Proposed Committee Amendment to LD 1487 An Act to Implement Managed Care in the MaineCare Program From Senator Roger Kat

! Fe"r#ar$ %&! %'14 Amend the bill by striking the title and inserting a new title to read: “An Act to Provide Fiscal Predictability to the MaineCare Program and Health Security to Maine People ! Amend the bill by striking everything a"ter the enacting clause and by inserting the "ollowing:

PAR( A Sec) A*1) %% MRSA +,174*-- is enacted to read: + ,174*--) Patient*centered MaineCare re.orm 1) De.initions) As used in this section# unless the conte$t otherwise indicates# the "ollowing terms have the "ollowing meanings A “%epartment! means the Maine %epartment o" Health and Human Services & 'Managed care plan' means an entity that contracts with the department to provide managed care in the MaineCare program# providing managed care through a health insurer or health maintenance organi(ation authori(ed under )itle *+,A that bears "ull risk under a capitated payment C 'Managed care program' means the program o" integrated managed care "or all covered MaineCare services implemented in accordance with this section %) Managed care program )he department shall implement a managed care program "or all covered MaineCare services )he department shall include in the re-uests "or proposals and in the contract with each managed care plan the re-uirement that the provision o" services to members o" the MaineCare program must be managed on a phased,in schedule over three years as provided in this subsection A )he "ollowing members must be enrolled in year one o" the implementation o" managed care and in each year therea"ter: persons who are eligible "or MaineCare under section ./0+,1# subsection /# paragraphs A# 2# 1# H and 3# and nondisabled children who are eligible under section ./0+,1# subsection /# paragraphs & or % & All o" the remaining eligibility groups under section ./0+,1 may be re-uired to enroll in the managed care program a"ter the "irst year o" implementation and in subse-uent years a"ter the department has sought stakeholder input# approval "rom the "ederal %epartment o" Health and Human Services# Centers "or Medicare and

Medicaid Services and a"ter ma4or substantive rulemaking C A member who is not in an enrollment group re-uired to be enrolled under paragraph A or & may voluntarily enroll in a managed care plan that provides services in the region o" the state in which the member lives % A member may not be re-uired to enroll in a managed care plan unless there are at least three unrelated issuers o" state,wide managed care plans that can each meet all the re-uirements in this Act ,) Managed care plans) )he "ollowing re-uirements apply to contracts with managed care plans A )he department shall re-uire services in the managed care program to be provided by managed care plans that are capable o" coordinating and delivering all MaineCare covered services on a statewide basis to all enrollees & )he department shall select managed care plans using re-uests "or proposals )he procurement method must give the department broad "le$ibility and power to negotiate value and must provide potential bidders the broad "le$ibility to innovate C )he department shall use a procurement method that results in . or + plans that the department will authori(e to enroll MaineCare members upon negotiation o" rates consistent with this section and applicable re-uirements o" the "ederal %epartment o" Health and Human Services# Centers "or Medicare and Medicaid Services % At least one o" the managed care plans must be operated by a non,pro"it organi(ation which may be controlled by a health care provider or providers or an a""iliate o" a provider or providers# unless no organi(ation meeting this description meets the minimum criteria "or selection established in the re-uest "or proposals 2 )he department shall consider -uality "actors in the selection o" managed care plans# including# but not limited to: 5/6 Accreditation by a nationally recogni(ed accrediting body7 5*6 %ocumented policies and procedures "or preventing "raud and abuse7 5.6 2$perience in serving enrollees and achieving -uality standards7 5+6 Availability and accessibility o" primary and specialty care physicians in the relevant network7

586 Provision o" non,mandatory bene"its# particularly dental care and disease management# and other initiatives that improve health outcomes7 and 596 An o""ice or a commitment to establishing an o""ice "or the managed care plan in the State F A"ter negotiations are conducted# the department shall select managed care plans that the department determines to be responsive# to have signed contracts with providers o" covered services in su""icient numbers to meet access standards established in this section and by rule and to provide the best value to the department 1 All contracts with managed care plans entered into under this section are contingent upon the appropriation and allocation by the :egislature "or the managed care program o" su""icient "unding to pay "or the managed care program H All contracts with managed care plans entered into under this section are contingent upon the plan having signed provider contracts as re-uired in paragraph F 4) Plan acco#nta"ilit$) )he "ollowing provisions on managed care plan accountability apply to all managed care plans entered into under this section and provide standards "or plan accountability A )he term o" a contract with a managed care plan under this section is 8 years or less# with an option "or the department to renew "or a period or periods o" * years At the end o" a contract period the department may authori(e a short,term e$tension o" the contract i" needed to provide "or a transition to a new managed care plan with minimal disruption o" services and care provided to MaineCare members & )he department shall establish contract re-uirements that are necessary "or the operation o" the managed care program and consistent with the re-uirements o" this section 3n addition to any other provisions the department may determine to be necessary# the contract must contain the "ollowing contractual obligations 5/6 )hat the managed care plan participate in and coordinate with departmental e""orts in health care payment re"orm including value based purchasing7 -uality improvement7 delivery system improvement7 improvement in patients; e$perience o" care7 participation in other departmental initiatives# including the State 3nnovation Model grant initiative7 and participation in the Maine Primary Care Medical Home initiative# including the "inancial support o" -uali"ying Primary Care Medical Homes )he department may re-uire the managed care plan to participate in initiatives regarding compensation "or physicians "or coordination o" care7 management o" chronic disease7 and avoidance o" the need "or more costly services7 Managed care plans must

