There is a newer version of the New York Consolidated Laws
2013 New York Consolidated Laws
PBH - Public Health
Article 44 - (4400 - 4414) HEALTH MAINTENANCE ORGANIZATIONS
4403-F - Managed long term care plans.
NY Pub Health L § 4403-F (2012) What's This?
* § 4403-f. Managed long term care plans. 1. Definitions. As used in
this section:
(a) "Managed long term care plan" means an entity that has received a
certificate of authority pursuant to this section to provide, or arrange
for, health and long term care services, on a capitated basis in
accordance with this section, for a population, age eighteen and over,
which the plan is authorized to enroll.
(b) "Eligible applicant" means an entity controlled or wholly owned by
one or more of the following: a hospital as defined in subdivision one
of section twenty-eight hundred one of this chapter; a home care agency
licensed or certified pursuant to article thirty-six of this chapter; an
entity that has received a certificate of authority pursuant to sections
forty-four hundred three, forty-four hundred three-a or forty-four
hundred eight-a of this article (as added by chapter six hundred
thirty-nine of the laws of nineteen hundred ninety-six), or a health
maintenance organization authorized under article forty-three of the
insurance law; or a not-for-profit organization which has a history of
providing or coordinating health care services and long term care
services to the elderly and disabled.
(c) "Operating demonstration" means the following entities: the
chronic care management demonstration programs authorized by chapter
five hundred thirty of the laws of nineteen hundred eighty-eight,
chapter five hundred ninety-seven of the laws of nineteen hundred
ninety-four and chapter eighty-one of the laws of nineteen hundred
ninety-five as amended.
(d) "Health and long term care services" means services including, but
not limited to home and community-based and institution-based long term
care and ancillary services (that shall include medical supplies and
nutritional supplements) that are necessary to meet the needs of persons
whom the plan is authorized to enroll. The managed long term care plan
may also cover primary care and acute care if so authorized.
2. Certificate of authority; form. An eligible applicant shall submit
an application for a certificate of authority to operate a managed long
term care plan upon forms prescribed by the commissioner. Such eligible
applicant shall submit information and documentation to the commissioner
which shall include, but not be limited to:
(a) a description of the service area proposed to be served by the
plan with projections of enrollment that will result in a fiscally sound
plan;
(b) a description of the proposed target population and the marketing
plan;
(c) adequate documentation of the appropriate licenses, certifications
or approvals to provide care as planned, including contracts with such
providers as may be necessary to provide the full complement of services
required to be provided under this section.
3. Certificate of authority; approval. The commissioner shall not
approve an application for a certificate of authority unless the
applicant demonstrates to the commissioner's satisfaction:
(a) that it will have in place acceptable quality-assurance
mechanisms, grievance procedures, mechanisms to protect the rights of
enrollees and case management services to ensure continuity, quality,
appropriateness and coordination of care;
(b) that it will include an enrollment process which shall ensure that
enrollment in the plan is informed. The application shall describe the
disenrollment process, which shall provide that an otherwise eligible
enrollee shall not be involuntarily disenrolled on the basis of health
status;
(c) satisfactory evidence of the character and competence of the
proposed operators and reasonable assurance that the applicant will
provide high quality services to an enrolled population;
(d) sufficient management systems capacity to meet the requirements of
this section and the ability to efficiently process payment for covered
services;
(e) readiness and capability to maximize reimbursement of and
coordinate services reimbursed pursuant to title XVIII of the federal
social security act and all other applicable benefits, with such benefit
coordination including, but not limited to, measures to support sound
clinical decisions, reduce administrative complexity, coordinate access
to services, maximize benefits available pursuant to such title and
ensure that necessary care is provided;
(f) readiness and capability to arrange and manage covered services
and coordinate non-covered services which could include primary,
specialty, and acute care services reimbursed pursuant to title XIX of
the federal social security act;
(g) willingness and capability of taking, or cooperating in, all steps
necessary to secure and integrate any potential sources of funding for
services provided by the managed long term care plan, including, but not
limited to, funding available under titles XVI, XVIII, XIX and XX of the
federal social security act, the federal older Americans act of nineteen
hundred sixty-five, as amended, or any successor provisions subject to
approval of the director of the state office for aging, and through
financing options such as those authorized pursuant to section three
hundred sixty-seven-f of the social services law;
(h) that the contractual arrangements for providers of health and long
term care services in the benefit package are sufficient to ensure the
availability and accessibility of such services to the proposed enrolled
population consistent with guidelines established by the commissioner;
with respect to individuals in receipt of such services prior to
enrollment, such guidelines shall require the managed long term care
plan to contract with agencies currently providing such services, in
order to promote continuity of care. In addition, such guidelines shall
require managed long term care plans to offer and cover consumer
directed personal assistance services for eligible individuals who elect
such services pursuant to section three hundred sixty-five-f of the
social services law; and
(i) that the applicant is financially responsible and may be expected
to meet its obligations to its enrolled members.
