SubPart 360-6 - ENTITLEMENT TO MEDICAL ASSISTANCE

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Effective Date: 
Wednesday, May 7, 2014

Section 360-6.1 - Introduction.

Section 360-6.1 Introduction. This Subpart contains:

(a) the steps to be taken by the social services district after finding an applicant eligible for MA;

(b) a description of the MA identification card to be used in obtaining MA care and services;

(c) the right of a recipient to choose a qualified provider of care and services;

(d) a description of where care and services may be provided; and

(e) restrictions of recipient utilization of care and services.

 

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Section 360-6.2 - Authorization for MA.

Section 360-6.2 Authorization for MA. (a) When a social services district finds an applicant eligible, it will prepare an authorization for MA for the applicant and eligible applying members of the applicant's household. No initial authorization may be effective for more than one year from the date of application. No reauthorization will be effective for more than one year.

(b) Identification cards.

(1) The department will issue an MA identification card to every MA recipient with the exception of:

(i) persons residing in residential health care facilities licensed pursuant to Article 28 of the Public Health Law;

(ii) persons residing in developmental centers operated by the Office of Mental Retardation and Development Disabilities;

(iii) persons residing in psychiatric centers operated by the Office of Mental Health;

(iv) persons residing in residential treatment facilities required to have an operating certificate issued by the Commissioner of Mental Health pursuant to section 31.02(a)(4) of the Mental Hygiene Law; and

(v) foster care children placed with authorized child care agencies, as defined in subdivision 10 of section 371 of the Social Services Law, that are
receiving MA per diem payments.

(2) An identification card issued pursuant to paragraph (1) of this subdivision will contain a photo image unless the MA recipient is:

(i) a recipient of benefits under the Supplemental Security Income program;

(ii) a child under the age of 21 living with a caretaker relative, foster parent or guardian;

(iii) a person who applies at a location authorized by the department other than a social services district office, until the district's next contact with
the person or the first time MA eligibility is recertified, whichever is earlier;

(iv) a person who is confined to his or her home due to an illness or injury, including such persons who are receiving personal care, home health care, or long term home health care services, for the period of such confinement;

(v) a foster child placed with an authorized child care agency, as defined in subdivision 10 of section 371 of the Social Services Law, who is not receiving MA per diem payments;

(vi) a person residing in a facility or institution required to have an operating certificate issued by the Commissioner of Mental Retardation and
Development Disabilities pursuant to Article 16 of the Mental Hygiene Law;

(vii) a person residing in a residential facility, residential care center for adults, or in an institution operated by the Commissioner of Mental Health
pursuant to Article 31 of the Mental Hygiene Law;

(viii) a person whose MA eligibility is determined by the department pursuant to section 365 of the Social Services Law;

(ix) a person receiving MA services through the Office of Mental Retardation and Developmental Disabilities Home and Community Based Services (HCBS) waiver; and

(x) at the option of the social services district, a person who is over 18 years of age but less than 21 years of age and who is not living with a
caretaker relative, foster parent or guardian.

(3) If the authorization for MA is limited to a specific care or service, an MA identification card will not be issued.

(4) A recipient must present the MA identification card or a department approved equivalent to the MA provider before receiving medical services or
supplies.

(5) If the authorization for MA is limited because of utilization thresholds or improper use, the MA provider will be informed of the limitations when he/she verifies the recipient's MA eligibility.

(6) The social services district may make provisions for obtaining surrender of the MA identification card when a recipient is no longer eligible for MA.

(c) An initial authorization will be made effective for inpatient and outpatient care and services provided to a recipient during the three month period preceding the month of application for MA, if the recipient was eligible in the month in which the care and services were provided. An authorization can never be issued for care or services provided prior to this three-month period.

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Effective Date: 
Wednesday, July 26, 2000

Section 360-6.3 - Free choice by recipient guaranteed.

360-6.3 Free choice by recipient guaranteed. (a) Once authorized, MA recipients are entitled to obtain MA care and services from any provider enrolled in the MA program who is both qualified and agrees to provide the care and services. Exceptions to this provision are found in section 360-6.4 of this Subpart.

(b) (1) A social services district must offer to persons eligible for MA the option of membership in any health maintenance organization or other entity which offers comprehensive health services plans to persons residing within the district. This option must be provided unless the district is granted a waiver by the commissioner on the grounds that the organization or entity is not geographically accessible to eligible recipients who reside within the district, the capitation rate is above the expected average fee-for-service cost within the district, or the entity refuses to enter into a contract with the district.

