Senate amendment #1 makes the following changes to the 5th edition.
Amends GS 143B-1405 by adding that for one year following the expiration of service on the Board of the Department of Medical Benefits (Board), a board member may not accept employment or enter into a contract with an entity described in (d), which lists individuals who may not serve on the Board.
Amends GS 143B-1410 by adding that neither the Board nor the Department of Medical Benefits may enter into a contract with an entity to provide a health plan if: (1) that entity employs or contract with a current member of the Board; (2) that entity employs or contracts with a former member of the Board whose service ended less than 24 months before entering into the contract; (3) a member of the Board also serves on the governing board of the entity; or (4) a former member of the board, who service ended less than 24 months before entering into the contract, serves on the governing board of the entity.
Summary date: Jul 24 2014 - View Summary
Summary date: Jul 23 2014 - View Summary
Senate committee substitute makes the following changes to the 4th edition.
Amends Section 2 of this act to add to the principal building blocks of the Medicaid reform as directed by Section 1 (Intent and Goals) of this act. Provides that the capitated health plans (a health care system in which the provider is given a set fee per patient regardless of the treatment required) authorized by this act may work in collaboration with the Local Management Entity/Managed Care Organizations (LME/MCOs) created to serve the Medicaid population (in SL 2011-264).
Amends Section 3 of this act regarding the timeline for the milestones for Medicaid reform under this act. Provides that the new legislative oversight committee to oversee the Medicaid and NC Health Choice programs is to be created when this act becomes law (was, no later than August 1, 2014). Declares that the new Department of Medical Benefits (DMB) is to be created no later than September 1, 2014 (was, August 1, 2014). Moves the dates forward for additional milestones on the timeline as follows: (1) requires the DMB to submit its initial report on reform plan details by April 15, 2015 (was, March 1, 2015), and (2) requires final approvals from the Centers for Medicare & Medicaid Services (CMS) for the reform plan by February 1, 2016 (was, January 1, 2016). Makes conforming changes to amend additional occurrences of these changes in milestone dates. Provides that if the detailed plan cannot be reasonably completed by the April 15 deadline, the DMB is to inform the General Assembly by March 15 that the April 15 report will be a progress report and provide an update on the progress made on completing a plan and report on the parts of the plan that have been completed by April 15.
Corrects a statutory citation in Section 9, deleting a reference to GS 143B-1410(a)(8) and replacing it with GS 143B-1410(a)(10) as enacted by Section 10 of this act.
Amends GS 143B-1415 to correct a statutory reference,deleting a reference to GS 143B-1410(a)(8) and replacing it with GS 143B-1410(a)(10) as enacted by Section 10 of this act.
Amends new GS 143B-1405(d) to further clarify which individuals may not serve on the Board of the DMB. Makes technical changes to renumber the subdivision provisions in subsection (d) accordingly. Inserts the words "North Carolina" before each occurrence of the word "Medicaid" in this subsection. Amends subsection (d) of this section to define the term providerto have the same meaning as in GS 108C-2.
Amends new GS 143B-1410(a)(10) to require the Board of the DMB to develop and present information as specified in this subdivision for the Medicaid and NC Health Choice programs to the General Assembly and the Office of State Budget and Management by January 1 of each year, beginning in 2016 (was, present the information to the General Assembly).
Provides that Sections 10 (creating the DMB) and 11 (regarding initial board compensation) become effective September 1, 2014 (was, Sections 10, 11, and 12 become effective August 1, 2014).
Summary date: Jul 17 2014 - View Summary
Senate committee substitute makes the following changes to the 3rd edition.
Amends Section 1, Intent and goals, to include as goals: (1) provide whole-person integrated care, (2) maintain access to care for the state's Medicaid population, and (3) provide accountability for budget and program outcomes (was, require provider accountability for budget and program outcomes).
Rewrites Section 2 of this act, which specifies the principal building blocks of the reform of North Carolina's Medicaid program. Includes as one of the principal building blocks a new Department of Medical Benefits (Department), created in Section 10 of this act, to be managed by a board consisting of experienced business, health care, and health insurance leaders appointed by the Governor and General Assembly. Prescribes that the Department is to focus on the Medicaid and NC Health Choice programs.
