EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD12571-01-9
S. 1507 2 A. 2007
for general hospital inpatient services, in relation to the effective-
ness thereof; to amend chapter 56 of the laws of 2013, amending the
public health law relating to the general public health work program,
in relation to the effectiveness thereof; to amend chapter 59 of the
laws of 2011, amending the public health law and other laws relating
to known and projected department of health state fund medical expend-
itures, in relation to extending the provisions thereof; to amend the
public health law, in relation to hospital assessments; to amend chap-
ter 474 of the laws of 1996, amending the education law and other laws
relating to rates for residential health care facilities, in relation
to the effectiveness thereof; to amend chapter 58 of the laws of 2007,
amending the social services law and other laws relating to enacting
the major components of legislation necessary to implement the health
and mental hygiene budget for the 2007-2008 state fiscal year, in
relation to delay of certain administrative costs; to amend chapter 81
of the laws of 1995, amending the public health law and other laws
relating to medical reimbursement and welfare reform, in relation to
the effectiveness thereof; to amend chapter 56 of the laws of 2013,
amending chapter 59 of the laws of 2011 amending the public health law
and other laws relating to general hospital reimbursement for annual
rates, in relation to rates of payments; to amend the public health
law, in relation to reimbursement rate promulgation for residential
health care facilities; to amend the public health law, in relation to
residential health care facility, and certified home health agency
services payments; to amend chapter 81 of the laws of 1995, amending
the public health law and other laws relating to medical reimbursement
and welfare reform, in relation to the effectiveness thereof; to amend
chapter 56 of the laws of 2013 amending chapter 59 of the laws of 2011
amending the public health law and other laws relating to general
hospital reimbursement for annual rates, in relation to extending
government rates for behavioral services and adding an alternative
payment methodology requirement; to amend chapter 111 of the laws of
2010 relating to increasing Medicaid payments to providers through
managed care organizations and providing equivalent fees through an
ambulatory patient group methodology, in relation to extending govern-
ment rates for behavioral services and adding an alternative payment
methodology requirement; to amend section 2 of part H of chapter 111
of the laws of 2010, relating to increasing Medicaid payments to
providers through managed care organizations and providing equivalent
fees through an ambulatory patient group methodology, in relation to
transfer of funds and the effectiveness thereof; and to amend chapter
649 of the laws of 1996, amending the public health law, the mental
hygiene law and the social services law relating to authorizing the
establishment of special needs plans, in relation to the effectiveness
thereof (Part E); to amend chapter 266 of the laws of 1986, amending
the civil practice law and rules and other laws relating to malprac-
tice and professional medical conduct, in relation to apportioning
premium for certain policies; to amend part J of chapter 63 of the
laws of 2001 amending chapter 266 of the laws of 1986, amending the
civil practice law and rules and other laws relating to malpractice
and professional medical conduct, relating to the effectiveness of
certain provisions of such chapter, in relation to extending certain
provisions concerning the hospital excess liability pool; and to amend
part H of chapter 57 of the laws of 2017, amending the New York Health
Care Reform Act of 1996 and other laws relating to extending certain
provisions relating thereto, in relation to extending provisions
S. 1507 3 A. 2007
relating to excess coverage (Part F); to amend the social services
law, in relation to eliminating the ability of legally responsible
spouses to refuse to support non-institutionalized spouses; to create
a state fiscal intermediary for the consumer directed personal assist-
ance program; and to repeal certain provisions of such law relating
thereto (Part G); to amend the public health law, in relation to waiv-
er of certain regulations; to amend the public health law in relation
to certain rates and payment methodologies; and to repeal certain
provisions of such law relating thereto (Part H); to amend the insur-
ance law, in relation to registration and licensing of pharmacy bene-
fit managers (Part I); to amend the insurance law and the public
health law, in relation to guaranteed availability, pre-existing
conditions and employee welfare funds; and to repeal certain
provisions of the insurance law relating thereto (Subpart A); to amend
the insurance law, in relation to actuarial value requirements and
essential health benefits (Subpart B); to amend the insurance law, in
relation to coverage for medically necessary abortions, and exceptions
thereto (Subpart C); to amend the insurance law, in relation to
prescription drug coverage (Subpart D); to amend the insurance law, in
relation to discrimination based on sex and gender identity (Subpart
E); and to amend the insurance law, in relation to insurance certif-
icate delivery (Subpart F) (Part J); to amend the public health law,
in relation to the medical indemnity fund; and to amend chapter 517 of
the laws of 2016 amending the public health law relating to payments
from the New York state medical indemnity fund, in relation to the
effectiveness thereof (Part K); to amend the insurance law, in
relation to in-vitro fertilization (Part L); to amend the insurance
law and the social services law, in relation to requiring health
insurance policies to include coverage of all FDA-approved contracep-
tive drugs, devices, and products, as well as voluntary sterilization
procedures, contraceptive education and counseling, and related follow
up services and prohibiting a health insurance policy from imposing
any cost-sharing requirements or other restrictions or delays with
respect to this coverage (Part M); to establish a universal access
commission to consider the options for achieving universal access to
health care (Part N); to amend the public health law, in relation to
the general public health work program (Part O); to amend the public
health law, in relation to lead levels in residential rental proper-
ties (Part P); to amend the public health law, in relation to the
healthcare facility transformation program state III authorizing addi-
tional awards for statewide II applications (Part Q); to amend the
public health law, in relation to maternal mortality review boards and
the maternal mortality and morbidity advisory council (Part R); to
amend the public health law, in relation to enacting the reproductive
health act and revising existing provisions of law regarding abortion;
to amend the penal law, the criminal procedure law, the county law and
the judiciary law, in relation to abortion; to repeal certain
provisions of the public health law relating to abortion; to repeal
certain provisions of the education law relating to the sale of
contraceptives; and to repeal certain provisions of the penal law
relating to abortion (Part S); to amend the public health law, in
relation to codifying the creation of NY State of Health, the official
Health Plan Marketplace within the department of health (Part T); to
amend the elder law, in relation to the private pay program (Part U);
to amend the social services law, in relation to compliance of managed
care organizations and providers participating in the Medicaid program
S. 1507 4 A. 2007
(Part V); to amend part D of chapter 111 of the laws of 2010 relating
to the recovery of exempt income by the office of mental health for
community residences and family-based treatment programs, in relation
to the effectiveness thereof (Part W); to amend the criminal procedure
law, in relation to authorizing restorations to competency within
correctional facility based residential settings; and providing for
the repeal of such provisions upon expiration thereof (Part X); to
amend part C of chapter 57 of the laws of 2006, relating to establish-
ing a cost of living adjustment for designated human services
programs, in relation to the inclusion and development of certain cost
of living adjustments (Part Y); to amend the public health law and the
mental hygiene law, in relation to integrated services (Part Z); to
amend the social services law, in relation to the definition of a
facility or a provider agency (Part AA); and to amend the insurance
law, in relation to mental health and substance use disorder health
insurance parity; to amend the public health law, in relation to
health maintenance organizations; and to repeal certain provisions of
the insurance law relating thereto (Subpart A); to amend the public
health law, in relation to general hospital policies for substance use
disorder treatment (Subpart B); to repeal subparagraph (v) of para-
graph (a) of subdivision 2 of section 3343-a of the public health law
relating to general hospital prescription drug monitoring (Subpart C);
to amend the social services law, in relation to court ordered
substance use disorder treatment (Subpart D); and to amend the public
health law, in relation to including fentanyl analogs as controlled
substances (Subpart E)(Part BB)
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. This act enacts into law major components of legislation
which are necessary to implement the state fiscal plan for the 2019-2020
state fiscal year. Each component is wholly contained within a Part
identified as Parts A through BB. The effective date for each particular
provision contained within such Part is set forth in the last section of
such Part. Any provision in any section contained within a Part, includ-
ing the effective date of the Part, which makes a reference to a section
"of this act", when used in connection with that particular component,
shall be deemed to mean and refer to the corresponding section of the
Part in which it is found. Section three of this act sets forth the
general effective date of this act.
PART A
Section 1. Subdivision 4 of section 365-h of the social services law,
as separately amended by section 50 of part B and section 24 of part D
of chapter 57 of the laws of 2015, is amended to read as follows:
4. The commissioner of health is authorized to assume responsibility
from a local social services official for the provision and reimburse-
ment of transportation costs under this section. If the commissioner
elects to assume such responsibility, the commissioner shall notify the
local social services official in writing as to the election, the date
upon which the election shall be effective and such information as to
transition of responsibilities as the commissioner deems prudent. The
commissioner is authorized to contract with a transportation manager or
S. 1507 5 A. 2007
managers to manage transportation services in any local social services
district, other than transportation services provided or arranged for
enrollees of [managed long term care plans issued certificates of
authority under section forty-four hundred three-f of the public health
law] A PROGRAM DESIGNATED AS A PROGRAM OF ALL-INCLUSIVE CARE FOR THE
ELDERLY (PACE) AS AUTHORIZED BY FEDERAL PUBLIC LAW 105-33, SUBTITLE I OF
TITLE IV OF THE BALANCED BUDGET ACT OF 1997. Any transportation manager
or managers selected by the commissioner to manage transportation
services shall have proven experience in coordinating transportation
services in a geographic and demographic area similar to the area in New
York state within which the contractor would manage the provision of
services under this section. Such a contract or contracts may include
responsibility for: review, approval and processing of transportation
orders; management of the appropriate level of transportation based on
documented patient medical need; and development of new technologies
leading to efficient transportation services. If the commissioner elects
to assume such responsibility from a local social services district, the
commissioner shall examine and, if appropriate, adopt quality assurance
measures that may include, but are not limited to, global positioning
tracking system reporting requirements and service verification mech-
anisms. Any and all reimbursement rates developed by transportation
managers under this subdivision shall be subject to the review and
approval of the commissioner.
§ 2. The opening paragraph of subdivision 1 and subdivision 3 of
section 367-s of the social services law, as amended by section 53 of
part B of chapter 57 of the laws of 2015, are amended to read as
follows:
Notwithstanding any provision of law to the contrary, a supplemental
medical assistance payment shall be made on an annual basis to providers
of emergency medical transportation services in an aggregate amount not
to exceed four million dollars for two thousand six, six million dollars
for two thousand seven, six million dollars for two thousand eight, six
million dollars for the period May first, two thousand fourteen through
March thirty-first, two thousand fifteen, and six million dollars [annu-
ally beginning with] ON AN ANNUAL BASIS FOR the period April first, two
thousand fifteen through March thirty-first, two thousand [sixteen]
NINETEEN pursuant to the following methodology:
3. If all necessary approvals under federal law and regulation are not
obtained to receive federal financial participation in the payments
authorized by this section, payments under this section shall be made in
an aggregate amount not to exceed two million dollars for two thousand
six, three million dollars for two thousand seven, three million dollars
for two thousand eight, three million dollars for the period May first,
two thousand fourteen through March thirty-first, two thousand fifteen,
and three million dollars [annually beginning with] ON AN ANNUAL BASIS
FOR the period April first, two thousand fifteen through March thirty-
first, two thousand [sixteen] NINETEEN. In such case, the multiplier
set forth in paragraph (b) of subdivision one of this section shall be
deemed to be two million dollars or three million dollars as applicable
to the annual period.
§ 3. Subdivision 5 of section 365-h of the social services law is
REPEALED.
§ 4. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019; provided,
however, that section one of this act shall take effect October 1, 2019;
provided, further that the amendments to subdivision 4 of section 365-h
S. 1507 6 A. 2007
of the social services law made by section one of this act shall not
affect the repeal of such section and shall expire and be deemed
repealed therewith.
PART B
Section 1. Paragraph (a) of subdivision 4 of section 365-a of the
social services law, as amended by chapter 493 of the laws of 2010, is
amended to read as follows:
(a) drugs which may be dispensed without a prescription as required by
section sixty-eight hundred ten of the education law; provided, however,
that the state commissioner of health may by regulation specify certain
of such drugs which may be reimbursed as an item of medical assistance
in accordance with the price schedule established by such commissioner.
Notwithstanding any other provision of law, [additions] MODIFICATIONS to
the list of drugs reimbursable under this paragraph may be filed as
regulations by the commissioner of health without prior notice and
comment;
§ 2. Paragraph (c) of subdivision 6 of section 367-a of the social
services law is amended by adding a new subparagraph (v) to read as
follows:
(V) NOTWITHSTANDING ANY OTHER PROVISION OF THIS PARAGRAPH, CO-PAYMENTS
CHARGED FOR DRUGS DISPENSED WITHOUT A PRESCRIPTION AS REQUIRED BY
SECTION SIXTY-EIGHT HUNDRED TEN OF THE EDUCATION LAW BUT WHICH ARE REIM-
BURSED AS AN ITEM OF MEDICAL ASSISTANCE PURSUANT TO PARAGRAPH (A) OF
SUBDIVISION FOUR OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THIS TITLE
SHALL BE ONE DOLLAR.
§ 3. Paragraph (b) of subdivision 3 of section 273 of the public
health law, as added by section 10 of part C of chapter 58 of the laws
of 2005, is amended to read as follows:
(b) In the event that the patient does not meet the criteria in para-
graph (a) of this subdivision, the prescriber may provide additional
information to the program to justify the use of a prescription drug
that is not on the preferred drug list. The program shall provide a
reasonable opportunity for a prescriber to reasonably present his or her
justification of prior authorization. [If, after consultation with the
program, the prescriber, in his or her reasonable professional judgment,
determines that the use of a prescription drug that is not on the
preferred drug list is warranted, the prescriber's determination shall
be final.] THE PROGRAM WILL CONSIDER THE ADDITIONAL INFORMATION AND THE
JUSTIFICATION PRESENTED TO DETERMINE WHETHER THE USE OF A PRESCRIPTION
DRUG THAT IS NOT ON THE PREFERRED DRUG LIST IS WARRANTED.
§ 4. Subdivisions 25 and 25-a of section 364-j of the social services
law are REPEALED.
§ 5. Paragraphs (b) and (c) of subdivision 2 of section 280 of the
public health law, paragraph (b) as amended and paragraph (c) as added
by section 8 of part D of chapter 57 of the laws of 2018, are amended
and a new paragraph (d) is added to read as follows:
(b) for state fiscal year two thousand eighteen--two thousand nine-
teen, be limited to the ten-year rolling average of the medical compo-
nent of the consumer price index plus four percent and minus a pharmacy
savings target of eighty-five million dollars; [and]
(c) for state fiscal year two thousand nineteen--two thousand twenty,
be limited to the ten-year rolling average of the medical component of
the consumer price index plus four percent and minus a pharmacy savings
target of eighty-five million dollars[.]; AND
S. 1507 7 A. 2007
(D) FOR STATE FISCAL YEAR TWO THOUSAND TWENTY--TWO THOUSAND TWENTY-
ONE, BE LIMITED TO THE TEN-YEAR ROLLING AVERAGE OF THE MEDICAL COMPONENT
OF THE CONSUMER PRICE INDEX PLUS FOUR PERCENT AND MINUS A PHARMACY
SAVINGS TARGET OF EIGHTY-FIVE MILLION DOLLARS.
§ 6. Subdivision 3 of section 280 of the public health law, as amended
by section 8 of part D of chapter 57 of the laws of 2018, is amended to
read as follows:
3. The department and the division of the budget shall assess on a
quarterly basis the projected total amount to be expended in the year on
a cash basis by the Medicaid program for each drug, and the projected
annual amount of state funds Medicaid drug expenditures on a cash basis
for all drugs, which shall be a component of the projected department of
health state funds Medicaid expenditures calculated for purposes of
sections ninety-one and ninety-two of part H of chapter fifty-nine of
the laws of two thousand eleven. For purposes of this section, state
funds Medicaid drug expenditures include amounts expended for drugs in
both the Medicaid fee-for-service program and Medicaid managed care
programs, minus the amount of any drug rebates or supplemental drug
rebates received by the department, including rebates pursuant to subdi-
vision five of this section with respect to rebate targets. [The depart-
ment and the division of the budget shall report quarterly to the drug
utilization review board the projected state funds Medicaid drug expend-
itures including the amounts, in aggregate thereof, attributable to the
net cost of: changes in the utilization of drugs by Medicaid recipients;
changes in the number of Medicaid recipients; changes to the cost of
brand name drugs and changes to the cost of generic drugs. The informa-
tion contained in the report shall not be publicly released in a manner
that allows for the identification of an individual drug or manufacturer
or that is likely to compromise the financial competitive, or proprie-
tary nature of the information.]
(a) In the event the director of the budget determines, based on Medi-
caid drug expenditures for the previous quarter or other relevant infor-
mation, that the total department of health state funds Medicaid drug
expenditure is projected to exceed the annual growth limitation imposed
by subdivision two of this section, the commissioner may identify and
refer drugs to the drug utilization review board established by section
three hundred sixty-nine-bb of the social services law for a recommenda-
tion as to whether a target supplemental Medicaid rebate should be paid
by the manufacturer of the drug to the department and the target amount
of the rebate.
(b) If the department intends to refer a drug to the drug utilization
review board pursuant to paragraph (a) of this subdivision, the depart-
ment shall notify the manufacturer of such drug and shall attempt to
reach agreement with the manufacturer on a rebate for the drug prior to
referring the drug to the drug utilization review board for review.
SUCH REBATE MAY BE BASED ON EVIDENCE-BASED RESEARCH, INCLUDING, BUT NOT
LIMITED TO, SUCH RESEARCH OPERATED OR CONDUCTED BY OR FOR OTHER STATE
GOVERNMENTS, THE FEDERAL GOVERNMENT, THE GOVERNMENTS OF OTHER NATIONS,
AND THIRD PARTY PAYERS OR MULTI-STATE COALITIONS.
(c) [In the event that the commissioner and the manufacturer have
previously agreed to a supplemental rebate for a drug pursuant to para-
graph (b) of this subdivision or paragraph (e) of subdivision seven of
section three hundred sixty-seven-a of the social services law, the drug
shall not be referred to the drug utilization review board for any
further supplemental rebate for the duration of the previous rebate
agreement.
S. 1507 8 A. 2007
(d)] The department shall consider a drug's actual cost to the state,
including current rebate amounts, prior to seeking an additional rebate
pursuant to paragraph (b) [or (c)] of this subdivision [and shall take
into consideration whether the manufacturer of the drug is providing
significant discounts relative to other drugs covered by the Medicaid
program].
[(e)] (D) The commissioner shall be authorized to take the actions
described in this section only so long as total Medicaid drug expendi-
tures are projected to exceed the annual growth limitation imposed by
subdivision two of this section.
§ 7. Paragraph (a) of subdivision 5 of section 280 of the public
health law, as amended by section 8 of part D of chapter 57 of the laws
of 2018, is amended to read as follows:
(a) If the drug utilization review board recommends a target rebate
amount on a drug referred by the commissioner, the [commissioner shall
require] DEPARTMENT SHALL NEGOTIATE WITH THE DRUG'S MANUFACTURER FOR a
supplemental rebate to be paid by the [drug's] manufacturer in an amount
not to exceed such target rebate amount. [With respect to a] A rebate
[required in state fiscal year two thousand seventeen--two thousand
eighteen, the rebate] requirement shall apply beginning with the [month
of April, two thousand seventeen,] FIRST DAY OF THE STATE FISCAL YEAR
DURING WHICH THE REBATE WAS REQUIRED without regard to the date the
department enters into the rebate agreement with the manufacturer.
§ 8. Paragraph (a) of subdivision 7 of section 280 of the public
health law, as amended by section 8 of part D of chapter 57 of the laws
of 2018, is amended to read as follows:
(a) If, after taking into account all rebates and supplemental rebates
received by the department, including rebates received to date pursuant
to this section, total Medicaid drug expenditures are still projected to
exceed the annual growth limitation imposed by subdivision two of this
section, the commissioner may: subject any drug of a manufacturer
referred to the drug utilization review board under this section to
prior approval in accordance with existing processes and procedures when
such manufacturer has not entered into a supplemental rebate agreement
as required by this section; [directing] DIRECT managed care plans to
remove from their Medicaid formularies those drugs that the drug utili-
zation review board recommends a target rebate amount for and the
manufacturer has failed to enter into a rebate agreement required by
this section; [promoting] PROMOTE the use of cost effective and clin-
ically appropriate drugs other than those of a manufacturer who has a
drug that the drug utilization review board recommends a target rebate
amount and the manufacturer has failed to enter into a rebate agreement
required by this section; [allowing] ALLOW manufacturers to accelerate
rebate payments under existing rebate contracts; and such other actions
as authorized by law. The commissioner shall provide written notice to
the legislature thirty days prior to taking action pursuant to this
paragraph, unless action is necessary in the fourth quarter of a fiscal
year to prevent total Medicaid drug expenditures from exceeding the
limitation imposed by subdivision two of this section, in which case
such notice to the legislature may be less than thirty days.
§ 9. Subdivision 8 of section 280 of the public health law, as added
by section 8 of part D of chapter 57 of the laws of 2018, is amended to
read as follows:
8. The commissioner shall report by [February] JULY first annually to
the drug utilization review board on savings achieved through the drug
cap in the last FISCAL year. Such report shall provide data on what
S. 1507 9 A. 2007
savings were achieved through actions pursuant to subdivisions three,
five and seven of this section, respectively, and what savings were
achieved through other means and how such savings were calculated and
implemented.
§ 10. Section 4406-c of the public health law is amended by adding a
new subdivision 10 to read as follows:
10. (A) ANY CONTRACT OR OTHER ARRANGEMENT ENTERED INTO BY A HEALTH
CARE PLAN FOR PHARMACY BENEFIT MANAGEMENT SERVICES ON BEHALF OF INDIVID-
UALS ENROLLED IN A MANAGED CARE PROVIDER AS DEFINED IN SECTION THREE
HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW SHALL INCLUDE PROVISIONS
THAT ENSURE THE FOLLOWING:
(I) PAYMENT TO THE PHARMACY BENEFIT MANAGER FOR PHARMACY BENEFIT
MANAGEMENT SERVICES IS LIMITED TO THE ACTUAL INGREDIENT COSTS, A
DISPENSING FEE, AND AN ADMINISTRATIVE FEE FOR EACH CLAIM PROCESSED. THE
DEPARTMENT OF HEALTH MAY ESTABLISH A MAXIMUM ADMINISTRATIVE FEE;
(II) THE PHARMACY BENEFIT MANAGER IDENTIFIES ALL SOURCES OF INCOME
RELATED TO THE PROVISION OF PHARMACY BENEFIT MANAGEMENT SERVICES ON
BEHALF OF THE HEALTH CARE PLAN, INCLUDING, BUT NOT LIMITED TO, ANY
DISCOUNTS OR SUPPLEMENTAL REBATES, AND THAT ANY PORTION OF SUCH INCOME
IS PASSED THROUGH TO THE HEALTH CARE PLAN IN FULL TO REDUCE THE REPORT-
ABLE INGREDIENT COST; AND
(III) THE PHARMACY BENEFIT MANAGER SHALL NOT RETAIN ANY PORTION OF
SPREAD PRICING. FOR PURPOSES OF THIS SUBDIVISION "SPREAD PRICING" MEANS
ANY AMOUNT CHARGED OR CLAIMED BY THE PHARMACY BENEFIT MANAGER IN EXCESS
OF THE AMOUNT PAID TO PHARMACIES ON BEHALF OF THE HEALTH CARE PLAN LESS
AN ADMINISTRATIVE FEE AS DESCRIBED IN THIS PARAGRAPH. ANY SUCH EXCESS
AMOUNT SHALL BE REMITTED TO THE HEALTH CARE PLAN ON A QUARTERLY BASIS.
(B) THE COMMISSIONER MAY PROMULGATE REGULATIONS AS NECESSARY TO ESTAB-
LISH ADDITIONAL STANDARDS FOR CONTRACTS OR OTHER ARRANGEMENTS RELATED TO
THE SERVICES DESCRIBED IN THIS SUBDIVISION.
§ 11. Health care plans subject to subdivision 10 of section 4406-c of
the public health law, as added by section ten of this act, shall
provide evidence of compliance with such section to the department of
health, and in a manner and form determined by the department of health,
within 90 days and again within 180 days of the effective date of this
act. The department of health shall take no enforcement action with
regards to the requirements of subdivision 10 of section 4406-c of the
public health law, as added by section ten of this act, prior to the
passage of 180 days from the effective date of this act, nor shall
enforcement action be taken related to any non-compliance occurring
prior to the passage of the same 180 days.
§ 12. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019; provided,
however, that sections one and two of this act shall take effect July 1,
2019; and provided further, however, that the amendments to paragraph
(c) of subdivision 6 of section 367-a of the social services law made by
section two of this act shall not affect the repeal of such paragraph
and shall be deemed repealed therewith.
PART C
Section 1. Subdivision 2 of section 365-a of the social services law
is amended by adding a new paragraph (ff) to read as follows:
(FF) EVIDENCE-BASED PREVENTION AND SUPPORT SERVICES RECOGNIZED BY THE
FEDERAL CENTERS FOR DISEASE CONTROL (CDC), PROVIDED BY A COMMUNITY-BASED
S. 1507 10 A. 2007
ORGANIZATION, AND DESIGNED TO PREVENT INDIVIDUALS AT RISK OF DEVELOPING
DIABETES FROM DEVELOPING TYPE 2 DIABETES.
§ 2. Subparagraph (ii) of paragraph (d) of subdivision 1 of section
367-a of the social services law, as amended by section 1 of part J1 of
chapter 63 of the laws of 2003, is amended to read as follows:
(ii) Amounts payable under this title for medical assistance for items
and services provided to eligible persons who are also beneficiaries
under part B of title XVIII of the federal social security act and items
and services provided to qualified medicare beneficiaries under part B
of title XVIII of the federal social security act shall not [be less
than the amount of any deductible liability of such eligible persons or
for which such eligible persons or such qualified medicare beneficiaries
would be liable under federal law were they not eligible for medical
assistance or were they not qualified medicare beneficiaries with
respect to such benefits under such part B.] EXCEED THE AMOUNT THAT
OTHERWISE WOULD BE MADE UNDER THIS TITLE IF PROVIDED TO AN ELIGIBLE
PERSON OTHER THAN A PERSON WHO IS ALSO A BENEFICIARY UNDER PART B OR IS
A QUALIFIED MEDICARE BENEFICIARY MINUS THE AMOUNT PAYABLE UNDER PART B.
§ 3. Subparagraph (iii) of paragraph (d) of subdivision 1 of section
367-a of the social services law, as amended by section 31 of part B of
chapter 57 of the laws of 2015, is amended to read as follows:
(iii) With respect to items and services provided to eligible persons
who are also beneficiaries under part B of title XVIII of the federal
social security act and items and services provided to qualified medi-
care beneficiaries under part B of title XVIII of the federal social
security act, the amount payable for services covered under this title
shall be the amount of any co-insurance liability of such eligible
persons pursuant to federal law were they not eligible for medical
assistance or were they not qualified medicare beneficiaries with
respect to such benefits under such part B, but shall not exceed the
amount that otherwise would be made under this title if provided to an
eligible person other than a person who is also a beneficiary under part
B or is a qualified medicare beneficiary minus the amount payable under
part B; provided, however, amounts payable under this title for items
and services provided to eligible persons who are also beneficiaries
under part B or to qualified medicare beneficiaries by [an ambulance
service under the authority of an operating certificate issued pursuant
to article thirty of the public health law, a psychologist licensed
under article one hundred fifty-three of the education law, or] a facil-
ity under the authority of an operating certificate issued pursuant to
article sixteen, thirty-one or thirty-two of the mental hygiene law and
with respect to outpatient hospital and clinic items and services
provided by a facility under the authority of an operating certificate
issued pursuant to article twenty-eight of the public health law, shall
not be less than the amount of any co-insurance liability of such eligi-
ble persons or such qualified medicare beneficiaries, or for which such
eligible persons or such qualified medicare beneficiaries would be
liable under federal law were they not eligible for medical assistance
or were they not qualified medicare beneficiaries with respect to such
benefits under part B.
§ 4. This act shall take effect July 1, 2019.
PART D
Section 1. Subdivision 1 of section 92 of part H of chapter 59 of the
laws of 2011, amending the public health law and other laws relating to
S. 1507 11 A. 2007
known and projected department of health state fund medicaid expendi-
tures, as amended by section 2 of part K of chapter 57 of the laws of
2018, is amended to read as follows:
1. For state fiscal years 2011-12 through [2019-20] 2020-2021, the
director of the budget, in consultation with the commissioner of health
referenced as "commissioner" for purposes of this section, shall assess
on a monthly basis, as reflected in monthly reports pursuant to subdivi-
sion five of this section known and projected department of health state
funds medicaid expenditures by category of service and by geographic
regions, as defined by the commissioner, and if the director of the
budget determines that such expenditures are expected to cause medicaid
disbursements for such period to exceed the projected department of
health medicaid state funds disbursements in the enacted budget finan-
cial plan pursuant to subdivision 3 of section 23 of the state finance
law, the commissioner of health, in consultation with the director of
the budget, shall develop a medicaid savings allocation plan to limit
such spending to the aggregate limit level specified in the enacted
budget financial plan, provided, however, such projections may be
adjusted by the director of the budget to account for any changes in the
New York state federal medical assistance percentage amount established
pursuant to the federal social security act, changes in provider reven-
ues, reductions to local social services district medical assistance
administration, minimum wage increases, and beginning April 1, 2012 the
operational costs of the New York state medical indemnity fund and state
costs or savings from the basic health plan. Such projections may be
adjusted by the director of the budget to account for increased or expe-
dited department of health state funds medicaid expenditures as a result
of a natural or other type of disaster, including a governmental decla-
ration of emergency.
§ 2. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019.
PART E
Section 1. Section 4 of chapter 505 of the laws of 1995, amending the
public health law relating to the operation of department of health
facilities, as amended by section 27 of part D of chapter 57 of the laws
of 2015, is amended to read as follows:
§ 4. This act shall take effect immediately; provided, however, that
the provisions of paragraph (b) of subdivision 4 of section 409-c of the
public health law, as added by section three of this act, shall take
effect January 1, 1996 and shall expire and be deemed repealed [twenty-
four] TWENTY-NINE years from the effective date thereof.
§ 2. Subdivision p of section 76 of part D of chapter 56 of the laws
of 2013, amending the social services law relating to eligibility condi-
tions, is amended to read as follows:
p. the amendments [made] to subparagraph [(7)] 7 of paragraph (b) of
subdivision 1 of section 366 of the social services law made by section
one of this act shall expire and be deemed repealed October 1, [2019]
2024.
§ 3. Section 11 of chapter 884 of the laws of 1990, amending the
public health law relating to authorizing bad debt and charity care
allowances for certified home health agencies, as amended by section 1
of part I of chapter 57 of the laws of 2017, is amended to read as
follows:
§ 11. This act shall take effect immediately and:
S. 1507 12 A. 2007
(a) sections one and three shall expire on December 31, 1996,
(b) sections four through ten shall expire on June 30, [2019] 2024,
and
(c) provided that the amendment to section 2807-b of the public health
law by section two of this act shall not affect the expiration of such
section 2807-b as otherwise provided by law and shall be deemed to
expire therewith.
§ 4. Section 3 of chapter 303 of the laws of 1999, amending the New
York state medical care facilities finance agency act relating to
financing health facilities, as amended by section 16 of part D of chap-
ter 57 of the laws of 2015, is amended to read as follows:
§ 3. This act shall take effect immediately, provided, however, that
subdivision 15-a of section 5 of section 1 of chapter 392 of the laws of
1973, as added by section one of this act, shall expire and be deemed
repealed June 30, [2019] 2024; and provided further, however, that the
expiration and repeal of such subdivision 15-a shall not affect or
impair in any manner any health facilities bonds issued, or any lease or
purchase of a health facility executed, pursuant to such subdivision
15-a prior to its expiration and repeal and that, with respect to any
such bonds issued and outstanding as of June 30, [2019] 2024, the
provisions of such subdivision 15-a as they existed immediately prior to
such expiration and repeal shall continue to apply through the latest
maturity date of any such bonds, or their earlier retirement or redemp-
tion, for the sole purpose of authorizing the issuance of refunding
bonds to refund bonds previously issued pursuant thereto.
§ 5. Subdivision (a) of section 40 of part B of chapter 109 of the
laws of 2010, amending the social services law relating to transporta-
tion costs, as amended by section 8 of part I of chapter 57 of the laws
of 2017, is amended to read as follows:
(a) sections two, three, three-a, three-b, three-c, three-d, three-e
and twenty-one of this act shall take effect July 1, 2010; sections
fifteen, sixteen, seventeen, eighteen and nineteen of this act shall
take effect January 1, 2011; and provided further that section twenty of
this act shall be deemed repealed [eight] THIRTEEN years after the date
the contract entered into pursuant to section 365-h of the social
services law, as amended by section twenty of this act, is executed;
provided that the commissioner of health shall notify the legislative
bill drafting commission upon the execution of the contract entered into
pursuant to section 367-h of the social services law in order that the
commission may maintain an accurate and timely effective data base of
the official text of the laws of the state of New York in furtherance of
effectuating the provisions of section 44 of the legislative law and
section 70-b of the public officers law;
§ 6. Subdivision (f) of section 129 of part C of chapter 58 of the
laws of 2009, amending the public health law relating to payment by
governmental agencies for general hospital inpatient services, as
amended by section 4 of part D of chapter 59 of the laws of 2016, is
amended to read as follows:
(f) section twenty-five of this act shall expire and be deemed
repealed April 1, [2019] 2024;
§ 7. Subdivision (c) of section 122 of part E of chapter 56 of the
laws of 2013 amending the public health law relating to the general
public health work program, as amended by section 5 of part D of chapter
59 of the laws of 2016, is amended to read as follows:
(c) section fifty of this act shall take effect immediately [and shall
expire six years after it becomes law];
S. 1507 13 A. 2007
§ 8. Subdivision (i) of section 111 of part H of chapter 59 of the
laws of 2011, amending the public health law and other laws relating to
known and projected department of health state fund medical expendi-
tures, as amended by section 19 of part D of chapter 57 of the laws of
2015, is amended to read as follows:
(i) the amendments to paragraph (b) and subparagraph (i) of paragraph
(g) of subdivision 7 of section 4403-f of the public health law made by
section forty-one-b of this act shall expire and be repealed April 1,
[2019] 2024;
§ 9. Subparagraph (vi) of paragraph (b) of subdivision 2 of section
2807-d of the public health law, as amended by section 3 of part I of
chapter 57 of the laws of 2017, is amended to read as follows:
(vi) Notwithstanding any contrary provision of this paragraph or any
other provision of law or regulation to the contrary, for residential
health care facilities the assessment shall be six percent of each resi-
dential health care facility's gross receipts received from all patient
care services and other operating income on a cash basis for the period
April first, two thousand two through March thirty-first, two thousand
three for hospital or health-related services, including adult day
services; provided, however, that residential health care facilities'
gross receipts attributable to payments received pursuant to title XVIII
of the federal social security act (medicare) shall be excluded from the
assessment; provided, however, that for all such gross receipts received
on or after April first, two thousand three through March thirty-first,
two thousand five, such assessment shall be five percent, and further
provided that for all such gross receipts received on or after April
first, two thousand five through March thirty-first, two thousand nine,
and on or after April first, two thousand nine through March thirty-
first, two thousand eleven such assessment shall be six percent, and
further provided that for all such gross receipts received on or after
April first, two thousand eleven through March thirty-first, two thou-
sand thirteen such assessment shall be six percent, and further provided
that for all such gross receipts received on or after April first, two
thousand thirteen through March thirty-first, two thousand fifteen such
assessment shall be six percent, and further provided that for all such
gross receipts received on or after April first, two thousand fifteen
through March thirty-first, two thousand seventeen such assessment shall
be six percent, and further provided that for all such gross receipts
received on or after April first, two thousand seventeen through March
thirty-first, two thousand nineteen such assessment shall be six
percent, AND FURTHER PROVIDED THAT FOR ALL SUCH GROSS RECEIPTS RECEIVED
ON OR AFTER APRIL FIRST, TWO THOUSAND NINETEEN THROUGH MARCH THIRTY-
FIRST, TWO THOUSAND TWENTY-FOUR SUCH ASSESSMENT SHALL BE SIX PERCENT.
