2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 4403-G - Developmental Disabilty Individual Support and Care Coordination Organizations.

* §  4403-g.  Developmental  disability  individual  support  and care
coordination organizations. 1. Definitions. As used in this section:
(a) "Developmental disability individual support and care coordination
organization" or "DISCO" means an entity that has received a certificate
of authority pursuant to this section to provide, or arrange for, health
and long term care services, as determined by the commissioner  and  the
commissioner  of  the office for people with developmental disabilities,
on a capitated basis in accordance with this section, for  a  population
of  persons  with developmental disabilities, as such term is defined in
section 1.03 of the  mental  hygiene  law,  which  the  organization  is
authorized to enroll.
(b)  "Eligible  applicant"  means  an entity controlled by one or more
non-profit  organizations  which  have  a  history   of   providing   or
coordinating  health  and  long  term  care  services  to  persons  with
developmental disabilities.
(c) "Habilitation  services"  means  services  available  through  the
state's  home  and  community  based  services  waiver  for persons with
developmental disabilities, state plan for medical assistance,  and  any
other  authorized  federal  funding for such services designed to assist
persons  in  acquiring,  retaining,   and   improving   the   self-help,
socialization,  and  adaptive skills necessary to reside successfully in
home and community based settings.
(d) "Health and long term care services"  means  comprehensive  health
services  and  other  services as determined by the commissioner and the
commissioner of the office for people with  developmental  disabilities,
whether  provided by state-operated programs or not-for-profit entities,
including,  but  not  limited  to,  habilitation  services,   home   and
community-based  and  institution-based  long  term  care  services, and
ancillary services, that shall include medical supplies and  nutritional
supplements,  that  are  necessary to meet the needs of persons whom the
plan is authorized to enroll. Each person  enrolled  in  a  DISCO  shall
receive   health  and  long  term  care  services  designed  to  achieve
person-centered outcomes, to enable that person  to  live  in  the  most
integrated  setting  appropriate  to  that person's needs, and to enable
that person to interact with nondisabled persons to the  fullest  extent
possible  in  social,  workplace  and other community settings, provided
that all such services are consistent with such person's wishes  to  the
extent  that  such wishes are known and in accordance with such person's
needs.
2. Approval authority. An applicant shall be issued a  certificate  of
authority  as  a DISCO for purposes of participating in the people first
waiver program pursuant to section 13.40 of the mental hygiene law  upon
a  determination  by the commissioner and the commissioner of the office
for people with developmental disabilities that the  applicant  complies
with the operating requirements for a DISCO under this section.
3.  Application  for  certificate of authority; form. The commissioner
and the  commissioner  of  the  office  for  people  with  developmental
disabilities  shall  jointly develop application forms for a certificate
of authority to operate a DISCO. An eligible applicant shall  submit  an
application for a certificate of authority to operate a DISCO upon forms
prescribed  by  such commissioners. Such eligible applicant shall submit
information and documentation to the commissioner which  shall  include,
but not be limited to:
(a)  A  description  of  the service area proposed to be served by the
DISCO with projections of enrollment that  will  result  in  a  fiscally
sound plan;
(b)  A  description of the services to be covered by such DISCO, which
must include all health and long  term  care  services,  as  defined  in

paragraph  (d) of subdivision one of this section, and other services as
determined by the commissioner and the commissioner of  the  office  for
people with developmental disabilities;
(c)  A  description  of  the proposed marketing plan and how marketing
materials will be presented to persons with  developmental  disabilities
or their authorized decision makers for the purposes of enabling them to
make an informed choice;
(d) The names of the providers proposed to be in the DISCO's network;
(e)  Evidence  of  the  character  and  competence  of the applicant's
proposed operators, and of the incorporators, directors, stockholders or
members of the applicant;
(f) Adequate documentation of the appropriate licenses, certifications
or approvals to provide care as planned, including affiliate  agreements
or proposed contracts with such providers as may be necessary to provide
the  full  complement  of  services  required  to be provided under this
section;
(g)  A  description  of  the  proposed  quality-assurance  mechanisms,
grievance  procedures, mechanisms to protect the rights of enrollees and
care   coordination   services   to    ensure    continuity,    quality,
appropriateness and coordination of care;
(h)  A  description of the proposed quality assessment and performance
improvement program that includes performance and outcome based  quality
standards   for  enrollee  health  status  and  satisfaction,  and  data
collection and reporting for standard performance measures;
(i) A description of the management systems  and  systems  to  process
payment for covered services;
(j)  A  description of how achievement of person-centered outcomes, as
defined by the commissioner of the office for people with  developmental
disabilities,  shall be assessed, as well as a description of how health
and long term care services shall be used to meet such outcomes;
(k) A description of the mechanism to maximize  reimbursement  of  and
coordinate  services  reimbursed  pursuant to title XVIII of the federal
social security act and all other applicable benefits, with such benefit
coordination including, but not limited to, measures  to  support  sound
clinical  decisions, reduce administrative complexity, coordinate access
to services, maximize benefits available  pursuant  to  such  title  and
ensure that necessary care is provided;
(l)  A  description  of  the  systems for securing and integrating any
potential sources of funding for services provided  by  or  through  the
organization,  including,  but  not  limited to, funding available under
titles XVI, XVIII, XIX and XX of the federal social security act and all
other available sources of funding;
(m)  A  description  of  the  proposed  contractual  arrangements  for
providers  of health and long term care services in the benefit package;
and
(n) Information related to the financial condition of the applicant.
