N.Y. Comp. Codes R. & Regs. tit. 18 § 505.2

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

Section 505.2 - Physicians' services

(a) General policies. Care provided by physicians to eligible persons shall not be reimbursable as an item of medical assistance when such care does not meet the standards for coverability pursuant to Part 85 of Department of Health regulations or when such care does not meet the definition of medical care or is not considered to be an available service as defined in this Subchapter.

(1) Qualifications of physicians. Physicians shall be licensed and currently registered by the New York State Education Department, or, if in practice in another state, by the appropriate agency of that state. In addition thereto, services ordinarily performed by general practitioners shall be provided only by physicians meeting the qualifications set forth in subparagraph (i) of this paragraph and services ordinarily performed by specialists shall be provided only by physicians meeting the qualifications set forth in subparagraph (ii) of this paragraph.

(i) Qualifications of general practitioners. A general practitioner is a physician who:

(a) is a member of the active or attending staff at a hospital holding a valid operating certificate from the New York State Department of Health; or

(b) is a member in good standing of the American Academy of General Practice or of the American College of General Practitioners in Osteopathic Medicine and Surgery; or

(c) has given satisfactory evidence of completion of a total of 150 hours of continuation education over a three-year period based on standards approved by the State Commissioner of Health in accordance with the following:

(1) not less than 50 hours of the 150 hours required shall be attendance at planned instruction which shall include one or more of the following:

(i) courses conducted by a medical school or school of osteopathy;

(ii) planned continuation education preceptorships or similar practical training approved on an individual basis by the Medical Society of the State of New York or the New York State Osteopathic Society, jointly with the Office of Medical Manpower of the State Department of Health;

(iii) for not more than 20 hours' credit in any given year, preparation and/or presentation of acceptable scientific exhibits or papers evaluated by the Medical Society of the State of New York or the New York State Osteopathic Society, jointly with the Office of Medical Manpower of the State Department of Health;

(iv) continuation education approved for this purpose by the Medical Society of the State of New York or the New York State Osteopathic Society, jointly with the Office of Medical Manpower of the State Department of Health;

(2) the remaining 100 hours of continuation education shall be satisfied by allowing credit on an hour-for-hour basis for attendance at specific scientific meetings, such as the following:

(i) attendance at meetings of medical groups, such as local, State or national, including but not limited to county medical societies, county osteopathic societies, academies of medicine, academies of general practice, district and State medical societies, district and State osteopathic societies, specialty medical meetings and meetings of the American Medical Association and of the American Osteopathic Association;

(ii) attendance at scientific programs, hospital staff meetings or similar medical meetings;

(iii) teaching responsibilities in a teaching hospital or in a medical school, a nursing school or other accredited school which teaches some branch of the health sciences;

(iv) as a preceptor for medical students;

(v) other continuation education activities accepted by the Office of Professional Education of the State Department of Health, jointly with the Medical Society of the State of New York or the New York State Osteopathic Society, as meeting these requirements.

(d) Physicians not possessing the above qualifications shall be given not less than one year, from a date to be determined by the State Commissioner of Health, to meet the qualifications.

(e) If qualification is to be achieved by approved continuation education as provided for in clause (c) of this subparagraph, the physician shall complete such continuation education within three years of the date specified in clause (d).

(f) In extenuating circumstances involving personal or family illness or disability, health emergencies or epidemics in the community endangering the public health, or unavailability of adequate medical coverage through other sources, the above requirements may be waived for any individual physician at the discretion of the State Commissioner of Health.

(ii) Qualifications of specialists. A specialist is a licensed physician who has submitted his or her credentials to the Office of Health Systems Management for review, has been designated a specialist by that office, and who, on the basis of standards approved by the State Commissioner of Health:

(a) is a diplomate of the appropriate American board, or osteopathic board; or

(b) has been notified of admissibility to examination by the appropriate American board, or osteopathic board, or presents evidence of completion of an appropriate qualifying residency approved by the American Medical Association or American Osteopathic Association; or

(c) holds an active staff appointment, with specialty privileges, in a voluntary or governmental hospital which is approved for training in the specialty in which the physician has privileges; or

(d) in psychiatry, a physician may be recognized as a specialist if he satisfies the following additional alternatives:

(1) has been chief or assistant chief psychiatrist in an approved psychiatric clinic and who is recommended for approval by the director of psychiatry of the community mental health board; or

(2) who graduated from medical school prior to July 1, 1946, and who during the last five years has restricted his practice essentially to psychiatry, and is certified by the Commissioner of Mental Hygiene after approval by a committee of the New York State Council of District Branches of the American Psychiatric Association appointed for this purpose by the president of the council.

(b) Dispensary and clinic services and care.

(1) Dispensary and clinic services may be utilized for complete office care, including services by general practitioners and specialists, or may be utilized for special diagnostic, therapeutic or rehabilitative procedures.

(2) Dispensary and/or clinic care shall be provided only in facilities which are operated in compliance with applicable provisions of law and the State Hospital Code.

(c) Specialists.

(1) In addition to the services of general practitioners, the services of specialists and consultants shall be provided when required.

