Title: 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.