Title: Section 98-1.2 - Managed Care Organizations

98-1.2 Definitions. The following words or terms when used in this Part 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 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 (1) above, 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.

(h) Comprehensive health services plan or plan means a plan through which each member of an enrolled population is entitled to receive comprehensive health services in consideration for a basic advance or periodic charge.

(i) Comprehensive HIV special needs plan or HIV SNP means an MCO certified pursuant to section 4403-c of article 44 of the Public Health Law which provides or arranges for the provision of comprehensive health and supportive services and specialized HIV care to HIV positive persons and their related children up to the age of 19, as defined in the HIV SNP contract with a local social services district (LDSS) or the commissioner, who are eligible to receive benefits under title XIX or other public programs.

(j) Control, which shall be synonymous with the terms controlling, controlled by and under common control with, means the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities or voting rights, by contract (except a commercial contract for goods or nonmanagement services) or otherwise; but no person shall be deemed to control another person solely by reason of his or her being an officer or director of such other person. Control shall be presumed to exist if any person directly or indirectly owns, controls or holds the power to vote 10 percent or more of the voting securities or voting rights of any other person, or is a corporate member of a not-for-profit corporation.

(k) Controlled MCO means any proposed or certified MCO that is controlled directly or indirectly by a holding company.

(l) Controlled person means any person, other than a controlled MCO, that is controlled directly or indirectly by a holding company.

(m) Department means the Department of Health of the State of New York.

(n) Enrolled population means a group of persons which receives comprehensive health services from an MCO in consideration for a basic advance or periodic charge. An enrolled population is composed of enrollees who are entitled by contract to receive comprehensive health services from the MCO. Except for HMOs, MCOs may only enroll certain populations as authorized in the Public Health Law.

(o) Enrollee means an individual who has entered into a contractual relationship with the MCO, or an individual on whose behalf a contractual arrangement has been entered into with the MCO, under which the MCO assumes the responsibility for the provision to the individual of comprehensive health services.

(p) Enrollment means the act of an individual signing a contract, or having someone sign it on his or her behalf, which obligates the MCO to provide comprehensive health services, and which obligates the individual enrolling, or someone on his or her behalf, to pay a periodic premium or fee for all covered services. A signature may be made electronically to the extent permitted by applicable law and regulation.

(q) Governing authority of the MCO means the policymaking body that is responsible for the operation of an MCO, including:

(1) the policymaking body of a public MCO;

(2) the board of directors or trustees of a corporation;

(3) partners of a partnership operating an MCO;

(4) the owners of a proprietary business operating an MCO; and

(5) the members, or managers who are also members of a limited liability company. Managers who are not members of a limited liability company participate in the management of an MCO pursuant to the provisions of Section 98-1.11 of this Subpart governing management contracts, and in no way comprise the governing authority.

(r) Health Maintenance Organization or HMO means any person, natural or corporate, or any groups of such persons who enter into an arrangement, agreement or plan, or any combination of arrangements or plans, which proposes to provide or offer, or which does provide or offer, a comprehensive health services plan to individuals and groups.

(s) HIV SNP case management means a process which includes clinical coordination and medical/clinical case management in consultation with the PCP, service utilization monitoring, assessment and service plan development that address identified patient needs, case manager involvement in quality assurance and quality improvement and non-intensive HIV psychosocial case management as defined by the department.

(t) HIV specialist primary care provider or HIV specialist PCP means a primary care provider who meets the qualifications for HIV Specialist as defined by the Medical Care Criteria Committee of the Department’s AIDS Institute.

(u) Holding company means any person who directly or indirectly controls any proposed or certified MCO.

(v) Holding company system means a holding company together with a controlled MCO and/or controlled persons.

(w) Independent practice association or IPA means a corporation, limited liability company, or professional services limited liability company, other than a corporation or limited liability company established pursuant to articles 28, 36, 40, 44 or 47 of the Public Health Law, which contracts directly with providers of medical or medically related services or another IPA in order that it may then contract with one or more MCOs and/or workers’ compensation preferred provider organizations to make the services of such providers available to the enrollees of an MCO and/or to injured workers participating in a workers’ compensation preferred provider arrangement. An IPA may also be considered a provider within the meaning of section 4403(1)(c) of the Public Health Law, but only for the purpose of and to the extent it shares risk with an MCO and/or the IPA’s contracting providers, and shall be considered a provider for the purposes of paragraphs (1) and (2) of subdivision (a) of Section 98-1.21 of this Subpart. An IPA may be certified as an Accountable Care Organization pursuant to Article 29-E of the Public Health Law and Part 1003 of this title, and upon obtaining a certificate of authority may contract with third party health care payers defined in section 1003.2(x) of this title. To the extent allowed under New York’s Partnership Plan section 1115(a) Medicaid Demonstration extension, as amended April 14, 2014, an IPA may participate in a Performing Provider System (“PPS”) established as part of a Delivery System Reform Incentive Payment (“DSRIP”) Program project.

