§ 364-J — Managed care programs

New York § 364-J

• Jurisdiction: New York
• Law SOS: Social Services
• Title 11: Medical Assistance For Needy Persons
• Art. 5: Assistance and Care

Text

* § 364-j. Managed care programs. 1. Definitions. As used in this\nsection, unless the context clearly requires otherwise, the following\nterms shall mean:\n (a) "Participant". A medical assistance recipient who receives, is\nrequired to receive or elects to receive his or her medical assistance\nservices from a managed care provider.\n (b) "Managed care provider". An entity that provides or arranges for\nthe provision of medical assistance services and supplies to\nparticipants directly or indirectly (including by referral), including\ncase management; and:\n (i) is authorized to operate under article forty-four of the public\nhealth law or article forty-three of the insurance law and provides or\narranges, directly or indirectly (including by referral) for covered\ncomprehensive health services on a full capitation basis, including a\nspecial needs managed care plan or comprehensive HIV special needs plan;\nor\n ** (ii) is authorized as a partially capitated program pursuant to\nsection three hundred sixty-four-f of this title or section forty-four\nhundred three-e of the public health law or section 1915b of the social\nsecurity act; or\n ** NB Effective until December 31, 2027\n ** (ii) is authorized as a partially capitated program pursuant to\nsection three hundred sixty-four-f of this title or section forty-four\nhundred three-e of the public health law or section 1915b of the social\nsecurity act.\n ** NB Effective December 31, 2027\n ** (iii) is authorized to operate under section forty-four hundred\nthree-g of the public health law.\n ** NB Repealed December 31, 2027\n (c) "Managed care program". A statewide program in which medical\nassistance recipients enroll on a voluntary or mandatory basis to\nreceive medical assistance services, including case management, directly\nand indirectly (including by referral) from a managed care provider,\nincluding as applicable, a special needs managed care plan or a\ncomprehensive HIV special needs plan, under this section.\n (d) "Medical services provider". A physician, nurse, nurse\npractitioner, physician assistant, licensed midwife, dentist,\noptometrist or other licensed health care practitioner authorized to\nprovide medical assistance services.\n (e) "Center of excellence." A health care facility certified to\noperate under article twenty-eight of the public health law that offers\nspecialized treatment expertise in HIV care services as defined by the\ncommissioner of health.\n (f) "Primary care practitioner". A physician or nurse practitioner\nproviding primary care to and management of the medical and health care\nservices of a participant served by a managed care provider.\n (g) "AIDS". AIDS shall have the same meaning as in article\ntwenty-seven-f of the public health law.\n (h) "HIV infection". HIV infection shall have the same meaning as in\narticle twenty-seven-f of the public health law.\n (i) "HIV-related illness". HIV-related illness shall have the same\nmeaning as in article twenty-seven-f of the public health law.\n (j) "Specialty care center". A "specialty care center" shall mean only\nsuch centers as are accredited or designated by an agency of the state\nor federal government or by a voluntary national health organization as\nhaving special expertise in treating the disease or condition for which\nit is accredited or designated.\n (k) "Special care". Care, services and supplies relating to the\ntreatment of mental illness, developmental disabilities, alcoholism,\nalcohol abuse or substance abuse, or HIV infection/AIDS.\n (l) "Responsible special care agency". Whichever of the following\nstate agencies has responsibility for the special care in question: the\ndepartment of health, the office of mental health, the office for people\nwith developmental disabilities, or the office of alcoholism and\nsubstance abuse services.\n (m) "Special needs managed care plan" shall have the same meaning as\nin section forty-four hundred one of the public health law.\n (n) "Comprehensive HIV special needs plan" shall have the same meaning\nas in section forty-four hundred three-c of the public health law.\n (o) "Third-party payor". Any entity or program that is or may be\nliable to pay the costs of health and medical care of a recipient of\nmedical assistance benefits, including insurers licensed pursuant to\narticle thirty-two or forty-three of the insurance law, or organizations\ncertified pursuant to article forty-four of the public health law.\n (p) "Grievance". Any complaint presented by a participant or a\nparticipant's representative for resolution through the grievance\nprocess of a managed care provider.\n (q) "Emergency medical condition". A medical or behavioral condition,\nthe onset of which is sudden, that manifests itself by symptoms of\nsufficient severity, including severe pain, that a prudent layperson,\nwho possesses an average knowledge of medicine and health, could\nreasonably expect the absence of immediate medical attention to result\nin: (i) placing the health of the person afflicted with such condition\nin serious jeopardy, or in the case of a behavioral condition placing\nthe health of the person or others in serious jeopardy; or (ii) serious\nimpairment to such person's bodily functions; or (iii) serious\ndysfunction of any bodily organ or part of such person; or (iv) serious\ndisfigurement of such person.\n (r) "Emergency care". Health care procedures, treatments or services,\nincluding psychiatric stabilization and medical detoxification from\ndrugs or alcohol, that are provided for an emergency medical condition.\n (s) "Existing rates". The rates paid pursuant to the most recent\nexecuted contract between a local social services district or the state\nand a managed care provider.\n (t) "Managed care rating regions". The regions established by the\ndepartment of health for the purpose of setting regional premium rates\nfor managed care providers.\n (u) "Premium group". The various demographic, gender and recipient\ncategories utilized for rate-setting purposes by the department of\nhealth.\n (v) "Upper payment limit". The maximum reimbursement that the\ndepartment of health may pay a managed care provider for providing or\narranging for medical services to participants in a managed care program\nin accordance with the federal social security act and regulations\npromulgated thereunder.\n (x) "Persons with serious mental illness". Individuals who meet\ncriteria established by the commissioner of mental health, which shall\ninclude persons who have a designated diagnosis of mental illness under\nthe most recent edition of the diagnostic and statistical manual of\nmental disorders, and (i) whose severity and duration of mental illness\nresults in substantial functional disability or (ii) who require mental\nhealth services on more than an incidental basis.\n (y) "Children and adolescents with serious emotional disturbances".\nIndividuals under eighteen years of age who meet criteria established by\nthe commissioner of mental health, which shall include children and\nadolescents who have a designated diagnosis of mental illness under the\nmost recent edition of the diagnostic and statistical manual of mental\ndisorders, and (i) whose severity and duration of mental illness results\nin substantial functional disability or (ii) who require mental health\nservices on more than an incidental basis.\n (z) "Credentialed alcoholism and substance abuse counselor (CASAC)".\nAn individual credentialed by the office of alcoholism and substance\nabuse services in accordance with applicable regulations of the\ncommissioner of alcoholism and substance abuse services.\n 2. (a) The commissioner of health, in cooperation with the\ncommissioner and the commissioners of the responsible special care\nagencies shall establish managed care programs, under the medical\nassistance program, in accordance with applicable federal law and\nregulations. The commissioner of health, in cooperation with the\ncommissioner, is authorized and directed, subject to the approval of the\ndirector of the state division of the budget, to apply for federal\nwaivers when such action would be necessary to assist in promoting the\nobjectives of this section.\n (b) The commissioner of health has authority to allow social services\ndistricts to seek an exemption from this section for up to two years if\nthe social services district can demonstrate and the commissioner of\nhealth and the commissioner of responsible special care agencies concurs\nthat the district has insufficient capacity to participate in the\nprogram. An exemption under this paragraph may be renewed for additional\ntwo year periods.\n (c) The commissioner of health, jointly with the commissioner of\nmental health and the commissioner of alcoholism and substance abuse\nservices shall be authorized to establish special needs managed care\nplans, under the medical assistance program, in accordance with\napplicable federal law and regulations. The commissioner of health, in\ncooperation with such commissioners, is authorized, subject to the\napproval of the director of the division of the budget, to apply for\nfederal waivers when such action would be necessary to assist in\npromoting the objectives of this section. With regard to such special\nneeds managed care plans, in addition to the applicable requirements\nestablished in this section, such commissioners shall jointly establish\nstandards and requirements to:\n (i) ensure that any special needs managed care plan shall have an\nadequate network of providers to meet the behavioral health and health\nneeds of enrollees, and shall review the adequacy prior to approval of\nany special needs managed care plan, and upon contract renewal or\nexpansion. To the extent that the network has been determined to meet\nstandards set forth in subdivision five of section four thousand four\nhundred three of the public health law, such network shall be deemed\nadequate;\n (ii) ensure that any special needs managed care plan shall make level\nof care and coverage determinations utilizing evidence-based tools or\nguidelines designed to address the behavioral health needs of enrollees;\n (iii) ensure sufficient access to behavioral health and health\nservices for eligible enrollees by establishing and monitoring\npenetration rates of special needs managed care plans; and\n (iv) establish standards to encourage the use of services, products\nand care recommended, ordered or prescribed by a provider to\nsufficiently address the behavioral health and health services needs of\nenrollees; and monitor the application of such standards to ensure that\nthey sufficiently address the behavioral health and health services\nneeds of enrollees.\n (d) Whenever the commissioner of health makes changes to the terms,\nconditions or time frames contained in the model contract that serves as\nthe basis for contracts with managed care providers in the managed care\nprogram under this section, the changes shall be posted on the\ndepartment's website. The department shall post on its website any\nchanges required to be submitted to the centers for medicare and\nmedicaid services (CMS) for approval prior to submission of the changes.\nA summary of any changes shall also be published in the state register.\nA notification of any request for proposals issued by the department for\nmanaged care providers to participate in the managed care program shall\nalso be published in the state register.\n 3. (a) Every person eligible for or receiving medical assistance under\nthis article, who resides in a social services district providing\nmedical assistance, which has implemented the state's managed care\nprogram shall participate in the program authorized by this section.\nProvided, however, that participation in a comprehensive HIV special\nneeds plan also shall be in accordance with article forty-four of the\npublic health law and participation in a special needs managed care plan\nshall also be in accordance with article forty-four of the public health\nlaw and article thirty-one of the mental hygiene law.\n (d) Until such time as program features and reimbursement rates are\napproved by the commissioner of health, in consultation with the\ncommissioners of the office of mental health, the office for people with\ndevelopmental disabilities, the office of children and family services,\nand the office of alcoholism and substance abuse services, as\nappropriate, the following services shall not be provided to medical\nassistance recipients through managed care programs established pursuant\nto this section, and shall continue to be provided outside of managed\ncare programs and in accordance with applicable reimbursement\nmethodologies; provided, however, that no medical assistance recipient\nshall be required to obtain services that are certified, funded,\nauthorized or approved by the commissioner of the office for people with\ndevelopmental disabilities through a managed care program until the\nprogram features approved by the commissioner of health, in consultation\nwith the commissioner of the office for people with developmental\ndisabilities, include features for habilitation services as defined in\nparagraph c of subdivision one of section forty-four hundred three-g of\nthe public health law:\n (i) day treatment services provided to individuals with developmental\ndisabilities;\n (ii) comprehensive medicaid case management services provided to\nindividuals with developmental disabilities;\n (iii) services provided pursuant to article eighty-nine of the\neducation law;\n (iv) mental health services provided by a certified voluntary\nfree-standing day treatment program where such services are provided in\nconjunction with educational services authorized in an individualized\neducation program in accordance with regulations promulgated pursuant to\narticle eighty-nine of the education law;\n (v) long term services as determined by the commissioner of the office\nfor people with developmental disabilities, provided to individuals with\ndevelopmental disabilities at facilities licensed pursuant to article\nsixteen of the mental hygiene law or clinics serving individuals with\ndevelopmental disabilities at facilities licensed pursuant to article\ntwenty-eight of the public health law;\n (vi) TB directly observed therapy;\n (vii) AIDS adult day health care;\n (viii) HIV COBRA case management; and\n (ix) other services as determined by the commissioner of health.\n (d-1) Services provided pursuant to title two-A of article twenty-five\nof the public health law shall not be provided to medical assistance\nrecipients through managed care programs established pursuant to this\nsection, and shall continue to be provided outside of managed care\nprograms and in accordance with applicable reimbursement methodologies.