2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 364-J - 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, including a
special needs managed care plan or comprehensive HIV special needs plan;
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; or
** NB Effective until December 31, 2025
** (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.
** NB Effective December 31, 2025
** (iii) is authorized to operate  under  section  forty-four  hundred
three-g of the public health law.
** NB Repealed December 31, 2025
(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,
including as  applicable,  a  special  needs  managed  care  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,  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 for people
with  developmental  disabilities,  or  the  office  of  alcoholism  and
substance abuse services.
(m) "Special needs managed care plan" shall have the same  meaning  as
in section forty-four hundred one 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.
(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.
(z) "Credentialed alcoholism and substance abuse  counselor  (CASAC)".
An  individual  credentialed  by  the office of alcoholism and substance
abuse  services  in  accordance  with  applicable  regulations  of   the
commissioner of alcoholism and substance abuse services.
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.
(c) The commissioner of  health,  jointly  with  the  commissioner  of
mental  health  and  the  commissioner of alcoholism and substance abuse
services shall be authorized to establish  special  needs  managed  care
plans,   under  the  medical  assistance  program,  in  accordance  with
applicable federal law and regulations. The commissioner of  health,  in
cooperation  with  such  commissioners,  is  authorized,  subject to the
approval of the director of the division of the  budget,  to  apply  for
federal  waivers  when  such  action  would  be  necessary  to assist in
promoting the objectives of this section. With regard  to  such  special
needs  managed  care  plans,  in addition to the applicable requirements
established in this section, such commissioners shall jointly  establish
standards and requirements to:
(i)  ensure  that  any  special  needs managed care plan shall have an
adequate network of providers to meet the behavioral health  and  health
needs  of  enrollees, and shall review the adequacy prior to approval of
any special needs managed  care  plan,  and  upon  contract  renewal  or
expansion.  To  the  extent that the network has been determined to meet
standards set forth in subdivision five of section  four  thousand  four
hundred  three  of  the  public health law, such network shall be deemed
adequate;
(ii) ensure that any special needs managed care plan shall make  level
of  care  and  coverage determinations utilizing evidence-based tools or
guidelines designed to address the behavioral health needs of enrollees;
(iii)  ensure  sufficient  access  to  behavioral  health  and  health
services   for   eligible   enrollees  by  establishing  and  monitoring
penetration rates of special needs managed care plans; and
(iv) establish standards to encourage the use  of  services,  products
and   care   recommended,   ordered  or  prescribed  by  a  provider  to
sufficiently address the behavioral health and health services needs  of
enrollees;  and monitor the application of such standards to ensure that
they sufficiently address the  behavioral  health  and  health  services
needs of enrollees.
(d)  Whenever  the  commissioner of health makes changes to the terms,
conditions or time frames contained in the model contract that serves as
the basis for contracts with managed care providers in the managed  care
program  under  this  section,  the  changes  shall  be  posted  on  the
department's  website.  The  department  shall  post  on its website any
changes required to  be  submitted  to  the  centers  for  medicare  and
medicaid services (CMS) for approval prior to submission of the changes.
A  summary of any changes shall also be published in the state register.
A notification of any request for proposals issued by the department for
managed care providers to participate in the managed care program  shall
also be published in the state register.
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 special needs managed care plan
shall also be in accordance with article forty-four of the public health
law and article thirty-one of the mental hygiene law.
(d) Until such time as program features and  reimbursement  rates  are
approved  by  the  commissioner  of  health,  in  consultation  with the
commissioners of the office of mental health, the office for people with
developmental disabilities, the office of children and family  services,
and   the   office  of  alcoholism  and  substance  abuse  services,  as
appropriate, 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;  provided,  however, that no medical assistance recipient
shall be  required  to  obtain  services  that  are  certified,  funded,
authorized or approved by the commissioner of the office for people with
developmental  disabilities  through  a  managed  care program until the
program features approved by the commissioner of health, in consultation
with the commissioner  of  the  office  for  people  with  developmental
disabilities,  include  features for habilitation services as defined in
paragraph c of subdivision one of section forty-four hundred three-g  of
the public health law:
(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  article  eighty-nine  of  the
education law;
(iv)  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;
(v) long term services as determined by the commissioner of the office
for people with 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;
(vi) TB directly observed therapy;
(vii) AIDS adult day health care;
(viii) HIV COBRA case management; and
(ix) other services as determined by the commissioner of health.
(d-1) Services provided pursuant to title two-A of article twenty-five
of  the  public  health  law 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.
(d-2) Services provided  pursuant  to  waivers,  granted  pursuant  to
subsection  (c)  of  section 1915 of the federal social security act, to
persons suffering  from  traumatic  brain  injuries  or  qualifying  for
nursing home diversion and transition services, shall not be provided to
medical  assistance  recipients  through  managed care programs until at
least January first, two thousand twenty-six.
(d-3) Services provided in school-based health centers  shall  not  be
provided  to medical assistance recipients through managed care programs
established pursuant to this section until at  least  April  first,  two
thousand twenty-five.
(e)  The following categories of individuals may be required to enroll
with a managed care program  when  program  features  and  reimbursement
rates  are  approved  by the commissioner of health and, as appropriate,
the commissioners of the office of mental health, the office for  people
with  developmental  disabilities,  the  office  of  children and family
services, and the office of alcoholism and substance abuse services:
(i) an individual dually eligible for medical assistance and  benefits
under  the  federal  Medicare program; provided, however, nothing herein
shall: (a) require an individual enrolled in a managed  long  term  care
plan,  pursuant  to  section  forty-four  hundred  three-f of the public
health law, to disenroll from such program; or (b) make enrollment in  a
Medicare managed care plan a condition of the individual's participation
in  the  managed  care  program  pursuant to this section, or affect the
individual's entitlement to payment of applicable Medicare managed  care
or  fee  for  service  coinsurance  and  deductibles by the individual's
managed care provider.
