NY Soc Serv L § 367-B (2021)
2021 New York Laws SOS - Social Services Article 5 - Assistance and Care Title 11 - Medical Assistance for Needy Persons 367-B - Medical Assistance Information and Payment System.

§  367-b.  Medical  assistance  information and payment system. 1. The department shall design and implement  a  statewide  medical  assistance information  and payments system for the purpose of providing individual and aggregate data to social services districts to assist them in making basic management decisions, to the department and other  state  agencies to  assist  in the administration of the medical assistance program, and to the governor and the legislature as may be  necessary  to  assist  in making major administrative and policy decisions affecting such program. Such system shall be designed so as to be capable of the following:   a. receiving and processing information relating to the eligibility of each  person  applying  for  medical assistance and of issuing a medical assistance  identification  card  to  persons  determined  by  a  social services official to be eligible for such assistance;   b.  receiving  and  processing  information relating to each qualified provider of medical assistance furnishing care, services or supplies for which claims for payment are made pursuant to this title;   c. receiving and processing, in a form and manner  prescribed  by  the department,  all  claims  for  medical  care, services and supplies, and making payments for valid claims to providers of medical care,  services and supplies on behalf of social services districts;   d.   maintaining   information  necessary  to  allow  the  department, consistent with the powers and duties of the department  of  health,  to review the appropriateness, scope and duration of medical care, services and  supplies  provided to any eligible person pursuant to this chapter; and   e. initiating  implementation  of  such  a  system  for  the  district comprising  the  city of New York, in a manner compatible with expansion of such system to districts other than the district comprising the  city of New York.   2. Consistent with the capabilities of the system established pursuant to  subdivision one of this section, the department shall assume payment responsibilities on behalf of social services districts by  promulgation of  regulations approved by the director of the budget. Such regulations shall specify the providers of medical assistance and the medical  care, services  and/or  supplies  for  the district or districts for which the department will assume payment responsibilities and the  date  on  which such  responsibilities  shall  be  assumed.  Such  regulations  shall be published  for  comment  at  least  thirty  days  in  advance  of  their promulgation  and  shall  be  filed with the secretary of state at least sixty days in advance of the date  of  assumption  of  responsibilities; provided,  however,  that  with  respect  to  a  particular district the requirements for advance publications and/or filing may  be  waived,  or the  time  limits  reduced,  with the written consent of the district to such waiver or reduction. Providers of medical care and  services  shall submit  claims  to  the  social services district for all items of care, services and supplies furnished prior to the date of state assumption of payment responsibilities and to the state for all such  items  furnished subsequent  to  such  date.  Such regulations shall also specify a final transition date after which any claiming submitted shall be  enforceable by  such provider only against the state and shall not be enforceable by such provider against the social services district;  provided,  however, that  the department and the district may enter into a written agreement by which the department agrees on the basis of  eligibility  information provided by such district to pay claims submitted to such district prior to the final transition date.   3.  Upon  notice  to  a  social  services  district in accordance with subdivision  two,  that  the  department  intends  to   assume   payment responsibilities  on  behalf  of  such district, (a) such district shall  promptly submit to the department requested information  regarding  each person  who  applies  for  or  has  been determined eligible for medical assistance and each provider of medical assistance in such district; and (b) notwithstanding the provisions of paragraph (b) of subdivision three of  section  three  hundred  sixty-six-a of this chapter, the department shall provide each person found by such  district  to  be  eligible  for medical   assistance   under   this  title  with  a  medical  assistance identification card.   4. Information relating to persons applying for or  receiving  medical assistance  shall  be considered confidential and shall not be disclosed to persons or agencies other than  those  considered  entitled  to  such information  in accordance with section one hundred thirty-six when such disclosure  is  necessary  for  the  proper  administration  of   public assistance programs.   