4. Certificate of  authority  approval.  The  commissioner  shall  not
approve  an  application  for  a  certificate  of  authority  unless the
applicant demonstrates to the satisfaction of the commissioner  and  the
commissioner of the office for people with developmental disabilities:
(a)   That   it  will  have  in  place  acceptable  quality  assurance
mechanisms, grievance procedures and mechanisms to protect the rights of
enrollees and care coordination services to ensure continuity,  quality,
appropriateness and coordination of care;
(b)  That  it  will  have in place a mechanism or means to assure that
persons with developmental disabilities can make informed choices either
individually or through  an  authorized  decision  maker  regarding  the

development of a person-centered plan, as defined by the commissioner of
the office for people with developmental disabilities;
(c)  That  it  has  developed  a  quality  assessment  and performance
improvement program that includes performance and outcome based  quality
standards  for  enrollee  health status and satisfaction, which shall be
reviewed by the commissioner and the  commissioner  of  the  office  for
people  with  developmental disabilities. The program shall include data
collection and reporting for standard performance measures  as  required
by  the  commissioner and the commissioner of the office for people with
developmental disabilities;
(d) That an otherwise eligible enrollee  shall  not  be  involuntarily
disenrolled without the prior approval of the commissioner of the office
for people with developmental disabilities;
(e)  That  the applicant shall not use deceptive or coercive marketing
methods to encourage participants to enroll and that the applicant shall
not distribute marketing materials to potential  enrollees  before  such
materials have been approved by the commissioner and the commissioner of
the office for people with developmental disabilities;
(f)  Satisfactory  evidence  of  the  character  and competence of the
applicant's proposed operators, incorporators,  directors,  stockholders
and members;
(g)  Reasonable assurance that the applicant will provide high quality
services to an enrolled population,  that  the  applicant's  network  of
providers   is  adequate  and  that  such  providers  have  demonstrated
sufficient competency to deliver high quality services to  the  enrolled
population  and that policies and procedures will be in place to address
the cultural and linguistic needs of the enrolled population;
(h) Sufficient management systems capacity to meet the requirements of
this section and the ability to efficiently process payment for  covered
services;
(i)   Readiness  and  capability  to  maximize  reimbursement  of  and
coordinate services reimbursed pursuant to title XVIII  of  the  federal
social security act and all other applicable benefits, with such benefit
coordination  including,  but  not limited to, measures to support sound
clinical decisions, reduce administrative complexity, coordinate  access
to  services,  maximize  benefits  available  pursuant to such title and
ensure that necessary care is provided;
(j) Readiness  and  capability  of  organizing,  marketing,  managing,
promoting  and  operating  a health and long term care services plan, or
has an affiliation agreement with an entity that has such readiness  and
capability;
(k) Willingness and capability of taking, or cooperating in, all steps
necessary  to  secure and integrate any potential sources of funding for
services provided by or through the DISCO, including,  but  not  limited
to, funding available under titles XVI, XVIII, XIX and XX of the federal
social security act and all other available sources of funding;
(l) That the contractual arrangements for providers of health and long
term  care  services in the benefit package are sufficient to ensure the
availability and accessibility of such services to the proposed enrolled
population consistent with guidelines established  by  the  commissioner
and  the  commissioner  of  the  office  for  people  with developmental
disabilities.  With  respect  to  a  person  receiving   non-residential
services  operated,  certified,  funded,  authorized  or approved by the
office for people with developmental disabilities prior to enrollment in
the DISCO, such guidelines shall require the DISCO to contract with  the
current provider of non-residential services at the rates established by
the  office for ninety days, in order to ensure continuity of care. With
respect to a  person  living  in  a  residential  facility  operated  or

certified by the office for people with developmental disabilities prior
to  enrollment  in the DISCO, such guidelines shall require the DISCO to
contract with the provider of residential services for that residence at
the rates established by the office for so long as such individual lives
in that residence pursuant to an approved plan of care;
(m)  That  the  applicant  is  financially  responsible  and  shall be
expected to meet its obligations to its enrolled members; and
(n) That  the  applicant  shall  assess  person-centered  outcomes  as
defined  by the commissioner of the office for people with developmental
disabilities, and has satisfactory mechanisms by which  it  will  assess
how  health  and  long  term  care  services  will  be used to meet such
outcomes.
