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 98-1.2 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
The following words or terms when used in this Subpart
						shall have the following meanings:
(a)
					 Admitted assets means assets recognized and accepted by the State Insurance
					 Department under article 13 of the Insurance Law in determining the solvency of
					 insurors. Admitted assets shall be the sole basis for determining compliance
					 with any applicable financial requirement or quantitative limitation imposed
					 upon an MCO, as further specified in Insurance Department Regulation 172 (11
					 NYCRR Part 83).
(b) Article 44
					 service area means the geographic area, defined by counties or other geographic
					 subdivisions, identified in the application for a certificate of authority to
					 operate an MCO for which there is identified a provider network capable of
					 providing comprehensive health services of sufficient availability and
					 accessibility to the projected enrolled population within the meaning of
					 article 44 of the Public Health Law and this Subpart, as approved by the
					 commissioner. Enrollment within the article 44 service area must be offered to
					 any eligible persons who work or reside within the service area, except that
					 for MLTCPs and, for programs authorized by title XIX, enrollment may be offered
					 only to eligible persons who reside within the service area.
(c) Capitation means a payment made on a per
					 enrollee basis.
(d) Care management
					 within an MLTCP means a process which assists enrollees with establishing a
					 written care plan and accessing necessary covered services. It also provides
					 referral to and coordination of other medical, social, educational,
					 psychosocial, financial and other services in support of the care plan
					 irrespective of whether such services are covered by the plan.
(e) Commissioner means the Commissioner of
					 Health of the State of New York.
(f) Community rating means a rating
					 methodology in which the premium for all persons covered by a policy or
					 contract form is the same based on the experience of the entire pool of risks
					 covered by that policy or contract form without regard to age, sex, health
					 status or occupation. Refunds, rebates, credits or dividends based on such
					 factors are also prohibited.
(g)
					 Comprehensive health services means:
(1) for
					 HMOs and PHSPs, all those health services which an enrolled population might
					 require in order to be maintained in good health, and shall include, but shall
					 not be limited to, physician and other provider services (including consultant
					 and referral services), inpatient and outpatient hospital services, diagnostic
					 laboratory and therapeutic and diagnostic radiologic services, and emergency
					 and preventive health services, including providing HIV counseling and
					 recommending voluntary HIV testing to pregnant women, which counseling and
					 testing shall be conducted pursuant to Public Health Law, article 27-F,
					 referring HIV positive persons for necessary, clinically appropriate services,
					 and services required to be covered under article 43 of the Insurance
					 Law;
(2) for MLTCPs, health and
					 long-term care services, including but not limited to, primary care, acute
					 care, home and community based and institution based long-term care and
					 ancillary services that are necessary to meet the needs of persons whom the
					 plan is authorized to serve. However, consistent with the provisions of section 4403-f  of the Public Health Law, while an
					 MLTCP may provide less than comprehensive services, it remains subject to the
					 provisions of this Subpart;
(3) for
					 PCPCPs, comprehensive primary and preventive care and case management of
					 inpatient, emergency room and specialty services; and
(4) for HIV SNPs, all those health and
					 supportive services provided as necessary to meet the specialized needs of the
					 persons whom the plan is authorized to serve by providers with appropriate
					 training and experience in the care, treatment and prevention of HIV/AIDS, as
					 determined by the commissioner. These comprehensive services include, but are
					 not limited to, those described in paragraph (1) of this subdivision, those set
					 forth in subdivision (8) of section 4403-c  of the Public Health Law and the
					 following: primary care services by a qualified HIV specialist; HIV primary and
					 secondary prevention and risk reduction services; treatment adherence services;
					 HIV SNP case management; and access and referral to community health and social
					 service providers that support members' ability to sustain wellness and adhere
					 to treatment regimes. Such term may also be further defined by agreement with
					 enrolled populations to provide for additional benefits necessary, desirable or
					 appropriate to meet their health care needs.