New York Laws
Article 44 - Health Maintenance Organizations
4403-C - Comprehensive HIV Special Needs Plan Certification.

(a) a copy of the applicant's basic organizational documents and
agreements of the applicant and all network members, including all
contracts and agreements relating to the provision of HIV services;
(b) a copy of any current licensure or certification maintained by the
applicant;
(c) a description of any experience the applicant may have had in
providing HIV services which are licensed, certified, funded or approved
by the department, including identification of any disciplinary,
administrative or criminal proceedings related to such services in the
past ten years, the resolution thereof, and any other proceedings
currently pending;
(d) full disclosure of the financial condition of the applicant and of
members of the board, officers, controlling persons, owners and
partners, including, but not limited to, a statement of the applicant's
assets, resources, accounts receivable, liabilities and proposed sources
and uses of funds and the most recent certified income statement and
balance sheet;
(e) a demonstration of the applicant's ability to provide or continue
to provide quality HIV services;
(f) a description of the geographic area served and to be served by
the applicant;
(g) a description of the applicant's current capacity, and proposed
capacity, to provide or arrange for the provision of comprehensive HIV
services for a defined geographic area to a defined population; and
(h) such other information as the commissioner shall require.
3. The commissioner shall not issue a comprehensive HIV special needs
plan certificate of authority to an applicant therefor unless the
applicant demonstrates that:
(a) it has defined an enrolled population to which the comprehensive
HIV special needs plan proposes to provide comprehensive HIV health
services, has demonstrated a willingness to enroll any person who is
eligible for enrollment within its defined catchment area and has
established a mechanism by which the enrolled population may participate
in determining the policies of the organization;
(b) it has defined a specific network of providers and facilities that
are capable of providing comprehensive HIV special needs services to the
enrolled population described in paragraph (a) of this subdivision;
(c) it has the capability of organizing, marketing, managing,
promoting and operating a comprehensive HIV special needs plan;
(d) it is financially responsible and sound and may be expected to
meet its obligations to its enrolled members. For the purposes of this
paragraph, "financially responsible" means that the applicant is capable
of assuming full financial risk on a prospective basis for the provision
of comprehensive HIV special needs services within the geographic
catchment area defined by the applicant except that it may allow
providers to share financial risk under the terms of their contract, or
it may obtain insurance or make other arrangements for the cost of
providing comprehensive HIV special needs health services to enrollees;
any insurance or other arrangements proposed to meet this requirement

shall be approved as to adequacy as a prerequisite to the issuance of
any comprehensive HIV special needs certificate of authority by the
commissioner. In making a determination of financial soundness, the
commissioner shall consider financial information, contracts and
agreements required as part of the application for a certificate of
authority and any other information that the commissioner shall deem
necessary to make that determination. For purposes of this section, any
grants awarded to an applicant contingent upon its approval as a HIV
special needs plan certified pursuant to this section, shall be
considered when making a determination of fiscal soundness;
(e) it has established a system which appropriately accounts for costs
and a uniform system of reports and audits meeting the requirements of
the commissioner;
(f) the character, competence and standing in the community of the
proposed incorporators, directors, sponsors, or stockholders of the
plan, and its network providers, are satisfactory to the commissioner;
(g) it is willing and able to assure that necessary HIV services will
be provided in a timely manner to assure the availability and
accessibility of adequate personnel and facilities; to assure continuity
of care for enrollees; and to implement procedures for referrals, as
requested, to appropriate care for affected family members of the
enrolled population;
(h) the prepayment mechanism of its comprehensive HIV special needs
plan, the bases upon which the providers of health care are compensated,
and the anticipated use of allied health personnel are conducive to the
use of ambulatory care and the efficient use of hospital services;
(i) acceptable procedures have been established for the conduct of
outreach and enrollment of persons with HIV infection including persons
who are homeless, substance users and other vulnerable populations;
(j) acceptable procedures have been developed to communicate with
participants in a linguistically and culturally competent manner;
(k) acceptable procedures have been established to monitor the quality
of care provided by the plan and to assure that all care rendered meets
clinical standards of HIV care as established and maintained by the AIDS
Institute of the New York state department of health;
(l) approved mechanisms exist to resolve complaints and grievances
initiated by any enrolled member; and
(m) the requirements of this article and any regulations promulgated
pursuant thereto have been met and will continue to be met.
4. The commissioner shall not issue a comprehensive HIV special needs
certificate of authority unless the applicant has demonstrated to the
commissioner's satisfaction that the requirements of this article and
any regulations promulgated pursuant thereto have been met and will
continue to be met, provided, however, that the commissioner may impose
alternative requirements, or portions thereof, particularly those
related to capitalization, if he or she determines that such alternative
requirements will serve to promote the high quality, efficient provision
of comprehensive health services or services required by HIV positive
persons, will promote the development of HIV special needs plans and
that the proposed plan will provide an appropriate and cost-effective
alternative method for the delivery of such services in a manner which
will meet the needs of the population to be served.
5. The commissioner shall make a determination on an application after
receipt of all required and requested information and documentation.
6. The commissioner shall review and approve any current or proposed
contracts or agreements with current or prospective network members, and
provided further, that the commissioner shall specifically review and
approve any proposed provisions in such contracts or agreements with the

