§ 2111. Disease management demonstration programs. 1. The department
may establish disease management demonstration programs through a
request for proposals process to enhance the quality and
cost-effectiveness of care rendered to medicaid-eligible persons with
chronic health problems whose care and treatment, because of one or more
hospitalizations, multiple disabling conditions requiring residential
treatment or other health care requirements, results in high medicaid
expenditures. In order to be eligible to sponsor and to undertake a
disease management demonstration program, the proposed sponsor may be a
not-for-profit, for-profit or local government organization that has
demonstrated expertise in the management or coordination of care to
persons with chronic diseases or that has the experience of providing
cost-effective community-based care to such patients, or in the case of
a local government organization, has expressed a strong willingness to
sponsor such a program. The department may also approve disease
management demonstration programs which include, but are not limited to,
the promotion of adherence to evidence-based guidelines, improvement of
provider and patient communication and provide information on provider
and beneficiary utilization of services. The department shall grant no
fewer than six demonstration programs, no more than one-third of such
programs shall be selected to provide these services in any single
social services district; provided further, where the department grants
less than six demonstration programs, no more than one such program
shall be selected to provide these services in any single social
services district. The department shall approve disease management
demonstration programs which are geographically diverse and
representative of both urban and rural social services districts. The
program sponsor must establish, to the satisfaction of the department,
its capacity to enroll and serve sufficient numbers of enrollees to
demonstrate the cost-effectiveness of the demonstration program.

2. The department shall establish the criteria by which individuals
will be identified as eligible for enrollment in the demonstration
programs. Persons eligible for enrollment in the disease management
demonstration program shall be limited to individuals who: receive
medical assistance pursuant to title eleven of article five of the
social services law and may be eligible for benefits pursuant to title
18 of the social security act (Medicare); are not enrolled in a Medicaid
managed care plan, including individuals who are not required or not
eligible to participate in Medicaid managed care programs pursuant to
section three hundred sixty-four-j of the social services law; are
diagnosed with chronic health problems as may be specified by the entity
undertaking the demonstration program, including, but not limited to one
or more of the following: congestive heart failure, chronic obstructive
pulmonary disease, asthma, diabetes or other chronic health conditions
as may be specified by the department; or have experienced or are likely
to experience one or more hospitalizations or are otherwise expected to
incur excessive costs and high utilization of health care services.

3. Enrollment in a demonstration program shall be voluntary. A
participating individual may discontinue his or her enrollment at any
time without cause. The commissioner shall review and approve all
enrollment and marketing materials for a demonstration program.

4. The demonstration program shall offer evidence-based services and
interventions designed to ensure that the enrollees receive high
quality, preventative and cost-effective care, aimed at reducing the
necessity for hospitalization or emergency room care or at reducing
lengths of stay when hospitalization is necessary. The demonstration
program may include screening of eligible enrollees, developing an
individualized care management plan for each enrollee and implementing
that plan. Disease management demonstration programs that utilize
information technology systems that allow for continuous application of
evidence-based guidelines to medical assistance claims data and other
available data to identify specific instances in which clinical
interventions are justified and communicate indicated interventions to
physicians, health care providers and/or patients, and monitor physician
and health care provider response to such interventions, shall have the
enrollees, or groups of enrollees, approved by the department for
participation. The services provided by the demonstration program as
part of the care management plan may include, but are not limited to,
case management, social work, individualized health counselors,
multi-behavioral goals plans, claims data management, health and
self-care education, drug therapy management and oversight, personal
emergency response systems and other monitoring technologies, telehealth
services and similar services designed to improve the quality and
cost-effectiveness of health care services.

5. The department shall be responsible for monitoring the quality,
appropriateness and cost-effectiveness of a demonstration program. The
department shall utilize, to the extent possible, all potential sources
of funding for demonstration programs, including, but not limited to,
private payments and donations. All such funds shall be deposited by the
commissioner and credited to the disease management account which shall
be established by the comptroller in the special revenue-other fund.
Additionally, to the extent of funds appropriated therefor, medical
assistance funds, including any funding or shared savings as may become
available through federal waivers or otherwise under titles 18 and 19 of
the federal social security act, may be used by the department for
expenditures in support of the disease management program.

6. Payments shall be made by the department to the entity responsible
for the operation of the demonstration program on a fixed amount per
member per month of enrollment and shall reimburse the program sponsor
for the services rendered pursuant to subdivision four of this section.
The amount paid shall be an amount reasonably necessary to meet the
costs of providing such services, provided that the total amount paid
for medical assistance to enrollees in any such disease management
demonstration program, including any demonstration program expenditures,
shall not exceed ninety-five percent of the medical assistance
expenditure related to such enrollee that would reasonably have been
anticipated if the enrollee had not been enrolled in such demonstration
program. The department may make payments to demonstration programs that
provide administrative services only, provided that expenditures made
for enrollees, or a group of enrollees, participating in the
demonstration program shall provide sufficient savings as determined by
the department, had the enrollees, or groups of enrollees, not been
enrolled in such demonstration. The department shall provide an interim
report to the governor, and the legislature on or before December
thirty-first, two thousand six and a final report on or before December
thirty-first, two thousand seven on the results of demonstration
programs. Both reports shall include findings as to the demonstration
programs' contribution to improving quality of care and their
cost-effectiveness. In the final report, the department shall offer
recommendations as to whether demonstration programs should be extended,
modified, eliminated or made permanent.