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- VOLUME A-2 (Title 10)
- Part 98 - Managed Care Organizations
- Title: SubPart 98-1 - Managed Care Organizations
Title: SubPart 98-1 - Managed Care Organizations
Effective Date
10/25/2023
Statutory Authority
Public Health Law, Sections 4403(2), 4403-f(7), 4414
Volume
VOLUME A-2 (Title 10)
- VOLUME A-2 (Title 10)
- Part 86 - Reporting And Rate Certifications For Facilities
- SubPart 86-1 - Medical Facilities
- Section 86-1.1 - Definition
- Section 86-1.2 - Financial and statistical data required
- Section 86-1.3 - Uniform system of accounting and reporting
- Section 86-1.4 - Audits
- Section 86-1.5 - Effective period of reimbursement rates
- Section 86-1.6 - Allowable costs
- Section 86-1.7 - Recoveries of expense
- Section 86-1.8 - Research and educational activities
- Section 86-1.9 - Compensation of operators and relatives of operators
- Section 86-1.10 - Related organizations
- Section 86-1.11 - Termination of service
- Section 86-1.12 - Federal financial participation
- Section 86-1.13 - Certified home health agency rates
- Section 86-1.14 - Allowance for certified home health agencies providing a disproportionate share of bad debt and charity care
- Section 86-1.15 - Definitions
- Section 86-1.16 - Statewide base price
- Section 86-1.17 - Exclusion of outlier and transfer costs
- Section 86-1.18 - Service Intensity Weights (SIW) and average length-of-stay (LOS)
- Section 86-1.19 - Wage Equalization Factor (WEF)
- Section 86-1.20 - Add-ons to the case payment rate per discharge
- Section 86-1.21 - Outlier and transfer cases rates of payment
- Section 86-1.22 - Alternate level of care payments
- Section 86-1.23 - Exempt units and hospitals
- Section 86-1.24 - Trend factor
- Section 86-1.25 - Capital expense reimbursement
- Section 86-1.26 - Statewide Planning and Research Cooperative System (SPARCS)
- Section 86-1.27 - Federal upper limit compliance
- Section 86-1.28 - Adding or deleting hospital services or units
- Section 86-1.29 - New hospitals and hospitals on budgeted rates
- Section 86-1.30 - Swing bed reimbursement
- Section 86-1.31 - Mergers, acquisitions and consolidations
- Section 86-1.32 - Administrative rate appeals
- Section 86-1.33 - Out-of-state providers
- Section 86-1.34 - Supplemental indigent care distributions
- Section 86-1.35 - Disproportionate share limitations
- Section 86-1.36 - Hospital physician billing
- Section 86-1.37 - Readmissions
- Section 86-1.38 - Transition pool for 2010-2013 period
- Section 86-1.39 - Inpatient psychiatric services
- Section 86-1.41 - Hospital Quality Contribution
- Section 86-1.42 - Potentially preventable negative outcomes
- Section 86-1.43 - Certified home health care agency ceilings
- Section 86-1.44 - Episodic Payments for Certified Home Health Agency Services
- Section 86-1.45 - Reimbursement for language assistance services in hospital inpatient settings
- Section 86-1.46 - Empire Clinical Research Investigator Program (ECRIP)
- Section 86-1.47 - Hospital indigent care pool payments
- Section 86-1.50 Repealed
- Section 86-1.51 Repealed
- Section 86-1.52 Repealed
- Section 86-1.53 Repealed
- Section 86-1.54 Repealed
- Section 86-1.55 Repealed
- Section 86-1.57 Repealed
- Section 86-1.60 Repealed
- Section 86-1.61 Repealed
- Section 86-1.62 Repealed
- Section 86-1.63 Repealed
- Section 86-1.64 Repealed
- Section 86-1.65 Repealed
- Section 86-1.66 Repealed
- Section 86-1.70 Repealed
- Section 86-1.71 Repealed
- Section 86-1.74 Repealed
- Section 86-1.75 Repealed
- Section 86-1.80 Repealed
- Section 86-1.81 Repealed
- Section 86-1.82 Repealed
- Section 86-1.83 Repealed
- Section 86-1.84 Repealed
- Section 86-1.86 Repealed
- Section 86-1.88 Repealed
- Section 86-1.89 Repealed
- SubPart 86-2 - Residential Health Care Facilities
- Section 86-2.1 - Definitions
- Section 86-2.2 - Financial and statistical data required
- Section 86-2.3 - Uniform system of accounting and reporting
- Section 86-2.4 - Generally accepted accounting principles
- Section 86-2.5 - Accountant's certification
- Section 86-2.6 - Certification by operator or officer
- Section 86-2.7 - Audits
- Section 86-2.8 - Patient days
- Section 86-2.9 - Adult day health care in residential health care facilities
