S T A T E O F N E W Y O R K
________________________________________________________________________
5389--A
2013-2014 Regular Sessions
I N A S S E M B L Y
February 25, 2013
___________
Introduced by M. of A. GOTTFRIED, ABINANTI, BENEDETTO, BOYLAND, BRONSON,
BROOK-KRASNY, COLTON, CRESPO, CYMBROWITZ, DINOWITZ, ENGLEBRIGHT, ESPI-
NAL, GANTT, HIKIND, JACOBS, JAFFEE, KAVANAGH, KELLNER, LAVINE, LIFTON,
LUPARDO, MAISEL, PEOPLES-STOKES, ROBERTS, ROSA, ROSENTHAL, SEPULVEDA,
STECK, STEVENSON, SWEENEY, TITONE, TITUS, WEINSTEIN, SCHIMEL, RODRI-
GUEZ -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, BARRON, BRENNAN,
CAHILL, CAMARA, CLARK, COOK, FAHY, FARRELL, GIBSON, GLICK, GUNTHER,
HEASTIE, HOOPER, LENTOL, V. LOPEZ, MAGEE, MAGNARELLI, MARKEY, MAYER,
McDONALD, MILLMAN, MOSLEY, O'DONNELL, ORTIZ, PAULIN, PERRY, PRETLOW,
RAMOS, RIVERA, ROBINSON, ROZIC, SCARBOROUGH, SKARTADOS, THIELE, WEIS-
ENBERG, WEPRIN, WRIGHT -- read once and referred to the Committee on
Health -- committee discharged, bill amended, ordered reprinted as
amended and recommitted to said committee
AN ACT to amend the public health law and the state finance law, in
relation to establishing New York Health
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Legislative findings and intent. 1. The state constitution
states: "The protection and promotion of the health of the inhabitants
of the state are matters of public concern and provision therefor shall
be made by the state and by such of its subdivisions and in such manner,
and by such means as the legislature shall from time to time determine."
(Article XVII, S3.) The legislature finds and declares that all resi-
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
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01606-02-3
A. 5389--A 2
York state. A large portion of voluntary and public hospitals, health
centers and other providers now experience substantial losses due to the
provision of care that is uncompensated. Individuals often find that
they are deprived of affordable care and choice because of decisions by
health plans guided by the plan's economic needs rather than their
health care needs. To address the fiscal crisis facing the health care
system and the state and to assure New Yorkers can exercise their right
to health care, affordable and comprehensive health coverage must be
provided. Pursuant to the state constitution's charge to the legislature
to provide for the health of New Yorkers, this legislation is an enact-
ment of state concern for the purpose of establishing a comprehensive
universal single-payer health care coverage program and a health care
cost control system for the benefit of all residents of the state of New
York.
2. It is the intent of the Legislature to create the New York Health
program to provide a universal health plan for every New Yorker, funded
by broad-based revenue based on ability to pay. The state shall work to
obtain waivers relating to Medicaid, Family Health Plus, Child Health
Plus, Medicare, the Patient Protection and Affordable Care Act, and any
other appropriate federal programs, under which federal funds and other
subsidies that would otherwise be paid to New York State and New Yorkers
for health coverage that will be equaled or exceeded by New York Health
will be paid by the federal government to New York State and deposited
in the New York Health trust fund. Under such a waiver, health coverage
under those programs will be replaced and merged into New York Health,
which will operate as a true single-payer program.
If such a waiver is not obtained, the state shall use state plan
amendments and seek waivers to maximize, and make as seamless as possi-
ble, the use of federally-matched health programs and federal health
programs in New York Health. Thus, even where other programs such as
Medicaid or Medicare may contribute to paying for care, it is the goal
of this legislation that the coverage will be delivered by New York
Health and, as much as possible, the multiple sources of funding will be
pooled with other New York Health funds and not be apparent to New York
Health members or participating providers. This program will promote
movement away from fee-for-service payment, which tends to reward quan-
tity and requires excessive administrative expense, and towards alter-
nate payment methodologies, such as global or capitated payments to
providers or health care organizations, that promote quality, efficien-
cy, investment in primary and preventive care, and innovation and inte-
gration in the organizing of health care.
