N.Y. Public Health Law Section 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 44 (Health Maintenance Organizations)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through June thirtieth, nineteen hundred ninety-nine; provided, however, that this section shall expire and be deemed repealed on and after the date on which New York state is granted the authority, by federal waiver, agreed upon by the state and the secretary of the federal department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 Tax Law § 1096 (General powers of tax commission)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 § 2807-C (General hospital inpatient reimbursement for annual rate periods beginning on or after January first, nineteen hundred eighty-eight)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.

Source: Section 2807-F — Health maintenance organization payment factor, https://www.­nysenate.­gov/legislation/laws/PBH/2807-F (updated Sep. 22, 2014; accessed Apr. 13, 2024).

2800
Declaration of policy and statement of purpose 2801
Definitions 2801–A
Establishment or incorporation of hospitals 2801–B
Improper practices in hospital staff appointments and extension of professional privileges prohibited 2801–C
Injunctions 2801–D
Private actions by patients of residential health care facilities 2801–E
Voluntary residential health care facility rightsizing demonstration program 2801–F
Residential health care facility quality incentive payment program 2801–G
Community forum on hospital closure 2801–H
Personal caregiving and compassionate caregiving visitors to nursing home residents during declared local or state health emergencies 2802
Approval of construction 2802–A
Transitional care unit demonstration program 2802–B
Health equity impact assessments 2803
Commissioner and council 2803–A
Authority to contract 2803–AA
Sickle cell disease information distribution 2803–AA*2
Nursing home infection control competency audit 2803–B
Uniform reports and accounting systems for hospital costs 2803–C
Rights of patients in certain medical facilities 2803–C–1
Rights of patients in certain medical facilities 2803–C–2
Lesbian, gay, bisexual and transgender, and people living with HIV long-term care facility residents’ bill of rights 2803–D
Reporting abuses of persons receiving care or services in residential health care facilities 2803–E
Residential health care facilities 2803–E*2
Reporting incidents of possible professional misconduct 2803–F
Respite projects 2803–G
Board of visitors in county owned residential health care facility 2803–H
Health related facility 2803–I
General hospital inpatient discharge review program 2803–J
Information for maternity patients 2803–J*2
Nursing home nurse aide registry 2803–K
In-patient nasogastric feeding procedures 2803–L
Community service plans 2803–M
Discharge of hospital patients to adult homes 2803–N
Hospital care for maternity patients 2803–O
Hospital care for mastectomy, lumpectomy, and lymph node dissection patients 2803–O–1
Required protocols for fetal demise 2803–P
Disclosure of information concerning family violence 2803–Q
Family councils in residential health care facilities 2803–R
Dissemination of information about the abandoned infant protection act 2803–S
Access to product recall information 2803–T
Preadmission information 2803–U
Hospital substance use disorder policies and procedures 2803–V
Lymphedema information distribution 2803–V*2
Standing orders for newborn care in a hospital 2803–W
Independent quality monitors for residential health care facilities 2803–W*2
Disclosure of information concerning pregnancy complications 2803–X
Requirements related to nursing homes and related assets and operations 2803–Y
Provision of residency agreement 2803–Z
Transfer, discharge and voluntary discharge requirements for residential health care facilities 2803–Z*2
Antimicrobial resistance prevention and education 2804
Units for hospital and health-related affairs 2804–A
State task force on clinical practice guidelines and medical technology assessment 2805
Approval of hospitals 2805–A
Disclosure of financial transactions 2805–B
Admission of patients and emergency treatment of nonadmitted patients 2805–C
Every private proprietary nursing home having a capacity of eighty patients or more may have a licensed medical doctor in attendance, upo... 2805–D
Limitation of medical, dental or podiatric malpractice action based on lack of informed consent 2805–E
Reports of residential health care facilities 2805–F
Money deposited or advanced for admittance to nursing homes 2805–G
Maintenance of records 2805–H
Immunizations 2805–I
Treatment of sexual offense victims and maintenance of evidence in a sexual offense 2805–J
Medical, dental and podiatric malpractice prevention program 2805–K
Investigations prior to granting or renewing privileges 2805–L
Adverse event reporting 2805–M
