N.Y. Public Health Law § 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, 2029