2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 4403-F - Managed Long Term Care Plans.

* §  4403-f.  Managed long term care plans. 1. Definitions. As used in
this section:
(a) "Managed long term care plan" 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,  on  a capitated basis in
accordance with this section, for a population, age eighteen  and  over,
which the plan is authorized to enroll.
(b) "Eligible applicant" means an entity controlled or wholly owned by
one  or  more of the following: a hospital as defined in subdivision one
of section twenty-eight hundred one of this chapter; a home care  agency
licensed or certified pursuant to article thirty-six of this chapter; an
entity that has received a certificate of authority pursuant to sections
forty-four  hundred  three,  forty-four  hundred  three-a  or forty-four
hundred eight-a of  this  article  (as  added  by  chapter  six  hundred
thirty-nine  of  the  laws  of nineteen hundred ninety-six), or a health
maintenance organization authorized under  article  forty-three  of  the
insurance  law;  or a not-for-profit organization which has a history of
providing or coordinating  health  care  services  and  long  term  care
services to the elderly and disabled.
(c)  "Operating  demonstration"  means  the  following  entities:  the
chronic care management demonstration  programs  authorized  by  chapter
five  hundred  thirty  of  the  laws  of  nineteen hundred eighty-eight,
chapter five hundred  ninety-seven  of  the  laws  of  nineteen  hundred
ninety-four  and  chapter  eighty-one  of  the  laws of nineteen hundred
ninety-five as amended.
(d) "Health and long term care services" means services including, but
not limited to home and community-based and institution-based long  term
care  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. The managed long term  care  plan
may  also  cover primary care, acute care and behavioral health services
if so authorized.
2. Certificate of authority; form. An eligible applicant shall  submit
an  application for a certificate of authority to operate a managed long
term care plan upon forms prescribed by the commissioner. 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
plan with projections of enrollment that will result in a fiscally sound
plan;
(b) a description of the proposed target population and the  marketing
plan;
(c) adequate documentation of the appropriate licenses, certifications
or  approvals  to provide care as planned, including contracts with such
providers as may be necessary to provide the full complement of services
required to be provided under this section.
3. Certificate of authority;  approval.  The  commissioner  shall  not
approve  an  application  for  a  certificate  of  authority  unless the
applicant demonstrates to the commissioner's satisfaction:
(a)  that  it  will  have  in   place   acceptable   quality-assurance
mechanisms,  grievance  procedures,  mechanisms to protect the rights of
enrollees and case management services to  ensure  continuity,  quality,
appropriateness and coordination of care;
(b) that it will include an enrollment process which shall ensure that
enrollment  in  the plan is informed. The application shall describe the
disenrollment process, which shall provide that  an  otherwise  eligible
enrollee  shall  not be involuntarily disenrolled on the basis of health
status;
(c) satisfactory evidence of  the  character  and  competence  of  the
proposed  operators  and  reasonable  assurance  that the applicant will
provide high quality services to an enrolled population;
(d) sufficient management systems capacity to meet the requirements of
this  section and the ability to efficiently process payment for covered
services;
(e)  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;
(f)  readiness  and  capability to arrange and manage covered services
and  coordinate  non-covered  services  which  could  include   primary,
specialty,  and  acute care services reimbursed pursuant to title XIX of
the federal social security act;
(g) willingness and capability of taking, or cooperating in, all steps
necessary to secure and integrate any potential sources of  funding  for
services provided by the managed long term care plan, including, but not
limited to, funding available under titles XVI, XVIII, XIX and XX of the
federal social security act, the federal older Americans act of nineteen
hundred  sixty-five,  as amended, or any successor provisions subject to
approval of the director of the state  office  for  aging,  and  through
financing  options  such  as  those authorized pursuant to section three
hundred sixty-seven-f of the social services law;
(h) 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;
with respect to  individuals  in  receipt  of  such  services  prior  to
enrollment,  such  guidelines  shall  require the managed long term care
plan to contract with agencies currently  providing  such  services,  in
order  to promote continuity of care. In addition, such guidelines shall
require managed long  term  care  plans  to  offer  and  cover  consumer
directed personal assistance services for eligible individuals who elect
such  services  pursuant  to  section  three hundred sixty-five-f of the
social services law; and
(i) that the applicant is financially responsible and may be  expected
to meet its obligations to its enrolled members.
4. Solvency. (a) The commissioner shall be responsible for evaluating,
approving  and  regulating  all  matters  relating  to  fiscal solvency,
including reserves, surplus and provider contracts. The commissioner may
promulgate regulations to implement this section. The  commissioner,  in
the administration of this subdivision:
(i)  shall be guided by the standards which 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 managed long term care
plans.   The commissioner shall be satisfied that the eligible applicant

is financially sound, and  has  made  adequate  provisions  to  pay  for
services.
4-a.  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.
5. Applicability of other laws. A managed long term care plan shall be
subject   to  the  provisions  of  the  insurance  law  and  regulations
applicable  to  health  maintenance  organizations,  this  article   and
regulations  promulgated  pursuant  thereto.  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.
6. Approval authority.  (a) An applicant shall be issued a certificate
of authority as a managed long term care plan upon  a  determination  by
the   commissioner  that  the  applicant  complies  with  the  operating
requirements for a managed long term care plan under this  section.  The
commissioner  shall  issue  no  more  than  seventy-five certificates of
authority to managed long term care plans pursuant to this section.
(a-1) Nothing in this section shall  be  construed  as  requiring  the
department  to  contract  with  or  to contract for a particular line of
business with an entity certified under this section for  the  provision
of  services  available under title eleven of article five of the social
services law. A managed long term care  plan  that  has  been  issued  a
certificate of authority, or an applicant for a certificate of authority
as  a  managed long term care plan that has in any of the three calendar
years immediately preceding the application, met any  of  the  following
criteria  shall  not  be  eligible  for  a contract for the provision of
services available under title eleven of  article  five  of  the  social
services  law:  (i)  classified  as  a  poor performer, or substantially
similar terminology, by the centers for medicare and medicaid  services;
or  (ii)  an  excessive  volume  of  penalties,  statements of findings,
statements of deficiency, intermediate sanctions or enforcement actions,
regardless of whether the applicant  has  addressed  such  issues  in  a
timely manner.
