2013 New York Consolidated Laws
PBH - Public Health
Article 44 - (4400 - 4414) HEALTH MAINTENANCE ORGANIZATIONS
4403-G - Developmental disabilty individual support and care coordination organizations.

 
    * §  4403-g.  Developmental  disability  individual  support  and care
  coordination organizations. 1. Definitions. As used in this section:
    (a) "Developmental disability individual support and care coordination
  organization" or "DISCO" 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, as determined by the commissioner  and  the
  commissioner  of  the office for people with developmental disabilities,
  on a capitated basis in accordance with this section, for  a  population
  of  persons  with developmental disabilities, as such term is defined in
  section 1.03 of the  mental  hygiene  law,  which  the  organization  is
  authorized to enroll.
    (b)  "Eligible  applicant"  means  an entity controlled by one or more
  non-profit  organizations  which  have  a  history   of   providing   or
  coordinating  health  and  long  term  care  services  to  persons  with
  developmental disabilities.
    (c) "Habilitation  services"  means  services  available  through  the
  state's  home  and  community  based  services  waiver  for persons with
  developmental disabilities, state plan for medical assistance,  and  any
  other  authorized  federal  funding for such services designed to assist
  persons  in  acquiring,  retaining,   and   improving   the   self-help,
  socialization,  and  adaptive skills necessary to reside successfully in
  home and community based settings.
    (d) "Health and long  term  care  services"  means  services,  whether
  provided   by   state-operated   programs  or  not-for-profit  entities,
  including,  but  not  limited  to,  habilitation  services,   home   and
  community-based  and  institution-based  long  term  care  services, 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, and may include  primary  care  and  acute
  care if the DISCO is authorized to provide or arrange for such services.
  Each  person enrolled in a DISCO shall receive health and long term care
  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 and in
  accordance with such person's needs.
    2. Approval authority. An applicant shall be issued a  certificate  of
  authority  as  a DISCO for purposes of participating in the people first
  waiver program pursuant to section 13.40 of the mental hygiene law  upon
  a  determination  by the commissioner and the commissioner of the office
  for people with developmental disabilities that the  applicant  complies
  with the operating requirements for a DISCO under this section.
    3.  Application  for  certificate of authority; form. The commissioner
  and the  commissioner  of  the  office  for  people  with  developmental
  disabilities  shall  jointly develop application forms for a certificate
  of authority to operate a DISCO. An eligible applicant shall  submit  an
  application for a certificate of authority to operate a DISCO upon forms
  prescribed  by  such commissioners. 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
  DISCO with projections of enrollment that  will  result  in  a  fiscally
  sound plan;
    (b) A description of the services to be covered by such DISCO;
    (c)  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;
    (d) The names of the providers proposed to be in the DISCO's network;
    (e)  Evidence  of  the  character  and  competence  of the applicant's
  proposed operators, and of the incorporators, directors, stockholders or
  members of the applicant;
    (f) Adequate documentation of the appropriate licenses, certifications
  or approvals to provide care as planned, including affiliate  agreements
  or proposed contracts with such providers as may be necessary to provide
  the  full  complement  of  services  required  to be provided under this
  section;
    (g)  A  description  of  the  proposed  quality-assurance  mechanisms,
  grievance  procedures, mechanisms to protect the rights of enrollees and
  care   coordination   services   to    ensure    continuity,    quality,
  appropriateness and coordination of care;
    (h)  A  description of the proposed quality assessment and performance
  improvement program that includes performance and outcome based  quality
  standards   for  enrollee  health  status  and  satisfaction,  and  data
  collection and reporting for standard performance measures;
    (i) A description of the management systems  and  systems  to  process
  payment for covered services;
    (j)  A  description of how achievement of person-centered outcomes, as
  defined by the commissioner of the office for people with  developmental
  disabilities,  shall be assessed, as well as a description of how health
  and long term care services shall be used to meet such outcomes;
    (k) A description of the mechanism 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;
    (l)  A  description  of  the  systems for securing and integrating any
  potential sources of funding for services provided  by  or  through  the
  organization,  including,  but  not  limited to, funding available under
  titles XVI, XVIII, XIX and XX of the federal social security act and all
  other available sources of funding;
    (m)  A  description  of  the  proposed  contractual  arrangements  for
  providers  of health and long term care services in the benefit package;
  and
    (n) Information related to the financial condition of the applicant.
