2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 365-M - Administration and Management of Behavioral Health Services.

§  365-m. Administration and management of behavioral health services.
1.  The commissioners of the office of mental health and the  office  of
alcoholism  and  substance  abuse  services,  in  consultation  with the
commissioner of health, the impacted local governmental units  and  with
the  approval  of  the division of the budget, shall have responsibility
for jointly designating regional entities to provide administrative  and
management services for the purposes of prior approving and coordinating
the provision of behavioral health services, facilitating the continuity
of   post-hospitalization  behavioral  health  and  the  integration  of
behavioral health services with  other  services  available  under  this
title,  for  recipients  of  medical  assistance who are not enrolled in
managed  care,  and  for  such  approval,   coordination,   facilitating
continuity  and  integration  of behavioral health services that are not
provided through managed care programs under this title for  individuals
regardless  of  whether  or not such individuals are enrolled in managed
care programs. Such regional entities  shall  also  be  responsible  for
promoting  appropriate  care  and service utilization while safeguarding
against unnecessary utilization of such care and services  and  assuring
that  payments are consistent with the efficient and economical delivery
of quality care.
2. In exercising this responsibility, the commissioners of the  office
of  mental  health  and  the  office  of  alcoholism and substance abuse
services  are  authorized  to  contract,  after  consultation  with  the
commissioner  of  health and the impacted local governmental units, with
regional  behavioral  health  organizations  or  other  entities.   Such
contracts   may   include   responsibility   for  receipt,  review,  and
determination of prior authorization requests for behavioral health care
and services under subdivision one  of  this  section,  consistent  with
criteria  established  or approved by the commissioners of mental health
and alcoholism  and  substance  abuse  services,  and  authorization  of
appropriate care and services based on documented patient medical need.
3.  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 commissioners of the office of  mental  health  and
the  office of alcoholism and substance abuse services are authorized to
enter into a contract or contracts under subdivisions  one  and  two  of
this  section without a competitive bid or request for proposal process,
provided, however, that:
(a) the office of mental health  and  the  office  of  alcoholism  and
substance  abuse  services shall post on their websites, for a period of
no less than thirty days:
(i) a description of the proposed services to be provided pursuant  to
the contractor contracts;
(ii) the criteria for selection of a contractor or contractors;
(iii)  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
(iv)  the  manner  by  which  a  prospective  contractor may seek such
selection, which may include submission by electronic means;
(b) all reasonable and responsive submissions that are  received  from
prospective  contractors  in  timely  fashion  shall  be reviewed by the
commissioners; and
(c) the commissioners of the office of mental health and the office of
alcoholism and  substance  abuse  services,  in  consultation  with  the
commissioner  of health and the impacted local governmental units, shall
select such contractor or contractors that, in  their  discretion,  have
demonstrated  the  ability to effectively, efficiently, and economically

