N.Y. Mental Hygiene Law § 13.40: People first waiver program

§ 13.40 People first waiver program.

(a) The commissioner and the commissioner of health shall jointly

establish a people first waiver program for purposes of developing a

care coordination model that integrates various long-term habilitation

supports and/or health care. The people first waiver program shall

include the use of developmental disability individual support and care

coordination organizations, herein referred to as DISCOs, pursuant to

section forty-four hundred three-g of the public health law, health

maintenance organizations, herein referred to as HMOs, providing

services under subdivision eight of section forty-four hundred three of

the public health law, and managed long term care plans, herein referred

to as MLTCs, providing services under subdivisions twelve, thirteen and

fourteen of section forty-four hundred three-f of the public health law.

Services shall be provided as described in section forty-four hundred

three-g of the public health law, subdivision eight of section

forty-four hundred three of the public health law, and subdivisions

twelve, thirteen and fourteen of section forty-four hundred three-f of

the public health law.

(b) Entities providing services pursuant to this section shall provide

health and long term care services as the term is defined in section

forty-four hundred three-g of the public health law.

(c) No person with a developmental disability who is receiving or

applying for medical assistance and who is receiving, or eligible to

receive, services operated, funded, certified, authorized or approved by

the office, shall be required to enroll in a DISCO, HMO or MLTC in order

to receive such services until program features and reimbursement rates

are approved by the commissioner and the commissioner of health, and

until such commissioners determine that a sufficient number of plans

that are authorized to coordinate care for individuals pursuant to this

section or that are authorized to operate and to exclusively enroll

persons with developmental disabilities pursuant to subdivision

twenty-seven of section three hundred sixty-four-j of the social

services law are operating in such person's county of residence to meet

the needs of persons with developmental disabilities, and that such

entities meet the standards of this section. No person shall be required

to enroll in a DISCO, HMO or MLTC in order to receive services operated,

funded, certified, authorized or approved by the office until there are

at least two entities operating under this section 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. Notwithstanding the foregoing or any other law to the contrary,

any health care provider: (i) enrolled in the Medicaid program and (ii)

rendering hospital services, as such term is defined in section

twenty-eight hundred one of the public health law, to an individual with

a developmental disability who is enrolled in a DISCO, HMO or MLTC, or a

prepaid health services plan operating pursuant to section forty-four

hundred three-a of the public health law, including, but not limited to,

an individual who is enrolled in a plan authorized by section three

hundred sixty-four-j or the social services law, shall accept as full

reimbursement the negotiated rate or, in the event that there is no

negotiated rate, the rate of payment that the applicable government

agency would otherwise pay for such rendered hospital services.

(d) DISCOs, HMOs and MLTCs operating under this section shall ensure,

to the greatest extent practicable, that their assessment, services, and

the grievance and appeals processes are culturally and linguistically

competent.

(e) 1. The commissioner and the commissioner of health shall identify

one or more valid and reliable quality assurance instruments that

include assessments of individual and family satisfaction, provision of

services, and personal outcomes. The instruments shall:

(1) provide nationally validated, benchmarked, consistent, reliable

and measurable data for a comprehensive quality improvement and review

process, and

(2) include outcome-based measures such as health, safety, well-being,

relationships, interactions with people who do not have a disability,

employment, quality of life, integration, choice, service and consumer

satisfaction.

2. Within available appropriations, the instruments identified in this

subdivision may be expanded to collect additional data requested by

other offices, departments or agencies of the state, local or federal

government.

3. The commissioner may contract with an independent agency or

organization for the development of the quality assurance instruments

described in this subdivision.

4. The commissioner shall establish the methodology by which the

quality assurance instruments shall be administered.

5. The commissioner, in consultation with stakeholders, shall annually

review the data collected from the quality assurance instruments

described in this subdivision and shall review recommendations regarding

additional or different criteria for the quality assurance instruments

in order to assess the performance of the state's developmental

disabilities services system and improve services for consumers.