- Section 86-2.10 - Computation of basic rate
- Section 86-2.11 - Adjustments to direct component of the rate
- Section 86-2.12 - Adjustments to basic rate
- Section 86-2.13 - Adjustments to provisional rates based on errors
- Section 86-2.14 - Revisions in certified rates
- Section 86-2.15 - Rates for residential health care facilities without adequate cost experience
- Section 86-2.16 - Less expensive alternatives
- Section 86-2.17 - Allowable costs
- Section 86-2.18 - Recoveries of expense
- Section 86-2.19 - Depreciation for voluntary and public residential health care facilities
- Section 86-2.20 - Interest for all residential health care facilities
- Section 86-2.21 - Capital cost reimbursement for proprietary residential health care facilities
- Section 86-2.22 - Movable equipment
- Section 86-2.23 - Research
- Section 86-2.24 - Educational activities
- Section 86-2.25 - Compensation of operators or relatives of operators
- Section 86-2.26 - Related organizations
- Section 86-2.27 - Termination of service
- Section 86-2.28 - Return on investment
- Section 86-2.29 - Payments to receivers
- Section 86-2.30 - Residential health care facilities patient assessment for certified rates
- Section 86-2.31 - Recalibration
- Section 86-2.32 - Nurse aide competency exam
- Section 86-2.33 - Dementia pilot demonstration projects
- Section 86-2.34 - Affiliation changes
- Section 86-2.36 - Scheduled short term care
- Section 86-2.37 - Submission of resident assessments
- Section 86-2.38 - Nursing home incentive payment
- Section 86-2.39 - Closures, mergers, acquisitions, consolidations and restructurings
- Section 86-2.35 - Reserved
- Section 86-2.40 - Statewide prices for non-capital reimbursement.
- Section 86-2.41 - Sprinkler systems
- Section 86-2.42 - Residential health care facility quality pool
- SubPart 86-3 - Health Maintenance Organizations
- SubPart 86-4 - Free-standing Ambulatory Care Facilities
- Section 86-4.1 - Definitions
- Section 86-4.2 - Facility rates
- Section 86-4.3 - Recording and reporting of financial and statistical data
- Section 86-4.4 - Certification of reports
- Section 86-4.5 - Correction and supplementation of reports
- Section 86-4.6 - Audits
- Section 86-4.7 - Title XVIII (Medicare) certification
- Section 86-4.8 Reserved
- Section 86-4.9 - Units of service
- Section 86-4.10 - Minimum utilization standards
- Section 86-4.11 - Computation of basic rate for facilities other than licensed free-standing ambulatory surgery centers
- Section 86-4.12 - Allowance for diagnostic and/or treatment centers providing a disproportionate share of bad debt and charity care
- Section 86-4.13 - Groupings
- Section 86-4.14 - Ceilings on payments
- Section 86-4.15 - Calculation of trend factor
- Section 86-4.16 - Revisions in certified rates
- Section 86-4.17 - Appeal process
- Section 86-4.18 Reserved
- Section 86-4.19 - Rates for facilities without adequate cost experience
- Section 86-4.20 - Capital cost reimbursement
- Section 86-4.21 - Allowable costs
- Section 86-4.22 - Recoveries of expense
- Section 86-4.23 - Depreciation
- Section 86-4.24 - Interest
- Section 86-4.25 - Return on investment
- Section 86-4.26 - Sales, leases and realty transactions
- Section 86-4.27 - Compensation of operators and relatives of operators
- Section 86-4.28 - Related organizations
- Section 86-4.29 Reserved
- Section 86-4.30 Reserved
- Section 86-4.31 - Termination of service
- Section 86-4.32 Reserved
- Section 86-4.33 Reserved
- Section 86-4.34 - Pilot reimbursement projects
- Section 86-4.35 - Computation of basic rates for clinic services provided to Acquired Immune Deficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV) sero-positive patients by freestanding ambulatory care facilities and hospital clinic outpatient
- Section 86-4.36 REPEALED
- Section 86-4.37 - Computation of basic rates of payment for services provided to Medicaid patients by preferred primary care providers
- Section 86-4.38 - Computation of basic rates of payment for services provided to Medicaid patients by specialty clinics
- Section 86-4.39 - Computation of basic rates for methadone maintenance treatment services provided by freestanding ambulatory care facilities and hospital outpatient clinic services.
