NY Pub Health L § 2111 (2021)
2021 New York Laws PBH - Public Health Article 21 - Control of Acute Communicable Diseases Title 1 - General Provisions 2111 - Disease Management Demonstration Programs.

§  2111.  Disease management demonstration programs. 1. The department   may  establish  disease  management  demonstration  programs  through  a   request   for   proposals   process   to   enhance   the   quality   and   cost-effectiveness of care rendered to  medicaid-eligible  persons  with   chronic health problems whose care and treatment, because of one or more   hospitalizations,  multiple  disabling  conditions requiring residential   treatment or other health care requirements, results  in  high  medicaid   expenditures.  In  order  to  be  eligible to sponsor and to undertake a   disease management demonstration program, the proposed sponsor may be  a   not-for-profit,  for-profit  or  local  government organization that has   demonstrated expertise in the management  or  coordination  of  care  to   persons  with  chronic  diseases or that has the experience of providing   cost-effective community-based care to such patients, or in the case  of   a  local  government organization, has expressed a strong willingness to   sponsor  such  a  program.  The  department  may  also  approve  disease   management demonstration programs which include, but are not limited to,   the  promotion of adherence to evidence-based guidelines, improvement of   provider and patient communication and provide information  on  provider   and  beneficiary  utilization of services. The department shall grant no   fewer than six demonstration programs, no more than  one-third  of  such   programs  shall  be  selected  to  provide  these services in any single   social services district; provided further, where the department  grants   less  than  six  demonstration  programs,  no more than one such program   shall be selected  to  provide  these  services  in  any  single  social   services  district.  The  department  shall  approve  disease management   demonstration   programs   which   are   geographically   diverse    and   representative  of  both  urban and rural social services districts. The   program sponsor must establish, to the satisfaction of  the  department,   its  capacity  to  enroll  and  serve sufficient numbers of enrollees to   demonstrate the cost-effectiveness of the demonstration program.2. The department shall establish the criteria  by  which  individuals   will  be  identified  as  eligible  for  enrollment in the demonstration   programs.  Persons eligible for enrollment  in  the  disease  management   demonstration  program  shall  be  limited  to  individuals who: receive   medical assistance pursuant to title  eleven  of  article  five  of  the   social  services  law and may be eligible for benefits pursuant to title   18 of the social security act (Medicare); are not enrolled in a Medicaid   managed care plan, including individuals who are  not  required  or  not   eligible  to  participate  in Medicaid managed care programs pursuant to   section three hundred sixty-four-j  of  the  social  services  law;  are   diagnosed with chronic health problems as may be specified by the entity   undertaking the demonstration program, including, but not limited to one   or  more of the following: congestive heart failure, chronic obstructive   pulmonary disease, asthma, diabetes or other chronic  health  conditions   as may be specified by the department; or have experienced or are likely   to  experience one or more hospitalizations or are otherwise expected to   incur excessive costs and high utilization of health care services.3. Enrollment  in  a  demonstration  program  shall  be  voluntary.  A   participating  individual  may  discontinue his or her enrollment at any   time without cause.  The  commissioner  shall  review  and  approve  all   enrollment and marketing materials for a demonstration program.4.  The  demonstration program shall offer evidence-based services and   interventions  designed  to  ensure  that  the  enrollees  receive  high   quality,  preventative  and  cost-effective  care, aimed at reducing the   necessity for hospitalization or emergency  room  care  or  at  reducing   lengths  of  stay  when  hospitalization is necessary. The demonstration   program may include  screening  of  eligible  enrollees,  developing  an   individualized  care  management plan for each enrollee and implementing    that  plan.  Disease  management  demonstration  programs  that  utilize   information  technology systems that allow for continuous application of   evidence-based guidelines to medical assistance claims  data  and  other   available   data  to  identify  specific  instances  in  which  clinical   interventions are justified and communicate indicated  interventions  to   physicians, health care providers and/or patients, and monitor physician   and  health care provider response to such interventions, shall have the   enrollees, or groups  of  enrollees,  approved  by  the  department  for   participation.  The  services  provided  by the demonstration program as   part of the care management plan may include, but are  not  limited  to,   case   management,   social   work,  individualized  health  counselors,   multi-behavioral  goals  plans,  claims  data  management,  health   and   self-care  education,  drug  therapy  management and oversight, personal   emergency response systems and other monitoring technologies, telehealth   services and similar  services  designed  to  improve  the  quality  and   cost-effectiveness of health care services.5.  The  department  shall  be responsible for monitoring the quality,   appropriateness and cost-effectiveness of a demonstration  program.  The   department  shall utilize, to the extent possible, all potential sources   of funding for demonstration programs, including, but  not  limited  to,   private payments and donations. All such funds shall be deposited by the   commissioner  and credited to the disease management account which shall   be established by the comptroller in  the  special  revenue-other  fund.   Additionally,  to  the  extent  of  funds appropriated therefor, medical   assistance funds, including any funding or shared savings as may  become   available through federal waivers or otherwise under titles 18 and 19 of   the  federal  social  security  act,  may  be used by the department for   expenditures in support of the disease management program.6. Payments shall be made by the department to the entity  responsible   for  the  operation  of  the demonstration program on a fixed amount per   member per month of enrollment and shall reimburse the  program  sponsor   for  the services rendered pursuant to subdivision four of this section.   The amount paid shall be an amount  reasonably  necessary  to  meet  the   costs  of  providing  such services, provided that the total amount paid   for medical assistance to  enrollees  in  any  such  disease  management   demonstration program, including any demonstration program expenditures,   shall   not   exceed  ninety-five  percent  of  the  medical  assistance   expenditure related to such enrollee that  would  reasonably  have  been   anticipated  if the enrollee had not been enrolled in such demonstration   program. The department may make payments to demonstration programs that   provide administrative services only, provided  that  expenditures  made   for   enrollees,   or   a  group  of  enrollees,  participating  in  the   demonstration program shall provide sufficient savings as determined  by   the  department,  had  the  enrollees,  or groups of enrollees, not been   enrolled in such demonstration. The department shall provide an  interim   report  to  the  governor,  and  the  legislature  on or before December   thirty-first, two thousand six and a final report on or before  December   thirty-first,  two  thousand  seven  on  the  results  of  demonstration   programs. Both reports shall include findings as  to  the  demonstration   programs'   contribution   to   improving  quality  of  care  and  their   cost-effectiveness. In the final  report,  the  department  shall  offer   recommendations as to whether demonstration programs should be extended,   modified, eliminated or made permanent.