4. Solvency. (a) The commissioner shall be responsible for evaluating,
approving and regulating all matters relating to fiscal solvency,
including reserves, surplus and provider contracts. The commissioner may
promulgate regulations to implement this section. The commissioner, in
the administration of this subdivision:
(i) shall be guided by the standards which govern the fiscal solvency
of a health maintenance organization, provided, however, that the
commissioner shall recognize the specific delivery components,
operational capacity and financial capability of the eligible applicant
for a certificate of authority;
(ii) shall not apply financial solvency standards that exceed those
required for a health maintenance organization; and
(iii) shall establish reasonable capitalization and contingent reserve
requirements.
(b) Standards established pursuant to this subdivision shall be
adequate to protect the interests of enrollees in managed long term care
plans. The commissioner shall be satisfied that the eligible applicant
is financially sound, and has made adequate provisions to pay for
services.
4-a. Role of the superintendent of financial services. (a) The
superintendent of financial services shall determine and approve
premiums in accordance with the insurance law whenever any population of
enrollees not eligible under title XIX of the federal social security
act is to be covered. The determination and approval of the
superintendent of financial services shall relate to premiums charged to
such enrollees not eligible under title XIX of the federal social
security act.
(b) The superintendent of financial services shall evaluate and
approve any enrollee contracts whenever such enrollee contracts are to
cover any population of enrollees not eligible under title XIX of the
federal social security act.
5. Applicability of other laws. A managed long term care plan shall be
subject to the provisions of the insurance law and regulations
applicable to health maintenance organizations, this article and
regulations promulgated pursuant thereto. To the extent that the
provisions of this section are inconsistent with the provisions of this
chapter or the provisions of the insurance law, the provisions of this
section shall prevail.
6. Approval authority. (a) An applicant shall be issued a certificate
of authority as a managed long term care plan upon a determination by
the commissioner that the applicant complies with the operating
requirements for a managed long term care plan under this section. The
commissioner shall issue no more than seventy-five certificates of
authority to managed long term care plans pursuant to this section.
(b) An operating demonstration shall be issued a certificate of
authority as a managed long term care plan upon a determination by the
commissioner that such demonstration complies with the operating
requirements for a managed long term care plan under this section.
Nothing in this section shall be construed to affect the continued legal
authority of an operating demonstration to operate its previously
approved program.
(c) For the period beginning April first, two thousand twelve and
ending March thirty-first, two thousand fifteen, the majority leader of
the senate and the speaker of the assembly may each recommend to the
commissioner, in writing, up to four eligible applicants to convert to
be approved managed long term care plans. An applicant shall only be
approved and issued a certificate of authority if the commissioner
determines that the applicant meets the requirements of subdivision
three of this section. The majority leader of the senate or the speaker
of the assembly may assign their authority to recommend one or more
applicants under this section to the commissioner.