    4. Certificate of  authority  approval.  The  commissioner  shall  not
  approve  an  application  for  a  certificate  of  authority  unless the
  applicant demonstrates to the satisfaction of the commissioner  and  the
  commissioner of the office for people with developmental disabilities:
    (a)   That   it  will  have  in  place  acceptable  quality  assurance
  mechanisms, grievance procedures and mechanisms to protect the rights of
  enrollees and care coordination services to ensure continuity,  quality,
  appropriateness and coordination of care;
    (b)  That  it  will  have in place a mechanism or means to assure that
  persons with developmental disabilities can make informed choices either
  individually or through  an  authorized  decision  maker  regarding  the
  development of a person-centered plan, as defined by the commissioner of
  the office for people with developmental disabilities;
    (c)  That  it  has  developed  a  quality  assessment  and performance
  improvement program that includes performance and outcome based  quality
  standards  for  enrollee  health status and satisfaction, which shall be
  reviewed by the commissioner and the  commissioner  of  the  office  for

  people  with  developmental disabilities. The program shall include data
  collection and reporting for standard performance measures  as  required
  by  the  commissioner and the commissioner of the office for people with
  developmental disabilities;
    (d)  That  an  otherwise  eligible enrollee shall not be involuntarily
  disenrolled without the prior approval of the commissioner of the office
  for people with developmental disabilities;
    (e) That the applicant shall not use deceptive or  coercive  marketing
  methods to encourage participants to enroll and that the applicant shall
  not  distribute  marketing  materials to potential enrollees before such
  materials have been approved by the commissioner and the commissioner of
  the office for people with developmental disabilities;
    (f) Satisfactory evidence of  the  character  and  competence  of  the
  applicant's  proposed  operators, incorporators, directors, stockholders
  and members;
    (g) Reasonable assurance that the applicant will provide high  quality
  services  to  an  enrolled  population,  that the applicant's network of
  providers  is  adequate  and  that  such  providers  have   demonstrated
  sufficient  competency  to deliver high quality services to the enrolled
  population and that policies and procedures will be in place to  address
  the cultural and linguistic needs of the enrolled population;
    (h) Sufficient management systems capacity to meet the requirements of
  this  section and the ability to efficiently process payment for covered
  services;
    (i)  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;
    (j) Readiness and capability to arrange and manage covered services;
    (k) Willingness and capability of taking, or cooperating in, all steps
  necessary  to  secure and integrate any potential sources of funding for
  services provided by or through the DISCO, including,  but  not  limited
  to, funding available under titles XVI, XVIII, XIX and XX of the federal
  social security act and all other available sources of funding;
    (l) 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
  and  the  commissioner  of  the  office  for  people  with developmental
  disabilities.  With  respect  to  a  person  receiving   non-residential
  services  operated,  certified,  funded,  authorized  or approved by the
  office for people with developmental disabilities prior to enrollment in
  the DISCO, such guidelines shall require the DISCO to contract with  the
  current provider of non-residential services at the rates established by
  the  office for ninety days, in order to ensure continuity of care. With
  respect to a  person  living  in  a  residential  facility  operated  or
  certified by the office for people with developmental disabilities prior
  to  enrollment  in the DISCO, such guidelines shall require the DISCO to
  contract with the provider of residential services for that residence at
  the rates established by the office for so long as such individual lives
  in that residence pursuant to an approved plan of care;
    (m) That  the  applicant  is  financially  responsible  and  shall  be
  expected to meet its obligations to its enrolled members; and
    (n)  That  the  applicant  shall  assess  person-centered  outcomes as
  defined by the commissioner of the office for people with  developmental

  disabilities,  and  has  satisfactory mechanisms by which it will assess
  how health and long term  care  services  will  be  used  to  meet  such
  outcomes.
    5.  Enrollment.  (a)  Only persons with developmental disabilities, as
  determined by the office for  people  with  developmental  disabilities,
  shall be eligible to enroll in DISCOs.
    (b)  The  office  for  people  with  developmental disabilities or its
  designee shall enroll an eligible person in the DISCO chosen by  him  or
  her,  his  or  her guardian or other legal representative, provided that
  such DISCO is authorized to enroll such person.
