2012 New York Consolidated Laws
PBH - Public Health
Article 44 - (4400 - 4414) HEALTH MAINTENANCE ORGANIZATIONS
4403-C - Comprehensive HIV special needs plan certification.

 
    * §  4403-c. Comprehensive HIV special needs plan certification. 1. No
  person or group of persons may operate a comprehensive HIV special needs
  plan without  first  obtaining  a  certificate  of  authority  from  the
  commissioner. Any person may apply for a comprehensive HIV special needs
  certificate  of  authority,  provided,  however,  that  a  shared health
  facility, as defined in article forty-seven of this chapter,  shall  not
  be eligible for such a certificate.
    2.   An   applicant  for  certification  shall  submit  the  following
  information and documentation to the satisfaction of the commissioner:
    (a) a copy of  the  applicant's  basic  organizational  documents  and
  agreements  of  the  applicant  and  all  network members, including all
  contracts and agreements relating to the provision of HIV services;
    (b) a copy of any current licensure or certification maintained by the
  applicant;
    (c) a description of any experience the  applicant  may  have  had  in
  providing HIV services which are licensed, certified, funded or approved
  by   the  department,  including  identification  of  any  disciplinary,
  administrative or criminal proceedings related to such services  in  the
  past  ten  years,  the  resolution  thereof,  and  any other proceedings
  currently pending;
    (d) full disclosure of the financial condition of the applicant and of
  members  of  the  board,  officers,  controlling  persons,  owners   and
  partners,  including, but not limited to, a statement of the applicant's
  assets, resources, accounts receivable, liabilities and proposed sources
  and uses of funds and the most recent  certified  income  statement  and
  balance sheet;
    (e)  a demonstration of the applicant's ability to provide or continue
  to provide quality HIV services;
    (f) a description of the geographic area served and to  be  served  by
  the applicant;
    (g)  a  description  of the applicant's current capacity, and proposed
  capacity, to provide or arrange for the provision of  comprehensive  HIV
  services for a defined geographic area to a defined population; and
    (h) such other information as the commissioner shall require.
    3.  The commissioner shall not issue a comprehensive HIV special needs
  plan certificate of  authority  to  an  applicant  therefor  unless  the
  applicant demonstrates that:
    (a)  it  has defined an enrolled population to which the comprehensive
  HIV special needs plan proposes  to  provide  comprehensive  HIV  health
  services,  has  demonstrated  a  willingness to enroll any person who is
  eligible for enrollment  within  its  defined  catchment  area  and  has
  established a mechanism by which the enrolled population may participate
  in determining the policies of the organization;
    (b) it has defined a specific network of providers and facilities that
  are capable of providing comprehensive HIV special needs services to the
  enrolled population described in paragraph (a) of this subdivision;
    (c)   it  has  the  capability  of  organizing,  marketing,  managing,
  promoting and operating a comprehensive HIV special needs plan;
    (d) it is financially responsible and sound and  may  be  expected  to
  meet  its  obligations to its enrolled members. For the purposes of this
  paragraph, "financially responsible" means that the applicant is capable
  of assuming full financial risk on a prospective basis for the provision
  of comprehensive  HIV  special  needs  services  within  the  geographic
  catchment  area  defined  by  the  applicant  except  that  it may allow
  providers to share financial risk under the terms of their contract,  or
  it  may  obtain  insurance  or  make  other arrangements for the cost of
  providing comprehensive HIV special needs health services to  enrollees;
  any  insurance  or  other arrangements proposed to meet this requirement

  shall be approved as to adequacy as a prerequisite to  the  issuance  of
  any  comprehensive  HIV  special  needs  certificate of authority by the
  commissioner. In making a  determination  of  financial  soundness,  the
  commissioner   shall   consider  financial  information,  contracts  and
  agreements required as part of the  application  for  a  certificate  of
  authority  and  any  other  information that the commissioner shall deem
  necessary to make that determination. For purposes of this section,  any
  grants  awarded  to  an  applicant contingent upon its approval as a HIV
  special  needs  plan  certified  pursuant  to  this  section,  shall  be
  considered when making a determination of fiscal soundness;
    (e) it has established a system which appropriately accounts for costs
  and  a  uniform system of reports and audits meeting the requirements of
  the commissioner;