7. Program oversight and administration. (a)(i) The commissioner shall
promulgate regulations to implement this section and to ensure the
quality, appropriateness and cost-effectiveness of the services provided
by managed long term care plans. The commissioner may waive rules and
regulations of the department, including but not limited to, those
pertaining to duplicative requirements concerning record keeping, boards
of directors, staffing and reporting, when such waiver will promote the
efficient delivery of appropriate, quality, cost-effective services and
when the health, safety and general welfare of enrollees will not be
impaired as a result of such waiver. In order to achieve managed long
term care plan system efficiencies and coordination and to promote the
objectives of high quality, integrated and cost effective care, the
commissioner may establish a single coordinated surveillance process,
allow for a comprehensive quality improvement and review process to meet
component quality requirements, and require a uniform cost report. The
commissioner shall require managed long term care plans to utilize
quality improvement measures, based on health outcomes data, for
internal quality assessment processes and may utilize such measures as
part of the single coordinated surveillance process.
(ii) Notwithstanding any inconsistent provision of the social services
law to the contrary, the commissioner shall, pursuant to regulation,
determine whether and the extent to which the applicable provisions of
the social services law or regulations relating to approvals and
authorizations of, and utilization limitations on, health and long term
care services reimbursed pursuant to title XIX of the federal social
security act, including, but not limited to, fiscal assessment
requirements, are inconsistent with the flexibility necessary for the
efficient administration of managed long term care plans and such
regulations shall provide that such provisions shall not be applicable
to enrollees or managed long term care plans, provided that such
determinations are consistent with applicable federal law and
regulation.
* (b) (i) The commissioner shall, to the extent necessary, submit the
appropriate waivers, including, but not limited to, those authorized
pursuant to sections eleven hundred fifteen and nineteen hundred fifteen
of the federal social security act, or successor provisions, and any
other waivers necessary to achieve the purposes of high quality,
integrated, and cost effective care and integrated financial eligibility
policies under the medical assistance program or pursuant to title XVIII
of the federal social security act. In addition, the commissioner is
authorized to submit the appropriate waivers, including but not limited
to those authorized pursuant to sections eleven hundred fifteen and
nineteen hundred fifteen of the federal social security act or successor
provisions, and any other waivers necessary to require on or after April
first, two thousand twelve, medical assistance recipients who are
twenty-one years of age or older and who require community-based long
term care services, as specified by the commissioner, for more than one
hundred and twenty days, to receive such services through an available
plan certified pursuant to this section or other program model that
meets guidelines specified by the commissioner that support coordination
and integration of services. Such guidelines shall address the
requirements of paragraphs (a), (b), (c), (d), (e), (f), (g), (h), and
(i) of subdivision three of this section as well as payment methods that
ensure provider accountability for cost effective quality outcomes. Such
other program models may include long term home health care programs
that comply with such guidelines. Copies of such original waiver
applications and amendments thereto shall be provided to the chairs of
the senate finance committee, the assembly ways and means committee and
the senate and assembly health committees simultaneously with their
submission to the federal government.
(ii) The commissioner, shall seek input from representatives of home
and community-based long term care services providers, recipients, and
the Medicaid managed care advisory review panel, among others, to
further evaluate and promote the transition of persons in receipt of
home and community-based long term care services into managed long term
care plans and other care coordination models and to develop guidelines
for such care coordination models. The guidelines shall be finalized and
posted on the department's website no later than November fifteen, two
thousand eleven.
(v) The following medical assistance recipients shall not be eligible
to participate in a managed long term care program or other care
coordination model established pursuant to this paragraph until program
features and reimbursement rates are approved by the commissioner and,
as applicable, the commissioner of developmental disabilities:
(1) a person enrolled in a managed care plan pursuant to section three
hundred sixty-four-j of the social services law;
(2) a participant in the traumatic brain injury waiver program;
(3) a participant in the nursing home transition and diversion waiver
program;
(4) a person enrolled in the assisted living program;
(5) a person enrolled in home and community based waiver programs
administered by the office for people with developmental disabilities;
(6) a person who is expected to be eligible for medical assistance for
less than six months, for a reason other than that the person is
eligible for medical assistance only through the application of excess
income toward the cost of medical care and services;
(7) a person who is eligible for medical assistance benefits only with
respect to tuberculosis-related services;
(8) a person receiving hospice services at time of enrollment;
provided, however, that this clause shall not be construed to require an
individual enrolled in a managed long term care plan or another care
coordination model, who subsequently elects hospice, to disenroll from
such program;
(9) a person who has primary medical or health care coverage available
from or under a third-party payor which may be maintained by payment, or
part payment, of the premium or cost sharing amounts, when payment of
such premium or cost sharing amounts would be cost-effective, as
determined by the social services district;
(10) a person receiving family planning services pursuant to
subparagraph six of paragraph (b) of subdivision one of section three
hundred sixty-six of the social services law;
(11) a person who is eligible for medical assistance pursuant to
paragraph (b) of subdivision four of section three hundred sixty-six of
the social services law; and
(12) Native Americans.