(ii) an individual eligible for supplemental security income;
(iii) HIV positive individuals;
(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;
(v) a person receiving services provided by a residential  alcohol  or
substance abuse program or facility for the developmentally disabled;
(vi)  a  person  receiving  services  provided by an intermediate care
facility for the developmentally disabled or who has characteristics and
needs similar to such persons;
(vii) a  person  with  a  developmental  or  physical  disability  who
receives  home  and  community-based  services  or care-at-home services
through a demonstration waiver under section eleven hundred  fifteen  of
the federal social security act, existing waivers under section nineteen
hundred  fifteen  (c)  of  the  federal  social security act, or who has
characteristics and needs similar to such persons;
(viii) 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;
(ix) 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;
(x)  certified  blind  or  disabled  children living or expected to be
living separate and apart from the parent for thirty days or more;
(xi) residents of nursing facilities;
(xii) a foster child in the placement of a voluntary agency or in  the
direct care of the local social services district;
(xiii) a person or family that is homeless;
(xiv)   individuals   for   whom   a  managed  care  provider  is  not
geographically accessible so as to reasonably provide  services  to  the
person.  A managed care provider is not geographically accessible if the
person cannot access the provider's services in a timely fashion due  to
distance or travel time;
(xv)  a  person  eligible  for  Medicare  participating in a capitated
demonstration program for long term care;
(xvi) an infant living with an incarcerated mother in a state or local
correctional facility as defined in section two of the correction law;
(xvii) a person who is expected to be eligible for medical  assistance
for less than six months;
(xviii)  a person who is eligible for medical assistance benefits only
with respect to tuberculosis-related services;
(xix) individuals receiving hospice services at  time  of  enrollment;
provided, however, that this clause shall not be construed to require an
individual  enrolled  in  a  managed long term care plan or another care
coordination model, who subsequently elects hospice, to  disenroll  from
such program;
(xx)  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 cost sharing amounts, when
payment of such premium or cost sharing amounts would be cost-effective,
as determined by the local social services district;
(xxi)  a  person  receiving  family  planning  services  pursuant   to
subparagraph  six  of  paragraph (b) of subdivision one of section three
hundred sixty-six of this title;
(xxii) a person who is eligible for  medical  assistance  pursuant  to
paragraph  (d) of subdivision four of section three hundred sixty-six of
this title;
(xxiii) individuals with a chronic medical  condition  who  are  being
treated  by a specialist physician that is not associated with a managed
care provider in the individual's social services district; and
(xxiv) Native Americans.
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) the services are optometric services, as defined  in  article  one
hundred  forty-three  of  the  education  law,  and  are  provided  by a
diagnostic and treatment center licensed under article  twenty-eight  of
the  public health law which is affiliated with the college of optometry
of the state university of New  York  and  which  has  been  granted  an
operating  certificate  pursuant  to  article twenty-eight of the public
health law to provide  such  optometric  services.  Any  diagnostic  and
treatment  center  providing optometric 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  optometric benefits as a covered
service; and the number of visits  made  by  the  uninsured  during  the
immediately preceding calendar year; or
(E-1) the services are vision care services rendered to a student at a
school based health center approved by the commissioner pursuant to this
clause. The commissioner may approve up to five pilot programs at school
based  health  centers  in partnership with a charitable foundation that
agrees to provide free of charge  eyeglass  frames  and  lenses  at  the
centers   pursuant   to  a  memorandum  of  agreement  approved  by  the
commissioner. The commissioner may approve the rate for such vision care
services at the rate for such services  when  provided  by  a  federally
qualified  health  center  or  when  provided by another entity licensed
pursuant to article twenty-eight of the public health law  and  eligible

for  the ambulatory patient group rate approved for vision care services
by the commissioner; or
(F) 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.  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.
(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, 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; the available managed care providers 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 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
shall be approved by the  department  of  health  or  the  local  social
services  district,  and  the  commissioner  of  mental  health  and the
commissioner  of  alcoholism  and  substance   abuse   services,   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 choose a managed care provider at the time
of application for medical  assistance;  if  the  participant  does  not
choose such a provider the commissioner shall assign such participant to
a  managed  care  provider in accordance with subparagraphs (ii), (iii),
(iv) and (v) of this  paragraph.  Participants  already  in  receipt  of
medical  assistance  shall  have  no less than thirty days from the date
selected by the district to enroll in the managed care program to select
a managed care provider and shall be provided with information  to  make
an informed choice. Where a participant has not selected such a provider
the  commissioner  of  health shall assign such participant to a managed
care provider which, if appropriate, may be a special needs managed care
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;  provided,  however,  that  the  commissioner  shall   assign
individuals  meeting  the  criteria  for  enrollment  in a special needs
managed care plan to such plan or plans where available.
(g) If another managed care provider 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 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.  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  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  special needs managed care plan must comply with
the standards  of  the  commissioner  of  health,  the  commissioner  of
alcoholism  and substance abuse services, and the commissioner of mental
health. A managed care provider 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 managed care provider that is a special needs  managed
care  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 special needs managed care plan
may, where clinically appropriate, disenroll individuals who  no  longer
require  the  level of services provided by a special needs managed care
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 in  accordance  with
standards adopted by the department of health.
(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
special needs managed care plan.
(p) A managed care provider 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 shall comply with applicable state and
federal law  provisions  prohibiting  discrimination  on  the  basis  of
disability.
(r)  A  managed  care  provider 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, provided that services for a substance use disorder
shall  be  provided  by  a  program  licensed,  certified  or  otherwise
authorized by the office of alcoholism and substance abuse services.
(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.
(u) A managed care provider that provides  coverage  for  prescription
drugs  shall  permit  each  participant  to  fill any mail order covered
prescription, at his or her  option,  at  any  mail  order  pharmacy  or
non-mail-order  retail pharmacy in the managed care provider network. If
the managed care provider has designated  one  or  more  pharmacies  for
filling  prescriptions  for  a  particular  drug  or  drugs,  then  such
prescriptions may be filled, at the participant's option, at  any  other
pharmacy  in  the  network,  if  the  network  pharmacy  chosen  by  the
participant offers to accept a price that is comparable to that  of  the
pharmacy  designated  by  the managed care provider. For the purposes of
this section, "mail order  pharmacy"  means  a  pharmacy  whose  primary
business  is  to  receive  prescriptions  by  mail,  telefax  or through
electronic submissions, and to dispense medication to  patients  through
the  use  of  the United States mail or other common or contract carrier
services, and provides any  consultation  with  patients  electronically
rather  than  face  to face. Every non-mail-order retail pharmacy in the
managed care provider's network with respect to  any  prescription  drug
shall  be  deemed to be in the managed care provider's network for every
covered prescription drug.