§ 10. Subdivision 1 of section 194 of chapter 474 of the laws of 1996,
amending the education law and other laws relating to rates for residen-
tial health care facilities, as amended by section 4 of part I of chap-
ter 57 of the laws of 2017, is amended to read as follows:
1. Notwithstanding any inconsistent provision of law or regulation,
the trend factors used to project reimbursable operating costs to the
rate period for purposes of determining rates of payment pursuant to
article 28 of the public health law for residential health care facili-
ties for reimbursement of inpatient services provided to patients eligi-
ble for payments made by state governmental agencies on and after April
1, 1996 through March 31, 1999 and for payments made on and after July
1, 1999 through March 31, 2000 and on and after April 1, 2000 through
March 31, 2003 and on and after April 1, 2003 through March 31, 2007 and
S. 1507 14 A. 2007
on and after April 1, 2007 through March 31, 2009 and on and after April
1, 2009 through March 31, 2011 and on and after April 1, 2011 through
March 31, 2013 and on and after April 1, 2013 through March 31, 2015,
and on and after April 1, 2015 through March 31, 2017, and on and after
April 1, 2017 through March 31, 2019, AND ON AND AFTER APRIL 1, 2019
THROUGH MARCH 31, 2024 shall reflect no trend factor projections or
adjustments for the period April 1, 1996, through March 31, 1997.
§ 11. Subdivision 1 of section 89-a of part C of chapter 58 of the
laws of 2007, amending the social services law and other laws relating
to enacting the major components of legislation necessary to implement
the health and mental hygiene budget for the 2007-2008 state fiscal
year, as amended by section 5 of part I of chapter 57 of the laws of
2017, is amended to read as follows:
1. Notwithstanding paragraph (c) of subdivision 10 of section 2807-c
of the public health law and section 21 of chapter 1 of the laws of
1999, as amended, and any other inconsistent provision of law or regu-
lation to the contrary, in determining rates of payments by state
governmental agencies effective for services provided beginning April 1,
2006, through March 31, 2009, and on and after April 1, 2009 through
March 31, 2011, and on and after April 1, 2011 through March 31, 2013,
and on and after April 1, 2013 through March 31, 2015, and on and after
April 1, 2015 through March 31, 2017, and on and after April 1, 2017
through March 31, 2019, AND ON AND AFTER APRIL 1, 2019 THROUGH MARCH 31,
2024 for inpatient and outpatient services provided by general hospitals
and for inpatient services and outpatient adult day health care services
provided by residential health care facilities pursuant to article 28 of
the public health law, the commissioner of health shall apply a trend
factor projection of two and twenty-five hundredths percent attributable
to the period January 1, 2006 through December 31, 2006, and on and
after January 1, 2007, provided, however, that on reconciliation of such
trend factor for the period January 1, 2006 through December 31, 2006
pursuant to paragraph (c) of subdivision 10 of section 2807-c of the
public health law, such trend factor shall be the final US Consumer
Price Index (CPI) for all urban consumers, as published by the US
Department of Labor, Bureau of Labor Statistics less twenty-five
hundredths of a percentage point.
§ 12. Subdivision 5-a of section 246 of chapter 81 of the laws of
1995, amending the public health law and other laws relating to medical
reimbursement and welfare reform, as amended by section 6 of part I of
chapter 57 of the laws of 2017, is amended to read as follows:
5-a. Section sixty-four-a of this act shall be deemed to have been in
full force and effect on and after April 1, 1995 through March 31, 1999
and on and after July 1, 1999 through March 31, 2000 and on and after
April 1, 2000 through March 31, 2003 and on and after April 1, 2003
through March 31, 2007, and on and after April 1, 2007 through March 31,
2009, and on and after April 1, 2009 through March 31, 2011, and on and
after April 1, 2011 through March 31, 2013, and on and after April 1,
2013 through March 31, 2015, and on and after April 1, 2015 through
March 31, 2017 and on and after April 1, 2017 through March 31, 2019,
AND ON AND AFTER APRIL 1, 2019 THROUGH MARCH 31, 2024;
§ 13. Section 64-b of chapter 81 of the laws of 1995, amending the
public health law and other laws relating to medical reimbursement and
welfare reform, as amended by section 7 of part I of chapter 57 of the
laws of 2017, is amended to read as follows:
§ 64-b. Notwithstanding any inconsistent provision of law, the
provisions of subdivision 7 of section 3614 of the public health law, as
S. 1507 15 A. 2007
amended, shall remain and be in full force and effect on April 1, 1995
through March 31, 1999 and on July 1, 1999 through March 31, 2000 and on
and after April 1, 2000 through March 31, 2003 and on and after April 1,
2003 through March 31, 2007, and on and after April 1, 2007 through
March 31, 2009, and on and after April 1, 2009 through March 31, 2011,
and on and after April 1, 2011 through March 31, 2013, and on and after
April 1, 2013 through March 31, 2015, and on and after April 1, 2015
through March 31, 2017 and on and after April 1, 2017 through March 31,
2019, AND ON AND AFTER APRIL 1, 2019 THROUGH MARCH 31, 2024.
§ 14. Section 4-a of part A of chapter 56 of the laws of 2013, amend-
ing chapter 59 of the laws of 2011 amending the public health law and
other laws relating to general hospital reimbursement for annual rates,
as amended by section 5 of part T of chapter 57 of the laws of 2018, is
amended to read as follows:
§ 4-a. Notwithstanding paragraph (c) of subdivision 10 of section
2807-c of the public health law, section 21 of chapter 1 of the laws of
1999, or any other contrary provision of law, in determining rates of
payments by state governmental agencies effective for services provided
on and after January 1, 2017 through March 31, [2019] 2024, for inpa-
tient and outpatient services provided by general hospitals, for inpa-
tient services and adult day health care outpatient services provided by
residential health care facilities pursuant to article 28 of the public
health law, except for residential health care facilities or units of
such facilities providing services primarily to children under twenty-
one years of age, for home health care services provided pursuant to
article 36 of the public health law by certified home health agencies,
long term home health care programs and AIDS home care programs, and for
personal care services provided pursuant to section 365-a of the social
services law, the commissioner of health shall apply no greater than
zero trend factors attributable to the 2017, 2018, [and] 2019, 2020,
2021, 2022, AND 2023 calendar years in accordance with paragraph (c) of
subdivision 10 of section 2807-c of the public health law, provided,
however, that such no greater than zero trend factors attributable to
such 2017, 2018, [and] 2019, 2020, 2021, 2022, AND 2023 calendar years
shall also be applied to rates of payment provided on and after January
1, 2017 through March 31, [2019] 2024 for personal care services
provided in those local social services districts, including New York
city, whose rates of payment for such services are established by such
local social services districts pursuant to a rate-setting exemption
issued by the commissioner of health to such local social services
districts in accordance with applicable regulations; and provided
further, however, that for rates of payment for assisted living program
services provided on and after January 1, 2017 through March 31, [2019]
2024, such trend factors attributable to the 2017, 2018, [and] 2019,
2020, 2021, 2022, AND 2023 calendar years shall be established at no
greater than zero percent.
§ 15. Paragraph (b) of subdivision 17 of section 2808 of the public
health law, as amended by section 21 of part D of chapter 57 of the laws
of 2015, is amended to read as follows:
(b) Notwithstanding any inconsistent provision of law or regulation to
the contrary, for the state fiscal years beginning April first, two
thousand ten and ending March thirty-first, two thousand [nineteen]
TWENTY-FOUR, the commissioner shall not be required to revise certified
rates of payment established pursuant to this article for rate periods
prior to April first, two thousand [nineteen] TWENTY-FOUR, based on
consideration of rate appeals filed by residential health care facili-
S. 1507 16 A. 2007
ties or based upon adjustments to capital cost reimbursement as a result
of approval by the commissioner of an application for construction under
section twenty-eight hundred two of this article, in excess of an aggre-
gate annual amount of eighty million dollars for each such state fiscal
year provided, however, that for the period April first, two thousand
eleven through March thirty-first, two thousand twelve such aggregate
annual amount shall be fifty million dollars. In revising such rates
within such fiscal limit, the commissioner shall, in prioritizing such
rate appeals, include consideration of which facilities the commissioner
determines are facing significant financial hardship as well as such
other considerations as the commissioner deems appropriate and, further,
the commissioner is authorized to enter into agreements with such facil-
ities or any other facility to resolve multiple pending rate appeals
based upon a negotiated aggregate amount and may offset such negotiated
aggregate amounts against any amounts owed by the facility to the
department, including, but not limited to, amounts owed pursuant to
section twenty-eight hundred seven-d of this article; provided, however,
that the commissioner's authority to negotiate such agreements resolving
multiple pending rate appeals as hereinbefore described shall continue
on and after April first, two thousand [nineteen] TWENTY-FOUR. Rate
adjustments made pursuant to this paragraph remain fully subject to
approval by the director of the budget in accordance with the provisions
of subdivision two of section twenty-eight hundred seven of this arti-
cle.
§ 16. Paragraph (a) of subdivision 13 of section 3614 of the public
health law, as amended by section 22 of part D of chapter 57 of the laws
of 2015, is amended to read as follows:
(a) Notwithstanding any inconsistent provision of law or regulation
and subject to the availability of federal financial participation,
effective April first, two thousand twelve through March thirty-first,
two thousand [nineteen] TWENTY-FOUR, payments by government agencies for
services provided by certified home health agencies, except for such
services provided to children under eighteen years of age and other
discreet groups as may be determined by the commissioner pursuant to
regulations, shall be based on episodic payments. In establishing such
payments, a statewide base price shall be established for each sixty day
episode of care and adjusted by a regional wage index factor and an
individual patient case mix index. Such episodic payments may be further
adjusted for low utilization cases and to reflect a percentage limita-
tion of the cost for high-utilization cases that exceed outlier thresh-
olds of such payments.
§ 17. Subdivision 2 of section 246 of chapter 81 of the laws of 1995,
amending the public health law and other laws relating to medical
reimbursement and welfare reform, as amended by section 18 of part I of
chapter 57 of the laws of 2017, is amended to read as follows:
2. Sections five, seven through nine, twelve through fourteen, and
eighteen of this act shall be deemed to have been in full force and
effect on and after April 1, 1995 through March 31, 1999 and on and
after July 1, 1999 through March 31, 2000 and on and after April 1, 2000
through March 31, 2003 and on and after April 1, 2003 through March 31,
2006 and on and after April 1, 2006 through March 31, 2007 and on and
after April 1, 2007 through March 31, 2009 and on and after April 1,
2009 through March 31, 2011 and sections twelve, thirteen and fourteen
of this act shall be deemed to be in full force and effect on and after
April 1, 2011 through March 31, 2015 and on and after April 1, 2015
S. 1507 17 A. 2007
through March 31, 2017 and on and after April 1, 2017 through March 31,
2019, AND ON AND AFTER APRIL 1, 2019 THROUGH MARCH 31, 2024;
§ 18. Section 48-a of part A of chapter 56 of the laws of 2013 amend-
ing chapter 59 of the laws of 2011 amending the public health law and
other laws relating to general hospital reimbursement for annual rates,
as amended by section 1 of part P of chapter 57 of the laws of 2017, is
amended to read as follows:
§ 48-a. 1. Notwithstanding any contrary provision of law, the commis-
sioners of the office of alcoholism and substance abuse services and the
office of mental health are authorized, subject to the approval of the
director of the budget, to transfer to the commissioner of health state
funds to be utilized as the state share for the purpose of increasing
payments under the medicaid program to managed care organizations
licensed under article 44 of the public health law or under article 43
of the insurance law. Such managed care organizations shall utilize such
funds for the purpose of reimbursing providers licensed pursuant to
article 28 of the public health law or article 31 or 32 of the mental
hygiene law for ambulatory behavioral health services, as determined by
the commissioner of health, in consultation with the commissioner of
alcoholism and substance abuse services and the commissioner of the
office of mental health, provided to medicaid enrolled outpatients and
for all other behavioral health services except inpatient included in
New York state's Medicaid redesign waiver approved by the centers for
medicare and Medicaid services (CMS). Such reimbursement shall be in
the form of fees for such services which are equivalent to the payments
established for such services under the ambulatory patient group (APG)
rate-setting methodology as utilized by the department of health, the
office of alcoholism and substance abuse services, or the office of
mental health for rate-setting purposes or any such other fees pursuant
to the Medicaid state plan or otherwise approved by CMS in the Medicaid
redesign waiver; provided, however, that the increase to such fees that
shall result from the provisions of this section shall not, in the
aggregate and as determined by the commissioner of health, in consulta-
tion with the commissioner of alcoholism and substance abuse services
and the commissioner of the office of mental health, be greater than the
increased funds made available pursuant to this section. The increase
of such ambulatory behavioral health fees to providers available under
this section shall be for all rate periods on and after the effective
date of section [29] 1 of part [B] P of chapter [59] 57 of the laws of
[2016] 2017 through March 31, [2020] 2022 for patients in the city of
New York, for all rate periods on and after the effective date of
section [29] 1 of part [B] P of chapter [59] 57 of the laws of [2016]
2017 through [March 31, 2020] MARCH 31, 2022 for patients outside the
city of New York, and for all rate periods on and after the effective
date of such chapter through [March 31, 2020] MARCH 31, 2022 for all
services provided to persons under the age of twenty-one; provided,
however, the commissioner of health, in consultation with the commis-
sioner of alcoholism and substance abuse services and the commissioner
of mental health, may require, as a condition of approval of such ambu-
latory behavioral health fees, that aggregate managed care expenditures
to eligible providers meet the alternative payment methodology require-
ments as set forth in attachment I of the New York state medicaid
section one thousand one hundred fifteen medicaid redesign team waiver
as approved by the centers for medicare and medicaid services. The
commissioner of health shall, in consultation with the commissioner of
alcoholism and substance abuse services and the commissioner of mental
S. 1507 18 A. 2007
health, waive such conditions if a sufficient number of providers, as
determined by the commissioner, suffer a financial hardship as a conse-
quence of such alternative payment methodology requirements, or if he or
she shall determine that such alternative payment methodologies signif-
icantly threaten individuals access to ambulatory behavioral health
services. Such waiver may be applied on a provider specific or industry
wide basis. Further, such conditions may be waived, as the commissioner
determines necessary, to comply with federal rules or regulations
governing these payment methodologies. Nothing in this section shall
prohibit managed care organizations and providers from negotiating
different rates and methods of payment during such periods described
above, subject to the approval of the department of health. The depart-
ment of health shall consult with the office of alcoholism and substance
abuse services and the office of mental health in determining whether
such alternative rates shall be approved. The commissioner of health
may, in consultation with the commissioner of alcoholism and substance
abuse services and the commissioner of the office of mental health,
promulgate regulations, including emergency regulations promulgated
prior to October 1, 2015 to establish rates for ambulatory behavioral
health services, as are necessary to implement the provisions of this
section. Rates promulgated under this section shall be included in the
report required under section 45-c of part A of this chapter.
2. Notwithstanding any contrary provision of law, the fees paid by
managed care organizations licensed under article 44 of the public
health law or under article 43 of the insurance law, to providers
licensed pursuant to article 28 of the public health law or article 31
or 32 of the mental hygiene law, for ambulatory behavioral health
services provided to patients enrolled in the child health insurance
program pursuant to title [one-A] 1-A of article 25 of the public health
law, shall be in the form of fees for such services which are equivalent
to the payments established for such services under the ambulatory
patient group (APG) rate-setting methodology or any such other fees
established pursuant to the Medicaid state plan. The commissioner of
health shall consult with the commissioner of alcoholism and substance
abuse services and the commissioner of the office of mental health in
determining such services and establishing such fees. Such ambulatory
behavioral health fees to providers available under this section shall
be for all rate periods on and after the effective date of this chapter
through [March 31, 2020] MARCH 31, 2022, provided, however, that managed
care organizations and providers may negotiate different rates and meth-
ods of payment during such periods described above, subject to the
approval of the department of health. The department of health shall
consult with the office of alcoholism and substance abuse services and
the office of mental health in determining whether such alternative
rates shall be approved. The report required under section 16-a of part
C of chapter 60 of the laws of 2014 shall also include the population of
patients enrolled in the child health insurance program pursuant to
title [one-A] 1-A of article 25 of the public health law in its examina-
tion on the transition of behavioral health services into managed care.
§ 19. Section 1 of part H of chapter 111 of the laws of 2010 relating
to increasing Medicaid payments to providers through managed care organ-
izations and providing equivalent fees through an ambulatory patient
group methodology, as amended by section 2 of part P of chapter 57 of
the laws of 2017, is amended to read as follows:
Section 1. a. Notwithstanding any contrary provision of law, the
commissioners of mental health and alcoholism and substance abuse
S. 1507 19 A. 2007
services are authorized, subject to the approval of the director of the
budget, to transfer to the commissioner of health state funds to be
utilized as the state share for the purpose of increasing payments under
the medicaid program to managed care organizations licensed under arti-
cle 44 of the public health law or under article 43 of the insurance
law. Such managed care organizations shall utilize such funds for the
purpose of reimbursing providers licensed pursuant to article 28 of the
public health law, or pursuant to article 31 or article 32 of the mental
hygiene law for ambulatory behavioral health services, as determined by
the commissioner of health in consultation with the commissioner of
mental health and commissioner of alcoholism and substance abuse
services, provided to medicaid enrolled outpatients and for all other
behavioral health services except inpatient included in New York state's
Medicaid redesign waiver approved by the centers for medicare and Medi-
caid services (CMS). Such reimbursement shall be in the form of fees for
such services which are equivalent to the payments established for such
services under the ambulatory patient group (APG) rate-setting methodol-
ogy as utilized by the department of health or by the office of mental
health or office of alcoholism and substance abuse services for rate-
setting purposes or any such other fees pursuant to the Medicaid state
plan or otherwise approved by CMS in the Medicaid redesign waiver;
provided, however, that the increase to such fees that shall result from
the provisions of this section shall not, in the aggregate and as deter-
mined by the commissioner of health in consultation with the commission-
ers of mental health and alcoholism and substance abuse services, be
greater than the increased funds made available pursuant to this
section. The increase of such behavioral health fees to providers avail-
able under this section shall be for all rate periods on and after the
effective date of section [30] 2 of part [B] P of chapter [59] 57 of the
laws of [2016] 2017 through March 31, [2020] 2022 for patients in the
city of New York, for all rate periods on and after the effective date
of section [30] 2 of part [B] P of chapter [59] 57 of the laws of [2016]
2017 through March 31, [2020] 2022 for patients outside the city of New
York, and for all rate periods on and after the effective date of
section [30] 2 of part [B] P of chapter [59] 57 of the laws of [2016]
2017 through March 31, [2020] 2022 for all services provided to persons
under the age of twenty-one; provided, however, the commissioner of
health, in consultation with the commissioner of alcoholism and
substance abuse services and the commissioner of mental health, may
require, as a condition of approval of such ambulatory behavioral health
fees, that aggregate managed care expenditures to eligible providers
meet the alternative payment methodology requirements as set forth in
attachment I of the New York state medicaid section one thousand one
hundred fifteen medicaid redesign team waiver as approved by the centers
for medicare and medicaid services. The commissioner of health shall, in
consultation with the commissioner of alcoholism and substance abuse
services and the commissioner of mental health, waive such conditions if
a sufficient number of providers, as determined by the commissioner,
suffer a financial hardship as a consequence of such alternative payment
methodology requirements, or if he or she shall determine that such
alternative payment methodologies significantly threaten individuals
access to ambulatory behavioral health services. Such waiver may be
applied on a provider specific or industry wide basis. Further, such
conditions may be waived, as the commissioner determines necessary, to
comply with federal rules or regulations governing these payment method-
ologies. Nothing in this section shall prohibit managed care organiza-
S. 1507 20 A. 2007
tions and providers from negotiating different rates and methods of
payment during such periods described, subject to the approval of the
department of health. The department of health shall consult with the
office of alcoholism and substance abuse services and the office of
mental health in determining whether such alternative rates shall be
approved. The commissioner of health may, in consultation with the
commissioners of mental health and alcoholism and substance abuse
services, promulgate regulations, including emergency regulations
promulgated prior to October 1, 2013 that establish rates for behavioral
health services, as are necessary to implement the provisions of this
section. Rates promulgated under this section shall be included in the
report required under section 45-c of part A of chapter 56 of the laws
of 2013.
b. Notwithstanding any contrary provision of law, the fees paid by
managed care organizations licensed under article 44 of the public
health law or under article 43 of the insurance law, to providers
licensed pursuant to article 28 of the public health law or article 31
or 32 of the mental hygiene law, for ambulatory behavioral health
services provided to patients enrolled in the child health insurance
program pursuant to title [one-A] 1-A of article 25 of the public health
law, shall be in the form of fees for such services which are equivalent
to the payments established for such services under the ambulatory
patient group (APG) rate-setting methodology. The commissioner of health
shall consult with the commissioner of alcoholism and substance abuse
services and the commissioner of the office of mental health in deter-
mining such services and establishing such fees. Such ambulatory behav-
ioral health fees to providers available under this section shall be for
all rate periods on and after the effective date of this chapter through
March 31, [2020] 2022, provided, however, that managed care organiza-
tions and providers may negotiate different rates and methods of payment
during such periods described above, subject to the approval of the
department of health. The department of health shall consult with the
office of alcoholism and substance abuse services and the office of
mental health in determining whether such alternative rates shall be
approved. The report required under section 16-a of part C of chapter
60 of the laws of 2014 shall also include the population of patients
enrolled in the child health insurance program pursuant to title [one-A]
1-A of article 25 of the public health law in its examination on the
transition of behavioral health services into managed care.
§ 20. Section 2 of part H of chapter 111 of the laws of 2010, relating
to increasing Medicaid payments to providers through managed care organ-
izations and providing equivalent fees through an ambulatory patient
group methodology, as amended by section 16 of part C of chapter 60 of
the laws of 2014, is amended to read as follows:
§ 2. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2010, and shall
expire on [January 1, 2018] MARCH 31, 2022.
§ 21. Section 10 of chapter 649 of the laws of 1996, amending the
public health law, the mental hygiene law and the social services law
relating to authorizing the establishment of special needs plans, as
amended by section 2 of part D of chapter 59 of the laws of 2016, is
amended to read as follows:
§ 10. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after July 1, 1996; provided,
however, that sections one, two and three of this act shall expire and
be deemed repealed on March 31, [2020] 2025 provided, however that the
S. 1507 21 A. 2007
amendments to section 364-j of the social services law made by section
four of this act shall not affect the expiration of such section and
shall be deemed to expire therewith and provided, further, that the
provisions of subdivisions 8, 9 and 10 of section 4401 of the public
health law, as added by section one of this act; section 4403-d of the
public health law as added by section two of this act and the provisions
of section seven of this act, except for the provisions relating to the
establishment of no more than twelve comprehensive HIV special needs
plans, shall expire and be deemed repealed on July 1, 2000.
§ 22. Paragraph (a) of subdivision 1 of section 212 of chapter 474 of
the laws of 1996, amending the education law and other laws relating to
rates for residential healthcare facilities, as amended by section 1 of
part D of chapter 59 of the laws of 2016, is amended to read as follows:
(a) Notwithstanding any inconsistent provision of law or regulation to
the contrary, effective beginning August 1, 1996, for the period April
1, 1997 through March 31, 1998, April 1, 1998 for the period April 1,
1998 through March 31, 1999, August 1, 1999, for the period April 1,
1999 through March 31, 2000, April 1, 2000, for the period April 1, 2000
through March 31, 2001, April 1, 2001, for the period April 1, 2001
through March 31, 2002, April 1, 2002, for the period April 1, 2002
through March 31, 2003, and for the state fiscal year beginning April 1,
2005 through March 31, 2006, and for the state fiscal year beginning
April 1, 2006 through March 31, 2007, and for the state fiscal year
beginning April 1, 2007 through March 31, 2008, and for the state fiscal
year beginning April 1, 2008 through March 31, 2009, and for the state
fiscal year beginning April 1, 2009 through March 31, 2010, and for the
state fiscal year beginning April 1, 2010 through March 31, 2016, and
for the state fiscal year beginning April 1, 2016 through March 31, 2019
AND ANNUALLY THEREAFTER, the department of health is authorized to pay
public general hospitals, as defined in subdivision 10 of section 2801
of the public health law, operated by the state of New York or by the
state university of New York or by a county, which shall not include a
city with a population of over one million, of the state of New York,
and those public general hospitals located in the county of Westchester,
the county of Erie or the county of Nassau, additional payments for
inpatient hospital services as medical assistance payments pursuant to
title 11 of article 5 of the social services law for patients eligible
for federal financial participation under title XIX of the federal
social security act in medical assistance pursuant to the federal laws
and regulations governing disproportionate share payments to hospitals
up to one hundred percent of each such public general hospital's medical
assistance and uninsured patient losses after all other medical assist-
ance, including disproportionate share payments to such public general
hospital for 1996, 1997, 1998, and 1999, based initially for 1996 on
reported 1994 reconciled data as further reconciled to actual reported
1996 reconciled data, and for 1997 based initially on reported 1995
reconciled data as further reconciled to actual reported 1997 reconciled
data, for 1998 based initially on reported 1995 reconciled data as
further reconciled to actual reported 1998 reconciled data, for 1999
based initially on reported 1995 reconciled data as further reconciled
to actual reported 1999 reconciled data, for 2000 based initially on
reported 1995 reconciled data as further reconciled to actual reported
2000 data, for 2001 based initially on reported 1995 reconciled data as
further reconciled to actual reported 2001 data, for 2002 based initial-
ly on reported 2000 reconciled data as further reconciled to actual
reported 2002 data, and for state fiscal years beginning on April 1,
S. 1507 22 A. 2007
2005, based initially on reported 2000 reconciled data as further recon-
ciled to actual reported data for 2005, and for state fiscal years
beginning on April 1, 2006, based initially on reported 2000 reconciled
data as further reconciled to actual reported data for 2006, for state
fiscal years beginning on and after April 1, 2007 through March 31,
2009, based initially on reported 2000 reconciled data as further recon-
ciled to actual reported data for 2007 and 2008, respectively, for state
fiscal years beginning on and after April 1, 2009, based initially on
reported 2007 reconciled data, adjusted for authorized Medicaid rate
changes applicable to the state fiscal year, and as further reconciled
to actual reported data for 2009, for state fiscal years beginning on
and after April 1, 2010, based initially on reported reconciled data
from the base year two years prior to the payment year, adjusted for
authorized Medicaid rate changes applicable to the state fiscal year,
and further reconciled to actual reported data from such payment year,
and to actual reported data for each respective succeeding year. The
payments may be added to rates of payment or made as aggregate payments
to an eligible public general hospital.
§ 23. This act shall take effect immediately; provided that the amend-
ments to section 1 of part H of chapter 111 of the laws of 2010 made by
section nineteen of this act shall not affect the expiration of such
section and shall expire therewith; and provided further that section
twenty of this act shall be deemed to have been in full force and effect
on and after January 1, 2018.
PART F
Section 1. Paragraph (a) of subdivision 1 of section 18 of chapter 266
of the laws of 1986, amending the civil practice law and rules and other
laws relating to malpractice and professional medical conduct, as
amended by section 1 of part M of chapter 57 of the laws of 2018, is
amended to read as follows:
(a) The superintendent of financial services and the commissioner of
health or their designee shall, from funds available in the hospital
excess liability pool created pursuant to subdivision 5 of this section,
purchase a policy or policies for excess insurance coverage, as author-
ized by paragraph 1 of subsection (e) of section 5502 of the insurance
law; or from an insurer, other than an insurer described in section 5502
of the insurance law, duly authorized to write such coverage and actual-
ly writing medical malpractice insurance in this state; or shall
purchase equivalent excess coverage in a form previously approved by the
superintendent of financial services for purposes of providing equiv-
alent excess coverage in accordance with section 19 of chapter 294 of
the laws of 1985, for medical or dental malpractice occurrences between
July 1, 1986 and June 30, 1987, between July 1, 1987 and June 30, 1988,
between July 1, 1988 and June 30, 1989, between July 1, 1989 and June
30, 1990, between July 1, 1990 and June 30, 1991, between July 1, 1991
and June 30, 1992, between July 1, 1992 and June 30, 1993, between July
1, 1993 and June 30, 1994, between July 1, 1994 and June 30, 1995,
between July 1, 1995 and June 30, 1996, between July 1, 1996 and June
30, 1997, between July 1, 1997 and June 30, 1998, between July 1, 1998
and June 30, 1999, between July 1, 1999 and June 30, 2000, between July
1, 2000 and June 30, 2001, between July 1, 2001 and June 30, 2002,
between July 1, 2002 and June 30, 2003, between July 1, 2003 and June
30, 2004, between July 1, 2004 and June 30, 2005, between July 1, 2005
and June 30, 2006, between July 1, 2006 and June 30, 2007, between July
S. 1507 23 A. 2007
1, 2007 and June 30, 2008, between July 1, 2008 and June 30, 2009,
between July 1, 2009 and June 30, 2010, between July 1, 2010 and June
30, 2011, between July 1, 2011 and June 30, 2012, between July 1, 2012
and June 30, 2013, between July 1, 2013 and June 30, 2014, between July
1, 2014 and June 30, 2015, between July 1, 2015 and June 30, 2016,
between July 1, 2016 and June 30, 2017, between July 1, 2017 and June
30, 2018, [and] between July 1, 2018 and June 30, 2019, AND BETWEEN JULY
1, 2019 AND JUNE 30, 2020 or reimburse the hospital where the hospital
purchases equivalent excess coverage as defined in subparagraph (i) of
paragraph (a) of subdivision 1-a of this section for medical or dental
malpractice occurrences between July 1, 1987 and June 30, 1988, between
July 1, 1988 and June 30, 1989, between July 1, 1989 and June 30, 1990,
between July 1, 1990 and June 30, 1991, between July 1, 1991 and June
30, 1992, between July 1, 1992 and June 30, 1993, between July 1, 1993
and June 30, 1994, between July 1, 1994 and June 30, 1995, between July
1, 1995 and June 30, 1996, between July 1, 1996 and June 30, 1997,
between July 1, 1997 and June 30, 1998, between July 1, 1998 and June
30, 1999, between July 1, 1999 and June 30, 2000, between July 1, 2000
and June 30, 2001, between July 1, 2001 and June 30, 2002, between July
1, 2002 and June 30, 2003, between July 1, 2003 and June 30, 2004,
between July 1, 2004 and June 30, 2005, between July 1, 2005 and June
30, 2006, between July 1, 2006 and June 30, 2007, between July 1, 2007
and June 30, 2008, between July 1, 2008 and June 30, 2009, between July
1, 2009 and June 30, 2010, between July 1, 2010 and June 30, 2011,
between July 1, 2011 and June 30, 2012, between July 1, 2012 and June
30, 2013, between July 1, 2013 and June 30, 2014, between July 1, 2014
and June 30, 2015, between July 1, 2015 and June 30, 2016, between July
1, 2016 and June 30, 2017, between July 1, 2017 and June 30, 2018, [and]
between July 1, 2018 and June 30, 2019, AND BETWEEN JULY 1, 2019 AND
JUNE 30, 2020 for physicians or dentists certified as eligible for each
such period or periods pursuant to subdivision 2 of this section by a
general hospital licensed pursuant to article 28 of the public health
law; provided that no single insurer shall write more than fifty percent
of the total excess premium for a given policy year; and provided,
however, that such eligible physicians or dentists must have in force an
individual policy, from an insurer licensed in this state of primary
malpractice insurance coverage in amounts of no less than one million
three hundred thousand dollars for each claimant and three million nine
hundred thousand dollars for all claimants under that policy during the
period of such excess coverage for such occurrences or be endorsed as
additional insureds under a hospital professional liability policy which
is offered through a voluntary attending physician ("channeling")
program previously permitted by the superintendent of financial services
during the period of such excess coverage for such occurrences. During
such period, such policy for excess coverage or such equivalent excess
coverage shall, when combined with the physician's or dentist's primary
malpractice insurance coverage or coverage provided through a voluntary
attending physician ("channeling") program, total an aggregate level of
two million three hundred thousand dollars for each claimant and six
million nine hundred thousand dollars for all claimants from all such
policies with respect to occurrences in each of such years provided,
however, if the cost of primary malpractice insurance coverage in excess
of one million dollars, but below the excess medical malpractice insur-
ance coverage provided pursuant to this act, exceeds the rate of nine
percent per annum, then the required level of primary malpractice insur-
ance coverage in excess of one million dollars for each claimant shall
S. 1507 24 A. 2007
be in an amount of not less than the dollar amount of such coverage
available at nine percent per annum; the required level of such coverage
for all claimants under that policy shall be in an amount not less than
three times the dollar amount of coverage for each claimant; and excess
coverage, when combined with such primary malpractice insurance cover-
age, shall increase the aggregate level for each claimant by one million
dollars and three million dollars for all claimants; and provided
further, that, with respect to policies of primary medical malpractice
coverage that include occurrences between April 1, 2002 and June 30,
2002, such requirement that coverage be in amounts no less than one
million three hundred thousand dollars for each claimant and three
million nine hundred thousand dollars for all claimants for such occur-
rences shall be effective April 1, 2002.
§ 2. Subdivision 3 of section 18 of chapter 266 of the laws of 1986,
amending the civil practice law and rules and other laws relating to
malpractice and professional medical conduct, as amended by section 2 of
part M of chapter 57 of the laws of 2018, is amended to read as follows:
(3)(a) The superintendent of financial services shall determine and
certify to each general hospital and to the commissioner of health the
cost of excess malpractice insurance for medical or dental malpractice
occurrences between July 1, 1986 and June 30, 1987, between July 1, 1988
and June 30, 1989, between July 1, 1989 and June 30, 1990, between July
1, 1990 and June 30, 1991, between July 1, 1991 and June 30, 1992,
between July 1, 1992 and June 30, 1993, between July 1, 1993 and June
30, 1994, between July 1, 1994 and June 30, 1995, between July 1, 1995
and June 30, 1996, between July 1, 1996 and June 30, 1997, between July
1, 1997 and June 30, 1998, between July 1, 1998 and June 30, 1999,
between July 1, 1999 and June 30, 2000, between July 1, 2000 and June
30, 2001, between July 1, 2001 and June 30, 2002, between July 1, 2002
and June 30, 2003, between July 1, 2003 and June 30, 2004, between July
1, 2004 and June 30, 2005, between July 1, 2005 and June 30, 2006,
between July 1, 2006 and June 30, 2007, between July 1, 2007 and June
30, 2008, between July 1, 2008 and June 30, 2009, between July 1, 2009
and June 30, 2010, between July 1, 2010 and June 30, 2011, between July
1, 2011 and June 30, 2012, between July 1, 2012 and June 30, 2013, and
between July 1, 2013 and June 30, 2014, between July 1, 2014 and June
30, 2015, between July 1, 2015 and June 30, 2016, and between July 1,
2016 and June 30, 2017, between July 1, 2017 and June 30, 2018, [and]
between July 1, 2018 and June 30, 2019, AND BETWEEN JULY 1, 2019 AND
JUNE 30, 2020 allocable to each general hospital for physicians or
dentists certified as eligible for purchase of a policy for excess
insurance coverage by such general hospital in accordance with subdivi-
sion 2 of this section, and may amend such determination and certif-
ication as necessary.
