NY Pub Health L § 2807-F (2021)
2021 New York Laws PBH - Public Health Article 28 - Hospitals 2807-F - Health Maintenance Organization Payment Factor.

§  2807-f.  Health  maintenance  organization  payment  factor. 1. For purposes of this section, the following terms shall have  the  following meaning:  (a)  "HMO"  shall  mean a health maintenance organization operating in accordance with the provisions of article forty-four of this chapter  or article forty-three of the insurance law.  (b)  "Medicaid"  shall mean the medical assistance program established pursuant to title eleven of article five of the social services law.   2. For periods commencing on or after  July  first,  nineteen  hundred ninety-eight,  an  HMO  payment factor shall be determined in accordance with subdivision three of this section.  Such  subdivision  shall  apply during the period July first, nineteen hundred ninety-eight through June thirtieth,  nineteen  hundred  ninety-nine; provided, however, that this section shall expire and be deemed repealed on and  after  the  date  on which New York state is granted the authority, by federal waiver, agreed upon  by the state and the secretary of the federal department of health and human services, or federal statute, to operate a mandatory  medicaid managed care program.   3.  (a) In recognition of the public benefits resulting from enrolling medicaid enrollees into managed care plans, HMOs are required to make  a good  faith  effort  to  enroll medicaid recipients. A good faith effort shall be defined as:  (i) submitting a reasonable bid in  response  to  a  state  or  county procurement process;  (ii)  willingness to enter into reasonable managed care contracts with counties in its approved service area;  (iii)  demonstrating  a  willingness  to  enroll  medicaid  recipients including    accepting    referrals    from    counties,   brokers   and auto-assignments; and  (iv) such other factors as may be established by the commissioner.  (b) In the event that an HMO has not  made  a  good  faith  effort  to enroll  medicaid  recipients,  the  commissioner  shall impose a payment factor of nine percent on payments to general hospitals for the calendar year by such HMO. The commissioner shall notify HMOs of any  failure  to make  a  good  faith effort and the application of the payment factor by November first preceding the applicable calendar year.   4. (a) Each HMO on behalf  of  general  hospitals  shall  pay  into  a statewide   health   maintenance   organization   pool  created  by  the commissioner the factor established pursuant to subdivision two or three and this  subdivision  for  each  patient  discharged  in  the  previous calendar  month  commencing with July first, nineteen hundred ninety-six through  December  thirty-first,   nineteen   hundred   ninety-nine   or contracted  hospital  inpatient  service  obligations  for periods on or after  July  first,  nineteen  hundred   ninety-six   through   December thirty-first,  nineteen  hundred  ninety-nine.  Funds accumulated in the pool, including income from invested funds, shall be  deposited  by  the commissioner and credited to the general fund.  (b)  Payments  by  HMOs  to  the  pool  shall  be due on or before the fifteenth day following the end of each month.  (c) (i) If a payment made for  a  month  to  which  a  payment  factor applies  is  less  than ninety percent of the actual amount due for such month, interest shall be due and payable to the commissioner by a health maintenance organization on the difference between the amount  paid  and the  amount  due from the day of the month the payment was due until the date of payment. The rate of interest shall be twelve percent per  annum or,  if  greater,  at  the  rate  of interest set by the commissioner of taxation and finance with respect to underpayments of  tax  pursuant  to subsection  (e)  of section one thousand ninety-six of the tax law minus  four percentage points. Interest under this paragraph shall not be  paid if the amount thereof is less than one dollar.  (ii)  If  a payment made for a month to which a payment factor applies is less than seventy percent of the actual amount due for such month,  a penalty  shall  be  due  and  payable  to  the  commissioner by a health maintenance organization of five percent of the difference  between  the amount paid and the amount due for such month when the failure to pay is for  a  duration  of  not  more than one month after the due date of the payment with an additional five percent for  each  additional  month  or fraction  thereof  during  which  such  failure continues, not exceeding twenty-five percent in the aggregate.  (iii) Overpayment by a health maintenance organization  of  a  payment shall  be applied to any other payment due pursuant to this section, or, if no payment  is  due,  at  the  election  of  the  health  maintenance organization  shall  be  applied  to  future payments or refunded to the health maintenance organization. Interest shall be paid on  overpayments from  the  date of overpayment to the date of crediting or refund at the rate determined in accordance with paragraph  (a)  of  this  subdivision only  if  the overpayment was made at the direction of the commissioner. Interest under this paragraph shall not be paid if the amount thereof is less than one dollar.  (d)  The  commissioner  is  authorized  to  contract   with   a   pool administrator designated for purposes of administering pools pursuant to subdivision  two-a  of  section  twenty-eight  hundred  seven-c  of this article as in effect on June thirtieth, nineteen hundred ninety-six,  or if  not  available  such  other administrators as the commissioner shall designate, to receive and  distribute  health  maintenance  organization pool  funds.  In  the  event contracts are effectuated, the commissioner shall conduct or cause to be conducted annual audits of the receipt  and distribution  of the pool funds. The reasonable costs and expenses of an administrator as  approved  by  the  commissioner,  not  to  exceed  for personnel  services  on  an  annual  basis two hundred thousand dollars, shall be paid from the pooled funds.   5. Payment factors established pursuant  to  this  section  shall  not apply   to  payments  for  subscribers  who  are  eligible  for  medical assistance pursuant to the social services law, participants in regional pilot projects established pursuant to chapter seven  hundred  three  of the  laws  of  nineteen  hundred  eighty-eight  or  successor  insurance programs, and enrollees in the child health insurance  program  pursuant to  sections  twenty-five  hundred ten and twenty-five hundred eleven of this title.   6.  Notwithstanding  any  inconsistent   provisions   of   the   state administrative  procedure  act  or  any  other  provision  of  law,  the commissioner is authorized to adopt or amend on an emergency  basis  any regulation he or she determines necessary to implement this section.   7.  HMOs  shall  provide  to  the commissioner such information as the commissioner may require to effectuate the provisions of this section.