Parity Compliance Program Certification Form
- Form is also available in Portable Document Format (PDF)
New York State Department of Health and Department of Financial Services
Mental Health and Substance Use Disorder Treatment Parity Compliance Program
Annual Certification
Instructions:
- Type the information in the space provided.
- Check the appropriate box(es) for the line(s) of business.
- Have the certification signed by the certifying official.
- Submit the certification to the Department of Health (BHParity@health.ny.gov) and/or to the Department of Financial Services (mentalhealthparity@dfs.ny.gov), as appropriate, by December 31st of each year. Managed Care Organizations (MCOs) certified pursuant to Public Health Law Article 44 should submit the certification to the Department of Health, for both government and commercial plans. All other insurers should submit the certification to the Department of Financial Services.
MCO/Insurer Name:__________________________________________________________
Line of business for certification (check all that apply):
☐ Medicaid Managed Care
☐ Child Health Plus
☐ Essential Plan
☐ Commercial (Certified under PHL Article 44)
☐ Commercial (Insurer authorized to write accident and health insurance in New York)
☐ Commercial (Corporation authorized pursuant to IL Article 43)
☐ Commercial (Student health plan certified pursuant to IL § 1124)
☐ Commercial (Municipal cooperative health benefit plan certified pursuant to Insurance Law Article 47)
Certifying Official Information (Must be either the Chief Executive Officer or the Individual responsible for assessing, monitoring, and managing the compliance program)
Name: __________________________________________________________
Title: ___________________________________________________________
Phone Number: __________________________________________________
Email Address: ___________________________________________________
Business Address: ________________________________________________
City: ________________________________ State:______________________
Zip Code:________________________________________________________
Compliance Individual Information (Please provide contact person information if different than the Certifying Official)
Name: __________________________________________________________
Title: ___________________________________________________________
Phone Number: __________________________________________________
Email Address: ___________________________________________________
Business Address: ________________________________________________
City: ________________________________ State:______________________
Zip Code:________________________________________________________
Certification
Important: The New York State Department of Health and Department of Financial Services are relying upon this certification as part of the review of your MCO´s/Insurer´s compliance with 10 NYCRR Subpart 98-4 and 11 NYCRR Part 230 . Should it be determined that this certification is materially false or incomplete or incorrect, appropriate enforcement action may be taken. Acceptance of this certification by the New York State Department of Health or Department of Financial Services is not a determination of compliance with New York State or federal parity requirements.
I, __________________________ , declare, affirm and certify under penalty of perjury, that the information entered as part of this certification is true to the best of my knowledge and belief and that:
- I have undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and have sufficient knowledge to complete this certification,
- a copy of the certification has been provided to the MCO´s/Insurer´s board of directors or other governing body, or the appropriate committee thereof,
- the MCO/Insurer listed above has adopted, implemented, and maintains a mental health and substance use disorder parity compliance program that meets the requirements of 10 NYCRR Subpart 98-4 and 11 NYCRR Part 230 , including:
- written policies and procedures that implement the parity compliance program, and describe how the MCO´s/Insurer´s parity compliance is assessed, monitored, and managed;
- methodologies for the identification and remediation of improper practices, as described in 10 NYCRR § 98-4.4(b)(1)(i)-(iv) and 11 NYCRR § 230.3(b)(1)(i)-(iv);
- a system for the ongoing assessment of parity compliance, which includes the review of the areas described in 10 NYCRR § 98-4.4(a)(4)(i)-(ix) and 11 NYCRR § 230.3(a)(4)(i)-(ix);
- a process for the actuarial certification, in compliance with actuarial standards of practice, of the data used for, and the outcome of, the analyses of the financial requirements and quantitative treatment limitations applicable to mental health and substance use disorder benefits to ensure that they are no more restrictive than the predominant financial requirements and quantitative treatment limitations applied to substantially all the medical and surgical benefits;
- training and education on federal and state mental health and substance use disorder parity requirements for all employees, directors or other governing body members, agents, and other representatives engaged in functions that are subject to federal or state mental health and substance use disorder parity requirements or involved in analysis as a part of the compliance program; provided that such training shall occur at least annually and shall be made a part of the orientation for such new employees, directors or other governing body members, agents, and other representatives;
- methods by which employees, directors or other governing body members, agents, and other representatives may report parity compliance issues to the individual responsible for compliance, including a method for anonymous and confidential reporting of potential compliance issues as they are identified; and
- a policy of non-intimidation and non-retaliation for good faith participation in the compliance program, including reporting and investigating potential issues and reporting to appropriate officials as provided in Labor Law sections 740 and 741,
- the MCO/Insurer listed above monitored for improper practices, as described in 10 NYCRR § 98-4.4(b)(1)(i)-(iv) and 11 NYCRR § 230.3(b)(1)(i)-(iv), and to the extent any improper practice was detected at least 60 days prior to this certification, the MCO/Insurer remediated or developed a plan to remediate the improper practice as soon as was practicable, but in no event later than 60 days after discovery and provided written notification to affected insureds and the commissioner or superintendent and conspicuously posted on the MCO/Insurer´s website notice regarding the improper practice, including a description of the MCO/Insurer´s efforts to remediate the improper practice or its plan for remediation, within 60 days of discovery,
- the MCO/Insurer listed above maintains complete documentation regarding the actions that form the basis for this certification, which shall be made available to the New York State Department of Health and Department of Financial Services upon request, and
- the Certifying Official and the MCO/Insurer acknowledge that this certification is being made to comply with the requirements of 10 NYCRR Subpart 98-4 and 11 NYCRR Part 230 .
Signature:
__________________________________________________________________________
Certifying Official Date
