Title: Section 98-1.16 - Audited Financial Statements for Managed Care Organizations
98-1.16 Disclosure and filing. (a) Every MCO, other than a PHSP that only serves enrollees eligible for benefits under title XIX, HIV SNPs and PCPCPs, shall file in duplicate with both the commissioner and the superintendent a financial statement on or before April 1 of each year, in the form and containing such information as the commissioner and the superintendent shall prescribe, showing its condition at last year-end and containing information required by section 4408 of the Public Health Law and the following information:
(1) a statement of financial condition, including a balance sheet and summary of receipts and disbursements and an income statement;
(2) an analysis of its enrolled population, identifying numbers of enrollees by age groups and sex, and numbers of enrollee contracts by type (family and individual), by contract months, except that for MLTCPs, the analysis may contain other identifying information relevant to the enrolled population; and
(3) an analysis of utilization of services, including all services covered by the MCO.
(b) MCOs that serve enrollees eligible for benefits under title XIX shall file annual financial statements with the commissioner on or before April 1 of each year which shall be in such format and contain such information as prescribed by the commissioner.
(c) every MCO shall submit annual financial statements together with an opinion of an independent certified public accountant of the financial statement of such MCO, and an evaluation by such accountant of the accounting procedures and internal control systems of the MCO, by April 1 of each year, pursuant to Subpart 98-3.
(d) Every MCO shall make available to the general public and its enrollees those items set forth in paragraph (a)(1) of this section, and a summary of those items set forth in paragraphs (a)(2) and (3) of this section.
(e) Every controlled MCO shall file with the commissioner such reports or material as the commissioner, with the advice of the superintendent, may direct for the purpose of disclosing information on the operations within the holding company system which materially affect the operations, management or financial condition of the MCO.
(f) Every MCO, other than a PHSP that only serves enrollees eligible for benefits under title XIX, HIV SNPs and PCPCPs, shall file quarterly statements in duplicate with both the superintendent and commissioner, in the form and containing matters as the commissioner, with the advice of the superintendent, shall prescribe not later than 45 days after the end of each quarter.
(g) MCOs that serve enrollees eligible for benefits under title XIX shall file quarterly statements with the commissioner, in such format and containing such information as prescribed by the commissioner, not later than 45 days after the end of each quarter.
(h) In the event an MCO does not provide substantially complete reports or other information required under this Subpart by the due date, or provide requested information within 30 days of any written request for a specific analysis or report by the superintendent or commissioner, the superintendent or commissioner is authorized to levy a civil penalty, after notice and hearing, pursuant to section 12 of the Public Health Law or sections 307 and 308 of the Insurance Law.
(i) Every MCO shall maintain and update, on a quarterly basis, a listing by specialty of the names, addresses and telephone numbers of all participating providers, including facilities, and in the case of physicians, board certification. Where the MCO contracts with behavioral health facilities rather than directly with behavioral health providers, the provider types available at the facilities must be included in the listing. Members must be notified of updates in writing at least annually in one of the following methods: provide updates in hardcopy; provide a new full listing/directory in hardcopy; provide written notification that a new full listing/directory is available and will be mailed in hardcopy or electronically upon request. New members, and upon request, current and potential members must receive the most current full listing in hardcopy, or electronically at the request of the member or potential member, along with any updates to such listing.
(j) No later than 20 business days after the beginning of each calendar year, every MCO shall submit provider network information in an electronic format and including such information as prescribed by the commissioner. Such information shall reflect all signed and implemented contracts in effect as of the first day of such calendar year for all providers and service centers participating in the MCO’s network. In addition, a notarized statement attestating to the accuracy of the electronic provider network information submission shall be required. Any modifications or updates to the provider network information must be communicated to the enrolled population, and upon request to potential enrollees, as prescribed in subdivision (i) of this section. Those MCOs that serve enrollees eligible for benefits under title XIX shall submit provider network information in an electronic format and including such information as prescribed by the commissioner no later than 15 business days after the end of each quarter.
(k) In order to serve enrollees eligible for benefits under title XIX, an MCO must submit a plan for compliance with the federal Americans with Disabilities Act (ADA). Such ADA compliance plan shall be submitted in a form and manner as prescribed by the commissioner.
(l) An MLTCP shall submit data to the commissioner annually or at such other times as requested and in such manner and form as prescribed by the commissioner regarding enrollee characteristics, utilization of services, enrollments, disenrollments, complaints and grievances and other information deemed necessary to monitor plan operations and care management.
VOLUME A-2 (Title 10)