2006 New York Code - Medical Assistance Information And Payment System.

 
    §  367-b.  Medical  assistance  information and payment system. 1. The
  department shall design and implement  a  statewide  medical  assistance
  information  and payments system for the purpose of providing individual
  and aggregate data to social services districts to assist them in making
  basic management decisions, to the department and other  state  agencies
  to  assist  in the administration of the medical assistance program, and
  to the governor and the legislature as may be  necessary  to  assist  in
  making major administrative and policy decisions affecting such program.
  Such system shall be designed so as to be capable of the following:
    a. receiving and processing information relating to the eligibility of
  each  person  applying  for  medical assistance and of issuing a medical
  assistance  identification  card  to  persons  determined  by  a  social
  services official to be eligible for such assistance;
    b.  receiving  and  processing  information relating to each qualified
  provider of medical assistance furnishing care, services or supplies for
  which claims for payment are made pursuant to this title;
    c. receiving and processing, in a form and manner  prescribed  by  the
  department,  all  claims  for  medical  care, services and supplies, and
  making payments for valid claims to providers of medical care,  services
  and supplies on behalf of social services districts;
    d.   maintaining   information  necessary  to  allow  the  department,
  consistent with the powers and duties of the department  of  health,  to
  review the appropriateness, scope and duration of medical care, services
  and  supplies  provided to any eligible person pursuant to this chapter;
  and
    e. initiating  implementation  of  such  a  system  for  the  district
  comprising  the  city of New York, in a manner compatible with expansion
  of such system to districts other than the district comprising the  city
  of New York.
    2. Consistent with the capabilities of the system established pursuant
  to  subdivision one of this section, the department shall assume payment
  responsibilities on behalf of social services districts by  promulgation
  of  regulations approved by the director of the budget. Such regulations
  shall specify the providers of medical assistance and the medical  care,
  services  and/or  supplies  for  the district or districts for which the
  department will assume payment responsibilities and the  date  on  which
  such  responsibilities  shall  be  assumed.  Such  regulations  shall be
  published  for  comment  at  least  thirty  days  in  advance  of  their
  promulgation  and  shall  be  filed with the secretary of state at least
  sixty days in advance of the date  of  assumption  of  responsibilities;
  provided,  however,  that  with  respect  to  a  particular district the
  requirements for advance publications and/or filing may  be  waived,  or
  the  time  limits  reduced,  with the written consent of the district to
  such waiver or reduction. Providers of medical care and  services  shall
  submit  claims  to  the  social services district for all items of care,
  services and supplies furnished prior to the date of state assumption of
  payment responsibilities and to the state for all such  items  furnished
  subsequent  to  such  date.  Such regulations shall also specify a final
  transition date after which any claiming submitted shall be  enforceable
  by  such provider only against the state and shall not be enforceable by
  such provider against the social services district;  provided,  however,
  that  the department and the district may enter into a written agreement
  by which the department agrees on the basis of  eligibility  information
  provided by such district to pay claims submitted to such district prior
  to the final transition date.
    3.  Upon  notice  to  a  social  services  district in accordance with
  subdivision  two,  that  the  department  intends  to   assume   payment
  responsibilities  on  behalf  of  such district, (a) such district shall
  promptly submit to the department requested information  regarding  each
  person  who  applies  for  or  has  been determined eligible for medical
  assistance and each provider of medical assistance in such district; and
  (b) notwithstanding the provisions of paragraph (b) of subdivision three
  of  section  three  hundred  sixty-six-a of this chapter, the department
  shall provide each person found by such  district  to  be  eligible  for
  medical   assistance   under   this  title  with  a  medical  assistance
  identification card.
    4. Information relating to persons applying for or  receiving  medical
  assistance  shall  be considered confidential and shall not be disclosed
  to persons or agencies other than  those  considered  entitled  to  such
  information  in accordance with section one hundred thirty-six when such
  disclosure  is  necessary  for  the  proper  administration  of   public
  assistance programs.
    5. By no later than forty-five days following the end of each calendar
  quarter  after  the  second  quarter  of  calendar year nineteen hundred
  seventy-six, the department shall, until full  implementation  has  been
  achieved  in  all  social services districts, report to the governor and
  the legislature regarding the current status of the  medical  assistance
  information and payment system, summarizing the progress achieved during
  the  previous  quarter  and  the  anticipated  major achievements of the
  succeeding two calendar quarters. The report shall include  the  current
  and  anticipated  overall  expenditure and staffing levels for functions
  relating to the system, and shall  specify  each  district  affected  or
  anticipated  to  be affected during the succeeding two calendar quarters
  and summarize  the  manner  in  which  each  such  district  is,  or  is
  anticipated  to  be, affected. In addition, the department shall prepare
  and submit  to  the  governor  and  the  legislature  a  special  report
  demonstrating  the  appropriateness  and  relative cost-effectiveness of
  utilizing a fiscal intermediary.
