reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter Q - State Environmental Quality Review › Part 97 - Regulations Implementing State Environmental Quality Review › Section 97.16 - Fees and costs

Current through Register Vol. 46, No. 28, July 10, 2024
(a) When an
				  action subject to this Part involves an applicant, the department, if it is
				  lead agency, may charge a fee to the applicant in order to recover the actual
				  costs of preparing or reviewing the EIS; providing, however, that an applicant
				  may not be charged a separate fee for both the preparation and review of an
				  EIS, and provided further, that any fee charged must reflect the actual costs
				  to the lead agency for such preparation or review. Where an applicant does not
				  choose to prepare the EIS, the department shall provide the applicant, upon
				  request, with an estimate of the costs for preparing such statement based on
				  the total cost of the project for which funding or approval is
				  sought.
(b) For residential
				  projects, the total project cost shall be the cost of the land plus the cost of
				  all site improvements required, not including the cost of buildings and
				  structures. In the case of a residential project, the fee charged by the
				  department may not exceed two percent of the total project cost.
(c) For nonresidential construction projects,
				  the total project cost shall be the cost of supplying utility service to the
				  project, the cost of site preparation and the cost of labor and material as
				  determined with reference to a current cost data publication in common usage,
				  such as Building Construction Cost Data by Means. In the case of construction
				  projects, the fee charged may not exceed one half of one percent of the total
				  project cost.
(d) Appeals
				  procedure. When a dispute arises concerning fees charged to an applicant by the
				  department, the applicant may make a written request setting forth reasons why
				  it is felt that such fees are inequitable. Upon receipt of a request, the chief
				  fiscal officer of the department or his designee shall examine the agency
				  record and prepare a written response to the applicant setting forth reasons
				  why the applicant's claims are valid or invalid.
(e) Any fees paid by the department for the
				  technical services of the Department of Environmental Conservation will be
				  reflected in the fee charged to any applicant pursuant to subdivision (a) of
				  this section.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter Q - State Environmental Quality Review › Part 97 - Regulations Implementing State Environmental Quality Review › Section 97.17 - Programmatic or generic environmental impact statements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A programmatic or generic environmental
				  impact statement may be used to assess the environmental effects of:
(1) a number of separate actions in a given
				  geographic area which, if considered singly may have minor effects, but if
				  considered together may have significant effects;
(2) a sequence of actions, contemplated by a
				  single agency or individual;
(3)
				  separate actions having generic or common impacts; or
(4) programs or plans having wide application
				  or restricting the range of future alternatives policies or projects.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter Q - State Environmental Quality Review › Part 97 - Regulations Implementing State Environmental Quality Review › Section 97.18 - Confidentiality

Current through Register Vol. 46, No. 28, July 10, 2024
When an applicant submits a completed EAF, draft or final
					 EIS, or otherwise provides information concerning the environmental impact of a
					 proposed project, the applicant may request that specifically identified
					 information be held confidential upon a showing by the applicant that such
					 information constitutes a trade secret. Prior to divulging any such
					 information, the department shall notify the applicant of its determination of
					 whether or not it will hold the information confidential.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter Q - State Environmental Quality Review › Part 97 - Regulations Implementing State Environmental Quality Review › Section 97.19 - Effective date

Current through Register Vol. 46, No. 28, July 10, 2024
This Part shall take effect as provided in article 8 of the
					 Environmental Conservation Law.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.1 - Applicability

Current through Register Vol. 46, No. 28, July 10, 2024
This Subpart shall be applicable to all persons who
						propose to establish and/or operate a health maintenance organization (HMO),
						special purpose health maintenance organization, also known as a prepaid health
						services plan (PHSP), comprehensive HIV special needs plan (HIV SNP) or, as
						specified, a primary care partial capitation provider (PCPCP) or managed long
						term care plan (MLTCP) or who currently operate an HMO, PHSP, HIV SNP or, as
						specified, a PCPCP or MLTCP certified under article 44 of the Public Health Law
						within the State of New York, which may hereinafter be referred to individually
						or collectively as managed care organization (MCOs).
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.4 - Certificate of incorporation or articles of organization

