S T A T E O F N E W Y O R K
________________________________________________________________________
8072
I N S E N A T E
June 10, 2016
___________
Introduced by Sen. HANNON -- read twice and ordered printed, and when
printed to be committed to the Committee on Rules
AN ACT to amend the public health law and the social services law, in
relation to actuarially sound and adequate rates of payment for
managed care plans and service providers
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Subdivision 8 of section 4403-f of the public health law,
as amended by section 21 of part B of chapter 59 of the laws of 2016, is
amended to read as follows:
8. Payment rates for managed long term care plan enrollees eligible
for medical assistance. The commissioner shall establish payment rates
for services provided to enrollees eligible under title XIX of the
federal social security act. Such payment rates shall be subject to
approval by the director of the division of the budget and shall reflect
savings to both state and local governments when compared to costs which
would be incurred by such program if enrollees were to receive compara-
ble health and long term care services on a fee-for-service basis in the
geographic region in which such services are proposed to be provided.
Payment rates shall be risk-adjusted to take into account the character-
istics of enrollees, or proposed enrollees, including, but not limited
to: frailty, disability level, health and functional status, age,
gender, the nature of services provided to such enrollees, and other
factors as determined by the commissioner. The risk adjusted premiums
may also be combined with disincentives or requirements designed to
mitigate any incentives to obtain higher payment categories. In setting
such payment rates, the commissioner shall consider costs borne by the
managed care program to ensure actuarially sound and adequate rates of
payment to MANAGED CARE PLANS, INCLUDING THE COSTS FOR REIMBURSING THEIR
CONTRACTED PROVIDERS, TO ensure quality of care shall comply with all
applicable laws and regulations, state and federal, including, BUT NOT
LIMITED TO: regulations as to actuarial soundness for medicaid managed
care; THE PROVISIONS OF SECTION THIRTY-SIX HUNDRED FOURTEEN-C OF THIS
CHAPTER; PROVISIONS OF SUBDIVISION ONE OF SECTION SIX HUNDRED FIFTY-TWO
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD15742-03-6
S. 8072 2
OF THE LABOR LAW; PROVISIONS OF SECTION TEN OF THE WORKERS' COMPENSATION
LAW; PROVISIONS OF THE FEDERAL FAIR LABOR STANDARDS ACT FOR EMPLOYEE
OVERTIME AND OTHER MANDATORY BENEFITS; AND OTHER EXPENSES MANDATED UPON
PLANS OR PROVIDERS FOR EMPLOYEES UNDER THIS CHAPTER OR ANY OTHER
PROVISION OF LAW, PLUS AN ADMINISTRATIVE AND GENERAL COST FACTOR THAT IS
NO LESS THAN ALLOWED PURSUANT TO SUBDIVISION SIX OF SECTION THREE THOU-
SAND SIX HUNDRED TWELVE OF THIS ARTICLE OR PURSUANT TO SUBDIVISIONS
SEVEN OR SEVEN-A OF SECTION THREE THOUSAND SIX HUNDRED FOURTEEN OF THIS
ARTICLE, AS APPLICABLE. THE AMOUNT OF REIMBURSEMENT REQUIRED TO MEET THE
COSTS OF THE AFOREMENTIONED LABOR, ADMINISTRATIVE AND OTHER MANDATED
EXPENSES SHALL BE SPECIFICALLY IDENTIFIED AS PART OF THE RATES OF
PAYMENT TO MANAGED CARE PLANS AND TO CONTRACTED PROVIDERS; PROVIDED,
HOWEVER, NO REIMBURSEMENT CHANGES PURSUANT TO THIS PARAGRAPH SHALL
PROVIDE A DIMINUTION OF THE CURRENT RATE OF PAYMENT TO LICENSED HOME
CARE AGENCIES.
THE COMMISSIONER SHALL ALSO TAKE NECESSARY STEPS TO ENSURE THAT A
UNIFORM PROCESS IS ESTABLISHED FOR THE PAYMENT OF SUCH MANDATED COSTS OR
BENEFITS TO PROVIDERS.
