2013 New York Consolidated Laws
PBH - Public Health
Article 29-E - (2999-N - 2999-R) ACCOUNTABLE CARE ORGANIZATIONS
2999-Q - Accountable care organizations; requirements.

 
    §   2999-q.  Accountable  care  organizations;  requirements.  1.  The
  commissioner  shall   make   regulations   establishing   criteria   for
  certificates   of  authority,  quality  standards  for  ACOs,  reporting
  requirements and other matters deemed to be appropriate and necessary in
  the operation and evaluation of ACOs under this article. In making  such
  regulations,  the  commissioner shall consult with the superintendent of
  financial services,  health  care  providers,  third-party  health  care
  payers,  advocates representing patients, and other appropriate parties.
  Such regulations shall  be  consistent,  to  the  extent  practical  and
  consistent  with this article, with CMS regulations for accountable care
  organizations under the Medicare program.
    2. Such regulations may, and shall as necessary for purposes  of  this
  article, address matters including but not limited to:
    (a)  The  governance,  leadership  and management structure of the ACO
  that reasonably and equitably represents the ACO's participants and  the
  ACO's   patients,   including   the   manner   in   which  clinical  and
  administrative systems and clinical participation will be managed;
    (b) Definition of the population proposed to be  served  by  the  ACO,
  which   may  include  reference  to  a  geographical  area  and  patient
  characteristics;
    (c) The character, competence and fiscal responsibility and  soundness
  of an ACO and its principals, if and to the extent deemed appropriate by
  the commissioner;
    (d)  The  adequacy  of  an  ACO's network of participating health care
  providers, including primary care health care providers;
    (e) Mechanisms by which an ACO will provide,  manage,  and  coordinate
  quality  health  care  for  its  patients  including  where  practicable
  elevating the services of primary care health  care  providers  to  meet
  patient-centered  medical  home  standards,  coordinating  services  for
  complex  high-need  patients,  and  providing  access  to  health   care
  providers that are not participants in the ACO;
    (f)  Mechanisms by which the ACO shall receive and distribute payments
  to its participating health care providers, which may include  incentive
  payments  (which  may  include  medical home payments) or mechanisms for
  pooling payments received by participating health  care  providers  from
  third-party payers and patients;
    (g)  Mechanisms  and  criteria  for accepting health care providers to
  participate in the ACO that are related to  the  needs  of  the  patient
  population  to  be  served  and  needs  and  purposes  of  the  ACO, and
  preventing unreasonable discrimination;
    (h) Mechanisms for quality  assurance  and  grievance  procedures  for
  patients  or health care providers where appropriate, and procedures for
  reviewing and appealing patient care decisions;
    (i)  Mechanisms  that  promote  evidence-based  health  care,  patient
  engagement,  coordination  of care, electronic health records, including
  participation  in   health   information   exchanges,   other   enabling
  technologies   and  integrated,  efficient  and  effective  health  care
  services;
    (j) Performance standards for, and measures to assess, the quality and
  utilization of care provided by an ACO;
    (k) Appropriate requirements for ACOs to promote compliance  with  the
  purposes of this article;
    (l)  Posting  on  the department's website information about ACOs that
  would be useful to health care providers and patients, including similar
  metrics as the commissioner publishes for other  organizations  such  as
  Medicaid managed care providers under section three hundred sixty-four-j
  of  the social services law and health homes under section three hundred
  sixty-five-l of the social services law;

