S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  6956

                            I N  S E N A T E

                              March 1, 2010
                               ___________

Introduced  by  Sen.  DUANE  -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health

AN ACT to amend the public health  law,  in  relation  to  medical  home
  multipayor programs

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. The article heading of article 27-L of  the  public  health
law,  as  added  by  section  16 of part OO of chapter 57 of the laws of
2008, is amended to read as follows:
                   MEDICAL HOME [DEMONSTRATION] PROGRAMS
  S 2. The public health law is amended by adding a new  section  2799-t
to read as follows:
  S 2799-T. MEDICAL HOME MULTIPAYOR PROGRAMS. 1. (A) THE COMMISSIONER IS
AUTHORIZED  TO  ESTABLISH  MEDICAL HOME MULTIPAYOR PROGRAMS (REFERRED TO
IN THIS SECTION AS A "PROGRAM") AND IN RELATION TO A PROGRAM MAY CERTIFY
CERTAIN CLINICIANS AND CLINICS AS MEDICAL HOMES  ELIGIBLE  FOR  ENHANCED
PAYMENTS  FOR  SERVICES  PROVIDED  TO:  RECIPIENTS ELIGIBLE FOR MEDICAID
FEE-FOR-SERVICE; ENROLLEES ELIGIBLE FOR AND ENROLLED IN MEDICAID MANAGED
CARE; ENROLLEES ELIGIBLE FOR AND ENROLLED IN FAMILY HEALTH PLUS;  ENROL-
LEES  ELIGIBLE  FOR  AND  ENROLLED  IN  CHILD HEALTH PLUS; ENROLLEES AND
SUBSCRIBERS OF COMMERCIAL MANAGED CARE  PLANS  OPERATING  UNDER  ARTICLE
FORTY-FOUR OF THIS CHAPTER OR HEALTH MAINTENANCE ORGANIZATIONS OPERATING
UNDER  ARTICLE FORTY-THREE OF THE INSURANCE LAW; ENROLLEES AND SUBSCRIB-
ERS  OF  OTHER  COMMERCIAL  INSURANCE   PRODUCTS;   AND   EMPLOYEES   OF
EMPLOYER-SPONSORED SELF-INSURED PLANS. THE PURPOSE OF THE PROGRAMS IS TO
IMPROVE  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  A
DIAGNOSTIC  AND TREATMENT CENTER, LICENSED UNDER ARTICLE TWENTY-EIGHT OF
THIS CHAPTER; AND
  (II) "CLINICIAN" MEANS A HEALTH CARE PRACTITIONER ACTING WITHIN HIS OR
HER LAWFUL SCOPE OF PRACTICE UNDER TITLE EIGHT OF THE EDUCATION LAW  WHO
IS:  (A)  A PHYSICIAN OR NURSE PRACTITIONER PRACTICING IN A PRIMARY CARE

