Section 364-F. Primary care case management programs

1. The department is
  authorized to establish primary care case management programs, under the
  medical  assistance  program,  in accordance with applicable federal law
  and regulations. Primary care case management  programs  shall  only  be
  authorized  in  areas  of  the state where comprehensive health services
  plans, as defined in section forty-four hundred one of the public health
  law, are not yet available. Subject to the approval of the  director  of
  the  budget, the commissioner is authorized to apply for the appropriate
  waivers under federal law and regulation,  and  may  waive  any  of  the
  provisions   of  sections  three  hundred  sixty-five-a,  three  hundred
  sixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a  and
  three  hundred  sixty-four-j  of  this  chapter or any regulation of the
  department when such action would be necessary to  assist  in  promoting
  the objectives of this section.
    2.   (a)   A  primary  care  case  management  program  shall  provide
  individuals eligible for medical  assistance  with  the  opportunity  to
  select  a primary care case manager who shall provide medical assistance
  services to such  eligible  individuals,  either  directly,  or  through
  referral.
    (b) Primary care case managers shall be limited to qualified, licensed
  primary  care  practitioners, as defined in paragraph (f) of subdivision
  one of section three hundred sixty-four-j  of  this  chapter,  who  meet
  standards  established  by  the  commissioner  for  the purposes of this
  program.
    (c) Services that may be covered by the primary care  case  management
  program  are defined by the commissioner in the benefit package. Covered
  services may include  all  medical  assistance  services  defined  under
  section three hundred sixty-five-a of this chapter, except:
    (i)  services  excluded  under  paragraph  (e) of subdivision three of
  section three hundred sixty-four-j of this  chapter  shall  be  excluded
  under this section;
    (ii)  services  provided  by  residential health care facilities, long
  term home health  care  programs,  child  care  agencies,  and  entities
  offering comprehensive health services plans;
    (iii) services provided by dentists and optometrists; and
    (iv)  eyeglasses,  emergency  care,  mental health services and family
  planning services.
    (d) Case management services provided by primary  care  case  managers
  shall include, but need not be limited to:
    (i)  management  of  the  medical and health care of each recipient to
  assure  that  all  services  provided  under  paragraph  (c)   of   this
  subdivision and which are found to be necessary, are made available in a
  timely manner;
    (ii)  referral  to,  and  coordination,  monitoring  and follow-up of,
  appropriate providers for diagnosis and treatment, the  need  for  which
  has  been  identified  by the primary care case manager but which is not
  directly available from the primary care  case  manager,  and  assisting
  medical  assistance  recipients  in  the  prudent  selection  of medical
  services;
    (iii)  arrangements  for  referral  of   recipients   to   appropriate
  providers; and
    (iv)  all  early periodic screening, diagnosis and treatment services,
  as well as interperiodic screening and  referral,  to  each  participant
  under the age of twenty-one at regular intervals.
    3.  (a) Primary care case management programs may be conducted only in
  accordance with guidelines established  by  the  commissioner.  For  the
  purpose   of  implementing  and  administering  the  primary  care  case
  management  programs,  the  commissioner  may  contract   with   private

  not-for-profit  and public agencies as defined in guidelines established
  by the commissioner for the management and administration of the primary
  care case management program.
    (b) The primary care case management program must:
    (i) assure access to and delivery of high quality, appropriate medical
  services;
    (ii)  participate  in  quality assurance activities as required by the
  commissioner, as well as other mechanisms designed to protect  recipient
  rights under such program;
    (iii)  ensure  that  persons  eligible  for medical assistance will be
  provided  sufficient  information  regarding  the  program  to  make  an
  informed and voluntary choice whether to participate; and
    (iv)  provide for adequate safeguards to protect recipients from being
  misled concerning the program and from being coerced into  participating
  in the primary care case management program.
    4.  (a)  Individuals eligible to participate in Medicaid managed care,
  to participate in Medicaid managed care may  participate  in  a  primary
  care  case  management  program,  subject  to the availability of such a
  program within the  applicable  social  services  district,  except  for
  individuals:  (i) required by Medicaid managed care to be enrolled in an
  entity  offering  a  comprehensive  health  services  plan as defined in
  paragraph (k) of subdivision two of section three  hundred  sixty-five-a
  of  this  chapter;  (ii)  participating  in  another  medical assistance
  reimbursed demonstration or pilot project, or (iii)  receiving  services
  as  an  inpatient  from  a nursing home or intermediate care facility or
  residential services from a child care agency or services  from  a  long
  term home health care program.
    (b)  Individuals  choosing  to  participate  in  a  primary  care case
  management program will be given thirty days from the effective date  of
  enrollment  in the program to disenroll without cause. After this thirty
  day disenrollment period, all individuals participating in  the  program
  will  be  enrolled  for  a  period  of  twelve  months,  except that all
  participants will be permitted to disenroll for good cause,  as  defined
  in guidelines established by the commissioner.
    5.  (a)  Primary  care case management programs may include provisions
  for innovative  payment  mechanisms,  including,  but  not  limited  to,
  payment   of   case   management   fees,  capitation  arrangements,  and
  fee-for-service payments.
    (b) Any new payment mechanisms and levels of payment implemented under
  the primary care case management  program  shall  be  developed  by  the
  commissioner subject to the approval of the director of the budget.
    6.   Notwithstanding  any  inconsistent  provision  of  this  section,
  participation in  a  primary  care  case  management  program  will  not
  diminish the scope of available medical services to which a recipient is
  entitled.
    7.  This  section  shall  be  effective  if,  and  as long as, federal
  financial participation is available therefor.
    * NB Expires March 31, 2012