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Title: Section 360-10.3 - Definitions

Effective Date


Section 360-10.3 Definitions. As used in this Subpart, unless expressly stated otherwise or unless the context of the subject matter requires different interpretation:

(a) "Action" means, in the case of an MMCO or its management contractor:

(1) the denial or limited authorization of a requested service, including type or level of service; or

(2) the reduction, suspension, or termination of a previously authorized service; or

(3) the denial, in whole or in part, of payment for a service; or

(4) the failure to provide services in a timely manner, as set forth in the guidelines established by the commissioner; or

(5) the failure to act to resolve service authorization requests, complaints, grievances, and appeals with reasonable promptness. Reasonable promptness shall mean compliance with the timeframes established by public health law and applicable federal regulations, as set forth in the guidelines established by the commissioner;

(6) the denial of a request for out of network services for a managed care enrollee who is required to receive medical assistance services from an MMCO and who resides in a social services district where there is only one MMCO participating in the Medicaid managed care program; or

(7) the restriction of an enrollee to certain providers under the MMCO's recipient restriction program.

The decision of a primary care practitioner participating in a primary care partial capitation provider (PCPCP) exercising his or her professional judgment is not an action.

(b) "Disenrollment" means the process by which a Medicaid recipient's enrollment in an MMCO is terminated.

(c) "Enrollee" (Participant) means a Medicaid recipient who receives, is required to receive, or elects to receive his or her health care services from an MMCO, or an FHP eligible individual who is required to receive health care services from an MMCO.

(d) "Enrollment" means the process by which an enrollee's membership in an MMCO begins.

(e) "Grace period" means the period prescribed by federal or State statute during which an enrollee may elect to change MMCOs for any reason.

(f) "Lock-in period" means the period of time during which the enrollee may not disenroll from the MMCO unless the enrollee can demonstrate that he/she has good cause as defined in section 360-10.6 of this Subpart. The lock-in period shall begin on the effective date of enrollment and end after the first twelve months of enrollment, provided however, an enrollee may disenroll from an MMCO without cause during the grace period.

(g) "Management contractor," means any company, organization, or other entity that has entered into a management agreement with an MMCO, pursuant to section 98-1.11(j) of Title 10, to take an action on behalf of an MMCO. If so provided under the terms of such management agreement, the management contractor may, on behalf of the MMCO, accept appeals regarding the action and make appeal determinations.

(h) "Medicaid managed care organization (MMCO)," means one of the following entities that meets the requirements of section 364-j of the Social Services Law and is authorized to participate in the Medicaid managed care and/or Family Health Plus Programs: health maintenance organizations (HMOs), prepaid health services plans (PHSPs), comprehensive HIV special needs plans (HIV SNPs), and primary care partial capitation providers (PCPCPs). An MMCO is required to enter into a contract with the State; such contract must specify the services provided under the MMCO's benefit package, subject to any exclusions or limitations imposed by federal or State law.

(i) "Notice of action" means a notice issued by an MMCO or its management contractor when an action is taken. Also known as the "notice of intent to restrict" in the case of an MMCO's determination to restrict an enrollee under the MMCO's recipient restriction program.

(j) "Participating provider" means a provider of medical care and/or services that has a provider agreement with an MMCO.

(k) "Primary care practitioner (provider)" or "PCP" means a physician or nurse practitioner providing primary care to and management of medical and health care services of an enrollee.

(l) "Prospective Enrollee" means any individual residing in the MMCO's service area that has not yet enrolled in a MMCO's Medicaid managed care or FHP product.

(m) "Recipient restriction program" means an MMCO's procedures for review and assessment of an enrollee's misuse or abuse of medical assistance services and subsequent determination to restrict the enrollee to access certain medical assistance services through a designated provider or providers, or the MMCO's implementation of an enrollee restriction as directed by the Office of the Medicaid Inspector General. The MMCO's recipient restriction program is conducted in accordance with section 360-6.4(d) of this Part and the guidelines in the contract between the MMCO and the State.

(n) "Social services district" means the social services district or other designee of the department.

(o) "Service authorization request" means a request by an enrollee, or a provider on the enrollee's behalf, to an MMCO for the provision of a service, including a request for a referral or for a non-covered service.


VOLUME A-1 (Title 18)