S T A T E O F N E W Y O R K
________________________________________________________________________
3637--A
2011-2012 Regular Sessions
I N A S S E M B L Y
January 26, 2011
___________
Introduced by M. of A. GOTTFRIED, SCHIMMINGER, JACOBS, GALEF, MAISEL,
SCARBOROUGH, HOOPER, JAFFEE, PERRY, CASTRO, BARRON -- Multi-Sponsored
by -- M. of A. BOYLAND, BURLING, CALHOUN, DESTITO, DUPREY, FINCH,
JORDAN, LENTOL, MARKEY, PHEFFER, SCHIMEL, TOBACCO, TOWNS -- read once
and referred to the Committee on Health -- reported and referred to
the Committee on Ways and Means -- committee discharged, bill amended,
ordered reprinted as amended and recommitted to said committee
AN ACT to amend the public health law, in relation to medical home
multipayor programs; and to amend part OO of chapter 57 of the laws of
2008 amending the public health law relating to medical home demon-
stration programs, in relation to the effectiveness thereof
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 PRIMARY CARE 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 MEDI-
CAID MANAGED CARE; ENROLLEES ELIGIBLE FOR AND ENROLLED IN FAMILY HEALTH
PLUS; ENROLLEES ELIGIBLE FOR AND ENROLLED IN CHILD HEALTH PLUS; ENROL-
LEES 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
SUBSCRIBERS OF OTHER COMMERCIAL INSURANCE PRODUCTS; AND EMPLOYEES OF
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD02272-03-1
A. 3637--A 2
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) "PRIMARY CARE 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 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;
(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 HOSPI-
TALS, DIAGNOSTIC AND TREATMENT CENTERS, PRIVATE PRACTICES AND INDEPEND-
ENT 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 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 AND
AMONG 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, AND WITH REGU-
LATION UNDER THIS SECTION 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 OPERATION 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 FOR A PROGRAM 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 ADOPTED WITH CONSIDERATION
OF EXISTING STANDARDS DEVELOPED BY NATIONAL ACCREDITING AND PROFESSIONAL
ORGANIZATIONS INCLUDING, BUT NOT LIMITED TO, 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 PHYSI-
CIANS, THE AMERICAN ACADEMY OF FAMILY PHYSICIANS, THE AMERICAN ACADEMY
OF PEDIATRICS, AND THE AMERICAN OSTEOPATHIC ASSOCIATION;
A. 3637--A 3
(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, OR PATIENT CASE MIX 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 SUCH AS THE SERVICES OF COMMUNITY HEALTH
WORKERS;
(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 PRIMARY CARE 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 MEDICAID 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 PRIMARY CARE 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) 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 PARTIC-
IPATING IN A PROGRAM AS TO MATTERS RELATING TO THE PROGRAM, INCLUDING
ACHIEVING MEDICAL HOME STANDARDS;
A. 3637--A 4
(D) CARE COORDINATION PROVIDER TECHNICAL AND OTHER ASSISTANCE TO INDI-
VIDUALS 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.
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-
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. Paragraph o of section 21 of part OO of chapter 57 of the laws of
2008, amending the public health law relating to medical home demon-
stration programs, is amended to read as follows:
o. section sixteen of this act shall take effect January 1, 2009 and;
PROVIDED THAT SECTION 2799-S OF THE PUBLIC HEALTH LAW AS ADDED BY THAT
SECTION shall expire and be deemed repealed 3 years after such effective
date; and
S 5. This act shall take effect immediately.