New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 4 - Fees and Reimbursement
Part 533 - State Reimbursement For Payment To Physicians
Section 533.8 - Human Immunodeficiency Virus Enhanced Fees for Physicians Program (HIV-EFP)
Universal Citation: 18 NY Comp Codes Rules and Regs ยง 533.8
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Scope. The HIV-EFP is a program under which a written agreement is entered into by a provider and the department pursuant to which the department agrees to pay enhanced fees for certain medical services provided to HIV-infected Medical Assistance (MA) recipients. Only qualified primary care and specialist physicians meeting the requirements of this section are eligible to participate in the HIV-EFP. Physicians who wish to participate in the HIV-EFP must apply in writing on forms provided by the department. Applications will be reviewed by and must receive approval of the department and the Department of Health. Participating physicians may obtain payment at the enhanced fees for medical services provided to HIV-infected MA recipients by using special HIV-EFP procedure codes on their MA claims.
(b) Purpose. The purpose of the HIV-EFP is to improve access to quality medical care for HIV-infected MA recipients by paying enhanced fees to physicians meeting the minimum criteria for program participation.
(c) Definitions.
(1) Medical care coordination, for purposes
of this section, means providing or arranging for the provision of:
(i) scheduling of elective hospital
admissions;
(ii) assistance with
emergency admissions;
(iii)
management of and/or participation in hospital care and discharge
planning;
(iv) scheduling of
referral appointments with written referrals as necessary and with requests for
follow-up reports;
(v) scheduling
of necessary ancillary services such as laboratory, radiology, aerosolized
pentamidine, physical therapy and infusion therapy;
(vi) telephone notification to the social
services district responsible for furnishing MA to the recipient when
transportation services are essential to ensure the MA recipient's access to
medically necessary care and services provided under the MA program;
and
(vii) maintenance of complete
medical records in compliance with the requirements of section
540.7 of
this Title including, but not limited to, notation of referrals and
hospitalizations, and copies of test results and reports.
(2) Qualified primary care physician, for
purposes of this section, means a physician who:
(i) has current admitting privileges at a
hospital which has a valid operating certificate issued in accordance with
article 28 of the Public Health Law and accredited by the Joint Commission on
Accreditation of Hospitals (JCAH). The Department of Health may waive this
requirement for a physician who qualifies for hospital admitting privileges but
does not have such privileges for one of the reasons listed in paragraph (e)(1)
of this section and who complies with the requirements of subdivision (e) of
this section; however, the Department of Health will not waive this requirement
for a physician who has been denied or who has lost hospital admitting
privileges based on findings that the physician provided poor quality care or
was guilty of misconduct;
(ii) is:
(a) board-certified in family practice,
internal medicine, obstetrics and gynecology, or pediatrics; or
(b) board-admissible in one of the
specialties specified in clause (a) of this subparagraph and no more than five
years have elapsed since the physician's completion of a residency program
accredited by the American Medical Association Council for Graduate Medical
Education or the American Osteopathic Association Committee on Postdoctoral
Training in that specialty; or
(c)
certified by the Royal College of Physicians and Surgeons of Canada or La
Corporation Professelle des Medicins du Quebec;
(iii) provides 24-hour telephone coverage of
his or her practice and ensures timely access to a practitioner qualified to
respond to patient health needs; this requirement cannot be met by a recording
referring patients to emergency rooms;
(iv) provides medical care
coordination;
(v) maintains
referral linkages with drug treatment programs and local acquired immune
deficiency syndrome (AIDS) community-based organizations;
(vi) participates in training recommended by
the AIDS Institute of the Department of Health;
(vii) complies with all applicable statutory
and regulatory requirements of the MA program; and
(viii) is enrolled in the MA program and
accepted for participation in the HIV-EFP by the department and the Department
of Health.
(3) Qualified
specialist physician, for purposes of this section, means a physician who:
(i) has current admitting privileges at a
hospital which has a valid operating certificate issued in accordance with
article 28 of the Public Health Law and is accredited by the JCAH;
(ii) is:
(a) board-certified in a specialty recognized
by the Department of Health; or
(b)
board-admissible in a specialty recognized by the Department of Health and no
more than five years have elapsed since the physician's completion of a
residency program accredited by the American Medical Association Council for
Graduate Medical Education or the American Osteopathic Association Committee on
Postdoctoral Training; or
(c)
certified by the Royal College of Physicians and Surgeons of Canada or La
Corporation Professelle des Medicins du Quebec;
(iii) provides consultation summaries or
appropriate periodic progress notes to a qualified primary care physician on a
timely basis following a referral or routinely scheduled consultant
visit;
(iv) notifies the primary
care physician when scheduling a hospital admission;
(v) maintains complete medical records in
compliance with the requirements of section
540.7 of
this Title including, but not limited to, notation of referrals and
hospitalizations, and copies of test results and reports;
(vi) complies with all applicable statutory
and regulatory requirements of the MA program; and
(vii) is enrolled in the MA program and
accepted for participation in the HIV-EFP by the department and the Department
of Health.