(b)  An  operating  demonstration  shall  be  issued  a certificate of
authority as a managed long term care plan upon a determination  by  the
commissioner   that  such  demonstration  complies  with  the  operating
requirements for a managed long  term  care  plan  under  this  section.
Nothing in this section shall be construed to affect the continued legal
authority  of  an  operating  demonstration  to  operate  its previously
approved program.
(c) For the period beginning April  first,  two  thousand  twelve  and
ending  March thirty-first, two thousand fifteen, the majority leader of
the senate and the speaker of the assembly may  each  recommend  to  the
commissioner,  in  writing, up to four eligible applicants to convert to
be approved managed long term care plans. An  applicant  shall  only  be
approved  and  issued  a  certificate  of  authority if the commissioner
determines that the applicant  meets  the  requirements  of  subdivision
three  of this section. The majority leader of the senate or the speaker

of the assembly may assign their authority  to  recommend  one  or  more
applicants under this section to the commissioner.
(d) (i) Effective April first, two thousand twenty, and expiring March
thirty-first,  two thousand twenty-seven, the commissioner shall place a
moratorium on the processing and  approval  of  applications  seeking  a
certificate  of  authority  as a managed long term care plan pursuant to
this section, including applications seeking authorization to expand  an
existing managed long term care plan's approved service area or scope of
eligible enrollee populations. Such moratorium shall not apply to:
(A)  applications  submitted to the department prior to January first,
two thousand twenty;
(B) applications seeking approval to transfer ownership or control  of
an existing managed long term care plan;
(C) applications demonstrating to the commissioner's satisfaction that
submission  of the application for consideration would be appropriate to
address a serious concern with care delivery, such as a lack of adequate
access to managed long term care plans in a geographic area or a lack of
adequate and appropriate care,  language  and  cultural  competence,  or
special needs services; and
(D)  applications  seeking  to  operate  under  the  PACE  (Program of
All-Inclusive Care for the  Elderly)  model  as  authorized  by  federal
public  law 105-33, subtitle I of title IV of the Balanced Budget Act of
1997, or to serve individuals dually eligible for services and  benefits
under  titles  XVIII  and  XIX  of  the  federal  social security act in
conjunction with an affiliated  Medicare  Dual  Eligible  Special  Needs
Plan,  based on the need for such plans and the experience of applicants
in serving dually eligible individuals as determined by the commissioner
in their discretion.
(ii) For the duration of the moratorium, the commissioner shall assess
the public need for managed long term care plans that are not integrated
with an affiliated Medicare plan, the ability of such plans  to  provide
high  quality and cost effective care for their membership, and based on
such assessment develop a process and conduct an orderly  wind-down  and
elimination  of  such plans, which shall coincide with the expiration of
the  moratorium  unless  the  commissioner  determines  that  a   longer
wind-down period is needed.
(e)  For  the  duration  of the moratorium under paragraph (d) of this
subdivision, the commissioner shall establish, and enforce by means of a
premium withholding equal to three percent of the base rate,  an  annual
cap on total enrollment (enrollment cap) for each managed long term care
plan,  subject  to subparagraphs (ii) and (iii) of this paragraph, based
on a percentage of each plan's reported enrollment as of October  first,
two thousand twenty.
(i)  The  specific  percentage  of each plan's enrollment cap shall be
established by the commissioner based on: (A) the ability of individuals
eligible for such plans to access health and long  term  care  services,
(B)  plan quality of care scores, (C) historical plan disenrollment, (D)
the projected growth of individuals eligible for such plans in different
regions of the state, (E) historical plan enrollment  of  patients  with
varying  levels  of  need  and  acuity,  and  (F)  other  factors in the
commissioner's   discretion   to   ensure   compliance   with    federal
requirements,  appropriate  access  to  plan  services,  and  choice  by
eligible individuals.
(ii) In the event that a plan exceeds its annual enrollment  cap,  the
commissioner  is  authorized  under  this  paragraph  to retain all or a
portion of the premium withheld based on the amount over  which  a  plan
exceeds   its  enrollment  cap.  Penalties  assessed  pursuant  to  this
subdivision shall be determined by regulation.
(iii) The commissioner may  not  establish  an  annual  cap  on  total
enrollment  under  this paragraph for plans' lines of business operating
under the PACE (Program of All-Inclusive Care for the Elderly) model  as
authorized  by  federal public law 105-33, subtitle I of title IV of the
Balanced  Budget  Act of 1997, or that serve individuals dually eligible
for services and benefits under titles XVIII  and  XIX  of  the  federal
social  security  act  in  conjunction  with an affiliated Medicare Dual
Eligible Special Needs Plan.
(f) In implementing the provisions of paragraphs (d) and (e)  of  this
subdivision, the commissioner shall, to the extent practicable, consider
and  select  methodologies  that seek to maximize continuity of care and
minimize disruption to the provider labor workforce, and shall,  to  the
extent  practicable  and  consistent  with  the ratios set forth herein,
continue to support contracts between managed long term care  plans  and
licensed  home  care services agencies that are based on a commitment to
quality and value.
6-a. Performance standards.  (a)  On  or  before  January  first,  two
thousand  twenty-four,  each  managed  long term care plan that has been
issued a certificate of authority pursuant to this section shall have an
active Medicare Dual Eligible Special  Needs  Plan  in  operation  whose
H-contract either has a current quality star rating from the Centers for
Medicare and Medicaid Services of three stars or higher, or has not been
issued  a quality star rating from the Centers for Medicare and Medicaid
Services.    In  addition,  the  managed  long  term  care  plan   shall
sufficiently   demonstrate   success   in   the   following  performance
categories:
(i) in addition to  meeting  the  requirements  of  paragraph  (j)  of
subdivision seven of this section, in order to ensure network adequacy a
commitment  to contracting with an adequate number of licensed home care
service agencies needed to provide necessary personal care  services  to
the  greatest  practicable  number  of  enrollees,  and with an adequate
number of fiscal intermediaries needed  to  provide  necessary  consumer
directed personal assistance services to the greatest practicable number
of  enrollees  in  accordance with section three hundred sixty-five-f of
the social services law;
(ii) readiness to timely implement and adhere  to  maximum  wait  time
criteria  for  key  categories of service in accordance with laws, rules
and regulations of the  department  or  the  Centers  for  Medicare  and
Medicaid Services;
(iii) commitment to quality improvement;
(iv)  accessibility  and geographic distribution of network providers,
taking into account the needs  of  persons  with  disabilities  and  the
differences between rural, suburban, and urban settings;
(v)  demonstrated  cultural  and language competencies specific to the
population of participants;
(vi) ability to serve enrollees  across  the  continuum  of  care,  as
demonstrated  by  the  type and number of products the managed long term
care operates or has applied to operate, including integrated  care  for
participants  who  are  dually  eligible  for Medicaid and Medicare, and
those operated under title one-A of article twenty-five of this  chapter
and section three hundred sixty-nine-gg of the social services law; and
(vii) value based care readiness and experience.
