SB767 HFA Perdue and Morgan 4-9 adopted

Adopted by House 4-9-2009
SB767 HFA Perdue and Morgan 4-9
B. Thompson 3192

Delegates Perdue and Morgan move to amend the bill on page two, after the enacting clause by striking out the remainder of the bill and inserting in lieu thereof the following:
" That §9-2-9 of the Code of West Virginia, 1931, as amended, be amended and reenacted; that said code be amended by adding thereto a new section, designated §9-2-9a; and that §9-4-3 of said code be amended and reenacted, all to read as follows:
ARTICLE 2. DEPARTMENT OF HEALTH AND HUMAN RESOURCES, AND OFFICE OF
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 July 1, 2006; and
(3) Specific utilization data by provider, member eligibility groups and service no later than October 1, 2006.
(g) The secretary shall provide public notice of any proposed amendment to the state plan for Medicaid or proposed changes to the reimbursement schedule for Medicaid. The notice shall be filed with the Secretary of State, for publication in the State Register, including the text of the proposed amendment and 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 may not be filed for federal approval until after the close of a thirty day public comment period. If the Secretary of the Department of Health and Human Resources determines a submission or amendment of a proposed amendment to the state plan for Medicaid or proposed changes to the reimbursement schedule for Medicaid will have a substantial impact on services, on benefits, or on payments to providers he or she may, solely at his or her discretion, convene a public hearing. When rules are necessary to conform to changes in state or federal law where no agency discretion as to the substance of the rule is involved, then the provisions of this subsection shall not apply. However, if the Department of Health and Human Resources finds an emergency exists requiring that emergency rules be promulgated earlier than this subsection would permit, then such emergency rules together with a statement of the circumstances constituting the emergency shall be filed with the Secretary of State and a notice of such filing shall be published in the State Register. Such emergency rules shall become effective upon the approval of the Secretary of State in accordance with section fifteen-a, article three, chapter twenty-nine-a of this code, but promulgation of such emergency rules shall not otherwise waive the department's obligation to comply with this subsection.
§9-2-9a. Contract procedure for the Medicaid program.
(a) The secretary is authorized to execute a contract to implement professional health care, managed care, actuarial and health care-related monitoring, quality review/utilization, claims processing and independent professional consultant contracts for the Medicaid program.
(b) The provisions of article three, chapter five-a of this code do not apply to contracts set out in subsection (a) of this section: Provided, That the secretary shall comply with the requirements set forth in this section.
(c) The secretary shall develop procedures and requirements for competitive bidding and the awarding of contracts set out in subsection (a) of this section, which procedures and requirements shall include, but are not limited to, the following:
(1) Submitting public notice bids;
(2) The general terms and conditions for the contract;
(3) Awarding contracts; and
(4) The description of the commodities and services required for the contract, stated with sufficient clarity to assure that there is a comprehensive understanding of the contact's scope and requirements; and
(5) Contract management procedures which will ensure the assessment of contractor performance and compliance with contract requirements on a regular basis as appropriate for the specific contract, and no less frequently than on an annual basis for any contract awarded pursuant to the provisions of this section.
(d) The awarding of the contract may be based on:
(1) Best value;
(2) Low bid;
(3) Sole source; or
(4) Any other basis the secretary chooses to award or reject the bid: Provided, That the secretary shall document the basis of any decision made pursuant to the provisions of this subsection.
(e) The secretary may employ the services of independent professional consultants to assist in preparing solicitations or for the evaluation of any responses to such solicitations: Provided, That the independent professional consultant, or member of his or her immediate family, or business with which he or she is associated, may not have any interest in the profits or benefits of the contract for which he or she may participate in the preparation of the solicitation or in the evaluation of the response.
(f) The secretary may terminate any contract with thirty days' prior written notice.

ARTICLE 4. STATE ADVISORY BOARD; MEDICAL SERVICES FUND; ADVISORY COUNCIL; GENERAL RELIEF FUND.

§9-4-3. Advisory council.
The advisory council, created by chapter one hundred forty-three, Acts of the Legislature, regular session, 1953, as an advisory body to the State Medicaid Agency with respect to the medical services fund and disbursements therefrom and to advise about health and medical services, is continued so long as the medical services fund remains in existence, and thereafter so long as the State Medicaid Agency considers the advisory council to be necessary or desirable, and it is organized as provided by this section and applicable federal law and has those advisory powers and duties as are granted and imposed by this section and elsewhere by law: Provided, That the continuation of the advisory council is subject to a preliminary performance review pursuant to the provisions of article ten, chapter four of this code, evaluating the effectiveness and efficiency of the advisory council, to be conducted during the interim of the Legislature in the year 2006 by the Joint Committee on Government Operations.
The term of office of those members serving on the advisory council, on the effective date of the amendments made to this section by the Legislature during its regular session in the year 1998, shall continue until they are reappointed or replaced in accordance with the provisions of this section.
The advisory council shall consist of not less than nine members, nor more than ~~thirteen~~ 15 members, all but ~~two~~ four of whom shall be appointed by the State Medicaid Agency and serve until replaced or reappointed on a rotating basis. The heads of the ~~Public Health and Public Welfare Agencies~~ Bureau of Public Health and Bureau for Medical Services are members ex officio. The cochairs of the Legislative Oversight Commission on Health and Human Resources Accountability, or their designees, are nonvoting ex officio members. The remaining members comprising the council consist of a person of recognized ability in the field of medicine and surgery with respect to whose appointment the State Medical Association shall be afforded the opportunity of making nomination of three qualified persons, one member shall be a person of recognized ability in the field of dentistry with respect to whose appointment the State Dental Association shall be afforded the opportunity of nominating three qualified persons, and the remaining members shall be chosen from persons of recognized ability in the fields of hospital administration, nursing and allied professions and from consumers groups, including Medicaid recipients, members of the West Virginia Directors of Senior and Community Services, Labor Unions, Cooperatives and Consumer-sponsored Prepaid Group Practices Plans.
The council shall meet on call of the state Medicaid Agency.
Each member of the advisory council shall receive reimbursement for reasonable and necessary travel expenses for each day actually served in attendance at meetings of the council in accordance with the state's travel regulations. Requisitions for the expenses shall be accompanied by an itemized statement, which shall be filed with the Auditor and preserved as a public record.
The advisory council shall assist the State Medicaid Agency in the establishment of rules, standards and bylaws necessary to carry out the provisions of this section and shall serve as consultants to the State Medicaid Agency in carrying out the provisions of this section.