(b) The superintendent of financial services shall determine and
certify to each general hospital and to the commissioner of health the
cost of excess malpractice insurance or equivalent excess coverage for
medical or dental malpractice occurrences between July 1, 1987 and June
30, 1988, between July 1, 1988 and June 30, 1989, between July 1, 1989
and June 30, 1990, between July 1, 1990 and June 30, 1991, between July
1, 1991 and June 30, 1992, between July 1, 1992 and June 30, 1993,
between July 1, 1993 and June 30, 1994, between July 1, 1994 and June
30, 1995, between July 1, 1995 and June 30, 1996, between July 1, 1996
and June 30, 1997, between July 1, 1997 and June 30, 1998, between July
1, 1998 and June 30, 1999, between July 1, 1999 and June 30, 2000,
between July 1, 2000 and June 30, 2001, between July 1, 2001 and June
S. 1507 25 A. 2007
30, 2002, between July 1, 2002 and June 30, 2003, between July 1, 2003
and June 30, 2004, between July 1, 2004 and June 30, 2005, between July
1, 2005 and June 30, 2006, between July 1, 2006 and June 30, 2007,
between July 1, 2007 and June 30, 2008, between July 1, 2008 and June
30, 2009, between July 1, 2009 and June 30, 2010, between July 1, 2010
and June 30, 2011, between July 1, 2011 and June 30, 2012, between July
1, 2012 and June 30, 2013, between July 1, 2013 and June 30, 2014,
between July 1, 2014 and June 30, 2015, between July 1, 2015 and June
30, 2016, between July 1, 2016 and June 30, 2017, between July 1, 2017
and June 30, 2018, [and] between July 1, 2018 and June 30, 2019, AND
BETWEEN JULY 1, 2019 AND JUNE 30, 2020 allocable to each general hospi-
tal for physicians or dentists certified as eligible for purchase of a
policy for excess insurance coverage or equivalent excess coverage by
such general hospital in accordance with subdivision 2 of this section,
and may amend such determination and certification as necessary. The
superintendent of financial services shall determine and certify to each
general hospital and to the commissioner of health the ratable share of
such cost allocable to the period July 1, 1987 to December 31, 1987, to
the period January 1, 1988 to June 30, 1988, to the period July 1, 1988
to December 31, 1988, to the period January 1, 1989 to June 30, 1989, to
the period July 1, 1989 to December 31, 1989, to the period January 1,
1990 to June 30, 1990, to the period July 1, 1990 to December 31, 1990,
to the period January 1, 1991 to June 30, 1991, to the period July 1,
1991 to December 31, 1991, to the period January 1, 1992 to June 30,
1992, to the period July 1, 1992 to December 31, 1992, to the period
January 1, 1993 to June 30, 1993, to the period July 1, 1993 to December
31, 1993, to the period January 1, 1994 to June 30, 1994, to the period
July 1, 1994 to December 31, 1994, to the period January 1, 1995 to June
30, 1995, to the period July 1, 1995 to December 31, 1995, to the period
January 1, 1996 to June 30, 1996, to the period July 1, 1996 to December
31, 1996, to the period January 1, 1997 to June 30, 1997, to the period
July 1, 1997 to December 31, 1997, to the period January 1, 1998 to June
30, 1998, to the period July 1, 1998 to December 31, 1998, to the period
January 1, 1999 to June 30, 1999, to the period July 1, 1999 to December
31, 1999, to the period January 1, 2000 to June 30, 2000, to the period
July 1, 2000 to December 31, 2000, to the period January 1, 2001 to June
30, 2001, to the period July 1, 2001 to June 30, 2002, to the period
July 1, 2002 to June 30, 2003, to the period July 1, 2003 to June 30,
2004, to the period July 1, 2004 to June 30, 2005, to the period July 1,
2005 and June 30, 2006, to the period July 1, 2006 and June 30, 2007, to
the period July 1, 2007 and June 30, 2008, to the period July 1, 2008
and June 30, 2009, to the period July 1, 2009 and June 30, 2010, to the
period July 1, 2010 and June 30, 2011, to the period July 1, 2011 and
June 30, 2012, to the period July 1, 2012 and June 30, 2013, to the
period July 1, 2013 and June 30, 2014, to the period July 1, 2014 and
June 30, 2015, to the period July 1, 2015 and June 30, 2016, [and
between] TO THE PERIOD July 1, 2016 and June 30, 2017, [and] to the
period July 1, 2017 to June 30, 2018, [and] to the period July 1, 2018
to June 30, 2019, AND TO THE PERIOD JULY 1, 2019 TO JUNE 30, 2020.
§ 3. Paragraphs (a), (b), (c), (d) and (e) of subdivision 8 of section
18 of chapter 266 of the laws of 1986, amending the civil practice law
and rules and other laws relating to malpractice and professional
medical conduct, as amended by section 3 of part M of chapter 57 of the
laws of 2018, are amended to read as follows:
(a) To the extent funds available to the hospital excess liability
pool pursuant to subdivision 5 of this section as amended, and pursuant
S. 1507 26 A. 2007
to section 6 of part J of chapter 63 of the laws of 2001, as may from
time to time be amended, which amended this subdivision, are insuffi-
cient to meet the costs of excess insurance coverage or equivalent
excess coverage for coverage periods during the period July 1, 1992 to
June 30, 1993, during the period July 1, 1993 to June 30, 1994, during
the period July 1, 1994 to June 30, 1995, during the period July 1, 1995
to June 30, 1996, during the period July 1, 1996 to June 30, 1997,
during the period July 1, 1997 to June 30, 1998, during the period July
1, 1998 to June 30, 1999, during the period July 1, 1999 to June 30,
2000, during the period July 1, 2000 to June 30, 2001, during the period
July 1, 2001 to October 29, 2001, during the period April 1, 2002 to
June 30, 2002, during the period July 1, 2002 to June 30, 2003, during
the period July 1, 2003 to June 30, 2004, during the period July 1, 2004
to June 30, 2005, during the period July 1, 2005 to June 30, 2006,
during the period July 1, 2006 to June 30, 2007, during the period July
1, 2007 to June 30, 2008, during the period July 1, 2008 to June 30,
2009, during the period July 1, 2009 to June 30, 2010, during the period
July 1, 2010 to June 30, 2011, during the period July 1, 2011 to June
30, 2012, during the period July 1, 2012 to June 30, 2013, during the
period July 1, 2013 to June 30, 2014, during the period July 1, 2014 to
June 30, 2015, during the period July 1, 2015 to June 30, 2016, during
the period July 1, 2016 to June 30, 2017, during the period July 1, 2017
to June 30, 2018, [and] during the period July 1, 2018 to June 30, 2019,
AND DURING THE PERIOD JULY 1, 2019 TO JUNE 30, 2020 allocated or reallo-
cated in accordance with paragraph (a) of subdivision 4-a of this
section to rates of payment applicable to state governmental agencies,
each physician or dentist for whom a policy for excess insurance cover-
age or equivalent excess coverage is purchased for such period shall be
responsible for payment to the provider of excess insurance coverage or
equivalent excess coverage of an allocable share of such insufficiency,
based on the ratio of the total cost of such coverage for such physician
to the sum of the total cost of such coverage for all physicians applied
to such insufficiency.
(b) Each provider of excess insurance coverage or equivalent excess
coverage covering the period July 1, 1992 to June 30, 1993, or covering
the period July 1, 1993 to June 30, 1994, or covering the period July 1,
1994 to June 30, 1995, or covering the period July 1, 1995 to June 30,
1996, or covering the period July 1, 1996 to June 30, 1997, or covering
the period July 1, 1997 to June 30, 1998, or covering the period July 1,
1998 to June 30, 1999, or covering the period July 1, 1999 to June 30,
2000, or covering the period July 1, 2000 to June 30, 2001, or covering
the period July 1, 2001 to October 29, 2001, or covering the period
April 1, 2002 to June 30, 2002, or covering the period July 1, 2002 to
June 30, 2003, or covering the period July 1, 2003 to June 30, 2004, or
covering the period July 1, 2004 to June 30, 2005, or covering the peri-
od July 1, 2005 to June 30, 2006, or covering the period July 1, 2006 to
June 30, 2007, or covering the period July 1, 2007 to June 30, 2008, or
covering the period July 1, 2008 to June 30, 2009, or covering the peri-
od July 1, 2009 to June 30, 2010, or covering the period July 1, 2010 to
June 30, 2011, or covering the period July 1, 2011 to June 30, 2012, or
covering the period July 1, 2012 to June 30, 2013, or covering the peri-
od July 1, 2013 to June 30, 2014, or covering the period July 1, 2014 to
June 30, 2015, or covering the period July 1, 2015 to June 30, 2016, or
covering the period July 1, 2016 to June 30, 2017, or covering the peri-
od July 1, 2017 to June 30, 2018, or covering the period July 1, 2018 to
June 30, 2019, OR COVERING THE PERIOD JULY 1, 2019 TO JUNE 30, 2020
S. 1507 27 A. 2007
shall notify a covered physician or dentist by mail, mailed to the
address shown on the last application for excess insurance coverage or
equivalent excess coverage, of the amount due to such provider from such
physician or dentist for such coverage period determined in accordance
with paragraph (a) of this subdivision. Such amount shall be due from
such physician or dentist to such provider of excess insurance coverage
or equivalent excess coverage in a time and manner determined by the
superintendent of financial services.
(c) If a physician or dentist liable for payment of a portion of the
costs of excess insurance coverage or equivalent excess coverage cover-
ing the period July 1, 1992 to June 30, 1993, or covering the period
July 1, 1993 to June 30, 1994, or covering the period July 1, 1994 to
June 30, 1995, or covering the period July 1, 1995 to June 30, 1996, or
covering the period July 1, 1996 to June 30, 1997, or covering the peri-
od July 1, 1997 to June 30, 1998, or covering the period July 1, 1998 to
June 30, 1999, or covering the period July 1, 1999 to June 30, 2000, or
covering the period July 1, 2000 to June 30, 2001, or covering the peri-
od July 1, 2001 to October 29, 2001, or covering the period April 1,
2002 to June 30, 2002, or covering the period July 1, 2002 to June 30,
2003, or covering the period July 1, 2003 to June 30, 2004, or covering
the period July 1, 2004 to June 30, 2005, or covering the period July 1,
2005 to June 30, 2006, or covering the period July 1, 2006 to June 30,
2007, or covering the period July 1, 2007 to June 30, 2008, or covering
the period July 1, 2008 to June 30, 2009, or covering the period July 1,
2009 to June 30, 2010, or covering the period July 1, 2010 to June 30,
2011, or covering the period July 1, 2011 to June 30, 2012, or covering
the period July 1, 2012 to June 30, 2013, or covering the period July 1,
2013 to June 30, 2014, or covering the period July 1, 2014 to June 30,
2015, or covering the period July 1, 2015 to June 30, 2016, or covering
the period July 1, 2016 to June 30, 2017, or covering the period July 1,
2017 to June 30, 2018, or covering the period July 1, 2018 to June 30,
2019, OR COVERING THE PERIOD JULY 1, 2019 TO JUNE 30, 2020 determined in
accordance with paragraph (a) of this subdivision fails, refuses or
neglects to make payment to the provider of excess insurance coverage or
equivalent excess coverage in such time and manner as determined by the
superintendent of financial services pursuant to paragraph (b) of this
subdivision, excess insurance coverage or equivalent excess coverage
purchased for such physician or dentist in accordance with this section
for such coverage period shall be cancelled and shall be null and void
as of the first day on or after the commencement of a policy period
where the liability for payment pursuant to this subdivision has not
been met.
(d) Each provider of excess insurance coverage or equivalent excess
coverage shall notify the superintendent of financial services and the
commissioner of health or their designee of each physician and dentist
eligible for purchase of a policy for excess insurance coverage or
equivalent excess coverage covering the period July 1, 1992 to June 30,
1993, or covering the period July 1, 1993 to June 30, 1994, or covering
the period July 1, 1994 to June 30, 1995, or covering the period July 1,
1995 to June 30, 1996, or covering the period July 1, 1996 to June 30,
1997, or covering the period July 1, 1997 to June 30, 1998, or covering
the period July 1, 1998 to June 30, 1999, or covering the period July 1,
1999 to June 30, 2000, or covering the period July 1, 2000 to June 30,
2001, or covering the period July 1, 2001 to October 29, 2001, or cover-
ing the period April 1, 2002 to June 30, 2002, or covering the period
July 1, 2002 to June 30, 2003, or covering the period July 1, 2003 to
S. 1507 28 A. 2007
June 30, 2004, or covering the period July 1, 2004 to June 30, 2005, or
covering the period July 1, 2005 to June 30, 2006, or covering the peri-
od July 1, 2006 to June 30, 2007, or covering the period July 1, 2007 to
June 30, 2008, or covering the period July 1, 2008 to June 30, 2009, or
covering the period July 1, 2009 to June 30, 2010, or covering the peri-
od July 1, 2010 to June 30, 2011, or covering the period July 1, 2011 to
June 30, 2012, or covering the period July 1, 2012 to June 30, 2013, or
covering the period July 1, 2013 to June 30, 2014, or covering the peri-
od July 1, 2014 to June 30, 2015, or covering the period July 1, 2015 to
June 30, 2016, or covering the period July 1, 2016 to June 30, 2017, or
covering the period July 1, 2017 to June 30, 2018, or covering the peri-
od July 1, 2018 to June 30, 2019, OR COVERING THE PERIOD JULY 1, 2019 TO
JUNE 30, 2020 that has made payment to such provider of excess insurance
coverage or equivalent excess coverage in accordance with paragraph (b)
of this subdivision and of each physician and dentist who has failed,
refused or neglected to make such payment.
(e) A provider of excess insurance coverage or equivalent excess
coverage shall refund to the hospital excess liability pool any amount
allocable to the period July 1, 1992 to June 30, 1993, and to the period
July 1, 1993 to June 30, 1994, and to the period July 1, 1994 to June
30, 1995, and to the period July 1, 1995 to June 30, 1996, and to the
period July 1, 1996 to June 30, 1997, and to the period July 1, 1997 to
June 30, 1998, and to the period July 1, 1998 to June 30, 1999, and to
the period July 1, 1999 to June 30, 2000, and to the period July 1, 2000
to June 30, 2001, and to the period July 1, 2001 to October 29, 2001,
and to the period April 1, 2002 to June 30, 2002, and to the period July
1, 2002 to June 30, 2003, and to the period July 1, 2003 to June 30,
2004, and to the period July 1, 2004 to June 30, 2005, and to the period
July 1, 2005 to June 30, 2006, and to the period July 1, 2006 to June
30, 2007, and to the period July 1, 2007 to June 30, 2008, and to the
period July 1, 2008 to June 30, 2009, and to the period July 1, 2009 to
June 30, 2010, and to the period July 1, 2010 to June 30, 2011, and to
the period July 1, 2011 to June 30, 2012, and to the period July 1, 2012
to June 30, 2013, and to the period July 1, 2013 to June 30, 2014, and
to the period July 1, 2014 to June 30, 2015, and to the period July 1,
2015 to June 30, 2016, to the period July 1, 2016 to June 30, 2017, and
to the period July 1, 2017 to June 30, 2018, and to the period July 1,
2018 to June 30, 2019, AND TO THE PERIOD JULY 1, 2019 TO JUNE 30, 2020
received from the hospital excess liability pool for purchase of excess
insurance coverage or equivalent excess coverage covering the period
July 1, 1992 to June 30, 1993, and covering the period July 1, 1993 to
June 30, 1994, and covering the period July 1, 1994 to June 30, 1995,
and covering the period July 1, 1995 to June 30, 1996, and covering the
period July 1, 1996 to June 30, 1997, and covering the period July 1,
1997 to June 30, 1998, and covering the period July 1, 1998 to June 30,
1999, and covering the period July 1, 1999 to June 30, 2000, and cover-
ing the period July 1, 2000 to June 30, 2001, and covering the period
July 1, 2001 to October 29, 2001, and covering the period April 1, 2002
to June 30, 2002, and covering the period July 1, 2002 to June 30, 2003,
and covering the period July 1, 2003 to June 30, 2004, and covering the
period July 1, 2004 to June 30, 2005, and covering the period July 1,
2005 to June 30, 2006, and covering the period July 1, 2006 to June 30,
2007, and covering the period July 1, 2007 to June 30, 2008, and cover-
ing the period July 1, 2008 to June 30, 2009, and covering the period
July 1, 2009 to June 30, 2010, and covering the period July 1, 2010 to
June 30, 2011, and covering the period July 1, 2011 to June 30, 2012,
S. 1507 29 A. 2007
and covering the period July 1, 2012 to June 30, 2013, and covering the
period July 1, 2013 to June 30, 2014, and covering the period July 1,
2014 to June 30, 2015, and covering the period July 1, 2015 to June 30,
2016, and covering the period July 1, 2016 to June 30, 2017, and cover-
ing the period July 1, 2017 to June 30, 2018, and covering the period
July 1, 2018 to June 30, 2019, AND COVERING THE PERIOD JULY 1, 2019 TO
JUNE 30, 2020 for a physician or dentist where such excess insurance
coverage or equivalent excess coverage is cancelled in accordance with
paragraph (c) of this subdivision.
§ 4. Section 40 of chapter 266 of the laws of 1986, amending the civil
practice law and rules and other laws relating to malpractice and
professional medical conduct, as amended by section 4 of part M of chap-
ter 57 of the laws of 2018, is amended to read as follows:
§ 40. The superintendent of financial services shall establish rates
for policies providing coverage for physicians and surgeons medical
malpractice for the periods commencing July 1, 1985 and ending June 30,
[2019;] 2020; provided, however, that notwithstanding any other
provision of law, the superintendent shall not establish or approve any
increase in rates for the period commencing July 1, 2009 and ending June
30, 2010. The superintendent shall direct insurers to establish segre-
gated accounts for premiums, payments, reserves and investment income
attributable to such premium periods and shall require periodic reports
by the insurers regarding claims and expenses attributable to such peri-
ods to monitor whether such accounts will be sufficient to meet incurred
claims and expenses. On or after July 1, 1989, the superintendent shall
impose a surcharge on premiums to satisfy a projected deficiency that is
attributable to the premium levels established pursuant to this section
for such periods; provided, however, that such annual surcharge shall
not exceed eight percent of the established rate until July 1, [2019,]
2020, at which time and thereafter such surcharge shall not exceed twen-
ty-five percent of the approved adequate rate, and that such annual
surcharges shall continue for such period of time as shall be sufficient
to satisfy such deficiency. The superintendent shall not impose such
surcharge during the period commencing July 1, 2009 and ending June 30,
2010. On and after July 1, 1989, the surcharge prescribed by this
section shall be retained by insurers to the extent that they insured
physicians and surgeons during the July 1, 1985 through June 30, [2019]
2020 policy periods; in the event and to the extent physicians and
surgeons were insured by another insurer during such periods, all or a
pro rata share of the surcharge, as the case may be, shall be remitted
to such other insurer in accordance with rules and regulations to be
promulgated by the superintendent. Surcharges collected from physicians
and surgeons who were not insured during such policy periods shall be
apportioned among all insurers in proportion to the premium written by
each insurer during such policy periods; if a physician or surgeon was
insured by an insurer subject to rates established by the superintendent
during such policy periods, and at any time thereafter a hospital,
health maintenance organization, employer or institution is responsible
for responding in damages for liability arising out of such physician's
or surgeon's practice of medicine, such responsible entity shall also
remit to such prior insurer the equivalent amount that would then be
collected as a surcharge if the physician or surgeon had continued to
remain insured by such prior insurer. In the event any insurer that
provided coverage during such policy periods is in liquidation, the
property/casualty insurance security fund shall receive the portion of
surcharges to which the insurer in liquidation would have been entitled.
S. 1507 30 A. 2007
The surcharges authorized herein shall be deemed to be income earned for
the purposes of section 2303 of the insurance law. The superintendent,
in establishing adequate rates and in determining any projected defi-
ciency pursuant to the requirements of this section and the insurance
law, shall give substantial weight, determined in his discretion and
judgment, to the prospective anticipated effect of any regulations
promulgated and laws enacted and the public benefit of stabilizing
malpractice rates and minimizing rate level fluctuation during the peri-
od of time necessary for the development of more reliable statistical
experience as to the efficacy of such laws and regulations affecting
medical, dental or podiatric malpractice enacted or promulgated in 1985,
1986, by this act and at any other time. Notwithstanding any provision
of the insurance law, rates already established and to be established by
the superintendent pursuant to this section are deemed adequate if such
rates would be adequate when taken together with the maximum authorized
annual surcharges to be imposed for a reasonable period of time whether
or not any such annual surcharge has been actually imposed as of the
establishment of such rates.
§ 5. Section 5 and subdivisions (a) and (e) of section 6 of part J of
chapter 63 of the laws of 2001, amending chapter 266 of the laws of
1986, amending the civil practice law and rules and other laws relating
to malpractice and professional medical conduct, relating to the effec-
tiveness of certain provisions of such chapter, as amended by section 5
of part M of chapter 57 of the laws of 2018, are amended to read as
follows:
§ 5. The superintendent of financial services and the commissioner of
health shall determine, no later than June 15, 2002, June 15, 2003, June
15, 2004, June 15, 2005, June 15, 2006, June 15, 2007, June 15, 2008,
June 15, 2009, June 15, 2010, June 15, 2011, June 15, 2012, June 15,
2013, June 15, 2014, June 15, 2015, June 15, 2016, June 15, 2017, June
15, 2018, [and] June 15, 2019, AND JUNE 15, 2020 the amount of funds
available in the hospital excess liability pool, created pursuant to
section 18 of chapter 266 of the laws of 1986, and whether such funds
are sufficient for purposes of purchasing excess insurance coverage for
eligible participating physicians and dentists during the period July 1,
2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July 1, 2003
to June 30, 2004, or July 1, 2004 to June 30, 2005, or July 1, 2005 to
June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007 to June
30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to June 30,
2010, or July 1, 2010 to June 30, 2011, or July 1, 2011 to June 30,
2012, or July 1, 2012 to June 30, 2013, or July 1, 2013 to June 30,
2014, or July 1, 2014 to June 30, 2015, or July 1, 2015 to June 30,
2016, or July 1, 2016 to June 30, 2017, or July 1, 2017 to June 30,
2018, or July 1, 2018 to June 30, 2019, OR JULY 1, 2019 TO JUNE 30, 2020
as applicable.
(a) This section shall be effective only upon a determination, pursu-
ant to section five of this act, by the superintendent of financial
services and the commissioner of health, and a certification of such
determination to the state director of the budget, the chair of the
senate committee on finance and the chair of the assembly committee on
ways and means, that the amount of funds in the hospital excess liabil-
ity pool, created pursuant to section 18 of chapter 266 of the laws of
1986, is insufficient for purposes of purchasing excess insurance cover-
age for eligible participating physicians and dentists during the period
July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July
1, 2003 to June 30, 2004, or July 1, 2004 to June 30, 2005, or July 1,
S. 1507 31 A. 2007
2005 to June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007
to June 30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to
June 30, 2010, or July 1, 2010 to June 30, 2011, or July 1, 2011 to June
30, 2012, or July 1, 2012 to June 30, 2013, or July 1, 2013 to June 30,
2014, or July 1, 2014 to June 30, 2015, or July 1, 2015 to June 30,
2016, or July 1, 2016 to June 30, 2017, or July 1, 2017 to June 30,
2018, or July 1, 2018 to June 30, 2019, OR JULY 1, 2019 TO JUNE 30, 2020
as applicable.
(e) The commissioner of health shall transfer for deposit to the
hospital excess liability pool created pursuant to section 18 of chapter
266 of the laws of 1986 such amounts as directed by the superintendent
of financial services for the purchase of excess liability insurance
coverage for eligible participating physicians and dentists for the
policy year July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30,
2003, or July 1, 2003 to June 30, 2004, or July 1, 2004 to June 30,
2005, or July 1, 2005 to June 30, 2006, or July 1, 2006 to June 30,
2007, as applicable, and the cost of administering the hospital excess
liability pool for such applicable policy year, pursuant to the program
established in chapter 266 of the laws of 1986, as amended, no later
than June 15, 2002, June 15, 2003, June 15, 2004, June 15, 2005, June
15, 2006, June 15, 2007, June 15, 2008, June 15, 2009, June 15, 2010,
June 15, 2011, June 15, 2012, June 15, 2013, June 15, 2014, June 15,
2015, June 15, 2016, June 15, 2017, June 15, 2018, [and] June 15, 2019,
AND JUNE 15, 2020 as applicable.
§ 6. Section 20 of part H of chapter 57 of the laws of 2017, amending
the New York Health Care Reform Act of 1996 and other laws relating to
extending certain provisions thereto, as amended by section 6 of part M
of chapter 57 of the laws of 2018, is amended to read as follows:
§ 20. Notwithstanding any law, rule or regulation to the contrary,
only physicians or dentists who were eligible, and for whom the super-
intendent of financial services and the commissioner of health, or their
designee, purchased, with funds available in the hospital excess liabil-
ity pool, a full or partial policy for excess coverage or equivalent
excess coverage for the coverage period ending the thirtieth of June,
two thousand [eighteen,] NINETEEN, shall be eligible to apply for such
coverage for the coverage period beginning the first of July, two thou-
sand [eighteen;] NINETEEN; provided, however, if the total number of
physicians or dentists for whom such excess coverage or equivalent
excess coverage was purchased for the policy year ending the thirtieth
of June, two thousand [eighteen] NINETEEN exceeds the total number of
physicians or dentists certified as eligible for the coverage period
beginning the first of July, two thousand [eighteen,] NINETEEN, then the
general hospitals may certify additional eligible physicians or dentists
in a number equal to such general hospital's proportional share of the
total number of physicians or dentists for whom excess coverage or
equivalent excess coverage was purchased with funds available in the
hospital excess liability pool as of the thirtieth of June, two thousand
[eighteen,] NINETEEN, as applied to the difference between the number of
eligible physicians or dentists for whom a policy for excess coverage or
equivalent excess coverage was purchased for the coverage period ending
the thirtieth of June, two thousand [eighteen] NINETEEN and the number
of such eligible physicians or dentists who have applied for excess
coverage or equivalent excess coverage for the coverage period beginning
the first of July, two thousand [eighteen] NINETEEN.
§ 7. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019.
S. 1507 32 A. 2007
PART G
Section 1. Paragraph (a) of subdivision 3 of section 366 of the social
services law is REPEALED and a new paragraph (a) is added to read as
follows:
(A) MEDICAL ASSISTANCE SHALL BE FURNISHED WITHOUT CONSIDERATION OF THE
INCOME AND RESOURCES OF AN APPLICANT'S LEGALLY RESPONSIBLE RELATIVE IF
THE APPLICANT'S ELIGIBILITY WOULD NORMALLY BE DETERMINED BY COMPARING
THE AMOUNT OF AVAILABLE INCOME AND/OR RESOURCES OF THE APPLICANT,
INCLUDING AMOUNTS DEEMED AVAILABLE TO THE APPLICANT FROM LEGALLY RESPON-
SIBLE RELATIVES, TO AN APPLICABLE ELIGIBILITY STANDARD, AND:
(1) (I) THE LEGALLY RESPONSIBLE RELATIVE IS A COMMUNITY SPOUSE, AS
DEFINED IN SECTION THREE HUNDRED SIXTY-SIX-C OF THIS TITLE;
(II) SUCH RELATIVE IS REFUSING TO MAKE HIS OR HER INCOME AND/OR
RESOURCES AVAILABLE TO MEET THE COST OF NECESSARY MEDICAL CARE,
SERVICES, AND SUPPLIES; AND
(III) THE APPLICANT EXECUTES AN ASSIGNMENT OF SUPPORT FROM THE COMMU-
NITY SPOUSE IN FAVOR OF THE SOCIAL SERVICES DISTRICT AND THE DEPARTMENT,
UNLESS THE APPLICANT IS UNABLE TO EXECUTE SUCH ASSIGNMENT DUE TO PHYS-
ICAL OR MENTAL IMPAIRMENT OR TO DENY ASSISTANCE WOULD CREATE AN UNDUE
HARDSHIP, AS DEFINED BY THE COMMISSIONER; OR
(2) THE LEGALLY RESPONSIBLE RELATIVE IS ABSENT FROM THE APPLICANT'S
HOUSEHOLD, AND FAILS OR REFUSES TO MAKE HIS OR HER INCOME AND/OR
RESOURCES AVAILABLE TO MEET THE COST OF NECESSARY MEDICAL CARE,
SERVICES, AND SUPPLIES.
IN SUCH CASES, HOWEVER, THE FURNISHING OF SUCH ASSISTANCE SHALL CREATE
AN IMPLIED CONTRACT WITH SUCH RELATIVE, AND THE COST THEREOF MAY BE
RECOVERED FROM SUCH RELATIVE IN ACCORDANCE WITH TITLE SIX OF ARTICLE
THREE OF THIS CHAPTER AND OTHER APPLICABLE PROVISIONS OF LAW.
§ 2. Paragraphs (b), (c), (d), (e), (f), (g), and (h) of subdivision
4-a and subdivisions 4-b and 4-c of section 365-f of the social services
law are REPEALED, and paragraph (i) of subdivision 4-a is relettered
paragraph (b).
§ 3. Section 365-f of the social services law is REPEALED, and a new
section 365-f is added to read as follows:
§ 365-F. CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM. 1. PURPOSE AND
INTENT. THE CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM IS INTENDED TO
PERMIT CHRONICALLY ILL AND/OR PHYSICALLY DISABLED INDIVIDUALS RECEIVING
HOME CARE SERVICES UNDER THE MEDICAL ASSISTANCE PROGRAM GREATER FLEXI-
BILITY AND FREEDOM OF CHOICE IN OBTAINING SUCH SERVICES. THE DEPARTMENT
SHALL REGULARLY MONITOR DISTRICT PARTICIPATION IN THE PROGRAM BY REVIEW-
ING THE IMPLEMENTATION PLANS SUBMITTED PURSUANT TO THIS SECTION. THE
DEPARTMENT SHALL PROVIDE GUIDANCE TO THE DISTRICTS TO IMPROVE COMPLIANCE
WITH IMPLEMENTATION PLANS AND PROMOTE CONSISTENCY AMONG COUNTIES
REGARDING APPROVED SERVICE LEVELS BASED ON THE ASSESSMENTS REQUIRED BY
THIS SECTION. IN ADDITION, THE DEPARTMENT SHALL PROVIDE TECHNICAL
ASSISTANCE AND SUCH OTHER ASSISTANCE AS MAY BE NECESSARY TO ASSIST SUCH
DISTRICTS IN ASSURING ACCESS TO THE PROGRAM FOR ELIGIBLE INDIVIDUALS.
2. ELIGIBILITY. ALL ELIGIBLE INDIVIDUALS RECEIVING HOME CARE SHALL BE
PROVIDED NOTICE OF THE AVAILABILITY OF THE PROGRAM, AND NO LESS
FREQUENTLY THAN ANNUALLY THEREAFTER, AND SHALL HAVE THE OPPORTUNITY TO
APPLY FOR PARTICIPATION IN THE PROGRAM. EACH SOCIAL SERVICES DISTRICT
SHALL FILE AN IMPLEMENTATION PLAN WITH THE COMMISSIONER OF THE DEPART-
MENT OF HEALTH, WHICH SHALL BE UPDATED ANNUALLY. SUCH UPDATES SHALL BE
SUBMITTED NO LATER THAN NOVEMBER THIRTIETH OF EACH YEAR. THE PLANS AND
UPDATES SUBMITTED BY DISTRICTS SHALL REQUIRE THE APPROVAL OF THE DEPART-
S. 1507 33 A. 2007
MENT. IMPLEMENTATION PLANS SHALL INCLUDE DISTRICT ENROLLMENT TARGETS,
DESCRIBE METHODS FOR THE PROVISION OF NOTICE AND ASSISTANCE TO INTER-
ESTED INDIVIDUALS ELIGIBLE FOR ENROLLMENT IN THE PROGRAM, AND SHALL
CONTAIN SUCH OTHER INFORMATION AS, SHALL BE REQUIRED BY THE DEPARTMENT.
AN "ELIGIBLE INDIVIDUAL", FOR PURPOSES OF THIS SECTION IS A PERSON WHO:
(A) IS ELIGIBLE FOR LONG TERM CARE AND SERVICES PROVIDED BY A CERTI-
FIED HOME HEALTH AGENCY, LONG TERM HOME HEALTH CARE PROGRAM OR AIDS HOME
CARE PROGRAM AUTHORIZED PURSUANT TO ARTICLE THIRTY-SIX OF THE PUBLIC
HEALTH LAW, OR IS ELIGIBLE FOR PERSONAL CARE SERVICES PROVIDED PURSUANT
TO THIS ARTICLE;
(B) IS ELIGIBLE FOR MEDICAL ASSISTANCE;
(C) HAS BEEN DETERMINED BY THE SOCIAL SERVICES DISTRICT OR AN ENTITY
CERTIFIED UNDER ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW, PURSUANT
TO AN ASSESSMENT OF THE PERSON'S APPROPRIATENESS FOR THE PROGRAM,
CONDUCTED WITH AN APPROPRIATE LONG TERM HOME HEALTH CARE PROGRAM, A
CERTIFIED HOME HEALTH AGENCY, OR AN AIDS HOME CARE PROGRAM OR PURSUANT
TO THE PERSONAL CARE PROGRAM, AS BEING IN NEED OF HOME CARE SERVICES OR
PRIVATE DUTY NURSING AND IS ABLE AND WILLING OR HAS A DESIGNATED REPRE-
SENTATIVE, INCLUDING A LEGAL GUARDIAN ABLE AND WILLING TO MAKE INFORMED
CHOICES, OR A DESIGNATED RELATIVE OR OTHER ADULT WHO IS ABLE AND WILLING
TO ASSIST IN MAKING INFORMED CHOICES, AS TO THE TYPE AND QUALITY OF
SERVICES, INCLUDING BUT NOT LIMITED TO SUCH SERVICES AS NURSING CARE,
PERSONAL CARE, TRANSPORTATION AND RESPITE SERVICES; AND
(D) MEETS SUCH OTHER CRITERIA, AS MAY BE ESTABLISHED BY THE COMMIS-
SIONER, WHICH ARE NECESSARY TO EFFECTIVELY IMPLEMENT THE OBJECTIVES OF
THIS SECTION.
3. ELIGIBLE INDIVIDUALS. ELIGIBLE INDIVIDUALS WHO ELECT TO PARTICIPATE
IN THE PROGRAM ASSUME THE RESPONSIBILITY FOR SERVICES UNDER SUCH
PROGRAM AS MUTUALLY AGREED TO BY THE ELIGIBLE INDIVIDUAL AND PROVIDER
AND AS DOCUMENTED IN THE ELIGIBLE INDIVIDUAL'S RECORD, INCLUDING, BUT
NOT LIMITED TO, RECRUITING, HIRING AND SUPERVISING THEIR PERSONAL
ASSISTANTS. FOR THE PURPOSES OF THIS SECTION, PERSONAL ASSISTANT SHALL
MEAN AN ADULT WHO PROVIDES SERVICES UNDER THIS SECTION TO THE ELIGIBLE
INDIVIDUAL UNDER THE ELIGIBLE INDIVIDUAL'S INSTRUCTION, SUPERVISION AND
DIRECTION OR UNDER THE INSTRUCTION, SUPERVISION AND DIRECTION OF THE
ELIGIBLE INDIVIDUAL'S DESIGNATED REPRESENTATIVE, PROVIDED THAT A PERSON
LEGALLY RESPONSIBLE FOR AN ELIGIBLE INDIVIDUAL'S CARE AND SUPPORT, AN
ELIGIBLE INDIVIDUAL'S SPOUSE OR DESIGNATED REPRESENTATIVE MAY NOT BE THE
PERSONAL ASSISTANT FOR THE ELIGIBLE INDIVIDUAL; HOWEVER, A PERSONAL
ASSISTANT MAY INCLUDE ANY OTHER ADULT RELATIVE OF THE ELIGIBLE INDIVID-
UAL, PROVIDED, HOWEVER, THAT THE PROGRAM DETERMINES THAT THE SERVICES
PROVIDED BY SUCH RELATIVE ARE CONSISTENT WITH AN INDIVIDUAL'S PLAN OF
CARE AND THAT THE AGGREGATE COST FOR SUCH SERVICES DOES NOT EXCEED THE
AGGREGATE COSTS FOR EQUIVALENT SERVICES PROVIDED BY A NON-RELATIVE
PERSONAL ASSISTANT. SUCH INDIVIDUALS SHALL BE ASSISTED AS APPROPRIATE
WITH SERVICE COVERAGE, SUPERVISION, ADVOCACY AND MANAGEMENT. PROVIDERS
SHALL NOT BE LIABLE FOR FULFILLMENT OF RESPONSIBILITIES AGREED TO BE
UNDERTAKEN BY THE ELIGIBLE INDIVIDUAL. THIS SUBDIVISION, HOWEVER, SHALL
NOT DIMINISH THE PARTICIPATING PROVIDER'S LIABILITY FOR FAILURE TO EXER-
CISE REASONABLE CARE IN PROPERLY CARRYING OUT ITS RESPONSIBILITIES
UNDER THIS PROGRAM, WHICH SHALL INCLUDE MONITORING SUCH INDIVIDUAL'S
CONTINUING ABILITY TO FULFILL THOSE RESPONSIBILITIES DOCUMENTED IN HIS
OR HER RECORDS. FAILURE OF THE INDIVIDUAL TO CARRY OUT HIS OR HER
AGREED TO RESPONSIBILITIES MAY BE CONSIDERED IN DETERMINING SUCH INDI-
VIDUAL'S CONTINUED APPROPRIATENESS FOR THE PROGRAM.