5. By no later than forty-five days following the end of each calendar quarter  after  the  second  quarter  of  calendar year nineteen hundred seventy-six, the department shall, until full  implementation  has  been achieved  in  all  social services districts, report to the governor and the legislature regarding the current status of the  medical  assistance information and payment system, summarizing the progress achieved during the  previous  quarter  and  the  anticipated  major achievements of the succeeding two calendar quarters. The report shall include  the  current and  anticipated  overall  expenditure and staffing levels for functions relating to the system, and shall  specify  each  district  affected  or anticipated  to  be affected during the succeeding two calendar quarters and summarize  the  manner  in  which  each  such  district  is,  or  is anticipated  to  be, affected. In addition, the department shall prepare and submit  to  the  governor  and  the  legislature  a  special  report demonstrating  the  appropriateness  and  relative cost-effectiveness of utilizing a fiscal intermediary.   In addition, for the purpose of  insuring  the  compatability  of  the system  servicing  the district comprising the city of New York with the system servicing all other social services districts in the  state,  the department  shall prepare and submit to the governor and the legislature on or before March first,  nineteen  hundred  seventy-eight,  a  special report and recommendation covering the appropriateness and relative cost effectiveness of utilizing a fiscal intermediary or fiscal agent for all districts other than the district comprising the city of New York.   6.  Each  social  services district shall be responsible for paying to the state a share of the state's expenditures for claims of providers of medical assistance attributable to such district, which shall  be  equal to  the  share of such expenditures such district would have borne after reimbursement from state and federal funds in  accordance  with  section three  hundred  sixty-eight-a  of this chapter, had the expenditure been made by such district; provided, however,  that  no  district  shall  be responsible for the state's expenditures for the administrative costs of developing,  maintaining  or  operating the statewide medical assistance information and payment system; and provided, further, that no  district shall  be responsible for paying to the state any portion of the cost of medical assistance which the department is  responsible  for  furnishing pursuant to section three hundred sixty-five of this chapter.   7.  In  any case in which the department has made payments for medical assistance on behalf of a social  services  district  pursuant  to  this section,  the  commissioner  on  behalf  of the social services official shall be empowered  to  bring  actions  to  recover  the  cost  of  such assistance, pursuant to this subdivision and the provisions of title six of article three of this chapter.    8.  (a)  For  the  purpose of orderly and timely implementation of the medical assistance information and payment  system,  the  department  is hereby authorized to enter into agreements with fiscal intermediaries or fiscal  agents  for  the design, development, implementation, operation, processing,  auditing  and  making  of payments, subject to audits being conducted by the state in accordance with the terms of such  agreements, for medical assistance claims under the system described by this section in  any  social  services  district.  Such agreements shall specifically provide that the state shall have complete oversight responsibility  for the  fiscal  intermediaries'  or fiscal agents' performance and shall be solely  responsible  for  establishing  eligibility   requirements   for recipients,  provider qualifications, rates of payment, investigation of suspected  fraud  and   abuse,   issuance   of   identification   cards, establishing  and  maintaining  recipient  eligibility  files,  provider profiles, and conducting state audits of the fiscal  intermediaries'  or agents' at least once annually. The system described in this subdivision shall  be operated by one or more fiscal intermediaries or fiscal agents in accordance with this subdivision unless the department  is  otherwise authorized  by  a  law  enacted subsequent to the effective date of this subdivision to operate the system in another manner. In no  event  shall such  intermediary  or  agent be a political subdivision of the state or any other governmental agency or entity. Notwithstanding the  foregoing, the  department  may make payments to a provider upon the commissioner's determination that the provider is temporarily  unable  to  comply  with billing  requirements.  The  department shall consult with the office of Medicaid inspector general regarding any activities  undertaken  by  the fiscal  intermediaries  or  fiscal  agents  regarding  investigation  of suspected fraud and abuse.  (b) The department of health,  in  consultation  with  the  office  of Medicaid  inspector  general,  shall  develop,  test  and  implement new methods  to  strengthen  the  capability  of  the   medical   assistance information  and  payment system to detect and control fraud and improve expenditure accountability, and  is  hereby  authorized  to  enter  into further  agreements with fiscal and/or information technology agents for the development, testing and implementation of  such  new  methods.  Any such  agreements  shall be with agents which have demonstrated expertise in the areas addressed by  the  agreement.  Such  methods  shall,  at  a minimum, address the following areas:  (1) Prepayment claims review. Develop, test and implement an automated claims  review  process  which,  prior to payment, shall subject medical assistance program services claims to review for proper coding and  such other  review  as  may  be  deemed necessary. Services subject to review shall be based on: the expected  cost-effectiveness  of  reviewing  such service;  the capabilities of the automated system for conducting such a review; and the potential  to  implement  such  review  with  negligible effect  on the turnaround of claims for provider payment or on recipient access to necessary services.  