\n (d-2) Services provided pursuant to a waiver, granted pursuant to\nsubsection (c) of section 1915 of the federal social security act, to\npersons suffering from traumatic brain injuries, shall not be provided\nto medical assistance recipients through managed care programs\nestablished pursuant to this section. Services provided pursuant to a\nwaiver, granted pursuant to subsection (c) of section 1915 of the\nfederal social security act, to persons qualifying for nursing home\ndiversion and transition services, shall not be provided to medical\nassistance recipients through managed care programs until at least\nJanuary first, two thousand twenty-seven.\n (d-3) Services provided in school-based health centers shall not be\nprovided to medical assistance recipients through managed care programs\nestablished pursuant to this section until at least April first, two\nthousand twenty-six.\n (d-4) Notwithstanding paragraph (a) of this subdivision, the following\nmedical assistance recipients shall not be eligible to participate in\nthe managed care program authorized by this section or other care\ncoordination model established by article forty-four of the public\nhealth law: any person who is permanently placed in a residential health\ncare facility for a consecutive period of three months or more. However,\nnothing in this paragraph should be construed to apply to enrollees in\nthe Medicaid Advantage Plus Program, developed to enroll persons in\nmanaged long-term care who are nursing home certifiable and who are\ndually eligible pursuant to section forty-four hundred three-f of the\npublic health law. In implementing this provision, the department shall\ncontinue to support service delivery and outcomes that result in\ncommunity living for enrollees.\n (e) The following categories of individuals may be required to enroll\nwith a managed care program when program features and reimbursement\nrates are approved by the commissioner of health and, as appropriate,\nthe commissioners of the office of mental health, the office for people\nwith developmental disabilities, the office of children and family\nservices, and the office of alcoholism and substance abuse services:\n (i) an individual dually eligible for medical assistance and benefits\nunder the federal Medicare program; provided, however, nothing herein\nshall: (a) require an individual enrolled in a managed long term care\nplan, pursuant to section forty-four hundred three-f of the public\nhealth law, to disenroll from such program; or (b) make enrollment in a\nMedicare managed care plan a condition of the individual's participation\nin the managed care program pursuant to this section, or affect the\nindividual's entitlement to payment of applicable Medicare managed care\nor fee for service coinsurance and deductibles by the individual's\nmanaged care provider.\n (ii) an individual eligible for supplemental security income;\n (iii) HIV positive individuals;\n (iv) persons with serious mental illness and children and adolescents\nwith serious emotional disturbances, as defined in section forty-four\nhundred one of the public health law;\n (v) a person receiving services provided by a residential alcohol or\nsubstance abuse program or facility for the developmentally disabled;\n (vi) a person receiving services provided by an intermediate care\nfacility for the developmentally disabled or who has characteristics and\nneeds similar to such persons;\n (vii) a person with a developmental or physical disability who\nreceives home and community-based services or care-at-home services\nthrough a demonstration waiver under section eleven hundred fifteen of\nthe federal social security act, existing waivers under section nineteen\nhundred fifteen (c) of the federal social security act, or who has\ncharacteristics and needs similar to such persons;\n (viii) a person who is eligible for medical assistance pursuant to\nsubparagraph twelve or subparagraph thirteen of paragraph (a) of\nsubdivision one of section three hundred sixty-six of this title;\n (ix) a person receiving services provided by a long term home health\ncare program, or a person receiving inpatient services in a\nstate-operated psychiatric facility or a residential treatment facility\nfor children and youth;\n (x) certified blind or disabled children living or expected to be\nliving separate and apart from the parent for thirty days or more;\n (xi) residents of nursing facilities;\n (xii) a foster child in the placement of a voluntary agency or in the\ndirect care of the local social services district;\n (xiii) a person or family that is homeless;\n (xiv) individuals for whom a managed care provider is not\ngeographically accessible so as to reasonably provide services to the\nperson. A managed care provider is not geographically accessible if the\nperson cannot access the provider's services in a timely fashion due to\ndistance or travel time;\n (xv) a person eligible for Medicare participating in a capitated\ndemonstration program for long term care;\n (xvi) an infant living with an incarcerated mother in a state or local\ncorrectional facility as defined in section two of the correction law;\n (xvii) a person who is expected to be eligible for medical assistance\nfor less than six months;\n (xviii) a person who is eligible for medical assistance benefits only\nwith respect to tuberculosis-related services;\n (xix) individuals receiving hospice services at time of enrollment;\nprovided, however, that this clause shall not be construed to require an\nindividual enrolled in a managed long term care plan or another care\ncoordination model, who subsequently elects hospice, to disenroll from\nsuch program;\n (xx) a person who has primary medical or health care coverage\navailable from or under a third-party payor which may be maintained by\npayment, or part payment, of the premium or cost sharing amounts, when\npayment of such premium or cost sharing amounts would be cost-effective,\nas determined by the local social services district;\n (xxi) a person receiving family planning services pursuant to\nsubparagraph six of paragraph (b) of subdivision one of section three\nhundred sixty-six of this title;\n (xxii) a person who is eligible for medical assistance pursuant to\nparagraph (d) of subdivision four of section three hundred sixty-six of\nthis title;\n (xxiii) individuals with a chronic medical condition who are being\ntreated by a specialist physician that is not associated with a managed\ncare provider in the individual's social services district; and\n (xxiv) Native Americans.\n 4. The managed care program shall provide participants access to\ncomprehensive and coordinated health care delivered in a cost effective\nmanner consistent with the following provisions:\n (a) (i) a managed care provider shall arrange for access to and\nenrollment of primary care practitioners and other medical services\nproviders. Each managed care provider shall possess the expertise and\nsufficient resources to assure the delivery of quality medical care to\nparticipants in an appropriate and timely manner and may include\nphysicians, nurse practitioners, county health departments, providers of\ncomprehensive health service plans licensed pursuant to article\nforty-four of the public health law, and hospitals and diagnostic and\ntreatment centers licensed pursuant to article twenty-eight of the\npublic health law or otherwise authorized by law to offer comprehensive\nhealth services or facilities licensed pursuant to articles sixteen,\nthirty-one and thirty-two of the mental hygiene law.\n (ii) provided, however, if a major public hospital, as defined in the\npublic health law, is designated by the commissioner of health as a\nmanaged care provider in a social services district the commissioner of\nhealth shall designate at least one other managed care provider which is\nnot a major public hospital or facility operated by a major public\nhospital; and\n (iii) under a managed care program, not all managed care providers\nmust be required to provide the same set of medical assistance services.\nThe managed care program shall establish procedures through which\nparticipants will be assured access to all medical assistance services\nto which they are otherwise entitled, other than through the managed\ncare provider, where:\n (A) the service is not reasonably available directly or indirectly\nfrom the managed care provider,\n (B) it is necessary because of emergency or geographic unavailability,\nor\n (C) the services provided are family planning services; or\n (D) the services are dental services and are provided by a diagnostic\nand treatment center licensed under article twenty-eight of the public\nhealth law which is affiliated with an academic dental center and which\nhas been granted an operating certificate pursuant to article\ntwenty-eight of the public health law to provide such dental services.\nAny diagnostic and treatment center providing dental services pursuant\nto this clause shall prior to June first of each year report to the\ngovernor, temporary president of the senate and speaker of the assembly\non the following: the total number of visits made by medical assistance\nrecipients during the immediately preceding calendar year; the number of\nvisits made by medical assistance recipients during the immediately\npreceding calendar year by recipients who were enrolled in managed care\nprograms; the number of visits made by medical assistance recipients\nduring the immediately preceding calendar year by recipients who were\nenrolled in managed care programs that provide dental benefits as a\ncovered service; and the number of visits made by the uninsured during\nthe immediately preceding calendar year; or\n (E) the services are optometric services, as defined in article one\nhundred forty-three of the education law, and are provided by a\ndiagnostic and treatment center licensed under article twenty-eight of\nthe public health law which is affiliated with the college of optometry\nof the state university of New York and which has been granted an\noperating certificate pursuant to article twenty-eight of the public\nhealth law to provide such optometric services. Any diagnostic and\ntreatment center providing optometric services pursuant to this clause\nshall prior to June first of each year report to the governor, temporary\npresident of the senate and speaker of the assembly on the following:\nthe total number of visits made by medical assistance recipients during\nthe immediately preceding calendar year; the number of visits made by\nmedical assistance recipients during the immediately preceding calendar\nyear by recipients who were enrolled in managed care programs; the\nnumber of visits made by medical assistance recipients during the\nimmediately preceding calendar year by recipients who were enrolled in\nmanaged care programs that provide optometric benefits as a covered\nservice; and the number of visits made by the uninsured during the\nimmediately preceding calendar year; or\n (E-1) the services are vision care services rendered to a student at a\nschool based health center approved by the commissioner pursuant to this\nclause. The commissioner may approve up to five pilot programs at school\nbased health centers in partnership with a charitable foundation that\nagrees to provide free of charge eyeglass frames and lenses at the\ncenters pursuant to a memorandum of agreement approved by the\ncommissioner. The commissioner may approve the rate for such vision care\nservices at the rate for such services when provided by a federally\nqualified health center or when provided by another entity licensed\npursuant to article twenty-eight of the public health law and eligible\nfor the ambulatory patient group rate approved for vision care services\nby the commissioner; or\n (F) other services as defined by the commissioner of health.\n (b) Participants shall select a managed care provider from among those\ndesignated under the managed care program, provided, however, a\nparticipant shall be provided with a choice of no less than two managed\ncare providers. Notwithstanding the foregoing, a local social services\ndistrict designated a rural area as defined in 42 U.S.C. 1395ww may\nlimit a participant to one managed care provider, if the commissioner\nand the local social services district find that only one managed care\nprovider is available. A managed care provider in a rural area shall\noffer a participant a choice of at least three primary care\npractitioners and permit the individual to obtain a service or seek a\nprovider outside of the managed care network where such service or\nprovider is not available from within the managed care provider network.\n (c) Participants shall select a primary care practitioner from among\nthose designated by the managed care provider. In all districts,\nparticipants shall be provided with a choice of no less than three\nprimary care practitioners. In the event that a participant does not\nselect a primary care practitioner, the participant's managed care\nprovider shall select a primary care practitioner for the participant,\ntaking into account geographic accessibility.\n (d) For all other medical services, except as provided in paragraph\n(c) of this subdivision, if a sufficient number of medical service\nproviders are available, a choice shall be offered.\n (e) (i) In any social services district which has not implemented a\nmandatory managed care program pursuant to this section, the\ncommissioner of health shall establish marketing and enrollment\nguidelines, including but not limited to regulations governing\nface-to-face marketing and enrollment encounters between managed care\nproviders and recipients of medical assistance and locations for such\nencounters. Such regulations shall prohibit, at a minimum, telephone\ncold-calling and door-to-door solicitation at the homes of medical\nassistance recipients. The regulations shall also require the\ncommissioner of health to approve any local district marketing\nguidelines. Managed care providers shall be permitted to assist\nparticipants in completion of enrollment forms at approved health care\nprovider sites and other approved locations. In no case may an emergency\nroom be deemed an approved location. Upon enrollment, participants will\nsign an attestation that: they have been informed that managed care is a\nvoluntary program; participants have a choice of managed care providers;\nparticipants have a choice of primary care practitioners; and\nparticipants must exclusively use their primary care practitioner and\nplan providers except as otherwise provided in this section including\nbut not limited to the exceptions listed in subparagraph (iii) of\nparagraph (a) of this subdivision. Managed care providers must submit\nenrollment forms to the local department of social services. The local\ndepartment of social services will provide or arrange for an audit of\nmanaged care provider enrollment forms; including telephone contacts to\ndetermine if participants were provided with the information required by\nthis subparagraph. The commissioner of health may suspend or curtail\nenrollment or impose sanctions for failure to appropriately notify\nclients as required in this subparagraph.