There is a newer version of the New York Consolidated Laws
2006 New York Code - Managed Care Programs.
* § 364-j. Managed care programs. 1. Definitions. As used in this
section, unless the context clearly requires otherwise, the following
terms shall mean:
(a) "Participant". A medical assistance recipient who receives, is
required to receive or elects to receive his or her medical assistance
services from a managed care provider.
(b) "Managed care provider". An entity that provides or arranges for
the provision of medical assistance services and supplies to
participants directly or indirectly (including by referral), including
case management; and:
(i) is authorized to operate under article forty-four of the public
health law or article forty-three of the insurance law and provides or
arranges, directly or indirectly (including by referral) for covered
comprehensive health services on a full capitation basis; or
(ii) is authorized as a partially capitated program pursuant to
section three hundred sixty-four-f of this title or section forty-four
hundred three-e of the public health law or section 1915b of the social
security act.
(c) "Managed care program". A statewide program in which medical
assistance recipients enroll on a voluntary or mandatory basis to
receive medical assistance services, including case management, directly
and indirectly (including by referral) from a managed care provider, and
as applicable, a mental health special needs plan or a comprehensive HIV
special needs plan, under this section.
(d) "Medical services provider". A physician, nurse, nurse
practitioner, physician assistant, licensed midwife, dentist,
optometrist or other licensed health care practitioner authorized to
provide medical assistance services.
(e) "Center of excellence." A health care facility certified to
operate under article twenty-eight of the public health law that offers
specialized treatment expertise in HIV care services as defined by the
commissioner of health.
(f) "Primary care practitioner". A physician or nurse practitioner
providing primary care to and management of the medical and health care
services of a participant served by a managed care provider.
(g) "AIDS". AIDS shall have the same meaning as in article
twenty-seven-f of the public health law.
(h) "HIV infection". HIV infection shall have the same meaning as in
article twenty-seven-f of the public health law.
(i) "HIV-related illness". HIV-related illness shall have the same
meaning as in article twenty-seven-f of the public health law.
(j) "Specialty care center". A "specialty care center" shall mean only
such centers as are accredited or designated by an agency of the state
or federal government or by a voluntary national health organization as
having special expertise in treating the disease or condition for which
it is accredited or designated.
(k) "Special care". Care, services and supplies relating to the
treatment of mental illness, mental retardation, developmental
disabilities, alcoholism, alcohol abuse or substance abuse, or HIV
infection/AIDS.
(l) "Responsible special care agency". Whichever of the following
state agencies has responsibility for the special care in question: the
department of health, the office of mental health, the office of mental
retardation and developmental disabilities, or the office of alcoholism
and substance abuse services.
(m) "Mental health special needs plan" shall have the same meaning as
in section forty-four hundred three-d of the public health law.
(n) "Comprehensive HIV special needs plan" shall have the same meaning
as in section forty-four hundred three-c of the public health law.
(o) "Third-party payor". Any entity or program that is or may be
liable to pay the costs of health and medical care of a recipient of
medical assistance benefits, including insurers licensed pursuant to
article thirty-two or forty-three of the insurance law, or organizations
certified pursuant to article forty-four of the public health law.
(p) "Grievance". Any complaint presented by a participant or a
participant's representative for resolution through the grievance
process of a managed care provider, comprehensive HIV special needs plan
or a mental health special needs plan.
(q) "Emergency medical condition". A medical or behavioral condition,
the onset of which is sudden, that manifests itself by symptoms of
sufficient severity, including severe pain, that a prudent layperson,
who possesses an average knowledge of medicine and health, could
reasonably expect the absence of immediate medical attention to result
in: (i) placing the health of the person afflicted with such condition
in serious jeopardy, or in the case of a behavioral condition placing
the health of the person or others in serious jeopardy; or (ii) serious
impairment to such person's bodily functions; or (iii) serious
dysfunction of any bodily organ or part of such person; or (iv) serious
disfigurement of such person.
(r) "Emergency care". Health care procedures, treatments or services,
including psychiatric stabilization and medical detoxification from
drugs or alcohol, that are provided for an emergency medical condition.
(s) "Existing rates". The rates paid pursuant to the most recent
executed contract between a local social services district or the state
and a managed care provider.
(t) "Managed care rating regions". The regions established by the
department of health for the purpose of setting regional premium rates
for managed care providers.
(u) "Premium group". The various demographic, gender and recipient
categories utilized for rate-setting purposes by the department of
health.
(v) "Upper payment limit". The maximum reimbursement that the
department of health may pay a managed care provider for providing or
arranging for medical services to participants in a managed care program
in accordance with the federal social security act and regulations
promulgated thereunder.
(x) "Persons with serious mental illness". Individuals who meet
criteria established by the commissioner of mental health, which shall
include persons who have a designated diagnosis of mental illness under
the most recent edition of the diagnostic and statistical manual of
mental disorders, and (i) whose severity and duration of mental illness
results in substantial functional disability or (ii) who require mental
health services on more than an incidental basis.
(y) "Children and adolescents with serious emotional disturbances".
Individuals under eighteen years of age who meet criteria established by
the commissioner of mental health, which shall include children and
adolescents who have a designated diagnosis of mental illness under the
most recent edition of the diagnostic and statistical manual of mental
disorders, and (i) whose severity and duration of mental illness results
in substantial functional disability or (ii) who require mental health
services on more than an incidental basis.
2. (a) The commissioner of health, in cooperation with the
commissioner and the commissioners of the responsible special care
agencies shall establish managed care programs, under the medical
assistance program, in accordance with applicable federal law and
regulations. The commissioner of health, in cooperation with the
commissioner, is authorized and directed, subject to the approval of the
director of the state division of the budget, to apply for federal
waivers when such action would be necessary to assist in promoting the
objectives of this section.
(b) The commissioner of health has authority to allow social services
districts to seek an exemption from this section for up to two years if
the social services district can demonstrate and the commissioner of
health and the commissioner of responsible special care agencies concurs
that the district has insufficient capacity to participate in the
program. An exemption under this paragraph may be renewed for additional
two year periods.
3. (a) Every person eligible for or receiving medical assistance under
this article, who resides in a social services district providing
medical assistance, which has implemented the state's managed care
program shall participate in the program authorized by this section.
