Amd §§365-a & 364-j, Soc Serv L; amd §4403-f, Pub Health L
Directs the commissioner of health to evaluate existing needs assessment tools and develop additional professionally and statistically valid assessment tools to be used to assist in determining the amount, nature and manner of services and care needs of individuals receiving medical assistance and care.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A6706
SPONSOR: Gottfried TITLE OF BILL: An act to amend the social services law and the public
health law, in relation to needs assessment and rate adequacy for medi-
caid
PURPOSE OR GENERAL IDEA OF BILL:
To improve the patient needs assessment; and to better inform actuarial-
ly sound Medicaid rates for long term care services and make sure fund-
ing is provided through rate adjustments for high-need patients, so that
home care workers are paid sufficiently to deliver care that is consist-
ent with the patient's needs.
SUMMARY OF SPECIFIC PROVISIONS:
The bill would provide for add-ons to assessment tools used to determine
services under various Medicaid programs to include accounting for fami-
ly, social or geographic determinants of health, primary or secondary
diagnoses of cognitive impairment or mental illness, and other appropri-
ate conditions or factors.
The bill would establish high-need rate cells or risk adjustments to
address the additional costs of nursing home placement, higher numbers
of hours of home care, and the difficulty of delivering care such as
rural distances between home care clients, or transportation challenges
in urban settings.
The bill would require that managed care plan contracts with service
providers support the recruitment, hiring, training and retention of a
qualified workforce capable of providing quality care, including compli-
ance with all applicable federal and state laws and regulations, includ-
ing, but not limited to, those relating to wages, labor, and actuarial
soundness.
The bill would require that service providers report to the department
they how they apply the amounts paid by the plans for recruitment,
hiring, training and retention of a qualified workforce capable of
providing quality care and consistent with the improved patient needs
assessment.
JUSTIFICATION:
There is extensive documentation of the challenges faced by the home
care workforce. Home care has become the predominant method of deliver-
ing support service to the elderly and other persons in need of ongoing
personal and health care. Without exception, stakeholders including
patients, caregivers, service agencies, and managed care plans testify
to a crisis resulting from inadequate rates of payment and non-transpar-
ent flow-through of money from plans to agencies to workers, resulting
in an inability to hire and retain a sufficient workforce. Consequently,
persons who are in need of care are experiencing shortened hours of
support and waitlists for any services at all -- sometimes resulting in
avoidable institutionalization.
This bill responds to the crisis by improving the needs assessment tool,
adjusting the actuarial calculation to accommodate high needs patients -
including accounting for challenges in service delivery -- and requiring
transparent cost reporting.
PRIOR LEGISLATIVE HISTORY:
New bill.
FISCAL IMPLICATIONS:
None to the state.
EFFECTIVE DATE:
Section one will take effect immediately, section two and three on April
1, 2018, and section 4 will only take effect as a prior-law reversion
upon the expiration of current law.
STATE OF NEW YORK
________________________________________________________________________
6706
2017-2018 Regular Sessions
IN ASSEMBLY
March 15, 2017
___________
Introduced by M. of A. GOTTFRIED, TITUS, LUPARDO, BARRETT, RAIA, WRIGHT,
McDONALD, STECK, SIMON, DICKENS, MAYER, JONES, WALLACE, ABINANTI,
JAFFEE -- read once and referred to the Committee on Health
AN ACT to amend the social services law and the public health law, in
relation to needs assessment and rate adequacy for medicaid
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Section 365-a of the social services law is amended by
2 adding a new subdivision 10 to read as follows:
3 10. For any determination of the amount, nature and manner of provid-
4 ing assistance under this article for which an assessment tool is used,
5 the department, in consultation with the independent actuary, represen-
6 tatives of medical assistance recipients, representatives of the managed
7 care programs, representatives of long term care providers and other
8 interested parties, shall evaluate existing assessment tools and develop
9 additional professionally and statistically valid assessment tools to be
10 used to assist in determining the amount, nature and manner of services
11 and care needs of individuals which shall involve consideration of vari-
12 ables including but not limited to physical and behavioral functioning;
13 activities of daily living and instrumental activities of daily living;
14 family, social or geographic determinants of health; primary or second-
15 ary diagnoses of cognitive impairment or mental illness; and other
16 appropriate conditions or factors.
17 § 2. Paragraphs (c) of subdivision 18 of section 364-j of the social
18 services law, as added by sections 40-c and 55 of part B of chapter 57
19 of the laws of 2015, are amended to read as follows:
20 (c) (i) In setting such reimbursement methodologies, the department
21 shall consider costs borne by the managed care program to ensure actuar-
22 ially sound and adequate rates of payment to ensure quality of care for
23 its enrollees and shall comply with all applicable federal and state
24 laws and regulations, including, but not limited to, those relating to
25 wages, labor, and actuarial soundness.
