Section 1003.11 - Payment and Third Party Health Care Payers

1003.11 Payment and Third Party Health Care Payers

(a) An ACO may enter into arrangements with one or more third party health care payers to establish payment methodologies for health care services provided to the third party health care payer’s enrollees provided by the ACO or for which the ACO is responsible.

(b) Unless it has in force and effect a valid license issued pursuant to Article 11 of the Insurance Law or a certificate of authority issued pursuant to Article 44 of the Public Health Law, an ACO or a participant may not enter into any arrangement that constitutes doing an insurance business under section 1101 of the Insurance Law, including an arrangement that provides for full or partial capitation, shared losses or any other arrangement in which the ACO or the provider contractually assumes the liability for the delivery of specified health care services except:

(1) an ACO or an ACO participant may enter into such an arrangement when the ACO contracts with a managed care organization certified pursuant to Article 44 of the Public Health Law, an insurer authorized pursuant to the Insurance Law to write accident and health insurance in New York, or a corporation licensed pursuant to Article 43 of the Insurance Law; or

(2) a Medicare-only ACO that contracts with CMS may enter into an arrangement that provides for shared losses provided that, if the shared losses may exceed ten percent of the benchmark, the ACO meets all of the requirements of sections 1003.5, 1003.6, 1003.11, 1003.12, 1003.13 and 1003.14 of this Part.

(c) The contract between an ACO and a managed care organization shall be subject to all the requirements and reviews applicable under Article 44 of the Public Health Law and the Insurance Law and regulations promulgated thereunder.

(d) The contract between an ACO and an insurer authorized pursuant to the Insurance Law to write accident and health insurance in New York or a corporation licensed pursuant to Article 43 of the Insurance Law shall be subject to all the requirements and reviews applicable under the Insurance Law and regulations promulgated thereunder.

Effective Date: 
Wednesday, December 31, 2014
Doc Status: 
Complete