* § 4403-e. Primary care partial capitation providers; partial
capitation certificate of authority. 1. The commissioner may issue
partial capitation certificates of authority to qualified individual
medical services providers, counties or entities comprised of medical
services providers, applying on forms prescribed by the commissioner,
seeking to offer medical assistance services, including primary and
preventive care and case management of inpatient, emergency room,
specialty, and pharmacy services, to recipients of medical assistance
eligible to enroll in managed care plans, on a partial capitation basis.
Partial capitation certificates of authority shall only be awarded to
qualified applicants in rural areas of the state where comprehensive
health services plans, as defined in section forty-four hundred one of
this article, are not yet available, provided that such certificate
shall be awarded only until full capitation becomes practicable.
Comprehensive primary and preventive care shall include all services and
related ancillary procedures routinely performed in a primary care
physicians office, including preventive care and immunizations in
accordance with CTH periodic schedules and routine
obstetrical-gynecological services. Notwithstanding, where partial
capitation providers currently exist, they will be allowed to continue
operation. Provided, however, that a shared health facility, as defined
in article forty-seven of this chapter, shall not be eligible for such a
certificate.

2. Applications for a partial capitation certificate of authority
shall include the following:

(a) current licensure or certification;

(b) a description of the applicant's experience in providing the
services included as part of comprehensive primary and preventive care,
including identification of any disciplinary, administrative or criminal
proceedings related to such license, certification or services and the
resolution thereof;

(c) a description of the applicant's financial resources, together
with a copy of the applicant's latest certified financial statement and
the medical malpractice insurance coverage maintained by such applicant;

(d) an assessment of the applicant's ability to continue to provide
high quality services in exchange for payments and to assume the
financial risk of operating on a partial capitation basis;

(e) the geographic area to be served by the applicant;

(f) the applicant's current capacity, and proposed capacity to provide
or directly arrange for the provision of medical care and services to
persons eligible for medical assistance;

(g) a statement of intent to contract from the local social services
district in which they will operate;

(h) a statement describing procedures to be used to monitor the
quality of care provided by the plan;

(i) such other information as the commissioner shall require; and

(j) in the case of an application from a local social services
district, such comparable information as the commissioner may require.

3. The commissioner may issue a partial capitation certificate of
authority to an applicant that meets the following criteria:

(a) the applicant can demonstrate its ability to control, arrange for
and manage in-patient hospital and emergency room care through written
agreements with participating hospitals;

(b) the applicant is board-certified or board-eligible in his or her
area of specialty, or has completed an accredited residency program, or
has admitting privileges at one or more hospitals, or in the case of an
entity, all medical services providers affiliated with the applicant are
board-certified or board-eligible in his or her area of specialty, has
completed an accredited residency program, or has admitting privileges
at one or more hospitals;

(c) the applicant directly provides or arranges for the delivery of
comprehensive primary and preventive care and services and access to
medical advice and emergency care on a twenty-four hour basis;

(d) the applicant has adequate medical malpractice liability insurance
coverage;

(e) the applicant has demonstrated it is financially responsible and
may be expected to meet its obligations to its enrolled members. For
purposes of this paragraph, "financially responsible" means that the
applicant shall assume financial risk on a prospective basis for the
provision of comprehensive primary care and preventive services, and can
support the necessary administrative costs associated with the
activities of a partial capitation plan, for its enrolled members;

(f) the applicant has demonstrated the ability to provide high quality
care, and to monitor the quality of care provided via an acceptable
formal quality assurance program;

(g) the local social services district has provided written evidence
of its intention to contract with the plan; and

(h) the applicant has demonstrated the ability to track and monitor
all services provided to its enrollees, and its ability to submit
periodic cost and utilization reports, as the commissioner may require.

* NB Repealed March 31, 2030