N.Y. Public Health Law § 2807-f: Health maintenance organization payment factor

§ 2807-f. Health maintenance organization payment factor. 1. For

purposes of this section, the following terms shall have the following

meaning:

(a) "HMO" shall mean a health maintenance organization operating in

accordance with the provisions of article forty-four of this chapter or

article forty-three of the insurance law.

(b) "Medicaid" shall mean the medical assistance program established

pursuant to title eleven of article five of the social services law.

2. For periods commencing on or after July first, nineteen hundred

ninety-eight, an HMO payment factor shall be determined in accordance

with subdivision three of this section. Such subdivision shall apply

during the period July first, nineteen hundred ninety-eight through June

thirtieth, nineteen hundred ninety-nine; provided, however, that this

section shall expire and be deemed repealed on and after the date on

which New York state is granted the authority, by federal waiver, agreed

upon by the state and the secretary of the federal department of health

and human services, or federal statute, to operate a mandatory medicaid

managed care program.

3. (a) In recognition of the public benefits resulting from enrolling

medicaid enrollees into managed care plans, HMOs are required to make a

good faith effort to enroll medicaid recipients. A good faith effort

shall be defined as:

(i) submitting a reasonable bid in response to a state or county

procurement process;

(ii) willingness to enter into reasonable managed care contracts with

counties in its approved service area;

(iii) demonstrating a willingness to enroll medicaid recipients

including accepting referrals from counties, brokers and

auto-assignments; and

(iv) such other factors as may be established by the commissioner.

(b) In the event that an HMO has not made a good faith effort to

enroll medicaid recipients, the commissioner shall impose a payment

factor of nine percent on payments to general hospitals for the calendar

year by such HMO. The commissioner shall notify HMOs of any failure to

make a good faith effort and the application of the payment factor by

November first preceding the applicable calendar year.

4. (a) Each HMO on behalf of general hospitals shall pay into a

statewide health maintenance organization pool created by the

commissioner the factor established pursuant to subdivision two or three

and this subdivision for each patient discharged in the previous

calendar month commencing with July first, nineteen hundred ninety-six

through December thirty-first, nineteen hundred ninety-nine or

contracted hospital inpatient service obligations for periods on or

after July first, nineteen hundred ninety-six through December

thirty-first, nineteen hundred ninety-nine. Funds accumulated in the

pool, including income from invested funds, shall be deposited by the

commissioner and credited to the general fund.

(b) Payments by HMOs to the pool shall be due on or before the

fifteenth day following the end of each month.

(c) (i) If a payment made for a month to which a payment factor

applies is less than ninety percent of the actual amount due for such

month, interest shall be due and payable to the commissioner by a health

maintenance organization on the difference between the amount paid and

the amount due from the day of the month the payment was due until the

date of payment. The rate of interest shall be twelve percent per annum

or, if greater, at the rate of interest set by the commissioner of

taxation and finance with respect to underpayments of tax pursuant to

subsection (e) of section one thousand ninety-six of the tax law minus

four percentage points. Interest under this paragraph shall not be paid

if the amount thereof is less than one dollar.

(ii) If a payment made for a month to which a payment factor applies

is less than seventy percent of the actual amount due for such month, a

penalty shall be due and payable to the commissioner by a health

maintenance organization of five percent of the difference between the

amount paid and the amount due for such month when the failure to pay is

for a duration of not more than one month after the due date of the

payment with an additional five percent for each additional month or

fraction thereof during which such failure continues, not exceeding

twenty-five percent in the aggregate.

(iii) Overpayment by a health maintenance organization of a payment

shall be applied to any other payment due pursuant to this section, or,

if no payment is due, at the election of the health maintenance

organization shall be applied to future payments or refunded to the

health maintenance organization. Interest shall be paid on overpayments

from the date of overpayment to the date of crediting or refund at the

rate determined in accordance with paragraph (a) of this subdivision

only if the overpayment was made at the direction of the commissioner.

Interest under this paragraph shall not be paid if the amount thereof is

less than one dollar.

(d) The commissioner is authorized to contract with a pool

administrator designated for purposes of administering pools pursuant to

subdivision two-a of section twenty-eight hundred seven-c of this

article as in effect on June thirtieth, nineteen hundred ninety-six, or

if not available such other administrators as the commissioner shall

designate, to receive and distribute health maintenance organization

pool funds. In the event contracts are effectuated, the commissioner

shall conduct or cause to be conducted annual audits of the receipt and

distribution of the pool funds. The reasonable costs and expenses of an

administrator as approved by the commissioner, not to exceed for

personnel services on an annual basis two hundred thousand dollars,

shall be paid from the pooled funds.

5. Payment factors established pursuant to this section shall not

apply to payments for subscribers who are eligible for medical

assistance pursuant to the social services law, participants in regional

pilot projects established pursuant to chapter seven hundred three of

the laws of nineteen hundred eighty-eight or successor insurance

programs, and enrollees in the child health insurance program pursuant

to sections twenty-five hundred ten and twenty-five hundred eleven of

this title.

6. Notwithstanding any inconsistent provisions of the state

administrative procedure act or any other provision of law, the

commissioner is authorized to adopt or amend on an emergency basis any

regulation he or she determines necessary to implement this section.

7. HMOs shall provide to the commissioner such information as the

commissioner may require to effectuate the provisions of this section.