(v) A managed care provider must allow enrollees  to  access  chemical
dependence treatment services from facilities certified by the office of
alcoholism  and  substance  abuse  services,  even  if such services are
rendered by  a  practitioner  who  would  not  otherwise  be  separately
reimbursed,  including  but not limited to a credentialed alcoholism and
substance abuse counselor (CASAC).
** (w) A managed care provider shall provide or arrange,  directly  or
indirectly,  including  by  referral,  for  access  to  and  coverage of
services provided by any  national  cancer  institute-designated  cancer
center  licensed  by  the  department  of health within the managed care
provider's  service  area  that  is  willing   to   agree   to   provide
cancer-related   inpatient,   outpatient   and   medical   services   to
participants in all managed care providers offering coverage to  medical
assistance  recipients  in  such  cancer center's service area under the
prevailing terms and conditions that the managed care provider  requires
of other similar providers to be included in the managed care provider's
network,  provided  that  such terms shall include reimbursement of such
center at no less than the fee-for-service  medicaid  payment  rate  and
methodology   applicable   to  the  center's  inpatient  and  outpatient
services.
** NB There are 2 par (w)'s
** NB Repealed January 1, 2028
** (w)(i) The department of health  or  a  managed  care  organization
contracted  to provide services pursuant to this section shall establish
a program for synchronization of medications. Under the  synchronization
program,  a  health  care  practitioner may prescribe a refill of one or

more of the patient's  medications  for  a  shorter  period  than  would
ordinarily be provided, for the purpose of synchronizing refill dates of
one or more of the patient's medications subject to the synchronization,
when  it is agreed among the recipient, the health care practitioner and
a pharmacist that synchronization  of  multiple  prescriptions  for  the
treatment  of  a  chronic illness is in the best interest of the patient
for the management or treatment of a chronic illness provided  that  the
following apply to such medications:
(A)  are  covered  by Medicaid services or a managed care organization
contracted to provide services pursuant to this chapter;
(B) are used for treatment and management of a  chronic  illness  that
are subject to refills;
(C)  are  not  a  schedule II controlled substance, nor a schedule III
controlled  substance  that  contains  hydrocodone   or   other   opioid
medication  as  scheduled  in  section  thirty-three  hundred six of the
public  health  law,  or  a  controlled  substance  under  the   federal
Controlled Substances Act;
(D)  meet all prior authorization criteria specific to the medications
at the time of the synchronization request;
(E) are of a formulation that can be effectively and lawfully  aligned
over required short fill periods to achieve synchronization; and
(F) do not have quantity limits or dose optimization criteria or state
or   federal   requirements   that   would  be  violated  in  fulfilling
synchronization.
(ii)  The  department  of  health  or  a  managed  care   organization
contracted  to  provide  services  under  this  section  shall  not deny
coverage for the dispensing of a medication by a pharmacy for a  partial
supply  when  it  is  for  the  purpose  of  synchronizing the patient's
medications. When applicable to permit synchronization,  the  department
of  health or a managed care organization contracted to provide services
under this title shall allow a pharmacy to  override  any  denial  codes
indicating  that  a  prescription  is  being  refilled  too soon for the
purposes of medication synchronization.
(iii) The dispensing fee paid to the pharmacy  contracted  to  provide
services  pursuant  to this section for a partial supply associated with
medication synchronization shall be paid in accordance with the Medicaid
state plan  as  approved  by  the  Centers  for  Medicare  and  Medicaid
Services.
(iv)  The  requirement  of  this  paragraph applies only once for each
prescription drug subject  to  medication  synchronization  except  when
either of the following occurs:
(A)  the  prescriber changes the dosage or frequency of administration
of the prescription drug subject to a medication synchronization; or
(B) the prescriber prescribes a different drug.
(v) Nothing in this paragraph shall be deemed to require  health  care
practitioners  and  pharmacists to synchronize the refilling of multiple
prescriptions for a covered individual.
(vi) The provisions of this paragraph are subject to  compliance  with
all  applicable  federal  and  state laws and regulations, including the
Centers for Medicare and Medicaid Services approved Medicaid state plan.
The commissioner shall apply for waivers and submit state Medicaid  plan
amendments as are necessary to implement the program for synchronization
of medications.
** NB There are 2 par (w)'s
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 to
participate in the program, including comprehensive  HIV  special  needs
plans  and  special  needs  managed  care  plans  in accordance with the
provisions   of  section  three  hundred  sixty-five-m  of  this  title;
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 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,  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,  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  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 under section
forty-four hundred eight-a and article forty-nine 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. Managed care providers  shall  provide
notice  of the name, address, phone number and website of the department
of health designated independent consumer  assistance  program  and  the
independent   substance   use   disorder  and  mental  health  ombudsman
established by section 33.27 of the mental hygiene law within notices of
adverse grievances and appeals determinations.
10. The commissioner  of  health  shall  be  authorized  to  establish
requirements regarding provision and reimbursement of emergency care.
10-a.  For managed care providers with negotiated rates of payment for
inpatient hospital services under contracts in effect  on  April  first,
two  thousand  eight,  that  have  a  payment  rate methodology for such
inpatient hospital  services  that  utilizes  rates  calculated  by  the
department  of  health pursuant to paragraph (a) or (a-2) of subdivision
one of section twenty-eight  hundred  seven-c  for  patients  under  the
medical  assistance  program,  such  rate  shall not include adjustments
pursuant to subdivision thirty-three  of  section  twenty-eight  hundred
seven-c  of  the public health law for contract periods prior to January
first, two thousand ten.
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.  (a)  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.