    (f) the character, competence and standing in  the  community  of  the
  proposed  incorporators,  directors,  sponsors,  or  stockholders of the
  plan, and its network providers, are satisfactory to the commissioner;
    (g) it is willing and able to assure that necessary HIV services  will
  be   provided  in  a  timely  manner  to  assure  the  availability  and
  accessibility of adequate personnel and facilities; to assure continuity
  of care for enrollees; and to implement  procedures  for  referrals,  as
  requested,  to  appropriate  care  for  affected  family  members of the
  enrolled population;
    (h) the prepayment mechanism of its comprehensive  HIV  special  needs
  plan, the bases upon which the providers of health care are compensated,
  and  the anticipated use of allied health personnel are conducive to the
  use of ambulatory care and the efficient use of hospital services;
    (i) acceptable procedures have been established  for  the  conduct  of
  outreach  and enrollment of persons with HIV infection including persons
  who are homeless, substance users and other vulnerable populations;
    (j) acceptable procedures have  been  developed  to  communicate  with
  participants in a linguistically and culturally competent manner;
    (k) acceptable procedures have been established to monitor the quality
  of  care provided by the plan and to assure that all care rendered meets
  clinical standards of HIV care as established and maintained by the AIDS
  Institute of the New York state department of health;
    (l) approved mechanisms exist to  resolve  complaints  and  grievances
  initiated by any enrolled member; and
    (m)  the  requirements of this article and any regulations promulgated
  pursuant thereto have been met and will continue to be met.
    4. The commissioner shall not issue a comprehensive HIV special  needs
  certificate  of  authority  unless the applicant has demonstrated to the
  commissioner's satisfaction that the requirements of  this  article  and
  any  regulations  promulgated  pursuant  thereto  have been met and will
  continue to be met, provided, however, that the commissioner may  impose
  alternative   requirements,  or  portions  thereof,  particularly  those
  related to capitalization, if he or she determines that such alternative
  requirements will serve to promote the high quality, efficient provision
  of comprehensive health services or services required  by  HIV  positive
  persons,  will  promote  the  development of HIV special needs plans and
  that the proposed plan will provide an  appropriate  and  cost-effective
  alternative  method  for the delivery of such services in a manner which
  will meet the needs of the population to be served.
    5. The commissioner shall make a determination on an application after
  receipt of all required and requested information and documentation.
    6. The commissioner shall review and approve any current  or  proposed
  contracts or agreements with current or prospective network members, and
  provided  further,  that  the commissioner shall specifically review and
  approve any proposed provisions in such contracts or agreements with the

  prospective or existing network members which specify any  risk  sharing
  arrangements.
    7.  The  commissioner  may  revoke, limit or annul a comprehensive HIV
  special needs plan certificate  of  authority  in  accordance  with  the
  provisions of section forty-four hundred four of this article.
    8.  A comprehensive HIV special needs plan, certified pursuant to this
  section, shall be responsible for providing or arranging for all medical
  assistance services defined under section three hundred sixty-five-a  of
  the  social  services law, including delivery of a comprehensive benefit
  package, which shall include early and  periodic  screening;  adolescent
  health;  diagnosis  and  treatment  and  child/teen  health  screenings;
  referrals  for  necessary  services;  linkages  to  HIV  counseling  and
  testing;  and  HIV  prevention and education activities. A comprehensive
  HIV special needs plan  provider  shall  be  responsible  for  assisting
  enrollees  in  the  prudent selection of such services including but not
  limited to:
    (a) referral, coordination, monitoring and follow-up  with  regard  to
  other  medical  services  providers,  as  appropriate  for diagnosis and
  treatment, or direct provision of all medical assistance services;
    (b) methods  of  assuring  enrollees'  access  to  specialty  services
  outside the comprehensive HIV special needs plan's network or panel when
  the  plan  does  not  have  a provider with the appropriate training and
  experience in its network to meet the particular health  care  needs  of
  the participant;
    (c)   the   establishment  of  appropriate  utilization  and  referral
  requirements for  physicians,  hospitals,  and  other  medical  services
  providers, including emergency room visits and inpatient admissions;
    (d)  the  creation  of  mechanisms  to ensure the participation of HIV
