§ 4403-C — Comprehensive HIV special needs plan certification

* § 4403-c. Comprehensive HIV special needs plan certification. 1. No\nperson or group of persons may operate a comprehensive HIV special needs\nplan without first obtaining a certificate of authority from the\ncommissioner. Any person may apply for a comprehensive HIV special needs\ncertificate of authority, provided, however, that a shared health\nfacility, as defined in article forty-seven of this chapter, shall not\nbe eligible for such a certificate.\n 2. An applicant for certification shall submit the following\ninformation and documentation to the satisfaction of the commissioner:\n (a) a copy of the applicant's basic organizational documents and\nagreements of the applicant and all network members, including all\ncontracts and agreements relating to the provision of HIV services;\n (b) a copy of any current licensure or certification maintained by the\napplicant;\n (c) a description of any experience the applicant may have had in\nproviding HIV services which are licensed, certified, funded or approved\nby the department, including identification of any disciplinary,\nadministrative or criminal proceedings related to such services in the\npast ten years, the resolution thereof, and any other proceedings\ncurrently pending;\n (d) full disclosure of the financial condition of the applicant and of\nmembers of the board, officers, controlling persons, owners and\npartners, including, but not limited to, a statement of the applicant's\nassets, resources, accounts receivable, liabilities and proposed sources\nand uses of funds and the most recent certified income statement and\nbalance sheet;\n (e) a demonstration of the applicant's ability to provide or continue\nto provide quality HIV services;\n (f) a description of the geographic area served and to be served by\nthe applicant;\n (g) a description of the applicant's current capacity, and proposed\ncapacity, to provide or arrange for the provision of comprehensive HIV\nservices for a defined geographic area to a defined population; and\n (h) such other information as the commissioner shall require.\n 3. The commissioner shall not issue a comprehensive HIV special needs\nplan certificate of authority to an applicant therefor unless the\napplicant demonstrates that:\n (a) it has defined an enrolled population to which the comprehensive\nHIV special needs plan proposes to provide comprehensive HIV health\nservices, has demonstrated a willingness to enroll any person who is\neligible for enrollment within its defined catchment area and has\nestablished a mechanism by which the enrolled population may participate\nin determining the policies of the organization;\n (b) it has defined a specific network of providers and facilities that\nare capable of providing comprehensive HIV special needs services to the\nenrolled population described in paragraph (a) of this subdivision;\n (c) it has the capability of organizing, marketing, managing,\npromoting and operating a comprehensive HIV special needs plan;\n (d) it is financially responsible and sound and may be expected to\nmeet its obligations to its enrolled members. For the purposes of this\nparagraph, "financially responsible" means that the applicant is capable\nof assuming full financial risk on a prospective basis for the provision\nof comprehensive HIV special needs services within the geographic\ncatchment area defined by the applicant except that it may allow\nproviders to share financial risk under the terms of their contract, or\nit may obtain insurance or make other arrangements for the cost of\nproviding comprehensive HIV special needs health services to enrollees;\nany insurance or other arrangements proposed to meet this requirement\nshall be approved as to adequacy as a prerequisite to the issuance of\nany comprehensive HIV special needs certificate of authority by the\ncommissioner. In making a determination of financial soundness, the\ncommissioner shall consider financial information, contracts and\nagreements required as part of the application for a certificate of\nauthority and any other information that the commissioner shall deem\nnecessary to make that determination. For purposes of this section, any\ngrants awarded to an applicant contingent upon its approval as a HIV\nspecial needs plan certified pursuant to this section, shall be\nconsidered when making a determination of fiscal soundness;\n (e) it has established a system which appropriately accounts for costs\nand a uniform system of reports and audits meeting the requirements of\nthe commissioner;\n (f) the character, competence and standing in the community of the\nproposed incorporators, directors, sponsors, or stockholders of