(b)  The provisions of this section regarding the furnishing of health
and behavioral health services through a special needs managed care plan
shall be effective if, and as long as, federal  financial  participation
is  available  for  expenditures  for  services  provided  by such plans
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.
* (c)  In  setting  such  reimbursement  methodologies, the department
shall consider costs  borne  by  the  managed  care  program  to  ensure
actuarially  sound  and  adequate  rates of payment to ensure quality of
care.
* NB There are 2 par (c)'s
* (c) The department of health shall require the  independent  actuary
selected  pursuant  to  paragraph  (b)  of this subdivision to provide a
complete actuarial memorandum, along with all actuarial assumptions made
and all other data, materials and methodologies used in the  development
of  rates,  to managed care providers thirty days prior to submission of
such rates to  the  centers  for  medicare  and  medicaid  services  for
approval.  Managed  care  providers may request additional review of the
actuarial soundness of the rate setting process and/or methodology.
* NB There are 2 par (c)'s
(d) The department of health shall annually provide to  the  temporary
president  of  the  senate  and  the  speaker of the assembly the annual
Medicaid managed care operating reports submitted to the department from
managed care plans that contract  with  the  state  to  manage  services
provided under the Medicaid program.
(e)  Increased  rates, terms or scope of payment for behavioral health
services under this title, where payment  is  made  by  a  managed  care
provider  under  this  section, as a result of a rate, coverage or other
change made pursuant to a law, regulation, rule  or  official  guidance,
shall  be  deemed in effect on the same date that such change would have
taken effect if payment  were  made  other  than  by  the  managed  care
provider.  Where  payment  is  not  made  as  of the effective date, the
managed care provider shall make retroactive payments to the appropriate
service providers.
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  special  needs
managed  care 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,  in  consultation  with the commissioners of the office of
mental health and the office of alcoholism and substance abuse services,
where appropriate, 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 financial
services 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.
24. Claims submitted to  a  managed  care  provider  for  payment  for
medical  care,  services,  or  supplies  furnished  by an out-of-network
medical services provider must be submitted within fifteen months of the
date the medical care,  services,  or  supplies  were  furnished  to  an
eligible  person  to  be  valid and enforceable against the managed care
provider. This deadline for claims submission shall not apply where  the
claims  submission  is  warranted to address findings or recommendations
identified in a state or federal audit  except  where  such  audit  also
indicates that an inappropriate provider payment was solely the fault of
the out-of-network health care provider.
25.  Effective  January  first, two thousand thirteen, notwithstanding
any provision of law to the contrary, managed care providers shall cover
medically necessary prescription drugs  in  the  atypical  antipsychotic
therapeutic  class, including non-formulary drugs, upon demonstration by
the prescriber, after consulting with the managed  care  provider,  that
such  drugs,  in  the prescriber's reasonable professional judgment, are
medically necessary and warranted.
25-a. Effective July first, two thousand thirteen, notwithstanding any
provision of law to the contrary, managed  care  providers  shall  cover
medically   necessary   prescription   drugs   in  the  anti-depressant,
anti-retroviral,   anti-rejection,   seizure,    epilepsy,    endocrine,
hematologic and immunologic therapeutic classes, including non-formulary
drugs,  upon  demonstration by the prescriber, after consulting with the
managed care provider, that such drugs, in the  prescriber's  reasonable
professional judgment, are medically necessary and warranted.
26.  The  commissioner  of  health  shall  develop  a  standard  prior
authorization request form or forms to be utilized by all  managed  care
providers  for purposes of submitting a request for a utilization review
determination for coverage of  prescription  drug  benefits  under  this
title.   The  managed  care  provider  shall  make  the  standard  prior

authorization request form or forms available to, and shall accept it or
them from, prescribing providers in paper and electronic form.
26-a.  Managed  care  providers  shall  require prior authorization of
prescriptions of opioid analgesics in excess of four prescriptions in  a
thirty-day  period,  provided,  however, that this subdivision shall not
apply if the patient is a recipient of hospice care, has a diagnosis  of
cancer  or  sickle cell disease, or any other condition or diagnosis for
which the commissioner of health determines prior authorization  is  not
required.
26-b. Managed care providers shall not require prior authorization for
any   buprenorphine   products,  methadone  or  long  acting  injectable
naltrexone for detoxification or maintenance treatment  of  a  substance
use   disorder  prescribed  according  to  generally  accepted  national
professional guidelines for the treatment of a substance use disorder.
26-c. Managed care providers shall not require prior authorization for
methadone, when  used  for  opioid  use  disorder  and  administered  or
dispensed in an opioid treatment program.
** 27.  The  commissioner  of  the  department  of health may make any
necessary amendments to a contract  pursuant  to  this  section  with  a
managed care provider, as defined in paragraph (b) of subdivision one of
this  section,  to  allow such managed care provider to participate as a
qualified health plan in a state  health  benefit  exchange  established
pursuant to the federal Patient Protection and Affordable Care Act (P.L.
111-148),   as   amended  by  the  federal  Health  Care  and  Education
Reconciliation Act of 2010 (P.L. 111-152).
** NB There are 2 sb 27's
** 27.  (a)  The  centers  for  medicare  and  medicaid  services  has
established  an  initiative  to  align  incentives  between medicare and
medicaid. The goal of the initiative is to increase access to  seamless,
quality  programs  that  integrate  services  for  the  dually  eligible
beneficiary as well as to achieve both state  and  federal  health  care
savings  by  improving health care delivery and encouraging high-quality
efficient care. In furtherance of this goal, the legislature  authorizes
the  commissioner  of  health  to  establish  a  fully  integrated  dual
advantage (FIDA) program.
(b)  The  FIDA  program  shall   provide   targeted   populations   of
medicare/medicaid  dually  eligible  persons  with  comprehensive health
services that include the full range of medicare  and  medicaid  covered
services,   including  but  not  limited  to  primary  and  acute  care,
prescription  drugs,  behavioral  health  services,  care   coordination
services,  and  long-term  supports  and  services,  as  well  as  other
services, through managed care providers, as defined in subdivision  one
of  this  section,  including  managed  long  term care plans, certified
pursuant to section forty-four hundred three-f of the public health law.