    In addition, for the purpose of  insuring  the  compatability  of  the
  system  servicing  the district comprising the city of New York with the
  system servicing all other social services districts in the  state,  the
  department  shall prepare and submit to the governor and the legislature
  on or before March first,  nineteen  hundred  seventy-eight,  a  special
  report and recommendation covering the appropriateness and relative cost
  effectiveness of utilizing a fiscal intermediary or fiscal agent for all
  districts other than the district comprising the city of New York.
    6.  Each  social  services district shall be responsible for paying to
  the state a share of the state's expenditures for claims of providers of
  medical assistance attributable to such district, which shall  be  equal
  to  the  share of such expenditures such district would have borne after
  reimbursement from state and federal funds in  accordance  with  section
  three  hundred  sixty-eight-a  of this chapter, had the expenditure been
  made by such district; provided, however,  that  no  district  shall  be
  responsible for the state's expenditures for the administrative costs of
  developing,  maintaining  or  operating the statewide medical assistance
  information and payment system; and provided, further, that no  district
  shall  be responsible for paying to the state any portion of the cost of
  medical assistance which the department is  responsible  for  furnishing
  pursuant to section three hundred sixty-five of this chapter.
    7.  In  any case in which the department has made payments for medical
  assistance on behalf of a social  services  district  pursuant  to  this
  section,  the  commissioner  on  behalf  of the social services official
  shall be empowered  to  bring  actions  to  recover  the  cost  of  such
  assistance, pursuant to this subdivision and the provisions of title six
  of article three of this chapter.
    8. For the purpose of orderly and timely implementation of the medical
  assistance  payments  and  information  system, the department is hereby
  authorized to enter into agreements with fiscal intermediaries or fiscal
  agents  for  the   design,   development,   implementation,   operation,
  processing,  auditing  and  making  of payments, subject to audits being
  conducted by the state in accordance with the terms of such  agreements,
  for medical assistance claims under the system described by this section
  in  any  social  services  district.  Such agreements shall specifically
  provide that the state shall have complete oversight responsibility  for
  the  fiscal  intermediaries'  or fiscal agents' performance and shall be
  solely  responsible  for  establishing  eligibility   requirements   for
  recipients,  provider qualifications, rates of payment, investigation of
  suspected  fraud  and   abuse,   issuance   of   identification   cards,
  establishing  and  maintaining  recipient  eligibility  files,  provider
  profiles, and conducting state audits of the fiscal  intermediaries'  or
  agents' at least once annually. The system described in this subdivision
  shall be operated by a fiscal intermediary or fiscal agent in accordance
  with this subdivision unless the department is otherwise authorized by a
  law  enacted  subsequent  to  the  effective date of this subdivision to
  operate  the  system  in  another  manner.  In  no  event   shall   such
  intermediary  or  agent  be  a political subdivision of the state or any
  other governmental agency or entity.
    9. (a) In order to accomplish a more orderly transition to the medical
  assistance payments and information system authorized by  this  section,
  and  to  continue  for  a  limited  transition  period the rate at which
  advanced revenues have been made available by local  governmental  units
  to  certain hospitals providing services to persons eligible for medical
  assistance, the  department  is  authorized  to  promulgate  regulations
  establishing  a  system of accelerated payments to hospitals meeting the
  criteria set forth in this section.
    (b) Such system of accelerated payments shall only be available  to  a
  general hospital, other than a public general hospital:
    (i)  which  prior  to  January  first,  nineteen hundred seventy-eight
  received regular, periodic and recurring advanced revenues from a  local
  governmental  unit, the amount of which was based on anticipated medical
  assistance claims payments; and
    (ii) which has demonstrated that  its  continued  financial  viability
  depends  in substantial part on the rate at which such advanced revenues
  were made available by local governmental units prior to  the  time  the
  department,  pursuant to this section, assumed payment for such hospital
  responsibilities on behalf of the social services district in  which  it
  is  located,  taking into account any funds remaining available from the
  local governmental unit under  its  system  of  advanced  revenues.  For
  purposes  of this subdivision, it shall be presumed that a hospital does
  not depend in substantial part on the rate at  which  advanced  revenues
  were  made  available  by  a local governmental unit if it received such
  revenues for a period of less than nine months preceding  the  month  in
  which the department assumed payment responsibilities for such hospital;
    (iii)  for  which  payment  responsibility is initially assumed by the
  department pursuant to this section during  the  period  beginning  June
  first,  nineteen  hundred  seventy-eight  and ending November thirtieth,
  nineteen hundred seventy-eight; and
    (iv)  which  meets  performance  criteria  established  by  department
  regulation  relating  to the ratio of acceptable claims for patient days
  submitted for medical assistance payment compared to the  total  patient
  days  of  the  hospital  and compared to such claims submitted in one or
  more previous months, and the time lapse between the  date  the  service
  was provided and the date the claim was submitted.