(vi) persons required to enroll in the managed long term care program
or other care coordination model established pursuant to this paragraph
shall have no less than thirty days to select a managed long term care
provider, and shall be provided with information to make an informed
choice. Where a participant has not selected such a provider, the
commissioner shall assign such participant to a managed long term care
provider, taking into account quality, capacity and geographic
accessibility.
(vii) Managed long term care provided and plans certified or other
care coordination model established pursuant to this paragraph shall
comply with the provisions of paragraphs (d), (i), (t), and (u) and
subparagraph (iii) of paragraph (a) and subparagraph (iv) of paragraph
(e) of subdivision four of section three hundred sixty-four-j of the
social services law.
(viii) (1) The commissioner shall report biannually on the
implementation of this subdivision. The reports shall include, but not
be limited to:
(A) satisfaction of enrollees with care coordination/case management;
timeliness of care;
(B) service utilization data including changes in the level, hours,
frequency, and types of services and providers;
(C) enrollment data, including auto-assignment rates by plan;
(D) quality data; and
(E) continuity of care for participants as they move to managed long
term care, with respect to community based and nursing home populations,
including pediatric nursing home populations, and medically fragile
children being served by home care agencies affiliated with pediatric
nursing homes and diagnostic and treatment centers primarily serving
medically fragile children.
(2) The commissioner shall publish the report on the department's
website and provide notice to the temporary president of the senate, the
speaker of the assembly, the chair of the senate standing committee on
health, the chair of the assembly health committee and the Medicaid
Managed Care Advisory Review Panel upon availability of the report. The
initial report shall be provided by September first, two thousand
twelve. The reports shall be made available by each February first, and
September first thereafter. Such reports shall be formatted to allow
comparisons between plans.
* NB Effective until April 1, 2015
* (b) The commissioner shall, to the extent necessary, submit the
appropriate waivers, including, but not limited to, those authorized
pursuant to sections eleven hundred fifteen and nineteen hundred fifteen
of the federal social security act, or successor provisions, and any
other waivers necessary to achieve the purposes of high quality,
integrated, and cost effective care and integrated financial eligibility
policies under the medical assistance program or pursuant to title XVIII
of the federal social security act. Copies of such original waiver
applications shall be provided to the chairman of the senate finance
committee and the chairman of the assembly ways and means committee
simultaneously with their submission to the federal government.
* NB Effective April 1, 2015
(c)(i) A managed long term care plan shall not use deceptive or
coercive marketing methods to encourage participants to enroll. A
managed long term care plan shall not distribute marketing materials to
potential enrollees before such materials have been approved by the
commissioner.
(ii) The commissioner shall ensure, through periodic reviews of
managed long term care plans, that enrollment was an informed choice;
such plan has only enrolled persons whom it is authorized to enroll, and
plan services are promptly available to enrollees when appropriate. Such
periodic reviews shall be made according to standards as determined by
the commissioner in regulations.
(d) Notwithstanding any provision of law, rule or regulation to the
contrary, the commissioner may issue a request for proposals to carry
out reviews of enrollment and assessment activities in managed long term
care plans and operating demonstrations with respect to enrollees
eligible to receive services under title XIX of the federal social
security act to determine if enrollment meets the requirements of
subparagraph (ii) of paragraph (c) of this subdivision; and that
assessments of such enrollees' health, functional and other status, for
the purpose of adjusting premiums, were accurate.
