Information for Health Plans

Managed Care Organizations (MCO) are required to establish a mental health and substance use disorder parity compliance program pursuant to 10 NYCRR Subpart 98-4. This regulation sets forth the requirements of such programs. The regulation further requires MCOs to submit a written certification to the Commissioner, certifying that the MCO satisfactorily meets the requirements of the regulation. The certification is required to be submitted by December 31, 2021 and annually thereafter.

The Parity Compliance Program Certification form was jointly developed by the Department of Financial Services and the Department of Health requires all MCOs subject to the regulation to use this form to certify that all requirements of the regulation have been met.

The completed certification form, and any questions are to be sent to the mailbox at BHParity@health.ny.gov

Health plans seeking certification as a New York State Managed Care Organization (MCO) for the sole purpose of providing health care coverage as a federal Medicare Advantage plan, will complete the NYS MCO Certification Application - Medicare Only (PDF)

Important dates for the Medicare Advantage* coordination only line of business.

This section does not apply to Medicare Advantage D-SNP associated with the Medicaid Advantage Plus (MAP) line of business or the Integrated Benefit-Dual (IB-Dual) program for Medicaid Managed Care and HARP.

*As per the State Medicaid Agency Contract (SMAC) applications for new Medicare Advantage coordination only D-SNP will not be accepted. Health Plans that currently offer a Medicare Advantage coordination only D-SNP may continue to provide such option, however, the Medicare Advantage coordination only D-SNP may not further expand into new service area counties.

