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A06706 Summary:

BILL NOA06706
 
SAME ASNo Same As
 
SPONSORGottfried
 
COSPNSRTitus, Lupardo, Barrett, Raia, Wright, McDonald, Steck, Simon, Dickens, Mayer, Jones, Wallace, Abinanti, Jaffee
 
MLTSPNSR
 
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.
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A06706 Actions:

BILL NOA06706
 
03/15/2017referred to health
01/03/2018referred to health
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A06706 Memo:

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.
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A06706 Text:



 
                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.
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