senate Bill S2078A

2013-2014 Legislative Session

Provides for establishment of the New York Health 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
Jan 08, 2014 referred to health
Apr 16, 2013 print number 2078a
amend and recommit to health
Mar 19, 2013 notice of committee consideration - requested
Jan 10, 2013 referred to health

Bill Amendments

Original
A (Active)
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A (Active)

Co-Sponsors

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S2078 - Bill Details

See Assembly Version of this Bill:
A5389A
Current Committee:
Law Section:
Appropriations
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 Previous Legislative Sessions:
2011-2012: S5425A, A7860A
2009-2010: S2370, A2356

S2078 - 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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BILL NUMBER:S2078

TITLE OF BILL: An act to amend the public health law and the state
finance law, in relation to establishing New York Health

PURPOSE OR GENERAL IDEA OF BILL: This bill would create a universal
single payer health plan - New York Health - to provide comprehensive
health coverage for all New Yorkers.

SUMMARY OF SPECIFIC PROVISIONS: Every New York resident would be
eligible to enroll, regardless of age, income, wealth, employment, or
other status.

There would be no premium, deductibles, or co-pays. Coverage would be
publicly funded. The benefits will include comprehensive outpatient
and inpatient medical care, primary and preventive care, prescription
drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc.
- all benefits required by current state insurance law or provided by
the state public employee package, Family Health Plus, Child Health
Plus, Medicare, or Medicaid, and others added by the plan.

Everyone would choose a primary care practitioner or other provider to
provide care coordination - helping to get the care and follow-up the
patient needs, referrals, and navigating the system. But there would
be no "gatekeeper" obstacles to care.

A broadly representative Board of Trustees will advise the
Commissioner of Health. Long-term care coverage is not included at the
start, but the bill requires that the Board develop a plan fox it
within five years of passage.

Health care providers, including those providing care coordination,
would be paid in full by New York Health, with no co-pays or other
charges to patients. The plan would develop alternative payment
methods to replace old-style fee-for-service (which rewards volume but
not quality), and would negotiate rates with health care provider
organizations. (Fee-for-service would continue until new methods are
phased in.)

The bill would authorize health care providers to form organizations
to collectively negotiate with New York Health.

Health care would no longer be paid for by insurance companies
charging a regressive "tax" premiums, deductibles and co-pays -
imposed regardless of ability to pay. Instead, New York Health would
be paid for by assessments based on ability to pay, through a
progressively-graduated payroll tax (paid 80% by employers and 20% by
employees, and 1D0t by self-employed) and a surcharge on other taxable
income. A specific revenue plan, following guidelines in the bill,
would be submitted to the Legislature by the Governor.

Federal funds now received for Medicare, Medicaid, Family Health and
Child Health Plus would be combined with the state revenue in a New
York Health Trust Fund. New York would seek federal waivers that will
allow New York to completely fold those programs into New York Health.
The "local share" of Medicaid funding - a major burden on local


property taxes - would be ended. Private insurance that duplicates
benefits offered under New York Health could not be offered to New
York residents. (Existing retiree coverage would be phased out and
replaced with New York Health.)

JUSTIFICATION: 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,
3.) All residents of the state have the right to health care.

New Yorkers - as individuals, 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, this legislation would establish a comprehensive universal
single payer health care coverage program, funded by broad-based
revenue based on ability to pay, and a health care cost control system
for the benefit of all residents of the state of New York.

The state will 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 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
possible, the use of federally-matched health programs and federal
health programs in New York Health. The goal of this legislation is
that coverage 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 quantity and requires excessive administrative
expense, and towards a tern ate payment methodologies, such as global
or capitated payments to providers or health care organizations, that


promote quality, efficiency, investment in primary and preventive
care, and innovation and integration in the organizing of health care.

This act does not create any employment benefit, nor does it require,
prohibit, or limit the providing of any employment benefit.