    (c) No person with a developmental  disability  who  is  receiving  or
  applying  for  medical  assistance  and who is receiving, or eligible to
  receive, services funded,  certified,  authorized  or  approved  by  the
  office  for people with developmental disabilities, shall be required to
  enroll in a DISCO in  order  to  receive  such  services  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
  such person's county of residence to meet  the  needs  of  persons  with
  developmental  disabilities,  and that such DISCOs meet the standards of
  this section. No person shall be required to enroll in a DISCO in  order
  to  receive services operated, funded, certified, authorized or approved
  by the office for people with developmental disabilities until there are
  at least two plans  authorized  to  coordinate  care  for  persons  with
  developmental  disabilities  pursuant  to  this article in such person's
  county of residence, unless  federal  approval  is  secured  to  require
  enrollment  when there are less than two such entities operating in such
  county.
    (d) Persons required to enroll in a DISCO  shall  have  no  less  than
  sixty  days  to  select a DISCO, and such persons and their guardians or
  other legal representatives shall be provided with information  to  make
  an   informed   choice.   Where   a  person,  guardian  or  other  legal
  representative has not selected a DISCO, the commissioner of the  office
  for  people with developmental disabilities or its designee shall enroll
  such person in a DISCO chosen by such commissioner, taking into  account
  quality,  capacity  and  geographic accessibility. The office for people
  with developmental disabilities  or  its  designee  shall  automatically
  re-enroll  a  person  with the same DISCO if there is a loss of medicaid
  eligibility of two months or less.
    (e) Enrolled persons may change their enrollment at any  time  without
  cause, provided, however, that a person required to enroll in a DISCO in
  order  to  receive  services funded, licensed, authorized or approved by
  the office for people with developmental disabilities may only disenroll
  from a DISCO if he or she enrolls in another DISCO authorized to  enroll
  him  or  her.  Such  disenrollment  shall be effective no later than the
  first day of the second month following the request.
    (f) A DISCO may request the involuntary disenrollment of  an  enrolled
  person   in   writing  to  the  office  for  people  with  developmental
  disabilities. Such  disenrollment  shall  not  be  effective  until  the
  request  is  reviewed  and  approved  by  such  office.  Notice shall be
  provided to the enrollee and the enrollee may  request  a  fair  hearing
  regarding  such  disenrollment. The department and the office for people
  with  developmental  disabilities  shall  adopt  rules  and  regulations
  governing this process.
    6. Assessments. The office for people with developmental disabilities,
  or  its  designee,  shall complete a comprehensive assessment that shall

  include, but not be limited to, an evaluation of  the  medical,  social,
  habilitative  and  environmental needs of each prospective enrollee in a
  DISCO 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 assessment shall  be  completed  by
  the office for people with developmental disabilities or in consultation
  with  the  prospective enrollee's health care practitioner as necessary.
  The  commissioner  of  the  office   for   people   with   developmental
  disabilities  shall prescribe the forms on which the assessment shall be
  made.  The  office  for  people  with  developmental  disabilities   may
  designate  the  DISCO  to perform reassessments, but shall not designate
  the DISCO to perform the initial assessment of a prospective enrollee.
    7. Program oversight and administration. (a) The commissioner and  the
  commissioner  of  the  office for people with developmental disabilities
  shall jointly promulgate  regulations  to  implement  this  section,  to
  provide  for  oversight  of  DISCOs,  including  on site reviews, and to
  ensure  the  quality,  appropriateness  and  cost-effectiveness  of  the
  services provided by DISCOs.
    (b)  The  commissioner  and  the commissioner of the office for people
  with developmental disabilities may waive rules and regulations of their
  respective department or office, including but  not  limited  to,  those
  pertaining to duplicative requirements concerning record keeping, boards
  of directors, staffing and reporting, when such waiver shall promote the
  efficient  delivery of appropriate, quality, cost-effective services and
  when the health, safety and general welfare of DISCO enrollees shall not
  be impaired as a result of such waiver. The commissioners  shall  report
  annually   to   the  legislature  and  to  the  joint  advisory  council
  established pursuant to section 13.40 of the mental hygiene law  on  all
  rules  and  regulations  waived  pursuant to this paragraph. In order to
  achieve DISCO system efficiencies and coordination and  to  promote  the
  objectives  of  high  quality,  integrated  and cost effective care, the
  commissioners shall 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
  commissioners  shall  require  DISCOs  to  utilize  quality  improvement
  measures, based on the achievement of personal outcomes and  quality  of
  life,  health  outcomes  data,  and assessments of individual and family
  satisfaction, for internal quality assessment processes and may  utilize
  such measures as part of the single coordinated surveillance process.