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
              

                                                           LBD15825-02-0

S. 6956                             2

SPECIALTY; (B) A PHYSICIAN, NURSE PRACTITIONER,  OR  MIDWIFE  PRACTICING
PRIMARY  GYNECOLOGICAL  CARE  FOR FEMALE PATIENTS; OR (C) A PHYSICIAN OR
NURSE PRACTITIONER PRACTICING IN A NON-PRIMARY  CARE  SPECIALTY,  FOR  A
PATIENT  WHO HAS A CHRONIC CONDITION THAT REQUIRES SPECIALTY CARE, WHERE
THE  SPECIALIST  HEALTH  CARE  PRACTITIONER  REGULARLY  AND  CONTINUALLY
PROVIDES TREATMENT FOR THAT CONDITION TO THE PATIENT.
  2.  (A)  IN  ORDER  TO PROMOTE IMPROVED QUALITY AND EFFICIENCY OF, AND
ACCESS TO, HEALTH CARE SERVICES AND PROMOTE IMPROVED CLINICAL  OUTCOMES,
IT  SHALL BE THE POLICY OF THE STATE RELATING TO THE PROGRAMS TO ENCOUR-
AGE COOPERATIVE,  COLLABORATIVE  AND  INTEGRATIVE  ARRANGEMENTS  BETWEEN
PAYORS  OF  HEALTH  CARE  SERVICES  AND  HEALTH CARE PROVIDERS WHO MIGHT
OTHERWISE BE COMPETITORS, UNDER THE ACTIVE SUPERVISION  OF  THE  COMMIS-
SIONER. TO THE EXTENT SUCH ARRANGEMENTS MIGHT BE ANTI-COMPETITIVE WITHIN
THE  MEANING AND INTENT OF THE FEDERAL ANTITRUST LAWS, THE INTENT OF THE
STATE IS TO SUPPLANT COMPETITION WITH SUCH ARRANGEMENTS  TO  THE  EXTENT
NECESSARY  TO  ACCOMPLISH  THE  PURPOSES OF THIS SECTION RELATING TO THE
PROGRAMS, AND PROVIDE STATE ACTION IMMUNITY UNDER THE STATE AND  FEDERAL
ANTITRUST  LAWS  WITH RESPECT TO THE PLANNING, IMPLEMENTATION AND OPERA-
TION OF THE PROGRAMS AND PAYORS OF HEALTH CARE SERVICES AND HEALTH  CARE
PROVIDERS.
  (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 TO VERIFY THAT  THE  PROGRAM
IS IMPLEMENTED IN ACCORDANCE WITH ITS INTENT AND PURPOSE.
  3.  THE  COMMISSIONER,  FOR  PURPOSES OF THE PROGRAM, IS AUTHORIZED TO
PARTICIPATE IN, ACTIVELY SUPERVISE, FACILITATE  AND  APPROVE  A  PRIMARY
CARE  MEDICAL  HOME COLLABORATIVE (AN ENTITY WHICH SHALL INCLUDE BUT NOT
BE LIMITED TO HEALTH CARE PROVIDERS, WHICH MAY INCLUDE BUT NOT BE LIMIT-
ED TO HOSPITALS, DIAGNOSTIC AND TREATMENT  CENTERS,  AND  PRIVATE  PRAC-
TICES,  AND PAYORS OF HEALTH CARE SERVICES, WHICH MAY INCLUDE BUT NOT BE
LIMITED TO EMPLOYERS, HEALTH PLANS AND INSURERS) TO ESTABLISH:
  (A) THE BOUNDARIES OF THE PROGRAM AND THE HEALTH CARE PROVIDERS ELIGI-
BLE TO PARTICIPATE; PROVIDED THAT THE BOUNDARIES OF PROGRAMS  MAY  OVER-
LAP;
  (B)  PRACTICE  STANDARDS FOR THE MEDICAL HOME CONSISTENT WITH EXISTING
STANDARDS DEVELOPED BY NATIONAL ACCREDITING AND  PROFESSIONAL  ORGANIZA-
TIONS  INCLUDING, BUT NOT LIMITED TO, THE JOINT PRINCIPLES OF THE AMERI-
CAN COLLEGE OF PHYSICIANS ("ACP"), THE AMERICAN ACADEMY OF FAMILY PHYSI-
CIANS ("AAFP"), THE AMERICAN ACADEMY OF PEDIATRICS ("AAP"), THE AMERICAN
OSTEOPATHIC ASSOCIATION ("AOA"), AND  AS  FURTHER  DEFINED  BY  "PATIENT
CENTERED  MEDICAL HOME," AS REPRESENTED IN CERTIFICATION PROGRAMS DEVEL-
OPED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE ("NCQA");
  (C) METHODOLOGIES BY WHICH  PAYORS  WILL  PROVIDE  ENHANCED  RATES  OF
PAYMENT TO CERTIFIED MEDICAL HOMES;
  (D)  METHODOLOGIES  TO  PAY  ADDITIONAL AMOUNTS FOR MEDICAL HOMES THAT
MEET SPECIFIC PROCESS OR OUTCOME STANDARDS ESTABLISHED  BY  THE  PRIMARY
CARE MEDICAL HOME COLLABORATIVE OF THE PROGRAM;
  (E)  ALTERNATIVE  METHODOLOGIES  FOR PAYORS OF HEALTH CARE SERVICES TO
HEALTH CARE PROVIDERS UNDER THE PROGRAM;
  (F) PROVISIONS FOR PAYMENTS TO PROVIDERS THAT MAY VARY BY SIZE OR FORM
OF ORGANIZATION OF THE PROVIDER,  TO  ACCOMMODATE  DIFFERENT  LEVELS  OF
RESOURCES AND DIFFICULTY TO MEET THE STANDARDS OF THE PROGRAM;
  (G)  PROVISIONS  FOR  PAYMENTS TO NOT-FOR-PROFIT ENTITIES THAT PROVIDE
SERVICES TO HEALTH CARE PROVIDERS TO ASSIST THEM IN MEETING MEDICAL HOME
STANDARDS UNDER THE PROGRAM;