- Section 86-4.40 - Computation of case-based rates of payment for licensed free-standing ambulatory surgery centers and hospital based ambulatory surgery services
- Section 86-4.41 - Computation of basic rates for day health care services provided by freestanding ambulatory care facilities to patients with acquired immune deficiency syndrome (AIDS) and other human immunodeficiency (HIV) related illnesses
- SubPart 86-5 - Long-term Home Health Care Programs
- Section 86-5.1 - Definitions
- Section 86-5.2 - Financial and statistical data required
- Section 86-5.3 - Patient assessment
- Section 86-5.4 - Generally accepted accounting principles
- Section 86-5.5 - Accountant's certification
- Section 86-5.6 - Certification by operator or officer
- Section 86-5.7 - Audits
- Section 86-5.8 - Patient visits/hourly rate
- Section 86-5.9 - Determining patient eligibility
- Section 86-5.10 - Computation of average monthly nursing home rates
- Section 86-5.11 - Computation of individual hourly or per-visit service rate
- Section 86-5.12 - Cost guidelines for reimbursement purposes
- Section 86-5.13 - Adjustments to provisional rates based on errors
- Section 86-5.14 - Revisions in certified rates
- Section 86-5.15 - Rates for LTHHCP without adequate cost experience
- Section 86-5.16 - Less expensive alternatives
- Section 86-5.17 - Allowable costs
- Section 86-5.18 - Recoveries of expense
- Section 86-5.19 - Depreciation for voluntary and public LTHHCP
- Section 86-5.20 - Interest for all LTHHCPs
- Section 86-5.21 - Capital cost reimbursement for proprietary LTHHCPs
- Section 86-5.22 - Return on investment for proprietary LTHHCPs
- Section 86-5.23 - Movable equipment
- Section 86-5.24 - Research
- Section 86-5.25 - Education activities
- Section 86-5.26 - Termination of services
- Section 86-5.27 - AIDS home care programs
- Section 86-5.28 - Related organizations.
