§ 367-B — Medical assistance information and payment system

§ 367-b. Medical assistance information and payment system. 1. The\ndepartment shall design and implement a statewide medical assistance\ninformation and payments system for the purpose of providing individual\nand aggregate data to social services districts to assist them in making\nbasic management decisions, to the department and other state agencies\nto assist in the administration of the medical assistance program, and\nto the governor and the legislature as may be necessary to assist in\nmaking major administrative and policy decisions affecting such program.\nSuch system shall be designed so as to be capable of the following:\n a. receiving and processing information relating to the eligibility of\neach person applying for medical assistance and of issuing a medical\nassistance identification card to persons determined by a social\nservices official to be eligible for such assistance;\n b. receiving and processing information relating to each qualified\nprovider of medical assistance furnishing care, services or supplies for\nwhich claims for payment are made pursuant to this title;\n c. receiving and processing, in a form and manner prescribed by the\ndepartment, all claims for medical care, services and supplies, and\nmaking payments for valid claims to providers of medical care, services\nand supplies on behalf of social services districts;\n d. maintaining information necessary to allow the department,\nconsistent with the powers and duties of the department of health, to\nreview the appropriateness, scope and duration of medical care, services\nand supplies provided to any eligible person pursuant to this chapter;\nand\n e. initiating implementation of such a system for the district\ncomprising the city of New York, in a manner compatible with expansion\nof such system to districts other than the district comprising the city\nof New York.\n 2. Consistent with the capabilities of the system established pursuant\nto subdivision one of this section, the department shall assume payment\nresponsibilities on behalf of social services districts by promulgation\nof regulations approved by the director of the budget. Such regulations\nshall specify the providers of medical assistance and the medical care,\nservices and/or supplies for the district or districts for which the\ndepartment will assume payment responsibilities and the date on which\nsuch responsibilities shall be assumed. Such regulations shall be\npublished for comment at least thirty days in advance of their\npromulgation and shall be filed with the secretary of state at least\nsixty days in advance of the date of assumption of responsibilities;\nprovided, however, that with respect to a particular district the\nrequirements for advance publications and/or filing may be waived, or\nthe time limits reduced, with the written consent of the district to\nsuch waiver or reduction. Providers of medical care and services shall\nsubmit claims to the social services district for all items of care,\nservices and supplies furnished prior to the date of state assumption of\npayment responsibilities and to the state for all such items furnished\nsubsequent to such date. Such regulations shall also specify a final\ntransition date after which any claiming submitted shall be enforceable\nby such provider only against the state and shall not be enforceable by\nsuch provider against the social services district; provided, however,\nthat the department and the district may enter into a written agreement\nby which the department agrees on the basis of eligibility information\nprovided by such district to pay claims submitted to such district prior\nto the final transition date.\n 3. Upon notice to a social services district in accordance with\nsubdivision two, that the department intends to assume payment\nresponsibilities on behalf of such district, (a) such district shall\npromptly submit to the department requested information regarding each\nperson who applies for or has been determined eligible for medical\nassistance and each provider of medical assistance in such district; and\n(b) notwithstanding the provisions of paragraph (b) of subdivision three\nof section three hundred sixty-six-a of this chapter, the department\nshall provide each person found by such district to be eligible for\nmedical assistance under this title with a medical assistance\nidentification card.\n 4. Information relating to persons applying for or receiving medical\nassistance shall be considered confidential and shall not be disclosed\nto persons or agencies other than those considered entitled to such\ninformation in accordance with section one hundred thirty-six when such\ndisclosure is necessary for the proper administration of public\nassistance programs.\n 5. By no later than forty-five days following the end of each calendar\nquarter after the second quarter of calendar year nineteen hundred\nseventy-six, the department shall, until full implementation has been\nachieved in all social services districts, report to the governor and\nthe legislature regarding the current status of the medical assistance\ninformation and payment system, summarizing the progress achieved during\nthe previous quarter and the anticipated major achievements of the\nsucceeding two calendar quarters. The report shall include the current\nand anticipated overall expenditure and staffing levels for functions\nrelating to the system, and shall specify each district affected or\nanticipated to be affected during the succeeding two calendar quarters\nand summarize the manner in which each such district is, or is\nanticipated to be, affected. In addition, the department shall prepare\nand submit to the governor and the legislature a special report\ndemonstrating the appropriateness and relative cost-effectiveness of\nutilizing a fiscal intermediary.