(c) A social services district must offer to eligible recipients the option of membership in the voluntary medical care coordinator program provided for in section 360-6.8 of this Part. This option must be provided unless a participating provider is not reasonably accessible to eligible recipients who reside within the district.

(2) Persons who, prior to becoming eligible for MA, are enrolled in a health maintenance organization or other entity offering a comprehensive health services plan must be offered the option of continuing that enrollment.

 

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Section 360-6.4 - Restriction of recipient access to services (recipient restriction program)

360-6.4 Restriction of recipient access to services (recipient restriction program). The social services district and the department may restrict a recipient's access to MA care and services if, upon review, it is found that the recipient has received duplicative, excessive, contraindicated or conflicting health care services, drugs, or supplies. In such cases, the social services district and the department may require that the recipient access specific types of medical care and services through a designated primary provider or providers. The State medical review team (SMRT) designated by the department performs recipient utilization reviews and identifies candidates for the recipient restriction program.

(a) Definitions. When used in this section:

(1) Good cause for a restricted recipient to request a change of primary provider means the existence of one or more of the following circumstances:

(i) the provider no longer wishes to be a primary provider for the recipient; or

(ii) the provider has closed his/her office or pharmacy, or moved to a location not convenient to the recipient; or

(iii) the provider has been suspended or disqualified from participation in the MA program; or

(iv) the provider is a pharmacist and/or a durable medical equipment (DME) dealer who cannot stock an item for which the recipient has a legitimate prescription or fiscal order; or

(v) the recipient has moved; or

(vi) other circumstances exist that make it necessary to change providers.

(2) Primary provider is a health care provider enrolled in the MA program who has agreed to oversee the health care needs of the restricted recipient. The primary provider will provide and/or direct all medically necessary care and services for which the recipient is eligible, within the provider's category of service or expertise. Primary provider includes physicians, clinics, inpatient hospitals, pharmacies, podiatrists, DME dealers, dentists, and dental clinics.

(3) Recipient is a person who is receiving or who has received MA benefits within the preceding six months, including both current and former recipients.

(4) Recipient information packet (RIP) is the utilization review summary prepared by the SMRT documenting the reason(s) for a recommended restriction. It will include a summary pharmacology assessment prepared by the pharmacist documenting misuse of pharmacy and DME services and summary medical assessments prepared by the registered professional nurse documenting misuse of health care services. A physician must sign the RIP, indicating review and approval of the restriction recommendation.

(5) Restriction is an administrative action limiting an MA recipient's access to specific types of medical care and services through a designated primary provider(s).

(6) SMRT means a team consisting of a registered nurse, a pharmacist and a physician, all of whom are licensed to practice by the State, who act for the department to:

(i) analyze recipient use of medical care and services under the MA program;

(ii) make recommendations concerning restrictions on recipient use; and

(iii) prepare recipient information packets.

(b) Recipient restriction. An MA recipient whose use of a category of MA care or service fulfills one or more of the conditions for restriction specified in subdivision (d) of this section may be recommended by the SMRT to the social services district for restriction to a primary provider in that category. A recipient recommended by the SMRT for restriction to a primary provider in a category of MA care or service other than physician or clinic also may be recommended for restriction to a primary physician or primary clinic if such additional restriction would more effectively control abuse or misuse of MA care, services, drugs, supplies, or appliances. A recipient whose use of hospital emergency room services fulfills the condition for restriction specified in paragraph (5) of subdivision (d) of this section may be recommended by the SMRT to the social services district for restriction to a primary physician or primary clinic; such a restriction will not apply to emergency services furnished to the recipient. A primary provider is responsible for providing MA care or services to a restricted recipient as follows:

(1) A primary physician or primary clinic is responsible for providing all medical care to the restricted recipient, either directly or through referral of such recipient to another medical provider for appropriate services. A primary physician or primary clinic providing medical care for a restricted recipient who also is restricted to a primary inpatient hospital must have admitting privileges to or a professional affiliation with such primary inpatient hospital. A primary physician will receive a management fee for the coordination and management of a restricted recipient's care. Such management fee will be in the amount of $5 for each month the physician acts as primary physical for a restricted recipient.