- SubPart 86-6 - Hospices
- Section 86-6.1 - Definitions
- Section 86-6.2 - Hospice rates of reimbursement
- Section 86-6.3 - Reimbursement for attending and consulting physician services
- Section 86-6.4 - Reporting requirements
- Section 86-6.5 - Trend factor
- Section 86-6.6 - Supplemental financial assistance program
- Section 86-6.7 - Hospice reimbursement for room and board provided to patients residing in a nursing facility
- SubPart 86-7 - Assisted Living Program
- SubPart 86-8 - Outpatient Services: Ambulatory Patient Group
- Section 86-8.1 - Scope
- Section 86-8.2 - Definitions
- Section 86-8.3 - Record keeping, reports and audits
- Section 86-8.4 - Capital reimbursement and rate add-ons
- Section 86-8.5 - Administrative rate appeals
- Section 86-8.6 - Rates for new facilities during the transition period
- Section 86-8.7 - APGs and relative weights
- Section 86-8.8 - Base rates
- Section 86-8.9 - Diagnostic coding and rate computation
- Section 86-8.10 - Exclusions from payment
- Section 86-8.11 - System updating and incorporation by reference
- Section 86-8.12 - Payments for extended hours of operation
- Section 86-8.13 - Out-of-state providers
- Section 86-8.14 - Non-APG payments
- Section 86-8.15 - Closures, mergers, acquisitions, consolidations, restructurings and inpatient bed de-certifications
- SubPart 86-9 - Limited Home Care Services Agencies
- SubPart 86-10 - Rates for Non-State Providers of Residential Habilitation in Community Residences, Including Individualized Residential Alternatives (IRAs) and for Non-State Providers of Day Habilitation
- Section 86-10.1 - Applicability
- Section 86-10.2 - Definitions
- Section 86-10.3 - Rates for residential habilitation services and for day habilitation services
- Section 86-10.4 - Reporting requirements
- Section 86-10.5 - Trend Factor, Increases to Compensation and Other Adjustments
- Section 86-10.6 - Transition periods and reimbursement
- Section 86-10.7 - Rate corrections
- Section 86-10.8 - Specialized template populations
- Section 86-10.9 - Severability
- SubPart 86-11 - Rate Setting for Non-State Providers: Intermediate Care Facilities for Persons with Developmental Disabilities
- Section 86-11.1 - Applicability
- Section 86-11.2 - Definitions
- Section 86-11.3 - Rates for providers of ICF/DD services
- Section 86-11.4 - Assessment
- Section 86-11.5 - Reporting requirements.
- Section 86-11.6 - Trend Factor, Increases to Compensation and Other Adjustments
- Section 86-11.7 - Transition to new methodology
- Section 86-11.8 - Rate corrections
- Section 86-11.9 - Specialized template populations
- Section 86-11.10 - Severability
- SubPart 86-12 - Outpatient Services Licensed Under the Mental Hygiene Law
- SubPart 86-13 - Rates for Non-State Providers of Prevocational Services (Site-based) and Respite (Hourly and Free-standing), and fees for Prevocational Services (Community-based), Residential Habilitation (Family Care) and Supported Employment
- Section 86-13.1 - Applicability
- Section 86-13.2 - Definitions
- Section 86-13.3 - Rates for prevocational services (site-based), respite (hourly and free-standing), prevocational services (community-based), supported employment, and residential habilitation (family care)
- Section 86-13.4 - Reporting requirements
- Section 86-13.5 - Trend Factor
- Section 86-13.6 - Transition periods and reimbursement
- Section 86-13.7 - Rate corrections for prevocational services (site-based) and respite (hourly and free-standing) rates
- Section 86-13.8 - Specialized template populations
- Section 86-13.9 - Severability
- Appendix 1 - Performance review of M/C faculty term appointments
- SubPart 86-1 - Medical Facilities
- Part 87 - Nursing Home Company And Hospital Mortgage Loans
- NURSING HOME COMPANIES
- Section 87.1 - General requirements
- Section 87.2 - Corporate organization
- Section 87.3 - Project development
- Section 87.4 - Project construction
- Section 87.5 - Development period records and reports
- Section 87.6 - Insurance
- Section 87.7 - Initial occupancy
- Section 87.8 - Operational period
