Section 364-J. Managed care programs

1. Definitions. As used in this
  section, unless the context clearly requires  otherwise,  the  following
  terms shall mean:
    (a)  "Participant".  A  medical  assistance recipient who receives, is
  required to receive or elects to receive his or her  medical  assistance
  services from a managed care provider.
    (b)  "Managed  care provider". An entity that provides or arranges for
  the  provision  of  medical  assistance   services   and   supplies   to
  participants  directly  or indirectly (including by referral), including
  case management; and:
    (i) is authorized to operate under article forty-four  of  the  public
  health  law  or article forty-three of the insurance law and provides or
  arranges, directly or indirectly (including  by  referral)  for  covered
  comprehensive health services on a full capitation basis; or
    (ii)  is  authorized  as  a  partially  capitated  program pursuant to
  section three hundred sixty-four-f of this title or  section  forty-four
  hundred  three-e of the public health law or section 1915b of the social
  security act.
    (c) "Managed care program".  A  statewide  program  in  which  medical
  assistance  recipients  enroll  on  a  voluntary  or  mandatory basis to
  receive medical assistance services, including case management, directly
  and indirectly (including by referral) from a managed care provider, and
  as applicable, a mental health special needs plan or a comprehensive HIV
  special needs plan, under this section.
    (d)  "Medical  services   provider".   A   physician,   nurse,   nurse
  practitioner,    physician   assistant,   licensed   midwife,   dentist,
  optometrist or other licensed health  care  practitioner  authorized  to
  provide medical assistance services.
    (e)  "Center  of  excellence."  A  health  care  facility certified to
  operate under article twenty-eight of the public health law that  offers
  specialized  treatment  expertise in HIV care services as defined by the
  commissioner of health.
    (f) "Primary care practitioner". A  physician  or  nurse  practitioner
  providing  primary care to and management of the medical and health care
  services of a participant served by a managed care provider.
    (g)  "AIDS".  AIDS  shall  have  the  same  meaning  as   in   article
  twenty-seven-f of the public health law.
    (h)  "HIV  infection". HIV infection shall have the same meaning as in
  article twenty-seven-f of the public health law.
    (i) "HIV-related illness". HIV-related illness  shall  have  the  same
  meaning as in article twenty-seven-f of the public health law.
    (j) "Specialty care center". A "specialty care center" shall mean only
  such  centers  as are accredited or designated by an agency of the state
  or federal government or by a voluntary national health organization  as
  having  special expertise in treating the disease or condition for which
  it is accredited or designated.
    (k) "Special care".  Care,  services  and  supplies  relating  to  the
  treatment   of   mental   illness,   mental  retardation,  developmental
  disabilities, alcoholism, alcohol  abuse  or  substance  abuse,  or  HIV
  infection/AIDS.
    (l)  "Responsible  special  care  agency".  Whichever of the following
  state agencies has responsibility for the special care in question:  the
  department  of health, the office of mental health, the office of mental
  retardation and developmental disabilities, or the office of  alcoholism
  and substance abuse services.
    (m)  "Mental health special needs plan" shall have the same meaning as
  in section forty-four hundred three-d of the public health law.

    (n) "Comprehensive HIV special needs plan" shall have the same meaning
  as in section forty-four hundred three-c of the public health law.
    (o)  "Third-party  payor".  Any  entity  or  program that is or may be
  liable to pay the costs of health and medical care  of  a  recipient  of
  medical  assistance  benefits,  including  insurers licensed pursuant to
  article thirty-two or forty-three of the insurance law, or organizations
  certified pursuant to article forty-four of the public health law.
    (p) "Grievance".  Any  complaint  presented  by  a  participant  or  a
  participant's   representative  for  resolution  through  the  grievance
  process of a managed care provider, comprehensive HIV special needs plan
  or a mental health special needs plan.
    (q) "Emergency medical condition". A medical or behavioral  condition,
  the  onset  of  which  is  sudden,  that manifests itself by symptoms of
  sufficient severity, including severe pain, that  a  prudent  layperson,
  who  possesses  an  average  knowledge  of  medicine  and  health, could
  reasonably expect the absence of immediate medical attention  to  result
  in:  (i)  placing the health of the person afflicted with such condition
  in serious jeopardy, or in the case of a  behavioral  condition  placing
  the  health of the person or others in serious jeopardy; or (ii) serious
  impairment  to  such  person's  bodily  functions;  or   (iii)   serious
  dysfunction  of any bodily organ or part of such person; or (iv) serious
  disfigurement of such person.
    (r) "Emergency care". Health care procedures, treatments or  services,
  including  psychiatric  stabilization  and  medical  detoxification from
  drugs or alcohol, that are provided for an emergency medical condition.
    (s) "Existing rates". The rates  paid  pursuant  to  the  most  recent
  executed  contract between a local social services district or the state
  and a managed care provider.
    (t) "Managed care rating regions".  The  regions  established  by  the
  department  of  health for the purpose of setting regional premium rates
  for managed care providers.
    (u) "Premium group". The various  demographic,  gender  and  recipient
  categories  utilized  for  rate-setting  purposes  by  the department of
  health.
    (v)  "Upper  payment  limit".  The  maximum  reimbursement  that   the
  department  of  health  may pay a managed care provider for providing or
  arranging for medical services to participants in a managed care program
  in accordance with the  federal  social  security  act  and  regulations
  promulgated thereunder.
    (x)  "Persons  with  serious  mental  illness".  Individuals  who meet
  criteria established by the commissioner of mental health,  which  shall
  include  persons who have a designated diagnosis of mental illness under
  the most recent edition of the  diagnostic  and  statistical  manual  of
  mental  disorders, and (i) whose severity and duration of mental illness
  results in substantial functional disability or (ii) who require  mental
  health services on more than an incidental basis.
    (y)  "Children  and  adolescents with serious emotional disturbances".
  Individuals under eighteen years of age who meet criteria established by
  the commissioner of mental health,  which  shall  include  children  and
  adolescents  who have a designated diagnosis of mental illness under the
  most recent edition of the diagnostic and statistical manual  of  mental
  disorders, and (i) whose severity and duration of mental illness results
  in  substantial  functional disability or (ii) who require mental health
  services on more than an incidental basis.
    2.  (a)  The  commissioner  of  health,  in   cooperation   with   the
  commissioner  and  the  commissioners  of  the  responsible special care
  agencies shall  establish  managed  care  programs,  under  the  medical
  assistance  program,  in  accordance  with  applicable  federal  law and