5*6 )hat each approved plan meet a minimum medical loss ratio o" at least <8= as de"ined in rules adopted by the department >ules adopted pursuant to this subdivision are ma4or substantive as de"ined in )itle 8# chapter .08# subchapter *,A 3n adopting rules pursuant to this subdivision the department must be guided by Section *0/< o" the Public Health Service Act and its implementing regulations and must seek input "rom the stakeholder group convened to provide input on capitated managed care 5.6 )hat the managed care plan meet established access standards that are speci"ic# population,based standards "or the number# type and regional distribution o" providers in managed care plan networks )he access standards must ensure access to care "or both adult members and child members that is e-ual or greater than available access to care that non,members have in the same geographic area )he access standards must ensure that payments to providers o" MaineCare services and bene"its re"lect mutually acceptable rates# methods and terms o" payment# are consistent with e""iciency# economy and -uality o" care and are su""icient to enlist an ade-uate number o" providers throughout the state )he access standards must re-uire the managed care plan to pay "or out,o",network care at a generally applicable rate when the plan is not able to deliver medically necessary services covered under the contract due to lack o" network availability or lack o" timely access to necessary care as de"ined through rulemaking 586 )hat the managed care plan maintain an accurate and complete electronic database# available on the publicly accessible 3nternet website o" the managed care plan or other accessible site that is updated periodically# and that contains but is not limited to the "ollowing in"ormation: 5a6 A list o" contracted providers# including whether the provider is currently accepting new MaineCare patients as o" the most recent in"ormation made available to the managed care plan and# to the e$tent available to the managed care plan# in"ormation about licensure or registration# locations and hours o" operation and specialty credentials and other certi"ications that allows comparison o" providers to network ade-uacy standards and that accepts and displays "eedback "rom patients satis"action in"ormation7 5b6 A pre"erred drug list that is searchable by members and providers# that is updated within *+ hours a"ter making any change# that includes prior authori(ation in"ormation and a prior authori(ation process "or prescribed drugs that is readily accessible to providers# displays appropriate contact in"ormation and provides timely responses to providers that meet or e$ceeds the standards prescribed by +* ? S C @ /.A9r,<5d65/65A6 596 )hat the managed care plan establish and maintain an encounter data system to

collect# process# store and report to the department "or all MaineCare members enrolled in the plan7 506 )hat the managed care plan meet speci"ic per"ormance standards and benchmarks or timelines "or improving per"ormance over the term o" the contract 5a6 A managed care plan shall establish an internal health care -uality improvement system# including member satis"action surveys as measured by a nationally recogni(ed assessment tool and disenrollment surveys 5b6 A managed care plan must be accredited by a nationally recogni(ed accrediting body# or have initiated the accreditation process# within one year a"ter the contract with the department is e$ecuted and must meet the re-uirements "or e$ternal -uality review 5<6 )hat the managed care plan must establish program integrity "unctions and activities to reduce the incidence o" "raud and abuse# including# at a minimum# a provider credentialing system and ongoing provider monitoring# procedures "or reporting instances o" "raud and abuse and designation o" a program integrity compliance o""icer7 5A6 )hat the managed care plan must establish an internal process "or reviewing and responding to grievances "rom enrollees and providers and submit -uarterly reports including the number# description and outcome o" grievances "iled by enrollees )he grievance procedure must provide "or oral or written appeal o" actions taken by the managed care plan )he grievance procedure must permit members or their authori(ed representatives access to the departmentBs administrative "air hearing process prior to e$hausting the internal grievance appeal process o" the managed care plan )he grievance procedure must provide "or publication and access "or the public to all "inal decisions o" the department and the managed care plan provided that all in"ormation that could directly or indirectly identi"y the member must be redacted prior to publishing or providing public access to the in"ormation7 5/C6 )hat a managed care plan must comply with re-uirements established by the department "or enrollment reduction and withdrawal and "or reporting encounter data )he re-uirements must provide "or penalties or termination o" a contract as a conse-uence o" "ailure to meet the re-uirements7 5//6 )hat a managed care plan and the planBs "iscal agent or intermediary must comply with the prompt payment re-uirements applicable to health carriers and health plans pursuant to )itle *+,A

5/*6 )hat a managed care plan must apply nationally endorsed -uality standards that are coordinated and consistent with department -uality initiatives and must at least include population improvement goals# improved health outcomes and improvement in early periodic screening# diagnosis and treatment periodicity compliance )he managed care plan must regularly track# monitor and publically report on health plan per"ormance in a "ormat approved by the department pursuant to rulemaking 5/.6 )hat# during a transition period to be determined by the department with stakeholder input# a managed care plan must contract with any e$isting and -uali"ied provider willing to accept the terms# conditions and rates associated with the Medicaid managed care plan A"ter the transition period# the standards must allow managed care plans to limit providers in their networks based on credentials# -uality indicators# and price provided that no limitation permitted by this subparagraph may be construed to modi"y or e$cuse noncompliance with the access standards established pursuant to 85&65.6# including without limitation access to "amily planning and "amily planning related services 3n addition# a"ter the transition period# the managed care plan must contract with any willing and -uali"ied provider who is a "ederally -uali"ied health center# rural health clinics# school,based health clinics# and a provider who serves high,risk populations or speciali(e in conditions that re-uire costly treatment )he department shall adopt rules to implement this subdivision >ules adopted pursuant to this subdivision are ma4or substantive rules as de"ined by )itle 8# chapter .08# subchapter *,A 5/+6 )hat a managed care plan must provide "or continuation o" health care bene"its and services at prior authori(ed levels when a member "iles a grievance or appeal o" a denial o" a renewed prior authori(ation re-uest )he managed care plan must provide that the member may not be charged "or services provided during the grievance or appeal process7 5/86 )hat a managed care plan must provide that the commissioner and the medical director o" MaineCare program have the authority to override any denial o" care by the managed care on the basis o" medical necessity7 5/96 )hat a managed care plan must provide that MaineCare members enrolled in the plan and providers be third party bene"iciaries under any contract between the plan and the department7 5/06 )hat a managed care plan must be sub4ect to "inancial conse-uences# backed by a