    (m) Requirements for the submission of information and  data  by  ACOs
  and   their  participating  and  affiliated  health  care  providers  as
  necessary for the evaluation of the success of ACOs;
    (n) Protection of patient rights as appropriate;
    (o) The impact of the establishment and operation of an ACO, including
  providing  that  it shall not diminish access to any health care service
  for the population served and in the area served; and
    (p) Establishment of standards, as appropriate, to promote the ability
  of an ACO to participate in applicable federal programs for ACOs.
    3. (a) The ACO shall  provide  for  meaningful  participation  in  the
  composition and control of the ACO's governing body for ACO participants
  or their designated representatives.
    (b)  The  ACO governing body shall include at least one representative
  of each of the following groups:  (i)  recipients  of  Medicaid,  family
  health  plus,  or  child  health  plus;  (ii)  persons with other health
  coverage; and (iii) persons  who  do  not  have  health  coverage.  Such
  representatives  shall  have no conflict of interest with the ACO and no
  immediate family member with a conflict of interest with the ACO.
    (c) At least seventy-five percent control of the ACO's governing  body
  shall be held by ACO participants.
    (d)  Members  of  the  ACO  governing  body  shall  have  a  fiduciary
  relationship with the ACO and shall be subject to conflict  of  interest
  requirements adopted by the ACO and in regulations of the commissioner.
    (e)  The  ACO's  finances,  including  dividends  and  other return on
  capital, debt structure, executive  compensation,  and  ACO  participant
  compensation,   shall   be   arranged  and  conducted  to  maximize  the
  achievement of the purposes of this article.
    4. (a) An ACO  shall  use  its  best  efforts  to  include  among  its
  participants,     on    reasonable    terms    and    conditions,    any
  federally-qualified health center that is willing to  be  a  participant
  and that serves the area and population served by the ACO.
    (b)  An  ACO  may  seek  to focus on providing health care services to
  patients with one or more chronic conditions or special needs.  However,
  an  ACO  may  not  otherwise,  on  the  basis  of  a person's medical or
  demographic characteristics, discriminate for or against  or  discourage
  or  encourage  any  person  or  person  with  respect  to  enrolling  or
  participating in the ACO.
    (c) An ACO shall not, by incentives or otherwise, discourage a  health
  care  provider  from  providing  or  an enrollee or patient from seeking
  appropriate health care services.
    (d) An ACO shall not discriminate against or disadvantage a patient or
  patient's representative for the exercise of patient autonomy.
    (e) An ACO may not limit or restrict beneficiaries to use of providers
  contracted or affiliated with the ACO. An ACO may not require a  patient
  to  obtain  the  prior  approval,  from  a  primary  care  gatekeeper or
  otherwise, before utilizing the services of other providers. An ACO  may
  not make adverse determinations as defined in article forty-nine of this
  chapter.
    5.  An  ACO  may  provide  care  coordination  for  its  participating
  patients, which (a) shall  include  but  not  be  limited  to  managing,
  referring   to,  locating,  coordinating,  and  monitoring  health  care
  services for the member to assure that all  medically  necessary  health
  care  services  are  made  available  to and are effectively used by the
  member in a timely manner, consistent with patient autonomy; and (b)  is
  not  a requirement for prior authorization for health care services, and
  referral shall not be required for a member to  receive  a  health  care
  service.

    6.  (a)  Subject  to  regulations  of the commissioner: (i) an ACO may
  enter into arrangements with one or more third-party health care  payers
  to  establish  payment  methodologies  for  health care services for the
  third-party health care payer's enrollees provided by  the  ACO  or  for
  which  the  ACO  is  responsible,  such as full or partial capitation or
  other arrangements; (ii) such arrangements may include provision for the
  ACO to receive and distribute payments to the ACO's participating health
  care providers, including incentive payments  and  payments  for  health
  care  services  from  third-party  health  care payers and patients; and
  (iii) an ACO may include mechanisms for  pooling  payments  received  by
  participating   health   care  providers  from  third-party  payers  and
  patients.
    (b) Subject to regulations of the commissioner, the  commissioner,  in
  consultation   with   the  superintendent  of  financial  services,  may
  authorize a third-party health care  payer  to  participate  in  payment
  methodologies  with  an  ACO under this subdivision, notwithstanding any
  contrary provision of  this  chapter,  the  insurance  law,  the  social
  services  law, or the elder law, on finding that the payment methodology
  is consistent with the purposes of this article.
    (c) An ACO may contract with a third-party health care payer to  serve
  as  all  or part of the third-party health care payer's provider network
  or care coordination agent, provided in  that  case  the  ACO  shall  be
  subject to all provisions of this chapter or the insurance law which are
  applicable to the provider network of the third-party health care payer.
    7.  The provision of health care services directly or indirectly by an
  ACO through health care providers shall not be considered  the  practice
  of a profession under title eight of the education law by the ACO.