prospective or existing network members which specify any risk sharing
arrangements.
7. The commissioner may revoke, limit or annul a comprehensive HIV
special needs plan certificate of authority in accordance with the
provisions of section forty-four hundred four of this article.
8. A comprehensive HIV special needs plan, certified pursuant to this
section, shall be responsible for providing or arranging for all medical
assistance services defined under section three hundred sixty-five-a of
the social services law, including delivery of a comprehensive benefit
package, which shall include early and periodic screening; adolescent
health; diagnosis and treatment and child/teen health screenings;
referrals for necessary services; linkages to HIV counseling and
testing; and HIV prevention and education activities. A comprehensive
HIV special needs plan provider shall be responsible for assisting
enrollees in the prudent selection of such services including but not
limited to:
(a) referral, coordination, monitoring and follow-up with regard to
other medical services providers, as appropriate for diagnosis and
treatment, or direct provision of all medical assistance services;
(b) methods of assuring enrollees' access to specialty services
outside the comprehensive HIV special needs plan's network or panel when
the plan does not have a provider with the appropriate training and
experience in its network to meet the particular health care needs of
the participant;
(c) the establishment of appropriate utilization and referral
requirements for physicians, hospitals, and other medical services
providers, including emergency room visits and inpatient admissions;
(d) the creation of mechanisms to ensure the participation of HIV
centers of excellence and community-based HIV care providers;
(e) implementation of procedures for managing the care of all
participants, including the use of facility and community-based case
managers with expertise in the care needs of persons with HIV infection,
and the designation of a specialist as a primary care practitioner;
(f) development of appropriate methods of managing the HIV care needs
of homeless, substance users and other vulnerable populations, who are
enrolled in the comprehensive HIV special needs plan, to assure that all
necessary services are made available in a timely manner, in accordance
with prevailing standards of professional medical practice, and that all
appropriate referrals and follow-up treatments are provided;
(g) provision of all early periodic screening, diagnosis and treatment
services, as well as periodic screening and referral, to each
participant under the age of twenty-one, at regular intervals and as
medically appropriate;
(h) direct provision of or arrangement for the provision of
comprehensive prenatal care services to all pregnant participants in
accordance with standards adopted by the department of health and with
statute and regulations governing HIV testing of pregnant women and
newborns;
(i) implementation of procedures for written agreements, which may
include contractual agreements, with community-based social service
providers to ensure access to the full continuum of services needed by
HIV infected persons; and
(j) permit the use of standing referrals to specialists and
subspecialists for participants who require the care of such
practitioners on a regular basis.
9. Notwithstanding any other provision of law, a comprehensive HIV
special needs plan certified pursuant to this section shall limit

