Provides for the establishment of medical home multipayor programs to improve health care outcomes and efficiency through improved access, patient care continuity, and coordination of health services.
STATE OF NEW YORK
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9917
IN ASSEMBLY
February 11, 2010
___________
Introduced by M. of A. GOTTFRIED -- read once and referred 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:
1 Section 1. The article heading of article 27-L of the public health
2 law, as added by section 16 of part OO of chapter 57 of the laws of
3 2008, is amended to read as follows:
4 MEDICAL HOME [DEMONSTRATION] PROGRAMS
5 § 2. The public health law is amended by adding a new section 2799-t
6 to read as follows:
7 § 2799-t. Medical home multipayor programs. 1. (a) The commissioner is
8 authorized to establish medical home multipayor programs (referred to
9 in this section as a "program") and in relation to a program may certify
10 certain clinicians and clinics as medical homes eligible for enhanced
11 payments for services provided to: recipients eligible for Medicaid
12 fee-for-service; enrollees eligible for and enrolled in Medicaid managed
13 care; enrollees eligible for and enrolled in family health plus; enrol-
14 lees eligible for and enrolled in child health plus; enrollees and
15 subscribers of commercial managed care plans operating under article
16 forty-four of this chapter or health maintenance organizations operating
17 under article forty-three of the insurance law; enrollees and subscrib-
18 ers of other commercial insurance products; and employees of employer-
19 sponsored self-insured plans. The purpose of the programs is to improve
20 health care outcomes and efficiency through improved access, patient
21 care continuity, and coordination of health services.
22 (b) As used in this section:
23 (i) "clinic" means a general hospital providing outpatient care or a
24 diagnostic and treatment center, licensed under article twenty-eight of
25 this chapter; and
26 (ii) "clinician" means a health care practitioner acting within his or
27 her lawful scope of practice under title eight of the education law who
28 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
A. 9917 2
1 specialty; (B) a physician, nurse practitioner, or midwife practicing
2 primary gynecological care for female patients; or (C) a physician or
3 nurse practitioner practicing in a non-primary care specialty, for a
4 patient who has a chronic condition that requires specialty care, where
5 the specialist health care practitioner regularly and continually
6 provides treatment for that condition to the patient.
7 2. (a) In order to promote improved quality and efficiency of, and
8 access to, health care services and promote improved clinical outcomes,
9 it shall be the policy of the state relating to the programs to encour-
10 age cooperative, collaborative and integrative arrangements between
11 payors of health care services and health care providers who might
12 otherwise be competitors, under the active supervision of the commis-
13 sioner. To the extent such arrangements might be anti-competitive within
14 the meaning and intent of the federal antitrust laws, the intent of the
15 state is to supplant competition with such arrangements to the extent
16 necessary to accomplish the purposes of this section relating to the
17 programs, and provide state action immunity under the state and federal
18 antitrust laws with respect to the planning, implementation and opera-
19 tion of the programs and payors of health care services and health care
20 providers.
21 (b) The commissioner or his or her duly authorized representative may
22 engage in appropriate state supervision necessary to promote state
23 action immunity under the state and federal antitrust laws, and may
24 inspect or request additional documentation to verify that the program
25 is implemented in accordance with its intent and purpose.
26 3. The commissioner, for purposes of the program, is authorized to
27 participate in, actively supervise, facilitate and approve a primary
28 care medical home collaborative (an entity which shall include but not
29 be limited to health care providers, which may include but not be limit-
30 ed to hospitals, diagnostic and treatment centers, and private prac-
31 tices, and payors of health care services, which may include but not be
32 limited to employers, health plans and insurers) to establish:
33 (a) the boundaries of the program and the health care providers eligi-
34 ble to participate; provided that the boundaries of programs may over-
35 lap;
36 (b) practice standards for the medical home consistent with existing
37 standards developed by national accrediting and professional organiza-
38 tions including, but not limited to, the joint principles of the Ameri-
39 can College of Physicians ("ACP"), the American Academy of Family Physi-
40 cians ("AAFP"), the American Academy of Pediatrics ("AAP"), the American
41 Osteopathic Association ("AOA"), and as further defined by "Patient
42 Centered Medical Home," as represented in certification programs devel-
43 oped by the National Committee for Quality Assurance ("NCQA");
44 (c) methodologies by which payors will provide enhanced rates of
45 payment to certified medical homes;
46 (d) methodologies to pay additional amounts for medical homes that
47 meet specific process or outcome standards established by the primary
48 care medical home collaborative of the program;
49 (e) alternative methodologies for payors of health care services to
50 health care providers under the program;
51 (f) provisions for payments to providers that may vary by size or form
52 of organization of the provider, to accommodate different levels of
53 resources and difficulty to meet the standards of the program;
54 (g) provisions for payments to not-for-profit entities that provide
55 services to health care providers to assist them in meeting medical home
56 standards under the program;
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1 (h) requirements for collecting data relating to the providing and
2 paying for health care services under the program and providing of data
3 to the commissioner, payors and health care providers under the program,
4 to promote the effective operation and evaluation of the program,
5 consistent with protection of the confidentiality of individual patient
6 information; and
7 (i) provisions under which the commissioner may terminate the program.