Provides that the building blocks are also to include full-risk capitated health plans to manage and coordinate all care for Medicaid recipients and cover all Medicaid health care items and services. (Such plans involve shared financial risk among all participants and place providers in the network not only for their own financial performance but also for the performance of other providers in the network. In a capitated health plan, the medical provider is given a set fee per patient regardless of the treatment required as in an HMO).
Also identifiescompetition between multiple provider-led and non-provider led health plansas a principal building block of transforming the state's Medicaid program. Provides that full risk for provider-led health plans is to be phased in over a two-year period in order to allow the provider-led plans to become established.
Other new building blocks include regional health plans, subject to four specified conditions; risk adjusted capitated rates based on eligibility categories, geographic areas, and clinical risk profiles of recipients; participant choice of plans offering customized benefits packages; mechanisms to provide incentives and encourage personal accountability for participating in the beneficiaries' own health outcomes; and mechanisms to identify Medicaid recipients who may benefit from other state services and programs to maximize opportunities and reduce reliance on Medicaid and refer those individuals to the appropriate other services and programs.
Establishes timelines from August 1, 2014, through July 1, 2018, by which specified milestones for Medicaid reform must happen, including creating the new Department by August 1, 2014, receiving final approvals from Centers for Medicare & Medicaid Services for reform plan by January 1, 2016, and provider-led plans at full risk by July 1, 2018.
Requires that the Department (was,Department of Health and Human ServicesDivision of Medical Assistance) develop,with stakeholder input, a detailed plan for Medicaid reform. Amends the items that must be included in the plan to add 14 items, including: proposed waivers or state plan amendments that may be necessary to implement and secure federal financial participation in reform; mechanisms for measuring the state's progress toward the reform goals; strategies for ensuring fair negotiations among plans, providers, and the Department of Medical Benefits; and a strategy for program integrity. No longer requires the following to be included in the plan: proposed time frames for implementing system transformation on a phased-in basis and the recommended effective date for full implementation and mechanisms for measuring the state's progress toward increased performance on six specified items, including budget predictability, access to service, and quality management systems.
Adds that the report of the detailed reform plan and the semiannual report on progress toward completing the reform must be provided to the Joint Legislative Oversight committee on Medical Benefits.
Replaces references to the Department of Health and Human Services (DHHS), Division of Medical Assistance, with the Department of Medical Benefits, which is created in this act.
Requires the Department of Medical Benefits to work with the Centers for Medicare & Medicaid Services to attempt to preserve existing levels of funding generated from Medicaid-specific funding streams to the extent that the levels of funding may be preserved (was, preserve existing Medicaid-specific funding streams as they currently exist). Requires the work to be facilitated by the Division of Medial Assistance.
Adds a new section requiring the Division of Medical Assistance, during the time of transition of the Medicaid program into its new form, to cooperate with the Department to ensure a smooth transition. Requires the Division to facilitate communications between the Department of Medial Benefits and the Centers for Medicare & Medicaid Services and submit requested state plan amendments. Requires DHHS to cease any activities related to implementing Medicaid reform within the existing divisions, except for activities directly related to assisting the new Department with the reform. Requires the two departments to enter into appropriate memoranda of understanding to define responsibilities.
Requires DHHS, Office of the Secretary, to organize a Medicaid stabilization team to do six specified activities, including maintaining the Medicaid and NC Health Choice programs until the transfer; making recommendations to the Joint Legislative Oversight Committee on Medical Benefits on any additional authorization or funding necessary to successfully complete these requirements; and reporting to the Joint Legislative Oversight Committee on Medical Benefits no later than September 1, 2014, on the plan to communicate to employees, as required in the section.
Adds a new section requiring the Secretary of Health and Human Services to identify and designate essential positions, by September 1, 2014, throughout DHHS without which the Medicaid and NC Health Choice programs cannot operate on a day-to-day basis. Provides specified bonuses to those employees serving in positions designated as essential positions, effective August 1, 2014. Appropriates $600,000 for 2014-15 to the Division of Medial Assistance from the funds appropriated in the Appropriations Act of 2014 for Medicaid reform to fund the state share of the bonuses.
