NY State Senate Bill 2011-S2145

Senate Bill S2145

2011-2012 Legislative Session

Establishes an alternative benefits demonstration program and creates health opportunity accounts

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Archive: Last Bill Status - In Senate Committee Health Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 04, 2012	referred to health
Jan 18, 2011	referred to health

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2011-S2145 (ACTIVE) - Details

Current Committee:: Senate Health
Law Section:: Public Health Law
Laws Affected:: Add Art 2 Title 5-B §§266 - 269-a, Pub Health L
Versions Introduced in 2009-2010 Legislative Session:: S1570

2011-S2145 (ACTIVE) - Summary

Establishes an alternative benefits demonstration program and creates health opportunity accounts to enable individuals to take responsibility for the outcomes of health care provided them, and to take control over the sources and kinds of care.

2011-S2145 (ACTIVE) - Sponsor Memo

                                BILL NUMBER:S2145

TITLE OF BILL:
An act
to amend the public health law, in relation
to establishing an
alternative benefits demonstration program and creating health
opportunity accounts

SUMMARY OF PROVISIONS:
Section 1. Creates a new Title 5-B of the
elder law to create the Interagency
demonstration acts office, to examine and make recommendations with
respect to opportunities to create demonstration programs under
federal waivers. Members include the director of the office of aging,
the commissioner of the department of health, and the commissioner of
the office of temporary and disability assistance.

Section 2 - Effective Date

JUSTIFICATION:
The DRA requires the Secretary of HHS to establish a demonstration
program under which up to 10 states may provide under their
Medicaid programs (including a plan operating under a statewide
1115 waiver) for qualified alternative benefits (a high deductible
plan and a health opportunity account (HOA) for eligible population

groups in one or more areas of the state. Demonstrations would
begin January 1, 2007.
Secretarial approval of a demonstration would be conditioned upon the
demonstration meeting specified criteria, including providing
incentives for preventive services and access to negotiated provider
payment rates.

The approach incorporates key components of health savings accounts
(HSAs) authorized in the Medicare Modernization Act (MMA) into a
new Medicaid demonstration pilot. Under the pilot, states could
allow participating beneficiaries to self-direct
a pre-funded account for medical care, rollover unspent
balances, and retain a portion of account funds after leaving
Medicaid to spend on medical care, health insurance, job training and
tuition expenses.

Allow demonstrations in three to ten counties, which participate
voluntarily, under which:

* The persons eligible would be working poor who are eligible for
Medicaid or other similar programs, e.g., Family Health Plus
(mandatory exclusion of individuals age 65 or older, or who are
disabled. pregnant, or receiving terminal care or long-term care.
* Participation would be voluntary.
* Participants can spend their accounts on services they choose.
* Annual deductibles would be 110% of the annualized amount of
contributions to the HOA.
* The state would provide the maximum contribution of $4,500 ($2,500
for the parent and $1,000 for each of the children) to the family's


Health Opportunity Account. The deductible would be set at the
maximum level: $4,950 (110 percent of the state's contribution).
* When spending reaches the deductible, standard Medicaid kicks in,
i.e., standard Medicaid coverage kicks in when the family reaches the
$4,950 expenditure point.
* Beneficiaries keep remaining balances when they are no longer
eligible for Medicaid.
* An advisory committee helps in implementation.

PRIOR LEGISLATIVE HISTORY:
S.6987 of 2006 - Aging, Finance
S.156  of 2008 - Aging
S.1570 of 2010 - Aging

FISCAL IMPLICATIONS:
To be determined, however, the federal cost in 2007 is estimated by CBO
at $10 million,
expanding to $15 million in 2008, 2009 and reaching $25 million by
2011. State costs based on this fiscal would be minimal, if any.

EFFECTIVE DATE:
Immediately.