- Section 87.9 - Real and personal tangible property
- Section 87.10 - Escrow funds
- Section 87.11 - Use of funds of the company
- Section 87.12 - Salaries or fees to officers or directors
- Section 87.13 - Purchases and contracts
- Section 87.14 - Default avoidance method
- MORTGAGE LOAN CHARGES
- HOSPITAL MORTGAGE LOANS
- Section 87.30 - General requirements
- Section 87.31 - Project development
- Section 87.32 - Project construction
- Section 87.33 - Development period records and reports
- Section 87.34 - Insurance
- Section 87.35 - Initial occupancy
- Section 87.36 - Operational period
- Section 87.37 - Personal tangible property
- Section 87.38 - Escrow funds
- Section 87.39 - Salaries or fees to officers or directors
- Section 87.40 - Purchases and contracts
- NURSING HOME COMPANIES
- Part 88 - Helen Hayes Hospital, New York State Veterans' Home and Roswell Park Memorial Institute
- SubPart 88-1 - Helen Hayes Hospital
- SubPart 88-2 - New York State Veterans' Homes
- SubPart 88-3 - Roswell Park Memorial Institute
- SubPart 88-4 - RESERVED
- SubPart 88-5 - Purchasing and Contracting
- Part 89 - Practice of Radiologic Technology
- Part 91 - Excess Liability Insurance Pool: Physicians And Dentists
- Section 91.1 - Required excess malpractice coverage
- Section 91.2 - Reporting requirements
- Section 91.3 - Determination of cost and reimbursement of excess medical malpractice coverage
- Section 91.4 - Pool administration
- SubChapter O - Physician's Assistants; Prohibited Discrimination in Hospital Staff Appointments and Privileges
- Part 92 - Infection Control Requirements
- SubPart 92-1 - Physician's, Registered Physician Assistants and Specialist Assistants: Required Course Work or Training in Infection Control and Barrier Precautions Every Four Years
- Section 92-1.1 - Course work or training
- Section 92-1.2 - Application
- Section 92-1.3 - Provider competency
- Section 92-1.4 - Approval period
- Section 92-1.5 - Denial or termination
- Section 92-1.6 - Certificate of completion
- Section 92-1.7 - Certificate of retention
- Section 92-1.8 - Submission of documentation to the department
- Section 92-1.9 - Exemptions
- Section 92-1.10 - Equivalencies
- SubPart 92-2 - Physicians, Registered Physician Assistants and Specialist Assistants Required Use of Infection Control Practices
- SubPart 92-1 - Physician's, Registered Physician Assistants and Specialist Assistants: Required Course Work or Training in Infection Control and Barrier Precautions Every Four Years
- Part 93 - Improper Practices in Hospital Staff Appointments and Extension of Professional Privileges
- Part 94 - Physician Assistants And Specialist Assistants
- Part 95 - Discrimination In Physician Staff Appointments And Privileges Based On Participation In A Medical Group Practice Or Non-Profit Health Insurance Plan
- Section 95.1 - Filing of complaint
- Section 95.2 - Contents of complaint
- Section 95.3 - Initial investigation
- Section 95.4 - Preliminary conference
- Section 95.5 - Notice of complaint
- Section 95.6 - Time for answer
- Section 95.7 - Pre-hearing procedures
- Section 95.8 - Subpoenas
- Section 95.9 - Conduct of the hearing
- Section 95.10 - Stenographic record
- Section 95.11 - Decision of hearing officer
- Section 95.12 - Order of commissioner
- SubChapter P - Licensure and Practice of Nursing Home Administration
- Part 96 - Licensure And Practice Of Nursing Home Administration
- Section 96.1 - Definitions
- Section 96.2 - Board of examiners; general powers
- Section 96.3 - Board of examiners; officers and duties
- Section 96.4 - Licenses and registrations
- Section 96.5 - Admission to the examination
- Section 96.6 - Grading of examination
- Section 96.7 - Petition for admission to examination
- Section 96.8 - Courses of study; standards for approval
- Section 96.9 - Approved courses of study
- Section 96.10 - Training agencies; administration, organization and faculty
- Section 96.11 - Continuing education requirements
- Section 96.12 - Applicants holding an out-of-state nursing home administrators license.
