N.Y. Comp. Codes R. & Regs. tit. 18 § 505.32

Current through Register Vol. 46, No. 51, December 18, 2024

Section 505.32 - Nurse practitioner services

(a) Definitions.

(1) Nurse practitioner means an individual who is licensed and currently registered as a professional nurse in the State and who is certified under section 6910 of the Education Law as a nurse practitioner.

(2) Nurse practitioner services means the provision of services to a medical assistance (MA) recipient which are in conformity with the provisions of sections 6902 and 6910 of the Education Law, regulations of the Education Department and regulations of the Department of Health.

(3) Collaborating physician means a physician who is not excluded from participation in either the MA or the Medicare programs, with whom the nurse practitioner maintains practice agreements and practice protocols in accordance with section 6902 of the Education Law.

(4) Practice agreements and practice protocols means written documents meeting the requirements of section 6902 of the Education Law and 8 NYCRR section 64.6 of the Education Department's regulations.

(b) Written practice agreement and practice protocols required. Written practice agreements and practice protocols between nurse practitioners and their collaborating physicians must contain the provisions required by the Education Law and regulations of the Education Department, including provisions for the collaborating physician's review of patient records at least every three months. The physician's review of patient records is not a billable service under the MA program. The nurse practitioner must make the written practice agreements and practice protocols and evidence that the collaborating physician has reviewed patient records available to the department and its agents for purposes of conducting audits under the MA program.

(c) Identification of collaborating physician required. The nurse practitioner must submit the name of and other identifying information concerning the collaborating physician with the nurse practitioner's MA enrollment application.

(d) Payment for nurse practitioner services. MA coverage for nurse practitioner services is available in accordance with the provisions of this subdivision.

(1) Except as otherwise provided in this subdivision, payment for nurse practitioner services must be in accordance with the fees established by the Department of Health and approved by the Director of the Budget.

(2) Payment is available for nurse practitioners' services which are part of the development of, or furnished pursuant to, an individualized education program and which are provided by a nurse practitioner employed by, or under contract to, a school district, an approved pre-school, or a county in the State or the city of New York. Reimbursement for such services must be made in accordance with the provider agreement.

(3) Payment is available for nurse practitioners' services which are part of the development of, or furnished pursuant to, an interim or final individualized family services plan and are provided by a nurse practitioner employed by, or under contract to, an approved early intervention program, or a municipality in the State. Reimbursement for such services must be made in accordance with the provider agreement.

(4) Payment for nurse practitioner services provided by a nurse practitioner who is paid a salary by a medical facility which is reimbursed under the MA program for its services on a rate basis will be made on a fee for service basis only if the cost of the nurse practitioner services is not included in the facility's cost-based rate.

(5) Payment will be made for medically necessary ancillary services which are covered under the MA program and which the nurse practitioner orders for an MA recipient. Payment will only be made for prescription drugs when prescribed by a nurse practitioner who has the authority to write prescriptions under the provisions of the Education Law and regulations of the Education Department.

(e) This section is effective for services provided by nurse practitioners on and after July 1, 1990.

(f) Preferred Physicians and Children Program.

(1) Scope. The Preferred Physicians and Children Program (PPAC) is a program under which a written agreement is entered into by a provider and the department pursuant to which the department pays enhanced fees for certain medical services provided to children under the age of 21 who are eligible for medical assistance (MA). Only qualified nurse practitioners meeting the requirements of this section are eligible to participate in PPAC. Nurse practitioners who wish to participate in PPAC must apply in writing on forms provided by the department. Applications for participation will be reviewed by and must receive approval of the department and the Department of Health. Participating nurse practitioners may obtain payment at the enhanced fees for medical services by using special PPAC procedure codes on their MA claims.

(2) Purpose. The purpose of PPAC is to improve access to quality medical care for MA-eligible children by paying enhanced MA fees to nurse practitioners meeting the criteria for PPAC participation.

(3) Definitions.

(i) Nurse practitioner, for the purposes of this subdivision, means a person who is licensed and currently registered pursuant to section 6910 of the Education Law to practice registered professional nursing which may include the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures within a specialty area of practice, in collaboration with a licensed physician qualified to collaborate in the specialty involved, provided such services are performed in accordance with a written practice agreement and written practice protocols; the written practice agreement must include explicit provisions for the resolution of any disagreement between the collaborating physician and the nurse practitioner regarding a matter of diagnosis or treatment that is within the scope of practice of both; and as defined at and in accordance with section 6902 of the Education Law.

(ii) Medical care coordination, for purposes of this subdivision, means providing or arranging for the provision of:

(a) scheduling of elective hospital admissions;

(b) assisting with emergency admissions;

(c) managing and/or participating in hospital care and discharge planning;

(d) scheduling of referral appointments with written referrals as necessary and with requests for follow-up reports;

(e) scheduling of ancillary services;

(f) notifying by telephone the social services district responsible for furnishing MA to the recipient when transportation services are essential to ensure the MA recipient's access to medically necessary care and services provided under the MA program; and

(g) maintaining complete medical records in compliance with the requirements of section 540.7 of this Title, including, but not limited to, notation of referrals and hospitalizations, and copies of test results and reports.

