Managed Care Reports

Reports on health plan performance are designed to help you choose a health plan that meets your needs and the needs of your family. The reports provide easy-to-read information on health plan performance with respect to primary and preventive health care, access to health care, behavioral health and enrollee satisfaction. Data is provided for commercial and government-sponsored managed care. Enrollment reports show the level of consumer participation in various types of managed care plans.

Managed Care Organization Focused Survey Citations

Focused Survey Overview:

The Department of Health monitors MCOs on an ongoing basis for compliance with Public Health Law Articles 44 and 49, 10 NYCRR Part 98, the Medicaid Model Contract for those plans offering Medicaid, and other State and federal laws and regulations as applicable. As part of its MCO oversight activities, the Department conducts focused surveys which identify specific issues requiring compliance monitoring and correction if needed. When the Department finds through a focused survey that a MCO is not complying, it issues a citation to the MCO. A citation may be a Statement of Deficiency (SOD) for failure to comply with law or regulation or a Statement of Finding (SOF) for failure to comply with the Medicaid Model Contract.

Once a citation is issued as a result of a focused survey, the MCO is given an opportunity to review and respond with a plan to correct the non-compliance. Once this plan is accepted by the Department, the citation and corrective action is final and is published on this website.

Mental Health Parity and Addiction Equity Act (MHPAEA) Focused Surveys (2018-present)

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) requires that generally coverage for mental health/substance use disorders (MH/SUD) cannot be more restrictive or more expensive than medical/surgical coverage. (For more information on MHPAEA, please click here.) MCOs are required to perform self-assessments of their payment and approval practices and report the results to the State. The focused survey reviewed MCO reporting documentation and issued citations to MCOs who did not provide adequate documentation to conduct the review. The citations and accepted corrective actions are located here.

Behavioral Health Claims Denial Root Cause Analysis Focused Surveys (2017-present)

Focused surveys were initiated to examine MCO behavioral health prior authorization and claims adjudication processes. It was determined that there was a high rate of improper denials for some MCOs who delegated prior authorization and claims adjudication of behavioral health services to a third-party vendor. The non-compliant MCOs were issued citations for failure to properly oversee their vendor, inappropriately denying claims for no prior authorization when prior authorization was not required and failure to pay BH claims correctly and timely. The citations and accepted corrective actions are located here.

Key Staffing Focus Surveys (October, 2021 to present)

MCOs are required to provide written notice to the State when there are changes in key staff at the MCO for behavioral health services. The notice shall include the name of an interim contact person, plan for replacing the key person, and an expected timeframe for replacement.  The State issued a reminder to MCOs of this requirement.  Several plans failed to provide the State with the required notification when key staff left the MCO. As a result, the non-compliant plans were issued a citation. The citations and accepted plan of corrections are located here.

