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 98-1.18 - Relationship between an mco and an ipa

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An MCO shall be responsible for its
					 agreements with an IPA, for the agreements between the IPA and other IPAs,
					 physicians and other health care providers and suppliers and for the care
					 provided through such arrangements to the same extent as it is responsible for
					 arrangements with all other types of health care providers.
(b) The requirements of article 44 of the
					 Public Health Law and this Subpart shall apply to an IPA and all physicians,
					 other IPAs, health care providers and suppliers contracting with an IPA to the
					 same extent they apply to all other health care providers participating with an
					 MCO in a comprehensive health services plan.
(c) Nothing in this Part shall prohibit an
					 IPA from employing providers or other persons to provide review of medical care
					 utilization patterns, quality of care issues, or other program review functions
					 on behalf of its panel of contracted participating providers, even though such
					 providers may also have contracted with the IPA as an independent member or
					 participating provider.
(d) An MCO
					 contracting with an IPA shall require that the financial records of the IPA
					 shall account in detail for all funds received from the MCO, including, where
					 applicable, fees for services performed by the IPA, and for the disbursement of
					 all such funds.
(e) An MCO
					 proposing a risk sharing arrangement with an IPA may not enter into any such
					 arrangement without first obtaining approval from the commissioner or
					 superintendent, as appropriate, in accordance with guidelines issued by the
					 commissioner in accordance with section
					 98-1.5(b)(6)(v) 
					 of this Subpart or the superintendent in accordance with Regulation 164. To
					 obtain the commissioner's approval, the MCO shall provide to the satisfaction
					 of the commissioner the following:
(1) a
					 current list of the owners, officers, directors, and limited liability company
					 managers and members of the IPA;
(2) the complete text of the proposed
					 contract(s), and all attachments thereto, which shall include provisions
					 whereby:
(i) the parties expressly agree to
					 amend or terminate the agreement at the direction of the
					 commissioner;
(ii) the IPA will
					 submit both quarterly and annual financial statements to the MCO and the MCO
					 will notify the commissioner of any substantial change in the financial
					 condition of the IPA; and
(iii) the
					 parties agree that all provider contracts shall contain a clause providing that
					 the provider shall not, in the event of default by the IPA, demand payment from
					 the MCO for any covered services rendered to the MCO's enrollees for which
					 payment was made by the MCO to the IPA pursuant to the financial risk sharing
					 agreement;
(3) in the
					 event that the MCO contracts with the IPA to delegate management functions, a
					 contract which complies with all the requirements of this Subpart;
(4) such information concerning the financial
					 condition of the IPA and any providers participating in a risk sharing
					 arrangement as the commissioner may require to make a determination, including
					 information demonstrating that the IPA and any providers sharing risk with the
					 IPA are financially responsible and capable of assuming such risk and have
					 satisfactory insurance, reserves or other arrangements to support an
					 expectation that they will meet their obligations to MCOs, providers and
					 enrollees; and
(5) a demonstration
					 by the MCO and the IPA, to the commissioner's satisfaction, that the elements
					 of a proposed arrangement will not constitute improper incentives to providers,
					 in accordance with physician incentive plan guidelines, and will not result in
					 a deterioration in access to or the quality of care provided to an MCO's
					 enrollees.