Information for Health Plans

Managed Care Organizations (MCO) are required to establish a mental health and substance use disorder parity compliance program pursuant to 10 NYCRR Subpart 98-4. This regulation sets forth the requirements of such programs. The regulation further requires MCOs to submit a written certification to the Commissioner, certifying that the MCO satisfactorily meets the requirements of the regulation. The certification is required to be submitted by December 31, 2021 and annually thereafter.

The Parity Compliance Program Certification form was jointly developed by the Department of Financial Services and the Department of Health requires all MCOs subject to the regulation to use this form to certify that all requirements of the regulation have been met.

The completed certification form, and any questions are to be sent to the mailbox at BHParity@health.ny.gov

Entities 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 need to complete the NYS MCO Certification Application - Medicare Only (PDF).

Important New York State Department of Health application due dates that must be submitted to the Division of Health Plan Contracting and Oversight related to Medicare Advantage as a requirement for participation.

Application Type (As Defined in Narrative Below the Chart) Complete DOH Application Due Date Letter of Intent Due to CMS with copy to DOH CMS Application Due Date (Including DOH State Certificate Form) Executed Model Contract *Applied to MAP and IB-Dual SMAC Due Date (As Defined in Narrative Below the Chart) Medicare Coverage Year
Medicare Coverage Year 2026 for IB-Duals, MAP, and Medicare Advantage
New Article 44 MCO Applicant for Medicare Advantage. February 1, 2024 November 1, 2024 Mid-February 2025 Not Applicable July 7, 2025 2026
New Line of Business Application for an Existing Article 44 MCO:
  • IB-Dual
  • MAP
  • Medicare Advantage (all other types below)
 August 1, 2024 November 1, 2024 Mid-February 2025 May 2025
*Applies to MAP and IB-Dual		 July 7, 2025 2026
Service Area Expansion (SAE) for an Existing Article 44 MCO for a new county or new Medicare type:
  • IB-Dual
  • MAP
  • Medicare Advantage (all other types below)
 November 1, 2024 November 1, 2024 Mid-February 2025 May 2025
*Applies to MAP and IB-Dual		 July 7, 2025 2026
Medicare Coverage Year 2027 for IB-Duals, MAP, and Medicare Advantage
New Article 44 MCO Applicant for:
  • MAP
  • Medicare Advantage (all other types below)
 February 1, 2025 November 1, 2025 Mid-February 2026 May 2026
*Applies to MAP and IB-Dual		 July 6, 2026 2027
New Line of Business Application for an Existing Article 44 MCO:
  • IB-Dual
  • MAP
  • Medicare Advantage (all other types below)
 July 1, 2025 November 1, 2025 Mid-February 2026 May 2026
*Applies to MAP and IB-Dual		 July 6, 2026 2027
Service Area Expansion (SAE) for an Existing Article 44 MCO for a new county or new Medicare type:
  • IB-Dual
  • MAP
  • Medicare Advantage (all other types below)
 November 1, 2025 November 1, 2025 Mid-February 2026 May 2026
*Applies to MAP and IB-Dual		 July 6, 2026 2027

Below is additional information from the New York State Department of Health regarding the types of Medicare Advantage applications that must be submitted by the due dates in the above chart.

For additional Medicare Advantage resources and information on the Medicare Advantage program types, please contact the New York State Department of Health and visit the Centers for Medicare & Medicaid Services (CMS).

