Development and Implementation of a Statewide Fully Integrated Risk-Based Long-Term Care System
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The commissioner shall develop and implement a statewide fully integrated risk-based long-term care system that integrates medicaid-reimbursed primary, acute and long-term care services, building in strong consumer protections and aligning incentives to ensure that the right care is delivered in the right place at the right time. The long-term care system shall rebalance the overall allocation of funding for medicaid-reimbursed long-term care services by expanding access to and utilization of cost-effective home and community-based alternatives to institutional care for medicaid-eligible individuals. The system may include, subject to the availability of funding in each year's appropriations bill, expansion of Programs of All Inclusive Care for the Elderly (PACE) sites in additional major metropolitan areas of the state.
The commissioner shall ensure that comprehensive, person-centered care coordination across all medicaid primary, acute and long-term care services is a central component of the integrated long-term care system and the contractor risk agreement. A qualified entity shall conduct a comprehensive individualized assessment of needs in accordance with protocols developed by the commissioner, and shall develop a care plan with active participation of the member and family or other caregivers that addresses the identified needs and builds on and does not supplant family and other caregiving supports. The entity responsible for care coordination shall cost-effectively implement the care plan, assure coordination and monitoring of all medicaid primary, acute and long-term care services to assist individuals and family or other caregivers in providing and securing necessary care and assure the availability of a qualified workforce, including backup workers when necessary, to timely provide necessary services.
Nothing in this part may be construed to create an entitlement to home and community-based services; provided, however, that the commissioner shall design and implement the integrated long-term care system in a manner that affords access to the appropriate level of cost-effective home and community-based services for the greatest number of medicaid-eligible elderly or physically disabled individuals, or both, possible, subject to the availability of funding in each year's appropriation bill.
The cost of home and community-based services provided to a medicaid-eligible individual, which includes the cost of home health services or private duty nursing, or both, to the extent covered under the medicaid program, shall not exceed the cost of institutional services for that individual in a nursing facility except as permitted under the current medicaid state plan or any federal waivers.