Title: Section 98-1.13 - Assurance of access to care

98-1.13 Assurance of access to care. (a) All covered services must be directly provided or arranged for within the approved provider network pursuant to written contracts developed and maintained in a form and manner prescribed by the commissioner, except that when services are unavailable within the provider network, such services must be arranged for outside of the approved provider network. An MCO shall establish a process for the resolution of requests for medically necessary services to be provided by out-of-network providers when such services are not available in network. Such process shall require the approval of the commissioner prior to implementation and shall thereupon be included in the member handbook. Emergency services do not require prior authorization; no MCO or utilization review agent may require enrollees to obtain prior authorization for the provision of such services.
(b) The limitation in subdivision (a) of this Subpart, and other limitations imposed on accessing the entire approved network, must be clearly transmitted to eligible persons and enrollees via marketing materials, member handbooks and subscriber contracts.

(c)(i) Prior approval of the Commissioner is required for assignment of an IPA or institutional network provider contract, or of a medical group provider contract that serves five percent or more of the enrolled population in a county.

(ii) A minimum of 45 days prior written notice to the commissioner is required for termination or non-renewal of an IPA or institutional network provider contract, or of a medical group provider contract that serves five percent or more of the enrolled population in a county or when the termination or non-renewal of the medical group provider will leave fewer than two participating providers of that type within the county. The notice shall include an impact analysis of the termination or non-renewal with regard to enrollee access to care.

(iii) All provider contracts assigned by an MCO or an IPA prior to, and which remain in effect following, the effective date hereof shall be amended within one year of such effective date or upon renewal, whichever first occurs, to achieve compliance with the provisions of this subpart and guidelines for provider and IPA contracts established by the commissioner.

(d) An MCO which provides primary care services shall make available to each enrollee a primary care practitioner to supervise and coordinate the health care of the enrollee. In the case of an HIV SNP, the primary care practitioners for enrollees with HIV infection must meet HIV specialist requirements as defined by the commissioner; the qualifications of HIV specialist primary care practioners shall be reassessed annually to assure the requirements for HIV specialist status are met. The HIV SNP member-to-primary care practitioner ratios shall be developed to reflect HIV SNP patient caseload characteristics as prescribed by the commissioner. When required by federal and/or state law or regulation, an enrollee of an MCO who is dissatisfied with the assigned or selected primary care practitioner shall be allowed to select another. However, the MCO may impose a reasonable waiting period to accomplish this transfer. Waiting times for enrollees eligible for benefits under title XIX shall be consistent with section 364-j of the Social Services Law.
(e) The HIV SNP shall ensure all enrollees access to a full continuum of HIV-specific care, treatment and prevention through:

(1) access to the services of facility and community based case managers with expertise in prevention and care needs of persons with HIV infection;

(2) access to designated AIDS center hospitals or other hospitals with proven experience in HIV care and treatment and to community based HIV prevention and health care providers, including community health centers and, where geographically accessible, co-located substance abuse and HIV primary care programs;

(3) access to health and social services providers that support members’ ability to sustain wellness and to adhere to treatment regimens;

(4) development and implementation of written agreements with community based social services providers to facilitate enrollee access to the full continuum of services needed by HIV-infected individuals, including access to care for vulnerable populations, such as those who are homeless, substance users or others; and

(5) mechanisms for monitoring referrals to care, treatment and supportive services and for documenting the outcome of the referral process for enrollees referred to organizations with which the HIV SNP is affiliated through a linkage agreement or memorandum of understanding.

(f) The MLTCP shall assure that all covered services are available and accessible by:

(1) establishing standards for timeliness of access to care and member services and frequent and consistent monitoring of the extent to which it meets such standards;

(2) implementing a process for selection and retention of network providers; and

(3) making care management and health care services available 24 hours a day, seven days a week.

