Provides for the external utilization review of services provided pursuant to the fully integrated dual advantage program

1 Co-sponsor

• William J. Larkin Jr.

BILL NUMBER:S5272

Title of bill

An act to amend the public health law and the insurance law, in relation to the right to external review of services provided pursuant to the fully integrated dual advantage program

Purpose

To extend access to the New York external appeals process for consumers and providers participating in the Department of Health's proposed managed care demonstration to integrate care for individuals dually eligible for Medicare and Medicaid.

Summary of provisions

Section 1 of the bill adds a new subdivision 5 to section 4910 of public health law to make the provisions of that section applicable to adverse determinations made with respect to services provided to individuals enrolled in the fully integrated dual advantage (FIDA) program, subject to federal approval.

Section 2 adds a new subsection (e) to section 4910 of insurance law to make the provisions of that section applicable to adverse determinations made with respect to services provided to individuals enrolled in the fully integrated dual advantage (FIDA) program, subject to federal approval.

Section 3 provides an immediate effective date.

Justification

The New York State Department of Health (DOH) is in discussions with the Centers for Medicare & Medicaid Services (CMS) to enter into a 3 year demonstration program beginning in 2014 to integrate care and services for individuals dually eligible for Medicare and Medicaid through managed care plan known as the FIDA program. The purpose of the demonstration is to reduce the fragmentation and inefficiency in the delivery of health care services to dual eligibles that results from having two sources of coverage. One of the important issues to be resolved in development of the demonstration is determining a simplified and unified set of consumer and provider appeal rights to be applicable to the demonstration.

Enrollees and providers have access to the New York State external appeal process under the Medicaid managed care program. They do not have access to this process under the Medicare Advantage program as Federal law preempts State law in this area. Individuals who are dually eligible for Medicare and Medicaid must use the federal external appeals process for Medicare benefits and the State external appeal process for Medicaid benefits. Multiple appeals processes can be confusing and burdensome for consumers, providers and insurers. A goal of the demonstration is to simplify rules for consumers, providers and insurers by developing a single process for dual eligibles. In addition, there is no independent right to external appeal for providers under Medicare Advantage and a provider contracted with a Medicare Advantage plan has no appeal right outside the plan. The FIDA demonstration provides an opportunity to integrate

New York State and Federal external appeal rules to simplify administration and assure that providers and consumers have equal protections. However, current State law would not permit access to the state external appeals benefit for adverse determinations regarding Medicare benefits. This bill removes that obstacle an d will give DOH and CMS the flexibility to develop a process that best meets the needs of consumer, provider and insurers.

Legislative history

New bill.

Fiscal implications

None.

Effective date

This Act shall take effect immediately and be implemented subject to CMS approval.