26 [(c)] (ii) The department [of health] shall require the independent
27 actuary selected pursuant to paragraph (b) of this subdivision to
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD10399-02-7
A. 6706 2
1 provide a complete actuarial memorandum, along with all actuarial
2 assumptions made and all other data, materials and methodologies used in
3 the development of rates, to managed care providers thirty days prior to
4 submission of such rates to the centers for medicare and medicaid
5 services for approval. Managed care providers may request additional
6 review of the actuarial soundness of the rate setting process and/or
7 methodology.
8 (iii) In fulfilling the requirements of this paragraph, the department
9 shall establish separate rate cells or risk adjustments to reflect the
10 costs of care for specific high-need enrollees in managed care provid-
11 ers. The commissioner shall make any necessary amendments to the state
12 plan for medical assistance under section three hundred sixty-three-a of
13 this title, and submit any applications for waivers of the federal
14 social security act, as may be necessary to ensure federal financial
15 participation. As used in this subparagraph and subparagraph (iv) of
16 this paragraph, "managed care provider" shall mean a managed care
17 provider operating on a full capitation basis or a managed long term
18 care plan operating under section forty-four hundred three-f of the
19 public health law; and "long term care entity" shall mean a nursing home
20 under article twenty-eight of the public health law, home care services
21 agency under article thirty-six of the public health law, a fiscal
22 intermediary in the consumer directed personal assistance program, other
23 long term care provider authorized under a home and community based
24 waiver administered by the department or the office for people with
25 developmental disabilities. The high-need rate cells or risk adjust-
26 ments established in accordance with this subparagraph shall be consist-
27 ent with subdivision ten of section three hundred sixty-five-a of this
28 title and include, but shall not be limited to:
29 (A) individuals who are either already residing in a skilled nursing
30 facility or are placed in a skilled nursing facility;
31 (B) individuals enrolled with a managed care provider, who remain in
32 the community and who daily receive live-in twenty-four hour personal
33 care or home health services or twelve hours or more of personal care,
34 home health services or home and community support services;
35 (C) such other individuals who, based on the assessment of their care
36 needs, their diagnosis or other factors, are determined to present espe-
37 cially high needs related to factors that would influence the delivery
38 (including but not limited to home location) or their use of services,
39 as may be identified by the department.
40 (iv) Any contract for services under this title by a managed care
41 provider with a long term care entity shall ensure that resources made
42 available by the payer under such contract will support the recruitment,
43 hiring, training and retention of a qualified workforce capable of
44 providing quality care, including compliance with all applicable federal
45 and state laws and regulations, including, but not limited to, those
46 relating to wages and labor. A managed care provider with a long term
47 care entity shall report its method of compliance with this subdivision
48 to the department as a component of cost reports required under section
49 forty-four hundred three-f of the public health law.
50 (v) A long term care entity that contracts with a managed care provid-
51 er shall annually submit written certification to the department as a
52 component of cost reports required under sections twenty-eight hundred
53 eight and thirty-six hundred twelve of the public health law and section
54 three hundred sixty-seven-q of this title, as applicable, as to how it
55 applied the amounts paid in compliance with this subdivision to support
56 the recruitment, hiring, training and retention of a qualified workforce
A. 6706 3
1 capable of providing quality care and consistent with section three
2 hundred sixty-five-a of this title.
3 § 3. Subparagraph (ii) of paragraph (a) and paragraph (g) of subdivi-
4 sion 7 and subdivision 8 of section 4403-f of the public health law,
5 subparagraph (ii) of paragraph (a) of subdivision 7 as amended by
6 section 43 of part C of chapter 60 of the laws of 2014, paragraph (g) of
7 subdivision 7 as amended by section 41-b of part H of chapter 59 of the
8 laws of 2011, subparagraph (iii) of paragraph (g) of subdivision 7 as
9 amended by section 54 of part A of chapter 56 of the laws of 2013 and
10 subdivision 8 as amended by section 21 of part B of chapter 59 of the
11 laws of 2016, are amended to read as follows:
12 (ii) Notwithstanding any inconsistent provision of the social services
13 law to the contrary, the commissioner shall, pursuant to regulation,
14 determine whether and the extent to which the applicable provisions of
15 the social services law or regulations relating to approvals and author-
16 izations of, and utilization limitations on, health and long term care
17 services reimbursed pursuant to title XIX of the federal social security
18 act, including, but not limited to, fiscal assessment requirements, are
19 inconsistent with the flexibility necessary for the efficient adminis-
20 tration of managed long term care plans and such regulations shall
21 provide that such provisions shall not be applicable to enrollees or
22 managed long term care plans, provided that such determinations are
23 consistent with applicable federal law and regulation, and subject to
24 the provisions of [subdivision] subdivisions eight and ten of section
25 three hundred sixty-five-a and paragraph (c) of subdivision eighteen of
26 section three hundred sixty-four-j of the social services law.
