Section 360-10.1 Policy.
(a) The regulations contained in this Subpart implement Chapter 165 of
the Laws of 1991 which amended section 364-j of the Social Services Law (SSL) to require
the establishment of managed care programs (MCPs) throughout the State. An MCP is a
program operating in a social services district in which Medical Assistance (MA)
recipients receive MA services, including case management services, directly and
indirectly (including by referral) from managed care providers. Every MA recipient who
resides in a social services district that provides MA under an MCP and is not excluded or
exempt from participating is eligible to participate in an MCP.
(b) MCPs will solve some of the problems MA recipients experience in
obtaining needed health care. MA recipients will enroll with a managed care provider who
will be responsible for providing or arranging for medical services to be provided to MA
recipients and assisting them to select needed services prudently. This includes ensuring
that participants are referred to primary care physicians who will serve as reliable
sources of prompt, on-going, and well- coordinated care.
(c) MCPs are designed to improve the relationship between an MA
recipient and his or her health care provider and to ensure the proper delivery of
preventive medical care. Such programs will help avoid the problem of MA recipients not
receiving needed medical care until the onset of advanced stages of an illness, at which
time the recipient will require a higher level of medical care such as emergency room care
or in-patient hospital care.
(d) Participation by an MA recipient in an MCP may be voluntary or
mandatory. A social services district that proposes a mandatory MCP cannot implement such
program until the department applies for and is granted necessary federal waivers.
(e) The commissioner of the department (commissioner), in consultation
with social services districts, will require 20 social services districts per year to
develop and submit managed care plans. After the commissioner designates the initial 20
social services districts, the commissioner will designate annually 20 additional social
services districts to develop managed care plans until all non-exempt social services
districts have been designated. A social services district may seek an exemption from the
requirement to submit a managed care plan on the basis that managed care would not be cost
effective or would reduce the quality of care provided to MA recipients in the district. A
social services district must submit its managed care plan to the commissioner within 180
days of the date on which the department notifies the district that the district has been
designated to develop and submit a managed care plan. Two or more social services
districts may join together in combination to develop and submit a managed care plan. A
social services district may also develop and submit a managed care plan to the
commissioner for review before the district is designated by the commissioner.