integrate behavioral health and  health  services;  have  the  requisite
expertise   and   financial  resources;  have  demonstrated  that  their
directors, sponsors, members, managers, partners or operators  have  the
requisite  character,  competence and standing in the community, and are
best suited to serve the purposes of this  section.  In  selecting  such
contractor or contractors, the commissioners shall:
(i)  ensure  that  any such contractor or contractors have an adequate
network of providers to meet the behavioral health and health  needs  of
enrollees,  and  shall review the adequacy prior to approval of any such
contract or contracts, and upon contract renewal or  expansion.  To  the
extent  that the network has been determined to meet standards set forth
in subdivision five of section four thousand four hundred three  of  the
public health law, such network shall be deemed adequate.
(ii)  ensure  that  such contractor or contractors shall make level of
care and  coverage  determinations  utilizing  evidence-based  tools  or
guidelines   designated  to  address  the  behavioral  health  needs  of
enrollees.
(iii)  ensure  sufficient  access  to  behavioral  health  and  health
services   for   eligible   enrollees  by  establishing  and  monitoring
penetration rates of any such contractor or contractors.
(iv) establish standards to encourage the use  of  services,  products
and   care   recommended,   ordered  or  prescribed  by  a  provider  to
sufficiently address the behavioral health and health services needs  of
enrollees;  and monitor the application of such standards to ensure that
they sufficiently address the  behavioral  health  and  health  services
needs of enrollees.
4.  The  commissioners  of  the office of mental health, the office of
alcoholism and substance abuse services and the  department  of  health,
shall  have  the  responsibility  for  jointly designating on a regional
basis, after consultation with the local social  services  district  and
local  governmental  unit, as such term is defined in the mental hygiene
law, of a city with a population of over one million persons, and  after
consultation  of  other  affected  counties, a limited number of special
needs managed care plans under section  three  hundred  sixty-four-j  of
this  title capable of managing the behavioral and physical health needs
of medical  assistance  enrollees  with  significant  behavioral  health
needs.  Initial  designations of such plans should be made no later than
April first, two thousand fourteen, provided, however, such designations
shall be contingent upon a determination  by  such  state  commissioners
that  the  entities  to  be  designated  have the capacity and financial
ability to provide services in such plans, and that  the  region  has  a
sufficient  population  and  service  base  to  support such plans. Once
designated, the commissioner of health shall make arrangements to enroll
such enrollees in such plans and to pay such plans  on  a  capitated  or
other  basis  to manage, coordinate, and pay for behavioral and physical
health medical assistance services for such  enrollees.  Notwithstanding
any inconsistent provision of section one hundred twelve and one hundred
sixty-three  of the state finance law, and section one hundred forty-two
of the economic development law, or any other law to the  contrary,  the
designations  of such plans, and any resulting contracts with such plans
or  providers  are  authorized  to  be  entered  into  by   such   state
commissioners without a competitive bid or request for proposal process,
provided however that:
(a)  the  department  of  health,  the office of mental health and the
office of alcoholism and substance abuse services shall  post  on  their
websites, for a period of not less than thirty days:
(i) a description of the proposed services to be provided by the plans
or systems;
(ii) the criteria for selection of a plan or system;
(iii) the period of time during which a prospective plan or system may
seek  selection,  which  shall  be  no  less than thirty days after such
information is first posted on the website; and
(iv) the manner by which a prospective plan or system  may  seek  such
selection, which may include submission by electronic means;
(b)  all  reasonable and responsive submissions that are received from
prospective plans or systems in timely fashion shall be reviewed by  the
commissioners; and
(c) the commissioners of the office of mental health and the office of
alcoholism  and  substance  abuse  services,  in  consultation  with the
commissioner of health, shall select such  plans  or  systems  that,  in
their   discretion,   have  demonstrated  the  ability  to  effectively,
efficiently, and economically manage the behavioral and physical  health
needs of medical assistance enrollees with significant behavioral health
needs;  have  the  requisite  expertise  and  financial  resources; have
demonstrated that their directors, sponsors, members, managers, partners
or operators have the requisite character, competence  and  standing  in
the  community,  and  are  best  suited  to  serve  the purposes of this
section. Oversight of such  contracts  with  such  plans,  providers  or
provider  systems  shall  be  the  joint  responsibility  of  such state
commissioners, and for contracts affecting a city with a  population  of
over  one  million  persons,  also with the city's local social services
district and local governmental unit, as such term  is  defined  in  the
mental hygiene law.
In selecting such plans or systems, the commissioners shall:
(i)  ensure that any such plans or systems have an adequate network of
providers to meet the behavioral health and health needs  of  enrollees,
and  shall  review  the  adequacy prior to approval of any such plans or
systems, and upon contract renewal or expansion. To the extent that  the
network  has  been determined to meet standards set forth in subdivision
five of section four thousand four hundred three of  the  public  health
law, such network shall be deemed adequate.
(ii)  ensure  that  such plans or systems shall make level of care and
coverage determinations utilizing  evidence-based  tools  or  guidelines
designed to address the behavioral health needs of enrollees.
(iii)  ensure  sufficient  access  to  behavioral  health  and  health
services  for  eligible  enrollees  by   establishing   and   monitoring
penetration rates of any such plans or systems.
(iv)  establish  standards  to encourage the use of services, products
and  care  recommended,  ordered  or  prescribed  by   a   provider   to
sufficiently  address the behavioral health and health services needs of
enrollees; and monitor the application of such standards to ensure  that
they  sufficiently  address  the  behavioral  health and health services
needs of enrollees.
5. (a) Pursuant to appropriations within the offices of mental  health
or  addiction  services  and  supports,  the  department of health shall
reinvest savings realized through the transition of populations  covered
by this section from the applicable Medicaid fee-for-service system to a
managed  care  model, including savings realized through the recovery of
premiums from managed care providers  which  represent  a  reduction  of
spending  on  qualifying  behavioral health services against established
premium targets for behavioral health  services  and  the  medical  loss
ratio applicable to special needs managed care plans, for the purpose of
increasing  investment  in  community  based behavioral health services,
including residential services certified  by  the  office  of  addiction
services  and  supports. The methodologies used to calculate the savings
shall be developed by the commissioner of health and the director of the

budget in consultation with the commissioners of the  office  of  mental
health  and  the  office of addiction services and supports. In no event
shall the full  annual  value  of  the  reinvestment  pursuant  to  this
subdivision exceed the value of the premiums recovered from managed care
providers   which  represent  a  reduction  of  spending  on  qualifying
behavioral health services. Within any fiscal year  where  appropriation
increases  are  recommended  for  reinvestment,  insofar as managed care
transition savings do not occur as estimated,  then  spending  for  such
reinvestment   may   be   reduced  in  the  next  year's  annual  budget
itemization.
(b) Beginning April first, two  thousand  twenty-two,  the  department
shall  post  on  its  website information about the recovery of premiums
from managed care providers which represent a reduction of  spending  on
qualifying   behavioral  health  services  against  established  premium
targets for behavioral  health  services  and  the  medical  loss  ratio
applicable  to  special needs managed care plans. Such information shall
include at a minimum: (i) a copy of  the  department's  notification  to
each  managed  care provider that seeks a recovery of such premiums; and
(ii) a list of managed care providers by name that have been subject  to
a  recovery  of such premiums, specifying the amount of premium that has
been recovered from each managed care provider and year. In the  initial
posting,  the department shall include all premiums recovered to date as
required by this subdivision, by named managed care provider, amount and
year.
(c) The commissioner shall include  information  regarding  the  funds
available for reinvestment, including how savings are calculated and how
the  reinvestment  was  utilized  pursuant to this section in the annual
report  required  under  section  forty-five-c  of  part  A  of  chapter
fifty-six of the laws of two thousand thirteen.