enrollment to HIV positive persons, except for the following persons who
may be enrolled regardless of their HIV status:
(a) related children up to the age of twenty-one; and
(b) individuals who are homeless or who are members of other high need
populations which, in the discretion of the commissioner, would benefit
from receiving services through a plan certified pursuant to this
section; provided however, that rates paid to special needs plans for
such populations shall be comparable to rates paid for the same
populations in other managed care plans.
10. Enrollment and disenrollment. (a) Enrollment in a comprehensive
HIV special needs plan shall be voluntary and persons eligible for
enrollment in such plans shall be afforded the opportunity to choose
among such plans, to the extent available in the locality where the
person currently resides; provided however that enrollment may be
automatic after federal approval of a waiver or waivers or other federal
action required to institute automatic enrollment, pursuant to
applicable provisions of the federal social security act, and that
persons automatically enrolled in a comprehensive HIV special needs plan
shall have the opportunity to withdraw from such plan in accordance with
paragraph (g) of subdivision four, paragragh (b) of subdivision three
and subdivision twelve of section three hundred sixty-four-j of the
social services law. The department shall ensure to the maximum extent
practicable that individuals are provided with a choice of comprehensive
HIV special needs plans.
(b) The commissioner shall promulgate regulations establishing
criteria which relate to enrollment and disenrollment of enrollees in
comprehensive HIV special needs plans. Comprehensive HIV special needs
plans shall not request disenrollment of an enrollee based on any
diagnosis, condition, or perceived diagnosis or condition, or an
enrollee's efforts to exercise his or her rights under a grievance
process.
(c) Prior to enrollment in a comprehensive HIV special needs plan
individuals are to be provided with a full written explanation of all
fee-for-service and other options and given a reasonable opportunity to
choose between the comprehensive HIV special needs plan and the other
options. In addition, enrollees shall be provided notice of their right
to disenroll from the plan, except as otherwise provided in this
subdivision.
(d) If an enrollee requests to change a provider or disenroll from a
comprehensive HIV special needs plan pursuant to this subdivision, the
social services district and the plan shall implement such change in a
timely manner in accordance with standards established by the
commissioner. When an enrollee changes comprehensive HIV special needs
plan providers the plan must effectuate the timely transfer of all
necessary medical records.
(e) Plans shall ensure that any new enrollee whose health care
provider is not a member of the plan's provider network, who enrolls in
the plan, can continue with an ongoing course of treatment with the
enrollee's current health care provider during a transitional period of
up to sixty days from the effective date of enrollment. If an enrollee
elects to continue to receive care from such health care provider
pursuant to this paragraph, such care shall be authorized by the
comprehensive HIV special needs plan for the transitional period only if
the health care provider agrees: (1) to accept reimbursement from the
comprehensive HIV special needs plan at rates established by the plan as
payment in full, which rates shall be no more than the level of
reimbursement applicable to similar providers within the plan's network
for such services; (2) to adhere to the plan's quality assurance