(b)  The  commissioner  shall  require any managed long term care plan
with a Medicare Dual Eligible Special Needs Plan in  operation  that  at
any time has a current quality star rating from the Centers for Medicare
and  Medicaid  Services  of  less  than  three  stars  to  establish and
implement a performance improvement plan acceptable to the commissioner,

and which shall  be  consistent  with  the  standards  of  the  Medicare
Advantage Quality Rating System.
(c)   The   commissioner   shall  have  the  authority  to  promulgate
regulations to effectuate the provisions of this subdivision.
(d) The provisions of this subdivision shall  not  apply  for  managed
long term care plans operating under a certificate of authority pursuant
to  subdivision  twelve,  as  added  by section seventy-six of part A of
chapter fifty-six of the laws of two thousand thirteen,  or  subdivision
thirteen  of  this  section, or to the program of all-inclusive care for
the elderly under article twenty-nine-EE of this chapter.
7. Program oversight and administration. (a)(i) The commissioner shall
promulgate regulations to implement  this  section  and  to  ensure  the
quality, appropriateness and cost-effectiveness of the services provided
by  managed  long  term care plans. The commissioner may waive rules and
regulations of the department,  including  but  not  limited  to,  those
pertaining to duplicative requirements concerning record keeping, boards
of  directors, staffing and reporting, when such waiver will promote the
efficient delivery of appropriate, quality, cost-effective services  and
when  the  health,  safety  and general welfare of enrollees will not be
impaired as a result of such waiver. In order to  achieve  managed  long
term  care  plan system efficiencies and coordination and to promote the
objectives of high quality, integrated  and  cost  effective  care,  the
commissioner  may  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
commissioner  shall  require  managed  long  term  care plans to utilize
quality  improvement  measures,  based  on  health  outcomes  data,  for
internal  quality  assessment processes and may utilize such measures as
part of the single coordinated surveillance process.
(ii) Notwithstanding any inconsistent provision of the social services
law to the contrary, the commissioner  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,   including,  but  not  limited  to,  fiscal  assessment
requirements, are inconsistent with the flexibility  necessary  for  the
efficient  administration  of  managed  long  term  care  plans and such
regulations shall provide that such provisions shall not  be  applicable
to  enrollees  or  managed  long  term  care  plans,  provided that such
determinations  are  consistent  with   applicable   federal   law   and
regulation,  and  subject  to  the  provisions  of  subdivision eight of
section three hundred sixty-five-a of the social services law.
* (b) (i) The commissioner shall, to the extent necessary, submit  the
appropriate  waivers,  including,  but  not limited to, those authorized
pursuant to sections eleven hundred fifteen and nineteen hundred fifteen
of the federal social security act, or  successor  provisions,  and  any
other  waivers  necessary  to  achieve  the  purposes  of  high quality,
integrated, and cost effective care and integrated financial eligibility
policies under the medical assistance program or pursuant to title XVIII
of the federal social security act. In  addition,  the  commissioner  is
authorized  to submit the appropriate waivers, including but not limited
to those authorized pursuant to  sections  eleven  hundred  fifteen  and
nineteen hundred fifteen of the federal social security act or successor
provisions, and any other waivers necessary to require on or after April
first,  two  thousand  twelve,  medical  assistance  recipients  who are
twenty-one years of age or older and who  require  community-based  long
term  care  services, as specified by the commissioner, for a continuous

period of more than  one  hundred  and  twenty  days,  to  receive  such
services through an available plan certified pursuant to this section or
other  program model that meets guidelines specified by the commissioner
that  support  coordination and integration of services. Such guidelines
shall address the requirements of paragraphs (a), (b),  (c),  (d),  (e),
(f),  (g),  (h), and (i) of subdivision three of this section as well as
payment methods that ensure provider accountability for  cost  effective
quality  outcomes.  Such other program models may include long term home
health care programs that comply with such guidelines.  Copies  of  such
original waiver applications and amendments thereto shall be provided to
the  chairs of the senate finance committee, the assembly ways and means
committee and the senate and assembly health  committees  simultaneously
with their submission to the federal government.
(ii)  The  commissioner, shall seek input from representatives of home
and community-based long term care services providers,  recipients,  and
the  Medicaid  managed  care  advisory  review  panel,  among others, to
further evaluate and promote the transition of  persons  in  receipt  of
home  and community-based long term care services into managed long term
care plans and other care coordination models and to develop  guidelines
for such care coordination models. The guidelines shall be finalized and
posted  on  the department's website no later than November fifteen, two
thousand eleven.
(iii) Notwithstanding and in addition to any provision of subparagraph
(i) of this paragraph and subject to any federal  requirements,  persons
dually  eligible  for  medical assistance and benefits under the federal
Medicare program who are enrolled in a Medicare  Dual  Eligible  Special
Needs  Plan  and  who  do  not  require  community-based  long term care
services, as specified by the commissioner, for a continuous  period  of
more  than  one hundred and twenty days shall be required to enroll with
an available affiliated plan certified pursuant  to  this  section  when
program   features   and   reimbursement   rates  are  approved  by  the
commissioner.