Provided, however, that participation in a comprehensive HIV special
needs plan also shall be in accordance with article forty-four of the
public health law and participation in a mental health special needs
plan shall also be in accordance with article forty-four of the public
health law and article thirty-one of the mental hygiene law.
(b) A medical assistance recipient shall not be required to
participate in, and shall be permitted to withdraw from the managed care
program upon a showing that:
(i) a managed care provider is not geographically accessible to the
person so as to reasonably provide services to the person, or upon a
showing of other good cause as defined in regulation. A managed care
provider is not geographically accessible if the person cannot access
its services in a timely fashion due to distance or travel time;
(ii) a pregnant woman with an established relationship, as defined by
the commissioner of health, with a comprehensive prenatal primary care
provider, including a prenatal care assistance program as defined in
title two of article twenty-five of the public health law, that is not
associated with a managed care provider in the participant's social
services district, may defer participation in the managed care program
while pregnant and for sixty days post-partum;
(iii) an individual with a chronic medical condition being treated by
a specialist physician that is not associated with a managed care
provider in the participant's social services district, may defer
participation in the managed care program until the course of treatment
is complete; and
(iv) a participant cannot be served by a managed care provider who
participates in a managed care program due to a language barrier.
(c) The following medical assistance recipients shall not be required
to participate in a managed care program established pursuant to this
section, but may voluntarily opt to do so:
(i) a person receiving services provided by a residential alcohol or
substance abuse program or facility for the mentally retarded;
(ii) a person receiving services provided by an intermediate care
facility for the mentally retarded or who has characteristics and needs
similar to such persons;
(iii) a person with a developmental or physical disability who
receives home and community-based services or care-at-home services
through existing waivers under section nineteen hundred fifteen (c) of
the federal social security act or who has characteristics and needs
similar to such persons;
(iv) Native Americans;
(v) Medicare/Medicaid dually eligible individuals not enrolled in a
Medicare TEFRA plan; or
(vi) a person who is eligible for medical assistance pursuant to
subparagraph twelve or subparagraph thirteen of paragraph (a) of
subdivision one of section three hundred sixty-six of this title, and
who is not required to pay a premium pursuant to subdivision twelve of
section three hundred sixty-seven-a of this title.
(d) The following medical assistance recipients shall not be eligible
to participate in a managed care program established pursuant to this
section:
(i) a person receiving services provided by a long term home health
care program, or a person receiving inpatient services in a
state-operated psychiatric facility or a residential treatment facility
for children and youth;
(ii) a person eligible for Medicare participating in a capitated
demonstration program for long term care;
(iii) an infant living with an incarcerated mother in a state or local
correctional facility as defined in section two of the correction law;
(iv) a person who is expected to be eligible for medical assistance
for less than six months;
(v) a person who is eligible for medical assistance benefits only with
respect to tuberculosis-related services;
(vi) certified blind or disabled children living or expected to be
living separate and apart from the parent for 30 days or more;
(vii) residents of nursing facilities at time of enrollment;
(viii) individuals receiving hospice services at time of enrollment;
(ix) individuals in the restricted recipient program;
(x) a person who has primary medical or health care coverage available
from or under a third-party payor which may be maintained by payment, or
part payment, of the premium or costsharing amounts, when payment of
such premium or costsharing amounts would be cost-effective, as
determined by the local social services district;
(xi) a foster child in the placement of a voluntary agency;
(xii) a person receiving family planning services pursuant to
subparagraph eleven of paragraph (a) of subdivision one of section three
hundred sixty-six of this title; and
(xiii) a person who is eligible for medical assistance pursuant to
paragraph (v) of subdivision four of section three hundred sixty-six of
this title; and
(xiv) a person who is eligible for medical assistance pursuant to
subparagraph twelve or subparagraph thirteen of paragraph (a) of
subdivision one of section three hundred sixty-six of this title, and
who is required to pay a premium pursuant to subdivision twelve of
section three hundred sixty-seven-a of this title.
(e) The following services shall not be provided to medical assistance
recipients through managed care programs established pursuant to this
section, and shall continue to be provided outside of managed care
programs and in accordance with applicable reimbursement methodologies:
(i) day treatment services provided to individuals with developmental
disabilities;
(ii) comprehensive medicaid case management services provided to
individuals with developmental disabilities;
(iii) services provided pursuant to title two-A of article twenty-five
of the public health law;
(iv) services provided pursuant to article eighty-nine of the
education law;
(v) mental health services provided by a certified voluntary
free-standing day treatment program where such services are provided in
conjunction with educational services authorized in an individualized
education program in accordance with regulations promulgated pursuant to
article eighty-nine of the education law;
(vi) long term services as determined by the commissioner of mental
retardation and developmental disabilities, provided to individuals with
developmental disabilities at facilities licensed pursuant to article
sixteen of the mental hygiene law or clinics serving individuals with
developmental disabilities at facilities licensed pursuant to article
twenty-eight of the public health law;
(vii) TB directly observed therapy;
(viii) AIDS adult day health care;
(ix) HIV COBRA case management; and
(x) other services as determined by the commissioner of health.
(f) The following medical assistance recipients shall not be eligible
to participate in a managed care program established pursuant to this
section, unless the local social services district permits them to do
so;
(i) a person or family that is homeless and is living in a shelter;
and
(ii) a foster care child in the direct care of the local social
services district.
(g) The following categories of individuals will not be required to
enroll with a managed care program until program features and
reimbursement rates are approved by the commissioner of health and, as
appropriate, the commissioner of mental health:
(i) an individual dually eligible for medical assistance and benefits
under the federal Medicare program and enrolled in a TEFRA plan;
(ii) an individual eligible for supplemental security income;
(iii) HIV positive individuals; and
(iv) persons with serious mental illness and children and adolescents
with serious emotional disturbances, as defined in section forty-four
hundred one of the public health law.
4. The managed care program shall provide participants access to
comprehensive and coordinated health care delivered in a cost effective
manner consistent with the following provisions:
(a) (i) a managed care provider shall arrange for access to and
enrollment of primary care practitioners and other medical services
providers. Each managed care provider shall possess the expertise and
sufficient resources to assure the delivery of quality medical care to
participants in an appropriate and timely manner and may include
physicians, nurse practitioners, county health departments, providers of
comprehensive health service plans licensed pursuant to article
forty-four of the public health law, and hospitals and diagnostic and
treatment centers licensed pursuant to article twenty-eight of the
public health law or otherwise authorized by law to offer comprehensive
health services or facilities licensed pursuant to articles sixteen,
thirty-one and thirty-two of the mental hygiene law.
