Section 365-G. Utilization thresholds for certain care, services and supplies

1. The department may implement  a  system  for  utilization
  controls,  pursuant  to  this section, for persons eligible for benefits
  under this title, including annual service  limitations  or  utilization
  thresholds  above  which the department may not pay for additional care,
  services or supplies, unless such care, services or supplies  have  been
  previously  approved  by the department or unless such care, services or
  supplies were provided pursuant to subdivision three, four  or  five  of
  this section.
    2.  The  department  may  implement utilization thresholds by provider
  service type, medical procedure and patient, in  consultation  with  the
  state  department  of  mental hygiene, other appropriate state agencies,
  and other stakeholders including provider and consumer  representatives.
  In  developing  utilization  thresholds  the  department  shall consider
  historical recipient utilization  patterns,  patient-specific  diagnoses
  and  burdens of illness, and the anticipated recipient needs in order to
  maintain good health.
    3. If the department implements a utilization threshold program, at  a
  minimum, such program must include:
    (a)  prior  notice  to  the  recipients  affected  by  the utilization
  threshold program, which notice must describe:
    (i) the nature and extent of the utilization program,  the  procedures
  for  obtaining an exemption from or increase in a utilization threshold,
  the recipients' fair hearing rights, and referral  to  an  informational
  toll-free hot-line operated by the department; and
    (ii)  alternatives  to  the  utilization  threshold  program  such  as
  enrollment in managed care programs and referral  to  preferred  primary
  care  providers  designated  pursuant  to  subdivision twelve of section
  twenty-eight hundred seven of the public health law; and
    (b) procedures for:
    (i) requesting an increase in amount of authorized services;
    (ii) extending amount of authorized services when an  application  for
  an increase in the amount of authorized services is pending;
    (iii)  requesting  an  exemption  from  utilization  thresholds, which
  procedure must:
    (A) allow the recipient, or a provider on behalf of  a  recipient,  to
  apply  to  the  department for an exemption from one or more utilization
  thresholds  based  upon  documentation  of  the  medical  necessity  for
  services in excess of the threshold,
    (B)  provided for exemptions consistent with department guidelines for
  approving exemptions,  which  guidelines  must  be  established  by  the
  department  in  consultation  with  the  department  of  health  and, as
  appropriate, with the department of mental hygiene, and consistent  with
  the  current  regulations  of  the  office  of  mental  health governing
  outpatient treatment.
    (C) provide for an exemption when medical and  clinical  documentation
  substantiates  a  condition  of  a chronic medical nature which requires
  ongoing and frequent use of medical care, services or supplies such that
  an increase in the amount of authorized services is  not  sufficient  to
  meet the medical needs of the recipient;
    (iv)  reimbursing  a  provider, regardless of the recipient's previous
  use of services, when care, services or supplies are provided in a  case
  of  urgent  medical need, as defined by the department, or when provided
  on an emergency basis, as defined by the department;
    (v) notifying recipients of and referring  recipients  to  appropriate
  and  accessible  managed  care  programs  and  to preferred primary care
  providers  designated  pursuant  to  subdivision   twelve   of   section
  twenty-eight  hundred  seven  of  the public health law at the same time

  such recipients are notified that they are nearing or have  reached  the
  utilization threshold for each specific provider type;
    (vi)  notifying  recipients  at  the  same  time  such  recipients are
  notified that  they  have  received  an  exemption  from  a  utilization
  threshold,  an  increase  in  the amount of authorized services, or that
  they are nearing or have reached their utilization threshold,  of  their
  possible  eligibility for federal disability benefits and directing such
  recipients  to  their  social  services  district  for  information  and
  assistance in securing such benefits;
    (vii)   cooperating   with   social   services  districts  in  sharing
  information  collected  and  developed  by  the   department   regarding
  recipients' medical records; and
    (viii)  assuring  that  no  request  for  an  increase  in  amount  of
  authorized services or for  an  exemption  from  utilization  thresholds
  shall  be  denied  unless the request is first reviewed by a health care
  professional possessing appropriate clinical expertise.
    4. The utilization thresholds established  pursuant  to  this  section
  shall  not  apply  to  mental retardation and developmental disabilities
  services provided in clinics certified under article twenty-eight of the
  public health law, or article twenty-two or article  thirty-one  of  the
  mental hygiene law.
    5.  Utilization  thresholds established pursuant to this section shall
  not apply to services, even though  such  services  might  otherwise  be
  subject to utilization thresholds, when provided as follows:
    (a) through a managed care program;
    (b) subject to prior approval or prior authorization;
    (c) as family planning services;
    (d) as methadone maintenance services;
    (e) on  a  fee-for-services  basis to in-patients in general hospitals
  certified under article twenty-eight of the public health law or article
  thirty-one of  the  mental  hygiene  law  and  residential  health  care
  facilities, with the exception of podiatrists' services;
    * (f) for hemodialysis;
    * NB Effective until July 1, 2011
    * (f) for hemodialysis; or
    * NB Effective July 1, 2011
    * (g) through  or  by  referral from a preferred primary care provider
  designated  pursuant  to  subdivision  twelve  of  section  twenty-eight
  hundred seven of the public health law;
    * NB Effective until July 1, 2011
    * (g) through  or  by  referral from a preferred primary care provider
  designated  pursuant  to  subdivision  twelve  of  section  twenty-eight
  hundred seven of the public health law.
    * NB Effective July 1, 2011
    * (h) pursuant to a court order; or
    * NB Repealed July 1, 2011
    * (i)  as  a  condition  of  eligibility for any other public program,
  including but not limited to public assistance.
    * NB Repealed July 1, 2011
    6. The  department  shall  consult  with  representatives  of  medical
  assistance providers, social services districts, voluntary organizations
  that  represent  or  advocate  on behalf of recipients, the managed care
  advisory  council  and  other  state  agencies  regarding  the   ongoing
  operation of a utilization threshold system.
    7.  On  or  before  February  first,  nineteen hundred ninety-two, the
  commissioner shall submit to the governor, the  temporary  president  of
  the  senate  and  the  speaker  of  the  assembly a report detailing the
  implementation of the utilization threshold program and  evaluating  the

  results  of  establishing  utilization  thresholds.  Such  report  shall
  include, but need not be limited to, a description  of  the  program  as
  implemented;  the  number of requests for increases in service above the
  threshold  amounts  by  provider  and  type  of  service;  the number of
  extensions granted;  the  number  of  claims  that  were  submitted  for
  emergency  care  or urgent care above the threshold level; the number of
  recipients referred to managed care; an estimate of the  fiscal  savings
  to   the  medical  assistance  program  as  a  result  of  the  program;
  recommendations for medical condition that  may  be  more  appropriately
  served  through managed care programs; and the costs of implementing the
  program.