S T A T E O F N E W Y O R K ________________________________________________________________________ 8869--B R. R. 101 I N A S S E M B L Y (PREFILED) January 4, 2012 ___________ Introduced by M. of A. GOTTFRIED, MAGNARELLI -- read once and referred to the Committee on Health -- reported and referred to the Committee on Ways and Means -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- amended on the special order of third reading, ordered reprinted as amended, retaining its place on the special order of third reading AN ACT to amend the public health law, in relation to accountable care organizations THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. Article 29-E of the public health law, as added by section 2 66 of part H of chapter 59 of the laws of 2011, is amended to read as 3 follows: 4 ARTICLE 29-E 5 ACCOUNTABLE CARE ORGANIZATIONS [DEMONSTRATION PROGRAM] 6 Section 2999-n. Accountable care organizations; findings; purpose. 7 2999-o. Definitions. 8 2999-p. Establishment of [ACO demonstration program] ACOS. 9 2999-q. Accountable care organizations; requirements. 10 2999-r. Other laws. 11 S 2999-n. Accountable care organizations; findings; purpose. [The 12 legislature intends to test the ability of accountable care organiza- 13 tions to assume a role in delivering an array of health care services, 14 from primary and preventive care through acute inpatient hospital and 15 post-hospital care.] The legislature finds that the formation and opera- 16 tion of accountable care organizations under this article, and subject 17 to appropriate regulation, can be consistent with the purposes of feder- 18 al and state anti-trust, anti-referral, and other statutes, including 19 reducing over-utilization and expenditures. The legislature finds that 20 the development of accountable care organizations under this article 21 will reduce health care costs, promote effective allocation of health 22 care resources, and enhance the quality and accessibility of health 23 care. The legislature finds that this article is necessary to promote EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD13268-10-2 A. 8869--B 2 1 the formation of accountable care organizations and protect the public 2 interest and the interests of patients and health care providers. 3 S 2999-o. Definitions. As used in this article, the following terms 4 shall have the following meanings, unless the context clearly requires 5 otherwise: 6 1. "Accountable care organization" or "ACO" means an organization of 7 clinically integrated health care providers certified by the commission- 8 er under this article. 9 2. "ACO PARTICIPANT" OR "PARTICIPANT" MEANS A HEALTH CARE PROVIDER 10 THAT IS ONE OF THE HEALTH CARE PROVIDERS THAT COMPRISE THE ACO. 11 3. Certificate of authority" or "certificate" means a certificate of 12 authority issued by the commissioner under this article. 13 [3.] 4. "CMS" MEANS THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID 14 SERVICES. 15 5. "CMS REGULATIONS" MEANS APPLICABLE FEDERAL LAWS AND CMS REGULATIONS 16 AND POLICIES. 17 6. "Health care provider" includes but is not limited to an entity 18 licensed or certified under article twenty-eight or thirty-six of this 19 chapter; an entity licensed or certified under article sixteen, thirty- 20 one or thirty-two of the mental hygiene law; or a health care practi- 21 tioner licensed or certified under title eight of the education law or a 22 lawful combination of such health care practitioners; and may also 23 include, to the extent provided by regulation of the commissioner, other 24 entities that provide technical assistance, information systems and 25 services, care coordination and other services to health care providers 26 and patients participating in an ACO. 27 [4.] 