S. 1507 34 A. 2007
4. PARTICIPATING PROVIDERS. ALL AGENCIES OR INDIVIDUALS WHO MEET THE
QUALIFICATIONS TO PROVIDE HOME HEALTH, PERSONAL CARE OR NURSING SERVICES
AND WHO ELECT TO PROVIDE SUCH SERVICES TO PERSONS RECEIVING MEDICAL
ASSISTANCE MAY PARTICIPATE IN THE PROGRAM. ANY AGENCY OR INDIVIDUALS
PROVIDING SERVICES UNDER A PATIENT MANAGED HOME CARE PROGRAM AUTHORIZED
UNDER THE FORMER SECTION THIRTY-SIX HUNDRED TWENTY-TWO OF THE PUBLIC
HEALTH LAW OR THE FORMER SECTION THREE HUNDRED SIXTY-FIVE-F OF THIS
CHAPTER MAY CONTINUE TO PROVIDE SUCH SERVICES UNDER THIS SECTION.
5. FISCAL INTERMEDIARIES. (A) FOR THE PURPOSES OF THIS SECTION "FISCAL
INTERMEDIARY" MEANS:
(I) AN ENTITY THAT HAS A CONTRACT WITH THE DEPARTMENT OF HEALTH TO
PROVIDE FISCAL INTERMEDIARY SERVICES PURSUANT TO PARAGRAPH (E) OF THIS
SUBDIVISION; OR
(II) AN ENTITY AUTHORIZED BY THE COMMISSIONER UPON APPLICATION WITH A
HISTORY OF PROVIDING FISCAL INTERMEDIARY SERVICES THAT:
(A) IS A SERVICE CENTER FOR INDEPENDENT LIVING UNDER SECTION ONE THOU-
SAND ONE HUNDRED TWENTY-ONE OF THE EDUCATION LAW; OR
(B) HAS EXPERIENCE PROVIDING FISCAL INTERMEDIARY SERVICES FOR PERSONS
WITH DISABILITIES, IN ACCORDANCE WITH SUCH CRITERIA AS THE DEPARTMENT
MAY DEVELOP, AS DEMONSTRATED BY HAVING A CONTINUOUS HISTORY OF ARRANGE-
MENTS WITH LOCAL DEPARTMENTS OF SOCIAL SERVICES BEGINNING NO LATER THAN
JANUARY FIRST, TWO THOUSAND TWELVE.
(B) AN APPLICATION FOR AUTHORIZATION AS A FISCAL INTERMEDIARY UNDER
SUBPARAGRAPH (II) OF PARAGRAPH (A) OF THIS SUBDIVISION SHALL BE FILED
WITH THE COMMISSIONER, TOGETHER WITH SUCH OTHER FORMS AND INFORMATION AS
SHALL BE PRESCRIBED BY, OR ACCEPTABLE TO THE COMMISSIONER.
(C) FISCAL INTERMEDIARY SERVICES SHALL INCLUDE THE FOLLOWING SERVICES,
PERFORMED ON BEHALF OF THE CONSUMER TO FACILITATE HIS OR HER ROLE AS THE
EMPLOYER:
(I) WAGE AND BENEFIT PROCESSING FOR CONSUMER DIRECTED PERSONAL ASSIST-
ANTS;
(II) PROCESSING ALL INCOME TAX AND OTHER REQUIRED WAGE WITHHOLDINGS;
(III) COMPLYING WITH WORKERS' COMPENSATION, DISABILITY AND UNEMPLOY-
MENT REQUIREMENTS;
(IV) MAINTAINING PERSONNEL RECORDS FOR EACH CONSUMER DIRECTED PERSONAL
ASSISTANTS INCLUDING TIME SHEETS AND OTHER DOCUMENTATION NEEDED FOR
WAGES AND BENEFIT PROCESSING AND A COPY OF THE MEDICAL DOCUMENTATION
REQUIRED PURSUANT TO REGULATIONS ESTABLISHED BY THE COMMISSIONER;
(V) ENSURING THAT THE HEALTH STATUS OF EACH CONSUMER DIRECTED PERSONAL
ASSISTANT IS ASSESSED PRIOR TO SERVICE DELIVERY PURSUANT TO REGULATIONS
ISSUED BY THE COMMISSIONER;
(VI) MAINTAINING RECORDS OF SERVICE AUTHORIZATIONS OR REAUTHORI-
ZATIONS;
(VII) MONITORING THE CONSUMER'S OR, IF APPLICABLE, THE DESIGNATED
REPRESENTATIVE'S CONTINUING ABILITY TO FULFILL THE CONSUMER'S RESPONSI-
BILITIES UNDER THE PROGRAM AND PROMPTLY NOTIFYING THE AUTHORIZING ENTITY
OF ANY CIRCUMSTANCE THAT MAY AFFECT THE CONSUMER'S OR, IF APPLICABLE,
THE DESIGNATED REPRESENTATIVE'S ABILITY TO FULFILL SUCH RESPONSIBIL-
ITIES;
(VIII) COMPLYING WITH REGULATIONS ESTABLISHED BY THE COMMISSIONER
SPECIFYING THE RESPONSIBILITIES OF FISCAL INTERMEDIARIES PROVIDING
SERVICES UNDER THIS TITLE; AND
(IX) ENTERING INTO A DEPARTMENT APPROVED MEMORANDUM OF UNDERSTANDING
WITH THE CONSUMER THAT DESCRIBES THE PARTIES' RESPONSIBILITIES UNDER
THIS PROGRAM.
S. 1507 35 A. 2007
(D) FISCAL INTERMEDIARIES ARE NOT RESPONSIBLE FOR, AND FISCAL INTERME-
DIARY SERVICES SHALL NOT INCLUDE, FULFILLMENT OF THE RESPONSIBILITIES OF
THE CONSUMER OR, IF APPLICABLE, THE CONSUMER'S DESIGNATED REPRESENTATIVE
AS ESTABLISHED BY THE COMMISSIONER. A FISCAL INTERMEDIARY'S RESPONSIBIL-
ITIES SHALL NOT INCLUDE, AND A FISCAL INTERMEDIARY SHALL NOT ENGAGE IN:
MANAGING THE PLAN OF CARE INCLUDING RECRUITING AND HIRING A SUFFICIENT
NUMBER OF INDIVIDUALS WHO MEET THE DEFINITION OF CONSUMER DIRECTED
PERSONAL ASSISTANT, AS SUCH TERM IS DEFINED BY THE COMMISSIONER, TO
PROVIDE AUTHORIZED SERVICES THAT ARE INCLUDED ON THE CONSUMER'S PLAN OF
CARE; TRAINING, SUPERVISING AND SCHEDULING EACH CONSUMER DIRECTED
PERSONAL ASSISTANT; TERMINATING THE CONSUMER DIRECTED PERSONAL ASSIST-
ANT'S EMPLOYMENT; OR ASSURING THAT EACH CONSUMER DIRECTED PERSONAL
ASSISTANT COMPETENTLY AND SAFELY PERFORMS THE PERSONAL CARE SERVICES,
HOME HEALTH AIDE SERVICES AND SKILLED NURSING TASKS THAT ARE INCLUDED
ON THE CONSUMER'S PLAN OF CARE. A FISCAL INTERMEDIARY SHALL EXERCISE
REASONABLE CARE IN PROPERLY CARRYING OUT ITS RESPONSIBILITIES UNDER THE
PROGRAM.
(E) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF SECTIONS ONE HUNDRED
TWELVE AND ONE HUNDRED SIXTY-THREE OF THE STATE FINANCE LAW, OR SECTION
ONE HUNDRED FORTY-TWO OF THE ECONOMIC DEVELOPMENT LAW, OR ANY OTHER LAW,
THE COMMISSIONER IS AUTHORIZED TO ENTER INTO A CONTRACT OR CONTRACTS
UNDER THIS SUBDIVISION WITH AN ENTITY OR ENTITIES WITHOUT A COMPETITIVE
BID OR REQUEST FOR PROPOSAL PROCESS, PROVIDED, HOWEVER, THAT:
(I) THE DEPARTMENT SHALL POST ON ITS WEBSITE, FOR A PERIOD OF NO LESS
THAN THIRTY DAYS:
(A) A DESCRIPTION OF THE PROPOSED SERVICES TO BE PROVIDED PURSUANT TO
THE CONTRACT OR CONTRACTS;
(B) THE CRITERIA FOR SELECTION OF A CONTRACTOR OR CONTRACTORS;
(C) THE PERIOD OF TIME DURING WHICH A PROSPECTIVE CONTRACTOR MAY SEEK
SELECTION, WHICH SHALL BE NO LESS THAN THIRTY DAYS AFTER SUCH INFORMA-
TION IS FIRST POSTED ON THE WEBSITE; AND
(D) THE MANNER BY WHICH A PROSPECTIVE CONTRACTOR MAY SEEK SUCH
SELECTION, WHICH MAY INCLUDE SUBMISSION BY ELECTRONIC MEANS;
(II) ALL REASONABLE AND RESPONSIVE SUBMISSIONS THAT ARE RECEIVED FROM
PROSPECTIVE CONTRACTORS IN A TIMELY FASHION SHALL BE REVIEWED BY THE
COMMISSIONER; AND
(III) THE COMMISSIONER SHALL SELECT SUCH CONTRACTOR OR CONTRACTORS
THAT, IN HIS OR HER DISCRETION, ARE BEST SUITED TO SERVE THE PURPOSES OF
THIS SECTION.
6. ACTIONS INVOLVING THE AUTHORIZATION OF A FISCAL INTERMEDIARY. (A) A
FISCAL INTERMEDIARY'S AUTHORIZATION UNDER SUBPARAGRAPH (II) OF PARAGRAPH
(A) OF SUBDIVISION FIVE OF THIS SECTION MAY BE REVOKED, SUSPENDED,
LIMITED OR ANNULLED UPON THIRTY DAYS' WRITTEN NOTICE TO THE FISCAL
INTERMEDIARY, IF THE COMMISSIONER FINDS THAT THE FISCAL INTERMEDIARY HAS
FAILED TO COMPLY WITH THE PROVISIONS OF THIS SUBDIVISION OR REGULATIONS
PROMULGATED HEREUNDER. NOTWITHSTANDING THE FOREGOING, UPON DETERMINING
THAT THE PUBLIC HEALTH OR SAFETY WOULD BE IMMINENTLY ENDANGERED BY THE
CONTINUED AUTHORIZATION OF THE FISCAL INTERMEDIARY, THE COMMISSIONER MAY
REVOKE, SUSPEND, LIMIT OR ANNUL THE FISCAL INTERMEDIARY'S AUTHORIZATION
IMMEDIATELY.
(B) ALL ORDERS OR DETERMINATIONS UNDER THIS SUBDIVISION SHALL BE
SUBJECT TO REVIEW AS PROVIDED IN ARTICLE SEVENTY-EIGHT OF THE CIVIL
PRACTICE LAW AND RULES.
7. WAIVERS, REGULATIONS AND EFFECTIVENESS. (A) THE COMMISSIONER MAY,
SUBJECT TO THE APPROVAL OF THE DIRECTOR OF BUDGET, FILE FOR SUCH FEDERAL
WAIVERS AS MAY BE NEEDED FOR THE IMPLEMENTATION OF THE PROGRAM.
S. 1507 36 A. 2007
(B) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, THE COMMISSIONER IS
AUTHORIZED TO WAIVE ANY PROVISION OF SECTION THREE HUNDRED SIXTY-SEVEN-B
OF THIS TITLE RELATED TO PAYMENT AND MAY PROMULGATE REGULATIONS NECES-
SARY TO CARRY OUT THE OBJECTIVES OF THE PROGRAM, AND WHICH DESCRIBE THE
RESPONSIBILITIES OF THE ELIGIBLE INDIVIDUALS IN ARRANGING AND PAYING FOR
SERVICES AND THE PROTECTIONS ASSURED SUCH INDIVIDUALS IF THEY ARE UNABLE
OR NO LONGER DESIRE TO CONTINUE IN THE PROGRAM.
8. NOTWITHSTANDING ANY INCONSISTENT PROVISION OF THIS SECTION OR ANY
OTHER CONTRARY PROVISION OF LAW, MANAGED CARE PROGRAMS ESTABLISHED
PURSUANT TO SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE AND MANAGED
LONG TERM CARE PLANS AND OTHER CARE COORDINATION MODELS ESTABLISHED
PURSUANT TO SECTION FOUR THOUSAND FOUR HUNDRED THREE-F OF THE PUBLIC
HEALTH LAW SHALL OFFER CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAMS TO
ENROLLEES.
9. NOTWITHSTANDING ANY PROVISION OF THIS SECTION OR ANY OTHER LAW TO
THE CONTRARY, THE PROVISIONS PERTAINING TO CONSUMER DIRECTED PERSONAL
ASSISTANCE SERVICES AND FISCAL INTERMEDIARIES PURSUANT TO THIS SECTION
SHALL ONLY BE AVAILABLE IF THE COMMISSIONER OF HEALTH DETERMINES THAT
THERE IS ADEQUATE FEDERAL FINANCIAL PARTICIPATION TO FUND SUCH PROGRAMS
AND/OR ENTITIES.
10. SUBJECT TO THE AVAILABILITY OF FEDERAL FINANCIAL PARTICIPATION,
THE PROVISIONS OF THIS SECTION GOVERNING CONSUMER DIRECTED PERSONAL
ASSISTANCE SERVICES SHALL ALSO APPLY TO SUCH SERVICES WHEN OFFERED UNDER
THE HOME AND COMMUNITY-BASED ATTENDANT SERVICES AND SUPPORTS STATE PLAN
OPTION, COMMUNITY FIRST CHOICE, PURSUANT TO 42 U.S.C. § 1396N(K).
§ 4. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019; provided
however, that section three of this act shall take effect January 1,
2020.
PART H
Section 1. Subparagraph (v) of paragraph (b) of subdivision 5-b of
section 2807-k of the public health law is REPEALED.
§ 2. Section 2807 of the public health law is amended by adding a new
subdivision 20-a to read as follows:
20-A. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, THE
COMMISSIONERS OF THE DEPARTMENT OF HEALTH, THE OFFICE OF MENTAL HEALTH,
THE OFFICE OF PEOPLE WITH DEVELOPMENTAL DISABILITIES, AND THE OFFICE OF
ALCOHOLISM AND SUBSTANCE ABUSE SERVICES ARE AUTHORIZED TO WAIVE ANY
REGULATORY REQUIREMENTS AS ARE NECESSARY, CONSISTENT WITH APPLICABLE
LAW, TO ALLOW PROVIDERS THAT ARE INVOLVED IN DSRIP PROJECTS OR REPLI-
CATION AND SCALING ACTIVITIES, AS APPROVED BY THE AUTHORIZING COMMIS-
SIONER, TO AVOID DUPLICATION OF REQUIREMENTS AND TO ALLOW THE EFFICIENT
SCALING AND REPLICATION OF DSRIP PROMISING PRACTICES, AS DETERMINED BY
THE AUTHORIZING COMMISSIONER; PROVIDED HOWEVER, THAT REGULATIONS
PERTAINING TO PATIENT SAFETY MAY NOT BE WAIVED, NOR SHALL ANY REGU-
LATIONS BE WAIVED IF SUCH WAIVER WOULD RISK PATIENT SAFETY.
§ 3. Subparagraph (i) of paragraph (e-1) of subdivision 4 of section
2807-c of the public health law, as amended by section 29 of part C of
chapter 60 of the laws of 2014, is amended to read as follows:
(i) For rate periods on and after April first, two thousand ten, the
commissioner, in consultation with the commissioner of the office of
mental health, shall promulgate regulations, and may promulgate emergen-
cy regulations, establishing methodologies for determining the operating
cost components of rates of payments for services described in this
S. 1507 37 A. 2007
paragraph. Such regulations shall utilize two thousand five operating
costs as submitted to the department prior to July first, two thousand
nine and [shall] MAY provide for methodologies establishing per diem
inpatient rates that utilize case mix adjustment mechanisms. Such regu-
lations [shall] MAY contain criteria for adjustments based on length of
stay and may also provide for a base year update, provided, however,
that such base year update shall take effect no earlier than April
first, two thousand fifteen, and provided further, however, that the
commissioner may make such adjustments to such utilization and to the
methodology for computing such rates as is necessary to achieve no
aggregate, net growth in overall Medicaid expenditures related to such
rates, as compared to such aggregate expenditures from the prior year.
In determining the updated base year to be utilized pursuant to this
subparagraph, the commissioner shall take into account the base year
determined in accordance with paragraph (c) of subdivision thirty-five
of this section.
§ 4. Paragraph (b) of subdivision 35 of section 2807-c of the public
health law is amended by adding a new subparagraph (xiv) to read as
follows:
(XIV) SUCH RATES AND PAYMENT METHODOLOGIES MAY INCORPORATE METHODOL-
OGIES TO REDUCE PAYMENTS TO FACILITIES WITH A HIGHER PERCENTAGE OF
POTENTIALLY AVOIDABLE INPATIENT SERVICES BY INSTITUTING LOWER INPATIENT
PAYMENT RATES FOR BOTH FEE-FOR-SERVICE AND MANAGED CARE TO INCENTIVIZE
THE PROVISION OF PREVENTATIVE CARE TO REDUCE PREVENTABLE EVENTS AND
OVERALL INPATIENT COSTS. A PORTION OF SUCH SAVINGS DERIVED FROM THE
IMPLEMENTATION OF SUCH PAYMENT METHODOLOGIES SHALL BE REINVESTED IN
INITIATIVES TO INCENTIVIZE THE PROVISION OF PREVENTATIVE CARE, MATERNITY
SERVICES, AND OTHER AMBULATORY CARE SERVICES TO REDUCE PREVENTABLE
HEALTH CARE COSTS.
§ 5. This act shall take effect immediately.
PART I
Section 1. The insurance law is amended by adding a new article 29 to
read as follows:
ARTICLE 29
PHARMACY BENEFIT MANAGERS
SECTION 2901. DEFINITIONS.
2902. ACTING WITHOUT A REGISTRATION.
2903. REGISTRATION REQUIREMENTS FOR PHARMACY BENEFIT MANAGERS.
2904. REPORTING REQUIREMENTS FOR PHARMACY BENEFIT MANAGERS.
2905. ACTING WITHOUT A LICENSE.
2906. LICENSING OF A PHARMACY BENEFIT MANAGER.
2907. REVOCATION OR SUSPENSION OF A REGISTRATION OR LICENSE OF A
PHARMACY BENEFIT MANAGER.
2908. PENALTIES FOR VIOLATIONS.
2909. STAY OR SUSPENSION OF SUPERINTENDENT'S DETERMINATION.
2910. REVOKED REGISTRATION OR LICENSES.
2911. CHANGE OF ADDRESS.
2912. APPLICABILITY OF OTHER LAWS.
2913. ASSESSMENTS.
§ 2901. DEFINITIONS. FOR PURPOSES OF THIS ARTICLE:
(A) "CONTROLLING PERSON" IS ANY PERSON OR OTHER ENTITY WHO OR WHICH
DIRECTLY OR INDIRECTLY HAS THE POWER TO DIRECT OR CAUSE TO BE DIRECTED
THE MANAGEMENT, CONTROL OR ACTIVITIES OF A PHARMACY BENEFIT MANAGER.
S. 1507 38 A. 2007
(B) "HEALTH INSURER" MEANS AN INSURANCE COMPANY AUTHORIZED IN THIS
STATE TO WRITE ACCIDENT AND HEALTH INSURANCE, A COMPANY ORGANIZED PURSU-
ANT TO ARTICLE FORTY-THREE OF THIS CHAPTER, A MUNICIPAL COOPERATIVE
HEALTH BENEFIT PLAN ESTABLISHED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS
CHAPTER, AN ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE
PUBLIC HEALTH LAW, AN INSTITUTION OF HIGHER EDUCATION CERTIFIED PURSUANT
TO SECTION ONE THOUSAND ONE HUNDRED TWENTY-FOUR OF THIS CHAPTER, OR THE
NEW YORK STATE HEALTH INSURANCE PLAN ESTABLISHED UNDER ARTICLE ELEVEN OF
THE CIVIL SERVICE LAW.
(C) "PHARMACY BENEFIT MANAGEMENT SERVICES" MEANS DIRECTLY OR THROUGH
AN INTERMEDIARY, MANAGING THE PRESCRIPTION DRUG COVERAGE PROVIDED BY A
HEALTH INSURER UNDER A CONTRACT OR POLICY DELIVERED OR ISSUED FOR DELIV-
ERY IN THIS STATE OR A PLAN SUBJECT TO SECTION THREE HUNDRED
SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW, INCLUDING THE PROCESSING AND
PAYMENT OF CLAIMS FOR PRESCRIPTION DRUGS, THE PERFORMANCE OF DRUG UTILI-
ZATION REVIEW, THE PROCESSING OF DRUG PRIOR AUTHORIZATION REQUESTS, THE
ADJUDICATION OF APPEALS OR GRIEVANCES RELATED TO PRESCRIPTION DRUG
COVERAGE, CONTRACTING WITH NETWORK PHARMACIES, AND CONTROLLING THE COST
OF COVERED PRESCRIPTION DRUGS.
(D) "PHARMACY BENEFIT MANAGER" MEANS A PERSON, FIRM, ASSOCIATION,
CORPORATION OR OTHER ENTITY THAT, PURSUANT TO A CONTRACT WITH A HEALTH
INSURER PROVIDES PHARMACY BENEFIT MANAGEMENT SERVICES, EXCEPT THAT TERM
SHALL NOT INCLUDE:
(1) AN OFFICER OR EMPLOYEE OF A REGISTERED OR LICENSED PHARMACY BENE-
FIT MANAGER; OR
(2) A HEALTH INSURER, OR ANY MANAGER THEREOF, INDIVIDUAL OR CORPORATE,
OR ANY OFFICER, DIRECTOR OR REGULAR SALARIED EMPLOYEE THEREOF, PROVIDING
PHARMACY BENEFIT MANAGEMENT SERVICES UNDER A POLICY OR CONTRACT ISSUED
BY THE HEALTH INSURER.
§ 2902. ACTING WITHOUT A REGISTRATION. (A) NO PERSON, FIRM, ASSOCI-
ATION, CORPORATION OR OTHER ENTITY MAY ACT AS A PHARMACY BENEFITS MANAG-
ER PRIOR TO JANUARY FIRST, TWO THOUSAND TWENTY WITHOUT HAVING A VALID
REGISTRATION AS A PHARMACY BENEFIT MANAGER FILED WITH THE SUPERINTENDENT
IN ACCORDANCE WITH THIS ARTICLE AND ANY REGULATIONS PROMULGATED THERE-
UNDER.
(B) PRIOR TO JANUARY FIRST, TWO THOUSAND TWENTY, NO HEALTH INSURER MAY
PAY ANY FEE OR OTHER COMPENSATION TO ANY PERSON, FIRM, ASSOCIATION,
CORPORATION OR OTHER ENTITY FOR PERFORMING PHARMACY BENEFIT MANAGEMENT
SERVICES UNLESS THE PERSON, FIRM, ASSOCIATION, CORPORATION OR OTHER
ENTITY IS REGISTERED AS A PHARMACY BENEFIT MANAGER IN ACCORDANCE WITH
THIS ARTICLE.
(C) ANY PERSON, FIRM, ASSOCIATION, CORPORATION OR OTHER ENTITY THAT
VIOLATES THIS SECTION SHALL, IN ADDITION TO ANY OTHER PENALTY PROVIDED
BY LAW, BE LIABLE FOR RESTITUTION TO ANY INSURER OR INSURED HARMED BY
THE VIOLATION AND SHALL ALSO BE SUBJECT TO A PENALTY OF THE GREATER OF
(1) ONE THOUSAND DOLLARS FOR THE FIRST VIOLATION AND TWO THOUSAND FIVE
HUNDRED DOLLARS FOR EACH SUBSEQUENT VIOLATION OR (2) THE AGGREGATE
ECONOMIC GROSS RECEIPTS ATTRIBUTABLE TO ALL VIOLATIONS.
§ 2903. REGISTRATION REQUIREMENTS FOR PHARMACY BENEFIT MANAGERS. (A)
EVERY PHARMACY BENEFIT MANAGER THAT PERFORMS PHARMACY BENEFIT MANAGEMENT
SERVICES PRIOR TO JANUARY FIRST, TWO THOUSAND TWENTY-ONE SHALL REGISTER
WITH THE SUPERINTENDENT IN A MANNER ACCEPTABLE TO THE SUPERINTENDENT,
AND SHALL PAY A FEE OF ONE THOUSAND DOLLARS FOR EACH YEAR OR FRACTION OF
A YEAR IN WHICH THE REGISTRATION SHALL BE VALID. THE SUPERINTENDENT, IN
CONSULTATION WITH THE COMMISSIONER OF HEALTH, MAY ESTABLISH, BY REGU-
LATION, MINIMUM REGISTRATION STANDARDS REQUIRED FOR A PHARMACY BENEFIT
S. 1507 39 A. 2007
MANAGER. THE SUPERINTENDENT CAN REJECT A REGISTRATION APPLICATION FILED
BY A PHARMACY BENEFIT MANAGER THAT FAILS TO COMPLY WITH THE MINIMUM
REGISTRATION STANDARDS.
(B) FOR EACH BUSINESS ENTITY, THE OFFICER OR OFFICERS AND DIRECTOR OR
DIRECTORS NAMED IN THE APPLICATION SHALL BE DESIGNATED RESPONSIBLE FOR
THE BUSINESS ENTITY'S COMPLIANCE WITH THE FINANCIAL SERVICES AND INSUR-
ANCE LAWS, RULES AND REGULATIONS OF THIS STATE.
(C) EVERY REGISTRATION WILL EXPIRE ON DECEMBER THIRTY-FIRST, TWO THOU-
SAND TWENTY REGARDLESS OF WHEN REGISTRATION WAS FIRST MADE.
(D) EVERY PHARMACY BENEFIT MANAGER THAT PERFORMS PHARMACY BENEFIT
MANAGEMENT SERVICES AT ANY TIME BETWEEN JANUARY FIRST, TWO THOUSAND
NINETEEN AND JUNE FIRST, TWO THOUSAND NINETEEN, SHALL MAKE THE REGISTRA-
TION AND FEE PAYMENT REQUIRED BY SUBSECTION (A) OF THIS SECTION ON OR
BEFORE JUNE FIRST, TWO THOUSAND NINETEEN. ANY OTHER PHARMACY BENEFIT
MANAGER SHALL MAKE THE REGISTRATION AND FEE PAYMENT REQUIRED BY
SUBSECTION (A) OF THIS SECTION PRIOR TO PERFORMING PHARMACY BENEFIT
MANAGEMENT SERVICES.
(E) REGISTRANTS UNDER THIS SECTION SHALL BE SUBJECT TO EXAMINATION BY
THE SUPERINTENDENT AS OFTEN AS THE SUPERINTENDENT MAY DEEM IT NECESSARY.
THE SUPERINTENDENT MAY PROMULGATE REGULATIONS ESTABLISHING METHODS AND
PROCEDURES FOR FACILITATING AND VERIFYING COMPLIANCE WITH THE REQUIRE-
MENTS OF THIS ARTICLE AND SUCH OTHER REGULATIONS AS NECESSARY TO ENFORCE
THE PROVISIONS OF THIS ARTICLE.
§ 2904. REPORTING REQUIREMENTS FOR PHARMACY BENEFIT MANAGERS. (A)(1)
ON OR BEFORE JULY FIRST OF EACH YEAR, BEGINNING IN TWO THOUSAND TWENTY,
EVERY PHARMACY BENEFIT MANAGER SHALL REPORT TO THE SUPERINTENDENT, IN A
STATEMENT SUBSCRIBED AND AFFIRMED AS TRUE UNDER PENALTIES OF PERJURY,
THE INFORMATION REQUESTED BY THE SUPERINTENDENT INCLUDING, WITHOUT LIMI-
TATION, DISCLOSURE OF ANY FINANCIAL INCENTIVE OR BENEFIT FOR PROMOTING
THE USE OF CERTAIN DRUGS AND OTHER FINANCIAL ARRANGEMENTS AFFECTING
HEALTH INSURERS OR THEIR POLICYHOLDERS OR INSUREDS AND ANY INFORMATION
RELATING TO THE BUSINESS, FINANCIAL CONDITION, OR MARKET CONDUCT OF THE
PHARMACY BENEFIT MANAGER. THE SUPERINTENDENT ALSO MAY REQUIRE THE FILING
OF QUARTERLY OR OTHER STATEMENTS, WHICH SHALL BE IN SUCH FORM AND SHALL
CONTAIN SUCH MATTERS AS THE SUPERINTENDENT SHALL PRESCRIBE.
(2) THE SUPERINTENDENT ALSO MAY ADDRESS TO ANY PHARMACY BENEFIT MANAG-
ER OR ITS OFFICERS ANY INQUIRY IN RELATION TO ITS PROVISION OF PHARMACY
BENEFIT MANAGEMENT SERVICES OR ANY MATTER CONNECTED THEREWITH. EVERY
PHARMACY BENEFIT MANAGER OR PERSON SO ADDRESSED SHALL REPLY IN WRITING
TO SUCH INQUIRY PROMPTLY AND TRUTHFULLY, AND SUCH REPLY SHALL BE, IF
REQUIRED BY THE SUPERINTENDENT, SUBSCRIBED BY SUCH INDIVIDUAL, OR BY
SUCH OFFICER OR OFFICERS OF THE PHARMACY BENEFIT MANAGER, AS THE SUPER-
INTENDENT SHALL DESIGNATE, AND AFFIRMED BY THEM AS TRUE UNDER THE PENAL-
TIES OF PERJURY.
(B) IN THE EVENT ANY PHARMACY BENEFIT MANAGER OR PERSON DOES NOT
SUBMIT THE REPORT REQUIRED BY PARAGRAPH ONE OF SUBSECTION (A) OF THIS
SECTION OR DOES NOT PROVIDE A GOOD FAITH RESPONSE TO AN INQUIRY FROM THE
SUPERINTENDENT PURSUANT TO PARAGRAPH TWO OF SUBSECTION (A) OF THIS
SECTION WITHIN A TIME PERIOD SPECIFIED BY THE SUPERINTENDENT OF NOT LESS
THAN FIFTEEN BUSINESS DAYS, THE SUPERINTENDENT IS AUTHORIZED TO LEVY A
CIVIL PENALTY, AFTER NOTICE AND HEARING, AGAINST SUCH PHARMACY BENEFIT
MANAGER OR PERSON NOT TO EXCEED FIVE HUNDRED DOLLARS PER DAY FOR EACH
DAY BEYOND THE DATE THE REPORT IS DUE OR THE DATE SPECIFIED BY THE
SUPERINTENDENT FOR RESPONSE TO THE INQUIRY.
(C) ALL INFORMATION DISCLOSED BY A PHARMACY BENEFIT MANAGER SHALL BE
DEEMED CONFIDENTIAL AND NOT SUBJECT TO DISCLOSURE UNLESS THE SUPERINTEN-
S. 1507 40 A. 2007
DENT DETERMINES THAT SUCH DISCLOSURE IS IN THE PUBLIC INTEREST, OR IS
NECESSARY TO CARRY OUT THIS ARTICLE OR TO ALLOW THE DEPARTMENT TO
PERFORM EXAMINATIONS OR INVESTIGATIONS AUTHORIZED BY LAW.
§ 2905. ACTING WITHOUT A LICENSE. (A) NO PERSON, FIRM, ASSOCIATION,
CORPORATION OR OTHER ENTITY MAY ACT AS A PHARMACY BENEFIT MANAGER ON OR
AFTER JANUARY FIRST, TWO THOUSAND TWENTY-ONE WITHOUT HAVING AUTHORITY TO
DO SO BY VIRTUE OF A LICENSE ISSUED IN FORCE PURSUANT TO THE PROVISIONS
OF THIS ARTICLE.
(B) NO HEALTH INSURER MAY PAY ANY FEE OR OTHER COMPENSATION TO ANY
PERSON, FIRM, ASSOCIATION, CORPORATION OR OTHER ENTITY FOR PERFORMING
PHARMACY BENEFIT MANAGEMENT SERVICES ON OR AFTER JANUARY FIRST, TWO
THOUSAND TWENTY-ONE UNLESS THE PERSON, FIRM, ASSOCIATION, CORPORATION OR
OTHER ENTITY IS LICENSED AS A PHARMACY BENEFIT MANAGER IN ACCORDANCE
WITH THIS ARTICLE.
(C) ANY PERSON, FIRM, ASSOCIATION, CORPORATION OR OTHER ENTITY THAT
VIOLATES THIS SECTION SHALL, IN ADDITION TO ANY OTHER PENALTY PROVIDED
BY LAW, BE SUBJECT TO A PENALTY OF THE GREATER OF (1) ONE THOUSAND
DOLLARS FOR THE FIRST VIOLATION AND TWO THOUSAND FIVE HUNDRED DOLLARS
FOR EACH SUBSEQUENT VIOLATION OR (2) THE AGGREGATE GROSS RECEIPTS
ATTRIBUTABLE TO ALL VIOLATIONS.
§ 2906. LICENSING OF A PHARMACY BENEFIT MANAGER. (A) THE SUPERINTEN-
DENT MAY ISSUE A PHARMACY BENEFIT MANAGER'S LICENSE TO ANY PERSON, FIRM,
ASSOCIATION OR CORPORATION WHO OR THAT HAS COMPLIED WITH THE REQUIRE-
MENTS OF THIS ARTICLE, INCLUDING REGULATIONS PROMULGATED BY THE SUPER-
INTENDENT. THE SUPERINTENDENT, IN CONSULTATION WITH THE COMMISSIONER OF
HEALTH, MAY ESTABLISH, BY REGULATION, MINIMUM STANDARDS FOR THE ISSUANCE
OF A LICENSE TO A PHARMACY BENEFIT MANAGER.
(B) THE MINIMUM STANDARDS ESTABLISHED UNDER THIS SUBSECTION MAY
ADDRESS, WITHOUT LIMITATION:
(1) CONFLICTS OF INTEREST BETWEEN PHARMACY BENEFIT MANAGERS AND HEALTH
INSURERS;
(2) DECEPTIVE PRACTICES IN CONNECTION WITH THE PERFORMANCE OF PHARMACY
BENEFIT MANAGEMENT SERVICES;
(3) ANTI-COMPETITIVE PRACTICES IN CONNECTION WITH THE PERFORMANCE OF
PHARMACY BENEFIT MANAGEMENT SERVICES;
(4) UNFAIR CLAIMS PRACTICES IN CONNECTION WITH THE PERFORMANCE OF
PHARMACY BENEFIT MANAGEMENT SERVICES; AND
(5) PROTECTION OF CONSUMERS.
(C)(1) ANY SUCH LICENSE ISSUED TO A FIRM OR ASSOCIATION SHALL AUTHOR-
IZE ALL OF THE MEMBERS OF THE FIRM OR ASSOCIATION AND ANY DESIGNATED
EMPLOYEES TO ACT AS PHARMACY BENEFIT MANAGERS UNDER THE LICENSE, AND ALL
SUCH PERSONS SHALL BE NAMED IN THE APPLICATION AND SUPPLEMENTS THERETO.
(2) ANY SUCH LICENSE ISSUED TO A CORPORATION SHALL AUTHORIZE ALL OF
THE OFFICERS AND ANY DESIGNATED EMPLOYEES AND DIRECTORS THEREOF TO ACT
AS PHARMACY BENEFIT MANAGERS ON BEHALF OF SUCH CORPORATION, AND ALL SUCH
PERSONS SHALL BE NAMED IN THE APPLICATION AND SUPPLEMENTS THERETO.
(3) FOR EACH BUSINESS ENTITY, THE OFFICER OR OFFICERS AND DIRECTOR OR
DIRECTORS NAMED IN THE APPLICATION SHALL BE DESIGNATED RESPONSIBLE FOR
THE BUSINESS ENTITY'S COMPLIANCE WITH THE INSURANCE LAWS, RULES AND
REGULATIONS OF THIS STATE.
(D)(1) BEFORE A PHARMACY BENEFIT MANAGER'S LICENSE SHALL BE ISSUED OR
RENEWED, THE PROSPECTIVE LICENSEE SHALL PROPERLY FILE IN THE OFFICE OF
THE SUPERINTENDENT A WRITTEN APPLICATION THEREFOR IN SUCH FORM OR FORMS
AND SUPPLEMENTS THERETO AS THE SUPERINTENDENT PRESCRIBES, AND PAY A FEE
OF ONE THOUSAND DOLLARS FOR EACH YEAR OR FRACTION OF A YEAR IN WHICH A
LICENSE SHALL BE VALID.
