Applicability; Definitions; Assurance of access to care; Disclosure and filing; Relationship between an MCO and an IPA
This entire entry falls under “Risk-Physicians Taking.” See the bold text below to find sections falling under additional categories.
Section 98-1.1. Applicability
This Subpart shall be applicable to all persons who propose to establish and/or operate a health maintenance organization (HMO), special purpose health maintenance organization, also known as a prepaid health services plan (PHSP), comprehensive HIV special needs plan (HIV SNP) or, as specified, a primary care partial capitation provider (PCPCP) or managed long term care plan (MLTCP) or who currently operate an HMO, PHSP, HIV SNP or, as specified, a PCPCP or MLTCP certified under article 44 of the Public Health Law within the State of New York, which may hereinafter be referred to individually or collectively as managed care organization (MCOs).
Section 98-1.2. Definitions
The following words or terms when used in this Subpart shall have the following meanings:
(a) Admitted assets means assets recognized and accepted by the State Insurance Department under article 13 of the Insurance Law in determining the solvency of insurors. Admitted assets shall be the sole basis for determining compliance with any applicable financial requirement or quantitative limitation imposed upon an MCO, as further specified in Insurance Department Regulation 172 (11 NYCRR Part 83).
(b) Article 44 service area means the geographic area, defined by counties or other geographic subdivisions, identified in the application for a certificate of authority to operate an MCO for which there is identified a provider network capable of providing comprehensive health services of sufficient availability and accessibility to the projected enrolled population within the meaning of article 44 of the Public Health Law and this Subpart, as approved by the commissioner. Enrollment within the article 44 service area must be offered to any eligible persons who work or reside within the service area, except that for MLTCPs and, for programs authorized by title XIX, enrollment may be offered only to eligible persons who reside within the service area.
(c) Capitation means a payment made on a per enrollee basis.
(d) Care management within an MLTCP means a process which assists enrollees with establishing a written care plan and accessing necessary covered services. It also provides referral to and coordination of other medical, social, educational, psychosocial, financial and other services in support of the care plan irrespective of whether such services are covered by the plan.
(e) Commissioner means the Commissioner of Health of the State of New York.
(f) Community rating means a rating methodology in which the premium for all persons covered by a policy or contract form is the same based on the experience of the entire pool of risks covered by that policy or contract form without regard to age, sex, health status or occupation. Refunds, rebates, credits or dividends based on such factors are also prohibited.
(g) Comprehensive health services means:
(1) for HMOs and PHSPs, all those health services which an enrolled population might require in order to be maintained in good health, and shall include, but shall not be limited to, physician and other provider services (including consultant and referral services), inpatient and outpatient hospital services, diagnostic laboratory and therapeutic and diagnostic radiologic services, and emergency and preventive health services, including providing HIV counseling and recommending voluntary HIV testing to pregnant women, which counseling and testing shall be conducted pursuant to Public Health Law, article 27-F, referring HIV positive persons for necessary, clinically appropriate services, and services required to be covered under article 43 of the Insurance Law;
(2) for MLTCPs, health and long-term care services, including but not limited to, primary care, acute care, home and community based and institution based long-term care and ancillary services that are necessary to meet the needs of persons whom the plan is authorized to serve. However, consistent with the provisions of section 4403-f of the Public Health Law, while an MLTCP may provide less than comprehensive services, it remains subject to the provisions of this Subpart;
(3) for PCPCPs, comprehensive primary and preventive care and case management of inpatient, emergency room and specialty services; and
(4) for HIV SNPs, all those health and supportive services provided as necessary to meet the specialized needs of the persons whom the plan is authorized to serve by providers with appropriate training and experience in the care, treatment and prevention of HIV/AIDS, as determined by the commissioner. These comprehensive services include, but are not limited to, those described in paragraph (1) of this subdivision, those set forth in subdivision (8) of section 4403-c of the Public Health Law and the following: primary care services by a qualified HIV specialist; HIV primary and secondary prevention and risk reduction services; treatment adherence services; HIV SNP case management; and access and referral to community health and social service providers that support members’ ability to sustain wellness and adhere to treatment regimes. Such term may also be further defined by agreement with enrolled populations to provide for additional benefits necessary, desirable or appropriate to meet their health care needs.
(h) Comprehensive health services plan or plan means a plan through which each member of an enrolled population is entitled to receive comprehensive health services in consideration for a basic advance or periodic charge.