Such  initiative  shall  be  designed  to provide  for  the  efficient  and  effective  operation  of  the medical assistance  program  claims  payment  system  by  performing   functions including,  but  not  limited to, capturing coding errors, misjudgments, incorrect or multiple billing for the same service and possible excesses in billing or service use, whether intentional or unintentional.  (2) Coordination of benefits. Develop, test and implement an automated process to improve the coordination  of  benefits  between  the  medical assistance  program and other sources of coverage for medical assistance recipients.  Such  initiative  shall  initially  examine   the   savings potential to the medical assistance program through retrospective review of  claims  paid  which  shall  be  completed  not  later  than  January  thirty-first,  two  thousand  seven.  If,  based   upon   such   initial experience,  the  Medicaid inspector general deems the automated process to be capable of including or  moving  to  a  prospective  review,  with negligible effect on the turnaround of claims for provider payment or on recipient  access  to  services,  then the Medicaid inspector general in subsequent  tests  shall   examine   the   savings   potential   through prospective, pre-claims payment review.  (3)  Comprehensive  review  of  paid  claims.  Take all reasonable and necessary actions to intensify the state's current level of  monitoring, analyzing, reporting and responding to medical assistance program claims data  maintained  by  the  state's  medical  assistance  information and payment  system  contract  agents.  Pursuant  to  this  initiative,  the department  of  health,  in  collaboration  with  the office of Medicaid inspector general, shall make efforts to improve the utilization of such data in order to better identify fraud  and  abuse  within  the  medical assistance  program  and  to  identify and implement further program and patient care reforms for the improvement of such program.  In  addition, the  department of health, in consultation with such contract agents and the office of Medicaid inspector general, shall identify additional data elements that are maintained and  otherwise  accessible  by  the  state, directly  or  through any of its contractors, that would, if coordinated with medical assistance data, further increase the effectiveness of data analysis for the  management  of  the  medical  assistance  program.  To further  the  objectives of this subparagraph, the department of health, in collaboration with the office of Medicaid  inspector  general,  shall provide  or  arrange  in-service  training  for state and county medical assistance personnel to increase the capability for state and local data analysis, leading to a more  cost-effective  operation  of  the  medical assistance program.  (4)   Targeted  claims  and  utilization  review.  Develop,  test  and implement an automated  process  for  the  targeted  review  of  claims, services  and/or  populations  not  later than January thirty-first, two thousand seven.  Such review shall be for the  purposes  of  identifying statistical  aberrations  in the use or billing of such services and for assisting in the development and implementation of  measures  to  ensure that service use and billing are appropriate to recipients' needs.  (c)  The  commissioner  of  health shall prepare and submit an interim report to the governor and legislature  on  the  implementation  of  the initiatives specified in paragraph (b) of this subdivision no later than December  first,  two  thousand  seven.  Such  report shall also include recommendations for any revisions  that  would  further  facilitate  the goals  of  such  paragraph,  including recommendations for expansion. In addition, the commissioner of health shall submit  a  final  report  not later than December first, two thousand eight. In preparing such interim and  final  reports,  the  commissioner of health shall consult with the Medicaid inspector general, third-party agents, providers and recipients associated with the implementation of paragraph (b) of this subdivision.   9. (a) In order to accomplish a more orderly transition to the medical assistance information and payment system authorized  by  this  section, and  to  continue  for  a  limited  transition  period the rate at which advanced revenues have been made available by local  governmental  units to  certain hospitals providing services to persons eligible for medical assistance, the  department  is  authorized  to  promulgate  regulations establishing  a  system of accelerated payments to hospitals meeting the criteria set forth in this section.  (b) Such system of accelerated payments shall only be available  to  a general hospital, other than a public general hospital:  (i)  which  prior  to  January  first,  nineteen hundred seventy-eight received regular, periodic and recurring advanced revenues from a  local governmental  unit, the amount of which was based on anticipated medical assistance claims payments; and  (ii)  which  has  demonstrated  that its continued financial viability depends in substantial part on the rate at which such advanced  revenues were  made  available  by local governmental units prior to the time the department, pursuant to this section, assumed payment for such  hospital responsibilities  on  behalf of the social services district in which it is located, taking into account any funds remaining available  from  the local  governmental  unit  under  its  system  of advanced revenues. For purposes of this subdivision, it shall be presumed that a hospital  does not  depend  in  substantial part on the rate at which advanced revenues were made available by a local governmental unit  if  it  received  such revenues  for  a  period of less than nine months preceding the month in which the department assumed payment responsibilities for such hospital;  (iii) for which payment responsibility is  initially  assumed  by  the department  pursuant  to  this  section during the period beginning June first, nineteen hundred seventy-eight  and  ending  November  thirtieth, nineteen hundred seventy-eight; and  (iv)  which  meets  performance  criteria  established  by  department regulation relating to the ratio of acceptable claims for  patient  days submitted  for  medical assistance payment compared to the total patient days of the hospital and compared to such claims  submitted  in  one  or more  previous  months,  and the time lapse between the date the service was provided and the date the claim was submitted.  (c)  The  regulations  promulgated  by  the  department  pursuant   to paragraph  (a)  of this subdivision shall provide that the amount of the accelerated payment for any month shall be determined for each  hospital meeting  the  criteria  set  forth  in  this  section  on  the  basis of acceptable medical assistance claims submitted by the hospital in one or more previous  months  and  the  amount  of  accelerated  revenues  made available to the hospital by a local governmental unit prior to the time the  department  assumed  payment responsibilities for the hospital. The amount of the accelerated payment for any given month shall  not  exceed the  amount of a monthly aggregate claim to be submitted by the hospital to the department, which claim shall reflect items of care, services and supplies authorized under the medical  assistance  program  pursuant  to this title which are in fact provided prior to the date of the aggregate claim   to  persons  who  have  been  determined  eligible  for  medical assistance, or based on the past performance of the hospital are  likely to  be  determined eligible for medical assistance, when no other source of payment including third party health insurance and payments  pursuant to  title  eighteen of the Federal Social Security Act are available for such items of care, service and supplies. Such aggregate claims shall be subject to the audit and warrant of the state comptroller.  (d) Any schedule of accelerated payments established by the department pursuant to this section shall assure that such payments are made for  a period of no more than six months from the month in which the department assumes  payment  responsibility for the hospital, and shall provide for repayment of any amounts in excess of current  audited  claims,  through reductions  in current claims, at a rate that will assure full repayment at the earliest time consistent with the purposes of this  section,  but in  no  event  more than twenty-four months following the month in which the  department  assumes  payment  responsibilities  for  the  hospital. However,  where  the  commissioner  of  health  has  determined with the concurrence of the state hospital review and  planning  council  that  a hospital  has  satisfied  the department of health regulations and is or  has  been  authorized  to  participate   in   the   emergency   hospital reimbursement  program pursuant to which repayment of all or part of any accelerated payments made  by  the  department  have  been  deferred  in accordance  with  such regulations, notwithstanding the time limitations set forth above repayment of such deferred  amounts  shall  be  made  in accordance  with  an  orderly  schedule  of repayment established by the commissioner of health after consultation with the commissioner.  In  no event shall any reduction be made against current claims, grant funds or any  amounts  due said hospital in settlement of rate appeals, claims or lawsuits to satisfy such repayment obligations.  (e) In making accelerated payments pursuant to  this  subdivision  and department  regulations, the department shall utilize federal funds made available, and local funds, for such purposes or for purposes of payment by the department  of  medical  assistance  payments  pursuant  to  this section.   * 10.  a.  For the purpose of timely payment, the department is hereby authorized to develop a concurrent payment system for general  hospitals which  elect  to  participate in the concurrent payment system and which are  included  in  the  payment  component  of  the  medical  assistance information  and payment system, and to promulgate regulations to govern such a system. The  department  may  implement  the  concurrent  payment system for any general hospital which has elected to participate and for which the department has chosen to implement the system.   b.  For  all  participating  general  hospitals  the  department shall determine  a  biweekly  concurrent  payment  which   shall   equal   one twenty-sixth  of  the  portion  of  the  hospital's imputed or certified inpatient revenue  cap  (as  defined  in  section  twenty-eight  hundred seven-a  of  the  public  health  law)  allocated for medical assistance payments. The concurrent payment shall be reviewed at the  beginning  of each  quarter  and  adjusted  to  reflect  any  changes to the inpatient revenue cap or portion allocated for medical assistance payments.   c.  