(ii) provided, however, if a major public hospital, as defined in the
public health law, is designated by the commissioner of health as a
managed care provider in a social services district the commissioner of
health shall designate at least one other managed care provider which is
not a major public hospital or facility operated by a major public
hospital; and
(iii) under a managed care program, not all managed care providers
must be required to provide the same set of medical assistance services.
The managed care program shall establish procedures through which
participants will be assured access to all medical assistance services
to which they are otherwise entitled, other than through the managed
care provider, where:
(A) the service is not reasonably available directly or indirectly
from the managed care provider,
(B) it is necessary because of emergency or geographic unavailability,
or
(C) the services provided are family planning services; or
(D) the services are dental services and are provided by a diagnostic
and treatment center licensed under article twenty-eight of the public
health law which is affiliated with an academic dental center and which
has been granted an operating certificate pursuant to article
twenty-eight of the public health law to provide such dental services.
Any diagnostic and treatment center providing dental services pursuant
to this clause shall prior to June first of each year report to the
governor, temporary president of the senate and speaker of the assembly
on the following: the total number of visits made by medical assistance
recipients during the immediately preceding calendar year; the number of
visits made by medical assistance recipients during the immediately
preceding calendar year by recipients who were enrolled in managed care
programs; the number of visits made by medical assistance recipients
during the immediately preceding calendar year by recipients who were
enrolled in managed care programs that provide dental benefits as a
covered service; and the number of visits made by the uninsured during
the immediately preceding calendar year; or
(E) other services as defined by the commissioner of health.
* (b) Participants shall select a managed care provider from among
those designated under the managed care program, provided, however, a
participant shall be provided with a choice of no less than two managed
care providers.
* NB Effective until July 1, 2006
* (b) Participants shall select a managed care provider from among
those designated under the managed care program, provided, however, a
participant shall be provided with a choice of no less than two managed
care providers. Notwithstanding the foregoing, a local social services
district designated a rural area as defined in 42 U.S.C. 1395ww may
limit a participant to one managed care provider, if the commissioner
and the local social services district find that only one managed care
provider is available. A managed care provider in a rural area shall
offer a participant a choice of at least three primary care
practitioners and permit the individual to obtain a service or seek a
provider outside of the managed care network where such service or
provider is not available from within the managed care provider network.
* NB Effective July 1, 2006
(c) Participants shall select a primary care practitioner from among
those designated by the managed care provider. In all districts,
participants shall be provided with a choice of no less than three
primary care practitioners. In the event that a participant does not
select a primary care practitioner, the participant's managed care
provider shall select a primary care practitioner for the participant,
taking into account geographic accessibility.
(d) For all other medical services, except as provided in paragraph
(c) of this subdivision, if a sufficient number of medical service
providers are available, a choice shall be offered.
(e) (i) In any social services district which has not implemented a
mandatory managed care program pursuant to this section, the
commissioner of health shall establish marketing and enrollment
guidelines, including but not limited to regulations governing
face-to-face marketing and enrollment encounters between managed care
providers and recipients of medical assistance and locations for such
encounters. Such regulations shall prohibit, at a minimum, telephone
cold-calling and door-to-door solicitation at the homes of medical
assistance recipients. The regulations shall also require the
commissioner of health to approve any local district marketing
guidelines. Managed care providers shall be permitted to assist
participants in completion of enrollment forms at approved health care
provider sites and other approved locations. In no case may an emergency
room be deemed an approved location. Upon enrollment, participants will
sign an attestation that: they have been informed that managed care is a
voluntary program; participants have a choice of managed care providers;
participants have a choice of primary care practitioners; and
participants must exclusively use their primary care practitioner and
plan providers except as otherwise provided in this section including
but not limited to the exceptions listed in subparagraph (iii) of
paragraph (a) of this subdivision. Managed care providers must submit
enrollment forms to the local department of social services. The local
department of social services will provide or arrange for an audit of
managed care provider enrollment forms; including telephone contacts to
determine if participants were provided with the information required by
this subparagraph. The commissioner of health may suspend or curtail
enrollment or impose sanctions for failure to appropriately notify
clients as required in this subparagraph.
(ii) In any social services district which has implemented a mandatory
managed care program pursuant to this section, the requirements of this
subparagraph shall apply to the extent consistent with federal law and
regulations. The department of health, may contract with one or more
independent organizations to provide enrollment counseling and
enrollment services, for participants required to enroll in managed care
programs, for each social services district requesting the services of
an enrollment broker. To select such organizations, the department of
health shall issue a request for proposals (RFP), shall evaluate
proposals submitted in response to such RFP and, pursuant to such RFP,
shall award a contract to one or more qualified and responsive
organizations. Such organizations shall not be owned, operated, or
controlled by any governmental agency, managed care provider,
comprehensive HIV special needs plan, mental health special needs plan,
or medical services provider.
(iii) Such independent organizations shall develop enrollment guides
for participants which shall be approved by the department of health
prior to distribution.
(iv) Local social services districts or enrollment organizations
through their enrollment counselors shall provide participants with the
opportunity for face to face counseling including individual counseling
upon request of the participant. Local social services districts or
enrollment organizations through their enrollment counselors shall also
provide participants with information in a culturally and linguistically
appropriate and understandable manner, in light of the participant's
needs, circumstances and language proficiency, sufficient to enable the
participant to make an informed selection of a managed care provider.
Such information shall include, but shall not be limited to: how to
access care within the program; a description of the medical assistance
services that can be obtained other than through a managed care
provider, mental health special needs plan or comprehensive HIV special
needs plan; the available managed care providers, mental health special
needs plans and comprehensive HIV special needs plans and the scope of
services covered by each; a listing of the medical services providers
associated with each managed care provider; the participants' rights
within the managed care program; and how to exercise such rights.
Enrollment counselors shall inquire into each participant's existing
relationships with medical services providers and explain whether and
how such relationships may be maintained within the managed care
program. For enrollments made during face to face counseling, if the
participant has a preference for particular medical services providers,
enrollment counselors shall verify with the medical services providers
that such medical services providers whom the participant prefers
participate in the managed care provider's network and are available to
serve the participant.
