Section 1003.2 - Definitions

1003.2 Definitions

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 subdivision (j) of this section, 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 coordination 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, or an arrangement for such payments or prepayments, 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 systematic 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) “Health care provider” includes but is not limited to an entity licensed or certified under article twenty-eight or thirty-six of the public health law; an entity licensed or certified under article sixteen, thirty-one or thirty-two of the mental hygiene law; or a health care practitioner licensed or certified under title eight of the education law or a lawful combination of such health care practitioners.

(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 a 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) “Provider/supplier” 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 recognized by the Commissioner. 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 defined 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” has its ordinary meanings and includes the following:

(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.

(y) “Two-sided model” means a model under which the ACO may have both shared savings or losses with a third party health care payer with which it has contracted, if the ACO meets the requirements for doing so, and may have shared losses incurred.

Effective Date: 
Wednesday, December 31, 2014
Doc Status: 
Complete