N.Y. Public Health Law § 4403-g: Developmental disability 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 comprehensive health

services and other services as determined by the commissioner and the

commissioner of the office for people with developmental disabilities,

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. 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, which

must include all health and long term care services, as defined in

paragraph (d) of subdivision one of this section, and other services as

determined by the commissioner and the commissioner of the office for

people with developmental disabilities;

(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 of organizing, marketing, managing,

promoting and operating a health and long term care services plan, or

has an affiliation agreement with an entity that has such readiness and

capability;

(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 December 31, 2027