(g) The MLTCP shall promote continuity of care and integration of services through:

(1) designation of a health care professional(s) responsible for care management. Services provided or arranged to address the care needs of such enrollee shall be in accordance with a current plan of care developed in consultation with the enrollee;

(2) coordination of covered health and long term care services with non-covered services and other community resources; and

(3) systematic and timely communication of clinical information among providers and maintenance of a care management record. Such records, which shall be retained for six years after the date of service rendered to enrollees, shall include but shall not be limited to:

(i) assessments and reassessments;

(ii) a plan of care which identifies health care goals of enrollees and covered services to be provided;

(iii) medical orders, as applicable;

(iv) documentation of non-covered services arranged and coordinated by the plan;

(v) advance directives;

(vi) signed enrollment agreement and disenrollment agreement; and

(vii) contacts with enrollees and their representatives, providers of covered and non-covered services, physicians, local social service districts and other agencies or facilities with whom the plan coordinates services.

(h) The MCO, or the primary care practitioner on behalf of the MCO, shall be responsible for the management of care for enrollees, including the identification and selection of an appropriate provider of care in each individual instance where services are determined to be necessary for the enrollee. An MCO shall provide, or make arrangements for the provision of the full range of comprehensive health services as defined in subdivision (g) of section 98-1.2 and as covered in the approved benefit package to enrollees. MCOs shall provide such comprehensive health services without exclusion of any appropriately registered, certified or licensed type of provider as a class from participation in such MCO.
(i) When an enrollee is referred by an MCO or by an MCO primary care practitioner or MCO provider authorized by the MCO to make such referrals to a participating or nonparticipating specialist for services included in the enrollee contract with such MCO, the enrollee shall incur no financial liability other than required co-payments.
(j) An MCO shall have a written procedure describing coverage for emergency health services received by an enrollee outside of the MCO's service area. The MCO coverage for emergency health services shall be consistent with article 49 of the Public Health Law and, in the case of an entity providing services to Medicare beneficiaries, consistent with federal law and regulation, and clearly described in both the enrollee contract and the enrollee handbook.
(k) Medical offices and premises not subject to the jurisdiction of article 28 of the Public Health Law, in which primary ambulatory care services are provided to MCO enrollees, shall conform to professional and generally accepted standards of medical practice.
(l) The MCO shall establish procedures to obtain consent from each enrollee for release of such enrollee's medical records to ensure that it has access to the medical records of enrollees upon request for review by the MCO and the department for the purposes authorized by law. This shall be assured through an explicit provision in the contracts between the MCO and providers, the MCO and an IPA and providers.

(m) MCOs shall require that network providers comply with all HIV confidentiality requirements pursuant to title 27-F and Section 2784 of the Public Health Law, through express provision in contracts with providers and express reference in provider manuals. An HIV SNP shall establish procedures for assuring the confidentiality of medical information of all enrolled HIV-infected individuals, including mechanisms to address breaches of confidentiality and a training program for all HIV SNP employees regarding confidentiality and disclosure of HIV-related information.

(n) Utilization review program standards for retrospective review of a pre-authorized treatment, service, or procedure. An MCO may reverse a pre-authorized treatment, service or procedure on retrospective review pursuant to section 4905(5) of the Public Health Law only when:

(1) the relevant medical information presented to the MCO or utilization review agent upon retrospective review is materially different from the information that was presented during the pre-authorization review; and

(2) the relevant medical information presented to the MCO or utilization review agent upon retrospective review existed at the time of the pre-authorization but was withheld from or not made available to the MCO or utilization review agent; and

(3) the MCO or utilization review agent was not aware of the existence of the information at the time of the pre-authorization review; and

(4) had the MCO or utilization review agent been aware of the information, the treatment, service, or procedure being requested would not have been authorized. This determination is to be made using the same specific standards, criteria or procedures as used during the pre-authorization review.

(o) An MCO shall have written procedures for the implementation of the transitional period provisions set forth in paragraphs (e) and (f) of subdivision (6) of section 4403 and subdivision (4) of section 4408 of the Public Health Law.