* § 4403-g. Developmental disability individual support and care
coordination organizations. 1. Definitions. As used in this section:

(a) "Developmental disability individual support and care coordination
organization" or "DISCO" 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, as determined by the commissioner and the
commissioner of the office for people with developmental disabilities,
on a capitated basis in accordance with this section, for a population
of persons with developmental disabilities, as such term is defined in
section 1.03 of the mental hygiene law, which the organization is
authorized to enroll.

(b) "Eligible applicant" means an entity controlled by one or more
non-profit organizations which have a history of providing or
coordinating health and long term care services to persons with
developmental disabilities.

(c) "Habilitation services" means services available through the
state's home and community based services waiver for persons with
developmental disabilities, state plan for medical assistance, and any
other authorized federal funding for such services designed to assist
persons in acquiring, retaining, and improving the self-help,
socialization, and adaptive skills necessary to reside successfully in
home and community based settings.

(d) "Health and long term care services" means comprehensive health
services and other services as determined by the commissioner and the
commissioner of the office for people with developmental disabilities,
whether provided by state-operated programs or not-for-profit entities,
including, but not limited to, habilitation services, home and
community-based and institution-based long term care services, 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. Each person enrolled in a DISCO shall
receive health and long term care 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 and in accordance with such person's
needs.

2. Approval authority. An applicant shall be issued a certificate of
authority as a DISCO for purposes of participating in the people first
waiver program pursuant to section 13.40 of the mental hygiene law upon
a determination by the commissioner and the commissioner of the office
for people with developmental disabilities that the applicant complies
with the operating requirements for a DISCO under this section.

3. Application for certificate of authority; form. The commissioner
and the commissioner of the office for people with developmental
disabilities shall jointly develop application forms for a certificate
of authority to operate a DISCO. An eligible applicant shall submit an
application for a certificate of authority to operate a DISCO upon forms
prescribed by such commissioners. 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
DISCO with projections of enrollment that will result in a fiscally
sound plan;

(b) A description of the services to be covered by such DISCO, which
must include all health and long term care services, as defined in
paragraph (d) of subdivision one of this section, and other services as
determined by the commissioner and the commissioner of the office for
people with developmental disabilities;

(c) 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;

(d) The names of the providers proposed to be in the DISCO's network;

(e) Evidence of the character and competence of the applicant's
proposed operators, and of the incorporators, directors, stockholders or
members of the applicant;

(f) Adequate documentation of the appropriate licenses, certifications
or approvals to provide care as planned, including affiliate agreements
or proposed contracts with such providers as may be necessary to provide
the full complement of services required to be provided under this
section;

(g) A description of the proposed quality-assurance mechanisms,
grievance procedures, mechanisms to protect the rights of enrollees and
care coordination services to ensure continuity, quality,
appropriateness and coordination of care;

(h) A description of the proposed quality assessment and performance
improvement program that includes performance and outcome based quality
standards for enrollee health status and satisfaction, and data
collection and reporting for standard performance measures;

(i) A description of the management systems and systems to process
payment for covered services;

(j) A description of how achievement of person-centered outcomes, as
defined by the commissioner of the office for people with developmental
disabilities, shall be assessed, as well as a description of how health
and long term care services shall be used to meet such outcomes;

(k) A description of the mechanism 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;

(l) A description of the systems for securing and integrating any
potential sources of funding for services provided by or through the
organization, including, but not limited to, funding available under
titles XVI, XVIII, XIX and XX of the federal social security act and all
other available sources of funding;

(m) A description of the proposed contractual arrangements for
providers of health and long term care services in the benefit package;
and

(n) Information related to the financial condition of the applicant.

4. Certificate of authority approval. The commissioner shall not
approve an application for a certificate of authority unless the
applicant demonstrates to the satisfaction of the commissioner and the
commissioner of the office for people with developmental disabilities:

(a) That it will have in place acceptable quality assurance
mechanisms, grievance procedures and mechanisms to protect the rights of
enrollees and care coordination services to ensure continuity, quality,
appropriateness and coordination of care;

(b) That it will have in place a mechanism or means to assure that
persons with developmental disabilities can make informed choices either
individually or through an authorized decision maker regarding the
development of a person-centered plan, as defined by the commissioner of
the office for people with developmental disabilities;

(c) That it has developed a quality assessment and performance
improvement program that includes performance and outcome based quality
standards for enrollee health status and satisfaction, which shall be
reviewed by the commissioner and the commissioner of the office for
people with developmental disabilities. The program shall include data
collection and reporting for standard performance measures as required
by the commissioner and the commissioner of the office for people with
developmental disabilities;

(d) That an otherwise eligible enrollee shall not be involuntarily
disenrolled without the prior approval of the commissioner of the office
for people with developmental disabilities;

(e) That the applicant shall not use deceptive or coercive marketing
methods to encourage participants to enroll and that the applicant shall
not distribute marketing materials to potential enrollees before such
materials have been approved by the commissioner and the commissioner of
the office for people with developmental disabilities;