per"ormance bond or similar guarantee# "or "ailure to meet -uality standards# access standards# patient satis"action standards and other re-uirements o" law or rule or o" the contract between the department and the managed care plan7 5/<6 )hat a managed care plan is sub4ect to the 4urisdiction and oversight o" the Maine &ureau o" 3nsurance and must comply with provisions o" title *+,A# including Chapter 89,A7 5/A6 )hat a managed care plan when providing to members and prospective members written communications# including but not limited to notices# decisions and e$planations o" bene"its# must provide those communications in a manner that is readable at or near a 9th grade reading level and o""er translated versions o" materials as re-uired by the department7 and 5*C6 )hat a managed care plan may allow "or cost sharing in accordance with the provisions o" +* ?nited States Code @ /.A9o 5*/6 )hat a managed care plan must provide a reasonable contribution to pay "or the "unding o" the ombudsman program under subsection 0 &) Pa$ments to managed care plans) )he "ollowing provisions apply to payments to managed care plans by the department A )he department shall pay managed care plans on the basis o" per member# per month payments negotiated pursuant to this subsection Payments must be at risk, ad4usted rates based on historical utili(ation and spending data# pro4ected and ad4usted to re"lect the eligibility category# geographic area and clinical risk pro"ile o" the members with the provision "or subse-uent ad4ustment based on actual enrollments and encounter data when available 3n negotiating rates with the plans# the department shall consider any ad4ustments necessary to encourage plans to use the most cost, e""ective means o" improving outcomes and providing speciali(ed management o" particular subgroups o" populations with comple$ or high,cost needs & For that portion o" the MaineCare enrolled population covered by managed care plans in the "ourth "iscal year o" the provision o" managed care coverage# the total amount e$pended by the department in that "iscal year to cover services to that portion o" the population may not e$ceed A8= o" the amount that would have been e$pended to cover the same number o" enrollees "or the same services in the same "iscal period in the absence o" a managed care plan )his limitation must be calculated on the basis o" historical e$perience# ad4usted "or actual increases in health care costs and reasonable pro4ections o" the trend in those costs )he method o" calculation o" the limitation must be established in rules adopted by the department

/) 0nrollment1 choice co#nseling1 eligi"ilit$) 2$cept as otherwise provided by law# the "ollowing provisions apply to enrollment o" MaineCare members in and choice counseling and eligibility "or managed care plans A )he member must be provided a choice o" plans and may select any available plan unless that plan is restricted by contract with the department to a speci"ic population that does not include the member A MaineCare member must be provided at least .C days in which to make a choice o" plans )he department and managed care plans must provide notices about enrollment rules that current and potential enrollees can easily understand & )he department shall implement a choice counseling system to ensure that a MaineCare member has timely access to accurate in"ormation on the available managed care plans Counselors providing enrollment support must re"lect the ethnic# linguistic and cultural demographics o" the population served )he counseling system must include plan,to,plan comparative in"ormation on bene"its# provider networks# pre"erred drug lists# -uality measures and other data points as determined by the department Choice counseling must be made available through "ace,to,"ace interaction# through the publicly accessible website o" the department# by telephone and in writing and through other "orms o" relevant media Materials must be provided in a culturally appropriate manner# readable at or below 9th grade reading level and consistent with "ederal re-uirements )he department shall implement a competitive bidding process "or procurement o" choice counseling "unctions )he choice counseling system may not be administered by a managed care plan C A"ter a MaineCare member has enrolled in a managed care plan# the member must have AC days to voluntarily disenroll and select another plan A"ter AC days# no "urther changes may be made e$cept "or good cause or during the annual open enrollment period 1ood cause "or disenrollment must include at a minimum when: 5/6 )he plan does not cover a service the member seeks due to religious or moral ob4ections7 5*6 )he enrollee needs related services that are not available in the planBs network and the member;s provider determines that receipt o" the service separately would sub4ect the member to unnecessary risk7 and 5.6 Dther reasons# including but not limited to poor -uality o" care or lack o" access to covered services and e$perienced providers % )he department shall automatically enroll into a managed care plan those MaineCare members who do not choose a plan 2$cept as otherwise outlined in this section# the department may not engage in practices that are designed to "avor one managed care plan over another

