(b) The limitation in subdivision (a) of this section, and other limitations imposed on accessing the entire approved network, must be clearly transmitted to eligible persons and enrollees via marketing materials, member handbooks and subscriber contracts.

1. (1) Prior approval of the commissioner is required for assignment of an IPA or institutional network provider contract, or of a medical group provider contract that serves five percent or more of the enrolled population in a county.
2. (2) A minimum of 45 days prior written notice to the commissioner is required for termination or non-renewal of an IPA or institutional network provider contract, or of a medical group provider contract that serves five percent or more of the enrolled population in a county or when the termination or non-renewal of the medical group provider will leave fewer than two participating providers of that type within the county. The notice shall include an impact analysis of the termination or non-renewal with regard to enrollee access to care.
3. (3) All provider contracts assigned by an MCO or an IPA prior to, and which remain in effect following, the effective date hereof shall be amended within one year of such effective date or upon renewal, whichever first occurs, to achieve compliance with the provisions of this subpart and guidelines for provider and IPA contracts established by the commissioner.

(c)

(e) The HIV SNP shall ensure all enrollees access to a full continuum of HIV-specific care, treatment and prevention through:

1. (1) access to the services of facility and community based case managers with expertise in prevention and care needs of persons with HIV infection;
2. (2) access to designated AIDS center hospitals or other hospitals with proven experience in HIV care and treatment and to community based HIV prevention and health care providers, including community health centers and, where geographically accessible, co-located substance abuse and HIV primary care programs;
3. (3) access to health and social services providers that support members' ability to sustain wellness and to adhere to treatment regimens;
4. (4) development and implementation of written agreements with community based social services providers to facilitate enrollee access to the full continuum of services needed by HIV-infected individuals, including access to care for vulnerable populations, such as those who are homeless, substance users or others; and
5. (5) mechanisms for monitoring referrals to care, treatment and supportive services and for documenting the outcome of the referral process for enrollees referred to organizations with which the HIV SNP is affiliated through a linkage agreement or memorandum of understanding.

(f) The MLTCP shall assure that all covered services are available and accessible by:

1. (1) establishing standards for timeliness of access to care and member services and frequent and consistent monitoring of the extent to which it meets such standards;
2. (2) implementing a process for selection and retention of network providers; and
3. (3) making care management and health care services available 24 hours a day, seven days a week.

(g) The MLTCP shall promote continuity of care and integration of services through:

1. (1) designation of a health care professional(s) responsible for care management. Services provided or arranged to address the care needs of such enrollee shall be in accordance with a current plan of care developed in consultation with the enrollee;
2. (2) coordination of covered health and long term care services with non-covered services and other community resources; and

3. (3) systematic and timely communication of clinical information among providers and maintenance of a care management record. Such records, which shall be retained for six years after the date of service rendered to enrollees, shall include but shall not be limited to:

   1. (i) assessments and reassessments;
   2. (ii) a plan of care which identifies health care goals of enrollees and covered services to be provided;
   3. (iii) medical orders, as applicable;
   4. (iv) documentation of non-covered services arranged and coordinated by the plan;
   5. (v) advance directives;
   6. (vi) signed enrollment agreement and disenrollment agreement; and
   7. (vii) contacts with enrollees and their representatives, providers of covered and non- covered services, physicians, local social service districts and other agencies or facilities with whom the plan coordinates services.

(n) Utilization review program standards for retrospective review of a pre-authorized treatment, service, or procedure. An MCO may reverse a pre-authorized treatment, service or procedure on retrospective review pursuant to section 4905(5) of the Public Health Law only when:

1. (1) the relevant medical information presented to the MCO or utilization review agent upon retrospective review is materially different from the information that was presented during the pre-authorization review; and
2. (2) the relevant medical information presented to the MCO or utilization review agent upon retrospective review existed at the time of the pre-authorization but was withheld from or not made available to the MCO or utilization review agent; and
3. (3) the MCO or utilization review agent was not aware of the existence of the information at the time of the pre-authorization review; and
4. (4) had the MCO or utilization review agent been aware of the information, the treatment, service, or procedure being requested would not have been authorized. This determination is to be made using the same specific standards, criteria or procedures as used during the pre-authorization review.