IN SETTING ACTUARIALLY SOUND AND ADEQUATE PAYMENT RATES, THE COMMIS-
SIONER SHALL CONSIDER THE ANALYSIS AND RECOMMENDATIONS OF AN INDEPENDENT
ACTUARY, WHICH SHALL ALSO PROVIDE ITS ANALYSIS DIRECTLY TO THE CHAIRS OF
THE SENATE AND ASSEMBLY COMMITTEES ON HEALTH, THE CHAIR OF THE SENATE
FINANCE COMMITTEE AND THE CHAIR OF THE ASSEMBLY COMMITTEE ON WAYS AND
MEANS.
S 2. Paragraph (a) of subdivision 13 of section 3614 of the public
health law, as amended by section 22 of part D of chapter 57 of the laws
of 2015, is amended to read as follows:
(a) Notwithstanding any inconsistent provision of law or regulation
and subject to the availability of federal financial participation,
effective April first, two thousand twelve through March thirty-first,
two thousand nineteen, payments by government agencies for services
provided by certified home health agencies, except for such services
provided to children under eighteen years of age and other discreet
groups as may be determined by the commissioner pursuant to regulations,
shall be based on episodic payments. In establishing such payments, a
statewide base price shall be established for each sixty day episode of
care and adjusted by a regional wage index factor and an individual
patient case mix index. Such episodic payments may be further adjusted
for low utilization cases and to reflect a percentage limitation of the
cost for high-utilization cases that exceed outlier thresholds of such
payments. EPISODIC PAYMENTS SHALL BE FURTHER ADJUSTED TO ENSURE ADEQUACY
FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND REGULATIONS, STATE AND
FEDERAL, INCLUDING: THE PROVISIONS OF SECTION THIRTY-SIX HUNDRED FOUR-
TEEN-C OF THIS CHAPTER; PROVISIONS OF SUBDIVISION ONE OF SECTION SIX
HUNDRED FIFTY-TWO OF THE LABOR LAW; PROVISIONS OF THE FEDERAL FAIR LABOR
STANDARDS ACT FOR EMPLOYEE OVERTIME AND OTHER MANDATORY BENEFITS; AND
OTHER EXPENSES MANDATED UPON PLANS OR PROVIDERS FOR EMPLOYEES UNDER THIS
CHAPTER OR ANY OTHER PROVISION OF LAW; PLUS AN ADMINISTRATIVE AND GENER-
AL COST FACTOR THAT IS NO LESS THAN ALLOWED PURSUANT TO SUBDIVISION
SEVEN OF THIS SECTION. THE AMOUNT OF REIMBURSEMENT REQUIRED TO MEET THE
COSTS OF THE AFOREMENTIONED LABOR, ADMINISTRATIVE AND OTHER MANDATED
EXPENSES SHALL BE SPECIFICALLY IDENTIFIED AS PART OF THE RATES OF
PAYMENT PROVIDED PURSUANT TO THIS SECTION. THE REIMBURSEMENT TO PROVID-
ERS PURSUANT TO THIS SUBDIVISION SHALL BE IN ADDITION TO THE CURRENT
RATE OF PAYMENT FOR ADMINISTRATIVE AND OTHER MANDATED EXPENSES;
PROVIDED, HOWEVER, NO REIMBURSEMENT CHANGES PURSUANT TO THIS PARAGRAPH
S. 8072 3
SHALL PROVIDE A DIMINUTION OF THE CURRENT RATE OF PAYMENT TO LICENSED
HOME CARE AGENCIES.