2011-S2145 (ACTIVE) - Bill Text download pdf

                            
                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  2145

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                            January 18, 2011
                               ___________

Introduced  by  Sens. GOLDEN, JOHNSON -- read twice and ordered printed,
  and when printed to be committed to the Committee on Health

AN ACT to amend the public health law, in relation  to  establishing  an
  alternative  benefits demonstration program and creating health oppor-
  tunity accounts

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Article 2 of the public health law is amended by adding a
new title 5-B to read as follows:

                                TITLE 5-B
               ALTERNATIVE BENEFITS DEMONSTRATION PROGRAM
SECTION 266. ALTERNATIVE BENEFITS DEMONSTRATION PROGRAM.
        267. DEFINITIONS.
        268. IMPLEMENTATION.
        269. USE OF HEALTH OPPORTUNITY ACCOUNTS.
        269-A. REPORTS.
  S 266. ALTERNATIVE BENEFITS DEMONSTRATION PROGRAM. ANY OTHER PROVISION
OF ANY OTHER LAW TO THE CONTRARY NOTWITHSTANDING,  THE  COMMISSIONER  IS
HEREBY  AUTHORIZED  AND DIRECTED TO APPLY TO THE SECRETARY OF HEALTH AND
HUMAN SERVICES TO ESTABLISH A DEMONSTRATION  PROGRAM  FOR  PROVISION  OF
ALTERNATE  BENEFITS THROUGH A HEALTH OPPORTUNITY ACCOUNTS PROGRAM PURSU-
ANT TO SECTION 6082 OF  THE  DEFICIT  REDUCTION  ACT  OF  2005,  (P.  L.
109-171),  AND  IF  APPROVED, TO ESTABLISH SUCH PROGRAM IN NOT MORE THAN
TEN, NOR LESS THAN FIVE COUNTIES, FOR ELIGIBLE INDIVIDUALS AS DEFINED IN
THIS TITLE, SUBJECT TO THE REQUIREMENTS AND RESTRICTIONS OF THIS  TITLE.
THE  PROGRAM  SHALL TERMINATE IF FEDERAL APPROVALS FOR THE PROGRAM SHALL
CEASE OR BE WITHDRAWN, OR IF  THERE  IS  NO  FEDERAL  FINANCIAL  PARTIC-
IPATION,  OR  IF THE COMMISSIONER SHALL DETERMINE, PURSUANT TO THE STUDY
AUTHORIZED IN THIS TITLE, THAT THE PROGRAM IS  NOT  MEETING  AND  CANNOT
MEET ITS GOALS.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD04313-01-1

