assembly Bill A7860A

2011-2012 Legislative Session

Provides for establishment of the New York Health plan and makes an appropriation to the temporary commission on implementation of the plan

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Archive: Last Bill Status - In Committee


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor

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Actions

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jun 18, 2012 reported referred to ways and means
Jun 05, 2012 reported referred to codes
May 18, 2012 print number 7860a
amend (t) and recommit to health
Jan 04, 2012 referred to health
May 19, 2011 referred to health

Bill Amendments

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A (Active)
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Co-Sponsors

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A7860 - Bill Details

See Senate Version of this Bill:
S5425A
Current Committee:
Law Section:
Public Health Law
Laws Affected:
Ren Art 50 §§5000 - 5003 to be Art 80 §§8000 - 8003, add Art 51 §§5100 - 5110, add Art 49 Title 3 §§4920 - 4927, amd §270, Pub Health L; add §89-h, St Fin L
Versions Introduced in 2009-2010 Legislative Session:
A2356, S2370

A7860 - Bill Texts

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Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents: provides for administrative structure of the plan; provides for powers and duties of the board of trustees, the scope of benefits, payment methodologies and care coordination; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; enacts provisions relating to financing of New York Health, including a payroll assessment, similar to the Medicare tax; establishes a temporary commission on implementation of the plan; provides for collective negotiations by health care providers with New York Health.

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                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

    S. 5425                                                  A. 7860

                       2011-2012 Regular Sessions

                      S E N A T E - A S S E M B L Y

                              May 19, 2011
                               ___________

IN  SENATE  --  Introduced  by  Sens.  DUANE,  PERKINS -- read twice and
  ordered printed, and when printed to be committed to the Committee  on
  Finance

IN  ASSEMBLY  --  Introduced  by M. of A. GOTTFRIED, BENEDETTO, BRONSON,
  BROOK-KRASNY, CYMBROWITZ, ENGLEBRIGHT, GANTT, HIKIND, JAFFEE,  JACOBS,
  KELLNER,  LAVINE,  MAISEL,  PEOPLES-STOKES, SCHROEDER, SWEENEY, TITUS,
  KAVANAGH -- Multi-Sponsored by -- M. of  A.  ABBATE,  AUBRY,  BOYLAND,
  BRENNAN,  CAHILL, CAMARA, CLARK, COLTON, COOK, FARRELL, GUNTHER, HOYT,
  LENTOL, V. LOPEZ, LUPARDO, MAGEE, MAGNARELLI, McENENY, MILLMAN, ORTIZ,
  PAULIN,  PERRY,  PRETLOW,   RAMOS,   REILLY,   J. RIVERA,   N. RIVERA,
  P. RIVERA,   ROBINSON,  ROSENTHAL,  SCARBOROUGH,  THIELE,  WEISENBERG,
  WEPRIN, WRIGHT -- read once and referred to the Committee on Health

AN ACT to amend the public health law, the state finance law and the tax
  law, in relation to the establishment of the New York health plan  and
  making  an appropriation to the temporary commission on implementation
  of the New York health plan and providing for the  repeal  of  certain
  provisions upon expiration thereof

  THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section 1. Article 50 and sections 5000, 5001, 5002 and  5003  of  the
public  health  law  are  renumbered article 80 and sections 8000, 8001,
8002 and 8003 and a new article 51 is added to read as follows:
                                ARTICLE 51
                          NEW YORK HEALTH PLAN
SECTION 5100. LEGISLATIVE FINDINGS.
        5101. SHORT TITLE.
        5102. DEFINITIONS.
        5103. PLAN CREATED.
        5104. BOARD OF GOVERNORS.
        5105. POWERS AND DUTIES OF THE BOARD.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02490-01-1

S. 5425                             2                            A. 7860

        5106. POWERS AND DUTIES OF THE EXECUTIVE DIRECTOR.
        5107. PLAN ELIGIBILITY.
        5108. PLAN BENEFITS.
        5109. PAYMENT FOR SERVICES.
        5110. OUT-OF-STATE PARTICIPATION AND PAYMENTS.
  S  5100. LEGISLATIVE FINDINGS. THE LEGISLATURE FINDS AND DECLARES THAT
ALL RESIDENTS OF THE  STATE  OF  NEW  YORK  HAVE  THE  RIGHT  TO  HEALTH
SERVICES, YET AN INCREASING NUMBER OF NEW YORKERS ARE UNABLE TO EXERCISE
THIS  RIGHT BECAUSE OF A LACK OF HEALTH COVERAGE. NEW YORKERS HAVE EXPE-
RIENCED A RAPID RISE IN THE COST OF HEALTH CARE IN  RECENT  YEARS.  THIS
INCREASE  HAS  RESULTED  IN  A  LARGE NUMBER OF PEOPLE   WHO HAVE HAD TO
DISCONTINUE THEIR HEALTH  COVERAGE.  BUSINESSES  HAVE  ALSO  EXPERIENCED
EXTRAORDINARY  INCREASES  IN THE COSTS OF HEALTH CARE BENEFITS FOR THEIR
EMPLOYEES. OVER THREE MILLION NEW YORKERS HAVE NO HEALTH  COVERAGE,  AND
ANOTHER ESTIMATED THREE MILLION ARE SEVERELY UNDERINSURED. HOSPITALS AND
OTHER  HEALTH  CARE  PROVIDERS  ARE  ALSO  AFFECTED BY INADEQUATE HEALTH
INSURANCE COVERAGE IN NEW YORK STATE. A LARGE PORTION OF  VOLUNTARY  AND
PUBLIC  HOSPITALS,  HEALTH  CENTERS  AND  OTHER PROVIDERS NOW EXPERIENCE
SUBSTANTIAL LOSSES DUE TO THE PROVISION OF CARE THAT  IS  UNCOMPENSATED.
TO ADDRESS THE FISCAL CRISIS FACING THE HEALTH CARE SYSTEM AND TO ASSURE
NEW  YORKERS  CAN  EXERCISE  THEIR  RIGHT TO HEALTH CARE, AFFORDABLE AND
COMPREHENSIVE HEALTH COVERAGE MUST BE PROVIDED. PURSUANT  TO  THE  STATE
CONSTITUTION'S  CHARGE  TO  THE LEGISLATURE TO PROVIDE FOR THE HEALTH OF
NEW YORKERS, THIS ARTICLE IS AN  ENACTMENT  OF  STATE  CONCERN  FOR  THE
PURPOSE  OF  ESTABLISHING A COMPREHENSIVE UNIVERSAL HEALTH CARE COVERAGE
PROGRAM AND A HEALTH CARE COST CONTROL SYSTEM FOR  THE  BENEFIT  OF  ALL
RESIDENTS OF THE STATE OF NEW YORK.
  S  5101.  SHORT TITLE. THIS ARTICLE SHALL BE KNOWN AND MAY BE CITED AS
THE "NEW YORK HEALTH PLAN".
  S 5102. DEFINITIONS. FOR THE PURPOSES  OF  THIS  ARTICLE,  UNLESS  THE
CONTEXT CLEARLY REQUIRES OTHERWISE:
  1. "BOARD" MEANS THE BOARD OF GOVERNORS OF THE NEW YORK HEALTH PLAN AS
CREATED BY SECTION FIFTY-ONE HUNDRED FOUR OF THIS ARTICLE.
  2.  "PLAN" MEANS THE NEW YORK HEALTH PLAN AS CREATED BY SECTION FIFTY-
ONE HUNDRED THREE OF THIS ARTICLE.
  3. "PLAN MEMBER" MEANS ANY PERSON WHO QUALIFIES FOR BENEFITS UNDER THE
PLAN UNDER SECTION FIFTY-ONE HUNDRED SEVEN OF THIS ARTICLE.
  4. "PARTICIPATING PROVIDER" MEANS ANY PERSON, PARTNERSHIP, CORPORATION
OR OTHER ENTITY, AUTHORIZED TO FURNISH COVERED SERVICES PURSUANT TO THIS
ARTICLE.
  5. "PLAN RATE" MEANS THE RATE OF PAYMENT FOR A COVERED SERVICE,  UNDER
THE PLAN, ESTABLISHED IN ACCORDANCE WITH THIS ARTICLE.
  6.  "GLOBAL BUDGET" MEANS AN INSTITUTION-WIDE BUDGET FOR THE FIXED AND
OPERATING COSTS FOR THE PROVISION OF HEALTH CARE SERVICES, EXCLUSIVE  OF
CAPITAL  EXPENDITURES  COVERED UNDER SUBPARAGRAPH (III) OF PARAGRAPH (E)
OF SUBDIVISION TWO OF SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE.
  7. "RESIDENT" MEANS A PERSON WHO HAS ESTABLISHED THEIR  PRIMARY  PLACE
OF  ABODE  IN  THIS STATE, AS DETERMINED ACCORDING TO REGULATIONS OF THE
BOARD.
  S 5103. PLAN CREATED. THERE IS HEREBY ESTABLISHED THE NEW YORK  HEALTH
PLAN,  TO  PROVIDE, AS SET OUT IN THIS ARTICLE, AND RELATED LEGISLATION,
UNIVERSAL HEALTH COVERAGE FOR ALL RESIDENTS OF THIS STATE, ACCESS TO AND
CHOICE OF HEALTH CARE PROVIDERS, CONTROLS ON HEALTH CARE COSTS, DEVELOP-
MENT OF HEALTH CARE SERVICES, AND  PUBLIC  FINANCING  FOR  THE  PROGRAM.
SUCH PLAN SHALL BE A CORPORATE GOVERNMENTAL AGENCY CONSTITUTING A PUBLIC
BENEFIT CORPORATION.

S. 5425                             3                            A. 7860

  S  5104. BOARD OF GOVERNORS. 1. A BOARD OF GOVERNORS TO ADMINISTER THE
PLAN IS HEREBY CREATED. THE BOARD SHALL BE COMPOSED OF EIGHTEEN MEMBERS,
TO CONSIST OF THE CHAIR AND SEVENTEEN ADDITIONAL MEMBERS,  APPOINTED  BY
THE  GOVERNOR WITH THE ADVICE AND CONSENT OF THE SENATE. THE COMMISSION-
ER,  THE  SUPERINTENDENT  OF INSURANCE, AND THE COMMISSIONER OF TAXATION
AND FINANCE SHALL SERVE AS NONVOTING EX OFFICIO MEMBERS OF THE BOARD.
  OF THE SEVENTEEN ADDITIONAL MEMBERS APPOINTED BY THE GOVERNOR:
  (A) FIVE SHALL BE REPRESENTATIVE  OF  HEALTH  CARE  CONSUMER  ADVOCACY
ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY,  WHO HAVE
BEEN  INVOLVED  IN  ACTIVITIES RELATED TO HEALTH CARE CONSUMER ADVOCACY,
INCLUDING ISSUES OF INTEREST TO LOW AND MODERATE-INCOME INDIVIDUALS;
  (B) THREE SHALL BE REPRESENTATIVE OF LABOR ORGANIZATIONS;
  (C) THREE SHALL BE REPRESENTATIVE OF BUSINESS AND INDUSTRY;
  (D) TWO SHALL BE REPRESENTATIVE OF HOSPITALS;
  (E) TWO SHALL BE REPRESENTATIVE OF PHYSICIANS; AND
  (F) TWO SHALL BE REPRESENTATIVE OF LICENSED NON-PHYSICIAN HEALTH  CARE
PROFESSIONALS.
  2.  MEMBERS  SHALL SERVE FOR A TERM OF FIVE YEARS; EACH TERM SHALL END
ON DECEMBER THIRTY-FIRST. EACH MEMBER OF THE  BOARD  SHALL  HOLD  OFFICE
FROM  THE DATE OF QUALIFICATION FOR OFFICE UNTIL THE END OF THE TERM FOR
WHICH THE MEMBER WAS APPOINTED. ANY MEMBER APPOINTED TO FILL  A  VACANCY
OCCURRING  PRIOR  TO THE EXPIRATION OF A TERM, SHALL HOLD OFFICE FOR THE
REMAINDER OF THAT TERM.
  3. EACH MEMBER SHALL CONTINUE IN OFFICE SUBSEQUENT TO  THE  EXPIRATION
DATE OF THE TERM UNTIL A SUCCESSOR TAKES OFFICE.
  4. THE GOVERNOR MAY REMOVE THE CHAIR OF THE BOARD FOR GOOD CAUSE PRIOR
TO  THE  EXPIRATION OF HIS OR HER TERM. IN THE EVENT OF A VACANCY IN THE
CHAIR, THE GOVERNOR MAY APPOINT A PERSON TO  BE  ACTING  CHAIR  UNTIL  A
CHAIR SHALL BE CONFIRMED BY THE SENATE.
  5. THE BOARD SHALL MEET AT LEAST FOUR TIMES IN A CALENDAR YEAR.
  6.  MEETINGS  SHALL BE HELD UPON THE CALL OF THE CHAIR AND AS PROVIDED
BY THE BOARD.
  7. TEN MEMBERS OF THE BOARD SHALL CONSTITUTE A QUORUM, AND THE  AFFIR-
MATIVE VOTE OF TEN MEMBERS SHALL BE NECESSARY FOR ANY ACTION TO BE TAKEN
BY THE BOARD.
  8.  THE  BOARD  MAY  ESTABLISH AN EXECUTIVE COMMITTEE TO CARRY OUT ANY
POWERS OR DUTIES OF THE BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO
ASSIST THE BOARD OR THE EXECUTIVE COMMITTEE.  THE  CHAIR  OF  THE  BOARD
SHALL  BE  THE  CHAIR  OF  THE EXECUTIVE COMMITTEE AND SHALL APPOINT THE
CHAIRS OF OTHER  COMMITTEES.  THE  BOARD  MAY  ALSO  ESTABLISH  ADVISORY
COMMITTEES, CONSISTING OF PERSONS OTHER THAN MEMBERS OF THE BOARD.
  9.  MEMBERS OF THE BOARD, WITH THE EXCEPTION OF THE CHAIR, SHALL SERVE
WITHOUT COMPENSATION, BUT SHALL BE REIMBURSED FOR  THEIR  NECESSARY  AND
ACTUAL EXPENSES INCURRED WHILE ENGAGED IN THE BUSINESS OF THE BOARD.
  10.  NOTWITHSTANDING  ANY  INCONSISTENT  PROVISIONS  OF  LAW, GENERAL,
SPECIAL OR LOCAL, NO OFFICER OR EMPLOYEE OF THE STATE OR  OF  ANY  CIVIL
DIVISION  THEREOF SHALL BE DEEMED TO HAVE FORFEITED OR SHALL FORFEIT HIS
OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A MEMBER OF THE BOARD.
  S 5105. POWERS AND DUTIES OF THE BOARD.  1. EXCEPT AS OTHERWISE LIMIT-
ED BY THIS ARTICLE, THE BOARD SHALL HAVE THE FOLLOWING CORPORATE POWERS:
  (A) TO SUE AND BE SUED;
  (B) TO HAVE A SEAL AND ALTER THE SAME AT PLEASURE;
  (C) TO MAKE AND EXECUTE CONTRACTS AND ALL OTHER INSTRUMENTS  NECESSARY
OR  CONVENIENT  FOR  THE EXERCISE OF ITS POWERS AND FUNCTIONS UNDER THIS
ARTICLE;

S. 5425                             4                            A. 7860

  (D) TO MAKE AND  ALTER  BY-LAWS  FOR  ITS  ORGANIZATION  AND  INTERNAL
MANAGEMENT;
  (E)  TO  ACQUIRE, HOLD AND DISPOSE OF PERSONAL PROPERTY FOR ITS CORPO-
RATE PURPOSES;
  (F) TO APPOINT OFFICERS, AGENTS AND EMPLOYEES, PRESCRIBE THEIR  DUTIES
AND QUALIFICATIONS AND FIX THEIR COMPENSATION;
  (G)  TO  BORROW MONEY AND ISSUE NEGOTIABLE NOTES, BONDS OR OTHER OBLI-
GATIONS FOR ITS CORPORATE PURPOSES AND TO PROVIDE FOR THE RIGHTS OF  THE
HOLDERS THEREOF;
  (H)  TO  INVEST  ANY  FUNDS  HELD  IN RESERVE OR SINKING FUNDS, OR ANY
MONIES NOT REQUIRED FOR  THE  IMMEDIATE  USE  OR  DISBURSEMENT,  AT  THE
DISCRETION OF THE PLAN, IN OBLIGATIONS OF THE STATE OR THE UNITED STATES
GOVERNMENT,  OR IN ANY OTHER OBLIGATIONS IN WHICH THE COMPTROLLER OF THE
STATE  OF  NEW  YORK  IS  AUTHORIZED  TO  INVEST  PURSUANT  TO   SECTION
NINETY-EIGHT OF THE STATE FINANCE LAW;
  (I)  TO  ACCEPT  ANY  GIFTS OR GRANTS OR LOANS OF FUNDS OR PROPERTY OR
FINANCIAL OR OTHER AID IN ANY FORM FROM THE FEDERAL  GOVERNMENT  OR  ANY
AGENCY  OR  INSTRUMENTALITY  THEREOF OR FROM THE STATE OR FROM ANY OTHER
SOURCE AND TO COMPLY, SUBJECT TO THE PROVISIONS OF  THIS  ARTICLE,  WITH
THE TERMS AND CONDITIONS THEREOF; AND
  (J)  TO DO ANY AND ALL THINGS NECESSARY OR CONVENIENT TO CARRY OUT ITS
PURPOSES AND EXERCISE THE POWERS EXPRESSLY GIVEN  AND  GRANTED  IN  THIS
ARTICLE.
  2. THE BOARD SHALL HAVE THE ADDITIONAL POWER TO DO THE FOLLOWING:
  (A)  (I)  ESTABLISH  A  BUDGET TO INCLUDE ALL HEALTH CARE EXPENDITURES
MADE BY THE PLAN, INCLUDING THE ESTABLISHMENT OF  AGGREGATE  EXPENDITURE
TARGETS  APPLICABLE TO CATEGORIES OF HEALTH SERVICES. (II) IN ESTABLISH-
ING THE BUDGET, THE BOARD SHALL LIMIT  THE  ANNUAL  AGGREGATE  LEVEL  OF
EXPENDITURES  FOR  ANY YEAR TO A SUM EQUIVALENT TO THE LEVEL OF EXPENDI-
TURES IN THE PRECEDING YEAR INCREASED BY ONE HUNDRED TWENTY  PERCENT  OF
THE  ANNUAL INCREASE IN THE CONSUMER PRICE INDEX - URBAN AS DEVELOPED BY
THE UNITED STATES DEPARTMENT OF COMMERCE.   (III)  IN  ESTABLISHING  THE
BUDGET,  GLOBAL BUDGETS, ALLOCATIONS FOR CAPITAL EXPENDITURES, AND OTHER
BUDGET AND EXPENDITURE ACTIONS, THE BOARD SHALL CONSIDER REGIONAL  NEEDS
AND  RESOURCES,  FOR  REGIONS  THAT  ARE  GEOGRAPHICAL  AREAS REASONABLY
RELATED TO THE NEED FOR, AND DELIVERY AND USE OF, PARTICULAR HEALTH CARE
FACILITIES AND SERVICES, AND SHALL ENCOURAGE THE SHARING AND COOPERATIVE
USE OF FACILITIES AND SERVICES BY HEALTH CARE PROVIDERS.
  (B) ESTABLISH PLAN RATES, IN ACCORDANCE WITH SECTION FIFTY-ONE HUNDRED
NINE OF THIS ARTICLE;
  (C) ESTABLISH  GLOBAL  BUDGETS,  AND  DEVELOP  RULES  AND  REGULATIONS
CONCERNING  ALLOWABLE EXPENDITURES TO BE INCLUDED IN GLOBAL BUDGETS, FOR
INSTITUTIONAL  PROVIDERS  OF  SERVICES,  IN  ACCORDANCE   WITH   SECTION
FIFTY-ONE HUNDRED NINE OF THIS ARTICLE;
  (D) ADMINISTER, IMPLEMENT AND MONITOR THE OPERATION OF THE PLAN;
  (E)  ADMINISTER  THE  NEW  YORK  HEALTH TRUST FUND CREATED PURSUANT TO
SECTION EIGHTY-NINE-H OF THE STATE FINANCE LAW, AND INCLUDE  WITHIN  THE
FUND ALLOCATIONS FOR THE FOLLOWING PURPOSES:
  (I)  HEALTH  PROMOTION  AND  PRIMARY  PREVENTION  PROGRAMS,  INCLUDING
PROGRAMS WHICH UTILIZE COMMUNITY SETTINGS, SCHOOLS AND PLACES  OF  WORK,
TO  PROMOTE HEALTHY LIFESTYLES, ENABLE CONSUMERS TO MAKE INFORMED HEALTH
DECISIONS AND PROVIDE SCREENING TESTS NOT PERFORMED AS PART  OF  ROUTINE
CARE.  MONEY ALLOCATED FOR THIS PURPOSE SHALL EQUAL AT LEAST ONE-HALF OF
ONE PERCENT OF THE MONIES IN THE TRUST FUND;
  (II) PAYING PARTICIPATING PROVIDERS IN ACCORDANCE WITH SECTION  FIFTY-
ONE HUNDRED NINE OF THIS ARTICLE;