the\nplan, and its network providers, are satisfactory to the commissioner;\n (g) it is willing and able to assure that necessary HIV services will\nbe provided in a timely manner to assure the availability and\naccessibility of adequate personnel and facilities; to assure continuity\nof care for enrollees; and to implement procedures for referrals, as\nrequested, to appropriate care for affected family members of the\nenrolled population;\n (h) the prepayment mechanism of its comprehensive HIV special needs\nplan, the bases upon which the providers of health care are compensated,\nand the anticipated use of allied health personnel are conducive to the\nuse of ambulatory care and the efficient use of hospital services;\n (i) acceptable procedures have been established for the conduct of\noutreach and enrollment of persons with HIV infection including persons\nwho are homeless, substance users and other vulnerable populations;\n (j) acceptable procedures have been developed to communicate with\nparticipants in a linguistically and culturally competent manner;\n (k) acceptable procedures have been established to monitor the quality\nof care provided by the plan and to assure that all care rendered meets\nclinical standards of HIV care as established and maintained by the AIDS\nInstitute of the New York state department of health;\n (l) approved mechanisms exist to resolve complaints and grievances\ninitiated by any enrolled member; and\n (m) the requirements of this article and any regulations promulgated\npursuant thereto have been met and will continue to be met.\n 4. The commissioner shall not issue a comprehensive HIV special needs\ncertificate of authority unless the applicant has demonstrated to the\ncommissioner's satisfaction that the requirements of this article and\nany regulations promulgated pursuant thereto have been met and will\ncontinue to be met, provided, however, that the commissioner may impose\nalternative requirements, or portions thereof, particularly those\nrelated to capitalization, if he or she determines that such alternative\nrequirements will serve to promote the high quality, efficient provision\nof comprehensive health services or services required by HIV positive\npersons, will promote the development of HIV special needs plans and\nthat the proposed plan will provide an appropriate and cost-effective\nalternative method for the delivery of such services in a manner which\nwill meet the needs of the population to be served.\n 5. The commissioner shall make a determination on an application after\nreceipt of all required and requested information and documentation.\n 6. The commissioner shall review and approve any current or proposed\ncontracts or agreements with current or prospective network members, and\nprovided further, that the commissioner shall specifically review and\napprove any proposed provisions in such contracts or agreements with the\nprospective or existing network members which specify any risk sharing\narrangements.\n 7. The commissioner may revoke, limit or annul a comprehensive HIV\nspecial needs plan certificate of authority in accordance with the\nprovisions of section forty-four hundred four of this article.\n 8. A comprehensive HIV special needs plan, certified pursuant to this\nsection, shall be responsible for providing or arranging for all medical\nassistance services defined under section three hundred sixty-five-a of\nthe social services law, including delivery of a comprehensive benefit\npackage, which shall include early and periodic screening; adolescent\nhealth; diagnosis and treatment and child/teen health screenings;\nreferrals for necessary services; linkages to HIV counseling and\ntesting; and HIV prevention and education activities. A comprehensive\nHIV special needs plan provider shall be responsible for assisting\nenrollees in the prudent selection of such services including but not\nlimited to:\n (a) referral, coordination, monitoring and follow-up with regard to\nother medical services providers, as appropriate for diagnosis and\ntreatment, or direct provision of all medical assistance services;\n (b) methods of assuring enrollees' access to specialty services\noutside the comprehensive HIV special needs plan's network or panel when\nthe plan does not have a provider with the appropriate training and\nexperience in its network to meet the particular health care needs of\nthe participant;\n (c) the establishment of appropriate utilization and referral\nrequirements for physicians, hospitals, and other medical services\nproviders, including emergency room visits and inpatient admissions;\n (d) the creation of mechanisms to ensure the participation of HIV\ncenters of excellence and community-based