§ 4403-E — Primary care partial capitation providers; partial capitation certificate of authority

* § 4403-e. Primary care partial capitation providers; partial\ncapitation certificate of authority. 1. The commissioner may issue\npartial capitation certificates of authority to qualified individual\nmedical services providers, counties or entities comprised of medical\nservices providers, applying on forms prescribed by the commissioner,\nseeking to offer medical assistance services, including primary and\npreventive care and case management of inpatient, emergency room,\nspecialty, and pharmacy services, to recipients of medical assistance\neligible to enroll in managed care plans, on a partial capitation basis.\nPartial capitation certificates of authority shall only be awarded to\nqualified applicants in rural areas of the state where comprehensive\nhealth services plans, as defined in section forty-four hundred one of\nthis article, are not yet available, provided that such certificate\nshall be awarded only until full capitation becomes practicable.\nComprehensive primary and preventive care shall include all services and\nrelated ancillary procedures routinely performed in a primary care\nphysicians office, including preventive care and immunizations in\naccordance with CTH periodic schedules and routine\nobstetrical-gynecological services. Notwithstanding, where partial\ncapitation providers currently exist, they will be allowed to continue\noperation. Provided, however, that a shared health facility, as defined\nin article forty-seven of this chapter, shall not be eligible for such a\ncertificate.\n 2. Applications for a partial capitation certificate of authority\nshall include the following:\n (a) current licensure or certification;\n (b) a description of the applicant's experience in providing the\nservices included as part of comprehensive primary and preventive care,\nincluding identification of any disciplinary, administrative or criminal\nproceedings related to such license, certification or services and the\nresolution thereof;\n (c) a description of the applicant's financial resources, together\nwith a copy of the applicant's latest certified financial statement and\nthe medical malpractice insurance coverage maintained by such applicant;\n (d) an assessment of the applicant's ability to continue to provide\nhigh quality services in exchange for payments and to assume the\nfinancial risk of operating on a partial capitation basis;\n (e) the geographic area to be served by the applicant;\n (f) the applicant's current capacity, and proposed capacity to provide\nor directly arrange for the provision of medical care and services to\npersons eligible for medical assistance;\n (g) a statement of intent to contract from the local social services\ndistrict in which they will operate;\n (h) a statement describing procedures to be used to monitor the\nquality of care provided by the plan;\n (i) such other information as the commissioner shall require; and\n (j) in the case of an application from a local social services\ndistrict, such comparable information as the commissioner may require.\n 3. The commissioner may issue a partial capitation certificate of\nauthority to an applicant that meets the following criteria:\n (a) the applicant can demonstrate its ability to control, arrange for\nand manage in-patient hospital and emergency room care through written\nagreements with participating hospitals;\n (b) the applicant is board-certified or board-eligible in his or her\narea of specialty, or has completed an accredited residency program, or\nhas admitting privileges at one or more hospitals, or in the case of an\nentity, all medical services providers affiliated with the applicant are\nboard-certified or board-eligible in his or her area of specialty, has\ncompleted an accredited residency program, or has admitting privileges\nat one or more hospitals;\n (c) the applicant directly provides or arranges for the delivery of\ncomprehensive primary and preventive care and services and access to\nmedical advice and emergency care on a twenty-four hour basis;\n (d) the applicant has adequate medical malpractice liability insurance\ncoverage;\n (e) the applicant has demonstrated it is financially responsible and\nmay be expected to meet its obligations to its enrolled members. For\npurposes of this paragraph, "financially responsible" means that the\napplicant shall assume financial risk on a prospective basis for the\nprovision of comprehensive primary care and preventive services, and can\nsupport the necessary administrative costs associated with the\nactivities of a partial capitation plan, for its enrolled members;\n (f) the applicant has demonstrated the ability to provide high quality\ncare, and to monitor the quality of care provided via an acceptable\nformal quality assurance program;\n (g) the local social services district has provided written evidence\nof its intention to contract with the plan; and\n (h) the applicant has demonstrated the ability to track and monitor\nall services provided to its enrollees, and its ability to submit\nperiodic cost and utilization reports, as the commissioner may require.\n * NB Repealed March 31, 2030\n