§ 4403-G — Developmental disability individual support and care coordination organizations

New York § 4403-G

• Jurisdiction: New York
• Law PBH: Public Health
• Art. 44: Health Maintenance Organizations

Text

* § 4403-g. Developmental disability individual support and care\ncoordination organizations. 1. Definitions. As used in this section:\n (a) "Developmental disability individual support and care coordination\norganization" or "DISCO" means an entity that has received a certificate\nof authority pursuant to this section to provide, or arrange for, health\nand long term care services, as determined by the commissioner and the\ncommissioner of the office for people with developmental disabilities,\non a capitated basis in accordance with this section, for a population\nof persons with developmental disabilities, as such term is defined in\nsection 1.03 of the mental hygiene law, which the organization is\nauthorized to enroll.\n (b) "Eligible applicant" means an entity controlled by one or more\nnon-profit organizations which have a history of providing or\ncoordinating health and long term care services to persons with\ndevelopmental disabilities.\n (c) "Habilitation services" means services available through the\nstate's home and community based services waiver for persons with\ndevelopmental disabilities, state plan for medical assistance, and any\nother authorized federal funding for such services designed to assist\npersons in acquiring, retaining, and improving the self-help,\nsocialization, and adaptive skills necessary to reside successfully in\nhome and community based settings.\n (d) "Health and long term care services" means comprehensive health\nservices and other services as determined by the commissioner and the\ncommissioner of the office for people with developmental disabilities,\nwhether provided by state-operated programs or not-for-profit entities,\nincluding, but not limited to, habilitation services, home and\ncommunity-based and institution-based long term care services, and\nancillary services, that shall include medical supplies and nutritional\nsupplements, that are necessary to meet the needs of persons whom the\nplan is authorized to enroll. Each person enrolled in a DISCO shall\nreceive health and long term care services designed to achieve\nperson-centered outcomes, to enable that person to live in the most\nintegrated setting appropriate to that person's needs, and to enable\nthat person to interact with nondisabled persons to the fullest extent\npossible in social, workplace and other community settings, provided\nthat all such services are consistent with such person's wishes to the\nextent that such wishes are known and in accordance with such person's\nneeds.\n 2. Approval authority. An applicant shall be issued a certificate of\nauthority as a DISCO for purposes of participating in the people first\nwaiver program pursuant to section 13.40 of the mental hygiene law upon\na determination by the commissioner and the commissioner of the office\nfor people with developmental disabilities that the applicant complies\nwith the operating requirements for a DISCO under this section.\n 3. Application for certificate of authority; form. The commissioner\nand the commissioner of the office for people with developmental\ndisabilities shall jointly develop application forms for a certificate\nof authority to operate a DISCO. An eligible applicant shall submit an\napplication for a certificate of authority to operate a DISCO upon forms\nprescribed by such commissioners. Such eligible applicant shall submit\ninformation and documentation to the commissioner which shall include,\nbut not be limited to:\n (a) A description of the service area proposed to be served by the\nDISCO with projections of enrollment that will result in a fiscally\nsound plan;\n (b) A description of the services to be covered by such DISCO, which\nmust include all health and long term care services, as defined in\nparagraph (d) of subdivision one of this section, and other services as\ndetermined by the commissioner and the commissioner of the office for\npeople with developmental disabilities;\n (c) A description of the proposed marketing plan and how marketing\nmaterials will be presented to persons with developmental disabilities\nor their authorized decision makers for the purposes of enabling them to\nmake an informed choice;\n (d) The names of the providers proposed to be in the DISCO's network;\n (e) Evidence of the character and competence of the applicant's\nproposed operators, and of the incorporators, directors, stockholders or\nmembers of the applicant;\n (f) Adequate documentation of the appropriate licenses, certifications\nor approvals to provide care as planned, including affiliate agreements\nor proposed contracts with such providers as may be necessary to provide\nthe full complement of services required to be provided under this\nsection;\n (g) A description of the proposed quality-assurance mechanisms,\ngrievance procedures, mechanisms to protect the rights of enrollees and\ncare coordination services to ensure continuity, quality,\nappropriateness and coordination of care;\n (h) A description of the proposed quality assessment and performance\nimprovement program that includes performance