HIV care providers;\n (e) implementation of procedures for managing the care of all\nparticipants, including the use of facility and community-based case\nmanagers with expertise in the care needs of persons with HIV infection,\nand the designation of a specialist as a primary care practitioner;\n (f) development of appropriate methods of managing the HIV care needs\nof homeless, substance users and other vulnerable populations, who are\nenrolled in the comprehensive HIV special needs plan, to assure that all\nnecessary services are made available in a timely manner, in accordance\nwith prevailing standards of professional medical practice, and that all\nappropriate referrals and follow-up treatments are provided;\n (g) provision of all early periodic screening, diagnosis and treatment\nservices, as well as periodic screening and referral, to each\nparticipant under the age of twenty-one, at regular intervals and as\nmedically appropriate;\n (h) direct provision of or arrangement for the provision of\ncomprehensive prenatal care services to all pregnant participants in\naccordance with standards adopted by the department of health and with\nstatute and regulations governing HIV testing of pregnant women and\nnewborns;\n (i) implementation of procedures for written agreements, which may\ninclude contractual agreements, with community-based social service\nproviders to ensure access to the full continuum of services needed by\nHIV infected persons; and\n (j) permit the use of standing referrals to specialists and\nsubspecialists for participants who require the care of such\npractitioners on a regular basis.\n 9. Notwithstanding any other provision of law, a comprehensive HIV\nspecial needs plan certified pursuant to this section shall limit\nenrollment to HIV positive persons, except for the following persons who\nmay be enrolled regardless of their HIV status:\n (a) related children up to the age of twenty-one; and\n (b) individuals who are homeless or who are members of other high need\npopulations which, in the discretion of the commissioner, would benefit\nfrom receiving services through a plan certified pursuant to this\nsection; provided however, that rates paid to special needs plans for\nsuch populations shall be comparable to rates paid for the same\npopulations in other managed care plans.\n 10. Enrollment and disenrollment. (a) Enrollment in a comprehensive\nHIV special needs plan shall be voluntary and persons eligible for\nenrollment in such plans shall be afforded the opportunity to choose\namong such plans, to the extent available in the locality where the\nperson currently resides; provided however that enrollment may be\nautomatic after federal approval of a waiver or waivers or other federal\naction required to institute automatic enrollment, pursuant to\napplicable provisions of the federal social security act, and that\npersons automatically enrolled in a comprehensive HIV special needs plan\nshall have the opportunity to withdraw from such plan in accordance with\nparagraph (g) of subdivision four, paragragh (b) of subdivision three\nand subdivision twelve of section three hundred sixty-four-j of the\nsocial services law. The department shall ensure to the maximum extent\npracticable that individuals are provided with a choice of comprehensive\nHIV special needs plans.\n (b) The commissioner shall promulgate regulations establishing\ncriteria which relate to enrollment and disenrollment of enrollees in\ncomprehensive HIV special needs plans. Comprehensive HIV special needs\nplans shall not request disenrollment of an enrollee based on any\ndiagnosis, condition, or perceived diagnosis or condition, or an\nenrollee's efforts to exercise his or her rights under a grievance\nprocess.\n (c) Prior to enrollment in a comprehensive HIV special needs plan\nindividuals are to be provided with a full written explanation of all\nfee-for-service and other options and given a reasonable opportunity to\nchoose between the comprehensive HIV special needs plan and the other\noptions. In addition, enrollees shall be provided notice of their right\nto disenroll from the plan, except as otherwise provided in this\nsubdivision.\n (d) If an enrollee requests to change a provider or disenroll from a\ncomprehensive HIV special needs plan pursuant to this subdivision, the\nsocial services district and the plan shall implement such change in a\ntimely manner in accordance with standards established by the\ncommissioner. When an enrollee changes comprehensive HIV special needs\nplan providers the plan must effectuate the timely transfer of all\nnecessary medical records.