senate Bill S3196A

2011-2012 Legislative Session

Authorizing the commissioner of health to apply for a medicaid reform demonstration waiver

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Archive: Last Bill Status - In Committee


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

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jan 17, 2012 print number 3196a
amend and recommit to health
Jan 04, 2012 referred to health
Feb 11, 2011 referred to health

Bill Amendments

Original
A (Active)
Original
A (Active)

Co-Sponsors

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S3196 - Bill Details

See Assembly Version of this Bill:
A2280A
Current Committee:
Law Section:
Social Services Law
Laws Affected:
Amd §366, Soc Serv L
Versions Introduced in 2009-2010 Legislative Session:
S2639, A6676

S3196 - Bill Texts

view summary

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, 2015.

view sponsor memo
BILL NUMBER:S3196

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:


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.

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

                                  3196

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                            February 11, 2011
                               ___________

Introduced  by  Sens. RANZENHOFER, DeFRANCISCO, GOLDEN, LARKIN, MAZIARZ,
  O'MARA, SALAND -- 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 IDENTIFY
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.
                                                           LBD02332-01-1

S. 3196                             2

MANAGEMENT  OF  THE ENROLLEES 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. PARTIC-
IPATION SHALL BE MANDATORY IN DEMONSTRATION AREAS FOR ALL MEDICAID POPU-
LATIONS NOT SPECIFICALLY EXCLUDED BY THE COMMISSIONER OF  HEALTH.  THOSE
NOT  REQUIRED TO PARTICIPATE SHALL BE PROVIDED THE OPTION TO VOLUNTARILY
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; AND

S. 3196                             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  INSURANCE  DEPART-
MENT.
  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 FOURTEEN.
  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.

Co-Sponsors

view additional co-sponsors

S3196A (ACTIVE) - Bill Details

See Assembly Version of this Bill:
A2280A
Current Committee:
Law Section:
Social Services Law
Laws Affected:
Amd §366, Soc Serv L
Versions Introduced in 2009-2010 Legislative Session:
S2639, A6676

S3196A (ACTIVE) - Bill Texts

view summary

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, 2015.

view sponsor memo
BILL NUMBER:S3196A

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:
2011 - S.3196 -- 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.

view full text
download pdf
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                 3196--A

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                            February 11, 2011
                               ___________

Introduced  by  Sens. RANZENHOFER, DeFRANCISCO, GOLDEN, LARKIN, MAZIARZ,
  O'MARA, SALAND -- read twice and ordered printed, and when printed  to
  be  committed to the Committee on Health -- recommitted to the Commit-
  tee on Health in accordance with Senate Rule 6, sec.  8  --  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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02332-02-2

S. 3196--A                          2

ASSUME THE CATASTROPHIC RISK FOR  TARGET  POPULATIONS  THEY  SERVE.  THE
CATASTROPHIC  COMPONENT  SHALL  ENCOURAGE  PROVIDER NETWORKS TO IDENTIFY
RECIPIENTS WITH UNDIAGNOSED CHRONIC ILLNESS AND  ENSURE  PROPER  DISEASE
MANAGEMENT  OF  THE ENROLLEES 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;

S. 3196--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 INSURANCE DEPART-
MENT.
  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 FIFTEEN.
  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.

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