and outcome based quality\nstandards for enrollee health status and satisfaction, and data\ncollection and reporting for standard performance measures;\n (i) A description of the management systems and systems to process\npayment for covered services;\n (j) A description of how achievement of person-centered outcomes, as\ndefined by the commissioner of the office for people with developmental\ndisabilities, shall be assessed, as well as a description of how health\nand long term care services shall be used to meet such outcomes;\n (k) A description of the mechanism to maximize reimbursement of and\ncoordinate services reimbursed pursuant to title XVIII of the federal\nsocial security act and all other applicable benefits, with such benefit\ncoordination including, but not limited to, measures to support sound\nclinical decisions, reduce administrative complexity, coordinate access\nto services, maximize benefits available pursuant to such title and\nensure that necessary care is provided;\n (l) A description of the systems for securing and integrating any\npotential sources of funding for services provided by or through the\norganization, including, but not limited to, funding available under\ntitles XVI, XVIII, XIX and XX of the federal social security act and all\nother available sources of funding;\n (m) A description of the proposed contractual arrangements for\nproviders of health and long term care services in the benefit package;\nand\n (n) Information related to the financial condition of the applicant.\n 4. Certificate of authority approval. The commissioner shall not\napprove an application for a certificate of authority unless the\napplicant demonstrates to the satisfaction of the commissioner and the\ncommissioner of the office for people with developmental disabilities:\n (a) That it will have in place acceptable quality assurance\nmechanisms, grievance procedures and mechanisms to protect the rights of\nenrollees and care coordination services to ensure continuity, quality,\nappropriateness and coordination of care;\n (b) That it will have in place a mechanism or means to assure that\npersons with developmental disabilities can make informed choices either\nindividually or through an authorized decision maker regarding the\ndevelopment of a person-centered plan, as defined by the commissioner of\nthe office for people with developmental disabilities;\n (c) That it has developed a quality assessment and performance\nimprovement program that includes performance and outcome based quality\nstandards for enrollee health status and satisfaction, which shall be\nreviewed by the commissioner and the commissioner of the office for\npeople with developmental disabilities. The program shall include data\ncollection and reporting for standard performance measures as required\nby the commissioner and the commissioner of the office for people with\ndevelopmental disabilities;\n (d) That an otherwise eligible enrollee shall not be involuntarily\ndisenrolled without the prior approval of the commissioner of the office\nfor people with developmental disabilities;\n (e) That the applicant shall not use deceptive or coercive marketing\nmethods to encourage participants to enroll and that the applicant shall\nnot distribute marketing materials to potential enrollees before such\nmaterials have been approved by the commissioner and the commissioner of\nthe office for people with developmental disabilities;\n (f) Satisfactory evidence of the character and competence of the\napplicant's proposed operators, incorporators, directors, stockholders\nand members;\n (g) Reasonable assurance that the applicant will provide high quality\nservices to an enrolled population, that the applicant's network of\nproviders is adequate and that such providers have demonstrated\nsufficient competency to deliver high quality services to the enrolled\npopulation and that policies and procedures will be in place to address\nthe cultural and linguistic needs of the enrolled population;\n (h) Sufficient management systems capacity to meet the requirements of\nthis section and the ability to efficiently process payment for covered\nservices;\n (i) Readiness and capability to maximize reimbursement of and\ncoordinate services reimbursed pursuant to title XVIII of the federal\nsocial security act and all other applicable benefits, with such benefit\ncoordination including, but not limited to, measures to support sound\nclinical decisions, reduce administrative complexity, coordinate access\nto services, maximize benefits available pursuant to such title and\nensure that necessary care is provided;\n (j) Readiness and capability of organizing, marketing, managing,\npromoting and operating a health and long term care services plan, or\nhas an affiliation agreement with an entity that has such readiness and\ncapability;\n (k) Willingness and capability of taking, or cooperating in, all steps\nnecessary to secure and integrate any potential sources of funding for\nservices provided by or through the DISCO, including, but not limited\nto, funding available under titles XVI, XVIII, XIX and XX of the federal\nsocial security act and all other available sources of funding;\n (l) That the contractual arrangements for providers of health and long\nterm