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
arrangements among health care providers who might otherwise be
competitors, under the active supervision of the commissioner. It is
the 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.

PRIOR LEGISLATIVE HISTORY: 1999-00: S.5611 Referred to Finance
2001-02: S.3354 Referred to Health 2003-04: S.3068 Referred to Health
2005-06: S.3459 Referred to Health 2007-08: S.3107 Referred to Finance
2009-10: S.2370 Referred to Health, Referred to Finance 2011-12:
S.5425A Referred to Finance

FISCAL IMPLICATIONS: Full funding for New York Health would come from
the revenue measures to be proposed by the Governor under guidelines
in the bill, plus available federal funds. The revenue package would
also replace: local share of Medicaid, the state share of Medicaid,
state and local payments for public employee health coverage, and
various other health case spending. Numerous analyses document that a
single-payer system would be most effective for reducing and
controlling costs, for taxpayers, employers and individuals.

EFFECTIVE DATE: Immediately. The program will actually begin
functioning when the Commissioner of Health declares the beginning of
the implementation period.

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

                                  2078

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                            January 10, 2013
                               ___________

Introduced  by  Sen. PERKINS -- read twice and ordered printed, and when
  printed to be committed to the Committee on Health

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-
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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01606-01-3

S. 2078                             2

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 it
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
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.

S. 2078                             3

        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 ARTICLE FIVE OF THE SOCIAL SERVICES
LAW AND THE PROGRAM THEREUNDER. "CHILD HEALTH PLUS" MEANS TITLE ONE-A OF
ARTICLE  TWENTY-FIVE  OF THIS CHAPTER AND THE PROGRAM THEREUNDER. "MEDI-
CARE" MEANS TITLE XVIII OF THE  FEDERAL  SOCIAL  SECURITY  ACT  AND  THE
PROGRAMS THEREUNDER.
  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.

S. 2078                             4

  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.
  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;

S. 2078                             5

  (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.
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

S. 2078                             6

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
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

S. 2078                             7

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
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

S. 2078                             8

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
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

S. 2078                             9

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
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:

S. 2078                            10

  (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-
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.

S. 2078                            11

  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
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.

S. 2078                            12

  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
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

S. 2078                            13

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 MINIMIS 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.
  (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.

S. 2078                            14

  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.
  (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.

S. 2078                            15

  (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
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.

S. 2078                            16

        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;
  (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;

S. 2078                            17

  (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;
  (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

S. 2078                            18

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
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 CHAPTER OF  THE  LAWS  OF
TWO THOUSAND THIRTEEN 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

S. 2078                            19

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
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.

Co-Sponsors

view additional co-sponsors

S2078A (ACTIVE) - Bill Details

See Assembly Version of this Bill:
A5389A
Current Committee:
Law Section:
Appropriations
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 Previous Legislative Sessions:
2011-2012: S5425A, A7860A
2009-2010: S2370, A2356

S2078A (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.

view sponsor memo
BILL NUMBER:S2078A

TITLE OF BILL: An act to amend the public health law and the state
finance law, in relation to establishing New York Health

PURPOSE OR GENERAL IDEA OF BILL: This bill would create a universal
single payer health plan - New York Health - to provide comprehensive
health coverage for all New Yorkers.

SUMMARY OF SPECIFIC PROVISIONS: Every New York resident would be
eligible to enroll, regardless of age, income, wealth, employment, or
other status.

There would be no premium, deductibles, or co-pays. Coverage would be
publicly funded. The benefits will include comprehensive outpatient
and inpatient medical care, primary and preventive care, prescription
drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc.
- all benefits required by current state insurance law or provided by
the state public employee package, Family Health Plus, Child Health
Plus, Medicare, or Medicaid, and others added by the plan.

Everyone would choose a primary care practitioner or other provider to
provide care coordination - helping to get the care and follow-up the
patient needs, referrals, and navigating the system. But there would
be no "gatekeeper" obstacles to care.