(v) Upon delivery of the pre-enrollment information, the local
district or the enrollment organization shall certify the participant's
receipt of such information. Upon verification that the participant has
received the pre-enrollment education information, a managed care
provider, a local district or the enrollment organization may enroll a
participant into a managed care provider. Managed care providers must
submit enrollment forms to the local department of social services. Upon
enrollment, participants will sign an attestation that they have been
informed that: participants have a choice of managed care providers;
participants have a choice of primary care practitioners; and, except as
otherwise provided in this section, including but not limited to the
exceptions listed in subparagraph (iii) of paragraph (a) of this
subdivision, participants must exclusively use their primary care
practitioners and plan providers. The commissioner of health or with
respect to a managed care plan serving participants in a city with a
population of over two million, the local department of social services
in such city, may suspend or curtail enrollment or impose sanctions for
failure to appropriately notify clients as required in this
subparagraph.
(vi) Enrollment counselors or local social services districts shall
further inquire into each participant's health status in order to
identify physical or behavioral conditions that require immediate
attention or continuity of care, and provide to participants information
regarding health care options available to persons with HIV and other
illnesses or conditions under the managed care program. Any information
disclosed to counselors shall be kept confidential in accordance with
applicable provisions of the public health law, and as appropriate, the
mental hygiene law.
(vii) Any marketing materials developed by a managed care provider,
comprehensive HIV special needs plan or mental health special needs plan
shall be approved by the department of health or the local social
services district and the commissioner of mental health, where
appropriate, within sixty days prior to distribution to recipients of
medical assistance. All marketing materials shall be reviewed within
sixty days of submission.
(viii) In any social services district which has implemented a
mandatory managed care program pursuant to this section, the
commissioner of health shall establish marketing and enrollment
guidelines, including but not limited to regulations governing
face-to-face marketing and enrollment encounters between managed care
providers and recipients of medical assistance and locations for such
encounters. Such regulations shall prohibit, at a minimum, telephone
cold-calling and door-to-door solicitation at the homes of medical
assistance recipients. The regulations shall also require the
commissioner of health to approve any local district marketing
guidelines.
(f) (i) Participants shall have no less than sixty days from the date
selected by the district to enroll in the managed care program to select
a managed care provider, and as appropriate, a mental health special
needs plan, and shall be provided with information to make an informed
choice. Where a participant has not selected such a provider or mental
health special needs plan, the commissioner of health shall assign such
participant to a managed care provider, and as appropriate, to a mental
health special needs plan, taking into account capacity and geographic
accessibility. The commissioner may after the period of time established
in subparagraph (ii) of this paragraph assign participants to a managed
care provider taking into account quality performance criteria and cost.
Provided however, cost criteria shall not be of greater value than
quality criteria in assigning participants.
(ii) The commissioner may assign participants pursuant to such
criteria on a weighted basis, provided however that for twelve months
following implementation of a mandatory program, pursuant to a federal
waiver, twenty-five percent of the participants that do not choose a
managed care provider shall be assigned to managed care providers that
satisfy the criteria set forth in subparagraph (i) of this paragraph,
and are controlled by, sponsored by, or otherwise affiliated through a
common governance or through a parent corporation with, one or more
private not-for-profit or public general hospitals or diagnostic and
treatment centers licensed pursuant to article twenty-eight of the
public health law.
(iii) For twelve months following the twelve months described in
subparagraph (ii) of this paragraph twenty-two and one-half percent of
the participants that do not choose a managed care provider shall be
assigned to managed care providers, that satisfy the criteria set forth
in subparagraph (i) of this paragraph and are controlled by, sponsored
by, or otherwise affiliated through a common governance or through a
parent corporation with, one or more private not-for-profit or public
general hospitals or diagnostic and treatment centers licensed pursuant
to article twenty-eight of the public health law.
(iv) For twelve months following the twelve months described in
subparagraph (iii) of this paragraph twenty percent of the participants
that do not choose a managed care provider shall be assigned equally
among each of the managed care providers, that satisfy the criteria set
forth in subparagraph (i) of this paragraph and are controlled by,
sponsored by, or otherwise affiliated through a common governance or
through a parent corporation with one or more private not-for-profit or
public general hospitals or diagnostic and treatment centers licensed
pursuant to article twenty-eight of the public health law.
(v) The commissioner shall assign all participants not otherwise
assigned to a managed care plan pursuant to subparagraphs (ii), (iii)
and (iv) of this paragraph equally among each of the managed care
providers that meet the criteria established in subparagraph (i) of this
paragraph.
(g) If another managed care provider, mental health special needs plan
or comprehensive HIV special needs plan is available, participants may
change such provider or plan without cause within thirty days of
notification of enrollment or the effective date of enrollment,
whichever is later with a managed care provider, mental health special
needs plan or comprehensive HIV special needs plan by making a request
of the local social services district except that such period shall be
forty-five days for participants who have been assigned to a provider by
the commissioner of health. However, after such thirty or forty-five day
period, whichever is applicable, a participant may be prohibited from
changing managed care providers more frequently than once every twelve
months, as permitted by federal law except for good cause as determined
by the commissioner of health through regulations.
(h) If another medical services provider is available, a participant
may change his or her provider of medical services (including primary
care practitioners) without cause within thirty days of the
participant's first appointment with a medical services provider by
making a request of the managed care provider, mental health special
needs plan or comprehensive HIV special needs plan. However, after that
thirty day period, no participant shall be permitted to change his or
her provider of medical services other than once every six months except
for good cause as determined by the commissioner through regulations.
(i) A managed care provider, mental health special needs plan, and
comprehensive HIV special needs plan requesting a disenrollment shall
not disenroll a participant without the prior approval of the local
social services district in which the participant resides, provided that
disenrollment from a mental health special needs plan must comply with
the standards of the commissioner of health and the commissioner of
mental health. A managed care provider, mental health special needs plan
or comprehensive HIV special needs plan shall not request disenrollment
of a participant based on any diagnosis, condition, or perceived
diagnosis or condition, or a participant's efforts to exercise his or
her rights under a grievance process, provided however, that a managed
care provider may, where medically appropriate, request permission to
refer participants to a mental health special needs plan or a
comprehensive HIV special needs plan after consulting with such
participant and upon obtaining his/her consent to such referral and,
provided further that a mental health special needs plan may, where
clinically appropriate, disenroll individuals who no longer require the
level of services provided by a mental health special needs plan.