care services in the benefit package are sufficient to ensure the\navailability and accessibility of such services to the proposed enrolled\npopulation consistent with guidelines established by the commissioner\nand the commissioner of the office for people with developmental\ndisabilities. With respect to a person receiving non-residential\nservices operated, certified, funded, authorized or approved by the\noffice for people with developmental disabilities prior to enrollment in\nthe DISCO, such guidelines shall require the DISCO to contract with the\ncurrent provider of non-residential services at the rates established by\nthe office for ninety days, in order to ensure continuity of care. With\nrespect to a person living in a residential facility operated or\ncertified by the office for people with developmental disabilities prior\nto enrollment in the DISCO, such guidelines shall require the DISCO to\ncontract with the provider of residential services for that residence at\nthe rates established by the office for so long as such individual lives\nin that residence pursuant to an approved plan of care;\n (m) That the applicant is financially responsible and shall be\nexpected to meet its obligations to its enrolled members; and\n (n) That the applicant shall assess person-centered outcomes as\ndefined by the commissioner of the office for people with developmental\ndisabilities, and has satisfactory mechanisms by which it will assess\nhow health and long term care services will be used to meet such\noutcomes.\n 5. Enrollment. (a) Only persons with developmental disabilities, as\ndetermined by the office for people with developmental disabilities,\nshall be eligible to enroll in DISCOs.\n (b) The office for people with developmental disabilities or its\ndesignee shall enroll an eligible person in the DISCO chosen by him or\nher, his or her guardian or other legal representative, provided that\nsuch DISCO is authorized to enroll such person.\n (c) No person with a developmental disability who is receiving or\napplying for medical assistance and who is receiving, or eligible to\nreceive, services funded, certified, authorized or approved by the\noffice for people with developmental disabilities, shall be required to\nenroll in a DISCO in order to receive such services until program\nfeatures and reimbursement rates are approved by the commissioner and\nthe commissioner of the office for people with developmental\ndisabilities, and until such commissioners determine that there are a\nsufficient number of plans authorized to coordinate care for persons\nwith developmental disabilities pursuant to this article operating in\nsuch person's county of residence to meet the needs of persons with\ndevelopmental disabilities, and that such DISCOs meet the standards of\nthis section. No person shall be required to enroll in a DISCO in order\nto receive services operated, funded, certified, authorized or approved\nby the office for people with developmental disabilities until there are\nat least two plans authorized to coordinate care for persons with\ndevelopmental disabilities pursuant to this article in such person's\ncounty of residence, unless federal approval is secured to require\nenrollment when there are less than two such entities operating in such\ncounty.\n (d) Persons required to enroll in a DISCO shall have no less than\nsixty days to select a DISCO, and such persons and their guardians or\nother legal representatives shall be provided with information to make\nan informed choice. Where a person, guardian or other legal\nrepresentative has not selected a DISCO, the commissioner of the office\nfor people with developmental disabilities or its designee shall enroll\nsuch person in a DISCO chosen by such commissioner, taking into account\nquality, capacity and geographic accessibility. The office for people\nwith developmental disabilities or its designee shall automatically\nre-enroll a person with the same DISCO if there is a loss of medicaid\neligibility of two months or less.\n (e) Enrolled persons may change their enrollment at any time without\ncause, provided, however, that a person required to enroll in a DISCO in\norder to receive services funded, licensed, authorized or approved by\nthe office for people with developmental disabilities may only disenroll\nfrom a DISCO if he or she enrolls in another DISCO authorized to enroll\nhim or her. Such disenrollment shall be effective no later than the\nfirst day of the second month following the request.\n (f) A DISCO may request the involuntary disenrollment of an enrolled\nperson in writing to the office for people with developmental\ndisabilities. Such disenrollment shall not be effective until the\nrequest is reviewed and approved by such office. Notice shall be\nprovided to the enrollee and the enrollee may request a fair hearing\nregarding such disenrollment. The department and the office for people\nwith developmental disabilities shall adopt rules and regulations\ngoverning this process.