2022 New York Laws
PBH - Public Health
Article 44 - Health Maintenance Organizations
4403-A - Special Purpose Certificate of Authority.

* §   4403-a.   Special  purpose  certificate  of  authority.  1.  The
commissioner may issue a special purpose certificate of authority  to  a
provider,  applying  on forms prescribed by the commissioner, seeking to
offer a comprehensive health services  plan  on  a  prepaid  contractual
basis  either  directly, or through an arrangement, agreement or plan or
combination thereof to an enrolled population,  which  is  substantially
composed  of persons eligible to receive benefits under title XIX of the
federal social security act or other public programs.
  2. A not-for-profit corporation  established  to  operate  a  hospital
pursuant  to  article twenty-eight of this chapter, a government agency,
an entity or a group of entities seeking to provide comprehensive health
services pursuant to the provisions of this  section  may  apply  for  a
special  purpose  certificate  of  authority;  provided, however, that a
shared health facility, as defined by article forty-seven of the  public
health law, shall not be eligible for such a certificate.
  3.  The  commissioner shall not issue a special purpose 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 waive one or more of such
requirements,  or  portions  thereof,  pertaining  to  financial   risk,
employer  requirements  and  subscriber  contracts if he determines that
such  waiver  will  serve  to  promote  the   efficient   provision   of
comprehensive health services 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.
  4. (a) No contract for the provision of comprehensive health  services
pursuant  to  this  section  shall  be  entered  into  by a local social
services district unless the commissioner certifies that  all  pertinent
requirements   with   respect  to  financial  arrangements,  rates,  and
standards relating to arrangements for and the delivery of patient  care
services   have  been  satisfied  and  that  the  contract  and  related
arrangements will ensure access to and the  delivery  of  high  quality,
appropriate  medical  services  including  an assurance that recipients'
access to preventive health services is not diminished.
  (b) No contract for the provision of comprehensive health services  to
persons  eligible  for  medical assistance under title eleven of article
five of the social services  law  shall  be  entered  into  without  the
approval  of  the  commissioner  of  social services pursuant to section
three hundred sixty-five-a of the social  services  law  and  the  state
director  of  the  budget. The commissioner of social services shall not
approve such a contract unless the contract:
  (i)  provides  that  enrollment  shall  be  voluntary   and   contains
provisions  to  ensure that persons eligible for medical assistance will
be provided  sufficient  information  regarding  the  plan  to  make  an
informed  and  voluntary  choice whether to enroll or, in the event that
enrollment  in  the  entity  is  pursuant  to  section   three   hundred
sixty-four-j of the social services law, provides that enrollment in the
entity is governed by that section;
  (ii)  provides  adequate  safeguards  to  protect persons eligible for
medical assistance from being misled concerning the plan and from  being
coerced  into  enrolling in the plan or, in the event that enrollment in
the entity is undertaken pursuant to section three hundred  sixty-four-j
of  the  social  services law, provides that enrollment in the entity is
governed by that section;
  (iii) establishes adequate opportunities for public review and comment
prior to implementation of the plan;
  (iv) provides adequate grievance procedures for recipients who  enroll
in the plan; and
  (v) establishes quality assurance mechanisms.
  5.  A  special  purpose certificate of authority shall be issued to an
approved  provider  of  comprehensive  health  services  for  a  maximum
effective  period  of  twenty-four  months  subject  to  the  applicable
provisions of section  forty-four  hundred  four  of  this  article  and
provided   that   federal   financial  participation  is  available  for
expenditures made on behalf of recipients  of  medical  assistance.  The
commissioner  upon application, after consultation with the commissioner
of social services, may issue a certificate for an additional period  of
up  to  twenty-four  months  if  satisfied  that  the  plan has and will
continue to demonstrate satisfactory performance and compliance with all
requirements imposed for initial certification.  If  the  plan  provides
comprehensive  services  pursuant  to  a  contract solely to individuals
eligible for medical assistance under title eleven of  article  five  of
the  social  services  law,  the  certificate  shall expire when (a) the
medical assistance contract is revoked or expires and is not extended or
renewed or (b) federal approval of the medical  assistance  contract  is
withdrawn.
  6.   All   individuals   eligible  for  medical  assistance  enrolling
voluntarily in a comprehensive health services plan offered by an entity
with a special purpose certificate of authority  will  be  given  thirty
days  from  the  effective  date  of enrollment in the plan to disenroll
without  cause.    After  this  thirty  day  disenrollment  period,  all
individuals  participating  in the plan will be enrolled for a period of
six months, except that all participants will be permitted to  disenroll
for  good  cause,  as  defined by the commissioner of social services in
regulation.
  7. Notwithstanding any inconsistent provision  of  this  section,  the
commissioner  shall  issue  special  purpose  certificates  of authority
pursuant to this section to no more than eighteen  entities  other  than
those  entities initially authorized by chapter seven hundred fifteen of
the laws of nineteen hundred eighty-two and by a chapter of the laws  of
nineteen  hundred  eighty-four  authorizing  the  Monroe  county medicap
demonstration project.
  * NB Expires March 31, 2026