  centers of excellence and community-based HIV care providers;
    (e)  implementation  of  procedures  for  managing  the  care  of  all
  participants,  including  the  use  of facility and community-based case
  managers with expertise in the care needs of persons with HIV infection,
  and the designation of a specialist as a primary care practitioner;
    (f) development of appropriate methods of managing the HIV care  needs
  of  homeless,  substance users and other vulnerable populations, who are
  enrolled in the comprehensive HIV special needs plan, to assure that all
  necessary services are made available in a timely manner, in  accordance
  with prevailing standards of professional medical practice, and that all
  appropriate referrals and follow-up treatments are provided;
    (g) provision of all early periodic screening, diagnosis and treatment
  services,   as   well  as  periodic  screening  and  referral,  to  each
  participant under the age of twenty-one, at  regular  intervals  and  as
  medically appropriate;
    (h)   direct   provision  of  or  arrangement  for  the  provision  of
  comprehensive prenatal care services to  all  pregnant  participants  in
  accordance  with  standards adopted by the department of health and with
  statute and regulations governing HIV  testing  of  pregnant  women  and
  newborns;
    (i)  implementation  of  procedures  for written agreements, which may
  include contractual  agreements,  with  community-based  social  service
  providers  to  ensure access to the full continuum of services needed by
  HIV infected persons; and
    (j)  permit  the  use  of  standing  referrals  to   specialists   and
  subspecialists   for   participants   who   require  the  care  of  such
  practitioners on a regular basis.
    9. Notwithstanding any other provision of  law,  a  comprehensive  HIV
  special  needs  plan  certified  pursuant  to  this  section shall limit

  enrollment to HIV positive persons, except for the following persons who
  may be enrolled regardless of their HIV status:
    (a) related children up to the age of twenty-one; and
    (b) individuals who are homeless or who are members of other high need
  populations  which, in the discretion of the commissioner, would benefit
  from receiving services  through  a  plan  certified  pursuant  to  this
  section;  provided  however,  that rates paid to special needs plans for
  such populations  shall  be  comparable  to  rates  paid  for  the  same
  populations in other managed care plans.
    10.  Enrollment  and  disenrollment. (a) Enrollment in a comprehensive
  HIV special needs plan shall  be  voluntary  and  persons  eligible  for
  enrollment  in  such  plans  shall be afforded the opportunity to choose
  among such plans, to the extent available  in  the  locality  where  the
  person  currently  resides;  provided  however  that  enrollment  may be
  automatic after federal approval of a waiver or waivers or other federal
  action  required  to  institute  automatic   enrollment,   pursuant   to
  applicable  provisions  of  the  federal  social  security act, and that
  persons automatically enrolled in a comprehensive HIV special needs plan
  shall have the opportunity to withdraw from such plan in accordance with
  paragraph (g) of subdivision four, paragragh (b)  of  subdivision  three
  and  subdivision  twelve  of  section  three hundred sixty-four-j of the
  social services law. The department shall ensure to the  maximum  extent
  practicable that individuals are provided with a choice of comprehensive
  HIV special needs plans.
    (b)   The   commissioner  shall  promulgate  regulations  establishing
  criteria which relate to enrollment and disenrollment  of  enrollees  in
  comprehensive  HIV  special needs plans. Comprehensive HIV special needs
  plans shall not request  disenrollment  of  an  enrollee  based  on  any
  diagnosis,  condition,  or  perceived  diagnosis  or  condition,  or  an
  enrollee's efforts to exercise his  or  her  rights  under  a  grievance
  process.
    (c)  Prior  to  enrollment  in  a comprehensive HIV special needs plan
  individuals are to be provided with a full written  explanation  of  all
  fee-for-service  and other options and given a reasonable opportunity to
  choose between the comprehensive HIV special needs plan  and  the  other
  options.  In addition, enrollees shall be provided notice of their right
  to disenroll from  the  plan,  except  as  otherwise  provided  in  this
  subdivision.
    (d)  If  an enrollee requests to change a provider or disenroll from a
  comprehensive HIV special needs plan pursuant to this  subdivision,  the
  social  services  district and the plan shall implement such change in a
  timely  manner  in  accordance  with  standards   established   by   the
  commissioner.  When  an enrollee changes comprehensive HIV special needs
  plan providers the plan must  effectuate  the  timely  transfer  of  all
  necessary medical records.