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No person shall file a certificate of
					 incorporation or articles of organization, or amendment thereto, containing
					 powers related to the operation of an MCO or an IPA with the Secretary of
					 State, without first having submitted the proposed certificate, articles or
					 amendment to the commissioner for his or her review and approval and received
					 all approvals required by law.
(b)
					 The proposed purpose and powers of an MCO shall include the following:
(1) to perform studies, feasibility surveys
					 and planning with respect to the development and formation of an MCO; and in
					 conjunction, to accumulate, compile and analyze statistics and such other data
					 that will promote the health, safety and welfare of the general public;
					 and
(2) upon obtaining a
					 certificate of authority from the commissioner, to own, operate and manage a
					 health maintenance organization or, as appropriate, a PHSP, or comprehensive
					 HIV special needs plan, or managed long-term care plan or primary care partial
					 capitation provider, including providing or arranging for the provision of
					 comprehensive health services, to an enrolled population, and to have and
					 exercise all powers necessary and convenient to effect any or all of the
					 foregoing purposes for which the entity is formed, together with all the powers
					 now or hereafter granted to it by the State of New York.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.7 - Limitations of a certificate of authority

Current through Register Vol. 46, No. 28, July 10, 2024
(a) A certificate of authority pursuant to
					 this Subpart shall be limited to the proposed article 44 service area described
					 in the application upon which the certificate is issued.
(b) A certified operating MCO which seeks to
					 extend its approved article 44 service area, and has defined a new potential
					 enrolled population therein, shall submit an application, and shall not extend
					 the service area until an amended certificate of authority is issued. An
					 application for extension of the service area shall include:
(1) identification of the new service area
					 for which approval is sought, and the projected enrollment on a monthly basis
					 for three years;
(2) copies of all
					 proposed contracts with providers of services for the proposed new service
					 area; these contracts shall include the provisions in section
					 98-1.5(b)(6)(i)-(v) 
					 of this Subpart;
(3) a list of
					 providers and facilities with whom contracts have been or will be executed,
					 including the location and specialty area of each provider; and
(4) except for PCPCPs, such other
					 information, including financial projections, as the commissioner, in
					 consultation with the superintendent, as appropriate, shall deem necessary to
					 determine the ability of the applicant to make services available and
					 accessible to the identified potential enrollment population, and to otherwise
					 approve the service area expansion application.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.8 - Continuance of a certificate of authority

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Continuance of a certificate of authority
					 shall be contingent upon satisfactory performance by the MCO of delivery,
					 continuity, accessibility and quality of the services to which an enrolled
					 member is entitled, compliance of the MCO with the provisions of article 44 of
					 the Public Health Law and this Subpart, the continuing fiscal solvency of the
					 MCO, except for PCPCPs, and compliance with all conditions set forth on the
					 certificate of authority. The commissioner may impose conditions and
					 limitations on a certificate of authority. Failure to comply with such
					 conditions and limitations shall be deemed unsatisfactory
					 performance.
(b) All new contracts
					 or forms of contracts and material amendments to existing contracts, including
					 all attachments thereto, between the MCO and health services providers,
					 whenever proposed, shall include the provisions in section
					 98-1.5(b)(6)(i)-(v) 
					 of this Subpart and shall require prior approval and be submitted to the
					 commissioner in advance of their proposed implementation in accordance with
					 guidelines issued by the commissioner as per section 98- 1.5(b)(6)(v) of this
					 Subpart.
(c) Any amendments to any
					 risk-sharing arrangements contained in any contracts between the MCO and
					 providers, with the exception of routine trending of fees or other
					 reimbursement amounts, shall not be entered into without prior approval of the
					 commissioner and, as appropriate, the superintendent.
(d) Any contemplated amendment to or revision
					 of an approved contract with, or on behalf of, the enrollees of an MCO shall be
					 submitted to the superintendent and approved by the superintendent prior to the
					 execution of an amended or revised contract with, or, as applicable, on behalf
					 of the enrollees of an MCO, except in the case of contracts entered into
					 between an MCO and a social services district or the State on behalf of the
					 enrollees of an MCO for services provided pursuant to title XIX, which shall
					 require prior approval by the commissioner and, as required by Federal law, the
					 Federal agency with oversight responsibility for such programs.
(e) Any revisions in rates of payment for
					 enrollees of programs authorized by title XIX must receive the prior approval
					 of the commissioner.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.9 - Acquisition or retention of control of mcos