\n (ii) In any social services district which has implemented a mandatory\nmanaged care program pursuant to this section, the requirements of this\nsubparagraph shall apply to the extent consistent with federal law and\nregulations. The department of health, may contract with one or more\nindependent organizations to provide enrollment counseling and\nenrollment services, for participants required to enroll in managed care\nprograms, for each social services district requesting the services of\nan enrollment broker. To select such organizations, the department of\nhealth shall issue a request for proposals (RFP), shall evaluate\nproposals submitted in response to such RFP and, pursuant to such RFP,\nshall award a contract to one or more qualified and responsive\norganizations. Such organizations shall not be owned, operated, or\ncontrolled by any governmental agency, managed care provider, or medical\nservices provider.\n (iii) Such independent organizations shall develop enrollment guides\nfor participants which shall be approved by the department of health\nprior to distribution.\n (iv) Local social services districts or enrollment organizations\nthrough their enrollment counselors shall provide participants with the\nopportunity for face to face counseling including individual counseling\nupon request of the participant. Local social services districts or\nenrollment organizations through their enrollment counselors shall also\nprovide participants with information in a culturally and linguistically\nappropriate and understandable manner, in light of the participant's\nneeds, circumstances and language proficiency, sufficient to enable the\nparticipant to make an informed selection of a managed care provider.\nSuch information shall include, but shall not be limited to: how to\naccess care within the program; a description of the medical assistance\nservices that can be obtained other than through a managed care\nprovider; the available managed care providers and the scope of services\ncovered by each; a listing of the medical services providers associated\nwith each managed care provider; the participants' rights within the\nmanaged care program; and how to exercise such rights. Enrollment\ncounselors shall inquire into each participant's existing relationships\nwith medical services providers and explain whether and how such\nrelationships may be maintained within the managed care program. For\nenrollments made during face to face counseling, if the participant has\na preference for particular medical services providers, enrollment\ncounselors shall verify with the medical services providers that such\nmedical services providers whom the participant prefers participate in\nthe managed care provider's network and are available to serve the\nparticipant.\n (v) Upon delivery of the pre-enrollment information, the local\ndistrict or the enrollment organization shall certify the participant's\nreceipt of such information. Upon verification that the participant has\nreceived the pre-enrollment education information, a managed care\nprovider, a local district or the enrollment organization may enroll a\nparticipant into a managed care provider. Managed care providers must\nsubmit enrollment forms to the local department of social services. Upon\nenrollment, participants will sign an attestation that they have been\ninformed that: participants have a choice of managed care providers;\nparticipants have a choice of primary care practitioners; and, except as\notherwise provided in this section, including but not limited to the\nexceptions listed in subparagraph (iii) of paragraph (a) of this\nsubdivision, participants must exclusively use their primary care\npractitioners and plan providers. The commissioner of health may suspend\nor curtail enrollment or impose sanctions for failure to appropriately\nnotify clients as required in this subparagraph.\n (vi) Enrollment counselors or local social services districts shall\nfurther inquire into each participant's health status in order to\nidentify physical or behavioral conditions that require immediate\nattention or continuity of care, and provide to participants information\nregarding health care options available to persons with HIV and other\nillnesses or conditions under the managed care program. Any information\ndisclosed to counselors shall be kept confidential in accordance with\napplicable provisions of the public health law, and as appropriate, the\nmental hygiene law.\n (vii) Any marketing materials developed by a managed care provider\nshall be approved by the department of health or the local social\nservices district, and the commissioner of mental health and the\ncommissioner of alcoholism and substance abuse services, where\nappropriate, within sixty days prior to distribution to recipients of\nmedical assistance. All marketing materials shall be reviewed within\nsixty days of submission.\n (viii) In any social services district which has implemented a\nmandatory managed care program pursuant to this section, the\ncommissioner of health shall establish marketing and enrollment\nguidelines, including but not limited to regulations governing\nface-to-face marketing and enrollment encounters between managed care\nproviders and recipients of medical assistance and locations for such\nencounters. Such regulations shall prohibit, at a minimum, telephone\ncold-calling and door-to-door solicitation at the homes of medical\nassistance recipients. The regulations shall also require the\ncommissioner of health to approve any local district marketing\nguidelines.\n (f) (i) Participants shall choose a managed care provider at the time\nof application for medical assistance; if the participant does not\nchoose such a provider the commissioner shall assign such participant to\na managed care provider in accordance with subparagraphs (ii), (iii),\n(iv) and (v) of this paragraph. Participants already in receipt of\nmedical assistance shall have no less than thirty days from the date\nselected by the district to enroll in the managed care program to select\na managed care provider and shall be provided with information to make\nan informed choice. Where a participant has not selected such a provider\nthe commissioner of health shall assign such participant to a managed\ncare provider which, if appropriate, may be a special needs managed care\nplan, taking into account capacity and geographic accessibility. The\ncommissioner may after the period of time established in subparagraph\n(ii) of this paragraph assign participants to a managed care provider\ntaking into account quality performance criteria and cost. Provided\nhowever, cost criteria shall not be of greater value than quality\ncriteria in assigning participants.\n (ii) The commissioner may assign participants pursuant to such\ncriteria on a weighted basis, provided however that for twelve months\nfollowing implementation of a mandatory program, pursuant to a federal\nwaiver, twenty-five percent of the participants that do not choose a\nmanaged care provider shall be assigned to managed care providers that\nsatisfy the criteria set forth in subparagraph (i) of this paragraph,\nand are controlled by, sponsored by, or otherwise affiliated through a\ncommon governance or through a parent corporation with, one or more\nprivate not-for-profit or public general hospitals or diagnostic and\ntreatment centers licensed pursuant to article twenty-eight of the\npublic health law.\n (iii) For twelve months following the twelve months described in\nsubparagraph (ii) of this paragraph twenty-two and one-half percent of\nthe participants that do not choose a managed care provider shall be\nassigned to managed care providers, that satisfy the criteria set forth\nin subparagraph (i) of this paragraph and are controlled by, sponsored\nby, or otherwise affiliated through a common governance or through a\nparent corporation with, one or more private not-for-profit or public\ngeneral hospitals or diagnostic and treatment centers licensed pursuant\nto article twenty-eight of the public health law.\n (iv) For twelve months following the twelve months described in\nsubparagraph (iii) of this paragraph twenty percent of the participants\nthat do not choose a managed care provider shall be assigned equally\namong each of the managed care providers, that satisfy the criteria set\nforth in subparagraph (i) of this paragraph and are controlled by,\nsponsored by, or otherwise affiliated through a common governance or\nthrough a parent corporation with one or more private not-for-profit or\npublic general hospitals or diagnostic and treatment centers licensed\npursuant to article twenty-eight of the public health law.\n (v) The commissioner shall assign all participants not otherwise\nassigned to a managed care plan pursuant to subparagraphs (ii), (iii)\nand (iv) of this paragraph equally among each of the managed care\nproviders that meet the criteria established in subparagraph (i) of this\nparagraph; provided, however, that the commissioner shall assign\nindividuals meeting the criteria for enrollment in a special needs\nmanaged care plan to such plan or plans where available.\n (g) If another managed care provider is available, participants may\nchange such provider or plan without cause within thirty days of\nnotification of enrollment or the effective date of enrollment,\nwhichever is later with a managed care provider by making a request of\nthe local social services district except that such period shall be\nforty-five days for participants who have been assigned to a provider by\nthe commissioner of health. However, after such thirty or forty-five day\nperiod, whichever is applicable, a participant may be prohibited from\nchanging managed care providers more frequently than once every twelve\nmonths, as permitted by federal law except for good cause as determined\nby the commissioner of health through regulations.\n (h) If another medical services provider is available, a participant\nmay change his or her provider of medical services (including primary\ncare practitioners) without cause within thirty days of the\nparticipant's first appointment with a medical services provider by\nmaking a request of the managed care provider. However, after that\nthirty day period, no participant shall be permitted to change his or\nher provider of medical services other than once every six months except\nfor good cause as determined by the commissioner through regulations.\n (i) A managed care provider requesting a disenrollment shall not\ndisenroll a participant without the prior approval of the local social\nservices district in which the participant resides, provided that\ndisenrollment from a special needs managed care plan must comply with\nthe standards of the commissioner of health, the commissioner of\nalcoholism and substance abuse services, and the commissioner of mental\nhealth. A managed care provider shall not request disenrollment of a\nparticipant based on any diagnosis, condition, or perceived diagnosis or\ncondition, or a participant's efforts to exercise his or her rights\nunder a grievance process, provided however, that a managed care\nprovider may, where medically appropriate, request permission to refer\nparticipants to a managed care provider that is a special needs managed\ncare plan or a comprehensive HIV special needs plan after consulting\nwith such participant and upon obtaining his/her consent to such\nreferral, and provided further that a special needs managed care plan\nmay, where clinically appropriate, disenroll individuals who no longer\nrequire the level of services provided by a special needs managed care\nplan.\n (j) A managed care provider shall be responsible for providing or\narranging for medical assistance services and assisting participants in\nthe prudent selection of such services, including but not limited to:\n (1) management of the medical and health care needs of participants by\nthe participant's designated primary care practitioners or group of\nprimary care practitioners to assure that all services provided under\nthe managed care program and which are found to be necessary are made\navailable in a timely manner, in accordance with prevailing standards of\nprofessional medical practice and conduct; and\n (2) use of appropriate patient assessment criteria to ensure that all\nparticipants are provided with appropriate services, including special\ncare;\n (3) implementation of procedures, consistent with the requirements of\nparagraph (c) of subdivision six of section forty-four hundred three of\nthe public health law for managing the care of participants requiring\nspecial care which may include the use of special case managers or the\ndesignation of a specialist as a primary care practitioner by a\nparticipant requiring special care on more than an incidental basis;\n (4) implementation of procedures, consistent with the requirements of\nparagraph (b) of subdivision six of section forty-four hundred three of\nthe public health law to permit the use of standing referrals to\nspecialists and subspecialists for participants who require the care of\nsuch practitioners on a regular basis; and\n (5) referral, coordination, monitoring and follow-up with regard to\nother medical services providers as appropriate for diagnosis and\ntreatment, or direct provision of some or all medical assistance\nservices.\n (k) A managed care provider shall establish appropriate utilization\nand referral requirements for physicians, hospitals, and other medical\nservices providers including emergency room visits and inpatient\nadmissions.\n (l) A managed care provider shall be responsible for developing\nappropriate methods of managing the health care and medical needs of\nhomeless and other vulnerable participants to assure that all necessary\nservices provided under the managed care program are made available and\nthat all appropriate referrals and follow-up treatment are provided, in\na timely manner, in accordance with prevailing standards of professional\nmedical practice and conduct.\n (m) A managed care provider shall provide all early periodic screening\ndiagnosis and treatment services, as well as interperiodic screening and\nreferral, to each participant under the age of twenty-one, at regular\nintervals, as medically appropriate.\n (n) A managed care provider shall provide or arrange, directly or\nindirectly (including by referral) for the provision of comprehensive\nprenatal care services to all pregnant participants in accordance with\nstandards adopted by the department of health.