Title: Section 533.8 - Human immunodeficiency virus enhanced fees for physicians

533.8 Human immunodeficiency virus enhanced fees for physicians program (HIV-EFP). (a) Scope. The HIV-EFP is a program under which a written agreement is entered into by a provider and the department pursuant to which the department agrees to pay enhanced fees for certain medical services provided to HIV-infected Medical Assistance (MA) recipients. Only qualified primary care and specialist physicians meeting the requirements of this section are eligible to participate in the HIV-EFP. Physicians who wish to participate in the HIV-EFP must apply in writing on forms provided by the department. Applications will be reviewed by and must receive approval of the department and the Department of Health. Participating physicians may obtain payment at the enhanced fees for medical services provided to HIV-infected MA recipients by using special HIV-EFP procedure codes on their MA claims.

(b) Purpose. The purpose of the HIV-EFP is to improve access to quality medical care for HIV-infected MA recipients by paying enhanced fees to physicians meeting the minimum criteria for program participation.

(c) Definitions. (l) Medical care coordination, for purposes of this section, means providing or arranging for the provision of:

(i) scheduling of elective hospital admissions;

(ii) assistance with emergency admissions;

(iii) management of and/or participation in hospital care and discharge planning;

(iv) scheduling of referral appointments with written referrals as necessary and with requests for follow-up reports;

(v) scheduling of necessary ancillary services such as laboratory, radiology, aerosolized pentamidine, physical therapy and infusion therapy;

(vi) telephone notification to the social services district responsible for furnishing MA to the recipient when transportation services are essential to ensure the MA recipient's access to medically necessary care and services provided under the MA program; and

(vii) maintenance of complete medical records in compliance with the requirements of section 540.7 of this Title including, but not limited to, notation of referrals and hospitalizations, and copies of test results and reports.

(2) Qualified primary care physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with Article 28 of the Public Health Law and accredited by the Joint Commission on Accreditation of Hospitals (JCAH). The Department of Health may waive this requirement for a physician who qualifies for hospital admitting privileges but does not have such privileges for one of the reasons listed in paragraph

(e)(1) of this section and who complies with the requirements of subdivision (e) of this section; however, the Department of Health will not waive this requirement for a physician who has been denied or who has lost hospital admitting privileges based on findings that the physician provided poor quality care or was guilty of misconduct;

(ii) is:

(a) board-certified in family practice, internal medicine, obstetrics and gynecology, or pediatrics; or

(b) board-admissible in one of the specialties specified in clause (a) of this subparagraph and no more than five years have elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in that specialty; or

(c) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides 24-hour telephone coverage of his or her practice and ensures timely access to a practitioner qualified to respond to patient health needs; this requirement cannot be met by a recording referring patients to emergency rooms;

(iv) provides medical care coordination;

(v) maintains referral linkages with drug treatment programs and local acquired immune deficiency syndrome (AIDS) community-based organizations;

(vi) participates in training recommended by the AIDS Institute of the Department of Health;

(vii) complies with all applicable statutory and regulatory requirements of the MA program; and

(viii) is enrolled in the MA program and accepted for participation in the HIV-EFP by the department and the Department of Health.

(3) Qualified specialist physician, for purposes of this section, means a physician who:

(i) has current admitting privileges at a hospital which has a valid operating certificate issued in accordance with Article 28 of the Public Health Law and is accredited by the JCAH;

(ii) is:

(a) board-certified in a specialty recognized by the Department of Health; or

(b) board-admissible in a specialty recognized by the Department of Health and no more than five years have elapsed since the physician's completion of a residency program accredited by the American Medical Association Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training; or

(c) certified by the Royal College of Physicians and Surgeons of Canada or La Corporation Professelle des Medicins du Quebec;

(iii) provides consultation summaries or appropriate periodic progress notes to a qualified primary care physician on a timely basis following a referral or routinely scheduled consultant visit;

(iv) notifies the primary care physician when scheduling a hospital admission;

(v) maintains complete medical records in compliance with the requirements of section 540.7 of this Title including, but not limited to, notation of referrals and hospitalizations, and copies of test results and reports;

(vi) complies with all applicable statutory and regulatory requirements of the MA program; and

(vii) is enrolled in the MA program and accepted for participation in the HIV-EFP by the department and the Department of Health.

(4) HIV-infected MA recipient, for purposes of this section, means a recipient:

(i) who has tested positive for HIV; or

(ii) who is seeking testing for HIV infection, pre-test counseling or post-test counseling.