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No person shall acquire control of any
					 New York State-certified MCO, whether by purchase of its securities or
					 otherwise, unless it receives the commissioner's prior approval, which shall
					 not be issued until the commissioner has consulted with the superintendent, as
					 appropriate.
(b) The commissioner
					 may disapprove such acquisition if he or she determines, upon notice and an
					 opportunity to be heard, that such disapproval is reasonably necessary to
					 protect the interests of the people of this State. The following factors shall
					 be considered in making such determination:
(1) the financial condition of the acquiring
					 person and the MCO;
(2) the
					 character, competence and standing in the community of the acquiring person
					 and, if the acquiring person is a holding company, the performance of the
					 holding company, its owners, directors, members and managers of a limited
					 liability company and any health care facilities operated by that holding
					 company or its controlled persons; and
(3) the continuing assurance that the MCO's
					 operations will be in compliance with article 44 of the Public Health Law and
					 this Subpart.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.10 - Transactions within a holding company system affecting controlled mcos

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Transactions
					 within a holding company system to which a controlled MCO is a party shall be
					 subject to the following guidelines:
(1) the
					 terms of the financial transaction shall be fair and equitable to the MCO at
					 the time of the transaction;
(2)
					 charges or fees for services performed shall be reasonable; and
(3) expenses incurred and payments received
					 shall be allocated to the MCO on an equitable basis in conformity with
					 customary accounting practices consistently applied.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.12 - Quality management program

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An MCO shall develop and implement a
					 quality management program, that is supervised by the medical director and that
					 includes organizational arrangements and ongoing procedures for the
					 identification, evaluation, resolution and follow-up of potential and actual
					 problems in health care administration and delivery to enrollees. MCOs shall
					 include in such quality management programs standards for management of access
					 to, continuity and quality of care and, except for PCPCPs, utilization and cost
					 of services.
(b) MCOs shall also
					 develop a quality assessment and performance improvement program that includes
					 performance and outcome-based quality standards for enrollee health status,
					 satisfaction, and for MLTCPs, functional status also. The program shall achieve
					 required minimum levels of performance on standardized quality measures
					 established by the commissioner. In the case of an HIV SNP, the quality
					 indicator measures must include HIV-specific quality measures.
(c) A health information system shall be
					 maintained that collects, analyzes, integrates, and reports data necessary to
					 develop and implement the quality assurance and performance improvement
					 programs.
(d) The quality
					 assessment and performance improvement programs shall be approved by the
					 commissioner prior to issuance of a certificate of authority and monitored
					 periodically thereafter by the commissioner.
(e) The quality assessment organizational
					 arrangements and ongoing procedures must be fully described in written form,
					 provided to all members of the governing authority, providers and staff, and
					 made available to enrollees in the MCO.
(f) The organizational arrangements for the
					 quality assessment program must be clearly defined and transmitted to all
					 individuals involved in the quality assessment program, and should include, but
					 not be limited to, the following:
(1) an
					 internal quality assurance committee or comparable designated committee
					 responsible for quality assurance activities;
(i) accountability of the committee to the
					 governing authority of the MCO, including periodic written and oral reports to
					 the governing authority;
(ii)
					 participation from an appropriate base of providers and support
					 staff;
(iii) regularly scheduled
					 meetings at appropriate periodic intervals, no fewer than four per year;
					 and
(iv) minutes or records of the
					 meetings, describing in detail the actions of the committee, including the
					 medical charts reviewed, problems discussed, recommendations made, and any
					 other pertinent discussions and activities; and
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.13 - Assurance of access to care

