of Health
Department
Human Services
Centers for Medicare
Medicaid Services
Plaza Room
New York NY 10278
37100 North
26 Federal
c
s
CENTERS for MEDICARE MEDICAID SERVICES
July 6 2011
Jason A Helgerson
Medicaid Director
Office of Health Insurance Programs
New York State Department of Health
Corning Tower
Empire State Plaza
Albany New York 12237
Dear Mr Helgerson
The New York State Plan Amendment SPA 11 78 received in our office on June 15 2011
has been approved This SPA implements the Medicaid payment provision Section 6505 ofthe
Affordable Care Act entitled Prohibition on Payments to Institutions or Entities Located
Outside ofthe United States
This provision requires that the State does not provide any
payments for items or services provided under the State plan or under a waiver to any financial
institution or entity located outside of the United States
Please note the approval date ofthis SPA is July 6 2011 and the effective date is June 1 2011
Enclosed please find copy of the approved pages for the State Plan Amendment 11 78 and the
signed CMS 179 form
If you have any questions please contact Ana J Balbuena at 212 6162410
Sincerer
Michael
Associate
4 endez
ional Administrator
Division of Medicaid and s
Children Health
DEPARTMENT OF HEALTH AND HUMAN SERVICES
HEALTH CARE FINANCING ADMINISTRATION
1
FORM APPROVED
OMB NO 0938 0
93
TRANSMITTAL AND NOTICE OF APPROVAL OF
f
STATE PLAN MATERIAL
i
STATE
i
11 7
I New York
FOR HEALTH CARE FINANCING ADMINISTRATION
4
i
1 TRANSMITTAL NUMBER
I
3
PROGRAM IDENTIFICATION TITLE XIX OF THE
SOCIAL SECURITY ACT MEDICAID
1
TO REGIONAL ADMINISTRATOR
4 PROPOSED EFFECTIVE DATE
HEALTH CARE FINANCING ADMINISTRATION
June 1 2011
DEPARTMENT OF HEALTH AND HUMAN SERVICES
5 TYPE OF PLAN MATERIAL Check One
NEW STATE PLAN
Q
AMENDMENT TO BE CONSIDERED AS NEW PLAN
A AMENDMENT
COMPLETE
BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT Separate Transmittalfor each amendment
6 FEDERAL STATUTE
REGULATION CITATION
Section
80
a
1902
of the Social
L111148 section
P
7 FEDERAL BUDGET IMPACT
Security Act
a
I
6505
8 PAGE NUMBER OF THE PLAN SECTION OR
ATTACHMENT
FFY 06
11
01
11 SO
30
09
b FFY 10101 I 1 0930
12 SO
9 PAGE NUMBER OF THE SUPERSEDED PLAN
SECTION OR ATTACHMENT IjApplicable
Attachment 1 Page 79 z
Attachment 1 New
10 SUBJECT OF AMENDMENT
Prohibition on Payments to Institutions or Entities Located Outside of the United States
I I GOVERNOR
SREVIEW Check One
S
GOVERNOR
OFFICE REPORTED NO COMMENT
0 OTHER AS SPECIFIED
COMMENTS OF GOVERNOR
S OFFICE ENCLOSED
NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL
1
12 SIG
T
F STATE AGENCY OFFICIAL
16 RETURN TO
New York State Department of Health
13 TY
14
1
i
Corning Tower
Empire State Plaza
Jason A Helgerson
TITLE Medicaid Director
Deputy Commissioner
Albany New York 12237
Department of Health
15 DATE SUBMITTED
2011
June27
W6
19
EFFDATE EM
TI
j
Ot
s
z
ice
i
A
5
4
PEjc
L
21 TYPEDNAME
I
2
i
n
MARK
z
z 1
FORM HCFA 179 0792
71
i
2
I
79z
State Territory New York
44
4
Medicaid Prohibition on Payments to Institutions or Entities Located
Outside of the United States
Citation Section 1902
8Qof Social Security Act P
a
L 111 148 Section 6505
JX
The State shall not provide any payments for items or services provided under the
State plan or under a waiver to any financial institution or entity located outside of the
United States
TN No
Effective Date
1178
JUIN 0 1 2811
L 0 6 Zell
Supersedes
TN No
NEW
Approval
Date