  regulations.  The  commissioner  of  health,  in  cooperation  with  the
  commissioner, is authorized and directed, subject to the approval of the
  director  of  the  state  division  of  the budget, to apply for federal
  waivers  when  such action would be necessary to assist in promoting the
  objectives of this section.
    (b) The commissioner of health has authority to allow social  services
  districts  to seek an exemption from this section for up to two years if
  the social services district can demonstrate  and  the  commissioner  of
  health and the commissioner of responsible special care agencies concurs
  that  the  district  has  insufficient  capacity  to  participate in the
  program. An exemption under this paragraph may be renewed for additional
  two year periods.
    3. (a) Every person eligible for or receiving medical assistance under
  this article, who  resides  in  a  social  services  district  providing
  medical  assistance,  which  has  implemented  the  state's managed care
  program shall participate in the program  authorized  by  this  section.
  Provided,  however,  that  participation  in a comprehensive HIV special
  needs plan also shall be in accordance with article  forty-four  of  the
  public  health  law  and  participation in a mental health special needs
  plan shall also be in accordance with article forty-four of  the  public
  health law and article thirty-one of the mental hygiene law.
    (b)   A   medical  assistance  recipient  shall  not  be  required  to
  participate in, and shall be permitted to withdraw from the managed care
  program upon a showing that:
    (i) a managed care provider is not geographically  accessible  to  the
  person  so  as  to  reasonably provide services to the person, or upon a
  showing of other good cause as defined in  regulation.  A  managed  care
  provider  is  not  geographically accessible if the person cannot access
  its services in a timely fashion due to distance or travel time;
    (ii) a pregnant woman with an established relationship, as defined  by
  the  commissioner  of health, with a comprehensive prenatal primary care
  provider, including a prenatal care assistance  program  as  defined  in
  title  two  of article twenty-five of the public health law, that is not
  associated with a managed care  provider  in  the  participant's  social
  services  district,  may defer participation in the managed care program
  while pregnant and for sixty days post-partum;
    (iii) an individual with a chronic medical condition being treated  by
  a  specialist  physician  that  is  not  associated  with a managed care
  provider in  the  participant's  social  services  district,  may  defer
  participation  in the managed care program until the course of treatment
  is complete; and
    (iv) a participant cannot be served by a  managed  care  provider  who
  participates in a managed care program due to a language barrier.
    (c)  The following medical assistance recipients shall not be required
  to participate in a managed care program established  pursuant  to  this
  section, but may voluntarily opt to do so:
    (i)  a  person receiving services provided by a residential alcohol or
  substance abuse program or facility for the mentally retarded;
    (ii) a person receiving services  provided  by  an  intermediate  care
  facility  for the mentally retarded or who has characteristics and needs
  similar to such persons;
    (iii) a  person  with  a  developmental  or  physical  disability  who
  receives  home  and  community-based  services  or care-at-home services
  through existing waivers under section nineteen hundred fifteen  (c)  of
  the  federal  social  security  act or who has characteristics and needs
  similar to such persons;
    (iv) Native Americans;

    (v) a person who  is  eligible  for  medical  assistance  pursuant  to
  subparagraph  twelve  or  subparagraph  thirteen  of  paragraph  (a)  of
  subdivision one of section three hundred sixty-six of  this  title,  and
  who  is  not required to pay a premium pursuant to subdivision twelve of
  section three hundred sixty-seven-a of this title.
    (d)  The following medical assistance recipients shall not be eligible
  to participate in a managed care program established  pursuant  to  this
  section:
    (i)  a  person  receiving services provided by a long term home health
  care  program,  or  a  person  receiving   inpatient   services   in   a
  state-operated  psychiatric facility or a residential treatment facility
  for children and youth;
    (ii) a person eligible  for  Medicare  participating  in  a  capitated
  demonstration program for long term care;
    (iii) an infant living with an incarcerated mother in a state or local
  correctional facility as defined in section two of the correction law;
    (iv)  a  person  who is expected to be eligible for medical assistance
  for less than six months;
    (v) a person who is eligible for medical assistance benefits only with
  respect to tuberculosis-related services;
    (vi) certified blind or disabled children living  or  expected  to  be
  living separate and apart from the parent for 30 days or more;
    (vii) residents of nursing facilities at time of enrollment;
    (viii) individuals receiving hospice services at time of enrollment;
    (ix) individuals in the restricted recipient program;
    (x) a person who has primary medical or health care coverage available
  from or under a third-party payor which may be maintained by payment, or
  part  payment,  of  the  premium or costsharing amounts, when payment of
  such  premium  or  costsharing  amounts  would  be  cost-effective,   as
  determined by the local social services district;
    (xi) a foster child in the placement of a voluntary agency;
    (xii)   a  person  receiving  family  planning  services  pursuant  to
  subparagraph eleven of paragraph (a) of subdivision one of section three
  hundred sixty-six of this title; and
    (xiii) a person who is eligible for  medical  assistance  pursuant  to
  paragraph  (v) of subdivision four of section three hundred sixty-six of
  this title; and
    (xiv) a person who is eligible  for  medical  assistance  pursuant  to
  subparagraph  twelve  or  subparagraph  thirteen  of  paragraph  (a)  of
  subdivision one of section three hundred sixty-six of  this  title,  and
  who  is  required  to  pay  a  premium pursuant to subdivision twelve of
  section three hundred sixty-seven-a of this title and
    (xv) a person who is Medicare/Medicaid dually eligible and who is  not
  enrolled in a Medicare managed care plan.
    (e) The following services shall not be provided to medical assistance
  recipients  through  managed  care programs established pursuant to this
  section, and shall continue to  be  provided  outside  of  managed  care
  programs and in accordance with applicable reimbursement methodologies:
    (i)  day treatment services provided to individuals with developmental
  disabilities;
    (ii) comprehensive  medicaid  case  management  services  provided  to
  individuals with developmental disabilities;
    (iii) services provided pursuant to title two-A of article twenty-five
  of the public health law;
    (iv)   services  provided  pursuant  to  article  eighty-nine  of  the
  education law;
    (v)  mental  health  services  provided  by  a   certified   voluntary
  free-standing  day treatment program where such services are provided in

  conjunction with educational services authorized  in  an  individualized
  education program in accordance with regulations promulgated pursuant to
  article eighty-nine of the education law;
    (vi)  long  term  services as determined by the commissioner of mental
  retardation and developmental disabilities, provided to individuals with
  developmental disabilities at facilities licensed  pursuant  to  article
  sixteen  of  the  mental hygiene law or clinics serving individuals with
  developmental disabilities at facilities licensed  pursuant  to  article
  twenty-eight of the public health law;
    (vii) TB directly observed therapy;
    (viii) AIDS adult day health care;
    (ix) HIV COBRA case management; and
    (x) other services as determined by the commissioner of health.
    (f)  The following medical assistance recipients shall not be eligible
  to participate in a managed care program established  pursuant  to  this
  section,  unless  the  local social services district permits them to do
  so;
    (i) a person or family that is homeless and is living  in  a  shelter;
  and
    (ii)  a  foster  care  child  in  the  direct care of the local social
  services district.
    (g) The following categories of individuals will not  be  required  to
  enroll   with   a  managed  care  program  until  program  features  and
  reimbursement rates are approved by the commissioner of health  and,  as
  appropriate, the commissioner of mental health:
    (i)  an individual dually eligible for medical assistance and benefits
  under the federal Medicare program and enrolled in  a  Medicare  managed
  care  plan  offered  by  an entity that is also a managed care provider;
  provided that (notwithstanding paragraph (g) of subdivision four of this
  section):
    (a) if the individual changes his or her Medicare managed care plan as
  authorized by title XVIII  of  the  federal  social  security  act,  and
  enrolls  in  another  Medicare  managed care plan that is also a managed
  care provider, the individual shall be (if required by the  commissioner
  under this paragraph) enrolled in that managed care provider;
    (b) if the individual changes his or her Medicare managed care plan as
  authorized  by  title  XVIII  of  the  federal  social security act, but
  enrolls in another Medicare managed care plan that is not also a managed
  care provider, the individual shall be disenrolled from the managed care
  provider in which he or she was enrolled and withdraw from  the  managed
  care program;
    (c) if the individual disenrolls from his or her Medicare managed care
  plan  as  authorized  by title XVIII of the federal social security act,
  and  does  not  enroll  in  another  Medicare  managed  care  plan,  the
  individual  shall be disenrolled from the managed care provider in which
  he or she was enrolled and withdraw from the managed care program;
    (d) nothing herein shall require an individual enrolled in  a  managed
  long  term  care plan, pursuant to section forty-four hundred three-f of
  the public health law, to disenroll from such program.
    (ii) an individual eligible for supplemental security income;
    (iii) HIV positive individuals; and
    (iv) persons with serious mental illness and children and  adolescents
  with  serious  emotional  disturbances, as defined in section forty-four
  hundred one of the public health law.
    4. The managed care  program  shall  provide  participants  access  to
  comprehensive  and coordinated health care delivered in a cost effective
  manner consistent with the following provisions:

