Part 511 - MEDICAL CARE - UTILIZATION THRESHOLDS

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Statutory Authority: 
Social Services Law, Sections 20(3)(d), 34(3)(f), 363-a(2), 365-g

Section 511.1 - Utilization thresholds.

Section 511.1 Utilization thresholds. (a) In accordance with section 365-g of the Social Services Law, the department has established utilization thresholds which apply to medical assistance (MA) recipients. Utilization thresholds are annual service limitations which are established by the department based upon provider service type. Utilization thresholds are designed to promote appropriate use of services consistent with quality care.

(b) Within a benefit year, as defined in section 511.4 of this Part, the MA program will pay for care, services and supplies provided to eligible recipients up to and including the number of service units established as a utilization threshold for the particular provider service type. A service unit is defined as one encounter, procedure, or formulary code, depending upon the provider service type.

(c) After a recipient has reached the utilization threshold established for a particular provider service type, the MA program will not pay for additional care, services or supplies for that provider service type unless one of the following conditions is satisfied:

(1) the department has exempted the recipient from the utilization threshold;

(2) the department has granted the recipient an increase in the utilization threshold;

(3) the provider certifies that the care, services, or supplies were furnished to address an urgent medical need. An urgent medical need exists when a patient has an acute or active medical problem which, if left untreated, could reasonably result in an increase in the severity of the symptoms of the problem, an increase in the patient's recovery time, or a medical emergency; or

(4) the provider certifies that the care, services or supplies were furnished to address a medical emergency. Emergency services are medical care, services or supplies provided after a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical treatment could reasonably result in serious impairment of bodily functions, serious dysfunction of a bodily organ or body part, or would otherwise place the recipient's health in serious jeopardy.

(d) The utilization thresholds for select provider service types are set forth in sections 511.10 through 511.13 of this Part.

 

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Section 511.2 - Notification to applicants and recipients.

511.2 Notification to applicants and recipients. (a) Initial notification. (1) Social services districts must notify MA applicants about utilization thresholds when the districts accept MA applications or issue MA identification cards.

(2) The notification will describe the nature and extent of the utilization thresholds, how to calculate recipients' use of services, how to obtain an exemption from or increase in utilization thresholds, the recipients' fair hearing rights under section 511.9 of this Part, and the toll-free telephone number to call for additional information. The notification also will describe alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law.

(b) Interim notification to recipients. (1) MA recipients will be sent written notices during their benefit year if they are using services of a specific provider service type at a rate which would cause them to reach the utilization threshold before the end of the benefit year. This notification will describe how to apply for an increase in or exemption from utilization thresholds, and how to contest the amount of service usage stated in the notice. This notification also will direct MA recipients to contact their social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(2) MA providers who request an authorization for MA reimbursement for a service which is subject to a utilization threshold will also be informed, when they verify recipients' eligibility, if the recipients are using those services at a rate which would cause the recipients to reach the utilization thresholds before the end of the benefit year.

(c) Final notification to recipients. (1) Recipients will be sent written notification during the benefit year upon reaching utilization thresholds for each specific provider type. This notification will inform recipients that the threshold has been reached and that the MA program will not pay for further care, services, or supplies of this provider service type unless such care, services, or supplies is furnished to address an urgent medical need or medical emergency. This notification will describe how to apply for an increase in or exemption from the threshold, and how to contest the amount of service usage stated in the notification. This notification also will direct MA recipients to contact their social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(2) Final notification will also include a statement describing recipients' fair hearing rights if a request for an increase in or exemption from a utilization threshold is denied.

(3) Providers who request authorization to render care, services, or supplies to recipients after the threshold has been reached will also be advised that the recipients have reached the threshold for that provider service type.

 

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Section 511.3 - Excluded services.

511.3 Excluded services. Utilization thresholds do not apply to the following services:

(a) services furnished by or through a managed care program to persons enrolled in and receiving medical care from such program. Managed care programs include health maintenance organizations, preferred provider plans, physician case management programs or other managed medical care programs recognized by the Department;

(b) services otherwise subject to prior approval or prior authorization;

(c) reproductive health and family planning services including: diagnosis, treatment, drugs, supplies, and related counseling furnished or prescribed by a physician or under a physician's supervision;

(d) until September 1, 1992, services provided by or under the direction of a primary provider under the recipient restriction program, as established by section 360-6.4 of this Title;

(e) methadone maintenance treatment services;

(f) services provided by private practitioners on a fee-for-service basis to inpatients in general hospitals certified under Article 28 of the Public Health Law or Article 31 of the Mental Hygiene Law and residential health care facilities;

(g) hemodialysis services;

(h) obstetrical services provided by a physician, hospital outpatient department, or free-standing diagnostic and treatment center-certified under Article 28 of the Public Health Law; or

(i) services provided through or by referral from a preferred primary care provider designated pursuant to Section 2807(12) of the Public Health Law.