7. "MEDICARE-ONLY ACO" MEANS AN ACO ISSUED A CERTIFICATE OF 28 AUTHORITY UNDER SUBDIVISION FOUR OF SECTION TWENTY-NINE HUNDRED NINETY- 29 NINE-P OF THIS ARTICLE. 30 8. "Primary care" means the health care fields of family practice, 31 general pediatrics, primary care internal medicine, primary care obstet- 32 rics, or primary care gynecology, without regard to board certification, 33 provided by a health care provider acting within his, her, or its lawful 34 scope of practice. 35 [5.] 9. "Third-party health care payer" has its ordinary meanings and 36 may include any entities provided for by regulation of the commissioner, 37 which may include an entity such as a pharmacy benefits manager, fiscal 38 administrator, or administrative services provider that participates in 39 the administration of a third-party health care payer system. 40 [6. Any references to the "department of financial services" and the 41 "superintendent of financial services" in this article shall mean, prior 42 to October third, two thousand eleven, respectively, the "department of 43 insurance" and the "superintendent of insurance."] 44 S 2999-p. Establishment of [ACO demonstration program] ACOS. 1. An 45 accountable care organization: (a) is an organization of clinically 46 integrated health care providers that work together to provide, manage, 47 and coordinate health care (including primary care) for a defined popu- 48 lation; with a mechanism for shared governance; the ability to negoti- 49 ate, receive, and distribute payments; and accountability for the quali- 50 ty, cost, and delivery of health care to the ACO's patients; in 51 accordance with this article; and (b) has been issued a certificate of 52 authority by the commissioner under this article. 53 2. The commissioner shall establish a [demonstration] program within 54 the department to [test the ability] PROMOTE AND REGULATE THE USE of 55 ACOs to deliver an array of health care services for the purpose of A. 8869--B 3 1 improving the quality, coordination and accountability of services 2 provided to patients in New York. 3 3. The commissioner may issue a certificate of authority to an entity 4 that meets conditions for ACO certification as set forth in regulations 5 [promulgated] MADE by the commissioner pursuant to section twenty-nine 6 hundred ninety-nine-q of this article. The commissioner shall not [issue 7 more than seven certificates under this article, and shall not] issue 8 any new certificate under this article after December thirty-first, two 9 thousand [fifteen] SIXTEEN. 10 4. (A) NOTWITHSTANDING SUBDIVISION THREE OF THIS SECTION, THE COMMIS- 11 SIONER SHALL ISSUE A CERTIFICATE OF AUTHORITY AS A MEDICARE-ONLY ACO TO 12 AN ENTITY AUTHORIZED BY CMS TO BE AN ACCOUNTABLE CARE ORGANIZATION UNDER 13 THE MEDICARE PROGRAM, UPON RECEIVING AN APPLICATION TO BE A 14 MEDICARE-ONLY ACO FROM THE ENTITY DOCUMENTING ITS STATUS UNDER THIS 15 SUBDIVISION. A CERTIFICATE OF AUTHORITY UNDER THIS SUBDIVISION SHALL 16 ONLY APPLY TO THE MEDICARE-ONLY ACO'S ACTIONS IN RELATION TO MEDICARE 17 BENEFICIARIES UNDER ITS AUTHORIZATION FROM CMS. 18 (B) TO THE EXTENT CONSISTENT WITH CMS REGULATIONS, A MEDICARE-ONLY ACO 19 SHALL BE SUBJECT TO: 20 (I) SUBDIVISION SEVEN OF SECTION TWENTY-NINE HUNDRED NINETY-NINE-Q AND 21 SUBDIVISIONS ONE, TWO AND THREE OF SECTION TWENTY-NINE HUNDRED 22 NINETY-NINE-R OF THIS ARTICLE, WITHOUT REGARD TO WHETHER THE COMMISSION- 23 ER HAS MADE REGULATIONS UNDER THIS ARTICLE; AND 24 (II) OTHER PROVISIONS OF THIS ARTICLE TO THE EXTENT SPECIFICALLY 25 PROVIDED BY THE COMMISSIONER IN REGULATIONS CONSISTENT WITH THIS ARTI- 26 CLE. 27 5. The commissioner may limit, suspend, or terminate a certificate of 28 authority if an ACO is not operating in accordance with this article. 