2023 New York Laws › SOS - Social Services › Article 5 - Assistance and Care › Title 11 - Medical Assistance for Needy Persons › 364-F - Primary Care Case Management Programs.

* § 364-f. Primary care case management programs. 1. The department is
authorized to establish primary care case management programs, under the
medical  assistance  program,  in accordance with applicable federal law
and regulations. Primary care case management  programs  shall  only  be
authorized  in  areas  of  the state where comprehensive health services
plans, as defined in section forty-four hundred one of the public health
law, are not yet available. Subject to the approval of the  director  of
the  budget, the commissioner is authorized to apply for the appropriate
waivers under federal law and regulation,  and  may  waive  any  of  the
provisions   of  sections  three  hundred  sixty-five-a,  three  hundred
sixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a  and
three  hundred  sixty-four-j  of  this  chapter or any regulation of the
department when such action would be necessary to  assist  in  promoting
the objectives of this section.
2.   (a)   A  primary  care  case  management  program  shall  provide
individuals eligible for medical  assistance  with  the  opportunity  to
select  a primary care case manager who shall provide medical assistance
services to such  eligible  individuals,  either  directly,  or  through
referral.
(b) Primary care case managers shall be limited to qualified, licensed
primary  care  practitioners, as defined in paragraph (f) of subdivision
one of section three hundred sixty-four-j  of  this  chapter,  who  meet
standards  established  by  the  commissioner  for  the purposes of this
program.
(c) Services that may be covered by the primary care  case  management
program  are defined by the commissioner in the benefit package. Covered
services may include  all  medical  assistance  services  defined  under
section three hundred sixty-five-a of this chapter, except:
(i)  services  excluded  under  paragraph  (e) of subdivision three of
section three hundred sixty-four-j of this  chapter  shall  be  excluded
under this section;
(ii)  services  provided  by  residential health care facilities, long
term home health  care  programs,  child  care  agencies,  and  entities
offering comprehensive health services plans;
(iii) services provided by dentists and optometrists; and
(iv)  eyeglasses,  emergency  care,  mental health services and family
planning services.
(d) Case management services provided by primary  care  case  managers
shall include, but need not be limited to:
(i)  management  of  the  medical and health care of each recipient to
assure  that  all  services  provided  under  paragraph  (c)   of   this
subdivision and which are found to be necessary, are made available in a
timely manner;
(ii)  referral  to,  and  coordination,  monitoring  and follow-up of,
appropriate providers for diagnosis and treatment, the  need  for  which
has  been  identified  by the primary care case manager but which is not
directly available from the primary care  case  manager,  and  assisting
medical  assistance  recipients  in  the  prudent  selection  of medical
services;
(iii)  arrangements  for  referral  of   recipients   to   appropriate
providers; and
(iv)  all  early periodic screening, diagnosis and treatment services,
as well as interperiodic screening and  referral,  to  each  participant
under the age of twenty-one at regular intervals.
3.  (a) Primary care case management programs may be conducted only in
accordance with guidelines established  by  the  commissioner.  For  the
purpose   of  implementing  and  administering  the  primary  care  case
management  programs,  the  commissioner  may  contract   with   private

not-for-profit  and public agencies as defined in guidelines established
by the commissioner for the management and administration of the primary
care case management program.
(b) The primary care case management program must:
(i) assure access to and delivery of high quality, appropriate medical
services;
(ii)  participate  in  quality assurance activities as required by the
commissioner, as well as other mechanisms designed to protect  recipient
rights under such program;
(iii)  ensure  that  persons  eligible  for medical assistance will be
provided  sufficient  information  regarding  the  program  to  make  an
informed and voluntary choice whether to participate; and
(iv)  provide for adequate safeguards to protect recipients from being
misled concerning the program and from being coerced into  participating
in the primary care case management program.
4.  (a)  Individuals eligible to participate in Medicaid managed care,
to participate in Medicaid managed care may  participate  in  a  primary
care  case  management  program,  subject  to the availability of such a
program within the  applicable  social  services  district,  except  for
individuals:  (i) required by Medicaid managed care to be enrolled in an
entity  offering  a  comprehensive  health  services  plan as defined in
paragraph (k) of subdivision two of section three  hundred  sixty-five-a
of  this  chapter;  (ii)  participating  in  another  medical assistance
reimbursed demonstration or pilot project, or (iii)  receiving  services
as  an  inpatient  from  a nursing home or intermediate care facility or
residential services from a child care agency or services  from  a  long
term home health care program.
(b)  Individuals  choosing  to  participate  in  a  primary  care case
management program will be given thirty days from the effective date  of
enrollment  in the program to disenroll without cause. After this thirty
day disenrollment period, all individuals participating in  the  program
will  be  enrolled  for  a  period  of  twelve  months,  except that all
participants will be permitted to disenroll for good cause,  as  defined
in guidelines established by the commissioner.
5.  (a)  Primary  care case management programs may include provisions
for innovative  payment  mechanisms,  including,  but  not  limited  to,
payment   of   case   management   fees,  capitation  arrangements,  and
fee-for-service payments.
(b) Any new payment mechanisms and levels of payment implemented under
the primary care case management  program  shall  be  developed  by  the
commissioner subject to the approval of the director of the budget.
6.   Notwithstanding  any  inconsistent  provision  of  this  section,
participation in  a  primary  care  case  management  program  will  not
diminish the scope of available medical services to which a recipient is
entitled.
7.  This  section  shall  be  effective  if,  and  as long as, federal
financial participation is available therefor.
* NB Expires March 31, 2026