(2) A primary inpatient hospital is responsible for providing all non-emergency inpatient services to the restricted recipient except for services provided pursuant to an authorized referral. A recipient who is restricted to a primary inpatient hospital also must be restricted to a primary physician or primary clinic.

(3) A primary pharmacy is responsible for providing all necessary drugs and pharmaceutical supplies to the restricted recipient. The primary pharmacy must institute and maintain a current patient profile for the restricted recipient. Such profile must contain, at a minimum: the identity of the prescriber of the drugs and supplies; the strength, quantity and dosage regimen of any drugs; and the dates of service for all drugs and supplies dispensed. The profile must be made readily accessible to the department and its agents.

(4) A primary dentist or primary dental clinic is responsible for providing or directing the provision of all dental care for the restricted recipient.

(5) A primary podiatrist is responsible for providing or directing the provision of all podiatric care for the restricted recipient.

(6) A primary DME dealer is responsible for providing all necessary medical supplies and appliances to the restricted recipient and for repairing and adjusting such appliances.

(7) A primary physician, primary clinic, primary dentist or primary dental clinic is responsible for ordering the following services for the restricted recipient:

(i) transportation services; if the recipient is restricted to a primary physician or primary clinic and a primary dentist or primary dental clinic, the primary physician or primary clinic will be the only allowed orderer of transportation services;

(ii) laboratory services;

(iii) DME services; if the recipient also is restricted to a primary DME dealer, that provider will be the only allowed dispenser of DME services; and

(iv) pharmacy services; if the recipient also is restricted to a primary pharmacy, that provider will be the only allowed dispenser of pharmacy services.

(8) A primary physician or primary clinic is responsible for ordering inpatient hospital services for a restricted recipient who also is restricted to a primary inpatient hospital.

(c) Responsibilities of the SMRT. The professional judgment of the SMRT is applied to each case review. Use of professional judgment includes, but is not limited to:

(1) identifying potential hazards to the health of the recipient;

(2) identifying instances in which the misuse of services appears to be caused by the provider. In such instances, the SMRT will refer the provider to the appropriate agency for quality of care review and/or administrative or criminal action. The SMRT will not recommend that the recipient be restricted;

(3) identifying instances where the recipient may have met one of the conditions of restriction, but it appears to have been an isolated occurrence, or there appears to have been a legitimate reason for the use cited. In these instances, the SMRT will not recommend that the recipient be restricted; and

(4) recommending the type of restriction that will control the misuse most effectively.

(d) Conditions for restriction. Restrictions will be recommended to the social services district if a recipient displays a pattern of receiving one or more of the following:

(1) Excessive drugs, supplies or appliances. The recipient has received more of a drug, medical supply or appliance in a specified time period than is necessary, according to acceptable medical practice.

(2) Duplicative drugs, supplies or appliances. The recipient has received two or more similarly acting drugs in an overlapping time frame or has received duplicative supplies or appliances. The drugs, if taken together, may result in harmful drug interaction(s) or adverse reaction(s). Duplicative supplies and appliances, while not harmful, have no medical indication and are therefore unwarranted.

(3) Duplicative health care services. The recipient has received health care services from two or more providers for the same or similar conditions in an overlapping time frame. Health care services include, but are not limited to, physician, clinic, pharmacy, dental, podiatry and DME services.

(4) Contraindicated care or conflicting care. The recipient has received drugs, supplies or appliances and/or health care services which may be inadvisable in the presence of certain medical conditions or which conflict with care being provided or ordered by another provider.

(5) Unnecessary hospital emergency room services. The recipient has received services in a hospital emergency room for a condition which does not require emergency care or treatment.

(6) Excessive inpatient hospital services. The recipient has received multiple inpatient hospital discharges for the same or similar conditions which are more than necessary, according to acceptable medical practice, including but not limited to multiple inpatient hospital discharges against medical advice. For purposes of this paragraph, discharge against medical advice means discontinuance by a recipient of inpatient hospital services contrary to the advice of the attending physician.

(7) Abusive practices by recipients.