5. Enrollment. (a) Only persons with  developmental  disabilities,  as
determined  by  the  office  for people with developmental disabilities,
shall be eligible to enroll in DISCOs.
(b) The office for  people  with  developmental  disabilities  or  its
designee  shall  enroll an eligible person in the DISCO chosen by him or
her, his or her guardian or other legal  representative,  provided  that
such DISCO is authorized to enroll such person.
(c)  No  person  with  a  developmental disability who is receiving or
applying for medical assistance and who is  receiving,  or  eligible  to
receive,  services  funded,  certified,  authorized  or  approved by the
office for people with developmental disabilities, shall be required  to
enroll  in  a  DISCO  in  order  to  receive such services until program
features and reimbursement rates are approved by  the  commissioner  and
the   commissioner   of   the   office  for  people  with  developmental
disabilities, and until such commissioners determine that  there  are  a
sufficient  number  of  plans  authorized to coordinate care for persons
with developmental disabilities pursuant to this  article  operating  in
such  person's  county  of  residence  to meet the needs of persons with
developmental disabilities, and that such DISCOs meet the  standards  of
this  section. No person shall be required to enroll in a DISCO in order
to receive services operated, funded, certified, authorized or  approved
by the office for people with developmental disabilities until there are
at  least  two  plans  authorized  to  coordinate  care for persons with
developmental disabilities pursuant to this  article  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.
(d)  Persons  required  to  enroll  in a DISCO shall have no less than
sixty days to select a DISCO, and such persons and  their  guardians  or
other  legal  representatives shall be provided with information to make
an  informed  choice.  Where  a  person,   guardian   or   other   legal
representative  has not selected a DISCO, the commissioner of the office
for people with developmental disabilities or its designee shall  enroll
such  person in a DISCO chosen by such commissioner, taking into account
quality, capacity and geographic accessibility. The  office  for  people
with  developmental  disabilities  or  its  designee shall automatically
re-enroll a person with the same DISCO if there is a  loss  of  medicaid
eligibility of two months or less.
(e)  Enrolled  persons may change their enrollment at any time without
cause, provided, however, that a person required to enroll in a DISCO in
order to receive services funded, licensed, authorized  or  approved  by
the office for people with developmental disabilities may only disenroll
from  a DISCO if he or she enrolls in another DISCO authorized to enroll
him or her. Such disenrollment shall be  effective  no  later  than  the
first day of the second month following the request.
(f)  A  DISCO may request the involuntary disenrollment of an enrolled
person  in  writing  to  the  office  for  people   with   developmental
disabilities.  Such  disenrollment  shall  not  be  effective  until the
request is reviewed  and  approved  by  such  office.  Notice  shall  be
provided  to  the  enrollee  and the enrollee may request a fair hearing
regarding such disenrollment. The department and the office  for  people
with  developmental  disabilities  shall  adopt  rules  and  regulations
governing this process.
6. Assessments. The office for people with developmental disabilities,
or its designee, shall complete a comprehensive  assessment  that  shall
include,  but  not  be limited to, an evaluation of the medical, social,
habilitative and environmental needs of each prospective enrollee  in  a
DISCO  as  such needs relate to each individual's health, safety, living
environment and wishes, to the extent that such wishes are  known.  This
assessment  shall  also  serve  as  the  basis  for  the development and
provision of an appropriate plan of care for the enrollee. Such plan  of
care shall be focused on the achievement of person-centered outcomes and
shall  be consistent with and help inform any other person-centered plan
required for the enrollee by the commissioner of the office  for  people
with  developmental  disabilities.  The assessment shall be completed by
the office for people with developmental disabilities or in consultation
with the prospective enrollee's health care practitioner  as  necessary.