S. 2145                             2

  S 267. DEFINITIONS. AS USED IN THIS TITLE:
  1. "ELIGIBLE INDIVIDUAL" MEANS AN INDIVIDUAL WHO IS WORKING OR LOOKING
FOR  WORK,  OR  WHO  IS  ENROLLED  IN A JOB TRAINING PROGRAM, AND WHO IS
ELIGIBLE FOR THE MEDICAL ASSISTANCE PROGRAM OR SUCH  OTHER  PROGRAMS  AS
WILL ALLOW SUCH INDIVIDUAL TO QUALIFY FOR THE DEMONSTRATION PROGRAM, AND
WHO  VOLUNTARILY  ENROLLS  IN  THE  DEMONSTRATION PROGRAM. SUCH ELIGIBLE
INDIVIDUALS MAY INCLUDE INDIVIDUALS WHO ARE ENROLLED IN MEDICAID MANAGED
CARE PLANS, IF THE  COMMISSIONER,  ON  RECOMMENDATION  OF  THE  ADVISORY
COMMITTEE,  DETERMINES TO INCLUDE THEM; PROVIDED HOWEVER THAT THE DETER-
MINATION TO  INCLUDE  SUCH  INDIVIDUALS  SHALL  BE  SUBJECT  TO  FEDERAL
REQUIREMENTS  AND  LIMITATIONS  CONCERNING SUCH INDIVIDUALS. AN ELIGIBLE
INDIVIDUAL SHALL NOT INCLUDE INDIVIDUALS (A) WHO ARE SIXTY-FIVE YEARS OF
AGE OR OLDER; OR (B) WHO ARE DISABLED;  OR  (C)  WHO  ARE  ELIGIBLE  FOR
MEDICAL  ASSISTANCE  ONLY  BECAUSE THEY ARE (OR WERE WITHIN THE PREVIOUS
SIXTY DAYS) PREGNANT; OR (D) WHO HAVE BEEN ELIGIBLE FOR MEDICAL  ASSIST-
ANCE  FOR  A  CONTINUOUS  PERIOD  OF  LESS THAN THREE MONTHS; OR (E) ANY
OTHERS PROHIBITED FROM ELIGIBILITY BY FEDERAL REQUIREMENTS, OR  WHO  ARE
EXCLUDED  BY  THE COMMISSIONER ON RECOMMENDATION OF THE ADVISORY COMMIT-
TEE.
  2. "ENROLLMENT" MEANS THE VOLUNTARY ENROLLMENT BY AN ELIGIBLE INDIVID-
UAL IN THE ALTERNATIVE BENEFITS PLAN AUTHORIZED BY THIS  TITLE.  ENROLL-
MENT  SHALL  BE  FOR  A PERIOD OF TWELVE MONTHS, AND MAY BE EXTENDED FOR
ADDITIONAL PERIODS OF TWELVE MONTHS AT THE OPTION OF THE ELIGIBLE  INDI-
VIDUAL.  AN  ELIGIBLE  INDIVIDUAL  WHO,  FOR ANY REASON, UNENROLLS OR IS
UNENROLLED FROM THE PROGRAM SHALL NOT BE PERMITTED  TO  REENROLL  FOR  A
PERIOD OF TWELVE MONTHS FROM THE DATE OF SUCH UNENROLLMENT.
  3.  "DEDUCTIBLE"  MEANS  AN AMOUNT WHICH IS ONE HUNDRED TEN PERCENT OF
