Governor Signs Managed Care Reforms with HCA-backed Provisions

Download: Governor Signs Managed Care Reform Bill

For Immediate Release: July 29, 2009

Contact:

Roger Noyes (HCA) 518-810-0665

Ann Duckett (VNS of Rochester and Monroe County) 585-787-2233

Home Care Association of New York State (HCA) Applauds Governor's
Signing of Landmark Managed Care Reform Bill Containing Provisions Negotiated by HCA to Improve Home Care Access

A statement from Rochester-based HCA Board Chair Victoria Hines and
HCA President Joanne Cunningham in response to today's bill signing in Rochester

Home Care Association of New York State (HCA) Board Chair Victoria Hines, President and CEO of the Visiting Nurse Service of Rochester and Monroe County, and HCA President Joanne Cunningham applauded Governor Paterson's signing today of landmark managed care reform legislation.

The bill includes provisions negotiated by HCA to ensure timely and expeditious authorization for home health services covered by managed care plans. Originating as a program bill by Governor Paterson's administration through the State Insurance Department (SID), the legislation was sponsored by Assemblyman Joseph Morelle (D-Irondequoit) and Senator Neil Breslin (D-Delmar).

A Statement from HCA Board Chair Hines

"The home care community applauds Governor Paterson, Assemblyman Morelle, Senator Breslin and the Legislature as a whole for advancing these critical managed care reforms," Ms. Hines said. "By helping to remove service authorization hurdles that often impede or needlessly delay access to care, this landmark bill allows providers to initiate care urgently needed for patients to return home from the hospital."

She added: "When a person undergoes surgery in the hospital and is ready for discharge, home care often lays the final path to recovery through a mix of nursing, therapy or aide services delivered directly to the patient at home. More timely approval of these necessary covered services by managed care plans will allow patients to more quickly and safely return home under an agency's care while supporting the hospital's capacity to provide its level of services to individuals in need."

"These reforms are a win for patients, who prefer to be and therefore should be at home, and for the health care system as a whole in permitting the most appropriate use of services at each stage of an individual's treatment," she concluded.

A Statement from HCA President Cunningham

Ms. Cunningham said: "This bill's provisions will improve the interface between health care providers and health plans in a number of significant areas, and will promote the mutual goal of supporting access, coverage and delivery of health care services to the consumer."

She added: "HCA was pleased and privileged to have been a part of the evolution and negotiation over this legislation. We thank the Governor, the State Insurance and Health Departments and the Legislature for the receptiveness to our input and for the attention to our concerns."

HCA's advocacy specifically led to the inclusion of the following major provisions in S.5472-A/ A.8402-A:

New protections for hospital discharge to home care providers.

This provision requires a health plan's utilization review (UR) agent to make a determination within one business day of receiving the necessary information associated with a request for home health services following an inpatient hospital admission, and to notify the patient and/or provider of this determination within the same timeframe. The determination/notification timeframe extends to 72 hours when the date of request immediately precedes a weekend or holiday.

These new timeframes are vital for successful care after a hospitalization. In addition, it is expected that the tighter timeframes, combined with the requirements for health plans to be provided with "the necessary information," may also prompt improvements in the overall hospital discharge planning process, which in itself will benefit the consumers, providers and payors as well.

Requirements that the health plan cover home care services following inpatient discharge while the UR agent's determination is pending.

This provision specifically prohibits denial of coverage on the basis of medical necessity or a lack of prior authorization during the course of a UR, effectively creating the opportunity for home care agencies to secure/identify the status of initial coverage prior to accepting a hospital discharge.

Explicit expedited appeal rights for home care, which may be exercised directly by home care providers and which provide further access to external appeals.

Under this provision, an explicit right to an expedited appeal is provided to home care patients and providers for adverse determinations related to home care services following a hospital discharge. The expedited appeal must be processed within two business days and would further lead to the ability to request an external appeal if the initial appeal is denied. This process guarantees that providers who accept patients following hospital discharge will have access to an immediate review of services commenced or otherwise determined necessary by the provider as part of the plan of care but denied by the health plan.

Additional related provisions in the bill require that, upon determinations following an appeal for external review, the external appeal agent must directly notify the provider of its determinations. (Currently, only the insured and the plan must be notified.)

For more details about the bill, including provisions that affect all health providers, view the summary sheet.

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