\n (o) A managed care provider shall provide or arrange, directly or\nindirectly, (including by referral) for the full range of covered\nservices to all participants, notwithstanding that such participants may\nbe eligible to be enrolled in a comprehensive HIV special needs plan or\nspecial needs managed care plan.\n (p) A managed care provider shall implement procedures to communicate\nappropriately with participants who have difficulty communicating in\nEnglish and to communicate appropriately with visually-impaired and\nhearing-impaired participants.\n (q) A managed care provider shall comply with applicable state and\nfederal law provisions prohibiting discrimination on the basis of\ndisability.\n (r) A managed care provider shall provide services to participants\npursuant to an order of a court of competent jurisdiction, provided\nhowever, that such services shall be within such provider's or plan's\nbenefit package and are reimbursable under title xix of the federal\nsocial security act, provided that services for a substance use disorder\nshall be provided by a program licensed, certified or otherwise\nauthorized by the office of alcoholism and substance abuse services.\n (s) Managed care providers shall be provided with the date of\nrecertification for medical assistance of each of their enrolled\nparticipants in conjunction with the monthly enrollment information\nconveyed to managed care providers.\n (t) Prospective enrollees shall be advised, in written materials\nrelated to enrollment, to verify with the medical services providers\nthey prefer, or have an existing relationship with, that such medical\nservices providers participate in the selected managed care provider's\nnetwork and are available to serve the participant.\n (u) A managed care provider that provides coverage for prescription\ndrugs shall permit each participant to fill any mail order covered\nprescription, at his or her option, at any mail order pharmacy or\nnon-mail-order retail pharmacy in the managed care provider network. If\nthe managed care provider has designated one or more pharmacies for\nfilling prescriptions for a particular drug or drugs, then such\nprescriptions may be filled, at the participant's option, at any other\npharmacy in the network, if the network pharmacy chosen by the\nparticipant offers to accept a price that is comparable to that of the\npharmacy designated by the managed care provider. For the purposes of\nthis section, "mail order pharmacy" means a pharmacy whose primary\nbusiness is to receive prescriptions by mail, telefax or through\nelectronic submissions, and to dispense medication to patients through\nthe use of the United States mail or other common or contract carrier\nservices, and provides any consultation with patients electronically\nrather than face to face. Every non-mail-order retail pharmacy in the\nmanaged care provider's network with respect to any prescription drug\nshall be deemed to be in the managed care provider's network for every\ncovered prescription drug.\n (v) A managed care provider must allow enrollees to access chemical\ndependence treatment services from facilities certified by the office of\nalcoholism and substance abuse services, even if such services are\nrendered by a practitioner who would not otherwise be separately\nreimbursed, including but not limited to a credentialed alcoholism and\nsubstance abuse counselor (CASAC).\n ** (w) A managed care provider shall provide or arrange, directly or\nindirectly, including by referral, for access to and coverage of\nservices provided by any national cancer institute-designated cancer\ncenter licensed by the department of health within the managed care\nprovider's service area that is willing to agree to provide\ncancer-related inpatient, outpatient and medical services to\nparticipants in all managed care providers offering coverage to medical\nassistance recipients in such cancer center's service area under the\nprevailing terms and conditions that the managed care provider requires\nof other similar providers to be included in the managed care provider's\nnetwork, provided that such terms shall include reimbursement of such\ncenter at no less than the fee-for-service medicaid payment rate and\nmethodology applicable to the center's inpatient and outpatient\nservices.\n ** NB There are 2 par (w)'s\n ** NB Repealed January 1, 2028\n ** (w)(i) The department of health or a managed care organization\ncontracted to provide services pursuant to this section shall establish\na program for synchronization of medications. Under the synchronization\nprogram, a health care practitioner may prescribe a refill of one or\nmore of the patient's medications for a shorter period than would\nordinarily be provided, for the purpose of synchronizing refill dates of\none or more of the patient's medications subject to the synchronization,\nwhen it is agreed among the recipient, the health care practitioner and\na pharmacist that synchronization of multiple prescriptions for the\ntreatment of a chronic illness is in the best interest of the patient\nfor the management or treatment of a chronic illness provided that the\nfollowing apply to such medications:\n (A) are covered by Medicaid services or a managed care organization\ncontracted to provide services pursuant to this chapter;\n (B) are used for treatment and management of a chronic illness that\nare subject to refills;\n (C) are not a schedule II controlled substance, nor a schedule III\ncontrolled substance that contains hydrocodone or other opioid\nmedication as scheduled in section thirty-three hundred six of the\npublic health law, or a controlled substance under the federal\nControlled Substances Act;\n (D) meet all prior authorization criteria specific to the medications\nat the time of the synchronization request;\n (E) are of a formulation that can be effectively and lawfully aligned\nover required short fill periods to achieve synchronization; and\n (F) do not have quantity limits or dose optimization criteria or state\nor federal requirements that would be violated in fulfilling\nsynchronization.\n (ii) The department of health or a managed care organization\ncontracted to provide services under this section shall not deny\ncoverage for the dispensing of a medication by a pharmacy for a partial\nsupply when it is for the purpose of synchronizing the patient's\nmedications. When applicable to permit synchronization, the department\nof health or a managed care organization contracted to provide services\nunder this title shall allow a pharmacy to override any denial codes\nindicating that a prescription is being refilled too soon for the\npurposes of medication synchronization.\n (iii) The dispensing fee paid to the pharmacy contracted to provide\nservices pursuant to this section for a partial supply associated with\nmedication synchronization shall be paid in accordance with the Medicaid\nstate plan as approved by the Centers for Medicare and Medicaid\nServices.\n (iv) The requirement of this paragraph applies only once for each\nprescription drug subject to medication synchronization except when\neither of the following occurs:\n (A) the prescriber changes the dosage or frequency of administration\nof the prescription drug subject to a medication synchronization; or\n (B) the prescriber prescribes a different drug.\n (v) Nothing in this paragraph shall be deemed to require health care\npractitioners and pharmacists to synchronize the refilling of multiple\nprescriptions for a covered individual.\n (vi) The provisions of this paragraph are subject to compliance with\nall applicable federal and state laws and regulations, including the\nCenters for Medicare and Medicaid Services approved Medicaid state plan.\nThe commissioner shall apply for waivers and submit state Medicaid plan\namendments as are necessary to implement the program for synchronization\nof medications.\n ** NB There are 2 par (w)'s\n 5. Managed care programs shall be conducted in accordance with the\nrequirements of this section and, to the extent practicable, encourage\nthe provision of comprehensive medical services, pursuant to this\narticle.\n (a) The managed care program shall provide for the selection of\nqualified managed care providers by the commissioner of health to\nparticipate in the program, including comprehensive HIV special needs\nplans and special needs managed care plans in accordance with the\nprovisions of section three hundred sixty-five-m of this title;\nprovided, however, that the commissioner of health may contract directly\nwith comprehensive HIV special needs plans consistent with standards set\nforth in this section, and assure that such providers are accessible\ntaking into account the needs of persons with disabilities and the\ndifferences between rural, suburban, and urban settings, and in\nsufficient numbers to meet the health care needs of participants, and\nshall consider the extent to which major public hospitals are included\nwithin such providers' networks.\n (b) A proposal submitted by a managed care provider to participate in\nthe managed care program shall:\n (i) designate the geographic area to be served by the provider, and\nestimate the number of eligible participants and actual participants in\nsuch designated area;\n (ii) include a network of health care providers in sufficient numbers\nand geographically accessible to service program participants;\n (iii) describe the procedures for marketing in the program location,\nincluding the designation of other entities which may perform such\nfunctions under contract with the organization;\n (iv) describe the quality assurance, utilization review and case\nmanagement mechanisms to be implemented;\n (v) demonstrate the applicant's ability to meet the data analysis and\nreporting requirements of the program;\n (vi) demonstrate financial feasibility of the program; and\n (vii) include such other information as the commissioner of health may\ndeem appropriate.\n (c) The commissioner of health shall make a determination whether to\napprove, disapprove or recommend modification of the proposal.\n (d) Notwithstanding any inconsistent provision of this title and\nsection one hundred sixty-three of the state finance law, the\ncommissioner of health may contract with managed care providers approved\nunder paragraph (b) of this subdivision, without a competitive bid or\nrequest for proposal process, to provide coverage for participants\npursuant to this title.\n (e) Notwithstanding any inconsistent provision of this title and\nsection one hundred forty-three of the economic development law, no\nnotice in the procurement opportunities newsletter shall be required for\ncontracts awarded by the commissioner of health, to qualified managed\ncare providers pursuant to this section.\n (f) The care and services described in subdivision four of this\nsection will be furnished by a managed care provider pursuant to the\nprovisions of this section when such services are furnished in\naccordance with an agreement with the department of health, and meet\napplicable federal law and regulations.\n (g) The commissioner of health may delegate some or all of the tasks\nidentified in this section to the local districts.\n (h) Any delegation pursuant to paragraph (g) of this subdivision shall\nbe reflected in the contract between a managed care provider and the\ncommissioner of health.\n 6. A managed care provider shall not engage in the following\npractices:\n (a) use deceptive or coercive marketing methods to encourage\nparticipants to enroll; or\n (b) distribute marketing materials to recipients of medical\nassistance, unless such materials are approved by the department of\nhealth and, as appropriate, the office of mental health.\n 7. The department, the department of health or other agency of the\nstate as appropriate shall provide technical assistance at the request\nof a social services district for the purpose of development and\nimplementation of managed care programs pursuant to this section. Such\nassistance shall include but need not be limited to provision and\nanalysis of data, design of managed care programs and plans, innovative\npayment mechanisms, and ongoing consultation. In addition, the\ndepartment and the department of health shall make available materials\nto social services districts for purposes of educating persons eligible\nto receive medical assistance on how their care will be provided through\nmanaged care as required under paragraph (e) of subdivision five of this\nsection.\n 8. (a) The commissioner of health shall institute a comprehensive\nquality assurance system for managed care providers that includes\nperformance and outcome-based quality standards for managed care.\n (b) Every managed care provider shall implement internal quality\nassurance systems adequate to identify, evaluate and remedy problems\nrelating to access, continuity and quality of care, utilization, and\ncost of services, provided, however, that the commissioner shall waive\nthe implementation of internal quality assurance systems, where\nappropriate, for managed care providers described in subparagraph (ii)\nof paragraph (b) of subdivision one of this section. Such internal\nquality assurance systems shall conform to the internal quality\nassurance requirements imposed on health maintenance organizations\npursuant to the public health law and regulations and shall provide for:\n (i) the designation of an organizational unit or units to perform\ncontinuous monitoring of health care delivery;\n (ii) the utilization of epidemiological data, chart reviews, patterns\nof care, patient surveys, and spot checks;\n (iii) reports to medical services providers assessing timeliness and\nquality of care;\n (iv) the identification, evaluation and remediation of problems\nrelating to access, continuity and quality of care; and\n (v) a process for credentialing and recredentialing licensed\nproviders.\n (c) The department of health, in consultation with the responsible\nspecial care agencies, shall contract with one or more independent\nquality assurance organizations to monitor and evaluate the quality of\ncare and services furnished by managed care providers. To select such\norganization or organizations, the department of health shall issue\nrequests for proposals (RFP), shall evaluate proposals submitted in\nresponse to such RFP, and pursuant to such RFP, shall award one or more\ncontracts to one or more qualified and responsive organizations. Such\nquality assurance organizations shall evaluate and review the quality of\ncare delivered by each managed care provider, on at least an annual\nbasis. Such review and evaluation shall include compliance with the\nperformance and outcome-based quality standards promulgated by the\ncommissioner of health.\n (d) Every managed care provider shall collect and submit to the\ndepartment of health, in a standardized format prescribed by the\ndepartment of health, patient specific medical information, including\nencounter data, maintained by such provider for the purposes of quality\nassurance and oversight. Any information or encounter data collected\npursuant to this paragraph, however, shall be kept confidential in\naccordance with section forty-four hundred eight-a of the public health\nlaw and section 33.13 of the mental hygiene law and any other applicable\nstate or federal law.