Information for Health Plans
Health Plan Certification in New York State
To apply for certification under Public Health Law Article 44 (PDF, 637KB, 70pg.) as a Health Maintenance Organization or Prepaid Health Services Plan, contact:
Division of Managed CareBureau of Managed Care Certification and Surveillance
Corning Tower Room 1911
Empire State Plaza
Albany, New York 12237
(518) 474-5515
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, 137KB, 10pg.)
For MCOs offering Medicare Advantage to participate in the New York State Medicaid Advantage program for dual eligible populations plans must meet programmatic guidelines and standards as described in the Application for Participation in Medicaid Advantage (PDF, 74KB, 24pg.)
To certify as a preferred provider organization (PPO) delivering workers' compensation medical care, see the Workers' Compensation PPO Application.
Health Plan Guidelines
- HMO and IPA provider contracts
- New York State Medicaid Prenatal Care Standards
- Medicaid Managed Care Model Member Handbook (PDF, 183KB, 36pg.)
- Family Health Plus Model Member Handbook (PDF, 202KB, 36pg.)
- 2011 Quality Assurance Reporting Requirements Technical Specifications Manual (PDF, 973KB, 54pg.)
- Clarification #1 - January 2012 (PDF,241KB, 2pg.)
- New York State Medicaid "Serious Adverse Event Reimbursement" (also known as New York State Medicaid "Never Events")
- Workers' Compensation PPO Application
- Americans with Disabilities Act (ADA) Guidelines for Medicaid Managed Care Program (PDF, 95KB, 14 pg.)
Utilization Review Agent Registration
Article 49 of the NYS Public Health Law (PDF, 181KB, 32pg.) requires that independent utilization review agents register with the Department of Health every two years, prior to conducting utilization review services for MCOs in New York State. NYCRR Title 10 Part 732-2(f) requires agents to register with the Department prior to conducting utilization review services for New York State Workers' Compensation PPOs. Contact DMC for assistance.
Character and Competency Forms
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 108KB, 10pg.)
- Affiliations with Other Health Care Operations (DOH-793C) (PDF, 51KB, 2pg.)
- Regulatory Compliance Statement (DOH-794) (PDF, 61KB, 2pg.)
Quality Review Reports
- 2008 Medicaid Performance Improvement Projects (PDF, 159KB, 28pg.)
- Plan-Specific Reports of NYS Medicaid Managed Care Plans
- Dental Care Survey, Medicaid Managed Care Members, February, 2007 (PDF, 460KB, 88pg.)