\n In addition, for the purpose of insuring the compatability of the\nsystem servicing the district comprising the city of New York with the\nsystem servicing all other social services districts in the state, the\ndepartment shall prepare and submit to the governor and the legislature\non or before March first, nineteen hundred seventy-eight, a special\nreport and recommendation covering the appropriateness and relative cost\neffectiveness of utilizing a fiscal intermediary or fiscal agent for all\ndistricts other than the district comprising the city of New York.\n 6. Each social services district shall be responsible for paying to\nthe state a share of the state's expenditures for claims of providers of\nmedical assistance attributable to such district, which shall be equal\nto the share of such expenditures such district would have borne after\nreimbursement from state and federal funds in accordance with section\nthree hundred sixty-eight-a of this chapter, had the expenditure been\nmade by such district; provided, however, that no district shall be\nresponsible for the state's expenditures for the administrative costs of\ndeveloping, maintaining or operating the statewide medical assistance\ninformation and payment system; and provided, further, that no district\nshall be responsible for paying to the state any portion of the cost of\nmedical assistance which the department is responsible for furnishing\npursuant to section three hundred sixty-five of this chapter.\n 7. In any case in which the department has made payments for medical\nassistance on behalf of a social services district pursuant to this\nsection, the commissioner on behalf of the social services official\nshall be empowered to bring actions to recover the cost of such\nassistance, pursuant to this subdivision and the provisions of title six\nof article three of this chapter.\n 8. (a) For the purpose of orderly and timely implementation of the\nmedical assistance information and payment system, the department is\nhereby authorized to enter into agreements with fiscal intermediaries or\nfiscal agents for the design, development, implementation, operation,\nprocessing, auditing and making of payments, subject to audits being\nconducted by the state in accordance with the terms of such agreements,\nfor medical assistance claims under the system described by this section\nin any social services district. Such agreements shall specifically\nprovide that the state shall have complete oversight responsibility for\nthe fiscal intermediaries' or fiscal agents' performance and shall be\nsolely responsible for establishing eligibility requirements for\nrecipients, provider qualifications, rates of payment, investigation of\nsuspected fraud and abuse, issuance of identification cards,\nestablishing and maintaining recipient eligibility files, provider\nprofiles, and conducting state audits of the fiscal intermediaries' or\nagents' at least once annually. The system described in this subdivision\nshall be operated by one or more fiscal intermediaries or fiscal agents\nin accordance with this subdivision unless the department is otherwise\nauthorized by a law enacted subsequent to the effective date of this\nsubdivision to operate the system in another manner. In no event shall\nsuch intermediary or agent be a political subdivision of the state or\nany other governmental agency or entity. Notwithstanding the foregoing,\nthe department may make payments to a provider upon the commissioner's\ndetermination that the provider is temporarily unable to comply with\nbilling requirements. The department shall consult with the office of\nMedicaid inspector general regarding any activities undertaken by the\nfiscal intermediaries or fiscal agents regarding investigation of\nsuspected fraud and abuse.\n (b) The department of health, in consultation with the office of\nMedicaid inspector general, shall develop, test and implement new\nmethods to strengthen the capability of the medical assistance\ninformation and payment system to detect and control fraud and improve\nexpenditure accountability, and is hereby authorized to enter into\nfurther agreements with fiscal and/or information technology agents for\nthe development, testing and implementation of such new methods. Any\nsuch agreements shall be with agents which have demonstrated expertise\nin the areas addressed by the agreement. Such methods shall, at a\nminimum, address the following areas:\n (1) Prepayment claims review. Develop, test and implement an automated\nclaims review process which, prior to payment, shall subject medical\nassistance program services claims to review for proper coding and such\nother review as may be deemed necessary. Services subject to review\nshall be based on: the expected cost-effectiveness of reviewing such\nservice; the capabilities of the automated system for conducting such a\nreview; and the potential to implement such review with negligible\neffect on the turnaround of claims for provider payment or on recipient\naccess to necessary services. Such initiative shall be designed to\nprovide for the efficient and effective operation of the medical\nassistance program claims payment system by performing functions\nincluding, but not limited to, capturing coding errors, misjudgments,\nincorrect or multiple billing for the same service and possible excesses\nin billing or service use, whether intentional or unintentional.