S. 1507 41 A. 2007
(2) EVERY PHARMACY BENEFIT MANAGER'S LICENSE ISSUED TO A BUSINESS
ENTITY PURSUANT TO THIS SECTION SHALL EXPIRE ON THE THIRTIETH DAY OF
NOVEMBER OF EVEN-NUMBERED YEARS. EVERY LICENSE ISSUED PURSUANT TO THIS
SECTION TO AN INDIVIDUAL PHARMACY BENEFIT MANAGER WHO WAS BORN IN AN
ODD-NUMBERED YEAR, SHALL EXPIRE ON THE INDIVIDUAL'S BIRTHDAY IN EACH
ODD-NUMBERED YEAR. EVERY LICENSE ISSUED PURSUANT TO THIS SECTION TO AN
INDIVIDUAL PHARMACY BENEFIT MANAGER WHO WAS BORN IN AN EVEN-NUMBERED
YEAR, SHALL EXPIRE ON THE INDIVIDUAL'S BIRTHDAY IN EACH EVEN-NUMBERED
YEAR. EVERY LICENSE ISSUED PURSUANT TO THIS SECTION MAY BE RENEWED FOR
THE ENSUING PERIOD OF TWENTY-FOUR MONTHS UPON THE FILING OF AN APPLICA-
TION IN CONFORMITY WITH THIS SUBSECTION.
(E)(1) IF AN APPLICATION FOR A RENEWAL LICENSE SHALL HAVE BEEN FILED
WITH THE SUPERINTENDENT BEFORE OCTOBER FIRST OF THE YEAR OF EXPIRATION,
THEN THE LICENSE SOUGHT TO BE RENEWED SHALL CONTINUE IN FULL FORCE AND
EFFECT EITHER UNTIL THE ISSUANCE BY THE SUPERINTENDENT OF THE RENEWAL
LICENSE APPLIED FOR OR UNTIL FIVE DAYS AFTER THE SUPERINTENDENT SHALL
HAVE REFUSED TO ISSUE SUCH RENEWAL LICENSE AND GIVEN NOTICE OF SUCH
REFUSAL TO THE APPLICANT.
(2) BEFORE REFUSING TO RENEW ANY LICENSE PURSUANT TO THIS SECTION FOR
WHICH A RENEWAL APPLICATION HAS BEEN FILED PURSUANT TO PARAGRAPH ONE OF
THIS SUBSECTION, THE SUPERINTENDENT SHALL NOTIFY THE APPLICANT OF THE
SUPERINTENDENT'S INTENTION TO DO SO AND SHALL GIVE SUCH APPLICANT A
HEARING.
(F) THE SUPERINTENDENT MAY REFUSE TO ISSUE A PHARMACY BENEFIT MANAG-
ER'S LICENSE IF, IN THE SUPERINTENDENT'S JUDGMENT, THE APPLICANT OR ANY
MEMBER, PRINCIPAL, OFFICER OR DIRECTOR OF THE APPLICANT, IS NOT TRUST-
WORTHY AND COMPETENT TO ACT AS OR IN CONNECTION WITH A PHARMACY BENEFIT
MANAGER, OR THAT ANY OF THE FOREGOING HAS GIVEN CAUSE FOR REVOCATION OR
SUSPENSION OF SUCH LICENSE, OR HAS FAILED TO COMPLY WITH ANY PREREQUI-
SITE FOR THE ISSUANCE OF SUCH LICENSE.
(G) LICENSEES AND APPLICANTS FOR A LICENSE UNDER THIS SECTION SHALL BE
SUBJECT TO EXAMINATION BY THE SUPERINTENDENT AS OFTEN AS THE SUPERINTEN-
DENT MAY DEEM IT EXPEDIENT. THE SUPERINTENDENT MAY PROMULGATE REGU-
LATIONS ESTABLISHING METHODS AND PROCEDURES FOR FACILITATING AND VERIFY-
ING COMPLIANCE WITH THE REQUIREMENTS OF THIS SECTION AND SUCH OTHER
REGULATIONS AS NECESSARY.
(H) THE SUPERINTENDENT MAY ISSUE A REPLACEMENT FOR A CURRENTLY
IN-FORCE LICENSE THAT HAS BEEN LOST OR DESTROYED. BEFORE THE REPLACEMENT
LICENSE SHALL BE ISSUED, THERE SHALL BE ON FILE IN THE OFFICE OF THE
SUPERINTENDENT A WRITTEN APPLICATION FOR THE REPLACEMENT LICENSE,
AFFIRMING UNDER PENALTY OF PERJURY THAT THE ORIGINAL LICENSE HAS BEEN
LOST OR DESTROYED, TOGETHER WITH A FEE OF ONE HUNDRED DOLLARS.
§ 2907. REVOCATION OR SUSPENSION OF A REGISTRATION OR LICENSE OF A
PHARMACY BENEFIT MANAGER. (A) THE SUPERINTENDENT MAY REFUSE TO RENEW,
MAY REVOKE, OR MAY SUSPEND FOR A PERIOD THE SUPERINTENDENT DETERMINES
THE REGISTRATION OR LICENSE OF ANY PHARMACY BENEFIT MANAGER IF, AFTER
NOTICE AND HEARING, THE SUPERINTENDENT DETERMINES THAT THE REGISTRANT OR
LICENSEE OR ANY MEMBER, PRINCIPAL, OFFICER, DIRECTOR, OR CONTROLLING
PERSON OF THE REGISTRANT OR LICENSEE, HAS:
(1) VIOLATED ANY INSURANCE LAWS, OR VIOLATED ANY REGULATION, SUBPOENA
OR ORDER OF THE SUPERINTENDENT OR OF ANOTHER STATE'S INSURANCE COMMIS-
SIONER, OR HAS VIOLATED ANY LAW IN THE COURSE OF HIS OR HER DEALINGS IN
SUCH CAPACITY;
(2) PROVIDED MATERIALLY INCORRECT, MATERIALLY MISLEADING, MATERIALLY
INCOMPLETE OR MATERIALLY UNTRUE INFORMATION IN THE REGISTRATION OR
LICENSE APPLICATION;
S. 1507 42 A. 2007
(3) OBTAINED OR ATTEMPTED TO OBTAIN A REGISTRATION OR LICENSE THROUGH
MISREPRESENTATION OR FRAUD;
(4)(A) USED FRAUDULENT, COERCIVE OR DISHONEST PRACTICES;
(B) DEMONSTRATED INCOMPETENCE;
(C) DEMONSTRATED UNTRUSTWORTHINESS; OR
(D) DEMONSTRATED FINANCIAL IRRESPONSIBILITY IN THE CONDUCT OF BUSINESS
IN THIS STATE OR ELSEWHERE;
(5) IMPROPERLY WITHHELD, MISAPPROPRIATED OR CONVERTED ANY MONIES OR
PROPERTIES RECEIVED IN THE COURSE OF BUSINESS IN THIS STATE OR ELSE-
WHERE;
(6) INTENTIONALLY MISREPRESENTED THE TERMS OF AN ACTUAL OR PROPOSED
INSURANCE CONTRACT;
(7) BEEN CONVICTED OF A FELONY;
(8) ADMITTED OR BEEN FOUND TO HAVE COMMITTED ANY INSURANCE UNFAIR
TRADE PRACTICE OR FRAUD;
(9) HAD A PHARMACY BENEFIT MANAGER REGISTRATION OR LICENSE, OR ITS
EQUIVALENT, DENIED, SUSPENDED OR REVOKED IN ANY OTHER STATE, PROVINCE,
DISTRICT OR TERRITORY;
(10) FAILED TO PAY STATE INCOME TAX OR COMPLY WITH ANY ADMINISTRATIVE
OR COURT ORDER DIRECTING PAYMENT OF STATE INCOME TAX; OR
(11) CEASED TO MEET THE REQUIREMENTS FOR REGISTRATION OR LICENSURE
UNDER THIS ARTICLE.
(B) BEFORE REVOKING OR SUSPENDING THE REGISTRATION OR LICENSE OF ANY
PHARMACY BENEFIT MANAGER PURSUANT TO THE PROVISIONS OF THIS ARTICLE, THE
SUPERINTENDENT SHALL GIVE NOTICE TO THE REGISTRANT OR LICENSEE AND TO
EVERY SUB-LICENSEE AND SHALL HOLD, OR CAUSE TO BE HELD, A HEARING NOT
LESS THAN TEN DAYS AFTER THE GIVING OF SUCH NOTICE.
(C) IF A REGISTRATION OR LICENSE PURSUANT TO THE PROVISIONS OF THIS
ARTICLE IS REVOKED OR SUSPENDED BY THE SUPERINTENDENT, THEN THE SUPER-
INTENDENT SHALL FORTHWITH GIVE NOTICE TO THE REGISTRANT OR LICENSEE.
(D) THE REVOCATION OR SUSPENSION OF ANY REGISTRATION OR LICENSE PURSU-
ANT TO THE PROVISIONS OF THIS ARTICLE SHALL TERMINATE FORTHWITH SUCH
REGISTRATION OR LICENSE AND THE AUTHORITY CONFERRED THEREBY UPON ALL
SUB-LICENSEES. FOR GOOD CAUSE SHOWN, THE SUPERINTENDENT MAY DELAY THE
EFFECTIVE DATE OF A REVOCATION OR SUSPENSION TO PERMIT THE REGISTRANT OR
LICENSEE TO SATISFY SOME OR ALL OF ITS CONTRACTUAL OBLIGATIONS TO
PERFORM PHARMACY BENEFIT MANAGEMENT SERVICES IN THE STATE.
(E)(1) NO INDIVIDUAL, CORPORATION, FIRM OR ASSOCIATION WHOSE REGISTRA-
TION OR LICENSE AS A PHARMACY BENEFIT MANAGER HAS BEEN REVOKED PURSUANT
TO SUBSECTION (A) OF THIS SECTION, AND NO FIRM OR ASSOCIATION OF WHICH
SUCH INDIVIDUAL IS A MEMBER, AND NO CORPORATION OF WHICH SUCH INDIVIDUAL
IS AN OFFICER OR DIRECTOR, AND NO CONTROLLING PERSON OF THE REGISTRANT
OR LICENSEE SHALL BE ENTITLED TO OBTAIN ANY REGISTRATION OR LICENSE
UNDER THE PROVISIONS OF THIS ARTICLE FOR A PERIOD OF ONE YEAR AFTER SUCH
REVOCATION, OR, IF SUCH REVOCATION BE JUDICIALLY REVIEWED, FOR ONE YEAR
AFTER THE FINAL DETERMINATION THEREOF AFFIRMING THE ACTION OF THE SUPER-
INTENDENT IN REVOKING SUCH LICENSE.
(2) IF ANY SUCH REGISTRATION OR LICENSE HELD BY A FIRM, ASSOCIATION OR
CORPORATION BE REVOKED, NO MEMBER OF SUCH FIRM OR ASSOCIATION AND NO
OFFICER OR DIRECTOR OF SUCH CORPORATION OR ANY CONTROLLING PERSON OF THE
REGISTRANT OR LICENSEE SHALL BE ENTITLED TO OBTAIN ANY REGISTRATION OR
LICENSE, OR TO BE NAMED AS A SUB-LICENSEE IN ANY SUCH LICENSE, UNDER
THIS ARTICLE FOR THE SAME PERIOD OF TIME, UNLESS THE SUPERINTENDENT
DETERMINES, AFTER NOTICE AND HEARING, THAT SUCH MEMBER, OFFICER OR
DIRECTOR WAS NOT PERSONALLY AT FAULT IN THE MATTER ON ACCOUNT OF WHICH
SUCH REGISTRATION OR LICENSE WAS REVOKED.
S. 1507 43 A. 2007
(F) IF ANY REGISTERED OR LICENSED PHARMACY BENEFIT MANAGER OR ANY
PERSON AGGRIEVED SHALL FILE WITH THE SUPERINTENDENT A VERIFIED COMPLAINT
SETTING FORTH FACTS TENDING TO SHOW SUFFICIENT GROUND FOR THE REVOCATION
OR SUSPENSION OF ANY PHARMACY BENEFIT MANAGER'S REGISTRATION OR LICENSE,
THEN THE SUPERINTENDENT SHALL, AFTER NOTICE AND A HEARING, DETERMINE
WHETHER SUCH REGISTRATION OR LICENSE SHALL BE SUSPENDED OR REVOKED.
(G) THE SUPERINTENDENT SHALL RETAIN THE AUTHORITY TO ENFORCE THE
PROVISIONS OF AND IMPOSE ANY PENALTY OR REMEDY AUTHORIZED BY THIS CHAP-
TER AGAINST ANY PERSON OR ENTITY WHO IS UNDER INVESTIGATION FOR OR
CHARGED WITH A VIOLATION OF THIS CHAPTER, EVEN IF THE PERSON'S OR ENTI-
TY'S REGISTRATION OR LICENSE HAS BEEN SURRENDERED, OR HAS EXPIRED OR HAS
LAPSED BY OPERATION OF LAW.
(H) A REGISTRANT OR LICENSEE SUBJECT TO THIS ARTICLE SHALL REPORT TO
THE SUPERINTENDENT ANY ADMINISTRATIVE ACTION TAKEN AGAINST THE REGIS-
TRANT OR LICENSEE IN ANOTHER JURISDICTION OR BY ANOTHER GOVERNMENTAL
AGENCY IN THIS STATE WITHIN THIRTY DAYS OF THE FINAL DISPOSITION OF THE
MATTER. THIS REPORT SHALL INCLUDE A COPY OF THE ORDER, CONSENT TO ORDER
OR OTHER RELEVANT LEGAL DOCUMENTS.
(I) WITHIN THIRTY DAYS OF THE INITIAL PRETRIAL HEARING DATE, A REGIS-
TRANT OR LICENSEE SUBJECT TO THIS ARTICLE SHALL REPORT TO THE SUPER-
INTENDENT ANY CRIMINAL PROSECUTION OF THE REGISTRANT OR LICENSEE TAKEN
IN ANY JURISDICTION. THE REPORT SHALL INCLUDE A COPY OF THE INITIAL
COMPLAINT FILED, THE ORDER RESULTING FROM THE HEARING AND ANY OTHER
RELEVANT LEGAL DOCUMENTS.
§ 2908. PENALTIES FOR VIOLATIONS. (A) THE SUPERINTENDENT, IN LIEU OF
REVOKING OR SUSPENDING THE REGISTRATION OR LICENSE OF A REGISTRANT OR
LICENSEE IN ACCORDANCE WITH THE PROVISIONS OF THIS ARTICLE, MAY IN ANY
ONE PROCEEDING BY ORDER, REQUIRE THE REGISTRANT OR LICENSEE TO PAY TO
THE PEOPLE OF THIS STATE A PENALTY IN A SUM NOT EXCEEDING THE GREATER OF
(1) ONE THOUSAND DOLLARS FOR EACH OFFENSE AND TWO THOUSAND FIVE HUNDRED
DOLLARS FOR EACH SUBSEQUENT VIOLATION OR (2) THE AGGREGATE GROSS
RECEIPTS ATTRIBUTABLE TO ALL OFFENSES.
(B) UPON THE FAILURE OF SUCH A REGISTRANT OR LICENSEE TO PAY THE
PENALTY ORDERED PURSUANT TO SUBSECTION (A) OF THIS SECTION WITHIN TWENTY
DAYS AFTER THE MAILING OF THE ORDER, POSTAGE PREPAID, REGISTERED, AND
ADDRESSED TO THE LAST KNOWN PLACE OF BUSINESS OF THE LICENSEE, UNLESS
THE ORDER IS STAYED BY AN ORDER OF A COURT OF COMPETENT JURISDICTION,
THE SUPERINTENDENT MAY REVOKE THE REGISTRATION OR LICENSE OF THE REGIS-
TRANT OR LICENSEE OR MAY SUSPEND THE SAME FOR SUCH PERIOD AS THE SUPER-
INTENDENT DETERMINES.
§ 2909. STAY OR SUSPENSION OF SUPERINTENDENT'S DETERMINATION. THE
COMMENCEMENT OF A PROCEEDING UNDER ARTICLE SEVENTY-EIGHT OF THE CIVIL
PRACTICE LAW AND RULES, TO REVIEW THE ACTION OF THE SUPERINTENDENT IN
SUSPENDING OR REVOKING OR REFUSING TO RENEW ANY CERTIFICATE UNDER THIS
ARTICLE, SHALL STAY SUCH ACTION OF THE SUPERINTENDENT FOR A PERIOD OF
THIRTY DAYS. SUCH STAY SHALL NOT BE EXTENDED FOR A LONGER PERIOD UNLESS
THE COURT SHALL DETERMINE, AFTER A PRELIMINARY HEARING OF WHICH THE
SUPERINTENDENT IS NOTIFIED FORTY-EIGHT HOURS IN ADVANCE, THAT A STAY OF
THE SUPERINTENDENT'S ACTION PENDING THE FINAL DETERMINATION OR FURTHER
ORDER OF THE COURT WILL NOT UNDULY INJURE THE INTERESTS OF THE PEOPLE OF
THE STATE.
§ 2910. REVOKED REGISTRATIONS OR LICENSES. (A)(1) NO PERSON, FIRM,
ASSOCIATION, CORPORATION OR OTHER ENTITY SUBJECT TO THE PROVISIONS OF
THIS ARTICLE WHOSE REGISTRATION OR LICENSE UNDER THIS ARTICLE HAS BEEN
REVOKED, OR WHOSE REGISTRATION OR LICENSE TO ENGAGE IN THE BUSINESS OF
PHARMACY BENEFIT MANAGEMENT IN ANY CAPACITY HAS BEEN REVOKED BY ANY
S. 1507 44 A. 2007
OTHER STATE OR TERRITORY OF THE UNITED STATES SHALL BECOME EMPLOYED OR
APPOINTED BY A PHARMACY BENEFIT MANAGER AS AN OFFICER, DIRECTOR, MANAG-
ER, CONTROLLING PERSON OR FOR OTHER SERVICES, WITHOUT THE PRIOR WRITTEN
APPROVAL OF THE SUPERINTENDENT, UNLESS SUCH SERVICES ARE FOR MAINTENANCE
OR ARE CLERICAL OR MINISTERIAL IN NATURE.
(2) NO PERSON, FIRM, ASSOCIATION, CORPORATION OR OTHER ENTITY SUBJECT
TO THE PROVISIONS OF THIS ARTICLE SHALL KNOWINGLY EMPLOY OR APPOINT ANY
PERSON OR ENTITY WHOSE REGISTRATION OR LICENSE ISSUED UNDER THIS ARTICLE
HAS BEEN REVOKED, OR WHOSE REGISTRATION OR LICENSE TO ENGAGE IN THE
BUSINESS OF PHARMACY BENEFIT MANAGEMENT IN ANY CAPACITY HAS BEEN REVOKED
BY ANY OTHER STATE OR TERRITORY OF THE UNITED STATES, AS AN OFFICER,
DIRECTOR, MANAGER, CONTROLLING PERSON OR FOR OTHER SERVICES, WITHOUT THE
PRIOR WRITTEN APPROVAL OF THE SUPERINTENDENT, UNLESS SUCH SERVICES ARE
FOR MAINTENANCE OR ARE CLERICAL OR MINISTERIAL IN NATURE.
(3) NO CORPORATION OR PARTNERSHIP SUBJECT TO THE PROVISIONS OF THIS
ARTICLE SHALL KNOWINGLY PERMIT ANY PERSON WHOSE REGISTRATION OR LICENSE
ISSUED UNDER THIS ARTICLE HAS BEEN REVOKED, OR WHOSE REGISTRATION OR
LICENSE TO ENGAGE IN THE BUSINESS OF PHARMACY BENEFIT MANAGEMENT IN ANY
CAPACITY HAS BEEN REVOKED BY ANY OTHER STATE, OR TERRITORY OF THE UNITED
STATES, TO BE A SHAREHOLDER OR HAVE AN INTEREST IN SUCH CORPORATION OR
PARTNERSHIP, NOR SHALL ANY SUCH PERSON BECOME A SHAREHOLDER OR PARTNER
IN SUCH CORPORATION OR PARTNERSHIP, WITHOUT THE PRIOR WRITTEN APPROVAL
OF THE SUPERINTENDENT.
(B) THE SUPERINTENDENT MAY APPROVE THE EMPLOYMENT, APPOINTMENT OR
PARTICIPATION OF ANY SUCH PERSON WHOSE REGISTRATION OR LICENSE HAS BEEN
REVOKED:
(1) IF THE SUPERINTENDENT DETERMINES THAT THE DUTIES AND RESPONSIBIL-
ITIES OF SUCH PERSON ARE SUBJECT TO APPROPRIATE SUPERVISION AND THAT
SUCH DUTIES AND RESPONSIBILITIES WILL NOT HAVE AN ADVERSE EFFECT UPON
THE PUBLIC, OTHER REGISTRANTS OR LICENSEES, OR THE REGISTRANT OR LICEN-
SEE PROPOSING EMPLOYMENT OR APPOINTMENT OF SUCH PERSON; OR
(2) IF SUCH PERSON HAS FILED AN APPLICATION FOR REREGISTRATION OR
RELICENSING PURSUANT TO THIS ARTICLE AND THE APPLICATION FOR REREGISTRA-
TION OR RELICENSING HAS NOT BEEN APPROVED OR DENIED WITHIN ONE HUNDRED
TWENTY DAYS FOLLOWING THE FILING THEREOF, UNLESS THE SUPERINTENDENT
DETERMINES WITHIN THE SAID TIME THAT EMPLOYMENT OR APPOINTMENT OF SUCH
PERSON BY A REGISTRANT OR LICENSEE IN THE CONDUCT OF A PHARMACY BENEFIT
MANAGEMENT BUSINESS WOULD NOT BE IN THE PUBLIC INTEREST.
(C) THE PROVISIONS OF THIS SECTION SHALL NOT APPLY TO THE OWNERSHIP OF
SHARES OF ANY CORPORATION REGISTERED OR LICENSED PURSUANT TO THIS ARTI-
CLE IF THE SHARES OF SUCH CORPORATION ARE PUBLICLY HELD AND TRADED IN
THE OVER-THE-COUNTER MARKET OR UPON ANY NATIONAL OR REGIONAL SECURITIES
EXCHANGE.
§ 2911. CHANGE OF ADDRESS. A REGISTRANT OR LICENSEE UNDER THIS ARTICLE
SHALL INFORM THE SUPERINTENDENT BY A MEANS ACCEPTABLE TO THE SUPERINTEN-
DENT OF A CHANGE OF ADDRESS WITHIN THIRTY DAYS OF THE CHANGE.
§ 2912. APPLICABILITY OF OTHER LAWS. NOTHING IN THIS ARTICLE SHALL BE
CONSTRUED TO EXEMPT A PHARMACY BENEFIT MANAGER FROM COMPLYING WITH THE
PROVISIONS OF ARTICLES TWENTY-ONE AND FORTY-NINE OF THIS CHAPTER AND
ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW OR ANY OTHER PROVISION OF
THIS CHAPTER OR THE FINANCIAL SERVICES LAW.
§ 2913. ASSESSMENTS. PHARMACY BENEFIT MANAGERS THAT FILE A REGISTRA-
TION WITH THE DEPARTMENT OR ARE LICENSED BY THE DEPARTMENT SHALL BE
ASSESSED BY THE SUPERINTENDENT FOR THE OPERATING EXPENSES OF THE DEPART-
MENT THAT ARE SOLELY ATTRIBUTABLE TO REGULATING SUCH PHARMACY BENEFIT
S. 1507 45 A. 2007
MANAGERS IN SUCH PROPORTIONS AS THE SUPERINTENDENT SHALL DEEM JUST AND
REASONABLE.
§ 2. Subsection (b) of section 2402 of the insurance law, as amended
by section 71 of part A of chapter 62 of the laws of 2011, is amended to
read as follows:
(b) "Defined violation" means the commission by a person of an act
prohibited by: subsection (a) of section one thousand one hundred two,
section one thousand two hundred fourteen, one thousand two hundred
seventeen, one thousand two hundred twenty, one thousand three hundred
thirteen, subparagraph (B) of paragraph two of subsection (i) of section
one thousand three hundred twenty-two, subparagraph (B) of paragraph two
of subsection (i) of section one thousand three hundred twenty-four, two
thousand one hundred two, two thousand one hundred seventeen, two thou-
sand one hundred twenty-two, two thousand one hundred twenty-three,
subsection (p) of section two thousand three hundred thirteen, section
two thousand three hundred twenty-four, two thousand five hundred two,
two thousand five hundred three, two thousand five hundred four, two
thousand six hundred one, two thousand six hundred two, two thousand six
hundred three, two thousand six hundred four, two thousand six hundred
six, two thousand seven hundred three, TWO THOUSAND NINE HUNDRED TWO,
TWO THOUSAND NINE HUNDRED FIVE, three thousand one hundred nine, three
thousand two hundred twenty-four-a, three thousand four hundred twenty-
nine, three thousand four hundred thirty-three, paragraph seven of
subsection (e) of section three thousand four hundred twenty-six, four
thousand two hundred twenty-four, four thousand two hundred twenty-five,
four thousand two hundred twenty-six, seven thousand eight hundred nine,
seven thousand eight hundred ten, seven thousand eight hundred eleven,
seven thousand eight hundred thirteen, seven thousand eight hundred
fourteen and seven thousand eight hundred fifteen of this chapter; or
section 135.60, 135.65, 175.05, 175.45, or 190.20, or article one
hundred five of the penal law.
§ 3. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019.
PART J
Section 1. This Part enacts into law major components of legislation
which are necessary to protect health care consumers; increase access to
more affordable quality health insurance coverage; and preserve and
foster New York's health insurance markets. Each component is wholly
contained within a Subpart identified as Subparts A through F. The
effective date for each particular provision contained within such
Subpart is set forth in the last section of such Subpart. Any provision
in any section contained within a Subpart, including the effective date
of the Subpart, which makes a reference to a section "of this act," when
used in connection with that particular component, shall be deemed to
mean and refer to the corresponding section of the Subpart in which it
is found. Section five of this Part sets forth the general effective
date of this Part.
SUBPART A
Section 1. Section 3221 of the insurance law is amended by adding a
new subsection (t) to read as follows:
(T) (1) ANY INSURER THAT DELIVERS OR ISSUES FOR DELIVERY IN THIS STATE
HOSPITAL, SURGICAL OR MEDICAL EXPENSE GROUP POLICIES IN THE SMALL GROUP
S. 1507 46 A. 2007
OR LARGE GROUP MARKET SHALL OFFER TO ANY EMPLOYER IN THIS STATE ALL SUCH
POLICIES IN THE APPLICABLE MARKET, AND SHALL ACCEPT AT ALL TIMES
THROUGHOUT THE YEAR ANY EMPLOYER THAT APPLIES FOR ANY OF THOSE POLICIES.
(2) THE REQUIREMENTS OF PARAGRAPH ONE OF THIS SUBSECTION SHALL APPLY
WITH RESPECT TO AN EMPLOYER THAT APPLIES FOR COVERAGE EITHER DIRECTLY
FROM THE INSURER OR THROUGH AN ASSOCIATION OR TRUST TO WHICH THE INSURER
HAS ISSUED COVERAGE AND IN WHICH THE EMPLOYER PARTICIPATES.
§ 2. Paragraph 1 of subsection (g) of section 3231 of the insurance
law, as amended by section 70 of part D of chapter 56 of the laws of
2013, is amended to read as follows:
(1) This section shall also apply to policies issued to a group
defined in subsection (c) of section four thousand two hundred thirty-
five, including but not limited to an association or trust of employers,
if the group includes one or more member employers or other member
groups which have [fifty] ONE HUNDRED or fewer employees or members
exclusive of spouses and dependents. For policies issued or renewed on
or after January first, two thousand fourteen, if the group includes one
or more member small group employers eligible for coverage subject to
this section, then such member employers shall be classified as small
groups for rating purposes and the remaining members shall be rated
consistent with the rating rules applicable to such remaining members
pursuant to paragraph two of this subsection.
§ 3. Subsections (h) and (i) of section 3232 of the insurance law are
REPEALED.
§ 4. Subsections (f) and (g) of section 3232 of the insurance law, as
added by chapter 219 of the laws of 2011, are amended to read as
follows:
(f) [With respect to an individual under age nineteen, an insurer may
not impose any pre-existing condition exclusion in an individual or
group policy of hospital, medical, surgical or prescription drug expense
insurance pursuant to the requirements of section 2704 of the Public
Health Service Act, 42 U.S.C. § 300gg-3, as made effective by section
1255(2) of the Affordable Care Act, except for an individual under age
nineteen covered under an individual policy of hospital, medical, surgi-
cal or prescription drug expense insurance that is a grandfathered
health plan.
(g) Beginning January first, two thousand fourteen, pursuant to
section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, an]
AN insurer [may] SHALL not impose any pre-existing condition exclusion
in an individual or group policy of hospital, medical, surgical or
prescription drug expense insurance [except in an individual policy that
is a grandfathered health plan].
§ 5. Subparagraph (A) of paragraph 1 of subsection (c) of section 4235
of the insurance law, as amended by chapter 515 of the laws of 2010, is
amended to read as follows:
(A) A policy issued to an employer or to a trustee or trustees of a
fund established by an employer, which employer or trustee or trustees
shall be deemed the policyholder, insuring with or without evidence of
insurability satisfactory to the insurer, employees of such employer,
and insuring, except as hereinafter provided, all of such employees or
all of any class or classes thereof determined by conditions pertaining
to the employment or a combination of such conditions and conditions
pertaining to the family status of the employee, for insurance coverage
on each person insured based upon some plan [which] THAT will preclude
individual selection. However, such a plan may permit a limited number
of selections by employees if the selections offered utilize consistent
S. 1507 47 A. 2007
plans of coverage for individual group members so that the resulting
plans of coverage are reasonable. The premium for the policy shall be
paid by the policyholder, either from the employer's funds, or from
funds contributed by the insured employees, or from funds contributed
jointly by the employer and employees. If all or part of the premium is
to be derived from funds contributed by the insured employees, then
[such] THE INSURER ISSUING THE policy [must insure not less than fifty
percent of such eligible employees or, if less, fifty or more] SHALL NOT
REQUIRE A MINIMUM NUMBER OR MINIMUM PERCENTAGE of such employees BE
INSURED when [such] THE policy is providing coverage for group hospital,
medical, major medical or similar comprehensive types of expense reim-
bursed insurance and, for all other types of group accident and health
insurance, [must] THE POLICY SHALL insure a minimum of fifty percent or
five of such eligible employees, whichever is fewer.
§ 6. Section 4305 of the insurance law is amended by adding a new
subsection (n) to read as follows:
(N) (1) ANY CORPORATION SUBJECT TO THE PROVISIONS OF THIS ARTICLE THAT
ISSUES HOSPITAL, SURGICAL OR MEDICAL EXPENSE CONTRACTS IN THE SMALL
GROUP OR LARGE GROUP MARKET IN THIS STATE SHALL OFFER TO ANY EMPLOYER IN
THIS STATE ALL SUCH CONTRACTS IN THE APPLICABLE MARKET, AND SHALL ACCEPT
AT ALL TIMES THROUGHOUT THE YEAR ANY EMPLOYER THAT APPLIES FOR ANY OF
THOSE CONTRACTS.
(2) THE REQUIREMENTS OF PARAGRAPH ONE OF THIS SUBSECTION SHALL APPLY
WITH RESPECT TO AN EMPLOYER THAT APPLIES FOR COVERAGE EITHER DIRECTLY
FROM THE CORPORATION OR THROUGH AN ASSOCIATION OR TRUST TO WHICH THE
CORPORATION HAS ISSUED COVERAGE AND IN WHICH THE EMPLOYER PARTICIPATES.
§ 7. Paragraph 1 of subsection (d) of section 4317 of the insurance
law, as amended by section 72 of part D of chapter 56 of the laws of
2013, is amended to read as follows:
(1) This section shall also apply to a contract issued to a group
defined in subsection (c) of section four thousand two hundred thirty-
five of this chapter, including but not limited to an association or
trust of employers, if the group includes one or more member employers
or other member groups which have [fifty] ONE HUNDRED or fewer employees
or members exclusive of spouses and dependents. For contracts issued or
renewed on or after January first, two thousand fourteen, if the group
includes one or more member small group employers eligible for coverage
subject to this section, then such member employers shall be classified
as small groups for rating purposes and the remaining members shall be
rated consistent with the rating rules applicable to such remaining
members pursuant to paragraph two of this subsection.
§ 8. Subsections (h) and (i) of section 4318 of the insurance law are
REPEALED.
§ 9. Subsections (f) and (g) of section 4318 of the insurance law, as
added by chapter 219 of the laws of 2011, are amended to read as
follows:
(f) [With respect to an individual under age nineteen, a corporation
may not impose any pre-existing condition exclusion in an individual or
group contract of hospital, medical, surgical or prescription drug
expense insurance pursuant to the requirements of section 2704 of the
Public Health Service Act, 42 U.S.C. § 300gg-3, as made effective by
section 1255(2) of the Affordable Care Act, except for an individual
under age nineteen covered under an individual contract of hospital,
medical, surgical or prescription drug expense insurance that is a
grandfathered health plan.
S. 1507 48 A. 2007
(g) Beginning January first, two thousand fourteen, pursuant to
section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A
corporation [may] SHALL not impose any pre-existing condition exclusion
in an individual or group contract of hospital, medical, surgical or
prescription drug expense insurance [except in an individual contract
that is a grandfathered health plan].
§ 10. Section 4413 of the insurance law is amended by adding a new
subsection (h) to read as follows:
(H) (1) ON OR AFTER JUNE FIRST, TWO THOUSAND NINETEEN, AN EMPLOYEE
WELFARE FUND REGISTERED WITH THE SUPERINTENDENT SHALL NOT PROVIDE
MEDICAL, SURGICAL OR HOSPITAL CARE OR BENEFITS IN THE EVENT OF SICKNESS
OR INJURY FOR EMPLOYEES OR THEIR FAMILIES OR DEPENDENTS, OR FOR BOTH,
UNLESS PROVIDED UNDER A GROUP COMPREHENSIVE-TYPE HEALTH INSURANCE POLICY
OR CONTRACT IN ACCORDANCE WITH THE REQUIREMENTS OF THIS CHAPTER AND
DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE BY AN AUTHORIZED INSURER
OR A HEALTH MAINTENANCE ORGANIZATION ISSUED A CERTIFICATE OF AUTHORITY
UNDER ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW.
(2) NOTWITHSTANDING PARAGRAPH ONE OF THIS SUBSECTION, AN EMPLOYEE
WELFARE FUND REGISTERED WITH THE SUPERINTENDENT PRIOR TO JUNE FIRST, TWO
THOUSAND NINETEEN, WHICH, AS OF FEBRUARY FIRST, TWO THOUSAND NINETEEN
DIRECTLY PROVIDED MEDICAL, SURGICAL OR HOSPITAL CARE OR BENEFITS IN THE
EVENT OF SICKNESS OR INJURY FOR EMPLOYEES OR THEIR FAMILIES OR DEPEN-
DENTS, OR FOR BOTH, MAY CONTINUE TO PROVIDE THOSE BENEFITS DIRECTLY
RATHER THAN UNDER A GROUP COMPREHENSIVE-TYPE HEALTH INSURANCE POLICY OR
CONTRACT DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE BY AN AUTHORIZED
INSURER OR A HEALTH MAINTENANCE ORGANIZATION ISSUED A CERTIFICATE OF
AUTHORITY UNDER ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW; PROVIDED,
HOWEVER, THAT, IF THE EMPLOYEE WELFARE FUND CEASES OFFERING THE BENEFITS
DIRECTLY, IT MAY NOT RESUME PROVIDING THE BENEFITS DIRECTLY.
§ 11. Subdivision 1 of section 4406 of the public health law, as
amended by section 46-a of part D of chapter 56 of the laws of 2013, is
amended to read as follows:
1. The contract between a health maintenance organization and an
enrollee shall be subject to regulation by the superintendent as if it
were a health insurance subscriber contract, and shall include, but not
be limited to, all mandated benefits required by article forty-three of
the insurance law. Such contract shall fully and clearly state the bene-
fits and limitations therein provided or imposed, so as to facilitate
understanding and comparisons, and to exclude provisions which may be
misleading or unreasonably confusing. Such contract shall be issued to
any individual and dependents of such individual and any group of
[fifty] ONE HUNDRED or fewer employees or members, exclusive of spouses
and dependents, or TO any employee or member of the group, including
dependents, applying for such contract at any time throughout the year[,
and may include a pre-existing condition provision as provided for in
section four thousand three hundred eighteen of the insurance law,
provided, however, that, the]. AN INDIVIDUAL DIRECT PAYMENT CONTRACT
SHALL BE ISSUED ONLY IN ACCORDANCE WITH SECTION FOUR THOUSAND THREE
HUNDRED TWENTY-EIGHT OF THE INSURANCE LAW. THE superintendent may, after
giving consideration to the public interest, exempt a health maintenance
organization from the requirements of this section provided that another
health insurer or health maintenance organization within the health
maintenance organization's same holding company system, as defined in
article fifteen of the insurance law, including a health maintenance
organization operated as a line of business of a health service corpo-
ration licensed under article forty-three of the insurance law, offers
S. 1507 49 A. 2007
coverage that, at a minimum, complies with this section and provides all
of the consumer protections required to be provided by a health mainte-
nance organization pursuant to this chapter and regulations, including
those consumer protections contained in sections four thousand four
hundred three and four thousand four hundred eight-a of this chapter.