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 All covered services must be directly provided or arranged for within the
					 approved provider network pursuant to written contracts developed and
					 maintained in a form and manner prescribed by the commissioner, except that
					 when services are unavailable within the provider network, such services must
					 be arranged for outside of the approved provider network. An MCO shall
					 establish a process for the resolution of requests for medically necessary
					 services to be provided by out-of-network providers when such services are not
					 available in network. Such process shall require the approval of the
					 commissioner prior to implementation and shall thereupon be included in the
					 member handbook. Emergency services do not require prior authorization; no MCO
					 or utilization review agent may require enrollees to obtain prior authorization
					 for the provision of such services.
(b) The limitation in subdivision (a) of this
					 section, and other limitations imposed on accessing the entire approved
					 network, must be clearly transmitted to eligible persons and enrollees via
					 marketing materials, member handbooks and subscriber contracts.
(c)
(1)
					 Prior approval of the commissioner is required for assignment of an IPA or
					 institutional network provider contract, or of a medical group provider
					 contract that serves five percent or more of the enrolled population in a
					 county.
(2) A minimum of 45 days
					 prior written notice to the commissioner is required for termination or
					 non-renewal of an IPA or institutional network provider contract, or of a
					 medical group provider contract that serves five percent or more of the
					 enrolled population in a county or when the termination or non-renewal of the
					 medical group provider will leave fewer than two participating providers of
					 that type within the county. The notice shall include an impact analysis of the
					 termination or non-renewal with regard to enrollee access to care.
(3) All provider contracts assigned by an MCO
					 or an IPA prior to, and which remain in effect following, the effective date
					 hereof shall be amended within one year of such effective date or upon renewal,
					 whichever first occurs, to achieve compliance with the provisions of this
					 subpart and guidelines for provider and IPA contracts established by the
					 commissioner.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.14 - Enrollee services and grievance procedures

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The MCO shall supply enrollee handbooks
					 to each enrollee, and upon request to each prospective enrollee, which explain
					 the operation of the plan. The MCO shall also provide information as required
					 by section 4408  of the Public Health Law. Except where
					 precluded by applicable law or regulation, changes in operations that affect
					 the enrollee shall be communicated to the enrollee prior to the effective date
					 of the change via the enrollee handbook or by other direct means of
					 communication.
(1) For MLTCPs, the enrollee
					 handbook and complete provider network directory shall be provided to
					 individuals who have expressed a desire for enrollment. MLTCPs shall also
					 comply with the provisions of section
					 98-1.16(i) 
					 of this Subpart.
(2) Information
					 disclosed in the enrollee handbook and changes made thereto shall be approved
					 prior to use of the handbook by:
(i) for
					 programs authorized by title XIX, the commissioner and, when such approval is
					 required, the Federal agency with oversight responsibility for programs
					 authorized by title XIX;
(ii) for
					 programs authorized by title XXI, the commissioner;
(iii) for commercial and private pay
					 insurance products, the commissioner; and
(iv) for MLTCPs, the superintendent in
					 consultation with the commissioner and director of the State Office for Aging
					 and, as appropriate, the Federal agencies with oversight responsibility for
					 programs authorized by titles XIX and XVIII of the Social Security
					 Act.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.15 - Employer requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All
					 employers subject to the provisions of the Unemployment Insurance Law, except
					 those employers with fewer than 25 employees, shall include in any health
					 benefits plan offered to their employees the option of membership in an HMO
					 which provides or offers a comprehensive health services plan in accordance
					 with the provisions of this Subpart, but only if such plan serves an area in
					 which 25 of such employer's employees reside and the HMO has been issued a
					 certificate of authority by the commissioner.
(b) For those employees of an employer
					 represented by a bargaining representative, the offer of the HMO option shall
					 be subject only to the collective bargaining process. For those employees not
					 represented by a bargaining representative, the offer of the health maintenance
					 organization alternative shall be made directly to the employee.
(c) Employer option.
(1) For the purposes of this section, the
					 following definitions shall apply:
(i) Staff
					 model/group model category:
(a) Staff model
					 is an HMO that provides more than one half of its basic health services through
					 physicians and other professionals who work in centralized health centers as
					 salaried employees of the HMO and where health care is delivered at a health
					 center owned or leased by the HMO.
(b) Group model is an HMO that provides more
					 than one half of its basic health services through physicians and other
					 professionals who are not salaried employees of the organization but instead
					 are members of one or more medical groups which contract with the HMO to
					 deliver health care at a health center.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.16 - Disclosure and filing

