2023 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.