(e) The commissioner may, in his or her discretion for the purpose of
protection of enrollees, impose measures including, but not limited to,
bans on further enrollments and requirements for use of enrollment
brokers until any identified problems are resolved to the satisfaction
of the commissioner.
(f) Continuation of a certificate of authority issued under this
section shall be contingent upon satisfactory performance by the managed
long term care plan in the delivery, continuity, accessibility, cost
effectiveness and quality of the services to enrolled members;
compliance with applicable provisions of this section and rules and
regulations promulgated thereunder; the continuing fiscal solvency of
the organization; and, federal financial participation in payments on
behalf of enrollees who are eligible to receive services under title XIX
of the federal social security act.
(g) * (i) Managed long term care plans and demonstrations may enroll
eligible persons in the plan or demonstration upon the completion of a
comprehensive assessment that shall include, but not be limited to, an
evaluation of the medical, social and environmental needs of each
prospective enrollee in such program. This assessment shall also serve
as the basis for the development and provision of an appropriate plan of
care for the enrollee. Upon approval of federal waivers pursuant to
paragraph (b) of this subdivision which require medical assistance
recipients who require community-based long term care services to enroll
in a plan, and upon approval of the commissioner, a plan may enroll an
applicant who is currently receiving home and community-based services
and complete the comprehensive assessment within thirty days of
enrollment provided that the plan continues to cover transitional care
until such time as the assessment is completed.
* NB Effective until April 1, 2015
* (i) Managed long term care plans and demonstrations may enroll
eligible persons in the plan or demonstration upon the completion of a
comprehensive assessment that shall include, but not be limited to, an
evaluation of the medical, social and environmental needs of each
prospective enrollee in such program. This assessment shall also serve
as the basis for the development and provision of an appropriate plan of
care for the prospective enrollee.
* NB Effective April 1, 2015
(ii) The assessment shall be completed by a representative of the
managed long term care plan or demonstration, in consultation with the
prospective enrollee's health care practitioner as necessary. The
commissioner shall prescribe the forms on which the assessment shall be
made.
(iii) The enrollment application shall be submitted by the managed
long term care plan or demonstration to the entity designated by the
department prior to the commencement of services under the managed long
term care plan or demonstration. Enrollments conducted by a plan or
demonstration shall be subject to review and audit by the department or
a contractor selected pursuant to paragraph (d) of this subdivision.
(iv) Continued enrollment in a managed long term care plan or
demonstration paid for by government funds shall be based upon a
comprehensive assessment of the medical, social and environmental needs
of the recipient of the services. Such assessment shall be performed at
least every six months by the managed long term care plan serving the
enrollee. The commissioner shall prescribe the forms on which the
assessment will be made.
(h) * The commissioner and, in the case of a plan arranging for or
providing services operated, certified, funded, authorized or approved
by the office for people with developmental disabilities, the
commissioner of the office for people with developmental disabilities,
shall, upon request by a managed long term care plan or operating
demonstration, and consistent with federal regulations promulgated
pursuant to the Health Insurance Portability and Accountability Act,
share with such plan or demonstration the following data if it is
available:
* NB Effective until September 30, 2019
* The commissioner shall, upon request by a managed long term care
plan or operating demonstration, and consistent with federal regulations
promulgated pursuant to the Health Insurance Portability and
Accountability Act, share with such plan or demonstration the following
data if it is available:
* NB Effective September 30, 2019
(i) information concerning utilization of services and providers by
each of its enrollees prior to and during enrollment, including but not
limited to utilization of emergency department services, prescription
drugs, and hospital and nursing facility admissions.
(ii) aggregate data concerning utilization and costs for enrollees and
for comparable cohorts served through the Medicaid fee-for-service
program.
8. Payment rates for managed long term care plan enrollees eligible
for medical assistance. The commissioner shall establish payment rates
for services provided to enrollees eligible under title XIX of the
federal social security act. Such payment rates shall be subject to
approval by the director of the division of the budget and shall reflect
savings to both state and local governments when compared to costs which
would be incurred by such program if enrollees were to receive
comparable health and long term care services on a fee-for-service basis
in the geographic region in which such services are proposed to be
provided. Payment rates shall be risk-adjusted to take into account the
characteristics of enrollees, or proposed enrollees, including, but not
limited to: frailty, disability level, health and functional status,
age, gender, the nature of services provided to such enrollees, and
other factors as determined by the commissioner. The risk adjusted
premiums may also be combined with disincentives or requirements
designed to mitigate any incentives to obtain higher payment categories.