(2) Services ordinarily interpreted to be specialist procedures shall be provided only by physicians qualified as specialists in accordance with this section.

(d) Obstetrical care. Obstetrical care shall include prenatal care in a physician's office or dispensary, delivery in the home or hospital, post-partum care, and, in addition, care for any complications that arise in the course of pregnancy and/or the puerperium.

(e) Abortion.

(1) Definition. For purposes of this section, an abortion shall include medication and procedural abortion that both a pregnant person and provider agree are needed.

(2) Who may provide service. Abortion may be performed by a health care practitioner licensed, certified, or authorized under title eight of the Education Law, acting within their lawful scope of practice.

(3) Establishment of diagnosis of pregnancy. Prior to the performance of an abortion, the health care practitioner must determine and document the estimated duration of the pregnancy in accordance with evidence based clinical guidelines and section 2599-bb of the Public Health Law.

(f) Chronic hemodialysis service in the home. Provision of chronic hemodialysis service in the home shall be based on the recommendation for such home treatment plan from a renal dialysis center or renal dialysis facility and shall require prior approval of the local professional director, except as provided for in section 505.30 of this Part.

(g) Methadone treatment.

(1) Methadone maintenance treatment. Methadone maintenance treatment shall be provided only by physicians, groups of physicians or medical facilities authorized to administer methadone to addicts under a program authorized by State and Federal authorities in accordance with the provisions of 10 NYCRR 80.23. Medical facilities in this subdivision shall mean:

(i) the outpatient service of a hospital with a valid operating certificate; and

(ii) an independent out-of-hospital health facility possessing a valid operating certificate as provided for in article 28 of the Public Health Law or such a facility approved, as appropriate, by the State Department of Mental Hygiene.

(2) Interim methadone treatment. Interim methadone treatment of a drug addict who is on a waiting list for admission to a narcotic facility conducting an authorized methadone maintenance program may be provided by an approved medical facility or by a private physician in accordance with the provisions of 10 NYCRR 80.22.

(3) Reimbursement for methadone treatment and for interim treatment.

(i) Reimbursement for methadone treatment by medical facilities shall be at rates promulgated by the State Director of the Budget.

(ii) Reimbursement for methadone treatment by a private physician shall be in accordance with the applicable fee schedule.

(iii) Methadone dispensed by a private physician shall be reimbursable at cost.

(h) Payment for hysterectomy.

(1) Payment is not available for a hysterectomy if:

(i) it is performed solely for the purpose of rendering an individual permanently incapable or reproducing; or

(ii) if there was more than one purpose to the procedure, it would not have been performed but for the purpose of rendering the individual permanently incapable of reproducing.

(2) Payment is available for a hysterectomy not excluded by paragraph (1) of this subdivision, if:

(i) the person who secured authorization to perform the hysterectomy has informed the individual and her representative, if any, orally and in writing, that the hysterectomy will make the individual permanently incapable of reproducing, and the individual or her representative, if any, has signed a written acknowledgment of receipt of such information; or

(ii) the physician who performed the hysterectomy certifies that one of the following conditions existed:

(a) the woman was sterile before the hysterectomy was performed;

(b) the hysterectomy was performed in a life-threatening emergency in which prior acknowledgment by the recipient was not possible; or

(c) the woman was not a recipient of medical assistance at the time the hysterectomy was performed but subsequently applied for medical assistance and was determined to qualify for medical assistance payment of medical bills incurred before her application, and the woman was informed before the hysterectomy that the procedure would make her permanently incapable of reproducing.

(i) Utilization review.

(1) The department has established utilization review for physician and clinic services. Part 511 of this Title authorizes the department to establish a system for utilization review for specific provider service types including physician and clinic services. Part 511 also describes the services and procedures excluded from the utilization review for all provider service types.

(2) Exclusions. In addition to those services and procedures generally excluded from any utilization review by Section 511.2 of this Title, the following services are excluded from the utilization review established by this subdivision:

(i) Physician services.

(a) anesthesiology services; and

(b) psychiatric services.

(ii) Clinic services.

(a) mental health services, alcoholism treatment services, and developmental disability treatment services provided in clinics certified under Article 28 of the Public Health Law or Article 31 of the Mental Hygiene Law;

(b) ambulatory services ordered by a qualified practitioner;

(c) services provided in a speech and hearing clinic program for children with physical disabilities; and

(d) services provided in an amputee center for children with physical disabilities.

(j) Payment is available for physicians' services which are part of the development of, or furnished pursuant to, an individualized education program and which are provided by a physician employed by, or under contract to, a school district, an approved pre-school, a county in the State or the city of New York. Reimbursement for such services must be made in accordance with the provider agreement.

(k) Payment is available for physicians' services which are part of the development of, or furnished pursuant to, an interim or final individualized family services plan and which are provided by a physician employed by, or under contract to, an approved early intervention program or a municipality in the State. Reimbursement for such services must be made in accordance with the provider agreement.

(l) Gender dysphoria treatment.

(1) As provided in this subdivision, payment is available for medically necessary hormone therapy and/or gender reassignment surgery for the treatment of gender dysphoria.