3. This act does not create any employment benefit, nor does 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.
A. 5389--A 3
S 2. Article 50 and sections 5000, 5001, 5002 and 5003 of the public
health law are renumbered article 80 and sections 8000, 8001, 8002 and
8003, respectively, and a new article 51 is added to read as follows:
ARTICLE 51
NEW YORK HEALTH
SECTION 5100. DEFINITIONS.
5101. PROGRAM CREATED.
5102. BOARD OF TRUSTEES.
5103. ELIGIBILITY AND ENROLLMENT.
5104. BENEFITS.
5105. HEALTH CARE PROVIDERS; CARE COORDINATION; PAYMENT METHOD-
OLOGIES.
5106. HEALTH CARE ORGANIZATIONS.
5107. PROGRAM STANDARDS.
5108. REGULATIONS.
5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS.
5110. ADDITIONAL PROVISIONS.
S 5100. DEFINITIONS. AS USED IN THIS ARTICLE, THE FOLLOWING TERMS
SHALL HAVE THE FOLLOWING MEANINGS, UNLESS THE CONTEXT CLEARLY REQUIRES
OTHERWISE:
1. "BOARD" MEANS THE BOARD OF TRUSTEES OF THE NEW YORK HEALTH PROGRAM
CREATED BY SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE, AND "TRUSTEE"
MEANS A TRUSTEE OF THE BOARD.
2. "CARE COORDINATION" MEANS SERVICES PROVIDED BY A CARE COORDINATOR
UNDER PARAGRAPH (B) OF SUBDIVISION TWO OF SECTION FIFTY-ONE HUNDRED FIVE
OF THIS ARTICLE.
3. "CARE COORDINATOR" MEANS AN INDIVIDUAL OR ENTITY APPROVED TO
PROVIDE CARE COORDINATION UNDER PARAGRAPH (B) OF SUBDIVISION TWO OF
SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE.
4. "FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM" MEANS THE MEDICAL ASSIST-
ANCE PROGRAM UNDER TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES
LAW, THE FAMILY HEALTH PLUS PROGRAM UNDER TITLE ELEVEN-D OF ARTICLE FIVE
OF THE SOCIAL SERVICES LAW, AND THE CHILD HEALTH PLUS PROGRAM UNDER
TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.
5. "HEALTH CARE ORGANIZATION" MEANS AN ENTITY THAT IS APPROVED BY THE
COMMISSIONER UNDER SECTION FIFTY-ONE HUNDRED SIX OF THIS ARTICLE TO
PROVIDE HEALTH CARE SERVICES TO MEMBERS UNDER THE PROGRAM.
6. "HEALTH CARE SERVICE" MEANS ANY HEALTH CARE SERVICE, INCLUDING CARE
COORDINATION, INCLUDED AS A BENEFIT UNDER THE PROGRAM.
7. "IMPLEMENTATION PERIOD" MEANS THE PERIOD UNDER SUBDIVISION THREE OF
SECTION FIFTY-ONE HUNDRED ONE OF THIS ARTICLE DURING WHICH THE PROGRAM
WILL BE SUBJECT TO SPECIAL ELIGIBILITY AND FINANCING PROVISIONS UNTIL IT
IS FULLY IMPLEMENTED UNDER THAT SECTION.
8. "LONG TERM CARE" MEANS LONG TERM CARE, TREATMENT, MAINTENANCE, OR
SERVICES NOT COVERED UNDER FAMILY HEALTH PLUS OR CHILD HEALTH PLUS, AS
APPROPRIATE, WITH THE EXCEPTION OF SHORT TERM REHABILITATION, AS DEFINED
BY THE COMMISSIONER.
9. "MEDICAID" OR "MEDICAL ASSISTANCE" MEANS TITLE ELEVEN OF ARTICLE
FIVE OF THE SOCIAL SERVICES LAW AND THE PROGRAM THEREUNDER. "FAMILY
HEALTH PLUS" MEANS TITLE ELEVEN-D OF 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.
A. 5389--A 4
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.
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.