The requirements shall not apply to a health maintenance organization
exclusively serving individuals enrolled pursuant to title eleven of
article five of the social services law, title eleven-D of article five
of the social services law, title one-A of article twenty-five of [the
public health law] THIS CHAPTER or title eighteen of the federal Social
Security Act, and, further provided, that such health maintenance organ-
ization shall not discontinue a contract for an individual receiving
comprehensive-type coverage in effect prior to January first, two thou-
sand four who is ineligible to purchase policies offered after such date
pursuant to this section or section four thousand three hundred [twen-
ty-two of this article] TWENTY-EIGHT OF THE INSURANCE LAW due to the
provision of 42 U.S.C. 1395ss in effect prior to January first, two
thousand four. [Subject to the creditable coverage requirements of
subsection (a) of section four thousand three hundred eighteen of the
insurance law, the organization may, as an alternative to the use of a
pre-existing condition provision, elect to offer contracts without a
pre-existing condition provision to such groups but may require that
coverage shall not become effective until after a specified affiliation
period of not more than sixty days after the application for coverage is
submitted. The organization is not required to provide health care
services or benefits during such period and no premium shall be charged
for any coverage during the period. After January first, nineteen
hundred ninety-six, all individual direct payment contracts shall be
issued only pursuant to sections four thousand three hundred twenty-one
and four thousand three hundred twenty-two of the insurance law. Such
contracts may not, with respect to an eligible individual (as defined in
section 2741(b) of the federal Public Health Service Act, 42 U.S.C. §
300gg-41(b), impose any pre-existing condition exclusion.]
§ 12. This act shall take effect immediately, provided that:
(1) sections one, three, four, five, six, eight and nine of this act
shall apply to all policies and contracts issued, renewed, modified,
altered or amended on or after January 1, 2020; and
(2) sections two and seven of this act shall take effect on the same
date as the reversion of paragraph 1 of subsection (g) of section 3231
and paragraph 1 of subsection (d) of section 4317 of the insurance law,
as provided in section 5 of chapter 588 of the laws of 2015, as amended.
SUBPART B
Section 1. Subparagraph (A) of paragraph 5 of subsection (c) of
section 3216 of the insurance law, as amended by chapter 388 of the laws
of 2014, is amended to read as follows:
(A) Any family policy providing hospital or surgical expense insurance
(but not including such insurance against accidental injury only) shall
provide that, in the event such insurance on any person, other than the
policyholder, is terminated because the person is no longer within the
definition of the family as set forth in the policy but before such
person has attained the limiting age, if any, for coverage of adults
specified in the policy, such person shall be entitled to have issued to
that person by the insurer, without evidence of insurability, upon
application therefor and payment of the first premium, within sixty days
S. 1507 50 A. 2007
after such insurance shall have terminated, an individual conversion
policy that contains the ESSENTIAL HEALTH benefits PACKAGE described in
paragraph [one] THREE of subsection [(b)] (F) of section [four thousand
three hundred twenty-eight of this chapter. The insurer shall offer one
policy at each level of coverage as defined in section 1302(d) of the
affordable care act, 42 U.S.C. § 18022(d).] THREE THOUSAND TWO HUNDRED
SEVENTEEN-I OF THIS ARTICLE. THE INSURER SHALL OFFER ONE POLICY AT EACH
LEVEL OF COVERAGE AS DEFINED IN SUBSECTION (C) OF SECTION THREE THOUSAND
TWO HUNDRED SEVENTEEN-I OF THIS ARTICLE. The individual may choose any
such policy offered by the insurer. Provided, however, the superinten-
dent may, after giving due consideration to the public interest, approve
a request made by an insurer for the insurer to satisfy the requirements
of this subparagraph through the offering of policies that comply with
this subparagraph by another insurer, corporation or health maintenance
organization within the insurer's holding company system, as defined in
article fifteen of this chapter. The conversion privilege afforded here-
in shall also be available upon the divorce or annulment of the marriage
of the policyholder to the former spouse of such policyholder.
§ 2. Subparagraph (E) of paragraph 2 of subsection (g) of section 3216
of the insurance law, as added by chapter 388 of the laws of 2014, is
amended to read as follows:
(E) The superintendent may, after giving due consideration to the
public interest, approve a request made by an insurer for the insurer to
satisfy the requirements of subparagraph (C) of this paragraph through
the offering of policies at each level of coverage as defined in
SUBSECTION (C) OF section [1302(d) of the affordable care act, 42 U.S.C.
§ 18022(d)] THREE THOUSAND TWO HUNDRED SEVENTEEN-I OF THIS ARTICLE that
contains the ESSENTIAL HEALTH benefits PACKAGE described in paragraph
[one] THREE of subsection [(b)] (F) of section [four thousand three
hundred twenty-eight of this chapter] THREE THOUSAND TWO HUNDRED SEVEN-
TEEN-I OF THIS ARTICLE by another insurer, corporation or health mainte-
nance organization within the insurer's same holding company system, as
defined in article fifteen of this chapter.
§ 3. Items (i) and (ii) of subparagraph (D) of paragraph 11 of
subsection (i) of section 3216 of the insurance law, as added by chapter
219 of the laws of 2011, are amended, and a new item (iii) is added to
read as follows:
(i) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
(ii) with respect to women, such additional preventive care and
screenings for mammography not described in item (i) of this subpara-
graph and as provided for in comprehensive guidelines supported by the
health resources and services administration[.]; AND
(III) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE
SUPERINTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR
PREVIOUS RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) AND (II)
OF THIS SUBPARAGRAPH.
§ 4. Items (i) and (ii) of subparagraph (D) of paragraph 15 of
subsection (i) of section 3216 of the insurance law, as added by chapter
219 of the laws of 2011, are amended, and a new item (iii) is added to
read as follows:
(i) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
S. 1507 51 A. 2007
(ii) with respect to women, such additional preventive care and
screenings for cervical cytology not described in item (i) of this
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration[.]; AND
(III) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE
SUPERINTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR
PREVIOUS RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) AND (II)
OF THIS SUBPARAGRAPH.
§ 5. Items (iii) and (iv) of subparagraph (E) of paragraph 17 of
subsection (i) of section 3216 of the insurance law, as added by chapter
219 of the laws of 2011, are amended and a new item (v) is added to read
as follows:
(iii) with respect to children, including infants and adolescents,
evidence-informed preventive care and screenings provided for in compre-
hensive guidelines supported by the health resources and services admin-
istration; [and]
(iv) with respect to women, such additional preventive care and
screenings not described in item (i) of this subparagraph and as
provided for in comprehensive guidelines supported by the health
resources and services administration[.]; AND
(V) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) THROUGH (IV) OF
THIS SUBPARAGRAPH.
§ 6. Paragraph 21 of subsection (i) of section 3216 of the insurance
law, as amended by chapter 469 of the laws of 2018, is amended to read
as follows:
(21) Every policy [which] THAT provides coverage for prescription
drugs shall include coverage for the cost of enteral formulas for home
use, whether administered orally or via tube feeding, for which a physi-
cian or other licensed health care provider legally authorized to
prescribe under title eight of the education law has issued a written
order. Such written order shall state that the enteral formula is clear-
ly medically necessary and has been proven effective as a disease-spe-
cific treatment regimen. Specific diseases and disorders for which
enteral formulas have been proven effective shall include, but are not
limited to, inherited diseases of amino acid or organic acid metabolism;
Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal
motility such as chronic intestinal pseudo-obstruction; and multiple,
severe food allergies including, but not limited to immunoglobulin E and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders; and
impaired absorption of nutrients caused by disorders affecting the
absorptive surface, function, length, and motility of the gastrointesti-
nal tract. Enteral formulas [which] THAT are medically necessary and
taken under written order from a physician for the treatment of specific
diseases shall be distinguished from nutritional supplements taken elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic acid metabolism as well as severe protein allergic conditions shall
include modified solid food products that are low protein [or which],
contain modified protein, or are amino acid based [which] THAT are
medically necessary[, and such coverage for such modified solid food
products for any calendar year or for any continuous period of twelve
months for any insured individual shall not exceed two thousand five
hundred dollars].
S. 1507 52 A. 2007
§ 7. Paragraph 30 of subsection (i) of section 3216 of the insurance
law, as amended by chapter 377 of the laws of 2014, is amended to read
as follows:
(30) Every policy [which] THAT provides medical coverage that includes
coverage for physician services in a physician's office and every policy
[which] THAT provides major medical or similar comprehensive-type cover-
age shall include coverage for equipment and supplies used for the
treatment of ostomies, if prescribed by a physician or other licensed
health care provider legally authorized to prescribe under title eight
of the education law. Such coverage shall be subject to annual deduct-
ibles and coinsurance as deemed appropriate by the superintendent. The
coverage required by this paragraph shall be identical to, and shall not
enhance or increase the coverage required as part of essential health
benefits as [required pursuant to] DEFINED IN SUBSECTION (A) OF section
[2707 (a) of the public health services act 42 U.S.C. 300 gg-6(a)] THREE
THOUSAND TWO HUNDRED SEVENTEEN-I OF THIS ARTICLE.
§ 8. Subsection (l) of section 3216 of the insurance law, as added by
section 42 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(l) [On and after October first, two thousand thirteen, an] AN insurer
shall not offer individual hospital, medical or surgical expense insur-
ance policies unless the policies meet the requirements of subsection
(b) of section four thousand three hundred twenty-eight of this chapter.
Such policies that are offered within the health benefit exchange estab-
lished [pursuant to section 1311 of the affordable care act, 42 U.S.C. §
18031, or any regulations promulgated thereunder,] BY THIS STATE also
shall meet any requirements established by the health benefit exchange.
§ 9. Subsection (m) of section 3216 of the insurance law, as added by
section 53 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(m) An insurer shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section if the
benefits must be covered as essential health benefits. For any policy
issued within the health benefit exchange established [pursuant to
section 1311 of the affordable care act, 42 U.S.C. § 18031] BY THIS
STATE, an insurer shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section. For
purposes of this subsection, "essential health benefits" shall have the
meaning set forth in SUBSECTION (A) OF section [1302(b) of the afforda-
ble care act, 42 U.S.C. § 18022(b)] THREE THOUSAND TWO HUNDRED SEVEN-
TEEN-I OF THIS ARTICLE.
§ 10. The insurance law is amended by adding a new section 3217-i to
read as follows:
§ 3217-I. ESSENTIAL HEALTH BENEFITS PACKAGE AND LIMIT ON COST-SHARING.
(A) FOR PURPOSES OF THIS ARTICLE, "ESSENTIAL HEALTH BENEFITS" SHALL MEAN
THE FOLLOWING CATEGORIES OF BENEFITS:
(1) AMBULATORY PATIENT SERVICES;
(2) EMERGENCY SERVICES;
(3) HOSPITALIZATION;
(4) MATERNITY AND NEWBORN CARE;
(5) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES, INCLUDING
BEHAVIORAL HEALTH TREATMENT;
(6) PRESCRIPTION DRUGS;
(7) REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES;
(8) LABORATORY SERVICES;
S. 1507 53 A. 2007
(9) PREVENTIVE AND WELLNESS SERVICES AND CHRONIC DISEASE MANAGEMENT;
AND
(10) PEDIATRIC SERVICES, INCLUDING ORAL AND VISION CARE.
(B) THE SUPERINTENDENT, IN CONSULTATION WITH THE COMMISSIONER OF
HEALTH, MAY SELECT AS A BENCHMARK, A PLAN OR COMBINATION OF PLANS THAT
TOGETHER CONTAIN ESSENTIAL HEALTH BENEFITS, IN ACCORDANCE WITH THIS
SECTION AND ANY APPLICABLE FEDERAL REGULATION.
(C) (1) EVERY INDIVIDUAL AND SMALL GROUP ACCIDENT AND HEALTH INSURANCE
POLICY THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE AND
IS NOT A GRANDFATHERED HEALTH PLAN SHALL PROVIDE COVERAGE THAT MEETS THE
ACTUARIAL REQUIREMENTS OF ONE OF THE FOLLOWING LEVELS OF COVERAGE:
(A) BRONZE LEVEL. A PLAN IN THE BRONZE LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO SIXTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN;
(B) SILVER LEVEL. A PLAN IN THE SILVER LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO SEVENTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENE-
FITS PROVIDED UNDER THE PLAN;
(C) GOLD LEVEL. A PLAN IN THE GOLD LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO EIGHTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN; OR
(D) PLATINUM LEVEL. A PLAN IN THE PLATINUM LEVEL SHALL PROVIDE A LEVEL
OF COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO NINETY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN.
(2) THE SUPERINTENDENT MAY PROVIDE FOR A VARIATION IN THE ACTUARIAL
VALUES USED IN DETERMINING THE LEVEL OF COVERAGE OF A PLAN TO ACCOUNT
FOR THE DIFFERENCES IN ACTUARIAL ESTIMATES.
(3) EVERY STUDENT ACCIDENT AND HEALTH INSURANCE POLICY SHALL PROVIDE
COVERAGE THAT MEETS AT LEAST SIXTY PERCENT OF THE FULL ACTUARIAL VALUE
OF THE BENEFITS PROVIDED UNDER THE POLICY. THE POLICY'S SCHEDULE OF
BENEFITS SHALL INCLUDE THE LEVEL AS DESCRIBED IN PARAGRAPH ONE OF THIS
SUBSECTION NEAREST TO, BUT BELOW THE ACTUAL ACTUARIAL VALUE.
(D) EVERY INDIVIDUAL OR GROUP ACCIDENT AND HEALTH INSURANCE POLICY
THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE AND IS NOT
A GRANDFATHERED HEALTH PLAN, AND EVERY STUDENT ACCIDENT AND HEALTH
INSURANCE POLICY SHALL LIMIT THE INSURED'S COST-SHARING FOR IN-NETWORK
SERVICES IN A POLICY YEAR TO NOT MORE THAN THE MAXIMUM OUT-OF-POCKET
AMOUNT DETERMINED BY THE SUPERINTENDENT FOR ALL POLICIES SUBJECT TO THIS
SECTION. SUCH AMOUNT SHALL NOT EXCEED ANY ANNUAL OUT-OF-POCKET LIMIT ON
COST-SHARING SET BY THE UNITED STATES SECRETARY OF HEALTH AND HUMAN
SERVICES, IF AVAILABLE.
(E) THE SUPERINTENDENT MAY REQUIRE THE USE OF MODEL LANGUAGE DESCRIB-
ING THE COVERAGE REQUIREMENTS FOR ANY ACCIDENT AND HEALTH INSURANCE
POLICY FORM THAT IS SUBJECT TO THE SUPERINTENDENT'S APPROVAL PURSUANT TO
SECTION THREE THOUSAND TWO HUNDRED ONE OF THIS ARTICLE.
(F) FOR PURPOSES OF THIS SECTION:
(1) "ACTUARIAL VALUE" MEANS THE PERCENTAGE OF THE TOTAL EXPECTED
PAYMENTS BY THE INSURER FOR BENEFITS PROVIDED TO A STANDARD POPULATION,
WITHOUT REGARD TO THE POPULATION TO WHOM THE INSURER ACTUALLY PROVIDES
BENEFITS;
(2) "COST-SHARING" MEANS ANNUAL DEDUCTIBLES, COINSURANCE, COPAYMENTS,
OR SIMILAR CHARGES, FOR COVERED SERVICES;
(3) "ESSENTIAL HEALTH BENEFITS PACKAGE" MEANS COVERAGE THAT:
S. 1507 54 A. 2007
(A) PROVIDES FOR ESSENTIAL HEALTH BENEFITS;
(B) LIMITS COST-SHARING FOR SUCH COVERAGE IN ACCORDANCE WITH
SUBSECTION (D) OF THIS SECTION; AND
(C) PROVIDES ONE OF THE LEVELS OF COVERAGE DESCRIBED IN SUBSECTION (C)
OF THIS SECTION;
(4) "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN INSURER
IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND
TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS IN
ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. §
18011(E);
(5) "SMALL GROUP" MEANS A GROUP OF ONE HUNDRED OR FEWER EMPLOYEES OR
MEMBERS EXCLUSIVE OF SPOUSES AND DEPENDENTS; AND
(6) "STUDENT ACCIDENT AND HEALTH INSURANCE" SHALL HAVE THE MEANING SET
FORTH IN SUBSECTION (A) OF SECTION THREE THOUSAND TWO HUNDRED FORTY OF
THIS ARTICLE.
§ 11. Subsection (g) of section 3221 of the insurance law, as amended
by chapter 388 of the laws of 2014, is amended to read as follows:
(g) For conversion purposes, an insurer shall offer to the employee or
member a policy at each level of coverage as defined in SUBSECTION (C)
OF section [1302(d) of the affordable care act, 42 U.S.C. § 18022(d)]
THREE THOUSAND TWO HUNDRED SEVENTEEN-I OF THIS ARTICLE that contains the
ESSENTIAL HEALTH benefits PACKAGE described in paragraph [one] THREE of
subsection [(b)] (F) of section [four thousand three hundred twenty-
eight of this chapter] THREE THOUSAND TWO HUNDRED SEVENTEEN-I OF THIS
ARTICLE. Provided, however, the superintendent may, after giving due
consideration to the public interest, approve a request made by an
insurer for the insurer to satisfy the requirements of this subsection
and subsections (e) and (f) of this section through the offering of
policies that comply with this subsection by another insurer, corpo-
ration or health maintenance organization within the insurer's holding
company system, as defined in article fifteen of this chapter.
§ 12. Subsection (h) of section 3221 of the insurance law, as added by
section 54 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(h) Every small group policy or association group policy delivered or
issued for delivery in this state that provides coverage for hospital,
medical or surgical expense insurance and is not a grandfathered health
plan shall provide coverage for the essential health [benefit] BENEFITS
package [as required in section 2707(a) of the public health service
act, 42 U.S.C. § 300gg-6(a)]. For purposes of this subsection:
(1) "essential health benefits package" shall have the meaning set
forth in PARAGRAPH THREE OF SUBSECTION (F) OF section [1302(a) of the
affordable care act, 42 U.S.C. § 18022(a)] THREE THOUSAND TWO HUNDRED
SEVENTEEN-I OF THIS ARTICLE;
(2) "grandfathered health plan" means coverage provided by an insurer
in which an individual was enrolled on March twenty-third, two thousand
ten for as long as the coverage maintains grandfathered status in
accordance with section 1251(e) of the affordable care act, 42 U.S.C. §
18011(e);
(3) "small group" means a group of [fifty or fewer employees or
members exclusive of spouses and dependents; provided, however, that
beginning January first, two thousand sixteen, "small group" means a
group of] one hundred or fewer employees or members exclusive of spouses
and dependents; and
S. 1507 55 A. 2007
(4) "association group" means a group defined in subparagraphs (B),
(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section
four thousand two hundred thirty-five of this chapter, provided that:
(A) the group includes one or more individual members; or
(B) the group includes one or more member employers or other member
groups that are small groups.
§ 13. Subsection (i) of section 3221 of the insurance law, as added by
section 54 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(i) An insurer shall not be required to offer the policyholder any
benefits that must be made available pursuant to this section if the
benefits must be covered pursuant to subsection (h) of this section. For
any policy issued within the health benefit exchange established [pursu-
ant to section 1311 of the affordable care act, 42 U.S.C. § 18031] BY
THIS STATE, an insurer shall not be required to offer the policyholder
any benefits that must be made available pursuant to this section.
§ 14. Paragraph 11 of subsection (k) of section 3221 of the insurance
law, as amended by chapter 469 of the laws of 2018, is amended to read
as follows:
(11) Every policy [which] THAT provides coverage for prescription
drugs shall include coverage for the cost of enteral formulas for home
use, whether administered orally or via tube feeding, for which a physi-
cian or other licensed health care provider legally authorized to
prescribe under title eight of the education law has issued a written
order. Such written order shall state that the enteral formula is clear-
ly medically necessary and has been proven effective as a disease-spe-
cific treatment regimen. Specific diseases and disorders for which
enteral formulas have been proven effective shall include, but are not
limited to, inherited diseases of amino-acid or organic acid metabolism;
Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal
motility such as chronic intestinal pseudo-obstruction; and multiple,
severe food allergies including, but not limited to immunoglobulin E and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders and
impaired absorption of nutrients caused by disorders affecting the
absorptive surface, function, length, and motility of the gastrointesti-
nal tract. Enteral formulas [which] THAT are medically necessary and
taken under written order from a physician for the treatment of specific
diseases shall be distinguished from nutritional supplements taken elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic acid metabolism as well as severe protein allergic conditions shall
include modified solid food products that are low protein [or which],
contain modified protein, or are amino acid based [which] THAT are
medically necessary[, and such coverage for such modified solid food
products for any calendar year or for any continuous period of twelve
months for any insured individual shall not exceed two thousand five
hundred dollars].
§ 15. Items (i) and (ii) of subparagraph (D) of paragraph 13 of
subsection (k) of section 3221 of the insurance law, as added by chapter
219 of the laws of 2011, are amended and a new item (iii) is added to
read as follows:
(i) evidence-based items or services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations of
the United States preventive services task force; [and]
(ii) with respect to women, such additional preventive care and
screenings for bone mineral density not described in item (i) of this
S. 1507 56 A. 2007
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration[.]; AND
(III) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE
SUPERINTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR
PREVIOUS RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) AND (II)
OF THIS SUBPARAGRAPH.
§ 16. Paragraph 19 of subsection (k) of section 3221 of the insurance
law, as amended by chapter 377 of the laws of 2014, is amended to read
as follows:
(19) Every group or blanket accident and health insurance policy
delivered or issued for delivery in this state [which] THAT provides
medical coverage that includes coverage for physician services in a
physician's office and every policy [which] THAT provides major medical
or similar comprehensive-type coverage shall include coverage for equip-
ment and supplies used for the treatment of ostomies, if prescribed by a
physician or other licensed health care provider legally authorized to
prescribe under title eight of the education law. Such coverage shall be
subject to annual deductibles and coinsurance as deemed appropriate by
the superintendent. The coverage required by this paragraph shall be
identical to, and shall not enhance or increase the coverage required as
part of essential health benefits as [required pursuant to] DEFINED IN
SUBSECTION (A) OF section [2707 (a) of the public health services act 42
U.S.C. 300 gg-6(a)] THREE THOUSAND TWO HUNDRED SEVENTEEN-I OF THIS
ARTICLE.
§ 17. Items (iii) and (iv) of subparagraph (E) of paragraph 8 of
subsection (l) of section 3221 of the insurance law, as added by chapter
219 of the laws of 2011, are amended and a new item (v) is added to read
as follows:
(iii) with respect to children, including infants and adolescents,
evidence-informed preventive care and screenings provided for in compre-
hensive guidelines supported by the health resources and services admin-
istration; [and]
(iv) with respect to women, such additional preventive care and
screenings not described in item (i) of this subparagraph and as
provided for in comprehensive guidelines supported by the health
resources and services administration[.]; AND
(V) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) THROUGH (IV) OF
THIS SUBPARAGRAPH.
§ 18. Items (i) and (ii) of subparagraph (D) of paragraph 11 of
subsection (l) of section 3221 of the insurance law, as added by chapter
219 of the laws of 2011, are amended and a new item (iii) is added to
read as follows:
(i) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
(ii) with respect to women, such additional preventive care and
screenings for mammography not described in item (i) of this subpara-
graph and as provided for in comprehensive guidelines supported by the
health resources and services administration[.]; AND
(III) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE
SUPERINTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR
PREVIOUS RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) AND (II)
OF THIS SUBPARAGRAPH.
S. 1507 57 A. 2007
§ 19. Items (i) and (ii) of subparagraph (D) of paragraph 14 of
subsection (l) of section 3221 of the insurance law, as added by chapter
219 of the laws of 2011, are amended and a new item (iii) is added to
read as follows:
(i) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
(ii) with respect to women, such additional preventive care and
screenings for cervical cytology not described in item (i) of this
subparagraph and as provided for in comprehensive guidelines supported
by the health resources and services administration[.]; AND
(III) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE
SUPERINTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR
PREVIOUS RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN ITEMS (I) AND (II)
OF THIS SUBPARAGRAPH.
§ 20. Paragraph 4 of subsection (a) of section 3231 of the insurance
law, as amended by section 69 of part D of chapter 56 of the laws of
2013, is amended to read as follows:
(4) For the purposes of this section, "community rated" means a rating
methodology in which the premium for all persons covered by a policy
form is the same based on the experience of the entire pool of risks of
all individuals or small groups covered by the insurer without regard to
age, sex, health status, tobacco usage or occupation, excluding those
individuals or small groups covered by medicare supplemental insurance.
For medicare supplemental insurance coverage, "community rated" means a
rating methodology in which the premiums for all persons covered by a
policy or contract form is the same based on the experience of the
entire pool of risks covered by that policy or contract form without
regard to age, sex, health status, tobacco usage or occupation.
[Catastrophic health insurance policies issued pursuant to section
1302(e) of the affordable care act, 42 U.S.C. § 18022(e), shall be clas-
sified in a distinct community rating pool.]
§ 21. Subsection (d) of section 3240 of the insurance law, as added by
section 41 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(d) A student accident and health insurance policy or contract shall
provide coverage for essential health benefits as defined in SUBSECTION
(A) OF section [1302(b) of the affordable care act, 42 U.S.C. §
18022(b)] THREE THOUSAND TWO HUNDRED SEVENTEEN-I OR SUBSECTION (A) OF
SECTION FOUR THOUSAND THREE HUNDRED SIX-H OF THIS CHAPTER, AS
APPLICABLE.
§ 22. Subparagraph (A) of paragraph 3 of subsection (d) of section
4235 of the insurance law, as added by section 60 of part D of chapter
56 of the laws of 2013, is amended to read as follows:
(A) "employee" shall have the meaning set forth in [section 2791 of
the public health service act, 42 U.S.C. § 300gg-91(d)(5) or any regu-
lations promulgated thereunder] THE EMPLOYEE RETIREMENT INCOME SECURITY
ACT OF 1974, 29 U.S.C. § 1002(6); and
§ 23. Subparagraphs (C) and (D) of paragraph 3 of subsection (j) of
section 4303 of the insurance law, as added by chapter 219 of the laws
of 2011, are amended and a new subparagraph (E) is added to read as
follows:
(C) with respect to children, including infants and adolescents,
evidence-informed preventive care and screenings provided for in compre-
hensive guidelines supported by the health resources and services admin-
istration; [and]
S. 1507 58 A. 2007
(D) with respect to women, such additional preventive care and screen-
ings not described in subparagraph (A) of this paragraph and as provided
for in comprehensive guidelines supported by the health resources and
services administration[.]; AND
(E) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN SUBPARAGRAPHS (A) THROUGH
(D) OF THIS PARAGRAPH.
§ 24. Subparagraphs (A) and (B) of paragraph 3 of subsection (p) of
section 4303 of the insurance law, as added by chapter 219 of the laws
of 2011, are amended and a new subparagraph (C) is added to read as
follows:
(A) evidence-based items or services for mammography that have in
effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
(B) with respect to women, such additional preventive care and screen-
ings for mammography not described in subparagraph (A) of this paragraph
and as provided for in comprehensive guidelines supported by the health
resources and services administration[.]; AND
(C) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN SUBPARAGRAPHS (A) AND (B) OF
THIS PARAGRAPH.
§ 25. Subparagraphs (A) and (B) of paragraph 3 of subsection (t) of
section 4303 of the insurance law, as added by chapter 219 of the laws
of 2011, are amended and a new subparagraph (C) is added to read as
follows:
(A) evidence-based items or services for cervical cytology that have
in effect a rating of 'A' or 'B' in the current recommendations of the
United States preventive services task force; [and]
(B) with respect to women, such additional preventive care and screen-
ings for cervical cytology not described in subparagraph (A) of this
paragraph and as provided for in comprehensive guidelines supported by
the health resources and services administration[.]; AND
(C) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN SUBPARAGRAPHS (A) AND (B) OF
THIS PARAGRAPH.
§ 26. Subsection (u-1) of section 4303 of the insurance law, as
amended by chapter 377 of the laws of 2014, is amended to read as
follows:
(u-1) A medical expense indemnity corporation or a health service
corporation which provides medical coverage that includes coverage for
physician services in a physician's office and every policy which
provides major medical or similar comprehensive-type coverage shall
include coverage for equipment and supplies used for the treatment of
ostomies, if prescribed by a physician or other licensed health care
provider legally authorized to prescribe under title eight of the educa-
tion law. Such coverage shall be subject to annual deductibles and coin-
surance as deemed appropriate by the superintendent. The coverage
required by this subsection shall be identical to, and shall not enhance
or increase the coverage required as part of essential health benefits
as [required pursuant to] DEFINED IN SUBSECTION (A) OF section [2707(a)
of the public health services act 42 U.S.C. 300 gg-6(a)] FOUR THOUSAND
THREE HUNDRED SIX-H OF THIS ARTICLE.
S. 1507 59 A. 2007
§ 27. Subsection (y) of section 4303 of the insurance law, as amended
by chapter 469 of the laws of 2018, is amended to read as follows:
(y) Every contract [which] THAT provides coverage for prescription
drugs shall include coverage for the cost of enteral formulas for home
use, whether administered orally or via tube feeding, for which a physi-
cian or other licensed health care provider legally authorized to
prescribe under title eight of the education law has issued a written
order. Such written order shall state that the enteral formula is clear-
ly medically necessary and has been proven effective as a disease-spe-
cific treatment regimen. Specific diseases and disorders for which
enteral formulas have been proven effective shall include, but are not
limited to, inherited diseases of amino-acid or organic acid metabolism;
Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal
motility such as chronic intestinal pseudo-obstruction; and multiple,
severe food allergies including, but not limited to immunoglobulin E and
nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
food protein induced enterocolitis syndrome; eosinophilic disorders; and
impaired absorption of nutrients caused by disorders affecting the
absorptive surface, function, length, and motility of the gastrointesti-
nal tract. Enteral formulas [which] THAT are medically necessary and
taken under written order from a physician for the treatment of specific
diseases shall be distinguished from nutritional supplements taken elec-
tively. Coverage for certain inherited diseases of amino acid and organ-
ic acid metabolism as well as severe protein allergic conditions shall
include modified solid food products that are low protein, [or which]
contain modified protein, or are amino acid based [which] THAT are
medically necessary[, and such coverage for such modified solid food
products for any calendar year or for any continuous period of twelve
months for any insured individual shall not exceed two thousand five
hundred dollars].
§ 28. Subparagraphs (A) and (B) of paragraph 4 of subsection (bb) of
section 4303 of the insurance law, as added by chapter 219 of the laws
of 2011, are amended and a new subparagraph (C) is added to read as
follows:
(A) evidence-based items or services for bone mineral density that
have in effect a rating of 'A' or 'B' in the current recommendations of
the United States preventive services task force; [and]
(B) with respect to women, such additional preventive care and screen-
ings for bone mineral density not described in subparagraph (A) of this
paragraph and as provided for in comprehensive guidelines supported by
the health resources and services administration[.]; AND
(C) ANY OTHER PREVENTIVE CARE AND SCREENINGS DESIGNATED BY THE SUPER-
INTENDENT IN A REGULATION THAT ARE CONSISTENT WITH CURRENT OR PREVIOUS
RECOMMENDATIONS OR GUIDELINES IDENTIFIED IN SUBPARAGRAPHS (A) AND (B) OF
THIS PARAGRAPH.
§ 29. Subsection (ll) of section 4303 of the insurance law, as added
by section 55 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(ll) Every small group contract or association group contract [deliv-
ered or issued for delivery in this state] ISSUED BY A CORPORATION
SUBJECT TO THE PROVISIONS OF THIS ARTICLE that provides coverage for
hospital, medical or surgical expense insurance and is not a grandfa-
thered health plan shall provide coverage for the essential health
[benefit] BENEFITS package [as required in section 2707(a) of the public
health service act, 42 U.S.C. § 300gg-6(a)]. For purposes of this
subsection:
S. 1507 60 A. 2007
(1) "essential health benefits package" shall have the meaning set
forth in PARAGRAPH THREE OF SUBSECTION (F) OF section [1302(a) of the
affordable care act, 42 U.S.C. § 18022(a)] FOUR THOUSAND THREE HUNDRED
SIX-H OF THIS ARTICLE;
(2) "grandfathered health plan" means coverage provided by a corpo-
ration in which an individual was enrolled on March twenty-third, two
thousand ten for as long as the coverage maintains grandfathered status
in accordance with section 1251(e) of the affordable care act, 42 U.S.C.
§ 18011(e); and
(3) "small group" means a group of [fifty or fewer employees or
members exclusive of spouses and dependents. Beginning January first,
two thousand sixteen, "small group" means a group of] one hundred or
fewer employees or members exclusive of spouses and dependents; and
(4) "association group" means a group defined in subparagraphs (B),
(D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section
four thousand two hundred thirty-five of this chapter, provided that:
(A) the group includes one or more individual members; or
(B) the group includes one or more member employers or other member
groups that are small groups.
§ 30. Subsection (mm) of section 4303 of the insurance law, as added
by section 55 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(mm) A corporation shall not be required to offer the contract holder
any benefits that must be made available pursuant to this section if
such benefits must be covered pursuant to subsection (kk) of this
section. For any contract issued within the health benefit exchange
established [pursuant to section 1311 of the affordable care act, 42
U.S.C. § 18031] BY THIS STATE, a corporation shall not be required to
offer the contract holder any benefits that must be made available
pursuant to this section.
§ 31. Item (i) of subparagraph (C) of paragraph 2 of subsection (c) of
section 4304 of the insurance law, as amended by chapter 317 of the laws
of 2017, is amended to read as follows:
(i) Discontinuance of a class of contract upon not less than ninety
days' prior written notice. In exercising the option to discontinue
coverage pursuant to this item, the corporation must act uniformly with-
out regard to any health status-related factor of enrolled individuals
or individuals who may become eligible for such coverage and must offer
to subscribers or group remitting agents, as may be appropriate, the
option to purchase all other individual health insurance coverage
currently being offered by the corporation to applicants in that market.
Provided, however, the superintendent may, after giving due consider-
ation to the public interest, approve a request made by a corporation
for the corporation to satisfy the requirements of this item through the
offering of contracts at each level of coverage as defined in SUBSECTION
(C) OF section [1302(d) of the affordable care act, 42 U.S.C. §
18022(d)] FOUR THOUSAND THREE HUNDRED SIX-H OF THIS ARTICLE that
contains the ESSENTIAL HEALTH benefits PACKAGE described in paragraph
[one] THREE of subsection [(b)] (F) of section four thousand three
hundred [twenty-eight] SIX-H of this [chapter] ARTICLE by another corpo-
ration, insurer or health maintenance organization within the corpo-
ration's same holding company system, as defined in article fifteen of
this chapter.
§ 32. Paragraph 1 of subsection (e) of section 4304 of the insurance
law, as amended by chapter 388 of the laws of 2014, is amended to read
as follows:
S. 1507 61 A. 2007
(1) (A) If any such contract is terminated in accordance with the
provisions of paragraph one of subsection (c) of this section, or any
such contract is terminated because of a default by the remitting agent
in the payment of premiums not cured within the grace period and the
remitting agent has not replaced the contract with similar and contin-
uous coverage for the same group whether insured or self-insured, or any
such contract is terminated in accordance with the provisions of subpar-
agraph (E) of paragraph two of subsection (c) of this section, or if an
individual other than the contract holder is no longer covered under a
"family contract" because the individual is no longer within the defi-
nition set forth in the contract, or a spouse is no longer covered under
the contract because of divorce from the contract holder or annulment of
the marriage, or any such contract is terminated because of the death of
the contract holder, then such individual, former spouse, or in the case
of the death of the contract holder the surviving spouse or other depen-
dents of the deceased contract holder covered under the contract, as the
case may be, shall be entitled to convert, without evidence of insura-
bility, upon application therefor and the making of the first payment
thereunder within sixty days after the date of termination of such
contract, to a contract that contains the ESSENTIAL HEALTH benefits
PACKAGE described in paragraph [one] THREE of subsection [(b)] (F) of
section four thousand three hundred [twenty-eight] SIX-H of this [chap-
ter] ARTICLE.