    (a) (i) a managed care  provider  shall  arrange  for  access  to  and
  enrollment  of  primary  care  practitioners  and other medical services
  providers. Each managed care provider shall possess  the  expertise  and
  sufficient  resources  to assure the delivery of quality medical care to
  participants  in  an  appropriate  and  timely  manner  and  may include
  physicians, nurse practitioners, county health departments, providers of
  comprehensive  health  service  plans  licensed  pursuant   to   article
  forty-four  of  the  public health law, and hospitals and diagnostic and
  treatment centers licensed  pursuant  to  article  twenty-eight  of  the
  public  health law or otherwise authorized by law to offer comprehensive
  health services or facilities licensed  pursuant  to  articles  sixteen,
  thirty-one and thirty-two of the mental hygiene law.
    (ii)  provided, however, if a major public hospital, as defined in the
  public health law, is designated by the  commissioner  of  health  as  a
  managed  care provider in a social services district the commissioner of
  health shall designate at least one other managed care provider which is
  not a major public hospital or  facility  operated  by  a  major  public
  hospital; and
    (iii)  under  a  managed  care program, not all managed care providers
  must be required to provide the same set of medical assistance services.
  The managed  care  program  shall  establish  procedures  through  which
  participants  will  be assured access to all medical assistance services
  to which they are otherwise entitled, other  than  through  the  managed
  care provider, where:
    (A)  the  service  is  not reasonably available directly or indirectly
  from the managed care provider,
    (B) it is necessary because of emergency or geographic unavailability,
  or
    (C) the services provided are family planning services; or
    (D) the services are dental services and are provided by a  diagnostic
  and  treatment  center licensed under article twenty-eight of the public
  health law which is affiliated with an academic dental center and  which
  has   been   granted   an  operating  certificate  pursuant  to  article
  twenty-eight of the public health law to provide such  dental  services.
  Any  diagnostic  and treatment center providing dental services pursuant
  to this clause shall prior to June first of  each  year  report  to  the
  governor,  temporary president of the senate and speaker of the assembly
  on the following: the total number of visits made by medical  assistance
  recipients during the immediately preceding calendar year; the number of
  visits  made  by  medical  assistance  recipients during the immediately
  preceding calendar year by recipients who were enrolled in managed  care
  programs;  the  number  of  visits made by medical assistance recipients
  during the immediately preceding calendar year by  recipients  who  were
  enrolled  in  managed  care  programs  that provide dental benefits as a
  covered service; and the number of visits made by the  uninsured  during
  the immediately preceding calendar year; or
    (E) other services as defined by the commissioner of health.
    (b) Participants shall select a managed care provider from among those
  designated   under  the  managed  care  program,  provided,  however,  a
  participant shall be provided with a choice of no less than two  managed
  care  providers.  Notwithstanding the foregoing, a local social services
  district designated a rural area as defined  in  42  U.S.C.  1395ww  may
  limit  a  participant  to one managed care provider, if the commissioner
  and the local social services district find that only one  managed  care
  provider  is  available.  A  managed care provider in a rural area shall
  offer  a  participant  a  choice  of  at  least   three   primary   care
  practitioners  and  permit  the individual to obtain a service or seek a

  provider outside of the managed  care  network  where  such  service  or
  provider is not available from within the managed care provider network.
    (c)  Participants  shall select a primary care practitioner from among
  those designated  by  the  managed  care  provider.  In  all  districts,
  participants  shall  be  provided  with  a  choice of no less than three
  primary care practitioners. In the event that  a  participant  does  not
  select  a  primary  care  practitioner,  the  participant's managed care
  provider shall select a primary care practitioner for  the  participant,
  taking into account geographic accessibility.
    (d)  For  all  other medical services, except as provided in paragraph
  (c) of this subdivision, if  a  sufficient  number  of  medical  service
  providers are available, a choice shall be offered.
    (e)  (i)  In  any social services district which has not implemented a
  mandatory  managed  care  program  pursuant   to   this   section,   the
  commissioner   of   health  shall  establish  marketing  and  enrollment
  guidelines,  including  but  not  limited   to   regulations   governing
  face-to-face  marketing  and  enrollment encounters between managed care
  providers and recipients of medical assistance and  locations  for  such
  encounters.  Such  regulations  shall  prohibit, at a minimum, telephone
  cold-calling and door-to-door  solicitation  at  the  homes  of  medical
  assistance   recipients.   The   regulations   shall  also  require  the
  commissioner  of  health  to  approve  any  local   district   marketing
  guidelines.   Managed  care  providers  shall  be  permitted  to  assist
  participants in completion of enrollment forms at approved  health  care
  provider sites and other approved locations. In no case may an emergency
  room  be deemed an approved location. Upon enrollment, participants will
  sign an attestation that: they have been informed that managed care is a
  voluntary program; participants have a choice of managed care providers;
  participants  have  a  choice  of  primary   care   practitioners;   and
  participants  must  exclusively  use their primary care practitioner and
  plan providers except as otherwise provided in  this  section  including
  but  not  limited  to  the  exceptions  listed  in subparagraph (iii) of
  paragraph (a) of this subdivision. Managed care  providers  must  submit
  enrollment  forms  to the local department of social services. The local
  department of social services will provide or arrange for  an  audit  of
  managed  care provider enrollment forms; including telephone contacts to
  determine if participants were provided with the information required by
  this subparagraph. The commissioner of health  may  suspend  or  curtail
  enrollment  or  impose  sanctions  for  failure  to appropriately notify
  clients as required in this subparagraph.
    (ii) In any social services district which has implemented a mandatory
  managed care program pursuant to this section, the requirements of  this
  subparagraph  shall  apply to the extent consistent with federal law and
  regulations. The department of health, may contract  with  one  or  more
  independent   organizations   to   provide   enrollment  counseling  and
  enrollment services, for participants required to enroll in managed care
  programs, for each social services district requesting the  services  of
  an  enrollment  broker.  To select such organizations, the department of
  health shall  issue  a  request  for  proposals  (RFP),  shall  evaluate
  proposals  submitted  in response to such RFP and, pursuant to such RFP,
  shall  award  a  contract  to  one  or  more  qualified  and  responsive
  organizations.  Such  organizations  shall  not  be  owned, operated, or
  controlled  by  any  governmental   agency,   managed   care   provider,
  comprehensive  HIV special needs plan, mental health special needs plan,
  or medical services provider.
    (iii) Such independent organizations shall develop  enrollment  guides
  for  participants  which  shall  be approved by the department of health
  prior to distribution.