Confidentiality 2805–N
Child abuse prevention 2805–O
Identification of veterans and their spouses by nursing homes, residential health care facilities, and adult care facilities 2805–P
Emergency treatment of rape survivors 2805–Q
Hospital visitation by domestic partner 2805–R
Patients unable to verbally communicate 2805–S
Circulating nurse required 2805–T
Clinical staffing committees and disclosure of nursing quality indicators 2805–U
Credentialing and privileging of health care practitioners providing telemedicine services 2805–V
Observation services 2805–W
Patient notice of observation services 2805–X
Hospital-home care-physician collaboration program 2805–Y
Identification and assessment of human trafficking victims 2805–Z
Hospital domestic violence policies and procedures 2806
Hospital operating certificates 2806–A
Temporary operator 2806–B
Residential health care facilities 2807
Hospital reimbursement provisions 2807–A
General hospital nineteen hundred eighty-six and nineteen hundred eighty-seven inpatient rates and charges 2807–AA
Nurse loan repayment program 2807–B
Outstanding payments and reports due under subdivision eighteen of section twenty-eight hundred seven-c, sections twenty-eight hundred se... 2807–C
General hospital inpatient reimbursement for annual rate periods beginning on or after January first, nineteen hundred eighty-eight 2807–D
Hospital assessments 2807–D–1
Hospital quality contributions 2807–DD
Temporary nursing home stability contributions 2807–E
Uniform bills 2807–F
Health maintenance organization payment factor 2807–I
Service and quality improvement grants 2807–J
Patient services payments 2807–K
General hospital indigent care pool 2807–L
Health care initiatives pool distributions 2807–M
Distribution of the professional education pools 2807–N
Palliative care education and training 2807–O
Early intervention services pool 2807–P
Comprehensive diagnostic and treatment centers indigent care program 2807–R
Funding for expansion of cancer services 2807–S
Professional education pool funding 2807–T
Assessments on covered lives 2807–U
Transfers for tax credits 2807–V
Tobacco control and insurance initiatives pool distributions 2807–W
High need indigent care adjustment pool 2807–X
Grants for long term care demonstration projects 2807–Y
Pool administration 2807–Z
Review of eligible federally qualified health center capital projects 2808
Residential health care facilities 2808–A
Liability of certain persons 2808–B
Certification of financial statements and financial information 2808–C
Reimbursement of general hospital inpatient services 2808–D
Nursing home quality improvement demonstration program 2808–E
Residential health care for children with medical fragility in transition to young adults and young adults with medical fragility demonst... 2808–E*2
Nursing home ratings 2809
Residential health care facilities 2810
Residential health care facilities 2811
Discounts and splitting fees with medical referral services 2812
Construction 2813
Separability 2814
Health networks, global budgeting, and health care demonstrations 2815
Health facility restructuring program 2815–A
Community health care revolving capital fund 2816
Statewide planning and research cooperative system 2816–A
Cardiac services information 2817
Community health centers capital program 2818
Health care efficiency and affordability law of New Yorkers (HEAL NY) capital grant program 2819
Hospital acquired infection reporting 2820
Home based primary care for the elderly demonstration project 2821
State electronic health records (EHR) loan program 2822
Residential care off-site facility demonstration project 2823
Supportive housing development program 2824
Central service technicians 2824*2
Surgical technology and surgical technologists 2825
Capital restructuring financing program 2825–A
Health care facility transformation program: Kings county project 2825–B
Oneida county health care facility transformation program: Oneida county project 2825–C
Essential health care provider support program 2825–D
Health care facility transformation program: statewide 2825–E
Health care facility transformation program: statewide II 2825–F
Health care facility transformation program: statewide III 2825–G
Health care facility transformation program: statewide IV 2825–H
Health care facility transformation program: statewide V 2826
Temporary adjustment to reimbursement rates 2827
Plant-based food options 2828
Residential health care facilities 2828*2
Essential support persons allowed for individuals with disabilities during a state of emergency 2829
Nursing homes 2830
Surgical smoke evacuation 2830*2
Regulation of the billing of facility fees
Green check means up to date. Up to date

Accessed:
Apr. 13, 2024

Last modified:
Sep. 22, 2014

§ 2807-F’s source at nysenate​.gov

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