Adds a section requiring the Division of Medical Assistance to ensure that any Medicaid-related or NC Health Choice-related state contract entered into after the effective date of the act contain a clause allowing DHHS or the Division to terminate the contract without cause upon 30 days' notice. Any contract signed by DHHS or the Division after the act becomes effective that does not have such a clause is deemed to include such a clause and is cancellable without cause with 30 days' notice.
Deletes sections that required the Division to begin the restructuring of the Medicaid Program by transitioning into a system for provider lead capitated health plans, and that required specified DHHS divisions to conduct an integrated care pilot and study.
Amends GS 108A-54.1A to allow DHHS to submit amendments to the state plan if the Department requires that DHHS submit an amendment.
Enacts new Article 14, Department of Medical Benefits, in GS Chapter 143B. Establishes the Department of Medical Benefits (Department) to operate the Medicaid and NC Health Choice Programs. Requires that the Department be governed by a Board, which is responsible for ensuring that the programs provide quality medical assistance to eligible recipients at a predictable cost. Require the Medicaid program to be operated through full-risk capitated health plans that include all aspects of care so that the state bears only the risk of enrollment numbers and enrollment mix. Effective August 1, 2014.
Establishes the 7-member Board of The Department of Medical Benefits (Board), with three members appointed by the Governor, two by the General Assembly on recommendation of the President Pro Tempore, and two by the General Assembly on recommendation of the Speaker of the House. The Secretary of Health and Human Services serves as an ex officio non-voting member. Sets out initial appointment term lengths and establishes staggered terms for later appointees; sets terms at four years and allows members to serve up to two consecutive terms. Specifies five categories of individuals who may not serve on the Board, including those who are or have been registered lobbyists for a provider receiving payments from the Medicaid or NC Health Choice program or an employee of such a lobbyist. Provides that Board members serve as fiduciaries for the Medicaid and NC Health Choice programs and are subject to the duties of care, loyalty, and obedience as established under nonprofit corporate law, in addition to duties placed on the Board members as public servants. Provides that Board members are not state employees. Establishes the Board's eleven powers and duties, including employing the Medicaid Director and other staff (including legal staff); setting compensation for the employees and Board of the Department, including performance-based bonuses; and entering into and managing contracts for the administration of the Medicaid and NC Health Choice programs. Provides that until the Board is designated as the single state agency for administering and operating the programs, the Department of Health and Human Services retains its authority as the single state agency, and the Department's powers are limited to the extent that they conflict with the authority of the Department of Health and Human Services as the single state agency. Provides that the General Assembly retains the authority to determine the eligibility requirements for the Medicaid and NC Health Choice programs. Effective August 1, 2014.
Sets out the following six exemptions, limitations, and modifications of state law that apply to the Department: exempting employees of the Department from portions of the State Personnel Act, but allowing after July 1, 2016, the Department to designate employee positions as subject to the Act; allowing the Department to choose to retain legal counsel other than the Attorney General; exempting personnel contracts from review and approval by the Office of State Human Resources; exempting the Department from state contract review and approval requirements if the Department establishes alternative procedures; allowing the Board to move into a closed session for discussions of four specified topics; and exempting documents created for or developed during a closed session of the Board for one of those four reasons, as well as minutes of the session, from public records until the item under discussion has been made public through the publishing of the relevant rate, finding, or budget forecast report or General Assembly report.
Amends GS 126-5 to add that except as to GS 126-13 (Appropriate political activity of State employees defined), 126-14 (Promise or threat to obtain political contribution or support), 126-14.1 (Threat to obtain political contribution or support), 126-14.2 (Political hirings limited), and the provisions of Articles 6 (Equal Employment and Compensation Opportunity; Assisting in Obtaining State Employment), 7 (The Privacy of State Employee Personnel Records), 14 (Protection for Reporting Improper Government Activities), 15 (Communications With Members of the General Assembly), and 16 (Flexible Compensation Plan) of GS Chapter 126, the provisions of the Chapter (State Personnel System) do not apply to employees of the Department, except for employees designated by the Board as subject to the Chapter. Effective August 1, 2014.
