April 8, 2022
It appears that the Department of Health will be required to contract with an outside consultant whose job is to first examine and then make recommendations pertaining to the state’s Medicaid managed care program. The consultant is charged with making recommendations re: the relative strengths/challenges associated with implementing a competitive MCO procurement to identify contractors to manage carved-in Medicaid services. The language focuses closely on whether competitive procurement for MCOs in the behavioral health sector (HARP) would make sense, and what the impact of such a move would be on consumers. The Report must include recommendations regarding the current state oversight of MCO performance metrics, and whether there should be revised/new performance standards for MCOs. Finally, it must discuss current state oversight practices including enforcement of performance requirements and use of fines. The Report must be turned over to the Exec and Legislative leaders by October 2022.
NYS Council Note: This proposal reflects some of the major concerns the NYS Council has been raising for more than 5 years regarding MCO conduct in the Medicaid managed care program. The language seems to have a particular focus on issues in the behavioral health carve in with references to performance metrics (a nod to the Medical Loss Ratios and Behavioral Health Expenditure Targets issues we worked so hard to bring to light), and whether a competitive procurement of the HARP would make sense. The focus on enforcement is a welcomed addition as is the focus on network adequacy. These are issues we have been highlighting for the Administration and DOH for years and years.
Notwithstanding sections 112 and 163 of the state finance 10 law, the department of health shall select an independent contractor to 11 generate a report that reviews and makes recommendations concerning the 12 status of services offered by managed care organizations contracting 13 with the state to manage services provided under the Medicaid program. 14 Such report shall be provided to the governor, the temporary president 15 of the senate and the speaker of the assembly no later than October 31, 16 2022, and shall be for the purpose of informing the development of a 17 plan to reform the delivery of services offered by managed care organ- 18 izations in the Medicaid program. The report shall include the follow- 19 ing: 1. A market assessment of the managed care organizations offering 20 products in each market, including the appropriate number of managed 21 care organizations to each region to address member needs; 2. Analysis 22 of areas of potential improvements or challenges as they relate to 23 healthcare access, delivery, outcomes, administrative costs, efficien- 24 cies and oversight that may result from competitive procurement; 3. Cost 25 savings analysis that may result from a competitive procurement, if 26 any; 4. The current approach for addressing Person Centered care for 27 people with behavioral health needs enrolled with Medicaid managed care 28 plans, including but not limited to special needs managed care organ- 29 izations authorized to offer Health and Recovery Plans (HARPs) and the 30 integration of those benefits with Mainstream Medicaid Managed Care 31 (MMMC); 5. Provider network access that may result from competitively 32 procuring plans in each region and potential improvements in standards 33 governing network adequacy; 6. Managed care enrollee service 34 disruptions that may result from competitively procuring managed care 35 plans in each region; 7. Impacts to providers that contract or are 36 affiliated with Medicaid managed care organizations that may result 37 from a competitive procurement; 8. An evaluation of new performance 38 standards or requirements that could be imposed upon Medicaid managed 39 care organizations that participate in the managed care program pursu- 40 ant to a contract with the department of health; and 9. An assessment 41 of current mechanisms for enforcement of performance requirements, 42 including but not limited to oversight of Medicaid managed care organ- 43 izations and penalties.
44 § 2. Subparagraphs (v) and (vi) of paragraph (b) of subdivision 1 of 45 section 268-d of the public health law, as added by section 2 of part T 46 of chapter 57 of the laws of 2019, are amended to read as follows:
47 (v) meets standards specified and determined by the Marketplace, 48 provided that the standards do not conflict with or prevent the applica- 49 tion of federal requirements; [and]
50 (vi) contracts with any national cancer institute-designated cancer 51 center licensed by the department within the health plan’s service area 52 that is willing to agree to provide cancer-related inpatient, outpatient 53 and medical services to enrollees in all health plans offering coverage 54 through the Marketplace in such cancer center’s service area under the
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1 prevailing terms and conditions that the plan requires of other similar 2 providers to be included in the plan’s provider network, provided that 3 such terms shall include reimbursement of such center at no less than 4 the fee-for-service medicaid payment rate and methodology applicable to 5 the center’s inpatient and outpatient services; and
6 (vii) complies with the insurance law and this chapter requirements 7 applicable to health insurance issued in this state and any regulations 8 promulgated pursuant thereto that do not conflict with or prevent the 9 application of federal requirements; and
10 § 3. Subdivision 4 of section 364-j of the social services law is 11 amended by adding a new paragraph (w) to read as follows:
12 (w) A managed care provider shall provide or arrange, directly or 13 indirectly, including by referral, for access to and coverage of 14 services provided by any national cancer institute-designated cancer 15 center licensed by the department of health within the managed care 16 provider’s service area that is willing to agree to provide cancer-re- 17 lated inpatient, outpatient and medical services to participants in all 18 managed care providers offering coverage to medical assistance recipi- 19 ents in such cancer center’s service area under the prevailing terms and 20 conditions that the managed care provider requires of other similar 21 providers to be included in the managed care provider’s network, 22 provided that such terms shall include reimbursement of such center at 23 no less than the fee-for-service medicaid payment rate and methodology 24 applicable to the center’s inpatient and outpatient services.
25 § 4. Paragraph (c) of subdivision 1 of section 369-gg of the social 26 services law, as amended by section 2 of part H of chapter 57 of the 27 laws of 2021, is amended to read as follows:
28 (c) “Health care services” means (i) the services and supplies as 29 defined by the commissioner in consultation with the superintendent of 30 financial services, and shall be consistent with and subject to the 31 essential health benefits as defined by the commissioner in accordance 32 with the provisions of the patient protection and affordable care act 33 (P.L. 111-148) and consistent with the benefits provided by the refer- 34 ence plan selected by the commissioner for the purposes of defining such 35 benefits, and shall include coverage of and access to the services of 36 any national cancer institute-designated cancer center licensed by the 37 department of health within the service area of the approved organiza- 38 tion that is willing to agree to provide cancer-related inpatient, 39 outpatient and medical services to all enrollees in approved organiza- 40 tions’ plans in such cancer center’s service area under the prevailing 41 terms and conditions that the approved organization requires of other 42 similar providers to be included in the approved organization’s network, 43 provided that such terms shall include reimbursement of such center at 44 no less than the fee-for-service medicaid payment rate and methodology 45 applicable to the center’s inpatient and outpatient services; and (ii) 46 dental and vision services as defined by the commissioner;
47 § 5. Severability. If any clause, sentence, paragraph, section or part 48 of this act shall be adjudged by any court of competent jurisdiction to 49 be invalid and after exhaustion of all further judicial review, the 50 judgment shall not affect, impair or invalidate the remainder thereof, 51 but shall be confined in its operation to the clause, sentence, para- 52 graph, section or part of this act directly involved in the controversy 53 in which the judgment shall have been rendered.
54 § 6. Sections one and five of this act shall take effect immediately 55 and shall be deemed to have been in full force and effect on and after 56 April 1, 2022. Sections two, three, and four of this act shall take
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1 effect on the first of January next succeeding the date on which it 2 shall have become a law and shall apply to all coverage or policies 3 issued or renewed on or after such effective date and shall expire and 4 be deemed repealed five years after such date; provided, however, that 5 the amendments to section 364-j of the social services law made by 6 section three of this act, and the amendments to paragraph (c) of subdi- 7 vision 1 of section 369-gg of the social services law made by section 8 four of this act shall not affect the repeal of such sections or such 9 paragraph and shall be deemed repealed therewith.