9. Reports. The department shall provide an interim report to the
governor, temporary president of the senate and the speaker of the
assembly on or before April first, two thousand three and a final report
on or before April first, two thousand six on the results of the managed
long term care plans under this section. Such results shall be based on
data provided by the managed long term care plans and shall include but
not be limited to the quality, accessibility and appropriateness of
services; consumer satisfaction; the mean and distribution of impairment
measures of the enrollees by payor for each plan; the current method of
calculating premiums and the cost of comparable health and long term
care services provided on a fee-for-service basis for enrollees eligible
for services under title XIX of the federal social security act; and the
results of periodic reviews of enrollment levels and practices. Such
reports shall provide data on the demographic and clinical
characteristics of enrollees, voluntary and involuntary disenrollments
from plans, and utilization of services and shall examine the
feasibility of increasing the number of plans that may be approved. Data
collected pursuant to this section shall be available to the public in
an aggregated format to protect individual confidentiality, however
under no circumstance will data be released on items with cells with
smaller than statistically acceptable standards.
10. Notwithstanding any inconsistent provision to the contrary, the
enrollment and disenrollment process and services provided or arranged
by all operating demonstrations or any program that receives designation
as a Program of All-Inclusive Care for the Elderly (PACE) as authorized
by federal public law 105-33, subtitle I of title IV of the Balanced
Budget Act of 1997, must meet all applicable federal requirements.
Services may include, but need not be limited to, housing, inpatient and
outpatient hospital services, nursing home care, home health care, adult
day care, assisted living services provided in accordance with article
forty-six-B of this chapter, adult care facility services, enriched
housing program services, hospice care, respite care, personal care,
homemaker services, diagnostic laboratory services, therapeutic and
diagnostic radiologic services, emergency services, emergency alarm
systems, home delivered meals, physical adaptations to the client's
home, physician care (including consultant and referral services),
ancillary services, case management services, transportation, and
related medical services.
11. The department shall develop transition and continuity of care
policies for participants in home and community based long term care,
including the long term home health care program, as they move to
managed long term care plans addressing:
(a) a timetable and plan for implementation and transition by
participants, plans and providers;
(b) informative disclosure of participants' options as to impending
actions affecting or relating to the home care services they receive;
(c) reasonable opportunity for plans' and providers' good faith
pursuit of contracts, program changes or state approvals relevant to
plan implementation;
(d) notice that a participant with a previously established plan of
care provided by a certified home health agency or long term home health
care program, or provided pursuant to the personal care or consumer
directed personal assistance service programs, may elect to have such
care plan continued subject to the participant's next comprehensive
assessment; and
(e) delineation of responsibilities for service delivery and care
coordination, so as to avoid conflict, duplication and unnecessary
disruption of direct care staffing for the patient, and maintain
compliance with state and federal statute and regulation, including the
provisions of this section, article thirty-six of this chapter and
section three hundred sixty-five-f of the social services law.
In addition, the department shall provide technical assistance to long
term home health care providers with contracting options under this
section. The department shall work with affected stakeholders in the
development of these policies.
11-a. In transitioning individuals to managed long term care, the
department shall provide oversight of long term managed care by
ensuring:
(a) participants are appropriately notified of the upcoming changes to
their health care, and their rights and options;
(b) access to appropriate enrollment assistance, consumer assistance
and complaint mechanisms;
(c) access to quality care by requiring network transparency and
choice of long term care plans, allowing patients to choose the plan
that best fits their needs;
(d) transparency and accountability from providers, which shall
include a mechanism by which staff, participants and family members can
confidentially report concerns relating to quality to the plan and the
state;
(e) plans and providers are assessed periodically and data is
published regarding enrollment in integrated care designs, network
adequacy, new service designs, outcome measures, including the extent to
which care plans are continued or altered based upon new comprehensive
assessments, and the types and amounts of services health plans have
authorized;
(f) mechanisms are in place to state oversight of enrollment and
services to prevent waste and abuse in the managed long term care
system; and
(g) incentives are provided for a variety of indicators, including but
not limited to, smooth patient transitions, appropriate enrollment,
quality care, high staff retention and positive health care outcomes
achieved at a low cost.
