Bill Text: NJ A4932 | 2018-2019 | Regular Session | Amended


Bill Title: Establishes perinatal episode of care pilot program in Medicaid.

Spectrum: Partisan Bill (Democrat 11-0)

Status: (Introduced) 2019-03-25 - Substituted by S3365 (2R) [A4932 Detail]

Download: New_Jersey-2018-A4932-Amended.html

[First Reprint]

ASSEMBLY, No. 4932

STATE OF NEW JERSEY

218th LEGISLATURE

 

INTRODUCED JANUARY 17, 2019

 


 

Sponsored by:

Assemblywoman  GABRIELA M. MOSQUERA

District 4 (Camden and Gloucester)

Assemblyman  ADAM J. TALIAFERRO

District 3 (Cumberland, Gloucester and Salem)

Assemblyman  DANIEL R. BENSON

District 14 (Mercer and Middlesex)

 

Co-Sponsored by:

Assemblywomen Murphy, Reynolds-Jackson, Lampitt, Assemblyman Greenwald and Assemblywoman Tucker

 

 

 

 

SYNOPSIS

     Establishes perinatal episode of care pilot program in Medicaid.

 

CURRENT VERSION OF TEXT

     As reported by the Assembly Appropriations Committee on March 18, 2019, with amendments.

 


An Act establishing a Medicaid perinatal episode of care pilot program.

 

     Be It Enacted by the Senate and General Assembly of the State of New Jersey:

 

     1.    As used in this act:

     "Commencement date" means the date 1[in] on1 which the perinatal episode of care pilot program is first implemented pursuant to this act, which shall be no later than 1[January 1, 2020] January 1, 2021 unless a later date is recommended by the steering committee and is approved by the division1.

     "Division" means the Division of Medical Assistance and Health Services in the Department of Human Services.

     "Perinatal episode of care" or "episode" means all pregnancy-related care 1,1 including prenatal care, labor and birth, and postpartum care 1,1 provided to a mother and infant, beginning 40 weeks prior to the delivery and ending 60 days after the delivery of the infant, or as otherwise defined by the perinatal episode of care 1[learning network, as established pursuant to section 2 of this act,] steering committee1 and approved by the division.

     "Perinatal episode of care 1[learning network" or "learning network"] steering committee or "steering committee"1 means 1[a group of ten or more members including but not limited to Medicaid managed care organizations, maternity healthcare providers, and division representatives, convened by the division or a multi-stakeholder entity well versed in alternative payment models designated by the division] the perinatal episode of care steering committee established pursuant to section 2 of this act1.

     "Perinatal episode of care payment model" means a provider reimbursement model based on target total cost of care for services provided within a perinatal episode of care.

     "Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

     "Participating provider" means an obstetrical provider or group of obstetrical providers approved to participate in the Medicaid program that meet a specified minimum volume of Medicaid live births per year, as defined by the 1[learning network] steering committee1 and approved by the division, and that has entered into a voluntary provider agreement with 1[a] on or more1 Medicaid managed care organization to participate in the perinatal episode of care pilot program. 

     "Total cost of care" means all costs for a perinatal episode of care as calculated by claims data, with a risk adjustment for clinical factors that affect the cost of delivering an episode for specific patients.

 

     2.    a.   The division shall establish a perinatal episode of care 1[learning network] steering committee1.  The 1[learning network] steering committee1 may be administered by the division, or 1, at the division's discretion,1 a designated entity 1[, at the division's discretion] that is well versed in alternative payment models1.  Any entity designated by the division to administer the 1[learning network] steering committee1 shall enter into a data sharing agreement with the division in order to fulfill the provisions of this act.

     The 1[learning network] steering committee1 shall consist of 1[ten] 101 or more members with knowledge regarding alternative payment methodologies for pregnancy-related services within Medicaid, including 1,1 but not limited to:  the Director of the 1[division] Division of Medical Assistance and Health Services in the Department of Human Services1, or the director's designee; representatives from each of the 1[current]1 Medicaid 1[Managed Care Organizations] managed care organizations (MCOs) currently1 contracted with the division to provide Medicaid benefits; 1at least two representatives of federally qualified health centers, with at least one representative from a federally qualified health center located in the northern region of the State and at least one representative from a federally qualified health center located in the southern region of the State;1 and at least three maternity healthcare providers, representing 1[Northern, Central, and Southern] northern, central, and southern1 New Jersey, approved to participate in Medicaid.

