NY Soc Serv L § 365-G (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11 - Medical Assistance for Needy Persons 365-G - Utilization Thresholds for Certain Care, Services and Supplies.

§  365-g.  Utilization  thresholds  for  certain  care,  services  and supplies.   1. The department may implement  a  system  for  utilization controls,  pursuant  to  this section, for persons eligible for benefits under this title, including annual service  limitations  or  utilization thresholds  above  which the department may not pay for additional care, services or supplies, unless such care, services or supplies  have  been previously  approved  by the department or unless such care, services or supplies were provided pursuant to subdivision three, four  or  five  of this section.   2.  The  department  may  implement utilization thresholds by provider service type, medical procedure and patient, in  consultation  with  the state  department  of  mental hygiene, other appropriate state agencies, and other stakeholders including provider and consumer  representatives. In  developing  utilization  thresholds  the  department  shall consider historical recipient utilization  patterns,  patient-specific  diagnoses and  burdens of illness, and the anticipated recipient needs in order to maintain good health.   3. If the department implements a utilization threshold program, at  a minimum, such program must include:  (a)  prior  notice  to  the  recipients  affected  by  the utilization threshold program, which notice must describe:  (i) the nature and extent of the utilization program,  the  procedures for  obtaining an exemption from or increase in a utilization threshold, the recipients' fair hearing rights, and referral  to  an  informational toll-free hot-line operated by the department; and  (ii)  alternatives  to  the  utilization  threshold  program  such  as enrollment in managed care programs and referral  to  preferred  primary care  providers  designated  pursuant  to  subdivision twelve of section twenty-eight hundred seven of the public health law; and  (b) procedures for:  (i) requesting an increase in amount of authorized services;  (ii) extending amount of authorized services when an  application  for an increase in the amount of authorized services is pending;  (iii)  requesting  an  exemption  from  utilization  thresholds, which procedure must:  (A) allow the recipient, or a provider on behalf of  a  recipient,  to apply  to  the  department for an exemption from one or more utilization thresholds  based  upon  documentation  of  the  medical  necessity  for services in excess of the threshold,  (B)  provided for exemptions consistent with department guidelines for approving exemptions,  which  guidelines  must  be  established  by  the department  in  consultation  with  the  department  of  health  and, as appropriate, with the department of mental hygiene, and consistent  with the  current  regulations  of  the  office  of  mental  health governing outpatient treatment.  (C) provide for an exemption when medical and  clinical  documentation substantiates  a  condition  of  a chronic medical nature which requires ongoing and frequent use of medical care, services or supplies such that an increase in the amount of authorized services is  not  sufficient  to meet the medical needs of the recipient;  (iv)  reimbursing  a  provider, regardless of the recipient's previous use of services, when care, services or supplies are provided in a  case of  urgent  medical need, as defined by the department, or when provided on an emergency basis, as defined by the department;  (v) notifying recipients of and referring  recipients  to  appropriate and  accessible  managed  care  programs  and  to preferred primary care providers  designated  pursuant  to  subdivision   twelve   of   section twenty-eight  hundred  seven  of  the public health law at the same time  such recipients are notified that they are nearing or have  reached  the utilization threshold for each specific provider type;  (vi)  notifying  recipients  at  the  same  time  such  recipients are notified that  they  have  received  an  exemption  from  a  utilization threshold,  an  increase  in  the amount of authorized services, or that they are nearing or have reached their utilization threshold,  of  their possible  eligibility for federal disability benefits and directing such recipients  to  their  social  services  district  for  information  and assistance in securing such benefits;  (vii)   cooperating   with   social   services  districts  in  sharing information  collected  and  developed  by  the   department   regarding recipients' medical records; and  (viii)  assuring  that  no  request  for  an  increase  in  amount  of authorized services or for  an  exemption  from  utilization  thresholds shall  be  denied  unless the request is first reviewed by a health care professional possessing appropriate clinical expertise.   4. The utilization thresholds established  pursuant  to  this  section shall  not  apply  to  mental retardation and developmental disabilities services provided in clinics certified under article twenty-eight of the public health law, or article twenty-two or article  thirty-one  of  the mental hygiene law.   5.  Utilization  thresholds established pursuant to this section shall not apply to services, even though  such  services  might  otherwise  be subject to utilization thresholds, when provided as follows:  (a) through a managed care program;  (b) subject to prior approval or prior authorization;  (c) as family planning services;  (d) as methadone maintenance services;  (e) on  a  fee-for-services  basis to in-patients in general hospitals certified under article twenty-eight of the public health law or article thirty-one of  the  mental  hygiene  law  and  residential  health  care facilities, with the exception of podiatrists' services;   * (f) for hemodialysis;   * NB Effective until July 1, 2023   * (f) for hemodialysis; or   * NB Effective July 1, 2023   * (g) through  or  by  referral from a preferred primary care provider designated  pursuant  to  subdivision  twelve  of  section  twenty-eight hundred seven of the public health law;   * NB Effective until July 1, 2023   * (g) through  or  by  referral from a preferred primary care provider designated  pursuant  to  subdivision  twelve  of  section  twenty-eight hundred seven of the public health law.   * NB Effective July 1, 2023   * (h) pursuant to a court order; or   * NB Repealed July 1, 2023   * (i)  as  a  condition  of  eligibility for any other public program, including but not limited to public assistance.   * NB Repealed July 1, 2023   6. The  department  shall  consult  with  representatives  of  medical assistance providers, social services districts, voluntary organizations that  represent  or  advocate  on behalf of recipients, the managed care advisory  council  and  other  state  agencies  regarding  the   ongoing operation of a utilization threshold system.   7.  On  or  before  February  first,  nineteen hundred ninety-two, the commissioner shall submit to the governor, the  temporary  president  of the  senate  and  the  speaker  of  the  assembly a report detailing the implementation of the utilization threshold program and  evaluating  the  results  of  establishing  utilization  thresholds.  Such  report  shall include, but need not be limited to, a description  of  the  program  as implemented;  the  number of requests for increases in service above the threshold  amounts  by  provider  and  type  of  service;  the number of extensions granted;  the  number  of  claims  that  were  submitted  for emergency  care  or urgent care above the threshold level; the number of recipients referred to managed care; an estimate of the  fiscal  savings to   the  medical  assistance  program  as  a  result  of  the  program; recommendations for medical condition that  may  be  more  appropriately served  through managed care programs; and the costs of implementing the program.