S. 5425                             5                            A. 7860

  (III) CAPITAL EXPENDITURES FOR THE FOLLOWING PURPOSES:
  (A)  CONSTRUCTION,  RENOVATION,  AND  EQUIPPING  OF HEALTH CARE INSTI-
TUTIONS, INCLUDING INSTITUTIONAL PROVIDERS OF INPATIENT CARE AND AMBULA-
TORY FACILITIES FOR DIAGNOSIS, TREATMENT  AND  SURGERY,  DIAGNOSTIC  AND
TREATMENT CENTERS PROVIDING A COMPREHENSIVE RANGE OF PRIMARY HEALTH CARE
SERVICES,  AND MAJOR MEDICAL EQUIPMENT ACQUIRED FOR USE IN PRIVATE PRAC-
TITIONER OFFICES;
  (B) A LOAN PROGRAM FOR FACILITIES AND EQUIPMENT FOR USE BY HEALTH CARE
PROFESSIONALS WHO DESIRE TO ESTABLISH PRACTICES IN AREAS OF  THIS  STATE
IN  WHICH,  ACCORDING TO CRITERIA ESTABLISHED BY THE BOARD, THE LEVEL OF
DELIVERY OF HEALTH CARE SERVICES IS INADEQUATE;
  (IV) TRANSPORTATION OF PLAN MEMBERS FROM ONE GLOBALLY-BUDGETED  INSTI-
TUTION  TO  ANOTHER FOR THE PROVISION OF COVERED SERVICES, AND OTHERWISE
TO EFFECT COOPERATION AND COMMUNICATION  BETWEEN  INSTITUTIONS  FOR  THE
DELIVERY OF HEALTH CARE SERVICES; AND
  (V)  EDUCATION  AND  TRAINING  OF  WORKERS  IN  THE HEALTH CARE FIELD,
INCLUDING, BUT NOT LIMITED TO, RETRAINING OF WORKERS WHO EXPERIENCE  JOB
LOSS  OR  DISLOCATION ASSOCIATED WITH THE IMPLEMENTATION OF THE NEW YORK
HEALTH PLAN; AND A PROGRAM OF LOAN REPAYMENTS  OR  OTHER  INCENTIVES  TO
ENCOURAGE  HEALTH  CARE  PRACTITIONERS  TO  SERVE  IN UNDERSERVED AREAS,
SPECIALTIES  OR  FACILITIES.  MONIES  ALLOCATED  SHALL  EQUAL  AT  LEAST
ONE-QUARTER OF ONE PERCENT OF THE MONIES IN THE TRUST FUND.
  (F)  IN  CARRYING  OUT ITS POWERS AND DUTIES, ESTABLISH REASONABLE AND
EFFECTIVE MEANS OF:
  (I) COST CONTAINMENT, INCLUDING BUT NOT LIMITED TO:  REDUCING  INEFFI-
CIENCIES  IN  HEALTH  CARE DELIVERY; PROMOTING EFFECTIVE AND APPROPRIATE
USE OF ADVANCEMENTS IN CLINICAL PRACTICE AND TECHNOLOGY; ENCOURAGING THE
USE OF LESS COSTLY ALTERNATIVE PROVIDERS WHERE APPROPRIATE;  AND  ESTAB-
LISHING  TREATMENT  NORMS  FOR  PROVIDERS  TO  REDUCE  THE INAPPROPRIATE
PROVISION OR USE OF SERVICES;
  (II) QUALITY ASSURANCE, INCLUDING BUT NOT LIMITED TO: DEVELOPING CLIN-
ICAL PRACTICE GUIDELINES; AND PROMOTING SYSTEMS FOR  REVIEW  OF  PATIENT
OUTCOMES, AND QUALITY AND APPROPRIATENESS OF SERVICES;
  (III)  PROMOTING  ACCESS  TO  SERVICES,  INCLUDING BUT NOT LIMITED TO:
AVAILABILITY OF PRIMARY, PREVENTIVE AND OTHER SERVICES FOR CONTINUITY OF
CARE; ASSURING CONSUMERS FREEDOM TO SELECT AMONG QUALIFIED PROVIDERS FOR
APPROPRIATE SERVICES WITHIN THEIR RECOGNIZED SCOPE OF PRACTICE; RESPECT-
ING THE PROFESSIONAL JUDGMENT OF PROVIDERS AND THE RIGHTS  OF  PATIENTS,
AND THEIR FAMILIES AND REPRESENTATIVES WHERE APPROPRIATE, TO PARTICIPATE
IN  DECISIONS AFFECTING THEIR CARE; AND ELIMINATING AND PREVENTING INEQ-
UITIES IN, OR BARRIERS TO, ACCESS TO SERVICES BASED ON GEOGRAPHY, SOCIAL
OR ECONOMIC STATUS, RACE, RELIGION, GENDER,  AGE,  ETHNICITY,  LANGUAGE,
SEXUAL ORIENTATION, FAMILY STATUS OR DEFINITION, AND HEALTH CONDITION;
  (G)  ESTABLISH,  AS  THE  BOARD  CONSIDERS  IT  NECESSARY, A SYSTEM TO
PROMOTE CONTINUITY OF CARE;
  (H) ESTABLISH AN INDEMNITY PLAN TO CARRY OUT THE PURPOSES SET FORTH IN
SECTION FIFTY-ONE HUNDRED TEN OF THIS ARTICLE;
  (I) ESTABLISH  A  PRESCRIPTION  DRUG  FORMULARY,  IN  ACCORDANCE  WITH
SECTION FIFTY-ONE HUNDRED EIGHT OF THIS ARTICLE;
  (J)  AWARD  CONTRACTS TO ADMINISTER THE PAYMENT OF COVERED SERVICES TO
PARTICIPATING PROVIDERS, AND OTHER ELEMENTS OF THE  PLAN  AS  THE  BOARD
DEEMS APPROPRIATE;
  (K)  (I)  STUDY  AND EVALUATE THE OPERATION OF THE PLAN, INCLUDING BUT
NOT LIMITED TO THE ADEQUACY AND QUALITY OF SERVICES  COVERED  UNDER  THE
PLAN,  THE  COST  OF  EACH TYPE OF SERVICE AND THE EFFECTIVENESS OF COST
CONTAINMENT MEASURES UNDER THE PLAN; AND

S. 5425                             6                            A. 7860

  (II) STUDY UTILIZATION OF HEALTH CARE SERVICES UNDER THE PLAN, ENROLL-
MENT OF NEW PLAN MEMBERS, EFFECT OF THE PLAN ON  PROVIDERS  AND  PRACTI-
TIONERS, INCLUDING RECRUITMENT AND RETENTION OF PRACTITIONERS, AND OTHER
MATTERS  RELATING  TO  PLAN  EXPERIENCE, OPERATION AND IMPACT. THE BOARD
SHALL  ESPECIALLY EXAMINE THE PHENOMENON OF INDIVIDUALS BECOMING MEMBERS
OF THE PLAN (OTHER THAN BY BIRTH) FOR  THE  PURPOSE  OF  OBTAINING  PLAN
BENEFITS FOR PRE-EXISTING CONDITIONS FOR WHICH THEY HAD INADEQUATE OR NO
HEALTH  CARE  COVERAGE,  AND ITS EXTENT, NATURE AND FINANCIAL AND HEALTH
CARE SYSTEM IMPACTS.  THE BOARD SHALL CONSIDER THE NEED FOR, AND  PROBA-
BLE  EFFECTIVENESS, ADVANTAGES AND DISADVANTAGES OF, POSSIBLE CHANGES IN
THE PLAN INCLUDING LIMITING PLAN BENEFITS  FOR  SUCH  CONDITIONS  FOR  A
PERIOD OF TIME TO EXCLUDE SUCH CONDITIONS OR IMPOSE REQUIREMENTS SUCH AS
DEDUCTIBLES, MAXIMUM BENEFITS OR CO-INSURANCE;
  (L)  REPORT ANNUALLY TO THE GOVERNOR AND THE LEGISLATURE ON ITS ACTIV-
ITIES AND RECOMMEND ANY CHANGES IN LAWS TO  IMPROVE  ACCESS  TO  QUALITY
HEALTH  CARE  AND TO MORE EFFECTIVELY CONTROL COSTS OF SERVICES PROVIDED
UNDER THE PLAN, CONSISTENT WITH QUALITY HEALTH CARE;
  (M) DISSEMINATE, TO PROVIDERS OF SERVICES AND TO THE PUBLIC,  INFORMA-
TION  CONCERNING  THE PLAN AND THE PERSONS ELIGIBLE TO RECEIVE THE BENE-
FITS UNDER THE PLAN;
  (N) CONDUCT NECESSARY INVESTIGATIONS AND  INQUIRIES  AND  REQUIRE  THE
SUBMISSION  OF INFORMATION, DOCUMENTS AND RECORDS IT CONSIDERS NECESSARY
TO CARRY OUT ITS DUTIES UNDER THIS ARTICLE;
  (O) CREATE A PROGRAM FOR THE RESOLUTION OF COMPLAINTS BROUGHT BY  PLAN
MEMBERS  OR PARTICIPATING PROVIDERS REGARDING ANY MATTER ASSOCIATED WITH
COVERAGE UNDER THE PLAN, OR THE OPERATION OF THE PLAN;
  (P) NO LATER THAN FIVE YEARS AFTER THE EFFECTIVE  DATE  OF  THE  PLAN,
DEVELOP  A  PROPOSAL FOR PROVISION BY THE PLAN OF LONG-TERM CARE  COVER-
AGE, INCLUDING THE DEVELOPMENT OF A PROPOSAL FOR ITS FUNDING. IN  DEVEL-
OPING  THE PROPOSAL, THE BOARD SHALL CONSULT WITH AN ADVISORY COMMITTEE,
APPOINTED BY THE  CHAIR  OF  THE  BOARD,  INCLUDING  REPRESENTATIVES  OF
CONSUMERS  AND POTENTIAL CONSUMERS OF LONG-TERM CARE, PROVIDERS OF LONG-
TERM CARE, BUSINESS, LABOR, SOCIAL SERVICES DISTRICTS, AND OTHER  INTER-
ESTED PARTIES;
  (Q)  DEVELOP  A  PLAN TO COORDINATE ITS ACTIVITIES, INCLUDING PLANNING
FOR THE ADEQUACY OF HEALTH CARE SERVICES AND  THE  APPROVAL  OF  CAPITAL
EXPENDITURES,  WITH APPROPRIATE STATE AND LOCAL BODIES, INCLUDING HEALTH
SYSTEMS AGENCIES AND THE HOSPITAL REVIEW AND PLANNING COUNCIL;
  (R) NO LATER THAN ONE YEAR AFTER  THE  EFFECTIVE  DATE  OF  THE  PLAN,
RECOMMEND  TO  THE  GOVERNOR AND STATE LEGISLATURE THE REORGANIZATION OF
STATE GOVERNMENT AGENCIES TO MOST EFFECTIVELY CARRY OUT ACTIVITIES TO BE
CONDUCTED BY THE BOARD; AND
  (S) CONDUCT OTHER ACTIVITIES NECESSARY AND APPROPRIATE  TO  CARRY  OUT
THE  PURPOSES  OF THIS ARTICLE, INCLUDING THE EMPLOYMENT OF STAFF AND AN
EXECUTIVE DIRECTOR.
  3. THE BOARD, AFTER PROVIDING NOTICE TO THE  PUBLIC    AND  INTERESTED
PARTIES, MAY HOLD HEARINGS IN CONNECTION WITH ANY ACTIVITIES IT PROPOSES
TO UNDERTAKE.
  4.  THE BOARD SHALL MAINTAIN THE CONFIDENTIALITY OF ALL DATA AND OTHER
INFORMATION COLLECTED IN FULFILLING ITS DUTIES WHEN SUCH DATA  WOULD  BE
NORMALLY  CONSIDERED CONFIDENTIAL DATA BETWEEN A PATIENT AND HEALTH CARE
PROVIDER.  AGGREGATE DATA WHICH IS DERIVED FROM  CONFIDENTIAL  DATA  BUT
DOES  NOT  VIOLATE  PATIENT  CONFIDENTIALITY  SHALL BE CONSIDERED PUBLIC
INFORMATION.
  S 5106. POWERS AND DUTIES OF THE EXECUTIVE DIRECTOR. 1. THE  EXECUTIVE
DIRECTOR OF THE PLAN SHALL BE THE CHIEF EXECUTIVE OFFICER OF THE PLAN.

S. 5425                             7                            A. 7860

  2.  THE  EXECUTIVE  DIRECTOR SHALL PERFORM SUCH DUTIES IN THE ADMINIS-
TRATION OF THE PLAN AS THE BOARD MAY ASSIGN,  INCLUDING  THE  EMPLOYMENT
AND SUPERVISION OF STAFF.
  3.  THE  BOARD MAY DELEGATE TO THE EXECUTIVE DIRECTOR ANY OF ITS FUNC-
TIONS OR DUTIES UNDER THIS ARTICLE OTHER THAN THE ISSUANCE OF RULES  AND
REGULATIONS AND THE ESTABLISHMENT OF THE ANNUAL PLAN BUDGET.
  S  5107.  PLAN  ELIGIBILITY. 1. EVERY PERSON WHO IS A RESIDENT OF THIS
STATE IS ELIGIBLE TO RECEIVE BENEFITS FOR  COVERED  SERVICES  UNDER  THE
PLAN AND SHALL BE A PLAN MEMBER.
  2.  EVERY  PLAN MEMBER IS ENTITLED TO RECEIVE BENEFITS FOR ANY COVERED
SERVICE FURNISHED WITHIN THIS STATE BY A PARTICIPATING PROVIDER, IF  THE
SERVICE IS NECESSARY OR APPROPRIATE FOR THE MAINTENANCE OF HEALTH OR FOR
THE  DIAGNOSIS  OR  TREATMENT  OF,  OR REHABILITATION FOLLOWING, INJURY,
DISABILITY OR DISEASE.
  S 5108. PLAN BENEFITS.  1.  COVERED  SERVICES  UNDER  THE  PLAN  SHALL
INCLUDE,  BUT  ARE NOT LIMITED TO, ALL OF THE FOLLOWING MEDICALLY NECES-
SARY INPATIENT AND OUTPATIENT SERVICES:
  (A) HOSPITAL SERVICES;
  (B) MEDICAL AND OTHER PROFESSIONAL SERVICES  FURNISHED  BY  AUTHORIZED
HEALTH  CARE  PROFESSIONALS  WHO ARE AUTHORIZED TO PROVIDE SUCH SERVICES
UNDER THE LAWS OF THIS STATE INCLUDING PRIMARY, PREVENTIVE AND SPECIALTY
SERVICES;
  (C) LABORATORY TESTS AND IMAGING PROCEDURES;
  (D) SHORT-TERM HOME HEALTH SERVICES  FOR  PERSONS  REQUIRING  SERVICES
PERFORMED  BY  OR  UNDER  THE  SUPERVISION  OF PROFESSIONAL OR TECHNICAL
PERSONNEL;
  (E) REHABILITATIVE SERVICES WHERE A PATIENT IS RECEIVING  ACTIVE  CARE
WITH A THERAPEUTIC OUTCOME;
  (F)  PRESCRIPTION  DRUGS AND DEVICES, PROVIDED, HOWEVER, THAT THE PLAN
SHALL PARTIALLY COVER THE COST OF A DRUG DISPENSED IN A PACKAGE, OR FORM
OF DOSAGE OR ADMINISTRATION, AS TO WHICH THE  BOARD  DETERMINES  THAT  A
LESS EXPENSIVE PACKAGE, OR FORM OF DOSAGE OR ADMINISTRATION IS AVAILABLE
THAT  IS  PHARMACEUTICALLY  EQUIVALENT AND EQUIVALENT IN ITS THERAPEUTIC
EFFECT. IF A PLAN MEMBER CHOOSES TO PURCHASE A MORE EXPENSIVE DRUG  THAT
HAS  A  PHARMACEUTICAL AND THERAPEUTIC EQUIVALENT, THE PLAN MEMBER SHALL
BE FINANCIALLY RESPONSIBLE FOR PAYING THE AMOUNT EQUAL TO THE DIFFERENCE
BETWEEN THE COST OF SUCH DRUG AND ITS EQUIVALENT UNLESS THE  PRESCRIBING
PRACTITIONER  CERTIFIES THAT THE MORE EXPENSIVE DRUG IS MEDICALLY NECES-
SARY, IN WHICH CASE THE PLAN SHALL COVER THE FULL COST;
  (G) MENTAL HEALTH SERVICES SUBJECT TO APPROPRIATENESS  GUIDELINES  AND
REVIEW;
  (H) SUBSTANCE ABUSE TREATMENT SERVICES;
  (I) PRIMARY AND ACUTE DENTAL SERVICES;
  (J)  VISION  APPLIANCES,  INCLUDING LENSES, FRAMES AND CONTACT LENSES,
ACCORDING TO A SCHEDULE ESTABLISHED BY THE BOARD;
  (K) MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT AND SELECTED ASSISTIVE
DEVICES; AND
  (L) HOSPICE CARE.
  2. COVERED SERVICES DO NOT INCLUDE ANY OF THE FOLLOWING:
  (A) SURGERY  FOR  COSMETIC  PURPOSES  OTHER  THAN  FOR  RECONSTRUCTIVE
SURGERY;
  (B)  MEDICAL  EXAMINATIONS  CONDUCTED AND MEDICAL REPORTS PREPARED FOR
ANY OF THE FOLLOWING PURPOSES:
  (I) PURCHASING OR RENEWING LIFE INSURANCE;
  (II) APPLICATIONS FOR EMPLOYMENT; OR

S. 5425                             8                            A. 7860

  (III) PARTICIPATING AS A PLAINTIFF OR DEFENDANT IN A CIVIL ACTION  FOR
THE RECOVERY OR SETTLEMENT OF DAMAGES;
  (C) BASIC OR CUSTODIAL CARE RENDERED IN A NURSING HOME;
  (D)  CUSTODIAL  CARE  RENDERED IN A FACILITY LICENSED UNDER THE MENTAL
HYGIENE LAW; OR
  (E) COSMETIC DENTAL SERVICES.
  3. COINSURANCES, DEDUCTIBLES AND COPAYMENTS SHALL NOT BE APPLICABLE TO
BENEFITS COVERED UNDER THE PLAN.
  4. INSURERS AUTHORIZED TO UNDERWRITE COVERAGE PURSUANT TO  THE  INSUR-
ANCE  LAW  OR  A HEALTH MAINTENANCE ORGANIZATION CERTIFIED IN ACCORDANCE
WITH ARTICLE FORTY-FOUR OF THIS CHAPTER, MAY OFFER BENEFITS THAT DO  NOT
DUPLICATE  COVERAGE  THAT  IS  OFFERED  UNDER THE PLAN BUT MAY NOT OFFER
BENEFITS THAT DUPLICATE COVERAGE THAT IS COVERED BY THE PLAN.  PROVIDED,
HOWEVER, THAT NOTHING IN THIS SUBDIVISION SHALL PROHIBIT THE OFFERING OF
BENEFITS  TO  OR FOR PERSONS, INCLUDING THEIR FAMILIES, WHO ARE EMPLOYED
OR SELF-EMPLOYED IN THIS STATE BUT ARE NOT RESIDENTS OF THE STATE.
  5. NO PARTICIPATING PROVIDER SHALL REFUSE TO  FURNISH  SERVICES  TO  A
PLAN  MEMBER  ON  THE BASIS OF RACE, COLOR, CREED, AGE, NATIONAL ORIGIN,
ALIENAGE OR CITIZENSHIP STATUS, GENDER, SEXUAL ORIENTATION,  DISABILITY,
MARITAL  STATUS,  OR ARREST RECORD, EXCEPT AS APPROPRIATE TO THE PROVID-
ER'S PROFESSIONAL SPECIALIZATION, OR OTHER MEDICALLY APPROPRIATE CIRCUM-
STANCES.
  6. A PLAN MEMBER MAY CHOOSE ANY PARTICIPATING PROVIDER, WHETHER  PRAC-
TICING  ON  AN  INDEPENDENT  BASIS,  IN A SMALL GROUP, OR IN A CAPITATED
PRACTICE. A PLAN MEMBER WHO ENROLLS IN A  CAPITATED  PRACTICE  SHALL  BE
SUBJECT  TO  RULES  AND  REQUIREMENTS  OF  THE PLAN AS TO DISENROLLMENT,
CHOICE OF PROVIDER, AND AVAILABILITY OF BENEFITS OUTSIDE  THE  CAPITATED
PRACTICE.
  S  5109.  PAYMENT  FOR SERVICES. 1. THE PLAN SHALL PAY THE EXPENSES OF
INSTITUTIONAL PROVIDERS LICENSED  UNDER  ARTICLE  TWENTY-EIGHT  OF  THIS
CHAPTER  FOR  COVERED  SERVICES  ON THE BASIS OF GLOBAL BUDGETS THAT ARE
APPROVED BY THE BOARD.
  2. THE GLOBAL BUDGET OF EACH INSTITUTIONAL PROVIDER SHALL BE SET ANNU-
ALLY BY THE PLAN AFTER CONSULTATION AND NEGOTIATION  WITH  THE  INSTITU-
TIONAL  PROVIDERS, AND SHALL COVER THE COSTS OF ITS ANTICIPATED SERVICES
FOR THE NEXT YEAR, BASED ON PAST PERFORMANCE AND  PROJECTED  CHANGES  IN
FACTOR PRICES AND SERVICE LEVELS.
  3.  EVERY INDIVIDUAL HEALTH CARE PROVIDER EMPLOYED BY A GLOBALLY BUDG-
ETED INSTITUTIONAL PROVIDER SHALL BE PAID THROUGH AND IN A MANNER DETER-
MINED BY THE INSTITUTIONAL PROVIDER.
  4. THE BUDGETING PROCEDURE DESCRIBED  IN  SUBDIVISIONS  ONE,  TWO  AND
THREE  OF  THIS  SECTION  ALSO APPLIES TO INSTITUTIONS THAT PROVIDE PLAN
SERVICES AND THAT ARE FUNDED BY ANY POLITICAL SUBDIVISION OR ANY  AGENCY
OR INSTRUMENTALITY OF A POLITICAL SUBDIVISION.
  5.  THE PLAN SHALL REIMBURSE NON-INSTITUTIONAL PARTICIPATING PROVIDERS
ON A FEE-FOR-SERVICE BASIS, ESTABLISHED BY THE BOARD. THE  FEE  SCHEDULE
SHALL  VARY  THE  PAYMENT  AMOUNT  AMONG DIFFERENT SERVICES BASED ON THE
RELATIVE VALUE OF THE INPUT FACTORS TO PROVIDE THE SERVICES.
  6. FEE SCHEDULES MAY TAKE INTO ACCOUNT  RECOGNIZED  DIFFERENCES  AMONG
GEOGRAPHIC AREAS REGARDING COST OF PRACTICE.
  7.  TO  THE  GREATEST  EXTENT  FEASIBLE, FEE SCHEDULE CATEGORIES SHALL
INCLUDE PAYMENT FOR ALL PROCEDURES ROUTINELY PERFORMED FOR A GIVEN DIAG-
NOSIS.
  8. (A) A MULTI-SPECIALTY ORGANIZATION OF PROVIDERS  MAY  ELECT  TO  BE
REIMBURSED ON A CAPITATION BASIS, IN LIEU OF A FEE-FOR-SERVICE BASIS.