(c) Under the FIDA program established pursuant to  this  subdivision,
up  to  three  managed  long  term  care  plans  may  be  authorized  to
exclusively enroll individuals with developmental disabilities, as  such
term  is  defined  in  section  1.03  of  the  mental  hygiene  law. The
commissioner of health may waive any of the department's regulations  as
such  commissioner,  in consultation with the commissioner of the office
for people with developmental disabilities,  deems  necessary  to  allow
such  managed long term care plans to provide or arrange for service for
individuals  with  developmental  disabilities  that  are  adequate  and
appropriate  to  meet the needs of such individuals and that will ensure
their health and safety. The commissioner of the office for people  with
developmental  disabilities  may waive any of the office for people with
developmental  disabilities'  regulations  as  such   commissioner,   in
consultation  with  the commissioner of health, deems necessary to allow

such managed long term care plans to provide or arrange for services for
individuals  with  developmental  disabilities  that  are  adequate  and
appropriate  to  meet the needs of such individuals and that will ensure
their health and safety.
(d)  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.
(e) 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.
(f) Notwithstanding any inconsistent provisions of  this  section  and
sections  one  hundred  twelve  and one hundred sixty-three of the state
finance  law,  or  section  one  hundred  forty-two  of   the   economic
development  law,  or any other law to the contrary, the commissioner of
health and, in the  case  of  FIDAs  authorized  exclusively  to  enroll
persons  with developmental disabilities, the commissioner of health and
the  commissioner  of  the  office   for   people   with   developmental
disabilities,  may  contract  with  FIDAs  approved  under  this section
without  a  competitive  bid  or  request  for  proposal  process,   are
authorized  to  enter  into  a contract or contracts under this section,
provided, however, that:
(i) the department of health shall post on its website, for  a  period
of no less than thirty days:
(A)  a description of the proposed services to be provided pursuant to
the contract or contracts;
(B) the criteria for selection of a contractor or contractors;
(C) the period of time during which a prospective contractor may  seek
selection,   which  shall  be  no  less  than  thirty  days  after  such
information is first posted on the website; and
(D) the manner  by  which  a  prospective  contractor  may  seek  such
selection, which may include submission by electronic means;
(ii)  all reasonable and responsive submissions that are received from
prospective contractors in a timely fashion shall  be  reviewed  by  the
commissioner of health or commissioners, as applicable; and
(iii) the commissioner or, in the case of FIDAs authorized exclusively
to  enroll  persons with developmental disabilities, the commissioner of
health and the commissioner of the office for people with  developmental
disabilities,  may  select such contractor or contractors that, in their
discretion, have demonstrated the ability  to  effectively,  efficiently
and  economically integrate health and long term care services, and meet
the standards for a certificate of authority under the public health law
for the provision of services applicable to the  type  of  managed  long
term care plan that such contractor proposes to operate.
(g)  Nothing  in  this  section  shall  be  construed  as requiring an
individual with a developmental disability to enroll in a FIDA  that  is
authorized   to   exclusively   enroll  individuals  with  developmental
disabilities.
(h) Nothing in this  section  shall  make  enrollment  in  a  medicare
managed  care  plan  a condition of an individual's participation in the
FIDA program, or affect  the  individual's  entitlement  to  payment  of
applicable   medicare   managed   care  or  fee-for-service  coinsurance
deductibles by the individual's FIDA plan.
** NB There are 2 sb 27's
** 28.  To  the  extent  that  any  provision  of  this   section   is
inconsistent with any provision of section forty-four hundred three-g of

the public health law, such provision of this section shall not apply to
an  entity  authorized to operate pursuant to section forty-four hundred
three-g of the public health law.
** NB Repealed December 31, 2025
29.  In  the  event  that  the  department  receives approval from the
Centers for Medicare and Medicaid Services to amend its 1115  waiver  or
receives  approval  for  a  new  1115  waiver  prior to or following the
effective date of the chapter of the laws of  two  thousand  twenty-four
that  amended  this subdivision, the commissioner is authorized to enter
into contracts and to amend the terms of contracts awarded prior to  the
effective  date  of  the chapter of the laws of two thousand twenty-four
that  amended  this  subdivision,  for  the  purpose  of  assisting  the
department  of  health  with implementing projects authorized under such
waiver approval.  Notwithstanding the provisions of sections one hundred
twelve and one hundred sixty-three of the state finance law, or sections
one hundred forty-two  and  one  hundred  forty-three  of  the  economic
development  law,  or  any  contrary  provision of law, contracts may be
entered or contract amendments may be made pursuant to this  subdivision
until   March   thirty-first,   two   thousand  twenty-seven  without  a
competitive bid or request for proposal process; provided,  however,  in
the  case  of  a  contract entered into after the effective date of this
subdivision, that:
(a) The department of health shall post on its website, for  a  period
of no less than thirty days:
(i)  A description of the proposed services to be provided pursuant to
the contract or contracts;
(ii) The criteria for selection of a contractor or contractors;
(iii) The period of time during which  a  prospective  contractor  may
seek  selection,  which  shall  be  no  less than thirty days after such
information is first posted on the website; and
(iv) The manner by  which  a  prospective  contractor  may  seek  such
selection, which may include submission by electronic means;
(b)  All  reasonable and responsive submissions that are received from
prospective contractors in timely  fashion  shall  be  reviewed  by  the
commissioner of health; and
(c)  The  commissioner  of  health  shall  select  such  contractor or
contractors that, in such commissioner's discretion, are best suited  to
serve the purposes of this section.
