New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IV - Financial Condition Of Insurer and Reports to Superintendent › Subchapter B - Life Insurers › Part 101 - Standards For Financial Risk Transfer Between Insurers And Health Care Providers › Section 101.3 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The term
				  capitation or capitation arrangement shall mean contractually based prepayments
				  (any payments made prior to the last day of the month shall be deemed a
				  prepayment of the entire month's capitation) made to a health care provider, on
				  a per member per month or a percentage of premium basis, in exchange for one or
				  more covered health care services to be rendered, referred or otherwise
				  arranged by such provider and by its participating providers; however, the
				  estimated part of the prepayment needed to provide the covered services to be
				  referred or otherwise arranged by the health care provider to nonparticipating
				  providers shall be deposited by the insurer into a separate account to be
				  designated as the "out-of-network health care provider account" which account
				  shall be maintained on the books of the insurer for the sole purpose of paying
				  for the services covered by the capitation arrangement that were rendered by
				  nonparticipating providers. Payments into such account shall be designated as
				  "capitation outside of the health care provider's network" and the payments
				  made for services to be rendered by the health care provider and its
				  participating providers shall be designated as the "health care provider's
				  in-network capitation."
(b) The
				  term financial responsibility shall mean that, on a prospective basis, the
				  health care provider has demonstrated to the insurer and the superintendent
				  that it can faithfully perform its obligations under a financial risk transfer
				  agreement by demonstrating its compliance with the provisions of this
				  Part.
(c) The term financial risk
				  transfer shall mean the contractual assumption of liability by the health care
				  provider by means of a capitation arrangement for the delivery of specified
				  health care services to subscribers of the insurer.
(d) The term financial solvency or
				  financially solvent shall mean that the most recent health care provider's
				  financial statement or guaranteeing parent corporation's consolidated financial
				  statement evidences an excess of assets over liabilities and the health care
				  provider has demonstrated to the satisfaction of the insurer and the
				  superintendent that the health care provider has adopted and has in place the
				  necessary safeguards to ensure that the health care provider's in-network
				  capitation will first be used for the payment of medical and hospital services
				  to be rendered by the health care provider and its participating providers
				  which derive from a financial risk transfer agreement, including any necessary
				  administrative costs associated with the rendering of such services.
(e) The term guaranteeing parent corporation
				  shall mean an entity that controls a health care provider and guarantees the
				  performance of the provider's obligations under the financial risk transfer
				  agreement including the payment of any amounts owed by the health care provider
				  to participating providers for services rendered pursuant to a risk transfer
				  agreement. The guaranteeing parent corporation must include the financial
				  condition of the controlled health care provider in its consolidated financial
				  statement as required by section
				  101.9(a)(3) 
				  of this Part.
(f) The term health
				  care facility shall mean a hospital as defined in and licensed under article 28
				  of the Public Health Law or a similar facility licensed under article 19, 31,
				  or 32 of the Mental Hygiene Law.
(g) The term health care provider shall mean
				  a person or entity licensed or certified pursuant to article 28, 36 or 40 of
				  the Public Health Law; a facility licensed pursuant to article 19, 31 or 32 of
				  the Mental Hygiene Law; a health care professional licensed, registered or
				  certified pursuant to title 8 of the Education Law (including a group of such
				  health care professionals); a clinical laboratory certified pursuant to Title V
				  of the Public Health Law; and a dispenser or provider of pharmaceutical
				  products, healthcare services or durable medical equipment. A health care
				  provider shall also include a health care facility and an intermediary entity
				  as defined in this section.
(h) The
				  term insurer shall mean an insurance company licensed to do accident and health
				  insurance in this state, a corporation licensed pursuant to article 43 of the
				  Insurance Law or an entity possessi ng a certificate of authority under article
				  44 of the Public Health Law.
(i) The
				  term intermediary entity shall mean a person or entit y that enters into a
				  financial risk transfer agreement with one or more insurers, and that contracts
				  with one or more participating providers to perform the services that are set
				  forth in the financial risk transfer agreement. The term shall include an
				  accountable care organization as defined in 10 NYCRR Part 1003. When the
				  insurer is an entity certified pursuant to article 44 of the Public Health Law,
				  the term shal l also mean an independent practice association as defined in 10
				  NYCRR Part 98.
(j) The term
				  participating provider shall mean the person or entity who is contractually
				  obligated to the health care provider to provide the services that are covered
				  by the insurer's financial risk transfer agreement with such health care
				  provider.
(k) The term subscriber
				  shall mean an enrollee, a policyholder or a contract holder.
(l) The term withhold shall mean a percentage
				  of payments or set dollar amounts deducted from a health care provider's
				  contractual payment and that may or may not be returned to the health care
				  provider, depending on specific predetermined factors, including any necessary
				  approvals by the insurer's board of directors.
(m) The definitions contained in section 107  of the Insurance Law and 10 NYCRR 98-1.2
				  shall also apply to this Part.