(i) Comprehensive HIV special needs plan or HIV SNP means an MCO certified pursuant to section 4403-c of article 44 of the Public Health Law which provides or arranges for the provision of comprehensive health and supportive services and specialized HIV care to HIV positive persons and their related children up to the age of 19, as defined in the HIV SNP contract with a local social services district (LDSS) or the commissioner, who are eligible to receive benefits under title XIX or other public programs.
(j) Control, which shall be synonymous with the terms controlling, controlled by and under common control with, means the possession, directly or indirectly, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities or voting rights, by contract (except a commercial contract for goods or nonmanagement services) or otherwise; but no person shall be deemed to control another person solely by reason of his or her being an officer or director of such other person. Control shall be presumed to exist if any person directly or indirectly owns, controls or holds the power to vote 10 percent or more of the voting securities or voting rights of any other person, or is a corporate member of a not-for-profit corporation.
(k) Controlled MCO means any proposed or certified MCO that is controlled directly or indirectly by a holding company.
(l) Controlled person means any person, other than a controlled MCO, that is controlled directly or indirectly by a holding company.
(m) Department means the Department of Health of the State of New York.
(n) Enrolled population means a group of persons which receives comprehensive health services from an MCO in consideration for a basic advance or periodic charge. An enrolled population is composed of enrollees who are entitled by contract to receive comprehensive health services from the MCO. Except for HMOs, MCOs may only enroll certain populations as authorized in the Public Health Law.
(o) Enrollee means an individual who has entered into a contractual relationship with the MCO, or an individual on whose behalf a contractual arrangement has been entered into with the MCO, under which the MCO assumes the responsibility for the provision to the individual of comprehensive health services.
(p) Enrollment means the act of an individual signing a contract, or having someone sign it on his or her behalf, which obligates the MCO to provide comprehensive health services, and which obligates the individual enrolling, or someone on his or her behalf, to pay a periodic premium or fee for all covered services. A signature may be made electronically to the extent permitted by applicable law and regulation.
(q) Governing authority of the MCO means the policymaking body that is responsible for the operation of an MCO, including:
(1) the policymaking body of a public MCO;
(2) the board of directors or trustees of a corporation;
(3) partners of a partnership operating an MCO;
(4) the owners of a proprietary business operating an MCO; and
(5) the members, or managers who are also members of a limited liability company. Managers who are not members of a limited liability company participate in the management of an MCO pursuant to the provisions of section 98-1.11 of this Subpart governing management contracts, and in no way comprise the governing authority.
(r) Health Maintenance Organization or HMO means any person, natural or corporate, or any groups of such persons who enter into an arrangement, agreement or plan, or any combination of arrangements or plans, which proposes to provide or offer, or which does provide or offer, a comprehensive health services plan to individuals and groups.
(s) HIV SNP case management means a process which includes clinical coordination and medical/clinical case management in consultation with the PCP, service utilization monitoring, assessment and service plan development that address identified patient needs, case manager involvement in quality assurance and quality improvement and non-intensive HIV psychosocial case management as defined by the department.
(t) HIV specialist primary care provider or HIV specialist PCP means a primary care provider who meets the qualifications for HIV Specialist as defined by the Medical Care Criteria Committee of the department’s AIDS Institute.
(u) Holding company means any person who directly or indirectly controls any proposed or certified MCO.
(v) Holding company system means a holding company together with a controlled MCO and/or controlled persons.
(w) Independent Practice Association or IPA means a corporation, limited liability company, or professional services limited liability company, other than a corporation or limited liability company established pursuant to articles 28, 36, 40, 44 or 47 of the Public Health Law, which contracts directly with providers of medical or medically related services or another IPA in order that it may then contract with one or more MCOs and/or workers’ compensation preferred provider organizations to make the services of such providers available to the enrollees of an MCO and/or to injured workers participating in a workers’ compensation preferred provider arrangement. An IPA may also be considered a provider within the meaning of section 4403 (1)(c) of the Public Health law, but only for the purpose of and to the extent it shares risk with an MCO and/or the IPA’s contracting providers, and shall be considered a provider for the purposes of paragraphs (1) and (2) of subdivision (a) of Section 98-1.21 of this Subpart. An IPA may be certified as an Accountable Care Organization pursuant to Article 29-E of the Public Health Law and Part 1003 of this title, and upon obtaining a certificate of authority may contract with third party health care payers defined in section 1003.2(x) of this title. To the extent allowed under New York’s Partnership Plan section 1115(a) Medicaid Demonstration extension, as amended April 14, 2014, an IPA may participate in a Performing Provider System (“PPS”) established as part of a Delivery System Reform Incentive Payment (“DSRIP”) Program project.