30.  Notwithstanding the provisions of section one hundred sixty-three
of the state finance law, or sections  one  hundred  forty-two  and  one
hundred  forty-three  of  the  economic development law, or any contrary
provision of law, in the event that the state  receives  prior  approval
and  enhanced  financial participation from the Centers for Medicaid and
Medicare Services, Administration for  Children  and  Families  and  the
Federal  Food  and  Nutrition  Services for reimbursement pursuant to an
A-87  cost  allocation  waiver  for  enhanced  funding  for   integrated
eligibility  systems,  the  state is authorized to enter into contracts,
and/or to amend the terms of contracts awarded prior  to  the  effective
date  of  this  subdivision,  without  a  competitive bid or request for
proposal process, consistent with federal requirements, for the  purpose
of   implementing  projects  authorized  under  such  waiver  amendment;
provided, however, in the case of a  contract  entered  into  after  the
effective date of this subdivision, that:
(a)  The  office of temporary and disability assistance and the office
of general services, or another state agency, shall post on its  website
and concurrently provide to the chair of the senate health committee and
the chair of the assembly health committee, for a period of no less than
thirty days:
(i)  A description of the proposed services to be provided pursuant to
the contract or contracts;
(ii) The criteria for selection of a contractor or contractors;
(iii)  The  period  of  time during which a prospective contractor may
submit an offer, which shall be no less  than  thirty  days  after  such
information is first posted on the website; and
(iv) The manner by which a prospective contractor may submit an offer,
which may include submission by electronic means;
(b)  All  responsive  and  reasonable  offers  that  are received from
prospective contractors in timely  fashion  shall  be  reviewed  by  the
commissioner  of  temporary  and  disability  assistance  or other state
agency; and
(c) The commissioners of the  department  of  health,  the  office  of
temporary  and  disability  assistance  and  the  office of children and
family services, working in cooperation with the state chief information
officer and the office of general services, shall award such contract to
the contractor or contractors offer that provides the best value as such
term is defined in section one hundred sixty-three of the state  finance
law,  to  the  state.  At  notification the commissioner of health shall
provide this information to the chair  of  the  senate  standing  health
committee and the chair of the assembly health committee.
(d)   All  decisions  made  and  approaches  taken  pursuant  to  this
subdivision shall be documented in a procurement record  as  defined  in
section one hundred sixty-three of the state finance law.
(e)  In accordance with all federal advance planning document guidance
and  within  the  parameters  established  by  the  enhanced   financial
participation  from  the  centers  for  Medicaid  and Medicare services,
administration for children  and  families  and  the  federal  food  and
nutrition  services  for reimbursement to an A-87 cost allocation waiver
for enhanced funding for integrated eligibility systems,  Phase  1  will
include  foundational  allowable  shared  service components required to
successfully meet the requirements  for  non-MAGI  Medicaid  such  as  a
common  client  portal,  document  management,  rules  engines, workflow
management tools, case management, notices and training.
(f) The contract will require training to be provided at  no  cost  to
the social services districts.
(g)  The  contract  shall  require  the  completion  of shared service
components by the timelines necessary to receive the enhanced  financial
participation  from  the  centers  for  Medicaid  and Medicare services,
administration for children  and  families  and  the  federal  food  and
nutrition services for reimbursement to an A-87 cost allocation waiver.
(h)  The  commissioner  shall  provide, within thirty days of award of
such contract or contracts, the chair of the senate  standing  committee
on  health  and the chair of the assembly health committee with a report
outlining the procurement and awards.
31. (a) The commissioner shall require managed  care  providers  under
this  section,  managed  long-term  care  plans under section forty-four
hundred three-f the public health law and  other  appropriate  long-term
service  programs  to  adopt expedited procedures for approving personal
care services for a medical assistance recipient who requires  immediate
personal care or consumer directed personal assistance services pursuant
to   paragraph   (e)   of  subdivision  two  of  section  three  hundred
sixty-five-a of this title or section three hundred sixty-five-f of this
title, respectively, or other long-term care, and provide such  care  or
services as appropriate, pending approval by such provider or program.
32.  (a) The commissioner, or for the purposes of subparagraph (iv) of
paragraph (c) of this subdivision, the  Medicaid  inspector  general  in
consultation with the commissioner, may, in his or her discretion, apply

penalties  to  managed  care  organizations  subject to this section and
article forty-four of the public health law, including managed long term
care plans, for untimely or inaccurate  submission  of  encounter  data;
provided  however,  no  penalty  shall  be  assessed if the managed care
organization submits, in good faith, timely  and  accurate  data  and  a
material  amount  of  such  data  is  not  successfully  received by the
department as a result of department system failures or technical issues
that are beyond the control of the managed care organization.
(b) The commissioner, or for the  purposes  of  subparagraph  (iv)  of
paragraph  (c)  of  this  subdivision, the Medicaid inspector general in
consultation with the commissioner, shall consider  the  following  when
determining   whether  to  assess  a  penalty  against  a  managed  care
organization and the amount of such penalty:
(i) the degree  to  which  the  managed  care  organization  submitted
inaccurate data at a category of service level and the frequency of such
inaccurate data submissions by the managed care organization;
(ii)  the  degree  to  which  the  managed care organization submitted
untimely data or no  data  and  the  frequency  of  such  untimely  data
submissions or failures to submit by the managed care organization; and
(iii)  the  timeliness  of  the managed care organization in curing or
correcting inaccurate or untimely data.
For  purposes  of  this  section,  "encounter  data"  shall  mean  all
encounter  records  or adjustments to previously submitted records which
the managed care organization has received and processed  from  provider
encounter  or  claim  records  of all contracted services rendered to an
enrollee of  the  managed  care  organization  in  the  current  or  any
preceding  month.  Any  penalty assessed under this subdivision shall be
calculated as a percentage of the Medicaid capitated premium  calculated
by the department and paid to the managed care organization.
(c)  (i)  Penalties  assessed  pursuant  to this subdivision against a
managed care organization other than  a  managed  long  term  care  plan
certified  pursuant  to section forty-four hundred three-f of the public
health law shall be as follows:
(A) for encounter data submitted or resubmitted past the deadlines set
forth in the model contract, the Medicaid capitated  premiums  shall  be
reduced by one-third percent; and
(B)  for  incomplete  or  inaccurate  encounter  data,  evaluated at a
category of service level, that fails to conform to department developed
benchmarks  for  completeness  and  accuracy,  the  Medicaid   capitated
premiums shall be reduced by one and one-third percent; and
(C)  for  submitted data that results in a rejection rate in excess of
ten percent of department  developed  volume  benchmarks,  the  Medicaid
capitated premiums shall be reduced by one-third percent.
