TO PARTICIPATE SHALL BE PROVIDED THE OPTION TO VOLUN-
TARILY PARTICIPATE IN THE DEMONSTRATION WAIVER;
  (II) A CHOICE OF MANAGED CARE PROVIDER WHICH SHALL REST WITH THE INDI-
VIDUAL RECIPIENT, PROVIDED FAILURE TO CHOOSE SHALL RESULT IN AN AUTOMAT-
IC ASSIGNMENT. AFTER A LIMITED OPEN ENROLLMENT PERIOD, RECIPIENTS MAY BE
LOCKED  IN A CAPITATED MANAGED CARE NETWORK FOR TWELVE MONTHS. A RECIPI-
ENT SHALL BE ALLOWED TO SELECT ANOTHER CAPITATED  MANAGED  CARE  NETWORK
AFTER  TWELVE  MONTHS  OF  ENROLLMENT.  HOWEVER, NOTHING SHALL PREVENT A
MEDICAID RECIPIENT FROM CHANGING PRIMARY CARE PROVIDERS WITHIN THE CAPI-
TATED MANAGED CARE NETWORK DURING THE TWELVE MONTH PERIOD;
  (III) AN OPT-OUT PROVISION WHEREBY MEDICAID RECIPIENTS SHALL  BE  ABLE
TO  USE  THEIR MEDICAID PREMIUM TO PURCHASE HEALTH CARE COVERAGE THROUGH
AN EMPLOYER SPONSORED HEALTH INSURANCE PLAN INSTEAD OF THROUGH  A  MEDI-
CAID CERTIFIED PLAN;
  (IV)  AN ENHANCED BENEFIT PACKAGE UNDER WHICH MEDICAID RECIPIENTS WILL
RECEIVE FINANCIAL INCENTIVES AS A REWARD FOR HEALTHIER  BEHAVIOR.  FUNDS
SHALL  BE  DEPOSITED INTO A SPECIAL HEALTH SAVINGS ACCOUNT AND AVAILABLE
TO THE INDIVIDUAL TO OFFSET HEALTH CARE RELATED COSTS SUCH AS  OVER  THE
COUNTER  MEDICINES,  VITAMINS  OR OTHER EXPENSES NOT COVERED UNDER THEIR
PLAN OR TO RETAIN FOR USE IN PURCHASING EMPLOYER PROVIDED INSURANCE;
  (V) A MECHANISM TO REQUIRE CAPITATED MANAGED CARE PLANS  TO  REIMBURSE
QUALIFIED  EMERGENCY SERVICE PROVIDERS, INCLUDING AMBULANCE SERVICES AND
EMERGENCY MEDICAL SERVICES, PROVIDED THE DEMONSTRATION SHALL  INCLUDE  A
PROVISION FOR CONTINUING FEE-FOR-SERVICE PAYMENTS FOR EMERGENCY SERVICES
FOR INDIVIDUALS WHO ARE SUBSEQUENTLY DETERMINED TO BE ELIGIBLE FOR MEDI-
CAID;
  (VI)  A  CHOICE  COUNSELING SYSTEM TO ASSIST RECIPIENTS IN SELECTING A
CAPITATED MANAGED CARE PLAN  THAT  BEST  MEETS  THEIR  NEEDS,  INCLUDING
INFORMATION ON BENEFITS PROVIDED, COST SHARING AND OTHER CONTRACT INFOR-
MATION. THE COMMISSIONER OF HEALTH SHALL PROHIBIT PLANS, THEIR EMPLOYEES
OR  CONTRACTEES  FROM  RECRUITING RECIPIENTS, SEEKING ENROLLMENT THROUGH
INDUCEMENTS, OR PREJUDICING RECIPIENTS AGAINST OTHER CAPITATED PLANS;
  (VII) A SYSTEM TO MONITOR THE PROVISIONS OF HEALTH  CARE  SERVICES  IN
THE  PILOT  PROGRAM, INCLUDING UTILIZATION AND QUALITY OF CARE TO ENSURE
ACCESS TO MEDICALLY NECESSARY SERVICES;
  (VIII) A GRIEVANCE RESOLUTION PROCESS FOR MEDICAID RECIPIENTS ENROLLED
IN THE PILOT PROGRAM INCLUDING AN EXPEDITED REVIEW  IF  THE  LIFE  OF  A
MEDICAID RECIPIENT IS IN IMMINENT AND EMERGENT JEOPARDY;

A. 5986--A                          3

  (IX) A GRIEVANCE RESOLUTION PROCESS FOR HEALTH CARE PROVIDERS EMPLOYED
BY  OR CONTRACTED WITH A CAPITATED MANAGED CARE NETWORK UNDER THE DEMON-
STRATION WAIVER TO SETTLE DISPUTES; AND
  (X)  A TECHNICAL ADVISORY PANEL CONVENED BY THE COMMISSIONER OF HEALTH
TO ADVISE THE AGENCY IN THE AREAS OF RISK-ADJUSTED-RATE SETTING, BENEFIT
DESIGN INCLUDING THE ACTUARIAL EQUIVALENCE AND SUFFICIENCY STANDARDS  TO
BE  USED,  CHOICE  COUNSELING AND ANY OTHER ASPECTS OF THE DEMONSTRATION
IDENTIFIED BY THE COMMISSIONER OF HEALTH. THE PANEL SHALL  INCLUDE,  BUT
SHALL  NOT BE LIMITED TO, REPRESENTATIVES FROM THE STATE'S HEALTH PLANS,
REPRESENTATIVES FROM PROVIDER-SPONSORED NETWORKS,  A  MEDICAID  CONSUMER
REPRESENTATIVE, AND A REPRESENTATIVE FROM THE STATE DEPARTMENT OF FINAN-
CIAL SERVICES.