    (c)   The  regulations  promulgated  by  the  department  pursuant  to
  paragraph (a) of this subdivision shall provide that the amount  of  the
  accelerated  payment for any month shall be determined for each hospital
  meeting the  criteria  set  forth  in  this  section  on  the  basis  of
  acceptable medical assistance claims submitted by the hospital in one or
  more  previous  months  and  the  amount  of  accelerated  revenues made
  available to the hospital by a local governmental unit prior to the time
  the department assumed payment responsibilities for  the  hospital.  The
  amount  of  the accelerated payment for any given month shall not exceed
  the amount of a monthly aggregate claim to be submitted by the  hospital
  to the department, which claim shall reflect items of care, services and
  supplies  authorized  under  the  medical assistance program pursuant to
  this title which are in fact provided prior to the date of the aggregate
  claim  to  persons  who  have  been  determined  eligible  for   medical
  assistance,  or based on the past performance of the hospital are likely
  to be determined eligible for medical assistance, when no  other  source
  of  payment including third party health insurance and payments pursuant
  to title eighteen of the Federal Social Security Act are  available  for
  such items of care, service and supplies. Such aggregate claims shall be
  subject to the audit and warrant of the state comptroller.
    (d) Any schedule of accelerated payments established by the department
  pursuant  to this section shall assure that such payments are made for a
  period of no more than six months from the month in which the department
  assumes payment responsibility for the hospital, and shall  provide  for
  repayment  of  any  amounts in excess of current audited claims, through
  reductions in current claims, at a rate that will assure full  repayment
  at  the  earliest time consistent with the purposes of this section, but
  in no event more than twenty-four months following the  month  in  which
  the  department  assumes  payment  responsibilities  for  the  hospital.
  However, where the  commissioner  of  health  has  determined  with  the
  concurrence  of  the  state  hospital review and planning council that a
  hospital has satisfied the department of health regulations  and  is  or
  has   been   authorized   to   participate  in  the  emergency  hospital
  reimbursement program pursuant to which repayment of all or part of  any
  accelerated  payments  made  by  the  department  have  been deferred in
  accordance with such regulations, notwithstanding the  time  limitations
  set  forth  above  repayment  of  such deferred amounts shall be made in
  accordance with an orderly schedule  of  repayment  established  by  the
  commissioner  of  health after consultation with the commissioner. In no
  event shall any reduction be made against current claims, grant funds or
  any amounts due said hospital in settlement of rate appeals,  claims  or
  lawsuits to satisfy such repayment obligations.
    (e)  In  making  accelerated payments pursuant to this subdivision and
  department regulations, the department shall utilize federal funds  made
  available, and local funds, for such purposes or for purposes of payment
  by  the  department  of  medical  assistance  payments  pursuant to this
  section.
    * 10. a. For the purpose of timely payment, the department  is  hereby
  authorized  to develop a concurrent payment system for general hospitals
  which elect to participate in the concurrent payment  system  and  which
  are  included  in  the  payment  component  of  the  medical  assistance
  information and payment system, and to promulgate regulations to  govern
  such  a  system.  The  department  may  implement the concurrent payment
  system for any general hospital which has elected to participate and for
  which the department has chosen to implement the system.
    b. For  all  participating  general  hospitals  the  department  shall
  determine   a   biweekly   concurrent  payment  which  shall  equal  one
  twenty-sixth of the portion  of  the  hospital's  imputed  or  certified
  inpatient  revenue  cap  (as  defined  in  section  twenty-eight hundred
  seven-a of the public  health  law)  allocated  for  medical  assistance
  payments.  The  concurrent payment shall be reviewed at the beginning of
  each  quarter  and  adjusted  to  reflect  any  changes to the inpatient
  revenue cap or portion allocated for medical assistance payments.