** 12. The commissioner may make any necessary amendments to a
contract pursuant to this section with a managed long term care plan, as
defined in paragraph (a) of subdivision one of this section, to allow
such managed long term care plan to participate as a qualified health
plan in a state health benefit exchange established pursuant to the
federal Patient Protection and Affordable Care Act (P.L. 111-148), as
amended by the federal Health Care and Education Reconciliation Act of
2010 (P.L. 111-152).
** NB There are 2 sb 12's
** 12. Notwithstanding any provision to the contrary, a managed long
term care plan may expand the services it provides or arranges for to
include services operated, certified, funded, authorized or approved by
the office for people with developmental disabilities for a population
of persons with developmental disabilities, as such term is defined in
the mental hygiene law, including habiltiation services as defined in
paragraph (c) of subdivision one of section forty-four hundred three-g
of this article, subject to the following:
(a) Such plan must have the ability to provide or coordinate services
for persons with developmental disabilities as demonstrated by criteria
to be determined by the commissioner and the commissioner of the office
for people with developmental disabilities. Such criteria shall include,
but not be limited to, adequate experience providing or coordinating
services for persons with developmental disabilities;
(a-1) If the commissioner and the commissioner of the office for
people with developmental disabilities determine that such plan lacks
the experience required in paragraph (a) of this subdivision, the plan
shall have an affiliation arrangement with an entity or entities with
experience serving persons with developmental disabilities such that the
affiliated entity will coordinate and plan services operated, certified,
funded, authorized or approved by the office for people with
developmental disabilities or will oversee and approve such coordination
and planning;
(a-2) Each enrollee shall receive services designed to achieve
person-centered outcomes, to enable that person to live in the most
integrated setting appropriate to that person's needs, and to enable
that person to interact with nondisabled persons to the fullest extent
possible in social, workplace and other community settings, provided
that all such services are consistent with such person's wishes to the
extent that such wishes are known. With respect to an individual
receiving non-residential services operated, certified, funded,
authorized or approved by the office for people with developmental
disabilities prior to enrollment in the plan, such guidelines shall
require the plan to contract with the current provider of such
non-residential services at the rates established by the office for
ninety days in order to ensure continuity of care. With respect to an
individual living in a residential facility operated or certified by the
office for people with developmental disabilities prior to enrollment in
the plan, the plan shall contract with the provider of residential
services for that residence at the rates established by the office for
people with developmental disabilities for so long as such individual
lives in that residence pursuant to an approved plan of care;
(b) The provision by such plan of services operated, certified,
funded, authorized or approved by the office for people with
developmental disabilities shall be subject the joint oversight and
review of both the department and the office for people with
developmental disabilities. The department and such office shall
require such organization to provide comprehensive care planning, assess
quality, meet quality assurance requirements and ensure the enrollee is
involved in care planning;
(c) Such plan shall not provide or arrange for services operated,
certified, funded, authorized or approved by the office for people with
developmental disabilities until the commissioner and the commissioner
of the office for people with developmental disabilities approve program
features and rates that include such services, and determine that such
organization meets the requirements of this subdivision and any other
requirements set forth by the commissioner of the office for people with
developmental disabilities;
(d) An otherwise eligible enrollee receiving services through the plan
that are operated, certified, funded, authorized or approved by the
office for people with developmental disabilities shall not be
involuntarily disenrolled from such plan without the prior approval of
the commissioner of the office for people with developmental
disabilities. Notice shall be provided to the enrollee and the enrollee
may request a fair hearing regarding such disenrollment;
(e) The office for people with developmental disabilities shall
determine the eligibility of individuals receiving services operated,
certified, funded, authorized or approved by such office to enroll in
such plan and shall enroll individuals it determines eligible in a plan
chosen by such individual, guardian or other legal representative;
(f) The office for people with developmental disabilities, or its
designee, shall complete a comprehensive assessment for enrollees who
receive services operated, certified, funded, authorized or approved by
such office. This assessment shall include, but not be limited to, an
evaluation of the medical, social, habilitative and environmental needs
of each prospective enrollee as such needs relate to each individual's
health, safety, living environment and wishes, to the extent that such
wishes are known. This assessment shall also serve as the basis for the
development and provision of an appropriate plan of care for the
enrollee. Such plan of care shall be focused on the achievement of
person-centered outcomes and shall be consistent with and help inform
any other person-centered plan required for the enrollee by the
commissioner of the office for people with developmental disabilities.