\n (2) Coordination of benefits. Develop, test and implement an automated\nprocess to improve the coordination of benefits between the medical\nassistance program and other sources of coverage for medical assistance\nrecipients. Such initiative shall initially examine the savings\npotential to the medical assistance program through retrospective review\nof claims paid which shall be completed not later than January\nthirty-first, two thousand seven. If, based upon such initial\nexperience, the Medicaid inspector general deems the automated process\nto be capable of including or moving to a prospective review, with\nnegligible effect on the turnaround of claims for provider payment or on\nrecipient access to services, then the Medicaid inspector general in\nsubsequent tests shall examine the savings potential through\nprospective, pre-claims payment review.\n (3) Comprehensive review of paid claims. Take all reasonable and\nnecessary actions to intensify the state's current level of monitoring,\nanalyzing, reporting and responding to medical assistance program claims\ndata maintained by the state's medical assistance information and\npayment system contract agents. Pursuant to this initiative, the\ndepartment of health, in collaboration with the office of Medicaid\ninspector general, shall make efforts to improve the utilization of such\ndata in order to better identify fraud and abuse within the medical\nassistance program and to identify and implement further program and\npatient care reforms for the improvement of such program. In addition,\nthe department of health, in consultation with such contract agents and\nthe office of Medicaid inspector general, shall identify additional data\nelements that are maintained and otherwise accessible by the state,\ndirectly or through any of its contractors, that would, if coordinated\nwith medical assistance data, further increase the effectiveness of data\nanalysis for the management of the medical assistance program. To\nfurther the objectives of this subparagraph, the department of health,\nin collaboration with the office of Medicaid inspector general, shall\nprovide or arrange in-service training for state and county medical\nassistance personnel to increase the capability for state and local data\nanalysis, leading to a more cost-effective operation of the medical\nassistance program.\n (4) Targeted claims and utilization review. Develop, test and\nimplement an automated process for the targeted review of claims,\nservices and/or populations not later than January thirty-first, two\nthousand seven. Such review shall be for the purposes of identifying\nstatistical aberrations in the use or billing of such services and for\nassisting in the development and implementation of measures to ensure\nthat service use and billing are appropriate to recipients' needs.\n (c) The commissioner of health shall prepare and submit an interim\nreport to the governor and legislature on the implementation of the\ninitiatives specified in paragraph (b) of this subdivision no later than\nDecember first, two thousand seven. Such report shall also include\nrecommendations for any revisions that would further facilitate the\ngoals of such paragraph, including recommendations for expansion. In\naddition, the commissioner of health shall submit a final report not\nlater than December first, two thousand eight. In preparing such interim\nand final reports, the commissioner of health shall consult with the\nMedicaid inspector general, third-party agents, providers and recipients\nassociated with the implementation of paragraph (b) of this subdivision.\n 9. (a) In order to accomplish a more orderly transition to the medical\nassistance information and payment system authorized by this section,\nand to continue for a limited transition period the rate at which\nadvanced revenues have been made available by local governmental units\nto certain hospitals providing services to persons eligible for medical\nassistance, the department is authorized to promulgate regulations\nestablishing a system of accelerated payments to hospitals meeting the\ncriteria set forth in this section.\n (b) Such system of accelerated payments shall only be available to a\ngeneral hospital, other than a public general hospital:\n (i) which prior to January first, nineteen hundred seventy-eight\nreceived regular, periodic and recurring advanced revenues from a local\ngovernmental unit, the amount of which was based on anticipated medical\nassistance claims payments; and\n (ii) which has demonstrated that its continued financial viability\ndepends in substantial part on the rate at which such advanced revenues\nwere made available by local governmental units prior to the time the\ndepartment, pursuant to this section, assumed payment for such hospital\nresponsibilities on behalf of the social services district in which it\nis located, taking into account any funds remaining available from the\nlocal governmental unit under