    (e)  Plans  shall  ensure  that  any  new  enrollee  whose health care
  provider is not a member of the plan's provider network, who enrolls  in
  the  plan,  can  continue  with  an ongoing course of treatment with the
  enrollee's current health care provider during a transitional period  of
  up  to  sixty days from the effective date of enrollment. If an enrollee
  elects to continue to  receive  care  from  such  health  care  provider
  pursuant  to  this  paragraph,  such  care  shall  be  authorized by the
  comprehensive HIV special needs plan for the transitional period only if
  the health care provider agrees: (1) to accept  reimbursement  from  the
  comprehensive HIV special needs plan at rates established by the plan as
  payment  in  full,  which  rates  shall  be  no  more  than the level of
  reimbursement applicable to similar providers within the plan's  network
  for  such  services;  (2)  to  adhere  to  the  plan's quality assurance

  requirements and agrees to provide to the  plan  any  necessary  medical
  information  related  to  such  care; and (3) to otherwise adhere to the
  plan's policies and procedures including, but not limited to  procedures
  regarding referrals and obtaining pre-authorization and a treatment plan
  approved  by the comprehensive HIV special needs plan. In no event shall
  this paragraph be construed to require a comprehensive HIV special needs
  plan to provide coverage for benefits not otherwise covered;
    (f) Comprehensive HIV special needs plans shall ensure that for  those
  enrollees  whose  health  care  provider  leaves  the  comprehensive HIV
  special needs  plan's  network  of  providers,  the  enrollee  shall  be
  permitted  to  continue an ongoing course of treatment with such current
  health care provider during a transitional period of up to  ninety  days
  from the date of notice to the enrollee of the provider's disaffiliation
  from  the  plan's  network. If an enrollee elects to continue to receive
  care from such health care provider pursuant  to  this  paragraph,  such
  care shall be authorized by the comprehensive HIV special needs plan for
  the  transitional period only if the health care provider agrees: (1) to
  accept reimbursement from the comprehensive HIV special  needs  plan  at
  rates  established  by the plan as payment in full, which rates shall be
  no more than the level of reimbursement applicable to similar  providers
  within  the  plan's  network  for  such  services;  (2) to adhere to the
  organization's quality assurance requirements and agrees to  provide  to
  the plan any necessary medical information related to such care; and (3)
  to otherwise adhere to the plan's policies and procedures including, but
  not   limited   to   procedures   regarding   referrals   and  obtaining
  pre-authorization and a treatment plan approved by the comprehensive HIV
  special needs plan. In no event shall this  paragraph  be  construed  to
  require  a  comprehensive HIV special needs plan to provide coverage for
  benefits not otherwise covered;
    11. The commissioner shall develop and certify capitated payment rates
  for comprehensive HIV special needs plans, subject to  the  approval  of
  the  director  of  the  division of the budget. In developing capitation
  rates the commissioner shall be authorized to consider,  at  a  minimum,
  the  age, eligibility category, historic cost and utilization of covered
  enrollees and  covered  services,  anticipated  costs  of  emerging  HIV
  treatment modalities and the expected impact of delivering services in a
  managed care environment.
    12.  Plans  certified under this section must submit financial reports
  in a manner and frequency established by the commissioner.
    13. The department shall establish a stop-loss reinsurance program for
  comprehensive HIV special needs plans. The stop-loss reinsurance program
  shall be designed in a manner which promotes the development and ongoing
  financial viability of the  comprehensive  HIV  special  needs  plan  by
  providing  reasonable  protection  for  catastrophic  cases  and adverse
  selection.