(ii)  Penalties  assessed  pursuant  to  this  subdivisions  against a
managed long term care plan certified  pursuant  to  section  forty-four
hundred three-f of the public health law shall be as follows:
(A) for encounter data submitted or resubmitted past the deadlines set
forth  in  the  model contract, the Medicaid capitated premiums shall be
reduced by one-quarter percent;
(B) for incomplete  or  inaccurate  encounter  data,  evaluated  at  a
category of service level, that fails to conform to department developed
benchmarks   for  completeness  and  accuracy,  the  Medicaid  capitated
premiums shall be reduced by one percent; and
(C) for submitted data that results in a rejection rate in  excess  of
ten  percent  of  department  developed  volume benchmarks, the Medicaid
capitated premiums shall be reduced by one-quarter percent.
(iii) For incomplete or inaccurate encounter data, identified  in  the
course  of  an  audit, investigation or review by the Medicaid inspector

general,  the  Medicaid  capitated  premiums  shall  be  reduced  by  an
additional one percent.
(d) (i) Penalties under this subdivision may be applied to any and all
circumstances  described  in paragraph (b) of this subdivision until the
managed care organization complies with the requirements for  submission
of encounter data.
(ii)  No  penalties  for late, incomplete or inaccurate encounter data
shall be assessed against managed  care  organizations  in  addition  to
those  provided for in this subdivision, provided, however, that nothing
in this paragraph shall prohibit the imposition of penalties,  in  cases
of fraud, waste or abuse, otherwise authorized by law.
33.  For services under this title provided by residential health care
facilities under article twenty-eight of  the  public  health  law,  the
commissioner  shall  direct  managed  care  organizations licensed under
article forty-four of the public health law, article forty-three of  the
insurance law, and this section, to continue to reimburse at a benchmark
rate  which  is  to  be  the fee-for-service rate calculated pursuant to
section twenty-eight  hundred  eight  of  the  public  health  law.  The
benchmark fee-for-service rate shall continue to be paid by such managed
care  organizations  for all services provided by residential healthcare
facilities from the effective date of this subdivision  at  least  until
December   thirty-first,  two  thousand  twenty.  The  commissioner  may
require, as a  condition  of  continuing  to  require  payment  at  such
benchmark  rate  that aggregate managed care expenditures to residential
health  care  facilities  meet  the  alternative   payment   methodology
requirements  set  forth  in  attachment I of the New York State section
1115 medicaid redesign team  waiver  as  approved  by  the  centers  for
medicare  and  medicaid services. The commissioner of health shall waive
such requirements if a sufficient number of providers, as determined  by
the  commissioner,  suffer a financial hardship as a consequence of such
alternative payment methodology requirements,  or  if  the  commissioner
determines  that  such  alternative  payment methodologies significantly
threaten  individuals'  access  to  residential  health  care   facility
services;   such  waiver  may  be  applied  on  a  provider-specific  or
industry-wide basis. Further, such requirements may be  waived,  as  the
commissioner  determines  necessary,  to  comply  with  federal rules or
regulations governing these payment methodologies.
34. For purposes of recovery of overpayments pursuant  to  subdivision
thirty-five  of  this  section, any payment made pursuant to the state's
managed care program, including payments made by managed long term  care
plans,  shall  be  deemed  a  payment  by the state's medical assistance
program, provided that this subdivision shall not permit the  imposition
of  a  lien  or  recovery against property of an individual or estate on
account of medical assistance payments where recovery  is  made  against
the individual's managed care provider or provider of medical assistance
program  items or services. Provided however nothing in this subdivision
shall be construed to limit recoveries under other relevant sections  of
law.
35.  Recovery  of  overpayments  from network providers. (a) Where the
Medicaid inspector general during the course of an audit, investigation,
or review, or the deputy attorney general for the Medicaid fraud control
unit during the course of an investigation or prosecution  for  Medicaid
fraud, identifies medical assistance overpayments made by a managed care
provider  or  managed  long  term  care  plan  to  its  subcontractor or
subcontractors or provider or providers, the state shall have the  right
to  recover  the  overpayment  from the subcontractor or subcontractors,
provider or providers, or the managed care provider or managed long term

care plan; provided, however, in no event shall the state duplicate  the
recovery of an overpayment from a provider or subcontractor.
(b)  Where the state is unsuccessful in recovering an overpayment from
the subcontractor  or  subcontractors  or  provider  or  providers,  the
Medicaid  inspector  general  may  require  the managed care provider or
managed  long  term  care  plan  to  recover  the   medical   assistance
overpayment identified in paragraph (a) of this subdivision on behalf of
the  state.  The  managed  care  provider or managed long term care plan
shall remit to the state the full amount of the  identified  overpayment
no  later than six months after receiving notice of the overpayment from
the state.
36. Medicaid Program Integrity  Reviews.  (a)  For  purposes  of  this
subdivision,  managed care provider shall also include managed long term
care plans.
(b) The Medicaid inspector general shall conduct periodic  reviews  of
the  contractual performance of each managed care provider as it relates
to the managed care provider's program integrity obligations  under  its
contract  with  the  department.  The  Medicaid  inspector  general,  in
consultation with the commissioner, shall publish on its website, a list
of those contractual obligations pursuant  to  which  the  managed  care
provider's  program  integrity performance shall be evaluated, including
benchmarks, prior to commencing any review. A Medicaid program integrity
review  of  a  managed  care  provider  conducted   pursuant   to   this
subdivision,  may  be completed no more than annually. Reviews performed
pursuant to this subdivision shall include a review of  compliance  with
contractual  standards  which  prevent  fraud,  waste,  or  abuse.  Such
standards may  include  but  are  not  limited  to  excluded  providers,
restricted   recipient   program,   reporting   obligations,  compliance
programs, and suspension of payments. However, if the Medicaid inspector
general  determines  that  a  subsequent  review,   pursuant   to   this
subdivision, is necessary, a second review may occur within one year.
