2023 New York Laws › PBH - Public Health › Article 29-E - Accountable Care Organizations › 2999-Q - Accountable Care Organizations; Requirements.

§   2999-q.  Accountable  care  organizations;  requirements.  1.  The
commissioner  shall   make   regulations   establishing   criteria   for
certificates   of  authority,  quality  standards  for  ACOs,  reporting
requirements and other matters deemed to be appropriate and necessary in
the operation and evaluation of ACOs under this article. In making  such
regulations,  the  commissioner shall consult with the superintendent of
financial services,  health  care  providers,  third-party  health  care
payers,  advocates representing patients, and other appropriate parties.
Such regulations shall  be  consistent,  to  the  extent  practical  and
consistent  with this article, with CMS regulations for accountable care
organizations under the Medicare program.
2. Such regulations may, and shall as necessary for purposes  of  this
article, address matters including but not limited to:
(a)  The  governance,  leadership  and management structure of the ACO
that reasonably and equitably represents the ACO's participants and  the
ACO's   patients,   including   the   manner   in   which  clinical  and
administrative systems and clinical participation will be managed;
(b) Definition of the population proposed to be  served  by  the  ACO,
which   may  include  reference  to  a  geographical  area  and  patient
characteristics;
(c) The character, competence and fiscal responsibility and  soundness
of an ACO and its principals, if and to the extent deemed appropriate by
the commissioner;
(d)  The  adequacy  of  an  ACO's network of participating health care
providers, including primary care health care providers;
(e) Mechanisms by which an ACO will provide,  manage,  and  coordinate
quality  health  care  for  its  patients  including  where  practicable
elevating the services of primary care health  care  providers  to  meet
patient-centered  medical  home  standards,  coordinating  services  for
complex  high-need  patients,  and  providing  access  to  health   care
providers that are not participants in the ACO;
(f)  Mechanisms by which the ACO shall receive and distribute payments
to its participating health care providers, which may include  incentive
payments  (which  may  include  medical home payments) or mechanisms for
pooling payments received by participating health  care  providers  from
third-party payers and patients;
(g)  Mechanisms  and  criteria  for accepting health care providers to
participate in the ACO that are related to  the  needs  of  the  patient
population  to  be  served  and  needs  and  purposes  of  the  ACO, and
preventing unreasonable discrimination;
(h) Mechanisms for quality  assurance  and  grievance  procedures  for
patients  or health care providers where appropriate, and procedures for
reviewing and appealing patient care decisions;
(i)  Mechanisms  that  promote  evidence-based  health  care,  patient
engagement,  coordination  of care, electronic health records, including
participation  in   health   information   exchanges,   other   enabling
technologies   and  integrated,  efficient  and  effective  health  care
services;
(j) Performance standards for, and measures to assess, the quality and
utilization of care provided by an ACO;
(k) Appropriate requirements for ACOs to promote compliance  with  the
purposes of this article;
(l)  Posting  on  the department's website information about ACOs that
would be useful to health care providers and patients, including similar
metrics as the commissioner publishes for other  organizations  such  as
Medicaid managed care providers under section three hundred sixty-four-j
of  the social services law and health homes under section three hundred
sixty-five-l of the social services law;
(m) Requirements for the submission of information and  data  by  ACOs
and   their  participating  and  affiliated  health  care  providers  as
necessary for the evaluation of the success of ACOs;
(n) Protection of patient rights as appropriate;
(o) The impact of the establishment and operation of an ACO, including
providing  that  it shall not diminish access to any health care service
for the population served and in the area served; and
(p) Establishment of standards, as appropriate, to promote the ability
of an ACO to participate in applicable federal programs for ACOs.
3. (a) The ACO shall  provide  for  meaningful  participation  in  the
composition and control of the ACO's governing body for ACO participants
or their designated representatives.
