N.Y. Social Services Law § 365-G – Utilization thresholds for certain care, services and supplies

1. The department may implement a system for utilization controls, pursuant to this section, for persons eligible for benefits under this title, including annual service limitations or utilization thresholds above which the department may not pay for additional care, services or supplies, unless such care, services or supplies have been previously approved by the department or unless such care, services or supplies were provided pursuant to subdivision three, four or five of this section.
2. The department may implement utilization thresholds by provider service type, medical procedure and patient, in consultation with the state department of mental hygiene, other appropriate state agencies, and other stakeholders including provider and consumer representatives. In developing utilization thresholds the department shall consider historical recipient utilization patterns, patient-specific diagnoses and burdens of illness, and the anticipated recipient needs in order to maintain good health.
3. If the department implements a utilization threshold program, at a minimum, such program must include:
1. (a) prior notice to the recipients affected by the utilization threshold program, which notice must describe:
  1. (i) the nature and extent of the utilization program, the procedures for obtaining an exemption from or increase in a utilization threshold, the recipients' fair hearing rights, and referral to an informational toll-free hot-line operated by the department; and
  2. (ii) alternatives to the utilization threshold program such as enrollment in managed care programs and referral to preferred primary care providers designated pursuant to subdivision twelve of section twenty-eight hundred seven of the public health law; and
2. (b) procedures for:
  1. (i) requesting an increase in amount of authorized services;
  2. (ii) extending amount of authorized services when an application for an increase in the amount of authorized services is pending;
  3. (iii) requesting an exemption from utilization thresholds, which procedure must:
    1. (A) allow the recipient, or a provider on behalf of a recipient, to apply to the department for an exemption from one or more utilization thresholds based upon documentation of the medical necessity for services in excess of the threshold,
    2. (B) provided for exemptions consistent with department guidelines for approving exemptions, which guidelines must be established by the department in consultation with the department of health and, as appropriate, with the department of mental hygiene, and consistent with the current regulations of the office of mental health governing outpatient treatment.
    3. (C) provide for an exemption when medical and clinical documentation substantiates a condition of a chronic medical nature which requires ongoing and frequent use of medical care, services or supplies such that an increase in the amount of authorized services is not sufficient to meet the medical needs of the recipient;
  4. (iv) reimbursing a provider, regardless of the recipient's previous use of services, when care, services or supplies are provided in a case of urgent medical need, as defined by the department, or when provided on an emergency basis, as defined by the department;
  5. (v) notifying recipients of and referring recipients to appropriate and accessible managed care programs and to preferred primary care providers designated pursuant to subdivision twelve of section twenty-eight hundred seven of the public health law at the same time such recipients are notified that they are nearing or have reached the utilization threshold for each specific provider type;
  6. (vi) notifying recipients at the same time such recipients are notified that they have received an exemption from a utilization threshold, an increase in the amount of authorized services, or that they are nearing or have reached their utilization threshold, of their possible eligibility for federal disability benefits and directing such recipients to their social services district for information and assistance in securing such benefits;
  7. (vii) cooperating with social services districts in sharing information collected and developed by the department regarding recipients' medical records; and
  8. (viii) assuring that no request for an increase in amount of authorized services or for an exemption from utilization thresholds shall be denied unless the request is first reviewed by a health care professional possessing appropriate clinical expertise.
4. The utilization thresholds established pursuant to this section shall not apply to mental retardation and developmental disabilities services provided in clinics certified under article twenty-eight of the public health law, or article twenty-two or article thirty-one of the mental hygiene law.
5. Utilization thresholds established pursuant to this section shall not apply to services, even though such services might otherwise be subject to utilization thresholds, when provided as follows:
1. (a) through a managed care program;
2. (b) subject to prior approval or prior authorization;
3. (c) as family planning services;
4. (d) as methadone maintenance services;
5. (e) on a fee-for-services basis to in-patients in general hospitals certified under article twenty-eight of the public health law or article thirty-one of the mental hygiene law and residential health care facilities, with the exception of podiatrists' services; * (f) for hemodialysis; * NB Effective until July 1, 2020 * (f) for hemodialysis; or * NB Effective July 1, 2020 * (g) through or by referral from a preferred primary care provider designated pursuant to subdivision twelve of section twenty-eight hundred seven of the public health law; * NB Effective until July 1, 2020 * (g) through or by referral from a preferred primary care provider designated pursuant to subdivision twelve of section twenty-eight hundred seven of the public health law. * NB Effective July 1, 2020 * (h) pursuant to a court order; or * NB Repealed July 1, 2020 * (i) as a condition of eligibility for any other public program, including but not limited to public assistance. * NB Repealed July 1, 2020
6. The department shall consult with representatives of medical assistance providers, social services districts, voluntary organizations that represent or advocate on behalf of recipients, the managed care advisory council and other state agencies regarding the ongoing operation of a utilization threshold system.
7. On or before February first, nineteen hundred ninety-two, the commissioner shall submit to the governor, the temporary president of the senate and the speaker of the assembly a report detailing the implementation of the utilization threshold program and evaluating the results of establishing utilization thresholds. Such report shall include, but need not be limited to, a description of the program as implemented; the number of requests for increases in service above the threshold amounts by provider and type of service; the number of extensions granted; the number of claims that were submitted for emergency care or urgent care above the threshold level; the number of recipients referred to managed care; an estimate of the fiscal savings to the medical assistance program as a result of the program; recommendations for medical condition that may be more appropriately served through managed care programs; and the costs of implementing the program.