A. 5389--A 5
5. A COLLEGE, UNIVERSITY OR OTHER INSTITUTION OF HIGHER EDUCATION IN
THE STATE MAY PURCHASE COVERAGE UNDER THE PROGRAM FOR ANY STUDENT, OR
STUDENT'S DEPENDENT, WHO IS NOT A RESIDENT OF THE STATE.
S 5102. BOARD OF TRUSTEES. 1. THE NEW YORK HEALTH BOARD OF TRUSTEES IS
HEREBY CREATED IN THE DEPARTMENT. THE BOARD OF TRUSTEES SHALL, AT THE
REQUEST OF THE COMMISSIONER, CONSIDER ANY MATTER TO EFFECTUATE THE
PROVISIONS AND PURPOSES OF THIS ARTICLE, AND MAY ADVISE THE COMMISSIONER
THEREON; AND IT MAY, FROM TIME TO TIME, SUBMIT TO THE COMMISSIONER ANY
RECOMMENDATIONS TO EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS ARTI-
CLE. THE COMMISSIONER MAY PROPOSE REGULATIONS UNDER THIS ARTICLE AND
AMENDMENTS THERETO FOR CONSIDERATION BY THE BOARD. THE BOARD OF TRUSTEES
SHALL HAVE NO EXECUTIVE, ADMINISTRATIVE OR APPOINTIVE DUTIES EXCEPT AS
OTHERWISE PROVIDED BY LAW. THE BOARD OF TRUSTEES SHALL HAVE POWER TO
ESTABLISH, AND FROM TIME TO TIME, AMEND REGULATIONS TO EFFECTUATE THE
PROVISIONS AND PURPOSES OF THIS ARTICLE, SUBJECT TO APPROVAL BY THE
COMMISSIONER.
2. THE BOARD SHALL BE COMPOSED OF:
(A) THE COMMISSIONER, THE SUPERINTENDENT OF FINANCIAL SERVICES, AND
THE DIRECTOR OF THE BUDGET, OR THEIR DESIGNEES, AS EX OFFICIO MEMBERS;
(B) SEVENTEEN TRUSTEES APPOINTED BY THE GOVERNOR;
(I) FIVE OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE CONSUMER
ADVOCACY ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY,
WHO HAVE BEEN INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER
ADVOCACY, INCLUDING ISSUES OF INTEREST TO LOW- AND MODERATE-INCOME INDI-
VIDUALS;
(II) TWO OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
TIONS REPRESENTING PHYSICIANS;
(III) TWO OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
TIONS REPRESENTING LICENSED OR REGISTERED HEALTH CARE PROFESSIONALS
OTHER THAN PHYSICIANS;
(IV) THREE OF WHOM SHALL BE REPRESENTATIVES OF HOSPITALS, ONE OF WHOM
SHALL BE A REPRESENTATIVE OF PUBLIC HOSPITALS;
(V) ONE OF WHOM SHALL BE REPRESENTATIVE OF COMMUNITY HEALTH CENTERS;
(VI) TWO OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE ORGANIZA-
TIONS; AND
(VIII) TWO OF WHOM SHALL BE REPRESENTATIVES OF ORGANIZED LABOR;
(C) THREE TRUSTEES APPOINTED BY THE SPEAKER OF THE ASSEMBLY; THREE
TRUSTEES APPOINTED BY THE TEMPORARY PRESIDENT OF THE SENATE; ONE TRUSTEE
APPOINTED BY THE MINORITY LEADER OF THE ASSEMBLY; AND ONE TRUSTEE
APPOINTED BY THE MINORITY LEADER OF THE SENATE.
AFTER THE END OF THE IMPLEMENTATION PERIOD, NO PERSON SHALL BE A TRUS-
TEE UNLESS HE OR SHE IS A MEMBER OF THE PROGRAM, EXCEPT THE EX OFFICIO
TRUSTEES. EACH TRUSTEE SHALL SERVE AT THE PLEASURE OF THE APPOINTING
OFFICER, EXCEPT THE EX OFFICIO TRUSTEES.