27 (g) (i) Managed long term care plans and demonstrations may enroll
28 eligible persons in the plan or demonstration upon the completion of a
29 comprehensive assessment [that shall include, but not be limited to, an
30 evaluation of the medical, social and environmental needs] of each
31 prospective enrollee in such program consistent with section three
32 hundred sixty-five-a of the social services law. This assessment shall
33 also serve as the basis for the development and provision of an appro-
34 priate plan of care for the enrollee. Upon approval of federal waivers
35 pursuant to paragraph (b) of this subdivision which require medical
36 assistance recipients who require community-based long term care
37 services to enroll in a plan, and upon approval of the commissioner, a
38 plan may enroll an applicant who is currently receiving home and commu-
39 nity-based services and complete the comprehensive assessment within
40 thirty days of enrollment provided that the plan continues to cover
41 transitional care until such time as the assessment is completed.
42 (ii) The assessment shall be completed by a representative of the
43 managed long term care plan or demonstration, in consultation with the
44 prospective enrollee's health care practitioner as necessary. The
45 commissioner shall prescribe the forms on which the assessment shall be
46 made.
47 (iii) The enrollment application shall be submitted by the managed
48 long term care plan or demonstration to the entity designated by the
49 department prior to the commencement of services under the managed long
50 term care plan or demonstration. Enrollments conducted by a plan or
51 demonstration shall be subject to review and audit by the department or
52 a contractor selected pursuant to paragraph (d) of this subdivision.
53 (iv) Continued enrollment in a managed long term care plan or demon-
54 stration paid for by government funds shall be based upon a comprehen-
55 sive assessment [of the medical, social and environmental needs] of the
56 recipient of the services consistent with section three hundred sixty-
A. 6706 4
1 five-a of this social services law. Such assessment shall be performed
2 at least every six months by the managed long term care plan serving the
3 enrollee. The commissioner shall prescribe the forms on which the
4 assessment will be made.
5 8. Payment rates for managed long term care plan enrollees eligible
6 for medical assistance. The commissioner shall establish payment rates
7 for services provided to enrollees eligible under title XIX of the
8 federal social security act. Such payment rates shall be subject to
9 approval by the director of the division of the budget and shall reflect
10 savings to both state and local governments when compared to costs which
11 would be incurred by such program if enrollees were to receive compara-
12 ble health and long term care services on a fee-for-service basis in the
13 geographic region in which such services are proposed to be provided.
14 Payment rates shall be risk-adjusted to take into account the character-
15 istics of enrollees, or proposed enrollees, including, but not limited
16 to: frailty, disability level, health and functional status, age,
17 gender, the nature of services provided to such enrollees, and other
18 factors as determined by the commissioner. The risk adjusted premiums
19 may also be combined with disincentives or requirements designed to
20 mitigate any incentives to obtain higher payment categories. In setting
21 such payment rates, the commissioner shall consider costs borne by the
22 managed care program to ensure actuarially sound and adequate rates of
23 payment to ensure quality of care and shall comply with all applicable
24 laws and regulations, state and federal, including [regulations as to],
25 but not limited to, those relating to wages, labor and actuarial sound-
26 ness [for medicaid managed care].
27 § 4. Subparagraph (i) of paragraph (g) of subdivision 7 of section
28 4403-f of the public health law, as added by section 65-c of part A of
29 chapter 57 of the laws of 2006 and such paragraph as relettered by
30 section 20 of part C of chapter 58 of the laws of 2007, is amended to
31 read as follows:
32 (i) Managed long term care plans and demonstrations may enroll eligi-
33 ble persons in the plan or demonstration upon the completion of a
34 comprehensive assessment [that shall include, but not be limited to, an
35 evaluation of the medical, social and environmental needs] of each
36 prospective enrollee in such program consistent with section three
37 hundred sixty-five-a of the social services law. This assessment shall
38 also serve as the basis for the development and provision of an appro-
39 priate plan of care for the prospective enrollee.
40 § 5. This act shall take effect immediately; provided that sections
41 two and three of this act shall take effect April 1, 2018; and provided,
42 further that:
43 a. the amendments to section 364-j of the social services law made by
44 section two of this act shall not affect the repeal of such section and
45 shall be deemed repealed therewith;
46 b. the amendments to section 4403-f of the public health law made by
47 section three of this act shall not affect the repeal of such section
48 and shall be deemed repealed therewith; and
49 c. the amendments to subparagraph (i) of paragraph (g) of subdivision
50 7 of section 4403-f of the public health law made by section three of
51 this act shall not affect the expiration and reversion of such subpara-
52 graph, pursuant to subdivision (i) of section 111 of part H of chapter
53 59 of the laws of 2011, as amended, when upon such date the provisions
54 of section four of this act shall take effect.
