N.Y. Public Health Law § 2959-a: Multipayor patient centered medical home program

§ 2959-a. Multipayor patient centered medical home program. 1. (a) The

commissioner is authorized to establish medical home multipayor programs

(referred to in this section as a "program") whereby enhanced payments

are made to primary care clinicians and clinics statewide that are

certified as medical homes for the purpose of improving health care

outcomes and efficiency through improved access, patient care continuity

and coordination of health services.

(b) As used in this section:

(i) "clinic" means a general hospital providing outpatient care or

diagnostic and treatment center, licensed under article twenty-eight of

this chapter; and

(ii) "primary care clinician" means a physician, nurse practitioner,

or midwife acting within his or her lawful scope of practice under title

eight of the education law and who is practicing in a primary care

specialty.

(iii) "primary care medical home collaborative" means an entity

approved by the commissioner which shall include but not be limited to

health care providers, which may include but not be limited to

hospitals, diagnostic and treatment centers, private practices and

independent practice associations, and payors of health care services,

which may include but not be limited to employers, health plans and

insurers.

2. (a) In order to promote improved quality of, and access to, health

care services and promote improved clinical outcomes, it is the policy

of the state to encourage cooperative, collaborative and integrative

arrangements among payors of health care services and health care

services providers who might otherwise be competitors, under the active

supervision of the commissioner. It is the intent of the state to

supplant competition with such arrangements and regulation only to the

extent necessary to accomplish the purposes of this article, and to

provide state action immunity under the state and federal antitrust laws

to payors of health care services and health care services providers

with respect to the planning, implementation and operation of the

multipayor patient centered medical home program.

(b) The commissioner or his or her duly authorized representative may

engage in appropriate state supervision necessary to promote state

action immunity under the state and federal antitrust laws, and may

inspect or request additional documentation from payors of health care

services and health care services providers to verify that medical homes

certified pursuant to this section operate in accordance with its intent

and purpose.

3. The commissioner is authorized to participate in, actively

supervise, facilitate and approve a primary care medical home

collaborative for each program around the state to establish: (a) the

boundaries of each program and the providers eligible to participate,

provided that the boundaries of programs may overlap; (b) practice

standards for each medical home program adopted with consideration of

existing standards developed by the National Committee for Quality

Assurance ("NCQA"), the Joint Commission of Accreditation of Healthcare

Organizations ("JCAHCO" or the "Joint Commission"), American

Accreditation Healthcare Commission ("URAC"), American College of

Physicians, the American Academy of Family Physicians, the American

Academy of Pediatrics, and the American Osteopathic Association; the

American Academy of Nurse Practitioners, and the American College of

Nurse Practitioners; (c) standards for implementation and use of health

information technology, including participation in health information

exchanges through the statewide health information network; (d)

methodologies by which payors will provide enhanced rates of payment to

certified medical homes; (e) requirements for collecting data relating

to the providing and paying for health care services under the program

and providing of data to the commissioner, payors and health care

providers under the program, to promote the effective operation and

evaluation of the program, consistent with protection of the

confidentiality of individual patient information; and (f) provisions

under which the commissioner may terminate the program.

3-a. The commissioner may develop or approve (a) methodologies to pay

additional amounts for medical homes that meet specific process or

outcome standards established by each multipayor patient centered

medical home collaborative; (b) alternative methodologies for payors of

health care services to health care providers under the program; (c)

provisions for payments to providers that may vary by size or form of

organization of the provider, or patient case mix, to accommodate

different levels of resources and difficulty to meet the standards of

the program; (d) provisions for payments to entities that provide

services to health care providers to assist them in meeting medical home

standards under the program such as the services of community health

workers.

4. The commissioner is authorized to establish an advisory group of

state agencies and stakeholders, such as professional organizations and

associations, and consumers, to identify legal and/or administrative

barriers to the sharing of care management and care coordination

services among participating health care services providers and to make

recommendations for statutory and/or regulatory changes to address such

barriers.

5. Patient, payor and health care services provider participation in

the multipayor patient centered medical home program shall be on a

voluntary basis.

6. Clinics and primary care clinicians participating in a program are

not eligible for additional enhancements or bonuses under the statewide

patient centered medical home program established pursuant to section

three hundred sixty-four-m of the social services law. The commissioner

shall develop or approve a method for determining payment under a

program where a provider participates, or a patient is served, in an

area where program boundaries overlap.

7. Subject to the availability of funding and federal financial

participation, the commissioner is authorized:

(a) To pay enhanced rates of payment under Medicaid fee-for-service,

Medicaid managed care, family health plus and child health plus to

clinics and clinicians that are certified as patient centered medical

homes under this title;

(b) To pay additional amounts for medical homes that meet specific

process or outcome standards specified by the commissioner in

consultation with each multipayor patient centered medical home

collaborative;

(c) To authorize alternative payment methodologies under Medicaid

fee-for-service, Medicaid managed care, family health plus and child

health plus for health care providers and to serve the purposes of the

program, including payments to entities under paragraph (g) of

subdivision three of this section; and

(d) To test new models of payment to high volume Medicaid primary care

medical home practices that incorporate risk adjusted global payments

combined with care management and pay for performance adjustments.

8. (a) The commissioner is authorized to contract with one or more

entities to assist the state in implementing the provisions of this

section. Such entity or entities shall be the same entity or entities

chosen to assist in the implementation of the health home provisions of

section three hundred sixty-five-l of the social services law.

Responsibilities of the contractor shall include but not be limited to:

developing recommendations with respect to program policy,

reimbursement, system requirements, reporting requirements, evaluation

protocols, and provider and patient enrollment; providing technical

assistance to potential medical home and health home providers; data

collection; data sharing; program evaluation, and preparation of

reports.

(b) 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,

the commissioner is authorized to enter into a contract or contracts

under paragraph (a) of this subdivision without a request for proposal

process, provided, however, that:

(i) The department 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;

(ii) All reasonable and responsive submissions that are received from

prospective contractors in timely fashion shall be reviewed by the

commissioner; and

(iii) The commissioner shall select such contractor or contractors

that, in his or her discretion, are best suited to serve the purposes of

this section.

9. The commissioner may directly, or by contract, provide:

(a) technical assistance to a primary care medical home collaborative

in relation to establishing and operating a program;

(b) consumer assistance to patients participating in a program as to

matters relating to the program;

(c) technical and other assistance to health care providers

participating in a program as to matters relating to the program,

including achieving medical home standards;

(d) care coordination provider technical and other assistance to

individuals and entities providing care coordination services to health

care providers under a program; and

(e) information sharing and other assistance among programs to improve

the operation of programs, consistent with applicable laws relating to

patient confidentiality.

10. The commissioner shall, to the extent necessary for the purpose of

this section, submit the appropriate waivers and other applications,

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 or

applications necessary to achieve the purposes of high quality,

integrated, and cost effective care and integrated financial eligibility

policies under Medicaid, family health plus and child health plus or

Medicare. Copies of such original waiver and other 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.

11. The Adirondack medical home multipayor demonstration program

(including the Adirondack medical home collaborative) previously

established under section twenty-nine hundred fifty-nine of this chapter

is continued and shall be deemed to be a program under this section.