NY Soc Serv L § 364-F (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11 - Medical Assistance for Needy Persons 364-F - Primary Care Case Management Programs.

* § 364-f. Primary care case management programs. 1. The department is authorized to establish primary care case management programs, under the medical  assistance  program,  in accordance with applicable federal law and regulations. Primary care case management  programs  shall  only  be authorized  in  areas  of  the state where comprehensive health services plans, as defined in section forty-four hundred one of the public health law, are not yet available. Subject to the approval of the  director  of the  budget, the commissioner is authorized to apply for the appropriate waivers under federal law and regulation,  and  may  waive  any  of  the provisions   of  sections  three  hundred  sixty-five-a,  three  hundred sixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a  and three  hundred  sixty-four-j  of  this  chapter or any regulation of the department when such action would be necessary to  assist  in  promoting the objectives of this section.   2.   (a)   A  primary  care  case  management  program  shall  provide individuals eligible for medical  assistance  with  the  opportunity  to select  a primary care case manager who shall provide medical assistance services to such  eligible  individuals,  either  directly,  or  through referral.  (b) Primary care case managers shall be limited to qualified, licensed primary  care  practitioners, as defined in paragraph (f) of subdivision one of section three hundred sixty-four-j  of  this  chapter,  who  meet standards  established  by  the  commissioner  for  the purposes of this program.  (c) Services that may be covered by the primary care  case  management program  are defined by the commissioner in the benefit package. Covered services may include  all  medical  assistance  services  defined  under section three hundred sixty-five-a of this chapter, except:  (i)  services  excluded  under  paragraph  (e) of subdivision three of section three hundred sixty-four-j of this  chapter  shall  be  excluded under this section;  (ii)  services  provided  by  residential health care facilities, long term home health  care  programs,  child  care  agencies,  and  entities offering comprehensive health services plans;  (iii) services provided by dentists and optometrists; and  (iv)  eyeglasses,  emergency  care,  mental health services and family planning services.  (d) Case management services provided by primary  care  case  managers shall include, but need not be limited to:  (i)  management  of  the  medical and health care of each recipient to assure  that  all  services  provided  under  paragraph  (c)   of   this subdivision and which are found to be necessary, are made available in a timely manner;  (ii)  referral  to,  and  coordination,  monitoring  and follow-up of, appropriate providers for diagnosis and treatment, the  need  for  which has  been  identified  by the primary care case manager but which is not directly available from the primary care  case  manager,  and  assisting medical  assistance  recipients  in  the  prudent  selection  of medical services;  (iii)  arrangements  for  referral  of   recipients   to   appropriate providers; and  (iv)  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.   3.  (a) Primary care case management programs may be conducted only in accordance with guidelines established  by  the  commissioner.  For  the purpose   of  implementing  and  administering  the  primary  care  case management  programs,  the  commissioner  may  contract   with   private  not-for-profit  and public agencies as defined in guidelines established by the commissioner for the management and administration of the primary care case management program.  (b) The primary care case management program must:  (i) assure access to and delivery of high quality, appropriate medical services;  (ii)  participate  in  quality assurance activities as required by the commissioner, as well as other mechanisms designed to protect  recipient rights under such program;  (iii)  ensure  that  persons  eligible  for medical assistance will be provided  sufficient  information  regarding  the  program  to  make  an informed and voluntary choice whether to participate; and  (iv)  provide for adequate safeguards to protect recipients from being misled concerning the program and from being coerced into  participating in the primary care case management program.   4.  (a)  Individuals eligible to participate in Medicaid managed care, to participate in Medicaid managed care may  participate  in  a  primary care  case  management  program,  subject  to the availability of such a program within the  applicable  social  services  district,  except  for individuals:  (i) required by Medicaid managed care to be enrolled in an entity  offering  a  comprehensive  health  services  plan as defined in paragraph (k) of subdivision two of section three  hundred  sixty-five-a of  this  chapter;  (ii)  participating  in  another  medical assistance reimbursed demonstration or pilot project, or (iii)  receiving  services as  an  inpatient  from  a nursing home or intermediate care facility or residential services from a child care agency or services  from  a  long term home health care program.  (b)  Individuals  choosing  to  participate  in  a  primary  care case management program will be given thirty days from the effective date  of enrollment  in the program to disenroll without cause. After this thirty day disenrollment period, all individuals participating in  the  program will  be  enrolled  for  a  period  of  twelve  months,  except that all participants will be permitted to disenroll for good cause,  as  defined in guidelines established by the commissioner.   5.  (a)  Primary  care case management programs may include provisions for innovative  payment  mechanisms,  including,  but  not  limited  to, payment   of   case   management   fees,  capitation  arrangements,  and fee-for-service payments.  (b) Any new payment mechanisms and levels of payment implemented under the primary care case management  program  shall  be  developed  by  the commissioner subject to the approval of the director of the budget.   6.   Notwithstanding  any  inconsistent  provision  of  this  section, participation in  a  primary  care  case  management  program  will  not diminish the scope of available medical services to which a recipient is entitled.   7.  This  section  shall  be  effective  if,  and  as long as, federal financial participation is available therefor.   * NB Expires March 31, 2023