\n (e) Information collected and submitted to the department of health by\nthe independent quality assurance organization or managed care provider\npursuant to this subdivision shall be made available to the public,\nsubject to any other limitations of federal or state law regarding\ndisclosure thereof to third parties.\n (f) Every managed care provider shall ensure that the provider\nmaintains a network of health care providers adequate to meet the\ncomprehensive health needs of its participants and to provide an\nappropriate choice of providers sufficient to provide the services to\nits participants by determining that:\n (i) there are a sufficient number of geographically accessible\nparticipating providers;\n (ii) there are opportunities to select from at least three primary\ncare providers; and\n (iii) there are sufficient providers in each area of specialty\npractice to meet the needs of the enrolled population.\n (g) The commissioner of health shall establish standards to ensure\nthat managed care providers have sufficient capacity to meet the needs\nof their enrollees, which shall include patient to provider ratios,\ntravel and distance standards and appropriate waiting times for\nappointments.\n 9. Managed care providers shall inform participants of such provider's\ngrievance procedure and utilization review procedures under section\nforty-four hundred eight-a and article forty-nine of the public health\nlaw. A managed care provider or local social services district, as\nappropriate, shall provide notice to participants of their respective\nrights to a fair hearing and aid continuing in accordance with\napplicable state and federal law. Managed care providers shall provide\nnotice of the name, address, phone number and website of the department\nof health designated independent consumer assistance program and the\nindependent substance use disorder and mental health ombudsman\nestablished by section 33.27 of the mental hygiene law within notices of\nadverse grievances and appeals determinations.\n 10. The commissioner of health shall be authorized to establish\nrequirements regarding provision and reimbursement of emergency care.\n 10-a. For managed care providers with negotiated rates of payment for\ninpatient hospital services under contracts in effect on April first,\ntwo thousand eight, that have a payment rate methodology for such\ninpatient hospital services that utilizes rates calculated by the\ndepartment of health pursuant to paragraph (a) or (a-2) of subdivision\none of section twenty-eight hundred seven-c for patients under the\nmedical assistance program, such rate shall not include adjustments\npursuant to subdivision thirty-three of section twenty-eight hundred\nseven-c of the public health law for contract periods prior to January\nfirst, two thousand ten.\n 12. The commissioner, by regulation, shall provide that a participant\nmay withdraw from participation in a managed care program upon a showing\nof good cause.\n 13. (a) Notwithstanding any inconsistent provisions of this section,\nparticipation in a managed care program will not diminish a recipient's\nmedical assistance eligibility or the scope of available medical\nservices to which he or she is entitled. Once a program is implemented\nby or in the district in accordance with this section, medical\nassistance for persons who require such assistance, who are eligible for\nor in receipt of such assistance in the district and who are covered by\nthe program shall be limited to payment of the cost of care, services\nand supplies covered by the managed care program, only when furnished,\nprescribed, ordered or approved by a managed care provider, mental\nhealth special needs plan or comprehensive HIV special needs plan and\notherwise under the program, together with the costs of medically\nnecessary medical and remedial care, services or supplies which are not\navailable to participants under the program, but which would otherwise\nbe available to such persons under this title and the regulations of the\ndepartment provided, however, that the program may contain provision for\npayment to be made for non-emergent care furnished in hospital emergency\nrooms consistent with subdivision ten of this section.\n (b) Notwithstanding any inconsistent provision of law, payment for\nclaims for services as specified in paragraph (a) of this subdivision\nfurnished to eligible persons under this title, who are enrolled in a\nmanaged care program pursuant to this section and section three hundred\nsixty-four-f of this title or other comprehensive health services plans,\nshall not be made when such services are the contractual responsibility\nof a managed care provider but are provided by another medical services\nprovider contrary to the managed care plan.\n 14. The commissioner of health is authorized and directed, subject to\nthe approval of the director of the division of budget, to make grants\nto social services districts to aid in the planning and development of\nmanaged care programs. The total amount expended pursuant to this\nsection shall not exceed the amount appropriated for such purposes in\nany fiscal year.\n 15. The managed medical care demonstration program advisory council is\nabolished.\n 16. Any waiver application to the federal department of health and\nhuman services pursuant to this article and any amendments to such\napplication shall be a public document.\n 17. (a) The provisions of this section regarding participation of\npersons receiving family assistance and supplemental security income in\nmanaged care programs shall be effective if, and as long as, federal\nfinancial participation is available for expenditures for services\nprovided pursuant to this section.\n (b) The provisions of this section regarding the furnishing of health\nand behavioral health services through a special needs managed care plan\nshall be effective if, and as long as, federal financial participation\nis available for expenditures for services provided by such plans\npursuant to this section.\n 18. (a) The department of health may, where not inconsistent with the\nrate setting authority of other state agencies and subject to approval\nof the director of the division of the budget, develop reimbursement\nmethodologies and fee schedules for determining the amount of payment to\nbe made to managed care providers under the managed care program. Such\nreimbursement methodologies and fee schedules may include provisions for\npayment of managed care fees and capitation arrangements.\n (b) The department of health in consultation with organizations\nrepresenting managed care providers shall select an independent actuary\nto review any such reimbursement rates. Such independent actuary shall\nreview and make recommendations concerning appropriate actuarial\nassumptions relevant to the establishment of rates including but not\nlimited to the adequacy of the rates in relation to the population to be\nserved adjusted for case mix, the scope of services the plans must\nprovide, the utilization of services and the network of providers\nnecessary to meet state standards. The independent actuary shall issue a\nreport no later than December thirty-first, nineteen hundred\nninety-eight and annually thereafter. Such report shall be provided to\nthe governor, the temporary president and the minority leader of the\nsenate and the speaker and the minority leader of the assembly. The\ndepartment of health shall assess managed care providers under the\nmanaged care program on a per enrollee basis to cover the cost of such\nreport.\n * (c) In setting such reimbursement methodologies, the department\nshall consider costs borne by the managed care program to ensure\nactuarially sound and adequate rates of payment to ensure quality of\ncare.\n * NB There are 2 par (c)'s\n * (c) The department of health shall require the independent actuary\nselected pursuant to paragraph (b) of this subdivision to provide a\ncomplete actuarial memorandum, along with all actuarial assumptions made\nand all other data, materials and methodologies used in the development\nof rates, to managed care providers thirty days prior to submission of\nsuch rates to the centers for medicare and medicaid services for\napproval. Managed care providers may request additional review of the\nactuarial soundness of the rate setting process and/or methodology.\n * NB There are 2 par (c)'s\n (d) The department of health shall annually provide to the temporary\npresident of the senate and the speaker of the assembly the annual\nMedicaid managed care operating reports submitted to the department from\nmanaged care plans that contract with the state to manage services\nprovided under the Medicaid program.\n (e) Increased rates, terms or scope of payment for behavioral health\nservices under this title, where payment is made by a managed care\nprovider under this section, as a result of a rate, coverage or other\nchange made pursuant to a law, regulation, rule or official guidance,\nshall be deemed in effect on the same date that such change would have\ntaken effect if payment were made other than by the managed care\nprovider. Where payment is not made as of the effective date, the\nmanaged care provider shall make retroactive payments to the appropriate\nservice providers.\n 19. (a) The commissioner of health, in consultation with the\ncommissioner, shall promulgate such regulations as are necessary to\nimplement the provisions of this section provided, however, that the\nprovisions of this subdivision shall not limit specific actions taken by\nthe department of health or the department in order to ensure federal\nfinancial participation.\n 20. Upon a determination that a participant appears to be suitable for\nadmission to a comprehensive HIV special needs plan or a special needs\nmanaged care plan, a managed care provider shall inform the participant\nof the availability of such plans, where available and appropriate.\n 21. (a) An amount equal to seven million dollars together with any\nmatching federal and local government funds shall be made available for\nrate adjustments for managed care providers whose rates were set under\nthe competitive bidding process. Such adjustment shall be made in\naccordance with this paragraph.\n (i) Such amount shall be allocated by the department of health among\nthe managed care rating regions based on each region's percentage of\nstatewide Medicaid managed care enrollment as of January first, nineteen\nhundred ninety-seven excluding from such calculation enrollment in local\nsocial services districts that did not participate in the competitive\nbidding process.\n (ii) From among the funds allocated in a managed care rating region,\nthe department of health shall adjust the existing rates paid to managed\ncare providers for each premium group for the period from January first,\nnineteen hundred ninety-seven through March thirty-first, nineteen\nhundred ninety-eight in a manner that raises the rates of all managed\ncare providers in the region to the highest uniform percentage of the\nupper payment limit possible based on the funds available; provided,\nhowever, that no managed care provider's rate for any premium group\nshall be reduced as a result of such adjustment. For the purpose of\ncalculating appropriate rate increases under this subparagraph, the\ndepartment of health shall assume that, for the entire period between\nJanuary first, nineteen hundred ninety-seven and March thirty-first,\nnineteen hundred ninety-eight, enrollment in each premium group shall be\nequal to enrollment in the premium group as of July first, nineteen\nhundred ninety-seven.\n (b) In addition to the increases made available in paragraph (a) of\nthis subdivision for the period beginning January first, nineteen\nhundred ninety-seven through March thirty-first, nineteen hundred\nninety-eight, an additional ten million dollars, together with any\nmatching federal and local government funds, shall be added to provide a\nuniform percentage increase, based on July first, nineteen hundred\nninety-seven enrollment to the existing rates paid for all premium\ngroups to all managed care providers whose rates were set by the\ncompetitive bidding process.\n (c) In addition to the increases made available in paragraphs (a) and\n(b) of this subdivision for the period beginning January first, nineteen\nhundred ninety-seven through March thirty-first, nineteen hundred\nninety-eight, an additional amount equal to three million dollars\ntogether with any matching federal and local government funds, shall be\nmade available to be added to the rates of health plans operating in\ngeographic areas where capacity is insufficient to allow attainment of\nenrollment goals consistent with the federal 1115 waiver known as the\nPartnership Plan. Such amount shall be distributed subject to a\ndemonstration to the commissioner's satisfaction that the plan has\nexecuted a contract amendment providing for an increase in enrollment\nproportional to the size of the plan and the remaining unenrolled\npopulation in the county. In evaluating the plan's demonstration, the\ncommissioner shall consider the degree to which the plan has increased\nthe number of primary or specialty care practitioners or diagnostic and\ntreatment centers in its network or whether the additional rate increase\nwould permit the plan to generate greater enrollments while continuing\nto meet the financial requirements of the public health law or the\ninsurance law whichever is applicable and regulations promulgated\npursuant thereto.\n Any amount identified in this paragraph remaining uncommitted by\nDecember thirty-first, nineteen hundred ninety-seven shall be\ndistributed in a manner consistent with paragraph (b) of this\nsubdivision.\n (d) A plan shall be eligible for payments pursuant to paragraphs (a),\n(b) and (c) of this subdivision for such periods as the plan has a\ncontract with one or more social services districts; provided, however\nthat the plan has a contract, or has made a good faith effort to enter\ninto a contract, in that district effective through March thirty-first,\nnineteen hundred ninety-eight.\n (e) For the period from April first, nineteen hundred ninety-eight\nthrough March thirty-first, nineteen hundred ninety-nine, the premium\nrates paid by the department of health to all managed care providers\nwhose rates were set under the competitive bidding process shall be\nequal to (i) the managed care provider's rate as of March thirty-first,\nnineteen hundred ninety-eight increased by a uniform trend factor; plus,\n(ii) four million dollars together with any matching federal and local\ngovernment funds to be added as a uniform percentage increase to such\nprovider's rate as of March thirty-first, nineteen hundred ninety-eight,\nbased on enrollment in the premium group as of April first, nineteen\nhundred ninety-eight.