  C. THE DEMONSTRATION WAIVER SHALL BE IMPLEMENTED IN NO LESS THAN THREE
GEOGRAPHIC  AREAS  OF  THE STATE TO BE DETERMINED BY THE COMMISSIONER OF
HEALTH.
  D.  THE  DEPARTMENT  OF  HEALTH  SHALL  COMPREHENSIVELY  EVALUATE  THE
PROGRAMS  CREATED  IN  THIS SUBDIVISION AND CONTINUE SUCH EVALUATION FOR
TWENTY-FOUR MONTHS AFTER  THE  PILOT  PROGRAMS  HAVE  ENROLLED  MEDICAID
RECIPIENTS  AND  PROVIDED  HEALTH  CARE  SERVICES.  THE EVALUATION SHALL
INCLUDE ASSESSMENTS OF THE  LEVEL  OF  CONSUMER  EDUCATION,  CHOICE  AND
ACCESS TO SERVICES, COORDINATION OF CARE, QUALITY OF CARE BY EACH ELIGI-
BILITY  CATEGORY  AND  MANAGED CARE PLAN IN EACH PILOT SITE AND ANY COST
SAVINGS.  THE EVALUATION SHALL DESCRIBE ADMINISTRATIVE OR LEGAL BARRIERS
TO THE IMPLEMENTATION AND OPERATION OF EACH PILOT  PROGRAM  AND  INCLUDE
RECOMMENDATIONS  REGARDING STATEWIDE EXPANSION OF THE MANAGED CARE PILOT
PROGRAMS. THE DEPARTMENT OF HEALTH SHALL SUBMIT AN EVALUATION REPORT  TO
THE  GOVERNOR,  THE TEMPORARY PRESIDENT OF THE SENATE AND THE SPEAKER OF
THE ASSEMBLY BY DECEMBER THIRTY-FIRST, TWO THOUSAND NINETEEN.
  E. UPON COMPLETION OF THE EVALUATION CONDUCTED UNDER  PARAGRAPH  D  OF
THIS  SUBDIVISION,  THE  COMMISSIONER  OF  HEALTH  MAY REQUEST STATEWIDE
EXPANSION OF THE DEMONSTRATION PROJECTS. STATEWIDE EXPANSION INTO  ADDI-
TIONAL  AREAS SHALL BE CONTINGENT UPON REVIEW AND APPROVAL BY THE LEGIS-
LATURE.
  F. THIS WAIVER AUTHORITY  IS  CONTINGENT  UPON  FEDERAL  APPROVAL  AND
FEDERAL FINANCIAL PARTICIPATION (FFP) FOR:
  (I)  THOSE  MEDICAID BENEFITS AND ELIGIBILITY CATEGORIES PARTICIPATING
IN THE WAIVER, INCLUDING THE LOCK-IN PROVISIONS;
  (II) THE EMPLOYER SPONSORED INSURANCE OPTION WITH COST SHARING;
  (III) ANY ENHANCED BENEFIT  EXPENDITURES,  INCLUDING  THE  ABILITY  TO
DISBURSE  HEALTH SAVINGS ACCOUNT FUNDS TO FORMER MEDICAID RECIPIENTS WHO
ACCRUED FUNDS WHILE ON MEDICAID; AND
  (IV) ANY OTHER FEDERAL APPROVALS OR  FEDERAL  FINANCIAL  PARTICIPATION
CONTINGENCIES THAT THE COMMISSIONER OF HEALTH MAY DEEM NECESSARY.
  S  2.  This act shall take effect immediately; provided, however, that
the department of health shall submit the medicaid reform  demonstration
waiver  pursuant  to the provisions of subdivision 6-b of section 366 of
the social services law, as added by section one of this act, within six
months of the effective date of this act.