NY Ment Hygiene L § 13.40 (2021)
2021 New York Laws MHY - Mental Hygiene Title C - Developmental Disabilties Act Article 13 - Office for People With Developmental Disabilities 13.40 - People First Waiver Program.

§ 13.40 People first waiver program.  (a)  The  commissioner  and  the  commissioner of health shall jointly establish a people first waiver program for  purposes  of  developing  a care  coordination  model that integrates various long-term habilitation supports and/or health care.  The  people  first  waiver  program  shall include  the use of developmental disability individual support and care coordination organizations, herein referred to as  DISCOs,  pursuant  to section  forty-four  hundred  three-g  of  the public health law, health maintenance  organizations,  herein  referred  to  as  HMOs,   providing services  under subdivision eight of section forty-four hundred three of the public health law, and managed long term care plans, herein referred to as MLTCs, providing services under subdivisions twelve, thirteen  and fourteen of section forty-four hundred three-f of the public health law. Services  shall  be  provided as described in section forty-four hundred three-g  of  the  public  health  law,  subdivision  eight  of   section forty-four  hundred  three  of  the  public health law, and subdivisions twelve, thirteen and fourteen of section forty-four hundred  three-f  of the public health law.  (b) Entities providing services pursuant to this section shall provide health  and  long  term  care services as the term is defined in section forty-four hundred three-g of the public health law.  (c) No person with a developmental  disability  who  is  receiving  or applying  for  medical  assistance  and who is receiving, or eligible to receive, services operated, funded, certified, authorized or approved by the office, shall be required to enroll in a DISCO, HMO or MLTC in order to receive such services until program features and reimbursement  rates are  approved  by  the  commissioner and the commissioner of health, and until such commissioners determine that a  sufficient  number  of  plans that  are authorized to coordinate care for individuals pursuant to this section or that are authorized to  operate  and  to  exclusively  enroll persons   with   developmental   disabilities  pursuant  to  subdivision twenty-seven  of  section  three  hundred  sixty-four-j  of  the  social services  law are operating in such person's county of residence to meet the needs of persons with  developmental  disabilities,  and  that  such entities meet the standards of this section. No person shall be required to enroll in a DISCO, HMO or MLTC in order to receive services operated, funded,  certified, authorized or approved by the office until there are at least two entities operating under  this  section  in  such  person's county  of  residence,  unless  federal  approval  is secured to require enrollment when there are less than two such entities operating in  such county.  Notwithstanding the foregoing or any other law to the contrary, any health care provider: (i) enrolled in the Medicaid program and  (ii) rendering  hospital  services,  as  such  term  is  defined  in  section twenty-eight hundred one of the public health law, to an individual with a developmental disability who is enrolled in a DISCO, HMO or MLTC, or a prepaid health services plan operating pursuant  to  section  forty-four hundred three-a of the public health law, including, but not limited to, an  individual  who  is  enrolled  in a plan authorized by section three hundred sixty-four-j or the social services law, shall  accept  as  full reimbursement  the  negotiated  rate  or,  in the event that there is no negotiated rate, the rate of  payment  that  the  applicable  government agency would otherwise pay for such rendered hospital services.  (d)  DISCOs, HMOs and MLTCs operating under this section shall ensure, to the greatest extent practicable, that their assessment, services, and the grievance and appeals processes are  culturally  and  linguistically competent.  (e)  1. The commissioner and the commissioner of health shall identify one or more  valid  and  reliable  quality  assurance  instruments  that  include  assessments of individual and family satisfaction, provision of services, and personal outcomes. The instruments shall:  (1)  provide  nationally  validated, benchmarked, consistent, reliable and measurable data for a comprehensive quality improvement  and  review process, and  (2) include outcome-based measures such as health, safety, well-being, relationships,  interactions  with  people who do not have a disability, employment, quality of life, integration, choice, service  and  consumer satisfaction.   2. Within available appropriations, the instruments identified in this subdivision  may  be  expanded  to  collect additional data requested by other offices, departments or agencies of the state,  local  or  federal government.   3.  The  commissioner  may  contract  with  an  independent  agency or organization for the development of the  quality  assurance  instruments described in this subdivision.   4.  The  commissioner  shall  establish  the  methodology by which the quality assurance instruments shall be administered.   5. The commissioner, in consultation with stakeholders, shall annually review  the  data  collected  from  the  quality  assurance  instruments described in this subdivision and shall review recommendations regarding additional  or  different criteria for the quality assurance instruments in  order  to  assess  the  performance  of  the  state's  developmental disabilities services system and improve services for consumers.  (f)   There   shall  be  a  joint  advisory  council  chaired  by  the commissioner and the commissioner of health that shall be  charged  with advising  both  commissioners in regard to the oversight of DISCOs, HMOs providing services under subdivision eight of section forty-four hundred three of the public health  law,  and  MLTCs  providing  services  under subdivisions twelve, thirteen and fourteen of section forty-four hundred three-f  of  the  public  health  law. The joint advisory council may be comprised of the  members  of  existing  advisory  councils  or  similar entities  serving  the  office,  provided  that it shall be comprised of twelve members, including individuals with  developmental  disabilities, family  members  of,  advocates for, and providers of services to people with developmental disabilities. Three members  of  the  joint  advisory council  shall  also  be members of the special advisory review panel on medicaid  managed  care  established   under   section   three   hundred sixty-four-jj  of  the  social  services law. The joint advisory council shall review all managed  care  options  provided  to  individuals  with developmental  disabilities,  including:  the  adequacy  of habilitation services;  the  record  of  compliance  with  person-centered  planning, person-centered  services  and  community  integration;  the adequacy of rates paid to providers in accordance with the provisions  of  paragraph one  of  subdivision  four  of  section  forty-four hundred three of the public health law, paragraph  a-two  of  subdivision  eight  of  section forty-four  hundred three of the public health law or paragraph a-two of subdivision twelve of section forty-four hundred three-f of  the  public health   law;   and  quality  of  life,  health,  safety  and  community integration of individuals with developmental disabilities  enrolled  in managed  care.    The  commissioner  and  commissioner of the office for people with developmental disabilities or their designees  shall  attend all  meetings  of the joint advisory council. The joint advisory council shall report its findings, recommendations, and any proposed  amendments to   pertinent   sections  of  the  law  to  the  commissioner  and  the commissioner of health, the senate majority leader and  speaker  of  the assembly.  The  joint  advisory council shall have access to any and all  information that may be lawfully disclosed to it and that  is  necessary to perform its functions under this section.  (g) 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 to  the  contrary,  the  commissioner and the commissioner of health are authorized  to  enter  into  a  contract  or  contracts  under   section forty-four  hundred  three-g of the public health law, subdivision eight of section forty-four hundred  three  of  the  public  health  law,  and subdivision  twelve  of section forty-four hundred three-f of the public health law, provided, however, that:   1. the office 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;   2.  all  reasonable  and responsive submissions that are received from prospective contractors in a timely fashion shall  be  reviewed  by  the commissioners; and   3.  the commissioner and the commissioner of health may jointly select such  contractor  or  contractors  that,  in  their   discretion,   have demonstrated  the  ability  to effectively, efficiently and economically integrate health and long term  care  services  as  defined  in  section forty-four  hundred  three-g  of  the  public  health  law, and meet the standards for a certificate of authority in the public  health  law  for the  provision  of  services  operated, funded, certified, authorized or approved by the office for people with  developmental  disabilities  and applicable  to  the  type  of  managed  care  plan  that such contractor proposes to operate.   * (h) Consistent with and subject to the terms  of  federal  approval, the  commissioner  shall  establish  the  managed  care for persons with developmental disabilities advocacy program, hereinafter referred to  as the  advocacy  program.  The activities of the advocacy program shall be coordinated with the independent Medicaid managed care  ombuds  services provided  to  persons  with  disabilities  enrolling in Medicaid managed care. The advocacy program shall advise individuals of applicable rights and responsibilities, provide information and assistance to address  the needs of individuals with disabilities, and pursue legal, administrative and other appropriate remedies or approaches to ensure the protection of and advocacy for the rights of the enrollees. The advocacy program shall provide  support to eligible individuals with developmental disabilities enrolling  in  developmental  disability  individual  support  and  care coordination   organizations  pursuant  to  section  forty-four  hundred three-g of the  public  health  law,  health  maintenance  organizations providing  services  pursuant to subdivision eight of section forty-four hundred three of the public health law, managed  long  term  care  plans providing  services  under subdivisions twelve, thirteen and fourteen of section forty-four hundred three-f of the public health law,  and  fully integrated  dual  advantage  plans  providing services under subdivision twenty-seven  of  section  three  hundred  sixty-four-j  of  the  social services  law. The commissioner shall select an independent organization or organizations to provide advocacy services under this subdivision.    * NB Effective upon approval by the federal centers for  medicare  and medicaid  services  of  a  managed care advocacy program for individuals with developmental disabilities