2 A member eligible "or coverage pursuant to section ./0+,1# subsection /# paragraphs H and 3 must be re-uired to participate in the Private Health 3nsurance Premium Program in accordance with section /< )he department shall identi"y all members who have access to group health plan coverage and shall in"orm the member o" that participation is mandatory "or the member 7) 2m"#dsman program) )he department shall ensure the establishment o" an e$ternal and independent ombudsman who is not within the control o" the managed care plans )he ombudsperson shall identi"y and report to the department and the committee o" 4urisdiction within the :egislature on systemic issues and possible solutions to those issues and be able to assist MaineCare members and providers with grievances and appeals either within the ombudsman program or under contract with an e$ternal entity )he department and any plan that provides services to MaineCare members must provide de,identi"ied data to the ombudsperson as necessary "or the ombudsperson to carry out the "unctions o" the position re-uired by this paragraph 8) MaineCare "ene.its #nder managed care plans) )he "ollowing provisions govern bene"its under MaineCare managed care plans A A managed care plan must provide coverage "or all services and bene"its re-uired by the department "or the applicable category o" eligible members & As approved by the department# a managed care plan may customi(e bene"it packages "or nonpregnant adults and provide coverage "or additional services Customi(ed bene"it packages must provide all services and bene"its that were provided to nonpregnant adults on April /# *C/+ )he department shall evaluate the proposed bene"it packages to ensure services are su""icient to meet the needs o" the planBs enrollees and to veri"y actuarial e-uivalence 3) R#lema4ing) )he department shall adopt rules as necessary to implement this section >ules adopted pursuant to this subsection are ma4or substantive rules as de"ined in )itle 8# chapter .08# subchapter *,A Sec) A*%) Sta4eholder gro#p on capitated managed care in the MaineCare program) &y August /# *C/+ the Commissioner o" Health and Human Services shall convene a stakeholders group to design and plan "or the implementation o" a capitated managed care program "or MaineCare enrollees )he stakeholder group shall make recommendations to the department regarding the implementation o" ** M>SA section ./0+,EE# including# but not limited to# the "ollowing issues: the development o" the selection and phase,in process7 consumer choice and access to providers and network ade-uacy7 accountability and transparency7 incentives to encourage and reward health behaviors7 alignment with e$isting e""orts related to payment re"orm and care coordination7 establishment o" clear -uality metrics and -uality improvements7 comprehensive and coordinated data analytics and access to data7 usage and payment o" emergency department services7 and consumer protections )he stakeholder group shall include but not be limited to representatives o" the "ollowing: MaineCare members and advocates representing MaineCare members7 consumer advocates#

representatives o" health insurance carriers7 primary health care providers7 acute care and critical access hospitals7 behavioral health providers# including substance abuse providers7 academics with a concentration in health care policy7 pharmacy bene"its managers# the %epartment o" Health and Human Services7 the &ureau o" 3nsurance and representatives o" the State 3nnovation Model grant process )he stakeholder group shall work until managed care implementation and the phase in o" all mandatory populations is "ully complete )he stakeholder group shall provide input on the implementation o" )itle ** Maine >evised Statutes# section ./0+,EE Sec) A*,) Iss#ance o. Re5#est .or In.ormation) &y Dctober /# *C/+# the %epartment o" Health and Human Services shall issue a >e-uest "or 3n"ormation based upon the provisions o" ** M>SA section ./0+,EE and the criteria developed through the stakeholder process )he purpose o" the re-uest "or in"ormation process is to determine whether there is su""icient interest among managed care companies to provide "ull risk capitated managed care to all or part o" the MaineCare program in a manner that is consistent with and compatible with the goals and structure o" the value based purchasing initiatives being undertaken by the department# including but not limited to health homes# patient centered medical homes# accountable communities# peer support organi(ations and other issues that are identi"ied in the responsibilities to the managed care stakeholder group Sec) A*4) Report to the Legislat#re) &y March /# *C/8# the %epartment o" Health and Human Services shall report to the Foint Standing Committee on Health and Human Services on the status o" implementation o" managed care pursuant to ** M>SA section ./0+,EE# each o" the areas addressed by the stakeholders group# the speci"ic recommendations o" the stakeholder group# the department;s value based purchasing initiative# including accountable care )he report must include actual and pro4ected cost savings and the structure o" managed care program &eginning April /# *C/8 the department shall provide a report every month to the Foint Standing Committee on Health and Human Services on the implementation o" managed care Sec) A*&) R#lema4ing Re5#ired )he "ollowing rulemaking re-uirements apply to the implementation o" managed care in the Maine Care program by the %epartment o" Health and Human Services pursuant to ** M>SA section ./0+,EE 5a6 &y May /# *C/8# the department shall propose ma4or substantive rules to implement managed care based on the recommendations o" the stakeholder group 5b6 &y September /# *C/8# the department shall provisionally adopt a managed care rule and provide copies o" the rule to the 2$ecutive %irector o" the :egislative Council and the in accordance with the provisions o" 8 M>SA <C0* 5.6 and 5+6 5c6 &y Fanuary /8# *C/9# the Foint Standing Committee on Health and Human Services shall make its recommendation to the "ull legislature on the managed care ma4or substantive rule in accordance with 8 M>SA <C0* 586

5d6 )he department shall issue a re-uest "or proposals to prospective bidders no later than .C days "ollowing "inal legislative action on the provisional managed care rule 5e6 Eithin 9 months o" awarding o" the re-uest "or proposals the department shall start implementation o" managed care Sec) A*/) State plan amendment and 6ai7ers1 contingent e..ecti7e date) )he %epartment o" Health and Human Services shall apply to the "ederal %epartment o" Health and Human Services# Centers "or Medicare and Medicaid Services "or approval o" a state plan amendment under the ?nited States Social Security Act# Section /A.*5a6 to implement the provisions o" this Act and "or all necessary waivers )he provisions o" this Act take e""ect upon noti"ication "rom the %epartment o" Health and Human Services to the >evisor o" Statutes that all necessary approvals under this section have been granted PAR( 8 Sec) 8*1) %% MRSA +,174*9! s#"*+1! :F! as amended by P: *C//# c .<C# Pt GG# @*# is "urther amended to read: F A person *C to 9+ years o" age who is not otherwise covered under paragraphs A to 2 when the personBs "amily income is below or e-ual to /*8= o" the non"arm income o""icial poverty line# provided that the commissioner shall ad4ust the ma$imum eligibility level in accordance with the re-uirements o" the paragraph 5*6 3" the commissioner reasonably anticipates the cost o" the program to e$ceed the budget o" the population described in this paragraph# the commissioner shall lower the ma$imum eligibility level to the e$tent necessary to provide coverage to as many persons as possible within the program budget 5.6 )he commissioner shall give at least .C daysB notice o" the proposed change in ma$imum eligibility level to the 4oint standing committee o" the :egislature having 4urisdiction over appropriations and "inancial a""airs and the 4oint standing committee o" the :egislature having 4urisdiction over health and human services matters7 and Sec) 8*%) %% MRSA +,174*9! s#"*+1! :9! as enacted by P: *C//# c .<C# Pt GG# @.# is amended to read: 1 A person who is a nonciti(en legally admitted to the ?nited States to the e$tent that coverage is allowable by "ederal law i" the person is: 5/6 A woman during her pregnancy and up to 9C days "ollowing delivery7 or