29 [5.] 6. The commissioner is authorized to seek federal approvals and 30 waivers to implement this article, including but not limited to those 31 approvals or waivers necessary to obtain federal financial partic- 32 ipation. 33 S 2999-q. Accountable care organizations; requirements. 1. The commis- 34 sioner shall [promulgate] MAKE regulations establishing criteria for 35 certificates of authority, quality standards for ACOs, reporting 36 requirements and other matters deemed to be appropriate and necessary in 37 the operation and evaluation of [the demonstration program] ACOS UNDER 38 THIS ARTICLE. In [promulgating] MAKING such regulations, the commission- 39 er shall consult with the superintendent of financial services, health 40 care providers, third-party health care payers, advocates representing 41 patients, and other appropriate parties. SUCH REGULATIONS SHALL BE 42 CONSISTENT, TO THE EXTENT PRACTICAL AND CONSISTENT WITH THIS ARTICLE, 43 WITH CMS REGULATIONS FOR ACCOUNTABLE CARE ORGANIZATIONS UNDER THE MEDI- 44 CARE PROGRAM. 45 2. Such regulations may, and shall as necessary for purposes of this 46 article, address matters including but not limited to: 47 (a) The governance, leadership and management structure of the ACO 48 THAT REASONABLY AND EQUITABLY REPRESENTS THE ACO'S PARTICIPANTS AND THE 49 ACO'S PATIENTS, including the manner in which clinical and administra- 50 tive systems and clinical participation will be managed; 51 (b) Definition of the population proposed to be served by the ACO, 52 which may include reference to a geographical area and patient charac- 53 teristics; 54 (c) The character, competence and fiscal responsibility and soundness 55 of an ACO and its principals, if and to the extent deemed appropriate by 56 the commissioner; A. 8869--B 4 1 (d) The adequacy of an ACO's network of participating health care 2 providers, including primary care health care providers; 3 (e) Mechanisms by which an ACO will provide, manage, and coordinate 4 quality health care for its patients [and provide] INCLUDING WHERE PRAC- 5 TICABLE ELEVATING THE SERVICES OF PRIMARY CARE HEALTH CARE PROVIDERS TO 6 MEET PATIENT-CENTERED MEDICAL HOME STANDARDS, COORDINATING SERVICES FOR 7 COMPLEX HIGH-NEED PATIENTS, AND PROVIDING access to health care provid- 8 ers that are not participants in the ACO; 9 (f) Mechanisms by which the ACO shall receive and distribute payments 10 to its participating health care providers, which may include incentive 11 payments (WHICH MAY INCLUDE MEDICAL HOME PAYMENTS) or mechanisms for 12 pooling payments received by participating health care providers from 13 third-party payers and patients; 14 (g) Mechanisms and criteria for accepting health care providers to 15 participate in the ACO that are related to the needs of the patient 16 population to be served and needs and purposes of the ACO, and prevent- 17 ing unreasonable discrimination; 18 (h) Mechanisms for quality assurance and grievance procedures for 19 patients or health care providers where appropriate, AND PROCEDURES FOR 20 REVIEWING AND APPEALING PATIENT CARE DECISIONS; 21 (i) Mechanisms that promote evidence-based health care, patient 22 engagement, coordination of care, electronic health records, including 23 participation in health information exchanges, [and] other enabling 24 technologies AND INTEGRATED, EFFICIENT AND EFFECTIVE HEALTH CARE 25 SERVICES; 26 (j) Performance standards for, and measures to assess, the quality and 27 utilization of care provided by an ACO; 28 (k) Appropriate requirements for ACOs to promote compliance with the 29 purposes of this article; 