(f) Satisfactory evidence of the character and competence of the
applicant's proposed operators, incorporators, directors, stockholders
and members;

(g) Reasonable assurance that the applicant will provide high quality
services to an enrolled population, that the applicant's network of
providers is adequate and that such providers have demonstrated
sufficient competency to deliver high quality services to the enrolled
population and that policies and procedures will be in place to address
the cultural and linguistic needs of the enrolled population;

(h) Sufficient management systems capacity to meet the requirements of
this section and the ability to efficiently process payment for covered
services;

(i) 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;

(j) Readiness and capability of organizing, marketing, managing,
promoting and operating a health and long term care services plan, or
has an affiliation agreement with an entity that has such readiness and
capability;

(k) Willingness and capability of taking, or cooperating in, all steps
necessary to secure and integrate any potential sources of funding for
services provided by or through the DISCO, including, but not limited
to, funding available under titles XVI, XVIII, XIX and XX of the federal
social security act and all other available sources of funding;

(l) 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
and the commissioner of the office for people with developmental
disabilities. With respect to a person receiving non-residential
services operated, certified, funded, authorized or approved by the
office for people with developmental disabilities prior to enrollment in
the DISCO, such guidelines shall require the DISCO to contract with the
current provider of non-residential services at the rates established by
the office for ninety days, in order to ensure continuity of care. With
respect to a person living in a residential facility operated or
certified by the office for people with developmental disabilities prior
to enrollment in the DISCO, such guidelines shall require the DISCO to
contract with the provider of residential services for that residence at
the rates established by the office for so long as such individual lives
in that residence pursuant to an approved plan of care;

(m) That the applicant is financially responsible and shall be
expected to meet its obligations to its enrolled members; and

(n) That the applicant shall assess person-centered outcomes as
defined by the commissioner of the office for people with developmental
disabilities, and has satisfactory mechanisms by which it will assess
how health and long term care services will be used to meet such
outcomes.

5. Enrollment. (a) Only persons with developmental disabilities, as
determined by the office for people with developmental disabilities,
shall be eligible to enroll in DISCOs.

(b) The office for people with developmental disabilities or its
designee shall enroll an eligible person in the DISCO chosen by him or
her, his or her guardian or other legal representative, provided that
such DISCO is authorized to enroll such person.

(c) No person with a developmental disability who is receiving or
applying for medical assistance and who is receiving, or eligible to
receive, services funded, certified, authorized or approved by the
office for people with developmental disabilities, shall be required to
enroll in a DISCO in order to receive such services 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
such person's county of residence to meet the needs of persons with
developmental disabilities, and that such DISCOs meet the standards of
this section. No person shall be required to enroll in a DISCO in order
to receive services operated, funded, certified, authorized or approved
by the office for people with developmental disabilities until there are
at least two plans authorized to coordinate care for persons with
developmental disabilities pursuant to this article in such person's
county of residence, unless federal approval is secured to require
enrollment when there are less than two such entities operating in such
county.

(d) Persons required to enroll in a DISCO shall have no less than
sixty days to select a DISCO, and such persons and their guardians or
other legal representatives shall be provided with information to make
an informed choice. Where a person, guardian or other legal
representative has not selected a DISCO, the commissioner of the office
for people with developmental disabilities or its designee shall enroll
such person in a DISCO chosen by such commissioner, taking into account
quality, capacity and geographic accessibility. The office for people
with developmental disabilities or its designee shall automatically
re-enroll a person with the same DISCO if there is a loss of medicaid
eligibility of two months or less.

(e) Enrolled persons may change their enrollment at any time without
cause, provided, however, that a person required to enroll in a DISCO in
order to receive services funded, licensed, authorized or approved by
the office for people with developmental disabilities may only disenroll
from a DISCO if he or she enrolls in another DISCO authorized to enroll
him or her. Such disenrollment shall be effective no later than the
first day of the second month following the request.

(f) A DISCO may request the involuntary disenrollment of an enrolled
person in writing to the office for people with developmental
disabilities. Such disenrollment shall not be effective until the
request is reviewed and approved by such office. Notice shall be
provided to the enrollee and the enrollee may request a fair hearing
regarding such disenrollment. The department and the office for people
with developmental disabilities shall adopt rules and regulations
governing this process.

6. Assessments. The office for people with developmental disabilities,
or its designee, shall complete a comprehensive assessment that shall
include, but not be limited to, an evaluation of the medical, social,
habilitative and environmental needs of each prospective enrollee in a
DISCO 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 assessment shall be completed by
the office for people with developmental disabilities or in consultation
with the prospective enrollee's health care practitioner as necessary.
The commissioner of the office for people with developmental
disabilities shall prescribe the forms on which the assessment shall be
made. The office for people with developmental disabilities may
designate the DISCO to perform reassessments, but shall not designate
the DISCO to perform the initial assessment of a prospective enrollee.