(j) A managed care provider shall be responsible for providing or
arranging for medical assistance services and assisting participants in
the prudent selection of such services, including but not limited to:
(1) management of the medical and health care needs of participants by
the participant's designated primary care practitioners or group of
primary care practitioners to assure that all services provided under
the managed care program and which are found to be necessary are made
available in a timely manner, in accordance with prevailing standards of
professional medical practice and conduct; and
(2) use of appropriate patient assessment criteria to ensure that all
participants are provided with appropriate services, including special
care;
(3) implementation of procedures, consistent with the requirements of
paragraph (c) of subdivision six of section forty-four hundred three of
the public health law for managing the care of participants requiring
special care which may include the use of special case managers or the
designation of a specialist as a primary care practitioner by a
participant requiring special care on more than an incidental basis;
(4) implementation of procedures, consistent with the requirements of
paragraph (b) of subdivision six of section forty-four hundred three of
the public health law to permit the use of standing referrals to
specialists and subspecialists for participants who require the care of
such practitioners on a regular basis; and
(5) referral, coordination, monitoring and follow-up with regard to
other medical services providers as appropriate for diagnosis and
treatment, or direct provision of some or all medical assistance
services.
(k) A managed care provider shall establish appropriate utilization
and referral requirements for physicians, hospitals, and other medical
services providers including emergency room visits and inpatient
admissions.
(l) A managed care provider shall be responsible for developing
appropriate methods of managing the health care and medical needs of
homeless and other vulnerable participants to assure that all necessary
services provided under the managed care program are made available and
that all appropriate referrals and follow-up treatment are provided, in
a timely manner, in accordance with prevailing standards of professional
medical practice and conduct.
(m) A managed care provider shall provide all early periodic screening
diagnosis and treatment services, as well as interperiodic screening and
referral, to each participant under the age of twenty-one, at regular
intervals, as medically appropriate.
(n) A managed care provider shall provide or arrange, directly or
indirectly (including by referral) for the provision of comprehensive
prenatal care services to all pregnant participants including all
services enumerated in subdivision one of section twenty-five hundred
twenty-two of the public health law in accordance with standards adopted
by the department of health pursuant to such section.
(o) A managed care provider shall provide or arrange, directly or
indirectly, (including by referral) for the full range of covered
services to all participants, notwithstanding that such participants may
be eligible to be enrolled in a comprehensive HIV special needs plan or
mental health special needs plan.
(p) A managed care provider, comprehensive HIV special needs plan and
mental health special needs plan shall implement procedures to
communicate appropriately with participants who have difficulty
communicating in English and to communicate appropriately with
visually-impaired and hearing-impaired participants.
(q) A managed care provider, comprehensive HIV special needs plan and
mental health special needs plan shall comply with applicable state and
federal law provisions prohibiting discrimination on the basis of
disability.
(r) A managed care provider, comprehensive HIV special needs plan and
mental health special needs plan shall provide services to participants
pursuant to an order of a court of competent jurisdiction, provided
however, that such services shall be within such provider's or plan's
benefit package and are reimbursable under title xix of the federal
social security act.
(s) Managed care providers shall be provided with the date of
recertification for medical assistance of each of their enrolled
participants in conjunction with the monthly enrollment information
conveyed to managed care providers.
(t) Prospective enrollees shall be advised, in written materials
related to enrollment, to verify with the medical services providers
they prefer, or have an existing relationship with, that such medical
services providers participate in the selected managed care provider's
network and are available to serve the participant.
5. Managed care programs shall be conducted in accordance with the
requirements of this section and, to the extent practicable, encourage
the provision of comprehensive medical services, pursuant to this
article.
(a) The managed care program shall provide for the selection of
qualified managed care providers by the commissioner of health and, as
appropriate, mental health special needs plans and comprehensive HIV
special needs plans to participate in the program, provided, however,
that the commissioner of health may contract directly with comprehensive
HIV special needs plans consistent with standards set forth in this
section, and assure that such providers are accessible taking into
account the needs of persons with disabilities and the differences
between rural, suburban, and urban settings, and in sufficient numbers
to meet the health care needs of participants, and shall consider the
extent to which major public hospitals are included within such
providers' networks.
(b) A proposal submitted by a managed care provider to participate in
the managed care program shall:
(i) designate the geographic area to be served by the provider, and
estimate the number of eligible participants and actual participants in
such designated area;
(ii) include a network of health care providers in sufficient numbers
and geographically accessible to service program participants;
(iii) describe the procedures for marketing in the program location,
including the designation of other entities which may perform such
functions under contract with the organization;
(iv) describe the quality assurance, utilization review and case
management mechanisms to be implemented;
(v) demonstrate the applicant's ability to meet the data analysis and
reporting requirements of the program;
(vi) demonstrate financial feasibility of the program; and
(vii) include such other information as the commissioner of health may
deem appropriate.
(c) The commissioner of health shall make a determination whether to
approve, disapprove or recommend modification of the proposal.
(d) Notwithstanding any inconsistent provision of this title and
section one hundred sixty-three of the state finance law, the
commissioner of health or the local department of social services in a
city with a population of over two million may contract with managed
care providers approved under paragraph (b) of this subdivision, without
a competitive bid or request for proposal process, to provide coverage
for participants pursuant to this title.
(e) Notwithstanding any inconsistent provision of this title and
section one hundred forty-three of the economic development law, no
notice in the procurement opportunities newsletter shall be required for
contracts awarded by the commissioner of health or the local department
of social services in a city with a population of over two million, to
qualified managed care providers pursuant to this section.
(f) The care and services described in subdivision four of this
section will be furnished by a managed care provider pursuant to the
provisions of this section when such services are furnished in
accordance with an agreement with the department of health or the local
department of social services in a city with a population of over two
million, and meet applicable federal law and regulations.
(g) The commissioner of health may delegate some or all of the tasks
identified in this section to the local districts.
(h) Any delegation pursuant to paragraph (g) of this subdivision shall
be reflected in the contract between a managed care provider and the
commissioner of health.
6. A managed care provider, mental health special needs plan or
comprehensive HIV special needs plan provider shall not engage in the
following practices:
(a) use deceptive or coercive marketing methods to encourage
participants to enroll; or
(b) distribute marketing materials to recipients of medical
assistance, unless such materials are approved by the department of
health and, as appropriate, the office of mental health.