    c.  The  department  shall  promulgate  regulations,  consistent  with
  federal requirements for participation, governing the concurrent payment
  system.    The regulations shall address, among other things, the method
  of calculating the concurrent payment, the method of reconciliation, the
  adjustment of the concurrent payment for the calculated difference,  the
  manner  of  eliminating  underpayments  or  overpayments to hospitals in
  exceptional circumstances such as  significantly  changing  utilization,
  changes  in  bed  or  service  capacity,  or  imminent  insolvency.  The
  department shall promulgate regulations  establishing  a  procedure  for
  recognizing  open cases as of the date of reconciliation. The department
  shall also  promulgate  regulations  setting  forth  standards  for  the
  timeliness  and quality of billings and may lower the concurrent payment
  calculated in accordance  with  paragraph  b  of  this  subdivision  for
  noncompliance with such regulations.
    d.  Any  payment  claims  made to the department for days of inpatient
  care provided prior to the effective date of this subdivision  shall  be
  paid  or denied in accordance with department regulations in effect when
  the care was provided.
    e. For any general hospital which is not afforded the  opportunity  of
  participating   in  the  concurrent  payment  system  and  which  is  in
  compliance  with  the  billing  requirements  of  the  department,   the
  department  shall  pay any financing or working capital charge levied by
  the hospital as authorized in section twenty-eight  hundred  seven-a  of
  the public health law.
    f.  This  subdivision shall be effective only if federal participation
  is available.
    * NB Expires January 1, 1986
    11. a. For the purpose of timely payment,  the  department  is  hereby
  authorized  to develop a concurrent payment system for general hospitals
  which elect to participate in the concurrent payment  system  and  which
  are  included  in  the  payment  component  of  the  medical  assistance
  information and payment system, and to promulgate regulations to  govern
  such  a  system.  The  department  may  implement the concurrent payment
  system for any general hospital which has elected to participate and for
  which the department has chosen to implement the system.
    b. For  all  participating  general  hospitals  the  department  shall
  determine   a   biweekly   concurrent  payment  which  shall  equal  one
  twenty-sixth of the hospital's estimated yearly inpatient  revenue  from
  medical assistance payments. The concurrent payment shall be reviewed at
  the beginning of each quarter and adjusted to reflect any changes to the
  rates for medical assistance payments.
    c.  The  department  shall  promulgate  regulations,  consistent  with
  federal requirements for participation, governing the concurrent payment
  system.  The regulations shall address, among other things,  the  method
  of calculating the concurrent payment, the method of reconciliation, the
  adjustment  of the concurrent payment for the calculated difference, the
  manner of eliminating underpayments  or  overpayments  to  hospitals  in
  exceptional  circumstances  such  as significantly changing utilization,
  changes  in  bed  or  service  capacity,  or  imminent  insolvency.  The
  department  shall  promulgate  regulations  establishing a procedure for
  recognizing open cases as of the date of reconciliation. The  department
  shall  promulgate regulations setting forth standards for the timeliness
  and quality of billings and may lower the concurrent payment  calculated
  in  accordance  with  paragraph  b of this subdivision for noncompliance
  with such regulations.
    d.  Any  payment  claims  made to the department for days of inpatient
  care provided prior to the effective date of this subdivision  shall  be
  paid  or denied in accordance with department regulations in effect when
  the care was provided.
    e. For any general hospital which is not afforded the  opportunity  of
  participating   in  the  concurrent  payment  system  and  which  is  in
  compliance  with  the  billing  requirements  of  the  department,   the
  department  shall  pay any financing or working capital charge levied by
  the hospital as authorized in section twenty-eight  hundred  seven-a  of
  the public health law.
    f.  This  subdivision shall be effective only if federal participation
  is available.
    12. (a) For the purpose of regulating cash flow for general hospitals,
  the department shall develop and  implement  a  payment  methodology  to
  provide for timely payments for inpatient hospital services eligible for
  case  based  payments  per  discharge  based on diagnosis-related groups
  provided during the period January first, nineteen hundred  eighty-eight
  through  June  thirtieth,  two  thousand  seven, by such hospitals which
  elect to participate in the system.
    (b) In developing a payment methodology the department shall  consider
  a  system  under  which  hospitals  may  be  reimbursed  on the basis of
  inpatient admissions, adjusted to payment  on  the  basis  of  discharge
  data,  with reconciliations established at time periods specified by the
  department.  Under such a system variances between amounts  paid  on  an
  admission  basis  and  actual  amounts due and to be paid on a discharge
  basis may be reflected in the amounts to be paid in a subsequent period.