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Every
					 MCO, other than a PHSP that only serves enrollees eligible for benefits under
					 title XIX, HIV SNPs and PCPCPs, shall file in duplicate with both the
					 commissioner and the superintendent a financial statement on or before April
					 1st of each year, in the form and containing such information as the
					 commissioner and the superintendent shall prescribe, showing its condition at
					 last year-end and containing information required by section 4408  of the Public Health Law and the
					 following information:
(1) a statement of
					 financial condition, including a balance sheet and summary of receipts and
					 disbursements and an income statement;
(2) an analysis of its enrolled population,
					 identifying numbers of enrollees by age groups and sex, and numbers of enrollee
					 contracts by type (family and individual), by contract months, except that for
					 MLTCPs, the analysis may contain other identifying information relevant to the
					 enrolled population; and
(3) an
					 analysis of utilization of services, including all services covered by the
					 MCO.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.17 - Audits and examinations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 commissioner, or his or her representative, and in the case of paragraph (5) of
					 this subdivision, the superintendent, may examine at any time each MCO, and all
					 participating entities through which such MCO offers health services, as to the
					 quality of health care services offered, and the adequacy of its provider
					 arrangements. Such examination may include, but shall not necessarily be
					 limited to:
(1) all records and reports
					 relative to the number and characteristics (e.g., age and sex) of
					 enrollees;
(2) all records and
					 reports relative to utilization of services, by type;
(3) all records of complaints or grievances
					 submitted by enrollees to the health maintenance organization, and the
					 disposition thereof;
(4) evidence
					 of the operation of a mechanism through which the enrolled population provides
					 advice about the policies of an MCO (e.g., enrollee representation on the
					 governing board); and
(5) contracts
					 with providers of health services and other vendors.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.19 - Marketing by mltcps

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An MLTCP
					 shall prepare a marketing plan. Marketing plans shall not be implemented
					 without the prior written consent of the commissioner.
(b) Marketing means any activity of an MLTCP,
					 a subcontractor of the MLTCP or individuals or entities affiliated with the
					 MLTCP, by which information about the MLTCP is made known to potential
					 enrollees for the purpose of persuading such persons to enroll with the MLTCP.
					 Marketing activities are occasions during which marketing information and
					 material regarding managed long term care and a particular MLTCP are presented.
					 Such information may be presented through verbal exchanges and the distribution
					 of written materials and the giving away of nominal gifts (value of $5 or
					 less).
(c) Each marketing plan for
					 an MLTCP submitted to the department for approval shall include but not be
					 limited to:
(1) goals and general marketing
					 strategy;
(2) a description of
					 marketing activities and copies of all draft marketing materials;
(3) staffing plan including training and
					 compensation methodology and levels;
(4) a description of how the MLTCP will meet
					 the informational needs of eligible persons, including those who speak a
					 language other than English as a first language and/or who have a hearing,
					 visual, physical or cognitive impairment, and enable the person to make a
					 voluntary and informed choice;
(5)
					 a description of the MLTCP's monitoring activities to ensure compliance with
					 this section; and
(6)
					 identification of the primary marketing locations at which marketing will be
					 conducted.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.20 - Waved requirements for MLTCPs