(x) Managed care organization or MCO means an HMO, PHSP, HIV SNP and, where specified in this Subpart, PCPCP and MLTCP. An HIV SNP may be an entity that is independently incorporated and certified to operate an HIV SNP or an incorporated and certified MCO that is issued a separate certificate of authority to operate the HIV SNP.
(y) Managed long term care plan or MLTCP means an entity that has received a certificate of authority pursuant to section 4403-f of the Public Health Law to provide or arrange for health and long term care services on a capitated basis for a population which the plan is authorized to enroll.
(z) Management contractor means any person, other than staff employed by the MCO, entering into an agreement with the governing authority of an MCO for the purpose of managing the day-to-day operations of the MCO.
(aa) Material change to a contract between an MCO and a provider or an IPA, other than a management contract, means:
(1) any change to a required contract provision or appendix as per contract guidelines issued by the commissioner;
(2) any change to or addition of a risk sharing arrangement, other than the routine trending of fees or other reimbursement amounts;
(3) any proposed addition of an exclusivity, most favored nation or non-compete clause;
(4) any proposed subcontracting of the existing contractual obligations of an IPA;
(5) any proposed subcontracting of the statutory or regulatory responsibilities of an MCO, and
(6) any proposed revocation of an approved delegation as set forth in paragraphs (4) and (5) of this subdivision.
(bb) Medical director, other than the medical director of a utilization review agent as defined in section 4900 of the Public Health Law who shall be licensed by at least one of the United States, means a New York State-licensed physician whose responsibilities include, but are not limited to, the supervision of the quality assurance and improvement and utilization review programs and advising the governing authority on the adoption and enforcement of policies concerning medical services.
(cc) Net premium income means the gross amount of revenue derived from premiums less any returned premium.
(dd) Person means an individual, partnership, corporation, any other legal entity, including a joint venture, or any combination of the foregoing acting in concert.
(ee) Premium means the amount of money the MCO charges each enrollee or payer for the specified benefit package.
(ff) Prepaid health services plan or PHSP means a provider, including a not-for-profit corporation established to operate a hospital pursuant to article 28 of the Public Health Law, a government agency or an entity or group of entities, other than a shared health facility, seeking to provide comprehensive health care services which has received a special purpose certificate of authority pursuant to section 4403-a of the Public Health Law to deliver comprehensive health care services on a prepaid contractual basis either directly, or through an arrangement, agreement or plan or combination thereof to an enrolled population which is substantially composed of persons eligible to receive benefits under title XIX or other public programs.
(gg) Primary care partial capitation provider or PCPCP means a qualified individual medical services provider or a county or entity comprised of medical services providers offering comprehensive primary and preventive care and case management of inpatient, emergency room and specialty services to persons eligible to receive benefits under title XIX and to enroll in managed care plans.
(hh) Primary care practitioner or PCP means a physician or other licensed provider who supervises, coordinates and provides initial and basic care to enrollees and maintains continuity of care for enrollees.
(ii) Referral means the internal mechanism utilized by the MCO to allow members to access needed services.
(jj) Reinsurance means a transaction whereby the reinsuror, for a consideration, agrees to indemnify the MCO, or other provider, against all or part of the loss which the latter may sustain under the subscriber contracts which it has issued.
(kk) Risk-sharing means the contractual assumption of liability by the health care provider or IPA by means of a capitation arrangement or other mechanism whereby the provider or IPA assumes financial risk from the MCO for the delivery of specified health care services to enrollees of the MCO.
(ll) Superintendent means the Superintendent of Insurance of the State of New York.
(mm) Title XIX, as referenced in this Subpart, means any federally authorized Medicaid program under such title of the Social Security Act and any programs authorized by State law that cover the Medicaid population, specifically, titles 11 and 11-D of article 5 of the Social Services Law.
(nn) Title XXI, as referenced in this Subpart, means any federally authorized Child Health Insurance Program under such title of the Social Security Act and any programs authorized by State law that cover the State’s Child Health Plus population, specifically, title I-A of article 25 of the Public Health Law.
(oo) Transitional period shall for the purposes of subparagraph (i) of paragraph (e)(1) of subdivision (6) of section 4403 of the Public Health Law mean a period commencing on the date a provider’s contractual obligation to provide services to an MCO’s enrollees terminates and ending no more than 90 days thereafter.
