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, 2016.
TITLE OF BILL: An act to amend the social services law, in relation to authorizing the commissioner of health to apply for a medicaid reform demonstration waiver
PURPOSE: This bill amends the Social Services Law directing the Commissioner of the Department of Health to apply for a federal Medicaid Reform Demonstration Waiver to be implemented in no less than three geographic areas of the state. The waiver shall be developed 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.
SUMMARY OF PROVISIONS: Section 1 of the bill amends section 366 of the Social Services Law by adding a new subdivision 6-b directing the department to develop and apply for a federal Medicaid waiver to demonstrate, in no less than three geographic areas, a more efficient, effective and flexible Medicaid delivery system. The demonstration would include, among other things:
A) a risk adjusted capitated managed care program that is separated into three components comprehensive care, catastrophic care, and an enhanced services component that will allow for flexible health spending accounts. Plans would also be encouraged to develop customized benefit packages targeted toward special needs populations. The commissioner may exclude specific Medicaid populations from the demonstration, and all other recipients would be given a choice of provider before being automatically assigned.
B) an opt out provision to allow Medicaid recipients to use their Medicaid premium to purchase health care coverage through an employer sponsored plan.
C) a choice counseling system to assist recipients in choosing a plan.
D) a system to monitor the provisions of health care services in the pilot program.
E) separate grievance resolution processes for Medicaid recipients and for Medicaid providers.
F) an advisory panel to advise the Department of Health on aspects of the demonstration. The department would comprehensively evaluate the demonstration for 24 months after the pilots have enrolled Medicaid recipients. Upon completion the commissioner may request statewide expansion to be approved by the legislature. Section two of the bill provides for an immediate effective date, provided the department is directed to submit a waiver within six months of the effective date.
PRIOR LEGISLATIVE HISTORY: 201112 - S.3196/A.2280-A -- HEALTH/Health 2010 - S.2639/A.6676 - HEALTH/Health 2008 - S.679 - SOCIAL SERV./A.3142 - Health 2007 - S.679 - HEALTH/A.3142-Health 2006 - S.6860 - RULES/A.10177 - Health
JUSTIFICATION: Federal Medicaid waivers provide states with the flexibility they need to pilot new and innovative ways of delivering Medicaid services. New York State has a long history of establishing waiver programs that have improved the lives of those receiving care while at the same time saving taxpayers money. The Medicaid Reform Demonstration Waiver would follow in that tradition. It would create a consumer centered system that provides options for Medicaid recipients based on their particular health care needs. More particularly, it would provide the needed flexibility to use Medicaid funds to pay for employer sponsored health insurance where a recipient so chooses, to establish Health Savings Accounts, and to create plans for special needs populations that may benefit from services not traditionally covered by Medicaid. The demonstration would provide quality care at the most appropriate level and is expected to result in improved access, outcomes and consumer satisfaction while at the same time limiting the growth in Medicaid spending for taxpayers. This bill is closely modeled after a Medicaid waiver proposed in the state of Florida which was approved by the federal government in October 2005. New York State should follow Florida's lead and submit a waiver application to pilot fundamental change in the way New York State delivers Medicaid services. Applying a similar model under the unique characteristics of New York State will provide a broader understanding of the benefits of altering Medicaid delivery nationwide.
FISCAL IMPLICATIONS: Given federal waivers require that the demonstration program be cost neutral, this bill would not have fiscal implications and may produce savings.
EFFECTIVE DATE: This act shall take effect immediately, provided the department is directed to submit a waiver within six months of the effective date.
STATE OF NEW YORK ________________________________________________________________________ 1438 2013-2014 Regular Sessions IN SENATE (PREFILED) January 9, 2013 ___________Introduced by Sens. RANZENHOFER, DeFRANCISCO, GOLDEN, LARKIN, MAZIARZ -- 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: 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 CATASTROPHIC COMPONENT SHALL ENCOURAGE PROVIDER NETWORKS TO IDENTIFYEXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD04846-01-3 S. 1438 2
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; (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; ANDS. 1438 3
(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 SIXTEEN. 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.