As with most health coverage, New York Health covers health care
services when a member is out of state, either because health care is
needed while the member is traveling or because there is a clinical
reason for going to a particular out-of-state provider.

A broadly representative Board of Trustees will advise the
Commissioner of Health. Long-term care coverage is not included at the
start, but the bill requires that the Board develop a plan for it
within five years of passage.

Health care providers, including those providing care coordination,
would be paid in full by New York Health, with no co-pays or other
charges to patients. The plan would develop alternative payment
methods to replace old-style fee-for-service (which rewards volume but
not quality), and would negotiate rates with health care provider
organizations. (Fee-for-service would continue until new methods are
phased in.)

The bill would authorize health care providers to form organizations
to collectively negotiate with New York Health.

Health care would no longer be paid for by insurance companies
charging a regressive "tax" - premiums, deductibles and co-pays -
imposed regardless of ability to pay. Instead, New York Health would
be paid for by assessments based on ability to pay, through a
progressively-graduated payroll tax (paid 80% by employers and 20% by
employees, and 100% by self-employed) and a surcharge on other taxable
income. A specific revenue plan, following guidelines in the bill,
would be submitted to the Legislature by the Governor.


Federal funds now received for Medicare, Medicaid, Family Health and
Child Health Plus would be combined with the state revenue in a New
York Health Trust Fund, New York would seek federal waivers that will
allow New York to completely fold those programs into New York Health.
The "local share" of Medicaid funding - a major burden on local
property taxes - would be ended.

Private insurance that duplicates benefits offered under New York
Health could not be offered to New York residents. (Existing retiree
coverage would be phased out and replaced with New York Health.)

JUSTIFICATION: The state constitution states: "The protection and
promotion of the health of the inhabitants of the state are matters of
public concern and provision therefore 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,
3.) All residents of the state have the right to health care.

New Yorkers - as individuals, 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, this legislation would establish a comprehensive universal
single-payer health care coverage program, funded by broad-based
revenue based on ability to pay, and a health care cost control system
for the benefit of all residents of the state of New York.

The state will 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 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
possible, the use of federally-matched health programs and federal
health programs in New York Health. The goal of this legislation is
that coverage 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 quantity and requires excessive administrative
expense, and towards alternate payment methodologies, such as global
or capitated payments to providers or health care organizations, that
promote quality, efficiency, investment in primary and preventive
care, and innovation and integration in the organizing of health care.

This act does not create any employment benefit, nor does it require,
prohibit, or limit the providing of any employment benefit.

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
arrangements among health care providers who might otherwise be
competitors, under the active supervision of the commissioner. It is
the 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.

PRIOR LEGISLATIVE HISTORY: 1999-00: S.5611 Referred to Finance
2001-02: S.3354 Referred to Health 2003-04: S.3068 Referred to Health
2005-06: S.3459 Referred to Health 2007-08: S.3107 Referred to Finance
2009-10: S.2370 Referred to Health, Referred to Finance 2011-12:
S.5425A Referred to Finance

FISCAL IMPLICATIONS: Full funding for New York Health would come from
the revenue measures to be proposed by the Governor under guidelines
in the bill, plus available federal funds. The revenue package would
also replace: local share of Medicaid, the state share of Medicaid,
state and local payments for public employee health coverage, and
various other health care spending. Numerous analyses document that a
single-payer system would be most effective for reducing and
controlling costs, for taxpayers, employers and individuals.

EFFECTIVE DATE: Immediately. The program will actually begin
functioning when the Commissioner of Health declares the beginning of
the implementation period.