    (iv) Local  social  services  districts  or  enrollment  organizations
  through  their enrollment counselors shall provide participants with the
  opportunity for face to face counseling including individual  counseling
  upon  request  of  the  participant.  Local social services districts or
  enrollment  organizations through their enrollment counselors shall also
  provide participants with information in a culturally and linguistically
  appropriate and understandable manner, in  light  of  the  participant's
  needs,  circumstances and language proficiency, sufficient to enable the
  participant to make an informed selection of a  managed  care  provider.
  Such  information  shall  include,  but  shall not be limited to: how to
  access care within the program; a description of the medical  assistance
  services  that  can  be  obtained  other  than  through  a  managed care
  provider, mental health special needs plan or comprehensive HIV  special
  needs  plan; the available managed care providers, mental health special
  needs plans and comprehensive HIV special needs plans and the  scope  of
  services  covered  by  each; a listing of the medical services providers
  associated with each managed care  provider;  the  participants'  rights
  within  the  managed  care  program;  and  how  to exercise such rights.
  Enrollment counselors shall inquire  into  each  participant's  existing
  relationships  with  medical  services providers and explain whether and
  how such  relationships  may  be  maintained  within  the  managed  care
  program.  For  enrollments  made  during face to face counseling, if the
  participant has a preference for particular medical services  providers,
  enrollment  counselors  shall verify with the medical services providers
  that such  medical  services  providers  whom  the  participant  prefers
  participate  in the managed care provider's network and are available to
  serve the participant.
    (v)  Upon  delivery  of  the  pre-enrollment  information,  the  local
  district  or the enrollment organization shall certify the participant's
  receipt of such information. Upon verification that the participant  has
  received  the  pre-enrollment  education  information,  a  managed  care
  provider, a local district or the enrollment organization may  enroll  a
  participant  into  a  managed care provider. Managed care providers must
  submit enrollment forms to the local department of social services. Upon
  enrollment, participants will sign an attestation that  they  have  been
  informed  that:  participants  have  a choice of managed care providers;
  participants have a choice of primary care practitioners; and, except as
  otherwise provided in this section, including but  not  limited  to  the
  exceptions  listed  in  subparagraph  (iii)  of  paragraph  (a)  of this
  subdivision,  participants  must  exclusively  use  their  primary  care
  practitioners  and  plan  providers.  The commissioner of health or with
  respect to a managed care plan serving participants in  a  city  with  a
  population  of over two million, the local department of social services
  in such city, may suspend or curtail enrollment or impose sanctions  for
  failure   to   appropriately   notify   clients   as  required  in  this
  subparagraph.
    (vi) Enrollment counselors or local social  services  districts  shall
  further  inquire  into  each  participant's  health  status  in order to
  identify  physical  or  behavioral  conditions  that  require  immediate
  attention or continuity of care, and provide to participants information
  regarding  health  care  options available to persons with HIV and other
  illnesses or conditions under the managed care program. Any  information
  disclosed  to  counselors  shall be kept confidential in accordance with
  applicable provisions of the public health law, and as appropriate,  the
  mental hygiene law.
    (vii)  Any  marketing  materials developed by a managed care provider,
  comprehensive HIV special needs plan or mental health special needs plan
  shall be approved by the  department  of  health  or  the  local  social

  services   district   and  the  commissioner  of  mental  health,  where
  appropriate, within sixty days prior to distribution  to  recipients  of
  medical  assistance.  All  marketing  materials shall be reviewed within
  sixty days of submission.
    (viii)  In  any  social  services  district  which  has  implemented a
  mandatory  managed  care  program  pursuant   to   this   section,   the
  commissioner   of   health  shall  establish  marketing  and  enrollment
  guidelines,  including  but  not  limited   to   regulations   governing
  face-to-face  marketing  and  enrollment encounters between managed care
  providers and recipients of medical assistance and  locations  for  such
  encounters.  Such  regulations  shall  prohibit, at a minimum, telephone
  cold-calling and door-to-door  solicitation  at  the  homes  of  medical
  assistance   recipients.   The   regulations   shall  also  require  the
  commissioner  of  health  to  approve  any  local   district   marketing
  guidelines.
    (f)  (i) Participants shall have no less than sixty days from the date
  selected by the district to enroll in the managed care program to select
  a managed care provider, and as appropriate,  a  mental  health  special
  needs  plan,  and shall be provided with information to make an informed
  choice. Where a participant has not selected such a provider  or  mental
  health  special needs plan, the commissioner of health shall assign such
  participant to a managed care provider, and as appropriate, to a  mental
  health  special  needs plan, taking into account capacity and geographic
  accessibility. The commissioner may after the period of time established
  in subparagraph (ii) of this paragraph assign participants to a  managed
  care provider taking into account quality performance criteria and cost.
  Provided  however,  cost  criteria  shall  not  be of greater value than
  quality criteria in assigning participants.
    (ii)  The  commissioner  may  assign  participants  pursuant  to  such
  criteria  on  a  weighted basis, provided however that for twelve months
  following implementation of a mandatory program, pursuant to  a  federal
  waiver,  twenty-five  percent  of  the participants that do not choose a
  managed care provider shall be assigned to managed care  providers  that
  satisfy  the  criteria  set forth in subparagraph (i) of this paragraph,
  and are controlled by, sponsored by, or otherwise affiliated  through  a
  common  governance  or  through  a  parent corporation with, one or more
  private not-for-profit or public general  hospitals  or  diagnostic  and
  treatment  centers  licensed  pursuant  to  article  twenty-eight of the
  public health law.
    (iii) For twelve months  following  the  twelve  months  described  in
  subparagraph  (ii)  of this paragraph twenty-two and one-half percent of
  the participants that do not choose a managed  care  provider  shall  be
  assigned  to managed care providers, that satisfy the criteria set forth
  in subparagraph (i) of this paragraph and are controlled  by,  sponsored
  by,  or  otherwise  affiliated  through a common governance or through a
  parent corporation with, one or more private  not-for-profit  or  public
  general  hospitals or diagnostic and treatment centers licensed pursuant
  to article twenty-eight of the public health law.
    (iv) For twelve  months  following  the  twelve  months  described  in
  subparagraph  (iii) of this paragraph twenty percent of the participants
  that do not choose a managed care provider  shall  be  assigned  equally
  among  each of the managed care providers, that satisfy the criteria set
  forth in subparagraph (i) of  this  paragraph  and  are  controlled  by,
  sponsored  by,  or  otherwise  affiliated through a common governance or
  through a parent corporation with one or more private not-for-profit  or
  public  general  hospitals  or diagnostic and treatment centers licensed
  pursuant to article twenty-eight of the public health law.

    (v) The commissioner  shall  assign  all  participants  not  otherwise
  assigned  to  a  managed care plan pursuant to subparagraphs (ii), (iii)
  and (iv) of this paragraph  equally  among  each  of  the  managed  care
  providers that meet the criteria established in subparagraph (i) of this
  paragraph.
    (g) If another managed care provider, mental health special needs plan
  or  comprehensive  HIV special needs plan is available, participants may
  change such provider  or  plan  without  cause  within  thirty  days  of
  notification   of  enrollment  or  the  effective  date  of  enrollment,
  whichever is later with a managed care provider, mental  health  special
  needs  plan  or comprehensive HIV special needs plan by making a request
  of the local social services district except that such period  shall  be
  forty-five days for participants who have been assigned to a provider by
  the commissioner of health. However, after such thirty or forty-five day
  period,  whichever  is  applicable, a participant may be prohibited from
  changing managed care providers more frequently than once  every  twelve
  months,  as permitted by federal law except for good cause as determined
  by the commissioner of health through regulations.
    (h) If another medical services provider is available,  a  participant
  may  change  his  or her provider of medical services (including primary
  care  practitioners)  without  cause   within   thirty   days   of   the
  participant's  first  appointment  with  a  medical services provider by
  making a request of the managed care  provider,  mental  health  special
  needs  plan or comprehensive HIV special needs plan. However, after that
  thirty day period, no participant shall be permitted to  change  his  or
  her provider of medical services other than once every six months except
  for good cause as determined by the commissioner through regulations.
    (i)  A  managed  care  provider, mental health special needs plan, and
  comprehensive HIV special needs plan requesting  a  disenrollment  shall
  not  disenroll  a  participant  without  the prior approval of the local
  social services district in which the participant resides, provided that
  disenrollment from a mental health special needs plan must  comply  with
  the  standards  of  the  commissioner  of health and the commissioner of
  mental health. A managed care provider, mental health special needs plan
  or comprehensive HIV special needs plan shall not request  disenrollment
  of  a  participant  based  on  any  diagnosis,  condition,  or perceived
  diagnosis or condition, or a participant's efforts to  exercise  his  or
  her  rights  under a grievance process, provided however, that a managed
  care provider may, where medically appropriate,  request  permission  to
  refer   participants  to  a  mental  health  special  needs  plan  or  a
  comprehensive  HIV  special  needs  plan  after  consulting  with   such
  participant  and  upon  obtaining  his/her consent to such referral and,
  provided further that a mental health  special  needs  plan  may,  where
  clinically  appropriate, disenroll individuals who no longer require the
  level of services provided by a mental health special needs plan.
    (j) A managed care provider shall  be  responsible  for  providing  or
  arranging  for medical assistance services and assisting participants in
  the prudent selection of such services, including but not limited to:
    (1) management of the medical and health care needs of participants by
  the participant's designated primary  care  practitioners  or  group  of
  primary  care  practitioners  to assure that all services provided under
  the managed care program and which are found to be  necessary  are  made
  available in a timely manner, in accordance with prevailing standards of
  professional medical practice and conduct; and
    (2)  use of appropriate patient assessment criteria to ensure that all
  participants are provided with appropriate services,  including  special
  care;

