S T A T E O F N E W Y O R K
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6582
I N S E N A T E
February 29, 2012
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Introduced by Sens. KLEIN, PARKER, RANZENHOFER -- read twice and ordered
printed, and when printed to be committed to the Committee on Health
AN ACT to amend the public health law, in relation to authorizing the
commissioner of health, in consultation with the superintendent of
financial services, to develop uniform plan-provider contracts and the
provisions thereof; and providing for the repeal of such provisions
upon the expiration thereof
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Legislative intent. The legislature finds that the public
would benefit greatly if the commissioner of health, in consultation
with the superintendent of financial services, were to develop uniform
plan-provider contracts (UPPCs) and the provisions thereof, not includ-
ing rate sheets, through a process that requires support from represen-
tatives of health plans, health care providers, consumers and employers,
and to adopt and require the use of such UPPCs and provisions thereof by
health plans and health care providers when contracting for the
provision of health care services to fee-for-service plan enrollees.
The legislature finds that the use of UPPCs and such provisions there-
of would: (a) significantly reduce expenditures by health plans and
health care providers in the drafting, review, negotiation and implemen-
tation of plan-provider contracts; (b) reduce expenditures by the state
and municipalities in the contract-by-contract review and approval of
such agreements; (c) reduce or eliminate unclear provisions, unfair
provisions and non-compliant provisions in plan-provider contracts; (d)
make it practical for provider clinical and administrative staff to
learn and follow requirements in plan-provider contracts; (e) reduce
interpretive disputes; and (f) help plans meet their medical loss ratio
requirements under the federal health care reform law.
S 2. The public health law is amended by adding a new section 4406-f
to read as follows:
S 4406-F. UNIFORM PLAN-PROVIDER CONTRACTS. 1. DEFINITIONS. AS USED IN
THIS SECTION:
(A) "CONTRACT PROVISION" MEANS ANY INDIVIDUAL PROVISION OF A UPPC.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD14232-05-2
S. 6582 2
(B) "COUNCIL" MEANS THE UPPC COUNCIL ESTABLISHED IN SUBDIVISION THREE
OF THIS SECTION.
(C) "HEALTH CARE PROVIDER" OR "PROVIDER" MEANS A HEALTH CARE FACILITY
OR PROGRAM THAT IS ESTABLISHED OR LICENSED, OR THAT HOLDS AN OPERATING
CERTIFICATE ISSUED PURSUANT TO THIS CHAPTER OR THE MENTAL HYGIENE LAW,
OR A PHYSICIAN OR OTHER HEALTH CARE PROVIDER LICENSED, REGISTERED OR
CERTIFIED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW, OR ANY ORGANIZA-
TION COMPOSED OF HEALTH CARE PROVIDERS LICENSED, REGISTERED AND/OR
CERTIFIED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW.
(D) "HEALTH PLAN" OR "PLAN" MEANS AN INSURER LICENSED TO WRITE ACCI-
DENT AND HEALTH INSURANCE PURSUANT TO THE INSURANCE LAW, OR A CORPO-
RATION LICENSED PURSUANT TO ARTICLE FORTY-THREE OF THE INSURANCE LAW, OR
A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO THIS ARTICLE.
(E) "UNIFORM PLAN-PROVIDER CONTRACT" OR "UPPC" MEANS A CONTRACT FORM
OR PART THEREOF THAT IS ESTABLISHED, IN REGULATION, BY THE COMMISSIONER,
IN CONSULTATION WITH THE SUPERINTENDENT OF FINANCIAL SERVICES, WHICH
PLANS AND PROVIDERS SHALL BE REQUIRED TO USE WHEN CONTRACTING FOR
FEE-FOR-SERVICE PLAN ENROLLEES.