      b.   The 1[learning network] steering committee1, as approved by the division, shall develop the parameters for a 1[three year] three-year1 perinatal episode of care pilot program within Medicaid.  The purpose of this pilot program is to improve perinatal health care outcomes and to reduce the cost of perinatal care.  To effectuate the goals of the program, the 1[learning network] steering committee1 shall design a perinatal episode of care payment model, which shall be approved by the division and implemented by 1[Medicaid managed care organizations (MCOs)] MCOs1, according to section 3 of this act. 

      c.    1[Subject to the approval of the division, the learning network shall:] The steering committee shall make recommendations on how the division shall:1

     (1)   Identify the services to be covered under each episode, including 1[wrap around] any wraparound1 patient support services, such as childbirth education and community doula services for the mother; 

     (2)   Establish patient volume minimums for participating providers;

     (3)   Identify quality metrics and quality metric targets to be included in the episode;

     (4)   Establish a methodology to calculate the target total cost of care for an episode and 1[the distribution of any shared savings] calculate any risk sharing payments1 between a MCO and a participating provider.  1[The] Such1 methodology for shared savings shall align payments to a participating provider with the quality metrics and quality metric targets, as determined by the 1[learning network] steering committee1, regarding the provider's provision of care; 1[and]1

     (5)   Establish additional episode parameters 1,1 including the episode trigger, duration, principal accountable provider, exclusions, adjustments, and quality reporting methodology between providers and 1[managed care organizations] MCOs; and1

     (6)   Define the scope of the pilot program, including whether implementation should be focused on selected geographic areas, populations, providers, health systems, or MCOs.

      d.   The 1[learning network] steering committee1 shall report to the Governor, and 1, pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1),1 to the Legislature, 1[pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1),] no later than1 four years following the commencement date, on the effectiveness of the perinatal episode of care pilot program in improving the quality and reducing the cost of maternity and infant care 1[and make] .  The report shall include1 any recommendations that the 1[learning network] steering committee1 network deems appropriate to 1continue,1 revise, restrict, or expand the program.  The division shall make copies of the 1[learning network's] steering committee's1 report available to the public on the Department of Human Services' website.

 

     3.    1[A] The division shall require at least one1 managed care organization that has contracted with the division to provide benefits under the Medicaid 1[Program shall] program to1 enter into a provider agreement with an obstetrical provider or group of obstetrical providers to implement the perinatal episode of care payment model, as established by the 1[learning network] steering committee1, and approved by the division, pursuant to section 2 of this act.

 

     4.    a. A participating provider shall submit all information required to fulfill the provisions of this act to the 1[learning network] division1, in a format and at a frequency to be determined by the 1[learning network]1 and approved by the division.

     b.    A participating provider shall conduct a risk assessment for all episodes using the Perinatal Risk Assessment form, as used by the division, to determine each mother's level of need for 1[State sponsored] State-sponsored1 support services. 1[When the assessment tool indicates a need for services,] With the mother's consent,1 the provider shall 1forward the completed risk assessment form to the appropriate county central intake agency, which shall review the form and, if the form indicates a need for services, contact the mother to1 provide 1[the mother with the appropriate] her with information and1 referrals 1to appropriate services1.  The 1[referral of]1 services 1to which mothers may be referred pursuant to this subsection1 shall include, but 1shall1 not be limited to: home visitation programs 1[,] ;1 mental health and substance use disorder treatment 1[,] ;1 domestic violence support and intervention; transportation and housing assistance; and group prenatal counseling.

 

     5.    The Commissioner of Human Services shall apply for such State plan amendments or waivers as may be necessary to implement the provisions of this act and to secure federal financial participation for State Medicaid expenditures under the Medicaid program.

 

     6.    The Commissioner Human Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt rules and regulations necessary to implement the provisions of this act. 

 

     7.    This act shall take effect immediately, with the 1steering committee convening no later than July 1, 2019, and the1 pilot program commencing no later than January 1, 1[2020,] 2021, unless a later date is recommended by the steering committee and approved by the division,1 and shall expire upon the submission of the report by the 1[learning network] steering committee1 to the Governor and the Legislature pursuant to subsection d. of section 2 of this act.

feedback