1. The Laws of New York
  2. Consolidated Laws
  3. Public Health
  4. Article 44: Health Maintenance Organizations


Section 4403-E Primary care partial capitation providers; partial capitation certificate of authority

Public Health (PBH)

Primary care partial capitation providers; partial capitation certificate of authority. 1. The commissioner may issue partial capitation certificates of authority to qualified individual medical services providers, counties or entities comprised of medical services providers, applying on forms prescribed by the commissioner, seeking to offer medical assistance services, including primary and preventive care and case management of inpatient, emergency room, specialty, and pharmacy services, to recipients of medical assistance eligible to enroll in managed care plans, on a partial capitation basis. Partial capitation certificates of authority shall only be awarded to qualified applicants in rural areas of the state where comprehensive health services plans, as defined in section forty-four hundred one of this article, are not yet available, provided that such certificate shall be awarded only until full capitation becomes practicable. Comprehensive primary and preventive care shall include all services and related ancillary procedures routinely performed in a primary care physicians office, including preventive care and immunizations in accordance with CTH periodic schedules and routine obstetrical-gynecological services. Notwithstanding, where partial capitation providers currently exist, they will be allowed to continue operation. Provided, however, that a shared health facility, as defined in article forty-seven of this chapter, shall not be eligible for such a certificate.

  2. Applications for a partial capitation certificate of authority shall include the following:

  (a) current licensure or certification;

  (b) a description of the applicant's experience in providing the services included as part of comprehensive primary and preventive care, including identification of any disciplinary, administrative or criminal proceedings related to such license, certification or services and the resolution thereof;

  (c) a description of the applicant's financial resources, together with a copy of the applicant's latest certified financial statement and the medical malpractice insurance coverage maintained by such applicant;

  (d) an assessment of the applicant's ability to continue to provide high quality services in exchange for payments and to assume the financial risk of operating on a partial capitation basis;

  (e) the geographic area to be served by the applicant;

  (f) the applicant's current capacity, and proposed capacity to provide or directly arrange for the provision of medical care and services to persons eligible for medical assistance;

  (g) a statement of intent to contract from the local social services district in which they will operate;

  (h) a statement describing procedures to be used to monitor the quality of care provided by the plan;

  (i) such other information as the commissioner shall require; and

  (j) in the case of an application from a local social services district, such comparable information as the commissioner may require.

  3. The commissioner may issue a partial capitation certificate of authority to an applicant that meets the following criteria:

  (a) the applicant can demonstrate its ability to control, arrange for and manage in-patient hospital and emergency room care through written agreements with participating hospitals;

  (b) the applicant is board-certified or board-eligible in his or her area of specialty, or has completed an accredited residency program, or has admitting privileges at one or more hospitals, or in the case of an entity, all medical services providers affiliated with the applicant are board-certified or board-eligible in his or her area of specialty, has completed an accredited residency program, or has admitting privileges at one or more hospitals;

  (c) the applicant directly provides or arranges for the delivery of comprehensive primary and preventive care and services and access to medical advice and emergency care on a twenty-four hour basis;

  (d) the applicant has adequate medical malpractice liability insurance coverage;

  (e) the applicant has demonstrated it is financially responsible and may be expected to meet its obligations to its enrolled members. For purposes of this paragraph, "financially responsible" means that the applicant shall assume financial risk on a prospective basis for the provision of comprehensive primary care and preventive services, and can support the necessary administrative costs associated with the activities of a partial capitation plan, for its enrolled members;

  (f) the applicant has demonstrated the ability to provide high quality care, and to monitor the quality of care provided via an acceptable formal quality assurance program;

  (g) the local social services district has provided written evidence of its intention to contract with the plan; and

  (h) the applicant has demonstrated the ability to track and monitor all services provided to its enrollees, and its ability to submit periodic cost and utilization reports, as the commissioner may require.

  * NB Repealed March 31, 2025