The   commissioner   of   the   office  for  people  with  developmental
disabilities shall prescribe the forms on which the assessment shall  be
made.   The  office  for  people  with  developmental  disabilities  may
designate the DISCO to perform reassessments, but  shall  not  designate
the DISCO to perform the initial assessment of a prospective enrollee.
7.  Program oversight and administration. (a) The commissioner and the
commissioner of the office for people  with  developmental  disabilities
shall  jointly  promulgate  regulations  to  implement  this section, to
provide for oversight of DISCOs,  including  on  site  reviews,  and  to
ensure  the  quality,  appropriateness  and  cost-effectiveness  of  the
services provided by DISCOs.
(b) The commissioner and the commissioner of  the  office  for  people
with developmental disabilities may waive rules and regulations of their
respective  department  or  office,  including but not limited to, those
pertaining to duplicative requirements concerning record keeping, boards
of directors, staffing and reporting, when such waiver shall promote the
efficient delivery of appropriate, quality, cost-effective services  and
when the health, safety and general welfare of DISCO enrollees shall not
be  impaired  as a result of such waiver. The commissioners shall report
annually  to  the  legislature  and  to  the  joint   advisory   council
established  pursuant  to section 13.40 of the mental hygiene law on all
rules and regulations waived pursuant to this  paragraph.  In  order  to
achieve  DISCO  system  efficiencies and coordination and to promote the
objectives of high quality, integrated  and  cost  effective  care,  the
commissioners shall establish a single coordinated surveillance process,
allow for a comprehensive quality improvement and review process to meet
component  quality  requirements, and require a uniform cost report. The
commissioners  shall  require  DISCOs  to  utilize  quality  improvement
measures,  based  on the achievement of personal outcomes and quality of
life, health outcomes data, and assessments  of  individual  and  family
satisfaction,  for internal quality assessment processes and may utilize
such measures as part of the single coordinated surveillance process.
(c) Notwithstanding any inconsistent provision of the social  services
law   to  the  contrary,  the  commissioner  in  consultation  with  the
commissioner of the office for people  with  developmental  disabilities
shall, pursuant to regulation, determine whether and the extent to which

the  applicable  provisions  of  the  social services law or regulations
relating to approvals and authorizations of, and utilization limitations
on, health and long term care services reimbursed pursuant to title  XIX
of the federal social security act are inconsistent with the flexibility
necessary   for   the  efficient  administration  of  DISCOs,  and  such
regulations shall provide that such provisions shall not  be  applicable
to enrollees of DISCOs, provided that such determinations are consistent
with applicable federal law and regulation.
(d)  The  commissioner  and  the commissioner of the office for people
with developmental disabilities shall ensure, through  periodic  reviews
of   DISCOs,  that  organization  services  are  promptly  available  to
enrollees  when  appropriate.  Such  periodic  reviews  shall  be   made
according   to   standards   as   determined  by  the  commissioners  in
regulations.
(e) The commissioner and the commissioner of  the  office  for  people
with developmental disabilities shall have the authority to conduct both
on  site  and  off site reviews of DISCOs. Such reviews may include, but
not be limited to, the  following  components:  governance;  fiscal  and
financial   reporting;   recordkeeping;  internal  controls;  marketing;
network  contracting  and  adequacy;   program   integrity   assurances;
utilization  control  and review systems; grievance and appeals systems;
quality assessment and assurance systems;  care  management;  enrollment
and disenrollment; management information systems, and other operational
and management components.
8.   Solvency.   (a)   The  commissioner,  in  consultation  with  the
commissioner of the office for people with  developmental  disabilities,
shall  be  responsible  for  evaluating,  approving  and  regulating all
matters relating to fiscal solvency,  including  reserves,  surplus  and
provider  contracts.  The  commissioner  shall promulgate regulations to
implement this section. The commissioner, in the administration of  this
subdivision:
(i)  shall  be guided by the standards that govern the fiscal solvency
of a  health  maintenance  organization,  provided,  however,  that  the
commissioner   shall   recognize   the   specific  delivery  components,
operational capacity and financial capability of the eligible  applicant
for a certificate of authority;
(ii)  shall  not  apply financial solvency standards that exceed those
required for a health maintenance organization; and
(iii) shall establish reasonable capitalization and contingent reserve
requirements.
