§ 365-M — Administration and management of behavioral health services

New York § 365-M

• Jurisdiction: New York
• Law SOS: Social Services
• Title 11: Medical Assistance For Needy Persons
• Art. 5: Assistance and Care

Text

§ 365-m. Administration and management of behavioral health services.\n1. The commissioners of the office of mental health and the office of\nalcoholism and substance abuse services, in consultation with the\ncommissioner of health, the impacted local governmental units and with\nthe approval of the division of the budget, shall have responsibility\nfor jointly designating regional entities to provide administrative and\nmanagement services for the purposes of prior approving and coordinating\nthe provision of behavioral health services, facilitating the continuity\nof post-hospitalization behavioral health and the integration of\nbehavioral health services with other services available under this\ntitle, for recipients of medical assistance who are not enrolled in\nmanaged care, and for such approval, coordination, facilitating\ncontinuity and integration of behavioral health services that are not\nprovided through managed care programs under this title for individuals\nregardless of whether or not such individuals are enrolled in managed\ncare programs. Such regional entities shall also be responsible for\npromoting appropriate care and service utilization while safeguarding\nagainst unnecessary utilization of such care and services and assuring\nthat payments are consistent with the efficient and economical delivery\nof quality care.\n 2. In exercising this responsibility, the commissioners of the office\nof mental health and the office of alcoholism and substance abuse\nservices are authorized to contract, after consultation with the\ncommissioner of health and the impacted local governmental units, with\nregional behavioral health organizations or other entities. Such\ncontracts may include responsibility for receipt, review, and\ndetermination of prior authorization requests for behavioral health care\nand services under subdivision one of this section, consistent with\ncriteria established or approved by the commissioners of mental health\nand alcoholism and substance abuse services, and authorization of\nappropriate care and services based on documented patient medical need.\n 3. Notwithstanding any inconsistent provision of sections one hundred\ntwelve and one hundred sixty-three of the state finance law, or section\none hundred forty-two of the economic development law, or any other law\nto the contrary, the commissioners of the office of mental health and\nthe office of alcoholism and substance abuse services are authorized to\nenter into a contract or contracts under subdivisions one and two of\nthis section without a competitive bid or request for proposal process,\nprovided, however, that:\n (a) the office of mental health and the office of alcoholism and\nsubstance abuse services shall post on their websites, for a period of\nno less than thirty days:\n (i) a description of the proposed services to be provided pursuant to\nthe contractor contracts;\n (ii) the criteria for selection of a contractor or contractors;\n (iii) the period of time during which a prospective contractor may\nseek selection, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n (iv) the manner by which a prospective contractor may seek such\nselection, which may include submission by electronic means;\n (b) all reasonable and responsive submissions that are received from\nprospective contractors in timely fashion shall be reviewed by the\ncommissioners; and\n (c) the commissioners of the office of mental health and the office of\nalcoholism and substance abuse services, in consultation with the\ncommissioner of health and the impacted local governmental units, shall\nselect such contractor or contractors that, in their discretion, have\ndemonstrated the ability to effectively, efficiently, and economically\nintegrate behavioral health and health services; have the requisite\nexpertise and financial resources; have demonstrated that their\ndirectors, sponsors, members, managers, partners or operators have the\nrequisite character, competence and standing in the community, and are\nbest suited to serve the purposes of this section. In selecting such\ncontractor or contractors, the commissioners shall:\n (i) ensure that any such contractor or contractors have an adequate\nnetwork of providers to meet the behavioral health and health needs of\nenrollees, and shall review the adequacy prior to approval of any such\ncontract or contracts, and upon contract renewal or expansion. To the\nextent that the network has been determined to meet standards set forth\nin subdivision five of section four thousand four hundred three of the\npublic health law, such network shall be deemed adequate.\n (ii) ensure that such contractor or contractors shall make level of\ncare and coverage determinations utilizing evidence-based tools or\nguidelines designated to address the behavioral health needs of\nenrollees.\n (iii) ensure sufficient access to behavioral health and health\nservices for eligible enrollees by establishing and monitoring\npenetration rates of any such contractor or contractors.\n (iv) establish standards to encourage the use of services, products\nand care recommended, ordered or prescribed by a provider to\nsufficiently address the behavioral health and health services needs of\nenrollees; and monitor the application of such standards to ensure that\nthey sufficiently address the behavioral health and health services\nneeds of enrollees.\n 4. The commissioners of the office of mental health, the office of\nalcoholism and substance abuse services and the department of health,\nshall have the responsibility for jointly designating on a regional\nbasis, after consultation with the local social services district and\nlocal governmental unit, as such term is defined in the mental hygiene\nlaw, of a city with a population of over one million persons, and after\nconsultation of other affected counties, a limited number of special\nneeds managed care plans under section three hundred sixty-four-j of\nthis title capable of managing the behavioral and physical health needs\nof medical assistance enrollees with significant behavioral health\nneeds. Initial designations of such plans should be made no later than\nApril first, two thousand fourteen, provided, however, such designations\nshall be contingent upon a determination by such state commissioners\nthat the entities to be designated have the capacity and financial\nability to provide services in such plans, and that the region has a\nsufficient population