    (3)  implementation of procedures, consistent with the requirements of
  paragraph (c) of subdivision six of section forty-four hundred three  of
  the  public  health  law for managing the care of participants requiring
  special care which may include the use of special case managers  or  the
  designation  of  a  specialist  as  a  primary  care  practitioner  by a
  participant requiring special care on more than an incidental basis;
    (4) implementation of procedures, consistent with the requirements  of
  paragraph  (b) of subdivision six of section forty-four hundred three of
  the public health law  to  permit  the  use  of  standing  referrals  to
  specialists  and subspecialists for participants who require the care of
  such practitioners on a regular basis; and
    (5) referral, coordination, monitoring and follow-up  with  regard  to
  other  medical  services  providers  as  appropriate  for  diagnosis and
  treatment, or  direct  provision  of  some  or  all  medical  assistance
  services.
    (k)  A  managed  care provider shall establish appropriate utilization
  and referral requirements for physicians, hospitals, and  other  medical
  services   providers  including  emergency  room  visits  and  inpatient
  admissions.
    (l) A managed  care  provider  shall  be  responsible  for  developing
  appropriate  methods  of  managing  the health care and medical needs of
  homeless and other vulnerable participants to assure that all  necessary
  services  provided under the managed care program are made available and
  that all appropriate referrals and follow-up treatment are provided,  in
  a timely manner, in accordance with prevailing standards of professional
  medical practice and conduct.
    (m) A managed care provider shall provide 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, as medically appropriate.
    (n) A managed care provider shall  provide  or  arrange,  directly  or
  indirectly  (including  by  referral) for the provision of comprehensive
  prenatal care  services  to  all  pregnant  participants  including  all
  services  enumerated  in  subdivision one of section twenty-five hundred
  twenty-two of the public health law in accordance with standards adopted
  by the department of health pursuant to such section.
    (o) A managed care provider shall  provide  or  arrange,  directly  or
  indirectly,  (including  by  referral)  for  the  full  range of covered
  services to all participants, notwithstanding that such participants may
  be eligible to be enrolled in a comprehensive HIV special needs plan  or
  mental health special needs plan.
    (p)  A managed care provider, comprehensive HIV special needs plan and
  mental  health  special  needs  plan  shall  implement   procedures   to
  communicate   appropriately   with   participants  who  have  difficulty
  communicating  in  English  and  to   communicate   appropriately   with
  visually-impaired and hearing-impaired participants.
    (q)  A managed care provider, comprehensive HIV special needs plan and
  mental health special needs plan shall comply with applicable state  and
  federal  law  provisions  prohibiting  discrimination  on  the  basis of
  disability.
    (r) A managed care provider, comprehensive HIV special needs plan  and
  mental  health special needs plan shall provide services to participants
  pursuant to an order of a  court  of  competent  jurisdiction,  provided
  however,  that  such  services shall be within such provider's or plan's
  benefit package and are reimbursable under  title  xix  of  the  federal
  social security act.
    (s)  Managed  care  providers  shall  be  provided  with  the  date of
  recertification  for  medical  assistance  of  each  of  their  enrolled

  participants  in  conjunction  with  the  monthly enrollment information
  conveyed to managed care providers.
    (t)  Prospective  enrollees  shall  be  advised,  in written materials
  related to enrollment, to verify with  the  medical  services  providers
  they  prefer,  or  have an existing relationship with, that such medical
  services providers participate in the selected managed  care  provider's
  network and are available to serve the participant.
    5.  Managed  care  programs  shall be conducted in accordance with the
  requirements of this section and, to the extent  practicable,  encourage
  the  provision  of  comprehensive  medical  services,  pursuant  to this
  article.
    (a) The managed care  program  shall  provide  for  the  selection  of
  qualified  managed  care providers by the commissioner of health and, as
  appropriate, mental health special needs  plans  and  comprehensive  HIV
  special  needs  plans  to participate in the program, provided, however,
  that the commissioner of health may contract directly with comprehensive
  HIV special needs plans consistent with  standards  set  forth  in  this
  section,  and  assure  that  such  providers  are accessible taking into
  account the needs of  persons  with  disabilities  and  the  differences
  between  rural,  suburban, and urban settings, and in sufficient numbers
  to meet the health care needs of participants, and  shall  consider  the
  extent  to  which  major  public  hospitals  are  included  within  such
  providers' networks.
    (b) A proposal submitted by a managed care provider to participate  in
  the managed care program shall:
    (i)  designate  the  geographic area to be served by the provider, and
  estimate the number of eligible participants and actual participants  in
  such designated area;
    (ii)  include a network of health care providers in sufficient numbers
  and geographically accessible to service program participants;
    (iii) describe the procedures for marketing in the  program  location,
  including  the  designation  of  other  entities  which may perform such
  functions under contract with the organization;
    (iv) describe the  quality  assurance,  utilization  review  and  case
  management mechanisms to be implemented;
    (v)  demonstrate the applicant's ability to meet the data analysis and
  reporting requirements of the program;
    (vi) demonstrate financial feasibility of the program; and
    (vii) include such other information as the commissioner of health may
  deem appropriate.
    (c) The commissioner of health shall make a determination  whether  to
  approve, disapprove or recommend modification of the proposal.
    (d)  Notwithstanding  any  inconsistent  provision  of  this title and
  section  one  hundred  sixty-three  of  the  state  finance   law,   the
  commissioner  of  health or the local department of social services in a
  city with a population of over two million  may  contract  with  managed
  care providers approved under paragraph (b) of this subdivision, without
  a  competitive  bid or request for proposal process, to provide coverage
  for participants pursuant to this title.
    (e) Notwithstanding any  inconsistent  provision  of  this  title  and
  section  one  hundred  forty-three  of  the economic development law, no
  notice in the procurement opportunities newsletter shall be required for
  contracts awarded by the commissioner of health or the local  department
  of  social  services in a city with a population of over two million, to
  qualified managed care providers pursuant to this section.
    (f) The care and  services  described  in  subdivision  four  of  this
  section  will  be  furnished  by a managed care provider pursuant to the
  provisions  of  this  section  when  such  services  are  furnished   in