The initial assessment shall be completed by such office or a designee
other than the plan and shall be completed in consultation with the
prospective enrollee's health care practitioner as necessary.
Reassessments shall be completed by such office or its designee, which
may be the managed long term care plan in which the person is enrolled
or proposes to enroll. The commissioner of the office for people with
developmental disabilities shall prescribe the forms on which the
assessment shall be made.
(f-1) The plan shall provide the department and the office for people
with developmental disabilities with a description of the proposed
marketing plan and how marketing materials will be presented to persons
with developmental disabilities or their authorized decision makers for
the purposes of enabling them to make an informed choice.
(g) Plans providing services operated, certified, funded, authorized
or approved by the office for people with developmental disabilities
shall be subject to all requirements applicable to DISCOs operating
under section forty-four hundred three-g of this article with respect to
quality assurance, grievances and appeals, informed choice,
participation in development of plans of care and requirements with
respect to marketing, to the extent that such requirements are not
inconsistent with this section.
(h) No person with a developmental disability shall be required to
enroll in a managed long term care plan as a condition of receiving
medical assistance and services operated, certified, funded, authorized
or approved by the office for people with developmental disabilities
until program features and reimbursement rates are approved by the
commissioner and the commissioner of the office for people with
developmental disabilities and until such commissioners determine that
there are a sufficient number of plans authorized to coordinate care for
persons with developmental disabilities pursuant to this article
operating in the person's county of residence to meet the needs of
persons with developmental disabilities, and that such plans meet the
standards of this section.
** NB Repealed September 30, 2019
** NB There are 2 sb 12's
** 13. Notwithstanding any inconsistent provision to the contrary, the
commissioner may issue a certificate of authority to no more than three
eligible applicants who are eligible for Medicare and medical assistance
to operate managed long term care plans that are authorized to
exclusively enroll persons with developmental disabilities, as such term
is defined in section 1.03 of the mental hygiene law. The commissioner
may only issue certificates of authority pursuant to this subdivision
if, and to the extent that, the department has received federal approval
to operate a fully integrated duals advantage program for the
integration of services for persons enrolled in Medicare and medical
assistance. The commissioner may waive any of the department's
regulations as the commissioner, in consultation with the commissioner
of the office for people with developmental disabilities, deems
necessary to allow such managed long term care plans to provide or
arrange for services for persons with developmental disabilities that
are adequate and appropriate to meet the needs of such individuals and
that will ensure their health and safety.
** NB Repealed September 30, 2019
** 14. The provisions of subdivisions twelve and thirteen of this
section shall only be effective if, for so long as, and to the extent
that federal financial participation is available for the costs of
services provided thereunder to recipients of medical assistance
pursuant to title eleven of article five of the social services law. The
commissioner shall make any necessary amendments to the state plan for
medical assistance submitted pursuant to section three hundred
sixty-three-a of the social services law, and/or submit one or more
applications for waivers of the federal social security act, as may be
necessary to ensure such federal financial participation. To the extent
that the provisions of subdivision twelve and thirteen of this section
are inconsistent with other provisions of this article or with the
provisions of section three hundred sixty-four-j of the social services
law, the provisions of this subdivision shall prevail.
** NB Repealed September 30, 2019
* NB Repealed December 31, 2015
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