(i) The following practices engaged in by an MA recipient are abusive practices which warrant restriction of such recipient to an appropriate type(s) of restriction:

(a) a recipient uses or permits an MA identification card to be used to obtain services for an unauthorized person;

(b) a recipient presents a forged or altered prescription or fiscal order to an enrolled MA provider to obtain supplies, drugs or services under the MA Program;

(c) a recipient is in possession of two or more MA identification cards which represent two or more MA cases; or

(d) a recipient sells or trades, or attempts to sell or trade, drugs or supplies acquired with an MA identification card.

(ii) When an MA recipient engages in an abusive practice identified in subparagraph (i) of this paragraph, a restriction may be imposed on the recipient for all eligible categories of services or only for those categories of services deemed appropriate by the SMRT.

(iii) The imposition of a restriction under this paragraph does not limit the taking by a social services official, district attorney or other prosecuting official of any other action authorized under law with respect to an act which constitutes a violation of the Social Services Law or Penal Law.

(e) Recipient's rights. (1) Selection of primary provider. The social services district, in consultation with the department, must either designate a primary provider for a restricted recipient or afford the recipient a limited choice of primary providers for the type of services that are to be restricted. If the recipient fails to choose a primary provider when asked to do so, the social services district must designate a single provider in the restriction category for the recipient. A recipient may request a change of primary provider every three months, or at an earlier time for good cause.

(2) Recipient notification. A notice of intent to restrict must be sent to the recipient. The notice must conform with the requirements of Part 358 of this Title. The notice must include the following information:

(i) the date the restriction will begin;

(ii) the effect and scope of the restriction;

(iii) the reason for the restriction;

(iv) the recipient's right to a fair hearing;

(v) instructions for requesting a fair hearing including the right to receive aid continuing if the request is made before the effective date of the intended action. Part 358 of this Title contains the provisions on instructions for requesting a fair hearing;

(vi) the right of a social services district to designate a primary provider for recipient;

(vii) the right of the recipient to select a primary provider within two weeks of the date of the notice of intent to restrict, if the social services district affords the recipient a limited choice of primary providers;

(viii) the right of the recipient to request a change of primary provider every three months, or at an earlier time for good cause;

(ix) the right to a conference with a social services district person to discuss the reason for and effect of the intended restriction;

(x) the right of the recipient to explain and present documentation, either at a conference or by submission, showing the medical necessity of any services cited as misused in the RIP;

(xi) the name and telephone number of the person to contact to arrange a conference;

(xii) the fact that a conference does not suspend the effective date listed on the notice of intent to restrict;

(xiii) the fact that the conference does not take the place of or abridge the recipient's right to a fair hearing;

(xiv) the right of the recipient to examine his/her case record; and

(xv) the right of the recipient to examine records maintained by the social services district which can identify MA services paid for on behalf of the recipient. This information is generally referred to as "claim detail" or "recipient profile" information.

(f) Social services district responsibilities. (1) Timeliness. The social services district must begin to process a restriction recommendation and contact the recipient within 30 days of receipt of the SMRT's recommendation to restrict.

(2) Reversal, change, or non-implementation of restriction by the social services district. The social services district may direct not to follow a restriction recommendation after a conference or upon receipt of additional information only in the following situations:

(i) Administrative reasons. (a) the recipient's case is closed for more than three months from receipt of recommendation;

(b) the recipient is institutionalized;

(c) the social services district cannot locate a primary provider of one type to accept responsibility for the recipient and has to substitute another type of provider for example, physician for clinic provider; or

(d) the recipient participates in another case management or managed care type program authorized by the department which the social services district believes will benefit the recipient more.

(ii) Medical reasons. The recipient can demonstrate a medical necessity for the services received. If, after a conference with the recipient or receipt of additional information, the social services district decides not to follow the SMRT's recommendation for medical reasons, the steps below must be followed:

(a) the recipient must present the RIP summary to an appropriate provider(s) listed in the summary. The provider(s) must submit a statement acknowledging full awareness of all the services, drugs, and supplies listed in the RIP. The provider(s) must explain why the services, drugs and supplies are medically necessary;

(b) the social services district must contact such provider(s) who must submit a statement to verify that he/she saw the RIP summary and that the information on the statement is accurate;

(c) the social services district medical director or a consulting physician having no involvement in the case must sign the case decision not to follow the SMRT's recommendation for medical reasons; and

(d) documentation and a summary must be forwarded to the department within 30 days of the date on which the decision not to follow the recommended restriction is made.