(iii) Qualified primary care nurse practitioner, for the purposes of this subdivision, means a nurse practitioner who:

(a) is licensed and currently registered as a professional nurse in this State and who is certified and currently registered as a nurse practitioner under section 6910 of the Education Law;

(b) has a collaborative agreement with a physician who has an agreement with the MA program to participate in PPAC as a primary care provider;

(c) provides 24-hour telephone coverage of his or her practice and ensures timely access to a practitioner qualified to respond to patients' health care needs. This requirement cannot be met by a recording which refers patients to emergency rooms;

(d) provides medical care coordination;

(e) provides periodic health assessment examinations in accordance with the standards of the Child/Teen Health Plan (C/THP), as set forth in Part 508 of this Title;

(f) complies with all applicable statutory and regulatory requirements of the MA program; and

(g) is enrolled in the MA program and accepted for participation in PPAC by the department and the Department of Health.

(iv) Qualified specialist nurse practitioner, for purposes of this subdivision, means a nurse practitioner who:

(a) is licensed and currently registered as a professional nurse in this State and who is certified under section 6910 of the Education Law as a nurse practitioner;

(b) has a collaborative agreement with a physician who has an agreement with the MA program to participate in PPAC as a qualified non-primary care specialist physician;

(c) provides consultation summaries or appropriate periodic progress notes to qualified primary care physicians on a timely basis following referrals or routinely scheduled consultant visits;

(d) notifies the qualified primary care physician when scheduling a hospital admission;

(e) maintains complete medical records in compliance with the requirements of section 540.7 of this Title, including but not limited to, notation of referrals and hospitalizations, and copies of test results and reports;

(f) complies with all applicable statutory and regulatory requirements of the MA program; and

(g) is enrolled in the MA program and accepted for participation in PPAC by the department and the Department of Health.

(4) Written agreement required.

(i) As a condition of participation in PPAC, each nurse practitioner must certify to the department that he or she meets the standards for participation set forth in either subparagraph (3)(iii) or (iv) of this subdivision.

(ii) Each qualified primary care and qualified specialist nurse practitioner must agree in writing that:

(a) informational material provided by the department concerning MA eligibility and services for persons under 21 years of age and pregnant women will be conspicuously displayed on the nurse practitioner's premises and that the nurse practitioner will request additional informational material from the department as necessary;

(b) the nurse practitioner will notify the department within 30 days of circumstances resulting in his or her ineligibility to participate in PPAC and/or the inability to perform the activities and services required under the agreement;

(c) the Department of Health has the authority to establish fees for payment which supersede those in effect at the time the nurse practitioner first entered into an agreement to participate in PPAC and which are applied prospectively to services furnished under the program by the nurse practitioner;

(d) the nurse practitioner will comply with all policies, procedures and instructions provided by the department and the Department of Health to implement PPAC and make claims for payment under the MA program in accordance with the claiming procedures and the current fee schedule;

(e) the department may cancel the nurse practitioner's participation in PPAC at any time by providing at least 30 days' written notice for failing to comply with standards for participation in PPAC; and

(f) the nurse practitioner will provide the department with at least 30 days written notice of his or her intent to cancel the PPAC agreement, which notice must include a description of the basis for the cancellation. The nurse practitioner must agree to continue to provide and/or arrange for the provision of medical services for patients up to the date of termination of the PPAC agreement, to assist patients to maintain continuity of care, to provide patients with information to assist them in transferring their care to another provider and to make timely transfer of appropriate information in the patients' records upon request.

(5) Payment.

(i) Qualified primary care and qualified specialist nurse practitioners will be paid for their services pursuant to their agreement with the department at fees established by the Department of Health and approved by the Director of the Budget.

(ii) Qualified primary care and qualified specialist nurse practitioners who provide services in free-standing or hospital-based clinics licensed under article 28 of the Public Health Law may not submit claims for their services using the PPAC procedure codes if the clinic submits claims to the MA program and is paid for these services. When the nurse practitioner's services are not included in the clinic's MA rate, the nurse practitioner may submit claims using the regular (non-PPAC) MA procedure codes.

(iii) Qualified primary care and qualified specialist nurse practitioners who, either individually or as members of a group practice, provide services in the emergency rooms of facilities licensed under article 28 of the Public Health Law, pursuant to contracts with those facilities, may not submit MA claims for their services using the PPAC procedure codes. When an emergency room nurse practitioner's services are not included in the article 28 facility's MA rate, the nurse practitioner may submit claims using the regular (non-PPAC) MA procedure codes.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.32