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Title: Section 85.44 - Minimum Standards Preferred Primary Care Providers (PPCP)

Effective Date


85.44 Minimum Standards Preferred Primary Care Providers (PPCP).

(a) Purpose. The purpose of these regulations is to establish minimum standards to qualify as a Preferred Primary Care Provider (PPCP). Preferred primary care is a comprehensive range of services aimed at improving access to and availability of comprehensive primary health care to Medicaid eligible and medically indigent persons and persons in underserved areas and assuring that minimum standards of care and services will be upheld.

(b) Eligibility.

(1) Eligibility is extended to providers of comprehensive primary care services licensed under Article 28 of the Public Health Law:

(i) Licensed diagnostic and treatment centers which primarily provide a comprehensive range of primary medical services, or

(ii) Hospital-based outpatient departments.

(2) Providers included in PPCP shall have an approved provider agreement with the Department of Health and in addition shall meet minimum standards pursuant to this section and the goals and performance standards developed by the program and accepted by the Department. In the event the provider fails to abide by the provisions of the provider agreement, the Commissioner shall require prompt corrective action, impose sanctions or revoke the provider agreement as the facts may warrant.

(3) The facility shall participate in the Child/Teen Health Program.

(c) General requirements.

(1) Continuity of care. Continuity of care shall be assured by:

(i) assigning the same primary care practitioner, or team of such practitioners, who assume the principal responsibility for the care of each patient and follow the patient on each health care encounter;

(ii) provision of a tracking and referral system to document care given to the patient when patient is sent to an emergency service, hospital, or other provider of health care services. Facility staff shall assist the patient with arrangements or make arrangements for the patients for off-site services, facilitate receipt of those services, monitor reports of results of off site services, and integrate results into patient records;

(iii) provision for follow-up of missed appointments via telephone, outreach worker visit, letter or telegram that is appropriate to the urgency of the patient's need; and

(iv) approved hospitals making specialty services available to hospital and diagnostic and treatment center-based PPCPs and to practitioners enrolled in the Preferred Physician and Children Program in their service area.

(2) PPCPs shall enroll eligible children and their families in the Child Health Insurance Program and accept such reimbursement for primary care services of the facility.

(3) Scheduling of appointments and hours of operation.

(i) Operational hours of the facility shall be at least 5 days per week for 40 hours during weekdays with an additional 8 hours during evenings or weekends. Alternate scheduling of hours may be established to meet the needs of patients upon written approval of the Commissioner.

(ii) Patients shall have prompt access via telephone to a clinical staff member on a 24 hours basis for health care emergency problems.

(iii) Service scheduling shall accommodate personal appointments, walk-in patients and referrals.

(iv) Appointment scheduling shall allow ample time to include physical examinations, treatments and patient teaching.

(v) Appointments for non-urgent visits for current patients of the program shall be available in no more than two weeks from the time of a request, 90 percent of the time. Appointments for non-urgent visits by new patients shall be available in no more than four weeks from the time of request. Patients shall be triaged to assure that urgent and emergency care patients which can be managed by the facility receive medical care in a timely manner.

(4) Practitioner credentials.

(i) Staff physicians shall have training, experience and qualifications appropriate to the needs of their patients.

(ii) Specialists shall be board certified or admissible or shall have equivalent training and experience to qualify them to practice in the specialty area.

(iii) Sufficient other practitioners duly licensed and qualified to meet the primary medical care needs of patients shall be available to meet patient need.

(iv) A portion of the physician members of the medical staff sufficient to meet patient needs of the PPCP shall have admitting privileges in affiliate hospitals. The PPCP, and its physicians who are affiliated with a hospital and sending or admitting patients to the hospital from the PPCP, shall work to facilitate coordination of care and information transfer about PPCP patients between the inpatient and ambulatory care facilities. Alternatively, where diagnostic and treatment center-based physicians are not able to gain hospital inpatient admission privileges, the facility shall have hospital backup agreements which provide prompt hospital admission and discharge information to the PPCP. (5) The facility shall participate in local social service district managed care programs for Medicaid recipients when requested by the local district.

(d) Primary Care Services.

(1) Primary care services shall include the fields of internal medicine, obstetrics/gynecology, family practice and pediatrics.

(2) The facility shall provide, directly or by contract, diagnostic radiology, pharmacy and clinical laboratory services, in accordance with patient needs; make arrangements for and assure receipt of services; and ensure receipt of radiology and laboratory reports.

(3) Services the facility provides under contract shall comply with section 400.4 of this Title and contracts shall:

(i) be available for review and inspection by the Department of Health;

(ii) include assurances that the Department of Health has access to agent or agency sites and records to conduct on-site program compliance reviews; and

(iii) require that the subcontractors provide contracted care and services that meet the minimum standards established in this section and are provided in accordance with generally accepted standards of practice and patient care services.

(4) PPCP shall provide or arrange for, but not be limited to, the following preventive health services:

(i) hypertension control;

(ii) diabetes control;

(iii) immunization;

(iv) healthy lifestyles promotion;

(v) cervical, breast and colon cancer screening;

(vi) HIV screening and counseling;

(vii) family planning;

(viii) sexually transmissible disease services; and

(ix) prenatal care and services.

(5) The PPCP shall be organized, equipped and staffed for effective management of the following medical conditions in an ambulatory setting which are associated with excess inpatient hospital admissions:

(i) adult otitis media;

(ii) pediatric otitis media;

(iii) respiratory infection;

(iv) chronic obstructive pulmonary disease;

(v) adult pneumonia;

(vi) pediatric pneumonia;

(vii) adult bronchitis/asthma;

(viii) pediatric bronchitis/asthma;

(ix) heart conditions including angina and chest pain;

(x) cellulitis and differential diagnosis.

(6) Providers shall conduct a psychosocial assessment of each patient, to identify social, economic, psychological and emotional problems which present obstacles to health and treatment. When problems are identified the PPCP shall make referral, as appropriate to the patient needs, to the local Department of Social Services, community mental health resources, alcohol and substance abuse providers and support groups or social/psychological specialists.

(7) Nutrition promotion services. The provider shall establish and implement, directly or by referral, a program of nutrition screening and counseling which includes:

(i) individual nutrition risk assessment, including screening for specific nutritional risk conditions at the initial visit and continuing reassessment as needed;

(ii) professional nutrition counseling, monitoring and follow-up of all patients at nutritional risk;

(8) Records. The facility shall collect such information and make it available in such form as the Commissioner shall require.

(e) Quality Assurance. Preferred Primary Care Providers shall monitor provision of quality care through the facility quality assurance program through performance indicators. The program shall include but not be limited to the following activities in addition to the facility-wide activities of the quality assurance program:

(1) determining patient satisfaction with all components of services including those provided through contracts and by arrangement,

(2) determining and documenting the extent to which the PPCP reaches medically underserved populations in the facility services area, and

(3) determining the extent to which services of the facility are successful in managing, on an ambulatory care basis, patient medical conditions which are associated with excess hospital admissions.


VOLUME A-1a (Title 10)