7. The department, the department of health or other agency of the
state as appropriate shall provide technical assistance at the request
of a social services district for the purpose of development and
implementation of managed care programs pursuant to this section. Such
assistance shall include but need not be limited to provision and
analysis of data, design of managed care programs and plans, innovative
payment mechanisms, and ongoing consultation. In addition, the
department and the department of health shall make available materials
to social services districts for purposes of educating persons eligible
to receive medical assistance on how their care will be provided through
managed care as required under paragraph (e) of subdivision five of this
section.
8. (a) The commissioner of health shall institute a comprehensive
quality assurance system for managed care providers that includes
performance and outcome-based quality standards for managed care.
(b) Every managed care provider shall implement internal quality
assurance systems adequate to identify, evaluate and remedy problems
relating to access, continuity and quality of care, utilization, and
cost of services, provided, however, that the commissioner shall waive
the implementation of internal quality assurance systems, where
appropriate, for managed care providers described in subparagraph (ii)
of paragraph (b) of subdivision one of this section. Such internal
quality assurance systems shall conform to the internal quality
assurance requirements imposed on health maintenance organizations
pursuant to the public health law and regulations and shall provide for:
(i) the designation of an organizational unit or units to perform
continuous monitoring of health care delivery;
(ii) the utilization of epidemiological data, chart reviews, patterns
of care, patient surveys, and spot checks;
(iii) reports to medical services providers assessing timeliness and
quality of care;
(iv) the identification, evaluation and remediation of problems
relating to access, continuity and quality of care; and
(v) a process for credentialing and recredentialing licensed
providers.
(c) The department of health, in consultation with the responsible
special care agencies, shall contract with one or more independent
quality assurance organizations to monitor and evaluate the quality of
care and services furnished by managed care providers. To select such
organization or organizations, the department of health shall issue
requests for proposals (RFP), shall evaluate proposals submitted in
response to such RFP, and pursuant to such RFP, shall award one or more
contracts to one or more qualified and responsive organizations. Such
quality assurance organizations shall evaluate and review the quality of
care delivered by each managed care provider, on at least an annual
basis. Such review and evaluation shall include compliance with the
performance and outcome-based quality standards promulgated by the
commissioner of health.
(d) Every managed care provider shall collect and submit to the
department of health, in a standardized format prescribed by the
department of health, patient specific medical information, including
encounter data, maintained by such provider for the purposes of quality
assurance and oversight. Any information or encounter data collected
pursuant to this paragraph, however, shall be kept confidential in
accordance with section forty-four hundred eight-a of the public health
law and section 33.13 of the mental hygiene law and any other applicable
state or federal law.
(e) Information collected and submitted to the department of health by
the independent quality assurance organization or managed care provider
pursuant to this subdivision shall be made available to the public,
subject to any other limitations of federal or state law regarding
disclosure thereof to third parties.
(f) Every managed care provider shall ensure that the provider
maintains a network of health care providers adequate to meet the
comprehensive health needs of its participants and to provide an
appropriate choice of providers sufficient to provide the services to
its participants by determining that:
(i) there are a sufficient number of geographically accessible
participating providers;
(ii) there are opportunities to select from at least three primary
care providers; and
(iii) there are sufficient providers in each area of specialty
practice to meet the needs of the enrolled population.
(g) The commissioner of health shall establish standards to ensure
that managed care providers have sufficient capacity to meet the needs
of their enrollees, which shall include patient to provider ratios,
travel and distance standards and appropriate waiting times for
appointments.
9. Managed care providers shall inform participants of such provider's
grievance procedure and utilization review procedures required pursuant
to sections forty-four hundred eight-c and forty-nine hundred of the
public health law. A managed care provider or local social services
district, as appropriate, shall provide notice to participants of their
respective rights to a fair hearing and aid continuing in accordance
with applicable state and federal law.
10. The commissioner of health shall be authorized to establish
requirements regarding provision and reimbursement of emergency care.
11. Notwithstanding section three hundred sixty-six of this chapter or
any other inconsistent provision of law, participants in the managed
care program under this section who have lost their eligibility for
medical assistance before the end of a six month period beginning on the
date of the participant's initial selection of or assignment to a
managed care provider shall have their eligibility for medical
assistance continued until the end of the six month enrollment period,
but only with respect to family planning services provided pursuant to
subparagraph (iii) of paragraph (a) of subdivision four of this section
and any services provided to the individual under the direction of the
managed care provider. Provided further, however, a pregnant woman with
an income in excess of the medically needy income level set forth in
section three hundred sixty-six of this title, who was eligible for
medical assistance solely as a result of paragraph (m) or (o) of
subdivision four of such section, shall continue to be eligible for
medical assistance benefits only through the end of the month in which
the sixtieth day following the end of her pregnancy occurs except for
eligibility for Federal Title X services which shall continue for
twenty-four months therefrom, and provided further that the services are
reimbursable by the federal government at a rate of ninety percent;
provided, however, that nothing in this subdivision shall be deemed to
affect payment for such services if federal financial participation is
not available for such care, services and supplies solely by reason of
the immigration status of the otherwise eligible woman.
12. The commissioner, by regulation, shall provide that a participant
may withdraw from participation in a managed care program upon a showing
of good cause.
13. (a) Notwithstanding any inconsistent provisions of this section,
participation in a managed care program will not diminish a recipient's
medical assistance eligibility or the scope of available medical
services to which he or she is entitled. Once a program is implemented
by or in the district in accordance with this section, medical
assistance for persons who require such assistance, who are eligible for
or in receipt of such assistance in the district and who are covered by
the program shall be limited to payment of the cost of care, services
and supplies covered by the managed care program, only when furnished,
prescribed, ordered or approved by a managed care provider, mental
health special needs plan or comprehensive HIV special needs plan and
otherwise under the program, together with the costs of medically
necessary medical and remedial care, services or supplies which are not
available to participants under the program, but which would otherwise
be available to such persons under this title and the regulations of the
department provided, however, that the program may contain provision for
payment to be made for non-emergent care furnished in hospital emergency
rooms consistent with subdivision ten of this section.
(b) Notwithstanding any inconsistent provision of law, payment for
claims for services as specified in paragraph (a) of this subdivision
furnished to eligible persons under this title, who are enrolled in a
managed care program pursuant to this section and section three hundred
sixty-four-f of this title or other comprehensive health services plans,
shall not be made when such services are the contractual responsibility
of a managed care provider but are provided by another medical services
provider contrary to the managed care plan.
