NY Pub Health L § 4403-E (2021)
2021 New York Laws PBH - Public Health Article 44 - Health Maintenance Organizations 4403-E - Primary Care Partial Capitation Providers; Partial Capitation Certificate of Authority.

* §   4403-e.  Primary  care  partial  capitation  providers;  partial capitation certificate of  authority.  1.  The  commissioner  may  issue partial  capitation  certificates  of  authority to qualified individual medical services providers, counties or entities  comprised  of  medical services  providers,  applying  on forms prescribed by the commissioner, seeking to offer medical  assistance  services,  including  primary  and preventive  care  and  case  management  of  inpatient,  emergency room, specialty, and pharmacy services, to recipients  of  medical  assistance eligible to enroll in managed care plans, on a partial capitation basis. Partial  capitation  certificates  of authority shall only be awarded to qualified applicants in rural areas of  the  state  where  comprehensive health  services  plans, as defined in section forty-four hundred one of this article, are not yet  available,  provided  that  such  certificate shall  be  awarded  only  until  full  capitation  becomes  practicable. Comprehensive primary and preventive care shall include all services and related ancillary procedures  routinely  performed  in  a  primary  care physicians  office,  including  preventive  care  and  immunizations  in accordance    with    CTH     periodic     schedules     and     routine obstetrical-gynecological   services.   Notwithstanding,  where  partial capitation providers currently exist, they will be allowed  to  continue operation.  Provided, however, that a shared health facility, as defined in article forty-seven of this chapter, shall not be eligible for such a certificate.   2. Applications for a  partial  capitation  certificate  of  authority shall include the following:  (a) current licensure or certification;  (b)  a  description  of  the  applicant's  experience in providing the services included as part of comprehensive primary and preventive  care, including identification of any disciplinary, administrative or criminal proceedings  related  to such license, certification or services and the resolution thereof;  (c) a description of the  applicant's  financial  resources,  together with  a copy of the applicant's latest certified financial statement and the medical malpractice insurance coverage maintained by such applicant;  (d) an assessment of the applicant's ability to  continue  to  provide high  quality  services  in  exchange  for  payments  and  to assume the financial risk of operating on a partial capitation basis;  (e) the geographic area to be served by the applicant;  (f) the applicant's current capacity, and proposed capacity to provide or directly arrange for the provision of medical care  and  services  to persons eligible for medical assistance;  (g)  a  statement of intent to contract from the local social services district in which they will operate;  (h) a statement describing  procedures  to  be  used  to  monitor  the quality of care provided by the plan;  (i) such other information as the commissioner shall require; and  (j)  in  the  case  of  an  application  from  a local social services district, such comparable information as the commissioner may require.   3. The commissioner may issue  a  partial  capitation  certificate  of authority to an applicant that meets the following criteria:  (a)  the applicant can demonstrate its ability to control, arrange for and manage in-patient hospital and emergency room care  through  written agreements with participating hospitals;  (b)  the  applicant is board-certified or board-eligible in his or her area of specialty, or has completed an accredited residency program,  or has  admitting privileges at one or more hospitals, or in the case of an entity, all medical services providers affiliated with the applicant are board-certified or board-eligible in his or her area of  specialty,  has  completed  an  accredited residency program, or has admitting privileges at one or more hospitals;  (c)  the  applicant  directly provides or arranges for the delivery of comprehensive primary and preventive care and  services  and  access  to medical advice and emergency care on a twenty-four hour basis;  (d) the applicant has adequate medical malpractice liability insurance coverage;  (e)  the  applicant has demonstrated it is financially responsible and may be expected to meet its obligations to  its  enrolled  members.  For purposes  of  this  paragraph,  "financially responsible" means that the applicant shall assume financial risk on a  prospective  basis  for  the provision of comprehensive primary care and preventive services, and can support   the   necessary   administrative  costs  associated  with  the activities of a partial capitation plan, for its enrolled members;  (f) the applicant has demonstrated the ability to provide high quality care, and to monitor the quality of  care  provided  via  an  acceptable formal quality assurance program;  (g)  the  local social services district has provided written evidence of its intention to contract with the plan; and  (h) the applicant has demonstrated the ability to  track  and  monitor all  services  provided  to  its  enrollees,  and  its ability to submit periodic cost and utilization reports, as the commissioner may require.   * NB Repealed March 31, 2025