(B) The corporation shall offer one contract at each level of coverage
as defined in SUBSECTION (C) OF section [1302(d) of the affordable care
act, 42 U.S.C. § 18022(d)] FOUR THOUSAND THREE HUNDRED SIX-H OF THIS
ARTICLE. The individual may choose any such contract offered by the
corporation. Provided, however, the superintendent may, after giving due
consideration to the public interest, approve a request made by a corpo-
ration for the corporation to satisfy the requirements of this paragraph
through the offering of contracts that comply with this paragraph by
another corporation, insurer or health maintenance organization within
the corporation's same holding company system, as defined in article
fifteen of this chapter.
(C) The effective date of the coverage provided by the converted
direct payment contract shall be the date of the termination of coverage
under the contract from which conversion was made.
§ 33. Subsection (l) of section 4304 of the insurance law, as added by
section 43 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(l) [On and after October first, two thousand thirteen, a] A corpo-
ration shall not offer individual hospital, medical, or surgical expense
insurance contracts unless the contracts meet the requirements of
subsection (b) of section four thousand three hundred twenty-eight of
this article. Such contracts that are offered within the health benefit
exchange established [pursuant to section 1311 of the affordable care
act, 42 U.S.C. § 18031, or any regulations promulgated thereunder,] BY
THIS STATE also shall meet any requirements established by the health
benefit exchange. To the extent that a holder of a special purpose
certificate of authority issued pursuant to section four thousand four
hundred three-a of the public health law offers individual hospital,
medical, or surgical expense insurance contracts, the contracts shall
meet the requirements of subsection (b) of section four thousand three
hundred twenty-eight of this article.
S. 1507 62 A. 2007
§ 34. Subparagraph (A) of paragraph 1 of subsection (d) of section
4305 of the insurance law, as amended by chapter 388 of the laws of
2014, is amended to read as follows:
(A) A group contract issued pursuant to this section shall contain a
provision to the effect that in case of a termination of coverage under
such contract of any member of the group because of (i) termination for
any reason whatsoever of the member's employment or membership, or (ii)
termination for any reason whatsoever of the group contract itself
unless the group contract holder has replaced the group contract with
similar and continuous coverage for the same group whether insured or
self-insured, the member shall be entitled to have issued to the member
by the corporation, without evidence of insurability, upon application
therefor and payment of the first premium made to the corporation within
sixty days after termination of the coverage, an individual direct
payment contract, covering such member and the member's eligible depen-
dents who were covered by the group contract, which provides coverage
that contains the ESSENTIAL HEALTH benefits PACKAGE described in para-
graph [one] THREE of subsection [(b)] (F) of section four thousand three
hundred [twenty-eight] SIX-H of this [chapter] ARTICLE. The corporation
shall offer one contract at each level of coverage as defined in
SUBSECTION (C) OF section [1302(d) of the affordable care act, 42 U.S.C.
§ 18022(d)] FOUR THOUSAND THREE HUNDRED SIX-H OF THIS ARTICLE. The
member may choose any such contract offered by the corporation.
Provided, however, the superintendent may, after giving due consider-
ation to the public interest, approve a request made by a corporation
for the corporation to satisfy the requirements of this subparagraph
through the offering of contracts that comply with this subparagraph by
another corporation, insurer or health maintenance organization within
the corporation's same holding company system, as defined in article
fifteen of this chapter.
§ 35. The insurance law is amended by adding a new section 4306-h to
read as follows:
§ 4306-H. ESSENTIAL HEALTH BENEFITS PACKAGE AND LIMIT ON COST-SHARING.
(A) FOR PURPOSES OF THIS ARTICLE, "ESSENTIAL HEALTH BENEFITS" SHALL MEAN
THE FOLLOWING CATEGORIES OF BENEFITS:
(1) AMBULATORY PATIENT SERVICES;
(2) EMERGENCY SERVICES;
(3) HOSPITALIZATION;
(4) MATERNITY AND NEWBORN CARE;
(5) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES, INCLUDING
BEHAVIORAL HEALTH TREATMENT;
(6) PRESCRIPTION DRUGS;
(7) REHABILITATIVE AND HABILITATIVE SERVICES AND DEVICES;
(8) LABORATORY SERVICES;
(9) PREVENTIVE AND WELLNESS SERVICES AND CHRONIC DISEASE MANAGEMENT;
AND
(10) PEDIATRIC SERVICES, INCLUDING ORAL AND VISION CARE.
(B) THE SUPERINTENDENT, IN CONSULTATION WITH THE COMMISSIONER OF
HEALTH, MAY SELECT AS A BENCHMARK, A PLAN OR COMBINATION OF PLANS THAT
TOGETHER CONTAIN ESSENTIAL HEALTH BENEFITS, IN ACCORDANCE WITH THIS
SECTION AND ANY APPLICABLE FEDERAL REGULATION.
(C) (1) EVERY INDIVIDUAL AND SMALL GROUP CONTRACT THAT PROVIDES HOSPI-
TAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE AND IS NOT A GRANDFATHERED
HEALTH PLAN SHALL PROVIDE COVERAGE THAT MEETS THE ACTUARIAL REQUIREMENTS
OF ONE OF THE FOLLOWING LEVELS OF COVERAGE:
S. 1507 63 A. 2007
(A) BRONZE LEVEL. A PLAN IN THE BRONZE LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO SIXTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN;
(B) SILVER LEVEL. A PLAN IN THE SILVER LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO SEVENTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENE-
FITS PROVIDED UNDER THE PLAN;
(C) GOLD LEVEL. A PLAN IN THE GOLD LEVEL SHALL PROVIDE A LEVEL OF
COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO EIGHTY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN; OR
(D) PLATINUM LEVEL. A PLAN IN THE PLATINUM LEVEL SHALL PROVIDE A LEVEL
OF COVERAGE THAT IS DESIGNED TO PROVIDE BENEFITS THAT ARE ACTUARIALLY
EQUIVALENT TO NINETY PERCENT OF THE FULL ACTUARIAL VALUE OF THE BENEFITS
PROVIDED UNDER THE PLAN.
(2) THE SUPERINTENDENT MAY PROVIDE FOR A VARIATION IN THE ACTUARIAL
VALUES USED IN DETERMINING THE LEVEL OF COVERAGE OF A PLAN TO ACCOUNT
FOR THE DIFFERENCES IN ACTUARIAL ESTIMATES.
(3) EVERY STUDENT ACCIDENT AND HEALTH INSURANCE CONTRACT SHALL PROVIDE
COVERAGE THAT MEETS AT LEAST SIXTY PERCENT OF THE FULL ACTUARIAL VALUE
OF THE BENEFITS PROVIDED UNDER THE CONTRACT. THE CONTRACT'S SCHEDULE OF
BENEFITS SHALL INCLUDE THE LEVEL AS DESCRIBED IN PARAGRAPH ONE OF THIS
SUBSECTION NEAREST TO, BUT BELOW THE ACTUAL ACTUARIAL VALUE.
(D) EVERY INDIVIDUAL OR GROUP CONTRACT THAT PROVIDES HOSPITAL, SURGI-
CAL, OR MEDICAL EXPENSE COVERAGE AND IS NOT A GRANDFATHERED HEALTH PLAN,
AND EVERY STUDENT ACCIDENT AND HEALTH INSURANCE CONTRACT SHALL LIMIT THE
INSURED'S COST-SHARING FOR IN-NETWORK SERVICES IN A CONTRACT YEAR TO NOT
MORE THAN THE MAXIMUM OUT-OF-POCKET AMOUNT DETERMINED BY THE SUPERINTEN-
DENT FOR ALL CONTRACTS SUBJECT TO THIS SECTION. SUCH AMOUNT SHALL NOT
EXCEED ANY ANNUAL OUT-OF-POCKET LIMIT ON COST-SHARING SET BY THE UNITED
STATES SECRETARY OF HEALTH AND HUMAN SERVICES, IF AVAILABLE.
(E) THE SUPERINTENDENT MAY REQUIRE THE USE OF MODEL LANGUAGE DESCRIB-
ING THE COVERAGE REQUIREMENTS FOR ANY FORM THAT IS SUBJECT TO THE
APPROVAL OF THE SUPERINTENDENT PURSUANT TO SECTION FOUR THOUSAND THREE
HUNDRED EIGHT OF THIS ARTICLE.
(F) FOR PURPOSES OF THIS SECTION:
(1) "ACTUARIAL VALUE" MEANS THE PERCENTAGE OF THE TOTAL EXPECTED
PAYMENTS BY THE CORPORATION FOR BENEFITS PROVIDED TO A STANDARD POPU-
LATION, WITHOUT REGARD TO THE POPULATION TO WHOM THE CORPORATION ACTUAL-
LY PROVIDES BENEFITS;
(2) "COST-SHARING" MEANS ANNUAL DEDUCTIBLES, COINSURANCE, COPAYMENTS,
OR SIMILAR CHARGES, FOR COVERED SERVICES;
(3) "ESSENTIAL HEALTH BENEFITS PACKAGE" MEANS COVERAGE THAT:
(A) PROVIDES FOR ESSENTIAL HEALTH BENEFITS;
(B) LIMITS COST-SHARING FOR SUCH COVERAGE IN ACCORDANCE WITH
SUBSECTION (D) OF THIS SECTION; AND
(C) PROVIDES ONE OF THE LEVELS OF COVERAGE DESCRIBED IN SUBSECTION (C)
OF THIS SECTION;
(4) "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY A CORPO-
RATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON MARCH TWENTY-THIRD, TWO
THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS
IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
§ 18011(E);
(5) "SMALL GROUP" MEANS A GROUP OF ONE HUNDRED OR FEWER EMPLOYEES OR
MEMBERS EXCLUSIVE OF SPOUSES AND DEPENDENTS; AND
S. 1507 64 A. 2007
(6) "STUDENT ACCIDENT AND HEALTH INSURANCE" SHALL HAVE THE MEANING SET
FORTH IN SUBSECTION (A) OF SECTION THREE THOUSAND TWO HUNDRED FORTY OF
THIS CHAPTER.
§ 36. Paragraph 4 of subsection (a) of section 4317 of the insurance
law, as amended by section 72 of part D of chapter 56 of the laws of
2013, is amended to read as follows:
(4) For the purposes of this section, "community rated" means a rating
methodology in which the premium for all persons covered by a policy or
contract form is the same, based on the experience of the entire pool of
risks of all individuals or small groups covered by the corporation
without regard to age, sex, health status, tobacco usage or occupation
excluding those individuals of small groups covered by Medicare supple-
mental insurance. For medicare supplemental insurance coverage, "commu-
nity rated" means a rating methodology in which the premiums for all
persons covered by a policy or contract form is the same based on the
experience of the entire pool of risks covered by that policy or
contract form without regard to age, sex, health status, tobacco usage
or occupation. [Catastrophic health insurance contracts issued pursuant
to section 1302(e) of the affordable care act, 42 U.S.C. § 18022(e),
shall be classified in a distinct community rating pool.]
§ 37. Subsections (d), (e) and (j) of section 4326 of the insurance
law, as amended by section 56 of part D of chapter 56 of the laws of
2013, are amended to read as follows:
(d) A qualifying group health insurance contract shall provide cover-
age for the essential health [benefit] BENEFITS package as [required in]
DEFINED IN PARAGRAPH THREE OF SUBSECTION (F) OF section [2707(a) of the
public health service act, 42 U.S.C. § 300gg-6(a). For purposes of this
subsection "essential health benefits package" shall have the meaning
set forth in section 1302(a) of the affordable care act, 42 U.S.C. §
18022(a)] FOUR THOUSAND THREE HUNDRED SIX-H OF THIS ARTICLE.
(e) A qualifying group health insurance contract [issued to a qualify-
ing small employer prior to January first, two thousand fourteen that
does not include all essential health benefits required pursuant to
section 2707(a) of the public health service act, 42 U.S.C. §
300gg-6(a), shall be discontinued, including grandfathered health plans.
For the purposes of this paragraph, "grandfathered health plans" means
coverage provided by a corporation to individuals who were enrolled on
March twenty-third, two thousand ten for as long as the coverage main-
tains grandfathered status in accordance with section 1251(e) of the
affordable care act, 42 U.S.C. § 18011(e). A qualifying small employer
shall be transitioned to a plan that provides: (1)] SHALL PROVIDE a
level of coverage that is designed to provide benefits that are actuari-
ally equivalent to eighty percent of the full actuarial value of the
benefits provided under the plan[; and (2) coverage for the essential
health benefit package as required in section 2707(a) of the public
health service act, 42 U.S.C. § 300gg-6(a)]. The superintendent shall
standardize the benefit package and cost sharing requirements of quali-
fied group health insurance contracts consistent with coverage offered
through the health benefit exchange established [pursuant to section
1311 of the affordable care act, 42 U.S.C. § 18031] BY THIS STATE.
(j) [Beginning January first, two thousand fourteen, pursuant to
section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A
corporation shall not impose any pre-existing condition limitation in a
qualifying group health insurance contract.
S. 1507 65 A. 2007
§ 38. Subsection (m-1) of section 4327 of the insurance law, as
amended by section 58 of part D of chapter 56 of the laws of 2013, is
amended to read as follows:
(m-1) In the event that the superintendent suspends the enrollment of
new individuals for qualifying group health insurance contracts, the
superintendent shall ensure that small employers seeking to enroll in a
qualified group health insurance contract pursuant to section forty-
three hundred twenty-six of this article are provided information on and
directed to coverage options available through the health benefit
exchange established [pursuant to section 1311 of the affordable care
act, 42 U.S.C. § 18031] BY THIS STATE.
§ 39. Paragraphs 1, 2 and 3 of subsection (b) of section 4328 of the
insurance law, as added by section 46 of part D of chapter 56 of the
laws of 2013, are amended to read as follows:
(1) The individual enrollee direct payment contract offered pursuant
to this section shall provide coverage for the essential health [bene-
fit] BENEFITS package as [required in] DEFINED IN PARAGRAPH THREE OF
SUBSECTION (F) OF section [2707(a) of the public health service act, 42
U.S.C. § 300gg-6(a). For purposes of this paragraph, "essential health
benefits package" shall have the meaning set forth in section 1302(a) of
the affordable care act, 42 U.S.C. § 18022(a)] FOUR THOUSAND THREE
HUNDRED SIX-H OF THIS ARTICLE.
(2) A health maintenance organization shall offer at least one indi-
vidual enrollee direct payment contract at each level of coverage as
defined in SUBSECTION (C) OF section [1302(d) of the affordable care
act, 42 U.S.C. § 18022(d)] FOUR THOUSAND THREE HUNDRED SIX-H OF THIS
ARTICLE. A health maintenance organization also shall offer one child-
only plan, AS REQUIRED BY SECTION 1302(F) OF THE AFFORDABLE CARE ACT, 42
U.S.C. § 18022(F), at each level of coverage [as required in section
2707(c) of the public health service act, 42 U.S.C. § 300gg-6(c)].
(3) Within the health benefit exchange established [pursuant to
section 1311 of the affordable care act, 42 U.S.C. § 18031] BY THIS
STATE, a health maintenance organization may offer an individual enrol-
lee direct payment contract that is a catastrophic health plan as
defined in section 1302(e) of the affordable care act, 42 U.S.C. §
18022(e), or any regulations promulgated thereunder.
§ 40. Subparagraph (A) of paragraph 4 of subsection (b) of section
4328 of the insurance law, as added by chapter 11 of the laws of 2016,
is amended to read as follows:
(A) The individual enrollee direct payment contract offered pursuant
to this section shall have the same enrollment periods, including
special enrollment periods, as required for an individual direct payment
contract offered within the health benefit exchange established [pursu-
ant to section 1311 of the affordable care act, 42 U.S.C. § 18031, or
any regulations promulgated thereunder] BY THIS STATE.
§ 41. Subsection (c) of section 4328 of the insurance law, as added by
section 46 of part D of chapter 56 of the laws of 2013, is amended to
read as follows:
(c) In addition to or in lieu of the individual enrollee direct
payment contracts required under this section, all health maintenance
organizations issued a certificate of authority under article forty-four
of the public health law or licensed under this article may offer indi-
vidual enrollee direct payment contracts within the health benefit
exchange established [pursuant to section 1311 of the affordable care
act, 42 U.S.C. § 18031, or any regulations promulgated thereunder] BY
THIS STATE, subject to any requirements established by the health bene-
S. 1507 66 A. 2007
fit exchange. If a health maintenance organization satisfies the
requirements of subsection (a) of this section by offering individual
enrollee direct payment contracts, only within the health benefit
exchange, the health maintenance organization, not including a holder of
a special purpose certificate of authority issued pursuant to section
four thousand four hundred three-a of the public health law, shall also
offer at least one individual enrollee direct payment contract at each
level of coverage as defined in SUBSECTION (C) section [1302 (d) of the
affordable care act, 42 U.S.C. § 18022 (d)] FOUR THOUSAND THREE HUNDRED
SIX-H OF THIS ARTICLE, outside the health benefit exchange.
§ 42. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
SUBPART C
Section 1. Subsection (i) of section 3216 of the insurance law is
amended by adding a new paragraph 35 to read as follows:
(35) NO POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE THAT
PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE SHALL LIMIT OR
EXCLUDE COVERAGE FOR ABORTIONS THAT ARE MEDICALLY NECESSARY. COVERAGE
FOR ABORTIONS THAT ARE MEDICALLY NECESSARY SHALL NOT BE SUBJECT TO ANNU-
AL DEDUCTIBLES OR COINSURANCE, INCLUDING CO-PAYMENTS, UNLESS THE POLICY
IS A HIGH DEDUCTIBLE HEALTH PLAN AS DEFINED IN SECTION 223(C)(2) OF THE
INTERNAL REVENUE CODE OF 1986; IN WHICH CASE COVERAGE FOR MEDICALLY
NECESSARY ABORTIONS MAY BE SUBJECT TO THE PLAN'S ANNUAL DEDUCTIBLE.
§ 2. Subsection (l) of section 3221 of the insurance law is amended by
adding a new paragraph 21 to read as follows:
(21) (A) NO POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE THAT
PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE SHALL LIMIT OR
EXCLUDE COVERAGE FOR ABORTIONS THAT ARE MEDICALLY NECESSARY. COVERAGE
FOR ABORTIONS THAT ARE MEDICALLY NECESSARY SHALL NOT BE SUBJECT TO ANNU-
AL DEDUCTIBLES OR COINSURANCE, INCLUDING CO-PAYMENTS, UNLESS THE POLICY
IS A HIGH DEDUCTIBLE HEALTH PLAN AS DEFINED IN SECTION 223(C)(2) OF THE
INTERNAL REVENUE CODE OF 1986; IN WHICH CASE COVERAGE FOR MEDICALLY
NECESSARY ABORTIONS MAY BE SUBJECT TO THE PLAN'S ANNUAL DEDUCTIBLE.
(B) NOTWITHSTANDING ANY OTHER PROVISION, A GROUP POLICY THAT PROVIDES
HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE DELIVERED OR ISSUED FOR
DELIVERY IN THIS STATE TO A RELIGIOUS EMPLOYER, AS DEFINED IN PARAGRAPH
SIXTEEN OF THIS SUBSECTION, MAY EXCLUDE COVERAGE FOR MEDICALLY NECESSARY
ABORTIONS ONLY IF THE INSURER:
(I) OBTAINS AN ANNUAL CERTIFICATION FROM THE GROUP POLICYHOLDER THAT
THE POLICYHOLDER IS A RELIGIOUS EMPLOYER AND THAT THE RELIGIOUS EMPLOYER
REQUESTS A POLICY WITHOUT COVERAGE FOR MEDICALLY NECESSARY ABORTIONS;
(II) ISSUES A RIDER TO EACH CERTIFICATEHOLDER AT NO PREMIUM TO BE
CHARGED TO THE CERTIFICATEHOLDER OR RELIGIOUS EMPLOYER FOR THE RIDER,
THAT PROVIDES COVERAGE FOR MEDICALLY NECESSARY ABORTIONS SUBJECT TO THE
SAME RULES AS WOULD HAVE BEEN APPLIED TO THE SAME CATEGORY OF TREATMENT
IN THE POLICY ISSUED TO THE RELIGIOUS EMPLOYER. THE RIDER SHALL CLEARLY
AND CONSPICUOUSLY SPECIFY THAT THE RELIGIOUS EMPLOYER DOES NOT ADMINIS-
TER MEDICALLY NECESSARY ABORTION BENEFITS, BUT THAT THE INSURER IS ISSU-
ING A RIDER FOR COVERAGE OF MEDICALLY NECESSARY ABORTIONS, AND SHALL
PROVIDE THE INSURER'S CONTACT INFORMATION FOR QUESTIONS; AND
(III) PROVIDES NOTICE OF THE ISSUANCE OF THE POLICY AND RIDER TO THE
SUPERINTENDENT IN A FORM AND MANNER ACCEPTABLE TO THE SUPERINTENDENT.
S. 1507 67 A. 2007
§ 3. Section 4303 of the insurance law is amended by adding a new
subsection (ss) to read as follows:
(SS) (1) NO CONTRACT ISSUED BY A CORPORATION SUBJECT TO THE PROVISIONS
OF THIS ARTICLE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE
COVERAGE SHALL LIMIT OR EXCLUDE COVERAGE FOR ABORTIONS THAT ARE
MEDICALLY NECESSARY. COVERAGE FOR ABORTIONS THAT ARE MEDICALLY NECESSARY
SHALL NOT BE SUBJECT TO ANNUAL DEDUCTIBLES OR COINSURANCE, INCLUDING
CO-PAYMENTS, UNLESS THE CONTRACT IS A HIGH DEDUCTIBLE HEALTH PLAN AS
DEFINED IN SECTION 223(C)(2) OF THE INTERNAL REVENUE CODE OF 1986 IN
WHICH CASE COVERAGE FOR MEDICALLY NECESSARY ABORTIONS MAY BE SUBJECT TO
THE CONTRACT'S ANNUAL DEDUCTIBLE.
(2) NOTWITHSTANDING ANY OTHER PROVISION, A GROUP CONTRACT THAT
PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE DELIVERED OR
ISSUED FOR DELIVERY IN THIS STATE TO A RELIGIOUS EMPLOYER AS DEFINED IN
SUBSECTION (CC) OF THIS SECTION MAY EXCLUDE COVERAGE FOR MEDICALLY
NECESSARY ABORTIONS ONLY IF THE CORPORATION:
(A) OBTAINS AN ANNUAL CERTIFICATION FROM THE GROUP CONTRACTHOLDER THAT
THE CONTRACTHOLDER IS A RELIGIOUS EMPLOYER AND THAT THE RELIGIOUS
EMPLOYER REQUESTS A CONTRACT WITHOUT COVERAGE FOR MEDICALLY NECESSARY
ABORTIONS;
(B) ISSUES A RIDER TO EACH CERTIFICATEHOLDER AT NO PREMIUM TO BE
CHARGED TO THE CERTIFICATEHOLDER OR RELIGIOUS EMPLOYER FOR THE RIDER,
THAT PROVIDES COVERAGE FOR MEDICALLY NECESSARY ABORTIONS SUBJECT TO THE
SAME RULES AS WOULD HAVE BEEN APPLIED TO THE SAME CATEGORY OF TREATMENT
IN THE CONTRACT ISSUED TO THE RELIGIOUS EMPLOYER. THE RIDER MUST CLEARLY
AND CONSPICUOUSLY SPECIFY THAT THE RELIGIOUS EMPLOYER DOES NOT ADMINIS-
TER MEDICALLY NECESSARY ABORTION BENEFITS, BUT THAT THE CORPORATION IS
ISSUING A RIDER FOR COVERAGE OF MEDICALLY NECESSARY ABORTIONS, AND SHALL
PROVIDE THE CORPORATION'S CONTACT INFORMATION FOR QUESTIONS; AND
(C) PROVIDES NOTICE OF THE ISSUANCE OF THE CONTRACT AND RIDER TO THE
SUPERINTENDENT IN A FORM AND MANNER ACCEPTABLE TO THE SUPERINTENDENT.
§ 4. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
SUBPART D
Section 1. The insurance law is amended by adding a new section 3242
to read as follows:
§ 3242. PRESCRIPTION DRUG COVERAGE. (A) EVERY INSURER THAT DELIVERS
OR ISSUES FOR DELIVERY IN THIS STATE A POLICY THAT PROVIDES COVERAGE FOR
PRESCRIPTION DRUGS SHALL, WITH RESPECT TO THE PRESCRIPTION DRUG COVER-
AGE, PUBLISH AN UP-TO-DATE, ACCURATE, AND COMPLETE LIST OF ALL COVERED
PRESCRIPTION DRUGS ON ITS FORMULARY DRUG LIST, INCLUDING ANY TIERING
STRUCTURE THAT IT HAS ADOPTED AND ANY RESTRICTIONS ON THE MANNER IN
WHICH A PRESCRIPTION DRUG MAY BE OBTAINED, IN A MANNER THAT IS EASILY
ACCESSIBLE TO INSUREDS AND PROSPECTIVE INSUREDS. THE FORMULARY DRUG LIST
SHALL CLEARLY IDENTIFY THE PREVENTIVE PRESCRIPTION DRUGS THAT ARE AVAIL-
ABLE WITHOUT ANNUAL DEDUCTIBLES OR COINSURANCE, INCLUDING CO-PAYMENTS.
(B) (1) EVERY POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE
THAT PROVIDES COVERAGE FOR PRESCRIPTION DRUGS SHALL INCLUDE IN THE POLI-
CY A PROCESS THAT ALLOWS AN INSURED, THE INSURED'S DESIGNEE, OR THE
INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO REQUEST A FORMULARY EXCEP-
TION. WITH RESPECT TO THE PROCESS FOR SUCH A FORMULARY EXCEPTION, AN
INSURER SHALL FOLLOW THE PROCESS AND PROCEDURES SPECIFIED IN ARTICLE
S. 1507 68 A. 2007
FORTY-NINE OF THIS CHAPTER AND ARTICLE FORTY-NINE OF THE PUBLIC HEALTH
LAW, EXCEPT AS OTHERWISE PROVIDED IN PARAGRAPHS TWO, THREE, FOUR AND
FIVE OF THIS SUBSECTION.
(2) (A) AN INSURER SHALL HAVE A PROCESS FOR AN INSURED, THE INSURED'S
DESIGNEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO REQUEST A
STANDARD REVIEW THAT IS NOT BASED ON EXIGENT CIRCUMSTANCES OF A FORMU-
LARY EXCEPTION FOR A PRESCRIPTION DRUG THAT IS NOT COVERED BY THE POLI-
CY.
(B) AN INSURER SHALL MAKE A DETERMINATION ON A STANDARD EXCEPTION
REQUEST THAT IS NOT BASED ON EXIGENT CIRCUMSTANCES AND NOTIFY THE
INSURED OR THE INSURED'S DESIGNEE AND THE INSURED'S PRESCRIBING HEALTH
CARE PROVIDER BY TELEPHONE OF ITS COVERAGE DETERMINATION NO LATER THAN
SEVENTY-TWO HOURS FOLLOWING RECEIPT OF THE REQUEST.
(C) AN INSURER THAT GRANTS A STANDARD EXCEPTION REQUEST THAT IS NOT
BASED ON EXIGENT CIRCUMSTANCES SHALL PROVIDE COVERAGE OF THE NON-FORMU-
LARY PRESCRIPTION DRUG FOR THE DURATION OF THE PRESCRIPTION, INCLUDING
REFILLS.
(D) FOR THE PURPOSE OF THIS SUBSECTION, "EXIGENT CIRCUMSTANCES" MEANS
WHEN AN INSURED IS SUFFERING FROM A HEALTH CONDITION THAT MAY SERIOUSLY
JEOPARDIZE THE INSURED'S LIFE, HEALTH, OR ABILITY TO REGAIN MAXIMUM
FUNCTION OR WHEN AN INSURED IS UNDERGOING A CURRENT COURSE OF TREATMENT
USING A NON-FORMULARY PRESCRIPTION DRUG.
(3) (A) AN INSURER SHALL HAVE A PROCESS FOR AN INSURED, THE INSURED'S
DESIGNEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO REQUEST
AN EXPEDITED REVIEW BASED ON EXIGENT CIRCUMSTANCES OF A FORMULARY EXCEP-
TION FOR A PRESCRIPTION DRUG THAT IS NOT COVERED BY THE POLICY.
(B) AN INSURER SHALL MAKE A DETERMINATION ON AN EXPEDITED REVIEW
REQUEST BASED ON EXIGENT CIRCUMSTANCES AND NOTIFY THE INSURED OR THE
INSURED'S DESIGNEE AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY
TELEPHONE OF ITS COVERAGE DETERMINATION NO LATER THAN TWENTY-FOUR HOURS
FOLLOWING RECEIPT OF THE REQUEST.
(C) AN INSURER THAT GRANTS AN EXCEPTION BASED ON EXIGENT CIRCUMSTANCES
SHALL PROVIDE COVERAGE OF THE NON-FORMULARY PRESCRIPTION DRUG FOR THE
DURATION OF THE EXIGENT CIRCUMSTANCES.
(4) AN INSURER THAT DENIES AN EXCEPTION REQUEST UNDER PARAGRAPH TWO OR
THREE OF THIS SUBSECTION SHALL PROVIDE WRITTEN NOTICE OF ITS DETERMI-
NATION TO THE INSURED OR THE INSURED'S DESIGNEE AND THE INSURED'S
PRESCRIBING HEALTH CARE PROVIDER WITHIN THREE BUSINESS DAYS OF RECEIPT
OF THE EXCEPTION REQUEST. THE WRITTEN NOTICE SHALL BE CONSIDERED A FINAL
ADVERSE DETERMINATION UNDER SECTION FOUR THOUSAND NINE HUNDRED FOUR OF
THIS CHAPTER OR SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THE PUBLIC
HEALTH LAW. WRITTEN NOTICE SHALL ALSO INCLUDE THE NAME OR NAMES OF CLIN-
ICALLY APPROPRIATE PRESCRIPTION DRUGS COVERED BY THE INSURER TO TREAT
THE INSURED.
(5) (A) IF AN INSURER DENIES A REQUEST FOR AN EXCEPTION UNDER PARA-
GRAPH TWO OR THREE OF THIS SUBSECTION, THE INSURED, THE INSURED'S DESIG-
NEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER SHALL HAVE THE
RIGHT TO REQUEST THAT SUCH DENIAL BE REVIEWED BY AN EXTERNAL APPEAL
AGENT CERTIFIED BY THE SUPERINTENDENT PURSUANT TO SECTION FOUR THOUSAND
NINE HUNDRED ELEVEN OF THIS CHAPTER IN ACCORDANCE WITH ARTICLE FORTY-
NINE OF THIS CHAPTER OR ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW.
(B) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION ON THE
EXTERNAL APPEAL AND NOTIFY THE INSURER, THE INSURED OR THE INSURED'S
DESIGNEE, AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY TELE-
PHONE OF ITS DETERMINATION NO LATER THAN SEVENTY-TWO HOURS FOLLOWING THE
EXTERNAL APPEAL AGENT'S RECEIPT OF THE REQUEST, IF THE ORIGINAL REQUEST
S. 1507 69 A. 2007
WAS A STANDARD EXCEPTION REQUEST UNDER PARAGRAPH TWO OF THIS SUBSECTION.
THE EXTERNAL APPEAL AGENT SHALL NOTIFY THE INSURER, THE INSURED OR THE
INSURED'S DESIGNEE, AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER
IN WRITING OF THE EXTERNAL APPEAL DETERMINATION WITHIN TWO BUSINESS DAYS
OF RENDERING SUCH DETERMINATION.
(C) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION ON THE
EXTERNAL APPEAL AND NOTIFY THE INSURER, THE INSURED OR THE INSURED'S
DESIGNEE, AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY TELE-
PHONE OF ITS DETERMINATION NO LATER THAN TWENTY-FOUR HOURS FOLLOWING THE
EXTERNAL APPEAL AGENT'S RECEIPT OF THE REQUEST, IF THE ORIGINAL REQUEST
WAS AN EXPEDITED EXCEPTION REQUEST UNDER PARAGRAPH THREE OF THIS
SUBSECTION AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER ATTESTS
THAT EXIGENT CIRCUMSTANCES EXIST. THE EXTERNAL APPEAL AGENT SHALL NOTIFY
THE INSURER, THE INSURED OR THE INSURED'S DESIGNEE, AND THE INSURED'S
PRESCRIBING HEALTH CARE PROVIDER IN WRITING OF THE EXTERNAL APPEAL
DETERMINATION WITHIN SEVENTY-TWO HOURS OF THE EXTERNAL APPEAL AGENT'S
RECEIPT OF THE EXTERNAL APPEAL.
(D) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION IN ACCORDANCE
WITH SUBPARAGRAPH (A) OF PARAGRAPH FOUR OF SUBSECTION (B) OF SECTION
FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS CHAPTER OR SUBPARAGRAPH (A)
OF PARAGRAPH (D) OF SUBDIVISION TWO OF SECTION FOUR THOUSAND NINE
HUNDRED FOURTEEN OF THE PUBLIC HEALTH LAW. WHEN MAKING A DETERMINATION,
THE EXTERNAL APPEAL AGENT SHALL CONSIDER WHETHER THE FORMULARY
PRESCRIPTION DRUG COVERED BY THE INSURER WILL BE OR HAS BEEN INEFFEC-
TIVE, WOULD NOT BE AS EFFECTIVE AS THE NON-FORMULARY PRESCRIPTION DRUG,
OR WOULD HAVE ADVERSE EFFECTS.
(E) IF AN EXTERNAL APPEAL AGENT OVERTURNS THE INSURER'S DENIAL OF A
STANDARD EXCEPTION REQUEST UNDER PARAGRAPH TWO OF THIS SUBSECTION, THEN
THE INSURER SHALL PROVIDE COVERAGE OF THE NON-FORMULARY PRESCRIPTION
DRUG FOR THE DURATION OF THE PRESCRIPTION, INCLUDING REFILLS. IF AN
EXTERNAL APPEAL AGENT OVERTURNS THE INSURER'S DENIAL OF AN EXPEDITED
EXCEPTION REQUEST UNDER PARAGRAPH THREE OF THIS SUBSECTION, THEN THE
INSURER SHALL PROVIDE COVERAGE OF THE NON-FORMULARY PRESCRIPTION DRUG
FOR THE DURATION OF THE EXIGENT CIRCUMSTANCES.
§ 2. The insurance law is amended by adding a new section 4329 to read
as follows:
§ 4329. PRESCRIPTION DRUG COVERAGE. (A) EVERY CORPORATION SUBJECT TO
THE PROVISIONS OF THIS ARTICLE THAT ISSUES A CONTRACT THAT PROVIDES
COVERAGE FOR PRESCRIPTION DRUGS SHALL, WITH RESPECT TO THE PRESCRIPTION
DRUG COVERAGE, PUBLISH AN UP-TO-DATE, ACCURATE, AND COMPLETE LIST OF ALL
COVERED PRESCRIPTION DRUGS ON ITS FORMULARY DRUG LIST, INCLUDING ANY
TIERING STRUCTURE THAT IT HAS ADOPTED AND ANY RESTRICTIONS ON THE MANNER
IN WHICH A PRESCRIPTION DRUG MAY BE OBTAINED, IN A MANNER THAT IS EASILY
ACCESSIBLE TO INSUREDS AND PROSPECTIVE INSUREDS. THE FORMULARY DRUG LIST
SHALL CLEARLY IDENTIFY THE PREVENTIVE PRESCRIPTION DRUGS THAT ARE AVAIL-
ABLE WITHOUT ANNUAL DEDUCTIBLES OR COINSURANCE, INCLUDING CO-PAYMENTS.
(B) (1) EVERY CONTRACT ISSUED BY A CORPORATION SUBJECT TO THE
PROVISIONS OF THIS ARTICLE THAT PROVIDES COVERAGE FOR PRESCRIPTION DRUGS
SHALL INCLUDE IN THE CONTRACT A PROCESS THAT ALLOWS AN INSURED, THE
INSURED'S DESIGNEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO
REQUEST A FORMULARY EXCEPTION. WITH RESPECT TO THE PROCESS FOR SUCH A
FORMULARY EXCEPTION, A CORPORATION SHALL FOLLOW THE PROCESS AND PROCE-
DURES SPECIFIED IN ARTICLE FORTY-NINE OF THIS CHAPTER AND ARTICLE
FORTY-NINE OF THE PUBLIC HEALTH LAW, EXCEPT AS OTHERWISE PROVIDED IN
PARAGRAPHS TWO, THREE, FOUR AND FIVE OF THIS SUBSECTION.