8 4. Patient and health care provider participation in the program shall
9 be on a voluntary basis.
10 5. Clinics and clinicians participating in a program are not eligible
11 for additional enhancements or bonuses under the statewide medical home
12 program, established pursuant to section three hundred sixty-four-m of
13 the social services law, for services provided to participants in Medi-
14 caid fee-for-service, Medicaid managed care, family health plus or child
15 health plus.
16 6. Subject to the availability of funding and federal financial
17 participation, the commissioner is authorized:
18 (a) To pay enhanced rates of payment under Medicaid fee-for-service,
19 Medicaid managed care, family health plus and child health plus to clin-
20 ics and clinicians that are certified as medical homes under this
21 section;
22 (b) To pay additional amounts for medical homes that meet specific
23 process or outcome standards specified by the commissioner, in consulta-
24 tion with the primary care medical home collaborative of the program;
25 and
26 (c) To authorize alternative payment methodologies under Medicaid
27 fee-for-service, Medicaid managed care, family health plus and child
28 health plus for health care providers and to serve the purposes of the
29 program, including payments to not-for-profit entities under paragraph
30 (g) of subdivision three of this section.
31 7. The commissioner may directly, or by contract with not-for-profit
32 organizations, provide:
33 (a) consumer assistance to patients participating in a program as to
34 matters relating to the program;
35 (b) technical and other assistance to health care providers partic-
36 ipating in a program as to matters relating to the program, including
37 achieving medical home standards;
38 (c) care coordination provider technical and other assistance to indi-
39 viduals and entities providing care coordination services to health care
40 providers under a program; and
41 (d) information sharing and other assistance among programs to improve
42 the operation of programs.
43 8. The commissioner shall, to the extent necessary for the purpose of
44 this section, submit the appropriate waivers and other applications,
45 including, but not limited to, those authorized pursuant to sections
46 eleven hundred fifteen and nineteen hundred fifteen of the federal
47 social security act, or successor provisions, and any other waivers or
48 applications necessary to achieve the purposes of high quality, inte-
49 grated, and cost effective care and integrated financial eligibility
50 policies under Medicaid, family health plus and child health plus or
51 Medicare. Copies of such original waiver and other applications shall be
52 provided to the chairman of the senate finance committee and the chair-
53 man of the assembly ways and means committee simultaneously with their
54 submission to the federal government.
55 9. The Adirondack medical home multipayor demonstration program
56 (including the Adirondack medical home collaborative) previously estab-
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1 lished under section twenty-nine hundred fifty-nine of this chapter is
2 continued and shall be deemed to be a program under this section.
3 10. The commissioner shall annually report to the governor and the
4 legislature on the operation of the programs and their effectiveness in
5 achieving the purposes of this section, with particular reference to the
6 quality, cost, and outcomes for enrollees in Medicaid fee-for-service,
7 Medicaid managed care, family health plus and child health plus.
8 11. No program shall be approved under this section after April first,
9 two thousand sixteen.
10 § 3. Subdivision 1 of section 2 of the public health law is amended by
11 adding six new paragraphs (o), (p), (q), (r), (s) and (t), to read as
12 follows:
13 (o) "Medicaid" or "medical assistance" means title eleven of article
14 five of the social services law and the program thereunder.
15 (p) "Family health plus" means title eleven-D of article five of the
16 social services law and the program thereunder.
17 (q) "Child health plus" means title one-A of article twenty-five of
18 this chapter and the program thereunder.
19 (r) "Medicaid managed care" means Medicaid provided under section
20 three hundred sixty-four-j of the social services law.
21 (s) "Medicaid fee-for-service" means Medicaid provided other than
22 under Medicaid managed care.
23 (t) "Medicare" means title XVIII of the federal social security act
24 and the programs thereunder.
25 § 4. This act shall take effect immediately; provided, however, that
26 the amendments to article 27-L of the public health law made by sections
27 one and two of this act shall not affect the repeal of such article and
28 shall be deemed repealed therewith.