(4)
HIV-infected MA recipient, for purposes of this section, means a recipient:
(i) who has tested positive for HIV;
or
(ii) who is seeking testing for
HIV infection, pre-test counseling or post-test counseling.
(d) Written agreement required.
(1) As a condition of participation
in the HIV-EFP, each qualified primary care and specialist physician must sign
an agreement with the department to meet the minimum standards for
participation set forth in either paragraph (2) or (3) of subdivision (c) of
this section.
(2) Each qualified
primary care and specialist physician must agree in writing that:
(i) the physician will notify the department
within 30 days of any circumstances resulting in his or her ineligibility to
participate in the HIV-EFP and/or inability to perform the activities and
services required under the agreement;
(ii) the Department of Health has the
authority to establish a new payment methodology which supersedes that in
effect at the time the physician first entered into an agreement to participate
in the HIV-EFP and which may be applied prospectively to services furnished
under the program by the physician;
(iii) the physician will comply with all
policies, procedures and instructions provided by the department and the
Department of Health to implement the HIV-EFP and make claims for payment under
the MA program in accordance with the claiming procedures and the payment
methodology which the department and the Department of Health
establish;
(iv) the department may
cancel the physician's participation in the HIV-EFP at any time by providing at
least 30 days' written notice; and
(v) the physician will provide the department
at least 30 days' written notice of his or her intent to cancel the HIV-EFP
agreement, which notice must include a description of the basis for the
cancellation. The physician must agree to continue to provide and/or arrange
for the provision of medical services for patients up to the date of
termination of the HIV-EFP agreement, to assist patients to maintain continuity
of care, to provide patients with information to assist them in transferring
their care to another provider and to make timely transfer of appropriate
information in the patients' records upon request.
(e) Waiver of admitting privileges.
(1) The Department of Health may
waive the hospital admitting privileges requirement of subparagraph (c)(2)(i)
of this section in individual cases only for a physician who does not have such
privileges for one of the following reasons:
(i) admitting privileges are not available at
area hospitals; or
(ii) the
physician's specialty is not accepted for admitting privileges at area
hospitals; or
(iii) the nearest
hospital at which admitting privileges could be granted is so far from the
physician's office that use of admitting privileges would be impractical;
or
(iv) the physician's hours of
practice are not sufficient to warrant hospital admitting privileges and the
physician has an agreement for provision of hospital care for his other
patients with a physician who does have admitting privileges.
(2) A physician requesting a
waiver of the requirement must submit the following documentation demonstrating
the physician's ability to guarantee coordinated care in the inpatient setting
and to meet the standards required for admitting privileges with the
application for participation in the HIV-EFP:
(i) a description of the circumstance that
merits consideration of a waiver of the requirement; and
(ii) evidence of an agreement between the
applicant and a primary care physician who is licensed to practice in New York
State and who has active hospital admitting privileges at a hospital certified
under article 28 of the Public Health Law and accredited by the JCAH for
monitoring and providing continuity of care to the applicant's patients who are
hospitalized;
(iii) a curriculum
vitae;
(iv) proof of medical
malpractice insurance; and
(v) two
letters of reference, each of which must be from a physician who has direct
knowledge of and attests to the applicant's qualifications as a practicing
physician.
(f) Waiver of board-certification or board admissibility requirements.
(1) The
Department of Health may waive the requirements of subparagraph (c)(2)(ii) of
this section based on a finding that the physician is a general practitioner
currently serving MA recipients in a geographic area where enrollment of
primary care physicians in the MA program is low.
(2) Physicians seeking a waiver under this
subdivision must submit the following with the application for participation in
the HIV-EFP:
(i) a description of the
physician's clinical experience treating persons who are HIV-infected,
including the physician's training, the population which the physician serves
and referral arrangements; and
(ii)
a listing of the primary ZIP code areas that the physician serves.
(g) Payment.
(1) Qualified primary care and specialist
physicians will be paid for their services at fees established by the
Department of Health and approved by the Director of the Budget.
(2) Qualified primary care physicians may
submit claims for HIV counseling performed by persons employed by the qualified
primary care physicians who have completed an HIV counseling training program
approved by the Department of Health.
(3) Qualified primary care and specialist
physicians who provide services in freestanding or hospital-based clinics
licensed under article 28 of the Public Health Law may not submit claims for
their services using the HIV-EFP procedure codes if the clinic submits a claim
to the MA program and is paid for these services by the program. When the
physician's services are not included in the clinic's MA rate, the physician
may submit a claim using the regular (non-HIV-EFP) MA procedure
codes.
(4) Qualified primary care
and specialist physicians who, either individually or as members of a group
practice, provide services in the emergency room of a facility licensed under
article 28 of the Public Health Law, pursuant to a contract with that facility,
may not submit MA claims for their services using the HIV-EFP procedure codes.
When the emergency room physician's services are not included in the article 28
facility's MA rate, the physician may submit a claim using the regular
(non-HIV-EFP) MA procedure codes.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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