5*6 A child under */ years o" age 7 Sec) 8*,) %% MRSA +,174*9! s#"*+1! ::; and I are enacted to read: H 2""ective Fuly /# *C/+# a person */ to 9+ years o" age who is not otherwise eligible "or medical assistance under this section# who -uali"ies "or medical assistance pursuant to +* ?nited States Code# Section /.A9a5a65/C65A65i65H3336 and who has income at or below /..= o" the non"arm income o""icial poverty line plus 8= "or the applicable "amily si(e as re-uired by "ederal law A person eligible "or medical assistance under this paragraph must receive the same coverage as is provided to a person eligible under paragraph 27 and 3 &eginning Dctober /# *C/A# a person /A or *C years o" age who is not otherwise eligible "or medical assistance under this section# who -uali"ies "or medical assistance pursuant to +* ?nited States Code# Section /.A9a5a65/C65A65i65H3336 and who has income at or below /..= o" the non"arm income o""icial poverty line plus 8= "or the applicable "amily si(e as re-uired by "ederal law A person eligible "or medical assistance under this paragraph must receive the same coverage as is provided to a person eligible under paragraph 2 Sec) 8*4) Contingent repeal) )he Maine >evised Statutes# )itle **# section ./0+,1# subsection /# paragraphs H and 3 are repealed i": 1) 0nhanced Federal Medical Assistance Percentage) )he enhanced Federal Medical Assistance Percentage with respect to amounts e$pended "or medical assistance "or newly eligible Medicaid individuals described in +* ?nited States Code# Section /.A9a5a65/C65A65i6 5H3336 is reduced below /CC= "or calendar -uarters in *C/+# *C/8 and *C/97 %) Red#ction in enhanced Federal Medical Assistance Percentage e..ecti7e) )he reduction in the enhanced Federal Medical Assistance Percentage described in subsection / has taken e""ect7 and ,) Legislati7e session o. at least ,' da$s) A"ter the reduction o" the enhanced Federal Medical Assistance Percentage as described in subsections / and *# the :egislature has convened and conducted a session o" at least .C calendar days Sec) 8*&) Repeal) )he Maine >evised Statutes# )itle **# section ./0+,1# subsection /# paragraphs H and 3 are repealed %ecember ./# *C/9 PAR( C Sec) C*1) Research organi ation e7al#ation) )he D""ice o" Fiscal and Program >eview shall contract with a nonpartisan research organi(ation to study the impact o" the MaineCare e$pansion authori(ed in Part & on programs and services that do not currently receive Federal Medical Assistance Percentage matching "unds or do not -uali"y "or enhanced Federal Medical Assistance Percentage matching "unds under the "ederal Patient Protection and A""ordable Care Act# +* ?nited States Code# Section /<CC/# et se- # with the goal o" identi"ying and ma$imi(ing 1eneral Fund savings )he Commissioner o" Health and Human Services# the Commissioner o"

Corrections and the 2$ecutive %irector o" the State &oard o" Corrections shall provide to the research organi(ation in"ormation and assistance re-uested "or preparation o" the evaluation 3n evaluating the programs and services under this Part# the research organi(ation shall at a minimum evaluate the impact on the "ollowing programs and services: the state,"unded Mental Health Services , Community# D""ice o" Substance Abuse and 1eneral Assistance , >eimbursement to Cities and )owns programs7 the elderly low,cost drug program under the Maine >evised Statutes# )itle **# section *8+%7 services provided "or individuals */ to 9+ years o" age who are currently eligible "or MaineCare under medically needy# spend,down criteria7 services provided under the Maine H3HIA3%S Section ///8 %emonstration Eaiver7 services provided "or parents participating in "amily reuni"ication activities7 services provided "or disabled individuals */ to 9+ years o" age with incomes below /.A= o" the "ederal poverty level7 services provided to individuals awaiting a MaineCare disability determination "or whom the applications are subse-uently granted7 services provided to individuals who would have been considered eligible on the basis o" a disability but "or whom the "ull determination process was not completed7 medical services provided to persons in the care and custody o" the %epartment o" Corrections or a county correctional "acility7 and the amount o" payment "or services that hospitals received during "iscal years *C/+,/8 and *C/8,/9 as a result o" the e$pansion o" MaineCare eligibility pursuant to Part & 3n addition# the research organi(ation shall evaluate any savings and the impact on health outcomes achieved through initiatives implemented pursuant to the State 3nnovation Models 3nitiative grant Sec) C*%) ;ealth Ins#rance Mar4etplace report) )he D""ice o" Fiscal and Program >eview shall contract with a nonpartisan research organi(ation to e$amine the "inancial "easibility o" providing health care coverage to newly eligible MaineCare members through the Health 3nsurance Marketplace modeled a"ter Medicaid e$pansion coverage in Arkansas or 3owa )he D""ice o" Fiscal and Program >eview shall report by February /8# *C/8 to the 4oint standing committee o" the :egislature having 4urisdiction over health and human services matters regarding the "easibility o" providing health care coverage to newly eligible MaineCare members through the Health 3nsurance Marketplace modeled a"ter Medicaid e$pansion coverage in Arkansas or 3owa Sec) C*,) Report) )he research organi(ation that conducts the evaluation under section / shall report no later than February /8# *C/8 and February /8# *C/9 to the 4oint standing committee o" the :egislature having 4urisdiction over appropriations and "inancial a""airs# the 4oint standing committee o" the :egislature having 4urisdiction over health and human services matters and the 4oint standing committee o" the :egislature having 4urisdiction over criminal 4ustice and public sa"ety matters on the amount o" 1eneral Fund savings resulting "rom the MaineCare e$pansion authori(ed in Part A and identi"ied in section / )he reports must include the amount o" savings e$pected and reali(ed during "iscal years *C/+,/8 and *C/8,/9 by service area or program# the amount deposited in the MaineCare Stabili(ation Fund pursuant to section . and the amount o" savings pro4ected to be achieved through state "iscal year *C*C,*/ by service area or program Sec) C*4) Calc#lation and trans.er) Jotwithstanding any other provision o" law# the State &udget D""icer shall calculate the amount o" savings identi"ied in this Part that applies against each 1eneral Fund account statewide as a result o" the e$pansion o" MaineCare eligibility authori(ed in Part & and shall trans"er the amounts up to the amounts speci"ied in section 9 by "inancial order upon the approval o" the 1overnor )hese trans"ers are