14. The commissioner of health is authorized and directed, subject to
the approval of the director of the division of budget, to make grants
to social services districts to aid in the planning and development of
managed care programs. The total amount expended pursuant to this
section shall not exceed the amount appropriated for such purposes in
any fiscal year.
15. The managed medical care demonstration program advisory council is
abolished.
16. Any waiver application to the federal department of health and
human services pursuant to this article and any amendments to such
application shall be a public document.
17. The provisions of this section regarding participation of persons
receiving family assistance and supplemental security income in managed
care programs shall be effective if, and as long as, federal financial
participation is available for expenditures for services provided
pursuant to this section.
18. (a) The department of health may, where not inconsistent with the
rate setting authority of other state agencies and subject to approval
of the director of the division of the budget, develop reimbursement
methodologies and fee schedules for determining the amount of payment to
be made to managed care providers under the managed care program. Such
reimbursement methodologies and fee schedules may include provisions for
payment of managed care fees and capitation arrangements.
(b) The department of health in consultation with organizations
representing managed care providers shall select an independent actuary
to review any such reimbursement rates. Such independent actuary shall
review and make recommendations concerning appropriate actuarial
assumptions relevant to the establishment of rates including but not
limited to the adequacy of the rates in relation to the population to be
served adjusted for case mix, the scope of services the plans must
provide, the utilization of services and the network of providers
necessary to meet state standards. The independent actuary shall issue a
report no later than December thirty-first, nineteen hundred
ninety-eight and annually thereafter. Such report shall be provided to
the governor, the temporary president and the minority leader of the
senate and the speaker and the minority leader of the assembly. The
department of health shall assess managed care providers under the
managed care program on a per enrollee basis to cover the cost of such
report.
19. (a) The commissioner of health, in consultation with the
commissioner, shall promulgate such regulations as are necessary to
implement the provisions of this section provided, however, that the
provisions of this subdivision shall not limit specific actions taken by
the department of health or the department in order to ensure federal
financial participation.
20. Upon a determination that a participant appears to be suitable for
admission to a comprehensive HIV special needs plan or a mental health
special needs plan, a managed care provider shall inform the participant
of the availability of such plans, where available and appropriate.
21. (a) An amount equal to seven million dollars together with any
matching federal and local government funds shall be made available for
rate adjustments for managed care providers whose rates were set under
the competitive bidding process. Such adjustment shall be made in
accordance with this paragraph.
(i) Such amount shall be allocated by the department of health among
the managed care rating regions based on each region's percentage of
statewide Medicaid managed care enrollment as of January first, nineteen
hundred ninety-seven excluding from such calculation enrollment in local
social services districts that did not participate in the competitive
bidding process.
(ii) From among the funds allocated in a managed care rating region,
the department of health shall adjust the existing rates paid to managed
care providers for each premium group for the period from January first,
nineteen hundred ninety-seven through March thirty-first, nineteen
hundred ninety-eight in a manner that raises the rates of all managed
care providers in the region to the highest uniform percentage of the
upper payment limit possible based on the funds available; provided,
however, that no managed care provider's rate for any premium group
shall be reduced as a result of such adjustment. For the purpose of
calculating appropriate rate increases under this subparagraph, the
department of health shall assume that, for the entire period between
January first, nineteen hundred ninety-seven and March thirty-first,
nineteen hundred ninety-eight, enrollment in each premium group shall be
equal to enrollment in the premium group as of July first, nineteen
hundred ninety-seven.
(b) In addition to the increases made available in paragraph (a) of
this subdivision for the period beginning January first, nineteen
hundred ninety-seven through March thirty-first, nineteen hundred
ninety-eight, an additional ten million dollars, together with any
matching federal and local government funds, shall be added to provide a
uniform percentage increase, based on July first, nineteen hundred
ninety-seven enrollment to the existing rates paid for all premium
groups to all managed care providers whose rates were set by the
competitive bidding process.
(c) In addition to the increases made available in paragraphs (a) and
(b) of this subdivision for the period beginning January first, nineteen
hundred ninety-seven through March thirty-first, nineteen hundred
ninety-eight, an additional amount equal to three million dollars
together with any matching federal and local government funds, shall be
made available to be added to the rates of health plans operating in
geographic areas where capacity is insufficient to allow attainment of
enrollment goals consistent with the federal 1115 waiver known as the
Partnership Plan. Such amount shall be distributed subject to a
demonstration to the commissioner's satisfaction that the plan has
executed a contract amendment providing for an increase in enrollment
proportional to the size of the plan and the remaining unenrolled
population in the county. In evaluating the plan's demonstration, the
commissioner shall consider the degree to which the plan has increased
the number of primary or specialty care practitioners or diagnostic and
treatment centers in its network or whether the additional rate increase
would permit the plan to generate greater enrollments while continuing
to meet the financial requirements of the public health law or the
insurance law whichever is applicable and regulations promulgated
pursuant thereto.
Any amount identified in this paragraph remaining uncommitted by
December thirty-first, nineteen hundred ninety-seven shall be
distributed in a manner consistent with paragraph (b) of this
subdivision.
(d) A plan shall be eligible for payments pursuant to paragraphs (a),
(b) and (c) of this subdivision for such periods as the plan has a
contract with one or more social services districts; provided, however
that the plan has a contract, or has made a good faith effort to enter
into a contract, in that district effective through March thirty-first,
nineteen hundred ninety-eight.
(e) For the period from April first, nineteen hundred ninety-eight
through March thirty-first, nineteen hundred ninety-nine, the premium
rates paid by the department of health to all managed care providers
whose rates were set under the competitive bidding process shall be
equal to (i) the managed care provider's rate as of March thirty-first,
nineteen hundred ninety-eight increased by a uniform trend factor; plus,
(ii) four million dollars together with any matching federal and local
government funds to be added as a uniform percentage increase to such
provider's rate as of March thirty-first, nineteen hundred ninety-eight,
based on enrollment in the premium group as of April first, nineteen
hundred ninety-eight.
(f) For the period from April first, nineteen hundred ninety-eight
through March thirty-first, nineteen hundred ninety-nine, an additional
amount equal to four million dollars together with any matching federal
and local government funds, shall be made available for managed care
rate adjustments consistent with the criteria set forth in paragraph (c)
of this subdivision. Any amount identified in this paragraph remaining
uncommitted by December thirty-first, nineteen hundred ninety-eight
shall be added as a uniform percentage increase to the rates of all
managed care providers eligible for an increase under paragraph (e) of
this subdivision.