(I) UPPCS AND CONTRACT PROVISIONS MAY INCLUDE, BUT SHALL NOT BE LIMIT-
ED TO:
(A) DEFINITIONS FOR TERMS THAT ARE COMMONLY FOUND IN PLAN-PROVIDER
CONTRACTS INCLUDING, BUT NOT LIMITED TO, TERMS SUCH AS "COVERED
SERVICE", "EMERGENCY", "MEDICALLY NECESSARY" AND ANY VARIATIONS THEREOF;
(B) PROVIDER REPRESENTATIONS AND OBLIGATIONS;
(C) PLAN REPRESENTATIONS AND OBLIGATIONS;
(D) THE PLAN'S OBLIGATION TO PAY FOR COVERED SERVICES AT THE
AGREED-UPON RATE (ALTHOUGH THE RATE SHEET ITSELF SHALL NOT BE PART OF
THE UPPC OR A TERM THEREOF);
(E) REQUIREMENTS RELATING TO PLAN POLICIES AND PROCEDURES;
(F) UTILIZATION REVIEW REQUIREMENTS;
(G) COORDINATION OF BENEFITS REQUIREMENTS;
(H) CONSTRAINTS ON THE PROVIDER BILLING PLAN ENROLLEES DIRECTLY;
(I) TERM AND TERMINATION LANGUAGE (BUT NOT THE ACTUAL TIME PERIOD);
(J) CONFIDENTIALITY REQUIREMENTS;
(K) DISPUTE RESOLUTION;
(L) AMENDMENTS;
(M) MISCELLANEOUS BOILERPLATE PROVISIONS; AND
(N) MEDICARE OR MEDICAID MANAGED CARE ADDENDUM.
(II) UPPC AND CONTRACT PROVISIONS SHALL NOT INCLUDE RATES, PAYMENT
METHODOLOGIES OR OTHER REIMBURSEMENT TERMS, WHICH SHALL REMAIN MATTERS
THAT PLANS AND PROVIDERS ARE FREE TO NEGOTIATE.
(III) UPPCS AND CONTRACT PROVISIONS MAY INCLUDE ALTERNATIVE
PROVISIONS, OPTIONAL PROVISIONS OR PROVISIONS WITH NEGOTIABLE COMPO-
NENTS.
(IV) UPPCS AND CONTRACT PROVISIONS MAY INCLUDE REQUIREMENTS OR
LANGUAGE PREVIOUSLY MANDATED BY THE COMMISSIONER BY REGULATION.
2. AUTHORITY OF COMMISSIONER. (A) SUBJECT TO THE PROVISIONS OF THIS
SECTION, THE COMMISSIONER, IN CONSULTATION WITH THE SUPERINTENDENT OF
FINANCIAL SERVICES, SHALL HAVE THE AUTHORITY TO PROMULGATE REGULATIONS
THAT ADOPT ONE OR MORE UPPCS OR CONTRACT PROVISIONS, AND TO REQUIRE THE
USE OF SUCH UPPCS OR CONTRACT PROVISIONS BY A PLAN AND PROVIDER WHEN
CONTRACTING FOR THE PROVIDER TO PROVIDE HEALTH CARE SERVICES TO THE
PLAN'S ENROLLEES ON A FEE-FOR-SERVICE BASIS.
(B) THE COMMISSIONER, IN CONSULTATION WITH THE SUPERINTENDENT OF
FINANCIAL SERVICES, MAY ADOPT ONE OR MORE UPPCS OR CONTRACT PROVISIONS
ONLY AFTER GAINING THE APPROVAL OF THE COUNCIL OF THE UPPC OR CONTRACT
S. 6582 3
PROVISION, OR A SUBSTANTIALLY SIMILAR UPPC OR CONTRACT PROVISION, PURSU-
ANT TO SUBDIVISION THREE OF THIS SECTION.
(C) NOTWITHSTANDING THE PROVISIONS OF THE STATE ADMINISTRATIVE PROCE-
DURE ACT, THE COMMISSIONER MAY IMPLEMENT ANY REGULATION ADOPTED PURSUANT
TO THIS SECTION ONLY AFTER A PERIOD OF TWO YEARS FROM THE DATE OF
ADOPTION, OR SUCH LONGER PERIOD AS MAY BE PRESCRIBED BY THE COMMISSION-
ER. DURING THE PERIOD BETWEEN THE DATE OF ADOPTION AND THE DATE OF
IMPLEMENTATION AND ENFORCEMENT REQUIRED, THE USE OF THE UPPC OR CONTRACT
PROVISION BY PLANS AND PROVIDERS SHALL BE VOLUNTARY.
(D) PLANS AND PROVIDERS SHALL REMAIN FREE TO NEGOTIATE AND AGREE UPON
ANY LAWFUL PROVISIONS IN PLAN-PROVIDER CONTRACTS THAT DO NOT CONFLICT
WITH REGULATIONS OF THE COMMISSIONER.
(E) ANNUALLY, ON OR BEFORE THE FIRST OF FEBRUARY, THE COMMISSIONER, IN
CONSULTATION WITH THE SUPERINTENDENT OF FINANCIAL SERVICES, SHALL SUBMIT
A REPORT TO THE GOVERNOR AND THE LEGISLATURE OF HIS OR HER FINDINGS,
CONCLUSIONS AND RECOMMENDATIONS WITH REGARD TO THE IMPLEMENTATION OF THE
PROVISIONS OF THIS SECTION, AND MAY SUBMIT THEREWITH SUCH LEGISLATIVE
PROPOSALS AS HE OR SHE SHALL DEEM NECESSARY TO IMPLEMENT SUCH RECOMMEN-
DATIONS.