S 3. Section 3614 of the public health law is amended by adding a new
subdivision 7-b to read as follows:
7-B. NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, RULE OR REGU-
LATION, THE COMMISSIONER SHALL ADJUST MEDICAL ASSISTANCE RATES OF
PAYMENT FOR SERVICES PROVIDED BY LONG TERM HOME HEALTH CARE PROGRAM
PROVIDERS TO ENSURE ADEQUACY FOR COMPLIANCE WITH ALL APPLICABLE LAWS AND
REGULATIONS, STATE AND FEDERAL, INCLUDING: THE PROVISIONS OF SECTION
THIRTY-SIX HUNDRED FOURTEEN-C OF THIS CHAPTER; PROVISIONS OF SUBDIVISION
ONE OF SECTION SIX HUNDRED FIFTY-TWO OF THE LABOR LAW; PROVISIONS OF
SECTION TEN OF THE WORKERS' COMPENSATION LAW; PROVISIONS OF THE FEDERAL
FAIR LABOR STANDARDS ACT FOR EMPLOYEE OVERTIME AND OTHER MANDATORY BENE-
FITS, AND OTHER EXPENSES MANDATED UPON PLANS OR PROVIDERS FOR EMPLOYEES
UNDER THIS CHAPTER OR ANY OTHER PROVISION OF LAW; PLUS AN ADMINISTRATIVE
AND GENERAL COST FACTOR THAT IS NO LESS THAN ALLOWED PURSUANT TO SUBDI-
VISION SEVEN-A OF THIS SECTION. THE AMOUNT OF REIMBURSEMENT REQUIRED TO
MEET THE COSTS OF THE AFOREMENTIONED LABOR, ADMINISTRATIVE AND OTHER
MANDATED EXPENSES SHALL BE SPECIFICALLY IDENTIFIED AS PART OF THE RATES
OF PAYMENT PROVIDED PURSUANT TO THIS SECTION. THE REIMBURSEMENT TO
PROVIDERS PURSUANT TO THIS SUBDIVISION SHALL NOT PROVIDE A DIMINUTION OF
THE CURRENT RATE OF PAYMENT TO PROVIDERS.
S 4. The public health law is amended by adding a new section 3614-f
to read as follows:
S 3614-F. REIMBURSEMENT OF MANDATORY WAGE AND BENEFIT COMPENSATION
EXPENSES. THE SPECIFICALLY IDENTIFIED FUNDING PROVIDED TO THE CERTIFIED
HOME HEALTH AGENCY PURSUANT TO SUBDIVISION THIRTEEN OF SECTION
THIRTY-SIX HUNDRED FOURTEEN OF THIS ARTICLE, LONG TERM HOME HEALTH
PROGRAM PURSUANT TO SUBDIVISION SEVEN-B OF SECTION THIRTY-SIX HUNDRED
FOURTEEN OF THIS ARTICLE OR MANAGED CARE PLAN PURSUANT TO SUBDIVISION
EIGHT OF SECTION FORTY-FOUR HUNDRED THREE-F OF THIS CHAPTER, FOR THE
SATISFACTION OF THE PROVIDER REIMBURSEMENT REQUIREMENTS OF SECTION THIR-
TY-SIX HUNDRED FOURTEEN-C OF THIS CHAPTER, PROVISIONS OF SUBDIVISION ONE
OF SECTION SIX HUNDRED FIFTY-TWO OF THE LABOR LAW, PROVISIONS OF SECTION
TEN OF THE WORKERS' COMPENSATION LAW, PROVISIONS OF THE FEDERAL FAIR
LABOR STANDARDS ACT FOR EMPLOYEE OVERTIME AND OTHER MANDATORY BENEFITS;
AND OTHER EXPENSES MANDATED UPON PLANS AND PROVIDERS FOR EMPLOYEES UNDER
THIS CHAPTER OR ANY OTHER PROVISION OF LAW, AND AN ADMINISTRATIVE AND
GENERAL COST FACTOR THAT IS NO LESS THAN ALLOWED PURSUANT TO SUBDIVISION
SIX OF SECTION THIRTY-SIX HUNDRED TWELVE OF THIS ARTICLE, SHALL BE USED
BY SUCH ENTITY IN REIMBURSING A LICENSED HOME CARE AGENCY FOR SUCH AGEN-
CY'S COMPLIANCE WITH THE AFOREMENTIONED PAYMENT AND BENEFIT REQUIRE-
MENTS. THE REIMBURSEMENT TO PROVIDERS PURSUANT TO THIS SECTION SHALL NOT
PROVIDE A DIMINUTION OF THE CURRENT RATE OF PAYMENT TO LICENSED HOME
CARE AGENCIES.
