N.Y. Comp. Codes R. & Regs. tit. 18 § 533.7

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

Section 533.7 - Preferred Physicians and Children Program

(a) Scope. The Preferred Physicians and Children Program (PPAC) is a program under which a written agreement is entered into by a provider and the department pursuant to which the department pays enhanced fees for certain medical services provided to children under the age of 21 who are eligible for Medical Assistance (MA). Only qualified primary care and specialist physicians meeting the requirements of this section are eligible to participate in PPAC. Physicians who wish to participate in PPAC must apply in writing on forms provided by the department. Applications for participation 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 by using special PPAC procedure codes on their MA claims.

(b) Purpose. The purpose of PPAC is to improve access to quality medical care for MA-eligible children by paying enhanced MA 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;

(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 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 is 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 clauses (a) through (d) of this subparagraph and who complies with the requirements of subdivision (e) of this section; however, the Department of Health will not waive the 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:

(a) admitting privileges are not available at area hospitals; or

(b) the physician's specialty is not accepted for admitting privileges at area hospitals; or

(c) the nearest hospital at which admitting privileges could be granted is so removed by time or distance from the physician's office that access to such hospital is impractical; or

(d) 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 or her patients with a physician who does have admitting privileges;

(ii) is either:

(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 has 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) a primary care physician continuously enrolled as a Child/Teen-Health Plan (C/THP) provider on or before August 1, 1990; or

(d) holds an active staff appointment with specialty privileges in a hospital accredited for residency training by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in the specialty in which the physician has privileges; or

(e) 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 patients' health care needs. This requirement cannot be met by a recording which refers patients to emergency rooms;

(iv) provides medical care coordination;

(v) provides periodic health assessment examinations in accordance with the standards of C/THP;

(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 PPAC 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. The Department of Health may waive this requirement for physicians whose specialty does not require the use of admitting privileges and who comply with the requirements of subdivision (e) of this section; however, the Department of Health will not waive the 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 either:

(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) holds an active staff appointment with specialty privileges in a hospital accredited for residency training by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association Committee on Postdoctoral Training in the specialty in which the physician has privileges; or

(d) 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 qualified 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 PPAC by the department and the Department of Health.

(d) Written agreement required.

(1) As a condition of participation in PPAC, 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) or subdivision (c) of this section.

(2) Each qualified primary care and specialist physician must agree in writing that:

(i) informational material provided by the department concerning MA eligibility and services for persons under 21 years of age and pregnant women will be conspicuously displayed on the physician's premises and that the physician will request additional informational material from the department as necessary;

(ii) the physician will notify the department within 30 days of circumstances resulting in his or her ineligibility to participate in PPAC and/or the inability to perform the activities and services required under the agreement;

(iii) the Department of Health has the authority to establish a new reimbursement methodology which supersedes that in effect at the time the physician first entered into an agreement to participate in PPAC and which may be applied prospectively to services furnished under the program by the physician;

(iv) the physician will comply with all policies, procedures and instructions provided by the department and the Department of Health to implement PPAC 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;

(v) the department may cancel the physician's participation in PPAC at any time by providing at least 30 days' written notice; and

(vi) the physician will provide the department with at least 30 days written notice of his or her intent to cancel the PPAC 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 PPAC 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. The Department of Health may waive the admitting privileges requirements of this section in individual cases. A physician requesting 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:

(1) a description of the circumstance that merits consideration of a waiver of the requirement; and

(2) 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; and

(3) a curriculum vitae; and

(4) proof of medical malpractice insurance; and

(5) 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) 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 and specialist physicians who provide services in free-standing or hospital-based clinics licensed under article 28 of the Public Health Law may not submit claims for their services using the PPAC procedure codes if the clinic submits a claim to the MA program and is paid for these services. When the physician's services are not included in the clinic's MA rate, the physician may submit a claim using the regular (non-PPAC) MA procedure codes.

(3) 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 PPAC 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-PPAC) MA procedure codes.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 533.7