senate Bill S5272

Provides for the external utilization review of services provided pursuant to the fully integrated dual advantage program

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Co-Sponsors

Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
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actions

  • 15 / May / 2013
    • REFERRED TO HEALTH
  • 04 / Jun / 2013
    • 1ST REPORT CAL.1127
  • 05 / Jun / 2013
    • 2ND REPORT CAL.
  • 10 / Jun / 2013
    • ADVANCED TO THIRD READING
  • 21 / Jun / 2013
    • COMMITTED TO RULES
  • 08 / Jan / 2014
    • REFERRED TO HEALTH

Summary

Provides for the external utilization review of services provided pursuant to the fully integrated dual advantage program.

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Bill Details

Versions:
S5272
Legislative Cycle:
2013-2014
Current Committee:
Senate Health
Law Section:
Public Health Law
Laws Affected:
Amd §4910, Pub Health L; amd §4910, Ins L

Votes

15
0
15
Aye
0
Nay
2
aye with reservations
0
absent
0
excused
0
abstained
show Health committee vote details

Sponsor Memo

BILL NUMBER:S5272

TITLE OF BILL: An act to amend the public health law and the
insurance law, in relation to the right to external review of services
provided pursuant to the fully integrated dual advantage program

PURPOSE:

To extend access to the New York external appeals process for
consumers and providers participating in the Department of Health's
proposed managed care demonstration to integrate care for individuals
dually eligible for Medicare and Medicaid.

SUMMARY OF PROVISIONS:

Section 1 of the bill adds a new subdivision 5 to section 4910 of
public health law to make the provisions of that section applicable to
adverse determinations made with respect to services provided to
individuals enrolled in the fully integrated dual advantage (FIDA)
program, subject to federal approval.

Section 2 adds a new subsection (e) to section 4910 of insurance law
to make the provisions of that section applicable to adverse
determinations made with respect to services provided to individuals
enrolled in the fully integrated dual advantage (FIDA) program,
subject to federal approval.

Section 3 provides an immediate effective date.

JUSTIFICATION:

The New York State Department of Health (DOH) is in discussions with
the Centers for Medicare & Medicaid Services (CMS) to enter into a 3
year demonstration program beginning in 2014 to integrate care and
services for individuals dually eligible for Medicare and Medicaid
through managed care plan known as the FIDA program. The purpose of
the demonstration is to reduce the fragmentation and inefficiency in
the delivery of health care services to dual eligibles that results
from having two sources of coverage. One of the important issues to be
resolved in development of the demonstration is determining a
simplified and unified set of consumer and provider appeal rights to
be applicable to the demonstration.

Enrollees and providers have access to the New York State external
appeal process under the Medicaid managed care program. They do not
have access to this process under the Medicare Advantage program as
Federal law preempts State law in this area. Individuals who are
dually eligible for Medicare and Medicaid must use the federal
external appeals process for Medicare benefits and the State external
appeal process for Medicaid benefits. Multiple appeals processes can
be confusing and burdensome for consumers, providers and insurers. A
goal of the demonstration is to simplify rules for consumers,
providers and insurers by developing a single process for dual
eligibles. In addition, there is no independent right to external
appeal for providers under Medicare Advantage and a provider
contracted with a Medicare Advantage plan has no appeal right outside
the plan. The FIDA demonstration provides an opportunity to integrate


New York State and Federal external appeal rules to simplify
administration and assure that providers and consumers have equal
protections. However, current State law would not permit access to the
state external appeals benefit for adverse determinations regarding
Medicare benefits. This bill removes that obstacle an d will give DOH
and CMS the flexibility to develop a process that best meets the needs
of consumer, provider and insurers.

LEGISLATIVE HISTORY:

New bill.

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

This Act shall take effect immediately and be implemented subject to
CMS approval.

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

                                  5272

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                              May 15, 2013
                               ___________

Introduced  by  Sen.  HANNON -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health

AN ACT to amend the public health law and the insurance law, in relation
  to the right to external review of services provided pursuant  to  the
  fully integrated dual advantage program

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Section 4910 of the public health law is amended by  adding
a new subdivision 5 to read as follows:
  5.  SUBJECT  TO  APPROVAL  BY  THE  CENTERS  FOR MEDICARE AND MEDICAID
SERVICES, THE PROVISIONS OF THIS TITLE ARE APPLICABLE TO ADVERSE  DETER-
MINATIONS MADE WITH RESPECT TO HEALTH CARE SERVICES PROVIDED TO INDIVID-
UALS  ENROLLED  IN  THE  FULLY  INTEGRATED DUAL ADVANTAGE (FIDA) PROGRAM
ESTABLISHED  PURSUANT  TO  SUBDIVISION  TWENTY-SEVEN  OF  SECTION  THREE
HUNDRED  SIXTY-FOUR-J  OF  THE  SOCIAL SERVICES LAW, AS ADDED BY SECTION
SEVENTY-TWO OF PART A OF CHAPTER FIFTY-SIX OF THE LAWS OF  TWO  THOUSAND
THIRTEEN.
  S  2.  Section  4910  of  the insurance law is amended by adding a new
subsection (e) to read as follows:
  (E) SUBJECT TO APPROVAL BY  THE  CENTERS  FOR  MEDICARE  AND  MEDICAID
SERVICES,  THE PROVISIONS OF THIS TITLE ARE APPLICABLE TO ADVERSE DETER-
MINATIONS MADE WITH RESPECT TO HEALTH CARE SERVICES PROVIDED TO INDIVID-
UALS ENROLLED IN THE FULLY  INTEGRATED  DUAL  ADVANTAGE  (FIDA)  PROGRAM
ESTABLISHED  PURSUANT  TO  SUBDIVISION  TWENTY-SEVEN  OF  SECTION  THREE
HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW,  AS  ADDED  BY  SECTION
SEVENTY-TWO  OF  PART A OF CHAPTER FIFTY-SIX OF THE LAWS OF TWO THOUSAND
THIRTEEN.
  S 3. This act shall take effect immediately.


 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10991-01-3

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