§ 364-F — Primary care case management programs

* § 364-f. Primary care case management programs. 1. The department is\nauthorized to establish primary care case management programs, under the\nmedical assistance program, in accordance with applicable federal law\nand regulations. Primary care case management programs shall only be\nauthorized in areas of the state where comprehensive health services\nplans, as defined in section forty-four hundred one of the public health\nlaw, are not yet available. Subject to the approval of the director of\nthe budget, the commissioner is authorized to apply for the appropriate\nwaivers under federal law and regulation, and may waive any of the\nprovisions of sections three hundred sixty-five-a, three hundred\nsixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a and\nthree hundred sixty-four-j of this chapter or any regulation of the\ndepartment when such action would be necessary to assist in promoting\nthe objectives of this section.\n 2. (a) A primary care case management program shall provide\nindividuals eligible for medical assistance with the opportunity to\nselect a primary care case manager who shall provide medical assistance\nservices to such eligible individuals, either directly, or through\nreferral.\n (b) Primary care case managers shall be limited to qualified, licensed\nprimary care practitioners, as defined in paragraph (f) of subdivision\none of section three hundred sixty-four-j of this chapter, who meet\nstandards established by the commissioner for the purposes of this\nprogram.\n (c) Services that may be covered by the primary care case management\nprogram are defined by the commissioner in the benefit package. Covered\nservices may include all medical assistance services defined under\nsection three hundred sixty-five-a of this chapter, except:\n (i) services excluded under paragraph (e) of subdivision three of\nsection three hundred sixty-four-j of this chapter shall be excluded\nunder this section;\n (ii) services provided by residential health care facilities, long\nterm home health care programs, child care agencies, and entities\noffering comprehensive health services plans;\n (iii) services provided by dentists and optometrists; and\n (iv) eyeglasses, emergency care, mental health services and family\nplanning services.\n (d) Case management services provided by primary care case managers\nshall include, but need not be limited to:\n (i) management of the medical and health care of each recipient to\nassure that all services provided under paragraph (c) of this\nsubdivision and which are found to be necessary, are made available in a\ntimely manner;\n (ii) referral to, and coordination, monitoring and follow-up of,\nappropriate providers for diagnosis and treatment, the need for which\nhas been identified by the primary care case manager but which is not\ndirectly available from the primary care case manager, and assisting\nmedical assistance recipients in the prudent selection of medical\nservices;\n (iii) arrangements for referral of recipients to appropriate\nproviders; and\n (iv) all early periodic screening, diagnosis and treatment services,\nas well as interperiodic screening and referral, to each participant\nunder the age of twenty-one at regular intervals.\n 3. (a) Primary care case management programs may be conducted only in\naccordance with guidelines established by the commissioner. For the\npurpose of implementing and administering the primary care case\nmanagement programs, the commissioner may contract with private\nnot-for-profit and public agencies as defined in guidelines established\nby the commissioner for the management and administration of the primary\ncare case management program.\n (b) The primary care case management program must:\n (i) assure access to and delivery of high quality, appropriate medical\nservices;\n (ii) participate in quality assurance activities as required by the\ncommissioner, as well as other mechanisms designed to protect recipient\nrights under such program;\n (iii) ensure that persons eligible for medical assistance will be\nprovided sufficient information regarding the program to make an\ninformed and voluntary choice whether to participate; and\n (iv) provide for adequate safeguards to protect recipients from being\nmisled concerning the program and from being coerced into participating\nin the primary care case management program.\n 4. (a) Individuals eligible to participate in Medicaid managed care,\nto participate in Medicaid managed care may participate in a primary\ncare case management program, subject to the availability of such a\nprogram within the applicable social services district, except for\nindividuals: (i) required by Medicaid managed care to be enrolled in an\nentity offering a comprehensive health services plan as defined in\nparagraph (k) of subdivision two of section three hundred sixty-five-a\nof this chapter; (ii) participating in another medical assistance\nreimbursed demonstration or pilot project, or (iii) receiving services\nas an inpatient from a nursing home or intermediate care facility or\nresidential services from a child care agency or services from a long\nterm home health care program.\n (b) Individuals choosing to participate in a primary care case\nmanagement program will be given thirty days from the effective date of\nenrollment in the program to disenroll without cause. After this thirty\nday disenrollment period, all individuals participating in the program\nwill be enrolled for a period of twelve months, except that all\nparticipants will be permitted to disenroll for good cause, as defined\nin guidelines established by the commissioner.\n 5. (a) Primary care case management programs may include provisions\nfor innovative payment mechanisms, including, but not limited to,\npayment of case management fees, capitation arrangements, and\nfee-for-service payments.\n (b) Any new payment mechanisms and levels of payment implemented under\nthe primary care case management program shall be developed by the\ncommissioner subject to the approval of the director of the budget.\n 6. Notwithstanding any inconsistent provision of this section,\nparticipation in a primary care case management program will not\ndiminish the scope of available medical services to which a recipient is\nentitled.\n 7. This section shall be effective if, and as long as, federal\nfinancial participation is available therefor.\n * NB Expires March 31, 2026\n