(x) Managed care organization or MCO means an HMO, PHSP, HIV SNP and, where specified in this Subpart, PCPCP and MLTCP. An HIV SNP may be an entity that is independently incorporated and certified to operate an HIV SNP or an incorporated and certified MCO that is issued a separate certificate of authority to operate the HIV SNP.

(y) Managed long term care plan or MLTCP means an entity that has received a certificate of authority pursuant to section 4403-f of the Public Health Law to provide or arrange for health and long term care services on a capitated basis for a population which the plan is authorized to enroll.

(z) Management contractor means any person, other than staff employed by the MCO, entering into an agreement with the governing authority of an MCO for the purpose of managing the day-to-day operations of the MCO.

(aa) Material change to a contract between an MCO and a provider or an IPA, other than a management contract, means: a) any change to a required contract provision or appendix as per contract guidelines issued by the commissioner; b) any change to or addition of a risk sharing arrangement, other than the routine trending of fees or other reimbursement amounts; c) any proposed addition of an exclusivity, most favored nation or non-compete clause; d) any proposed subcontracting of the existing contractual obligations of an IPA; e) any proposed subcontracting of the statutory or regulatory responsibilities of an MCO, and; f) any proposed revocation of an approved delegation as set forth in d) and e) above.

(bb) Medical director , other than the medical director of a utilization review agent as defined in Section 4900 of the Public Health Law who shall be licensed by at least one of the United States, means a New York State-licensed physician whose responsibilities include, but are not limited to, the supervision of the quality assurance and improvement and utilization review prorams and advising the governing authority on the adoption and enforcement of policies concerning medical services.

(cc) Net premium income means the gross amount of revenue derived from premiums less any returned premium.

(dd) Person means an individual, partnership, corporation, any other legal entity, including a joint venture, or any combination of the foregoing acting in concert.

(ee) Premium means the amount of money the MCO charges each enrollee or payer for the specified benefit package.

(ff) Prepaid health services plan or PHSP means a provider, including a not-for-profit corporation established to operate a hospital pursuant to article 28 of the Public Health Law, a government agency or an entity or group of entities, other than a shared health facility, seeking to provide comprehensive health care services which has received a special purpose certificate of authority pursuant to section 4403-a of the Public Health Law to deliver comprehensive health care services on a prepaid contractual basis either directly, or through an arrangement, agreement or plan or combination thereof to an enrolled population which is substantially composed of persons eligible to receive benefits under title XIX or other public programs.

(gg) Primary care partial capitation provider or PCPCP means a qualified individual medical services provider or a county or entity comprised of medical services providers offering comprehensive primary and preventive care and case management of inpatient, emergency room and specialty services to persons eligible to receive benefits under title XIX and to enroll in managed care plans.

(hh) Primary care practitioner or PCP means a physician or other licensed provider who supervises, coordinates and provides initial and basic care to enrollees and maintains continuity of care for enrollees.

(ii) Referral means the internal mechanism utilized by the MCO to allow members to access needed services.

(jj) Reinsurance means a transaction whereby the reinsuror, for a consideration, agrees to indemnify the MCO, or other provider, against all or part of the loss which the latter may sustain under the subscriber contracts which it has issued.

(kk) Risk-sharing means the contractual assumption of liability by the health care provider or IPA by means of a capitation arrangement or other mechanism whereby the provider or IPA assumes finanicial risk from the MCO for the delivery of specified health care services to enrollees of the MCO.

(ll) Superintendent means the Superintendent of Insurance of the State of New York.

(mm) Title XIX, as referenced in this Subpart, means any federally authorized Medicaid program under such title of the Social Security Act and any programs authorized by state law that cover the Medicaid population, specifically, Titles 11 and 11-D of Article 5 of the Social Services Law.

(nn) Title XXI, as referenced in this Subpart, means any federally authorized Child Health Insurance Program under such title of the Social Security Act and any programs authorized by state law that cover the state’s Child Health Plus population, specifically, Title I-A of Article 25 of the Public Health Law.

(oo) Transitional period shall for the purposes of subparagraph (i) of paragraph (e)(1) of subdivision (6) of section 4403 of the Public Health Law mean a period commencing on the date a provider's contractual obligation to provide services to an MCO's enrollees terminates and ending no more than 90 days thereafter.

(pp) HARP (Health and Recovery Plan) means a line of business operated by an MCO to administer the full continuum of mental health, substance use disorder, and physical health services covered under the Medicaid State Plan as well as the enhanced Home and Community Based Services benefits (1915 (i)) for adults with serious mental illness (SMI) and/or Substance Use Disorders (SUDs) who meet eligibility requirements.