Requirements for Managed Care Programs – N.Y. Soc. Serv. Law § 364-j

New York’s managed care program must provide “comprehensive and coordinated health care delivered in a cost effective manner.” Participants in the program must have the ability to choose their primary care provider from a minimum of three providers and must have the ability to choose their provider for other services if there are “a sufficient number” of providers available. 

Managed care providers must:

• Help participants arrange and select medical services.
• Ensure that participants receive services in a timely manner that meets their medical needs are delivered “in accordance with prevailing standards of professional medical practice and conduct.” 
• “[U]se… appropriate patient assessment criteria to ensure that all participants are provided with appropriate services…” 
• Implement appropriate procedures to facilitate the care of participants that need special care (e.g. use case managers, assign specialist as primary care practitioner). 
• Refer and coordinate participant visits to other providers for additional diagnosis or treatment services. 
• “[E]stablish appropriate utilization and referral requirements for physicians, hospitals, and other medical services providers including emergency room visits and inpatient admissions.” 
• Provide all participants under the age of 21 with “periodic screening diagnosis and treatment services.”
• Provide or arrange for pregnant participants to receive prenatal care. 
• Establish procedures to facilitate communication with persons that are visually-impaired, hearing-impaired, or not fluent in English. 

Managed care providers that wish to participate in the managed care program must submit a proposal that (1) describes their quality assurance, utilization review, and case management mechanisms; and (2) shows their ability to report data and conduct data analysis.

The commissioner of health must create a “comprehensive quality assurance system for managed care providers that includes performance and outcome-based quality standards…” Managed care providers must also “implement internal quality assurance system.”  These systems must continually monitor care delivery, use epidemiological data, present providers with quality reports, identify and remedy access, continuity and quality issues, and credential and recredential providers. 

The department of health must contract with at least one independent organization to monitor and evaluate the quality of care provided in the managed care program. The department of health may disclose information received from such an organization, but must do so in compliance with applicable state and federal laws.