(g) Provider cooperation. The social services district must obtain an agreement from the primary provider that he/she will act as a primary provider. A primary provider must be given written confirmation of the recipient's restriction. Such confirmation must include the following:

(1) the effective date of the restriction;

(2) restriction limitations; and

(3) provisions for handling referrals (not applicable for pharmacy or other ordered service restrictions).

(h) Length of restriction. (1) An initial restriction period will be for 24 consecutive months. After the initial period, the department will determine if the restriction should be continued. A second restriction period will be for three years. Any additional restriction periods will be for six years. If a restriction is to be continued or reinstated, the social services district must notify the recipient by sending a new letter of intent. The required content of the notice of intent is set forth in paragraph (2) of subdivision (e) of this section.

(2) Initial and additional restriction periods must be computed without regard to eligibility for, or receipt of, MA benefits. All periods of ineligibility or voluntary discontinuance of receipt of benefits must be counted in determining the length of restriction. Recipients who do not remain eligible for benefits or who do not continue to receive them, as well as those who are not receiving benefits at the time of the imposition of the restriction, will be treated similarly to those who remain eligible and continue to receive benefits. (For example, a recipient who becomes ineligible for benefits prior to the effective date of the restriction period and, upon subsequent reapplication for or redetermination of eligibility, regains eligibility within the restriction period will be eligible for benefits only in accordance with the restriction previously imposed.)

(i) Rereview for compliance with restriction. The department will monitor the recipient's compliance with a restriction and determine whether an additional restriction period is appropriate. The department will use evidence of MA identification card alterations, services received inappropriately from non-primary providers and other improper actions as the basis for an additional administrative restriction for other than medical reasons. A decision not to continue a restriction will in no way preclude any subsequent decisions to restrict for medical reasons. A recipient restricted for an additional period for non-compliance will have the same rights and is entitled to all appropriate notices informing his/her of the proposed action. These rights and notices are specified in Part 358 of this Title and subdivision (e) of this section.

 

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Section 360-6.5 - Fair hearing requirements in utilization review cases.

360-6.5 Fair hearing requirements in utilization review cases. When a utilization review committee determines that MA payments should be reduced or discontinued, the following steps must be taken:

(a) If the recipient is in a long-term care facility (a skilled nursing facility, intermediate care facility or mental hospital) or is a chronic care patient in a general hospital facility:

(1) The recipient, his/her representative, or an appropriate relative must be notified of the action in writing by the utilization review committee. The notice must be notified of the action in writing by the utilization review committee. The notice must be both timely and adequate as defined in Part 358 of this Title. The notice and action must be consistent with both State and Federal requirements on utilization review.

(2) If the recipient requests a fair hearing before the effective date of the action, payment for the recipient's care in a long-term care facility or for long-term care in a general hospital will be continued until the fair hearing decision is rendered.

(b) If the recipient is in a general hospital, but not receiving chronic care services:

(1) The recipient, his/her representative, or an appropriate relative must be notified of the action in writing by the utilization review committee. The notice must be adequate, as defined in Part 358 of this Title. The notice and action must be consistent with both State and Federal requirements on utilization review.

(2) MA payments on behalf of the recipient will be terminated on the effective date of the utilization review committee determination.

(3) MA payments will not be continued on behalf of the recipient if the recipient requests a fair hearing to contest a determination that hospitalization is no longer necessary.

(c) All provisions of Part 358 of this Title which are not inconsistent with subdivisions (a) and (b) of this section apply to utilization review committee determinations.

 

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Section 360-6.6 - Where care and services may be provided.

360-6.6 Where care and services may be provided. Medical care and services under the MA program may be provided to a recipient residing in his/her own home or in an approved medical institution or facility.

(a) A recipient's home may be a home where he/she receives room and board, a family home or boarding home, an approved nonprofit institution for child care, a licensed public child care institution which accommodates no more than 25 children and is not operated primarily for delinquent children or family-type group, or a family-type, family care or residential care facility certified by the department or an office of the State Department of Mental Hygiene.