 

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Section 511.4 - Benefit year; service units.

511.4 Benefit year; service units. Utilization thresholds are limitations on the number of service units of a given provider service type which the MA program will pay for within a benefit year.

(a) (1) For a person who is an MA recipient on March 1, 1991, who is at least 21 but less than 65 years of age, and who is eligible for MA benefits solely as a result of being an applicant for or recipient of benefits under the home relief program, the initial benefit year will begin on such date; a new benefit year will begin on March 1st of each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months. For such a person who is not an MA recipient on March 1, 1991 but who becomes eligible for MA after March 1, 1991 and prior to September 15, 1991, the initial benefit year will begin on the date such eligibility begins; a new benefit year will begin on the same day and month in each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months.

(2) For a person who is an MA recipient on September 15, 1991 and who is not subject to utilization thresholds pursuant to paragraph (1) of this subdivision, the initial benefit year will begin on such date; a new benefit year will begin on September 1st of each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months. For a person who is not an MA recipient on September 15, 1991 but who subsequently becomes eligible for MA, the initial benefit year will begin on the date such eligibility begins; a new benefit year will begin on the same day and month in each succeeding year, unless there is an interruption in MA eligibility of more than 24 consecutive months.

(b) A service unit is one service encounter, procedure, or formulary code, depending upon the provider service type. Service units are described more fully in sections 511.10 through 511.13 of this Part. One service unit for a specific provider service type will be recorded when the provider of care verifies recipient eligibility and obtains an authorization to provide care. If the department does not pay a claim for an authorized service unit within 180 days of the authorization, the recipient will receive one service unit credit.

 

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Section 511.5 - Applications for utilization threshold increases and exemptions.

511.5 Applications for utilization threshold increases and exemptions.

(a) An MA recipient, or a provider on behalf of a recipient, may apply to the department on a State-prescribed form for an increase in or exemption from a utilization threshold. Such an application may be made at any time the recipient or provider determines that there will be a medical need for care, services, or supplies in excess of the threshold amount. Recipients and providers are encouraged to apply as soon as they determine that an increase or exemption will be necessary.

(b) A recipient who requests an increase or exemption must submit medical documentation from his/her provider to the department or must arrange for the provider to submit medical documentation to the department on his/her behalf. The documentation must contain sufficient factual data and medical evidence to enable the department to objectively determine the medical need for the increase or exemption.

(c) A provider may not charge or collect any fee from an MA recipient for completing and submitting an application, on the MA recipient's behalf, for an increase in or exemption from a utilization threshold. Charging or collecting a fee in such circumstances is an unacceptable practice and the provider may be subject to a sanction in accordance with Part 515 of this Title.

 

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Section 511.6 - Review of applications.

511.6 Review of applications. Applications for increases in or exemptions from utilization thresholds will be reviewed by an independent contractor as follows:

(a) Automated review. All applications for increases and exemptions will be subject first to an automated review.

(1) Applications for increases will be granted during the automated review process if:

(i) the amount of additional service units requested does not exceed 200 percent of the initial utilization threshold established for the particular provider service type; and

(ii) the application is complete, and the medical necessity for the increase has been certified on the State-prescribed application form by a physician, physician's assistant, nurse practitioner, or nurse midwife, other than a person who is ineligible to participate as a provider of services under the MA program; and

(iii) the MA recipient's access to MA care, services, or supplies has never been restricted under the recipient restriction program established by section 360-6.4 of this Title.

(2) If an application is incomplete or if the certification of medical necessity is made by a provider who is ineligible to participate as a provider of services under the MA program, a letter will be sent to the MA recipient and to the provider advising them of the deficiency in the application and providing instructions for reapplying.

(3) Applications will be referred to a medical review team, as described in subdivision (b) of this section, if:

(i) the application requests an exemption from a utilization threshold; or

(ii) the application requests additional service units in excess of 200 percent of the initial utilization threshold established for the particular provider service type; or

(iii) the MA recipient's access to MA care, services, or supplies was restricted in the past under the recipient restriction program established by section 360-6.4 of this Title.