The New York State Department of Health due dates apply to the following applications:

  1. Integrated Benefit-Dual (IB-Dual) "Mini Application" - This application is required to certify the IB-Dual program for the Medicaid Managed Care and HARP lines of business that includes Medicare Advantage D-SNP for dual eligibles.
  2. Medicaid Advantage Plus (MAP) Application - This application is required to certify the MAP line of business that includes Medicare Advantage D-SNP that is exclusively aligned with the New York State Department of Health MAP benefits.
  3. Medicare Advantage Application - These applications are required to certify a new Medicare Advantage type in a county. To be clear, the MCO may already operate Medicare Advantage in that county, however, an application is required to add a new Medicare Advantage type in that county. Below are the Medicare Advantage types:
    1. Medicare Advantage D-SNP Coordination Only - This application is required to certify the Medicare Advantage line of business for the Medicare Advantage D-SNP type where members are dually eligible. The MCO covers the Medicare Advantage services only and is responsible for coordination of benefits with New York State Medicaid Fee-for-Service (FFS) for Medicaid services.
      • *As per the State Medicaid Agency Contract (SMAC) - agreement requirements, the New York State Department of Health will not accept new Medicare Advantage D-SNP Coordination Only Line of Business applications.
      • MCO's that currently offer a Medicare Advantage D-SNP Coordination Only may continue to operate in existing service areas, however, the MCO may not submit a Service Area Expansion (SAE) to further expand into new counties for Medicare Advantage D-SNP Coordination Only.
    2. Medicare Advantage C-SNP Application - The application is required to certify the Medicare Advantage line of business for the Medicare Advantage C-SNP type where members have specific severe or disabling chronic conditions as required per CMS. The MCO covers Medicare Advantage services only.
    3. Medicare Advantage I-SNP/IE-SNP Application - The application is required to certify the Medicare Advantage line of business for the Medicare Advantage I-SNP and IE-SNP types where members require placement in an Institution (I-SNP) or Institutional Equivalent (IE-SNP) facility. The MCO covers Medicare Advantage services only.
    4. Medicare Advantage MAPD Application - The application is required to certify the Medicare Advantage line of business for the Medicare Advantage MAPD type where members receive Medicare Advantage and prescription drug (MAPD) coverage. The MCO covers Medicare Advantage services only.
    5. Medicare Advantage Application - The application is required to certify the Medicare Advantage line of business for the Medicare Advantage where members receive Medicare Advantage, without prescription drug coverage. The MCO covers Medicare Advantage services only.
  • Guidance for Health Plans
    • Instructions for Completing the Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP for the Integrated Benefits for Dually Eligible Enrollees (IB-Dual) Program - (Web) - (PDF)
  • Additional Resources:
    • Integrated Care Plans for Dual Eligible New Yorkers - (Website)
    • D-SNPs: Integration & Unified Appeals & Grievance Requirements - (Website)
  • Guidelines - (Web) - (PDF) - Updated 11.16.2022
  • Template - (PDF) - (Word) - Updated 11.16.2022
  • Person Centered Service Planning Home and Community Based Services Final Rule Implementation Webinar - (YouTube).
  • Medicaid Managed Care Exclusion Exemption Chart - (Web) - (PDF) - 1.29.2024
  • MMC Guidance:
    • Process for Expedited Request for Assessment and the New York Independent Assessor (NYIA) - (Web) - (PDF) - 11.23.2022
