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 98-1.6 - Issuance of a certificate of authority

Current through Register Vol. 46, No. 28, July 10, 2024
Prior to issuance of a certificate of authority to an
						MCO, the commissioner, and in the case of an HMO or MLTCP, the superintendent
						where applicable, must be satisfied that the following conditions have been
						met:
(a) The applicant has
					 demonstrated its capability to organize, market, manage, promote and operate
					 the proposed MCO in order to provide comprehensive health services to a
					 proposed enrolled population that is identified in the application, the manner
					 in which the applicant will comply with the requirements of section
					 98-1.11(g) 
					 of this Subpart, that the governing authority shall assemble to conduct the
					 business of the MCO at least four times annually, once in each quarter, and
					 that the governing authority shall for each such assembly provide prior notice
					 to and shall include in each such assembly each enrollee or consumer
					 representative and/or enrollee advisory council member elected or appointed to
					 represent the MCO's enrollees.
(b)
					 Except for PCPCPs, the applicant has demonstrated, to the satisfaction of the
					 commissioner and, except for entities certified pursuant to sections 4403-a and
					 4403-c  of the Public Health Law, the
					 superintendent, that it is capable of assuming full financial risk for covered
					 services. The applicant may make risk sharing arrangements for the provision of
					 comprehensive health services to the population to be enrolled within the area
					 to be served by the plan as prescribed by regulations and guidelines of the
					 commissioner. When such an arrangement includes risk sharing as defined in this
					 Subpart, such an arrangement shall be approved by the superintendent pursuant
					 to the requirements of 11 NYCRR Part 101 (Regulation 164), where applicable, or
					 the commissioner pursuant to regulations and guidelines. In making a
					 determination of financial soundness, the commissioner and the superintendent
					 shall consider financial information, contracts and agreements required as part
					 of the application for a certificate of authority, and any other materials that
					 the commissioner or the superintendent shall deem necessary to make that
					 determination.
(c) The applicant
					 has demonstrated, to the satisfaction of the commissioner, that it will retain
					 full responsibility for the operation of the MCO and the protection of its
					 enrollees in compliance with article 44 of the Public Health Law and this
					 Subpart, including protection for enrollees from billing by providers for
					 services covered under the enrollee contract during the operation of the MCO or
					 in the event of insolvency.
(d)
					 Except for PCPCPs, the applicant has demonstrated, to the satisfaction of the
					 commissioner, that the medical director and the members of the board and
					 officers, controlling persons of a corporation or holding company or the
					 owners, or all the partners of a partnership, or the members and managers of a
					 limited liability company are of such character, experience, competence and
					 standing in the community as to give reasonable assurance of their ability to
					 conduct the affairs of the proposed MCO in the best interest of the MCO and in
					 the public interest, and to provide proper care for the enrollees. In the case
					 of an applicant that is controlled, the commissioner must be satisfied that the
					 holding company has conducted itself in a manner that is consistent with the
					 public interest. In determining the character and competence of applicants and
					 holding companies, the commissioner shall consider criminal convictions,
					 bankruptcy proceedings, and the quality of health-related services provided by
					 any facility or organization owned or operated by the applicant or its holding
					 company or other persons in the holding company system or with which an
					 officer, member of the board, controlling person, member or manager of a
					 limited liability company, owner, partner or medical director has been
					 affiliated. PCPCPs must provide the information prescribed in section 4403-e (2)(b)  of the
					 Public Health Law.
(e) Except for
					 PCPCPs, the applicant demonstrates that there are adequate finances and sources
					 of future revenue to properly establish and operate the proposed MCO. In the
					 case of a PCPCP, the applicant demonstrates financial responsibility pursuant
					 to section 4403-e (3)(e)  of the
					 Public Health Law.
(f) The
					 applicant demonstrates that the arrangements for health care services assure
					 the availability and accessibility of those services to the proposed enrolled
					 population, and are conducive to the appropriate and efficient use of
					 ambulatory care and hospital services, and that utilization review procedures,
					 if applicable, have been developed consistent with article 49 of the Public
					 Health Law and/or, in the case of an entity participating in federally
					 sponsored programs, consistent with Federal law and regulation.
(g) The applicant demonstrates that an
					 effective program has been developed to monitor and assess the quality of care
					 provided by the MCO, together with a performance improvement program, approved
					 prior to issuance of its certificate of authority, consistent with section
					 98-1.12 
					 of this Subpart, pursuant to which, actual and potential problems will be
					 identified and corrections accomplished promptly. In the case of an entity
					 participating in federally sponsored programs, quality of care monitoring and
					 quality improvement programs shall be consistent with Federal law and
					 regulations.
(h) The applicant
					 demonstrates that an acceptable mechanism has been developed, consistent with
					 sections 4403 (1)(g) and
					 4408-a  of the Public Health Law and/or,
					 in the case of an entity participating in federally sponsored programs,
					 consistent with Federal law and regulation, to receive and resolve complaints
					 and grievances initiated by enrollees of the MCO.
(i) The applicant demonstrates that
					 acceptable contracts between the potential enrollee or anyone on behalf of the
					 enrollee and the MCO have been developed. Such contracts shall be approved by
					 the superintendent pursuant to section 4406  of the Public Health Law. In the case
					 of contracts for services provided pursuant to title XIX, such contracts shall
					 require prior approval by the commissioner and, as required by Federal law or
					 regulation, the Federal agency with oversight responsibility for programs
					 authorized by such title.
(j) The
					 applicant demonstrates that the proposed premium rates have been submitted to
					 and approved by the superintendent or, in the case of services provided
					 pursuant to title XIX, the commissioner.
(k) Except for PCPCPs, the applicant
					 demonstrates that it has established a system which appropriately accounts for
					 costs and a uniform system of reports and audits meeting the requirements of
					 the commissioner and/or the superintendent, as appropriate.
(l) Demonstration by the HMO applicant of a
					 willingness to provide community services that include at least the following:
					 a willingness to enter into a contract with the local social services district
					 to enroll individuals eligible for benefits under title XIX, including the
					 steps and a time frame for entering into such contract; a willingness to
					 provide coverage to Medicare beneficiaries; and demonstration that the HMO
					 offers open enrollment, pursuant to articles 32 and 43 of the Insurance Law,
					 including steps and a time frame for offering such coverage. For the purpose of
					 this section, open enrollment shall mean offering enrollment throughout the
					 year to individuals and groups consisting of two or more eligible members who
					 elect to enroll, subject to such reasonable limitations as an affiliation or
					 waiting period not to exceed two months from the date of the enrollee's
					 application until the commencement of coverage, provided that coverage may not
					 be excluded based upon a preexisting condition for groups of more than
					 50.
(m) Requirements and conditions
					 for issuance of a certificate of authority for an MLTCP shall be as set forth
					 in section 4403-f  of the Public Health Law and
					 subdivisions (a) through (k) of this section.