(v) The following medical assistance recipients shall not be  eligible
to  participate  in  a  managed  long  term  care  program or other care
coordination model established pursuant to this paragraph until  program
features  and  reimbursement rates are approved by the commissioner and,
as applicable, the commissioner of developmental disabilities:
(1) a person enrolled in a managed care plan pursuant to section three
hundred sixty-four-j of the social services law;
(2) a participant in the traumatic brain injury waiver  program  or  a
person  whose  circumstances would qualify him or her for the program as
it existed on January first, two thousand fifteen;
(3) a participant in the nursing home transition and diversion  waiver
program or a person whose circumstances would qualify him or her for the
program as it existed on January first, two thousand fifteen;
(4) a person enrolled in the assisted living program;
(5)  a  person  enrolled  in  home and community based waiver programs
administered by the office for people with developmental disabilities;
(6) a person who is expected to be eligible for medical assistance for
less than six months, for  a  reason  other  than  that  the  person  is
eligible  for  medical assistance only through the application of excess
income toward the cost of medical care and services;
(7) a person who is eligible for medical assistance benefits only with
respect to tuberculosis-related services;
(8) a  person  receiving  hospice  services  at  time  of  enrollment;
provided, however, that this clause shall not be construed to require an
individual  enrolled  in  a  managed long term care plan or another care

coordination model, who subsequently elects hospice, to  disenroll  from
such program;
(9) a person who has primary medical or health care coverage available
from or under a third-party payor which may be maintained by payment, or
part  payment,  of  the premium or cost sharing amounts, when payment of
such premium  or  cost  sharing  amounts  would  be  cost-effective,  as
determined by the social services district;
(10)   a   person  receiving  family  planning  services  pursuant  to
subparagraph six of paragraph (b) of subdivision one  of  section  three
hundred sixty-six of the social services law;
(11)  a  person  who  is  eligible  for medical assistance pursuant to
paragraph (b) of subdivision four of section three hundred sixty-six  of
the social services law;
(12) Native Americans;
(13)  a  person  who  is  permanently  placed  in a nursing home for a
consecutive period  of  three  months  or  more.  In  implementing  this
provision, the department shall continue to support service delivery and
outcomes that result in community living for enrollees; and
(14)  a  person  who has not been assessed as needing at least limited
assistance with physical maneuvering with more than  two  activities  of
daily  living,  or  for  individuals  with  a  dementia  or  Alzheimer's
diagnosis, assessed as needing at least supervision with more  than  one
activity  of  daily living, as defined and determined using an evidenced
based validated assessment instrument approved by the  commissioner  and
in  accordance  with applicable state and federal law and regulations of
the department, provided that the provisions of this  clause  shall  not
apply  to  a person who has been continuously enrolled in a managed long
term care program beginning prior to October first, two thousand twenty.
(v-a)  For  purposes  of  clause  two  of  subparagraph  (v)  of  this
paragraph,  program  features shall be substantially comparable to those
services available to traumatic brain injury waiver participants  as  of
January  first,  two  thousand  fifteen,  subject  to  federal financial
participation.
(v-b) For purposes  of  clause  three  of  subparagraph  (v)  of  this
paragraph,  program  features shall be substantially comparable to those
services  offered  to  nursing  home  transition  and  diversion  waiver
participants  as  of  January  first,  two  thousand fifteen, subject to
federal financial participation.
(v-c) Any managed care program providing services under clause two  or
three  of  subparagraph  (v)  of  this  paragraph shall have an adequate
network of trained providers to meet the needs of enrollees and  provide
services under this subdivision.
(v-d)  Any  individual  providing  service  coordination  pursuant  to
subparagraph (v-a) or (v-b) of this paragraph shall exercise his or  her
professional  duties  in  the  interests of the patient. Nothing in this
subparagraph  shall  be  construed  as  diminishing  the  authority  and
obligations  of  a  managed  long  term care plan under this article and
article forty-nine of this chapter.
(vi) persons required to enroll in the managed long term care  program
or  other care coordination model established pursuant to this paragraph
shall have no less than thirty days to select a managed long  term  care
provider,  and  shall  be  provided with information to make an informed
choice. Where a participant  has  not  selected  such  a  provider,  the
commissioner  shall  assign such participant to a managed long term care
provider, taking into account consistency with any prior community-based
direct care  workers  having  recently  served  the  recipient,  quality
performance  criteria, capacity and geographic accessibility. During the
period prior to  receiving  services  from  a  managed  long  term  care

provider  assigned  under  this  subparagraph,  the  person  may receive
services under fee for service Medicaid.
(vii)  If  another long term care plan certified under this section is
available, medical assistance recipients  required  to  enroll  in  such
plans  pursuant  to  this  section,  including  recipients who have been
assigned to a provider by the commissioner,  may  change  plans  without
cause  within  ninety  days  of either notification of enrollment or the
effective date of  enrollment  into  a  plan,  whichever  is  later,  by
submitting  a  request  to  the entity designated by the department in a
format to be determined by the department. In  accordance  with  federal
statutes  and  regulations, after such ninety-day period, the department
may prohibit a recipient from changing plans more frequently  than  once
every  twelve months, except for good cause. Good cause may include poor
quality of care, lack of access to covered services, lack of  access  to
providers  experienced  in dealing with the enrollee's care needs, or as
otherwise determined by the commissioner.
(viii) Managed long term care provided and plans  certified  or  other
care  coordination  model  established  pursuant to this paragraph shall
comply with the provisions of paragraphs (d),  (i),  (t),  and  (u)  and
subparagraph  (iii)  of paragraph (a) and subparagraph (iv) of paragraph
(e) of subdivision four of section three  hundred  sixty-four-j  of  the
social services law.
(ix)   (1)   The   commissioner   shall   report   biannually  on  the
implementation of this subdivision. The reports shall include,  but  not
be limited to:
(A)  satisfaction of enrollees with care coordination/case management;
timeliness of care;
(B) service utilization data including changes in  the  level,  hours,
frequency, and types of services and providers;
(C) enrollment data, including auto-assignment rates by plan;
(D) quality data; and
(E)  continuity  of care for participants as they move to managed long
term care, with respect to community based and nursing home populations,
including pediatric nursing  home  populations,  and  medically  fragile
children  being  served  by home care agencies affiliated with pediatric
nursing homes and diagnostic and  treatment  centers  primarily  serving
medically fragile children.