Current through Register Vol. 46, No. 28, July 10, 2024
Section 365-i  of the Social Services Law, pertaining to
						prescription drug payments, is deemed waived for MLTCPs by the
						commissioner.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-1 - Managed Care Organizations › Section 98-1.22 - Warning statements

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All
					 paper claim forms for health insurance delivered to any person residing or
					 located in this State, in connection with health insurance policies, except
					 health insurance policies for title XVIII of the Federal Social Security Act,
					 or State or local department of social services contracts to be issued or
					 issued for delivery in this state shall, as of the date 90 days from the
					 effective date of these regulations, contain the following statement: "Any
					 person who, knowingly and with intent to defraud any MCO or other person, files
					 a statement of claim containing any materially false information, or conceals
					 for the purpose of misleading, information concerning any fact material
					 thereto, is guilty of committing a fraudulent insurance act, which is a crime
					 and shall be subject to a civil penalty not to exceed $5,000 and the stated
					 value of the claim for each such violation."
(b) Location of warning statements and type
					 size.
(1) The warning statements required by
					 subdivisions (a) and (c) of this section shall be placed immediately above the
					 space provided for the signature of the person executing the claim form and
					 shall be printed in type which will produce a warning statement of conspicuous
					 size. On claim forms which require execution by a person other than the
					 claimant, or in addition to the claimant, the warning statements required by
					 subdivisions (a) and (c) of this section shall be placed at the top of the
					 first page of the claim form or on the page containing instructions, either in
					 print, by stamp or by attachments and shall be in type size which will produce
					 a warning statement of conspicuous size.
(2) Notwithstanding the provisions of
					 paragraph (1) of this subdivision, MCOs may affix the warning statements
					 required by this Subpart to all claim forms by means of labels and/or stamps or
					 by attachment during the 90-day period following the effective date of these
					 regulations.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.1 - Preamble

Current through Register Vol. 46, No. 28, July 10, 2024
Enrollees, and in the case of a retrospective adverse
						determination, an enrollee's health care provider shall have the right to
						request an external appeal of a final adverse determination which is made by a
						health care plan on the grounds that the health care service is not medically
						necessary or is experimental or investigational. This Subpart shall be
						applicable to health care plans as defined in subdivision 4-e of section 4900  of the Public Health Law that offer
						health care services to an enrolled population that is not exclusively covered
						by title XVIII of the Social Security Act and to external appeal agents
						certified pursuant to title II of article 49 of the Public Health Law and
						Insurance Law and this Subpart and to applicants for certification as external
						appeal agents.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The following words or terms shall have the following
						meanings when used in this Subpart:
(a) Attending physician means, for the
					 purpose of requesting an external appeal of an experimental or investigational
					 treatment or service, a licensed, board-certified or board-eligible physician
					 who is qualified to practice in the area of medicine or in the specialty
					 appropriate to treat an enrollee's life-threatening or disabling condition or
					 disease who has recommended a service or treatment that is the subject of a
					 request for external appeal. For enrollees covered by a health care plan with
					 no out-of-network option, the attending physician must either participate in
					 the enrollee's health care plan or must be a physician to whom the enrollee's
					 health care plan referred the enrollee.
(b) Confidential HIV related information
					 means any information in the possession of a person who provides one or more
					 health or social services or who obtains the information pursuant to a release
					 of confidential HIV related information, concerning whether an individual has
					 been the subject of an HIV related test, or has HIV infection, HIV related
					 illness or AIDS, or information which identifies or reasonably could identify
					 an individual as having one or more of such conditions, including information
					 pertaining to such individual's contacts.
(c) Final adverse determination means an
					 adverse determination which has been upheld by a utilization review agent with
					 respect to a proposed health care service following a standard appeal, or an
					 expedited appeal where applicable, pursuant to section 4904  of the Public Health Law. If a health
					 care plan offers two levels of internal appeals, a final adverse determination
					 shall mean the adverse determination of the first level appeal.
(d) Material familial affiliation means any
					 relationship as a spouse, child, parent, sibling, spouse's parent, spouse's
					 child, child's parent, child's spouse, or sibling's spouse.
(e) Material financial affiliation means any
					 financial interest of more than five percent of total annual revenue or total
					 annual income of a certified external appeal agent or officer, director, or
					 management employee thereof; or clinical peer reviewer employed or engaged
					 thereby to conduct any external appeal. The term material financial affiliation
					 shall not include revenue received from a health care plan by:
(1) a certified external appeal agent to
					 conduct an external appeal pursuant to section 4914 of title II of article 49
					 of the Public Health Law and the Insurance Law; or
(2) a clinical peer reviewer for health care
					 services rendered to enrollees.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.4 - Certification of external appeal agents