3. UPPC COUNCIL. (A) THE COMMISSIONER SHALL, WITHIN SIXTY DAYS OF THE
EFFECTIVE DATE OF THIS SECTION, ESTABLISH A UPPC COUNCIL. THE COUNCIL
SHALL BE COMPOSED OF THE COMMISSIONER AND THE SUPERINTENDENT OF FINAN-
CIAL SERVICES, OR THEIR DESIGNEES, WHO SHALL BE THE CO-CHAIRS OF THE
COUNCIL, AND TWELVE MEMBERS APPOINTED BY THE COMMISSIONER AS FOLLOWS:
(I) FIVE MEMBERS REPRESENTING THE INTERESTS OF HEALTH PLANS;
(II) FIVE MEMBERS REPRESENTING THE INTERESTS OF PROVIDERS, SUCH AS
PHYSICIANS, HOSPITALS, NURSING HOMES, HOME CARE AGENCIES AND OTHER
HEALTH CARE PROVIDERS;
(III) ONE MEMBER REPRESENTING THE INTERESTS OF HEALTH CARE CONSUMERS;
AND
(IV) ONE MEMBER REPRESENTING THE INTERESTS OF EMPLOYERS THAT PURCHASE
HEALTH INSURANCE OR HEALTH CARE PLANS FOR THEIR EMPLOYEES.
(B) EACH APPOINTED MEMBER OF THE COUNCIL SHALL SERVE A TERM OF FOUR
YEARS; PROVIDED, HOWEVER, THAT OF THE INITIAL APPOINTMENTS THREE MEMBERS
SHALL SERVE A TERM OF ONE YEAR, THREE MEMBERS SHALL SERVE A TERM OF TWO
YEARS, THREE MEMBERS SHALL SERVE A TERM OF THREE YEARS AND THREE MEMBERS
SHALL SERVE A TERM OF FOUR YEARS, AS DETERMINED BY THE COMMISSIONER.
VACANCIES IN THE MEMBERSHIP OF THE COUNCIL SHALL BE FILLED IN THE MANNER
PROVIDED FOR ORIGINAL APPOINTMENTS.
(C) THE COUNCIL SHALL CONSIDER PROPOSED UPPCS AND CONTRACT PROVISIONS,
AND RECOMMEND SUITABLE AND ACCEPTABLE UPPCS AND CONTRACT PROVISIONS FOR
ADOPTION BY THE COMMISSIONER. IN REVIEWING UPPCS AND CONTRACT
PROVISIONS, THE COUNCIL SHALL CONSIDER THE FAIRNESS, CLARITY AND PRACTI-
CALITY OF THE CONTRACTS AND TERMS, AND THE EFFECTIVENESS OF THE
CONTRACTS AND TERMS IN ENSURING ACCESS TO MEDICALLY NECESSARY CARE AND
IN PROMOTING COST-EFFECTIVENESS OF HEALTH CARE.
(D) A RECOMMENDATION BY THE COUNCIL SHALL REQUIRE APPROVAL BY AT LEAST
NINE MEMBERS, INCLUDING AT LEAST THREE MEMBERS APPOINTED PURSUANT TO
SUBPARAGRAPH (I) AND THREE MEMBERS APPOINTED PURSUANT TO SUBPARAGRAPH
(II) OF PARAGRAPH (A) OF THIS SUBDIVISION.
(E) MEMBERS OF THE COUNCIL SHALL SERVE WITHOUT COMPENSATION, BUT SHALL
BE ENTITLED TO REIMBURSEMENT FOR ACTUAL AND NECESSARY EXPENSES INCURRED
IN THE PERFORMANCE OF OFFICIAL DUTIES.
(F) THE PROVISIONS OF SECTION SEVENTEEN OF THE PUBLIC OFFICERS LAW
SHALL APPLY TO THE MEMBERS OF THE COUNCIL, AND THE PROVISIONS OF ARTICLE
S. 6582 4
SEVEN OF THE PUBLIC OFFICERS LAW SHALL APPLY TO THE MEETINGS OF THE
COUNCIL.
S 3. This act shall take effect immediately and shall expire and be
deemed repealed five years after it shall have taken effect.