    13. Notwithstanding any inconsistent provision  of  law,  in  lieu  of
  payments  authorized  by  this chapter and/or any of the general fund or
  special revenue other appropriations made to the office of temporary and
  disability assistance and the office of children  and  family  services,
  from  funds  otherwise due to local social services districts or in lieu
  of payments of federal funds otherwise  due  to  local  social  services
  districts for programs provided under the federal social security act or
  the  federal  food  stamp  act  or the low income home energy assistance
  program, funds in amounts certified by the commissioner of the office of
  temporary and disability assistance or the commissioner of the office of
  children and family services or the commissioner of health as  due  from
  local social services districts as their share of payments made pursuant
  to  this  section,  may  be  set-aside  by  the  state comptroller in an
  interest-bearing account with such interest accruing to  the  credit  of
  the  locality,  pursuant  to an estimate provided by the commissioner of
  health of a local social services district's share of medical assistance
  payments, except that in  the  case  of  the  city  of  New  York,  such
  set-aside shall be subject first to the requirements of a section of the
  chapter  of  the  laws of two thousand one which enacted this provision,
  and then subject to the requirements of paragraph (i) of subdivision (b)
  of section two hundred twenty-two-a of chapter four hundred seventy-four
  of the laws of nineteen hundred ninety-six prior to the  application  of
  this  subdivision.  Should  funds  otherwise  payable  to a local social
  services district from appropriations made to the  office  of  temporary
  and  disability  assistance, the office of children and family services,
  and the department of health be insufficient to fully fund  the  amounts
  identified  by  the commissioner of health as necessary to liquidate the
  local share of payments to be made pursuant to this section on behalf of
  the local social services  district,  the  commissioner  of  health  may
  identify  other  state  or federal payments payable to that local social
  services district or any other county agency including, but not  limited
  to  the  county  department  of  health, from appropriations made to the
  state department of health, and may  authorize  the  state  comptroller,
  upon no less than five days written notice to such local social services
  district  or such other county agency, to set-aside such payments in the
  interest-bearing account with such interest accruing to  the  credit  of
  the locality. Upon such determination by the commissioner of health that
  insufficient  funds  are payable to a local social services district and
  any other county agency receiving payments from the office of  temporary
  and  disability  assistance, the office of children and family services,
  and the state department of health from  appropriations  made  to  these
  agencies,  the  state  comptroller  shall,  upon  no less than five days
  written notice to such local social  services  district  or  such  other
  county  agency,  withhold  payments from any of the general fund - local
  assistance accounts or payments made from any of the special  revenue  -
  federal  local assistance accounts, provided, however, that such federal
  payments shall be withheld only after such federal  funds  are  properly
  credited  to  the  county  through  vouchers,  claims  or other warrants
  properly received, approved, and paid  by  the  state  comptroller,  and
  set-aside  such  disbursements in the interest-bearing account with such
  interest accruing to the credit of the locality until such time that the
  amount withheld from each county is determined by  the  commissioner  of
  health  to be sufficient to fully liquidate the local share of payments,
  as estimated by the commissioner of health, to be made pursuant to  this
  section on behalf of that local social services district.
    14. Notwithstanding any other provision of law, effective on or before
  January  first,  two  thousand  one,  the local social services district
  share of medical assistance payments made by the state on behalf of  the
  local  social  services district shall be paid to the state by the local
  social services district  using  electronic  funds  transfer  under  the
  supervision   of  the  state  comptroller  and  pursuant  to  rules  and
  regulations of the commissioner of health. The state  comptroller  shall
  deposit  such  funds  in  the  medicaid  management  information  system
  statewide escrow fund to the credit of each local district. In the event
  that the state comptroller and commissioner  of  health  determine  that
  there  are  insufficient  funds  available  from  the  local district to
  liquidate  their  local  share  of  medical  assistance  payments,   the
  commissioner  of  health  shall  issue a repayment schedule to the state
  comptroller for purposes of reducing reimbursement from other sources of
  payment from the state to the city or county of which the  local  social
  services  district  is a part in accordance with subdivision thirteen of
  this section,  until  the  amounts  due  from  the  local  district  are
  recovered in full plus any interest that would have otherwise accrued to
  the  fund had such fund had sufficient balances from the local district.
  Upon determination by the state comptroller that insufficient sources of
  payment are available to  fully  liquidate  the  local  social  services
  district  share  of  medical  assistance  payments,  the commissioner of
  health shall include in such schedule a charge to the  county  equal  to
  the amount of interest otherwise earned by the state short-term interest
  pool,  plus  any  interest  penalty  as  the  commissioner of health may
  determine, until such time as the  district  has  fully  liquidated  its
  liability pursuant to the provisions of this chapter.