7. Program oversight and administration. (a) The commissioner and the
commissioner of the office for people with developmental disabilities
shall jointly promulgate regulations to implement this section, to
provide for oversight of DISCOs, including on site reviews, and to
ensure the quality, appropriateness and cost-effectiveness of the
services provided by DISCOs.

(b) The commissioner and the commissioner of the office for people
with developmental disabilities may waive rules and regulations of their
respective department or office, including but not limited to, those
pertaining to duplicative requirements concerning record keeping, boards
of directors, staffing and reporting, when such waiver shall promote the
efficient delivery of appropriate, quality, cost-effective services and
when the health, safety and general welfare of DISCO enrollees shall not
be impaired as a result of such waiver. The commissioners shall report
annually to the legislature and to the joint advisory council
established pursuant to section 13.40 of the mental hygiene law on all
rules and regulations waived pursuant to this paragraph. In order to
achieve DISCO system efficiencies and coordination and to promote the
objectives of high quality, integrated and cost effective care, the
commissioners shall 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
commissioners shall require DISCOs to utilize quality improvement
measures, based on the achievement of personal outcomes and quality of
life, health outcomes data, and assessments of individual and family
satisfaction, for internal quality assessment processes and may utilize
such measures as part of the single coordinated surveillance process.

(c) Notwithstanding any inconsistent provision of the social services
law to the contrary, the commissioner in consultation with the
commissioner of the office for people with developmental disabilities
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 are inconsistent with the flexibility
necessary for the efficient administration of DISCOs, and such
regulations shall provide that such provisions shall not be applicable
to enrollees of DISCOs, provided that such determinations are consistent
with applicable federal law and regulation.

(d) The commissioner and the commissioner of the office for people
with developmental disabilities shall ensure, through periodic reviews
of DISCOs, that organization services are promptly available to
enrollees when appropriate. Such periodic reviews shall be made
according to standards as determined by the commissioners in
regulations.

(e) The commissioner and the commissioner of the office for people
with developmental disabilities shall have the authority to conduct both
on site and off site reviews of DISCOs. Such reviews may include, but
not be limited to, the following components: governance; fiscal and
financial reporting; recordkeeping; internal controls; marketing;
network contracting and adequacy; program integrity assurances;
utilization control and review systems; grievance and appeals systems;
quality assessment and assurance systems; care management; enrollment
and disenrollment; management information systems, and other operational
and management components.

8. Solvency. (a) The commissioner, in consultation with the
commissioner of the office for people with developmental disabilities,
shall be responsible for evaluating, approving and regulating all
matters relating to fiscal solvency, including reserves, surplus and
provider contracts. The commissioner shall promulgate regulations to
implement this section. The commissioner, in the administration of this
subdivision:

(i) shall be guided by the standards that 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 the DISCO. The
commissioner shall be satisfied that the eligible applicant is
financially sound, and has made adequate provisions to pay for quality
services that are cost effective and appropriate to needs and the
protection of health, safety, welfare and satisfaction of those served.

9. 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.

10. Payment rates for DISCO 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. Payment rates shall be actuarially sound for
covered services, including but not limited to habilitation services,
and, when there is sufficient reliable data to permit, shall be
risk-adjusted to take into account the characteristics of enrollees, or
proposed enrollees, which may include: 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 and
the commissioner of the office for people with developmental
disabilities. The risk adjusted premiums may also be combined with
disincentives or requirements designed to mitigate any incentives to
obtain higher payment categories.

11. Continuation of certificate of authority. Continuation of a
certificate of authority issued under this section shall be contingent
upon compliance by the DISCO with applicable provisions of this section
and rules and regulations promulgated thereunder; the continuing fiscal
solvency of the DISCO; 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.

12. Protection of enrollees. The commissioner may, in his or her
discretion and with the concurrence of the commissioner of the office
for people with developmental disabilities, for the purpose of the
protection of enrollees, impose measures including, but not limited to
bans on further enrollments until any identified problems are resolved
to the satisfaction of the commissioner, or fines upon a finding that
the DISCO has failed to comply with the provisions of any applicable
statute, rule or regulation.

13. Information sharing. The commissioner and the commissioner of the
office for people with developmental disabilities shall, as necessary
and consistent with federal regulations promulgated pursuant to the
Health Insurance Portability and Accountability Act, share with such
DISCO the following data if it is available:

(a) information concerning utilization of services and providers by
each of its enrollees prior to and during enrollment.

(b) Aggregate data concerning utilization and costs for enrollees and
for comparable cohorts served through the Medicaid fee-for-service
program.

14. Applicability of other laws. DISCOs shall be subject to the
provisions of the insurance law and regulations applicable to health
maintenance organizations, this article and regulations promulgated
thereunder. 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.

15. Effectiveness. The provisions 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 by the
DISCOs to enrollees who are 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, in order to
ensure such federal financial participation.

* NB Repealed December 31, 2025