N.Y. MHY Law § 13.40 — New York Code / Act MHY / Title C / Article 13 / Section 13.40
People first waiver program
Status: in_force

§ 13.40 People first waiver program.\n  (a) The commissioner and the commissioner of health shall jointly\nestablish a people first waiver program for purposes of developing a\ncare coordination model that integrates various long-term habilitation\nsupports and/or health care. The people first waiver program shall\ninclude the use of developmental disability individual support and care\ncoordination organizations, herein referred to as DISCOs, pursuant to\nsection forty-four hundred three-g of the public health law, health\nmaintenance organizations, herein referred to as HMOs, providing\nservices under subdivision eight of section forty-four hundred three of\nthe public health law, and managed long term care plans, herein referred\nto as MLTCs, providing services under subdivisions twelve, thirteen and\nfourteen of section forty-four hundred three-f of the public health law.\nServices shall be provided as described in section forty-four hundred\nthree-g of the public health law, subdivision eight of section\nforty-four hundred three of the public health law, and subdivisions\ntwelve, thirteen and fourteen of section forty-four hundred three-f of\nthe public health law.\n  (b) Entities providing services pursuant to this section shall provide\nhealth and long term care services as the term is defined in section\nforty-four hundred three-g of the public health law.\n  (c) No person with a developmental disability who is receiving or\napplying for medical assistance and who is receiving, or eligible to\nreceive, services operated, funded, certified, authorized or approved by\nthe office, shall be required to enroll in a DISCO, HMO or MLTC in order\nto receive such services until program features and reimbursement rates\nare approved by the commissioner and the commissioner of health, and\nuntil such commissioners determine that a sufficient number of plans\nthat are authorized to coordinate care for individuals pursuant to this\nsection or that are authorized to operate and to exclusively enroll\npersons with developmental disabilities pursuant to subdivision\ntwenty-seven of section three hundred sixty-four-j of the social\nservices law are operating in such person's county of residence to meet\nthe needs of persons with developmental disabilities, and that such\nentities meet the standards of this section. No person shall be required\nto enroll in a DISCO, HMO or MLTC in order to receive services operated,\nfunded, certified, authorized or approved by the office until there are\nat least two entities operating under this section in such person's\ncounty of residence, unless federal approval is secured to require\nenrollment when there are less than two such entities operating in such\ncounty. Notwithstanding the foregoing or any other law to the contrary,\nany health care provider: (i) enrolled in the Medicaid program and (ii)\nrendering hospital services, as such term is defined in section\ntwenty-eight hundred one of the public health law, to an individual with\na developmental disability who is enrolled in a DISCO, HMO or MLTC, or a\nprepaid health services plan operating pursuant to section forty-four\nhundred three-a of the public health law, including, but not limited to,\nan individual who is enrolled in a plan authorized by section three\nhundred sixty-four-j or the social services law, shall accept as full\nreimbursement the negotiated rate or, in the event that there is no\nnegotiated rate, the rate of payment that the applicable government\nagency would otherwise pay for such rendered hospital services.\n  (d) DISCOs, HMOs and MLTCs operating under this section shall ensure,\nto the greatest extent practicable, that their assessment, services, and\nthe grievance and appeals processes are culturally and linguistically\ncompetent.\n  (e) 1. The commissioner and the commissioner of health shall identify\none or more valid and reliable quality assurance instruments that\ninclude assessments of individual and family satisfaction, provision of\nservices, and personal outcomes. The instruments shall:\n  (1) provide nationally validated, benchmarked, consistent, reliable\nand measurable data for a comprehensive quality improvement and review\nprocess, and\n  (2) include outcome-based measures such as health, safety, well-being,\nrelationships, interactions with people who do not have a disability,\nemployment, quality of life, integration, choice, service and consumer\nsatisfaction.\n  2. Within available appropriations, the instruments identified in this\nsubdivision may be expanded to collect additional data requested by\nother offices, departments or agencies of the state, local or federal\ngovernment.\n  3. The commissioner may contract with an independent agency or\norganization for the development of the quality assurance instruments\ndescribed in this subdivision.\n  4. The commissioner shall establish the methodology by which the\nquality assurance instruments shall be administered.\n  5. The commissioner, in consultation with stakeholders, shall annually\nreview the data collected from the quality assurance instruments\ndescribed in this subdivision and shall review recommendations regarding\nadditional or different criteria for the quality assurance instruments\nin order to assess the performance of the state's developmental\ndisabilities services system and improve services for consumers.