Title: Section 98-1.18 - Relationship between an MCO and an IPA

Effective Date

06/29/2005

98-1.18 Relationship between an MCO and an IPA.

(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.

(f) The commissioner may assess fines against an MCO in accordance with section 12 of the Public Health law after a hearing and finding of a violation, by an MCO and/or IPA and/or the physicians and any other health care providers and suppliers contracting with an IPA, of this Subpart and articles 28 and 44 and Title I of article 49 of the Public Health Law.

Volume

VOLUME A-2 (Title 10)

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