Information for Health Plans
Parity Compliance Program Certification
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 Plan Certification in New York State
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 |
Health Plan Guidelines
Person Centered Service Plan
Medicaid Managed Care (MMC)
- Medicaid Managed Care Exclusion Exemption Chart - (Web) - (PDF) - 11.29.2023
- 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
- HMO and IPA provider contracts - (Web)
- Management Contract Guidelines for MCOs and IPAs - (Web)
- 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
Cultural Competency Training
CMS Coordination of Benefit Agreement (COBA)
- COBA Presentation - (PDF) - Updated November 2022
- Redline Version - (PDF)
- COBA Attestation - (PDF)
- COBA Attachment Templates:
Archive
Quality Assurance Reporting Requirements (QARR)
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
- Technical Specifications Manual - (PDF) - Revised 10.11.2023
- Commercial MY2023 PLD File Specifications - (Web) - (PDF) - Revised 11.27.2023
- Medicaid MY2023 PLD File Specifications - (Web) - (PDF) - Revised 11.28.2023
- Exchange MY2023 PLD File Specifications - (Web) - (PDF) - Revised 11.28.2023
- 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
2022
- 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
Additional Resources
- 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 2023
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.