\n  (f) There shall be a joint advisory council chaired by the\ncommissioner and the commissioner of health that shall be charged with\nadvising both commissioners in regard to the oversight of DISCOs, HMOs\nproviding services under subdivision eight of section forty-four hundred\nthree of the public health law, and MLTCs providing services under\nsubdivisions twelve, thirteen and fourteen of section forty-four hundred\nthree-f of the public health law. The joint advisory council may be\ncomprised of the members of existing advisory councils or similar\nentities serving the office, provided that it shall be comprised of\ntwelve members, including individuals with developmental disabilities,\nfamily members of, advocates for, and providers of services to people\nwith developmental disabilities. Three members of the joint advisory\ncouncil shall also be members of the special advisory review panel on\nmedicaid managed care established under section three hundred\nsixty-four-jj of the social services law. The joint advisory council\nshall review all managed care options provided to individuals with\ndevelopmental disabilities, including: the adequacy of habilitation\nservices; the record of compliance with person-centered planning,\nperson-centered services and community integration; the adequacy of\nrates paid to providers in accordance with the provisions of paragraph\none of subdivision four of section forty-four hundred three of the\npublic health law, paragraph a-two of subdivision eight of section\nforty-four hundred three of the public health law or paragraph a-two of\nsubdivision twelve of section forty-four hundred three-f of the public\nhealth law; and quality of life, health, safety and community\nintegration of individuals with developmental disabilities enrolled in\nmanaged care.  The commissioner and commissioner of the office for\npeople with developmental disabilities or their designees shall attend\nall meetings of the joint advisory council. The joint advisory council\nshall report its findings, recommendations, and any proposed amendments\nto pertinent sections of the law to the commissioner and the\ncommissioner of health, the senate majority leader and speaker of the\nassembly. The joint advisory council shall have access to any and all\ninformation that may be lawfully disclosed to it and that is necessary\nto perform its functions under this section.\n  (g) Notwithstanding any inconsistent provision of sections one hundred\ntwelve and one hundred sixty-three of the state finance law, or section\none hundred forty-two of the economic development law, or any other law\nto the contrary, the commissioner and the commissioner of health are\nauthorized to enter into a contract or contracts under section\nforty-four hundred three-g of the public health law, subdivision eight\nof section forty-four hundred three of the public health law, and\nsubdivision twelve of section forty-four hundred three-f of the public\nhealth law, provided, however, that:\n  1. the office shall post on its website, for a period of no less than\nthirty days:\n  (1) a description of the proposed services to be provided pursuant to\nthe contract or contracts;\n  (2) the criteria for selection of a contractor or contractors;\n  (3) the period of time during which a prospective contractor may seek\nselection, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n  (4) the manner by which a prospective contractor may seek such\nselection, which may include submission by electronic means;\n  2. all reasonable and responsive submissions that are received from\nprospective contractors in a timely fashion shall be reviewed by the\ncommissioners; and\n  3. the commissioner and the commissioner of health may jointly select\nsuch contractor or contractors that, in their discretion, have\ndemonstrated the ability to effectively, efficiently and economically\nintegrate health and long term care services as defined in section\nforty-four hundred three-g of the public health law, and meet the\nstandards for a certificate of authority in the public health law for\nthe provision of services operated, funded, certified, authorized or\napproved by the office for people with developmental disabilities and\napplicable to the type of managed care plan that such contractor\nproposes to operate.\n  * (h) Consistent with and subject to the terms of federal approval,\nthe commissioner shall establish the managed care for persons with\ndevelopmental disabilities advocacy program, hereinafter referred to as\nthe advocacy program. The activities of the advocacy program shall be\ncoordinated with the independent Medicaid managed care ombuds services\nprovided to persons with disabilities enrolling in Medicaid managed\ncare. The advocacy program shall advise individuals of applicable rights\nand responsibilities, provide information and assistance to address the\nneeds of individuals with disabilities, and pursue legal, administrative\nand other appropriate remedies or approaches to ensure the protection of\nand advocacy for the rights of the enrollees. The advocacy program shall\nprovide support to eligible individuals with developmental disabilities\nenrolling in developmental disability individual support and care\ncoordination organizations pursuant to section forty-four hundred\nthree-g of the public health law, health maintenance organizations\nproviding services pursuant to subdivision eight of section forty-four\nhundred three of the public health law, managed long term care plans\nproviding services under subdivisions twelve, thirteen and fourteen of\nsection forty-four hundred three-f of the public health law, and fully\nintegrated dual advantage plans providing services under subdivision\ntwenty-seven of section three hundred sixty-four-j of the social\nservices law. The commissioner shall select an independent organization\nor organizations to provide advocacy services under this subdivision.\n  * NB Effective upon approval by the federal centers for medicare and\nmedicaid services of a managed care advocacy program for individuals\nwith developmental disabilities\n