22. Chemung county demonstration project. (a) The legislature finds
that the particular circumstances of Chemung county warrant authorizing
this demonstration project, including the rural nature of the county,
the absence of a comprehensive medicaid managed care provider serving
the area at this time, patient care needs, and aspects of the health
care provider base.
(b) within all or part of Chemung county (referred to in this
subdivision as "the catchment area"), the department of health and the
Chemung county department of social services are authorized to conduct a
Medicaid research and demonstration project (referred to in this
subdivision as the "demonstration project") for the purpose of testing
the use of innovative administrative techniques, new reimbursement
methods, and management of care models, so as to promote more efficient
use of health resources, a healthier population and containment of
Medicaid program costs.
(c) As part of the demonstration project, the Chemung county
department of social services is authorized to contract with a managed
care provider for the purposes of, without limitation, developing and
managing a provider of care network, establishing provider payment rates
and fees, paying provider claims, providing care management services to
project participants, and managing the utilization of project services.
(d) The demonstration project shall be consistent with the provisions
of this section, except:
(i) The department may waive any rules or regulations, as necessary to
implement and consistent with this subdivision.
(ii) The demonstration project shall not be subject to:
(A) paragraph (b) of subdivision four of this section;
(B) subparagraphs (i), (ii), (iii) (v) and (viii) of paragraph (e) of
subdivision four of this section;
(C) paragraph (f) of subdivision four of this section;
(D) paragraph (g) of subdivision four of this section;
(E) subdivision five of this section; provided that in approving the
demonstration project or modifications to it, the department shall
consider the criteria in that subdivision;
(F) sections two hundred seventy-two and two hundred seventy-three of
the public health law;
(G) section three hundred sixty-five-i of this title.
(iii) Notwithstanding subdivision three of this section, participation
in the project shall be mandatory for all or any specified categories of
persons eligible for services under this title for whom the Chemung
county department of social services has fiscal responsibility pursuant
to section three hundred sixty-five of this title and who reside within
the demonstration project catchment area, as determined by the
commissioner of health; provided, however, that eligible persons who are
also beneficiaries under title XVIII of the federal social security act
and persons who reside in residential health care facilities shall not
be eligible to participate in the project.
(e)(i) Persons who are enrolled in or apply for medical assistance on
or before the date the demonstration project takes effect shall receive
sixty days written notice prior to participating in the demonstration
project, including an explanation of the demonstration project and the
participant's rights and responsibilities. Persons who apply for medical
assistance thereafter shall receive such notice at the time of applying
for medical assistance.
(ii) The demonstration project shall provide adequate services to
overcome language barriers for participants.
(iii) Participants in the demonstration project whose participation in
a managed care program would not otherwise be mandatory under
subdivision three of this section, who, at the time they enter the
demonstration project, have an established relationship with and are
receiving services from one or more medical services providers that are
not included in the demonstration project's provider network (an
"out-of-network provider"), shall be permitted to continue to receive
services from such providers until their course of treatment is
complete, or in the case of a pregnant woman, while pregnant and for
sixty days post-partum. Out-of-network providers that provide services
pursuant to this subparagraph shall be subject to the utilization review
and care management procedures prescribed by the managed care provider
and shall be reimbursed at the rate that would be paid to such providers
by the medical assistance program on a fee for service basis pursuant to
this title, and shall accept such reimbursement as payment in full.
(f) The provisions of this subdivision shall not apply unless all
necessary approvals under federal law and regulation have been obtained
to receive federal financial participation in the costs of health care
services provided pursuant to this subdivision.
(g) The commissioner of health is authorized to submit amendments to
the state plan for medical assistance and/or submit one or more
applications for waivers of the federal social security act as may be
necessary to obtain the federal approvals necessary to implement this
subdivision.
(h) The demonstration project shall terminate five years after it is
approved by the department and all necessary approvals under federal law
and regulations under paragraph (f) of this subdivision have been
obtained, unless terminated sooner by the Chemung county department of
social services.
23. (a) As a means of protecting the health, safety and welfare of
recipients, in addition to any other sanctions that may be imposed, the
commissioner shall appoint temporary management of a managed care
provider upon determining that the managed care provider has repeatedly
failed to meet the substantive requirements of sections 1903(m) and 1932
of the federal Social Security Act and regulations. A hearing shall not
be required prior to the appointment of temporary management.
(b) The commissioner and/or his or her designees, which may be
individuals within the department or other individuals or entities with
appropriate knowledge and experience, may be appointed as temporary
management. The commissioner may appoint the superintendent of insurance
and/or his or her designees as temporary management of any managed care
provider which is subject to rehabilitation pursuant to article
seventy-four of the insurance law.
(c) The responsibilities of temporary management shall include
oversight of the managed care provider for the purpose of removing the
causes and conditions which led to the determination requiring temporary
management, the imposition of improvements to remedy violations and,
where necessary, the orderly reorganization, termination or liquidation
of the managed care provider.
(d) Temporary management may hire and fire managed care provider
personnel and expend managed care provider funds in carrying out the
responsibilities imposed pursuant to this subdivision.
(e) The commissioner, in consultation with the superintendent with
respect to any managed care provider subject to rehabilitation pursuant
to article seventy-four of the insurance law, may make available to
temporary management for the benefit of a managed care provider for the
maintenance of required reserves and deposits monies from such funds as
are appropriated for such purpose.
(f) The commissioner is authorized to establish in regulation
provisions for the payment of fees and expenses from funds appropriated
for such purpose for non-governmental individuals and entities appointed
as temporary management pursuant to this subdivision.
(g) The commissioner may not terminate temporary management prior to
his or her determination that the managed care provider has the
capability to ensure that the sanctioned behavior will not recur.
(h) During any period of temporary management individuals enrolled in
the managed care provider being managed may disenroll without cause.
Upon reaching a determination that requires temporary management of a
managed care provider, the commissioner shall notify all recipient
enrollees of such provider that they may terminate enrollment without
cause during the period of temporary management.
(i) The commissioner may adopt and amend rules and regulations to
effectuate the purposes and provisions of this subdivision.
* NB Repealed March 31, 2009
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