Section 360-11.3 Definitions. As used in this Subpart unless expressly stated otherwise
or unless the context of the subject matter requires a different interpretation:
(a) The terms defined in Section 360-10.3 of this Title have the same
meaning when used in this Subpart.
(b) Special care means care, services and supplies relating to the
treatment of mental illness, mental retardation, developmental disabilities, alcoholism,
alcohol abuse or substance abuse, the costs of which are covered under the MA program.
(c) Long term special care services for persons with chronic illness
means the following special care services:
(1) methadone maintenance treatment programs
(MMTP) as authorized by 14 NYCRR 1040;
(2) medically supervised ambulatory substance
abuse services as authorized by 14 NYCRR 1035;
(3) outpatient alcoholism rehabilitation
services as authorized by 14 NYCRR 372;
(4) intensive psychiatric rehabilitation
treatment programs (IPRT) as authorized by 14 NYCRR 587.12;
(5) day treatment as authorized by 14 NYCRR
585.11;
(6) continuing day treatment as authorized by
14 NYCRR 587.10;
(7) intensive case management (ICM) for persons
with mental illness as authorized by 18 NYCRR 505.16;
(8) partial hospitalization as authorized by 14
NYCRR 587.11;
(9) rehabilitation services provided to
residents of Office of Mental Health (OMH) licensed residential programs for adults or
children as authorized by 14 NYCRR 587.4;
(10) services for children with serious
emotional disturbance provided by certain OMH designated clinics as authorized by 14 NYCRR
587.9;
(11) services provided to retarded and
developmentally disabled persons through the care at home and home and community based
services waivers granted under 42 U.S.C. 1396n(c);
(12) habilitation services provided by
facilities licensed under Article 16 of the Mental Hygiene Law and certain clinic
treatment facilities licensed under Article 28 of the Public Health Law, as described in
14 NYCRR 679;
(13) day treatment as authorized by 14 NYCRR
690; and
(14) comprehensive medicaid case management
(CMCM) for developmentally disabled persons as authorized by 18 NYCRR 505.16.
(d) Special care furnished on more than an incidental basis means any
special care provided to a participant in an MCP who is a recipient of Supplemental
Security Income (SSI) under Title XVI of the federal Social Security Act and long term
special care services for persons with chronic illness provided to any other participant
in an MCP.
(e) Managed special care provider means an entity that provides,
directly or indirectly (including by referral), either special care, or special care in
conjunction with other services provided under the MA program, as part of an MCP.
(f) Health services only managed care provider means a managed care
provider that agrees to furnish a benefit package, excluding all special care services, to
participants receiving SSI and participants having established treatment relationships
with providers of special care in MCPs that exclude the provision of special care to
participants who require special care furnished on more than an incidental basis.
(g) Established treatment relationship with a provider of special care
means that an MA recipient has made 10 or more patient visits to a special care provider
in the past 12 months and is reasonably expected to continue to need such frequency of
special care in the next 12 months.
(h) Responsible special care agency (RSCA) means whichever of the
following State agencies has responsibility for the special care being provided: the OMH,
the Office of Mental Retardation and Developmental Disabilities (OMRDD); and the Office of
Alcoholism and Substance Abuse Services (OASAS).