\n (f) For the period from April first, nineteen hundred ninety-eight\nthrough March thirty-first, nineteen hundred ninety-nine, an additional\namount equal to four million dollars together with any matching federal\nand local government funds, shall be made available for managed care\nrate adjustments consistent with the criteria set forth in paragraph (c)\nof this subdivision. Any amount identified in this paragraph remaining\nuncommitted by December thirty-first, nineteen hundred ninety-eight\nshall be added as a uniform percentage increase to the rates of all\nmanaged care providers eligible for an increase under paragraph (e) of\nthis subdivision.\n 22. Chemung county demonstration project. (a) The legislature finds\nthat the particular circumstances of Chemung county warrant authorizing\nthis demonstration project, including the rural nature of the county,\nthe absence of a comprehensive medicaid managed care provider serving\nthe area at this time, patient care needs, and aspects of the health\ncare provider base.\n (b) within all or part of Chemung county (referred to in this\nsubdivision as "the catchment area"), the department of health and the\nChemung county department of social services are authorized to conduct a\nMedicaid research and demonstration project (referred to in this\nsubdivision as the "demonstration project") for the purpose of testing\nthe use of innovative administrative techniques, new reimbursement\nmethods, and management of care models, so as to promote more efficient\nuse of health resources, a healthier population and containment of\nMedicaid program costs.\n (c) As part of the demonstration project, the Chemung county\ndepartment of social services is authorized to contract with a managed\ncare provider for the purposes of, without limitation, developing and\nmanaging a provider of care network, establishing provider payment rates\nand fees, paying provider claims, providing care management services to\nproject participants, and managing the utilization of project services.\n (d) The demonstration project shall be consistent with the provisions\nof this section, except:\n (i) The department may waive any rules or regulations, as necessary to\nimplement and consistent with this subdivision.\n (ii) The demonstration project shall not be subject to:\n (A) paragraph (b) of subdivision four of this section;\n (B) subparagraphs (i), (ii), (iii) (v) and (viii) of paragraph (e) of\nsubdivision four of this section;\n (C) paragraph (f) of subdivision four of this section;\n (D) paragraph (g) of subdivision four of this section;\n (E) subdivision five of this section; provided that in approving the\ndemonstration project or modifications to it, the department shall\nconsider the criteria in that subdivision;\n (F) sections two hundred seventy-two and two hundred seventy-three of\nthe public health law;\n (G) section three hundred sixty-five-i of this title.\n (iii) Notwithstanding subdivision three of this section, participation\nin the project shall be mandatory for all or any specified categories of\npersons eligible for services under this title for whom the Chemung\ncounty department of social services has fiscal responsibility pursuant\nto section three hundred sixty-five of this title and who reside within\nthe demonstration project catchment area, as determined by the\ncommissioner of health; provided, however, that eligible persons who are\nalso beneficiaries under title XVIII of the federal social security act\nand persons who reside in residential health care facilities shall not\nbe eligible to participate in the project.\n (e)(i) Persons who are enrolled in or apply for medical assistance on\nor before the date the demonstration project takes effect shall receive\nsixty days written notice prior to participating in the demonstration\nproject, including an explanation of the demonstration project and the\nparticipant's rights and responsibilities. Persons who apply for medical\nassistance thereafter shall receive such notice at the time of applying\nfor medical assistance.\n (ii) The demonstration project shall provide adequate services to\novercome language barriers for participants.\n (iii) Participants in the demonstration project whose participation in\na managed care program would not otherwise be mandatory under\nsubdivision three of this section, who, at the time they enter the\ndemonstration project, have an established relationship with and are\nreceiving services from one or more medical services providers that are\nnot included in the demonstration project's provider network (an\n"out-of-network provider"), shall be permitted to continue to receive\nservices from such providers until their course of treatment is\ncomplete, or in the case of a pregnant woman, while pregnant and for\nsixty days post-partum. Out-of-network providers that provide services\npursuant to this subparagraph shall be subject to the utilization review\nand care management procedures prescribed by the managed care provider\nand shall be reimbursed at the rate that would be paid to such providers\nby the medical assistance program on a fee for service basis pursuant to\nthis title, and shall accept such reimbursement as payment in full.\n (f) The provisions of this subdivision shall not apply unless all\nnecessary approvals under federal law and regulation have been obtained\nto receive federal financial participation in the costs of health care\nservices provided pursuant to this subdivision.\n (g) The commissioner of health is authorized to submit amendments to\nthe state plan for medical assistance and/or submit one or more\napplications for waivers of the federal social security act as may be\nnecessary to obtain the federal approvals necessary to implement this\nsubdivision.\n (h) The demonstration project shall terminate five years after it is\napproved by the department and all necessary approvals under federal law\nand regulations under paragraph (f) of this subdivision have been\nobtained, unless terminated sooner by the Chemung county department of\nsocial services.\n 23. (a) As a means of protecting the health, safety and welfare of\nrecipients, in addition to any other sanctions that may be imposed, the\ncommissioner, in consultation with the commissioners of the office of\nmental health and the office of alcoholism and substance abuse services,\nwhere appropriate, shall appoint temporary management of a managed care\nprovider upon determining that the managed care provider has repeatedly\nfailed to meet the substantive requirements of sections 1903(m) and 1932\nof the federal Social Security Act and regulations. A hearing shall not\nbe required prior to the appointment of temporary management.\n (b) The commissioner and/or his or her designees, which may be\nindividuals within the department or other individuals or entities with\nappropriate knowledge and experience, may be appointed as temporary\nmanagement. The commissioner may appoint the superintendent of financial\nservices and/or his or her designees as temporary management of any\nmanaged care provider which is subject to rehabilitation pursuant to\narticle seventy-four of the insurance law.\n (c) The responsibilities of temporary management shall include\noversight of the managed care provider for the purpose of removing the\ncauses and conditions which led to the determination requiring temporary\nmanagement, the imposition of improvements to remedy violations and,\nwhere necessary, the orderly reorganization, termination or liquidation\nof the managed care provider.\n (d) Temporary management may hire and fire managed care provider\npersonnel and expend managed care provider funds in carrying out the\nresponsibilities imposed pursuant to this subdivision.\n (e) The commissioner, in consultation with the superintendent with\nrespect to any managed care provider subject to rehabilitation pursuant\nto article seventy-four of the insurance law, may make available to\ntemporary management for the benefit of a managed care provider for the\nmaintenance of required reserves and deposits monies from such funds as\nare appropriated for such purpose.\n (f) The commissioner is authorized to establish in regulation\nprovisions for the payment of fees and expenses from funds appropriated\nfor such purpose for non-governmental individuals and entities appointed\nas temporary management pursuant to this subdivision.\n (g) The commissioner may not terminate temporary management prior to\nhis or her determination that the managed care provider has the\ncapability to ensure that the sanctioned behavior will not recur.\n (h) During any period of temporary management individuals enrolled in\nthe managed care provider being managed may disenroll without cause.\nUpon reaching a determination that requires temporary management of a\nmanaged care provider, the commissioner shall notify all recipient\nenrollees of such provider that they may terminate enrollment without\ncause during the period of temporary management.\n (i) The commissioner may adopt and amend rules and regulations to\neffectuate the purposes and provisions of this subdivision.\n 24. Claims submitted to a managed care provider for payment for\nmedical care, services, or supplies furnished by an out-of-network\nmedical services provider must be submitted within fifteen months of the\ndate the medical care, services, or supplies were furnished to an\neligible person to be valid and enforceable against the managed care\nprovider. This deadline for claims submission shall not apply where the\nclaims submission is warranted to address findings or recommendations\nidentified in a state or federal audit except where such audit also\nindicates that an inappropriate provider payment was solely the fault of\nthe out-of-network health care provider.\n 25. Effective January first, two thousand thirteen, notwithstanding\nany provision of law to the contrary, managed care providers shall cover\nmedically necessary prescription drugs in the atypical antipsychotic\ntherapeutic class, including non-formulary drugs, upon demonstration by\nthe prescriber, after consulting with the managed care provider, that\nsuch drugs, in the prescriber's reasonable professional judgment, are\nmedically necessary and warranted.\n 25-a. Effective July first, two thousand thirteen, notwithstanding any\nprovision of law to the contrary, managed care providers shall cover\nmedically necessary prescription drugs in the anti-depressant,\nanti-retroviral, anti-rejection, seizure, epilepsy, endocrine,\nhematologic and immunologic therapeutic classes, including non-formulary\ndrugs, upon demonstration by the prescriber, after consulting with the\nmanaged care provider, that such drugs, in the prescriber's reasonable\nprofessional judgment, are medically necessary and warranted.\n 26. The commissioner of health shall develop a standard prior\nauthorization request form or forms to be utilized by all managed care\nproviders for purposes of submitting a request for a utilization review\ndetermination for coverage of prescription drug benefits under this\ntitle. The managed care provider shall make the standard prior\nauthorization request form or forms available to, and shall accept it or\nthem from, prescribing providers in paper and electronic form.\n 26-a. Managed care providers shall require prior authorization of\nprescriptions of opioid analgesics in excess of four prescriptions in a\nthirty-day period, provided, however, that this subdivision shall not\napply if the patient is a recipient of hospice care, has a diagnosis of\ncancer or sickle cell disease, or any other condition or diagnosis for\nwhich the commissioner of health determines prior authorization is not\nrequired.\n 26-b. Managed care providers shall not require prior authorization for\nany buprenorphine products, methadone or long acting injectable\nnaltrexone for detoxification or maintenance treatment of a substance\nuse disorder prescribed according to generally accepted national\nprofessional guidelines for the treatment of a substance use disorder.\n 26-c. Managed care providers shall not require prior authorization for\nmethadone, when used for opioid use disorder and administered or\ndispensed in an opioid treatment program.\n ** 27. The commissioner of the department of health may make any\nnecessary amendments to a contract pursuant to this section with a\nmanaged care provider, as defined in paragraph (b) of subdivision one of\nthis section, to allow such managed care provider to participate as a\nqualified health plan in a state health benefit exchange established\npursuant to the federal Patient Protection and Affordable Care Act (P.L.\n111-148), as amended by the federal Health Care and Education\nReconciliation Act of 2010 (P.L. 111-152).\n ** NB There are 2 sb 27's\n ** 27. (a) The centers for medicare and medicaid services has\nestablished an initiative to align incentives between medicare and\nmedicaid. The goal of the initiative is to increase access to seamless,\nquality programs that integrate services for the dually eligible\nbeneficiary as well as to achieve both state and federal health care\nsavings by improving health care delivery and encouraging high-quality\nefficient care. In furtherance of this goal, the legislature authorizes\nthe commissioner of health to establish a fully integrated dual\nadvantage (FIDA) program.\n (b) The FIDA program shall provide targeted populations of\nmedicare/medicaid dually eligible persons with comprehensive health\nservices that include the full range of medicare and medicaid covered\nservices, including but not limited to primary and acute care,\nprescription drugs, behavioral health services, care coordination\nservices, and long-term supports and services, as well as other\nservices, through managed care providers, as defined in subdivision one\nof this section, including managed long term care plans, certified\npursuant to section forty-four hundred three-f of the public health law.\n (c) Under the FIDA program established pursuant to this subdivision,\nup to three managed long term care plans may be authorized to\nexclusively enroll individuals with developmental disabilities, as such\nterm is defined in section 1.03 of the mental hygiene law. The\ncommissioner of health may waive any of the department's regulations as\nsuch commissioner, in consultation with the commissioner of the office\nfor people with developmental disabilities, deems necessary to allow\nsuch managed long term care plans to provide or arrange for service for\nindividuals with developmental disabilities that are adequate and\nappropriate to meet the needs of such individuals and that will ensure\ntheir health and safety. The commissioner of the office for people with\ndevelopmental disabilities may waive any of the office for people with\ndevelopmental disabilities' regulations as such commissioner, in\nconsultation with the commissioner of health, deems necessary to allow\nsuch managed long term care plans to provide or arrange for services for\nindividuals with developmental disabilities that are adequate and\nappropriate to meet the needs of such individuals and that will ensure\ntheir health and safety.