- Section 96.13 - Notification of change of address or employment
- SubChapter Q - State Environmental Quality Review
- Part 97 - Regulations Implementing State Environmental Quality Review
- Section 97.1 - Authority, purpose and policy
- Section 97.2 - Definitions
- Section 97.3 - Applicability
- Section 97.4 - General rule
- Section 97.5 - Responsibilities of applicants
- Section 97.6 - Initial review of actions
- Section 97.7 - Designation of lead agency and determination of significance for type I actions
- Section 97.8 - Designation of lead agency and determination of significance for unlisted actions
- Section 97.9 - Environmental impact statement procedures
- Section 97.10 - Decisionmaking and findings requirements
- Section 97.11 - Notice and filing requirements
- Section 97.12 - Contents of environmental impact statements
- Section 97.13 - Criteria for determining what actions may have a significant effect on the environment
- Section 97.14 - Lists of department actions
- Section 97.15 - Actions involving a Federal agency
- Section 97.16 - Fees and costs
- Section 97.17 - Programmatic or generic environmental impact statements
- Section 97.18 - Confidentiality
- Section 97.19 - Effective date
- SubChapter R - Managed Care Organizations
- Part 98 - Managed Care Organizations
- SubPart 98-1 - Managed Care Organizations
- Section 98-1.1 - Applicability
- Section 98-1.2 - Managed Care Organizations
- Section 98-1.3 - RESERVED
- Section 98-1.4 - Certificate of incorporation or articles of organization
- Section 98-1.5 - Application for a certificate of authority
- Section 98-1.6 - Issuance of a certificate of authority
- Section 98-1.7 - Limitations of a certificate of authority
- Section 98-1.8 - Continuance of a certificate of authority
- Section 98-1.9 - Acquisition or retention of control of HMO's
- Section 98-1.10 - Transactions within a holding company system affecting controlled HMO's
- Section 98-1.11 - Operational and financial requirements for MCOs
- Section 98-1.12 - Quality management program
- Section 98-1.13 - Assurance of access to care
- Section 98-1.14 - Enrollee services and grievance procedures
- Section 98-1.15 - Employer requirements
- Section 98-1.16 - Audited Financial Statements for Managed Care Organizations
- Section 98-1.17 - Audits and examinations
- Section 98-1.18 - Relationship between an MCO and an IPA
- Section 98-1.19 - Marketing by MLTCPs
- Section 98-1.20 - Waived requirements for MLTCPs
- Section 98-1.21 - Fraud and abuse prevention plans and special investigation units
- Section 98-1.22 - Warning Statements
- SubChapter S - Land Acquisition
- SubPart 98-2 - External Appeals of Adverse Determinations
- Section 98-2.1 - Preamble
- Section 98-2.2 - Definitions
- Section 98-2.3 - Standard description of the external appeal process
- Section 98-2.4 - Certification of external appeal agents
- Section 98-2.5 - Certification requirements
- Section 98-2.6 - Conflict of interest
- Section 98-2.7 - Screening of requests for external appeal
- Section 98-2.8 - Random assignment of external appeals
- Section 98-2.9 - Responsibilities of health care plans
- Section 98-2.10 - Responsibilities of certified external appeal agents
- Section 98-2.11 - Enrollee rights and responsibilities
- Section 98-2.12 - Confidentiality
- Section 98-2.13 - Audits and examinations
- Subpart 98-3 - Audited Financial Statements for Managed Care Organizations
- Section 98-3.1 - Purpose
- Section 98-3.2 - Definitions
- Section 98-3.3 - General requirements related to filing of annual audited financial reports and audit committee appointment
- Section 98-3.4 - Contents of annual audited financial report
- Section 98-3.5 - Designation of CPA
- Section 98-3.6 - Qualifications of CPA
- Section 98-3.7 - Consolidated or combined audits
- Section 98-3.8 - Scope of audit and report of CPA
- Section 98-3.9 - Notification of adverse financial condition
- Section 98-3.10 - Communication of internal control related matters noted in an audit
- Section 98-3.11 - CPA’s letter of qualifications
- Section 98-3.12 - Availability and maintenance of CPA work papers
- Section 98-3.13 - Requirements for audit committees
- Section 98-3.14 - Conduct of MCO in connection with the preparation of required reports and documents
- Section 98-3.15 - Management’s report of internal control over financial reporting
- Section 98-3.16 - Effective date and special rules
- Subpart 98-4 - Mental Health and Substance Use Disorder Treatment Parity Compliance Program
- SubPart 98-1 - Managed Care Organizations
- Part 99 - Payments To An Owner Or Tenant Of Residential Property Or Commercial Property Upon Application For Allowance Of Moving Expenses In Vacating Property Acquired By The Department Of Health
- SubChapter N - Professional Medical and Dental Services
- Part 86 - Reporting And Rate Certifications For Facilities