Sets the initial compensation of the Board members at $8,000 per month. Allocates and appropriates $280,000 to the Department from the funds appropriated in the Appropriations Act of 2014 for Medicaid reform for 2014-15, to fund the state share of the Board compensation. Effective August 1, 2014.
Enacts new Article 23B, Joint Legislative Oversight Committee on Medical Benefits, in GS Chapter 120. Establishes the 14-member Joint Legislative Oversight Committee on Medical Benefits (Committee), made up of seven members of the Senate and seven members of the House of Representatives with at least two members from each chamber coming from the minority party. Member terms are two years. Requires the Committee to examine budgeting, financing, administrative, and operational issues related to (1) the reform of Medicaid and the transition of the program from the Department of Health and Human Services to the Department; (2) any aspect of the Medicaid and NC Health Choice programs operated by the Division of Health and Human Services; and (3) the Medicaid and NC Health Choice programs, as operated by the Department. Gives the Committee access to any paper or document and allows compelling the attendance of any state official or employee before the Committee or securing evidence under GS 120-19 (State officers, etc., upon request, to furnish data and information to legislative committees or commissions). Effective August 1, 2014.
Amends GS 120-208.1 to remove the duty of the Joint Legislative Oversight Committee on Health and Human Services to examine issues relating to services provided by the Medical Assistance Division within the Department of Health and Human Services. Makes conforming changes. Effective August 1, 2014.
Requires any reports by the Department of Health and Human Services or the Division of Medial Assistance related to Medicaid that are due during the 2014-15 fiscal year to be made to the Joint Legislative Oversight Committee on Medical Benefits. Effective August 1, 2014.
Summary date: Jul 2 2014 - View Summary
House committee substitute makes the following changes to the 2nd edition.
Expands the building blocks of the Medicaid transformation as directed in Section 1 of this act to include allowing the provider-led capitated health plans (a health-care system in which a medical provider is given a set fee per patient regardless of the treatment required) authorized in this act to work in collaboration with the LME/MCOs created in SL 2011-264 (established requirements for the statewide expansion of the 1915(b)(c) Medicaid waiver) to serve the Medicaid population.
Directs the Division of Medical Assistance (DMA) and the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (DMH/DD/SA) of the Department of Health and Human Services (DHHS) to conduct an integrated care study to examine issues related to the development of a demonstration pilot to test the feasibility of a single payment to an entity that would cover a full array of Medicaid services for Medicaid recipients with intellectual and developmental disabilities (I/DD) who are currently enrolled under the 1915(c) North Carolina Innovations Waiver (was, directed DMA to establish a pilot program that provided for a single payment for the full array of services to Medicaid recipients with intellectual and developmental disabilities enrolled under 1915(c)).
Directs the DHHS Divisions to study the benefits of and any challenges to establishing a demonstration pilot. Also directs the Divisions to work collaboratively on the study with the NC Council for Developmental Disabilities and the NC Center for Excellence for Integrated Care, and to consult with local management entities that have been approved to operate as managed care organizations (LME/MCOs), I/DD provider organizations, I/DD advocacy organizations, the North Carolina Hospital Association, the North Carolina Medical society, the North Carolina Providers Council, Benchmarks, and self-advocates currently working with the Divisions. Requires the Divisions to submit the results of this collaborative study to the Joint Legislative Oversight Committee on Health and Human Services prior to the convening of the 2015 General Assembly.
Summary date: Jun 23 2014 - View Summary
House committee substitute makes the following changes to the 1st edition:
Changes the short and long titles.
Sets out intent and goals of the General Assembly to transform the state's Medicaid program from a traditional fee-for-service system into a system that provides budget predictability for the taxpayers of this state while ensuring quality care is provided. Sets out six goals the system should be designed to achieve, including slowing the rate of cost growth and improving health outcomes for the state's Medicaid population.
Sets out four building blocks of the Medicaid transformation, including a delivery system that builds upon the state's primary care medical home model and strong performance measures and metrics to hold providers accountable for quality.
