N.Y. Social Services Law § 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, 2029