considered ad4ustments to appropriations in "iscal year *C/+,/8 )he State Controller shall trans"er any amounts identi"ied under this Part greater than the amounts speci"ied in section 9 to the MaineCare Stabili(ation Fund established under the Maine >evised Statutes# )itle **# section ./0+,GG )he State &udget D""icer shall provide a report o" the trans"erred amounts to the 4oint standing committee o" the :egislature having 4urisdiction over appropriations and "inancial a""airs no later than Fune .C# *C/8 "or "iscal year *C/+,/8 and no later than Fune .C# *C/9 "or "iscal year *C/8,/9 Sec) C*&) Re7ie6 and responsi"ilit$) Following receipt o" the reports "rom the research organi(ation as re-uired under section .# the 4oint standing committee o" the :egislature having 4urisdiction over health and human services matters shall review the in"ormation provided in the reports and shall determine i" the net cost to the 1eneral Fund o" providing coverage under the MaineCare program to individuals pursuant to )itle ** Maine >evised Statutes section ./0+,1# subsection /# paragraphs H and 3 e$ceeds the savings to the 1eneral Fund# including any amount deposited in the MaineCare Stabili(ation Fund pursuant to section +# due to the e$pansion o" coverage "or those individuals Following its review o" the report received on February /8# *C/9# the 4oint standing committee may report out a bill to the /*0th :egislature regarding its determinations and conclusions Sec) C*/) Appropriations and allocations) allocations are made )he "ollowing appropriations and

<(o "e 6ritten "$ 2FPR=

PAR( D Sec) D*1) Appropriations and allocations) )he "ollowing appropriations and allocations are made <(o "e 6ritten "$ 2FPR= PAR( 0 Sec) 0*1) -ritten notices re5#ired regarding MaineCare co7erage) At the time o" enrolling in the MaineCare program a member who is eligible under )itle ** Maine >evised Statutes section ./0+,1# subsection /# paragraphs H or 3# the %epartment o" Health and Human Services shall provide written notice that is readable at the 9th grade reading level to the member as "ollows: 1) Primar$ care pro7ider )he department shall provide notice to the member that the member is re-uired to sign up as a patient with a primary health care provider promptly a"ter enrolling in the MaineCare program7 and

%) 8ene.it termination) )he department shall provide written notice to the member that the member;s MaineCare coverage will end on %ecember ./# *C/9 unless a law is passed to e$tend coverage past that date PAR( F Sec) F*1) (as4 Force to Create 2pport#nities .or Sta"le 0mplo$ment .or MaineCare Mem"ers )he )ask Force to Create Dpportunities "or Stable 2mployment "or MaineCare Members# re"erred to in this Part as 'the task "orce#' is established 1) (as4 .orce mem"ership )he task "orce consists o" < members appointed as "ollows: A )hree members o" the Senate appointed by the President o" the Senate# including * members o" the party holding the largest number o" seats in the Senate and / member o" the party holding the second largest number o" seats in the Senate7 and & Five members o" the House o" >epresentatives appointed by the Speaker o" the House# including . members o" the party holding the largest number o" seats in the House and * members o" the party holding the second largest number o" seats in the House %) Chairs) )he "irst,named Senate member is the Senate chair and the "irst,named House o" >epresentatives member is the House chair o" the task "orce ,) Appointments1 con7ening o. tas4 .orce All appointments must be made no later than .C days "ollowing the e""ective date o" this Act )he appointing authorities shall noti"y the 2$ecutive %irector o" the :egislative Council once all appointments have been completed A"ter appointment o" all members# the chairs shall call and convene the "irst meeting o" the task "orce 3" .C days or more a"ter the e""ective date o" this Act a ma4ority o" but not all appointments have been made# the chairs may re-uest authority and the :egislative Council may grant authority "or the task "orce to meet and conduct its business 4) D#ties) )he task "orce shall meet up to + times in order to identi"y any policies in MaineCare that penali(e or create a disincentive "or members to increase hours o" employment or earnings )he task "orce shall make recommendations to eliminate any such barriers and shall propose new policies that support and promote stable and lasting employment 3n per"orming its work# the task "orce shall e$amine current rules related to MaineCare )ransitional Assistance and any opportunities to "urther reduce the 'cli"" e""ect' impacting working "amilies that lose eligibility "or MaineCare )he task "orce shall consider solutions that provide continuity o" care and minimi(e persons; moving on and o"" o" the MaineCare program &) Sta.. assistance) )he :egislative Council shall provide necessary sta""ing services to the task "orce /) Report) )he task "orce shall submit a report that includes its "indings and

recommendations "or presentation to the Foint Standing Committee on Health and Human Services by Jovember +# *C/+