(f) There shall be a joint advisory council chaired by the

commissioner and the commissioner of health that shall be charged with

advising both commissioners in regard to the oversight of DISCOs, HMOs

providing services under subdivision eight of section forty-four hundred

three of the public health law, and MLTCs providing services under

subdivisions twelve, thirteen and fourteen of section forty-four hundred

three-f of the public health law. The joint advisory council may be

comprised of the members of existing advisory councils or similar

entities serving the office, provided that it shall be comprised of

twelve members, including individuals with developmental disabilities,

family members of, advocates for, and providers of services to people

with developmental disabilities. Three members of the joint advisory

council shall also be members of the special advisory review panel on

medicaid managed care established under section three hundred

sixty-four-jj of the social services law. The joint advisory council

shall review all managed care options provided to individuals with

developmental disabilities, including: the adequacy of habilitation

services; the record of compliance with person-centered planning,

person-centered services and community integration; the adequacy of

rates paid to providers in accordance with the provisions of paragraph

one of subdivision four of section forty-four hundred three of the

public health law, paragraph a-two of subdivision eight of section

forty-four hundred three of the public health law or paragraph a-two of

subdivision twelve of section forty-four hundred three-f of the public

health law; and quality of life, health, safety and community

integration of individuals with developmental disabilities enrolled in

managed care. The commissioner and commissioner of the office for

people with developmental disabilities or their designees shall attend

all meetings of the joint advisory council. The joint advisory council

shall report its findings, recommendations, and any proposed amendments

to pertinent sections of the law to the commissioner and the

commissioner of health, the senate majority leader and speaker of the

assembly. The joint advisory council shall have access to any and all

information that may be lawfully disclosed to it and that is necessary

to perform its functions under this section.

(g) Notwithstanding any inconsistent provision of sections one hundred

twelve and one hundred sixty-three of the state finance law, or section

one hundred forty-two of the economic development law, or any other law

to the contrary, the commissioner and the commissioner of health are

authorized to enter into a contract or contracts under section

forty-four hundred three-g of the public health law, subdivision eight

of section forty-four hundred three of the public health law, and

subdivision twelve of section forty-four hundred three-f of the public

health law, provided, however, that:

1. the office shall post on its website, for a period of no less than

thirty days:

(1) a description of the proposed services to be provided pursuant to

the contract or contracts;

(2) the criteria for selection of a contractor or contractors;

(3) the period of time during which a prospective contractor may seek

selection, which shall be no less than thirty days after such

information is first posted on the website; and

(4) the manner by which a prospective contractor may seek such

selection, which may include submission by electronic means;

2. all reasonable and responsive submissions that are received from

prospective contractors in a timely fashion shall be reviewed by the

commissioners; and

3. the commissioner and the commissioner of health may jointly select

such contractor or contractors that, in their discretion, have

demonstrated the ability to effectively, efficiently and economically

integrate health and long term care services as defined in section

forty-four hundred three-g of the public health law, and meet the

standards for a certificate of authority in the public health law for

the provision of services operated, funded, certified, authorized or

approved by the office for people with developmental disabilities and

applicable to the type of managed care plan that such contractor

proposes to operate.

* (h) Consistent with and subject to the terms of federal approval,

the commissioner shall establish the managed care for persons with

developmental disabilities advocacy program, hereinafter referred to as

the advocacy program. The activities of the advocacy program shall be

coordinated with the independent Medicaid managed care ombuds services

provided to persons with disabilities enrolling in Medicaid managed

care. The advocacy program shall advise individuals of applicable rights

and responsibilities, provide information and assistance to address the

needs of individuals with disabilities, and pursue legal, administrative

and other appropriate remedies or approaches to ensure the protection of

and advocacy for the rights of the enrollees. The advocacy program shall

provide support to eligible individuals with developmental disabilities

enrolling in developmental disability individual support and care

coordination organizations pursuant to section forty-four hundred

three-g of the public health law, health maintenance organizations

providing services pursuant to subdivision eight of section forty-four

hundred three of the public health law, managed long term care plans

providing services under subdivisions twelve, thirteen and fourteen of

section forty-four hundred three-f of the public health law, and fully

integrated dual advantage plans providing services under subdivision

twenty-seven of section three hundred sixty-four-j of the social

services law. The commissioner shall select an independent organization

or organizations to provide advocacy services under this subdivision.

* NB Effective upon approval by the federal centers for medicare and

medicaid services of a managed care advocacy program for individuals

with developmental disabilities