\n 6. Assessments. The office for people with developmental disabilities,\nor its designee, shall complete a comprehensive assessment that shall\ninclude, but not be limited to, an evaluation of the medical, social,\nhabilitative and environmental needs of each prospective enrollee in a\nDISCO as such needs relate to each individual's health, safety, living\nenvironment and wishes, to the extent that such wishes are known. This\nassessment shall also serve as the basis for the development and\nprovision of an appropriate plan of care for the enrollee. Such plan of\ncare shall be focused on the achievement of person-centered outcomes and\nshall be consistent with and help inform any other person-centered plan\nrequired for the enrollee by the commissioner of the office for people\nwith developmental disabilities. The assessment shall be completed by\nthe office for people with developmental disabilities or in consultation\nwith the prospective enrollee's health care practitioner as necessary.\nThe commissioner of the office for people with developmental\ndisabilities shall prescribe the forms on which the assessment shall be\nmade. The office for people with developmental disabilities may\ndesignate the DISCO to perform reassessments, but shall not designate\nthe DISCO to perform the initial assessment of a prospective enrollee.\n 7. Program oversight and administration. (a) The commissioner and the\ncommissioner of the office for people with developmental disabilities\nshall jointly promulgate regulations to implement this section, to\nprovide for oversight of DISCOs, including on site reviews, and to\nensure the quality, appropriateness and cost-effectiveness of the\nservices provided by DISCOs.\n (b) The commissioner and the commissioner of the office for people\nwith developmental disabilities may waive rules and regulations of their\nrespective department or office, including but not limited to, those\npertaining to duplicative requirements concerning record keeping, boards\nof directors, staffing and reporting, when such waiver shall promote the\nefficient delivery of appropriate, quality, cost-effective services and\nwhen the health, safety and general welfare of DISCO enrollees shall not\nbe impaired as a result of such waiver. The commissioners shall report\nannually to the legislature and to the joint advisory council\nestablished pursuant to section 13.40 of the mental hygiene law on all\nrules and regulations waived pursuant to this paragraph. In order to\nachieve DISCO system efficiencies and coordination and to promote the\nobjectives of high quality, integrated and cost effective care, the\ncommissioners shall establish a single coordinated surveillance process,\nallow for a comprehensive quality improvement and review process to meet\ncomponent quality requirements, and require a uniform cost report. The\ncommissioners shall require DISCOs to utilize quality improvement\nmeasures, based on the achievement of personal outcomes and quality of\nlife, health outcomes data, and assessments of individual and family\nsatisfaction, for internal quality assessment processes and may utilize\nsuch measures as part of the single coordinated surveillance process.\n (c) Notwithstanding any inconsistent provision of the social services\nlaw to the contrary, the commissioner in consultation with the\ncommissioner of the office for people with developmental disabilities\nshall, pursuant to regulation, determine whether and the extent to which\nthe applicable provisions of the social services law or regulations\nrelating to approvals and authorizations of, and utilization limitations\non, health and long term care services reimbursed pursuant to title XIX\nof the federal social security act are inconsistent with the flexibility\nnecessary for the efficient administration of DISCOs, and such\nregulations shall provide that such provisions shall not be applicable\nto enrollees of DISCOs, provided that such determinations are consistent\nwith applicable federal law and regulation.\n (d) The commissioner and the commissioner of the office for people\nwith developmental disabilities shall ensure, through periodic reviews\nof DISCOs, that organization services are promptly available to\nenrollees when appropriate. Such periodic reviews shall be made\naccording to standards as determined by the commissioners in\nregulations.\n (e) The commissioner and the commissioner of the office for people\nwith developmental disabilities shall have the authority to conduct both\non site and off site reviews of DISCOs. Such reviews may include, but\nnot be limited to, the following components: governance; fiscal and\nfinancial reporting; recordkeeping; internal controls; marketing;\nnetwork contracting and adequacy; program integrity assurances;\nutilization control and review systems; grievance and appeals systems;\nquality assessment and assurance systems; care management; enrollment\nand disenrollment; management information systems, and other operational\nand management components.\n 8. Solvency. (a) The commissioner, in consultation with the\ncommissioner of the office for people with developmental disabilities,\nshall be responsible for evaluating, approving and regulating all\nmatters relating to fiscal solvency, including reserves, surplus and\nprovider contracts. The commissioner shall promulgate regulations to\nimplement this section. The commissioner, in the administration of this\nsubdivision:\n (i) shall be guided by the standards that govern the fiscal solvency\nof a health maintenance organization, provided, however, that the\ncommissioner shall recognize the specific delivery components,\noperational capacity and financial capability of the eligible applicant\nfor a certificate of authority;\n (ii) shall not apply financial solvency standards that exceed those\nrequired for a health maintenance organization; and\n (iii) shall establish reasonable capitalization and contingent reserve\nrequirements.