Directs the Department of Health and Human Services (DHHS), Division of Medical Assistance (Division), to lead and begin the statewide restructuring of the state Medicaid program by transitioning the traditional fee-for-service system into a system of provider-led capitated health plans. Requires the new system to meet the above specified goals and integrate the building blocks.
Directs the Division to integrate stakeholder input into the development of a detailed plan for the Medicaid transformation and requires providing for a phased-in implementation of changes to the Medicaid system that must include five items, including proposed time frames for system transformation on a phased-in basis, with recommended effective dates, and proposed legislation that makes the necessary amendments to the General Statutes to enact the recommended changes.
Requires the Division to report the plan to the General Assembly by March 1, 2015. If a detailed plan cannot be reasonably completed by that date then the Division must (1) inform report recipients by February 1, 2015, that the March 1 report will be a progress report only and (2) provide by March 1, 2015, an update on the progress made toward completing the plan, and report which portions of the plan have been completed. The report/update is to be submitted to the House Appropriations Subcommittee on Health and Human Services, the Senate Appropriations Committee on Health and Human Services, and the Fiscal Research Division.
Beginning September 1, 2015, and every six months thereafter, until a final report on September 1, 2020, the DHHS Secretary must report to the Joint Legislative Oversight Committee on Health and Human Services on the State's progress toward completing the Medicaid transformation.
Directs the Division to work with the Centers for Medicare and Medicaid Services (CMS) to maintain existing Medicaid-specific funding streams. If not possible, then the Division must advise the General Assembly of necessary modifications to maintain as much revenue as possible within the context of Medicaid transformation. Specifies process and procedures for when if such funding cannot be maintained.
Directs DHHS to apply to CMS for any necessary waivers or state plan amendments as may be necessary to implement and secure federal financial participation in the transformation, especially Section 1115 waivers.
Provides that the General Assembly is committed to allowing the time and funding necessary to implement the Medicaid transformation as required by this act.
Directs the Division to develop a pilot program for single payment for Medicaid services provided to recipients of services provided under the 1915(c) Medicaid Waiver. Provides that the purpose of the pilot project is to determine if approved and operating LME/MCOs can provide and manage both physical and behavioral health care for recipients with recipients of services under the 1915(c) waiver, subject to three requirements, including that only LME/MCOs that have successfully managed the 1915(b)/(c) Medicaid waiver for at least five years and are meeting contract and SL 2013-85 requirements are eligible to operate the pilot.
Requires the Division to report to the Joint Legislative Oversight Committee on Health and Human Services no later than November 1, 2015, on the initiation of the pilot. Additional status reports are required annually for the following three years, being submitted no later than November 1 of each year.
Summary date: May 21 2014 - View Summary
Includes whereas clauses discussing the NC Medicaid program.
Enacts new GS Chapter 108E, Medicaid Accountable Care Organizations (ACOs), wherein is found the provisions for the establishment of a Medicaid ACO Program to reform the current fee-for-service system in a manner modeled by the federal Medicare Shared Savings Program. Provides that the intent of the General Assembly is that all Medicaid beneficiaries will receive services through a Medicaid ACO.
Sets out terms and definitions for use in this Chapter, including ACO and Local Management Entity Managed Care Organization.
Gives the Secretary of DHHS (Secretary) 16 specific duties regarding the development of the ACO Program, including overseeing the development and implementation of the Medicaid ACO Program and adopting rules for public reporting by the Medicaid ACO of quality measures and organizational information.
Requires DHHS to develop a process to certify applicants for participation in the Medicaid ACO Program and to ensure approved applicants meet the specified minimum requirements. Sets out information and capabilities required in order to be certified as an ACO, including a requirement that the applicant commit to becoming accountable for the quality, cost, and overall care of the beneficiaries assigned to it.
Sets out organizational and governance requirements for ACOs, including that they are recognized and authorized to conduct business in North Carolina. Sets out five ways or combinations in which a Medicaid ACO can be sponsored and constituted, including networks of individually licensed health care providers or joint venture arrangements of hospitals and health care providers. Sets out further governance requirements, such as requiring that the ACOs must be managed by a designated exedcutive and have a management structure that includes administrative and clinical controls. Requires governance by a body with authority to execute statutory functions of the ACO. Board must be comprised of a majority of health care providers or hospital representatives, with at least one individual representing the community without a conflict of interest with the ACO.
