Relates to pre-natal programs and services; repealer

Summary of provisions

Section 1 of the bill repeals PHL §§ 2520, 2521, 2523, 2524, 2525, 2526, 2527, 2528 and 2529.

Section 2 of the bill amends PHL § 2522 to remove provisions related to PCAP and expand the list of entities that can receive grants from the Commissioner for education and outreach and referral of pregnant women for prenatal care. This section also expands the purposes for which funding can be used so that also includes home visiting and improvement of regional perinatal health care systems.

Section 3 of the bill adds a new SSL § 366(4)(o)(4) to define the term "prenatal care services" with respect to Medicaid coverage provided to eligible and presumptively eligible-pregnant women.

Section 4 of the bill amends SSL § 365-a(6) to replace a reference to PCAP with references to SSL §§ 366(4)(o)(1) and 364-i(6).

Section 5 of the bill adds new SSL § 365-k authorizing the Commissioner to establish standards and guidelines for the provision of prenatal services under the Medicaid program. In establishing such standards and guidelines, the Commissioner must consider generally accepted standards of professional practice including the standards issued by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, and must consult with prenatal care providers. Section 5 also defines "prenatal care provider."

Section 6 of the bill adds SSL § 364-i(6) to provide that a pregnant woman would be presumed eligible for prenatal care services if her fami- ly's income is: (1) no more than 230 percent of the federal poverty level, measured on a gross basis if CMS approves, or (2) if CMS does not approve, no more than 200 percent of the federal poverty level on a net basis.

Presumptive eligibility would be effective beginning on the date that an approved prenatal care provider finds, based on preliminary information, that the pregnant individual meets the income test, and would continue either until a finding of eligibility is made or, if the woman does not file a Medicaid application, until the last day of the month following the month after the woman was first found to be presumptively eligible.

Section 6 also provides that a presumptively eligible pregnant woman would be eligible for coverage of all care, services and supplies avail- able under the Medicaid program if her gross family income is no higher than 120 percent of the federal poverty level (subject to CMS approval) or if her net family income is no more than 100 percent of the federal poverty level (if CMS does not grant approval). She would be eligible only for prenatal care if her family income is, on a gross basis (subject to CMS approval), greater than 120 percent but no more than 230 percent of the federal poverty level or, on a net basis (if CMS does not approve), greater than 100 percent but no more than 200 percent of the federal poverty level.

Section 6 further provides that the Department of Health (DOH) must give prenatal care providers the forms that a pregnant woman would need to apply for presumptive eligibility, and must give providers information on how to assist applicants in completing the forms. A provider must notify the local social services district within five days of finding that a woman is presumptively eligible. In addition, the provider is required to advise the individual that she must apply for eligibility by the last day of the following month.

Section 6 also provides that facilities licensed under PHL Article 28 which provide prenatal care services (generally hospitals and clinics) are required to make presumptive eligibility determinations, although a facility may apply to the Commissioner for a hardship exemption from the requirement. All other prenatal care providers are required to render prenatal care services to presumptively eligible women and to assist them in submitting appropriate documentation as required by the Commis- sioner.

Sections 7 through 15 of the bill amend PHL §§2803(8)(b), 2807-c(16)(e), 3607(2)(d) and 4403-c(8) and SSL §§ 364-j(3)(b)(ii), 364-j(4)(n), 366-g(l),(3) and (4)(a), 374(4)(a) and (7) and 381 to remove references to PCAP.

Section 16 of the bill provides that the bill would take effect imme- diately.

Existing law

PHL § 2520 establishes PCAP within DOH.

PHL § 2521 sets Forth certain definitions associated with PCAP.

PHL § 2522 describes the comprehensive prenatal care services available under PCAP, sets forth the Commissioner's authority to provide funds to public education organizations for public education, outreach and refer- ral to prenatal care service providers, and authorizes the Commissioner to set standards for such providers.

PHL § 2523 provides that prenatal care services providers are eligible to participate in PCAP if they meet certain criteria and are Medicaid providers.

PHL § 2524 sets forth the criteria to be considered by the Commissioner in considering applications from prenatal service providers and public education providers.

PHL § 2525 concerns insurance subrogation in the PCAP context.

PHL § 2527 requires the Commissioner to report annually on PCAP to the Governor and the Legislature.

PHL § 2528 authorizes the Commissioner to promulgate regulations for the implementation of PCAP.

PHL § 2529 governs the eligibility of pregnant women for PCAP, to be determined by the local social services district.

PHL § 2803(8)(b) authorizes the Commissioner to impose a civil penalty for violations of certain statutory or regulatory requirements pertain- ing to births to women receiving Medicaid or services under PCAP.

