S T A T E O F N E W Y O R K
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5986--A
2015-2016 Regular Sessions
I N A S S E M B L Y
March 9, 2015
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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.