For questions regarding citations, please contact

  • Issue 1: Statewide Executive Summary of Managed Care in New York State - (PDF)
  • Issue 2: Health Plan Comparison in New York State
    • eQARR - An Online Report on Quality Performance Results for Health Plans in New York State - (Web)
    • Quality Assurance Reporting Requirements Dataset (MY2008 - Present) - (Web)
  • Issue 3: Regional Consumer Guides - (Web)
  • Issue 4: Health Plan Service Use in New York State
    • Managed Care Plan Utilization Data: 2009-2021 - (Web)
  • Issue 5: Health Care Disparities in New York State
  • Quality Incentive for Medicaid Managed Care Plans in New York State
  • Medicaid Managed Care Satisfaction Survey
  • Asthma Medication Ratio Rates Among New York Medicaid Managed Care Members - (PDF)
  • Clinical Depression Screening and Follow-Up Among New York Medicaid Members - (PDF)
  • Diabetes Self-Management Education/Training Use Among Medicaid Recipients - (PDF)
  • Statin Therapy for Patients with Cardiovascular Disease - (Web) - (PDF)
  • Health Data NY Medicaid Program Enrollment by Month - (External Link)
  • Monthly Medicaid Managed Care Enrollment Report - (Web)
  • Utilization of Hospital Inpatient Services by Fee for Service and Managed Care Medicaid - (Web) - (PDF)
  • Potentially Preventable Hospital Readmissions Among Medicaid Recipients: - (Web) - (PDF)
  • Potentially Preventable Hospital Readmissions among Medicaid Recipients with Mental Health and/or Substance Abuse Health Conditions Compared with All Others - (Web) - (PDF)
  • A Comparison of Potentially Preventable Hospital Readmissions where Preceding Admission was a Behavioral Health, Medical or Surgical Admission - (Web) - (PDF)
  • Hospital Admissions for Ambulatory Sensitive Conditions and Subsequent Potentially Preventable Readmissions in the Medicaid Population - (Web) - (PDF)
  • Potentially Avoidable Hospitalizations: New York State Medicaid Program, 2009 - (Web) - (PDF)
  • Regional Variation in Children's Myringotomy Rates: New York State Medicaid Program, 2008 - (Web) - (PDF)
  • Medicaid Managed Care Quality Performance among Individuals with Developmental Disabilities, New York State, 2013 - (Web) - (PDF)
  • 2009-2010 Pediatric Obesity-Summary of Projects - (Web) - (PDF)
  • 2008 Medicaid Performance Improvement Projects - (Web) - (PDF)
  • 2010 Performance Improvement Project Abstracts Featuring Pediatric Obesity Prevention Projects, 2009-2010 - (Web) - (PDF)
  • 2011 Performance Improvement Project Abstracts - (Web) - (PDF)
  • 2011-2012 Performance Improvement Project Abstracts - (Web) - (PDF)
  • 2013-2014 Performance Improvement Project Abstracts - (Web) - (PDF)
  • Utilization of Smoking Cessation Benefits in Medicaid Managed Care, 2015-2017 - (Web) - (PDF)
  • Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis - (Web) - (PDF)
  • HIV Special Needs Plan-Specific Reports - (Web)
  • Annual External Quality Review Technical Reports of NYS Medicaid Managed Care Plans - (Web)
  • HARP Behavioral Health Focused Clinical Study: Identification, Coordination, and Follow-up of Co-occurring Cardio-metabolic Conditions Among Individuals with Serious Mental Illness Admitted to Hospital Inpatient Mental Health Units - (Web) - (PDF) - March 2018
  • National Association of Chronic Disease Directors (NACDD) Breast and Cervical Cancer Consumer Satisfaction Survey for Medicaid Enrollees in Erie County - (Web) - (PDF)

This Report serves as New York's parity compliance documentation in accordance with 42 CFR Parts 438, 440 & 457 for benefit packages with members enrolled in Medicaid Managed Care, Alternative Benefit Plan and Children's Health Insurance Program products. The findings contained in the Report stand as the first phase of robust parity monitoring and enforcement workplan for all health insurance products that the State is undertaking.

The Medical Loss Ratio (MLR) is set up to assist the New York State Department of Health (DOH) to ensure that each Managed Care Organization (MCO) calculates and reports a MLR in accordance with 42 CFR Part 438. For a summary of the MLR calculation and definition of terms go here.

MC MLR Report Summary by Line of Business

  • Medicaid - (Web) - (PDF)
  • Health and Recovery Plans (HARP) - (Web) - (PDF)
  • HIV Special Needs Plans (HIV-SNP) - (Web) - (PDF)
  • Managed Long Term Care (MLTC) Partial - (Web) - (PDF)
  • Medicaid Advantage (MA) - (Web) - (PDF)
  • Medicaid Advantage Plus (MAP) - (Web) - (PDF)
  • Program of All-Inclusive Care for the Elderly (PACE) (Informational ONLY) - (Web) - (PDF)
  • The Managed Care Organization Encounter Audit Report is an independent audit of the accuracy, truthfulness, and completeness of the encounter and financial data submitted by Managed Care Organizations in accordance with 42 CFR section 438.602(e) and (g); May 6, 2016, Federal Register (81 FR 27497); OMB No. 0938-0920).