(b)  The  ACO governing body shall include at least one representative
of each of the following groups:  (i)  recipients  of  Medicaid,  family
health  plus,  or  child  health  plus;  (ii)  persons with other health
coverage; and (iii) persons  who  do  not  have  health  coverage.  Such
representatives  shall  have no conflict of interest with the ACO and no
immediate family member with a conflict of interest with the ACO.
(c) At least seventy-five percent control of the ACO's governing  body
shall be held by ACO participants.
(d)  Members  of  the  ACO  governing  body  shall  have  a  fiduciary
relationship with the ACO and shall be subject to conflict  of  interest
requirements adopted by the ACO and in regulations of the commissioner.
(e)  The  ACO's  finances,  including  dividends  and  other return on
capital, debt structure, executive  compensation,  and  ACO  participant
compensation,   shall   be   arranged  and  conducted  to  maximize  the
achievement of the purposes of this article.
4. (a) An ACO  shall  use  its  best  efforts  to  include  among  its
participants,     on    reasonable    terms    and    conditions,    any
federally-qualified health center that is willing to  be  a  participant
and that serves the area and population served by the ACO.
(b)  An  ACO  may  seek  to focus on providing health care services to
patients with one or more chronic conditions or special needs.  However,
an  ACO  may  not  otherwise,  on  the  basis  of  a person's medical or
demographic characteristics, discriminate for or against  or  discourage
or  encourage  any  person  or  person  with  respect  to  enrolling  or
participating in the ACO.
(c) An ACO shall not, by incentives or otherwise, discourage a  health
care  provider  from  providing  or  an enrollee or patient from seeking
appropriate health care services.
(d) An ACO shall not discriminate against or disadvantage a patient or
patient's representative for the exercise of patient autonomy.
(e) An ACO may not limit or restrict beneficiaries to use of providers
contracted or affiliated with the ACO. An ACO may not require a  patient
to  obtain  the  prior  approval,  from  a  primary  care  gatekeeper or
otherwise, before utilizing the services of other providers. An ACO  may
not make adverse determinations as defined in article forty-nine of this
chapter.
5.  An  ACO  may  provide  care  coordination  for  its  participating
patients, which (a) shall  include  but  not  be  limited  to  managing,
referring   to,  locating,  coordinating,  and  monitoring  health  care
services for the member to assure that all  medically  necessary  health
care  services  are  made  available  to and are effectively used by the
member in a timely manner, consistent with patient autonomy; and (b)  is
not  a requirement for prior authorization for health care services, and
referral shall not be required for a member to  receive  a  health  care
service.
6.  (a)  Subject  to  regulations  of the commissioner: (i) an ACO may
enter into arrangements with one or more third-party health care  payers
to  establish  payment  methodologies  for  health care services for the
third-party health care payer's enrollees provided by  the  ACO  or  for
which  the  ACO  is  responsible,  such as full or partial capitation or
other arrangements; (ii) such arrangements may include provision for the
ACO to receive and distribute payments to the ACO's participating health
care providers, including incentive payments  and  payments  for  health
care  services  from  third-party  health  care payers and patients; and
(iii) an ACO may include mechanisms for  pooling  payments  received  by
participating   health   care  providers  from  third-party  payers  and
patients.
(b) Subject to regulations of the commissioner, the  commissioner,  in
consultation   with   the  superintendent  of  financial  services,  may
authorize a third-party health care  payer  to  participate  in  payment
methodologies  with  an  ACO under this subdivision, notwithstanding any
contrary provision of  this  chapter,  the  insurance  law,  the  social
services  law, or the elder law, on finding that the payment methodology
is consistent with the purposes of this article.
(c) An ACO may contract with a third-party health care payer to  serve
as  all  or part of the third-party health care payer's provider network
or care coordination agent, provided in  that  case  the  ACO  shall  be
subject to all provisions of this chapter or the insurance law which are
applicable to the provider network of the third-party health care payer.
7.  The provision of health care services directly or indirectly by an
ACO through health care providers shall not be considered  the  practice
of a profession under title eight of the education law by the ACO.