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

                                 2078--A

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                            January 10, 2013
                               ___________

Introduced  by Sens. PERKINS, AVELLA, BRESLIN, ESPAILLAT, HASSELL-THOMP-
  SON, HOYLMAN, KRUEGER, LATIMER, MONTGOMERY, PARKER,  PERALTA,  RIVERA,
  SAMPSON, SERRANO, STAVISKY, TKACZYK -- read twice and ordered printed,
  and when printed to be committed to the Committee on Health -- commit-
  tee  discharged, bill amended, ordered reprinted as amended and recom-
  mitted 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-
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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01606-03-3

S. 2078--A                          2

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 it
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
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.

S. 2078--A                          3

        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 ARTICLE FIVE OF THE SOCIAL SERVICES
LAW AND THE PROGRAM THEREUNDER. "CHILD HEALTH PLUS" MEANS TITLE ONE-A OF
ARTICLE TWENTY-FIVE OF THIS CHAPTER AND THE PROGRAM  THEREUNDER.  "MEDI-
CARE"  MEANS  TITLE  XVIII  OF  THE  FEDERAL SOCIAL SECURITY ACT AND THE
PROGRAMS THEREUNDER.
  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.  "OUT-OF-STATE  HEALTH  CARE  SERVICE" MEANS A HEALTH CARE SERVICE
PROVIDED TO A MEMBER WHILE THE MEMBER IS OUT OF THE STATE AND (A) IT  IS
MEDICALLY  NECESSARY  THAT THE HEALTH CARE SERVICE BE PROVIDED WHILE THE
MEMBER IS OUT OF THE STATE, OR (B) IT IS CLINICALLY APPROPRIATE THAT THE
HEALTH CARE SERVICE BE PROVIDED BY A  PARTICULAR  HEALTH  CARE  PROVIDER
LOCATED OUT OF THE STATE RATHER THAN IN THE STATE.

S. 2078--A                          4

  13.  "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.
  14.  "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.
  15. "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.
  16.  "PROGRAM"  MEANS  THE  NEW YORK HEALTH PROGRAM CREATED BY SECTION
FIFTY-ONE HUNDRED ONE OF THIS ARTICLE.
  17. "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.
  18. "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.
  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-

S. 2078--A                          5

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.
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.

S. 2078--A                          6

  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 PROPOSALS FOR: (I) INCORPORATING RETIREE
HEALTH BENEFITS INTO NEW YORK HEALTH; AND  (II)  ACCOMMODATING  EMPLOYER
RETIREE  HEALTH  BENEFITS  FOR  PEOPLE WHO HAVE BEEN MEMBERS OF NEW YORK
HEALTH BUT LIVE AS RETIREES OUT OF THE STATE.
  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
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

S. 2078--A                          7

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
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;

S. 2078--A                          8

  (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. (A) THE  COMMISSIONER  SHALL  ESTABLISH  AND
MAINTAIN PROCEDURES AND STANDARDS FOR HEALTH CARE PROVIDERS TO BE QUALI-
FIED  TO PARTICIPATE IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO PROCE-
DURES 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
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.

S. 2078--A                          9

  (B) THE COMMISSIONER SHALL ESTABLISH AND MAINTAIN PROCEDURES AND STAN-
DARDS FOR RECOGNIZING HEALTH CARE PROVIDERS LOCATED OUT OF THE STATE FOR
PURPOSES OF PROVIDING COVERAGE UNDER THE PROGRAM FOR OUT-OF-STATE HEALTH
CARE SERVICES.
  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.
  (F) THE COMMISSIONER SHALL PROVIDE BY  REGULATION FOR PAYMENT  METHOD-
OLOGIES AND PROCEDURES FOR PAYING FOR OUT-OF-STATE HEALTH CARE SERVICES.
  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. 2078--A                         10

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. 2078--A                         11

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. 2078--A                         12

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. 2078--A                         13

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 MINIMIS 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. 2078--A                         14

  (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. 2078--A                         15

  (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. 2078--A                         16

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. 2078--A                         17

  (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. 2078--A                         18

  (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

S. 2078--A                         19

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 CHAPTER OF THE LAWS OF
NEW YORK 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

S. 2078--A                         20

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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