N.Y. Public Health Law § 2959-A – Multipayor patient centered medical home program

1.
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.
2. (b) As used in this section:
  1. (i) "clinic" means a general hospital providing outpatient care or diagnostic and treatment center, licensed under article twenty-eight of this chapter; and
  2. (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.
  3. (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.
1. (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.
2. (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:
1. (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;
2. (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;
3. (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
4. (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.
1. (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.
2. (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:
  1. (i) The department shall post on its website, for a period of no less than thirty days:
    1. (1) A description of the proposed services to be provided pursuant to the contract or contracts;
    2. (2) The criteria for selection of a contractor or contractors;
    3. (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. (4) The manner by which a prospective contractor may seek such selection, which may include submission by electronic means;
  2. (ii) All reasonable and responsive submissions that are received from prospective contractors in timely fashion shall be reviewed by the commissioner; and
  3. (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:
1. (a) technical assistance to a primary care medical home collaborative in relation to establishing and operating a program;
2. (b) consumer assistance to patients participating in a program as to matters relating to the program;
3. (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;
4. (d) care coordination provider technical and other assistance to individuals and entities providing care coordination services to health care providers under a program; and
5. (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.
12. 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.