(2)  The  commissioner  shall  publish  the report on the department's
website and provide notice to the temporary president of the senate, the
speaker of the assembly, the chair of the senate standing  committee  on
health,  the  chair  of  the  assembly health committee and the Medicaid
Managed Care Advisory Review Panel upon availability of the report.  The
initial  report  shall  be  provided  by  September  first, two thousand
twelve. The reports shall be made available by each February first,  and
September  first  thereafter.  Such  reports shall be formatted to allow
comparisons between plans.
* NB Effective until April 1, 2027
* (b) The commissioner shall, to  the  extent  necessary,  submit  the
appropriate  waivers,  including,  but  not limited to, those authorized
pursuant to sections eleven hundred fifteen and nineteen hundred fifteen
of the federal social security act, or  successor  provisions,  and  any
other  waivers  necessary  to  achieve  the  purposes  of  high quality,
integrated, and cost effective care and integrated financial eligibility
policies under the medical assistance program or pursuant to title XVIII
of the federal social security  act.  Copies  of  such  original  waiver
applications  shall  be  provided  to the chairman of the senate finance
committee and the chairman of the  assembly  ways  and  means  committee
simultaneously with their submission to the federal government.
* NB Effective April 1, 2027
(c)(i)  A  managed  long  term  care  plan  shall not use deceptive or
coercive marketing  methods  to  encourage  participants  to  enroll.  A
managed  long term care plan shall not distribute marketing materials to
potential enrollees before such materials  have  been  approved  by  the
commissioner.
(ii)  The  commissioner  shall  ensure,  through  periodic  reviews of
managed long term care plans, that enrollment was  an  informed  choice;
such plan has only enrolled persons whom it is authorized to enroll, and
plan services are promptly available to enrollees when appropriate. Such
periodic  reviews  shall be made according to standards as determined by
the commissioner in regulations.
(d) Notwithstanding any provision of law, rule or  regulation  to  the
contrary,  the  commissioner  may issue a request for proposals to carry
out reviews of enrollment and assessment activities in managed long term
care plans  and  operating  demonstrations  with  respect  to  enrollees
eligible  to  receive  services  under  title  XIX of the federal social
security act to  determine  if  enrollment  meets  the  requirements  of
subparagraph  (ii)  of  paragraph  (c)  of  this  subdivision;  and that
assessments of such enrollees' health, functional and other status,  for
the purpose of adjusting premiums, were accurate.
(e)  The commissioner may, in his or her discretion for the purpose of
protection of enrollees, impose measures including, but not limited  to,
bans  on  further  enrollments  and  requirements  for use of enrollment
brokers until any identified problems are resolved to  the  satisfaction
of the commissioner.
(f)  Continuation  of  a  certificate  of  authority issued under this
section shall be contingent upon satisfactory performance by the managed
long term care plan in the  delivery,  continuity,  accessibility,  cost
effectiveness   and   quality  of  the  services  to  enrolled  members;
compliance with applicable provisions of  this  section  and  rules  and
regulations  promulgated  thereunder;  the continuing fiscal solvency of
the organization; 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.
(g)  * (i)  Managed long term care plans and demonstrations may enroll
eligible persons in the plan or demonstration upon the completion  of  a
comprehensive  assessment  that shall include, but not be limited to, an
evaluation of the medical, social, cognitive, and environmental needs of
each prospective enrollee in such program. This  assessment  shall  also
serve  as  the basis for the development and provision of an appropriate
plan of care for the  enrollee,  including  appropriate  community-based
referrals. Upon approval of federal waivers pursuant to paragraph (b) of
this subdivision which require medical assistance recipients who require
community-based  long  term  care services to enroll in a plan, and upon
approval of the commissioner, a plan may  enroll  an  applicant  who  is
currently  receiving  home and community-based services and complete the
comprehensive assessment within thirty days of enrollment provided  that
the  plan  continues  to  cover transitional care until such time as the
assessment is completed.
* NB Effective until April 1, 2027
* (i) Managed long term  care  plans  and  demonstrations  may  enroll
eligible  persons  in the plan or demonstration upon the completion of a
comprehensive assessment that shall include, but not be limited  to,  an
evaluation  of  the  medical,  social  and  environmental  needs of each
prospective enrollee in such program. This assessment shall  also  serve
as the basis for the development and provision of an appropriate plan of

care for the prospective enrollee, including appropriate community-based
referrals.
* NB Effective April 1, 2027
(ii)  The  assessment  shall  be  completed by a representative of the
managed long term care plan or demonstration, in consultation  with  the
prospective  enrollee's  health  care  practitioner  as  necessary.  The
commissioner shall prescribe the forms on which the assessment shall  be
made.
(iii)  The  enrollment  application  shall be submitted by the managed
long term care plan or demonstration to the  entity  designated  by  the
department  prior to the commencement of services under the managed long
term care plan or demonstration. Enrollments  conducted  by  a  plan  or
demonstration  shall be subject to review and audit by the department or
a contractor selected pursuant to paragraph (d) of this subdivision.
(iv) Continued  enrollment  in  a  managed  long  term  care  plan  or
demonstration  paid  for  by  government  funds  shall  be  based upon a
comprehensive assessment of the medical, social and environmental  needs
of  the recipient of the services. Such assessment shall be performed at
least annually by the managed long term care plan serving the  enrollee.
The  commissioner shall prescribe the forms on which the assessment will
be made.
(h) * The commissioner and, in the case of a  plan  arranging  for  or
providing  services  operated, certified, funded, authorized or approved
by  the  office  for  people  with   developmental   disabilities,   the
commissioner  of  the office for people with developmental disabilities,
shall, upon request by a  managed  long  term  care  plan  or  operating
demonstration,  and  consistent  with  federal  regulations  promulgated
pursuant to the Health Insurance  Portability  and  Accountability  Act,
share  with  such  plan  or  demonstration  the  following data if it is
available:
* NB Effective until December 31, 2025
* The commissioner shall, upon request by a  managed  long  term  care
plan or operating demonstration, and consistent with federal regulations
promulgated   pursuant   to   the   Health   Insurance  Portability  and
Accountability Act, share with such plan or demonstration the  following
data if it is available:
* NB Effective December 31, 2025
(i)  information  concerning  utilization of services and providers by
each of its enrollees prior to and during enrollment, including but  not
limited  to  utilization  of emergency department services, prescription
drugs, and hospital and nursing facility admissions.