\n (d) The provisions of this subdivision shall not apply unless all\nnecessary approvals under federal law and regulation have been obtained\nto receive federal financial participation in the costs of health care\nservices provided pursuant to this subdivision.\n (e) The commissioner of health is authorized to submit amendments to\nthe state plan for medical assistance and/or submit one or more\napplications for waivers of the federal social security act as may be\nnecessary to obtain the federal approvals necessary to implement this\nsubdivision.\n (f) Notwithstanding any inconsistent provisions of this section and\nsections one hundred twelve and one hundred sixty-three of the state\nfinance law, or section one hundred forty-two of the economic\ndevelopment law, or any other law to the contrary, the commissioner of\nhealth and, in the case of FIDAs authorized exclusively to enroll\npersons with developmental disabilities, the commissioner of health and\nthe commissioner of the office for people with developmental\ndisabilities, may contract with FIDAs approved under this section\nwithout a competitive bid or request for proposal process, are\nauthorized to enter into a contract or contracts under this section,\nprovided, however, that:\n (i) the department of health shall post on its website, for a period\nof no less than thirty days:\n (A) a description of the proposed services to be provided pursuant to\nthe contract or contracts;\n (B) the criteria for selection of a contractor or contractors;\n (C) the period of time during which a prospective contractor may seek\nselection, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n (D) the manner by which a prospective contractor may seek such\nselection, which may include submission by electronic means;\n (ii) all reasonable and responsive submissions that are received from\nprospective contractors in a timely fashion shall be reviewed by the\ncommissioner of health or commissioners, as applicable; and\n (iii) the commissioner or, in the case of FIDAs authorized exclusively\nto enroll persons with developmental disabilities, the commissioner of\nhealth and the commissioner of the office for people with developmental\ndisabilities, may select such contractor or contractors that, in their\ndiscretion, have demonstrated the ability to effectively, efficiently\nand economically integrate health and long term care services, and meet\nthe standards for a certificate of authority under the public health law\nfor the provision of services applicable to the type of managed long\nterm care plan that such contractor proposes to operate.\n (g) Nothing in this section shall be construed as requiring an\nindividual with a developmental disability to enroll in a FIDA that is\nauthorized to exclusively enroll individuals with developmental\ndisabilities.\n (h) Nothing in this section shall make enrollment in a medicare\nmanaged care plan a condition of an individual's participation in the\nFIDA program, or affect the individual's entitlement to payment of\napplicable medicare managed care or fee-for-service coinsurance\ndeductibles by the individual's FIDA plan.\n ** NB There are 2 sb 27's\n ** 28. To the extent that any provision of this section is\ninconsistent with any provision of section forty-four hundred three-g of\nthe public health law, such provision of this section shall not apply to\nan entity authorized to operate pursuant to section forty-four hundred\nthree-g of the public health law.\n ** NB Repealed December 31, 2027\n 29. In the event that the department receives approval from the\nCenters for Medicare and Medicaid Services to amend its 1115 waiver or\nreceives approval for a new 1115 waiver prior to or following the\neffective date of the chapter of the laws of two thousand twenty-four\nthat amended this subdivision, the commissioner is authorized to enter\ninto contracts and to amend the terms of contracts awarded prior to the\neffective date of the chapter of the laws of two thousand twenty-four\nthat amended this subdivision, for the purpose of assisting the\ndepartment of health with implementing projects authorized under such\nwaiver approval. Notwithstanding the provisions of sections one hundred\ntwelve and one hundred sixty-three of the state finance law, or sections\none hundred forty-two and one hundred forty-three of the economic\ndevelopment law, or any contrary provision of law, contracts may be\nentered or contract amendments may be made pursuant to this subdivision\nuntil March thirty-first, two thousand twenty-seven without a\ncompetitive bid or request for proposal process; provided, however, in\nthe case of a contract entered into after the effective date of this\nsubdivision, that:\n (a) The department of health shall post on its website, for a period\nof no less than thirty days:\n (i) A description of the proposed services to be provided pursuant to\nthe contract or contracts;\n (ii) The criteria for selection of a contractor or contractors;\n (iii) The period of time during which a prospective contractor may\nseek selection, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n (iv) The manner by which a prospective contractor may seek such\nselection, which may include submission by electronic means;\n (b) All reasonable and responsive submissions that are received from\nprospective contractors in timely fashion shall be reviewed by the\ncommissioner of health; and\n (c) The commissioner of health shall select such contractor or\ncontractors that, in such commissioner's discretion, are best suited to\nserve the purposes of this section.\n 30. Notwithstanding the provisions of section one hundred sixty-three\nof the state finance law, or sections one hundred forty-two and one\nhundred forty-three of the economic development law, or any contrary\nprovision of law, in the event that the state receives prior approval\nand enhanced financial participation from the Centers for Medicaid and\nMedicare Services, Administration for Children and Families and the\nFederal Food and Nutrition Services for reimbursement pursuant to an\nA-87 cost allocation waiver for enhanced funding for integrated\neligibility systems, the state is authorized to enter into contracts,\nand/or to amend the terms of contracts awarded prior to the effective\ndate of this subdivision, without a competitive bid or request for\nproposal process, consistent with federal requirements, for the purpose\nof implementing projects authorized under such waiver amendment;\nprovided, however, in the case of a contract entered into after the\neffective date of this subdivision, that:\n (a) The office of temporary and disability assistance and the office\nof general services, or another state agency, shall post on its website\nand concurrently provide to the chair of the senate health committee and\nthe chair of the assembly health committee, for a period of no less than\nthirty days:\n (i) A description of the proposed services to be provided pursuant to\nthe contract or contracts;\n (ii) The criteria for selection of a contractor or contractors;\n (iii) The period of time during which a prospective contractor may\nsubmit an offer, which shall be no less than thirty days after such\ninformation is first posted on the website; and\n (iv) The manner by which a prospective contractor may submit an offer,\nwhich may include submission by electronic means;\n (b) All responsive and reasonable offers that are received from\nprospective contractors in timely fashion shall be reviewed by the\ncommissioner of temporary and disability assistance or other state\nagency; and\n (c) The commissioners of the department of health, the office of\ntemporary and disability assistance and the office of children and\nfamily services, working in cooperation with the state chief information\nofficer and the office of general services, shall award such contract to\nthe contractor or contractors offer that provides the best value as such\nterm is defined in section one hundred sixty-three of the state finance\nlaw, to the state. At notification the commissioner of health shall\nprovide this information to the chair of the senate standing health\ncommittee and the chair of the assembly health committee.\n (d) All decisions made and approaches taken pursuant to this\nsubdivision shall be documented in a procurement record as defined in\nsection one hundred sixty-three of the state finance law.\n (e) In accordance with all federal advance planning document guidance\nand within the parameters established by the enhanced financial\nparticipation from the centers for Medicaid and Medicare services,\nadministration for children and families and the federal food and\nnutrition services for reimbursement to an A-87 cost allocation waiver\nfor enhanced funding for integrated eligibility systems, Phase 1 will\ninclude foundational allowable shared service components required to\nsuccessfully meet the requirements for non-MAGI Medicaid such as a\ncommon client portal, document management, rules engines, workflow\nmanagement tools, case management, notices and training.\n (f) The contract will require training to be provided at no cost to\nthe social services districts.\n (g) The contract shall require the completion of shared service\ncomponents by the timelines necessary to receive the enhanced financial\nparticipation from the centers for Medicaid and Medicare services,\nadministration for children and families and the federal food and\nnutrition services for reimbursement to an A-87 cost allocation waiver.\n (h) The commissioner shall provide, within thirty days of award of\nsuch contract or contracts, the chair of the senate standing committee\non health and the chair of the assembly health committee with a report\noutlining the procurement and awards.\n 31. (a) The commissioner shall require managed care providers under\nthis section, managed long-term care plans under section forty-four\nhundred three-f the public health law and other appropriate long-term\nservice programs to adopt expedited procedures for approving personal\ncare services for a medical assistance recipient who requires immediate\npersonal care or consumer directed personal assistance services pursuant\nto paragraph (e) of subdivision two of section three hundred\nsixty-five-a of this title or section three hundred sixty-five-f of this\ntitle, respectively, or other long-term care, and provide such care or\nservices as appropriate, pending approval by such provider or program.\n 32. (a) The commissioner, or for the purposes of subparagraph (iv) of\nparagraph (c) of this subdivision, the Medicaid inspector general in\nconsultation with the commissioner, may, in his or her discretion, apply\npenalties to managed care organizations subject to this section and\narticle forty-four of the public health law, including managed long term\ncare plans, for untimely or inaccurate submission of encounter data;\nprovided however, no penalty shall be assessed if the managed care\norganization submits, in good faith, timely and accurate data and a\nmaterial amount of such data is not successfully received by the\ndepartment as a result of department system failures or technical issues\nthat are beyond the control of the managed care organization.\n (b) The commissioner, or for the purposes of subparagraph (iv) of\nparagraph (c) of this subdivision, the Medicaid inspector general in\nconsultation with the commissioner, shall consider the following when\ndetermining whether to assess a penalty against a managed care\norganization and the amount of such penalty:\n (i) the degree to which the managed care organization submitted\ninaccurate data at a category of service level and the frequency of such\ninaccurate data submissions by the managed care organization;\n (ii) the degree to which the managed care organization submitted\nuntimely data or no data and the frequency of such untimely data\nsubmissions or failures to submit by the managed care organization; and\n (iii) the timeliness of the managed care organization in curing or\ncorrecting inaccurate or untimely data.\n For purposes of this section, "encounter data" shall mean all\nencounter records or adjustments to previously submitted records which\nthe managed care organization has received and processed from provider\nencounter or claim records of all contracted services rendered to an\nenrollee of the managed care organization in the current or any\npreceding month. Any penalty assessed under this subdivision shall be\ncalculated as a percentage of the Medicaid capitated premium calculated\nby the department and paid to the managed care organization.\n (c) (i) Penalties assessed pursuant to this subdivision against a\nmanaged care organization other than a managed long term care plan\ncertified pursuant to section forty-four hundred three-f of the public\nhealth law shall be as follows:\n (A) for encounter data submitted or resubmitted past the deadlines set\nforth in the model contract, the Medicaid capitated premiums shall be\nreduced by one-third percent; and\n (B) for incomplete or inaccurate encounter data, evaluated at a\ncategory of service level, that fails to conform to department developed\nbenchmarks for completeness and accuracy, the Medicaid capitated\npremiums shall be reduced by one and one-third percent; and\n (C) for submitted data that results in a rejection rate in excess of\nten percent of department developed volume benchmarks, the Medicaid\ncapitated premiums shall be reduced by one-third percent.\n (ii) Penalties assessed pursuant to this subdivisions against a\nmanaged long term care plan certified pursuant to section forty-four\nhundred three-f of the public health law shall be as follows:\n (A) for encounter data submitted or resubmitted past the deadlines set\nforth in the model contract, the Medicaid capitated premiums shall be\nreduced by one-quarter percent;\n (B) for incomplete or inaccurate encounter data, evaluated at a\ncategory of service level, that fails to conform to department developed\nbenchmarks for completeness and accuracy, the Medicaid capitated\npremiums shall be reduced by one percent; and\n (C) for submitted data that results in a rejection rate in excess of\nten percent of department developed volume benchmarks, the Medicaid\ncapitated premiums shall be reduced by one-quarter percent.\n (iii) For incomplete or inaccurate encounter data, identified in the\ncourse of an audit, investigation or review by the Medicaid inspector\ngeneral, the Medicaid capitated premiums shall be reduced by an\nadditional one percent.