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 86-3.5 - Health maintenance organization differential

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Pursuant to section 2807-c (2-a)  of the
					 Public Health Law, health maintenance organizations certified under article 44
					 of the Public Health Law or article 43 of the Insurance Law shall pay a nine
					 percent differential on their rates of payment for general hospital inpatient
					 services (hereinafter referred to as the HMO factor) into a statewide health
					 maintenance organization pool, unless the HMO factor is eliminated or reduced
					 in accordance with Public Health Law, section 2807-c (2-a). Payment of
					 the HMO factor shall not be required for subscribers who are eligible for
					 medical assistance pursuant to the Social Services Law, and/or participants in
					 regional pilot projects established pursuant to chapter 703 of the Laws of
					 1988.
(b)
(1) Commencing on August 15, 1992 and on a
					 monthly basis thereafter, each health maintenance organization shall pay the
					 HMO factor, established or adjusted in accordance with section 2807-c (2-a)  of the
					 Public Health Law, into a statewide health maintenance organization pool for
					 each patient discharged on or after July 1, 1992. Funds accumulated in the
					 statewide health maintenance organization pool, including income from invested
					 funds, shall be transferred and credited to the general fund.
(2) Payments to the statewide health
					 maintenance organization pool and reports required pursuant to paragraph (5) of
					 this subdivision shall be due on or before the 15th day following the end of
					 each month. Health maintenance organizations shall submit estimated amounts due
					 for patients discharged in a calendar month in accordance with this section
					 unless payment of actual amounts due for such calendar month has been made
					 within such 15-day time period. If a health maintenance organization fails to
					 submit actual or estimated payment in accordance with this subdivision, the
					 health maintenance organization shall be subject to interest and penalties in
					 accordance with section 2807-c(2- a)(c)(ii) of the Public Health Law.
(3) Estimated amounts due for patients
					 discharged in each calendar month shall be determined by multiplying the
					 applicable HMO factor established by section
					 2807-c(2-a) of the
					 Public Health Law by the sum of actual claims paid, and claims reported to the
					 HMO but not paid, and estimated incurred but not reported claims. The monthly
					 payment shall also include a prior period adjustment that reconciles actual
					 inpatient claims experience compared to prior estimates of amounts due,
					 consistent with methodologies used in preparation of the HMO's certified
					 financial statements.
(4) Each HMO
					 required to make payments shall make a final reconciliation and adjustment for
					 each differential payment period. For the year 1992, the differential payment
					 period shall be for the period July 1st through December 31st. For years
					 subsequent to 1992, the differential payment period shall be a calendar year
					 period, except that the differential payment period shall be the six-month
					 period ending June 30th if the HMO has qualified for a complete elimination of
					 the differential effective July 1st of that year. The final reconciliation for
					 any differential payment period shall be based on the audited inpatient claims
					 experience of the HMO and certified by a certified public accountant. The final
					 reconciliation shall be completed no earlier than three months following the
					 end of the period, and shall be due four months after the end of the
					 period.
(5) HMOs shall file reports
					 in such form and manner as designated by the Department of Health. Such reports
					 shall indicate the amounts paid based on the discharges in each calendar month
					 and shall separately indicate actual claims paid, claims reported but not paid
					 and claims incurred but not reported, as well as indicate the adjustments made
					 due to reconciliation of prior period estimated claims experience. If an HMO
					 fails to submit the differential payment, the Department of Health for purposes
					 of determining interest and penalties in accordance with section 2807-c (2-a)(c)(ii)  of
					 the Public Health Law shall estimate the amounts due pursuant to this section
					 based on the average inpatient monthly claims expense contained in the most
					 recent HMO financial reports submitted to the New York State Insurance
					 Department or the Department of Health.