(ii) aggregate data concerning utilization and costs for enrollees and
for comparable  cohorts  served  through  the  Medicaid  fee-for-service
program.
(j)  Limitations  on  licensed home care service agency contracts. (i)
The commissioner may establish methodologies  to  limit  the  number  of
licensed  home  care  services  agencies  licensed  pursuant  to article
thirty-six of the public health law with which managed  long  term  care
plans  may  enter  into  contracts,  provided  that such limitations are
consistent with the specifications set forth in this paragraph.
(ii) Managed long term care plans operating in the city  of  New  York
and/or  the  counties of Nassau, Suffolk, and Westchester may enter into
contracts with licensed home care services agencies in such region in  a
maximum number calculated based upon the following methodology:
(A)  As  of  October  first,  two  thousand eighteen, one contract per
seventy-five members enrolled in the plan within such region; and
(B) As of October first, two thousand nineteen, one contract  per  one
hundred members enrolled in the plan within such region.
(iii)  Managed  long  term care plans operating in counties other than
those in the city of New York and the counties of Nassau,  Suffolk,  and
Westchester  may  enter  into contracts with licensed home care services
agencies in such region in a maximum number calculated  based  upon  the
following methodology:
(A)  As  of  October  first,  two  thousand eighteen, one contract per
forty-five members enrolled in the plan within such region.
(B) As of October first, two thousand nineteen, one contract per sixty
members enrolled in the plan within such region.
(iv) Notwithstanding subparagraphs (ii) and (iii) of this paragraph, a
managed long term care plan shall not enter into less than the number of
contracts with licensed home care services agencies in  each  county  in
which  the  plan  operates  as  is  necessary  to remain consistent with
network  adequacy  standards,  as  determined  by  the   department   in
accordance with federal regulations.
(v) When calculating the number of additional contracts that a managed
long  term  care  plan  may  enter  using  the methodologies established
pursuant to this paragraph, any fractional result shall be rounded down.
(vi) The commissioner may increase the number of  licensed  home  care
services agencies with which a managed long term care plan may contract,
on  a  county  by county basis, if the commissioner determines that such
increase is necessary to: ensure adequate  access  to  services  in  the
geographic  area  including,  but not limited to, special needs services
and services that are culturally and linguistically appropriate;  or  to
avoid disruption in services in the geographic area.
(vii)  Any licensed home care services agency that ceases operation as
a  result  of  this  paragraph  shall  conform   with   all   applicable
requirements,   including  but  not  limited  to  demonstrating  to  the
department's satisfaction continuity of care for  individuals  receiving
services from the agency.
(viii)  The  commissioner  may require managed long term care plans to
provide evidence of compliance with this paragraph, on an annual basis.
(ix)  In  implementing  the  provisions   of   this   paragraph,   the
commissioner  shall,  to  the  extent  practicable,  consider and select
methodologies that seek to maximize  continuity  of  care  and  minimize
disruption  to  the  provider  labor workforce, and shall, to the extent
practicable and consistent with the ratios set forth herein, continue to
support contracts between managed long term care plans and licensed home
care services agencies that are based on a  commitment  to  quality  and
value.
(x)  This  subparagraph  applies where implementation of the limits on
contracts with licensed home care service agencies of this paragraph (i)
would otherwise require an enrollee's care to be  transferred  from  the
enrollee's current licensed home care service agency to another licensed
care service agency, and (ii) the enrollee (or the enrollee's authorized
representative) wants the enrollee to continue to be cared for by one or
more  employees  of  the  current licensed home care service agency, and
that continuation would otherwise be  provided.  In  such  a  case:  the
enrollee's  managed long term care plan may contract with the enrollee's
current licensed home care service agency for the purpose of  continuing
the  enrollee's  care  by  such  employee or employees, and the contract
shall not count towards the limits on contracts under this paragraph for
a period of three months.
(k) Increased rates, terms or scope of payment for  behavioral  health
services  under  this  section, where payment is made by an entity under
this section, as a result of a  rate,  coverage  or  other  change  made
pursuant  to  a  law,  regulation,  rule  or official guidance, shall be
deemed in effect on the same date that  such  change  would  have  taken

effect  if  payment were made other than by the entity. Where payment is
not made as of the effective date, the  entity  shall  make  retroactive
payments to the appropriate service providers.
8.  Payment  rates  for managed long term care plan 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 and shall reflect
savings to both state and local governments when compared to costs which
would  be  incurred  by  such  program  if  enrollees  were  to  receive
comparable health and long term care services on a fee-for-service basis
in the geographic region in which  such  services  are  proposed  to  be
provided.  Payment rates shall be risk-adjusted to take into account the
characteristics of enrollees, or proposed enrollees, including, but  not
limited  to:    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. The risk adjusted
premiums  may  also  be  combined  with  disincentives  or  requirements
designed to mitigate any incentives to obtain higher payment categories.
In  setting  such  payment  rates, the commissioner shall consider costs
borne by the managed  care  program  to  ensure  actuarially  sound  and
adequate  rates  of  payment to ensure quality of care shall comply with
all applicable  laws  and  regulations,  state  and  federal,  including
regulations as to actuarial soundness for medicaid managed care.
8-a.   Rates   for   certain   residential   health  care  facilities.
Notwithstanding  any  other  provision  of  law  or  regulation  to  the
contrary,  any  residential health care facility established pursuant to
article twenty-eight  of  this  chapter  located  in  a  county  with  a
population  of more than seventy-two thousand and less than seventy-five
thousand persons based on the two thousand ten federal census  shall  be
reimbursed by any managed long term care plan, approved pursuant to this
section  and  contracting with the department, at a rate of no less than
one hundred four  percent  of  the  average  rate  of  reimbursement  in
existence on March first, two thousand eighteen for such county.