(pp) HARP (Health and Recovery Plan) means a line of business operated by an MCO to administer the full continuum of mental health, substance use disorder, and physical health services covered under the Medicaid State Plan as well as the enhanced Home and Community Based Services benefits (1915 (i)) for adults with serious mental illness (SMI) and/or Substance Use Disorders (SUDs) who meet eligibility requirements.
Section 98-1.13 – Assurance of access to care
(a) All covered services must be directly provided or arranged for within the approved provider network pursuant to written contracts developed and maintained in a form and manner prescribed by the commissioner, except that when services are unavailable within the provider network, such services must be arranged for outside of the approved provider network. An MCO shall establish a process for the resolution of requests for medically necessary services to be provided by out-of-network providers when such services are not available in network. Such process shall require the approval of the commissioner prior to implementation and shall thereupon be included in the member handbook. Emergency services do not require prior authorization; no MCO or utilization review agent may require enrollees to obtain prior authorization for the provision of such services.
(b) The limitation in subdivision (a) of this section, and other limitations imposed on accessing the entire approved network, must be clearly transmitted to eligible persons and enrollees via marketing materials, member handbooks and subscriber contracts.
(c)
(3) All provider contracts assigned by an MCO or an IPA prior to, and which remain in effect following, the effective date hereof shall be amended within one year of such effective date or upon renewal, whichever first occurs, to achieve compliance with the provisions of this subpart and guidelines for provider and IPA contracts established by the commissioner.
(d) An MCO which provides primary care services shall make available to each enrollee a primary care practitioner to supervise and coordinate the health care of the enrollee. In the case of an HIV SNP, the primary care practitioners for enrollees with HIV infection must meet HIV specialist requirements as defined by the commissioner; the qualifications of HIV specialist primary care practitioners shall be reassessed annually to assure the requirements for HIV specialist status are met. The HIV SNP member-to-primary care practitioner ratios shall be developed to reflect HIV SNP patient caseload characteristics as prescribed by the commissioner. When required by Federal and/or State law or regulation, an enrollee of an MCO who is dissatisfied with the assigned or selected primary care practitioner shall be allowed to select another. However, the MCO may impose a reasonable waiting period to accomplish this transfer. Waiting times for enrollees eligible for benefits under title XIX shall be consistent with section 364-j of the Social Services Law.
(e) The HIV SNP shall ensure all enrollees access to a full continuum of HIV- specific care, treatment and prevention through:
(3) access to health and social services providers that support members’ ability to sustain wellness and to adhere to treatment regimens;
(4) development and implementation of written agreements with community based social services providers to facilitate enrollee access to the full continuum of services needed by HIV-infected individuals, including access to care for vulnerable populations, such as those who are homeless, substance users or others; and
(5) mechanisms for monitoring referrals to care, treatment and supportive services and for documenting the outcome of the referral process for enrollees referred to organizations with which the HIV SNP is affiliated through a linkage agreement or memorandum of understanding.
(f) The MLTCP shall assure that all covered services are available and accessible by:
(3) making care management and health care services available 24 hours a day, seven days a week.
(g) The MLTCP shall promote continuity of care and integration of services through:
(3) systematic and timely communication of clinical information among providers and maintenance of a care management record. Such records, which shall be retained for six years after the date of service rendered to enrollees, shall include but shall not be limited to:
(iii) medical orders, as applicable;
(iv) documentation of non-covered services arranged and coordinated by the plan;
(v) advance directives;
(vi) signed enrollment agreement and disenrollment agreement; and
(vii) contacts with enrollees and their representatives, providers of covered and non- covered services, physicians, local social service districts and other agencies or facilities with whom the plan coordinates services.
(h) The MCO, or the primary care practitioner on behalf of the MCO, shall be responsible for the management of care for enrollees, including the identification and selection of an appropriate provider of care in each individual instance where services are determined to be necessary for the enrollee. An MCO shall provide, or make arrangements for the provision of the full range of comprehensive health services as defined in section 98-1.2(g) of this Subpart and as covered in the approved benefit package to enrollees. MCOs shall provide such comprehensive health services without exclusion of any appropriately registered, certified or licensed type of provider as a class from participation in such MCO.
(i) When an enrollee is referred by an MCO or by an MCO primary care practitioner or MCO provider authorized by the MCO to make such referrals to a participating or nonparticipating specialist for services included in the enrollee contract with such MCO, the enrollee shall incur no financial liability other than required co-payments.
