§ 9-5-29 — Department of Human Services to develop outcome measures for substance use disorder; develop a quality withhold program; and develop and implement plan for day one enrollment of Medicaid enrollees

(a) For purposes of this section:

"Department" means the Department of Human Services.

"Managed care organizations" means a certified health maintenance organization (HMO) that provides health care services to Medicaid members pursuant to an agreement or contract with the Bureau for Medical Services.

“Quality withhold” means, in a capitated model, having a portion of a rate withheld subject to performance consistent with established quality requirements.

(b) The department, shall develop performance outcome measures to be implemented at the provider level for substance use disorder in-patient providers. These provider-level outcome measures will include, but not be limited to, nationally recognized measures of performance outcomes related to substance use disorder in-patient care. The Department will utilize national standards from Hedis and/or Atlas, as well as other standardized measures, in developing the provider-level outcome measures and will obtain input from the West Virginia Behavioral Healthcare Providers Association and West Virginia Association of Addiction and Prevention Professionals. The measures will be reported to the Legislative Oversight Commission on Health and Human Resources Accountability on or before August 30, 2024, and will be implemented no later than January 1, 2025, from the initial baseline. These measures shall be shared with the managed care organizations to inform contracting decisions.

(c) The department, shall develop a managed care quality withhold program based upon nationally recognized measures of performance outcomes, including those related to substance use disorder in-patient care. These measures will be reported to the Legislative Oversight Commission on Health and Human Resources Accountability on or before May 30, 2024, and implemented for baseline July 1, 2024. The baseline year will be to establish new entrant into the market. The capitation withhold will begin July 1, 2025.

(d) The department, shall plan for automatic day one enrollment to a managed care organization for all Medicaid enrollees who are eligible for managed care. This workplan shall be presented to the Legislative Oversight Commission on Health and Human Resources Accountability on or before September 30, 2024. The workplan will detail the steps to accomplish this goal, the system changes required, the Center for Medicare and Medicaid Service (CMS) authority changes required along with a detailed timeline of milestones, and a projected completion deadline.

Legislative History

2024 Reg. Sess., HB4274; 2024 Reg. Sess., SB820; 2022 Reg. Sess., SB247; 2022 Reg. Sess., SB419; 1953 Reg. Sess., HB366; 1941 Reg. Sess., HB202; 1941 Reg. Sess., HB1