  accordance  with an agreement with the department of health or the local
  department of social services in a city with a population  of  over  two
  million, and meet applicable federal law and regulations.
    (g)  The  commissioner of health may delegate some or all of the tasks
  identified in this section to the local districts.
    (h) Any delegation pursuant to paragraph (g) of this subdivision shall
  be reflected in the contract between a managed  care  provider  and  the
  commissioner of health.
    6.  A  managed  care  provider,  mental  health  special needs plan or
  comprehensive HIV special needs plan provider shall not  engage  in  the
  following practices:
    (a)   use   deceptive  or  coercive  marketing  methods  to  encourage
  participants to enroll; or
    (b)  distribute  marketing  materials   to   recipients   of   medical
  assistance,  unless  such  materials  are  approved by the department of
  health and, as appropriate, the office of mental health.
    7. The department, the department of health or  other  agency  of  the
  state  as  appropriate shall provide technical assistance at the request
  of a social  services  district  for  the  purpose  of  development  and
  implementation  of  managed care programs pursuant to this section. Such
  assistance shall include but  need  not  be  limited  to  provision  and
  analysis  of data, design of managed care programs and plans, innovative
  payment  mechanisms,  and  ongoing  consultation.   In   addition,   the
  department  and  the department of health shall make available materials
  to social services districts for purposes of educating persons  eligible
  to receive medical assistance on how their care will be provided through
  managed care as required under paragraph (e) of subdivision five of this
  section.
    8.  (a)  The  commissioner  of  health shall institute a comprehensive
  quality assurance  system  for  managed  care  providers  that  includes
  performance and outcome-based quality standards for managed care.
    (b)  Every  managed  care  provider  shall  implement internal quality
  assurance systems adequate to identify,  evaluate  and  remedy  problems
  relating  to  access,  continuity  and quality of care, utilization, and
  cost of services, provided, however, that the commissioner  shall  waive
  the   implementation   of  internal  quality  assurance  systems,  where
  appropriate, for managed care providers described in  subparagraph  (ii)
  of  paragraph  (b)  of  subdivision  one  of this section. Such internal
  quality  assurance  systems  shall  conform  to  the  internal   quality
  assurance  requirements  imposed  on  health  maintenance  organizations
  pursuant to the public health law and regulations and shall provide for:
    (i) the designation of an organizational  unit  or  units  to  perform
  continuous monitoring of health care delivery;
    (ii)  the utilization of epidemiological data, chart reviews, patterns
  of care, patient surveys, and spot checks;
    (iii) reports to medical services providers assessing  timeliness  and
  quality of care;
    (iv)  the  identification,  evaluation  and  remediation  of  problems
  relating to access, continuity and quality of care; and
    (v)  a  process  for  credentialing   and   recredentialing   licensed
  providers.
    (c)  The  department  of  health, in consultation with the responsible
  special care agencies, shall  contract  with  one  or  more  independent
  quality  assurance  organizations to monitor and evaluate the quality of
  care and services furnished by managed care providers.  To  select  such
  organization  or  organizations,  the  department  of health shall issue
  requests for proposals (RFP),  shall  evaluate  proposals  submitted  in
  response  to such RFP, and pursuant to such RFP, shall award one or more

  contracts to one or more qualified and  responsive  organizations.  Such
  quality assurance organizations shall evaluate and review the quality of
  care  delivered  by  each  managed  care provider, on at least an annual
  basis.  Such  review  and  evaluation  shall include compliance with the
  performance and  outcome-based  quality  standards  promulgated  by  the
  commissioner of health.
    (d)  Every  managed  care  provider  shall  collect  and submit to the
  department of  health,  in  a  standardized  format  prescribed  by  the
  department  of  health,  patient specific medical information, including
  encounter data, maintained by such provider for the purposes of  quality
  assurance  and  oversight.  Any  information or encounter data collected
  pursuant to this paragraph,  however,  shall  be  kept  confidential  in
  accordance  with section forty-four hundred eight-a of the public health
  law and section 33.13 of the mental hygiene law and any other applicable
  state or federal law.
    (e) Information collected and submitted to the department of health by
  the independent quality assurance organization or managed care  provider
  pursuant  to  this  subdivision  shall  be made available to the public,
  subject to any other limitations  of  federal  or  state  law  regarding
  disclosure thereof to third parties.
    (f)  Every  managed  care  provider  shall  ensure  that  the provider
  maintains a network of  health  care  providers  adequate  to  meet  the
  comprehensive  health  needs  of  its  participants  and  to  provide an
  appropriate choice of providers sufficient to provide  the  services  to
  its participants by determining that:
    (i)  there  are  a  sufficient  number  of  geographically  accessible
  participating providers;
    (ii) there are opportunities to select from  at  least  three  primary
  care providers; and
    (iii)  there  are  sufficient  providers  in  each  area  of specialty
  practice to meet the needs of the enrolled population.
    (g) The commissioner of health shall  establish  standards  to  ensure
  that  managed  care providers have sufficient capacity to meet the needs
  of their enrollees, which shall  include  patient  to  provider  ratios,
  travel   and  distance  standards  and  appropriate  waiting  times  for
  appointments.
    9. Managed care providers shall inform participants of such provider's
  grievance procedure and utilization review procedures required  pursuant
  to  sections  forty-four  hundred  eight-c and forty-nine hundred of the
  public health law. A managed care  provider  or  local  social  services
  district,  as appropriate, shall provide notice to participants of their
  respective rights to a fair hearing and  aid  continuing  in  accordance
  with applicable state and federal law.
    10.  The  commissioner  of  health  shall  be  authorized to establish
  requirements regarding provision and reimbursement of emergency care.
    10-a. For managed care providers with negotiated rates of payment  for
  inpatient  hospital  services  under contracts in effect on April first,
  two thousand eight, that  have  a  payment  rate  methodology  for  such
  inpatient  hospital  services  that  utilizes  rates  calculated  by the
  department of health pursuant to paragraph (a) or (a-2)  of  subdivision
  one  of  section  twenty-eight  hundred  seven-c  for patients under the
  medical assistance program, such  rate  shall  not  include  adjustments
  pursuant  to  subdivision  thirty-three  of section twenty-eight hundred
  seven-c of the public health law for contract periods prior  to  January
  first, two thousand ten.
    11. Notwithstanding section three hundred sixty-six of this chapter or
  any  other  inconsistent  provision  of law, participants in the managed
  care program under this section who  have  lost  their  eligibility  for

  medical assistance before the end of a six month period beginning on the
  date  of  the  participant's  initial  selection  of  or assignment to a
  managed  care  provider  shall  have  their  eligibility   for   medical
  assistance  continued  until the end of the six month enrollment period,
  but only with respect to family planning services provided  pursuant  to
  subparagraph  (iii) of paragraph (a) of subdivision four of this section
  and any services provided to the individual under the direction  of  the
  managed  care provider. Provided further, however, a pregnant woman with
  an income in excess of the medically needy income  level  set  forth  in
  section  three  hundred  sixty-six  of  this title, who was eligible for
  medical assistance solely as  a  result  of  paragraph  (m)  or  (o)  of
  subdivision  four  of  such  section,  shall continue to be eligible for
  medical assistance benefits only through the end of the month  in  which
  the  sixtieth  day  following the end of her pregnancy occurs except for
  eligibility  for  Federal  Title  X  services  which  are  eligible  for
  reimbursement  by  the  federal  government  at a rate of ninety percent
  which  shall  continue  for  twenty-four  months  therefrom;   provided,
  however,  that  such  ninety percent limitation shall not apply to those
  services identified by the commissioner as services, including treatment
  for sexually transmitted diseases, generally performed as part of or  as
  a follow-up to a service eligible for such ninety percent reimbursement;
  and provided further, however, that nothing in this subdivision shall be
  deemed  to affect payment for such Title X services if federal financial
  participation is not available for such care, services and supplies.
    12. The commissioner, by regulation, shall provide that a  participant
  may withdraw from participation in a managed care program upon a showing
  of good cause.
    13.  (a)  Notwithstanding any inconsistent provisions of this section,
  participation in a managed care program will not diminish a  recipient's
  medical  assistance  eligibility  or  the  scope  of  available  medical
  services to which he or she is entitled. Once a program  is  implemented
  by  or  in  the  district  in  accordance  with  this  section,  medical
  assistance for persons who require such assistance, who are eligible for
  or in receipt of such assistance in the district and who are covered  by
  the  program  shall  be limited to payment of the cost of care, services
  and supplies covered by the managed care program, only  when  furnished,
  prescribed,  ordered  or  approved  by  a  managed care provider, mental
  health special needs plan or comprehensive HIV special  needs  plan  and
  otherwise  under  the  program,  together  with  the  costs of medically
  necessary medical and remedial care, services or supplies which are  not
  available  to  participants under the program, but which would otherwise
  be available to such persons under this title and the regulations of the
  department provided, however, that the program may contain provision for
  payment to be made for non-emergent care furnished in hospital emergency
  rooms consistent with subdivision ten of this section.
    (b) Notwithstanding any inconsistent provision  of  law,  payment  for
  claims  for  services  as specified in paragraph (a) of this subdivision
  furnished to eligible persons under this title, who are  enrolled  in  a
  managed  care program pursuant to this section and section three hundred
  sixty-four-f of this title or other comprehensive health services plans,
  shall not be made when such services are the contractual  responsibility
  of  a managed care provider but are provided by another medical services
  provider contrary to the managed care plan.
    14. The commissioner of health is authorized and directed, subject  to
  the  approval  of the director of the division of budget, to make grants
  to social services districts to aid in the planning and  development  of
  managed  care  programs.  The  total  amount  expended  pursuant to this

