Senate Bill S7614

                                 
BILL NUMBER: S7614

SPONSOR: KRUEGER
 
TITLE OF BILL:

An act to amend the public health law and the social services law, in
relation to assuring more equitable access to specialized cancer care;
and providing for the repeal of such provisions upon expiration thereof

 
PURPOSE OR GENERAL IDEA OF BILL:

To ensure that individuals who are enrolled in Medicaid managed care,
the Essential Plan and individual and small group qualified health plans
offered on the New York State of Health Exchange have greater access to
National Cancer Institute (NCI)-designated cancer centers

 
SUMMARY OF PROVISIONS:

Section 1: Provides that the legislation may be cited as the "access to
comprehensive cancer enhanced services strategy (ACCESS) demonstration
project".

              

Section 2: Requires qualified health plans offering coverage through the
New York State of Health ACA Exchange to include in their provider
network any NCI-designated cancer center operating in the plan's service
area that is willing to contract for hospital services at prevailing
rates, which shall be no less than the Medicaid fee-for-service rate.

Section 3: Requires Medicaid managed care plans to include in their
provider network any NCI-designated cancer center operating in the
plan's service area that is willing to contract for hospital services at
prevailing rates, which shall be no less than the Medicaid fee-for-ser-
vice rate.

Section 4: Requires health plans offering coverage through the Basic
Health Program, known as the Essential Plan, to include in their provid-
er network any NCI-designated cancer center operating in the plan's
service area that is willing to contract for hospital services at
prevailing rates, which shall be no less than the FFS payment rate and
methodology applicable to Essential Plan (known in statute as Basic
Health Plan) payments for hospital inpatient and outpatient services.

Section 5: Sets forth the effective date for the legislation as the
first of January next succeeding the date of enactment and shall apply
to all coverage or policies issued or renewed on or after such effective
date, and it provides that the demonstration shall expire and be deemed
repealed five years after such date.

 
JUSTIFICATION:

Housed within the National Institutes of Health, the NCI administers the
NCI cancer centers designation program. This program recognizes cancer
centers that meet rigorous standards for transdisciplinary, state-of-
the-art research focused on developing new and better approaches to
preventing, diagnosing, and treating cancer.  NCI-designated cancer
centers enroll thousands of patients in clinical trials each year, and
they pioneer the discovery and dissemination of new cancer treatments.


The extraordinary resources that NCI-designated cancer centers bring to
bear on clinical care have been demonstrated to result in superior
outcomes for patients. For example, a 2015 analysis of outcomes for
cancer patients in JAMA Oncology demonstrated that risk-adjusted five-
year survival was higher for patients treated at NCI-designated cancer
centers compared to patients treated at other academic medical centers
or at community hospitals (see Pfister et al., 2015, JAMA Oncology).
Similarly, a 2015 study in Cancer concluded that patients first treated
at NCI-designated comprehensive cancer centers had better survival and
outcomes across multiple diagnoses than patients treated at other hospi-
tals (see Wolfson et al., 2015, Cancer).

Unfortunately, NCI-designated cancer centers are often excluded from
health plan networks for those plans offered to individuals and small
groups, including Medicaid managed care plans, qualified health plans,
and Essential plans. Health plans often cite the fear of "adverse
selection," In other words, health plans do not want to attract a
disproportionately high number of high-cost patients with a cancer diag-
nosis by including an NCI-designated cancer center in their plan
network. By requiring all plans to include any such hospitals operating
in their service area and willing to contract at prevailing rates with
all such plans in their networks, the risk of adverse selection is elim-
inated.

Public education and outreach programs on cancer prevention and screen-
ing are an important aspect of the mission of NCI-designated cancer
centers, and NCI-designated cancer centers are committed to ensuring
equitable access to their services, including for historically under-
served communities. At present, the exclusion of these centers from many
health plan networks makes their outreach, screening, and education
programming more difficult, because patients' health plans may not
permit them to receive treatment services from these institutions.

To avoid a fiscal impact to the state, in the absence of any other nego-
tiated agreement, the bill would require NCI-designated cancer centers
to accept the prevailing rate for hospital services, i.e., not lower
than the Medicaid 1-TS rate for Medicaid managed care and qualified
health plans and not less than the FFS rate applicable to the Essential
plan.

The bill does not require that any patient would have to be referred to
an NCI-designated cancer center for treatment. The bill would remove an
impediment to access to these centers of excellence in cancer care,
giving populations enrolled in Medicaid managed care, the Essential
Plan, and other qualified health plans in the individual and small group
market more equitable access to specialty cancer care.

 
PRIOR LEGISLATIVE HISTORY:

None.

 
FISCAL IMPLICATIONS:

Minimal, if any. The bill does not mandate that patients with cancer
would automatically be referred to an NCI-designated cancer center for
care, a determination that would still have to be made by the patient,
his or her treating physician and the health plan. Even if, as antic-
ipated and intended, more patients access services at NCI-designated
cancer centers, the bill requires, in the absence of an otherwise nego-
tiated rate, such hospitals to accept the fee-for-service Medicaid rate
for hospital services provided to those patients enrolled in Medicaid
managed care and qualified health plans and the FFS rate applicable to
the Essential plan for those patients enrolled in the Essential Plan.

 
EFFECTIVE DATE:
The bill would take effect on January 1 following its enactment and
shall expire and be deemed repealed five years after it has taken
effect.