New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter XII - Innovative Delivery Models › Part 1003 - Accountable Care Organizations › Section 1003.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The following words or terms when used in this Part shall
				  have the following meanings:
(a)
				"Accountable care organization" or "ACO" means an organization comprised of
				clinically integrated independent health care providers that work together to
				provide, manage, and coordinate health care (including primary care) for a
				defined population; with a mechanism for shared governance; the ability to
				negotiate, receive, and distribute payments; and to be accountable for the
				quality, cost, and delivery of health care to the ACO's patients; and has been
				issued a certificate of authority.
(b) "ACO participant" means a health care
				provider as defined in Article 29-E of the Public Health Law, a health home, an
				administrative services organization or a provider/supplier that is one of the
				health care providers or other entities that comprise the ACO.
(c) "Administrative services organization"
				means an entity that provides ancillary services to an ACO, such as but not
				limited to, technical assistance, information systems and services, and care
				management services. This includes, but is not limited to, an independent
				practice association that conforms to the requirements of this Part.
(d) "Capitation" or "capitation arrangement"
				means contractually based payments or prepayments (any payments made prior to
				the last day of the month shall be deemed a prepayment of the entire month's
				capitation) made to an ACO or a health care provider, on a per member per month
				or a percentage of premium basis, in exchange for one or more covered health
				care services to be rendered, referred or otherwise arranged by such provider
				and by its participating providers.
(e) "Certificate of Authority" or
				"certificate" means a certificate of authority issued by the Commissioner under
				Article 29-E of the Public Health Law and this Part.
(f) "Clinical integration" means the systemic
				coordination of evidence-based physical and behavioral health care for patients
				across a broad spectrum of settings in which care is provided, including
				inpatient, outpatient, institutional and community based settings in order to
				promote health and better outcomes, particularly for populations at risk, while
				also managing total cost of care.
(g) "Commissioner" means Commissioner of the
				New York State Department of Health.
(h) "Defined population" means the
				individuals that will be served by an ACO.
(i) "Federal and state antitrust laws" means
				any and all federal or state laws prohibiting monopolies or agreements in
				restraint of trade, including the federal Sherman Act, Clayton Act, Federal
				Trade Commission Act and laws set forth in Article 22 of the New York General
				Business Law, including amendments thereto.
(j) "Guaranteeing parent corporation" means
				an entity that controls, within the meaning of paragraph (16) of subdivision
				(a) of section
				107 of the
				Insurance Law, an ACO and guarantees the performance of the ACO's obligations
				under the financial risk transfer agreement including the payment of any
				amounts owed by the ACO to participating providers for services rendered
				pursuant to a risk transfer agreement.
(k) "Health home" means an entity designated
				by the Commissioner pursuant to section
				365-l of
				the Social Services Law.
(l)
				"Medicaid dual eligible" or "dual eligible" means an individual who is in
				receipt of medical coverage paid for by both the Medicare and Medicaid
				programs.
(m) "Medical director"
				means a New York State licensed physician under Title 8 of the Education Law
				whose responsibilities for an ACO include but are not limited to, the
				supervision of quality assurance and improvement, monitoring utilization
				patterns and advising the governing authority on the adoption and
				implementation of policies concerning medical services.
(n) "Medicare-only ACO" means an ACO
				certified pursuant to subdivision (4) of section
				2999-p of
				the Public Health Law that has been accepted by the Centers for Medicare and
				Medicaid Services (CMS), has entered into an approved participation agreement
				with CMS, and exclusively serves Medicare beneficiaries as its defined
				population that are not otherwise enrolled in Medicare Advantage or other
				Medicare managed care plans.
(o)
				"One-sided model" means a model under which an ACO may have shared savings with
				the third party health care payer with which it has contracted, if the ACO
				meets the requirements for doing so, but is not liable for shared losses
				incurred.
(p) "Patient centered
				medical home" means a health care setting recognized by a national accrediting
				organization that focuses on the patient and where the patient's primary care
				provider coordinates a team of health care professionals in arranging for and
				ensuring the patient receives necessary and appropriate care from other
				qualified individuals.
(q) "Primary
				care provider" means a physician, nurse practitioner, or midwife acting within
				his or her lawful scope of practice under Title 8 of the Education Law and who
				is practicing in a primary care specialty.
(r) "Primary service area" means the lowest
				number of postal zip codes from which the party draws at least 75 percent of
				its patients for each service or group of services provided.
(s) "Providers/suppliers" means an individual
				or entity that is a provider or supplier of health care services to an ACO and
				may be an ACO participant.
(t)
				"Qualified health information technology entity" or "QE" means a not-for-profit
				entity that has been certified as a QE through a QE certification process. QEs
				provide the governance and policy framework for health information exchange
				activities at a local or regional level by fulfilling the purposes for which
				they were incorporated, following their bylaws, and meeting their contractual
				obligations to the state designated entity and their participation agreements
				with their participants.
(u)
				"Shared losses" means that portion of the losses incurred by an ACO when its
				expenditures for health care services to its population are above projected
				benchmark expenditures.
(v) "Shared
				savings" means that portion of savings generated by an ACO when its
				expenditures for health care services to its population are below projected
				benchmark expenditures, with no downside risk to the ACO for losses.
(w) "Superintendent" means the Superintendent
				of Financial Services.
(x) "Third
				party health care payer" means:
(1) Centers
				for Medicare and Medicaid Services;
(2) the New York State Department of
				Health;
(3) insurers licensed under
				the laws of this state or any other state;
(4) managed care organizations certified
				under Article 44 of the Public Health Law;
(5) other entities doing an insurance
				business that are otherwise subject to the Insurance Law;
(6) entities exempted from being licensed
				under the Insurance Law pursuant to the federal Employee Retirement and Income
				Security Act (ERISA),
				29 U.S.C. sections
				1001 -
				1461;
				or
(7) administrators acting on
				behalf of entities exempted from being licensed under the Insurance Law
				pursuant to ERISA.