(b) Medical review. (1) When an application for an increase or exemption is referred to the medical review team pursuant to the provisions of paragraph (a)(3) of this section, the medical review team will review the application to determine:

(i) the medical necessity of the requested increase or exemption;

(ii) whether the MA recipient should participate in the restricted recipient program established by section 360-6.4 of this Title; and

(iii) whether the MA recipient should be referred to appropriate and accessible managed care programs.

In its discretion, the medical review team may contact the MA recipient or the requesting provider to clarify information provided within the application, or to obtain additional information.

(2) The medical review team will consist of a registered nurse and a registered pharmacist who are licensed to practice by the State. In addition, physicians specializing in relevant areas of medicine will be available for consultation with the medical review team as needed.

(3) The criteria to be used by the medical review team in determining whether a requested increase or exemption is medically necessary are the generally accepted standards of the medical profession. With respect to requests for exemptions, the medical review team must approve such requests 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 merely increasing the threshold amount is not sufficient to meet the medical needs of the MA recipient. In accordance with section 365-g of the Social Services Law, exemptions will be approved according to the Utilization Threshold Program Exemption Guidelines (June, 1991) established by the department in consultation with the Department of Health. Copies of these guidelines may be obtained from the Department of Social Services, Division of Medical Assistance, 99 Washington Ave., Albany, NY 12210.

 

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Section 511.7 - Additional service units pending determination of applications.

511.7 Additional service units pending determination of applications.

(a) When an MA recipient applies for an increase in or an exemption from a utilization threshold for a particular provider service type pursuant to sections 511.4 and 511.5 of this Part, the recipient is automatically eligible for additional service units of that provider service type, in addition to any medical care, services or supplies required to address an urgent medical need or medical emergency, if:

(1) the application indicates that the recipient has received notification pursuant to section 511.2(c) of this Part that he/she has reached the utilization threshold; and

(2) the application is rejected during the automated review process

(for reasons other than the inability to verify the applicant's status as an MA recipient) or the application is referred to the medical review team.

(b) An MA recipient who has reached the utilization threshold for a particular provider service type and whose application for an increase in or exemption from the threshold has been denied is eligible for additional service units of that provider service type, provided that the recipient requests a fair hearing to challenge such denial within 10 days of mailing of the determination denying the increase or exemption. The department will authorize these additional service units within 10 working days after receipt of the request for a fair hearing.

(c) An MA recipient who meets the requirements of subdivisions (a) or

(b) of this section will be authorized to receive additional service units as follows:

(1) for physician/medical clinic services, two encounters;

(2) for pharmacy services, six formulary codes;

(3) for laboratory services, four procedures; and

(4) for psychiatrist/mental health clinic services, four encounters.

 

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Section 511.8 - Determinations.

511.8 Determinations. (a) Based on the review conducted pursuant to section 511.6 of this Part, the department will issue a written determination approving, partially approving, or denying applications for increases in or exemptions from utilization thresholds, or will issue a letter pursuant to section 511.6(a)(2) of this Part advising the recipient and provider of a deficiency in the application.

(b) A copy of the written determination will be sent to the recipient, and to the provider if the provider submitted medical documentation directly to the department on the recipient's behalf. The determination will include a statement describing the recipient's fair hearing rights, and how to request a fair hearing, if a request for an increase or exemption is denied. The determination also will direct the recipient to contact the social services district for information and assistance concerning: alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to Section 2807(12) of the Public Health Law; and applying for federal disability benefits.

(c) The department will issue a written determination on an application for an increase or exemption within 25 days of receipt of the application. However, if the department requests further supporting factual or medical documentation from the recipient or the requesting provider, the time to issue a determination will be extended by the number of days from the request for additional documentation until its receipt by the department. The application will be deemed approved if the department does not make a determination within 25 days of receipt of the application or within such longer period as may be required by a request for additional documentation.

 

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Section 511.9 - Fair hearings.

511.9 Fair hearings. (a) The recipient is entitled to a fair hearing when:

(1) an application for an exemption is denied; or

(2) an application for an increase in a utilization threshold is denied and a recipient has reached the utilization threshold.

(b) (1) The fair hearing pursuant to this section will be limited to the issues set forth in the application for the increase or exemption, and the reasons for denial contained in the written determination. The hearing request and the procedures for the conduct of the hearing are governed by Part 358 of this Title.

(2) Notwithstanding the provisions of paragraph (1) of this subdivision, the recipient may raise at the fair hearing requested pursuant to this section the issue of whether the number of service units attributed to the recipient for a provider service type accurately reflects the recipient's use of such service type.

