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This entry was published on 2017-08-04
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SECTION 2959-A
Multipayor patient centered medical home program
Public Health (PBH) CHAPTER 45, ARTICLE 29-AA
§ 2959-a. Multipayor patient centered medical home program. 1. (a) The
commissioner is authorized to establish medical home multipayor programs
(referred to in this section as a "program") whereby enhanced payments
are made to primary care clinicians and clinics statewide that are
certified as medical homes for the purpose of improving 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
diagnostic and treatment center, licensed under article twenty-eight of
this chapter; and

(ii) "primary care clinician" means a physician, nurse practitioner,
or midwife acting within his or her lawful scope of practice under title
eight of the education law and who is practicing in a primary care
specialty.

(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
hospitals, diagnostic and treatment centers, private practices and
independent 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 of, and access to, health
care services and promote improved clinical outcomes, it is the policy
of the state to encourage cooperative, collaborative and integrative
arrangements among payors of health care services and health care
services providers who might otherwise be competitors, under the active
supervision of the commissioner. It is the intent of the state to
supplant competition with such arrangements and regulation only to the
extent necessary to accomplish the purposes of this article, and to
provide state action immunity under the state and federal antitrust laws
to payors of health care services and health care services providers
with respect to the planning, implementation and operation of the
multipayor patient centered medical home program.

(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 from payors of health care
services and health care services providers to verify that medical homes
certified pursuant to this section operate in accordance with its intent
and purpose.

3. The commissioner is authorized to participate in, actively
supervise, facilitate and approve a primary care medical home
collaborative for each program around the state to establish: (a) the
boundaries of each program and the providers eligible to participate,
provided that the boundaries of programs may overlap; (b) practice
standards for each medical home program adopted with consideration of
existing standards developed by 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
Physicians, the American Academy of Family Physicians, the American
Academy of Pediatrics, and the American Osteopathic Association; the
American Academy of Nurse Practitioners, and the American College of
Nurse Practitioners; (c) standards for implementation and use of health
information technology, including participation in health information
exchanges through the statewide health information network; (d)
methodologies by which payors will provide enhanced rates of payment to
certified medical homes; (e) 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 (f) provisions
under which the commissioner may terminate the program.

3-a. The commissioner may develop or approve (a) methodologies to pay
additional amounts for medical homes that meet specific process or
outcome standards established by each multipayor patient centered
medical home collaborative; (b) alternative methodologies for payors of
health care services to health care providers under the program; (c)
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; (d) provisions for payments to 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.

4. The commissioner is authorized to establish an advisory group of
state agencies and stakeholders, such as professional organizations and
associations, and consumers, to identify legal and/or administrative
barriers to the sharing of care management and care coordination
services among participating health care services providers and to make
recommendations for statutory and/or regulatory changes to address such
barriers.

5. Patient, payor and health care services provider participation in
the multipayor patient centered medical home program shall be on a
voluntary basis.

6. Clinics and primary care clinicians participating in a program are
not eligible for additional enhancements or bonuses under the statewide
patient centered medical home program established pursuant to section
three hundred sixty-four-m of the social services law. The commissioner
shall develop or approve a method for determining payment under a
program where a provider participates, or a patient is served, in an
area where program boundaries overlap.

7. 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
clinics and clinicians that are certified as patient centered medical
homes under this title;

(b) To pay additional amounts for medical homes that meet specific
process or outcome standards specified by the commissioner in
consultation with each multipayor patient centered medical home
collaborative;

(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 entities under paragraph (g) of
subdivision three of this section; and

(d) To test new models of payment to high volume Medicaid primary care
medical home practices that incorporate risk adjusted global payments
combined with care management and pay for performance adjustments.

8. (a) The commissioner is authorized to contract with one or more
entities to assist the state in implementing the provisions of this
section. Such entity or entities shall be the same entity or entities
chosen to assist in the implementation of the health home provisions of
section three hundred sixty-five-l of the social services law.
Responsibilities of the contractor shall include but not be limited to:
developing recommendations with respect to program policy,
reimbursement, system requirements, reporting requirements, evaluation
protocols, and provider and patient enrollment; providing technical
assistance to potential medical home and health home providers; data
collection; data sharing; program evaluation, and preparation of
reports.

(b) 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,
the commissioner is authorized to enter into a contract or contracts
under paragraph (a) of this subdivision without a request for proposal
process, provided, however, that:

(i) The department shall post on its website, for a period of no less
than thirty days:

(1) A description of the proposed services to be provided pursuant to
the contract or contracts;

(2) The criteria for selection of a contractor or contractors;

(3) 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

(4) The manner by which a prospective contractor may seek such
selection, which may include submission by electronic means;

(ii) All reasonable and responsive submissions that are received from
prospective contractors in timely fashion shall be reviewed by the
commissioner; and

(iii) The commissioner shall select such contractor or contractors
that, in his or her discretion, are best suited to serve the purposes of
this section.

9. The commissioner may directly, or by contract, 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
participating in a program as to matters relating to the program,
including achieving medical home standards;

(d) care coordination provider technical and other assistance to
individuals 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.

10. 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,
integrated, 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
chairman of the assembly ways and means committee simultaneously with
their submission to the federal government.

11. The Adirondack medical home multipayor demonstration program
(including the Adirondack medical home collaborative) previously
established under section twenty-nine hundred fifty-nine of this chapter
is continued and shall be deemed to be a program under this section.