Current through Register Vol. 46, No. 28, July 10, 2024
(a) External appeal agents shall be certified
					 jointly by the commissioner and superintendent pursuant to section 4912  of the Public Health Law, section 4912  of the Insurance Law and the
					 following:
(1) the applicant has demonstrated
					 to the satisfaction of the commissioner and the superintendent that it has
					 access to a pool of clinical peer reviewers sufficient to reasonably assure
					 that appropriately qualified reviewers will be available on a timely basis for
					 all appeals allowed by section 4910  of the Public Health Law and section 4910  of the Insurance Law and to avoid or
					 minimize conflicts of interest pursuant to section
					 98-2.6  of
					 this Subpart; and
(2) the applicant
					 has demonstrated its capability to comply with all applicable laws, rules,
					 regulations, contractual terms, policies and standards as set forth in section 4912  of the Public Health Law and section 4912  of the Insurance Law and as required
					 by the commissioner and superintendent.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.5 - Certification requirements

Current through Register Vol. 46, No. 28, July 10, 2024
Applicants for certification as external appeal agents
						shall be required to submit a signed and notarized application to the
						commissioner, in the form and manner prescribed jointly by the commissioner and
						the superintendent. Such application shall include the requirements of section 4912  of the Public Health Law and Insurance
						Law and the following:
(a) A
					 description of the applicant's organizational structure and capability to
					 operate a statewide external appeal program, including:
(1) certificate of incorporation, articles of
					 organization and by-laws or operating agreement of the applicant and, as
					 applicable, the applicant's holding company or parent company;
(2) the applicant's organizational chart;
					 and
(3) any existing or proposed
					 relationships between the applicant and any health care services entities,
					 health care providers and management service organizations. A certified
					 external appeal agent shall not delegate any management function related to
					 external appeal activities pursuant to title II of article 49 of the Public
					 Health Law and the Insurance Law to a management service organization or any
					 other entity.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.6 - Conflict of interest

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No
					 entity shall be qualified for certification as an external appeal agent if it
					 owns or controls, is owned or controlled by, or exercises common control with
					 any of the following:
(1) any national, State
					 or local illness, health benefit or public advocacy group;
(2) any national, State or local society or
					 association of hospitals, physicians, or other providers of health care
					 services; or
(3) any national,
					 State or local association of health care plans.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.8 - Random assignment of external appeals

Current through Register Vol. 46, No. 28, July 10, 2024
Requests for external appeals that have been determined
						to be eligible for external appeal shall be randomly assigned by the
						superintendent to a certified external appeal agent according to a process
						prescribed by the commissioner and superintendent. Such process must take into
						account conflicts of interest pursuant to section 4913  of the Public Health Law and Insurance
						Law and section
						98-2.6  of
						this Subpart.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.10 - Responsibilities of certified external appeal agents