PAR( 9 Sec) 9*1) Implement re.orms in programs .or ad#lts 6ith intellect#al disa"ilities) )he %epartment o" Health and Human Services shall implement "orthwith the re"orms identi"ied in this section and shall trans"er all savings resulting "rom those re"orms and ad4ust reimbursement rates "or providers o" services as necessary to develop the "unds that will reduce waiting lists "or services under the MaineCare program Sections */ and *A services "or adults with intellectual disabilities and autism to less than 9 months by Fanuary /8# *C/8 A )he department shall implement the "ollowing re"orms speci"ied in Public :aw *C/.# chapter .9<# Section SS,+# including implementing the plan "or services called "or by that law: / 2ach individual will receive a strength,based standardi(ed assessment o" that individualBs strengths or needs to in"orm a person,centered plan7 * 2ach individual will be assessed "or the natural "amily and community support networks potentially available to that individual7 . )he State will establish a broad menu option model designed to match the amount and kind o" paid support services needed by each individual7 + 2ach individual will have a designated community resource assistant whose 4ob it is to help individuals at any age navigate the local array o" services7 8 )he State will develop a thorough and accessible in"ormation repository7 9 )he State will establish early support and planning "or steps to transition individuals "rom childhood services to adult services7 0 )he State will undertake educational e""orts in each neighborhood to educate and "oster inclusiveness and awareness o" the community7 < )he StateBs developmental services will deliver only the paid services needed7 and A Formal services will be based on individual and realistic needs & )he department shall carry out the directives and proceed to implement the initiatives contained in the "ollowing resolves: / 3n >esolve *C/.# chapter *+ the directive to the department to add home support as a covered service permitting a member to live as independently as possible in the memberBs own home7 * 3n Public :aw *C/.# chapter .9<# part JJ the directive to the department to review rate methodology to reduce costs "or those with e$traordinarily high medical needs7 and

. 3n Public :aw *C/.# chapter .9<# part SS# section / the directive to the department to pursue waivers to use electronic technology to lessen dependence# reduce the need "or overnight support# and eliminate unnecessary sta""ing costs C )he department shall move "orward to accomplish the "ollowing re"orms that were identi"ied during the work o" the MaineCare >edesign )ask Force that was convened pursuant to Public :aw *C//# chapter 980# part ): / %ecrease the cost o" health care to persons with intellectual disabilities by implementing care management in long term support service providers7 * 3ncrease the census o" very small home support residential programs in all cases where it can be done without encountering behavioral impediments 3n many cases# homes are established with only / or * occupants when . or + might well be accommodated7 . 2$pedite the "illing o" residential beds by ensuring that vacancies are prioriti(ed "or individuals needing residential services7 + Add monitoring technology to replace on site sta""ing during low activity periods pursuant to waivers the department was directed to obtain in Public :aw *C/.# chapter .9<# part SS7 8 Substitute "oster homes "or hourly sta"" model care in those situations where individuals re-uire long term or permanent living arrangements "or daily support7 and 9 Accelerate the teaching o" independent living skills with "ocus on populations transitioning "rom school to adult living Sec) 9*%) Sa7ings .rom re.orms) )he savings generated by re"orming the MaineCare services "or adults with intellectual disabilities and autism cited in section / must be used to serve those on the waiting list "or MaineCare Section */ and *A programs )he department shall develop a plan with clear steps and a timeline to ensure that current and "uture waiting lists "or services under Sections */ and *A do not e$ceed 9 months by Fanuary /8# *C/8# and shall present its plan to the :egislature by Fune .C# *C/+ Sec) 9*,) 0mergenc$ r#le*ma4ing a#thorit$ )he department is authori(ed to adopt emergency rules under the Maine >evised Statutes# )itle 8# sections <C8+ and <C0. to implement the provisions o" this Part over which the department has sub4ect matter 4urisdiction without having to show that immediate adoption is necessary to avoid a threat to public health# sa"ety or general wel"are PAR( ; Sec) ;*1) Fra#d in7estigation) )he %epartment o" the Attorney 1eneral shall undertake an initiative to strengthen "raud investigation in the MaineCare program )he %epartment o" the Attorney 1eneral shall establish * new positions within the Health Care Crimes ?nit to investigate allegations o" misuse o" public "unds in the MaineCare program and to aid the Attorney 1eneral in the prosecution o" crimes and other legal actions related to misuse o" public "unds