    • ADDITIONAL REVISION Implementation Date for New York Independent Assessor (NYIA) to Conduct Assessments for Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) on an Expedited Basis - (Web) - (PDF) - 8.30.2022
    • REVISED Implementation Date for New York Independent Assessor (NYIA) to Conduct Assessments for Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) on an Expedited Basis - (Web) - (PDF) - 6.17.2022
    • Implementation of the New York Independent Assessor for Initial Assessments - (Web) - (PDF) - 4.28.2022
  • Article 44 MCO Sepsis Guidance - (Web) - (PDF) - 7.15.2019
  • Criteria Standards for the Authorization and Utilization Management of Treatment for Gender Dysphoria - (Web) - (PDF)
  • Criteria Standards for the Authorization and Utilization Management of Harm Reduction Services - (Web) - (PDF)
  • Service Authorization and Appeals for Mainstream Medicaid Managed Care Plans, HARP, and HIV SNP - (Web)
  • Implementation of 42 CFR 438 Pharmacy Provisions
    • CMS Medicaid Managed Care Final Rule:
  • HMO and IPA provider contracts - (Web)
  • Management Contract Guidelines for MCOs and IPAs - (Web)
    • Standard Clauses for Management Service Agreements - (Web) - (PDF) - 5.4.2011
    • Management Contract Statement and Certification (DOH-5038) (PDF) - September 2011
  • New York State Medicaid Perinatal Care Standards - (Web)
  • Medicaid Managed Care Model Member Handbook - (Web) - (PDF) - Revised January 2009
  • Medicaid Managed Care Guidance and Application to Offer Cost-effective Alternative Services (In Lieu of) - (Web) - (PDF) - Revised 11.9.2023
    • Updates to In Lieu of Services or Setting (ILS) Application Process and Guidance - (Web) - (PDF) - 11.9.2023
    • State Identified ILS MTM Reporting Template - (XLSX) - Updated 11.15.2022
    • State Identified ILS-MTM Presentation - (Web) - (PDF) - 7.3.2023
    • State Identified ILS-MTM Application - (PDF) - 11.16.2023
    • State Identified Request Form for In Lieu of Services in an Institute for Mental Disease - (Web) - (PDF)
    • State Identified ILS IMD Presentation - (Web) - (PDF) - 9.19.2019
  • Medicaid Managed Care Organizations Guidance for Telehealth Innovation Plans - (Web) - (PDF) - September 2017
    • Telehealth Innovations and 2018 Quality Incentive - (Web) - (PDF) - 12.17.2018
    • Announcing Medicaid Managed Care Telehealth Innovation - (Web) - (PDF) - 9.18.2017
  • Cultural Competency Completion - (Web) - (PDF) - 9.26.2022
  • Reminder Notice to Plans - (Web) - (PDF) - 8.16.2022
  • For Participating Providers - (Web) - (PDF) - 10.4.2021
  • COBA Presentation - (PDF) - Updated November 2022
    • Redline Version - (PDF)
  • COBA Attestation - (PDF)
  • COBA Attachment Templates:
    • Partial - (PDF) - July 2023
    • HARP - (PDF) - July 2023
    • HIV/SNP - (PDF) - July 2023
    • Mainstream - (PDF) - July 2023
    • Medicaid Advantage Plus - (PDF) - July 2023
  • COBA Presentation (PDF) - 5.25.2021
  • COBA Attachment Templates:
    • Partial - (PDF) - November 2022
    • HARP - (PDF) - November 2022
    • HIV/SNP - (PDF) - November 2022
    • Mainstream - (PDF) - November 2022
    • Medicaid Advantage Plus - (PDF) - November 2022
    • Medicaid Advantage - (PDF) - April 2022
  • Clarification #1 - (Web) - (PDF) - 5.9.2024
  • Technical Specifications Manual - (PDF) - Revised 5.9.2024
  • MY2024 Table 1: QARR List of Required Measures - (Web) - (XLSX) - Posted 12.11.2023
  • Commercial MY2024 PLD File Specifications - (PDF) - Revised 5.9.2024
  • Medicaid MY2024 PLD File Specifications - (PDF) - Revised 5.9.2024
  • Exchange MY2024 PLD File Specifications - (PDF) - Revised 5.9.2024
  • NYS QARR Value Set - (Web) - (XLSX) - Revised 5.9.2024