S 5. Paragraph (c) of subdivision 18 of section 364-j of the social
services law, as added by section 40-c of part B of chapter 57 of the
laws of 2015, is amended to read as follows:
(c) In setting such reimbursement methodologies, the department shall
consider costs borne by the managed care program to ensure actuarially
sound and adequate rates of payment to ensure quality of care, AND TO
COMPLY WITH ALL APPLICABLE LAWS AND REGULATIONS, STATE AND FEDERAL,
INCLUDING, BUT NOT LIMITED TO REGULATIONS AS TO ACTUARIAL SOUNDNESS FOR
MEDICAID MANAGED CARE; THE PROVISIONS OF SECTION THIRTY-SIX HUNDRED
FOURTEEN-C OF THIS CHAPTER; PROVISIONS OF SUBDIVISION ONE OF SECTION SIX
HUNDRED FIFTY-TWO OF THE LABOR LAW; PROVISIONS OF SECTION TEN OF THE
S. 8072 4
WORKERS' COMPENSATION LAW; PROVISIONS OF THE FEDERAL FAIR LABOR STAND-
ARDS ACT FOR EMPLOYEE OVERTIME AND OTHER MANDATORY BENEFITS; AND OTHER
EXPENSES MANDATED UPON PLANS OR PROVIDERS FOR EMPLOYEES UNDER THIS CHAP-
TER OR ANY OTHER PROVISION OF LAW, PLUS AN ADMINISTRATIVE AND GENERAL
COST FACTOR THAT IS NO LESS THAN ALLOWED PURSUANT TO SUBDIVISION SIX OF
SECTION THIRTY-SIX HUNDRED TWELVE OF THIS ARTICLE OR PURSUANT TO SUBDI-
VISION SEVEN OR SEVEN-A OF SECTION THIRTY-SIX HUNDRED FOURTEEN OF THIS
ARTICLE, AS APPLICABLE. THE AMOUNT OF REIMBURSEMENT REQUIRED TO MEET
THE COSTS OF THE AFOREMENTIONED LABOR, ADMINISTRATIVE AND OTHER MANDATED
EXPENSES SHALL BE SPECIFICALLY IDENTIFIED AS PART OF THE RATES OF
PAYMENT PROVIDED PURSUANT TO THIS SECTION. THE COMMISSIONER SHALL TAKE
NECESSARY STEPS TO ENSURE THAT A UNIFORM PROCESS IS ESTABLISHED FOR THE
PAYMENT FOR SUCH MANDATED COSTS OR BENEFITS TO PROVIDERS. THE REIMBURSE-
MENT TO PROVIDERS PURSUANT TO THIS SUBDIVISION SHALL NOT PROVIDE A DIMI-
NUTION OF THE CURRENT RATE OF PAYMENT TO LICENSED HOME CARE AGENCIES.
S 6. The commissioner of health shall provide for expeditious adjust-
ment and increase of managed care organization premiums to ensure actu-
arial soundness and adequacy of rates for timely compliance with the
amendments to subdivision 8 of section 4403-f of the public health law
made by section one of this act and the amendments to paragraph (c) of
subdivision 18 of section 364-j of the social services law made by
section five of this act.
The commissioner shall provide for such increases in managed care
organization rates, including: (i) developing a uniform process for the
payment of such increases to providers; and (ii) ensuring the expe-
ditious and duly adjusted rates paid to contracted providers to ensure
timely compliance with the amendments made by sections one, four and
five of this act.
Furthermore, the commissioner shall provide for the efficient imple-
mentation of this act, minimizing any new administrative, procedural or
documentation burden on managed care plans or providers.
S 7. This act shall take effect immediately; provided, however, that
the amendments to subdivision 8 of section 4403-f of the public health
law made by section one of this act shall not affect the repeal of such
section and shall be deemed repealed therewith; and provided, further,
that the amendments to paragraph (c) of subdivision 18 of section 364-j
of the social services law made by section five of this act shall not
affect the repeal of such section and shall be deemed repealed there-
with.