N.Y. Social Services Law § 365-m: Administration and management of behavioral health services

§ 365-m. Administration and management of behavioral health services.

1. The commissioners of the office of mental health and the office of

alcoholism and substance abuse services, in consultation with the

commissioner of health, the impacted local governmental units and with

the approval of the division of the budget, shall have responsibility

for jointly designating regional entities to provide administrative and

management services for the purposes of prior approving and coordinating

the provision of behavioral health services, facilitating the continuity

of post-hospitalization behavioral health and the integration of

behavioral health services with other services available under this

title, for recipients of medical assistance who are not enrolled in

managed care, and for such approval, coordination, facilitating

continuity and integration of behavioral health services that are not

provided through managed care programs under this title for individuals

regardless of whether or not such individuals are enrolled in managed

care programs. Such regional entities shall also be responsible for

promoting appropriate care and service utilization while safeguarding

against unnecessary utilization of such care and services and assuring

that payments are consistent with the efficient and economical delivery

of quality care.

2. In exercising this responsibility, the commissioners of the office

of mental health and the office of alcoholism and substance abuse

services are authorized to contract, after consultation with the

commissioner of health and the impacted local governmental units, with

regional behavioral health organizations or other entities. Such

contracts may include responsibility for receipt, review, and

determination of prior authorization requests for behavioral health care

and services under subdivision one of this section, consistent with

criteria established or approved by the commissioners of mental health

and alcoholism and substance abuse services, and authorization of

appropriate care and services based on documented patient medical need.

3. 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 commissioners of the office of mental health and

the office of alcoholism and substance abuse services are authorized to

enter into a contract or contracts under subdivisions one and two of

this section without a competitive bid or request for proposal process,

provided, however, that:

(a) the office of mental health and the office of alcoholism and

substance abuse services shall post on their websites, for a period of

no less than thirty days:

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

the contractor contracts;

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

(iii) 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

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

selection, which may include submission by electronic means;

(b) all reasonable and responsive submissions that are received from

prospective contractors in timely fashion shall be reviewed by the

commissioners; and

(c) the commissioners of the office of mental health and the office of

alcoholism and substance abuse services, in consultation with the

commissioner of health and the impacted local governmental units, shall

select such contractor or contractors that, in their discretion, have

demonstrated the ability to effectively, efficiently, and economically

integrate behavioral health and health services; have the requisite

expertise and financial resources; have demonstrated that their

directors, sponsors, members, managers, partners or operators have the

requisite character, competence and standing in the community, and are

best suited to serve the purposes of this section. In selecting such

contractor or contractors, the commissioners shall:

(i) ensure that any such contractor or contractors have an adequate

network of providers to meet the behavioral health and health needs of

enrollees, and shall review the adequacy prior to approval of any such

contract or contracts, and upon contract renewal or expansion. To the

extent that the network has been determined to meet standards set forth

in subdivision five of section four thousand four hundred three of the

public health law, such network shall be deemed adequate.

(ii) ensure that such contractor or contractors shall make level of

care and coverage determinations utilizing evidence-based tools or

guidelines designated to address the behavioral health needs of

enrollees.

(iii) ensure sufficient access to behavioral health and health

services for eligible enrollees by establishing and monitoring

penetration rates of any such contractor or contractors.

(iv) establish standards to encourage the use of services, products

and care recommended, ordered or prescribed by a provider to

sufficiently address the behavioral health and health services needs of

enrollees; and monitor the application of such standards to ensure that

they sufficiently address the behavioral health and health services

needs of enrollees.

4. The commissioners of the office of mental health, the office of

alcoholism and substance abuse services and the department of health,

shall have the responsibility for jointly designating on a regional

basis, after consultation with the local social services district and

local governmental unit, as such term is defined in the mental hygiene

law, of a city with a population of over one million persons, and after

consultation of other affected counties, a limited number of special

needs managed care plans under section three hundred sixty-four-j of

this title capable of managing the behavioral and physical health needs

of medical assistance enrollees with significant behavioral health

needs. Initial designations of such plans should be made no later than

April first, two thousand fourteen, provided, however, such designations

shall be contingent upon a determination by such state commissioners

that the entities to be designated have the capacity and financial

ability to provide services in such plans, and that the region has a

sufficient population and service base to support such plans. Once

designated, the commissioner of health shall make arrangements to enroll

such enrollees in such plans and to pay such plans on a capitated or

other basis to manage, coordinate, and pay for behavioral and physical

health medical assistance services for such enrollees. Notwithstanding

any inconsistent provision of section one hundred twelve and one hundred

sixty-three of the state finance law, and section one hundred forty-two

of the economic development law, or any other law to the contrary, the

designations of such plans, and any resulting contracts with such plans

or providers are authorized to be entered into by such state

commissioners without a competitive bid or request for proposal process,

provided however that:

(a) the department of health, the office of mental health and the

office of alcoholism and substance abuse services shall post on their

websites, for a period of not less than thirty days:

(i) a description of the proposed services to be provided by the plans

or systems;

(ii) the criteria for selection of a plan or system;

(iii) the period of time during which a prospective plan or system may

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

information is first posted on the website; and

(iv) the manner by which a prospective plan or system may seek such

selection, which may include submission by electronic means;

(b) all reasonable and responsive submissions that are received from

prospective plans or systems in timely fashion shall be reviewed by the

commissioners; and

(c) the commissioners of the office of mental health and the office of

alcoholism and substance abuse services, in consultation with the

commissioner of health, shall select such plans or systems that, in

their discretion, have demonstrated the ability to effectively,

efficiently, and economically manage the behavioral and physical health

needs of medical assistance enrollees with significant behavioral health

needs; have the requisite expertise and financial resources; have

demonstrated that their directors, sponsors, members, managers, partners

or operators have the requisite character, competence and standing in

the community, and are best suited to serve the purposes of this

section. Oversight of such contracts with such plans, providers or

provider systems shall be the joint responsibility of such state

commissioners, and for contracts affecting a city with a population of

over one million persons, also with the city's local social services

district and local governmental unit, as such term is defined in the

mental hygiene law.

In selecting such plans or systems, the commissioners shall:

(i) ensure that any such plans or systems have an adequate network of

providers to meet the behavioral health and health needs of enrollees,

and shall review the adequacy prior to approval of any such plans or

systems, and upon contract renewal or expansion. To the extent that the

network has been determined to meet standards set forth in subdivision

five of section four thousand four hundred three of the public health

law, such network shall be deemed adequate.

(ii) ensure that such plans or systems shall make level of care and

coverage determinations utilizing evidence-based tools or guidelines

designed to address the behavioral health needs of enrollees.

(iii) ensure sufficient access to behavioral health and health

services for eligible enrollees by establishing and monitoring

penetration rates of any such plans or systems.

(iv) establish standards to encourage the use of services, products

and care recommended, ordered or prescribed by a provider to

sufficiently address the behavioral health and health services needs of

enrollees; and monitor the application of such standards to ensure that

they sufficiently address the behavioral health and health services

needs of enrollees.

5. (a) Pursuant to appropriations within the offices of mental health

or addiction services and supports, the department of health shall

reinvest savings realized through the transition of populations covered

by this section from the applicable Medicaid fee-for-service system to a

managed care model, including savings realized through the recovery of

premiums from managed care providers which represent a reduction of

spending on qualifying behavioral health services against established

premium targets for behavioral health services and the medical loss

ratio applicable to special needs managed care plans, for the purpose of

increasing investment in community based behavioral health services,

including residential services certified by the office of addiction

services and supports. The methodologies used to calculate the savings

shall be developed by the commissioner of health and the director of the

budget in consultation with the commissioners of the office of mental

health and the office of addiction services and supports. In no event

shall the full annual value of the reinvestment pursuant to this

subdivision exceed the value of the premiums recovered from managed care

providers which represent a reduction of spending on qualifying

behavioral health services. Within any fiscal year where appropriation

increases are recommended for reinvestment, insofar as managed care

transition savings do not occur as estimated, then spending for such

reinvestment may be reduced in the next year's annual budget

itemization.

(b) Beginning April first, two thousand twenty-two, the department

shall post on its website information about the recovery of premiums

from managed care providers which represent a reduction of spending on

qualifying behavioral health services against established premium

targets for behavioral health services and the medical loss ratio

applicable to special needs managed care plans. Such information shall

include at a minimum: (i) a copy of the department's notification to

each managed care provider that seeks a recovery of such premiums; and

(ii) a list of managed care providers by name that have been subject to

a recovery of such premiums, specifying the amount of premium that has

been recovered from each managed care provider and year. In the initial

posting, the department shall include all premiums recovered to date as

required by this subdivision, by named managed care provider, amount and

year.

(c) The commissioner shall include information regarding the funds

available for reinvestment, including how savings are calculated and how

the reinvestment was utilized pursuant to this section in the annual

report required under section forty-five-c of part A of chapter

fifty-six of the laws of two thousand thirteen.