S. 5425                             9                            A. 7860

  (B) IF THE ORGANIZATION MEETS ENROLLMENT AND OTHER REQUIREMENTS ESTAB-
LISHED  BY THE BOARD, THE ORGANIZATION MAY ELECT TO HAVE INCLUDED IN ITS
CAPITATION PAYMENTS, INPATIENT SERVICES PROVIDED BY INSTITUTIONS  FUNDED
UNDER  A  BUDGET DESCRIBED IN SUBDIVISION ONE OF THIS SECTION. UPON THAT
ELECTION,  THE  INSTITUTIONAL  BUDGETS  OF  SUCH  INSTITUTIONS  SHALL BE
ADJUSTED ACCORDINGLY.
  (C) IF THE ORGANIZATION ELECTS, AND MEETS REQUIREMENTS OF  THE  BOARD,
THE BOARD MAY INCLUDE IN THE ORGANIZATION'S CAPITATION PAYMENTS FUNDS TO
BE  PASSED  ON  BY THE ORGANIZATION TO PLAN MEMBERS WHO ARE ITS ENROLLED
MEMBERS AS A REBATE OR INCENTIVE TO ENCOURAGE MEMBERSHIP IN  THE  ORGAN-
IZATION;  PROVIDED  THAT THE BOARD FINDS THAT THE REBATE OR INCENTIVE IS
IN THE FINANCIAL INTERESTS OF THE PLAN.
  9. EVERY PARTICIPATING PROVIDER SHALL FURNISH TO THE PLAN SUCH  INFOR-
MATION,  AND  PERMIT  EXAMINATION  OF ITS RECORDS BY THE PLAN, AS MAY BE
REASONABLY REQUIRED FOR PURPOSES OF UTILIZATION REVIEW,  QUALITY  ASSUR-
ANCE  AND  COST  CONTAINMENT, FOR THE MAKING OF PAYMENTS AND FOR STATIS-
TICAL OR OTHER STUDIES OF THE OPERATION OF THE PLAN.
  10. RATES OF PAYMENT ESTABLISHED UNDER THIS SECTION SHALL  BE  CONSID-
ERED PAYMENT IN FULL. A PROVIDER OF SERVICES SHALL NOT CHARGE RATES THAT
ARE  IN  EXCESS  OF SUCH REIMBURSEMENT LEVELS, NOR CHARGE SEPARATELY FOR
COVERED SERVICES PROVIDED UNDER SECTION FIFTY-ONE HUNDRED EIGHT OF  THIS
ARTICLE. PROVIDED, HOWEVER, THE PROVISIONS OF THIS SUBDIVISION SHALL NOT
APPLY  TO  SERVICES  RENDERED  OUTSIDE  OF  THIS  STATE,  OR TO SERVICES
RENDERED TO PERSONS WHO ARE NOT PLAN MEMBERS.
  S 5110. OUT-OF-STATE PARTICIPATION AND PAYMENTS. 1.  (A) THE PLAN,  IN
ACCORDANCE  WITH SUBDIVISION FOUR OF THIS SECTION AND EXCEPT AS PROVIDED
IN PARAGRAPH (B) OF THIS SUBDIVISION, SHALL PAY FOR SERVICES RENDERED TO
PLAN MEMBERS WHILE THEY ARE OUT OF THE STATE (I) WHILE THEY  ARE  TEMPO-
RARILY OUT OF THE STATE FOR REASONS OTHER THAN TO OBTAIN THE SERVICES OR
(II)  WHERE  THE  PLAN  MEMBER OBTAINS THE SERVICES OUT OF THE STATE FOR
COMPELLING REASONS RELATING TO THE SUITABILITY OF SERVICES,  THE  NATURE
OF THE CONDITION AND PERSONAL CIRCUMSTANCES.
  (B)  WHERE THE PLAN MEMBER IS ELIGIBLE FOR HEALTH BENEFITS UNDER TITLE
XVIII OR TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT, THEN OUT-OF-STATE
SERVICES FOR THE PLAN MEMBER SHALL, TO THE EXTENT  ALLOWED  BY  LAW,  BE
PAID FOR UNDER THOSE TITLES.
  2.  WHERE AN EMPLOYEE OR SELF-EMPLOYED INDIVIDUAL IS NOT A RESIDENT OF
NEW YORK STATE (AND THEREFORE NOT ELIGIBLE TO BE A PLAN MEMBER)  BUT  IS
EMPLOYED OR SELF-EMPLOYED IN THE STATE, THE EMPLOYER OR THE EMPLOYEE, OR
THE  SELF-EMPLOYED  INDIVIDUAL,  MAY  PURCHASE  HEALTH  COVERAGE FOR THE
PERSON, INCLUDING THE PERSON'S FAMILY, FROM  ANY  ENTITY  AUTHORIZED  TO
OFFER  THAT  COVERAGE  OR  FROM THE PLAN PURSUANT TO SUBDIVISION FIVE OF
THIS SECTION.
  3. ANY PRIVATE OR STATE COLLEGE, UNIVERSITY OR  OTHER  INSTITUTION  OF
HIGHER  EDUCATION SITUATED IN THIS STATE MAY PURCHASE COVERAGE UNDER THE
PLAN FOR ANY STUDENT, OR THEIR DEPENDENTS,   WHO IS NOT  A  RESIDENT  OF
THIS STATE.
  4.  THE BOARD SHALL ESTABLISH AND OPERATE AN INDEMNITY PLAN TO PROVIDE
PAYMENTS FOR  SERVICES  UNDER  SUBDIVISION  ONE  OF  THIS  SECTION.  THE
PAYMENTS  SHALL  BE MADE AT THE RATES ESTABLISHED BY THE BOARD FOR BENE-
FITS FOR COMPARABLE SERVICES PROVIDED BY THE PLAN IN THIS STATE. CHARGES
IN EXCESS OF THE PAYMENT  RATES  ESTABLISHED  IN  ACCORDANCE  WITH  THIS
SECTION SHALL BE THE RESPONSIBILITY OF THE PLAN MEMBER.
  5.  THE BOARD SHALL ESTABLISH AND OPERATE AN INDEMNITY PLAN TO PROVIDE
HEALTH COVERAGE FOR EMPLOYEES AND SELF-EMPLOYED INDIVIDUALS WHO ARE  NOT
RESIDENTS  OF THIS STATE BUT ARE EMPLOYED OR SELF-EMPLOYED IN THE STATE,

S. 5425                            10                            A. 7860

INCLUDING THEIR FAMILIES, TO BE OFFERED FOR PURCHASE BY THE EMPLOYER  OR
EMPLOYEE,  OR  SELF-EMPLOYED  INDIVIDUALS, UNDER SUBDIVISION TWO OF THIS
SECTION. THE INDEMNITY PLAN SHALL BE OFFERED ON A NOT-FOR-PROFIT  BASIS.
ITS  SCOPE  OF BENEFITS AND RATES OF PAYMENT SHALL BE ESTABLISHED BY THE
BOARD AND SHALL, TO THE EXTENT PRACTICABLE, BE COMPARABLE TO THOSE UNDER
THE NEW YORK HEALTH PLAN.
  6. NOTHING IN THIS ARTICLE SHALL IMPACT THE EXISTING OR  FUTURE  OBLI-
GATIONS  OF  EMPLOYERS TO PROVIDE SUPPLEMENTARY HEALTH BENEFITS TO RETI-
REES WHO NO LONGER RESIDE IN THIS STATE.
  S 2. The state finance law is amended by adding a new section 89-h  to
read as follows:
  S  89-H. NEW YORK HEALTH TRUST FUND. 1. THERE IS HEREBY ESTABLISHED IN
THE JOINT CUSTODY OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXA-
TION AND FINANCE A SPECIAL REVENUE FUND TO BE KNOWN  AS  THE  "NEW  YORK
HEALTH TRUST FUND", HEREINAFTER KNOWN AS "THE FUND".
  2. THE FUND SHALL CONSIST OF:
  (A)  ALL  MONIES  OBTAINED  FROM  PREMIUM PAYMENT REVENUES PURSUANT TO
ARTICLE THIRTY-FIVE OF THE TAX LAW;
  (B) FEDERAL PAYMENTS RECEIVED AS A RESULT OF ANY  WAIVER  OF  REQUIRE-
MENTS  GRANTED  BY  THE  UNITED  STATES  SECRETARY  OF  HEALTH AND HUMAN
SERVICES FOR HEALTH CARE PROGRAMS ESTABLISHED UNDER TITLES XVIII  (MEDI-
CARE)  AND  XIX  (MEDICAL  ASSISTANCE  FOR NEEDY PERSONS) OF THE FEDERAL
SOCIAL SECURITY ACT;
  (C) THE AMOUNTS PAID BY THE DEPARTMENT OF HEALTH AND BY  LOCAL  SOCIAL
SERVICES DISTRICTS THAT ARE EQUIVALENT TO THOSE AMOUNTS THAT ARE PAID ON
BEHALF  OF RESIDENTS OF THIS STATE UNDER TITLES XVIII (MEDICARE) AND XIX
(MEDICAL ASSISTANCE FOR NEEDY PERSONS) OF THE  FEDERAL  SOCIAL  SECURITY
ACT,  AND  ARTICLE  FIVE,  TITLE  ELEVEN  OF THE SOCIAL SERVICES LAW FOR
HEALTH BENEFITS WHICH ARE EQUIVALENT TO HEALTH  BENEFITS  COVERED  UNDER
ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW;
  (D)  ALL  SURCHARGES  THAT  ARE  IMPOSED ON RESIDENTS OF THIS STATE TO
REPLACE PAYMENTS MADE BY THE RESIDENTS UNDER THE COST-SHARING PROVISIONS
OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT;
  (E) FEDERAL, STATE AND LOCAL FUNDS FOR PURPOSES OF  THE  PROVISION  OF
SERVICES  AUTHORIZED  UNDER  TITLE XX OF THE FEDERAL SOCIAL SECURITY ACT
THAT WOULD OTHERWISE BE COVERED UNDER ARTICLE FIFTY-ONE  OF  THE  PUBLIC
HEALTH LAW; AND
  (F)  STATE  AND LOCAL GOVERNMENT MONIES THAT WOULD OTHERWISE BE APPRO-
PRIATED TO ANY GOVERNMENTAL AGENCY, OFFICE, PROGRAM, INSTRUMENTALITY  OR
INSTITUTION  WHICH  PROVIDES  HEALTH SERVICES, FOR SERVICES AND BENEFITS
COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH  LAW.  PAYMENTS  TO
THE  FUND  PURSUANT TO THIS PARAGRAPH SHALL BE IN AN AMOUNT EQUAL TO THE
MONEY APPROPRIATED FOR SUCH PURPOSES  IN  THE  FISCAL  YEAR  IMMEDIATELY
PRECEDING  THE  EFFECTIVE DATE OF ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH
LAW.
  3. MONIES IN THE FUND SHALL ONLY  BE  USED  FOR  PURPOSES  ESTABLISHED
UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
  4.  REVENUES HELD IN THE FUND SHALL NOT BE SUBJECT TO APPROPRIATION OR
ALLOTMENT BY THE STATE OR ANY POLITICAL SUBDIVISION THEREOF.
  5. THE BOARD OF GOVERNORS OF THE NEW YORK HEALTH  PLAN  UNDER  ARTICLE
FIFTY-ONE OF THE PUBLIC HEALTH LAW SHALL:
  (A)  ADMINISTER  THE  FUND AND SHALL CONDUCT A QUARTERLY REVIEW OF THE
EXPENDITURES FROM AND REVENUES RECEIVED BY THE FUND; AND
  (B) INVEST THE FUND IN INVESTMENTS THAT ARE AUTHORIZED BY THE LAWS  OF
THIS  STATE FOR THE INVESTMENT OF THE CAPITAL, SURPLUS AND ACCUMULATIONS

S. 5425                            11                            A. 7860

OF DOMESTIC LIFE INSURANCE COMPANIES. THE LIMITATIONS SET FORTH IN THESE
LAWS APPLY TO THE INVESTMENTS OF THE FUND.
  S  3.  The  tax  law  is amended by adding a new article 35 to read as
follows:
                                ARTICLE 35
                  NEW YORK HEALTH PLAN PREMIUM PAYMENTS
SECTION 1650. DEFINITIONS.
        1651. PREMIUM PAYMENTS.
        1652. PROCEDURAL PROVISIONS.
  S 1650. DEFINITIONS. FOR THE PURPOSES  OF  THIS  ARTICLE,  UNLESS  THE
CONTEXT CLEARLY REQUIRES OTHERWISE:
  1. "EMPLOY" MEANS TO SUFFER OR PERMIT TO WORK.
  2.  "EMPLOYER"  MEANS  AN INDIVIDUAL, PARTNERSHIP, ASSOCIATION, CORPO-
RATION, BUSINESS TRUST, THE STATE OF NEW YORK, ITS INSTRUMENTALITIES AND
ITS POLITICAL SUBDIVISIONS AND THEIR INSTRUMENTALITIES, OR ANY PERSON OR
GROUP OF PERSONS, ACTING IN THE INTEREST OF AN EMPLOYER IN  RELATION  TO
AN EMPLOYEE.
  3. "EMPLOYEE" MEANS ANY INDIVIDUAL WHO WORKS FOR AN EMPLOYER.
  S 1651. PREMIUM PAYMENTS. FOR THE PURPOSE OF PROVIDING REVENUE FOR THE
NEW  YORK  HEALTH  PLAN ESTABLISHED PURSUANT TO ARTICLE FIFTY-ONE OF THE
PUBLIC HEALTH LAW, AND TO PAY THE EXPENSE OF  PLAN  ADMINISTRATION,  THE
FOLLOWING PREMIUM PAYMENTS ARE HEREBY LEVIED:
  1.  ON  EACH  EMPLOYER,  A PREMIUM PAYMENT EQUAL TO TEN PERCENT OF THE
EMPLOYER'S PAYROLL. THE  EMPLOYER  MAY  CHOOSE,  SUBJECT  TO  COLLECTIVE
BARGAINING AGREEMENTS, TO DEDUCT TWO PERCENT OF EACH EMPLOYEE'S WAGES OR
GROSS SALARY AS PARTIAL PAYMENT OF THIS PREMIUM PAYMENT.
  2.  ON  EACH  SELF-EMPLOYED INDIVIDUAL, A PREMIUM PAYMENT EQUAL TO TEN
PERCENT OF THE INDIVIDUAL'S SELF-EMPLOYMENT INCOME, SUBJECT TO THE LIMIT
ON TAXABLE SELF-EMPLOYMENT INCOME FOR MEDICARE HOSPITAL INSURANCE  UNDER
THE  "FEDERAL  INSURANCE  CONTRIBUTIONS  ACT",  68A STAT. 415 (1954), 26
U.S.C.A. 3101, AS AMENDED.
  3. A PERSON SUBJECT TO TAXATION  UNDER  THIS  CHAPTER,  OTHER  THAN  A
PERSON  WHO  IS  ENTITLED  TO  COVERAGE UNDER TITLE XVIII OF THE FEDERAL
SOCIAL SECURITY ACT, WHO HAS NOT HAD THE PREMIUM PAID ON  FIFTY  PERCENT
OR MORE OF HIS OR HER ADJUSTED GROSS INCOME UNDER SUBDIVISION ONE OR TWO
OF  THIS  SECTION,  SHALL MAKE A PREMIUM PAYMENT EQUAL TO TEN PERCENT OF
THE DIFFERENCE BETWEEN FIFTY PERCENT OF THE INDIVIDUAL'S ADJUSTED  GROSS
INCOME  AND  THE  TOTAL AMOUNT OF INCOME ON WHICH THE INDIVIDUAL HAS HAD
PREMIUMS PAID UNDER SUBDIVISIONS ONE AND TWO OF THIS SECTION;  PROVIDED,
HOWEVER,  THAT  THE  TOTAL  AMOUNT  OF  ADJUSTED GROSS INCOME SUBJECT TO
PREMIUM PAYMENTS UNDER THIS SUBDIVISION SHALL NOT EXCEED  THE  LIMIT  ON
TAXABLE  SELF-EMPLOYMENT INCOME FOR MEDICAL HOSPITAL INSURANCE UNDER THE
"FEDERAL INSURANCE CONTRIBUTIONS ACT," 68A STAT. 415 (1954), 26 U.S.C.A.
3101, AS AMENDED.
  4. (A) WHERE A NEW YORK STATE RESIDENT IS EMPLOYED OUTSIDE  THE  STATE
BY  AN  EMPLOYER  THAT  DOES BUSINESS IN THE STATE, OR THAT ELECTS TO BE
SUBJECT TO THIS SUBDIVISION, THEN THE EMPLOYER  SHALL  PAY  THE  PREMIUM
UNDER  SUBDIVISION  ONE  OF  THIS  SECTION,  CALCULATED  ON THE PRO RATA
PORTION OF THE EMPLOYER'S PAYROLL ATTRIBUTABLE TO  ALL  NEW  YORK  STATE
RESIDENTS EMPLOYED BY THE EMPLOYER.
  (B)  WHERE  A  NEW  YORK  RESIDENT IS EMPLOYED OUTSIDE THE STATE BY AN
EMPLOYER THAT DOES NOT DO BUSINESS IN THE STATE AND THAT DOES NOT  ELECT
TO  BE  SUBJECT  TO  THIS  SUBDIVISION,  THEN THE EMPLOYEE SHALL PAY THE
PREMIUM UNDER SUBDIVISION ONE OF THIS  SECTION,  AS  IF  THE  EMPLOYEE'S
INCOME FROM THE EMPLOYER WAS SELF-EMPLOYMENT INCOME.