(b) Standards  established  pursuant  to  this  subdivision  shall  be
adequate  to  protect  the  interests  of  enrollees  in  the DISCO. The
commissioner  shall  be  satisfied  that  the  eligible   applicant   is
financially  sound,  and has made adequate provisions to pay for quality
services that are cost  effective  and  appropriate  to  needs  and  the
protection of health, safety, welfare and satisfaction of those served.
9.   Role  of  the  superintendent  of  financial  services.  (a)  The
superintendent  of  financial  services  shall  determine  and   approve
premiums in accordance with the insurance law whenever any population of
enrollees  not  eligible  under title XIX of the federal social security
act  is  to  be  covered.  The  determination  and   approval   of   the
superintendent of financial services shall relate to premiums charged to
such  enrollees  not  eligible  under  title  XIX  of the federal social
security act.
(b) The  superintendent  of  financial  services  shall  evaluate  and
approve  any  enrollee contracts whenever such enrollee contracts are to
cover any population of enrollees not eligible under title  XIX  of  the
federal social security act.
10. Payment rates for DISCO enrollees eligible for medical assistance.
The  commissioner shall establish payment rates for services provided to
enrollees eligible under title XIX of the federal social  security  act.
Such  payment  rates shall be subject to approval by the director of the
division  of  the  budget.  Payment rates shall be actuarially sound for
covered services, including but not limited  to  habilitation  services,
and,  when  there  is  sufficient  reliable  data  to  permit,  shall be
risk-adjusted to take into account the characteristics of enrollees,  or
proposed enrollees, which may include: frailty, disability level, health
and  functional  status, age, gender, the nature of services provided to
such enrollees, and other factors as determined by the commissioner  and
the   commissioner   of   the   office  for  people  with  developmental
disabilities. The risk adjusted  premiums  may  also  be  combined  with
disincentives  or  requirements  designed  to mitigate any incentives to
obtain higher payment categories.
11. Continuation  of  certificate  of  authority.  Continuation  of  a
certificate  of  authority issued under this section shall be contingent
upon compliance by the DISCO with applicable provisions of this  section
and  rules and regulations promulgated thereunder; the continuing fiscal
solvency of the DISCO; and federal financial participation  in  payments
on  behalf of enrollees who are eligible to receive services under title
XIX of the federal social security act.
12. Protection of enrollees. The  commissioner  may,  in  his  or  her
discretion  and  with  the concurrence of the commissioner of the office
for people with developmental  disabilities,  for  the  purpose  of  the
protection  of  enrollees, impose measures including, but not limited to
bans on further enrollments until any identified problems  are  resolved
to  the  satisfaction  of the commissioner, or fines upon a finding that
the DISCO has failed to comply with the  provisions  of  any  applicable
statute, rule or regulation.
13.  Information sharing. The commissioner and the commissioner of the
office for people with developmental disabilities  shall,  as  necessary
and  consistent  with  federal  regulations  promulgated pursuant to the
Health Insurance Portability and Accountability  Act,  share  with  such
DISCO the following data if it is available:
(a)  information  concerning  utilization of services and providers by
each of its enrollees prior to and during enrollment.
(b) Aggregate data concerning utilization and costs for enrollees  and
for  comparable  cohorts  served  through  the  Medicaid fee-for-service
program.
14. Applicability of other  laws.  DISCOs  shall  be  subject  to  the
provisions  of  the  insurance  law and regulations applicable to health
maintenance organizations,  this  article  and  regulations  promulgated
thereunder.  To  the  extent  that  the  provisions  of this section are
inconsistent with the provisions of this chapter or  the  provisions  of
the insurance law, the provisions of this section shall prevail.
15.  Effectiveness.  The  provisions  of  this  section  shall only be
effective if, for so long as, and to the extent that  federal  financial
participation  is  available  for  the costs of services provided by the
DISCOs to enrollees who are recipients of medical assistance pursuant to
title  eleven  of  article  five  of  the  social  services   law.   The
commissioner  shall  make any necessary amendments to the state plan for
medical  assistance  submitted  pursuant  to   section   three   hundred
sixty-three-a  of  the  social  services  law, and/or submit one or more
applications for waivers of the federal social security act, in order to
ensure such federal financial participation.
* NB Repealed December 31, 2025