(b) An approved medical institution or facility includes the following when operated according to the Public Health Law or other applicable law:

(1) a private proprietary or nonprofit nursing home;

(2) the approved infirmary section of a home for the aged;

(3) a public home infirmary or other similar public facility for the chronically ill;

(4) an intermediate care facility;

(5) a facility or part of a facility for the treatment of narcotic addiction which is operated pursuant to the provisions of article 23 of the Mental Hygiene Law as long as Federal aid is available;

(6) an inpatient alcoholism facility;

(7) an approved hospital, nursing home, or intermediate care facility section of a public institution operated for the care of the mentally disabled;

(8) a State hospital for the mentally disabled operated by the State Department of Mental Hygiene; and

(9) a hospital other than one caring primarily for the mentally disabled.

(c) Medical care and services may be provided to a recipient in a general or chronic disease hospital, regardless of the disease diagnosed.

(d) Medical care and services will be provided to eligible veterans and their dependents in those parts of the New York State Home for Veterans and their Dependents at Oxford which have been approved pursuant to law as either a nursing home or an intermediate care facility. Such recipients will have care and services provided in a hospital while on release from that home for the purpose of receiving care in such hospital.

(e) Medical care and services will be provided to an eligible person receiving inpatient psychiatric services in an institution used primarily for the care of the mentally ill as follows:

(1) For an eligible person under 21 years of age, such care and services must conform to Federal and State standards. A team, consisting of physicians and other qualified personnel, must determine that the care and services are necessary on an inpatient basis and can reasonably be expected to improve the condition being treated so that such care and services will no longer be necessary. If a person attains the age of 21 during the course of hospitalization, such services may continue until he/she reaches the age of 22.

(2) For an eligible person 65 years of age or over, such care and services must conform to Federal and State standards.

(3) Persons receiving inpatient, psychiatric services in an institution primarily for the care of the mentally ill who fall outside the categories in paragraphs (1) and (2) of this subdivision are ineligible for MA.

(f) MA will be provided to an eligible person who enters or leaves a public institution only for the part of the month in which the person is not residing in the institution.

 

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Section 360-6.7 - REPEALED

REPEALED

Effective Date: 
Wednesday, May 7, 2014

Section 360-6.8 - Medical care coordinator program (MCCP).

Section 360-6.8 Medical care coordinator program (MCCP).

(a) Policy. Effective July l, 1992, a recipient who is eligible for medical assistance (MA) solely as a result of being eligible for or in receipt of Home Relief (HR) and who is at least 21 years of age but under the age of 65 (MA/HR recipient), may receive certain MA services only if the recipient is enrolled in a health maintenance organization or other entity which provides comprehensive health services, a managed care program, a primary provider program, or a voluntary medical care coordinator program (MCCP).

(b) Scope. This section defines the MCCP; specifies the rights of participating recipients; establishes the qualifications and responsibilities of participating primary physicians, diagnostic and treatment centers, hospital out-patient departments and pharmacies in providing and coordinating medical care, services and supplies for participating recipients; and sets forth the responsibilities of social services districts in administering the MCCP.

(c) Definitions. As used in this section, unless expressly stated otherwise or unless the context of the subject matter requires a different interpretation:

(1) MCCP means a program in which an MA/HR recipient voluntarily enrolls with a primary physician, diagnostic and treatment center or hospital out-patient department and a primary pharmacy which will provide or refer the MA recipient to medically necessary services and will further coordinate the use of medical services to assure that the recipient receives appropriate medical care, services and supplies and that MA is provided in an appropriate and cost-effective manner.

(2) MA/HR recipient means a person who is eligible for MA solely as a result of being eligible for or in receipt of HR and who is at least 21 years of age but under the age of 65.

(3) Primary provider means a physician, diagnostic and treatment center, or hospital out-patient department enrolled in the MA program which has agreed to coordinate the health care of an MA/HR recipient and to provide and/or direct all medically necessary care, services and supplies for which the MA/HR recipient is eligible.

(4) Primary pharmacy means a pharmacy enrolled in the MA program which has agreed to provide all drugs and pharmaceutical supplies ordered for an MA/HR recipient enrolled in the MCCP.

(d) Recipient participation. participation by an MA/HR recipient in the MCCP is voluntary.

(e) Recipient responsibilities.

(1) An MA/HR recipient who wishes to participate in the MCCP must obtain a copy of the provider selection form from his or her social services district, complete the form and return it to the social services district.

(2) The MA/HR recipient must identify on such form his or her choice of primary physician, diagnostic and treatment center or hospital outpatient department, and his or her choice of primary pharmacy, and obtain agreement from the providers that they will be the primary provider and primary pharmacy. An identified provider agrees to be a primary provider or primary pharmacy for an MA/HR recipient by signing a selection form.

