Medicaid-elderly care.

WORKING DRAFT

ORIGINAL HOUSE

BILL

NO.
0086

ENROLLED ACT NO. 17, HOUSE OF REPRESENTATIVES

SIXTIETH LEGISLATURE OF THE STATE OF
WYOMING
2010 BUDGET SESSION

AN ACT relating to
Medicaid; authorizing as an optional Medicaid service a program of all-inclusive care for the elderly; providing program objectives; establishing program provider eligibility criteria; providing that
participating
program
organizations
do not
require a certificate of authority as an
insur
er
or health maintenance organization; granting rulemaking authority;

requiring reports;
and providing for an effective date.

Be It Enacted by the Legislature of the State of
Wyoming
:

Section 1.
W.S. 42
‑
4
‑
121 is created to read:

42
‑
4
‑
121.

Program of all-inclusive care for the elderly.

(a)

The department, as
an optional services program
of the
Medicaid
program,
may
develop and implement a program of all-inclusive care for the elderly
(PACE) in accordance with section 4802 of the Balanced Budget Act of 1997, P.L. 105-33, as amended
,
and 42 C.F.R
.
part 460.

(b)

The department
may contract with
approved PACE organizations
to
provide
,

in the manner and to the extent authorized by federal law, comprehensive, community based
acute and long term care services for
older Medicaid
eligible
participants
who
are
at least fifty-five (55) years old, living in a PACE service area, certified by the department as eligible for
long term care facility
placement
and who
elect to participate in the PACE program
.
Services provided through
a
PACE
organization

shall include all necessary medical and related care required by the PACE participant
,

including but not limited to
physician
and other health care provider
visits,
regular check ups, prescription drugs,
rehabilitation services,
home and
personal care services, medically necessary transportation
,
hospitalization
and skilled nursing facility services
.

(
c
)

The objective of the PACE program is to provide prepaid
, capitated,
quality

comprehensive health care services
that are
designed to
:

(
i
)

Enhance the quality of life and autonomy for frail, older adults
;

(
ii
)

Maximize dignity of, and respect for, older adults
;

(iii
)

Enable frail, older adults to live in the community as long as
medically and socially feasible;

(
iv
)

Preserve and support the older adult's family unit.

(
d
)

The department shall adopt rules as necessary to implement this section. In adopting rules, the department shall
:

(i)

Provide application
procedures
for
organizations
seeking to become a PACE program provider
;

(ii)

Establish the capitation rate for
Medicaid
participants
electing to participate in the PACE program instead of receiving Medicaid services on a fee for service basis.
The
capitation
rate shall be no less than ninety

percent (9
0
%) of the fee for service equivalent cost, including the department's cost of administration, that the department estimates would be payable for all services covered under the PACE organization contract if all of those services were to be provided on a fee for service basis
;

(iii)

Provide application procedures, including acknowledgment of informed consent, for Medicaid participants electing to participate in the PACE program in lieu of receiving fee for service Medicaid benefits.

(e
)

PACE provider organizations shall be public or private organizations providing or having the capacity to provide, as determined by the
department
, comprehensive health care services on a risk based capitated basis to PACE patients.

(f
)

To demonstrate
capacity as required by subsection (
e
) of this section, the department shall consider evidence such as an organization's insurance, reinsurance,
cash reserves, letter
s
of credit, guarantee
s
of compan
ies
affiliated with the
organization
or a combination of t
hose arrangements.

(g)

PACE organizations shall assume responsibility for all costs generated by PACE program participants, and shall create and maintain a risk reserve fund that will cover any cost overages for any participant. A PACE organization is responsible for the full financial risk that the cost of services required by a program participant might exceed the Medicaid
capitated fee for that participant.

(
h
)

The department shall develop
and implement a coordinated plan to promote
the
PACE
program
among prospective Medicaid long term care patients in the service area
s
of
approved
PACE
organizations
.

(
j
)

As soon as practicable after
July 1, 2010
, the department shall submit
to the federal centers for Medicare and Medicaid services
an amendment to the state Medicaid plan authorizing the state to implement the program of all-inclusive care for the elderly pursuant to this section. The department shall not
enter into a contract with any PACE provider organization until all necessary state plan amendments or waivers are approved. An
additional amendment to the state Medicaid plan
shall not be required
each time the department enters into a
contract with a
new
PACE
provider
organization
.

(k)

Nothing in this section shall be construed to require a PACE organization to hold a certificate of authority as an insurer or a health maintenance organization under title 26 of the
Wyoming
statutes.

(
m
)

The department shall provide a report to the joint labor, health and social services interim committee no later than October 1, 20
1
1
, and annually thereafter, with respect to
the program established by this section, including the number of PACE organizations authorized, the administrative structure of the program, the number of Medicaid eligible
persons
receiving services under the program and the
historical annual actual and next biennium
projected savings to the Medicaid program from the PACE program.
As used in this section "PACE" means a program of all-inclusive care for the elderly meeting the requirements of this section.

(n)

No PACE organization shall withhold any necessary medical or nonmedical services to any PACE participant in order to increase the organization's profit from the Medicaid capitated payment.

(o)

PACE participants may disenroll from the PACE program at any time. A PACE organization shall promptly report the identity of all disenrolled participants to the department.

Section 2.

This act is effective July 1, 2010.

(END)

Speaker of the House

President of the Senate

Governor

TIME APPROVED: _________

DATE APPROVED: _________

I hereby certify that this act originated in the House.

Chief Clerk

1