  section shall not exceed the amount appropriated for  such  purposes  in
  any fiscal year.
    15. The managed medical care demonstration program advisory council is
  abolished.
    16.  Any  waiver  application  to the federal department of health and
  human services pursuant to this  article  and  any  amendments  to  such
  application shall be a public document.
    17.  The provisions of this section regarding participation of persons
  receiving family assistance and supplemental security income in  managed
  care  programs  shall be effective if, and as long as, federal financial
  participation  is  available  for  expenditures  for  services  provided
  pursuant to this section.
    18.  (a) The department of health may, where not inconsistent with the
  rate setting authority of other state agencies and subject  to  approval
  of  the  director  of  the division of the budget, develop reimbursement
  methodologies and fee schedules for determining the amount of payment to
  be made to managed care providers under the managed care  program.  Such
  reimbursement methodologies and fee schedules may include provisions for
  payment of managed care fees and capitation arrangements.
    (b)  The  department  of  health  in  consultation  with organizations
  representing managed care providers shall select an independent  actuary
  to  review  any such reimbursement rates. Such independent actuary shall
  review  and  make  recommendations  concerning   appropriate   actuarial
  assumptions  relevant  to  the  establishment of rates including but not
  limited to the adequacy of the rates in relation to the population to be
  served adjusted for case mix, the  scope  of  services  the  plans  must
  provide,  the  utilization  of  services  and  the  network of providers
  necessary to meet state standards. The independent actuary shall issue a
  report  no  later   than   December   thirty-first,   nineteen   hundred
  ninety-eight  and  annually thereafter. Such report shall be provided to
  the governor, the temporary president and the  minority  leader  of  the
  senate  and  the  speaker  and  the minority leader of the assembly. The
  department of health shall  assess  managed  care  providers  under  the
  managed  care  program on a per enrollee basis to cover the cost of such
  report.
    19.  (a)  The  commissioner  of  health,  in  consultation  with   the
  commissioner,  shall  promulgate  such  regulations  as are necessary to
  implement the provisions of this section  provided,  however,  that  the
  provisions of this subdivision shall not limit specific actions taken by
  the  department  of  health or the department in order to ensure federal
  financial participation.
    20. Upon a determination that a participant appears to be suitable for
  admission to a comprehensive HIV special needs plan or a  mental  health
  special needs plan, a managed care provider shall inform the participant
  of the availability of such plans, where available and appropriate.
    21.  (a)  An  amount  equal to seven million dollars together with any
  matching federal and local government funds shall be made available  for
  rate  adjustments  for managed care providers whose rates were set under
  the competitive bidding  process.  Such  adjustment  shall  be  made  in
  accordance with this paragraph.
    (i)  Such  amount shall be allocated by the department of health among
  the managed care rating regions based on  each  region's  percentage  of
  statewide Medicaid managed care enrollment as of January first, nineteen
  hundred ninety-seven excluding from such calculation enrollment in local
  social  services  districts  that did not participate in the competitive
  bidding process.
    (ii) From among the funds allocated in a managed care  rating  region,
  the department of health shall adjust the existing rates paid to managed

  care providers for each premium group for the period from January first,
  nineteen  hundred  ninety-seven  through  March  thirty-first,  nineteen
  hundred ninety-eight in a manner that raises the rates  of  all  managed
  care  providers  in  the region to the highest uniform percentage of the
  upper payment limit possible based on  the  funds  available;  provided,
  however,  that  no  managed  care  provider's rate for any premium group
  shall be reduced as a result of such  adjustment.  For  the  purpose  of
  calculating  appropriate  rate  increases  under  this subparagraph, the
  department of health shall assume that, for the  entire  period  between
  January  first,  nineteen  hundred  ninety-seven and March thirty-first,
  nineteen hundred ninety-eight, enrollment in each premium group shall be
  equal to enrollment in the premium group  as  of  July  first,  nineteen
  hundred ninety-seven.
    (b)  In  addition  to the increases made available in paragraph (a) of
  this subdivision  for  the  period  beginning  January  first,  nineteen
  hundred   ninety-seven  through  March  thirty-first,  nineteen  hundred
  ninety-eight, an additional  ten  million  dollars,  together  with  any
  matching federal and local government funds, shall be added to provide a
  uniform  percentage  increase,  based  on  July  first, nineteen hundred
  ninety-seven enrollment to the  existing  rates  paid  for  all  premium
  groups  to  all  managed  care  providers  whose  rates  were set by the
  competitive bidding process.
    (c) In addition to the increases made available in paragraphs (a)  and
  (b) of this subdivision for the period beginning January first, nineteen
  hundred   ninety-seven  through  March  thirty-first,  nineteen  hundred
  ninety-eight, an  additional  amount  equal  to  three  million  dollars
  together  with any matching federal and local government funds, shall be
  made available to be added to the rates of  health  plans  operating  in
  geographic  areas  where capacity is insufficient to allow attainment of
  enrollment goals consistent with the federal 1115 waiver  known  as  the
  Partnership  Plan.  Such  amount  shall  be  distributed  subject  to  a
  demonstration to the  commissioner's  satisfaction  that  the  plan  has
  executed  a  contract  amendment providing for an increase in enrollment
  proportional to the size  of  the  plan  and  the  remaining  unenrolled
  population  in  the  county. In evaluating the plan's demonstration, the
  commissioner shall consider the degree to which the plan  has  increased
  the  number of primary or specialty care practitioners or diagnostic and
  treatment centers in its network or whether the additional rate increase
  would permit the plan to generate greater enrollments  while  continuing
  to  meet  the  financial  requirements  of  the public health law or the
  insurance  law  whichever  is  applicable  and  regulations  promulgated
  pursuant thereto.
    Any  amount  identified  in  this  paragraph  remaining uncommitted by
  December  thirty-first,   nineteen   hundred   ninety-seven   shall   be
  distributed   in   a  manner  consistent  with  paragraph  (b)  of  this
  subdivision.
    (d) A plan shall be eligible for payments pursuant to paragraphs  (a),
  (b)  and  (c)  of  this  subdivision  for such periods as the plan has a
  contract with one or more social services districts;  provided,  however
  that  the  plan has a contract, or has made a good faith effort to enter
  into a contract, in that district effective through March  thirty-first,
  nineteen hundred ninety-eight.
    (e)  For  the  period  from April first, nineteen hundred ninety-eight
  through March thirty-first, nineteen hundred  ninety-nine,  the  premium
  rates  paid  by  the  department of health to all managed care providers
  whose rates were set under the  competitive  bidding  process  shall  be
  equal  to (i) the managed care provider's rate as of March thirty-first,
  nineteen hundred ninety-eight increased by a uniform trend factor; plus,