S. 5425                            12                            A. 7860

  5.  WHERE  AN EMPLOYEE IS NOT A RESIDENT OF NEW YORK STATE (AND THERE-
FORE NOT ELIGIBLE TO BE A NEW YORK HEALTH PLAN MEMBER), AND THE EMPLOYER
PURCHASES HEALTH COVERAGE FOR THE  EMPLOYEE,  INCLUDING  THE  EMPLOYEE'S
FAMILY,  UNDER  SUBDIVISION  TWO OF SECTION FIFTY-ONE HUNDRED TEN OF THE
PUBLIC  HEALTH  LAW,  THE EMPLOYER MAY TAKE A CREDIT AGAINST THE PREMIUM
PAID UNDER SUBDIVISION ONE OF THIS SECTION, UP TO THE PRO  RATA  PORTION
OF  THE EMPLOYER'S PREMIUM ATTRIBUTABLE TO THAT EMPLOYEE, FOR THE AMOUNT
PAID BY THE EMPLOYER TO PURCHASE THAT COVERAGE. WHERE SUCH  AN  EMPLOYEE
PURCHASES  OR  PAYS A PORTION OF THE COST OF SUCH COVERAGE, THE EMPLOYEE
MAY TAKE A CREDIT FOR THE AMOUNT PAID BY HIM OR HER  FOR  THAT  COVERAGE
AGAINST  ANY  PREMIUM  THE  EMPLOYEE  IS REQUIRED BY THE EMPLOYER TO PAY
UNDER SUBDIVISION ONE OF THIS SECTION.
  6. WHERE A SELF-EMPLOYED INDIVIDUAL IS NOT  A  RESIDENT  OF  NEW  YORK
STATE  (AND THEREFORE NOT ELIGIBLE TO BE A NEW YORK HEALTH PLAN MEMBER),
AND THE PERSON  PURCHASES  HEALTH  COVERAGE  UNDER  SUBDIVISION  TWO  OF
SECTION  FIFTY-ONE  HUNDRED  TEN  OF THE PUBLIC HEALTH LAW, THE SELF-EM-
PLOYED INDIVIDUAL MAY TAKE A CREDIT FOR THE AMOUNT PAID BY  HIM  OR  HER
FOR  THAT  COVERAGE AGAINST THE PREMIUM PAID BY THE SELF-EMPLOYED PERSON
UNDER SUBDIVISION ONE OF THIS SECTION.
  7. THE TOTAL AMOUNT OF CREDITS TAKEN UNDER SUBDIVISIONS FIVE  AND  SIX
OF  THIS  SECTION,  AGAINST PREMIUMS PAID UNDER THIS SECTION, FOR HEALTH
COVERAGE FOR A PERSON, INCLUDING THAT PERSON'S FAMILY, SHALL NOT  EXCEED
THE  TOTAL  AMOUNT  OF  PREMIUM  PAID BY OR ATTRIBUTABLE TO THAT PERSON,
WHETHER PAID BY THAT PERSON OR BY AN EMPLOYER.
  8. NEW YORK HEALTH PLAN MEMBERS ENTITLED TO COVERAGE UNDER TITLE XVIII
OF THE FEDERAL SOCIAL SECURITY ACT, WHO ARE NOT ALSO ENTITLED TO  COVER-
AGE  UNDER  TITLE  XIX  OF  THE  FEDERAL SOCIAL SECURITY ACT, SHALL MAKE
PREMIUM PAYMENTS EQUAL TO THE PREMIUM PAYMENT DEVELOPED BY  THE  FEDERAL
SECRETARY  OF  HEALTH  AND  HUMAN  SERVICES FOR COVERAGE UNDER PART B OF
TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT; PROVIDED, HOWEVER,  THAT
PLAN  MEMBERS  WHO  MAKE  PREMIUM  PAYMENTS DIRECTLY TO THE SECRETARY OF
HEALTH AND HUMAN SERVICES SHALL BE ENTITLED  TO  A  CREDIT  AGAINST  THE
AMOUNT PAID UNDER THIS SUBDIVISION.
  S  1652. PROCEDURAL PROVISIONS. THE BOARD OF GOVERNORS OF THE NEW YORK
HEALTH PLAN SHALL ADOPT RULES REGARDING THE LEVY AND COLLECTION  OF  THE
PREMIUM  PAYMENTS  UNDER  THIS ARTICLE AND MAY ENTER INTO CONTRACTS WITH
THE DEPARTMENT FOR THE COLLECTION OF THE PREMIUM PAYMENTS LEVIED BY THIS
ARTICLE. FOR PURPOSES OF ENFORCEMENT, PREMIUM PAYMENTS  DUE  UNDER  THIS
ARTICLE SHALL BE SUBJECT TO THE PROVISIONS OF THIS CHAPTER APPLICABLE TO
INCOME TAXES DUE UNDER ARTICLE TWENTY-TWO OF THIS CHAPTER.
  S  4.  1. There is hereby established a temporary commission on imple-
mentation of the New York health plan, hereinafter to be  known  as  the
commission,  consisting  of fifteen members: five members, including the
chair, shall be  appointed  by  the  governor;  five  members  shall  be
appointed  by  the temporary president of the senate, two of which shall
be upon recommendation of the senate minority leader; and, five  members
shall be appointed by the speaker of the assembly, two of which shall be
upon  recommendation  of the assembly minority leader.  The commissioner
of health, the superintendent of  insurance,  and  the  commissioner  of
taxation  and  finance,  or  their  designees  shall serve as non-voting
ex-officio members of the commission.
  2.  Members of the commission shall receive such assistance as may  be
necessary  from  other  state  agencies  and entities, and shall receive
necessary expenses incurred in the  performance  of  their  duty.    The
commission  may  employ staff as needed, prescribe their duties, and fix
their compensation within amounts appropriate for the commission.

S. 5425                            13                            A. 7860

  3. The commission shall examine the statutes of this  state  and  make
such recommendations as are necessary to conform the laws of this state,
and  to  eliminate any inconsistency between the laws of this state, and
the provisions of article 51 of the public health law  establishing  the
New  York  health  plan  as  added by section one of this act, and other
provisions of law relating to the New York health plan, and  to  improve
and implement the plan.
  4.  On or before 270 days subsequent to the enactment of this act, the
commission shall report to the governor and the legislature, with recom-
mendations, as provided in subdivision three of this section.
  S  5.  The superintendent of insurance, in consultation with a techni-
cal advisory committee which shall include representation from insurers,
consumers, organized labor, and business, shall examine the premium rate
structure for insurance underwritten and offered in this state by insur-
ers licensed pursuant to the insurance law, and determine the extent  to
which  such  premiums  reflect  expenditures  for  health  care services
covered under the provisions of article 51  of  the  public  health  law
establishing  the  New  York health plan as added by section one of this
act.  On or before 270 days following the enactment  of  this  act,  the
superintendent  shall  report to the governor and the legislature on the
extent to which the premium rate structure for  insurance,  by  line  of
insurance,  underwritten and offered in this state reflects expenditures
for health care services covered under article 51 of the  public  health
law  as  added by section one of this act, and make such recommendations
as are necessary for an adjustment in such premium  rate  structures  to
reflect a reduction in health care expenditures due to implementation of
the New York health plan.
  S  6.  The sum of five hundred thousand dollars ($500,000), or so much
thereof as may be necessary, is hereby  appropriated  to  the  temporary
commission  on implementation of the New York health plan created pursu-
ant to section four of this act out of any moneys in the state  treasury
in  the  general  fund  to  the credit of the state purposes account not
otherwise appropriated.   Such sum shall be payable  on  the  audit  and
warrant  of  the  state comptroller on vouchers certified or approved by
the chair of the temporary commission on implementation of the New  York
health plan created pursuant to section four of this act.
  S  7.  (a)  This  act  shall  take effect on the first of January next
succeeding the date on which it shall have become a law provided, howev-
er, that sections four and five of this act shall take effect immediate-
ly and shall remain in full force and effect until the first of  January
following  the  date  upon which benefits under article 51 of the public
health law as added by section one of  this  act  begin  whereupon  such
sections  shall  be  deemed  repealed.  The commissioner of health shall
notify the Legislative Bill Drafting Commission of such event.
  (b) Not later than the thirty-first of March following  the  effective
date  of  this  act,  the  commissioner  of  health shall do both of the
following:
  1. Apply to the secretary of health and human services for all waivers
of requirements under health  care  programs  established  under  titles
XVIII  and  XIX of the federal social security act that are necessary to
enable this state to deposit all federal payments under  those  programs
in  the  state  treasury to the credit of the New York health trust fund
created pursuant to section 89-h of the state finance law, as  added  by
section two of this act;
  2.  Identify any other federal programs that provide federal funds for
payment of health care services  to  individuals.  The  commissioner  of

S. 5425                            14                            A. 7860

health shall comply with any requirements under those programs and apply
for  any waivers of those requirements that are necessary to enable this
state to deposit such federal funds to the credit of the New York health
trust fund.
  (c) No later than the thirty-first of December following the effective
date of this act, the board of governors of the New York health plan and
the  commissioner of health shall explore and cooperate with, enter into
any necessary contract or other arrangement with, and  otherwise  pursue
any  other reasonable course of action with, the secretary of health and
human services to establish procedures, standards and  conditions  under
which  the commissioner of health shall pay to the New York health trust
fund amounts equivalent to those amounts that, on the effective date  of
this  section,  are paid on behalf of residents of this state for health
benefits covered under the plan under titles XVIII and XIX of the feder-
al social security act.
  (d) Commencing on the first of January following the effective date of
this act the following shall occur:
  1. New York health premium payments that are  authorized  pursuant  to
article  35 of the tax law, as added by section three of this act, shall
be levied.
  2. Benefits under the New York health  plan  established  pursuant  to
article 51 of the public health law, as added by section one of this act
shall begin.
  3.  Payments  into  the New York health trust fund created pursuant to
section 89-h of the state finance law shall begin.
  (e) Not later than the twenty-eighth of February following the  effec-
tive  date of this act, the governor shall make the initial appointments
to the board of governors of the New York health plan established pursu-
ant to article 51 of the public health law, as added by section  one  of
this  act,  provided,  however, that of the initial appointments made by
the governor, four shall be for a term of one year; four shall be for  a
term of two years; three shall be for a term of three years; three shall
be for a term of four years; and four, including the chair, shall be for
a  term  of five years. Thereafter, all appointments shall be for a term
of five years, except in those instances where an appointment is to fill
a vacancy occurring prior to the expiration of a term.

Co-Sponsors

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A7860A (ACTIVE) - Bill Details

See Senate Version of this Bill:
S5425A
Current Committee:
Law Section:
Public Health Law
Laws Affected:
Ren Art 50 §§5000 - 5003 to be Art 80 §§8000 - 8003, add Art 51 §§5100 - 5110, add Art 49 Title 3 §§4920 - 4927, amd §270, Pub Health L; add §89-h, St Fin L
Versions Introduced in 2009-2010 Legislative Session:
A2356, S2370

A7860A (ACTIVE) - Bill Texts

view summary

Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents: provides for administrative structure of the plan; provides for powers and duties of the board of trustees, the scope of benefits, payment methodologies and care coordination; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; enacts provisions relating to financing of New York Health, including a payroll assessment, similar to the Medicare tax; establishes a temporary commission on implementation of the plan; provides for collective negotiations by health care providers with New York Health.

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                    S T A T E   O F   N E W   Y O R K
________________________________________________________________________

    S. 5425--A                                            A. 7860--A

                       2011-2012 Regular Sessions

                      S E N A T E - A S S E M B L Y

                              May 19, 2011
                               ___________

IN  SENATE  --  Introduced  by  Sens.  DUANE, PERKINS, DILAN, ESPAILLAT,
  KRUEGER, MONTGOMERY, OPPENHEIMER, RIVERA, SERRANO --  read  twice  and
  ordered  printed, and when printed to be committed to the Committee on
  Finance -- recommitted to the Committee on Finance in accordance  with
  Senate  Rule  6, sec. 8 -- committee discharged, bill amended, ordered
  reprinted as amended and recommitted to said committee

IN ASSEMBLY -- Introduced by M. of  A.  GOTTFRIED,  BENEDETTO,  BRONSON,
  BROOK-KRASNY,  CYMBROWITZ, ENGLEBRIGHT, GANTT, HIKIND, JAFFEE, JACOBS,
  KELLNER, LAVINE, MAISEL,  PEOPLES-STOKES,  SWEENEY,  TITUS,  KAVANAGH,
  DINOWITZ,  ABINANTI,  LIFTON,  STEVENSON,  LINARES,  ROBERTS, SCHIMEL,
  BARRON -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, BOYLAND, BREN-
  NAN, CAHILL, CAMARA, CLARK, COLTON,  COOK,  FARRELL,  GLICK,  GUNTHER,
  HEASTIE,  HOOPER, JEFFRIES, LATIMER, LENTOL, V. LOPEZ, LUPARDO, MAGEE,
  MAGNARELLI, MARKEY, McENENY, MILLMAN, O'DONNELL, ORTIZ, PAULIN, PERRY,
  PRETLOW, RAMOS, REILLY,  J. RIVERA,  N. RIVERA,  P. RIVERA,  ROBINSON,
  ROSENTHAL,  SCARBOROUGH,  THIELE,  WEISENBERG,  WEPRIN, WRIGHT -- read
  once and referred to the Committee on Health  --  recommitted  to  the
  Committee  on  Health  in  accordance  with Assembly Rule 3, sec. 2 --
  committee discharged, bill amended, ordered reprinted as  amended  and
  recommitted to said committee

AN  ACT  to  amend  the  public health law and the state finance law, in
  relation to establishing New York Health

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1. Legislative findings and intent. 1. The state constitution
states: "The protection and promotion of the health of  the  inhabitants
of  the state are matters of public concern and provision therefor shall
be made by the state and by such of its subdivisions and in such manner,
and by such means as the legislature shall from time to time determine."
(Article XVII, S3.) The legislature finds and declares  that  all  resi-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02490-03-2

S. 5425--A                          2                         A. 7860--A

dents of the state have the right to health care. New Yorkers - as indi-
viduals, employers, and taxpayers - have experienced a rapid rise in the
cost  of  health  care  and  coverage in recent years. This increase has
resulted in a large number of people without health coverage. Businesses
have  also  experienced  extraordinary  increases in the costs of health
care benefits for their employees. An unacceptable number of New Yorkers
have no health coverage, and many more are severely underinsured. Health
care providers are also affected by inadequate health  coverage  in  New
York  state.  A  large portion of voluntary and public hospitals, health
centers and other providers now experience substantial losses due to the
provision of care that is uncompensated.  Individuals  often  find  that
they  are deprived of affordable care and choice because of decisions by
health plans guided by the  plan's  economic  needs  rather  than  their
health  care  needs. To address the fiscal crisis facing the health care
system and the state and to assure New Yorkers can exercise their  right
to  health  care,  affordable  and comprehensive health coverage must be
provided. Pursuant to the state constitution's charge to the legislature
to provide for the health of New Yorkers, this legislation is an  enact-
ment  of  state  concern for the purpose of establishing a comprehensive
universal single-payer health care coverage program and  a  health  care
cost control system for the benefit of all residents of the state of New
York.
  2.  It  is the intent of the Legislature to create the New York Health
program to provide a universal health plan for every New Yorker,  funded
by broad-based revenue based on ability to pay.  The state shall work to
obtain  waivers  relating  to Medicaid, Family Health Plus, Child Health
Plus, Medicare, the Patient Protection and Affordable Care Act, and  any
other  appropriate federal programs, under which federal funds and other
subsidies that would otherwise be paid to New York State and New Yorkers
for health coverage that will be equaled or exceeded by New York  Health
will  be  paid by the federal government to New York State and deposited
in the New York Health trust fund. Under such a waiver, health  coverage
under  those  programs will be replaced and merged into New York Health,
which will operate as a true single-payer program.
  If such a waiver is not obtained,  the  state  shall  use  state  plan
amendments  and seek waivers to maximize, and make as seamless as possi-
ble, the use of federally-matched health  programs  and  federal  health
programs  in  New York Health.   Thus, even where other programs such as
Medicaid or Medicare may contribute to paying for care, it is  the  goal
of  this  legislation  that  the  coverage will be delivered by New York
Health and, as much as possible, the multiple sources of funding will be
pooled with other New York Health funds and not be apparent to New  York
Health  members  or participating providers.   This program will promote
movement away from fee-for-service payment, which tends to reward  quan-
tity  and  requires excessive administrative expense, and towards alter-
nate payment methodologies, such as  global  or  capitated  payments  to
providers  or health care organizations, that promote quality, efficien-
cy, investment in primary and preventive care, and innovation and  inte-
gration in the organizing of health care.
  3.  This  act  does  not  create  any  employment benefit, nor does is
require, prohibit, or limit the providing of any employment benefit.
  4. In order to promote improved quality of, and access to, health care
services and promote improved clinical outcomes, it is the policy of the
state to encourage cooperative, collaborative and  integrative  arrange-
ments  among  health  care providers who might otherwise be competitors,
under the active supervision of the commissioner of health.  It  is  the

S. 5425--A                          3                         A. 7860--A

intent  of  the state to supplant competition with such arrangements and
regulation only to the extent necessary to accomplish  the  purposes  of
this  act,  and  to  provide  state  action immunity under the state and
federal  antitrust  laws  to  health  care  providers, particularly with
respect to their relations with the single-payer New  York  Health  plan
created by this act.
  S  2.  Article 50 and sections 5000, 5001, 5002 and 5003 of the public
health law are renumbered article 80 and sections 8000, 8001,  8002  and
8003, respectively, and a new article 51 is added to read as follows:
                                ARTICLE 51
                             NEW YORK HEALTH
SECTION 5100. DEFINITIONS.
        5101. PROGRAM CREATED.
        5102. BOARD OF TRUSTEES.
        5103. ELIGIBILITY AND ENROLLMENT.
        5104. BENEFITS.
        5105. HEALTH  CARE PROVIDERS; CARE COORDINATION; PAYMENT METHOD-
                OLOGIES.
        5106. HEALTH CARE ORGANIZATIONS.
        5107. PROGRAM STANDARDS.
        5108. REGULATIONS.
        5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS.
        5110. ADDITIONAL PROVISIONS.
  S 5100. DEFINITIONS. AS USED IN  THIS  ARTICLE,  THE  FOLLOWING  TERMS
SHALL  HAVE  THE FOLLOWING MEANINGS, UNLESS THE CONTEXT CLEARLY REQUIRES
OTHERWISE:
  1. "BOARD" MEANS THE BOARD OF TRUSTEES OF THE NEW YORK HEALTH  PROGRAM
CREATED  BY SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE, AND "TRUSTEE"
MEANS A TRUSTEE OF THE BOARD.
  2. "CARE COORDINATION" MEANS SERVICES PROVIDED BY A  CARE  COORDINATOR
UNDER PARAGRAPH (B) OF SUBDIVISION TWO OF SECTION FIFTY-ONE HUNDRED FIVE
OF THIS ARTICLE.
  3.  "CARE  COORDINATOR"  MEANS  AN  INDIVIDUAL  OR  ENTITY APPROVED TO
PROVIDE CARE COORDINATION UNDER PARAGRAPH  (B)  OF  SUBDIVISION  TWO  OF
SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE.
  4. "FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM" MEANS THE MEDICAL ASSIST-
ANCE  PROGRAM  UNDER TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES
LAW, THE FAMILY HEALTH PLUS PROGRAM UNDER TITLE ELEVEN-D OF ARTICLE FIVE
OF THE SOCIAL SERVICES LAW, AND THE  CHILD  HEALTH  PLUS  PROGRAM  UNDER
TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.
  5.  "HEALTH CARE ORGANIZATION" MEANS AN ENTITY THAT IS APPROVED BY THE
COMMISSIONER UNDER SECTION FIFTY-ONE HUNDRED  SIX  OF  THIS  ARTICLE  TO
PROVIDE HEALTH CARE SERVICES TO MEMBERS UNDER THE PROGRAM.
  6. "HEALTH CARE SERVICE" MEANS ANY HEALTH CARE SERVICE, INCLUDING CARE
COORDINATION, INCLUDED AS A BENEFIT UNDER THE PROGRAM.
  7. "IMPLEMENTATION PERIOD" MEANS THE PERIOD UNDER SUBDIVISION THREE OF
SECTION  FIFTY-ONE  HUNDRED ONE OF THIS ARTICLE DURING WHICH THE PROGRAM
WILL BE SUBJECT TO SPECIAL ELIGIBILITY AND FINANCING PROVISIONS UNTIL IT
IS FULLY IMPLEMENTED UNDER THAT SECTION.
  8. "LONG TERM CARE" MEANS LONG TERM CARE, TREATMENT,  MAINTENANCE,  OR
SERVICES  NOT  COVERED UNDER FAMILY HEALTH PLUS OR CHILD HEALTH PLUS, AS
APPROPRIATE, WITH THE EXCEPTION OF SHORT TERM REHABILITATION, AS DEFINED
BY THE COMMISSIONER.
  9. "MEDICAID" OR "MEDICAL ASSISTANCE" MEANS TITLE  ELEVEN  OF  ARTICLE
FIVE  OF  THE  SOCIAL  SERVICES LAW AND THE PROGRAM THEREUNDER.  "FAMILY
HEALTH PLUS" MEANS TITLE ELEVEN-D OF THE SOCIAL  SERVICES  LAW  AND  THE

