N.Y. Social Services Law Section 364-F
Primary care case management programs

1.

The department is authorized to establish primary care case management programs, under the medical assistance program, in accordance with applicable federal law and regulations. Primary care case management programs shall only be authorized in areas of the state where comprehensive health services plans, as defined in Public Health Law § 4401 (Definitions)section forty-four hundred one of the public health law, are not yet available. Subject to the approval of the director of the budget, the commissioner is authorized to apply for the appropriate waivers under federal law and regulation, and may waive any of the provisions of sections three hundred sixty-five-a, three hundred sixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a and three hundred sixty-four-j of this chapter or any regulation of the department when such action would be necessary to assist in promoting the objectives of this section.

2.

(a) A primary care case management program shall provide individuals eligible for medical assistance with the opportunity to select a primary care case manager who shall provide medical assistance services to such eligible individuals, either directly, or through referral.

(b)

Primary care case managers shall be limited to qualified, licensed primary care practitioners, as defined in paragraph (f) of subdivision one of § 364-J (Managed care programs)section three hundred sixty-four-j of this chapter, who meet standards established by the commissioner for the purposes of this program.

(c)

Services that may be covered by the primary care case management program are defined by the commissioner in the benefit package. Covered services may include all medical assistance services defined under § 365-A (Character and adequacy of assistance)section three hundred sixty-five-a of this chapter, except:

(i)

services excluded under paragraph (e) of subdivision three of § 364-J (Managed care programs)section three hundred sixty-four-j of this chapter shall be excluded under this section;

(ii)

services provided by residential health care facilities, long term home health care programs, child care agencies, and entities offering comprehensive health services plans;

(iii)

services provided by dentists and optometrists; and

(iv)

eyeglasses, emergency care, mental health services and family planning services.

(d)

Case management services provided by primary care case managers shall include, but need not be limited to:

(i)

management of the medical and health care of each recipient to assure that all services provided under paragraph (c) of this subdivision and which are found to be necessary, are made available in a timely manner;

(ii)

referral to, and coordination, monitoring and follow-up of, appropriate providers for diagnosis and treatment, the need for which has been identified by the primary care case manager but which is not directly available from the primary care case manager, and assisting medical assistance recipients in the prudent selection of medical services;

(iii)

arrangements for referral of recipients to appropriate providers; and

(iv)

all early periodic screening, diagnosis and treatment services, as well as interperiodic screening and referral, to each participant under the age of twenty-one at regular intervals.

3.

(a) Primary care case management programs may be conducted only in accordance with guidelines established by the commissioner. For the purpose of implementing and administering the primary care case management programs, the commissioner may contract with private not-for-profit and public agencies as defined in guidelines established by the commissioner for the management and administration of the primary care case management program.

(b)

The primary care case management program must:

(i)

assure access to and delivery of high quality, appropriate medical services;

(ii)

participate in quality assurance activities as required by the commissioner, as well as other mechanisms designed to protect recipient rights under such program;

(iii)

ensure that persons eligible for medical assistance will be provided sufficient information regarding the program to make an informed and voluntary choice whether to participate; and

(iv)

provide for adequate safeguards to protect recipients from being misled concerning the program and from being coerced into participating in the primary care case management program.

4.

(a) Individuals eligible to participate in Medicaid managed care, to participate in Medicaid managed care may participate in a primary care case management program, subject to the availability of such a program within the applicable social services district, except for individuals:

(i)

required by Medicaid managed care to be enrolled in an entity offering a comprehensive health services plan as defined in paragraph (k) of subdivision two of § 365-A (Character and adequacy of assistance)section three hundred sixty-five-a of this chapter;

(ii)

participating in another medical assistance reimbursed demonstration or pilot project, or

(iii)

receiving services as an inpatient from a nursing home or intermediate care facility or residential services from a child care agency or services from a long term home health care program.

(b)

Individuals choosing to participate in a primary care case management program will be given thirty days from the effective date of enrollment in the program to disenroll without cause. After this thirty day disenrollment period, all individuals participating in the program will be enrolled for a period of twelve months, except that all participants will be permitted to disenroll for good cause, as defined in guidelines established by the commissioner.

5.

(a) Primary care case management programs may include provisions for innovative payment mechanisms, including, but not limited to, payment of case management fees, capitation arrangements, and fee-for-service payments.

(b)

Any new payment mechanisms and levels of payment implemented under the primary care case management program shall be developed by the commissioner subject to the approval of the director of the budget.