its system of advanced revenues. For\npurposes of this subdivision, it shall be presumed that a hospital does\nnot depend in substantial part on the rate at which advanced revenues\nwere made available by a local governmental unit if it received such\nrevenues for a period of less than nine months preceding the month in\nwhich the department assumed payment responsibilities for such hospital;\n (iii) for which payment responsibility is initially assumed by the\ndepartment pursuant to this section during the period beginning June\nfirst, nineteen hundred seventy-eight and ending November thirtieth,\nnineteen hundred seventy-eight; and\n (iv) which meets performance criteria established by department\nregulation relating to the ratio of acceptable claims for patient days\nsubmitted for medical assistance payment compared to the total patient\ndays of the hospital and compared to such claims submitted in one or\nmore previous months, and the time lapse between the date the service\nwas provided and the date the claim was submitted.\n (c) The regulations promulgated by the department pursuant to\nparagraph (a) of this subdivision shall provide that the amount of the\naccelerated payment for any month shall be determined for each hospital\nmeeting the criteria set forth in this section on the basis of\nacceptable medical assistance claims submitted by the hospital in one or\nmore previous months and the amount of accelerated revenues made\navailable to the hospital by a local governmental unit prior to the time\nthe department assumed payment responsibilities for the hospital. The\namount of the accelerated payment for any given month shall not exceed\nthe amount of a monthly aggregate claim to be submitted by the hospital\nto the department, which claim shall reflect items of care, services and\nsupplies authorized under the medical assistance program pursuant to\nthis title which are in fact provided prior to the date of the aggregate\nclaim to persons who have been determined eligible for medical\nassistance, or based on the past performance of the hospital are likely\nto be determined eligible for medical assistance, when no other source\nof payment including third party health insurance and payments pursuant\nto title eighteen of the Federal Social Security Act are available for\nsuch items of care, service and supplies. Such aggregate claims shall be\nsubject to the audit and warrant of the state comptroller.\n (d) Any schedule of accelerated payments established by the department\npursuant to this section shall assure that such payments are made for a\nperiod of no more than six months from the month in which the department\nassumes payment responsibility for the hospital, and shall provide for\nrepayment of any amounts in excess of current audited claims, through\nreductions in current claims, at a rate that will assure full repayment\nat the earliest time consistent with the purposes of this section, but\nin no event more than twenty-four months following the month in which\nthe department assumes payment responsibilities for the hospital.\nHowever, where the commissioner of health has determined with the\nconcurrence of the state hospital review and planning council that a\nhospital has satisfied the department of health regulations and is or\nhas been authorized to participate in the emergency hospital\nreimbursement program pursuant to which repayment of all or part of any\naccelerated payments made by the department have been deferred in\naccordance with such regulations, notwithstanding the time limitations\nset forth above repayment of such deferred amounts shall be made in\naccordance with an orderly schedule of repayment established by the\ncommissioner of health after consultation with the commissioner. In no\nevent shall any reduction be made against current claims, grant funds or\nany amounts due said hospital in settlement of rate appeals, claims or\nlawsuits to satisfy such repayment obligations.\n (e) In making accelerated payments pursuant to this subdivision and\ndepartment regulations, the department shall utilize federal funds made\navailable, and local funds, for such purposes or for purposes of payment\nby the department of medical assistance payments pursuant to this\nsection.\n * 10. a. For the purpose of timely payment, the department is hereby\nauthorized to develop a concurrent payment system for general hospitals\nwhich elect to participate in the concurrent payment system and which\nare included in the payment component of the medical assistance\ninformation and payment system, and to promulgate regulations to govern\nsuch a system. The department may implement the concurrent payment\nsystem for any general hospital which has elected to participate and for\nwhich the department has chosen to implement the system.\n b. For all participating general hospitals the department shall\ndetermine a biweekly concurrent payment which shall equal one\ntwenty-sixth of the portion of the hospital's imputed or certified\ninpatient revenue cap (as defined in section twenty-eight hundred\nseven-a of the public health law) allocated for medical assistance\npayments. The concurrent payment shall be reviewed at the beginning of\neach quarter and adjusted to reflect any changes to the inpatient\nrevenue cap or portion allocated for medical assistance payments.