2010 New York Code
PBH - Public Health
Article 28 - (2800 - 2822) HOSPITALS
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  section shall expire and be deemed repealed on and  after  the  date  on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.