The  department  shall  promulgate  regulations,  consistent  with federal requirements for participation, governing the concurrent payment system.    The regulations shall address, among other things, the method of calculating the concurrent payment, the method of reconciliation, the adjustment of the concurrent payment for the calculated difference,  the manner  of  eliminating  underpayments  or  overpayments to hospitals in exceptional circumstances such as  significantly  changing  utilization, changes  in  bed  or  service  capacity,  or  imminent  insolvency.  The department shall promulgate regulations  establishing  a  procedure  for recognizing  open cases as of the date of reconciliation. The department shall also  promulgate  regulations  setting  forth  standards  for  the timeliness  and quality of billings and may lower the concurrent payment calculated in accordance  with  paragraph  b  of  this  subdivision  for noncompliance with such regulations.   d.  Any  payment  claims  made to the department for days of inpatient care provided prior to the effective date of this subdivision  shall  be paid  or denied in accordance with department regulations in effect when the care was provided.   e. For any general hospital which is not afforded the  opportunity  of participating   in  the  concurrent  payment  system  and  which  is  in compliance  with  the  billing  requirements  of  the  department,   the department  shall  pay any financing or working capital charge levied by the hospital as authorized in section twenty-eight  hundred  seven-a  of the public health law.   f.  This  subdivision shall be effective only if federal participation is available.   * NB Expires January 1, 1986    11. a. For the purpose of timely payment,  the  department  is  hereby authorized  to develop a concurrent payment system for general hospitals which elect to participate in the concurrent payment  system  and  which are  included  in  the  payment  component  of  the  medical  assistance information  and payment system, and to promulgate regulations to govern such a system. The  department  may  implement  the  concurrent  payment system for any general hospital which has elected to participate and for which the department has chosen to implement the system.   b.  For  all  participating  general  hospitals  the  department shall determine  a  biweekly  concurrent  payment  which   shall   equal   one twenty-sixth  of  the hospital's estimated yearly inpatient revenue from medical assistance payments. The concurrent payment shall be reviewed at the beginning of each quarter and adjusted to reflect any changes to the rates for medical assistance payments.   c.  The  department  shall  promulgate  regulations,  consistent  with federal requirements for participation, governing the concurrent payment system.    The regulations shall address, among other things, the method of calculating the concurrent payment, the method of reconciliation, the adjustment of the concurrent payment for the calculated difference,  the manner  of  eliminating  underpayments  or  overpayments to hospitals in exceptional circumstances such as  significantly  changing  utilization, changes  in  bed  or  service  capacity,  or  imminent  insolvency.  The department shall promulgate regulations  establishing  a  procedure  for recognizing  open cases as of the date of reconciliation. The department shall promulgate regulations setting forth standards for the  timeliness and  quality of billings and may lower the concurrent payment calculated in accordance with paragraph b of  this  subdivision  for  noncompliance with such regulations.   d.  Any  payment  claims  made to the department for days of inpatient care provided prior to the effective date of this subdivision  shall  be paid  or denied in accordance with department regulations in effect when the care was provided.   e. For any general hospital which is not afforded the  opportunity  of participating   in  the  concurrent  payment  system  and  which  is  in compliance  with  the  billing  requirements  of  the  department,   the department  shall  pay any financing or working capital charge levied by the hospital as authorized in section twenty-eight  hundred  seven-a  of the public health law.   f.  This  subdivision shall be effective only if federal participation is available.   12. (a) For the purpose of regulating cash flow for general hospitals, the department shall develop and  implement  a  payment  methodology  to provide for timely payments for inpatient hospital services eligible for case  based  payments  per  discharge  based on diagnosis-related groups provided during the period January first, nineteen hundred  eighty-eight through  March thirty-first two thousand twenty-three, by such hospitals which elect to participate in the system.  (b) In developing a payment methodology the department shall  consider a  system  under  which  hospitals  may  be  reimbursed  on the basis of inpatient admissions, adjusted to payment  on  the  basis  of  discharge data,  with reconciliations established at time periods specified by the department.  Under such a system variances between amounts  paid  on  an admission  basis  and  actual  amounts due and to be paid on a discharge basis may be reflected in the amounts to be paid in a subsequent period.   