    14. Quality assurance. (a) The department  shall  be  responsible  for
  establishing a comprehensive quality assurance program for comprehensive
  HIV  special  needs  plans. This quality assurance program shall reflect
  clinical standards of HIV care established and maintained  by  the  AIDS
  Institute   in   the   department.  The  department  shall  monitor  the
  performance, quality and utilization of such plans on at least an annual
  basis. Such plans must describe and document the existence of a  formal,
  organized  quality  assurance  program  with  the  capacity to identify,
  address and follow-up on issues which  concern  the  care  and  services
  delivered  to enrollees. Such reviews are to include, but not be limited
  to, the following:
    (1) compliance with performance and  outcome-based  quality  standards
  promulgated by the department;

    (2)  appropriateness,  accessibility,  timeliness, and quality of care
  delivered by such providers;
    (3)  referrals,  coordination, monitoring and follow-up with regard to
  other medical service providers;
    (4) methods of ensuring enrollees access to specialty services outside
  the plan's network or panel when the plan does not have a provider  with
  the  appropriate training and experience in the network or panel to meet
  the particular HIV care needs of the participant;
    (5) delivery of a comprehensive benefit package, including  early  and
  periodic  screening;  adolescent  health;  diagnosis  and  treatment and
  child/teen health screenings;  referrals  for  necessary  services,  and
  linkages  to  HIV  counseling  and testing; HIV prevention and education
  activities;
    (6) mechanisms for the provision of all information  to  enrollees  in
  clear  and  coherent  terms  that  are commonly used in a culturally and
  linguistically appropriate and understandable manner;
    (7) existence of a management information system  to  support  quality
  assurance  activities, which system shall provide for the collection and
  utilization of data including but not limited to enrollment, complaints,
  encounters and specific performance indicators; and
    (b) the commissioner shall have access  to  patient  specific  medical
  information  and  enrollee  medical  records,  including encounter data,
  maintained by a comprehensive HIV special needs plan for the purposes of
  quality assurance and oversight.
    (c)  The  department  shall  be  responsible  for   establishing   and
  maintaining  a uniform system of reports relating to the quality of care
  and services furnished by comprehensive HIV special needs plans.
    15. The commissioner may revoke, limit or annul  a  comprehensive  HIV
  special needs certificate of authority in accordance with the provisions
  of section forty-four hundred four of this article.
    16.   Confidentiality.   Except   as  provided  in  paragraph  (c)  of
  subdivision  fourteen  of  this  section,   any   enrollee   information
  maintained  by  a  comprehensive  HIV  special  needs plan shall be kept
  confidential in accordance with section forty-four  hundred  eight-a  of
  this  article  and  where applicable section 33.13 of the mental hygiene
  law and any other applicable state or federal law.
    17.  Utilization  review.  A  comprehensive  HIV  special  needs  plan
  authorized under this section is required to meet requirements set forth
  in article forty-nine of this chapter.
    18.  Disclosure.  Each  enrollee  and  prospective  enrollee  prior to
  enrollment in a comprehensive HIV special needs plan shall  be  provided
  with written disclosure information related to enrollee benefits, rights
  and  obligations  pursuant  to  section forty-four hundred eight of this
  article.
    19.  Grievance  procedure.  Comprehensive  HIV  special  needs   plans
  authorized  under  this  section  shall  be  required  to meet grievance
  procedures requirements pursuant to section forty-four  hundred  eight-a
  of this article.
    20.  Prohibitions.  A  comprehensive HIV special needs plan authorized
  under this section shall be required to meet the requirements set  forth
  in section forty-four hundred six-c of this article.
    21.  The  commissioner  is  authorized, subject to the approval of the
  director of the division of the budget, and within amounts appropriated,
  to make grants to those entities  seeking  certification  to  operate  a
  comprehensive  HIV  special  needs plan to aid in the development of the
  systems, organizational structures and networks necessary to  operate  a
  managed care program. The commissioner is authorized to develop criteria
  for  distribution of the grants. The grants may also be used to meet the

  capitalization standards and the reserve and escrow deposit requirements
  established for comprehensive HIV special needs plans.
    22.  Comprehensive  HIV  special needs plans shall function distinctly
  from other comprehensive or non-comprehensive health plans  operated  by
  the  same organization, corporation, persons, county or municipality and
  shall be clearly distinguished from  any  other  functions  through  the
  maintenance   of   separate   records,  reports  and  accounts  for  the
  comprehensive HIV special needs plan function.
    23. The  commissioner  shall  establish  reserve  and  escrow  deposit
  requirements for HIV special needs plans.
    24.  Nothing  in  this  section  shall  be construed to require that a
  health maintenance organization, certified pursuant to the provisions of
  this  article,  apply  for  a  comprehensive  HIV  special  needs   plan
  certificate  of  authority  pursuant to this section; provided, however,
  that a  health  maintenance  organization,  certified  pursuant  to  the
  provisions  of  this  article, which proposes to operate a comprehensive
  HIV special needs  plan  shall  be  required  to  comply  with  all  the
  provisions of this section.
    * NB Repealed March 31, 2016