Be it enacted by the Senate and House of Representatives
in General Court assembled, and by the authority of the same,
SECTION 1. Chapter 19A of the General Laws is hereby amended by inserting after section 4A, as appearing in the 1994 Official Edition, the following section:-
Section 4B. The department shall be responsible for management of the home care program established in section four, and pursuant to the terms of an interagency service agreement entered into by the department with the division of medical assistance, for the management of clinical screening, service authorization activities and case management for medicaid community-based long term care made available to eligible elderly persons pursuant to the provisions of chapter one hundred and eighteen E and regulations promulgated thereunder; provided that the programs and activities authorized by this section shall be administered and coordinated in accordance with the single state agency requirement under 42 CFR Part 431 and other applicable requirements of Title XIX of the federal Social Security Act, or its successor title. The primary goal of said coordinated system of care shall be to assist elders maintain residence in the community consistent with their clinical and psycho-social needs and in the most cost-effective manner possible. As used in this section, the word medicaid shall mean medical care and assistance provided to eligible persons pursuant to the provisions of said chapter one hundred and eighteen E and said Title XIX or its successor title and the word division shall mean the division of medical assistance established by section sixteen A of chapter six A. The words community long term care shall mean those medicaid services mutually agreed to by the department and the division.
Said coordinated system of care shall be administered in accordance with said interagency service agreement by agencies under contract with the department, which shall be called aging services access points, and are hereinafter referred to as ASAPs. ASAPs shall be designated by the department and may be operated by one or more nonprofit agencies, one or more home care providers as defined in clause (c) of the third paragraph of section four, a combination of said home care corporations acting jointly, or by a state agency. Pursuant to said interagency service agreement and the terms of said contracts, ASAPs shall coordinate services on behalf of medicaid eligible elders; provided, however, that the division shall maintain exclusive responsibility for determining the financial or categorical eligibility of elders for medicaid and for the establishment of rates and methods of payment for medicaid services delivered pursuant to this section. Administrative payments to ASAPs for medicaid-funded functions, including, but not limited, to screenings, assessments, case management and coordination of care, shall be established by the division and shall not be subject to the jurisdiction of the rate setting commission. Administrative payments for home care-funded services under section four shall be established by the department. The division may develop a capitation system of payment for services in which ASAPs shall be at financial risk for any medicaid services that they authorize and purchase on behalf of an eligible that exceed the amount of said capitation payments.
Said interagency service agreement shall establish performance and outcome goals for medicaid and home care-related functions of ASAPs and may establish such goals for any other responsibilities contracted to ASAPs for managing said coordinated system. Continuation of the interagency service agreement authorized by this section shall be dependent on the achievement of said medicaid-related performance and outcome goals, as determined by the department.
ASAPs shall be responsible for: (1) providing information and referral services to all elders in the commonwealth; provided, however, that referrals for terminally ill elders shall include referral to a licensed and certified hospice for determination of eligibility, appropriateness and consumer interest in services; (2) conducting intake, comprehensive needs assessments, preadmission screening and clinical eligibility determinations for elders seeking institutional and community care services from medicaid or the home care program, which in the case of hospice clients, shall adhere to medicare and medicaid conditions of participation pursuant to 42CFR418 and 114.3CMR43.00; (3) developing a comprehensive service plan based on the needs of an elder, provided, however, that a medical plan of care for an elder be developed by a licensed or certified health provider; (4) arranging for, coordinating, authorizing and purchasing community long term care services called for in the comprehensive service plan; and (5) monitoring the outcomes of and making periodic adjustments to the service plan in consultation with service and health care providers. The establishment of a comprehensive service plan for an elder shall not establish an entitlement to services for any eligible person for services beyond that established by law or beyond the amounts appropriated therefore.
ASAP responsibilities for medicaid-related functions shall be those established by said interagency service agreement. When renewing the annual terms of said interagency service agreement for the subsequent fiscal year, the division shall seek to promote continuity in the said coordinated system of care consistent with the intent of this section; provided that substantive changes to the terms and provisions of any such annual agreement, including changes to the functional responsibilities of ASAP's as defined in this section, shall be negotiated after the making of a written finding by the division that such changes are necessary as a result of changes in federally reimbursable services, rates of federal reimbursement rates or state fiscal demands or a written finding that the division is prepared to implement a more comprehensive, cost-effective and coordinated system of long term care than that established by this section. The written finding required by this paragraph shall be submitted to the department, the secretary of administration and finance and the joint committee on human services and elderly affairs.
ASAPs shall not provide direct service except for case management; information and referral; and protective services as defined in regulations of the home care program established at 651 CMR 3.00 et seq. and nutrition services established at 651 CMR 4.00 et seq. and the Older Americans Acts, as amended (42 USC 3021 et seq.). Except for the direct services provided by ASAPs pursuant to this section, no ASAP shall have a direct or indirect financial ownership interest in an entity that provides institutional or community long term care services on a compensated basis. The secretary may grant a waiver of the restrictions in this paragraph upon a finding that public necessity and convenience require such a waiver.
Overall management, administration, and oversight activities related to the screening and authorization of community long term care services and related case management services shall be the responsibility of the department as delegated by the division pursuant to the terms of said interagency service agreement. The department shall actively explore with the division and interested parties programmatic options that would decrease the reliance of nursing facilities on medicaid funding and shall promote increased residential and community long term care program options for elders needing long term care services. The department shall also explore future coordinated systems of service delivery options as identified in the coordinated aging, rehabilitation and disability services project.
SECTION 2. A medicaid long term care system subject to the provisions of chapter one hundred and eighteen E of the General Laws which, upon implementation, would be more comprehensive, cost effective and coordinated than the system of long term care established by section four B of chapter nineteen A of the General Laws shall not be implemented without sixty days prior notice to the general court.