(3) The MA program will not pay for medical care, services, or supplies in excess of a utilization threshold pending the outcome of a fair hearing pursuant to this section, except as provided in Section 511.7 of this Part.

 

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Section 511.10 - Physician and clinic services - utilization threshold.

511.10 Physician and clinic services - utilization threshold. This section describes the utilization threshold that the department has established for physician and clinic services.

(a) General rule. The department will pay for up to 10 physician and clinic service encounters in a benefit year for MA recipients. As used in this subdivision, the term clinic means hospital out-patient department, free-standing diagnostic and treatment center, or hospital emergency room. As used in this section, the term encounter is defined as follows:

(1) all medical care, services and supplies received during a visit with a physician, a physician's assistant, a specialist, or a specialist's assistant, unless excluded by subdivision (b) of this section; or

(2) all medical care, services, and supplies received during a visit to a clinic certified under Article 28 of the Public Health Law, unless excluded by subdivision (b) of this section.

(b) Exclusions. In addition to those services and procedures generally excluded from any utilization threshold by section 511.3 of this Part, certain services are excluded from the utilization threshold established by this section.

(1) The following physician services are excluded:

(i) anesthesiology services; and

(ii) psychiatric services.

(2) The following clinic services are excluded:

(i) mental health continuing treatment and continuing day treatment, day treatment, partial hospital, and intensive psychiatric rehabilitative treatment services, alcoholism treatment services, substance abuse services and mental retardation and developmental disability treatment services provided in clinics certified under article 28 of the Public Health Law, or article 23 or article 31 of the Mental Hygiene Law; and

(ii) services performed by an article 28 hospital or diagnostic and treatment center on an ambulatory basis upon the order of a qualified practitioner to test, diagnose or treat the recipient.

(c) The department will pay for services provided in hospital emergency rooms as emergency services; however, each encounter counts as one service unit under the utilization threshold established by this section.

 

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Section 511.11 - Pharmacy services - utilization threshold.

511.11 Pharmacy services - utilization threshold. This section describes the utilization threshold that the department has established for pharmacy services. Beginning July 1, 1992, the department will pay for up to 28 pharmacy service formulary codes in a benefit year for MA recipients described in sections 360-3.3(a)(1) or 360-3.3(b)(7) of this Title. Beginning September 1, 1992, the department will pay for up to 40 pharmacy service formulary codes in a benefit year for MA recipients described in sections 360-3.3(a)(2)-(6), 360-3.3(b)(1)-(6), or 360-3.3(b)(8) of this Title. As used in this section, a formulary code is defined as follows:

(a) for prescription drugs, the first time a pharmacist fills a prescription is one formulary code; each refill of the original prescription is also one formulary code; and

(b) for nonprescription drugs and medical and surgical supplies, each initial fiscal order for the drug or supply is one formulary code; each refill of the fiscal order is also one formulary code.

 

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Section 511.12 - Laboratory services - utilization threshold.

511.12 Laboratory services - utilization threshold. This section describes the utilization threshold that the department has established for laboratory services. The department will pay for up to 18 laboratory service procedures in a benefit year. For purposes of this subdivision, a procedure consists of all services which are claimed for a single date of service and which are represented by a single laboratory procedure code, as listed and defined in the Medicaid Management Information System laboratory fee schedule (July 1990; a new laboratory fee schedule becomes effective on July 1, 1991). These fee schedules are available from the department and may also be found in the Medicaid Management Information System Provider Manual for laboratories. Copies of the fee schedules are available from the Department of Social Services, Division of Medical Assistance, 99 Washington Avenue, Albany, NY 12210. These manuals are provided free of charge to every MA laboratory provider.

 

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Section 511.13 - Mental health clinic programs - utilization threshold.

511.13 Mental health clinic programs - utilization threshold. This section describes the utilization threshold that the department has established for mental health clinic programs. The department will pay for up to 40 mental health clinic encounters in a benefit year. As used in this section, the term mental health clinic means a clinic treatment program certified by the office of Mental Health under article 31 of the Mental Hygiene Law.

 

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Section 511.14 - Dental clinic services - utilization threshold.

511.14 Dental clinic services - utilization threshold. This section describes the utilization threshold that the department has established for dental clinic services. The department will pay for up to three dental clinic service encounters in a benefit year. As used in this section, the term dental clinic services means dental care, services and supplies provided by a hospital out-patient department, free-standing diagnostic and treatment center, or hospital emergency room certified under article 28 of the Public Health Law.

 

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