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.

  • Reimbursement for Hospital Based & Free-Standing Behavioral Health Clinics Claims for Dually Eligible Members - (Web) - (PDF)
  • Cultural Competency Training for Participating Providers - (PDF)
  • CMS Coordination of Benefit Agreement (COBA)
    • COBA Presentation May 25, 2021 - (PDF)
    • COBA Attestation - (PDF)
    • COBA Attachment Templates:
  • Preparedness for Coronavirus (COVID-19) - (Web)
  • Article 44 MCO Sepsis Guidance - (Web)
  • Person Centered Service Plan Guidelines - (Web)
  • Person Centered Service Plan Template - (Web)
  • Medicaid Managed Care Criteria Standards for the Authorization and Utilization Management of Treatment for Gender Dysphoria - (Web)
  • Criteria Standards for the Authorization and Utilization Management of Harm Reduction Services - (Web)
  • 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:
      • Presentation - (PDF) - March 9, 2018
      • FAQ - (Web) - March 9, 2018
  • HMO and IPA provider contracts - (Web)
  • Management Contract Guidelines for MCOs and IPAs - (Web)
    • Standard Clauses for Management Service Agreements - (Web)
    • Management Contract Statement and Certification (DOH-5038) (PDF)
  • New York State Medicaid Prenatal Care Standards - (Web)
  • Medicaid Managed Care Model Member Handbook - (Web)
  • Medicaid Managed Care Guidance and Application to Offer Cost-effective Alternative Services (In Lieu of) - (Web) - (PDF)
    • State Identified Request Form for In Lieu of Services for Medically Tailored Meals (MTM) - (Web) - (PDF)
    • State Identified ILS-MTM Presentation - (PDF) - October 13, 2021
    • State Identified Request Form for In Lieu of Services in an Institute for Mental Disease - (Web)
    • State Identified ILS IMD Presentation - (Web) - August 19, 2019
  • Medicaid Managed Care Organizations Guidance for Telehealth Innovation Plans - (Web)
    • Telehealth Innovations and 2018 Quality Incentive - (Web) - 2018
    • Announcing Medicaid Managed Care Telehealth Innovation - (Web) - 2017
  • 2020-2021 Quality Assurance Reporting Requirements (QARR)
    • Clarification #1 - (PDF)
    • Clarification #2 - (PDF)
    • Clarification #3 - (PDF)
    • Clarification #4 - (PDF)
    • Clarification #5 - (PDF)
    • Clarification #6 - (PDF)
    • Clarification #7 - (PDF)
    • Clarification #8 - (PDF)
    • Clarification #9 - (PDF)
      • Technical Specifications Manual - (PDF)
      • Commercial MY2021 PLD File Specifications - (PDF)
      • Medicaid MY2021 PLD File Specifications - (PDF)
      • Exchange MY2021 PLD File Specifications - (PDF)
      • NYS QARR Value Set - (PDF)
      • NYS QARR Medication List - (PDF)
  • 2022 Quality Assurance Reporting Requirements (QARR)
    • Clarification #1 - (PDF)
    • Clarification #2 - (PDF)
      • Technical Specifications Manual - (PDF)
      • Commercial MY2022 PLD File Specifications - (PDF)
      • Medicaid MY2022 PLD File Specifications - (PDF)
      • Exchange MY2022 PLD File Specifications - (PDF)
      • NYS QARR Value Set - (PDF)
      • Medication List will be updated in April 2022
  • Antiretroviral Medication List - (Web) - October 2018
  • HIV Antiretroviral Diagnosis List - (Web) - 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)
  • Americans with Disabilities Act (ADA) Guidelines for Medicaid Managed Care Program - (Web)
  • HP-CMART3 Specification (v3.8) - (Web) - (PDF)

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) - October 2009
  • Plan-Specific Reports of NYS Medicaid Managed Care Plans - (Web)
  • Dental Care Survey, Medicaid Managed Care Members - (Web) - 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)