and service base to support such plans. Once\ndesignated, the commissioner of health shall make arrangements to enroll\nsuch enrollees in such plans and to pay such plans on a capitated or\nother basis to manage, coordinate, and pay for behavioral and physical\nhealth medical assistance services for such enrollees. Notwithstanding\nany inconsistent provision of section one hundred twelve and one hundred\nsixty-three of the state finance law, and section one hundred forty-two\nof the economic development law, or any other law to the contrary, the\ndesignations of such plans, and any resulting contracts with such plans\nor providers are authorized to be entered into by such state\ncommissioners without a competitive bid or request for proposal process,\nprovided however that:\n (a) the department of health, the office of mental health and the\noffice of alcoholism and substance abuse services shall post on their\nwebsites, for a period of not less than thirty days:\n (i) a description of the proposed services to be provided by the plans\nor systems;\n (ii) the criteria for selection of a plan or system;\n (iii) the period of time during which a prospective plan or system may\nseek selection, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n (iv) the manner by which a prospective plan or system may seek such\nselection, which may include submission by electronic means;\n (b) all reasonable and responsive submissions that are received from\nprospective plans or systems in timely fashion shall be reviewed by the\ncommissioners; and\n (c) the commissioners of the office of mental health and the office of\nalcoholism and substance abuse services, in consultation with the\ncommissioner of health, shall select such plans or systems that, in\ntheir discretion, have demonstrated the ability to effectively,\nefficiently, and economically manage the behavioral and physical health\nneeds of medical assistance enrollees with significant behavioral health\nneeds; have the requisite expertise and financial resources; have\ndemonstrated that their directors, sponsors, members, managers, partners\nor operators have the requisite character, competence and standing in\nthe community, and are best suited to serve the purposes of this\nsection. Oversight of such contracts with such plans, providers or\nprovider systems shall be the joint responsibility of such state\ncommissioners, and for contracts affecting a city with a population of\nover one million persons, also with the city's local social services\ndistrict and local governmental unit, as such term is defined in the\nmental hygiene law.\nIn selecting such plans or systems, the commissioners shall:\n (i) ensure that any such plans or systems have an adequate network of\nproviders to meet the behavioral health and health needs of enrollees,\nand shall review the adequacy prior to approval of any such plans or\nsystems, and upon contract renewal or expansion. To the extent that the\nnetwork has been determined to meet standards set forth in subdivision\nfive of section four thousand four hundred three of the public health\nlaw, such network shall be deemed adequate.\n (ii) ensure that such plans or systems shall make level of care and\ncoverage determinations utilizing evidence-based tools or guidelines\ndesigned to address the behavioral health needs of enrollees.\n (iii) ensure sufficient access to behavioral health and health\nservices for eligible enrollees by establishing and monitoring\npenetration rates of any such plans or systems.\n (iv) establish standards to encourage the use of services, products\nand care recommended, ordered or prescribed by a provider to\nsufficiently address the behavioral health and health services needs of\nenrollees; and monitor the application of such standards to ensure that\nthey sufficiently address the behavioral health and health services\nneeds of enrollees.\n 5. (a) Pursuant to appropriations within the offices of mental health\nor addiction services and supports, the department of health shall\nreinvest savings realized through the transition of populations covered\nby this section from the applicable Medicaid fee-for-service system to a\nmanaged care model, including savings realized through the recovery of\npremiums from managed care providers which represent a reduction of\nspending on qualifying behavioral health services against established\npremium targets for behavioral health services and the medical loss\nratio applicable to special needs managed care plans, for the purpose of\nincreasing investment in community based behavioral health services,\nincluding residential services certified by the office of addiction\nservices and supports. The methodologies used to calculate the savings\nshall be developed by the commissioner of health and the director of the\nbudget in consultation with the commissioners of the office of mental\nhealth and the office of addiction services and supports. In no event\nshall the full annual value of the reinvestment pursuant to this\nsubdivision exceed the value of the premiums recovered from managed care\nproviders which represent a reduction of spending on qualifying\nbehavioral health services. Within any fiscal year where appropriation\nincreases are recommended for reinvestment, insofar as managed care\ntransition savings do not occur as estimated, then spending for such\nreinvestment may be reduced in the next year's annual budget\nitemization.\n (b) Beginning April first, two thousand twenty-two, the department\nshall post on its website information about the recovery of premiums\nfrom managed care providers which represent a reduction of spending on\nqualifying behavioral health services against established premium\ntargets for behavioral health services and the medical loss ratio\napplicable to special needs managed care plans. Such information shall\ninclude at a minimum: (i) a copy of the department's notification to\neach managed care provider that seeks a recovery of such premiums; and\n(ii) a list of managed care providers by name that have been subject to\na recovery of such premiums, specifying the amount of premium that has\nbeen recovered from each managed care provider and year. In the initial\nposting, the department shall include all premiums recovered to date as\nrequired by this subdivision, by named managed care provider, amount and\nyear.\n (c) The commissioner shall include information regarding the funds\navailable for reinvestment, including how savings are calculated and how\nthe reinvestment was utilized pursuant to this section in the annual\nreport required under section forty-five-c of part A of chapter\nfifty-six of the laws of two thousand thirteen.\n