  (ii) four million dollars together with any matching federal  and  local
  government  funds  to  be added as a uniform percentage increase to such
  provider's rate as of March thirty-first, nineteen hundred ninety-eight,
  based  on  enrollment  in  the premium group as of April first, nineteen
  hundred ninety-eight.
    (f) For the period from April  first,  nineteen  hundred  ninety-eight
  through  March thirty-first, nineteen hundred ninety-nine, an additional
  amount equal to four million dollars together with any matching  federal
  and  local  government  funds,  shall be made available for managed care
  rate adjustments consistent with the criteria set forth in paragraph (c)
  of this subdivision. Any amount identified in this  paragraph  remaining
  uncommitted  by  December  thirty-first,  nineteen  hundred ninety-eight
  shall be added as a uniform percentage increase  to  the  rates  of  all
  managed  care  providers eligible for an increase under paragraph (e) of
  this subdivision.
    22. Chemung county demonstration project. (a)  The  legislature  finds
  that  the particular circumstances of Chemung county warrant authorizing
  this demonstration project, including the rural nature  of  the  county,
  the  absence  of  a comprehensive medicaid managed care provider serving
  the area at this time, patient care needs, and  aspects  of  the  health
  care provider base.
    (b)  within  all  or  part  of  Chemung  county  (referred  to in this
  subdivision as "the catchment area"), the department of health  and  the
  Chemung county department of social services are authorized to conduct a
  Medicaid  research  and  demonstration  project  (referred  to  in  this
  subdivision as the "demonstration project") for the purpose  of  testing
  the  use  of  innovative  administrative  techniques,  new reimbursement
  methods, and management of care models, so as to promote more  efficient
  use  of  health  resources,  a  healthier  population and containment of
  Medicaid program costs.
    (c)  As  part  of  the  demonstration  project,  the  Chemung   county
  department  of  social services is authorized to contract with a managed
  care provider for the purposes of, without  limitation,  developing  and
  managing a provider of care network, establishing provider payment rates
  and  fees, paying provider claims, providing care management services to
  project participants, and managing the utilization of project services.
    (d) The demonstration project shall be consistent with the  provisions
  of this section, except:
    (i) The department may waive any rules or regulations, as necessary to
  implement and consistent with this subdivision.
    (ii) The demonstration project shall not be subject to:
    (A) paragraph (b) of subdivision four of this section;
    (B)  subparagraphs (i), (ii), (iii) (v) and (viii) of paragraph (e) of
  subdivision four of this section;
    (C) paragraph (f) of subdivision four of this section;
    (D) paragraph (g) of subdivision four of this section;
    (E) subdivision five of this section; provided that in  approving  the
  demonstration  project  or  modifications  to  it,  the department shall
  consider the criteria in that subdivision;
    (F) sections two hundred seventy-two and two hundred seventy-three  of
  the public health law;
    (G) section three hundred sixty-five-i of this title.
    (iii) Notwithstanding subdivision three of this section, participation
  in the project shall be mandatory for all or any specified categories of
  persons  eligible  for  services  under  this title for whom the Chemung
  county department of social services has fiscal responsibility  pursuant
  to  section three hundred sixty-five of this title and who reside within
  the  demonstration  project  catchment  area,  as  determined   by   the

  commissioner of health; provided, however, that eligible persons who are
  also  beneficiaries under title XVIII of the federal social security act
  and persons who reside in residential health care facilities  shall  not
  be eligible to participate in the project.
    (e)(i)  Persons who are enrolled in or apply for medical assistance on
  or before the date the demonstration project takes effect shall  receive
  sixty  days  written  notice prior to participating in the demonstration
  project, including an explanation of the demonstration project  and  the
  participant's rights and responsibilities. Persons who apply for medical
  assistance  thereafter shall receive such notice at the time of applying
  for medical assistance.
    (ii) The demonstration project  shall  provide  adequate  services  to
  overcome language barriers for participants.
    (iii) Participants in the demonstration project whose participation in
  a   managed   care  program  would  not  otherwise  be  mandatory  under
  subdivision three of this section, who,  at  the  time  they  enter  the
  demonstration  project,  have  an  established relationship with and are
  receiving services from one or more medical services providers that  are
  not  included  in  the  demonstration  project's  provider  network  (an
  "out-of-network provider"), shall be permitted to  continue  to  receive
  services  from  such  providers  until  their  course  of  treatment  is
  complete, or in the case of a pregnant woman,  while  pregnant  and  for
  sixty  days  post-partum. Out-of-network providers that provide services
  pursuant to this subparagraph shall be subject to the utilization review
  and care management procedures prescribed by the managed  care  provider
  and shall be reimbursed at the rate that would be paid to such providers
  by the medical assistance program on a fee for service basis pursuant to
  this title, and shall accept such reimbursement as payment in full.
    (f)  The  provisions  of  this  subdivision shall not apply unless all
  necessary approvals under federal law and regulation have been  obtained
  to  receive  federal financial participation in the costs of health care
  services provided pursuant to this subdivision.
    (g) The commissioner of health is authorized to submit  amendments  to
  the  state  plan  for  medical  assistance  and/or  submit  one  or more
  applications for waivers of the federal social security act  as  may  be
  necessary  to  obtain  the federal approvals necessary to implement this
  subdivision.
    (h) The demonstration project shall terminate five years after  it  is
  approved by the department and all necessary approvals under federal law
  and  regulations  under  paragraph  (f)  of  this  subdivision have been
  obtained, unless terminated sooner by the Chemung county  department  of
  social services.
    23.  (a)  As  a  means of protecting the health, safety and welfare of
  recipients, in addition to any other sanctions that may be imposed,  the
  commissioner  shall  appoint  temporary  management  of  a  managed care
  provider upon determining that the managed care provider has  repeatedly
  failed to meet the substantive requirements of sections 1903(m) and 1932
  of  the federal Social Security Act and regulations. A hearing shall not
  be required prior to the appointment of temporary management.
    (b) The commissioner  and/or  his  or  her  designees,  which  may  be
  individuals  within the department or other individuals or entities with
  appropriate knowledge and experience,  may  be  appointed  as  temporary
  management. The commissioner may appoint the superintendent of insurance
  and/or  his or her designees as temporary management of any managed care
  provider  which  is  subject  to  rehabilitation  pursuant  to   article
  seventy-four of the insurance law.
    (c)   The  responsibilities  of  temporary  management  shall  include
  oversight of the managed care provider for the purpose of  removing  the

  causes and conditions which led to the determination requiring temporary
  management,  the  imposition  of  improvements to remedy violations and,
  where necessary, the orderly reorganization, termination or  liquidation
  of the managed care provider.
    (d)  Temporary  management  may  hire  and  fire managed care provider
  personnel and expend managed care provider funds  in  carrying  out  the
  responsibilities imposed pursuant to this subdivision.
    (e)  The  commissioner,  in  consultation with the superintendent with
  respect to any managed care provider subject to rehabilitation  pursuant
  to  article  seventy-four  of  the  insurance law, may make available to
  temporary management for the benefit of a managed care provider for  the
  maintenance  of required reserves and deposits monies from such funds as
  are appropriated for such purpose.
    (f)  The  commissioner  is  authorized  to  establish  in   regulation
  provisions  for the payment of fees and expenses from funds appropriated
  for such purpose for non-governmental individuals and entities appointed
  as temporary management pursuant to this subdivision.
    (g) The commissioner may not terminate temporary management  prior  to
  his  or  her  determination  that  the  managed  care  provider  has the
  capability to ensure that the sanctioned behavior will not recur.
    (h) During any period of temporary management individuals enrolled  in
  the  managed  care  provider  being managed may disenroll without cause.
  Upon reaching a determination that requires temporary  management  of  a
  managed  care  provider,  the  commissioner  shall  notify all recipient
  enrollees of such provider that they may  terminate  enrollment  without
  cause during the period of temporary management.
    (i)  The  commissioner  may  adopt  and amend rules and regulations to
  effectuate the purposes and provisions of this subdivision.
    24. Claims submitted to  a  managed  care  provider  for  payment  for
  medical  care,  services,  or  supplies  furnished  by an out-of-network
  medical services provider must be submitted within fifteen months of the
  date the medical care,  services,  or  supplies  were  furnished  to  an
  eligible  person  to  be  valid and enforceable against the managed care
  provider. This deadline for claims submission shall not apply where  the
  claims  submission  is  warranted to address findings or recommendations
  identified in a state or federal audit  except  where  such  audit  also
  indicates that an inappropriate provider payment was solely the fault of
  the out-of-network health care provider.
    * NB Repealed March 31, 2012