9.  Reports.  The  department  shall  provide an interim report to the
governor, temporary president of the  senate  and  the  speaker  of  the
assembly on or before April first, two thousand three and a final report
on or before April first, two thousand six on the results of the managed
long  term care plans under this section. Such results shall be based on
data provided by the managed long term care plans and shall include  but
not  be  limited  to  the  quality, accessibility and appropriateness of
services; consumer satisfaction; the mean and distribution of impairment
measures of the enrollees by payor for each plan; the current method  of
calculating  premiums  and  the  cost of comparable health and long term
care services provided on a fee-for-service basis for enrollees eligible
for services under title XIX of the federal social security act; and the
results of periodic reviews of enrollment  levels  and  practices.  Such
reports   shall   provide   data   on   the   demographic  and  clinical
characteristics of enrollees, voluntary and  involuntary  disenrollments
from   plans,   and  utilization  of  services  and  shall  examine  the
feasibility of increasing the number of plans that may be approved. Data
collected pursuant to this section shall be available to the  public  in
an  aggregated  format  to  protect  individual confidentiality, however
under no circumstance will data be released on  items  with  cells  with
smaller than statistically acceptable standards.
10.  Notwithstanding  any  inconsistent provision to the contrary, the
enrollment and disenrollment process and services provided  or  arranged
by all operating demonstrations or any program that receives designation

as  a Program of All-Inclusive Care for the Elderly (PACE) as authorized
by federal public law 105-33, subtitle I of title  IV  of  the  Balanced
Budget  Act  of  1997,  must  meet  all applicable federal requirements.
Services may include, but need not be limited to, housing, inpatient and
outpatient hospital services, nursing home care, home health care, adult
day  care,  assisted living services provided in accordance with article
forty-six-B of this chapter,  adult  care  facility  services,  enriched
housing  program  services,  hospice  care, respite care, personal care,
homemaker services,  diagnostic  laboratory  services,  therapeutic  and
diagnostic  radiologic  services,  emergency  services,  emergency alarm
systems, home delivered meals,  physical  adaptations  to  the  client's
home,  physician  care  (including  consultant  and  referral services),
ancillary  services,  case  management  services,  transportation,   and
related medical services.
11.  The  department  shall  develop transition and continuity of care
policies for participants in home and community based  long  term  care,
including  the  long  term  home  health  care  program, as they move to
managed long term care plans addressing:
(a)  a  timetable  and  plan  for  implementation  and  transition  by
participants, plans and providers;
(b)  informative  disclosure  of participants' options as to impending
actions affecting or relating to the home care services they receive;
(c) reasonable  opportunity  for  plans'  and  providers'  good  faith
pursuit  of  contracts,  program  changes or state approvals relevant to
plan implementation;
(d) notice that a participant with a previously  established  plan  of
care provided by a certified home health agency or long term home health
care  program,  or  provided  pursuant  to the personal care or consumer
directed personal assistance service programs, may elect  to  have  such
care  plan  continued  subject  to  the participant's next comprehensive
assessment; and
(e) delineation of responsibilities  for  service  delivery  and  care
coordination,  so  as  to  avoid  conflict,  duplication and unnecessary
disruption of  direct  care  staffing  for  the  patient,  and  maintain
compliance  with state and federal statute and regulation, including the
provisions of this section,  article  thirty-six  of  this  chapter  and
section three hundred sixty-five-f of the social services law.
In addition, the department shall provide technical assistance to long
term  home  health  care  providers  with contracting options under this
section. The department shall work with  affected  stakeholders  in  the
development of these policies.
11-a.  In  transitioning  individuals  to  managed long term care, the
department  shall  provide  oversight  of  long  term  managed  care  by
ensuring:
(a) participants are appropriately notified of the upcoming changes to
their health care, and their rights and options;
(b)  access  to appropriate enrollment assistance, consumer assistance
and complaint mechanisms;
(c) access to quality  care  by  requiring  network  transparency  and
choice  of  long  term  care plans, allowing patients to choose the plan
that best fits their needs;
(d)  transparency  and  accountability  from  providers,  which  shall
include  a mechanism by which staff, participants and family members can
confidentially report concerns relating to quality to the plan  and  the
state;
(e)  plans  and  providers  are  assessed  periodically  and  data  is
published regarding  enrollment  in  integrated  care  designs,  network
adequacy, new service designs, outcome measures, including the extent to

which  care  plans are continued or altered based upon new comprehensive
assessments, and the types and amounts of  services  health  plans  have
authorized;
(f)  mechanisms  are  in  place  to  state oversight of enrollment and
services to prevent waste and  abuse  in  the  managed  long  term  care
system; and
(g) incentives are provided for a variety of indicators, including but
not  limited  to,  smooth  patient  transitions, appropriate enrollment,
quality care, high staff retention and  positive  health  care  outcomes
achieved at a low cost.
11-b.  In  cases of a managed long term care plan merger, acquisition,
or other similar arrangement approved by the department,  any  receiving
plan  that  is  a  party to the arrangement shall submit a report to the
department  within  twelve  months  of  the  effective   date   of   the
transaction. Such reports shall be in a form and format to be determined
by  the department and shall include, but not be limited to, information
about the enrollees transferred and enrollee service authorization  data
before  and  after  transfer. The department shall make a summary of the
report available to the public.
** 12. The  commissioner  may  make  any  necessary  amendments  to  a
contract pursuant to this section with a managed long term care plan, as
defined  in  paragraph  (a) of subdivision one of this section, to allow
such managed long term care plan to participate as  a  qualified  health
plan  in  a  state  health  benefit exchange established pursuant to the
federal Patient Protection and Affordable Care Act  (P.L.  111-148),  as
amended  by  the federal Health Care and Education Reconciliation Act of
2010 (P.L.  111-152).