30 (l) Posting on the department's website information about ACOs that 31 would be useful to health care providers and patients, INCLUDING SIMILAR 32 METRICS AS THE COMMISSIONER PUBLISHES FOR OTHER ORGANIZATIONS SUCH AS 33 MEDICAID MANAGED CARE PROVIDERS UNDER SECTION THREE HUNDRED SIXTY-FOUR-J 34 OF THE SOCIAL SERVICES LAW AND HEALTH HOMES UNDER SECTION THREE HUNDRED 35 SIXTY-FIVE-L OF THE SOCIAL SERVICES LAW; 36 (m) Requirements for the submission of information and data by ACOs 37 and their participating and affiliated health care providers as neces- 38 sary for the evaluation of the success of [the demonstration program] 39 ACOS; 40 (n) Protection of patient rights as appropriate; 41 (o) The impact of the establishment and operation of an ACO [on], 42 INCLUDING PROVIDING THAT IT SHALL NOT DIMINISH access to any health care 43 service FOR THE POPULATION SERVED AND in the area served; and 44 (p) Establishment of standards, as appropriate, to promote the ability 45 of an ACO to participate in applicable federal programs for ACOs. 46 3. (A) THE ACO SHALL PROVIDE FOR MEANINGFUL PARTICIPATION IN THE 47 COMPOSITION AND CONTROL OF THE ACO'S GOVERNING BODY FOR ACO PARTICIPANTS 48 OR THEIR DESIGNATED REPRESENTATIVES. 49 (B) THE ACO GOVERNING BODY SHALL INCLUDE AT LEAST ONE REPRESENTATIVE 50 OF EACH OF THE FOLLOWING GROUPS: (I) RECIPIENTS OF MEDICAID, FAMILY 51 HEALTH PLUS, OR CHILD HEALTH PLUS; (II) PERSONS WITH OTHER HEALTH COVER- 52 AGE; AND (III) PERSONS WHO DO NOT HAVE HEALTH COVERAGE. SUCH REPRESEN- 53 TATIVES SHALL HAVE NO CONFLICT OF INTEREST WITH THE ACO AND NO IMMEDIATE 54 FAMILY MEMBER WITH A CONFLICT OF INTEREST WITH THE ACO. 55 (C) AT LEAST SEVENTY-FIVE PERCENT CONTROL OF THE ACO'S GOVERNING BODY 56 SHALL BE HELD BY ACO PARTICIPANTS. A. 8869--B 5 1 (D) MEMBERS OF THE ACO GOVERNING BODY SHALL HAVE A FIDUCIARY RELATION- 2 SHIP WITH THE ACO AND SHALL BE SUBJECT TO CONFLICT OF INTEREST REQUIRE- 3 MENTS ADOPTED BY THE ACO AND IN REGULATIONS OF THE COMMISSIONER. 4 (E) THE ACO'S FINANCES, INCLUDING DIVIDENDS AND OTHER RETURN ON CAPI- 5 TAL, DEBT STRUCTURE, EXECUTIVE COMPENSATION, AND ACO PARTICIPANT COMPEN- 6 SATION, SHALL BE ARRANGED AND CONDUCTED TO MAXIMIZE THE ACHIEVEMENT OF 7 THE PURPOSES OF THIS ARTICLE. 8 4. (A) AN ACO SHALL USE ITS BEST EFFORTS TO INCLUDE AMONG ITS PARTIC- 9 IPANTS, ON REASONABLE TERMS AND CONDITIONS, ANY FEDERALLY-QUALIFIED 10 HEALTH CENTER THAT IS WILLING TO BE A PARTICIPANT AND THAT SERVES THE 11 AREA AND POPULATION SERVED BY THE ACO. 12 (B) AN ACO MAY SEEK TO FOCUS ON PROVIDING HEALTH CARE SERVICES TO 13 PATIENTS WITH ONE OR MORE CHRONIC CONDITIONS OR SPECIAL NEEDS. HOWEVER, 14 AN ACO MAY NOT OTHERWISE, ON THE BASIS OF A PERSON'S MEDICAL OR DEMO- 15 GRAPHIC CHARACTERISTICS, DISCRIMINATE FOR OR AGAINST OR DISCOURAGE OR 16 ENCOURAGE ANY PERSON OR PERSON WITH RESPECT TO ENROLLING OR PARTICIPAT- 17 ING IN THE ACO. 18 (C) AN ACO SHALL NOT, BY INCENTIVES OR OTHERWISE, DISCOURAGE A HEALTH 19 CARE PROVIDER FROM PROVIDING OR AN ENROLLEE OR PATIENT FROM SEEKING 20 APPROPRIATE HEALTH CARE SERVICES. 21 (D) AN ACO SHALL NOT DISCRIMINATE AGAINST OR DISADVANTAGE A PATIENT OR 22 PATIENT'S REPRESENTATIVE FOR THE EXERCISE OF PATIENT AUTONOMY. 23 (E) AN ACO MAY NOT LIMIT OR RESTRICT BENEFICIARIES TO USE OF PROVIDERS 24 CONTRACTED OR AFFILIATED WITH THE ACO. AN ACO MAY NOT REQUIRE A PATIENT 25 TO OBTAIN THE PRIOR APPROVAL, FROM A PRIMARY CARE GATEKEEPER OR OTHER- 26 WISE, BEFORE UTILIZING THE SERVICES OF OTHER PROVIDERS. AN ACO MAY NOT 27 MAKE ADVERSE DETERMINATIONS AS DEFINED IN ARTICLE FORTY-NINE OF THIS 28 CHAPTER. 