N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-6.8

Current through Register Vol. 46, No. 45, November 2, 2024

Section 360-6.8 - Medical care coordinator program (MCCP)

(a) Policy. Effective July 1, 1992, a recipient who is eligible for medical assistance (MA) solely as a result of being eligible for or in receipt of home relief (HR) and who is at least 21 years of age but under the age of 65 (MA/HR recipient), may receive certain MA services only if the recipient is enrolled in a health maintenance organization or other entity which provides comprehensive health services, a managed care program, a primary provider program, or a voluntary medical care coordinator program (MCCP).

(b) Scope. This section defines the MCCP; specifies the rights of participating recipients; establishes the qualifications and responsibilities of participating primary physicians, diagnostic and treatment centers, hospital out-patient departments and pharmacies in providing and coordinating medical care, services and supplies for participating recipients; and sets forth the responsibilities of social services districts in administering the MCCP.

(c) Definitions. As used in this section, unless expressly stated otherwise or unless the context of the subject matter requires a different interpretation:

(1) MCCP means a program in which an MA/HR recipient voluntarily enrolls with a primary physician, diagnostic and treatment center or hospital out-patient department and a primary pharmacy which will provide or refer the MA recipient to medically necessary services and will further coordinate the use of medical services to assure that the recipient receives appropriate medical care, services and supplies and that MA is provided in an appropriate and cost-effective manner.

(2) MA/HR recipient means a person who is eligible for MA solely as a result of being eligible for or in receipt of HR and who is at least 21 years of age but under the age of 65.

(3) Primary provider means a physician, diagnostic and treatment center, or hospital out-patient department enrolled in the MA program which has agreed to coordinate the health care of an MA/HR recipient and to provide and/or direct all medically necessary care, services and supplies for which the MA/HR recipient is eligible.

(4) Primary pharmacy means a pharmacy enrolled in the MA program which has agreed to provide all drugs and pharmaceutical supplies ordered for an MA/HR recipient enrolled in the MCCP.

(d) Recipient participation. Participation by an MA/HR recipient in the MCCP is voluntary.

(e) Recipient responsibilities.

(1) An MA/HR recipient who wishes to participate in the MCCP must obtain a copy of the provider selection form from his or her social services district, complete the form and return it to the social services district.

(2) The MA/HR recipient must identify on such form his or her choice of primary physician, diagnostic and treatment center or hospital out-patient department, and his or her choice of primary pharmacy, and obtain agreement from the providers that they will be the primary provider and primary pharmacy. An identified provider agrees to be a primary provider or primary pharmacy for an MA/HR recipient by signing a selection form.

(3) An MA/HR recipient who participates in the MCCP may change his or her primary provider or primary pharmacy by completing a provider change form furnished by the social services district if another primary provider or primary pharmacy satisfactory to the recipient agrees to act as the primary provider or primary pharmacy.

(4) An MA/HR recipient who participates in the MCCP may withdraw from the MCCP at any time by completing a recipient withdrawal form furnished by the social services district.

(5) If an MA/HR recipient volunteers to participate in the MCCP but no primary provider or primary pharmacy is sufficiently accessible or no primary provider or primary pharmacy which is sufficiently accessible agrees to be the recipient's primary provider or primary pharmacy, the recipient may receive the MA services which are available to participating MA/HR recipients without enrolling in the MCCP. The recipient will continue to receive these services until a provider or pharmacy affiliated with a health maintenance organization or other entity which provides comprehensive health services, a managed care program, a primary provider program, or the MCCP is sufficiently accessible and agrees to provide medical care or pharmacy services to the recipient, at which time the MA/HR recipient must enroll in such program in order to continue to receive such MA services.

(f) Provider responsibilities.

(1) A primary provider or primary pharmacy must furnish written confirmation to a social services district, prior to acting as a primary provider or primary pharmacy, of the provider's agreement to act as primary provider or primary pharmacy and to comply with all requirements of this section. A provider confirms such agreement by signing the provider selection form presented by the MA/HR recipient.

(2) A primary provider or primary pharmacy may act as a primary provider or primary pharmacy with respect to a particular MA/HR recipient only on and after the effective date of the recipient's enrollment in the MCCP. The social services district will inform the primary provider or primary pharmacy in writing of the recipient's enrollment in the MCCP.

(3) A primary provider is responsible for providing, either directly or through referral to another qualified MA provider, all MA covered care, services and supplies to an MA/HR recipient enrolled in the MCCP. The primary provider is responsible for ordering or directing the following services for an enrolled MA/HR recipient:

(i) laboratory services;

(ii) durable medical equipment;

(iii) pharmacy services; and

(iv) medically necessary and appropriate nonemergency transportation services.

(4) A physician acting as primary provider for an enrolled MA/HR recipient will receive a monthly management fee of $10 for managing and coordinating the care of each MA/HR recipient for which the physician is the primary provider.

(5) A pharmacy acting as primary pharmacy must institute and maintain a current patient profile for each enrolled MA/HR recipient. A current patient profile must contain: the identity of the prescriber of a drug or pharmaceutical supply; the strength, quantity and dosage regimen of a drug; and the date of service for the dispensing of a drug or pharmaceutical supply. A current patient profile must be readily accessible to the department and its designated agents upon request. The primary pharmacy also must adhere to all drug utilization review requirements under the MA program.

(g) Social services district responsibilities.

(1) Each social services district will be primarily responsible for administration of the MCCP.

(2) Each social services district must take actions necessary for the efficient and effective functioning of the MCCP, including:

(i) assisting MA/HR recipients to enroll in the MCCP;

(ii) assisting enrolled MA/HR recipients to choose primary providers and primary pharmacies;

(iii) processing the provider selection forms promptly and determining the effective dates of recipients' enrollment in the MCCP;

(iv) providing written notice to MA/HR recipients and identified primary providers and primary pharmacies confirming the MA/HR recipients' effective dates of enrollment in the MCCP;

(v) processing primary provider and primary pharmacy change forms and recipient withdrawal forms promptly and determining the effective dates of changes or withdrawals from the MCCP;

(vi) providing to MA/HR recipients and the primary providers and primary pharmacies a written notice confirming the effective dates of MA/HR recipients' participation in or withdrawals from the MCCP and providing to MA/HR recipients a list of the MA services which the recipients will become ineligible to receive upon the effective dates of withdrawals unless the MA/HR recipients have enrolled in other managed care programs;

(vii) determining whether available primary providers are sufficiently accessible to MA/HR recipients so that services can be reasonably provided to recipients;

(viii) advising the department when recipients have problems obtaining access to primary providers or primary pharmacies; and

(ix) entering necessary data into WMS to support timely implementation of the MCCP and recipients' enrollment, changes in primary providers or primary pharmacies, or withdrawals from MCCP.

N.Y. Comp. Codes R. & Regs. Tit. 18 §§ 360-6.8