H. B. 4651

(By Delegates Perdue, Hatfield, Lawrence, Moye, Barill, Fleischauer, Perry, Moore, Poore, Ellington and Lane)

[Originating in the Committee on Health and Human Resources.]

A BILL to amend and reenact §9-2-9 of the Code of West Virginia, 1931, as amended, all relating to requiring public notice of state plan amendments, reimbursement changes, demonstration projects and waiver applications, requiring a response to all public comments and requiring approval by the Legislative Oversight Commission on Health and Human Resource Accountability prior to submission to the federal government for approval.

Be it enacted by the Legislature of West Virginia:

    That §9-2-9 of the Code of West Virginia, 1931, as amended, be amended and reenacted, all to read as follows:

ARTICLE 2. COMMISSIONER OF HUMAN SERVICES; POWERS, DUTIES AND RESPONSIBILITIES GENERALLY.

§9-2-9. Secretary to develop Medicaid monitoring and case management.

    (a) The Secretary of the Department of Health and Human Resources shall:

    (1) Develop a managed care system to monitor the services provided by the Medicaid program to individual clients;

    (2) Develop an independent referral service, including the review of individual cases for abuses of the program; and

    (3) Develop a schedule for implementation of the managed care and independent referral system. The managed care system shall focus on, but not be limited to, the behavioral health and mental health services.

    (b) In addition thereto, and in accordance with applicable federal Medicaid laws, the secretary shall prepare recommendations, to be submitted to the Joint Committee on Government and Finance. In developing recommendations the secretary shall consider as options the following:

    (1) Review of Medicaid services which are optional under federal Medicaid law and identification of services to be retained, reduced or eliminated;

    (2) The elimination, reduction or phase-out of: (I) Services which are not generally available to West Virginia citizens not covered under the state's Medicaid program; or (ii) services which are not generally covered under group policies of insurance made available to employees of employers within the state;

    (3) The elimination or reduction of services, or reduction of provider reimbursement rates, for identified services of marginal utility;

    (4) Higher reimbursement rates for primary and preventive care;

    (5) Changes in fee structure, which may include a system of prospective payments, and may include establishment of global fees for identified services or diagnoses including maternity care;

    (6) Utilization caps for certain health care procedures;

    (7) Restriction of coverage for cosmetic procedures;

    (8) Identification of excessive use of certain health care procedures by individuals and a policy to restrict excessive use;

    (9) Identification of services which reduce the need for more costly options for necessary care and retention or expansion of those programs;

    (10) Identification of services for which preauthorization is a requirement for Medicaid reimbursement;

    (11) Recommendations relating to the development of a demonstration project on long-term care, which demonstration project may be limited to patients with alzheimer's disease;

    (12) A policy concerning the department's procedures for compliance, monitoring and inspection; and

    (13) Such other options as may be developed.

    (c) The secretary shall utilize in-state health care facilities for inpatient treatment when such facilities are available. Prior authorization, consistent with applicable federal law, shall be required for out-of-state inpatient treatment.

    (d) The secretary shall report to the Joint Committee on Government and Finance on the development and implementation of Medicaid programs that provide incentives to working persons. The secretary shall consider: Subsidies for low income working persons; individual or small employer buy-ins to the State Medicaid Fund; prospective payment systems for primary care physicians in underserved areas; and a system to improve monitoring of collections, expenditures, service delivery and utilization.

    (e) The secretary shall report quarterly to the Joint Committee on Government and Finance regarding provider and facility compliance with federal and state Medicaid laws, including, but not limited to, the following: The number of inspections conducted during the previous quarter; description of programs, services and facilities reviewed; findings; and recommendations for corrections.

    (f) The secretary shall, upon federal certification of the claims management system, ensure that the claims management system processing Medicaid claims provides:

    (1) Detailed quarterly financial reports to the Legislative Oversight Commission on Health and Human Resources Accountability;

    (2) A management reporting system no later than the first day of July, two thousand six; and

    (3) Specific utilization data by provider, member eligibility groups and service no later than the first day of October, two thousand six.

    (g) The secretary shall provide public notice of any proposed amendment to the state plan for Medicaid, proposed changes to the reimbursement schedule for Medicaid, any demonstration projects permitted by federal law or any waiver applications. The notice shall be filed with the Secretary of State, for publication in the State Register, including the text of the proposed amendment, the proposed demonstration project, reimbursement changes and waiver applications including a fiscal note. The notice shall fix a date, time and place for the receipt of public comment in the form of written statements and any relevant documents. The proposed amendment, proposed demonstration project, reimbursement schedule change or waiver application must comply with the following:

(a) A review of and approval for all state plan amendments, reimbursement changes, proposed demonstration projects or waiver applications along with public comments and medicaid responses to the public comments by the Legislative Oversight Commission on Health and Human Resource Accountability;

(b) If a situation arises in which approval must occur in a shortened timeframe, the secretary may file the information required in subsection(a) with the co-chairs and the senior minority member of each house on the Legislative Oversight Commission on Health and Human Resource Accountability for an expedited process; and

(c)Upon approval by the Legislative Oversight Commission on Health and Human Resource Accountability, the secretary may file the proposed plans and changes with the federal government for final approval.

              NOTE: The purpose of this bill is to require public notice of state plan amendments, waiver applications, changes to reimbursement and demonstration projects, a public comment period and approval by LOCHHRA prior to submission for federal approval.

              Strike-throughs indicate language that would be stricken from the present law, and underscoring indicates new language that would be added.