29 5. AN ACO MAY PROVIDE CARE COORDINATION FOR ITS PARTICIPATING 30 PATIENTS, WHICH (A) SHALL INCLUDE BUT NOT BE LIMITED TO MANAGING, REFER- 31 RING TO, LOCATING, COORDINATING, AND MONITORING HEALTH CARE SERVICES FOR 32 THE MEMBER TO ASSURE THAT ALL MEDICALLY NECESSARY HEALTH CARE SERVICES 33 ARE MADE AVAILABLE TO AND ARE EFFECTIVELY USED BY THE MEMBER IN A TIMELY 34 MANNER, CONSISTENT WITH PATIENT AUTONOMY; AND (B) IS NOT A REQUIREMENT 35 FOR PRIOR AUTHORIZATION FOR HEALTH CARE SERVICES, AND REFERRAL SHALL NOT 36 BE REQUIRED FOR A MEMBER TO RECEIVE A HEALTH CARE SERVICE. 37 6. (a) Subject to regulations of the commissioner: (i) an ACO may 38 enter into arrangements with one or more third-party health care payers 39 to establish payment methodologies for health care services for the 40 third-party health care payer's enrollees provided by the ACO or for 41 which the ACO is responsible, such as full or partial capitation or 42 other arrangements; (ii) such arrangements may include provision for the 43 ACO to receive and distribute payments to the ACO's participating health 44 care providers, including incentive payments and payments for health 45 care services from third-party health care payers and patients; and 46 (iii) an ACO may include mechanisms for pooling payments received by 47 participating health care providers from third-party payers and 48 patients. 49 (b) Subject to regulations of the commissioner, the commissioner, in 50 consultation with the superintendent of financial services, may author- 51 ize a third-party health care payer to participate in payment methodol- 52 ogies with an ACO under this subdivision, notwithstanding any contrary 53 provision of this chapter, the insurance law, the social services law, 54 or the elder law, on finding that the payment methodology is consistent 55 with the purposes of this article. A. 8869--B 6 1 [4.] (C) AN ACO MAY CONTRACT WITH A THIRD-PARTY HEALTH CARE PAYER TO 2 SERVE AS ALL OR PART OF THE THIRD-PARTY HEALTH CARE PAYER'S PROVIDER 3 NETWORK OR CARE COORDINATION AGENT, PROVIDED IN THAT CASE THE ACO SHALL 4 BE SUBJECT TO ALL PROVISIONS OF THIS CHAPTER OR THE INSURANCE LAW WHICH 5 ARE APPLICABLE TO THE PROVIDER NETWORK OF THE THIRD-PARTY HEALTH CARE 6 PAYER. 7 7. The provision of health care services directly or indirectly by an 8 ACO through health care providers shall not be considered the practice 9 of a profession under title eight of the education law by the ACO. 10 S 2999-r. Other laws. 1. (a) It is the policy of the state to permit 11 and encourage cooperative, collaborative and integrative arrangements 12 among third-party health care payers and health care providers who might 13 otherwise be competitors under the active supervision of the commission- 14 er. To the extent that it is necessary to accomplish the purposes of 15 this article, competition may be supplanted and the state may provide 16 state action immunity under state and federal antitrust laws to payors 17 and health care providers. 18 (b) The commissioner [may] SHALL engage in state supervision to 19 promote state action immunity under state and federal antitrust laws and 20 may inspect, require, or request additional documentation and take other 21 actions under this article to verify and make sure that this article is 22 implemented in accordance with its intent and purpose. 23 2. With respect to the planning, implementation, and operation of 24 ACOs, the commissioner, by regulation, [may] SHALL specifically deline- 25 ate safe harbors that exempt ACOs from the application of the following 26 statutes: 27 (a) article twenty-two of the general business law relating to 28 arrangements and agreements in restraint of trade; 29 (b) article one hundred thirty-one-A of the education law relating to 30 fee-splitting arrangements; and 31 (c) title two-D of article two of this chapter relating to health care 32 practitioner referrals. 