§ 2999-Q — Accountable care organizations; requirements

§ 2999-q. Accountable care organizations; requirements. 1. The\ncommissioner shall make regulations establishing criteria for\ncertificates of authority, quality standards for ACOs, reporting\nrequirements and other matters deemed to be appropriate and necessary in\nthe operation and evaluation of ACOs under this article. In making such\nregulations, the commissioner shall consult with the superintendent of\nfinancial services, health care providers, third-party health care\npayers, advocates representing patients, and other appropriate parties.\nSuch regulations shall be consistent, to the extent practical and\nconsistent with this article, with CMS regulations for accountable care\norganizations under the Medicare program.\n 2. Such regulations may, and shall as necessary for purposes of this\narticle, address matters including but not limited to:\n (a) The governance, leadership and management structure of the ACO\nthat reasonably and equitably represents the ACO's participants and the\nACO's patients, including the manner in which clinical and\nadministrative systems and clinical participation will be managed;\n (b) Definition of the population proposed to be served by the ACO,\nwhich may include reference to a geographical area and patient\ncharacteristics;\n (c) The character, competence and fiscal responsibility and soundness\nof an ACO and its principals, if and to the extent deemed appropriate by\nthe commissioner;\n (d) The adequacy of an ACO's network of participating health care\nproviders, including primary care health care providers;\n (e) Mechanisms by which an ACO will provide, manage, and coordinate\nquality health care for its patients including where practicable\nelevating the services of primary care health care providers to meet\npatient-centered medical home standards, coordinating services for\ncomplex high-need patients, and providing access to health care\nproviders that are not participants in the ACO;\n (f) Mechanisms by which the ACO shall receive and distribute payments\nto its participating health care providers, which may include incentive\npayments (which may include medical home payments) or mechanisms for\npooling payments received by participating health care providers from\nthird-party payers and patients;\n (g) Mechanisms and criteria for accepting health care providers to\nparticipate in the ACO that are related to the needs of the patient\npopulation to be served and needs and purposes of the ACO, and\npreventing unreasonable discrimination;\n (h) Mechanisms for quality assurance and grievance procedures for\npatients or health care providers where appropriate, and procedures for\nreviewing and appealing patient care decisions;\n (i) Mechanisms that promote evidence-based health care, patient\nengagement, coordination of care, electronic health records, including\nparticipation in health information exchanges, other enabling\ntechnologies and integrated, efficient and effective health care\nservices;\n (j) Performance standards for, and measures to assess, the quality and\nutilization of care provided by an ACO;\n (k) Appropriate requirements for ACOs to promote compliance with the\npurposes of this article;\n (l) Posting on the department's website information about ACOs that\nwould be useful to health care providers and patients, including similar\nmetrics as the commissioner publishes for other organizations such as\nMedicaid managed care providers under section three hundred sixty-four-j\nof the social services law and health homes under section three hundred\nsixty-five-l of the social services law;\n (m) Requirements for the submission of information and data by ACOs\nand their participating and affiliated health care providers as\nnecessary for the evaluation of the success of ACOs;\n (n) Protection of patient rights as appropriate;\n (o) The impact of the establishment and operation of an ACO, including\nproviding that it shall not diminish access to any health care service\nfor the population served and in the area served; and\n (p) Establishment of standards, as appropriate, to promote the ability\nof an ACO to participate in applicable federal programs for ACOs.\n 3. (a) The ACO shall provide for meaningful participation in the\ncomposition and control of the ACO's governing body for ACO participants\nor their designated representatives.\n (b) The ACO governing body shall include at least one representative\nof each of the following groups: (i) recipients of Medicaid, family\nhealth plus, or child health plus; (ii) persons with other health\ncoverage; and (iii) persons who do not have health coverage. Such\nrepresentatives shall have no conflict of interest with the ACO and no\nimmediate family member with a conflict of interest with the ACO.\n (c) At least seventy-five percent control of the ACO's governing body\nshall be held by ACO participants.\n (d) Members of the ACO governing body shall have a fiduciary\nrelationship with the ACO and shall be subject to conflict of interest\nrequirements adopted by the ACO and in regulations of the commissioner.\n (e) The ACO's finances, including dividends and other return on\ncapital, debt structure, executive compensation, and ACO participant\ncompensation, shall be arranged and conducted to maximize the\nachievement of the purposes of this article.\n 4. (a) An ACO shall use its best efforts to include among its\nparticipants, on reasonable terms and conditions, any\nfederally-qualified health center that is willing to be a participant\nand that serves the area and population served by the ACO.\n (b) An ACO may seek to focus on providing health care services to\npatients with one or more chronic conditions or special needs. However,\nan ACO may not otherwise, on the basis of a person's medical or\ndemographic characteristics, discriminate for or against or discourage\nor encourage any person or person with respect to enrolling or\nparticipating in the ACO.\n (c) An ACO shall not, by incentives or otherwise, discourage a health\ncare provider from providing or an enrollee or patient from seeking\nappropriate health care services.\n (d) An ACO shall not discriminate against or disadvantage a patient or\npatient's representative for the exercise of patient autonomy.\n (e) An ACO may not limit or restrict beneficiaries to use of providers\ncontracted or affiliated with the ACO. An ACO may not require a patient\nto obtain the prior approval, from a primary care gatekeeper or\notherwise, before utilizing the services of other providers. An ACO may\nnot make adverse determinations as defined in article forty-nine of this\nchapter.\n 5. An ACO may provide care coordination for its participating\npatients, which (a) shall include but not be limited to managing,\nreferring to, locating, coordinating, and monitoring health care\nservices for the member to assure that all medically necessary health\ncare services are made available to and are effectively used by the\nmember in a timely manner, consistent with patient autonomy; and (b) is\nnot a requirement for prior authorization for health care services, and\nreferral shall not be required for a member to receive a health care\nservice.\n 6. (a) Subject to regulations of the commissioner: (i) an ACO may\nenter into arrangements with one or more third-party health care payers\nto establish payment methodologies for health care services for the\nthird-party health care payer's enrollees provided by the ACO or for\nwhich the ACO is responsible, such as full or partial capitation or\nother arrangements; (ii) such arrangements may include provision for the\nACO to receive and distribute payments to the ACO's participating health\ncare providers, including incentive payments and payments for health\ncare services from third-party health care payers and patients; and\n(iii) an ACO may include mechanisms for pooling payments received by\nparticipating health care providers from third-party payers and\npatients.\n (b) Subject to regulations of the commissioner, the commissioner, in\nconsultation with the superintendent of financial services, may\nauthorize a third-party health care payer to participate in payment\nmethodologies with an ACO under this subdivision, notwithstanding any\ncontrary provision of this chapter, the insurance law, the social\nservices law, or the elder law, on finding that the payment methodology\nis consistent with the purposes of this article.\n (c) An ACO may contract with a third-party health care payer to serve\nas all or part of the third-party health care payer's provider network\nor care coordination agent, provided in that case the ACO shall be\nsubject to all provisions of this chapter or the insurance law which are\napplicable to the provider network of the third-party health care payer.\n 7. The provision of health care services directly or indirectly by an\nACO through health care providers shall not be considered the practice\nof a profession under title eight of the education law by the ACO.\n