\n (b) Standards established pursuant to this subdivision shall be\nadequate to protect the interests of enrollees in the DISCO. The\ncommissioner shall be satisfied that the eligible applicant is\nfinancially sound, and has made adequate provisions to pay for quality\nservices that are cost effective and appropriate to needs and the\nprotection of health, safety, welfare and satisfaction of those served.\n 9. Role of the superintendent of financial services. (a) The\nsuperintendent of financial services shall determine and approve\npremiums in accordance with the insurance law whenever any population of\nenrollees not eligible under title XIX of the federal social security\nact is to be covered. The determination and approval of the\nsuperintendent of financial services shall relate to premiums charged to\nsuch enrollees not eligible under title XIX of the federal social\nsecurity act.\n (b) The superintendent of financial services shall evaluate and\napprove any enrollee contracts whenever such enrollee contracts are to\ncover any population of enrollees not eligible under title XIX of the\nfederal social security act.\n 10. Payment rates for DISCO enrollees eligible for medical assistance.\nThe commissioner shall establish payment rates for services provided to\nenrollees eligible under title XIX of the federal social security act.\nSuch payment rates shall be subject to approval by the director of the\ndivision of the budget. Payment rates shall be actuarially sound for\ncovered services, including but not limited to habilitation services,\nand, when there is sufficient reliable data to permit, shall be\nrisk-adjusted to take into account the characteristics of enrollees, or\nproposed enrollees, which may include: frailty, disability level, health\nand functional status, age, gender, the nature of services provided to\nsuch enrollees, and other factors as determined by the commissioner and\nthe commissioner of the office for people with developmental\ndisabilities. The risk adjusted premiums may also be combined with\ndisincentives or requirements designed to mitigate any incentives to\nobtain higher payment categories.\n 11. Continuation of certificate of authority. Continuation of a\ncertificate of authority issued under this section shall be contingent\nupon compliance by the DISCO with applicable provisions of this section\nand rules and regulations promulgated thereunder; the continuing fiscal\nsolvency of the DISCO; and federal financial participation in payments\non behalf of enrollees who are eligible to receive services under title\nXIX of the federal social security act.\n 12. Protection of enrollees. The commissioner may, in his or her\ndiscretion and with the concurrence of the commissioner of the office\nfor people with developmental disabilities, for the purpose of the\nprotection of enrollees, impose measures including, but not limited to\nbans on further enrollments until any identified problems are resolved\nto the satisfaction of the commissioner, or fines upon a finding that\nthe DISCO has failed to comply with the provisions of any applicable\nstatute, rule or regulation.\n 13. Information sharing. The commissioner and the commissioner of the\noffice for people with developmental disabilities shall, as necessary\nand consistent with federal regulations promulgated pursuant to the\nHealth Insurance Portability and Accountability Act, share with such\nDISCO the following data if it is available:\n (a) information concerning utilization of services and providers by\neach of its enrollees prior to and during enrollment.\n (b) Aggregate data concerning utilization and costs for enrollees and\nfor comparable cohorts served through the Medicaid fee-for-service\nprogram.\n 14. Applicability of other laws. DISCOs shall be subject to the\nprovisions of the insurance law and regulations applicable to health\nmaintenance organizations, this article and regulations promulgated\nthereunder. To the extent that the provisions of this section are\ninconsistent with the provisions of this chapter or the provisions of\nthe insurance law, the provisions of this section shall prevail.\n 15. Effectiveness. The provisions of this section shall only be\neffective if, for so long as, and to the extent that federal financial\nparticipation is available for the costs of services provided by the\nDISCOs to enrollees who are recipients of medical assistance pursuant to\ntitle eleven of article five of the social services law. The\ncommissioner shall make any necessary amendments to the state plan for\nmedical assistance submitted pursuant to section three hundred\nsixty-three-a of the social services law, and/or submit one or more\napplications for waivers of the federal social security act, in order to\nensure such federal financial participation.\n * NB Repealed December 31, 2027\n