§ 2111 — Disease management demonstration programs

§ 2111. Disease management demonstration programs. 1. The department\nmay establish disease management demonstration programs through a\nrequest for proposals process to enhance the quality and\ncost-effectiveness of care rendered to medicaid-eligible persons with\nchronic health problems whose care and treatment, because of one or more\nhospitalizations, multiple disabling conditions requiring residential\ntreatment or other health care requirements, results in high medicaid\nexpenditures. In order to be eligible to sponsor and to undertake a\ndisease management demonstration program, the proposed sponsor may be a\nnot-for-profit, for-profit or local government organization that has\ndemonstrated expertise in the management or coordination of care to\npersons with chronic diseases or that has the experience of providing\ncost-effective community-based care to such patients, or in the case of\na local government organization, has expressed a strong willingness to\nsponsor such a program. The department may also approve disease\nmanagement demonstration programs which include, but are not limited to,\nthe promotion of adherence to evidence-based guidelines, improvement of\nprovider and patient communication and provide information on provider\nand beneficiary utilization of services. The department shall grant no\nfewer than six demonstration programs, no more than one-third of such\nprograms shall be selected to provide these services in any single\nsocial services district; provided further, where the department grants\nless than six demonstration programs, no more than one such program\nshall be selected to provide these services in any single social\nservices district. The department shall approve disease management\ndemonstration programs which are geographically diverse and\nrepresentative of both urban and rural social services districts. The\nprogram sponsor must establish, to the satisfaction of the department,\nits capacity to enroll and serve sufficient numbers of enrollees to\ndemonstrate the cost-effectiveness of the demonstration program.\n 2. The department shall establish the criteria by which individuals\nwill be identified as eligible for enrollment in the demonstration\nprograms. Persons eligible for enrollment in the disease management\ndemonstration program shall be limited to individuals who: receive\nmedical assistance pursuant to title eleven of article five of the\nsocial services law and may be eligible for benefits pursuant to title\n18 of the social security act (Medicare); are not enrolled in a Medicaid\nmanaged care plan, including individuals who are not required or not\neligible to participate in Medicaid managed care programs pursuant to\nsection three hundred sixty-four-j of the social services law; are\ndiagnosed with chronic health problems as may be specified by the entity\nundertaking the demonstration program, including, but not limited to one\nor more of the following: congestive heart failure, chronic obstructive\npulmonary disease, asthma, diabetes or other chronic health conditions\nas may be specified by the department; or have experienced or are likely\nto experience one or more hospitalizations or are otherwise expected to\nincur excessive costs and high utilization of health care services.\n 3. Enrollment in a demonstration program shall be voluntary. A\nparticipating individual may discontinue his or her enrollment at any\ntime without cause. The commissioner shall review and approve all\nenrollment and marketing materials for a demonstration program.\n 4. The demonstration program shall offer evidence-based services and\ninterventions designed to ensure that the enrollees receive high\nquality, preventative and cost-effective care, aimed at reducing the\nnecessity for hospitalization or emergency room care or at reducing\nlengths of stay when hospitalization is necessary. The demonstration\nprogram may include screening of eligible enrollees, developing an\nindividualized care management plan for each enrollee and implementing\nthat plan. Disease management demonstration programs that utilize\ninformation technology systems that allow for continuous application of\nevidence-based guidelines to medical assistance claims data and other\navailable data to identify specific instances in which clinical\ninterventions are justified and communicate indicated interventions to\nphysicians, health care providers and/or patients, and monitor physician\nand health care provider response to such interventions, shall have the\nenrollees, or groups of enrollees, approved by the department for\nparticipation. The services provided by the demonstration program as\npart of the care management plan may include, but are not limited to,\ncase management, social work, individualized health counselors,\nmulti-behavioral goals plans, claims data management, health and\nself-care education, drug therapy management and oversight, personal\nemergency response systems and other monitoring technologies, telehealth\nservices and similar services designed to improve the quality and\ncost-effectiveness of health care services.\n 5. The department shall be responsible for monitoring the quality,\nappropriateness and cost-effectiveness of a demonstration program. The\ndepartment shall utilize, to the extent possible, all potential sources\nof funding for demonstration programs, including, but not limited to,\nprivate payments and donations. All such funds shall be deposited by the\ncommissioner and credited to the disease management account which shall\nbe established by the comptroller in the special revenue-other fund.\nAdditionally, to the extent of funds appropriated therefor, medical\nassistance funds, including any funding or shared savings as may become\navailable through federal waivers or otherwise under titles 18 and 19 of\nthe federal social security act, may be used by the department for\nexpenditures in support of the disease management program.\n 6. Payments shall be made by the department to the entity responsible\nfor the operation of the demonstration program on a fixed amount per\nmember per month of enrollment and shall reimburse the program sponsor\nfor the services rendered pursuant to subdivision four of this section.\nThe amount paid shall be an amount reasonably necessary to meet the\ncosts of providing such services, provided that the total amount paid\nfor medical assistance to enrollees in any such disease management\ndemonstration program, including any demonstration program expenditures,\nshall not exceed ninety-five percent of the medical assistance\nexpenditure related to such enrollee that would reasonably have been\nanticipated if the enrollee had not been enrolled in such demonstration\nprogram. The department may make payments to demonstration programs that\nprovide administrative services only, provided that expenditures made\nfor enrollees, or a group of enrollees, participating in the\ndemonstration program shall provide sufficient savings as determined by\nthe department, had the enrollees, or groups of enrollees, not been\nenrolled in such demonstration. The department shall provide an interim\nreport to the governor, and the legislature on or before December\nthirty-first, two thousand six and a final report on or before December\nthirty-first, two thousand seven on the results of demonstration\nprograms. Both reports shall include findings as to the demonstration\nprograms' contribution to improving quality of care and their\ncost-effectiveness. In the final report, the department shall offer\nrecommendations as to whether demonstration programs should be extended,\nmodified, eliminated or made permanent.\n