THE ANNUALIZED AMOUNT OF STATE AND FEDERAL  CONTRIBUTIONS  MADE  BY  THE
COMMISSIONER  TO  A HEALTH OPPORTUNITY ACCOUNT PURSUANT TO THIS SECTION.
UPON RECOMMENDATION OF THE  ADVISORY  COMMITTEE,  THE  COMMISSIONER  MAY
ESTABLISH  A  TIERED  SCHEDULE OF ANNUAL DEDUCTIBLES, BASED ON FAMILY OR
INDIVIDUAL INCOME, CONSISTENT WITH FEDERAL REQUIREMENTS FOR SUCH  TIERED
SCHEDULE.
  4.  "HEALTH  OPPORTUNITY  ACCOUNT"  MEANS  AN  ACCOUNT OPENED BY OR ON
BEHALF OF AN ELIGIBLE INDIVIDUAL PURSUANT TO THE  DEMONSTRATION  PROGRAM
AUTHORIZED  BY  THIS TITLE. SUCH ELIGIBLE INDIVIDUAL SHALL BE DEEMED THE
OWNER OF THE ACCOUNT, SUBJECT TO THE RESTRICTIONS  AND  REQUIREMENTS  OF
THIS  TITLE  AND  OF ANY FEDERAL REQUIREMENTS AND LIMITATIONS CONCERNING
SUCH ACCOUNTS. CONTRIBUTIONS TO A HEALTH OPPORTUNITY ACCOUNT MAY BE MADE
FROM THE STATE AND FEDERAL GOVERNMENTS, AND OTHER PERSONS AND  ENTITIES,
INCLUDING CHARITABLE ORGANIZATIONS, AS MAY BE PERMITTED BY THE SECRETARY
UNDER  THE TERMS OF THE DEMONSTRATION PROGRAM, PROVIDED HOWEVER THAT THE
COMBINED STATE AND FEDERAL SHARE OF CONTRIBUTIONS TO A  HEALTH  OPPORTU-
NITY  ACCOUNT  ON  BEHALF  OF AN INDIVIDUAL SHALL NOT EXCEED TWENTY-FIVE
HUNDRED DOLLARS ANNUALLY FOR EACH INDIVIDUAL OR FAMILY MEMBER WHO IS  AN
ADULT  AND ONE THOUSAND DOLLARS FOR EACH INDIVIDUAL OR FAMILY MEMBER WHO
IS A CHILD, AND PROVIDED FURTHER THAT THE LIMITATIONS ON  SUCH  CONTRIB-
UTIONS  SHALL  BE ANNUALLY ADJUSTED BY THE ANNUAL PERCENTAGE INCREASE IN
THE MEDICAL CARE COMPONENT OF THE CONSUMER PRICE  INDEX  FOR  ALL  URBAN
CONSUMERS  AS PERMITTED BY THE SECRETARY. THE COMMISSIONER SHALL SEEK TO
MAXIMIZE FEDERAL CONTRIBUTIONS TO  HEALTH  OPPORTUNITY  ACCOUNTS  ESTAB-
LISHED PURSUANT TO THIS SECTION.
  5. "SECRETARY" MEANS THE SECRETARY OF THE FEDERAL DEPARTMENT OF HEALTH
AND HUMAN SERVICES.
  6.  "ADVISORY  COMMITTEE" MEANS AN ADVISORY COMMITTEE APPOINTED BY THE
COMMISSIONER TO AID IN THE  DESIGN  AND  IMPLEMENTATION  OF  THE  DEMON-