S. 5425--A                          4                         A. 7860--A

PROGRAM  THEREUNDER.  "CHILD  HEALTH  PLUS" MEANS TITLE ONE-A OF ARTICLE
TWENTY-FIVE OF THIS CHAPTER AND THE PROGRAM THEREUNDER. "MEDICARE" MEANS
TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT AND THE  PROGRAMS  THERE-
UNDER.
  10. "MEMBER" MEANS AN INDIVIDUAL WHO IS ENROLLED IN THE PROGRAM.
  11.  "NEW YORK HEALTH TRUST FUND" MEANS THE NEW YORK HEALTH TRUST FUND
ESTABLISHED UNDER SECTION EIGHTY-NINE-H OF THE STATE FINANCE LAW.
  12. "PARTICIPATING PROVIDER" MEANS ANY INDIVIDUAL OR ENTITY THAT IS  A
HEALTH CARE PROVIDER THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS UNDER
THE PROGRAM, OR A HEALTH CARE ORGANIZATION.
  13.  "PATIENT  PROTECTION  AND  AFFORDABLE CARE ACT" MEANS THE FEDERAL
PATIENT PROTECTION AND AFFORDABLE  CARE  ACT,  PUBLIC  LAW  111-148,  AS
AMENDED  BY  THE  HEALTH  CARE AND EDUCATION RECONCILIATION ACT OF 2010,
PUBLIC LAW 111-152, AND ANY REGULATIONS OR GUIDANCE ISSUED THEREUNDER.
  14. "PERSON" MEANS ANY INDIVIDUAL OR NATURAL PERSON,  TRUST,  PARTNER-
SHIP,  ASSOCIATION,  UNINCORPORATED  ASSOCIATION,  CORPORATION, COMPANY,
LIMITED LIABILITY COMPANY, PROPRIETORSHIP, JOINT  VENTURE,  FIRM,  JOINT
STOCK ASSOCIATION, DEPARTMENT, AGENCY, AUTHORITY, OR OTHER LEGAL ENTITY,
WHETHER FOR-PROFIT, NOT-FOR-PROFIT OR GOVERNMENTAL.
  15.  "PROGRAM"  MEANS  THE  NEW YORK HEALTH PROGRAM CREATED BY SECTION
FIFTY-ONE HUNDRED ONE OF THIS ARTICLE.
  16. "PRESCRIPTION AND NON-PRESCRIPTION DRUGS" SHALL MEAN  PRESCRIPTION
DRUGS  AS  DEFINED  IN  SECTION TWO HUNDRED SEVENTY OF THIS CHAPTER, AND
NON-PRESCRIPTION SMOKING CESSATION PRODUCTS OR DEVICES.
  17. "RESIDENT" MEANS AN INDIVIDUAL WHOSE PRIMARY PLACE OF ABODE IS  IN
THE STATE, AS DETERMINED ACCORDING TO REGULATIONS OF THE COMMISSIONER.
  S  5101.  PROGRAM  CREATED.  1.  THE NEW YORK HEALTH PROGRAM IS HEREBY
CREATED IN THE DEPARTMENT. THE COMMISSIONER SHALL ESTABLISH  AND  IMPLE-
MENT  THE  PROGRAM UNDER THIS ARTICLE. THE PROGRAM SHALL PROVIDE COMPRE-
HENSIVE HEALTH COVERAGE TO EVERY RESIDENT WHO ENROLLS IN THE PROGRAM.
  2. THE COMMISSIONER SHALL, TO THE MAXIMUM EXTENT  POSSIBLE,  ORGANIZE,
ADMINISTER AND MARKET THE PROGRAM AND SERVICES AS A SINGLE PROGRAM UNDER
THE  NAME "NEW YORK HEALTH" OR SUCH OTHER NAME AS THE COMMISSIONER SHALL
DETERMINE, REGARDLESS OF UNDER WHICH LAW OR SOURCE THE DEFINITION  OF  A
BENEFIT  IS  FOUND INCLUDING (ON A VOLUNTARY BASIS) RETIREE HEALTH BENE-
FITS.  IN IMPLEMENTING THIS SUBDIVISION, THE  COMMISSIONER  SHALL  AVOID
JEOPARDIZING FEDERAL FINANCIAL PARTICIPATION IN THESE PROGRAMS AND SHALL
TAKE  CARE  TO  PROMOTE  PUBLIC UNDERSTANDING AND AWARENESS OF AVAILABLE
BENEFITS AND PROGRAMS.
  3. THE COMMISSIONER SHALL DETERMINE WHEN INDIVIDUALS MAY BEGIN ENROLL-
ING IN THE PROGRAM. THERE SHALL BE AN IMPLEMENTATION PERIOD, WHICH SHALL
BEGIN ON THE DATE THAT INDIVIDUALS MAY BEGIN ENROLLING  IN  THE  PROGRAM
AND SHALL END AS DETERMINED BY THE COMMISSIONER.
  4. AN INSURER AUTHORIZED TO PROVIDE COVERAGE PURSUANT TO THE INSURANCE
LAW  OR  A  HEALTH MAINTENANCE ORGANIZATION CERTIFIED UNDER THIS CHAPTER
MAY, IF OTHERWISE AUTHORIZED,  OFFER  BENEFITS  THAT  DO  NOT  DUPLICATE
COVERAGE  OFFERED  TO AN INDIVIDUAL UNDER THE PROGRAM, BUT MAY NOT OFFER
BENEFITS THAT DUPLICATE COVERAGE OFFERED  TO  AN  INDIVIDUAL  UNDER  THE
PROGRAM. PROVIDED, HOWEVER, THAT THIS SUBDIVISION SHALL NOT PROHIBIT (A)
THE  OFFERING  OF  ANY  BENEFITS  TO OR FOR INDIVIDUALS, INCLUDING THEIR
FAMILIES, WHO ARE EMPLOYED OR SELF-EMPLOYED IN THE STATE BUT WHO ARE NOT
RESIDENTS OF THE STATE, OR (B)  THE  OFFERING  OF  BENEFITS  DURING  THE
IMPLEMENTATION  PERIOD  TO  INDIVIDUALS  WHO  ENROLLED AS MEMBERS OF THE
PROGRAM, OR (C) THE OFFERING OF RETIREE HEALTH BENEFITS.

S. 5425--A                          5                         A. 7860--A

  5. A COLLEGE, UNIVERSITY OR OTHER INSTITUTION OF HIGHER  EDUCATION  IN
THE  STATE  MAY  PURCHASE COVERAGE UNDER THE PROGRAM FOR ANY STUDENT, OR
STUDENT'S DEPENDENT, WHO IS NOT A RESIDENT OF THE STATE.
  S 5102. BOARD OF TRUSTEES. 1. THE NEW YORK HEALTH BOARD OF TRUSTEES IS
HEREBY  CREATED  IN  THE DEPARTMENT. THE BOARD OF TRUSTEES SHALL, AT THE
REQUEST OF THE COMMISSIONER,  CONSIDER  ANY  MATTER  TO  EFFECTUATE  THE
PROVISIONS AND PURPOSES OF THIS ARTICLE, AND MAY ADVISE THE COMMISSIONER
THEREON;  AND  IT MAY, FROM TIME TO TIME, SUBMIT TO THE COMMISSIONER ANY
RECOMMENDATIONS TO EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS  ARTI-
CLE.  THE  COMMISSIONER  MAY  PROPOSE REGULATIONS UNDER THIS ARTICLE AND
AMENDMENTS THERETO FOR CONSIDERATION BY THE BOARD. THE BOARD OF TRUSTEES
SHALL HAVE NO EXECUTIVE, ADMINISTRATIVE OR APPOINTIVE DUTIES  EXCEPT  AS
OTHERWISE  PROVIDED  BY  LAW.  THE BOARD OF TRUSTEES SHALL HAVE POWER TO
ESTABLISH, AND FROM TIME TO TIME, AMEND REGULATIONS  TO  EFFECTUATE  THE
PROVISIONS  AND  PURPOSES  OF  THIS  ARTICLE, SUBJECT TO APPROVAL BY THE
COMMISSIONER.
  2. THE BOARD SHALL BE COMPOSED OF:
  (A) THE COMMISSIONER, THE SUPERINTENDENT OF  FINANCIAL  SERVICES,  AND
THE DIRECTOR OF THE BUDGET, OR THEIR DESIGNEES, AS EX OFFICIO MEMBERS;
  (B) SEVENTEEN TRUSTEES APPOINTED BY THE GOVERNOR;
  (I)  FIVE  OF  WHOM  SHALL  BE REPRESENTATIVES OF HEALTH CARE CONSUMER
ADVOCACY ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL  CONSTITUENCY,
WHO  HAVE  BEEN  INVOLVED  IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER
ADVOCACY, INCLUDING ISSUES OF INTEREST TO LOW- AND MODERATE-INCOME INDI-
VIDUALS;
  (II) TWO OF WHOM SHALL BE REPRESENTATIVES  OF  PROFESSIONAL  ORGANIZA-
TIONS REPRESENTING PHYSICIANS;
  (III)  TWO  OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
TIONS REPRESENTING LICENSED  OR  REGISTERED  HEALTH  CARE  PROFESSIONALS
OTHER THAN PHYSICIANS;
  (IV)  THREE OF WHOM SHALL BE REPRESENTATIVES OF HOSPITALS, ONE OF WHOM
SHALL BE A REPRESENTATIVE OF PUBLIC HOSPITALS;
  (V) ONE OF WHOM SHALL BE REPRESENTATIVE OF COMMUNITY HEALTH CENTERS;
  (VI) TWO OF WHOM SHALL BE REPRESENTATIVES  OF  HEALTH  CARE  ORGANIZA-
TIONS; AND
  (VIII) TWO OF WHOM SHALL BE REPRESENTATIVES OF ORGANIZED LABOR;
  (C)  THREE  TRUSTEES  APPOINTED  BY THE SPEAKER OF THE ASSEMBLY; THREE
TRUSTEES APPOINTED BY THE TEMPORARY PRESIDENT OF THE SENATE; ONE TRUSTEE
APPOINTED BY THE MINORITY  LEADER  OF  THE  ASSEMBLY;  AND  ONE  TRUSTEE
APPOINTED BY THE MINORITY LEADER OF THE SENATE.
  AFTER THE END OF THE IMPLEMENTATION PERIOD, NO PERSON SHALL BE A TRUS-
TEE  UNLESS  HE OR SHE IS A MEMBER OF THE PROGRAM, EXCEPT THE EX OFFICIO
TRUSTEES. EACH TRUSTEE SHALL SERVE AT THE  PLEASURE  OF  THE  APPOINTING
OFFICER, EXCEPT THE EX OFFICIO TRUSTEES.
  3.  THE  CHAIR  OF THE BOARD SHALL BE APPOINTED, AND MAY BE REMOVED AS
CHAIR, BY THE GOVERNOR FROM AMONG THE TRUSTEES. THE BOARD SHALL MEET  AT
LEAST  FOUR  TIMES  EACH  CALENDAR YEAR. MEETINGS SHALL BE HELD UPON THE
CALL OF THE CHAIR AND AS PROVIDED  BY  THE  BOARD.  A  MAJORITY  OF  THE
APPOINTED  TRUSTEES  SHALL BE A QUORUM OF THE BOARD, AND THE AFFIRMATIVE
VOTE OF A MAJORITY OF THE TRUSTEES VOTING, BUT NOT LESS THAN TEN,  SHALL
BE  NECESSARY  FOR  ANY  ACTION  TO BE TAKEN BY THE BOARD. THE BOARD MAY
ESTABLISH AN EXECUTIVE COMMITTEE TO EXERCISE ANY POWERS OR DUTIES OF THE
BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO ASSIST THE BOARD OR THE
EXECUTIVE COMMITTEE. THE CHAIR OF THE BOARD SHALL  CHAIR  THE  EXECUTIVE
COMMITTEE  AND  SHALL APPOINT THE CHAIR AND MEMBERS OF ALL OTHER COMMIT-
TEES. THE BOARD OF TRUSTEES MAY APPOINT ONE OR MORE ADVISORY COMMITTEES.

S. 5425--A                          6                         A. 7860--A

MEMBERS OF ADVISORY COMMITTEES NEED NOT BE MEMBERS OF THE BOARD OF TRUS-
TEES.
  4.  TRUSTEES  SHALL SERVE WITHOUT COMPENSATION BUT SHALL BE REIMBURSED
FOR THEIR NECESSARY AND ACTUAL EXPENSES INCURRED WHILE  ENGAGED  IN  THE
BUSINESS OF THE BOARD.
  5. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, NO OFFICER OR
EMPLOYEE OF THE STATE OR ANY LOCAL GOVERNMENT SHALL FORFEIT OR BE DEEMED
TO  HAVE  FORFEITED HIS OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A
TRUSTEE.
  6. THE BOARD AND ITS COMMITTEES AND ADVISORY  COMMITTEES  MAY  REQUEST
AND  RECEIVE  THE  ASSISTANCE  OF  THE DEPARTMENT AND ANY OTHER STATE OR
LOCAL GOVERNMENTAL ENTITY IN EXERCISING ITS POWERS AND DUTIES.
  7. NO LATER THAN FIVE YEARS AFTER THE EFFECTIVE DATE OF THIS ARTICLE:
  (A) THE BOARD SHALL DEVELOP A PROPOSAL, CONSISTENT WITH THE PRINCIPLES
OF THIS ARTICLE, FOR PROVISION BY THE PROGRAM OF LONG-TERM  CARE  COVER-
AGE,  INCLUDING THE DEVELOPMENT OF A PROPOSAL, CONSISTENT WITH THE PRIN-
CIPLES OF THIS ARTICLE, FOR ITS FUNDING.   IN DEVELOPING  THE  PROPOSAL,
THE  BOARD  SHALL  CONSULT  WITH AN ADVISORY COMMITTEE, APPOINTED BY THE
CHAIR OF THE BOARD, INCLUDING REPRESENTATIVES OF CONSUMERS AND POTENTIAL
CONSUMERS OF LONG-TERM CARE, PROVIDERS OF  LONG-TERM  CARE,  LABOR,  AND
OTHER  INTERESTED  PARTIES.  THE BOARD SHALL PRESENT ITS PROPOSAL TO THE
GOVERNOR AND THE LEGISLATURE.
  (B) THE BOARD SHALL  DEVELOP  A  PROPOSAL  FOR  INCORPORATING  RETIREE
HEALTH BENEFITS INTO NEW YORK HEALTH.
  S  5103.  ELIGIBILITY  AND  ENROLLMENT. 1. EVERY RESIDENT OF THE STATE
SHALL BE ELIGIBLE AND ENTITLED TO ENROLL AS A MEMBER UNDER THE PROGRAM.
  2. NO MEMBER SHALL BE REQUIRED TO PAY ANY PREMIUM OR OTHER CHARGE  FOR
ENROLLING IN OR BEING A MEMBER UNDER THE PROGRAM.
  S  5104.  BENEFITS.  1. THE PROGRAM SHALL PROVIDE COMPREHENSIVE HEALTH
COVERAGE TO EVERY MEMBER, WHICH SHALL INCLUDE ALL HEALTH  CARE  SERVICES
REQUIRED  TO  BE  COVERED  UNDER ANY OF THE FOLLOWING, WITHOUT REGARD TO
WHETHER THE MEMBER WOULD OTHERWISE BE ELIGIBLE FOR  OR  COVERED  BY  THE
PROGRAM OR SOURCE REFERRED TO:
  (A) FAMILY HEALTH PLUS;
  (B) FOR EVERY MEMBER UNDER THE AGE OF TWENTY-ONE, CHILD HEALTH PLUS;
  (C) MEDICAID;
  (D) MEDICARE;
  (E)  ARTICLE  FORTY-FOUR  OF  THIS  CHAPTER  OR  ARTICLE THIRTY-TWO OR
FORTY-THREE OF THE INSURANCE LAW;
  (F) ARTICLE ELEVEN OF THE CIVIL SERVICE LAW, AS OF THE DATE  ONE  YEAR
BEFORE THE BEGINNING OF THE IMPLEMENTATION PERIOD;
  (G)  ANY  ADDITIONAL HEALTH CARE SERVICE AUTHORIZED TO BE ADDED TO THE
PROGRAM'S BENEFITS BY THE PROGRAM; AND
  (H) PROVIDED THAT NONE OF THE ABOVE  SHALL  INCLUDE  LONG  TERM  CARE,
UNTIL  A  PROPOSAL  UNDER  PARAGRAPH (A) OF SUBDIVISION SEVEN OF SECTION
FIFTY-ONE HUNDRED TWO OF THIS ARTICLE IS ENACTED INTO LAW.
  2. NO MEMBER SHALL BE REQUIRED TO PAY ANY  DEDUCTIBLE,  CO-PAYMENT  OR
CO-INSURANCE UNDER THE PROGRAM.
  3.  THE  PROGRAM SHALL PROVIDE FOR PAYMENT UNDER THE PROGRAM FOR EMER-
GENCY AND TEMPORARY HEALTH CARE SERVICES PROVIDED TO MEMBERS OR INDIVID-
UALS ENTITLED TO BECOME MEMBERS WHO HAVE NOT HAD A  REASONABLE  OPPORTU-
NITY TO BECOME A MEMBER OR TO ENROLL WITH A CARE COORDINATOR.
  S  5105.  HEALTH  CARE PROVIDERS; CARE COORDINATION; PAYMENT METHODOL-
OGIES.  1. CHOICE OF HEALTH CARE PROVIDER. (A) ANY HEALTH CARE  PROVIDER
QUALIFIED  TO  PARTICIPATE  UNDER  THIS  SECTION MAY PROVIDE HEALTH CARE
SERVICES UNDER THE PROGRAM, PROVIDED THAT THE HEALTH  CARE  PROVIDER  IS

S. 5425--A                          7                         A. 7860--A

OTHERWISE  LEGALLY AUTHORIZED TO PERFORM THE HEALTH CARE SERVICE FOR THE
INDIVIDUAL AND UNDER THE CIRCUMSTANCES INVOLVED.
  (B)  A  MEMBER  MAY  CHOOSE  TO RECEIVE HEALTH CARE SERVICES UNDER THE
PROGRAM FROM ANY PARTICIPATING PROVIDER, CONSISTENT WITH  PROVISIONS  OF
THIS  ARTICLE  RELATING  TO  CARE COORDINATION AND HEALTH CARE ORGANIZA-
TIONS, THE WILLINGNESS OR  AVAILABILITY  OF  THE  PROVIDER  (SUBJECT  TO
PROVISIONS  OF  THIS ARTICLE RELATING TO DISCRIMINATION), AND THE APPRO-
PRIATE CLINICALLY-RELEVANT CIRCUMSTANCES.
  2. CARE COORDINATION.  (A) HEALTH CARE SERVICES PROVIDED TO  A  MEMBER
SHALL  NOT  BE SUBJECT TO PAYMENT UNDER THE PROGRAM UNLESS THE MEMBER IS
ENROLLED WITH A CARE COORDINATOR AT THE TIME THE HEALTH CARE SERVICE  IS
PROVIDED,  EXCEPT  WHERE  PROVIDED  UNDER  SUBDIVISION  THREE OF SECTION
FIFTY-ONE HUNDRED FOUR OF THIS ARTICLE. EVERY MEMBER SHALL ENROLL WITH A
CARE COORDINATOR THAT AGREES TO PROVIDE CARE COORDINATION TO THE  MEMBER
PRIOR  TO  RECEIVING  HEALTH  CARE  SERVICES  TO  BE  PAID FOR UNDER THE
PROGRAM. THE MEMBER SHALL REMAIN ENROLLED  WITH  THAT  CARE  COORDINATOR
UNTIL  THE  MEMBER BECOMES ENROLLED WITH A DIFFERENT CARE COORDINATOR OR
CEASES TO BE A MEMBER. THE COMMISSIONER SHALL  PROVIDE,  BY  REGULATION,
THAT MEMBERS HAVE THE RIGHT TO CHANGE THEIR CARE COORDINATOR ON TERMS AT
LEAST   AS  PERMISSIVE  AS  THE  PROVISIONS  OF  SECTION  THREE  HUNDRED
SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW RELATING TO AN INDIVIDUAL CHANG-
ING HIS OR HER PRIMARY CARE PROVIDER OR MANAGED CARE PROVIDER.
  (B) CARE COORDINATION SHALL BE PROVIDED TO THE MEMBER BY THE  MEMBER'S
CARE COORDINATOR.  A CARE COORDINATOR MAY EMPLOY OR UTILIZE THE SERVICES
OF  OTHER  INDIVIDUALS  OR  ENTITIES TO ASSIST IN PROVIDING CARE COORDI-
NATION FOR THE MEMBER, CONSISTENT WITH REGULATIONS OF THE  COMMISSIONER.
CARE COORDINATION SHALL INCLUDE, BUT NOT BE LIMITED TO, MANAGING, REFER-
RING TO, LOCATING, COORDINATING, AND MONITORING HEALTH CARE SERVICES FOR
THE  MEMBER  TO ASSURE THAT ALL MEDICALLY NECESSARY HEALTH CARE SERVICES
ARE MADE AVAILABLE TO AND ARE EFFECTIVELY USED BY THE MEMBER IN A TIMELY
MANNER, CONSISTENT WITH PATIENT AUTONOMY. CARE  COORDINATION  IS  NOT  A
REQUIREMENT  FOR PRIOR AUTHORIZATION FOR HEALTH CARE SERVICES AND REFER-
RAL SHALL NOT BE REQUIRED FOR A MEMBER TO RECEIVE A HEALTH CARE SERVICE.
HOWEVER: (I) A HEALTH CARE ORGANIZATION MAY ESTABLISH RULES RELATING  TO
CARE COORDINATION FOR MEMBERS IN THE HEALTH CARE ORGANIZATION, DIFFERENT
FROM  THIS  SUBDIVISION  BUT  OTHERWISE CONSISTENT WITH THIS ARTICLE AND
OTHER APPLICABLE LAWS;  AND  (II)  NOTHING  IN  THIS  SUBDIVISION  SHALL
AUTHORIZE  ANY  INDIVIDUAL  TO  ENGAGE  IN ANY ACT IN VIOLATION OF TITLE
EIGHT OF THE EDUCATION LAW.
  (C) WHERE A MEMBER RECEIVES CHRONIC MENTAL HEALTH  CARE  SERVICES,  AT
THE  OPTION OF THE MEMBER, THE MEMBER MAY ENROLL WITH A CARE COORDINATOR
FOR HIS OR HER MENTAL HEALTH CARE SERVICES AND ANOTHER CARE  COORDINATOR
APPROVED  FOR  HIS  OR  HER  OTHER HEALTH CARE SERVICES, CONSISTENT WITH
STANDARDS ESTABLISHED BY  THE  COMMISSIONER  IN  CONSULTATION  WITH  THE
COMMISSIONER OF MENTAL HEALTH. IN SUCH A CASE, THE TWO CARE COORDINATORS
SHALL WORK IN CLOSE CONSULTATION WITH EACH OTHER.
  (D) A CARE COORDINATOR MAY BE AN INDIVIDUAL OR ENTITY THAT IS APPROVED
BY THE PROGRAM THAT IS:
  (I)  A  HEALTH CARE PRACTITIONER WHO IS: (A) THE MEMBER'S PRIMARY CARE
PRACTITIONER; (B) AT THE OPTION OF A FEMALE MEMBER, THE MEMBER'S PROVID-
ER OF PRIMARY GYNECOLOGICAL CARE; OR (C) AT THE OPTION OF A  MEMBER  WHO
HAS  A  CHRONIC  CONDITION  THAT  REQUIRES  SPECIALTY CARE, A SPECIALIST
HEALTH CARE PRACTITIONER WHO REGULARLY AND CONTINUALLY  PROVIDES  TREAT-
MENT FOR THAT CONDITION TO THE MEMBER;
  (II)  AN ENTITY LICENSED UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR
CERTIFIED UNDER ARTICLE THIRTY-SIX OF THIS CHAPTER, A MANAGED LONG  TERM