Sec) ;*%) Appropriation and allocation <(o "e 6ritten "$ 2FPR=

S>MMAR? )his amendment replaces the bill 3t strikes the title and inserts a new title to read: “An Act to Provide Fiscal Predictability to the MaineCare Program and Health Security to Maine People ! )he amendment contains the "ollowing provisions Part A establishes managed care in the MaineCare program Part A includes re-uirements "or managed care plans and "or contracting by the %epartment o" Health and Human Services "or managed care services Part A speci"ies how MaineCare members enroll in managed care plans Part & e$pands medical coverage under the MaineCare program to adults who -uali"y under "ederal law with incomes up to /..= o" the non"arm income o""icial poverty line# with the 8= "ederal income ad4ustment "or "amily si(e# and -uali"ies Maine to receive "ederal "unding "or /CC= o" the cost o" coverage "or members who enroll under the e$pansion Adults who will be eligible are those */ to 9+ years o" age e""ective Fuly /# *C/+ and adults /A and *C years o" age beginning Dctober /# *C/A )he e$pansion o" Medicaid eligibility contained in this Part is repealed i" . circumstances occur: the enhanced Federal Medical Assistance Percentage "or calendar years *C/+ through *C*C is reduced below certain stated levels7 the reduced enhanced Federal Medical Assistance Percentage has taken e""ect7 and a"ter the occurrence o" the reduction o" the enhanced Federal Medical Assistance Percentage the :egislature has convened and conducted a session o" at least .C calendar days )his bill repeals the e$pansion o" medical coverage under the MaineCare program on %ecember ./# *C/9 Part C re-uires the D""ice o" Fiscal and Program >eview to contract with a nonpartisan research organi(ation to evaluate the "inancial "easibility o" providing health care coverage to newly eligible MaineCare members through the Health 3nsurance Marketplace modeled a"ter Medicaid e$pansion coverage in Arkansas or 3owa and to report the "indings o" the evaluation to the 4oint standing committee on health and human services by February /8# *C/8 Part C directs the D""ice o" Fiscal and Program >eview to contract "or an e$amination o" the impact o" the MaineCare e$pansion on programs and services that do not currently receive Federal Medical Assistance Percentage matching "unds or do not -uali"y "or enhanced Federal Medical Assistance Percentage matching "unds under the "ederal Patient Protection and A""ordable Care Act# +* ?nited States Code# Section /<CC/# et se- # with the goal o" identi"ying and ma$imi(ing 1eneral Fund savings Part C re-uires a report by February /8# *C/8 and February /8# *C/9 to the 4oint

standing committee o" the :egislature having 4urisdiction over appropriations and "inancial a""airs# the 4oint standing committee o" the :egislature having 4urisdiction over health and human services matters and the 4oint standing committee o" the :egislature having 4urisdiction over criminal 4ustice and public sa"ety matters on the amount o" 1eneral Fund savings resulting "rom the MaineCare e$pansion )he report must include the amount o" savings e$pected and reali(ed during "iscal years *C/+,/8 and *C/8,*C/9 by service area or program Part C re-uires the State &udget D""icer to calculate the amount o" savings that applies against each 1eneral Fund account "or all departments and agencies "rom savings associated with the MaineCare e$pansion and to trans"er the amounts by "inancial order upon the approval o" the 1overnor 3t re-uires the State Controller to trans"er any remaining savings to the MaineCare Stabili(ation Fund Part C re-uires the State &udget D""icer to provide a report o" the trans"erred amounts to the 4oint standing committee o" the :egislature having 4urisdiction over appropriations and "inancial a""airs no later than Fune .C# *C/8 "or "iscal year *C/+,/8 and no later than Fune .C# *C/9 "or "iscal year *C/8,/9 Part % provides "unding "or positions in the %epartment o" Health and Human Services# D""ice o" Family 3ndependence Part 2 re-uires the %epartment o" Health and Human Services# when enrolling a MaineCare member who is eligible under )itle ** Maine >evised Statutes section ./0+,1# subsection /# paragraphs H or 3# to provide written notice that is readable at the 9th grade reading level to the member o" the re-uirement to sign up as a patient with a primary health care provider promptly a"ter enrolling in the and that the member;s MaineCare coverage will end on %ecember ./# *C/9 unless a law is passed to e$tend coverage past that date Part F establishes the )ask Force to Create Dpportunities "or Stable 2mployment "or MaineCare Members )he task "orce is directed meet up to + times in order to identi"y any policies in MaineCare that penali(e or create a disincentive "or members to increase hours o" employment or earnings# to make recommendations to eliminate barriers and to propose new policies that support and promote stable and lasting employment# to e$amine current rules related to MaineCare )ransitional Assistance and any opportunities to "urther reduce the 'cli"" e""ect' impacting working "amilies that lose eligibility "or MaineCare and to consider solutions that provide continuity o" care and minimi(e persons; moving on and o"" o" the MaineCare program )he task "orce is directed to submit a report to the Foint Standing Committee on Health and Human Services by Jovember +# *C/+ Part 1 directs the %epartment o" Health and Human Services to implement re"orms speci"ied in Public :aw *C/.# chapter .9<# Section SS,+# to carry out the directives and proceed to implement the initiatives contained in >esolve *C/.# chapter *+ and chapter .9<# sections JJ and ss,/ and to move "orward to accomplish 9 re"orms identi"ied as part o" the work o" the MaineCare >edesign )ask Force that was convened pursuant to Public :aw *C//# chapter 980# part ) )his Part re-uires that savings resulting "rom accomplishing the re-uired re"orms be used to serve persons on the waiting lists "or MaineCare Sections */ and *A services )his Part directs the department to develop a plan with clear steps and a timeline to ensure that current and "uture

waiting lists "or services under Sections */ and *A do not e$ceed 9 months by Fanuary /8# *C/8# and to present the plan to the :egislature by Fune .C# *C/+ )his Part authori(es the department to adopt emergency rules to accomplish the duties contained in the law Part H directs the %epartment o" the Attorney 1eneral shall undertake an initiative to strengthen "raud investigation in the MaineCare program )he %epartment o" the Attorney 1eneral shall establish * new positions within the Health Care Crimes ?nit to investigate allegations o" misuse o" public "unds in the MaineCare program and to aid the Attorney 1eneral in the prosecution o" crimes and other legal actions related to misuse o" public "unds

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