(j) An MCO shall have a written procedure describing coverage for emergency health services received by an enrollee outside of the MCO’s service area. The MCO coverage for emergency health services shall be consistent with article 49 of the Public Health Law and, in the case of an entity providing services to Medicare beneficiaries, consistent with Federal law and regulation, and clearly described in both the enrollee contract and the enrollee handbook.
(k) Medical offices and premises not subject to the jurisdiction of article 28 of the Public Health Law, in which primary ambulatory care services are provided to MCO enrollees, shall conform to professional and generally accepted standards of medical practice.
(l) The MCO shall establish procedures to obtain consent from each enrollee for release of such enrollee’s medical records to ensure that it has access to the medical records of enrollees upon request for review by the MCO and the department for the purposes authorized by law. This shall be assured through an explicit provision in the contracts between the MCO and providers, the MCO and an IPA, and an IPA and providers.
(m) MCOs shall require that network providers comply with all HIV confidentiality requirements pursuant to title 27-F and section 2784 of the Public Health Law, through express provision in contracts with providers and express reference in provider manuals. An HIV SNP shall establish procedures for assuring the confidentiality of medical information of all enrolled HIV-infected individuals, including mechanisms to address breaches of confidentiality and a training program for all HIV SNP employees regarding confidentiality and disclosure of HIV-related information.
Retroactive Denial
(n) Utilization review program standards for retrospective review of a pre-authorized treatment, service, or procedure. An MCO may reverse a pre-authorized treatment, service or procedure on retrospective review pursuant to section 4905 (5) of the Public Health Law only when:
(3) the MCO or utilization review agent was not aware of the existence of the information at the time of the pre-authorization review; and
(4) had the MCO or utilization review agent been aware of the information, the treatment, service, or procedure being requested would not have been authorized. This determination is to be made using the same specific standards, criteria or procedures as used during the pre-authorization review.
(o) An MCO shall have written procedures for the implementation of the transitional period provisions set forth in sections 4403 (6)(e) and (f) and 4408 (4) of the Public Health Law.
Section 98-1.16. Disclosure and filing
(a) Every MCO, other than a PHSP that only serves enrollees eligible for benefits under title XIX, HIV SNPs and PCPCPs, shall file in duplicate with both the commissioner and the superintendent a financial statement on or before April 1st of each year, in the form and containing such information as the commissioner and the superintendent shall prescribe, showing its condition at last year-end and containing information required by section 4408 of the Public Health Law and the following information:
(3) an analysis of utilization of services, including all services covered by the MCO.
(b) MCOs that serve enrollees eligible for benefits under title XIX shall file annual financial statements with the commissioner on or before April 1st of each year which shall be in such format and contain such information as prescribed by the commissioner.
(c) every MCO shall submit annual financial statements together with an opinion of an independent certified public accountant of the financial statement of such MCO, and an evaluation by such accountant of the accounting procedures and internal control systems of the MCO, by April 1 of each year, pursuant to Subpart 98-3.
(d) Every MCO shall make available to the general public and its enrollees those items set forth in paragraph (a)(1) of this section, and a summary of those items set forth in paragraphs (a)(2) and (3) of this section.
(e) Every controlled MCO shall file with the commissioner such reports or material as the commissioner, with the advice of the superintendent, may direct for the purpose of disclosing information on the operations within the holding company system which materially affect the operations, management or financial condition of the MCO.
(f) Every MCO, other than a PHSP that only serves enrollees eligible for benefits under title XIX, HIV SNPs and PCPCPs, shall file quarterly statements in duplicate with both the superintendent and commissioner, in the form and containing matters as the commissioner, with the advice of the superintendent, shall prescribe not later than 45 days after the end of each quarter.
(g) MCOs that serve enrollees eligible for benefits under title XIX shall file quarterly statements with the commissioner, in such format and containing such information as prescribed by the commissioner, not later than 45 days after the end of each quarter.
(h) In the event an MCO does not provide substantially complete reports or other information required under this Subpart by the due date, or provide requested information within 30 days of any written request for a specific analysis or report by the superintendent or commissioner, the superintendent or commissioner is authorized to levy a civil penalty, after notice and hearing, pursuant to section 12 of the Public Health Law or sections 307 and 308 of the Insurance Law.