(3) An MA/HR recipient who participates in the MCCP may change his or her primary provider or primary pharmacy by completing a provider change form furnished by the social services district if another primary provider or primary pharmacy satisfactory to the recipient agrees to act as the primary provider or primary pharmacy.

(4) An MA/HR recipient who participates in the MCCP may withdraw from the MCCP at any time by completing a recipient withdrawal form furnished by the social services district.

(5) If an MA/HR recipient volunteers to participate in the MCCP but no primary provider or primary pharmacy is sufficiently accessible or no primary provider or primary pharmacy which is sufficiently accessible agrees to be the recipient's primary provider or primary pharmacy, the recipient may receive the MA services which are available to participating MA/HR recipients without enrolling in the MCCP. The recipient will continue to receive these services until a provider or pharmacy affiliated with a health maintenance organization or other entity which provides comprehensive health services, a managed care program, a primary provider program, or the MCCP is sufficiently accessible and agrees to provide medical care or pharmacy services to the recipient, at which time the MA/HR recipient must enroll in such program in order to continue to receive such MA services.

(f) Provider responsibilities.

(1) A primary provider or primary pharmacy must furnish written confirmation to a social services district, prior to acting as a primary provider or primary pharmacy, of the provider's agreement to act as primary provider or primary pharmacy and to comply with all requirements of this section. A provider confirms such agreement by signing the provider selection form presented by the MA/HR recipient.

(2) A primary provider or primary pharmacy may act as a primary provider or primary pharmacy with respect to a particular MA/HR recipient only on and after the effective date of the recipient's enrollment in the MCCP. The social services district will inform the primary provider or primary pharmacy in writing of the recipient's enrollment in the MCCP.

(3) A primary provider is responsible for providing, either directly or through referral to another qualified MA provider, all MA covered care, services and supplies to an MA/HR recipient enrolled in the MCCP. The primary provider is responsible for ordering or directing the following services for an enrolled MA/HR recipient:

(i) laboratory services;

(ii) durable medical equipment;

(iii) pharmacy services; and

(iv) medically necessary and appropriate non-emergency transportation services.

(4) A physician acting as primary provider for an enrolled MA/HR recipient will receive a monthly management fee of $10.00 for managing and coordinating the care of each MA/HR recipient for which the physician is the primary provider.

(5) A pharmacy acting as primary pharmacy must institute and maintain a current patient profile for each enrolled MA/HR recipient. A current patient profile must contain: the identity of the prescriber of a drug or pharmaceutical supply; the strength, quantity and dosage regimen of a drug; and the date of service for the dispensing of a drug or pharmaceutical supply. A current patient profile must be readily accessible to the department and its designated agents upon request. The primary pharmacy also must adhere to all drug utilization review requirements under the MA program.

(g) Social services district responsibilities.

(1) Each social services district will be primarily responsible for administration of the MCCP.

(2) Each social services district must take actions necessary for the efficient and effective functioning of the MCCP, including:

(i) assisting MA/HR recipients to enroll in the MCCP;

(ii) assisting enrolled MA/HR recipients to choose primary providers and primary pharmacies;

(iii) processing the provider selection forms promptly and determining the effective dates of recipients enrollment in the MCCP;

(iv) providing written notice to MA/HR recipients and identified primary providers and primary pharmacies confirming the MA/HR recipients' effective dates of enrollment in the MCCP;

(v) processing primary provider and primary pharmacy change forms and recipient withdrawal forms promptly and determining the effective dates of changes or withdrawals from the MCCP;

(vi) providing to MA/HR recipients and the primary providers and primary pharmacies a written notices confirming the effective dates of MA/HR recipients' participation in or withdrawals from the MCCP and providing to MA/HR recipients a list of the MA services which the recipients will become ineligible to receive upon the effective dates of withdrawals unless the MA/HR recipients have enrolled in other managed care programs;

(vii) determining whether available primary providers are suffi ciently accessible to MA/HR recipients so that services can be reasonably provided to recipients;

(viii) advising the department when recipients have problems obtaining access to primary providers or primary pharmacies; and

(ix) entering necessary data into WMS to support timely implementation of the MCCP and recipients' enrollment, changes in primary providers or primary pharmacies, or withdrawals from MCCP.

 

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