requirements and agrees to provide to the plan any necessary medical
information related to such care; and (3) to otherwise adhere to the
plan's policies and procedures including, but not limited to procedures
regarding referrals and obtaining pre-authorization and a treatment plan
approved by the comprehensive HIV special needs plan. In no event shall
this paragraph be construed to require a comprehensive HIV special needs
plan to provide coverage for benefits not otherwise covered;
(f) Comprehensive HIV special needs plans shall ensure that for those
enrollees whose health care provider leaves the comprehensive HIV
special needs plan's network of providers, the enrollee shall be
permitted to continue an ongoing course of treatment with such current
health care provider during a transitional period of up to ninety days
from the date of notice to the enrollee of the provider's disaffiliation
from the plan's network. If an enrollee elects to continue to receive
care from such health care provider pursuant to this paragraph, such
care shall be authorized by the comprehensive HIV special needs plan for
the transitional period only if the health care provider agrees: (1) to
accept reimbursement from the comprehensive HIV special needs plan at
rates established by the plan as payment in full, which rates shall be
no more than the level of reimbursement applicable to similar providers
within the plan's network for such services; (2) to adhere to the
organization's quality assurance requirements and agrees to provide to
the plan any necessary medical information related to such care; and (3)
to otherwise adhere to the plan's policies and procedures including, but
not limited to procedures regarding referrals and obtaining
pre-authorization and a treatment plan approved by the comprehensive HIV
special needs plan. In no event shall this paragraph be construed to
require a comprehensive HIV special needs plan to provide coverage for
benefits not otherwise covered;
11. The commissioner shall develop and certify capitated payment rates
for comprehensive HIV special needs plans, subject to the approval of
the director of the division of the budget. In developing capitation
rates the commissioner shall be authorized to consider, at a minimum,
the age, eligibility category, historic cost and utilization of covered
enrollees and covered services, anticipated costs of emerging HIV
treatment modalities and the expected impact of delivering services in a
managed care environment.
12. Plans certified under this section must submit financial reports
in a manner and frequency established by the commissioner.
13. The department shall establish a stop-loss reinsurance program for
comprehensive HIV special needs plans. The stop-loss reinsurance program
shall be designed in a manner which promotes the development and ongoing
financial viability of the comprehensive HIV special needs plan by
providing reasonable protection for catastrophic cases and adverse
selection.
14. Quality assurance. (a) The department shall be responsible for
establishing a comprehensive quality assurance program for comprehensive
HIV special needs plans. This quality assurance program shall reflect
clinical standards of HIV care established and maintained by the AIDS
Institute in the department. The department shall monitor the
performance, quality and utilization of such plans on at least an annual
basis. Such plans must describe and document the existence of a formal,
organized quality assurance program with the capacity to identify,
address and follow-up on issues which concern the care and services
delivered to enrollees. Such reviews are to include, but not be limited
to, the following:
(1) compliance with performance and outcome-based quality standards
promulgated by the department;
(2) appropriateness, accessibility, timeliness, and quality of care
delivered by such providers;
(3) referrals, coordination, monitoring and follow-up with regard to
other medical service providers;
(4) methods of ensuring enrollees access to specialty services outside
the plan's network or panel when the plan does not have a provider with
the appropriate training and experience in the network or panel to meet
the particular HIV care needs of the participant;
(5) delivery of a comprehensive benefit package, including early and
periodic screening; adolescent health; diagnosis and treatment and
child/teen health screenings; referrals for necessary services, and
linkages to HIV counseling and testing; HIV prevention and education
activities;
(6) mechanisms for the provision of all information to enrollees in
clear and coherent terms that are commonly used in a culturally and
linguistically appropriate and understandable manner;
(7) existence of a management information system to support quality
assurance activities, which system shall provide for the collection and
utilization of data including but not limited to enrollment, complaints,
encounters and specific performance indicators; and
(b) the commissioner shall have access to patient specific medical
information and enrollee medical records, including encounter data,
maintained by a comprehensive HIV special needs plan for the purposes of
quality assurance and oversight.
(c) The department shall be responsible for establishing and
maintaining a uniform system of reports relating to the quality of care
and services furnished by comprehensive HIV special needs plans.
15. The commissioner may revoke, limit or annul a comprehensive HIV
special needs certificate of authority in accordance with the provisions
of section forty-four hundred four of this article.
16. Confidentiality. Except as provided in paragraph (c) of
subdivision fourteen of this section, any enrollee information
maintained by a comprehensive HIV special needs plan shall be kept
confidential in accordance with section forty-four hundred eight-a of
this article and where applicable section 33.13 of the mental hygiene
law and any other applicable state or federal law.
17. Utilization review. A comprehensive HIV special needs plan
authorized under this section is required to meet requirements set forth
in article forty-nine of this chapter.
18. Disclosure. Each enrollee and prospective enrollee prior to
enrollment in a comprehensive HIV special needs plan shall be provided
with written disclosure information related to enrollee benefits, rights
and obligations pursuant to section forty-four hundred eight of this
article.
19. Grievance procedure. Comprehensive HIV special needs plans
authorized under this section shall be required to meet grievance
procedures requirements pursuant to section forty-four hundred eight-a
of this article.
20. Prohibitions. A comprehensive HIV special needs plan authorized
under this section shall be required to meet the requirements set forth
in section forty-four hundred six-c of this article.
21. The commissioner is authorized, subject to the approval of the
director of the division of the budget, and within amounts appropriated,
to make grants to those entities seeking certification to operate a
comprehensive HIV special needs plan to aid in the development of the
systems, organizational structures and networks necessary to operate a
managed care program. The commissioner is authorized to develop criteria
for distribution of the grants. The grants may also be used to meet the

capitalization standards and the reserve and escrow deposit requirements
established for comprehensive HIV special needs plans.
22. Comprehensive HIV special needs plans shall function distinctly
from other comprehensive or non-comprehensive health plans operated by
the same organization, corporation, persons, county or municipality and
shall be clearly distinguished from any other functions through the
maintenance of separate records, reports and accounts for the
comprehensive HIV special needs plan function.
23. The commissioner shall establish reserve and escrow deposit
requirements for HIV special needs plans.
24. Nothing in this section shall be construed to require that a
health maintenance organization, certified pursuant to the provisions of
this article, apply for a comprehensive HIV special needs plan
certificate of authority pursuant to this section; provided, however,
that a health maintenance organization, certified pursuant to the
provisions of this article, which proposes to operate a comprehensive
HIV special needs plan shall be required to comply with all the
provisions of this section.
* NB Repealed March 31, 2025

Structure New York Laws