\n (d) (i) Penalties under this subdivision may be applied to any and all\ncircumstances described in paragraph (b) of this subdivision until the\nmanaged care organization complies with the requirements for submission\nof encounter data.\n (ii) No penalties for late, incomplete or inaccurate encounter data\nshall be assessed against managed care organizations in addition to\nthose provided for in this subdivision, provided, however, that nothing\nin this paragraph shall prohibit the imposition of penalties, in cases\nof fraud, waste or abuse, otherwise authorized by law.\n 33. For services under this title provided by residential health care\nfacilities under article twenty-eight of the public health law, the\ncommissioner shall direct managed care organizations licensed under\narticle forty-four of the public health law, article forty-three of the\ninsurance law, and this section, to continue to reimburse at a benchmark\nrate which is to be the fee-for-service rate calculated pursuant to\nsection twenty-eight hundred eight of the public health law. The\nbenchmark fee-for-service rate shall continue to be paid by such managed\ncare organizations for all services provided by residential healthcare\nfacilities from the effective date of this subdivision at least until\nDecember thirty-first, two thousand twenty. The commissioner may\nrequire, as a condition of continuing to require payment at such\nbenchmark rate that aggregate managed care expenditures to residential\nhealth care facilities meet the alternative payment methodology\nrequirements set forth in attachment I of the New York State section\n1115 medicaid redesign team waiver as approved by the centers for\nmedicare and medicaid services. The commissioner of health shall waive\nsuch requirements if a sufficient number of providers, as determined by\nthe commissioner, suffer a financial hardship as a consequence of such\nalternative payment methodology requirements, or if the commissioner\ndetermines that such alternative payment methodologies significantly\nthreaten individuals' access to residential health care facility\nservices; such waiver may be applied on a provider-specific or\nindustry-wide basis. Further, such requirements may be waived, as the\ncommissioner determines necessary, to comply with federal rules or\nregulations governing these payment methodologies.\n 34. For purposes of recovery of overpayments pursuant to subdivision\nthirty-five of this section, any payment made pursuant to the state's\nmanaged care program, including payments made by managed long term care\nplans, shall be deemed a payment by the state's medical assistance\nprogram, provided that this subdivision shall not permit the imposition\nof a lien or recovery against property of an individual or estate on\naccount of medical assistance payments where recovery is made against\nthe individual's managed care provider or provider of medical assistance\nprogram items or services. Provided however nothing in this subdivision\nshall be construed to limit recoveries under other relevant sections of\nlaw.\n 35. Recovery of overpayments from network providers. (a) Where the\nMedicaid inspector general during the course of an audit, investigation,\nor review, or the deputy attorney general for the Medicaid fraud control\nunit during the course of an investigation or prosecution for Medicaid\nfraud, identifies medical assistance overpayments made by a managed care\nprovider or managed long term care plan to its subcontractor or\nsubcontractors or provider or providers, the state shall have the right\nto recover the overpayment from the subcontractor or subcontractors,\nprovider or providers, or the managed care provider or managed long term\ncare plan; provided, however, in no event shall the state duplicate the\nrecovery of an overpayment from a provider or subcontractor.\n (b) Where the state is unsuccessful in recovering an overpayment from\nthe subcontractor or subcontractors or provider or providers, the\nMedicaid inspector general may require the managed care provider or\nmanaged long term care plan to recover the medical assistance\noverpayment identified in paragraph (a) of this subdivision on behalf of\nthe state. The managed care provider or managed long term care plan\nshall remit to the state the full amount of the identified overpayment\nno later than six months after receiving notice of the overpayment from\nthe state.\n 36. Medicaid Program Integrity Reviews. (a) For purposes of this\nsubdivision, managed care provider shall also include managed long term\ncare plans.\n (b) The Medicaid inspector general shall conduct periodic reviews of\nthe contractual performance of each managed care provider as it relates\nto the managed care provider's program integrity obligations under its\ncontract with the department. The Medicaid inspector general, in\nconsultation with the commissioner, shall publish on its website, a list\nof those contractual obligations pursuant to which the managed care\nprovider's program integrity performance shall be evaluated, including\nbenchmarks, prior to commencing any review. A Medicaid program integrity\nreview of a managed care provider conducted pursuant to this\nsubdivision, may be completed no more than annually. Reviews performed\npursuant to this subdivision shall include a review of compliance with\ncontractual standards which prevent fraud, waste, or abuse. Such\nstandards may include but are not limited to excluded providers,\nrestricted recipient program, reporting obligations, compliance\nprograms, and suspension of payments. However, if the Medicaid inspector\ngeneral determines that a subsequent review, pursuant to this\nsubdivision, is necessary, a second review may occur within one year.\n (c) If, as a result of his or her review, the Medicaid inspector\ngeneral determines that a managed care provider is not meeting its\nprogram integrity obligations, the Medicaid inspector general may\nrecover from the managed care provider up to two percent of the Medicaid\npremiums paid to the managed care provider for the period under review.\nAny premium recovery under this subdivision shall be a percentage of the\nadministrative component of the Medicaid premium calculated by the\ndepartment and may be recovered by the department in the same manner it\nrecovers overpayments.\n (d) The managed care provider shall be entitled to receive a draft\naudit report and final audit report containing the results of the\nMedicaid inspector general's review. If the Medicaid inspector general\ndetermines to recover a percentage of the premium as described in\nparagraph (c) of this subdivision, the managed care provider shall be\nentitled to notice and an opportunity to be heard in accordance with\nsection twenty-two of this chapter.\n 37. Managed care providers shall report to the department all sources\nand amounts of income, payments, and financial benefits related to the\nprovision of pharmacy benefits, including, but not limited to, any\npricing discounts, rebates of any kind, inflationary payments, credits,\nclawbacks, fees, grants, chargebacks, reimbursements, or other benefits\nwhether such income, payments, or financial benefits are received\ndirectly by the managed care provider or passed through from a pharmacy\nbenefit manager or other entity. Managed care providers shall also\nreport to the department the amounts of any administrative fees paid to\ncover the cost of providing pharmacy benefit management services. The\nreporting required in this subdivision shall be supplemental to and\nincluded with other existing reporting requirements, including but not\nlimited to any quarterly reporting requirements.\n ** 38. (a) When a patient's health care provider prescribes an opioid\ndependence agent or opioid antagonist that is not on the statewide\nformulary of opioid dependence agents and opioid antagonists, the\nprescriber shall consult with the managed care plan to confirm that in\nhis or her reasonable professional judgment, the patient's clinical\ncondition is consistent with the criteria for approval of the\nnon-preferred or non-formulary drug. Such criteria shall include:\n (i) the preferred drug has been tried by the patient and has failed to\nproduce the desired health outcomes;\n (ii) the patient has tried the preferred drug and has experienced\nunacceptable side effects;\n (iii) the patient has been stabilized on a non-preferred drug and\ntransition to the preferred or formulary drug would be medically\ncontraindicated; or\n (iv) other clinical indications identified by the committee for the\npatient's use of the non-preferred drug, which shall include\nconsideration of the medical needs of special populations, including\nchildren, elderly, chronically ill, persons with mental health\nconditions, persons affected by HIV/AIDS and pregnant persons with a\nsubstance use disorder.\n (b) The managed care plan shall have a process for a patient, or the\npatient's prescribing health care provider, to request a review for a\nprescription drug that is not on the statewide formulary of opioid\ndependence agents and opioid antagonists, consistent with 42 C.F.R.\n438.210(d), or any successor regulation.\n (c) A managed care plan's failure to comply with the requirements of\nthis subdivision shall be subject to a one thousand dollar fine per\nviolation.\n ** NB There are 2 sb 38's\n ** 38. Penalties for the submission of misstated cost reports. (a) For\npurposes of this subdivision, managed care provider shall also include\nmanaged long-term care plans.\n (b) The Medicaid inspector general may, in his or her discretion and\nin consultation with the commissioner, impose a penalty on a managed\ncare provider whose filed cost report contained a misstatement of fact\nincluding:\n (i) unsubstantiated or improper costs;\n (ii) number of member months;\n (iii) number of events.\n For purposes of this paragraph, number of events shall include, but\nnot be limited to understated births or deliveries.\n (c) (i) For misstatements found in subparagraph (i) of paragraph (b)\nof this subdivision, the penalty shall be equal to the amount of the\nmisstatement multiplied by two.\n (ii) For misstatements found in subparagraph (ii) of paragraph (b) of\nthis subdivision, the penalty shall be the amount of the premium\ncapitation paid by the department for the region per member month.\n (iii) For misstatements found in subparagraph (iii) of paragraph (b)\nof this subdivision, the penalty shall be the amount of the supplemental\ncapitation paid by the department for the region per member event.\n (d) Any penalty imposed under this subdivision may be recovered by the\ndepartment in any manner authorized by law.\n (e) The managed care provider against whom a penalty is imposed\npursuant to this subdivision shall be entitled to notice and an\nopportunity to be heard in accordance with section twenty-two of this\nchapter.\n ** NB There are 2 sb 38's\n 39. Medicaid fraud, waste and abuse prevention. (a) For purposes of\nthis subdivision, managed care provider shall also include managed\nlong-term care plans.\n (b) Managed care providers shall adopt and implement policies and\nprocedures designed to detect and prevent fraud, waste and abuse. This\nshall include the adoption and implementation of a compliance program as\nrequired by section three hundred sixty-three-d of this title and the\nterms of the contract between the managed care provider and the state,\nand for managed care providers with an enrolled population of one\nthousand or more persons in the aggregate in any given year, the\nestablishment of a special investigation unit which will have primary\nresponsibility for implementing the managed care provider's policies and\nprocedures to detect and prevent fraud, waste and abuse, as it relates\nto the managed care provider's participation in the medical assistance\nprogram.\n (c) The managed care provider shall coordinate its fraud, waste and\nabuse prevention activities with the Medicaid inspector general and the\ndepartment of health. The Medicaid inspector general, in consultation\nwith the department of health, may promulgate regulations establishing\nstandards and requirements for the operation of managed care provider\nfraud, waste and abuse prevention activities, including requirements for\nspecial investigation units. The provisions of this subdivision\nnotwithstanding, the managed care provider shall continue to comply with\nall the requirements of section forty-four hundred fourteen of the\npublic health law.\n 40. (a) The commissioner shall be entitled to penalize managed care\nproviders for failure to meet the contractual obligations and\nperformance standards of the executed contract between the state and a\nmanaged care provider in place at the time of the failure.\n (b) The commissioner shall have sole discretion in determining whether\nto impose a penalty for noncompliance with any provision of such\ncontract.\n (c) (i) Penalties imposed by this subdivision against a managed care\nprovider shall be from two hundred fifty dollars up to twenty-five\nthousand dollars per violation depending on the severity of the\nnoncompliance as determined by the commissioner.\n (ii) The commissioner may elect, in their sole discretion, to assess\npenalties imposed by this section from, and as a set off against,\npayments due to the managed care provider, or payments that become due\nany time after the assessment of penalties. Deductions may continue\nuntil the full amount of the noticed penalties are paid in full.\n (iii) All penalties imposed by the commissioner pursuant to this\nsubdivision shall be paid out of the administrative costs and profits of\nthe managed care provider. The managed care provider shall not pass the\npenalties imposed by the commissioner pursuant to this subdivision\nthrough to any medical services provider and/or subcontractor.\n (d) For the purposes of this subdivision a violation shall mean a\ndetermination by the commissioner that the managed care provider failed\nto act as required under the contract between the state and the managed\ncare provider in place at the time of the failure, or applicable federal\nand state statutes, rules or regulations governing managed care\nproviders. Each instance of a managed care provider failing to furnish\nnecessary and/or required medical services or items to each enrollee\nshall be a separate violation and each day that an ongoing violation\ncontinues shall be a separate violation.\n (e) No penalties shall be assessed pursuant to this subdivision\nwithout providing an opportunity for a formal hearing conducted in\naccordance with section twelve-a of the public health law.\n (f) Nothing in this subdivision shall prohibit the imposition of\ndamages, penalties or other relief, otherwise authorized by law,\nincluding but not limited to cases of fraud, waste or abuse.\n (g) The commissioner may promulgate any regulations necessary to\nimplement the provisions of this subdivision.\n * NB Repealed March 31, 2026 (per ch. 165/1991)\n * NB Repealed March 31, 2026 (per ch. 710/1988)\n