33 3. For the purposes of this article, an ACO shall be deemed to be a 34 hospital for purposes of sections twenty-eight hundred five-j, twenty- 35 eight hundred five-k, twenty-eight hundred five-l and twenty-eight 36 hundred five-m of this chapter and subdivisions three and five of 37 section sixty-five hundred twenty-seven of the education law. 38 4. THE COMMISSIONER IS AUTHORIZED TO SEEK FEDERAL GRANTS, APPROVALS, 39 AND WAIVERS TO IMPLEMENT THIS ARTICLE, INCLUDING FEDERAL FINANCIAL 40 PARTICIPATION UNDER PUBLIC HEALTH COVERAGE. THE COMMISSIONER SHALL 41 PROVIDE COPIES OF APPLICATIONS AND OTHER DOCUMENTS, INCLUDING DRAFTS, 42 SUBMITTED TO THE FEDERAL GOVERNMENT SEEKING SUCH FEDERAL GRANTS, 43 APPROVALS, AND WAIVERS TO THE CHAIRS OF THE SENATE FINANCE COMMITTEE, 44 THE ASSEMBLY WAYS AND MEANS COMMITTEE, AND THE SENATE AND ASSEMBLY 45 HEALTH COMMITTEES SIMULTANEOUSLY WITH THEIR SUBMISSION TO THE FEDERAL 46 GOVERNMENT. 47 5. THE COMMISSIONER MAY DIRECTLY, OR BY CONTRACT WITH NOT-FOR-PROFIT 48 ORGANIZATIONS, PROVIDE: 49 (A) CONSUMER ASSISTANCE TO PATIENTS SERVED BY AN ACO AS TO MATTERS 50 RELATING TO ACOS; 51 (B) TECHNICAL AND OTHER ASSISTANCE TO HEALTH CARE PROVIDERS PARTIC- 52 IPATING IN AN ACO AS TO MATTERS RELATING TO THE ACO; 53 (C) ASSISTANCE TO ACOS TO PROMOTE THEIR FORMATION AND IMPROVE THEIR 54 OPERATION, INCLUDING ASSISTANCE UNDER SECTION TWENTY-EIGHT HUNDRED EIGH- 55 TEEN OF THIS CHAPTER; AND A. 8869--B 7 1 (D) INFORMATION SHARING AND OTHER ASSISTANCE AMONG ACOS TO IMPROVE THE 2 OPERATION OF ACOS. 3 S 2. The commissioner of health shall convene a workgroup to develop a 4 proposal whereby an ACO may serve, in place of a managed care plan: (a) 5 Medicaid enrollees otherwise required to participate in managed care, 6 care management, or care coordination under section 364-j of the social 7 services law, section 4403-f of the public health law, or other law; and 8 (b) enrollees in family health plus under section 369-ee or section 9 369-ff of the social services law and the child health insurance plan 10 under title 1-A of article 25 of the public health law. The workgroup 11 shall include, but not be limited to, representatives of: accountable 12 care organizations or entities seeking to form an accountable care 13 organization under article 29-E of the public health law; health care 14 providers serving Medicaid enrollees; Medicaid, family health plus, and 15 child health insurance plan enrollees; and the senate and the assembly. 16 The workgroup shall report its recommendations for regulatory or statu- 17 tory actions to the governor, the commissioner of health, and the legis- 18 lature. 19 S 3. Section 2818 of the public health law is amended by adding a new 20 subdivision 7 to read as follows: 21 7. NOTWITHSTANDING SUBDIVISIONS ONE AND TWO OF THIS SECTION, SECTIONS 22 ONE HUNDRED TWELVE AND ONE HUNDRED SIXTY-THREE OF THE STATE FINANCE LAW, 23 OR ANY OTHER INCONSISTENT PROVISION OF LAW, OF THE FUNDS AVAILABLE FOR 24 EXPENDITURE PURSUANT TO THIS SECTION, THE COMMISSIONER MAY ALLOCATE AND 25 DISTRIBUTE, WITHOUT A COMPETITIVE BID OR REQUEST FOR PROPOSAL PROCESS, 26 GRANTS TO ACCOUNTABLE CARE ORGANIZATIONS UNDER ARTICLE TWENTY-NINE-E OF 27 THIS CHAPTER FOR THE PURPOSE OF PROMOTING THEIR FORMATION AND IMPROVING 28 THEIR OPERATION. CONSIDERATION RELIED UPON BY THE COMMISSIONER IN 29 DETERMINING THE ALLOCATION AND DISTRIBUTION OF THESE FUNDS SHALL 30 INCLUDE, BUT NOT BE LIMITED TO, THE NEED FOR AND CAPACITY OF THE 31 ACCOUNTABLE CARE ORGANIZATION TO ACCOMPLISH THE PURPOSES OF ARTICLE 32 TWENTY-NINE-E OF THIS CHAPTER IN THE AREA TO BE SERVED. 33 S 4. This act shall take effect immediately.