\n c. The department shall promulgate regulations, consistent with\nfederal requirements for participation, governing the concurrent payment\nsystem. The regulations shall address, among other things, the method\nof calculating the concurrent payment, the method of reconciliation, the\nadjustment of the concurrent payment for the calculated difference, the\nmanner of eliminating underpayments or overpayments to hospitals in\nexceptional circumstances such as significantly changing utilization,\nchanges in bed or service capacity, or imminent insolvency. The\ndepartment shall promulgate regulations establishing a procedure for\nrecognizing open cases as of the date of reconciliation. The department\nshall also promulgate regulations setting forth standards for the\ntimeliness and quality of billings and may lower the concurrent payment\ncalculated in accordance with paragraph b of this subdivision for\nnoncompliance with such regulations.\n d. Any payment claims made to the department for days of inpatient\ncare provided prior to the effective date of this subdivision shall be\npaid or denied in accordance with department regulations in effect when\nthe care was provided.\n e. For any general hospital which is not afforded the opportunity of\nparticipating in the concurrent payment system and which is in\ncompliance with the billing requirements of the department, the\ndepartment shall pay any financing or working capital charge levied by\nthe hospital as authorized in section twenty-eight hundred seven-a of\nthe public health law.\n f. This subdivision shall be effective only if federal participation\nis available.\n * NB Expires January 1, 1986\n 11. a. For the purpose of timely payment, the department is hereby\nauthorized to develop a concurrent payment system for general hospitals\nwhich elect to participate in the concurrent payment system and which\nare included in the payment component of the medical assistance\ninformation and payment system, and to promulgate regulations to govern\nsuch a system. The department may implement the concurrent payment\nsystem for any general hospital which has elected to participate and for\nwhich the department has chosen to implement the system.\n b. For all participating general hospitals the department shall\ndetermine a biweekly concurrent payment which shall equal one\ntwenty-sixth of the hospital's estimated yearly inpatient revenue from\nmedical assistance payments. The concurrent payment shall be reviewed at\nthe beginning of each quarter and adjusted to reflect any changes to the\nrates for medical assistance payments.\n c. The department shall promulgate regulations, consistent with\nfederal requirements for participation, governing the concurrent payment\nsystem. The regulations shall address, among other things, the method\nof calculating the concurrent payment, the method of reconciliation, the\nadjustment of the concurrent payment for the calculated difference, the\nmanner of eliminating underpayments or overpayments to hospitals in\nexceptional circumstances such as significantly changing utilization,\nchanges in bed or service capacity, or imminent insolvency. The\ndepartment shall promulgate regulations establishing a procedure for\nrecognizing open cases as of the date of reconciliation. The department\nshall promulgate regulations setting forth standards for the timeliness\nand quality of billings and may lower the concurrent payment calculated\nin accordance with paragraph b of this subdivision for noncompliance\nwith such regulations.\n d. Any payment claims made to the department for days of inpatient\ncare provided prior to the effective date of this subdivision shall be\npaid or denied in accordance with department regulations in effect when\nthe care was provided.\n e. For any general hospital which is not afforded the opportunity of\nparticipating in the concurrent payment system and which is in\ncompliance with the billing requirements of the department, the\ndepartment shall pay any financing or working capital charge levied by\nthe hospital as authorized in section twenty-eight hundred seven-a of\nthe public health law.\n f. This subdivision shall be effective only if federal participation\nis available.\n 12. (a) For the purpose of regulating cash flow for general hospitals,\nthe department shall develop and implement a payment methodology to\nprovide for timely payments for inpatient hospital services eligible for\ncase based payments per discharge based on diagnosis-related groups\nprovided during the period January first, nineteen hundred eighty-eight\nthrough March thirty-first two thousand twenty-six, by such hospitals\nwhich elect to participate in the system.\n (b) In developing a payment methodology the department shall consider\na system under which hospitals may be reimbursed on the basis of\ninpatient admissions, adjusted to payment on the basis of discharge\ndata, with reconciliations established at time periods specified by the\ndepartment. Under such a system variances between amounts paid on an\nadmission basis and actual amounts due and to be paid on a discharge\nbasis may be reflected in the amounts to be paid in a subsequent period.