  • Language Value Set - (Web) - (PDF) - (XLSX) - Revised 5.9.2024
  • NYS QARR Medication List - (Web) - (PDF) - (XLSX) - 5.9.2024
  • Clarification #1 - (Web) - (PDF) - 6.5.2023
  • Clarification #2 - (Web) - (PDF) - 8.28.2023
  • Clarification #3 - (Web) - (PDF) - 10.11.2023
  • Clarification #4 - (Web) - (PDF) - 11.7.2023
  • Clarification #5 - (Web) - (PDF) - 11.21.2023
  • Clarification #6 - (Web) - (PDF) - 12.14.2023
  • Clarification #7 - (Web) - (PDF) - 2.14.2024
  • Clarification #8 - (Web) - (PDF) - 5.2.2024
    • Technical Specifications Manual - (PDF) - Revised 5.2.2024
      • MY2023 Table 1: QARR List of Required Measures - (Web) - (PDF) - (XLSX) - Revised 10.11.2023
    • Commercial MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • Medicaid MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • Exchange MY2023 PLD File Specifications - (Web) - (PDF) - Revised 2.14.2024
    • NYS QARR Value Set - (Web) - (XLSX) - Posted 1.9.2023
    • Language Value Set - (Web) - (PDF) - (XLSX) - Revised 10.11.2023
    • NYS QARR Medication List - (Web) - (XLSX) - Revised 6.5.2023
  • Clarification #1 - (Web) - (PDF) - 12.10.2021
  • Clarification #2 - (Web) - (PDF) - 1.3.2022
  • Clarification #3 - (Web) - (PDF) - 2.7.2022
  • Clarification #4 - (Web) - (PDF) - 6.30.2022
  • Clarification #5 - (Web) - (PDF) - 7.13.2022
  • Clarification #6 - (Web) - (PDF) - 9.8.2022
  • Clarification #7 - (Web) - (PDF) - 10.28.2022
  • Clarification #8 - (Web) - (PDF) - 11.17.2022
  • Clarification #9 - (Web) - (PDF) - 11.30.2022
  • Clarification #10 - (Web) - (PDF) - 1.5.2023
  • Clarification #11 - (Web) - (PDF) - 1.25.2023
  • Clarification #12 - (Web) - (PDF) - 2.13.2023
  • Clarification #13 - (Web) - (PDF) - 3.13.2023
  • Clarification #14 - (Web) - (PDF) - 4.20.2023
    • Technical Specifications Manual - (PDF)
    • Commercial MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • Medicaid MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • Exchange MY2022 PLD File Specifications - (Web) - (PDF) - Revised 11.30.2022
    • NYS QARR Value Set - (Web) - (XLSX)
    • NYS QARR Medication List - (Web) - (XLSX) - Revised 2.14.2023
  • 2018 HCBS Rule Systemic Compliance Chart - (Web) - (XLSX) - (PDF)
  • Reimbursement for Hospital Based & Free-Standing Behavioral Health Clinics Claims for Dually Eligible Members - (Web) - (PDF) - Updated 12.1.2021
  • Preparedness for Coronavirus (COVID-19) - (Web) - (PDF)
  • Antiretroviral Medication List - (Web) - (PDF) - October 2018
  • HIV Antiretroviral Diagnosis List - (Web) - (PDF) - June 2019
  • New York State Medicaid "Serious Adverse Event Reimbursement" (also known as New York State Medicaid "Never Events") - (Web)
  • Workers´ Compensation PPO Application - (Web)
  • New York State Department of Health Guidelines for Contractor Compliance with the Federal Americans with Disabilities Act - See Appendix J of the MMC/FHP/HIV SNP/HARP Model Contract - (PDF)
  • HP-CMART3 Specification (v3.8) - (Web) - (PDF) - Revised January 2024

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.

  • Character and Competency Review (DOH-793B) (PDF)
  • Affiliations with Other Health Care Operations (DOH-793C) (PDF)
  • Regulatory Compliance Statement (DOH-794) (PDF)
  • 2008 Medicaid Performance Improvement Projects - (Web) - (PDF) - October 2009
  • Plan-Specific Reports of NYS Medicaid Managed Care Plans - (Web)
  • Dental Care Survey, Medicaid Managed Care Members - (Web) - (PDF) - February 2007
  • New York State Public Health Law Article 49, Current through 2013, Chapters 1-383 - (PDF)
  • Important Phone Numbers for Patients and Providers - (Web)
  • ADA Accessibility Guidelines for Buildings and Facilities (ADAAG) - (Web)