New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter II - Administrative Rules and Regulations
Subchapter R - Health Maintenance Organizations
Part 98 - Health Maintenance Organizations
Subpart 98-1 - Managed Care Organizations
Section 98-1.13 - Assurance of access to care
Current through Register Vol. 47, No. 12, March 26, 2025
(a) All covered services must be directly provided or arranged for within the approved provider network pursuant to written contracts developed and maintained in a form and manner prescribed by the commissioner, except that when services are unavailable within the provider network, such services must be arranged for outside of the approved provider network. An MCO shall establish a process for the resolution of requests for medically necessary services to be provided by out-of-network providers when such services are not available in network. Such process shall require the approval of the commissioner prior to implementation and shall thereupon be included in the member handbook. Emergency services do not require prior authorization; no MCO or utilization review agent may require enrollees to obtain prior authorization for the provision of such services.
(b) The limitation in subdivision (a) of this section, and other limitations imposed on accessing the entire approved network, must be clearly transmitted to eligible persons and enrollees via marketing materials, member handbooks and subscriber contracts.
(c)
(d) An MCO which provides primary care services shall make available to each enrollee a primary care practitioner to supervise and coordinate the health care of the enrollee. In the case of an HIV SNP, the primary care practitioners for enrollees with HIV infection must meet HIV specialist requirements as defined by the commissioner; the qualifications of HIV specialist primary care practitioners shall be reassessed annually to assure the requirements for HIV specialist status are met. The HIV SNP member-to-primary care practitioner ratios shall be developed to reflect HIV SNP patient caseload characteristics as prescribed by the commissioner. When required by Federal and/or State law or regulation, an enrollee of an MCO who is dissatisfied with the assigned or selected primary care practitioner shall be allowed to select another. However, the MCO may impose a reasonable waiting period to accomplish this transfer. Waiting times for enrollees eligible for benefits under title XIX shall be consistent with section 364-j of the Social Services Law.
(e) The HIV SNP shall ensure all enrollees access to a full continuum of HIV- specific care, treatment and prevention through:
(f) The MLTCP shall assure that all covered services are available and accessible by:
(g) The MLTCP shall promote continuity of care and integration of services through:
(h) The MCO, or the primary care practitioner on behalf of the MCO, shall be responsible for the management of care for enrollees, including the identification and selection of an appropriate provider of care in each individual instance where services are determined to be necessary for the enrollee. An MCO shall provide, or make arrangements for the provision of the full range of comprehensive health services as defined in section 98-1.2(g) of this Subpart and as covered in the approved benefit package to enrollees. MCOs shall provide such comprehensive health services without exclusion of any appropriately registered, certified or licensed type of provider as a class from participation in such MCO.
(i) When an enrollee is referred by an MCO or by an MCO primary care practitioner or MCO provider authorized by the MCO to make such referrals to a participating or nonparticipating specialist for services included in the enrollee contract with such MCO, the enrollee shall incur no financial liability other than required co-payments.
(j) An MCO shall have a written procedure describing coverage for emergency health services received by an enrollee outside of the MCO's service area. The MCO coverage for emergency health services shall be consistent with article 49 of the Public Health Law and, in the case of an entity providing services to Medicare beneficiaries, consistent with Federal law and regulation, and clearly described in both the enrollee contract and the enrollee handbook.
(k) Medical offices and premises not subject to the jurisdiction of article 28 of the Public Health Law, in which primary ambulatory care services are provided to MCO enrollees, shall conform to professional and generally accepted standards of medical practice.
(l) The MCO shall establish procedures to obtain consent from each enrollee for release of such enrollee's medical records to ensure that it has access to the medical records of enrollees upon request for review by the MCO and the department for the purposes authorized by law. This shall be assured through an explicit provision in the contracts between the MCO and providers, the MCO and an IPA, and an IPA and providers.
(m) MCOs shall require that network providers comply with all HIV confidentiality requirements pursuant to title 27-F and section 2784 of the Public Health Law, through express provision in contracts with providers and express reference in provider manuals. An HIV SNP shall establish procedures for assuring the confidentiality of medical information of all enrolled HIV-infected individuals, including mechanisms to address breaches of confidentiality and a training program for all HIV SNP employees regarding confidentiality and disclosure of HIV-related information.
(n) Utilization review program standards for retrospective review of a pre-authorized treatment, service, or procedure. An MCO may reverse a pre-authorized treatment, service or procedure on retrospective review pursuant to section 4905 (5) of the Public Health Law only when:
(o) An MCO shall have written procedures for the implementation of the transitional period provisions set forth in sections 4403 (6)(e) and (f) and 4408 (4) of the Public Health Law.
(p) A MCO shall meet standards for network adequacy and access standards for mental health and substance use disorder treatment services set forth in Subpart 98-5.