Title: Section 1003.4 - Application Requirements

Effective Date

12/31/2014

1003.4 Application Requirements

(a) A person or entity seeking to obtain a certificate of authority shall submit such application on forms prescribed by the Commissioner. The application must be signed by the chief executive officer, president, chairman of the board, or other authorized representative of the applicant. The application shall include information about its ACO participants and its providers/suppliers participating in the program as is necessary to implement the program, including:

(1) The name and address of all ACO participants with a description of the services to be provided by each;

(2) Certification that the ACO and its ACO participants have agreed to become accountable for the quality, cost, and overall care of the individuals attributed to the ACO;

(3) Criteria for accepting health care providers and other ACO participants to participate in the ACO; and

(4) A plan detailing how the ACO will use best efforts to include among its participants federally qualified health center(s) (FQHCs) that are willing to be a participant and that serve the area and population served by the ACO.

(b) The application shall require applicants to submit copies of organizational documents or proposed organizational documents, including but not limited to, certificate of incorporation, bylaws, articles of organization, operating agreement, partnership agreement, a list of members of the governing body, and any additional applicable documents and agreements and all amendments thereto evidencing the ACO’s legal structure, which conforms to this Part.

(c) Copies of financial statements of the ACO shall be made available to the Commissioner upon request.

(d) The application shall require applicants to submit documentation pertaining to the character and competence of the proposed ACO’s participants and principals which shall include proposed incorporators, directors, officers, stockholders, sponsors, and individual operators or partners. This information shall include but not be limited to:

(1) Certification that the applicant has used best efforts to ascertain that none of its participants, principals or contractors and no individuals who are employees, principals or contractors of such entities are on any federal or state excluded list; and

(2) Any participation by the proposed ACO, its ACO participants, or its providers/suppliers in the federal Medicare Shared Savings Program under the same or different name:

(i) Existence of an affiliation with another ACO participating in the federal Medicare Shared Savings Program and whether the agreement is currently active or has been limited, suspended or terminated; and

(ii) If the agreement has been limited, suspended or terminated, an explanation of the circumstances including whether the action was voluntary or involuntary.

(e) Documents such as participation agreements, employment contracts, and operating policies sufficient to describe the ACO participants’ and providers’/suppliers’ rights and obligations in and representation by the ACO, including how the opportunity to receive shared savings or other financial arrangements will encourage ACO participants and providers/suppliers to adhere to the quality assurance and improvement program and evidence-based clinical guidelines, shall be made available to the Commissioner upon request.

(f) A copy of the ACO’s compliance plan, or documentation describing the plan that will be put in place at the time of issuance of the certificate of authority, shall be made available to the Commissioner upon request.

(g) The application shall require the applicant to provide a description of the population to be served by the proposed ACO, which may include reference to the geographic area and, if applicable, shall include patient characteristics to be served
.This shall include but not be limited to discussion of the impact of the establishment and operation of the ACO on access to health care for the population to be served in the defined area.

(h) The application shall require the applicant to provide a plan for care coordination to assure that all medically necessary health care services are available to and effectively used by the patient. Care coordination shall include but not be limited to, referral, service acquisition follow-up and monitoring. The ACO shall include a description of how it will act in a timely manner consistent with patient autonomy, including not requiring patients to obtain prior authorization or a referral to receive a health care service. Notwithstanding the foregoing, this section does not prohibit a managed care organization from requiring use of network providers, use of referrals and prior authorization for its members.

(i) The application shall require the applicant to provide a description of how the proposed ACO will use evidence-based health care, patient engagement, coordination of care, electronic health records including participation in Qualified Health Information Technology Entities and other enabling technologies and services that promote integrated, efficient and effective health care services.

(j) The application shall require the applicant to provide a description of the proposed quality assurance and improvement procedures, including how performance standards and measures will be utilized to assess and improve quality and utilization of care.

(k) The application shall require the applicant to provide a description of the proposed ACO’s policies and procedures for reviewing and responding to complaints from patients and providers.

(l) The application shall require the applicant to provide assurance that the proposed ACO will not by incentives or otherwise, discourage a health care provider from providing, or an enrollee or patient from seeking, appropriate health care services.

(m) The application shall require the applicant to provide assurance that the proposed ACO will not discriminate against or disadvantage a patient or patient's representative for the exercise of patient autonomy.

(n) The application shall require the applicant to provide assurance that the proposed ACO will not limit or restrict beneficiaries to providers contracted or affiliated with the ACO, including not requiring patients to obtain prior approval from a primary care gatekeeper or otherwise before utilizing the services of other providers. Notwithstanding the foregoing, this section does not prohibit a managed care organization from requiring use of network providers, use of referrals and prior authorization for its members.

(o) Entities seeking state action immunity from federal or state antitrust laws shall submit such information as is required pursuant to subdivision (a) of section 1003.14.

(p) In addition to the above application requirements, entities seeking to enter into any “two-sided model” contract arrangements also are required to provide the following information;

(1) Type of arrangement, e.g., fee-for-service with a shared savings and loss payment tabulated and transferred at year end or a full or partial capitated arrangement into which the ACO proposes to enter;

(2) Baseline benchmark from which any savings or losses will be calculated;

(3) Percentage of the potential savings or losses to be split between the ACO and third party health care payer;

(4) Any reserve requirements imposed on the ACO by the third party health care payer; and

(5) Any other documents deemed relevant by the Commissioner.

(q) The application shall require the applicant to attest to the accuracy of the information contained in the application submitted to the Commissioner.

Volume

VOLUME E (Title 10)

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