N.Y. Soc. Serv. Law § 365-g

§ 365-g. Utilization thresholds for certain care, services and\nsupplies. 1. The department may implement a system for utilization\ncontrols, pursuant to this section, for persons eligible for benefits\nunder this title, including annual service limitations or utilization\nthresholds above which the department may not pay for additional care,\nservices or supplies, unless such care, services or supplies have been\npreviously approved by the department or unless such care, services or\nsupplies were provided pursuant to subdivision three, four or five of\nthis section.\n 2. The department may implement utilization thresholds by provider\nservice type, medical procedure and patient, in consultation with the\nstate department of mental hygiene, other appropriate state agencies,\nand other stakeholders including provider and consumer representatives.\nIn developing utilization thresholds the department shall consider\nhistorical recipient utilization patterns, patient-specific diagnoses\nand burdens of illness, and the anticipated recipient needs in order to\nmaintain good health.\n 3. If the department implements a utilization threshold program, at a\nminimum, such program must include:\n (a) prior notice to the recipients affected by the utilization\nthreshold program, which notice must describe:\n (i) the nature and extent of the utilization program, the procedures\nfor obtaining an exemption from or increase in a utilization threshold,\nthe recipients' fair hearing rights, and referral to an informational\ntoll-free hot-line operated by the department; and\n (ii) alternatives to the utilization threshold program such as\nenrollment in managed care programs and referral to preferred primary\ncare providers designated pursuant to subdivision twelve of section\ntwenty-eight hundred seven of the public health law; and\n (b) procedures for:\n (i) requesting an increase in amount of authorized services;\n (ii) extending amount of authorized services when an application for\nan increase in the amount of authorized services is pending;\n (iii) requesting an exemption from utilization thresholds, which\nprocedure must:\n (A) allow the recipient, or a provider on behalf of a recipient, to\napply to the department for an exemption from one or more utilization\nthresholds based upon documentation of the medical necessity for\nservices in excess of the threshold,\n (B) provided for exemptions consistent with department guidelines for\napproving exemptions, which guidelines must be established by the\ndepartment in consultation with the department of health and, as\nappropriate, with the department of mental hygiene, and consistent with\nthe current regulations of the office of mental health governing\noutpatient treatment.\n (C) provide for an exemption when medical and clinical documentation\nsubstantiates a condition of a chronic medical nature which requires\nongoing and frequent use of medical care, services or supplies such that\nan increase in the amount of authorized services is not sufficient to\nmeet the medical needs of the recipient;\n (iv) reimbursing a provider, regardless of the recipient's previous\nuse of services, when care, services or supplies are provided in a case\nof urgent medical need, as defined by the department, or when provided\non an emergency basis, as defined by the department;\n (v) notifying recipients of and referring recipients to appropriate\nand accessible managed care programs and to preferred primary care\nproviders designated pursuant to subdivision twelve of section\ntwenty-eight hundred seven of the public health law at the same time\nsuch recipients are notified that they are nearing or have reached the\nutilization threshold for each specific provider type;\n (vi) notifying recipients at the same time such recipients are\nnotified that they have received an exemption from a utilization\nthreshold, an increase in the amount of authorized services, or that\nthey are nearing or have reached their utilization threshold, of their\npossible eligibility for federal disability benefits and directing such\nrecipients to their social services district for information and\nassistance in securing such benefits;\n (vii) cooperating with social services districts in sharing\ninformation collected and developed by the department regarding\nrecipients' medical records; and\n (viii) assuring that no request for an increase in amount of\nauthorized services or for an exemption from utilization thresholds\nshall be denied unless the request is first reviewed by a health care\nprofessional possessing appropriate clinical expertise.\n 4. The utilization thresholds established pursuant to this section\nshall not apply to mental retardation and developmental disabilities\nservices provided in clinics certified under article twenty-eight of the\npublic health law, or article twenty-two or article thirty-one of the\nmental hygiene law.\n 5. Utilization thresholds established pursuant to this section shall\nnot apply to services, even though such services might otherwise be\nsubject to utilization thresholds, when provided as follows:\n (a) through a managed care program;\n (b) subject to prior approval or prior authorization;\n (c) as family planning services;\n (d) as methadone maintenance services;\n (e) on a fee-for-services basis to in-patients in general hospitals\ncertified under article twenty-eight of the public health law or article\nthirty-one of the mental hygiene law and residential health care\nfacilities, with the exception of podiatrists' services;\n * (f) for hemodialysis;\n * NB Effective until July 1, 2017\n * (f) for hemodialysis; or\n * NB Effective July 1, 2017\n * (g) through or by referral from a preferred primary care provider\ndesignated pursuant to subdivision twelve of section twenty-eight\nhundred seven of the public health law;\n * NB Effective until July 1, 2017\n * (g) through or by referral from a preferred primary care provider\ndesignated pursuant to subdivision twelve of section twenty-eight\nhundred seven of the public health law.\n * NB Effective July 1, 2017\n * (h) pursuant to a court order; or\n * NB Repealed July 1, 2017\n * (i) as a condition of eligibility for any other public program,\nincluding but not limited to public assistance.\n * NB Repealed July 1, 2017\n 6. The department shall consult with representatives of medical\nassistance providers, social services districts, voluntary organizations\nthat represent or advocate on behalf of recipients, the managed care\nadvisory council and other state agencies regarding the ongoing\noperation of a utilization threshold system.\n 7. On or before February first, nineteen hundred ninety-two, the\ncommissioner shall submit to the governor, the temporary president of\nthe senate and the speaker of the assembly a report detailing the\nimplementation of the utilization threshold program and evaluating the\nresults of establishing utilization thresholds. Such report shall\ninclude, but need not be limited to, a description of the program as\nimplemented; the number of requests for increases in service above the\nthreshold amounts by provider and type of service; the number of\nextensions granted; the number of claims that were submitted for\nemergency care or urgent care above the threshold level; the number of\nrecipients referred to managed care; an estimate of the fiscal savings\nto the medical assistance program as a result of the program;\nrecommendations for medical condition that may be more appropriately\nserved through managed care programs; and the costs of implementing the\nprogram.\n