* § 364-f. Primary care case management programs. 1. The department is
authorized to establish primary care case management programs, under the
medical assistance program, in accordance with applicable federal law
and regulations. Primary care case management programs shall only be
authorized in areas of the state where comprehensive health services
plans, as defined in section forty-four hundred one of the public health
law, are not yet available. Subject to the approval of the director of
the budget, the commissioner is authorized to apply for the appropriate
waivers under federal law and regulation, and may waive any of the
provisions of sections three hundred sixty-five-a, three hundred
sixty-six, three hundred sixty-seven-b, three hundred sixty-eight-a and
three hundred sixty-four-j of this chapter or any regulation of the
department when such action would be necessary to assist in promoting
the objectives of this section.

2. (a) A primary care case management program shall provide
individuals eligible for medical assistance with the opportunity to
select a primary care case manager who shall provide medical assistance
services to such eligible individuals, either directly, or through
referral.

(b) Primary care case managers shall be limited to qualified, licensed
primary care practitioners, as defined in paragraph (f) of subdivision
one of section three hundred sixty-four-j of this chapter, who meet
standards established by the commissioner for the purposes of this
program.

(c) Services that may be covered by the primary care case management
program are defined by the commissioner in the benefit package. Covered
services may include all medical assistance services defined under
section three hundred sixty-five-a of this chapter, except:

(i) services excluded under paragraph (e) of subdivision three of
section three hundred sixty-four-j of this chapter shall be excluded
under this section;

(ii) services provided by residential health care facilities, long
term home health care programs, child care agencies, and entities
offering comprehensive health services plans;

(iii) services provided by dentists and optometrists; and

(iv) eyeglasses, emergency care, mental health services and family
planning services.

(d) Case management services provided by primary care case managers
shall include, but need not be limited to:

(i) management of the medical and health care of each recipient to
assure that all services provided under paragraph (c) of this
subdivision and which are found to be necessary, are made available in a
timely manner;

(ii) referral to, and coordination, monitoring and follow-up of,
appropriate providers for diagnosis and treatment, the need for which
has been identified by the primary care case manager but which is not
directly available from the primary care case manager, and assisting
medical assistance recipients in the prudent selection of medical
services;

(iii) arrangements for referral of recipients to appropriate
providers; and

(iv) all early periodic screening, diagnosis and treatment services,
as well as interperiodic screening and referral, to each participant
under the age of twenty-one at regular intervals.

3. (a) Primary care case management programs may be conducted only in
accordance with guidelines established by the commissioner. For the
purpose of implementing and administering the primary care case
management programs, the commissioner may contract with private
not-for-profit and public agencies as defined in guidelines established
by the commissioner for the management and administration of the primary
care case management program.

(b) The primary care case management program must:

(i) assure access to and delivery of high quality, appropriate medical
services;

(ii) participate in quality assurance activities as required by the
commissioner, as well as other mechanisms designed to protect recipient
rights under such program;

(iii) ensure that persons eligible for medical assistance will be
provided sufficient information regarding the program to make an
informed and voluntary choice whether to participate; and

(iv) provide for adequate safeguards to protect recipients from being
misled concerning the program and from being coerced into participating
in the primary care case management program.

4. (a) Individuals eligible to participate in Medicaid managed care,
to participate in Medicaid managed care may participate in a primary
care case management program, subject to the availability of such a
program within the applicable social services district, except for
individuals: (i) required by Medicaid managed care to be enrolled in an
entity offering a comprehensive health services plan as defined in
paragraph (k) of subdivision two of section three hundred sixty-five-a
of this chapter; (ii) participating in another medical assistance
reimbursed demonstration or pilot project, or (iii) receiving services
as an inpatient from a nursing home or intermediate care facility or
residential services from a child care agency or services from a long
term home health care program.

(b) Individuals choosing to participate in a primary care case
management program will be given thirty days from the effective date of
enrollment in the program to disenroll without cause. After this thirty
day disenrollment period, all individuals participating in the program
will be enrolled for a period of twelve months, except that all
participants will be permitted to disenroll for good cause, as defined
in guidelines established by the commissioner.

5. (a) Primary care case management programs may include provisions
for innovative payment mechanisms, including, but not limited to,
payment of case management fees, capitation arrangements, and
fee-for-service payments.

(b) Any new payment mechanisms and levels of payment implemented under
the primary care case management program shall be developed by the
commissioner subject to the approval of the director of the budget.

6. Notwithstanding any inconsistent provision of this section,
participation in a primary care case management program will not
diminish the scope of available medical services to which a recipient is
entitled.

7. This section shall be effective if, and as long as, federal
financial participation is available therefor.

* NB Expires March 31, 2026