3. THE CHAIR OF THE BOARD SHALL BE APPOINTED, AND MAY BE REMOVED AS
CHAIR, BY THE GOVERNOR FROM AMONG THE TRUSTEES. THE BOARD SHALL MEET AT
LEAST FOUR TIMES EACH CALENDAR YEAR. MEETINGS SHALL BE HELD UPON THE
CALL OF THE CHAIR AND AS PROVIDED BY THE BOARD. A MAJORITY OF THE
APPOINTED TRUSTEES SHALL BE A QUORUM OF THE BOARD, AND THE AFFIRMATIVE
VOTE OF A MAJORITY OF THE TRUSTEES VOTING, BUT NOT LESS THAN TEN, SHALL
BE NECESSARY FOR ANY ACTION TO BE TAKEN BY THE BOARD. THE BOARD MAY
ESTABLISH AN EXECUTIVE COMMITTEE TO EXERCISE ANY POWERS OR DUTIES OF THE
BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO ASSIST THE BOARD OR THE
EXECUTIVE COMMITTEE. THE CHAIR OF THE BOARD SHALL CHAIR THE EXECUTIVE
COMMITTEE AND SHALL APPOINT THE CHAIR AND MEMBERS OF ALL OTHER COMMIT-
TEES. THE BOARD OF TRUSTEES MAY APPOINT ONE OR MORE ADVISORY COMMITTEES.
A. 5389--A 6
MEMBERS OF ADVISORY COMMITTEES NEED NOT BE MEMBERS OF THE BOARD OF TRUS-
TEES.
4. TRUSTEES SHALL SERVE WITHOUT COMPENSATION BUT SHALL BE REIMBURSED
FOR THEIR NECESSARY AND ACTUAL EXPENSES INCURRED WHILE ENGAGED IN THE
BUSINESS OF THE BOARD.
5. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, NO OFFICER OR
EMPLOYEE OF THE STATE OR ANY LOCAL GOVERNMENT SHALL FORFEIT OR BE DEEMED
TO HAVE FORFEITED HIS OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A
TRUSTEE.
6. THE BOARD AND ITS COMMITTEES AND ADVISORY COMMITTEES MAY REQUEST
AND RECEIVE THE ASSISTANCE OF THE DEPARTMENT AND ANY OTHER STATE OR
LOCAL GOVERNMENTAL ENTITY IN EXERCISING ITS POWERS AND DUTIES.
7. NO LATER THAN FIVE YEARS AFTER THE EFFECTIVE DATE OF THIS ARTICLE:
(A) THE BOARD SHALL DEVELOP A PROPOSAL, CONSISTENT WITH THE PRINCIPLES
OF THIS ARTICLE, FOR PROVISION BY THE PROGRAM OF LONG-TERM CARE COVER-
AGE, INCLUDING THE DEVELOPMENT OF A PROPOSAL, CONSISTENT WITH THE PRIN-
CIPLES OF THIS ARTICLE, FOR ITS FUNDING. IN DEVELOPING THE PROPOSAL,
THE BOARD SHALL CONSULT WITH AN ADVISORY COMMITTEE, APPOINTED BY THE
CHAIR OF THE BOARD, INCLUDING REPRESENTATIVES OF CONSUMERS AND POTENTIAL
CONSUMERS OF LONG-TERM CARE, PROVIDERS OF LONG-TERM CARE, LABOR, AND
OTHER INTERESTED PARTIES. THE BOARD SHALL PRESENT ITS PROPOSAL TO THE
GOVERNOR AND THE LEGISLATURE.
(B) THE BOARD SHALL DEVELOP 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
A. 5389--A 7
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
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;
A. 5389--A 8
(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
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,
A. 5389--A 9
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.
(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
A. 5389--A 10
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:
(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
A. 5389--A 11
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.
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.
A. 5389--A 12
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.
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
A. 5389--A 13
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
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.
A. 5389--A 14
(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.
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
A. 5389--A 15
(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.
(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
A. 5389--A 16
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.
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. 5389--A 17
(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;
(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
A. 5389--A 18
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
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.
A. 5389--A 19
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
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
A. 5389--A 20
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.