N.Y. Public Health Law § 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