Application Type DOH Due Date CMS Due Date Medicare
Coverage
Year
New Medicare Advantage only line of business
(New MCO Applicant)
February 28, 2023 Mid-February 2024 2025
New Medicare Advantage only line of business
(Existing MCO)
July 1, 2023 Mid-February 2024 2025
Service Area Expansion
(SAE)
November 1, 2023 Mid-February 2024 2025
New Medicare Advantage only line of business
(New MCO Applicant)
February 1, 2024 Mid-February 2025 2026
New Medicare Advantage only line of business
(Existing MCO)
July 1, 2024 Mid-February 2025 2026
Service Area Expansion (SAE) November 1, 2024 Mid-February 2025 2026
  • Guidelines - (Web) - (PDF) - Updated 11.16.2022
  • Template - (PDF) - (Word) - Updated 11.16.2022
  • Person Centered Service Planning Home and Community Based Services Final Rule Implementation Webinar - (YouTube).
  • Medicaid Managed Care Exclusion Exemption Chart - (Web) - (PDF) - 1.29.2024
  • MMC Guidance:
    • Process for Expedited Request for Assessment and the New York Independent Assessor (NYIA) - (Web) - (PDF) - 11.23.2022
    • ADDITIONAL REVISION Implementation Date for New York Independent Assessor (NYIA) to Conduct Assessments for Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) on an Expedited Basis - (Web) - (PDF) - 8.30.2022
    • REVISED Implementation Date for New York Independent Assessor (NYIA) to Conduct Assessments for Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) on an Expedited Basis - (Web) - (PDF) - 6.17.2022
    • Implementation of the New York Independent Assessor for Initial Assessments - (Web) - (PDF) - 4.28.2022
  • Article 44 MCO Sepsis Guidance - (Web) - (PDF) - 7.15.2019
  • Criteria Standards for the Authorization and Utilization Management of Treatment for Gender Dysphoria - (Web) - (PDF)
  • Criteria Standards for the Authorization and Utilization Management of Harm Reduction Services - (Web) - (PDF)
  • Service Authorization and Appeals for Mainstream Medicaid Managed Care Plans, HARP, and HIV SNP - (Web)
  • Implementation of 42 CFR 438 Pharmacy Provisions
    • CMS Medicaid Managed Care Final Rule:
  • HMO and IPA provider contracts - (Web)
  • Management Contract Guidelines for MCOs and IPAs - (Web)
    • Standard Clauses for Management Service Agreements - (Web) - (PDF) - 5.4.2011
    • Management Contract Statement and Certification (DOH-5038) (PDF) - September 2011
  • New York State Medicaid Perinatal Care Standards - (Web)
  • Medicaid Managed Care Model Member Handbook - (Web) - (PDF) - Revised January 2009
  • Medicaid Managed Care Guidance and Application to Offer Cost-effective Alternative Services (In Lieu of) - (Web) - (PDF) - Revised 11.9.2023
    • Updates to In Lieu of Services or Setting (ILS) Application Process and Guidance - (Web) - (PDF) - 11.9.2023
    • State Identified ILS MTM Reporting Template - (XLSX) - Updated 11.15.2022
    • State Identified ILS-MTM Presentation - (Web) - (PDF) - 7.3.2023
    • State Identified ILS-MTM Application - (PDF) - 11.16.2023
    • State Identified Request Form for In Lieu of Services in an Institute for Mental Disease - (Web) - (PDF)
    • State Identified ILS IMD Presentation - (Web) - (PDF) - 9.19.2019
  • Medicaid Managed Care Organizations Guidance for Telehealth Innovation Plans - (Web) - (PDF) - September 2017
    • Telehealth Innovations and 2018 Quality Incentive - (Web) - (PDF) - 12.17.2018
    • Announcing Medicaid Managed Care Telehealth Innovation - (Web) - (PDF) - 9.18.2017
  • Cultural Competency Completion - (Web) - (PDF) - 9.26.2022
  • Reminder Notice to Plans - (Web) - (PDF) - 8.16.2022
  • For Participating Providers - (Web) - (PDF) - 10.4.2021
  • COBA Presentation - (PDF) - Updated November 2022
    • Redline Version - (PDF)
  • COBA Attestation - (PDF)
  • COBA Attachment Templates:
    • Partial - (PDF) - July 2023
    • HARP - (PDF) - July 2023
    • HIV/SNP - (PDF) - July 2023
    • Mainstream - (PDF) - July 2023
    • Medicaid Advantage Plus - (PDF) - July 2023
  • COBA Presentation (PDF) - 5.25.2021
  • COBA Attachment Templates:
    • Partial - (PDF) - November 2022
    • HARP - (PDF) - November 2022
    • HIV/SNP - (PDF) - November 2022
    • Mainstream - (PDF) - November 2022
    • Medicaid Advantage Plus - (PDF) - November 2022
    • Medicaid Advantage - (PDF) - April 2022
  • Technical Specifications Manual - (PDF) - Posted 12.11.2023
  • MY2024 Table 1: QARR List of Required Measures - (Web) - (XLSX) - Posted 12.11.2023
  • Commercial MY2024 PLD File Specifications - (Web) - (PDF) - Posted 12.11.2023
  • Medicaid MY2024 PLD File Specifications - (Web) - (PDF) - Posted 12.11.2023
  • Exchange MY2024 PLD File Specifications - (Web) - (PDF) - Posted 12.11.2023
  • NYS QARR Value Set - (Web) - (XLSX) - Posted 12.11.2023
  • Language Value Set - (Web) - (PDF) - (XLSX) - Posted 12.11.2023
  • Clarification #1 - (Web) - (PDF) - 6.5.2023
  • Clarification #2 - (Web) - (PDF) - 8.28.2023
  • Clarification #3 - (Web) - (PDF) - 10.11.2023
  • Clarification #4 - (Web) - (PDF) - 11.7.2023
  • Clarification #5 - (Web) - (PDF) - 11.21.2023
  • Clarification #6 - (Web) - (PDF) - 12.14.2023
  • Clarification #7 - (Web) - (PDF) - 2.14.2024
    • Technical Specifications Manual - (PDF) - Revised 10.11.2023
      • MY2023 Table 1: QARR List of Required Measures - (Web) - (PDF) - (XLSX) - Revised 10.11.2023
    • Commercial MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • Medicaid MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • Exchange MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • NYS QARR Value Set - (Web) - (XLSX) - Posted 1.9.2023
    • Language Value Set - (Web) - (PDF) - (XLSX) - Revised 10.11.2023
    • NYS QARR Medication List - (Web) - (XLSX) - Revised 6.5.2023
  • Clarification #1 - (Web) - (PDF) - 12.10.2021
  • Clarification #2 - (Web) - (PDF) - 1.3.2022
  • Clarification #3 - (Web) - (PDF) - 2.7.2022
  • Clarification #4 - (Web) - (PDF) - 6.30.2022
  • Clarification #5 - (Web) - (PDF) - 7.13.2022
  • Clarification #6 - (Web) - (PDF) - 9.8.2022
  • Clarification #7 - (Web) - (PDF) - 10.28.2022
  • Clarification #8 - (Web) - (PDF) - 11.17.2022
  • Clarification #9 - (Web) - (PDF) - 11.30.2022
  • Clarification #10 - (Web) - (PDF) - 1.5.2023
  • Clarification #11 - (Web) - (PDF) - 1.25.2023
  • Clarification #12 - (Web) - (PDF) - 2.13.2023
  • Clarification #13 - (Web) - (PDF) - 3.13.2023
  • Clarification #14 - (Web) - (PDF) - 4.20.2023
    • Technical Specifications Manual - (PDF)
    • Commercial MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • Medicaid MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • Exchange MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • NYS QARR Value Set - (Web) - (XLSX)
    • NYS QARR Medication List - (Web) - (XLSX) - Revised 2.14.2023
  • 2018 HCBS Rule Systemic Compliance Chart - (Web) - (XLSX) - (PDF)
  • Reimbursement for Hospital Based & Free-Standing Behavioral Health Clinics Claims for Dually Eligible Members - (Web) - (PDF) - Updated 12.1.2021
  • Preparedness for Coronavirus (COVID-19) - (Web) - (PDF)
  • Antiretroviral Medication List - (Web) - (PDF) - October 2018
  • HIV Antiretroviral Diagnosis List - (Web) - (PDF) - June 2019
  • New York State Medicaid "Serious Adverse Event Reimbursement" (also known as New York State Medicaid "Never Events") - (Web)
  • Workers´ Compensation PPO Application - (Web)
  • New York State Department of Health Guidelines for Contractor Compliance with the Federal Americans with Disabilities Act - See Appendix J of the MMC/FHP/HIV SNP/HARP Model Contract - (PDF)
  • HP-CMART3 Specification (v3.8) - (Web) - (PDF) - Revised January 2024

The following character and competency review forms are provided for the use and convenience of certified managed care plans in order to facilitate change of control, mergers, expansions, acquisitions etc. Contact DMC for assistance or for the character and competency forms for management contractors.

  • Character and Competency Review (DOH-793B) (PDF)
  • Affiliations with Other Health Care Operations (DOH-793C) (PDF)
  • Regulatory Compliance Statement (DOH-794) (PDF)
  • 2008 Medicaid Performance Improvement Projects - (Web) - (PDF) - October 2009
  • Plan-Specific Reports of NYS Medicaid Managed Care Plans - (Web)
  • Dental Care Survey, Medicaid Managed Care Members - (Web) - (PDF) - February 2007
  • New York State Public Health Law Article 49, Current through 2013, Chapters 1-383 - (PDF)
  • Important Phone Numbers for Patients and Providers - (Web)
  • ADA Accessibility Guidelines for Buildings and Facilities (ADAAG) - (Web)