Relates to accountable care organizations

Summary of provisions

Amends Article 29-E of the Public Health Law to remove the "demonstration" designation of the ACO program and remove the cap on the number of certificates of authority for accountable care organizations (ACO). The sunset of authority for the issuance of ACO certificates is extended from December 31, 2015 to December 31, 2016.

Provides for an expedited state certificate of authority to a federally authorized Medicare only ACO. To enable Medicare-only ACOs to begin functioning, the law's protections of an ACO from state laws relating to anti-trust, restraint of trade, fee-splitting, as well as protection for peer-review activities, would be granted to Medicare-only ACOs regardless of whether the Commissioner has made regulations on those items, including section 2999-g, subdiv. 7, which clarifies that the provision of services by an ACO be construed as the practice of a profession under title 8 of the Education Law.

Requires that an ACO shall have a governance system, modeled on the federal ACO governance regulations, that represents the participating health care providers and patients.

Requires the commissioner to provide public disclosure of additional statistical data relating to services, performance, quality and payment measures.

The ACO shall use best efforts to include federally-qualified health centers that are willing and available to join the ACO on reasonable terms.

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 persons with respect to enrolling or participating in the ACO.

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.

An ACO shall not discriminate against or disadvantage a patient or patient's representative for the exercise of patient autonomy.

Patient, and health care provider participation in an ACO shall be on a voluntary basis.

Authorizes the commissioner to seek federal grants, approvals and waivers to facilitate the development of ACOs, and requires detailed disclosure of such applications to the legislature.

Allows a third-party payer to offer incentives for consumers to participate in an ACO and prohibits discriminating against a consumer for participating.

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 persons with respect to enrolling or participating in the ACO. 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. An ACO shall not discriminate against or disadvantage a patient or patient's representative for the exercise of patient autonomy.

The bill amends section 2818 of the Public Health Law to allow HEAL-NY funding for allocation by the commissioner in relation to the development of ACOs without competitive bid.

DOH would have authority to provide technical assistance to health care providers and consumer assistance in a program, and to provide assistance to the establishment of programs.

A workgroup will consider how to include ACOs in Medicaid managed care and other Medicaid care management programs.

Justification

In 2011 the Legislature established a demonstration program for establishing accountable care organizations. ACO legislation was needed first to provide a legal "safe harbor" for payers and providers to come together without violating anti-trust and other laws. Second, Medicaid and other payers need legal authority to participate in new payment methodologies with ACOs.

However, the third, and perhaps most important need, to protect the rights and interests of patients, health care providers, and the general public, was only partly addressed. For this reason, and because of the newness of the ACO concept, the law allowed DOH to certify only 7 ACOs.

Since the passage of the demonstration program it has become clear that the limitation on the number of allowed ACOs is limiting the ability of New York organizations to apply for federal ACO designation. The bill provides a more complete legal structure for ACOs. Strengthening protections for patients and providers goes hand in hand with the removal of the limit on the number of ACOS that may be authorized.

Legislative history

New bill.

Fiscal implications

None.

Effective date

Immediately.