Sets out compliance and cooperation requirements as well as prohibited acts. Requires tax identification and national provider numbers to be submitted to DHHS. Requires ACOs to have a compliance plan that must include five things, including a lead compliance officer, mechanisms for identifying compliance issues, as well as compliance training. Prohibits ACOs from offering gifts, cash, or other remuneration to beneficiaries for choosing a particular provider. Also prohibits certain activites that would prevent an assigned beneficiary from receiving entitled benefits.
Provides limitations for primary care physicians (PCPs), including that PCPs can only be affiliated with one ACO at a time, while all other providers and facilities can be associated with one or more ACOs. Requires ACOs to have enough PCPs to serve a sizeable and diverse Medicaid population and have, at all times, the capacity to serve at least 5,000 Medicaid beneficiaries.
Sets out process by which eligibile beneficiaries are assigned to ACOs, providing that assignment of beneficiaries is based on the beneficiary's selection of a PCP. Sets out other assignment procedures, as well as assignment of beneficiaries receiving limited Medicaid benefits.
Requires DHHS to develop a formal methodology for determining a Medicaid ACO payment model. Requires stakeholder input and validation by an independent actuary in the creation of the methodology. Sets out three detailed features that, to the extent actuarially sound, must be incorporated in the payment model, including (1) a set of Medicaid-covered/NC Health Choice covered services to be included in the pool of funds for which ACOs will share savings and losses, (2) a process to determine and establish spending benchmarks for ACOs, and (3) a process to compute savings and losses and the share of savings owed to the ACO by the state or the share of loss owed to the state. Includes further details on the above three features of the payment system. Also requires DHHS to devise and implement a savings and loss arrangement for outpatient prescription drugs where ACOs and LME/MCOs jointly participate in the cost outcomes for beneficiaries. Sets out further requirements for this arrangement. Requires ACOs to be responsible for receiving and distributing shared savings and shared losses, and submitting repayment to DHHS. Exempts certified ACOs from Department of Insurance Licensure.
Sets out requirements to use stakeholder input to develop specified medical quality measurement protocols and benchmarks. Requires ACOs and DHHS to share specified clinical data for quality measurements such as health needs assessments, care coordination, treatment, health care operations, and performance evaluation. Provides that the above data and information disclosures will and must comply with HIPAA.
Authorizes DHHS, subject to approval by the Centers for Medicare & Medicaid Services, to develop different types of pilot projects, such as a model where an ACO assumes greater risk for health costs and quality than specified in this Chapter. Requires DHHS to regularly report to the Joint Legislative Oversight Committee.
Provides an immunity clause for state action in undertaking the Medicaid ACO program, specifically from state and federal antitrust laws. Provides limits on state immunity.
Sets out plan for applying for state plan amendments and waivers in order to implement GS Chapter 108E.
Amends GS 150B-1(d), to provide that Article 2A of GS Chapter 50B, Administrative Procedure Act rulemaking requirements, do not apply to DHHS with respect to GS Chapter 108E.
Amends GS 143C-9-1(a), to provide that the state's share of savings from the Medicaid ACO Program will go into the Medicaid Special Fund. Makes conforming changes.
Requires DHHS to annually evaluate the Medicaid ACO Program to assess cost savings realized through implementation. Results are to be reported to the Joint Legislative Oversight Committee on Health and Human Services.
Provides limitation clauses for the act, providing nothing in the act can or will be construed to limit choice or access for any type of health care services or preclude qualified providers from participating in other ACOs.
Appropriates $1 million from the General Fund to DHHS for necessary changes to NCTracks, benchmark setting and actuarial validation, and costs incurred to otherwise implement this act. Effective July 1, 2014.
Directs DHHS to report to the Joint Legislative Oversight Committee on Health and Human Services by February 16, 2015, on the findings and recommendations of the Department's strategic planning for long-term services and supports for Medicaid beneficiaries.