\n 13. Notwithstanding any inconsistent provision of law, in lieu of\npayments authorized by this chapter and/or any of the general fund or\nspecial revenue other appropriations made to the office of temporary and\ndisability assistance and the office of children and family services,\nfrom funds otherwise due to local social services districts or in lieu\nof payments of federal funds otherwise due to local social services\ndistricts for programs provided under the federal social security act or\nthe federal food stamp act or the low income home energy assistance\nprogram, funds in amounts certified by the commissioner of the office of\ntemporary and disability assistance or the commissioner of the office of\nchildren and family services or the commissioner of health as due from\nlocal social services districts as their share of payments made pursuant\nto this section, may be set-aside by the state comptroller in an\ninterest-bearing account with such interest accruing to the credit of\nthe locality, pursuant to an estimate provided by the commissioner of\nhealth of a local social services district's share of medical assistance\npayments, except that in the case of the city of New York, such\nset-aside shall be subject first to the requirements of a section of the\nchapter of the laws of two thousand one which enacted this provision,\nand then subject to the requirements of paragraph (i) of subdivision (b)\nof section two hundred twenty-two-a of chapter four hundred seventy-four\nof the laws of nineteen hundred ninety-six prior to the application of\nthis subdivision. Should funds otherwise payable to a local social\nservices district from appropriations made to the office of temporary\nand disability assistance, the office of children and family services,\nand the department of health be insufficient to fully fund the amounts\nidentified by the commissioner of health as necessary to liquidate the\nlocal share of payments to be made pursuant to this section on behalf of\nthe local social services district, the commissioner of health may\nidentify other state or federal payments payable to that local social\nservices district or any other county agency including, but not limited\nto the county department of health, from appropriations made to the\nstate department of health, and may authorize the state comptroller,\nupon no less than five days written notice to such local social services\ndistrict or such other county agency, to set-aside such payments in the\ninterest-bearing account with such interest accruing to the credit of\nthe locality. Upon such determination by the commissioner of health that\ninsufficient funds are payable to a local social services district and\nany other county agency receiving payments from the office of temporary\nand disability assistance, the office of children and family services,\nand the state department of health from appropriations made to these\nagencies, the state comptroller shall, upon no less than five days\nwritten notice to such local social services district or such other\ncounty agency, withhold payments from any of the general fund - local\nassistance accounts or payments made from any of the special revenue -\nfederal local assistance accounts, provided, however, that such federal\npayments shall be withheld only after such federal funds are properly\ncredited to the county through vouchers, claims or other warrants\nproperly received, approved, and paid by the state comptroller, and\nset-aside such disbursements in the interest-bearing account with such\ninterest accruing to the credit of the locality until such time that the\namount withheld from each county is determined by the commissioner of\nhealth to be sufficient to fully liquidate the local share of payments,\nas estimated by the commissioner of health, to be made pursuant to this\nsection on behalf of that local social services district.\n 14. Notwithstanding any other provision of law, effective on or before\nJanuary first, two thousand one, the local social services district\nshare of medical assistance payments made by the state on behalf of the\nlocal social services district shall be paid to the state by the local\nsocial services district using electronic funds transfer under the\nsupervision of the state comptroller and pursuant to rules and\nregulations of the commissioner of health. The state comptroller shall\ndeposit such funds in the medicaid management information system\nstatewide escrow fund to the credit of each local district. In the event\nthat the state comptroller and commissioner of health determine that\nthere are insufficient funds available from the local district to\nliquidate their local share of medical assistance payments, the\ncommissioner of health shall issue a repayment schedule to the state\ncomptroller for purposes of reducing reimbursement from other sources of\npayment from the state to the city or county of which the local social\nservices district is a part in accordance with subdivision thirteen of\nthis section, until the amounts due from the local district are\nrecovered in full plus any interest that would have otherwise accrued to\nthe fund had such fund had sufficient balances from the local district.\nUpon determination by the state comptroller that insufficient sources of\npayment are available to fully liquidate the local social services\ndistrict share of medical assistance payments, the commissioner of\nhealth shall include in such schedule a charge to the county equal to\nthe amount of interest otherwise earned by the state short-term interest\npool, plus any interest penalty as the commissioner of health may\ndetermine, until such time as the district has fully liquidated its\nliability pursuant to the provisions of this chapter.\n