(d) Written agreement required. (l) As a condition of participation in the HIV-EFP, each qualified primary care and specialist physician must sign an agreement with the department to meet the minimum standards for participation set forth in either paragraph (2) or paragraph (3) of subdivision (c) of this section.

(2) Each qualified primary care and specialist physician must agree in writing that:

(i) the physician will notify the department within 30 days of any circumstances resulting in his or her ineligibility to participate in the HIV-EFP and/or inability to perform the activities and services required under the agreement;

(ii) the Department of Health has the authority to establish a new payment methodology which supersedes that in effect at the time the physician first entered into an agreement to participate in the HIV-EFP and which may be applied prospectively to services furnished under the program by the physician;

(iii) the physician will comply with all policies, procedures and instructions provided by the department and the Department of Health to implement the HIV-EFP and make claims for payment under the MA program in accordance with the claiming procedures and the payment methodology which the department and the Department of Health establish;

(iv) the department may cancel the physician's participation in the HIV-EFP at any time by providing at least 30 days' written notice; and

(v) the physician will provide the department at least 30 days' written notice of his or her intent to cancel the HIV-EFP agreement, which notice must include a description of the basis for the cancellation. The physician must agree to continue to provide and/or arrange for the provision of medical services for patients up to the date of termination of the HIV-EFP agreement, to assist patients to maintain continuity of care, to provide patients with information to assist them in transferring their care to another provider and to make timely transfer of appropriate information in the patients' records upon request.

(e) Waiver of admitting privileges. (l) The Department of Health may waive the hospital admitting privileges requirement of subparagraph

(c)(2)(i) of this section in individual cases only for a physician who does not have such privileges for one of the following reasons:

(i) admitting privileges are not available at area hospitals; or

(ii) the physician's specialty is not accepted for admitting privileges at area hospitals; or

(iii) the nearest hospital at which admitting privileges could be granted is so far from the physician's office that use of admitting privileges would be impractical; or

(iv) the physician's hours of practice are not sufficient to warrant hospital admitting privileges and the physician has an agreement for provision of hospital care for his other patients with a physician who does have admitting privileges.

(2) A physician requesting a waiver of the requirement must submit the following documentation demonstrating the physician's ability to guarantee coordinated care in the in-patient setting and to meet the standards required for admitting privileges with the application for participation in the HIV-EFP:

(i) a description of the circumstance that merits consideration of a waiver of the requirement; and

(ii) evidence of an agreement between the applicant and a primary care physician who is licensed to practice in New York State and who has active hospital admitting privileges at a hospital certified under Article 28 of the Public Health Law and accredited by the JCAH for monitoring and providing continuity of care to the applicant's patients who are hospitalized;

(iii) a curriculum vitae;

(iv) proof of medical malpractice insurance; and

(v) two letters of reference, each of which must be from a physician who has direct knowledge of and attests to the applicant's qualifications as a practicing physician.

(f) Waiver of board-certification or board admissibility requirements.

(1) The Department of Health may waive the requirements of subparagraph

(c)(2)(ii) of this section based on a finding that the physician is a general practitioner currently serving MA recipients in a geographic area where enrollment of primary care physicians in the MA program is low.

(2) Physicians seeking a waiver under this subdivision must submit the following with the application for participation in the HIV-EFP:

(i) a description of the physician's clinical experience treating persons who are HIV-infected, including the physician's training, the population which the physician serves and referral arrangements; and

(ii) a listing of the primary zip code areas that the physician serves.

(g) Payment. (l) Qualified primary care and specialist physicians will be paid for their services at fees established by the Department of Health and approved by the Director of the Budget.

(2) Qualified primary care physicians may submit claims for HIV counseling performed by persons employed by the qualified primary care physicians who have completed an HIV counseling training program approved by the Department of Health.

(3) Qualified primary care and specialist physicians who provide services in freestanding or hospital-based clinics licensed under Article 28 of the Public Health Law may not submit claims for their services using the HIV-EFP procedure codes if the clinic submits a claim to the MA program and is paid for these services by the program. When the physician's services are not included in the clinic's MA rate, the physician may submit a claim using the regular (non-HIV-EFP) MA procedure codes.

(4) Qualified primary care and specialist physicians who, either individually or as members of a group practice, provide services in the emergency room of a facility licensed under Article 28 of the Public Health Law, pursuant to a contract with that facility, may not submit MA claims for their services using the HIV-EFP procedure codes. When the emergency room physician's services are not included in the Article 28 facility's MA rate, the physician may submit a claim using the regular

(non- HIV-EFP) MA procedure codes.