S. 5425--A                          8                         A. 7860--A

CARE  PLAN  UNDER  SECTION FORTY-FOUR HUNDRED THREE-F OF THIS CHAPTER OR
OTHER PROGRAM MODEL UNDER PARAGRAPH (B) OF  SUBDIVISION  SEVEN  OF  SUCH
SECTION, OR, WITH RESPECT TO A MEMBER WHO RECEIVES CHRONIC MENTAL HEALTH
CARE SERVICES, AN ENTITY LICENSED UNDER ARTICLE THIRTY-ONE OF THE MENTAL
HYGIENE LAW OR OTHER ENTITY APPROVED BY THE COMMISSIONER IN CONSULTATION
WITH THE COMMISSIONER OF MENTAL HEALTH;
  (III) A HEALTH CARE ORGANIZATION;
  (IV) A TAFT-HARTLEY FUND, WITH RESPECT TO ITS MEMBERS AND THEIR FAMILY
MEMBERS;  PROVIDED THAT THIS PROVISION SHALL NOT PRECLUDE A TAFT-HARTLEY
FUND FROM BECOMING A CARE COORDINATOR UNDER  SUBPARAGRAPH  (V)  OF  THIS
PARAGRAPH  OR A HEALTH CARE ORGANIZATION UNDER SECTION FIFTY-ONE HUNDRED
SIX OF THIS ARTICLE; OR
  (V) ANY NOT-FOR-PROFIT OR GOVERNMENTAL ENTITY APPROVED BY THE PROGRAM.
  (E) THE COMMISSIONER SHALL DEVELOP AND IMPLEMENT PROCEDURES AND STAND-
ARDS FOR AN INDIVIDUAL OR ENTITY TO BE APPROVED TO BE A CARE COORDINATOR
IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO  PROCEDURES  AND  STANDARDS
RELATING  TO  THE  REVOCATION,  SUSPENSION,  LIMITATION, OR ANNULMENT OF
APPROVAL ON A DETERMINATION THAT THE INDIVIDUAL OR ENTITY IS INCOMPETENT
TO BE A CARE COORDINATOR OR HAS EXHIBITED A COURSE OF CONDUCT  WHICH  IS
EITHER  INCONSISTENT  WITH  PROGRAM  STANDARDS  AND REGULATIONS OR WHICH
EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR  IS
A  POTENTIAL  THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES AND
STANDARDS SHALL NOT LIMIT APPROVAL TO  BE  A  CARE  COORDINATOR  IN  THE
PROGRAM  FOR ECONOMIC PURPOSES AND SHALL BE CONSISTENT WITH GOOD PROFES-
SIONAL PRACTICE. IN DEVELOPING THE PROCEDURES AND STANDARDS, THE COMMIS-
SIONER SHALL: (I) CONSIDER  EXISTING  STANDARDS  DEVELOPED  BY  NATIONAL
ACCREDITING  AND  PROFESSIONAL  ORGANIZATIONS;  AND  (II)  CONSULT  WITH
NATIONAL AND LOCAL ORGANIZATIONS WORKING ON CARE COORDINATION OR SIMILAR
MODELS, INCLUDING HEALTH CARE  PRACTITIONERS,  HOSPITALS,  CLINICS,  AND
CONSUMERS  AND  THEIR  REPRESENTATIVES. WHEN DEVELOPING AND IMPLEMENTING
STANDARDS OF APPROVAL OF CARE  COORDINATORS  FOR  INDIVIDUALS  RECEIVING
CHRONIC MENTAL HEALTH CARE SERVICES, THE COMMISSIONER SHALL CONSULT WITH
THE  COMMISSIONER OF MENTAL HEALTH. AN INDIVIDUAL OR ENTITY MAY NOT BE A
CARE COORDINATOR UNLESS THE SERVICES INCLUDED IN CARE  COORDINATION  ARE
WITHIN  THE  INDIVIDUAL'S PROFESSIONAL SCOPE OF PRACTICE OR THE ENTITY'S
LEGAL AUTHORITY.
  (F) TO MAINTAIN APPROVAL UNDER THE PROGRAM, A CARE  COORDINATOR  MUST:
(I)  RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE COMMISSIONER; AND
(II) PROVIDE DATA TO THE DEPARTMENT AS REQUIRED BY THE  COMMISSIONER  TO
ENABLE  THE  COMMISSIONER TO EVALUATE THE IMPACT OF CARE COORDINATORS ON
QUALITY, OUTCOMES AND COST.
  3. HEALTH CARE PROVIDERS. THE COMMISSIONER SHALL ESTABLISH  AND  MAIN-
TAIN  PROCEDURES AND STANDARDS FOR HEALTH CARE PROVIDERS TO BE QUALIFIED
TO PARTICIPATE IN THE PROGRAM, INCLUDING BUT NOT LIMITED  TO  PROCEDURES
AND  STANDARDS  RELATING  TO  THE REVOCATION, SUSPENSION, LIMITATION, OR
ANNULMENT OF QUALIFICATION TO PARTICIPATE ON A  DETERMINATION  THAT  THE
HEALTH  CARE PROVIDER IS AN INCOMPETENT PROVIDER OF SPECIFIC HEALTH CARE
SERVICES OR HAS EXHIBITED A COURSE OF CONDUCT WHICH IS EITHER INCONSIST-
ENT WITH PROGRAM STANDARDS AND REGULATIONS OR WHICH EXHIBITS AN  UNWILL-
INGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR IS A POTENTIAL THREAT
TO  THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES AND STANDARDS SHALL NOT
LIMIT HEALTH CARE PROVIDER PARTICIPATION IN  THE  PROGRAM  FOR  ECONOMIC
PURPOSES  AND  SHALL  BE CONSISTENT WITH GOOD PROFESSIONAL PRACTICE. ANY
HEALTH CARE PROVIDER WHO IS QUALIFIED  TO  PARTICIPATE  UNDER  MEDICAID,
FAMILY  HEALTH PLUS, CHILD HEALTH PLUS OR MEDICARE SHALL BE DEEMED TO BE
QUALIFIED TO PARTICIPATE IN THE PROGRAM, AND ANY HEALTH CARE  PROVIDER'S

S. 5425--A                          9                         A. 7860--A

REVOCATION,  SUSPENSION,  LIMITATION,  OR  ANNULMENT OF QUALIFICATION TO
PARTICIPATE IN ANY OF THOSE PROGRAMS SHALL  APPLY  TO  THE  HEALTH  CARE
PROVIDER'S  QUALIFICATION TO PARTICIPATE IN THE PROGRAM; PROVIDED THAT A
HEALTH  CARE  PROVIDER  QUALIFIED  UNDER  THIS SENTENCE SHALL FOLLOW THE
PROCEDURES TO BECOME QUALIFIED UNDER THE  PROGRAM  BY  THE  END  OF  THE
IMPLEMENTATION PERIOD.
  4. PAYMENT FOR HEALTH CARE SERVICES. (A) HEALTH CARE SERVICES PROVIDED
TO  MEMBERS  UNDER  THE  PROGRAM  SHALL BE PAID FOR ON A FEE-FOR-SERVICE
BASIS, EXCEPT FOR  CARE  COORDINATION.  HOWEVER,  THE  COMMISSIONER  MAY
ESTABLISH  BY  REGULATION  OTHER  PAYMENT  METHODOLOGIES FOR HEALTH CARE
SERVICES AND CARE COORDINATION PROVIDED TO MEMBERS UNDER THE PROGRAM  BY
PARTICIPATING  PROVIDERS,  CARE  COORDINATORS, AND HEALTH CARE ORGANIZA-
TIONS.   THERE MAY BE A  VARIETY  OF  DIFFERENT  PAYMENT  METHODOLOGIES,
INCLUDING  THOSE ESTABLISHED ON A DEMONSTRATION BASIS. ALL PAYMENT RATES
UNDER THE PROGRAM SHALL BE REASONABLE AND REASONABLY RELATED TO THE COST
OF EFFICIENTLY  PROVIDING  THE  HEALTH  CARE  SERVICE  AND  ASSURING  AN
ADEQUATE AND ACCESSIBLE SUPPLY OF HEALTH CARE SERVICE.
  (B)  THE  PROGRAM  SHALL ENGAGE IN GOOD FAITH NEGOTIATIONS WITH HEALTH
CARE PROVIDERS' REPRESENTATIVES UNDER TITLE III OF ARTICLE FORTY-NINE OF
THIS CHAPTER, INCLUDING, BUT NOT LIMITED TO, IN  RELATION  TO  RATES  OF
PAYMENT AND PAYMENT METHODOLOGIES.
  (C)  NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, PAYMENT FOR
DRUGS PROVIDED BY PHARMACIES UNDER THE PROGRAM SHALL BE MADE PURSUANT TO
ARTICLE TWO-A OF THIS CHAPTER AND  SUBDIVISION  FOUR  OF  SECTION  THREE
HUNDRED  SIXTY-FIVE-A  OF  THE SOCIAL SERVICES LAW. HOWEVER, THE PROGRAM
SHALL PROVIDE FOR PAYMENT FOR PRESCRIPTION DRUGS UNDER SECTION  340B  OF
THE   FEDERAL   PUBLIC   SERVICE   ACT  WHERE  APPLICABLE.  PAYMENT  FOR
PRESCRIPTION DRUGS PROVIDED BY HEALTH CARE PROVIDERS OTHER THAN  PHARMA-
CIES SHALL BE PURSUANT TO OTHER PROVISIONS OF THIS ARTICLE.
  (D)  PAYMENT  FOR  HEALTH CARE SERVICES ESTABLISHED UNDER THIS ARTICLE
SHALL BE CONSIDERED PAYMENT IN FULL. A PARTICIPATING PROVIDER SHALL  NOT
CHARGE  ANY RATE IN EXCESS OF THE PAYMENT ESTABLISHED UNDER THIS ARTICLE
FOR ANY HEALTH CARE SERVICE UNDER THE PROGRAM PROVIDED TO A  MEMBER  AND
SHALL  NOT  SOLICIT OR ACCEPT PAYMENT FROM ANY MEMBER OR THIRD PARTY FOR
ANY SUCH SERVICE EXCEPT AS PROVIDED UNDER THIS ARTICLE.   HOWEVER,  THIS
PARAGRAPH  SHALL  NOT  PRECLUDE  THE PROGRAM FROM ACTING AS A PRIMARY OR
SECONDARY PAYER IN CONJUNCTION  WITH  ANOTHER  THIRD-PARTY  PAYER  WHERE
PERMITTED UNDER THIS ARTICLE.
  (E)  THE  PROGRAM MAY PROVIDE IN PAYMENT METHODOLOGIES FOR PAYMENT FOR
CAPITAL RELATED EXPENSES FOR SPECIFICALLY  IDENTIFIED  CAPITAL  EXPENDI-
TURES  INCURRED  BY  NOT-FOR-PROFIT  OR  GOVERNMENTAL ENTITIES CERTIFIED
UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER. ANY CAPITAL RELATED  EXPENSE
GENERATED  BY  A  CAPITAL EXPENDITURE THAT REQUIRES OR REQUIRED APPROVAL
UNDER ARTICLE TWENTY-EIGHT OF  THIS  CHAPTER  MUST  HAVE  RECEIVED  THAT
APPROVAL  FOR  THE  CAPITAL  RELATED  EXPENSE  TO  BE PAID FOR UNDER THE
PROGRAM.
  5. (A) FOR PURPOSES  OF  THIS  SUBDIVISION,  "INCOME-ELIGIBLE  MEMBER"
MEANS  A  MEMBER  WHO  IS  ENROLLED IN A FEDERALLY-MATCHED PUBLIC HEALTH
PROGRAM AND (I) THERE IS FEDERAL FINANCIAL PARTICIPATION IN THE INDIVID-
UAL'S HEALTH COVERAGE, OR (II) THE MEMBER IS ELIGIBLE TO ENROLL  IN  THE
FEDERALLY-MATCHED  PUBLIC  HEALTH  PROGRAM BY REASON OF INCOME, AGE, AND
RESOURCES (WHERE APPLICABLE) UNDER STATE LAW IN EFFECT ON THE  EFFECTIVE
DATE OF THIS SECTION, BUT THERE IS NO FEDERAL FINANCIAL PARTICIPATION IN
THE  INDIVIDUAL'S HEALTH COVERAGE. A PERSON WHO IS ELIGIBLE TO ENROLL IN
A FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM SOLELY BY  REASON  OF  SECTION

S. 5425--A                         10                         A. 7860--A

THREE  HUNDRED  SIXTY-NINE-FF OF THE SOCIAL SERVICES LAW (EMPLOYER PART-
NERSHIPS FOR FAMILY HEALTH PLUS) IS NOT AN INCOME-ELIGIBLE MEMBER.
  (B)  THE  PROGRAM,  WITH  RESPECT TO INCOME-ELIGIBLE MEMBERS, SHALL BE
CONSIDERED A FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM OR GOVERNMENT PAYOR
UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER WITH RESPECT TO THE FOLLOWING
PROVISIONS, AND WITH RESPECT TO THOSE MEMBERS WHO ARE NOT  INCOME-ELIGI-
BLE  MEMBERS,  SHALL NOT BE CONSIDERED A FEDERALLY-MATCHED PUBLIC HEALTH
PROGRAM OR GOVERNMENTAL PAYOR UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER
WITH RESPECT TO THE FOLLOWING PROVISIONS:
  (I) PATIENT SERVICES PAYMENTS IN ACCORDANCE WITH SECTION  TWENTY-EIGHT
HUNDRED SEVEN-J OF THIS CHAPTER;
  (II)  PROFESSIONAL  EDUCATION  POOL FUNDING UNDER SECTION TWENTY-EIGHT
HUNDRED SEVEN-S OF THIS CHAPTER; OR
  (III) ASSESSMENTS ON COVERED LIVES UNDER SECTION TWENTY-EIGHT  HUNDRED
SEVEN-T OF THIS CHAPTER.
  S  5106.  HEALTH  CARE ORGANIZATIONS. 1. A MEMBER MAY CHOOSE TO ENROLL
WITH AND RECEIVE HEALTH CARE SERVICES UNDER THE PROGRAM  FROM  A  HEALTH
CARE ORGANIZATION.
  2.  A  HEALTH  CARE  ORGANIZATION SHALL BE A NOT-FOR-PROFIT OR GOVERN-
MENTAL ENTITY THAT IS APPROVED BY THE COMMISSIONER THAT IS:
  (A) AN ACCOUNTABLE CARE ORGANIZATION UNDER  ARTICLE  TWENTY-NINE-E  OF
THIS CHAPTER; OR
  (B)  A  TAFT-HARTLEY  FUND  (I)  WITH RESPECT TO ITS MEMBERS AND THEIR
FAMILY MEMBERS, AND (II) IF ALLOWED BY APPLICABLE LAW  AND  APPROVED  BY
THE  COMMISSIONER,  FOR  OTHER MEMBERS OF THE PROGRAM; PROVIDED THAT THE
COMMISSIONER SHALL PROVIDE BY REGULATION THAT WHERE A TAFT-HARTLEY  FUND
IS  ACTING UNDER THIS SUBPARAGRAPH THERE ARE PROTECTIONS FOR HEALTH CARE
PROVIDERS AND PATIENTS COMPARABLE TO  THOSE  APPLICABLE  TO  ACCOUNTABLE
CARE ORGANIZATIONS.
  3.  A  HEALTH  CARE ORGANIZATION MAY BE RESPONSIBLE FOR ALL OR PART OF
THE HEALTH CARE SERVICES TO WHICH ITS MEMBERS  ARE  ENTITLED  UNDER  THE
PROGRAM, CONSISTENT WITH THE TERMS OF ITS APPROVAL BY THE COMMISSIONER.
  4.  (A)  THE  COMMISSIONER  SHALL DEVELOP AND IMPLEMENT PROCEDURES AND
STANDARDS FOR AN ENTITY TO BE APPROVED TO BE A HEALTH CARE  ORGANIZATION
IN  THE  PROGRAM,  INCLUDING BUT NOT LIMITED TO PROCEDURES AND STANDARDS
RELATING TO THE REVOCATION,  SUSPENSION,  LIMITATION,  OR  ANNULMENT  OF
APPROVAL  ON  A  DETERMINATION  THAT  THE  ENTITY IS INCOMPETENT TO BE A
HEALTH CARE ORGANIZATION OR HAS EXHIBITED A COURSE OF CONDUCT  WHICH  IS
EITHER  INCONSISTENT  WITH  PROGRAM  STANDARDS  AND REGULATIONS OR WHICH
EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR  IS
A  POTENTIAL  THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES AND
STANDARDS SHALL NOT LIMIT APPROVAL TO BE A HEALTH CARE  ORGANIZATION  IN
THE  PROGRAM  FOR  ECONOMIC  PURPOSES  AND SHALL BE CONSISTENT WITH GOOD
PROFESSIONAL PRACTICE. IN DEVELOPING THE PROCEDURES AND  STANDARDS,  THE
COMMISSIONER   SHALL:  (I)  CONSIDER  EXISTING  STANDARDS  DEVELOPED  BY
NATIONAL ACCREDITING AND PROFESSIONAL ORGANIZATIONS;  AND  (II)  CONSULT
WITH  NATIONAL  AND  LOCAL  ORGANIZATIONS WORKING IN THE FIELD OF HEALTH
CARE ORGANIZATIONS,  INCLUDING  HEALTH  CARE  PRACTITIONERS,  HOSPITALS,
CLINICS,  AND  CONSUMERS  AND THEIR REPRESENTATIVES. WHEN DEVELOPING AND
IMPLEMENTING STANDARDS OF APPROVAL OF  HEALTH  CARE  ORGANIZATIONS,  THE
COMMISSIONER  SHALL  CONSULT  WITH THE COMMISSIONER OF MENTAL HEALTH AND
THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES.
  (B) TO MAINTAIN APPROVAL UNDER THE PROGRAM, A HEALTH CARE ORGANIZATION
MUST: (I) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE  COMMISSION-
ER;  AND  (II) PROVIDE DATA TO THE DEPARTMENT AS REQUIRED BY THE COMMIS-
SIONER TO ENABLE THE COMMISSIONER TO EVALUATE THE HEALTH CARE  ORGANIZA-

S. 5425--A                         11                         A. 7860--A

TION  IN  RELATION  TO  QUALITY  OF  HEALTH  CARE  SERVICES, HEALTH CARE
OUTCOMES, AND COST.
  5.  THE  COMMISSIONER  SHALL  MAKE REGULATIONS RELATING TO HEALTH CARE
ORGANIZATIONS CONSISTENT WITH AND TO ENSURE COMPLIANCE WITH  THIS  ARTI-
CLE.
  6.  THE  PROVISION OF HEALTH CARE SERVICES DIRECTLY OR INDIRECTLY BY A
HEALTH CARE ORGANIZATION THROUGH HEALTH  CARE  PROVIDERS  SHALL  NOT  BE
CONSIDERED  THE PRACTICE OF A PROFESSION UNDER TITLE EIGHT OF THE EDUCA-
TION LAW BY THE HEALTH CARE ORGANIZATION.
  S  5107.  PROGRAM  STANDARDS.  1.  THE  COMMISSIONER  SHALL  ESTABLISH
REQUIREMENTS AND STANDARDS FOR THE PROGRAM AND FOR HEALTH CARE ORGANIZA-
TIONS,  CARE COORDINATORS, AND HEALTH CARE PROVIDERS, INCLUDING REQUIRE-
MENTS AND STANDARDS FOR, AS APPLICABLE:
  (A) THE SCOPE, QUALITY AND ACCESSIBILITY OF HEALTH CARE SERVICES;
  (B) RELATIONS BETWEEN HEALTH CARE ORGANIZATIONS OR HEALTH CARE PROVID-
ERS AND MEMBERS, INCLUDING APPROVAL OF HEALTH CARE SERVICES; AND
  (C) RELATIONS  BETWEEN  HEALTH  CARE  ORGANIZATIONS  AND  HEALTH  CARE
PROVIDERS,  INCLUDING (I) CREDENTIALING AND PARTICIPATION IN HEALTH CARE
ORGANIZATION NETWORKS; AND (II) TERMS, METHODS AND RATES OF PAYMENT.
  2. REQUIREMENTS AND STANDARDS UNDER THE PROGRAM SHALL INCLUDE, BUT NOT
BE LIMITED TO, PROVISIONS TO PROMOTE THE FOLLOWING:
  (A) SIMPLIFICATION, TRANSPARENCY, UNIFORMITY, AND FAIRNESS  IN  HEALTH
CARE  PROVIDER  CREDENTIALING AND PARTICIPATION IN HEALTH CARE ORGANIZA-
TION NETWORKS, REFERRALS, PAYMENT PROCEDURES AND RATES, CLAIMS  PROCESS-
ING, AND APPROVAL OF HEALTH CARE SERVICES, AS APPLICABLE;
  (B)  PRIMARY  AND  PREVENTIVE  CARE,  CARE COORDINATION, EFFICIENT AND
EFFECTIVE HEALTH CARE SERVICES, QUALITY ASSURANCE, AND COORDINATION  AND
INTEGRATION  OF HEALTH CARE SERVICES, INCLUDING USE OF APPROPRIATE TECH-
NOLOGY;
  (C) ELIMINATION OF HEALTH CARE DISPARITIES;
  (D) NON-DISCRIMINATION WITH RESPECT TO MEMBERS AND HEALTH CARE PROVID-
ERS ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, RELIGION, DISABIL-
ITY, AGE, SEX, SEXUAL ORIENTATION, GENDER  IDENTITY  OR  EXPRESSION,  OR
ECONOMIC  CIRCUMSTANCES;  PROVIDED  THAT  HEALTH  CARE SERVICES PROVIDED
UNDER THE PROGRAM SHALL BE APPROPRIATE TO THE PATIENT'S CLINICALLY-RELE-
VANT CIRCUMSTANCES; AND
  (E) ACCESSIBILITY  OF  CARE  COORDINATION,  HEALTH  CARE  ORGANIZATION
SERVICES  AND  HEALTH  CARE SERVICES, INCLUDING ACCESSIBILITY FOR PEOPLE
WITH DISABILITIES AND PEOPLE WITH LIMITED ABILITY TO SPEAK OR UNDERSTAND
ENGLISH, AND THE PROVIDING OF  HEALTH  CARE  ORGANIZATION  SERVICES  AND
HEALTH CARE SERVICES IN A CULTURALLY COMPETENT MANNER.
  3. ANY PARTICIPATING PROVIDER OR CARE COORDINATOR THAT IS ORGANIZED AS
A  FOR-PROFIT ENTITY SHALL BE REQUIRED TO MEET THE SAME REQUIREMENTS AND
STANDARDS AS ENTITIES ORGANIZED AS NOT-FOR-PROFIT ENTITIES, AND PAYMENTS
UNDER THE PROGRAM PAID TO SUCH  ENTITIES  SHALL  NOT  BE  CALCULATED  TO
ACCOMMODATE  THE  GENERATION OF PROFIT OR REVENUE FOR DIVIDENDS OR OTHER
RETURN ON INVESTMENT OR THE PAYMENT OF TAXES THAT WOULD NOT BE PAID BY A
NOT-FOR-PROFIT ENTITY.
  4. EVERY PARTICIPATING PROVIDER SHALL  FURNISH  TO  THE  PROGRAM  SUCH
INFORMATION  TO,  AND PERMIT EXAMINATION OF ITS RECORDS BY, THE PROGRAM,
AS MAY BE REASONABLY REQUIRED FOR PURPOSES OF UTILIZATION REVIEW, QUALI-
TY ASSURANCE, AND COST CONTAINMENT, FOR THE MAKING OF PAYMENTS, AND  FOR
STATISTICAL OR OTHER STUDIES OF THE OPERATION OF THE PROGRAM.
  5.  IN  DEVELOPING  REQUIREMENTS AND STANDARDS AND MAKING OTHER POLICY
DETERMINATIONS UNDER THIS ARTICLE, THE COMMISSIONER SHALL  CONSULT  WITH