S. 2145                             3

STRATION  PROGRAM  AUTHORIZED BY THIS TITLE. THE COMMITTEE SHALL CONSIST
OF TEN PERSONS, OF WHOM FOUR SHALL BE PERSONS WITH AT LEAST  FIVE  YEARS
EXPERIENCE  AT  EXECUTIVE LEVELS IN THE PROVISION OF HEALTH CARE IN THIS
STATE,  THREE  SHALL  BE EXPERTS IN THE ELECTRONIC TRANSMISSION OF FUNDS
AND PAYMENT FOR SERVICES, OR  PERSONS  WITH  EXPERTISE  IN  THE  USE  OF
SAVINGS  ACCOUNTS  FOR  THE  PAYMENT  OF HEALTH CARE SERVICES, AND THREE
SHALL BE CONSUMERS OR ADVOCATES FOR CONSUMERS LIKELY  TO  BE  OR  BECOME
ELIGIBLE INDIVIDUALS PURSUANT TO THE TERMS OF THIS DEMONSTRATION.
  7.  "MEDICAID  ASSISTANCE  PROGRAM" MEANS MEDICAL ASSISTANCE FOR NEEDY
PERSONS AS AUTHORIZED BY TITLE ELEVEN OF  ARTICLE  FIVE  OF  THE  SOCIAL
SERVICES LAW AND OTHER APPLICABLE STATE LAW.
  S  268.  IMPLEMENTATION.  1. THE COMMISSIONER SHALL TAKE SUCH STEPS AS
SHALL BE NECESSARY TO DEVELOP THE APPLICATION FOR THE ALTERNATIVE  BENE-
FITS  PROGRAM AUTHORIZED BY THIS SECTION AND SECTION 6082 OF THE DEFICIT
REDUCTION ACT OF 2005 (P.L. 109-171), AND TO ESTABLISH  AGREEMENTS  WITH
AT  LEAST THREE BUT NOT MORE THAN TEN COUNTIES FOR THE IMPLEMENTATION OF
THE PROGRAM IF APPROVED BY THE SECRETARY. IF APPROVED BY THE  SECRETARY,
THE  COMMISSIONER  IS  AUTHORIZED  TO AND SHALL IMPLEMENT THE PROGRAM IN
COUNTIES SELECTED PURSUANT TO THIS SUBDIVISION. THE  COMMISSIONER  SHALL
CONSULT WITH THE ADVISORY COMMITTEE IN THE DESIGN AND DEVELOPMENT OF THE
APPLICATION.
  2.  THE  COMMISSIONER MAY COORDINATE ADMINISTRATION OF HEALTH OPPORTU-
NITY ACCOUNTS THROUGH THE USE OF A THIRD ADMINISTRATOR,  TO  THE  EXTENT
PERMITTED  BY  FEDERAL  REQUIREMENTS  FOR  THE PROGRAM. THE COMMISSIONER
SHALL NOT USE A THIRD PARTY ADMINISTRATOR IF EXPENDITURES FOR THE USE OF
SUCH ADMINISTRATOR ARE NOT REIMBURSABLE IN  THE  SAME  MANNER  AS  OTHER
ADMINISTRATIVE EXPENDITURES PURSUANT TO SECTION 1903(A)(7) OF THE SOCIAL
SECURITY  ACT.    THE  COMMISSIONER  MAY  USE A REQUEST FOR PROPOSALS OR
REQUEST FOR QUALIFICATIONS PROCESS IN SELECTING SUCH THIRD PARTY  ADMIN-
ISTRATOR, AND SHALL CONSULT WITH THE ADVISORY COMMITTEE IN THE DESIGN OF
SUCH RFP AND RFQ.
  3.  THE  COMMISSIONER  SHALL REQUIRE THAT PROVIDERS OF SERVICE PROVIDE
SUCH SERVICES TO THE OWNER OF A HEALTH OPPORTUNITY ACCOUNT IN  THE  SAME
MANNER  AND  FOR  THE  SAME  RATES AND PAYMENTS AS IF THE INDIVIDUAL WAS
ENROLLED IN THE MEDICAL ASSISTANCE PROGRAM AND  NOT  THIS  DEMONSTRATION
PROGRAM, AND AS IF THE DEDUCTIBLE WAS NOT APPLICABLE.
  4.  THE  COMMISSIONER,  AFTER  CONSULTING  WITH  THE SUPERINTENDENT OF
BANKS, THE ADVISORY COMMITTEE, AND OTHERS THE COMMISSIONER DEEMS  APPRO-
PRIATE,  SHALL PROVIDE FOR A METHOD WHEREBY WITHDRAWALS MAY BE MADE FROM
A HEALTH OPPORTUNITY  ACCOUNT  FOR  PAYMENT  OF  ELIGIBLE  MEDICAL  CARE
EXPENSES  USING AN ELECTRONIC SYSTEM.  IN NO CASE SHALL WITHDRAWALS FROM
THE ACCOUNT BE PERMITTED IN CASH.
  S 269. USE OF HEALTH  OPPORTUNITY  ACCOUNTS.  THE  COMMISSIONER  SHALL
PRESCRIBE  BY  RULE AND REGULATION THE PERMITTED USES OF FUNDS IN HEALTH
OPPORTUNITY ACCOUNTS. SUCH RULE AND REGULATION SHALL REQUIRE:
  1. EXCEPT AS OTHERWISE PROVIDED IN THIS SECTION,  FUNDS  IN  A  HEALTH
OPPORTUNITY  ACCOUNT  SHALL ONLY BE USED FOR PAYMENT OF MEDICAL CARE, AS
SUCH TERM IS DEFINED IN SECTION 213(D) OF THE INTERNAL REVENUE CODE,  OR
FOR THE PURCHASE OF HEALTH INSURANCE COVERAGE; IN THE CASE OF AN ACCOUNT
OWNER  WHO  HAS BEEN ENROLLED IN THE PROGRAM FOR AT LEAST ONE YEAR, SUCH
FUNDS MAY ALSO BE USED FOR EDUCATIONAL EXPENDITURES FOR JOB TRAINING AND
TUITION EXPENSES OR OTHER EXPENDITURES APPROVED BY THE  COMMISSIONER  ON
RECOMMENDATION OF THE ADVISORY COMMITTEE, PROVIDED (A) THAT SUCH EXPEND-
ITURES  SHALL  BE MADE ONLY TO INSTITUTIONS AND PROGRAMS APPROVED BY THE
COMMISSIONER, (B) THAT THE PURPOSE OF SUCH EXPENDITURES IS TO ENABLE THE