\n (e) Plans shall ensure that any new enrollee whose health care\nprovider is not a member of the plan's provider network, who enrolls in\nthe plan, can continue with an ongoing course of treatment with the\nenrollee's current health care provider during a transitional period of\nup to sixty days from the effective date of enrollment. If an enrollee\nelects to continue to receive care from such health care provider\npursuant to this paragraph, such care shall be authorized by the\ncomprehensive HIV special needs plan for the transitional period only if\nthe health care provider agrees: (1) to accept reimbursement from the\ncomprehensive HIV special needs plan at rates established by the plan as\npayment in full, which rates shall be no more than the level of\nreimbursement applicable to similar providers within the plan's network\nfor such services; (2) to adhere to the plan's quality assurance\nrequirements and agrees to provide to the plan any necessary medical\ninformation related to such care; and (3) to otherwise adhere to the\nplan's policies and procedures including, but not limited to procedures\nregarding referrals and obtaining pre-authorization and a treatment plan\napproved by the comprehensive HIV special needs plan. In no event shall\nthis paragraph be construed to require a comprehensive HIV special needs\nplan to provide coverage for benefits not otherwise covered;\n (f) Comprehensive HIV special needs plans shall ensure that for those\nenrollees whose health care provider leaves the comprehensive HIV\nspecial needs plan's network of providers, the enrollee shall be\npermitted to continue an ongoing course of treatment with such current\nhealth care provider during a transitional period of up to ninety days\nfrom the date of notice to the enrollee of the provider's disaffiliation\nfrom the plan's network. If an enrollee elects to continue to receive\ncare from such health care provider pursuant to this paragraph, such\ncare shall be authorized by the comprehensive HIV special needs plan for\nthe transitional period only if the health care provider agrees: (1) to\naccept reimbursement from the comprehensive HIV special needs plan at\nrates established by the plan as payment in full, which rates shall be\nno more than the level of reimbursement applicable to similar providers\nwithin the plan's network for such services; (2) to adhere to the\norganization's quality assurance requirements and agrees to provide to\nthe plan any necessary medical information related to such care; and (3)\nto otherwise adhere to the plan's policies and procedures including, but\nnot limited to procedures regarding referrals and obtaining\npre-authorization and a treatment plan approved by the comprehensive HIV\nspecial needs plan. In no event shall this paragraph be construed to\nrequire a comprehensive HIV special needs plan to provide coverage for\nbenefits not otherwise covered;\n 11. The commissioner shall develop and certify capitated payment rates\nfor comprehensive HIV special needs plans, subject to the approval of\nthe director of the division of the budget. In developing capitation\nrates the commissioner shall be authorized to consider, at a minimum,\nthe age, eligibility category, historic cost and utilization of covered\nenrollees and covered services, anticipated costs of emerging HIV\ntreatment modalities and the expected impact of delivering services in a\nmanaged care environment.\n 12. Plans certified under this section must submit financial reports\nin a manner and frequency established by the commissioner.\n 13. The department shall establish a stop-loss reinsurance program for\ncomprehensive HIV special needs plans. The stop-loss reinsurance program\nshall be designed in a manner which promotes the development and ongoing\nfinancial viability of the comprehensive HIV special needs plan by\nproviding reasonable protection for catastrophic cases and adverse\nselection.\n 14. Quality assurance. (a) The department shall be responsible for\nestablishing a comprehensive quality assurance program for comprehensive\nHIV special needs plans. This quality assurance program shall reflect\nclinical standards of HIV care established and maintained by the AIDS\nInstitute in the department. The department shall monitor the\nperformance, quality and utilization of such plans on at least an annual\nbasis. Such plans must describe and document the existence of a formal,\norganized quality assurance program with the capacity to identify,\naddress and follow-up on issues which concern the care and services\ndelivered to enrollees. Such reviews are to include, but not be limited\nto, the following:\n (1) compliance with performance and outcome-based quality standards\npromulgated by the department;\n (2) appropriateness, accessibility, timeliness, and quality of care\ndelivered