6.

Notwithstanding any inconsistent provision of this section, participation in a primary care case management program will not diminish the scope of available medical services to which a recipient is entitled.

7.

This section shall be effective if, and as long as, federal financial participation is available therefor. * NB Expires March 31, 2026

Source: Section 364-F — Primary care case management programs, https://www.­nysenate.­gov/legislation/laws/SOS/364-F (updated May 12, 2023; accessed Oct. 26, 2024).

363
Declaration of objects 363‑A
Federal aid 363‑B
Agreements for federal determination of eligibility of aged, blind and disabled persons for medical assistance 363‑C
Medicaid management 363‑D
Provider compliance program 363‑E
Medicaid plan, applications for waivers and plan amendments 363‑F
Electronic visit verification for personal care and home health providers 364
Responsibility for standards 364‑A
Cooperation of state departments 364‑B
Residential and medical care placement demonstration projects 364‑C
National long term care channeling demonstration project 364‑D
Medical assistance research and demonstration projects 364‑E
Aid to families with dependent children homemaker/home health aide demonstration projects 364‑F
Primary care case management programs 364‑G
Medical assistance capitation rate demonstration project 364‑H
Foster family care demonstration programs for elderly or disabled persons 364‑I
Medical assistance presumptive eligibility program 364‑J
Managed care programs 364‑J‑2
Transitional supplemental payments 364‑JJ
Special advisory review panel on Medicaid managed care 364‑KK
Condition of Participation 364‑M
Statewide patient centered medical home program 364‑N
Diabetes and chronic disease self-management pilot program 365
Responsibility for assistance 365‑A
Character and adequacy of assistance 365‑B
Local medical plans: professional directors 365‑C
Medical advisory committee 365‑D
Medicaid evidence based benefit review advisory committee 365‑E
Optional or continued membership in entities offering comprehensive health services plans 365‑F
Consumer directed personal assistance program 365‑G
Utilization review for certain care, services and supplies 365‑H
Provision and reimbursement of transportation costs 365‑J
Advisory opinions 365‑K
Provision of prenatal care services 365‑L
Health homes 365‑M
Administration and management of behavioral health services 365‑N
Department of health assumption of program administration 365‑O
Provision and coverage of services for living organ donors 365‑P
Doulas for Medicaid 366
Eligibility 366‑A
Applications for assistance 366‑B
Penalties for fraudulent practices 366‑C
Treatment of income and resources of institutionalized persons 366‑D
Medical assistance provider 366‑E
Certified home health agency medicare billing 366‑F
Persons acting in concert with a medical assistance provider 366‑G
Newborn enrollment for medical assistance 366‑H
Automated system 366‑I
Long-term care financing demonstration program 367
Authorization for hospital care 367‑A
Payments 367‑B
Medical assistance information and payment system 367‑C
Payment for long term home health care programs 367‑D
Personal care need determination 367‑E
Payment for AIDS home care programs 367‑F
Partnership for long term care program 367‑G
Authorization and provision of personal emergency response services 367‑H
Payment for assisted living programs 367‑I
Personal care services provider assessments 367‑O
Health insurance demonstration programs 367‑P
Responsibilities of local districts for personal care services, home care services and private duty nursing 367‑P*2
Payment for limited home care services agencies 367‑Q
Personal care services worker recruitment and retention program 367‑R
Private duty nursing services worker recruitment and retention program 367‑S
Long term care demonstration program 367‑S*2
Emergency medical transportation services 367‑T
Payment for emergency physician services 367‑U
Payment for home telehealth services 367‑V
County long-term care financing demonstration program 367‑W
Health care and mental hygiene worker bonuses 367‑X
Payment for violence prevention programs 367‑Y
Reimbursement for treatment in place and transportation to alternative health care settings 368
Quarterly estimates 368‑A
State reimbursement 368‑B
State reimbursement to local health districts 368‑C
Audit of state rates of payment to providers of health care services 368‑D
Reimbursement to public school districts and state operated/state supported schools which operate pursuant to article eighty-five, eighty... 368‑E
Reimbursement to counties for pre-school children with handicapping conditions 368‑F
Reimbursement of costs under the early intervention program 369
Application of other provisions
Green check means up to date. Up to date

Accessed:
Oct. 26, 2024

Last modified:
May 12, 2023

§ 364-F’s source at nysenate​.gov

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