2023 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section shall expire and be deemed repealed on and  after  the  date  on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.