S. 2145                             4

INDIVIDUAL TO ACQUIRE SKILLS AND TRAINING, AND (C) THAT ANY SUCH EXPEND-
ITURES FOR ITEMS OTHER THAN MEDICAL CARE ARE APPROVED BY THE SECRETARY.
  2.  IF THE OWNER OF A HEALTH OPPORTUNITY ACCOUNT BECOMES INELIGIBLE TO
CONTINUE AS AN ELIGIBLE INDIVIDUAL UNDER  THIS  SECTION  BECAUSE  OF  AN
INCREASE  IN  INCOME  OR ASSETS, (A) NO ADDITIONAL CONTRIBUTION SHALL BE
MADE TO THE ACCOUNT BY THE COMMISSIONER, (B) THE BALANCE IN THE  ACCOUNT
SHALL  BE  REDUCED  BY  TWENTY-FIVE  PERCENT  OF THE AMOUNT OF STATE AND
FEDERAL FUNDS DEPOSITED INTO THE ACCOUNT BY THE COMMISSIONER, EXCEPT  AS
OTHERWISE  PROVIDED  HEREIN; PROVIDED HOWEVER THAT (C) THE ACCOUNT SHALL
REMAIN AVAILABLE TO THE ACCOUNT HOLDER FOR THREE YEARS AFTER THE DATE ON
WHICH SUCH OWNER BECOMES INELIGIBLE FOR WITHDRAWALS UNDER THE SAME TERMS
AND CONDITIONS AS IF SUCH OWNER REMAINED ELIGIBLE, AND SUCH  WITHDRAWALS
SHALL  BE  TREATED  AS MEDICAL ASSISTANCE IN ACCORDANCE WITH THIS DEMON-
STRATION PROGRAM. FOR PURPOSES OF COMPUTING THE REDUCTION OF TWENTY-FIVE
PERCENT REQUIRED BY PARAGRAPH (B) OF THIS SUBDIVISION,  ANY  WITHDRAWALS
FROM THE ACCOUNT FOR PAYMENT OF ELIGIBLE EXPENSES SHALL FIRST BE CREDIT-
ED TO STATE AND FEDERAL CONTRIBUTIONS, AND NOT TO CONTRIBUTIONS BY OTHER
INDIVIDUALS AND ENTITIES.
  3. THE OWNER OF A HEALTH OPPORTUNITY ACCOUNT WHO BECOMES INELIGIBLE TO
CONTINUE  AS  AN  ELIGIBLE  INDIVIDUAL  UNDER  THIS SECTION SHALL NOT BE
REQUIRED TO PURCHASE INSURANCE AS A CONDITION OF CONTINUING  TO  USE  OR
MAINTAIN THE ACCOUNT.
  4. AMOUNTS CONTAINED IN OR CONTRIBUTED TO A HEALTH OPPORTUNITY ACCOUNT
SHALL  NOT  BE  COUNTED  AS INCOME OR ASSETS FOR PURPOSES OF DETERMINING
ELIGIBILITY FOR BENEFITS UNDER MEDICAL ASSISTANCE.
  5. THE COMMISSIONER, UPON RECOMMENDATION OF  THE  ADVISORY  COMMITTEE,
SHALL  ESTABLISH PROCEDURES TO PENALIZE AN INDIVIDUAL WHO MAKES UNQUALI-
FIED WITHDRAWALS FROM A HEALTH OPPORTUNITY ACCOUNT, INCLUDING  DISQUALI-
FYING  SUCH PERSON FROM CONTINUING ENROLLMENT IN THE PROGRAM AND CLOSING
THE ACCOUNT, RECOUPING COSTS FROM  SUCH  NONQUALIFIED  WITHDRAWALS,  AND
OTHER APPROPRIATE ACTIONS.
  6.  ANY OTHER PROVISION OF ANY OTHER LAW TO THE CONTRARY NOTWITHSTAND-
ING, THE COMMISSIONER MAY, UPON RECOMMENDATION OF THE ADVISORY COMMITTEE
AND IF THE SECRETARY SHALL APPROVE, PROVIDE APPROPRIATE  INCENTIVES  FOR
THE  USE  OF  PREVENTATIVE  CARE  BY THE OWNER OF THE ACCOUNT, INCLUDING
WAIVING THE DEDUCTIBLE FOR USE OF PREVENTATIVE  CARE  AND  REDUCING  THE
REDUCTION  REQUIRED PURSUANT TO PARAGRAPH (B) OF SUBDIVISION TWO OF THIS
SECTION FOR AN OWNER WHO BECOMES INELIGIBLE TO CONTINUE AS  AN  ELIGIBLE
INDIVIDUAL,  OR  WAIVING  OF CO-PAYS FOR SUCH CARE. FOR PURPOSES OF THIS
SUBDIVISION, PREVENTATIVE CARE IS ANY CARE THAT QUALIFIES  AS  PREVENTA-
TIVE  CARE  FOR PURPOSES OF SECTION 223(C)(2)(C) OF THE INTERNAL REVENUE
CODE, INCLUDING BUT NOT LIMITED TO, PERIODIC HEALTH EVALUATIONS, INCLUD-
ING TESTS AND DIAGNOSTIC PROCEDURES ORDERED IN CONNECTION  WITH  ROUTINE
EXAMINATIONS,  SUCH AS ANNUAL PHYSICALS; ROUTINE PRENATAL AND WELL-CHILD
CARE; CHILD AND ADULT IMMUNIZATIONS; TOBACCO CESSATION PROGRAMS; OBESITY
WEIGHT-LOSS PROGRAMS; SCREENING SERVICES; AND OTHER CARE WHICH QUALIFIES
UNDER SUCH SECTION.
  7. THE COMMISSIONER SHALL  ESTABLISH  ACCESS  TO  NEGOTIATED  PROVIDER
PAYMENT  RATES.   IN THE CASE OF AN ELIGIBLE INDIVIDUAL PARTICIPATING IN
THIS DEMONSTRATION PROGRAM WHO (A)  IS  NOT  ENROLLED  WITH  A  MEDICAID
MANAGED CARE ORGANIZATION, THE COMMISSIONER SHALL PROVIDE THAT THE INDI-
VIDUAL  MAY  OBTAIN  SERVICES  FROM (I) ANY PARTICIPATING PROVIDER UNDER
THIS TITLE AT THE SAME PAYMENT RATES THAT WOULD BE  APPLICABLE  TO  SUCH
SERVICES IF THE DEDUCTIBLE WAS NOT APPLICABLE; OR (II) ANY OTHER PROVID-
ER  AT  PAYMENT RATES THAT DO NOT EXCEED ONE HUNDRED TWENTY-FIVE PERCENT
OF THE PAYMENT RATE THAT WOULD BE APPLICABLE TO SUCH SERVICES  FURNISHED