Directories
(i) Every MCO shall maintain and update, on a quarterly basis, a listing by specialty of the names, addresses and telephone numbers of all participating providers, including facilities, and in the case of physicians, board certification. Where the MCO contracts with behavioral health facilities rather than directly with behavioral health providers, the provider types available at the facilities must be included in the listing. Members must be notified of updates in writing at least annually in one of the following methods: provide updates in hardcopy; provide a new full listing/directory in hardcopy; provide written notification that a new full listing/directory is available and will be mailed in hardcopy or electronically upon request. New members, and upon request, current and potential members must receive the most current full listing in hardcopy, or electronically at the request of the member or potential member, along with any updates to such listing.
(j) No later than 20 business days after the beginning of each calendar year, every MCO shall submit provider network information in an electronic format and including such information as prescribed by the commissioner. Such information shall reflect all signed and implemented contracts in effect as of the first day of such calendar year for all providers and service centers participating in the MCO’s network. In addition, a notarized statement attesting to the accuracy of the electronic provider network information submission shall be required. Any modifications or updates to the provider network information must be communicated to the enrolled population, and upon request to potential enrollees, as prescribed in subdivision (i) of this section. Those MCOs that serve enrollees eligible for benefits under title XIX shall submit provider network information in an electronic format and including such information as prescribed by the commissioner no later than 15 business days after the end of each quarter.
(k) In order to serve enrollees eligible for benefits under title XIX, an MCO must submit a plan for compliance with the Federal Americans with Disabilities Act (ADA). Such ADA compliance plan shall be submitted in a form and manner as prescribed by the commissioner.
(l) An MLTCP shall submit data to the commissioner annually or at such other times as requested and in such manner and form as prescribed by the commissioner regarding enrollee characteristics, utilization of services, enrollments, disenrollments, complaints and grievances and other information deemed necessary to monitor plan operations and care management.
Section 98-1.18. Relationship between an MCO and an IPA
(a) An MCO shall be responsible for its agreements with an IPA, for the agreements between the IPA and other IPAs, physicians and other health care providers and suppliers and for the care provided through such arrangements to the same extent as it is responsible for arrangements with all other types of health care providers.
(b) The requirements of article 44 of the Public Health Law and this Subpart shall apply to an IPA and all physicians, other IPAs, health care providers and suppliers contracting with an IPA to the same extent they apply to all other health care providers participating with an MCO in a comprehensive health services plan.
(c) Nothing in this Part shall prohibit an IPA from employing providers or other persons to provide review of medical care utilization patterns, quality of care issues, or other program review functions on behalf of its panel of contracted participating providers, even though such providers may also have contracted with the IPA as an independent member or participating provider.
(d) An MCO contracting with an IPA shall require that the financial records of the IPA shall account in detail for all funds received from the MCO, including, where applicable, fees for services performed by the IPA, and for the disbursement of all such funds.
(e) An MCO proposing a risk sharing arrangement with an IPA may not enter into any such arrangement without first obtaining approval from the commissioner or superintendent, as appropriate, in accordance with guidelines issued by the commissioner in accordance with section 98-1.5(b)(6)(v) of this Subpart or the superintendent in accordance with Regulation 164. To obtain the commissioner’s approval, the MCO shall provide to the satisfaction of the commissioner the following:
(iii) the parties agree that all provider contracts shall contain a clause providing that the provider shall not, in the event of default by the IPA, demand payment from the MCO for any covered services rendered to the MCO’s enrollees for which payment was made by the MCO to the IPA pursuant to the financial risk sharing agreement;
(3) in the event that the MCO contracts with the IPA to delegate management functions, a contract which complies with all the requirements of this Subpart;
(4) such information concerning the financial condition of the IPA and any providers participating in a risk sharing arrangement as the commissioner may require to make a determination, including information demonstrating that the IPA and any providers sharing risk with the IPA are financially responsible and capable of assuming such risk and have satisfactory insurance, reserves or other arrangements to support an expectation that they will meet their obligations to MCOs, providers and enrollees; and
Prohibited financial incentives
(5) a demonstration by the MCO and the IPA, to the commissioner’s satisfaction, that the elements of a proposed arrangement will not constitute improper incentives to providers, in accordance with physician incentive plan guidelines, and will not result in a deterioration in access to or the quality of care provided to an MCO’s enrollees.
(f) The commissioner may assess fines against an MCO in accordance with section 12 of the Public Health Law after a hearing and finding of a violation, by an MCO and/or IPA and/or the physicians and any other health care providers and suppliers contracting with an IPA, of this Subpart and articles 28 and 44 and title I of article 49 of the Public Health Law.