(2)

(i) Hormone therapy, whether or not in preparation for gender reassignment surgery, shall be covered as follows:

(a) treatment with gonadotropin-releasing hormone agents (pubertal suppressants), based upon a determination by a qualified medical professional that an individual is eligible and ready for such treatment, i.e., that the individual:

(1) meets the criteria for a diagnosis of gender dysphoria;

(2) has experienced puberty to at least Tanner stage 2, and pubertal changes have resulted in an increase in gender dysphoria;

(3) does not suffer from psychiatric comorbidity that interferes with the diagnostic work-up or treatment;

(4) has adequate psychological and social support during treatment; and

(5) demonstrates knowledge and understanding of the expected outcomes of treatment with pubertal suppressants and cross-sex hormones, as well as the medical and social risks and benefits of sex reassignment;

(b) treatment with cross-sex hormones for patients who are sixteen years of age and older, based upon a determination of medical necessity made by a qualified medical professional; patients who are under eighteen years of age must meet the applicable criteria set forth in clause (a).

(ii) Notwithstanding the requirement in clause (b) of subparagraph (i) of this paragraph that an individual be sixteen years of age or older, payment for cross-sex hormones for patients under sixteen years of age who otherwise meet the requirements of clause (b) of subparagraph (i) of this paragraph shall be made in specific cases if medical necessity is demonstrated and prior approval is received.

(3)

(i) Gender reassignment surgery shall be covered for an individual who is 18 years of age or older and has letters from two qualified New York State licensed health professionals who have independently assessed the individual and are referring the individual for the surgery. One of these letters must be from a psychiatrist, psychologist, psychiatric nurse practitioner, or licensed clinical social worker with whom the individual has an established and ongoing relationship. The other letter may be from a psychiatrist, psychologist, physician, psychiatric nurse practitioner, or licensed clinical social worker acting within the scope of his or her practice, who has only had an evaluative role with the individual. Together, the letters must establish that the individual:

(a) has a persistent and well-documented case of gender dysphoria;

(b) has received hormone therapy appropriate to the individual's gender goals, which shall be for a minimum of 12 months in the case of an individual seeking genital surgery, unless such therapy is medically contraindicated or the individual is otherwise unable to take hormones;

(c) has lived for 12 months in a gender role congruent with the individual's gender identity, and has received mental health counseling, as deemed medically necessary, during that time;

(d) has no other significant medical or mental health conditions that would be a contraindication to gender reassignment surgery, or if so, that those are reasonably well-controlled prior to the gender reassignment surgery; and

(e) has the capacity to make a fully informed decision and to consent to the treatment.

(ii) Notwithstanding subparagraph (i) of this paragraph, payment for gender reassignment surgery, services, and procedures for patients under eighteen years of age may be made in specific cases if medical necessity is demonstrated and prior approval is received.

(4) For individuals meeting the requirements of paragraph (3) of this subdivision, Medicaid coverage will be available for the following gender reassignment surgeries, services, and procedures, based upon a determination of medical necessity made by a qualified medical professional:

(i) mastectomy, hysterectomy, salpingectomy, oophorectomy, vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, penectomy, orchiectomy, vaginoplasty, labiaplasty, clitoroplasty, and/or placement of a testicular prosthesis and penile prosthesis;

(ii) breast augmentation, provided that: the patient has completed a minimum of 24 months of hormone therapy, during which time breast growth has been negligible; or hormone therapy is medically contraindicated; or the patient is otherwise unable to take hormones;

(iii) electrolysis when required for vaginoplasty or phalloplasty; and

(iv) such other surgeries, services, and procedures as may be specified by the Department in billing guidance to providers.

(5) For individuals meeting the requirements of paragraph (3) of this subdivision, surgeries, services, an d procedures in connection with gender reassignment not specified in paragraph (4) of this subdivision, or to be performed in situations other than those described in such paragraph, including those done to change the patient's physical appearance to more closely conform secondary sex characteristics to those of the patient's identified gender, shall be covered if it is demonstrated that such surgery, service, or procedure is medic ally necessary to treat a particular patient's gender dysphoria, and prior approval is received. Coverage is not available for surgeries, services, or procedures that are purely cosmetic, i.e., that enhance a patient's appearance but are not medically necessary to treat the patient's underlying gender dysphoria.

(6) All legal and program requirements related to providing and claiming reimbursement for sterilization procedures must be followed when transgender care involves sterilization.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.2

Amended New York State Register March 11, 2015/Volume XXXVII, Issue 10, eff. 3/11/2015

Amended New York State Register April 27, 2016/Volume XXXVIII, Issue 17, eff. 4/27/2016

Amended New York State Register August 31, 2016/Volume XXXVIII, Issue 35, eff. 8/31/2016

Amended New York State Register December 7, 2016/Volume XXXVIII, Issue 49, eff. 12/7/2016

Amended New York State Register September 13, 2023/Volume XLV, Issue 37, eff. 9/13/2023

Amended New York State Register October 2, 2024/Volume XLVI, Issue 40, eff. 10/2/2024