    (c)  Notwithstanding any inconsistent provision of the social services
  law  to  the  contrary,  the  commissioner  in  consultation  with   the
  commissioner  of  the  office for people with developmental disabilities
  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 are inconsistent with the flexibility
  necessary  for  the  efficient  administration  of  DISCOs,   and   such
  regulations  shall  provide that such provisions shall not be applicable
  to enrollees of DISCOs, provided that such determinations are consistent
  with applicable federal law and regulation.
    (d) The commissioner and the commissioner of  the  office  for  people
  with  developmental  disabilities shall ensure, through periodic reviews

  of  DISCOs,  that  organization  services  are  promptly  available   to
  enrollees   when  appropriate.  Such  periodic  reviews  shall  be  made
  according  to  standards  as  determined   by   the   commissioners   in
  regulations.
    (e)  The  commissioner  and  the commissioner of the office for people
  with developmental disabilities shall have the authority to conduct both
  on site and off site reviews of DISCOs. Such reviews  may  include,  but
  not  be  limited  to,  the  following components: governance; fiscal and
  financial  reporting;  recordkeeping;  internal   controls;   marketing;
  network   contracting   and   adequacy;  program  integrity  assurances;
  utilization control and review systems; grievance and  appeals  systems;
  quality  assessment  and  assurance systems; care management; enrollment
  and disenrollment; management information systems, and other operational
  and management components.
    8.  Solvency.  (a)  The  commissioner,  in   consultation   with   the
  commissioner  of  the office for people with developmental disabilities,
  shall be  responsible  for  evaluating,  approving  and  regulating  all
  matters  relating  to  fiscal  solvency, including reserves, surplus and
  provider contracts. The commissioner  shall  promulgate  regulations  to
  implement  this section. The commissioner, in the administration of this
  subdivision:
    (i) shall be guided by the standards that 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  the  DISCO.  The
  commissioner   shall   be  satisfied  that  the  eligible  applicant  is
  financially sound, and has made adequate provisions to pay  for  quality
  services  that  are  cost  effective  and  appropriate  to needs and the
  protection of health, safety, welfare and satisfaction of those served.
    9.  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.
    10. Payment rates for DISCO 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.  Payment rates shall be actuarially sound for
  covered services, including but not limited  to  habilitation  services,
  and,  when  there  is  sufficient  reliable  data  to  permit,  shall be
  risk-adjusted to take into account the characteristics of enrollees,  or
  proposed enrollees, which may include: 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  and
  the   commissioner   of   the   office  for  people  with  developmental
  disabilities. The risk adjusted  premiums  may  also  be  combined  with
  disincentives  or  requirements  designed  to mitigate any incentives to
  obtain higher payment categories.
    11. Continuation  of  certificate  of  authority.  Continuation  of  a
  certificate  of  authority issued under this section shall be contingent
  upon compliance by the DISCO with applicable provisions of this  section
  and  rules and regulations promulgated thereunder; the continuing fiscal
  solvency of the DISCO; 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.
    12. Protection of enrollees. The  commissioner  may,  in  his  or  her
  discretion  and  with  the concurrence of the commissioner of the office
  for people with developmental  disabilities,  for  the  purpose  of  the
  protection  of  enrollees, impose measures including, but not limited to
  bans on further enrollments until any identified problems  are  resolved
  to  the  satisfaction  of the commissioner, or fines upon a finding that
  the DISCO has failed to comply with the  provisions  of  any  applicable
  statute, rule or regulation.
    13.  Information sharing. The commissioner and the commissioner of the
  office for people with developmental disabilities  shall,  as  necessary
  and  consistent  with  federal  regulations  promulgated pursuant to the
  Health Insurance Portability and Accountability  Act,  share  with  such
  DISCO the following data if it is available:
    (a)  information  concerning  utilization of services and providers by
  each of its enrollees prior to and during enrollment.
    (b) Aggregate data concerning utilization and costs for enrollees  and
  for  comparable  cohorts  served  through  the  Medicaid fee-for-service
  program.
    14. Applicability of other  laws.  DISCOs  shall  be  subject  to  the
  provisions  of  the  insurance  law and regulations applicable to health
  maintenance organizations,  this  article  and  regulations  promulgated
  thereunder.  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.
    15.  Effectiveness.  The  provisions  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 by the
  DISCOs to enrollees who are 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, in order to
  ensure such federal financial participation.
    * NB Repealed September 30, 2019