New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-3 - Health Maintenance Organizations › Section 86-3.3 - Rates for hospital services

Current through Register Vol. 46, No. 28, July 10, 2024
Hospitals certified under article 28 of the Public Health
						Law may not deny admission solely on grounds of HMO membership. This section
						applies to the general prepaid membership of an HMO; Medicare and Medicaid
						reimbursement for such services shall be as described in subdivision (h) of
						this section. Reimbursement to be paid by HMO's to hospitals for these services
						shall be determined as follows:
(a)
					 Hospitals certified under article 28 of the Public Health Law shall be
					 reimbursed for the inpatient care of HMO members at a rate which does not
					 exceed the DRG case based rates of payment, adjusted for noncovered services
					 determined pursuant to section
					 86-1.51(a) 
					 of this Title, or equivalent mechanism for the local area if rates are not
					 being used. Hereafter these rates shall be called DRG case based rates. No
					 supplementary charges may be made by a hospital except as specified in
					 subdivision (c) or (d) of this section.
(b) When there is more than one DRG case
					 based rate in effect at a hospital, the rate covering the most comprehensive
					 range of services utilized by HMO patients shall be the HMO rate, unless the
					 difference between the comprehensive rate and a less inclusive rate is due to
					 categories of services not utilized in care of HMO inpatients, in which case
					 the less inclusive rate shall be utilized.
(c) When the HMO inpatient utilizes physician
					 or ancillary services whose allowable costs are not included in the DRG case
					 based rate being utilized, for example, anesthesiologist services if not
					 included in the DRG case based rate, reimbursement for such services shall be
					 negotiated by the HMO and the hospital or provider.
(d) In cases of nonmedically ordered patient
					 comfort or amenity services not covered by the DRG case based rate, a hospital
					 may bill an HMO member or HMO plan according to local practice or agreement
					 with the HMO.
(e) Health
					 maintenance organizations, except those affected by outpatient rate provisions
					 certified pursuant to hospital reimbursement formulas submitted under Subpart
					 86-1 of this Part, shall submit proposed outpatient reimbursement formulas
					 which are reasonable and adequate to meet the costs which must be incurred by
					 efficiently and economically operated facilities. In order to enable the full
					 exchange of information between health maintenance organizations and hospitals,
					 as may be necessary for submission and consideration of the proposed outpatient
					 reimbursement formulas as required hereunder and to minimize potential
					 litigation resulting from approval hereunder of any reimbursement formula and
					 rates submitted without benefit of such full information from hospitals, each
					 such health maintenance organization or a group of health maintenance
					 organizations may confer with a hospital, group or association of hospitals,
					 prior as well as subsequent to submission of its proposed reimbursement formula
					 and rates, concerning the reimbursement formula and rates to be submitted for
					 consideration and approval hereunder. Concerning any such conference with any
					 group or association of hospitals, the State Commissioner of Health may require
					 from any such health maintenance organizations such report, by way of summary
					 minutes or otherwise, as may be reasonably necessary to the discharge of the
					 responsibilities of the commissioner under this subdivision. However, nothing
					 in this subdivision shall prohibit an individual HMO and an individual hospital
					 from mutually agreeing to any other manner of payment for outpatient services,
					 provided the commissioner first approves such alternate method of
					 payment.
(f) Notwithstanding the
					 provisions of sections
					 86-1.51 and
					 86-1.57  of
					 this Part, health maintenance organizations operating in accordance with the
					 provisions of article 43 of the Insurance Law, or article 44 of the Public
					 Health Law may arrange special payment rate methodologies with hospitals
					 provided that the commissioner has been notified of the proposed arrangement,
					 has reviewed such proposed arrangement and has approved the arrangement in
					 writing. Such an arrangement shall not be approved if it will result in
					 payments to the hospital for inpatient services provided to subscribers of
					 health maintenance organizations which in the aggregate are less than what the
					 hospital would have otherwise received under the provisions of this Subpart and
					 Subpart 86-1 of this Part, unless the health maintenance organization
					 demonstrates that lower payments are justified because the arrangement will
					 result in lower hospital costs and the payments approximate cost.
					 Notwithstanding any inconsistent provision of this section, for the period
					 January 1, 1988 through December 31, 1990, negotiated agreements between health
					 maintenance organizations and general hospitals which were approved by the
					 commissioner in accordance with the provisions of chapter 906 of the Laws of
					 1985 and which were in effect on June 1, 1987 may continue.
(g) Nothing in this Subpart shall prohibit
					 article 44 HMO's from contracting with article 43 hospital service plans for
					 hospital reimbursement and/or other services, subject to the requirements of
					 the Superintendent of Insurance.
(h) Notwithstanding any inconsistent
					 provisions of this section, health maintenance organizations operating in
					 accordance with the provisions of article 43 of the Insurance Law or article 44
					 of the Public Health Law, having enrollees eligible for inpatient general
					 hospital payments as beneficiaries of title XVIII of the Federal Social
					 Security Act (Medicare) shall reimburse general hospitals for inpatient
					 services for these enrollees in accordance with the provisions contained in
					 title XVIII of the Federal Social Security Act (Medicare). Hospitals shall
					 receive Medicaid rates of payment for the care of HMO/Medicaid
					 clients.