** NB There are 2 sb 12's
** 12. Notwithstanding any provision to the contrary, a  managed  long
term  care  plan  may expand the services it provides or arranges for to
include services operated, certified, funded, authorized or approved  by
the  office  for people with developmental disabilities for a population
of persons with developmental disabilities, as such term is  defined  in
the  mental  hygiene  law, including habiltiation services as defined in
paragraph (c) of subdivision one of section forty-four  hundred  three-g
of this article, subject to the following:
(a)  Such plan must have the ability to provide or coordinate services
for persons with developmental disabilities as demonstrated by  criteria
to  be determined by the commissioner and the commissioner of the office
for people with developmental disabilities. Such criteria shall include,
but not be limited to, adequate  experience  providing  or  coordinating
services for persons with developmental disabilities;
(a-1)  If  the  commissioner  and  the  commissioner of the office for
people with developmental disabilities determine that  such  plan  lacks
the  experience  required in paragraph (a) of this subdivision, the plan
shall have an affiliation arrangement with an entity  or  entities  that
are  non-profit  organizations  or  organizations whose shareholders are
solely controlled by non-profit organizations  with  experience  serving
persons  with developmental disabilities, as demonstrated by criteria to
be determined by the commissioner and the commissioner of the office for
people with developmental disabilities, with  such  criteria  including,
but  not limited to, residential, day and employment services, such that
the affiliated  entity  will  coordinate  and  plan  services  operated,
certified,  funded, authorized or approved by the office for people with
developmental disabilities or will oversee and approve such coordination
and planning;
(a-2)  Each  enrollee  shall  receive  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.  With  respect  to  an  individual
receiving   non-residential   services   operated,   certified,  funded,
authorized or approved by  the  office  for  people  with  developmental
disabilities  prior  to  enrollment  in  the plan, such guidelines shall
require  the  plan  to  contract  with  the  current  provider  of  such
non-residential  services  at  the  rates  established by the office for
ninety days in order to ensure continuity of care. With  respect  to  an
individual living in a residential facility operated or certified by the
office for people with developmental disabilities prior to enrollment in
the  plan,  the  plan  shall  contract  with the provider of residential
services for that residence at the rates established by the  office  for
people  with  developmental  disabilities for so long as such individual
lives in that residence pursuant to an approved plan of care;
(b) The provision  by  such  plan  of  services  operated,  certified,
funded,   authorized   or   approved  by  the  office  for  people  with
developmental disabilities shall be  subject  the  joint  oversight  and
review   of   both  the  department  and  the  office  for  people  with
developmental disabilities.    The  department  and  such  office  shall
require such organization to provide comprehensive care planning, assess
quality,  meet quality assurance requirements and ensure the enrollee is
involved in care planning;
(c) Such plan shall not provide  or  arrange  for  services  operated,
certified,  funded, authorized or approved by the office for people with
developmental disabilities until the commissioner and  the  commissioner
of the office for people with developmental disabilities approve program
features  and  rates that include such services, and determine that such
organization meets the requirements of this subdivision  and  any  other
requirements set forth by the commissioner of the office for people with
developmental disabilities;
(d) An otherwise eligible enrollee receiving services through the plan
that  are  operated,  certified,  funded,  authorized or approved by the
office  for  people  with  developmental  disabilities  shall   not   be
involuntarily  disenrolled  from such plan without the prior approval of
the  commissioner  of  the  office   for   people   with   developmental
disabilities.  Notice shall be provided to the enrollee and the enrollee
may request a fair hearing regarding such disenrollment;
(e) The  office  for  people  with  developmental  disabilities  shall
determine  the  eligibility  of individuals receiving services operated,
certified, funded, authorized or approved by such office  to  enroll  in
such  plan and shall enroll individuals it determines eligible in a plan
chosen by such individual, guardian or other legal representative;
(f) The office for people  with  developmental  disabilities,  or  its
designee,  shall  complete  a comprehensive assessment for enrollees who
receive services operated, certified, funded, authorized or approved  by
such  office.  This  assessment shall include, but not be limited to, an
evaluation of the medical, social, habilitative and environmental  needs
of  each  prospective enrollee 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  initial  assessment shall be completed by such office or a designee
other than the plan and shall be  completed  in  consultation  with  the
prospective   enrollee's   health   care   practitioner   as  necessary.
Reassessments  shall  be completed by such office or its designee, which
may be the managed long term care plan in which the person  is  enrolled
or  proposes  to  enroll. The commissioner of the office for people with
developmental disabilities  shall  prescribe  the  forms  on  which  the
assessment shall be made.
(f-1)  The plan shall provide the department and the office for people
with developmental disabilities  with  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.
(g)  Plans  providing services operated, certified, funded, authorized
or approved by the office for  people  with  developmental  disabilities
shall  be  subject  to  all  requirements applicable to DISCOs operating
under section forty-four hundred three-g of this article with respect to
quality   assurance,   grievances   and   appeals,   informed    choice,
participation  in  development  of  plans  of care and requirements with
respect to marketing, to the  extent  that  such  requirements  are  not
inconsistent with this section.
(h)  No  person  with  a developmental disability shall be required to
enroll in a managed long term care plan  as  a  condition  of  receiving
medical  assistance and services operated, certified, funded, authorized
or approved by the office for  people  with  developmental  disabilities
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  the  person's  county  of  residence to meet the needs of
persons with developmental disabilities, and that such  plans  meet  the
standards of this section.
** NB Repealed December 31, 2025
** NB There are 2 sb 12's
** 13. Notwithstanding any inconsistent provision to the contrary, the
commissioner  may issue a certificate of authority to no more than three
eligible applicants who are eligible for Medicare and medical assistance
to  operate  managed  long  term  care  plans  that  are  authorized  to
exclusively enroll persons with developmental disabilities, as such term
is  defined  in section 1.03 of the mental hygiene law. The commissioner
may only issue certificates of authority pursuant  to  this  subdivision
if, and to the extent that, the department has received federal approval
to   operate   a  fully  integrated  duals  advantage  program  for  the
integration of services for persons enrolled  in  Medicare  and  medical
assistance.   The   commissioner  may  waive  any  of  the  department's
regulations as the commissioner, in consultation with  the  commissioner
of   the  office  for  people  with  developmental  disabilities,  deems
necessary to allow such managed long  term  care  plans  to  provide  or
arrange  for  services  for persons with developmental disabilities that
are adequate and appropriate to meet the needs of such  individuals  and
that will ensure their health and safety.
** NB Repealed December 31, 2025
** 14.  The  provisions  of  subdivisions  twelve and thirteen 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  thereunder  to  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, as may be
necessary to ensure such federal financial participation. To the  extent
that  the  provisions of subdivision twelve and thirteen of this section
are inconsistent with other provisions  of  this  article  or  with  the
provisions  of section three hundred sixty-four-j of the social services
law, the provisions of this subdivision shall prevail.
** NB Repealed December 31, 2025
* NB Repealed December 31, 2029