S. 5425--A                         12                         A. 7860--A

REPRESENTATIVES OF MEMBERS, HEALTH CARE PROVIDERS, HEALTH CARE ORGANIZA-
TIONS AND OTHER INTERESTED PARTIES.
  6.    THE  PROGRAM  SHALL MAINTAIN THE CONFIDENTIALITY OF ALL DATA AND
OTHER INFORMATION COLLECTED UNDER THE PROGRAM WHEN SUCH  DATA  WOULD  BE
NORMALLY  CONSIDERED CONFIDENTIAL DATA BETWEEN A PATIENT AND HEALTH CARE
PROVIDER.  AGGREGATE DATA OF THE PROGRAM WHICH IS DERIVED FROM CONFIDEN-
TIAL DATA BUT DOES NOT VIOLATE PATIENT CONFIDENTIALITY SHALL  BE  PUBLIC
INFORMATION.
  S  5108.  REGULATIONS.  THE  COMMISSIONER  MAY APPROVE REGULATIONS AND
AMENDMENTS THERETO, UNDER SUBDIVISION ONE OF SECTION  FIFTY-ONE  HUNDRED
TWO OF THIS ARTICLE. THE COMMISSIONER MAY MAKE REGULATIONS OR AMENDMENTS
THERETO  TO EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS ARTICLE ON AN
EMERGENCY BASIS UNDER SECTION TWO HUNDRED TWO OF THE  STATE  ADMINISTRA-
TIVE  PROCEDURE  ACT, PROVIDED THAT SUCH REGULATIONS OR AMENDMENTS SHALL
NOT BECOME PERMANENT UNLESS ADOPTED UNDER  SUBDIVISION  ONE  OF  SECTION
FIFTY-ONE HUNDRED TWO OF THIS ARTICLE.
  S 5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS. 1. THE COMMIS-
SIONER  SHALL  SEEK  ALL FEDERAL WAIVERS AND OTHER FEDERAL APPROVALS AND
ARRANGEMENTS AND SUBMIT STATE PLAN AMENDMENTS NECESSARY TO  OPERATE  THE
PROGRAM CONSISTENT WITH THIS ARTICLE.
  2.  (A)  THE  COMMISSIONER  SHALL APPLY TO THE SECRETARY OF HEALTH AND
HUMAN SERVICES OR OTHER APPROPRIATE FEDERAL OFFICIAL FOR ALL WAIVERS  OF
REQUIREMENTS,  AND MAKE OTHER ARRANGEMENTS, UNDER MEDICARE, ANY FEDERAL-
LY-MATCHED PUBLIC HEALTH PROGRAM, THE PATIENT PROTECTION AND  AFFORDABLE
CARE  ACT, AND ANY OTHER FEDERAL PROGRAMS THAT PROVIDE FEDERAL FUNDS FOR
PAYMENT FOR HEALTH CARE SERVICES, THAT ARE NECESSARY TO ENABLE  ALL  NEW
YORK  HEALTH  MEMBERS  TO RECEIVE ALL BENEFITS UNDER THE PROGRAM THROUGH
THE PROGRAM TO ENABLE THE STATE TO IMPLEMENT THIS ARTICLE AND TO RECEIVE
AND DEPOSIT ALL FEDERAL PAYMENTS UNDER THOSE PROGRAMS  (INCLUDING  FUNDS
THAT MAY BE PROVIDED IN LIEU OF PREMIUM TAX CREDITS, COST-SHARING SUBSI-
DIES, AND SMALL BUSINESS TAX CREDITS) IN THE STATE TREASURY TO THE CRED-
IT OF THE NEW YORK HEALTH TRUST FUND CREATED UNDER SECTION EIGHTY-NINE-H
OF  THE STATE FINANCE LAW AND TO USE THOSE FUNDS FOR THE NEW YORK HEALTH
PROGRAM AND OTHER PROVISIONS UNDER THIS ARTICLE. TO THE EXTENT POSSIBLE,
THE COMMISSIONER SHALL NEGOTIATE ARRANGEMENTS WITH THE  FEDERAL  GOVERN-
MENT  IN  WHICH  BULK  OR LUMP-SUM FEDERAL PAYMENTS ARE PAID TO NEW YORK
HEALTH  IN   PLACE   OF   FEDERAL   SPENDING   OR   TAX   BENEFITS   FOR
FEDERALLY-MATCHED HEALTH PROGRAMS OR FEDERAL HEALTH PROGRAMS.
  (B)  THE  COMMISSIONER MAY REQUIRE MEMBERS OR APPLICANTS TO BE MEMBERS
TO PROVIDE INFORMATION NECESSARY FOR THE  PROGRAM  TO  COMPLY  WITH  ANY
WAIVER OR ARRANGEMENT UNDER THIS SUBDIVISION.
  3.  (A)  IF ACTIONS TAKEN UNDER SUBDIVISION TWO OF THIS SECTION DO NOT
ACCOMPLISH ALL RESULTS INTENDED UNDER THAT SUBDIVISION, THEN THIS SUBDI-
VISION SHALL APPLY AND SHALL AUTHORIZE ADDITIONAL ACTIONS TO EFFECTIVELY
IMPLEMENT  NEW  YORK  HEALTH  TO  THE  MAXIMUM  EXTENT  POSSIBLE  AS   A
SINGLE-PAYER PROGRAM CONSISTENT WITH THIS ARTICLE.
  (B)  THE COMMISSIONER MAY TAKE ACTIONS CONSISTENT WITH THIS ARTICLE TO
ENABLE NEW YORK HEALTH TO ADMINISTER MEDICARE IN NEW YORK STATE  AND  TO
BE  A  PROVIDER  OF  DRUG  COVERAGE  UNDER  MEDICARE PART D FOR ELIGIBLE
MEMBERS OF NEW YORK HEALTH.
  (C)  THE  COMMISSIONER  MAY  WAIVE  OR  MODIFY  THE  APPLICABILITY  OF
PROVISIONS  OF  THIS  SECTION  RELATING  TO ANY FEDERALLY-MATCHED PUBLIC
HEALTH PROGRAM OR MEDICARE AS  NECESSARY  TO  IMPLEMENT  ANY  WAIVER  OR
ARRANGEMENT  UNDER  THIS  SECTION  OR TO MAXIMIZE THE BENEFIT TO THE NEW
YORK HEALTH PROGRAM UNDER THIS SECTION, PROVIDED THAT THE  COMMISSIONER,
IN  CONSULTATION  WITH  THE DIRECTOR OF THE BUDGET, SHALL DETERMINE THAT

S. 5425--A                         13                         A. 7860--A

SUCH WAIVER OR MODIFICATION IS IN THE  BEST  INTERESTS  OF  THE  MEMBERS
AFFECTED BY THE ACTION AND THE STATE.
  (D)    THE   COMMISSIONER   MAY   APPLY   FOR   COVERAGE   UNDER   ANY
FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM ON  BEHALF  OF  ANY  MEMBER  AND
ENROLL  THE MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM IF THE
MEMBER IS ELIGIBLE FOR IT.   ENROLLMENT IN  A  FEDERALLY-MATCHED  PUBLIC
HEALTH  PROGRAM  SHALL  NOT  CAUSE  ANY  MEMBER  TO LOSE ANY HEALTH CARE
SERVICE PROVIDED BY THE PROGRAM.
  (E) THE COMMISSIONER SHALL BY REGULATION INCREASE THE INCOME ELIGIBIL-
ITY LEVEL, INCREASE OR ELIMINATE  THE  RESOURCE  TEST  FOR  ELIGIBILITY,
SIMPLIFY ANY PROCEDURAL OR DOCUMENTATION REQUIREMENT FOR ENROLLMENT, AND
INCREASE  THE  BENEFITS FOR ANY FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM,
NOTWITHSTANDING ANY LAW OR REGULATION TO THE CONTRARY. THE  COMMISSIONER
MAY ACT UNDER THIS PARAGRAPH UPON A FINDING, APPROVED BY THE DIRECTOR OF
THE  BUDGET,  THAT  THE  ACTION  (I) WILL HELP TO INCREASE THE NUMBER OF
MEMBERS WHO ARE ELIGIBLE FOR AND ENROLLED  IN  FEDERALLY-MATCHED  PUBLIC
HEALTH  PROGRAMS;  (II) WILL NOT DIMINISH ANY INDIVIDUAL'S ACCESS TO ANY
HEALTH CARE SERVICE; AND (III) DOES NOT  REQUIRE  OR  HAS  RECEIVED  ANY
NECESSARY  FEDERAL  WAIVERS  OR  APPROVALS  TO  ENSURE FEDERAL FINANCIAL
PARTICIPATION. ACTIONS UNDER THIS PARAGRAPH SHALL NOT APPLY TO ELIGIBIL-
ITY FOR PAYMENT FOR LONG TERM CARE.
  (F) TO ENABLE THE COMMISSIONER TO APPLY FOR COVERAGE UNDER ANY  FEDER-
ALLY-MATCHED  PUBLIC  HEALTH  PROGRAM ON BEHALF OF ANY MEMBER AND ENROLL
THE MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM IF THE  MEMBER
IS  ELIGIBLE  FOR  IT, THE COMMISSIONER MAY REQUIRE THAT EVERY MEMBER OR
APPLICANT TO BE A MEMBER SHALL PROVIDE INFORMATION TO ENABLE THE COMMIS-
SIONER  TO  DETERMINE  WHETHER  THE  APPLICANT   IS   ELIGIBLE   FOR   A
FEDERALLY-MATCHED  PUBLIC  HEALTH  PROGRAM  AND  FOR  MEDICARE  (AND ANY
PROGRAM OR BENEFIT UNDER MEDICARE). THE PROGRAM SHALL MAKE A  REASONABLE
EFFORT  TO  NOTIFY  MEMBERS  OF  THEIR OBLIGATIONS UNDER THIS PARAGRAPH.
AFTER A REASONABLE EFFORT HAS BEEN  MADE  TO  CONTACT  THE  MEMBER,  THE
MEMBER  SHALL  BE  NOTIFIED  IN WRITING THAT HE OR SHE HAS SIXTY DAYS TO
PROVIDE SUCH REQUIRED INFORMATION. IF SUCH INFORMATION IS  NOT  PROVIDED
WITHIN THE SIXTY DAY PERIOD, THE MEMBER'S COVERAGE UNDER THE PROGRAM MAY
BE TERMINATED.
  (G)  AS  A CONDITION OF CONTINUED ELIGIBILITY FOR HEALTH CARE SERVICES
UNDER THE PROGRAM, A MEMBER WHO IS ELIGIBLE FOR BENEFITS UNDER  MEDICARE
SHALL ENROLL IN MEDICARE, INCLUDING PARTS A, B AND D.
  (H)  THE  PROGRAM  SHALL  PROVIDE  PREMIUM  ASSISTANCE FOR ALL MEMBERS
ENROLLING IN A MEDICARE PART D DRUG  COVERAGE  UNDER  SECTION  1860D  OF
TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT LIMITED TO THE LOW-INCOME
BENCHMARK PREMIUM AMOUNT ESTABLISHED BY THE FEDERAL CENTERS FOR MEDICARE
AND MEDICAID SERVICES AND ANY OTHER AMOUNT WHICH SUCH AGENCY ESTABLISHES
UNDER  ITS  DE MINIMUS PREMIUM POLICY, EXCEPT THAT SUCH PAYMENTS MADE ON
BEHALF OF MEMBERS ENROLLED IN A MEDICARE ADVANTAGE PLAN MAY  EXCEED  THE
LOW-INCOME  BENCHMARK  PREMIUM AMOUNT IF DETERMINED TO BE COST EFFECTIVE
TO THE PROGRAM.
  (I) IF THE COMMISSIONER HAS  REASONABLE  GROUNDS  TO  BELIEVE  THAT  A
MEMBER  COULD  BE  ELIGIBLE  FOR AN INCOME-RELATED SUBSIDY UNDER SECTION
1860D-14 OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT,  THE  MEMBER
SHALL  PROVIDE,  AND AUTHORIZE THE PROGRAM TO OBTAIN, ANY INFORMATION OR
DOCUMENTATION REQUIRED TO ESTABLISH THE MEMBER'S  ELIGIBILITY  FOR  SUCH
SUBSIDY,  PROVIDED THAT THE COMMISSIONER SHALL ATTEMPT TO OBTAIN AS MUCH
OF THE INFORMATION AND DOCUMENTATION AS POSSIBLE FROM RECORDS  THAT  ARE
AVAILABLE TO HIM OR HER.

S. 5425--A                         14                         A. 7860--A

  (J)  THE  PROGRAM  SHALL MAKE A REASONABLE EFFORT TO NOTIFY MEMBERS OF
THEIR OBLIGATIONS UNDER THIS SUBDIVISION. AFTER A REASONABLE EFFORT  HAS
BEEN MADE TO CONTACT THE MEMBER, THE MEMBER SHALL BE NOTIFIED IN WRITING
THAT  HE  OR SHE HAS SIXTY DAYS TO PROVIDE SUCH REQUIRED INFORMATION. IF
SUCH  INFORMATION  IS  NOT  PROVIDED  WITHIN  THE  SIXTY DAY PERIOD, THE
MEMBER'S COVERAGE UNDER THE PROGRAM MAY BE TERMINATED.
  S 5110. ADDITIONAL PROVISIONS.   1. THE  COMMISSIONER  SHALL  CONTRACT
WITH NOT-FOR-PROFIT ORGANIZATIONS TO PROVIDE:
  (A)  CONSUMER ASSISTANCE TO INDIVIDUALS WITH RESPECT TO SELECTION OF A
CARE COORDINATOR  OR  HEALTH  CARE  ORGANIZATION,  ENROLLING,  OBTAINING
HEALTH  CARE  SERVICES,  DISENROLLING, AND OTHER MATTERS RELATING TO THE
PROGRAM;
  (B) HEALTH CARE PROVIDER ASSISTANCE TO HEALTH CARE PROVIDERS PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  HEALTH  CARE  SERVICES
UNDER THE PROGRAM, WITH RESPECT TO PARTICIPATING IN A HEALTH CARE ORGAN-
IZATION AND DEALING WITH A HEALTH CARE ORGANIZATION; AND
  (C)  CARE COORDINATOR ASSISTANCE TO INDIVIDUALS AND ENTITIES PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  CARE  COORDINATION  TO
MEMBERS.
  2.  THE  COMMISSIONER  SHALL PROVIDE GRANTS FROM FUNDS IN THE NEW YORK
HEALTH TRUST FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE, TO  HEALTH
SYSTEMS  AGENCIES UNDER SECTION TWENTY-NINE HUNDRED FOUR-B OF THIS CHAP-
TER TO SUPPORT THE OPERATION OF SUCH HEALTH SYSTEMS AGENCIES.
  S 3. Financing of New York Health. 1. The governor shall submit to the
legislature a plan and legislative bills to implement the plan (referred
to collectively in this section as the "revenue  proposal")  to  provide
the revenue necessary to finance the New York Health program, as created
by  article  51 of the public health law (referred to in this section as
the "program"), taking into consideration  anticipated  federal  revenue
available  for  the  program. The revenue proposal shall be submitted to
the legislature as part of the executive budget under article VII of the
state constitution, for the fiscal year commencing on the first  day  of
April  in the calendar year after this act shall become a law. In devel-
oping the revenue proposal, the governor shall consult with  appropriate
officials  of  the  executive  branch;  the  temporary  president of the
senate; the speaker of the assembly; the chairs of the fiscal and health
committees of the senate and assembly; and representatives of  business,
labor, consumers and local government.
  2.  (a)  Basic  structure. The basic structure of the revenue proposal
shall be as follows: Revenue for the program shall come from two assess-
ments (referred to collectively in this section as  the  "assessments").
First,  there  shall  be  an assessment on all payroll and self-employed
income (referred to in this section as the "payroll  assessment"),  paid
by  employers, employees and self-employed, similar to the Medicare tax.
Higher brackets of income subject to this assessment shall  be  assessed
at a higher marginal rate than lower brackets.  Second, there shall be a
progressively-graduated  assessment on taxable income (such as interest,
dividends, and capital gains) not  subject  to  the  payroll  assessment
(referred  to  in  this  section  as  the "non-payroll assessment"). The
assessments will be set at  levels  anticipated  to  produce  sufficient
revenue to finance the program and other provisions of article 51 of the
public  health  law,  to  be  scaled up as enrollment grows, taking into
consideration anticipated federal revenue  available  for  the  program.
Provision  shall  be  made for state residents (who are eligible for the
program) who are employed out-of-state, and non-residents (who  are  not
eligible for the program) who are employed in the state.

