N.Y. PBH Law § 2807-F — New York Code / Act PBH / Article 28 / Section 2807-F
Health maintenance organization payment factor
Status: in_force

§ 2807-f. Health maintenance organization payment factor. 1. For\npurposes of this section, the following terms shall have the following\nmeaning:\n  (a) "HMO" shall mean a health maintenance organization operating in\naccordance with the provisions of article forty-four of this chapter or\narticle forty-three of the insurance law.\n  (b) "Medicaid" shall mean the medical assistance program established\npursuant to title eleven of article five of the social services law.\n  2. For periods commencing on or after July first, nineteen hundred\nninety-eight, an HMO payment factor shall be determined in accordance\nwith subdivision three of this section. Such subdivision shall apply\nduring the period July first, nineteen hundred ninety-eight through June\nthirtieth, nineteen hundred ninety-nine; provided, however, that this\nsection shall expire and be deemed repealed on and after the date on\nwhich New York state is granted the authority, by federal waiver, agreed\nupon by the state and the secretary of the federal department of health\nand human services, or federal statute, to operate a mandatory medicaid\nmanaged care program.\n  3. (a) In recognition of the public benefits resulting from enrolling\nmedicaid enrollees into managed care plans, HMOs are required to make a\ngood faith effort to enroll medicaid recipients. A good faith effort\nshall be defined as:\n  (i) submitting a reasonable bid in response to a state or county\nprocurement process;\n  (ii) willingness to enter into reasonable managed care contracts with\ncounties in its approved service area;\n  (iii) demonstrating a willingness to enroll medicaid recipients\nincluding accepting referrals from counties, brokers and\nauto-assignments; and\n  (iv) such other factors as may be established by the commissioner.\n  (b) In the event that an HMO has not made a good faith effort to\nenroll medicaid recipients, the commissioner shall impose a payment\nfactor of nine percent on payments to general hospitals for the calendar\nyear by such HMO. The commissioner shall notify HMOs of any failure to\nmake a good faith effort and the application of the payment factor by\nNovember first preceding the applicable calendar year.\n  4. (a) Each HMO on behalf of general hospitals shall pay into a\nstatewide health maintenance organization pool created by the\ncommissioner the factor established pursuant to subdivision two or three\nand this subdivision for each patient discharged in the previous\ncalendar month commencing with July first, nineteen hundred ninety-six\nthrough December thirty-first, nineteen hundred ninety-nine or\ncontracted hospital inpatient service obligations for periods on or\nafter July first, nineteen hundred ninety-six through December\nthirty-first, nineteen hundred ninety-nine. Funds accumulated in the\npool, including income from invested funds, shall be deposited by the\ncommissioner and credited to the general fund.\n  (b) Payments by HMOs to the pool shall be due on or before the\nfifteenth day following the end of each month.\n  (c) (i) If a payment made for a month to which a payment factor\napplies is less than ninety percent of the actual amount due for such\nmonth, interest shall be due and payable to the commissioner by a health\nmaintenance organization on the difference between the amount paid and\nthe amount due from the day of the month the payment was due until the\ndate of payment. The rate of interest shall be twelve percent per annum\nor, if greater, at the rate of interest set by the commissioner of\ntaxation and finance with respect to underpayments of tax pursuant to\nsubsection (e) of section one thousand ninety-six of the tax law minus\nfour percentage points. Interest under this paragraph shall not be paid\nif the amount thereof is less than one dollar.\n  (ii) If a payment made for a month to which a payment factor applies\nis less than seventy percent of the actual amount due for such month, a\npenalty shall be due and payable to the commissioner by a health\nmaintenance organization of five percent of the difference between the\namount paid and the amount due for such month when the failure to pay is\nfor a duration of not more than one month after the due date of the\npayment with an additional five percent for each additional month or\nfraction thereof during which such failure continues, not exceeding\ntwenty-five percent in the aggregate.\n  (iii) Overpayment by a health maintenance organization of a payment\nshall be applied to any other payment due pursuant to this section, or,\nif no payment is due, at the election of the health maintenance\norganization shall be applied to future payments or refunded to the\nhealth maintenance organization. Interest shall be paid on overpayments\nfrom the date of overpayment to the date of crediting or refund at the\nrate determined in accordance with paragraph (a) of this subdivision\nonly if the overpayment was made at the direction of the commissioner.\nInterest under this paragraph shall not be paid if the amount thereof is\nless than one dollar.\n  (d) The commissioner is authorized to contract with a pool\nadministrator designated for purposes of administering pools pursuant to\nsubdivision two-a of section twenty-eight hundred seven-c of this\narticle as in effect on June thirtieth, nineteen hundred ninety-six, or\nif not available such other administrators as the commissioner shall\ndesignate, to receive and distribute health maintenance organization\npool funds. In the event contracts are effectuated, the commissioner\nshall conduct or cause to be conducted annual audits of the receipt and\ndistribution of the pool funds. The reasonable costs and expenses of an\nadministrator as approved by the commissioner, not to exceed for\npersonnel services on an annual basis two hundred thousand dollars,\nshall be paid from the pooled funds.\n  5. Payment factors established pursuant to this section shall not\napply to payments for subscribers who are eligible for medical\nassistance pursuant to the social services law, participants in regional\npilot projects established pursuant to chapter seven hundred three of\nthe laws of nineteen hundred eighty-eight or successor insurance\nprograms, and enrollees in the child health insurance program pursuant\nto sections twenty-five hundred ten and twenty-five hundred eleven of\nthis title.\n  6. Notwithstanding any inconsistent provisions of the state\nadministrative procedure act or any other provision of law, the\ncommissioner is authorized to adopt or amend on an emergency basis any\nregulation he or she determines necessary to implement this section.\n  7. HMOs shall provide to the commissioner such information as the\ncommissioner may require to effectuate the provisions of this section.\n