13. Notwithstanding any inconsistent provision  of  law,  in  lieu  of payments  authorized  by  this chapter and/or any of the general fund or special revenue other appropriations made to the office of temporary and disability assistance and the office of children  and  family  services,  from  funds  otherwise due to local social services districts or in lieu of payments of federal funds otherwise  due  to  local  social  services districts for programs provided under the federal social security act or the  federal  food  stamp  act  or the low income home energy assistance program, funds in amounts certified by the commissioner of the office of temporary and disability assistance or the commissioner of the office of children and family services or the commissioner of health as  due  from local social services districts as their share of payments made pursuant to  this  section,  may  be  set-aside  by  the  state comptroller in an interest-bearing account with such interest accruing to  the  credit  of the  locality,  pursuant  to an estimate provided by the commissioner of health of a local social services district's share of medical assistance payments, except that in  the  case  of  the  city  of  New  York,  such set-aside shall be subject first to the requirements of a section of the chapter  of  the  laws of two thousand one which enacted this provision, and then subject to the requirements of paragraph (i) of subdivision (b) of section two hundred twenty-two-a of chapter four hundred seventy-four of the laws of nineteen hundred ninety-six prior to the  application  of this  subdivision.  Should  funds  otherwise  payable  to a local social services district from appropriations made to the  office  of  temporary and  disability  assistance, the office of children and family services, and the department of health be insufficient to fully fund  the  amounts identified  by  the commissioner of health as necessary to liquidate the local share of payments to be made pursuant to this section on behalf of the local social services  district,  the  commissioner  of  health  may identify  other  state  or federal payments payable to that local social services district or any other county agency including, but not  limited to  the  county  department  of  health, from appropriations made to the state department of health, and may  authorize  the  state  comptroller, upon no less than five days written notice to such local social services district  or such other county agency, to set-aside such payments in the interest-bearing account with such interest accruing to  the  credit  of the locality. Upon such determination by the commissioner of health that insufficient  funds  are payable to a local social services district and any other county agency receiving payments from the office of  temporary and  disability  assistance, the office of children and family services, and the state department of health from  appropriations  made  to  these agencies,  the  state  comptroller  shall,  upon  no less than five days written notice to such local social  services  district  or  such  other county  agency,  withhold  payments from any of the general fund - local assistance accounts or payments made from any of the special  revenue  - federal  local assistance accounts, provided, however, that such federal payments shall be withheld only after such federal  funds  are  properly credited  to  the  county  through  vouchers,  claims  or other warrants properly received, approved, and paid  by  the  state  comptroller,  and set-aside  such  disbursements in the interest-bearing account with such interest accruing to the credit of the locality until such time that the amount withheld from each county is determined by  the  commissioner  of health  to be sufficient to fully liquidate the local share of payments, as estimated by the commissioner of health, to be made pursuant to  this section on behalf of that local social services district.   14. Notwithstanding any other provision of law, effective on or before January  first,  two  thousand  one,  the local social services district share of medical assistance payments made by the state on behalf of  the local  social  services district shall be paid to the state by the local social services district  using  electronic  funds  transfer  under  the supervision   of  the  state  comptroller  and  pursuant  to  rules  and regulations of the commissioner of health. The state  comptroller  shall  deposit  such  funds  in  the  medicaid  management  information  system statewide escrow fund to the credit of each local district. In the event that the state comptroller and commissioner  of  health  determine  that there  are  insufficient  funds  available  from  the  local district to liquidate  their  local  share  of  medical  assistance  payments,   the commissioner  of  health  shall  issue a repayment schedule to the state comptroller for purposes of reducing reimbursement from other sources of payment from the state to the city or county of which the  local  social services  district  is a part in accordance with subdivision thirteen of this section,  until  the  amounts  due  from  the  local  district  are recovered in full plus any interest that would have otherwise accrued to the  fund had such fund had sufficient balances from the local district. Upon determination by the state comptroller that insufficient sources of payment are available to  fully  liquidate  the  local  social  services district  share  of  medical  assistance  payments,  the commissioner of health shall include in such schedule a charge to the  county  equal  to the amount of interest otherwise earned by the state short-term interest pool,  plus  any  interest  penalty  as  the  commissioner of health may determine, until such time as the  district  has  fully  liquidated  its liability pursuant to the provisions of this chapter.