BILL NUMBER: S7800
SPONSOR: RIVERA
 
TITLE OF BILL:
An act to amend the public health law, the social services law, the
elder law and the mental hygiene law, in relation to long term care
options; and to repeal certain provisions of the public health law
relating to managed long term care
 
PURPOSE:
The purpose of this bill is to eliminate the current partially capitated
Medicaid Long Term Care program and replace it with services delivered
through a fee-for-service model while preserving fully capitated models.
 
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 establishes legislative intent, including the desire of the
legislature to eliminate the partially capitated managed long term care
program and transition participants to a fee-forservice model while
preserving fully capitated programs such as Program of All-inclusive
Care of the Elderly (PACE), and Medicaid Advantage Plus (MAP).
Section 2 repeals and replaces section 4403-f of the public health law
which established MLTC plans. The new section directs the Commissioner
of Health (COH) to seek the appropriate federal approvals to provide
Medicaid long term care services utilizing PACE, MAP, or a fee-forser-
vice model with services coordinated by a care coordination entity. The
new section grants the COH the authority to establish guidelines for the
establishment and operation of care coordination entities. The new
section would also establish a process that allows persons eligible to
receive services to select either a PACE or MAP provider when appropri-
ate, or a care coordination entity to assist in the delivery of fee-for-
service based long term care care services. If a selection is not made
in a timely fashion the COH would assign a care coordination entity for
the person to receive long term care services in a fee-for-service
model.
Section 3 modifies the social services laws to direct the COH to make
regulations for a delivery of long term care services through a fee-for-
service model. The regulations would include but not be limited to: the
establishment and operation of care coordination entities; continuity of
care; and conflict-free case management. Section 3 would also direct
the Department of Health (DOH) to conduct an evaluation of the viability
of using care coordination entities in place of the independent assessor
for assessments or reassessments when determining an individual's needs.
Section 4 establishes a new section of unconsolidated law that directs
the COH to convene an advisory group that is composed of and informed by
stakeholder representatives. The advisory group would be tasked with:
promoting the transition of persons in receipt of home and community-
based long term care services into fee-for-service arrangements; and
determining a process to transition providers to a fee-for-service
reimbursement system. In implementing the transition to a fee-for-ser-
vice based model both the COH and the advisory board are directed to
consider and select programs and policies that seek to maximize continu-
ity of care, and minimize disruption to the provider labor workforce,
and shall continue to support providers based on a commitment to quality
and value. The section would establish a biannual reporting process on
implementation of the transition.
Sections 5 through 25 make conforming changes to various sections of law
replacing references to 4403-f of the public health law and Managed Long
Term Care (MLTC). The references are replaced by "PACE or MAP", or "long
term care options," which includes PACE, MAP, or fee-forservice based
long term care, where appropriate.
Section 26 establishes the effective date. Sections 1, 3, and 4 would
take effect immediately. The remaining sections would take effect April
1, 2026.
 
JUSTIFICATION:
New York State transitioned home care from a traditional fee-for-service
model to a Medicaid managed care program or MLTC Plans in 2011, under
direction from then Governor Andrew Cuomo's Medicaid Redesign Team.
Under this model, New York State began paying for-profit insurance
companies to manage and coordinate healthcare for several Medicaid
services, in an attempt to improve care by coordinating between doctors
and to save money by creating financial incentives to keep patients
healthy and out of high-cost hospitals and nursing homes. The original
intent was that MLTC plans would develop into fully capacitated plans
over time. This has not happened.
Instead, the majority of the services for-profit insurance companies
currently provide are solely home care. Because of this "care coordi-
nation" is limited, and the insurance companies administrative costs and
profit are a drain on the Medicaid system. These resources could be
reinvested to support the delivery of care through fee-for-service and
fully capitated models ensuring more uniform care for residents of the
state, as well as more adequate reimbursement to providers to support
wage increases. This will help to assist providers in addressing health-
care workforce challenges facing the state.
In the past 3.75 years, New York State has given $5.9 billion to the 24
for-profit insurance companies managing home care in administrative
costs and profit. In 2021 alone, the latest full year of data available,
private insurance companies posted $722 million in profits, twice the
national average.
To address this, the "Home Care Savings & Reinvestment Act" would repeal
the partially capitated MLTC program and instead provide appropriate
long term care benefits under a feefor-service model or through a fully
capitated model where appropriate.
This bill is estimated to generate significant annual savings, which can
be used to reinvest and support the Medicaid program while addressing
healthcare workforce issues.
 
PRIOR LEGISLATIVE HISTORY:
New bill.
 
FISCAL IMPLICATIONS:
To be determined.
 
EFFECTIVE DATE:
Sections 1, 3, and 4 of the bill would take effect immediately. The
remaining sections would take effect April 1, 2026.

Statutes affected:
S7800: 4403-f public health law, 2807-v public health law, 2807-v(1) public health law, 2807-x public health law, 3614 public health law, 3614(9) public health law