Information for Health Plans

Health Plan Certification in New York State

To apply for certification under Public Health Law Article 44 (PDF, 259KB, 66pg.) as a Health Maintenance Organization or Prepaid Health Services Plan, contact:

Division of Managed Care
Bureau of Managed Care Certification and Surveillance
Corning Tower Room 1911
Empire State Plaza
Albany, New York 12237
(518) 474-5515

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, 137KB, 10pg.)

For MCOs offering Medicare Advantage to participate in the New York State Medicaid Advantage program for dual eligible populations plans must meet programmatic guidelines and standards as described in the Application for Participation in Medicaid Advantage (PDF, 74KB, 24pg.)

For full-risk MCOs to qualify to participate in the New York State Medicaid managed care program in counties with mandatory or voluntary enrollment, including qualification requirements for serving dual eligible populations, plans must meet programmatic guidelines and standards as described in the Managed Care Organization Medicaid Qualification Guidelines (PDF, 565KB, 55pg.)

To certify as a preferred provider organization (PPO) delivering workers' compensation medical care, see the Workers' Compensation PPO Application.

Health Plan Guidelines

Utilization Review Agent Registration

Article 49 of the NYS Public Health Law (PDF, 121KB, 32pg.) requires that independent utilization review agents register with the Department of Health every two years, prior to conducting utilization review services for MCOs in New York State. NYCRR Title 10 Part 732-2(f) requires agents to register with the Department prior to conducting utilization review services for New York State Workers' Compensation PPOs. Contact DMC for assistance.

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.

Quality Review Reports

References