MCO's Certified by NYS Department of Health

Health Maintenance Organizations (HMO)

An HMO is a managed care organization (MCO) that operates under Article 44 of the Public Health Law and the Insurance Law and must be certified by Department of Health. Operation and structure of these organizations is further delineated in regulation (NYCRR Title 10 Part 98).

HMOs must ensure that comprehensive health care services are available to covered individuals. For primary care services, HMOs may own and operate clinics that directly serve the enrolled population and/or enter into contractual relationships with primary care physicians or physician groups to serve the enrolled population. Other medical services, such as inpatient hospital services, are usually provided through a contractual relationship between the plan and the medical provider. HMOs must designate their model of service provision at certification.

Other requirements for HMOs in New York state include: incorporation in New York State, specified fiscal reserves, quality assurance mechanisms, and information management systems.

Formal structures and processes must be in place for key functional areas such as Board oversight, member services, utilization review, complaints review, marketing, network development and others.

Prepaid Health Services Plans (PHSP)

A PHSP is a managed care organization specifically authorized by New York State Law. They must meet the same structure and operating criteria as HMOs, but at least 90 percent of the enrollees must be beneficiaries of government health care coverage programs such as Medicaid. The total number of PHSPs is limited by law.

Preferred Provider Organizations (PPO)

Commercial and general health PPOs operate under the Insurance Law and represent a less comprehensive contractual arrangement for the provision of health services. In 1996, the New York State Workers' Compensation Law was modified to authorize insurance carriers and self-insured employers to contract with Department of Health-certified PPOs to provide services to diagnose, treat and rehabilitate a claimant requiring medical treatment of an occupational disease or injury. Claimants receive coordinated medical services with a guarantee of continuity of care, access to second medical opinions, objective dispute resolution and other patient protections. Each Workers’ Compensation PPO is required to offer injured workers a choice of at least five accessible practitioners in each of twenty-six designated specialties within forty-eight hours of injury.

HIV Special Need Plans (SNP)

The Medicaid Managed Care Act of 1996 created standards for and authorized 12 fully capitated HIV SNPs to meet the health, medical and psychosocial needs of Medicaid eligible individuals who are living with HIV/AIDS and their related children. The HIV SNPs are an alternative to mainstream Medicaid managed care plans are required to have a network of experienced HIV-service providers, HIV specialist PCPs, and a comprehensive model of case management. SNPs are also required to promote access to essential support services, such as treatment adherence, housing and nutrition assistance; and reach multi-cultural/non-English speaking communities.

Managed Long-Term Care Plans (MLTC)

In 1997, The Long-term Care Integration and Finance Act (Chapter 659 of the Laws of 1997) was enacted, consolidating under one legislative authority all managed long-term care demonstrations and plans. There are two (2) basic models of managed long-term care in New York State: Programs of All-Inclusive Care for the Elderly (PACE) and partially-capitated long-term care plans. Enrollment in both types of managed long-term care plans is voluntary. PACE organizations provide a comprehensive array of services including: case management, physician, hospital, and nursing home care to adults age 55 and older who are medically eligible for nursing home care. The partially-capitated managed long-term care plans provide long-term care services, ancillary, and ambulatory services. Enrollees access many services through their primary care physician yet obtain inpatient hospital services on a fee-for-service basis. Enrollees must be medically-eligible for nursing home care and be at least age 21 or older; some plans have opted to enroll only those individuals age 65 and older.

Primary Care Partial Capitation Providers

Partial risk programs were an option for Medicaid recipients from 1987 until August 31, 2012, when the last PCPCPs were phased out. The original programs were capitated primary care case management programs called Physician Case Management Programs. Chapter 649 of the Laws of 1996 added a new Section 4403e to Public Health Law that authorized the certification of Primary Care Partial Capitation Providers and grandfathered the Physician Case Management Programs then in existence under 4403e.

Medicaid recipients enrolled with a partially capitated provider were assigned to a primary care practitioner who was responsible for providing primary and preventive care and coordinating, locating and monitoring access to other medically necessary services. The providers of the other services were reimbursed fee-for-service. In 2012, the three remaining PCPCPs were closed when a choice of full risk managed care plans became available.