by such providers;\n (3) referrals, coordination, monitoring and follow-up with regard to\nother medical service providers;\n (4) methods of ensuring enrollees access to specialty services outside\nthe plan's network or panel when the plan does not have a provider with\nthe appropriate training and experience in the network or panel to meet\nthe particular HIV care needs of the participant;\n (5) delivery of a comprehensive benefit package, including early and\nperiodic screening; adolescent health; diagnosis and treatment and\nchild/teen health screenings; referrals for necessary services, and\nlinkages to HIV counseling and testing; HIV prevention and education\nactivities;\n (6) mechanisms for the provision of all information to enrollees in\nclear and coherent terms that are commonly used in a culturally and\nlinguistically appropriate and understandable manner;\n (7) existence of a management information system to support quality\nassurance activities, which system shall provide for the collection and\nutilization of data including but not limited to enrollment, complaints,\nencounters and specific performance indicators; and\n (b) the commissioner shall have access to patient specific medical\ninformation and enrollee medical records, including encounter data,\nmaintained by a comprehensive HIV special needs plan for the purposes of\nquality assurance and oversight.\n (c) The department shall be responsible for establishing and\nmaintaining a uniform system of reports relating to the quality of care\nand services furnished by comprehensive HIV special needs plans.\n 15. The commissioner may revoke, limit or annul a comprehensive HIV\nspecial needs certificate of authority in accordance with the provisions\nof section forty-four hundred four of this article.\n 16. Confidentiality. Except as provided in paragraph (c) of\nsubdivision fourteen of this section, any enrollee information\nmaintained by a comprehensive HIV special needs plan shall be kept\nconfidential in accordance with section forty-four hundred eight-a of\nthis article and where applicable section 33.13 of the mental hygiene\nlaw and any other applicable state or federal law.\n 17. Utilization review. A comprehensive HIV special needs plan\nauthorized under this section is required to meet requirements set forth\nin article forty-nine of this chapter.\n 18. Disclosure. Each enrollee and prospective enrollee prior to\nenrollment in a comprehensive HIV special needs plan shall be provided\nwith written disclosure information related to enrollee benefits, rights\nand obligations pursuant to section forty-four hundred eight of this\narticle.\n 19. Grievance procedure. Comprehensive HIV special needs plans\nauthorized under this section shall be required to meet grievance\nprocedures requirements pursuant to section forty-four hundred eight-a\nof this article.\n 20. Prohibitions. A comprehensive HIV special needs plan authorized\nunder this section shall be required to meet the requirements set forth\nin section forty-four hundred six-c of this article.\n 21. The commissioner is authorized, subject to the approval of the\ndirector of the division of the budget, and within amounts appropriated,\nto make grants to those entities seeking certification to operate a\ncomprehensive HIV special needs plan to aid in the development of the\nsystems, organizational structures and networks necessary to operate a\nmanaged care program. The commissioner is authorized to develop criteria\nfor distribution of the grants. The grants may also be used to meet the\ncapitalization standards and the reserve and escrow deposit requirements\nestablished for comprehensive HIV special needs plans.\n 22. Comprehensive HIV special needs plans shall function distinctly\nfrom other comprehensive or non-comprehensive health plans operated by\nthe same organization, corporation, persons, county or municipality and\nshall be clearly distinguished from any other functions through the\nmaintenance of separate records, reports and accounts for the\ncomprehensive HIV special needs plan function.\n 23. The commissioner shall establish reserve and escrow deposit\nrequirements for HIV special needs plans.\n 24. Nothing in this section shall be construed to require that a\nhealth maintenance organization, certified pursuant to the provisions of\nthis article, apply for a comprehensive HIV special needs plan\ncertificate of authority pursuant to this section; provided, however,\nthat a health maintenance organization, certified pursuant to the\nprovisions of this article, which proposes to operate a comprehensive\nHIV special needs plan shall be required to comply with all the\nprovisions of this section.\n * NB Repealed March 31, 2030\n