360-10.4 MCP requirements.

    (a) An MCP will be operated by a social services district in accordance with a managed care plan approved by the commissioner.

    (b) An MCP must provide MA recipients with access to comprehensive and coordinated health care which is delivered in a cost-effective manner.

    (c) An MCP operating in a social services district with a general population over 350,000 must offer participants a choice of at least three managed care providers and must offer at least one managed care provider other than a general hospital. If the social services district designates a major public hospital, as defined by the Public Health Law, as a managed care provider, the district must designate at least two other managed care providers which are not major public hospitals or facilities operated by major public hospitals.

    (d) An MCP must establish procedures through which participants will be assured of access to all MA services to which they are otherwise entitled. Such services include those which are not provided through the managed care provider, emergency services, services which are not geographically accessible, and family planning services. A recipient's MA eligibility or the scope of medical services to which the recipient is entitled will not be diminished by participation in an MCP.

    (e) A social services district must provide participants with a choice of at least three primary care practitioners within a managed care provider.

    (f) For all other medical services, except as provided in subdivision (e) of this section, if enough medical services providers are affiliated with the managed care provider, a choice must be offered.

    (g) Managed care providers must provide or arrange for the provision of MA services to eligible participants, including primary care, case management and referral, coordination, monitoring and follow-up of the participant's medical and health care needs, in order that all necessary services provided under the MCP are made available in a timely manner.

    (h) Managed care providers may agree with a social services district to provide any MA service defined under section 365-a of the SSL, except services provided by residential health care facilities, Long Term Home Health Care Programs, and hospices where a participant is receiving services from such providers.

    (i) Managed care providers must establish appropriate utilization and referral requirements for furnishing of services to participants by non-participating primary care practitioners, hospitals, and other medical services providers, including emergency room visits and in- patient hospital admissions.

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