S. 5425--A                         15                         A. 7860--A

  (b)  Payroll  assessment.  The  income  to  be  subject to the payroll
assessment shall be all income subject to the Medicare tax. The  assess-
ment shall be set at a particular percentage of that income, which shall
be progressively graduated, so the percentage is higher on higher brack-
ets  of  income. For employed individuals, the employer shall pay eighty
percent of the assessment and the  employee  shall  pay  twenty  percent
(unless the employer agrees to pay a higher percentage). A self-employed
individual shall pay the full assessment.
  (c) Non-payroll income assessment. There shall be a second assessment,
on  upper-bracket  taxable  income  that  is  not subject to the payroll
assessment. It shall be progressively  graduated  and  structured  as  a
percentage of the personal income tax on that income.
  (d) Phased-in rates. Early in the program, when enrollment is growing,
the  amount  of  the  assessments  shall be at an appropriate level, and
shall be raised as anticipated enrollment grows,  to  cover  the  actual
cost  of  the  program  and other provisions of article 51 of the public
health law. The revenue proposal shall include a mechanism for determin-
ing the rates of the assessments.
  (e) Cross-border employees. (i) State residents employed out-of-state.
If an individual is employed out-of-state by an employer that is subject
to New York state law, the employer and employee shall  be  required  to
pay the payroll assessment as if the employment were in the state. If an
individual  is  employed out-of-state by an employer that is not subject
to New York state law, either (A) the employer and employee shall volun-
tarily comply with the assessment or (B)  the  employee  shall  pay  the
assessment as if he or she were self-employed.
  (ii)  Out-of-state  residents  employed in the state.  (A) The payroll
assessment shall apply to any out-of-state resident who is  employed  or
self-employed in the state.  (B) In the case of an out-of-state resident
who is employed or self-employed in the state, such individual's employ-
er  (which term shall include a Taft-Hartley fund) shall be able to take
a credit against the payroll assessments they would otherwise  pay,  for
amounts they spend on health benefits that would otherwise be covered by
the  program. For employers, the credit shall be available regardless of
the form of the health benefit (e.g., health insurance,  a  self-insured
plan, direct services, or reimbursement for services), to make sure that
the revenue proposal does not relate to employment benefits in violation
of  the  federal  ERISA.  An employee may take the credit for his or her
contribution to an employment-based health benefit. For  non-employment-
based  spending  by  individuals,  the credit shall be available for and
limited to spending for health coverage (not out-of-pocket health spend-
ing). The credit shall be available without  regard  to  how  little  is
spent  or  how  sparse the benefit. The credit may only be taken against
the payroll assessments. Any excess amount may not be applied  to  other
tax liability. For employment-based health benefits, the credit shall be
distributed  between the employer and employee in the same proportion as
the spending by each for the benefit. The employer and employee may each
apply their respective portion of the credit to their respective portion
of the assessment. If any provision of this clause (B) or  any  applica-
tion of it shall be ruled to violate federal ERISA, the provision or the
application of it shall be null and void and the ruling shall not affect
any  other  provision  or  application  of  this section or the act that
enacted it.
  3.  The  revenue  proposal  shall  include  a  plan  and   legislative
provisions   for  ending  the  requirement  for  local  social  services

S. 5425--A                         16                         A. 7860--A

districts to pay part of  the  cost  of  Medicaid  and  replacing  those
payments with revenue from the assessments under the revenue proposal.
  4.  To  the extent that the revenue proposal differs from the terms of
subdivision 2 of this section, the revenue proposal shall state  how  it
differs  from those terms and reasons for and the effects of the differ-
ences.
  5. All revenue from the assessments shall be deposited in the New York
Health trust fund account under section 89-h of the state finance law.
  S 4.  Article 49 of the public health law is amended by adding  a  new
title 3 to read as follows:
                                TITLE III
          COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
                             NEW YORK HEALTH
SECTION 4920. DEFINITIONS.
        4921. COLLECTIVE NEGOTIATION AUTHORIZED.
        4922. COLLECTIVE NEGOTIATION REQUIREMENTS.
        4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE.
        4924. CERTAIN COLLECTIVE ACTION PROHIBITED.
        4925. FEES.
        4926. CONFIDENTIALITY.
        4927. SEVERABILITY AND CONSTRUCTION.
  S 4920. DEFINITIONS. FOR PURPOSES OF THIS TITLE:
  1. "NEW YORK HEALTH" MEANS THE PROGRAM UNDER ARTICLE FIFTY-ONE OF THIS
CHAPTER.
  2.  "PERSON"  MEANS  AN  INDIVIDUAL,  ASSOCIATION, CORPORATION, OR ANY
OTHER LEGAL ENTITY.
  3. "HEALTH CARE PROVIDERS' REPRESENTATIVE" MEANS A THIRD PARTY WHO  IS
AUTHORIZED  BY  HEALTH  CARE PROVIDERS TO NEGOTIATE ON THEIR BEHALF WITH
NEW YORK HEALTH OVER TERMS AND CONDITIONS AFFECTING  THOSE  HEALTH  CARE
PROVIDERS.
  4. "STRIKE" MEANS A WORK STOPPAGE IN PART OR IN WHOLE, DIRECT OR INDI-
RECT,  BY  A  BODY OF WORKERS TO GAIN COMPLIANCE WITH DEMANDS MADE ON AN
EMPLOYER.
  5. "HEALTH CARE PROVIDER" MEANS A PERSON WHO IS  LICENSED,  CERTIFIED,
OR REGISTERED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW AND WHO PRAC-
TICES  AS  A HEALTH CARE PROVIDER AS AN INDEPENDENT CONTRACTOR OR WHO IS
AN OWNER, OFFICER, SHAREHOLDER, OR PROPRIETOR OF A HEALTH CARE PROVIDER;
OR AN ENTITY THAT EMPLOYS OR UTILIZES HEALTH CARE PROVIDERS  TO  PROVIDE
HEALTH  CARE  SERVICES, INCLUDING BUT NOT LIMITED TO A HOSPITAL LICENSED
UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR AN ACCOUNTABLE CARE ORGAN-
IZATION UNDER ARTICLE TWENTY-NINE-E  OF  THIS  CHAPTER.  A  HEALTH  CARE
PROVIDER  UNDER  TITLE  EIGHT  OF  THE EDUCATION LAW WHO PRACTICES AS AN
EMPLOYEE OF A HEALTH CARE PROVIDER SHALL NOT BE  DEEMED  A  HEALTH  CARE
PROVIDER FOR PURPOSES OF THIS TITLE.
  S  4921.  COLLECTIVE  NEGOTIATION AUTHORIZED. 1. HEALTH CARE PROVIDERS
MAY MEET AND COMMUNICATE FOR THE PURPOSE OF COLLECTIVELY NEGOTIATING THE
FOLLOWING TERMS AND CONDITIONS  OF  PROVIDER  CONTRACTS  WITH  NEW  YORK
HEALTH:
  (A)  THE DETAILS OF THE UTILIZATION REVIEW PLAN AS DEFINED PURSUANT TO
SUBDIVISION TEN OF SECTION FORTY-NINE HUNDRED OF THIS ARTICLE;
  (B) THE DEFINITION OF MEDICAL NECESSITY;
  (C) THE CLINICAL PRACTICE GUIDELINES USED TO  MAKE  MEDICAL  NECESSITY
AND UTILIZATION REVIEW DETERMINATIONS;
  (D) PREVENTIVE CARE AND OTHER MEDICAL COORDINATION PRACTICES;
  (E)  DRUG  FORMULARIES  AND  STANDARDS  AND PROCEDURES FOR PRESCRIBING
OFF-FORMULARY DRUGS;

S. 5425--A                         17                         A. 7860--A

  (F) THE DETAILS OF RISK TRANSFER ARRANGEMENTS WITH PROVIDERS;
  (G) ADMINISTRATIVE PROCEDURES;
  (H)  PROCEDURES  TO  BE  UTILIZED TO RESOLVE DISPUTES BETWEEN NEW YORK
HEALTH AND HEALTH CARE PROVIDERS;
  (I) PATIENT REFERRAL PROCEDURES;
  (J) THE FORMULATION AND APPLICATION OF HEALTH CARE PROVIDER REIMBURSE-
MENT PROCEDURES;
  (K) QUALITY ASSURANCE PROGRAMS;
  (L)  THE  PROCESS  FOR  RENDERING  UTILIZATION  REVIEW  DETERMINATIONS
INCLUDING:  ESTABLISHMENT  OF A PROCESS FOR RENDERING UTILIZATION REVIEW
DETERMINATIONS WHICH SHALL, AT A MINIMUM, INCLUDE: WRITTEN PROCEDURES TO
ASSURE THAT UTILIZATION REVIEWS AND DETERMINATIONS ARE CONDUCTED  WITHIN
THE  TIMEFRAMES  ESTABLISHED  IN  THIS  ARTICLE; PROCEDURES TO NOTIFY AN
ENROLLEE, AN  ENROLLEE'S  DESIGNEE  AND/OR  AN  ENROLLEE'S  HEALTH  CARE
PROVIDER OF ADVERSE DETERMINATIONS; AND PROCEDURES FOR APPEAL OF ADVERSE
DETERMINATIONS,  INCLUDING  THE  ESTABLISHMENT  OF  AN EXPEDITED APPEALS
PROCESS FOR DENIALS OF CONTINUED INPATIENT CARE OR WHERE THERE IS  IMMI-
NENT OR SERIOUS THREAT TO THE HEALTH OF THE ENROLLEE;
  (M)  HEALTH  CARE  PROVIDER SELECTION AND TERMINATION CRITERIA USED BY
NEW YORK HEALTH;
  (N) THE FEES ASSESSED BY NEW YORK HEALTH FOR SERVICES, INCLUDING  FEES
ESTABLISHED THROUGH THE APPLICATION OF REIMBURSEMENT PROCEDURES;
  (O) THE CONVERSION FACTORS USED BY NEW YORK HEALTH IN A RESOURCE-BASED
RELATIVE  VALUE SCALE REIMBURSEMENT METHODOLOGY OR OTHER SIMILAR METHOD-
OLOGY; PROVIDED THE SAME ARE  NOT  OTHERWISE  ESTABLISHED  BY  STATE  OR
FEDERAL LAW OR REGULATION;
  (P)  THE  AMOUNT OF ANY DISCOUNT GRANTED BY NEW YORK HEALTH ON THE FEE
OF HEALTH CARE SERVICES TO BE RENDERED BY HEALTH CARE PROVIDERS;
  (Q) THE DOLLAR AMOUNT OF CAPITATION OR FIXED PAYMENT FOR  HEALTH  CARE
SERVICES RENDERED BY HEALTH CARE PROVIDERS TO NEW YORK HEALTH MEMBERS;
  (R)  THE  PROCEDURE CODE OR OTHER DESCRIPTION OF A HEALTH CARE SERVICE
COVERED BY A PAYMENT AND  THE  APPROPRIATE  GROUPING  OF  THE  PROCEDURE
CODES; AND
  (S) THE AMOUNT OF ANY OTHER COMPONENT OF THE REIMBURSEMENT METHODOLOGY
FOR A HEALTH CARE SERVICE.
  2. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE AN
ALTERATION  OF  THE TERMS OF THE INTERNAL AND EXTERNAL REVIEW PROCEDURES
SET FORTH IN LAW.
  3. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW A STRIKE OF NEW
YORK HEALTH BY HEALTH CARE PROVIDERS.
  4. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO  ALLOW  OR  AUTHORIZE
TERMS OR CONDITIONS WHICH WOULD IMPEDE THE ABILITY OF NEW YORK HEALTH TO
OBTAIN  OR  RETAIN  ACCREDITATION  BY THE NATIONAL COMMITTEE FOR QUALITY
ASSURANCE OR A SIMILAR BODY OR TO COMPLY WITH APPLICABLE STATE OR FEDER-
AL LAW.
  5. NOTHING IN THIS SECTION SHALL BE DEEMED  TO  AFFECT  OR  LIMIT  THE
RIGHT  OF  A  HEALTH  CARE PROVIDER OR GROUP OF HEALTH CARE PROVIDERS TO
COLLECTIVELY PETITION A GOVERNMENT ENTITY FOR A CHANGE IN A  LAW,  RULE,
OR REGULATION.
  S 4922. COLLECTIVE NEGOTIATION REQUIREMENTS. 1. COLLECTIVE NEGOTIATION
RIGHTS GRANTED BY THIS TITLE MUST CONFORM TO THE FOLLOWING REQUIREMENTS:
  (A)  HEALTH  CARE  PROVIDERS  MAY  COMMUNICATE  WITH OTHER HEALTH CARE
PROVIDERS REGARDING THE TERMS AND CONDITIONS TO BE NEGOTIATED  WITH  NEW
YORK HEALTH;
  (B)  HEALTH CARE PROVIDERS MAY COMMUNICATE WITH HEALTH CARE PROVIDERS'
REPRESENTATIVES;

S. 5425--A                         18                         A. 7860--A

  (C) A HEALTH CARE PROVIDERS' REPRESENTATIVE IS THE ONLY PARTY  AUTHOR-
IZED  TO  NEGOTIATE  WITH  NEW  YORK HEALTH ON BEHALF OF THE HEALTH CARE
PROVIDERS AS A GROUP;
  (D)  A  HEALTH  CARE PROVIDER CAN BE BOUND BY THE TERMS AND CONDITIONS
NEGOTIATED BY THE HEALTH CARE PROVIDERS' REPRESENTATIVES; AND
  (E) IN COMMUNICATING OR NEGOTIATING WITH THE  HEALTH  CARE  PROVIDERS'
REPRESENTATIVE, NEW YORK HEALTH IS ENTITLED TO OFFER AND PROVIDE DIFFER-
ENT TERMS AND CONDITIONS TO INDIVIDUAL COMPETING HEALTH CARE PROVIDERS.
  2.  NOTHING  IN  THIS  TITLE  SHALL  BE CONSTRUED TO PROHIBIT OR LIMIT
COLLECTIVE ACTION OR COLLECTIVE BARGAINING ON THE  PART  OF  ANY  HEALTH
CARE  PROVIDER  WITH  HIS OR HER EMPLOYER OR ANY OTHER LAWFUL COLLECTIVE
ACTION OR COLLECTIVE BARGAINING.
  S 4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE. BEFORE
ENGAGING IN COLLECTIVE NEGOTIATIONS WITH NEW YORK HEALTH  ON  BEHALF  OF
HEALTH  CARE  PROVIDERS,  A  HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL
FILE WITH THE COMMISSIONER, IN THE MANNER PRESCRIBED BY THE  COMMISSION-
ER,  INFORMATION  IDENTIFYING  THE  REPRESENTATIVE, THE REPRESENTATIVE'S
PLAN OF OPERATION, AND THE REPRESENTATIVE'S PROCEDURES TO ENSURE COMPLI-
ANCE WITH THIS TITLE.
  S 4924. CERTAIN COLLECTIVE ACTION PROHIBITED. 1.  THIS  TITLE  IS  NOT
INTENDED  TO AUTHORIZE COMPETING HEALTH CARE PROVIDERS TO ACT IN CONCERT
IN RESPONSE TO A HEALTH CARE PROVIDERS' REPRESENTATIVE'S DISCUSSIONS  OR
NEGOTIATIONS WITH NEW YORK HEALTH.
  2. NO HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL NEGOTIATE ANY AGREE-
MENT  THAT  EXCLUDES,  LIMITS  THE PARTICIPATION OR REIMBURSEMENT OF, OR
OTHERWISE LIMITS THE SCOPE OF SERVICES TO BE PROVIDED BY ANY HEALTH CARE
PROVIDER OR GROUP OF HEALTH CARE PROVIDERS WITH RESPECT TO THE  PERFORM-
ANCE  OF  SERVICES  THAT  ARE WITHIN THE HEALTH CARE PROVIDER'S SCOPE OF
PRACTICE, LICENSE, REGISTRATION, OR CERTIFICATE.
  S 4925. FEES. EACH PERSON WHO ACTS AS THE REPRESENTATIVE OR  NEGOTIAT-
ING PARTIES UNDER THIS TITLE SHALL PAY TO THE DEPARTMENT A FEE TO ACT AS
A  REPRESENTATIVE.  THE COMMISSIONER, BY RULE, SHALL SET FEES IN AMOUNTS
DEEMED REASONABLE AND NECESSARY TO  COVER  THE  COSTS  INCURRED  BY  THE
DEPARTMENT IN ADMINISTERING THIS TITLE.
  S 4926. CONFIDENTIALITY. ALL REPORTS AND OTHER INFORMATION REQUIRED TO
BE  REPORTED  TO THE DEPARTMENT UNDER THIS TITLE SHALL NOT BE SUBJECT TO
DISCLOSURE UNDER ARTICLE SIX OF THE PUBLIC OFFICERS LAW OR ARTICLE THIR-
TY-ONE OF THE CIVIL PRACTICE LAW AND RULES.
  S 4927. SEVERABILITY AND CONSTRUCTION. IF ANY PROVISION OR APPLICATION
OF THIS TITLE SHALL BE HELD TO BE INVALID, OR TO VIOLATE  OR  BE  INCON-
SISTENT  WITH  ANY  APPLICABLE FEDERAL LAW OR REGULATION, THAT SHALL NOT
AFFECT OTHER PROVISIONS OR APPLICATIONS OF THIS TITLE WHICH CAN BE GIVEN
EFFECT WITHOUT THAT PROVISION OR  APPLICATION;  AND  TO  THAT  END,  THE
PROVISIONS  AND APPLICATIONS OF THIS TITLE ARE SEVERABLE. THE PROVISIONS
OF THIS TITLE SHALL  BE  LIBERALLY  CONSTRUED  TO  GIVE  EFFECT  TO  THE
PURPOSES THEREOF.
  S  5.  Subdivision  11  of  section  270  of the public health law, as
amended by section 2-a of part C of chapter 58 of the laws of  2008,  is
amended to read as follows:
  11.  "State  public  health plan" means the medical assistance program
established by title eleven of article five of the social  services  law
(referred  to in this article as "Medicaid"), the elderly pharmaceutical
insurance coverage program established by title three of article two  of
the  elder law (referred to in this article as "EPIC"), [and] the family
health plus program established by section three  hundred  sixty-nine-ee
of  the social services law to the extent that section provides that the

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program shall be subject to  this  article,  AND  THE  NEW  YORK  HEALTH
PROGRAM ESTABLISHED BY ARTICLE FIFTY-ONE OF THIS CHAPTER.
  S  6. The state finance law is amended by adding a new section 89-h to
read as follows:
  S 89-H. NEW YORK HEALTH TRUST FUND. 1. THERE IS HEREBY ESTABLISHED  IN
THE JOINT CUSTODY OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXA-
TION  AND  FINANCE  A  SPECIAL REVENUE FUND TO BE KNOWN AS THE "NEW YORK
HEALTH TRUST FUND", HEREINAFTER KNOWN AS "THE FUND". THE DEFINITIONS  IN
SECTION  FIFTY-ONE  HUNDRED OF THE PUBLIC HEALTH LAW SHALL APPLY TO THIS
SECTION.
  2. THE FUND SHALL CONSIST OF:
  (A) ALL MONIES  OBTAINED  FROM  ASSESSMENTS  PURSUANT  TO  LEGISLATION
ENACTED  AS  PROPOSED  UNDER  SECTION  THREE  OF THE ACT THAT ADDED THIS
SECTION;
  (B) FEDERAL PAYMENTS RECEIVED AS A RESULT OF ANY  WAIVER  OF  REQUIRE-
MENTS  GRANTED  OR  OTHER  ARRANGEMENTS  AGREED  TO BY THE UNITED STATES
SECRETARY OF HEALTH AND HUMAN  SERVICES  OR  OTHER  APPROPRIATE  FEDERAL
OFFICIALS  FOR  HEALTH  CARE  PROGRAMS  ESTABLISHED  UNDER MEDICARE, ANY
FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM, OR THE PATIENT  PROTECTION  AND
AFFORDABLE CARE ACT;
  (C)  THE  AMOUNTS PAID BY THE DEPARTMENT OF HEALTH AND BY LOCAL SOCIAL
SERVICES DISTRICTS THAT ARE EQUIVALENT TO THOSE AMOUNTS THAT ARE PAID ON
BEHALF OF RESIDENTS OF THIS STATE UNDER MEDICARE, ANY  FEDERALLY-MATCHED
PUBLIC HEALTH PROGRAM, OR THE PATIENT PROTECTION AND AFFORDABLE CARE ACT
FOR  HEALTH  BENEFITS  WHICH  ARE  EQUIVALENT TO HEALTH BENEFITS COVERED
UNDER NEW YORK HEALTH;
  (D) ALL SURCHARGES THAT ARE IMPOSED ON  RESIDENTS  OF  THIS  STATE  TO
REPLACE PAYMENTS MADE BY THE RESIDENTS UNDER THE COST-SHARING PROVISIONS
OF MEDICARE;
  (E)  FEDERAL,  STATE  AND LOCAL FUNDS FOR PURPOSES OF THE PROVISION OF
SERVICES AUTHORIZED UNDER TITLE XX OF THE FEDERAL  SOCIAL  SECURITY  ACT
THAT  WOULD  OTHERWISE  BE COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC
HEALTH LAW; AND
  (F) STATE AND LOCAL GOVERNMENT MONIES THAT WOULD OTHERWISE  BE  APPRO-
PRIATED  TO ANY GOVERNMENTAL AGENCY, OFFICE, PROGRAM, INSTRUMENTALITY OR
INSTITUTION WHICH PROVIDES HEALTH SERVICES, FOR  SERVICES  AND  BENEFITS
COVERED  UNDER  NEW  YORK  HEALTH. PAYMENTS TO THE FUND PURSUANT TO THIS
PARAGRAPH SHALL BE IN AN AMOUNT EQUAL TO THE MONEY APPROPRIATED FOR SUCH
PURPOSES IN THE FISCAL YEAR IMMEDIATELY PRECEDING THE EFFECTIVE DATE  OF
ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
  3.  MONIES  IN  THE  FUND  SHALL ONLY BE USED FOR PURPOSES ESTABLISHED
UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
  S 7. Temporary commission on implementation. 1. There is hereby estab-
lished a temporary commission on implementation of the New  York  Health
program,  hereinafter  to  be  known  as  the  commission, consisting of
fifteen members: five members, including the chair, shall  be  appointed
by the governor; four members shall be appointed by the temporary presi-
dent of the senate, one member shall be appointed by the senate minority
leader;  four members shall be appointed by the speaker of the assembly,
and one member shall be appointed by the assembly minority  leader.  The
commissioner  of  health,  the superintendent of financial services, and
the commissioner of taxation and finance, or their designees shall serve
as non-voting ex-officio members of the commission.
  2. Members of the commission shall receive such assistance as  may  be
necessary  from  other  state  agencies  and entities, and shall receive
necessary expenses incurred in the  performance  of  their  duties.  The

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commission  may  employ staff as needed, prescribe their duties, and fix
their compensation within amounts appropriate for the commission.
  3.  The commission shall examine the laws and regulations of the state
and make such recommendations as are necessary to conform the  laws  and
regulations  of the state and article 51 of the public health law estab-
lishing the New York Health program and other provisions of law relating
to the New York  Health  program,  and  to  improve  and  implement  the
program. The commission shall report its recommendations to the governor
and the legislature.
  S  8.  Severability. If any provision or application of this act shall
be held to be invalid, or to violate or be inconsistent with any  appli-
cable  federal law or regulation, that shall not affect other provisions
or applications of this act which  can  be  given  effect  without  that
provision  or  application; and to that end, the provisions and applica-
tions of this act are severable.
  S 9. This act shall take effect immediately.

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