Section 360-10.1 Policy.
(a) The regulations contained in this Subpart implement Chapter 165 of the Laws of 1991 which amended section 364-j of the Social Services Law (SSL) to require the establishment of managed care programs (MCPs) throughout the State. An MCP is a program operating in a social services district in which Medical Assistance (MA) recipients receive MA services, including case management services, directly and indirectly (including by referral) from managed care providers. Every MA recipient who resides in a social services district that provides MA under an MCP and is not excluded or exempt from participating is eligible to participate in an MCP.
(b) MCPs will solve some of the problems MA recipients experience in obtaining needed health care. MA recipients will enroll with a managed care provider who will be responsible for providing or arranging for medical services to be provided to MA recipients and assisting them to select needed services prudently. This includes ensuring that participants are referred to primary care physicians who will serve as reliable sources of prompt, on-going, and well- coordinated care.
(c) MCPs are designed to improve the relationship between an MA recipient and his or her health care provider and to ensure the proper delivery of preventive medical care. Such programs will help avoid the problem of MA recipients not receiving needed medical care until the onset of advanced stages of an illness, at which time the recipient will require a higher level of medical care such as emergency room care or in-patient hospital care.
(d) Participation by an MA recipient in an MCP may be voluntary or mandatory. A social services district that proposes a mandatory MCP cannot implement such program until the department applies for and is granted necessary federal waivers.
(e) The commissioner of the department (commissioner), in consultation with social services districts, will require 20 social services districts per year to develop and submit managed care plans. After the commissioner designates the initial 20 social services districts, the commissioner will designate annually 20 additional social services districts to develop managed care plans until all non-exempt social services districts have been designated. A social services district may seek an exemption from the requirement to submit a managed care plan on the basis that managed care would not be cost effective or would reduce the quality of care provided to MA recipients in the district. A social services district must submit its managed care plan to the commissioner within 180 days of the date on which the department notifies the district that the district has been designated to develop and submit a managed care plan. Two or more social services districts may join together in combination to develop and submit a managed care plan. A social services district may also develop and submit a managed care plan to the commissioner for review before the district is designated by the commissioner.
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