PHL § 2807-c(16)(e) requires hospitals that receive certain indigent care funding and provide obstetrical care and services to participate for a prenatal care program approved by DOH if requested by the program.

PHL § 3607(2)(d) requires certified home health agencies that provide certain maternal and child health services to establish provisions for referral to and coordination with prenatal care service providers.

PHL § 4403-c(8) requires comprehensive HIV special needs plans to assist pregnant enrollees in the selection of prenatal care services.

SSL § 364-j(3)(b)(ii) provides that a pregnant Medicaid recipient may defer until after pregnancy participation in a managed care program if she has an established relationship with a comprehensive prenatal prima- ry care provider that is not associated with a managed care provider in the social services district where she lives.

SSL § 364-j(4)(n) provides that a managed care provider must provide or arrange for the provision of comprehensive prenatal care services to all pregnant participants.

SSL § 365-a(6) provides that Medicaid reimbursement is available to providers for services rendered under PCAP if federal financial partic- ipation is available.

SSL § 366(4)(o)(1) provides that a pregnant woman who is not otherwise eligible for Medicaid is eligible for PCAP if her family income does not exceed 200 percent of the official poverty line.

SSL § 366-g provides for procedures designed to ensure that children born to mothers who receive Medicaid or services under PCAP are automat- ically enrolled in Medicaid.

SSL § 374(4)(a) and (7) provide that prenatal care providers may not serve as agencies that place children in foster homes or for adoption, and notice of violations of this provision will be given the appropriate licensing authorities.

SSL § 381 provides that certain prenatal care providers must keep appro- priate records of pregnant women and any children born to them.

Chapter 58 of the Laws of 2008, Part C, §18 establishes the new Ambula- tory Patient Group (APG) payment methodology for outpatient services offered by hospitals, clinics and ambulatory surgery services, to be phased in over several years beginning December 1, 2008.

Chapter 58 of the Laws of 2008, Part C, §33-b provides that DOH will review prenatal care standards under Medicaid, in consultation with experts and providers. A summary of actions taken and recommendations for statutory changes must be made available to the Legislature on an ongoing basis.

Lefislative history

This is a new proposal.

Statement in support

In 1987, PHL Article 25 was enacted to establish the prenatal care and nutrition program. In 1990, that program was transitioned from a wholly State-funded grant program to PCAP, a Medicaid reimbursement program for women with incomes at or below 185 percent of the federal poverty level. Currently, pregnant women with incomes up to 200 percent of the federal poverty level are eligible for Medicaid until at least 60 to 90 days postpartum.

Several significant changes have occurred that require elimination of PCAP and updating of the statutes pertaining to Medicaid eligibility of pregnant women for prenatal care services. In response to those changes, this bill will accomplish a transition from PCAP to a model designed to ensure that all low-income pregnant women, even those whose income is too high to qualify them for Medicaid, can access comprehensive prenatal care.

First, under PCAP. providers were certified to provide comprehensive services and in exchange received enhanced Medicaid reimbursement rates. Statutory changes made by the 2008-09 Enacted Budget (Chapter 58 of the Laws of 2008, Part C, § 18) established the new Ambulatory Patient Group (APG) payment methodology for outpatient services offered by - hospi- tals, clinics and ambulatory surgery services, which is being phased in over several years beginning December 1, 2008. As a result, enhanced global rates that supported a comprehensive services model will no long- er be available to PCAP providers. Instead, Medicaid reimbursement will be provided for services rendered and will not be based on any special designations, and there will no longer be any need to designate any PCAP providers. PCAP providers, like other providers of ambulatory care services, began the transition to the APG reimbursement methodology in December 2008.

Second, while much has been accomplished to improve access to high qual- ity prenatal services, more must be done to address access disparities, low birth weights, emerging problems of late preterm births, and the effect of obesity and diabetes on prenatal care. As required by the 2008-09 Enacted Budget (Chapter 58 of the Laws of 2008, Part C, §33-b), DOH has reviewed PCAP and prenatal standards for the Medicaid program and has determined, in conjunction with stakeholders, that changes are required to the standards of care applicable to prenatal care services provided under Medicaid. This bill requires DOH to update the standards and clarifies that all Medicaid providers - not just PCAP providers - must adhere to such updated standards.

Finally, the bill updates the income levels used to determine presump- tive eligibility of pregnant women for Medicaid services. With the approval of CMS, such eligibility will be measured by reference to gross family income rather than net family income. This is consistent with DOH's efforts to streamline access to and for Medicaid, Child Health Plus and Family Health Plus by using the same income standard for each program.

Budget implications

This bill will have no fiscal impact to State.

Effective date

This bill takes effect immediately.