(c)  If,  as  a  result  of  his or her review, the Medicaid inspector
general determines that a managed  care  provider  is  not  meeting  its
program  integrity  obligations,  the  Medicaid  inspector  general  may
recover from the managed care provider up to two percent of the Medicaid
premiums paid to the managed care provider for the period under  review.
Any premium recovery under this subdivision shall be a percentage of the
administrative  component  of  the  Medicaid  premium  calculated by the
department and may be recovered by the department in the same manner  it
recovers overpayments.
(d)  The  managed  care  provider shall be entitled to receive a draft
audit report and final  audit  report  containing  the  results  of  the
Medicaid  inspector  general's review. If the Medicaid inspector general
determines to recover a  percentage  of  the  premium  as  described  in
paragraph  (c)  of  this subdivision, the managed care provider shall be
entitled to notice and an opportunity to be  heard  in  accordance  with
section twenty-two of this chapter.
37.  Managed care providers shall report to the department all sources
and amounts of income, payments, and financial benefits related  to  the
provision  of  pharmacy  benefits,  including,  but  not limited to, any
pricing discounts, rebates of any kind, inflationary payments,  credits,
clawbacks,  fees, grants, chargebacks, reimbursements, or other benefits
whether such  income,  payments,  or  financial  benefits  are  received
directly  by the managed care provider or passed through from a pharmacy
benefit manager or other  entity.  Managed  care  providers  shall  also
report  to the department the amounts of any administrative fees paid to
cover the cost of providing pharmacy benefit  management  services.  The
reporting  required  in  this  subdivision  shall be supplemental to and

included with other existing reporting requirements, including  but  not
limited to any quarterly reporting requirements.
** 38.  (a) When a patient's health care provider prescribes an opioid
dependence agent or opioid antagonist  that  is  not  on  the  statewide
formulary  of  opioid  dependence  agents  and  opioid  antagonists, the
prescriber shall consult with the managed care plan to confirm  that  in
his  or  her  reasonable  professional  judgment, the patient's clinical
condition  is  consistent  with  the  criteria  for  approval   of   the
non-preferred or non-formulary drug. Such criteria shall include:
(i) the preferred drug has been tried by the patient and has failed to
produce the desired health outcomes;
(ii)  the  patient  has  tried  the preferred drug and has experienced
unacceptable side effects;
(iii) the patient has been stabilized  on  a  non-preferred  drug  and
transition  to  the  preferred  or  formulary  drug  would  be medically
contraindicated; or
(iv) other clinical indications identified by the  committee  for  the
patient's   use   of   the   non-preferred  drug,  which  shall  include
consideration of the medical needs  of  special  populations,  including
children,   elderly,   chronically   ill,  persons  with  mental  health
conditions, persons affected by HIV/AIDS and  pregnant  persons  with  a
substance use disorder.
(b)  The  managed care plan shall have a process for a patient, or the
patient's prescribing health care provider, to request a  review  for  a
prescription  drug  that  is  not  on  the statewide formulary of opioid
dependence agents and opioid  antagonists,  consistent  with  42  C.F.R.
438.210(d), or any successor regulation.
(c)  A  managed care plan's failure to comply with the requirements of
this subdivision shall be subject to a  one  thousand  dollar  fine  per
violation.
** NB There are 2 sb 38's
** 38. Penalties for the submission of misstated cost reports. (a) For
purposes  of  this subdivision, managed care provider shall also include
managed long-term care plans.
(b) The Medicaid inspector general may, in his or her  discretion  and
in  consultation  with  the  commissioner, impose a penalty on a managed
care provider whose filed cost report contained a misstatement  of  fact
including:
(i) unsubstantiated or improper costs;
(ii) number of member months;
(iii) number of events.
For  purposes  of  this paragraph, number of events shall include, but
not be limited to understated births or deliveries.
(c) (i) For misstatements found in subparagraph (i) of  paragraph  (b)
of  this  subdivision,  the  penalty shall be equal to the amount of the
misstatement multiplied by two.
(ii) For misstatements found in subparagraph (ii) of paragraph (b)  of
this  subdivision,  the  penalty  shall  be  the  amount  of the premium
capitation paid by the department for the region per member month.
(iii) For misstatements found in subparagraph (iii) of  paragraph  (b)
of this subdivision, the penalty shall be the amount of the supplemental
capitation paid by the department for the region per member event.
(d) Any penalty imposed under this subdivision may be recovered by the
department in any manner authorized by law.
(e)  The  managed  care  provider  against  whom  a penalty is imposed
pursuant to  this  subdivision  shall  be  entitled  to  notice  and  an
opportunity  to  be  heard in accordance with section twenty-two of this
chapter.
** NB There are 2 sb 38's
39.  Medicaid  fraud,  waste and abuse prevention. (a) For purposes of
this subdivision, managed  care  provider  shall  also  include  managed
long-term care plans.
(b)  Managed  care  providers  shall  adopt and implement policies and
procedures designed to detect and prevent fraud, waste and  abuse.  This
shall include the adoption and implementation of a compliance program as
required  by  section  three hundred sixty-three-d of this title and the
terms of the contract between the managed care provider and  the  state,
and  for  managed  care  providers  with  an  enrolled population of one
thousand or more persons  in  the  aggregate  in  any  given  year,  the
establishment  of  a  special investigation unit which will have primary
responsibility for implementing the managed care provider's policies and
procedures to detect and prevent fraud, waste and abuse, as  it  relates
to  the  managed care provider's participation in the medical assistance
program.
(c) The managed care provider shall coordinate its  fraud,  waste  and
abuse  prevention activities with the Medicaid inspector general and the
department of health. The Medicaid inspector  general,  in  consultation
with  the  department of health, may promulgate regulations establishing
standards and requirements for the operation of  managed  care  provider
fraud, waste and abuse prevention activities, including requirements for
special   investigation   units.  The  provisions  of  this  subdivision
notwithstanding, the managed care provider shall continue to comply with
all the requirements of  section  forty-four  hundred  fourteen  of  the
public health law.
* NB Repealed March 31, 2026 (per ch. 165/1991)
* NB Repealed March 31, 2026 (per ch. 710/1988)