2023 New York Laws › PBH - Public Health › Article 44 - Health Maintenance Organizations › 4403-E - Primary Care Partial Capitation Providers; Partial Capitation Certificate of Authority.

* §   4403-e.  Primary  care  partial  capitation  providers;  partial
capitation certificate of  authority.  1.  The  commissioner  may  issue
partial  capitation  certificates  of  authority to qualified individual
medical services providers, counties or entities  comprised  of  medical
services  providers,  applying  on forms prescribed by the commissioner,
seeking to offer medical  assistance  services,  including  primary  and
preventive  care  and  case  management  of  inpatient,  emergency room,
specialty, and pharmacy services, to recipients  of  medical  assistance
eligible to enroll in managed care plans, on a partial capitation basis.
Partial  capitation  certificates  of authority shall only be awarded to
qualified applicants in rural areas of  the  state  where  comprehensive
health  services  plans, as defined in section forty-four hundred one of
this article, are not yet  available,  provided  that  such  certificate
shall  be  awarded  only  until  full  capitation  becomes  practicable.
Comprehensive primary and preventive care shall include all services and
related ancillary procedures  routinely  performed  in  a  primary  care
physicians  office,  including  preventive  care  and  immunizations  in
accordance    with    CTH     periodic     schedules     and     routine
obstetrical-gynecological   services.   Notwithstanding,  where  partial
capitation providers currently exist, they will be allowed  to  continue
operation.  Provided, however, that a shared health facility, as defined
in article forty-seven of this chapter, shall not be eligible for such a
certificate.
2. Applications for a  partial  capitation  certificate  of  authority
shall include the following:
(a) current licensure or certification;
(b)  a  description  of  the  applicant's  experience in providing the
services included as part of comprehensive primary and preventive  care,
including identification of any disciplinary, administrative or criminal
proceedings  related  to such license, certification or services and the
resolution thereof;
(c) a description of the  applicant's  financial  resources,  together
with  a copy of the applicant's latest certified financial statement and
the medical malpractice insurance coverage maintained by such applicant;
(d) an assessment of the applicant's ability to  continue  to  provide
high  quality  services  in  exchange  for  payments  and  to assume the
financial risk of operating on a partial capitation basis;
(e) the geographic area to be served by the applicant;
(f) the applicant's current capacity, and proposed capacity to provide
or directly arrange for the provision of medical care  and  services  to
persons eligible for medical assistance;
(g)  a  statement of intent to contract from the local social services
district in which they will operate;
(h) a statement describing  procedures  to  be  used  to  monitor  the
quality of care provided by the plan;
(i) such other information as the commissioner shall require; and
(j)  in  the  case  of  an  application  from  a local social services
district, such comparable information as the commissioner may require.
3. The commissioner may issue  a  partial  capitation  certificate  of
authority to an applicant that meets the following criteria:
(a)  the applicant can demonstrate its ability to control, arrange for
and manage in-patient hospital and emergency room care  through  written
agreements with participating hospitals;
(b)  the  applicant is board-certified or board-eligible in his or her
area of specialty, or has completed an accredited residency program,  or
has  admitting privileges at one or more hospitals, or in the case of an
entity, all medical services providers affiliated with the applicant are
board-certified or board-eligible in his or her area of  specialty,  has

completed  an  accredited residency program, or has admitting privileges
at one or more hospitals;
(c)  the  applicant  directly provides or arranges for the delivery of
comprehensive primary and preventive care and  services  and  access  to
medical advice and emergency care on a twenty-four hour basis;
(d) the applicant has adequate medical malpractice liability insurance
coverage;
(e)  the  applicant has demonstrated it is financially responsible and
may be expected to meet its obligations to  its  enrolled  members.  For
purposes  of  this  paragraph,  "financially responsible" means that the
applicant shall assume financial risk on a  prospective  basis  for  the
provision of comprehensive primary care and preventive services, and can
support   the   necessary   administrative  costs  associated  with  the
activities of a partial capitation plan, for its enrolled members;
(f) the applicant has demonstrated the ability to provide high quality
care, and to monitor the quality of  care  provided  via  an  acceptable
formal quality assurance program;
(g)  the  local social services district has provided written evidence
of its intention to contract with the plan; and
(h) the applicant has demonstrated the ability to  track  and  monitor
all  services  provided  to  its  enrollees,  and  its ability to submit
periodic cost and utilization reports, as the commissioner may require.
* NB Repealed March 31, 2030