S. 2145                             5

BY  A  PARTICIPATING PROVIDER UNDER THIS TITLE IF THE DEDUCTIBLE WAS NOT
APPLICABLE; OR (B) WHO IS ENROLLED WITH A MEDICAID MANAGED  CARE  ORGAN-
IZATION,  THE  COMMISSIONER  SHALL  ENTER  INTO  AN ARRANGEMENT WITH THE
ORGANIZATION  UNDER  WHICH  THE  INDIVIDUAL MAY OBTAIN SERVICES FROM ANY
OTHER  PROVIDER  AT  PAYMENT  RATES  THAT  DO  NOT  EXCEED  ONE  HUNDRED
TWENTY-FIVE PERCENT OF THE PAYMENT RATE THAT WOULD BE APPLICABLE TO SUCH
SERVICES  FURNISHED  BY A PARTICIPATING PROVIDER UNDER THIS TITLE IF THE
DEDUCTIBLE WAS NOT APPLICABLE. SUCH  PAYMENT  RATES  SHALL  BE  COMPUTED
WITHOUT REGARD TO ANY COST SHARING THAT WOULD BE OTHERWISE APPLICABLE.
  8. NOTHING IN THIS SECTION SHALL BE CONSTRUED AS PREVENTING AN EMPLOY-
ER  FROM  PROVIDING  HEALTH  BENEFITS COVERAGE TO AN ELIGIBLE INDIVIDUAL
UNDER THE DEMONSTRATION PROJECT AUTHORIZED  BY  THIS  SECTION,  AND  THE
COMMISSIONER  SHALL  MAKE  APPROPRIATE EFFORTS TO PARTNER WITH EMPLOYERS
FOR THE PROVISION OF HEALTH CARE TO SUCH ELIGIBLE INDIVIDUALS.
  S 269-A. REPORTS. THE COMMISSIONER SHALL REPORT TO  THE  GOVERNOR  AND
THE  LEGISLATURE  FROM  TIME TO TIME ON THE IMPLEMENTATION OF THE DEMON-
STRATION PROGRAM, AND SHALL PROVIDE AN INTERIM REPORT NOT LATER THAN THE
THIRD YEAR OF THE PROGRAM, AND A FINAL REPORT NOT LATER THAN  MAY  FIRST
OF  THE  FIFTH  YEAR OF THE PROGRAM. THE INTERIM AND FINAL REPORTS SHALL
PROVE STATISTICAL NARRATIVES OF THE LEVELS OF ENROLLMENT IN THE PROGRAM,
THE COSTS AND SAVINGS ASSOCIATED WITH THE PROGRAM, AND AN EVALUATION  OF
THE SUCCESS OF THE PROGRAM IN ATTAINING ITS GOALS.
  S 2. This act shall take effect immediately.

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Senate Bill S2145

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Martin J. Golden