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 "only" line of business
(Please note, this guidance does not pertain to the Medicaid Advantage Plus (MAP) line of business or the Integrated Benefit-Dual (IB-D) program)

Application Type DOH Due Date CMS Due Date Medicare
Coverage
Year
New Medicare Advantage only line of business
(Existing MCO)
October 1, 2021 Mid-February 2022 2023
New Medicare Advantage only line of business
(New MCO Applicant)
October 1, 2021 Mid-February 2022 2023
Service Area Expansion
(SAE)
November 1, 2021 Mid-February 2022 2023
New Medicare Advantage only line of business
(New MCO Applicant)
February 1, 2022 Mid-February 2023 2024
New Medicare Advantage only line of business
(Existing MCO)
July 1, 2022 Mid-February 2023 2024
Service Area Expansion (SAE) November 1, 2022 Mid-February 2023 2024

All completed applications must be submitted to the DOH via email at bmccsmail@health.ny.gov with the subject line containing the "Applicant/MCO Legal Name-Medicare Advantage Application".

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

To certify as a preferred provider organization (PPO) delivering workers´ compensation medical care, see the Workers´ Compensation PPO Application.

  • Person Centered Service Plan Guidelines - (Web) - (PDF) - Updated 11.16.2022
  • Person Centered Service Plan Template - (PDF) - (Word) - Updated 11.16.2022
  • 2018 HCBS Rule Systemic Compliance Chart - (XLSX) - (PDF)
  • MMC Guidance - Process for Expedited Request for Assessment and the New York Independent Assessor (NYIA) - (Web) - (PDF) - 11.23.2022
  • MMC Guidance - 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
  • MMC Guidance - 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
  • MMC Guidance for the Implementation of the New York Independent Assessor for Initial Assessments - (Web) - (PDF) - 4.28.2022
  • Reimbursement for Hospital Based & Free-Standing Behavioral Health Clinics Claims for Dually Eligible Members - (Web) - (PDF) - Updated 12.1.2021
  • Cultural Competency Training for Participating Providers - (Web) - (PDF) - 10.4.2021
  • Reminder Notice to Plans - Cultural Competency Training - (Web) - (PDF) - 8.16.2022
  • Cultural Competency Completion - (Web) - (PDF) - 9.26.2022
  • CMS Coordination of Benefit Agreement (COBA)
    • COBA Presentation - (PDF) - Updated November 2022
      • Redline Version - (PDF)
    • COBA Attestation - (PDF)
    • 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
    • Archive
      • COBA Presentation (PDF) - 5.25.2021
      • COBA Attachment Templates:
        • Medicaid Advantage - (PDF) - April 2022
  • Preparedness for Coronavirus (COVID-19) - (Web) - (PDF)
  • Article 44 MCO Sepsis Guidance - (Web) - (PDF) - 7.15.2019
  • Medicaid Managed Care 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) - 4.21.2022
    • State Identified Request Form for In Lieu of Services for Medically Tailored Meals (MTM) - (Web) - (PDF) - Revised 4.21.2022
    • State Identified ILS MTM Reporting Template - (XLSX) - Updated 11.15.2022
    • State Identified ILS-MTM Presentation - (Web) - (PDF) - 10.13.2021
    • 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
  • 2022 Quality Assurance Reporting Requirements (QARR)
    • 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
      • Technical Specifications Manual - (PDF)
      • Commercial MY2022 PLD File Specifications - (PDF) - Revised 11.14.2022
      • Medicaid MY2022 PLD File Specifications - (PDF) - Revised 11.14.2022
      • Exchange MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.14.2022
      • NYS QARR Value Set - (Web) - (XLSX)
      • NYS QARR Medication List - (Web) - (XLSX)
  • 2020-2021 Quality Assurance Reporting Requirements (QARR)
    • Clarification #1 - (Web) - (PDF) - 12.8.2020
    • Clarification #2 - (Web) - (PDF) - 1.5.2021
    • Clarification #3 - (Web) - (PDF) - 2.9.2021
    • Clarification #4 - (Web) - (PDF) - 5.7.2021
    • Clarification #5 - (Web) - (PDF) - 7.19.2021
    • Clarification #6 - (Web) - (PDF) - 8.13.2021
    • Clarification #7 - (Web) - (PDF) - 10.8.2021
    • Clarification #8 - (Web) - (PDF) - 11.30.2021
    • Clarification #9 - (Web) - (PDF) - 1.3.2022
      • Technical Specifications Manual - (PDF) - Revised 10.15.2021
      • Commercial MY2021 PLD File Specifications - (Web) - (PDF) - Revised 12.13.2021
      • Medicaid MY2021 PLD File Specifications - (Web) - (PDF) - Revised 12.13.2021
      • Exchange MY2021 PLD File Specifications - (Web) - (PDF) - Revised 12.13.2021
      • NYS QARR Value Set - (Web) - (PDF)
      • NYS QARR Medication List - (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 October 2021

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)