S. 6956                             3

  (H) 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
  (I) PROVISIONS UNDER WHICH THE COMMISSIONER MAY TERMINATE THE PROGRAM.
  4. PATIENT AND HEALTH CARE PROVIDER PARTICIPATION IN THE PROGRAM SHALL
BE ON A VOLUNTARY BASIS.
  5. CLINICS AND CLINICIANS PARTICIPATING IN A PROGRAM ARE NOT  ELIGIBLE
FOR  ADDITIONAL ENHANCEMENTS OR BONUSES UNDER THE STATEWIDE MEDICAL HOME
PROGRAM, ESTABLISHED PURSUANT TO SECTION THREE HUNDRED  SIXTY-FOUR-M  OF
THE  SOCIAL SERVICES LAW, FOR SERVICES PROVIDED TO PARTICIPANTS IN MEDI-
CAID FEE-FOR-SERVICE, MEDICAID MANAGED CARE, FAMILY HEALTH PLUS OR CHILD
HEALTH PLUS.
  6. 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 CLIN-
ICS AND CLINICIANS THAT  ARE  CERTIFIED  AS  MEDICAL  HOMES  UNDER  THIS
SECTION;
  (B)  TO  PAY  ADDITIONAL  AMOUNTS FOR MEDICAL HOMES THAT MEET SPECIFIC
PROCESS OR OUTCOME STANDARDS SPECIFIED BY THE COMMISSIONER, IN CONSULTA-
TION WITH THE PRIMARY CARE MEDICAL HOME COLLABORATIVE  OF  THE  PROGRAM;
AND
  (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 NOT-FOR-PROFIT ENTITIES  UNDER  PARAGRAPH
(G) OF SUBDIVISION THREE OF THIS SECTION.
  7.  THE  COMMISSIONER MAY DIRECTLY, OR BY CONTRACT WITH NOT-FOR-PROFIT
ORGANIZATIONS, PROVIDE:
  (A) CONSUMER ASSISTANCE TO PATIENTS PARTICIPATING IN A PROGRAM  AS  TO
MATTERS RELATING TO THE PROGRAM;
  (B)  TECHNICAL  AND  OTHER ASSISTANCE TO HEALTH CARE PROVIDERS PARTIC-
IPATING IN A PROGRAM AS TO MATTERS RELATING TO  THE  PROGRAM,  INCLUDING
ACHIEVING MEDICAL HOME STANDARDS;
  (C) CARE COORDINATION PROVIDER TECHNICAL AND OTHER ASSISTANCE TO INDI-
VIDUALS AND ENTITIES PROVIDING CARE COORDINATION SERVICES TO HEALTH CARE
PROVIDERS UNDER A PROGRAM; AND
  (D) INFORMATION SHARING AND OTHER ASSISTANCE AMONG PROGRAMS TO IMPROVE
THE OPERATION OF PROGRAMS.
  8.  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,  INTE-
GRATED,  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 CHAIR-
MAN OF THE ASSEMBLY WAYS AND MEANS COMMITTEE SIMULTANEOUSLY  WITH  THEIR
SUBMISSION TO THE FEDERAL GOVERNMENT.
  9.  THE  ADIRONDACK  MEDICAL  HOME  MULTIPAYOR  DEMONSTRATION  PROGRAM
(INCLUDING THE ADIRONDACK MEDICAL HOME COLLABORATIVE) PREVIOUSLY  ESTAB-

S. 6956                             4

LISHED  UNDER  SECTION TWENTY-NINE HUNDRED FIFTY-NINE OF THIS CHAPTER IS
CONTINUED AND SHALL BE DEEMED TO BE A PROGRAM UNDER THIS SECTION.
  10.  THE  COMMISSIONER  SHALL  ANNUALLY REPORT TO THE GOVERNOR AND THE
LEGISLATURE ON THE OPERATION OF THE PROGRAMS AND THEIR EFFECTIVENESS  IN
ACHIEVING THE PURPOSES OF THIS SECTION, WITH PARTICULAR REFERENCE TO THE
QUALITY,  COST,  AND OUTCOMES FOR ENROLLEES IN MEDICAID FEE-FOR-SERVICE,
MEDICAID MANAGED CARE, FAMILY HEALTH PLUS AND CHILD HEALTH PLUS.
  11. NO PROGRAM SHALL BE APPROVED UNDER THIS SECTION AFTER APRIL FIRST,
TWO THOUSAND SIXTEEN.
  S 3. Subdivision 1 of section 2 of the public health law is amended by
adding six new paragraphs (o), (p), (q), (r), (s) and (t),  to  read  as
follows:
  (O)  "MEDICAID"  OR "MEDICAL ASSISTANCE" MEANS TITLE ELEVEN OF ARTICLE
FIVE OF THE SOCIAL SERVICES LAW AND THE PROGRAM THEREUNDER.
  (P) "FAMILY HEALTH PLUS" MEANS TITLE ELEVEN-D OF ARTICLE FIVE  OF  THE
SOCIAL SERVICES LAW AND THE PROGRAM THEREUNDER.
  (Q)  "CHILD  HEALTH  PLUS" MEANS TITLE ONE-A OF ARTICLE TWENTY-FIVE OF
THIS CHAPTER AND THE PROGRAM THEREUNDER.
  (R) "MEDICAID MANAGED CARE"  MEANS  MEDICAID  PROVIDED  UNDER  SECTION
THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW.
  (S)  "MEDICAID  FEE-FOR-SERVICE"  MEANS  MEDICAID  PROVIDED OTHER THAN
UNDER MEDICAID MANAGED CARE.
  (T) "MEDICARE" MEANS TITLE XVIII OF THE FEDERAL  SOCIAL  SECURITY  ACT
AND THE PROGRAMS THEREUNDER.
  S  4.  This act shall take effect immediately; provided, however, that
the amendments to article 27-L of the public health law made by sections
one and two of this act shall not affect the repeal of such article  and
shall be deemed repealed therewith.