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Within 24 hours of receiving assignment
					 from the superintendent of a request for external appeal, certified external
					 appeal agents shall send notification of such assignment to the enrollee
					 requesting an external appeal or on whose behalf an external appeal is
					 requested, the enrollee's health care plan, the attending physician, as
					 applicable, and, in the case of a provider initiated appeal of a retrospective
					 adverse determination, the enrollee's health care provider. The certified
					 external appeal agent shall include in such notification:
(1) a request for any additional
					 documentation that may be available to support the appeal;
(2) the address to which any required or
					 additional documentation should be sent;
(3) whether the appeal is a standard or
					 expedited appeal; and
(4) for
					 purposes of notifying the enrollee's health care plan, as applicable, copies of
					 the documents relied upon by the enrollee's attending physician to establish
					 medical and scientific evidence that the recommended health care service(s) is
					 likely to be more beneficial to the enrollee than any covered standard health
					 care service or procedure.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.11 - Enrollee rights and responsibilities

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Enrollees shall be responsible for:
(1) exhausting the health care plan's
					 internal appeal process under section 4904  of the Public Health Law, provided
					 however, that if a health care plan has two levels of internal appeals, the
					 enrollee must only exhaust the first level of appeal. In the alternative, the
					 enrollee and the enrollee's health care plan may jointly agree to waive the
					 internal appeal process;
(2)
					 ensuring that requests for external appeals are filed and completed within the
					 time frames provided for in paragraph (4) of this subdivision, except in the
					 case of transmittal of medical and treatment records, which shall be the
					 responsibility of the enrollee's health care plan;
(3) as applicable, providing the attending
					 physician with the documents necessary to complete the physician attestation
					 component of the external appeal request, and, as necessary, providing evidence
					 to the superintendent that such has occurred; and
(4) ensuring that, to the extent possible,
					 all supporting documentation, including but not limited to diagnostic test
					 results and medical literature, is submitted to the assigned certified external
					 appeal agent within the earlier of:
(i) 45
					 days from the date of the enrollee's receipt of a final adverse determination
					 notice or within 45 days of receiving a letter from the health care plan
					 affirming that both the enrollee and the enrollee's health care plan jointly
					 agreed to waive the internal appeal process; or
(ii) prior to the date the external appeal
					 determination is finalized by the certified external appeal agent;
					 and
(5) responding to
					 the superintendent's requests for information concerning an incomplete external
					 appeal request in a timely manner.
New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter R - Health Maintenance Organizations › Part 98 - Health Maintenance Organizations › Subpart 98-2 - External Appeals Of Adverse Determinations › Section 98-2.12 - Confidentiality

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No health care
					 plan may share an enrollee's medical and treatment records or any other
					 confidential information, including HIV related and mental health related
					 information, with a certified external appeal agent or a clinical peer reviewer
					 designated by such certified external appeal agent unless the enrollee, or a
					 person authorized pursuant to law to consent to health care for the enrollee,
					 has signed a specific release of information for HIV, mental health and drug
					 and alcohol abuse or otherwise appropriate release in a manner and in such form
					 as prescribed by the commissioner and superintendent in accordance with section 2782  of the Public Health Law for
					 confidential HIV related information and sections 33.13 and
					 33.16  of the Mental Hygiene Law for mental
					 health related information and as required by any applicable Federal law or
					 regulation.
(b) No certified
					 external appeal agent or clinical peer reviewer designated by such certified
					 external appeal agent shall, except as specifically authorized by an
					 appropriate release signed by the enrollee or by a person authorized pursuant
					 to law to consent to health care for the enrollee, divulge confidential medical
					 and treatment information or other information obtained through the review of
					 an external appeal to any individual or group except the certified external
					 appeal agent to whom the appeal was assigned and, as necessary, the
					 commissioner and superintendent.