S. 1507 70 A. 2007
(2) (A) A CORPORATION SHALL HAVE A PROCESS FOR AN INSURED, THE
INSURED'S DESIGNEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO
REQUEST A STANDARD REVIEW THAT IS NOT BASED ON EXIGENT CIRCUMSTANCES OF
A FORMULARY EXCEPTION FOR A PRESCRIPTION DRUG THAT IS NOT COVERED BY THE
CONTRACT.
(B) A CORPORATION SHALL MAKE A DETERMINATION ON A STANDARD EXCEPTION
REQUEST THAT IS NOT BASED ON EXIGENT CIRCUMSTANCES AND NOTIFY THE
INSURED OR THE INSURED'S DESIGNEE AND THE INSURED'S PRESCRIBING HEALTH
CARE PROVIDER BY TELEPHONE OF ITS COVERAGE DETERMINATION NO LATER THAN
SEVENTY-TWO HOURS FOLLOWING RECEIPT OF THE REQUEST.
(C) A CORPORATION THAT GRANTS A STANDARD EXCEPTION REQUEST THAT IS NOT
BASED ON EXIGENT CIRCUMSTANCES SHALL PROVIDE COVERAGE OF THE NON-FORMU-
LARY PRESCRIPTION DRUG FOR THE DURATION OF THE PRESCRIPTION, INCLUDING
REFILLS.
(D) FOR THE PURPOSE OF THIS SUBSECTION, "EXIGENT CIRCUMSTANCES" MEANS
WHEN AN INSURED IS SUFFERING FROM A HEALTH CONDITION THAT MAY SERIOUSLY
JEOPARDIZE THE INSURED'S LIFE, HEALTH, OR ABILITY TO REGAIN MAXIMUM
FUNCTION OR WHEN AN INSURED IS UNDERGOING A CURRENT COURSE OF TREATMENT
USING A NON-FORMULARY PRESCRIPTION DRUG.
(3) (A) A CORPORATION SHALL HAVE A PROCESS FOR AN INSURED, THE
INSURED'S DESIGNEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER TO
REQUEST AN EXPEDITED REVIEW BASED ON EXIGENT CIRCUMSTANCES OF A FORMU-
LARY EXCEPTION FOR A PRESCRIPTION DRUG IS NOT COVERED BY THE CONTRACT.
(B) A CORPORATION SHALL MAKE A DETERMINATION ON AN EXPEDITED REVIEW
REQUEST BASED ON EXIGENT CIRCUMSTANCES AND NOTIFY THE INSURED OR THE
INSURED'S DESIGNEE AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY
TELEPHONE OF ITS COVERAGE DETERMINATION NO LATER THAN TWENTY-FOUR HOURS
FOLLOWING RECEIPT OF THE REQUEST.
(C) A CORPORATION THAT GRANTS AN EXCEPTION BASED ON EXIGENT CIRCUM-
STANCES SHALL PROVIDE COVERAGE OF THE NON-FORMULARY PRESCRIPTION DRUG
FOR THE DURATION OF THE EXIGENT CIRCUMSTANCES.
(4) A CORPORATION THAT DENIES AN EXCEPTION REQUEST UNDER PARAGRAPH TWO
OR THREE OF THIS SUBSECTION SHALL PROVIDE WRITTEN NOTICE OF ITS DETERMI-
NATION TO THE INSURED OR THE INSURED'S DESIGNEE AND THE INSURED'S
PRESCRIBING HEALTH CARE PROVIDER WITHIN THREE BUSINESS DAYS OF RECEIPT
OF THE EXCEPTION REQUEST. THE WRITTEN NOTICE SHALL BE CONSIDERED A FINAL
ADVERSE DETERMINATION UNDER SECTION FOUR THOUSAND NINE HUNDRED FOUR OF
THIS CHAPTER OR SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THE PUBLIC
HEALTH LAW. WRITTEN NOTICE SHALL ALSO INCLUDE THE NAME OR NAMES OF CLIN-
ICALLY APPROPRIATE PRESCRIPTION DRUGS COVERED BY THE CORPORATION TO
TREAT THE INSURED.
(5) (A) IF A CORPORATION DENIES A REQUEST FOR AN EXCEPTION UNDER PARA-
GRAPH TWO OR THREE OF THIS SUBSECTION, THE INSURED, THE INSURED'S DESIG-
NEE, OR THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER SHALL HAVE THE
RIGHT TO REQUEST THAT SUCH DENIAL BE REVIEWED BY AN EXTERNAL APPEAL
AGENT CERTIFIED BY THE SUPERINTENDENT PURSUANT TO SECTION FOUR THOUSAND
NINE HUNDRED ELEVEN OF THIS CHAPTER IN ACCORDANCE WITH ARTICLE FORTY-
NINE OF THIS CHAPTER AND ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW.
(B) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION ON THE
EXTERNAL APPEAL AND NOTIFY THE CORPORATION, THE INSURED OR THE INSURED'S
DESIGNEE, AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY TELE-
PHONE OF ITS DETERMINATION NO LATER THAN SEVENTY-TWO HOURS FOLLOWING THE
EXTERNAL APPEAL AGENT'S RECEIPT OF THE REQUEST, IF THE ORIGINAL REQUEST
WAS A STANDARD EXCEPTION REQUEST UNDER PARAGRAPH TWO OF THIS SUBSECTION.
THE EXTERNAL APPEAL AGENT SHALL NOTIFY THE CORPORATION, THE INSURED OR
THE INSURED'S DESIGNEE AND THE INSURED'S PRESCRIBING HEALTH CARE PROVID-
S. 1507 71 A. 2007
ER IN WRITING OF THE EXTERNAL APPEAL DETERMINATION WITHIN TWO BUSINESS
DAYS OF RENDERING SUCH DETERMINATION.
(C) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION ON THE
EXTERNAL APPEAL AND NOTIFY THE CORPORATION, THE INSURED OR THE INSURED'S
DESIGNEE, AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER BY TELE-
PHONE OF ITS DETERMINATION NO LATER THAN TWENTY-FOUR HOURS FOLLOWING THE
EXTERNAL APPEAL AGENT'S RECEIPT OF THE REQUEST, IF THE ORIGINAL REQUEST
WAS AN EXPEDITED EXCEPTION REQUEST UNDER PARAGRAPH THREE OF THIS
SUBSECTION AND THE INSURED'S PRESCRIBING HEALTH CARE PROVIDER ATTESTS
THAT EXIGENT CIRCUMSTANCES EXIST. THE EXTERNAL APPEAL AGENT SHALL NOTIFY
THE CORPORATION, THE INSURED OR THE INSURED'S DESIGNEE AND THE INSURED'S
PRESCRIBING HEALTH CARE PROVIDER IN WRITING OF THE EXTERNAL APPEAL
DETERMINATION WITHIN SEVENTY-TWO HOURS OF THE EXTERNAL APPEAL AGENT'S
RECEIPT OF THE EXTERNAL APPEAL.
(D) AN EXTERNAL APPEAL AGENT SHALL MAKE A DETERMINATION IN ACCORDANCE
WITH SUBPARAGRAPH (A) OF PARAGRAPH FOUR OF SUBSECTION (B) OF SECTION
FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS CHAPTER AND SUBPARAGRAPH (A)
OF PARAGRAPH (D) OF SUBDIVISION TWO OF SECTION FOUR THOUSAND NINE
HUNDRED FOURTEEN OF THE PUBLIC HEALTH LAW. WHEN MAKING A DETERMINATION,
THE EXTERNAL APPEAL AGENT SHALL CONSIDER WHETHER THE FORMULARY
PRESCRIPTION DRUG COVERED BY THE CORPORATION WILL BE OR HAS BEEN INEF-
FECTIVE, WOULD NOT BE AS EFFECTIVE AS THE NON-FORMULARY PRESCRIPTION
DRUG, OR WOULD HAVE ADVERSE EFFECTS.
(E) IF AN EXTERNAL APPEAL AGENT OVERTURNS THE CORPORATION'S DENIAL OF
A STANDARD EXCEPTION REQUEST UNDER PARAGRAPH TWO OF THIS SUBSECTION,
THEN THE CORPORATION SHALL PROVIDE COVERAGE OF THE NON-FORMULARY
PRESCRIPTION DRUG FOR THE DURATION OF THE PRESCRIPTION, INCLUDING
REFILLS. IF AN EXTERNAL APPEAL AGENT OVERTURNS THE CORPORATION'S DENIAL
OF AN EXPEDITED EXCEPTION REQUEST UNDER PARAGRAPH THREE OF THIS
SUBSECTION, THEN THE CORPORATION SHALL PROVIDE COVERAGE OF THE NON-FOR-
MULARY PRESCRIPTION DRUG FOR THE DURATION OF THE EXIGENT CIRCUMSTANCES.
§ 3. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
SUBPART E
Section 1. Section 2607 of the insurance law is amended to read as
follows:
§ 2607. Discrimination because of sex or marital status. (A) No indi-
vidual or entity shall refuse to issue any policy of insurance, or
cancel or decline to renew [such] THE policy because of the sex or mari-
tal status of the applicant or policyholder OR ENGAGE IN SEXUAL STERE-
OTYPING.
(B) FOR THE PURPOSES OF THIS SECTION, "SEX" SHALL INCLUDE SEXUAL
ORIENTATION, GENDER IDENTITY OR EXPRESSION, AND TRANSGENDER STATUS.
§ 2. The insurance law is amended by adding a new section 3243 to read
as follows:
§ 3243. DISCRIMINATION BECAUSE OF SEX OR MARITAL STATUS IN HOSPITAL,
SURGICAL OR MEDICAL EXPENSE INSURANCE. (A) WITH REGARD TO AN ACCIDENT
AND HEALTH INSURANCE POLICY THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL
EXPENSE COVERAGE OR A POLICY OF STUDENT ACCIDENT AND HEALTH INSURANCE,
AS DEFINED IN SUBSECTION (A) OF SECTION THREE THOUSAND TWO HUNDRED FORTY
OF THIS ARTICLE, DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE, NO
INSURER SHALL BECAUSE OF SEX, MARITAL STATUS OR BASED ON PREGNANCY,
S. 1507 72 A. 2007
FALSE PREGNANCY, TERMINATION OF PREGNANCY, OR RECOVERY THEREFROM, CHILD-
BIRTH OR RELATED MEDICAL CONDITIONS:
(1) MAKE ANY DISTINCTION OR DISCRIMINATION BETWEEN PERSONS AS TO THE
PREMIUMS OR RATES CHARGED FOR THE POLICY OR IN ANY OTHER MANNER WHATEV-
ER;
(2) DEMAND OR REQUIRE A GREATER PREMIUM FROM ANY PERSON THAN IT
REQUIRES AT THAT TIME FROM OTHERS IN SIMILAR CASES;
(3) MAKE OR REQUIRE ANY REBATE, DISCRIMINATION OR DISCOUNT UPON THE
AMOUNT TO BE PAID OR THE SERVICE TO BE RENDERED ON ANY POLICY;
(4) INSERT IN THE POLICY ANY CONDITION, OR MAKE ANY STIPULATION,
WHEREBY THE INSURED BINDS HIS OR HERSELF, OR HIS OR HER HEIRS, EXECU-
TORS, ADMINISTRATORS OR ASSIGNS, TO ACCEPT ANY SUM OR SERVICE LESS THAN
THE FULL VALUE OR AMOUNT OF SUCH POLICY IN CASE OF A CLAIM THEREON
EXCEPT SUCH CONDITIONS AND STIPULATIONS AS ARE IMPOSED UPON OTHERS IN
SIMILAR CASES; AND ANY SUCH STIPULATION OR CONDITION SO MADE OR INSERTED
SHALL BE VOID;
(5) REJECT ANY APPLICATION FOR A POLICY ISSUED OR SOLD BY IT;
(6) CANCEL OR REFUSE TO ISSUE, RENEW OR SELL SUCH POLICY AFTER APPRO-
PRIATE APPLICATION THEREFOR;
(7) FIX ANY LOWER RATE OR DISCRIMINATE IN THE FEES OR COMMISSIONS OF
INSURANCE AGENTS OR INSURANCE BROKERS FOR WRITING OR RENEWING SUCH A
POLICY; OR
(8) ENGAGE IN SEXUAL STEREOTYPING.
(B) FOR THE PURPOSES OF THIS SECTION, "SEX" SHALL INCLUDE SEXUAL
ORIENTATION, GENDER IDENTITY OR EXPRESSION, AND TRANSGENDER STATUS.
§ 3. The insurance law is amended by adding a new section 4330 to read
as follows:
§ 4330. DISCRIMINATION BECAUSE OF SEX OR MARITAL STATUS IN HOSPITAL,
SURGICAL OR MEDICAL EXPENSE INSURANCE. (A) WITH REGARD TO A CONTRACT
ISSUED BY A CORPORATION SUBJECT TO THE PROVISIONS OF THIS ARTICLE THAT
PROVIDES HOSPITAL, SURGICAL, OR MEDICAL EXPENSE COVERAGE OR A CONTRACT
OF STUDENT ACCIDENT AND HEALTH INSURANCE, AS DEFINED IN SUBSECTION (A)
OF SECTION THREE THOUSAND TWO HUNDRED FORTY OF THIS CHAPTER, NO CORPO-
RATION SHALL BECAUSE OF SEX, MARITAL STATUS OR BASED ON PREGNANCY, FALSE
PREGNANCY, TERMINATION OF PREGNANCY, OR RECOVERY THEREFROM, CHILDBIRTH
OR RELATED MEDICAL CONDITIONS:
(1) MAKE ANY DISTINCTION OR DISCRIMINATION BETWEEN PERSONS AS TO THE
PREMIUMS OR RATES CHARGED FOR THE CONTRACT OR IN ANY OTHER MANNER WHAT-
EVER;
(2) DEMAND OR REQUIRE A GREATER PREMIUM FROM ANY PERSON THAN IT
REQUIRES AT THAT TIME FROM OTHERS IN SIMILAR CASES;
(3) MAKE OR REQUIRE ANY REBATE, DISCRIMINATION OR DISCOUNT UPON THE
AMOUNT TO BE PAID OR THE SERVICE TO BE RENDERED ON ANY CONTRACT;
(4) INSERT IN THE CONTRACT ANY CONDITION, OR MAKE ANY STIPULATION,
WHEREBY THE INSURED BINDS HIS OR HERSELF, OR HIS OR HER HEIRS, EXECU-
TORS, ADMINISTRATORS OR ASSIGNS, TO ACCEPT ANY SUM OR SERVICE LESS THAN
THE FULL VALUE OR AMOUNT OF SUCH CONTRACT IN CASE OF A CLAIM THEREON
EXCEPT SUCH CONDITIONS AND STIPULATIONS AS ARE IMPOSED UPON OTHERS IN
SIMILAR CASES; AND ANY SUCH STIPULATION OR CONDITION SO MADE OR INSERTED
SHALL BE VOID;
(5) REJECT ANY APPLICATION FOR A CONTRACT ISSUED OR SOLD BY IT;
(6) CANCEL OR REFUSE TO ISSUE, RENEW OR SELL SUCH CONTRACT AFTER
APPROPRIATE APPLICATION THEREFOR;
(7) FIX ANY LOWER RATE OR DISCRIMINATE IN THE FEES OR COMMISSIONS OF
INSURANCE AGENTS OR INSURANCE BROKERS FOR WRITING OR RENEWING SUCH A
CONTRACT; OR
S. 1507 73 A. 2007
(8) ENGAGE IN SEXUAL STEREOTYPING.
(B) FOR PURPOSES OF THIS SECTION, "SEX" SHALL INCLUDE SEXUAL ORIEN-
TATION, GENDER IDENTITY OR EXPRESSION, AND TRANSGENDER STATUS.
§ 4. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
SUBPART F
Section 1. Subparagraph (B) of paragraph 2 of subsection (b) of
section 1101 of the insurance law, as amended by chapter 369 of the laws
of 1985, is amended to read as follows:
(B) transactions with respect to group life, group annuity, group
accident and health or blanket accident and health insurance (other than
any transaction with respect to a group annuity contract funding indi-
vidual retirement accounts or individual retirement annuities, as
defined in section four hundred eight of the Internal Revenue Code,
funding annuities in accordance with subdivision (b) of section four
hundred three of such code or providing a plan of retirement annuities
under which the payments are derived wholly from funds contributed by
the persons covered):
(i) where such groups conform to the definitions of eligibility
contained in[;]:
(I) the following paragraphs of subsection (b) of section four thou-
sand two hundred sixteen of this chapter:
(aa) paragraph (1) or (2);
(bb) paragraph (3), if, with respect to those credit transactions
entered into in this state, the policy fully conforms with the require-
ments of sections three thousand two hundred one, three thousand two
hundred twenty and four thousand two hundred sixteen of this chapter; OR
(cc) paragraphs (4), (5), (6), (7), (8), (9) [and] OR (10)[.];
(II) the following subparagraphs of paragraph (1) of subsection (c) of
section four thousand two hundred thirty-five of this chapter:
(aa) subparagraph (A), (B), (C) or (D), (EXCEPT THAT WITH REGARD TO
SUBPARAGRAPHS (A), (B), AND (D), TRANSACTIONS WITH RESPECT TO AN EMPLOY-
ER THAT HAS ESTABLISHED OR PARTICIPATES IN A FUND TO INSURE EMPLOYEES OF
AN EMPLOYER OR AN EMPLOYER TO WHOM THE POLICY IS ISSUED, WHERE: (AAA)
THE EMPLOYER HAS ITS PRINCIPAL PLACE OF BUSINESS IN THIS STATE; OR (BBB)
THE LESSER OF TWENTY-FIVE PERCENT OF EMPLOYEES WORK IN THIS STATE OR
TWENTY-FIVE OR MORE EMPLOYERS WORK IN THIS STATE);
(bb) subparagraph (E), if, with respect to those credit transactions
entered into in this state, the policy fully conforms with the require-
ments of sections three thousand two hundred one, three thousand two
hundred twenty-one and four thousand two hundred thirty-five of this
chapter;
(cc) subparagraphs (F)[,] AND (G) [and (H).];
(III) section four thousand two hundred thirty-seven (except subpara-
graph (B) FOR TRANSACTIONS WITH RESPECT TO AN EMPLOYER TO WHOM THE POLI-
CY IS ISSUED WHERE THE EMPLOYER HAS ITS PRINCIPAL PLACE OF BUSINESS IN
THIS STATE OR THE LESSER OF TWENTY-FIVE PERCENT OF EMPLOYEES WORK IN
THIS STATE OR TWENTY-FIVE OR MORE EMPLOYEES WORK IN THIS STATE, (C),
(E), OR (F) of paragraph three of subsection (a) thereof) or four thou-
sand two hundred thirty-eight (except paragraphs six and seven of
subsection (b) thereof) of this chapter; and
S. 1507 74 A. 2007
(ii) where the master policies or contracts were lawfully issued with-
out this state in a jurisdiction where the insurer was authorized to do
an insurance business;
§ 2. Items (ii) and (iii) of subparagraph (A) of paragraph 8 of
subsection (b) of section 1101 of the insurance law, as added by chapter
449 of the laws of 2014, are amended to read as follows:
(ii) subparagraph (A), (B), (C), or (D) [(with respect to a policy
issued to a trustee or trustees of a fund established or participated in
by two or more employers, one or more labor unions, or by one or more
employers or labor unions, provided that all such employers or labor
unions are in the same industry)] of paragraph one of subsection (c) of
section four thousand two hundred thirty-five of this chapter (EXCEPT
THAT WITH REGARD TO SUBPARAGRAPHS (A), (B), AND (D), TRANSACTIONS WITH
RESPECT TO AN EMPLOYER THAT HAS ESTABLISHED OR PARTICIPATES IN A FUND TO
INSURE EMPLOYEES OF AN EMPLOYER OR AN EMPLOYER TO WHOM THE POLICY IS
ISSUED, WHERE: (I) THE EMPLOYER HAS ITS PRINCIPAL PLACE OF BUSINESS IN
THIS STATE; OR (II) THE LESSER OF TWENTY-FIVE PERCENT OF EMPLOYEES WORK
IN THIS STATE OR TWENTY-FIVE OR MORE EMPLOYEES WORK IN THIS STATE); or
(iii) paragraphs one, two, three or four of subsection (b) of section
four thousand two hundred thirty-eight of this chapter, but not includ-
ing a group annuity contract: (I) funding individual retirement accounts
or individual retirement annuities, as defined in section four hundred
eight of the Internal Revenue Code; (II) funding annuities in accordance
with subdivision (b) of section four hundred three of such code; or
(III) providing a plan of retirement annuities under which the payments
are derived wholly from funds contributed by the persons covered[.];
§ 3. Subsection (b) of section 1101 of the insurance law is amended by
adding a new paragraph 9 to read as follows:
(9) FOR PURPOSES OF THIS SUBSECTION, "PRINCIPAL PLACE OF BUSINESS"
SHALL MEAN THE PLACE WHERE AN EMPLOYER MAINTAINS ITS HEADQUARTERS OR
WHERE THE EMPLOYER'S HIGH-LEVEL OFFICERS DIRECT, CONTROL, AND COORDINATE
THE BUSINESS ACTIVITIES.
§ 4. Paragraph 1 of subsection (b) of section 3201 of the insurance
law, as amended by chapter 369 of the laws of 1985, is amended to read
as follows:
(1) (A) No policy form shall be delivered or issued for delivery in
this state unless it has been filed with and approved by the superinten-
dent as conforming to the requirements of this chapter and not incon-
sistent with law.
(B) A group life, group accident, group health, group accident and
health, BLANKET ACCIDENT, BLANKET HEALTH, or blanket accident and health
insurance certificate evidencing insurance coverage on a resident of
this state shall be deemed to have been delivered in this state, regard-
less of the place of actual delivery[, unless the insured group] OR THE
TYPE OF GROUP TO WHICH THE GROUP OR BLANKET POLICY OR CONTRACT IS
ISSUED.
(C) NOTWITHSTANDING SUBPARAGRAPH (B) OF THIS PARAGRAPH, A CERTIFICATE
SHALL NOT BE DEEMED TO HAVE BEEN DELIVERED IN THIS STATE WHEN: (I) THE
CERTIFICATE IS NOT ACTUALLY DELIVERED IN THIS STATE; (II) THE INSURED
GROUP is of the type described in[: (A)] section four thousand two
hundred sixteen OF THIS CHAPTER, except paragraph four where the group
policy is issued to a trustee or trustees of a fund established or
participated in by two or more employers not in the same industry with
respect to an employer principally located within the state, paragraph
twelve, thirteen or fourteen of subsection (b) thereof; AND (III) THE
MASTER POLICY OR CONTRACT IS LAWFULLY ISSUED WITHOUT THIS STATE IN A
S. 1507 75 A. 2007
JURISDICTION WHERE THE INSURER IS AUTHORIZED TO DO AN INSURANCE BUSI-
NESS.
(D) NOTWITHSTANDING SUBPARAGRAPH (B) OF THIS PARAGRAPH, WHERE THE
MASTER POLICY OR CONTRACT IS LAWFULLY ISSUED WITHOUT THIS STATE IN A
JURISDICTION WHERE THE INSURER IS AUTHORIZED TO DO AN INSURANCE BUSI-
NESS, A CERTIFICATE SHALL NOT BE DEEMED TO HAVE BEEN DELIVERED IN THIS
STATE EVEN IF IT IS ACTUALLY DELIVERED IN THIS STATE WHEN THE INSURED
GROUP IS OF THE TYPE DESCRIBED IN:
[(B)] (I) section four thousand two hundred thirty-five OF THIS CHAP-
TER, except [subparagraph]: (I) SUBPARAGRAPHS (A), (B) AND (D) [where
the group policy is issued to a trustee or trustees of a fund estab-
lished or participated in by two or more employers not in the same
industry with respect to an employer principally located within the
state, subparagraph] OF PARAGRAPH ONE OF SUBSECTION (C) THEREOF, WITH
RESPECT TO AN EMPLOYER THAT HAS ESTABLISHED OR PARTICIPATES IN A FUND TO
INSURE EMPLOYEES OF AN EMPLOYER OR AN EMPLOYER TO WHOM THE POLICY IS
ISSUED, WHERE THE EMPLOYER HAS ITS PRINCIPAL PLACE OF BUSINESS IN THIS
STATE OR THE LESSER OF TWENTY-FIVE PERCENT OF EMPLOYEES WORK IN THIS
STATE OR TWENTY-FIVE OR MORE EMPLOYEES WORK IN THIS STATE; OR (II)
SUBPARAGRAPHS (H), (K), (L) or (M) of paragraph one of subsection (c)
thereof; or
[(C)] (II) section four thousand two hundred thirty-seven [(] OF THIS
CHAPTER, except subparagraph (B) WITH RESPECT TO AN EMPLOYER TO WHOM THE
POLICY IS ISSUED WHERE THE EMPLOYER HAS ITS PRINCIPAL PLACE OF BUSINESS
IN THIS STATE OR THE LESSER OF TWENTY-FIVE PERCENT OF EMPLOYEES WORK IN
THIS STATE OR TWENTY-FIVE OR MORE EMPLOYEES WORK IN THIS STATE, (C), (E)
OR (F) of paragraph three of subsection (a) thereof[; of this chapter;
and where the master policies or contracts were lawfully issued without
this state in a jurisdiction where the insurer was authorized to do an
insurance business].
(E)(I) With regard to any GROUP LIFE INSURANCE certificate deemed to
have been delivered in this state by virtue of SUBPARAGRAPH (B) OR (C)
OF this paragraph, the superintendent shall [(i)]: (I) require that the
premiums charged be reasonable in relation to the benefits provided,
except in cases where the policyholder pays the entire premium; [(ii)]
(II) have power to issue regulations prescribing the required, optional
and prohibited provisions in such certificates; [(iii)] AND (III) estab-
lish an accelerated certificate form approval procedure available to an
insurer [which] THAT includes a statement in its policy form submission
letter that it is the company's opinion that the certificate form or
forms comply with applicable New York law and regulations. The super-
intendent, upon receipt of such a filing letter, shall grant conditional
approval of such certificate form or forms in reliance on the aforemen-
tioned statement by the company upon the condition that the company will
retroactively modify such certificate form or forms, to the extent
necessary, if it is found by the superintendent that the certificate
form fails to comply with applicable New York laws and regulations[.];
(II) The superintendent may, with regard to the approval of any GROUP
LIFE INSURANCE certificate deemed to have been delivered in this state
by virtue of SUBPARAGRAPH (B) OR (C) OF this paragraph, approve such
certificate if the superintendent finds that the certificate affords
insureds protections substantially similar to those [which] THAT have
been provided by certificates delivered in this state[.]; AND
(III) Any regulations issued by the superintendent pursuant to this
[paragraph] SUBPARAGRAPH may not impose stricter requirements than those
S. 1507 76 A. 2007
applicable to similar policies and certificates actually delivered in
this state.
(F)(I) A GROUP ACCIDENT, GROUP HEALTH, GROUP ACCIDENT AND HEALTH,
BLANKET ACCIDENT, BLANKET HEALTH, OR BLANKET ACCIDENT AND HEALTH INSUR-
ANCE CERTIFICATE DEEMED TO HAVE BEEN DELIVERED IN THIS STATE PURSUANT TO
SUBPARAGRAPH (B) OR (D) OF THIS PARAGRAPH, SHALL BE SUBJECT TO THE SAME
PROVISIONS OF THIS CHAPTER AS A CERTIFICATE ACTUALLY DELIVERED OR ISSUED
FOR DELIVERY IN THIS STATE.
(II) AN INSURER SHALL ISSUE TO THE GROUP OR PERSON IN WHOSE NAME THE
POLICY OR CONTRACT IS ISSUED, FOR DELIVERY TO EACH MEMBER OF THE INSURED
GROUP, A CERTIFICATE SETTING FORTH IN SUMMARY FORM A STATEMENT OF THE
ESSENTIAL FEATURES OF THE INSURANCE COVERAGE.
(G) FOR PURPOSES OF THIS PARAGRAPH:
(I) "INSTITUTION OF HIGHER EDUCATION" SHALL HAVE THE MEANING SET FORTH
IN PARAGRAPH TWO OF SUBSECTION (A) OF SECTION THREE THOUSAND TWO HUNDRED
FORTY OF THIS ARTICLE;
(II) "PRINCIPAL PLACE OF BUSINESS" SHALL MEAN THE PLACE WHERE AN
EMPLOYER MAINTAINS ITS HEADQUARTERS OR WHERE THE EMPLOYER'S HIGH-LEVEL
OFFICERS DIRECT, CONTROL, AND COORDINATE THE BUSINESS ACTIVITIES; AND
(III) "RESIDENT OF THIS STATE" SHALL INCLUDE A STUDENT WHO IS ENROLLED
IN AN INSTITUTION OF HIGHER EDUCATION IN THIS STATE THAT OFFERS COVERAGE
TO THE STUDENT THROUGH A GROUP OR BLANKET POLICY OR CONTRACT.
§ 5. Subparagraph (E) of paragraph 3 of subsection (a) of section 4237
of the insurance law is amended to read as follows:
(E) Under a policy or contract issued to [and in the name of] an
[incorporated or unincorporated] association [of persons having a common
interest or calling, which association shall be deemed the policyholder,
having not less than fifty members, covering all the members of such
association or if part or all of] OR THE TRUSTEE OR TRUSTEES OF A TRUST
ESTABLISHED, OR PARTICIPATED IN, BY ONE OR MORE ASSOCIATIONS, TO INSURE
ASSOCIATION MEMBERS, SUBJECT TO THE FOLLOWING:
(I) EACH ASSOCIATION SHALL HAVE:
(I) A MINIMUM OF TWO HUNDRED INSURED INDIVIDUALS AT THE POLICY OR
CONTRACT'S DATE OF ISSUE;
(II) BEEN ORGANIZED AND MAINTAINED IN GOOD FAITH FOR PURPOSES PRINCI-
PALLY OTHER THAN THAT OF OBTAINING INSURANCE;
(III) BEEN IN ACTIVE EXISTENCE FOR AT LEAST TWO YEARS; AND
(IV) A CONSTITUTION AND BY-LAWS THAT PROVIDE THAT:
(AA) THE ASSOCIATION HOLD REGULAR MEETINGS NOT LESS THAN ANNUALLY TO
FURTHER THE PURPOSES OF THE ASSOCIATION;
(BB) THE ASSOCIATION COLLECT DUES OR SOLICIT CONTRIBUTIONS FROM
MEMBERS; AND
(CC) THE MEMBERS HAVE VOTING PRIVILEGES AND REPRESENTATION ON THE
GOVERNING BOARD AND COMMITTEES;
(II) the premium [is to be derived] FOR THE POLICY OR CONTRACT SHALL
BE PAID BY THE ASSOCIATION OR THE TRUSTEES EITHER WHOLLY from funds
contributed by the ASSOCIATION OR BY THE insured [members and if the
opportunity to take such insurance is offered to all eligible] INDIVID-
UALS, OR FROM FUNDS CONTRIBUTED JOINTLY BY THE ASSOCIATION AND INSURED
[members, then such] INDIVIDUALS. A policy [must cover not less than
seventy-five percent of any class or classes of members determined by
conditions pertaining to membership in the association] OR CONTRACT ON
WHICH NO PART OF THE PREMIUM IS TO BE DERIVED FROM FUNDS CONTRIBUTED BY
THE INSURED INDIVIDUALS SPECIFICALLY FOR THEIR INSURANCE SHALL INSURE
ALL ELIGIBLE INDIVIDUALS, EXCLUDING ANY AS TO WHOM EVIDENCE OF INDIVID-
S. 1507 77 A. 2007
UAL INSURABILITY IS NOT SATISFACTORY TO THE INSURER TO THE EXTENT
PERMITTED BY LAW;
(III) THE AMOUNT OF INSURANCE UNDER THE POLICY OR CONTRACT SHALL BE
BASED UPON SOME PLAN PRECLUDING INDIVIDUAL SELECTION EITHER BY THE
INSURED INDIVIDUALS OR BY THE ASSOCIATION. HOWEVER, WITH RESPECT TO AN
ASSOCIATION, SUCH A PLAN MAY PERMIT A NUMBER OF SELECTIONS BY THE ASSO-
CIATION IF THE SELECTIONS OFFERED UTILIZE CONSISTENT PLANS OF INSURANCE
SO THAT THE RESULTING PLANS OF COVERAGE ARE REASONABLE. FURTHERMORE,
SUCH A PLAN MAY PERMIT A LIMITED NUMBER OF SELECTIONS BY INSURED INDI-
VIDUALS IF THE SELECTIONS OFFERED UTILIZE CONSISTENT PLANS OF INSURANCE
FOR INSURED INDIVIDUALS SO THAT THE RESULTING PLANS OF COVERAGE ARE
REASONABLE.
(IV) EXCEPT AS PROVIDED IN SUBSECTION (B) OF THIS SECTION, SUCH POLICY
OR CONTRACT SHALL PROVIDE FOR THE PAYMENT OF BENEFITS TO THE PERSON
INSURED OR TO SOME BENEFICIARY OR BENEFICIARIES OTHER THAN THE ASSOCI-
ATION OR ANY OFFICIALS, REPRESENTATIVES, TRUSTEES OR AGENTS THEREOF AND
SHALL PROVIDE FOR THE ISSUANCE OF A CERTIFICATE TO THE ASSOCIATION FOR
DELIVERY TO THE INSURED INDIVIDUAL OR SUCH BENEFICIARY, AS EVIDENCE OF
SUCH INSURANCE.
(V) THE PREMIUMS CHARGED SHALL BE REASONABLE IN RELATION TO THE BENE-
FITS PROVIDED.
§ 6. Subsection (d) of section 4237-a of the insurance law, as amended
by chapter 599 of the laws of 2003, is amended to read as follows:
(d) No stop-loss insurance contract shall be DELIVERED OR issued [or
renewed] FOR DELIVERY IN OR OUTSIDE THIS STATE BY AN INSURER OR HEALTH
SERVICE CORPORATION:
(1) TO A NEW YORK EMPLOYER WITH ONE HUNDRED OR FEWER EMPLOYEES,
PROVIDED THAT "NEW YORK EMPLOYER" SHALL MEAN AN EMPLOYER WHO HAS AT
LEAST ONE EMPLOYEE THAT WORKS IN THIS STATE; OR
(2) if issuance of the policy would be prohibited by section two thou-
sand six hundred thirteen, three thousand two hundred thirty-one, four
thousand three hundred seventeen or four thousand three hundred twenty
of this chapter.
§ 7. This act shall take effect on the one hundred eightieth day after
it shall have become a law and shall apply to all policies and contracts
issued, renewed, modified, altered, or amended on or after such date.
Effective immediately:
(1) the superintendent of financial services may promulgate any rules
or regulations necessary for the implementation of the provisions of
this act on its effective date; and
(2) insurers may submit to the superintendent and the superintendent
may approve filings necessary to comply with the provisions of this act
on its effective date.
§ 2. Severability clause. If any clause, sentence, paragraph, subdivi-
sion, section or subpart of this act shall be adjudged by any court of
competent jurisdiction to be invalid, such judgment shall not affect,
impair, or invalidate the remainder thereof, but shall be confined in
its operation to the clause, sentence, paragraph, subdivision, section
or subpart thereof directly involved in the controversy in which such
judgment shall have been rendered. It is hereby declared to be the
intent of the legislature that this act would have been enacted even if
such invalid provisions had not been included herein.
§ 3. Interpretations by the superintendent. The superintendent of
financial services has special expertise and experience in the regu-
lation of insurance in this state. As such his or her interpretations of
the insurance law shall be afforded the highest level of deference.
S. 1507 78 A. 2007
§ 4. Legislative intent. It is hereby declared to be the intent of the
legislature in enacting this act, that the laws of this state provide
consumer and market protections at least as robust as those under the
federal Patient Protection and Affordable Care Act, public law 111-148,
as that law existed and was interpreted on January 19, 2017. In addition
to any other power conferred by law, the superintendent of financial
services is hereby specifically empowered to promulgate regulations
under, and issue interpretations of, this act as necessary to ensure
that the intent of the legislature as expressed in this section is real-
ized.
§ 5. This act shall take effect immediately provided, however, that
the applicable effective date of Subparts A through F of this act shall
be as specifically set forth in the last section of such Subparts.
PART K
Section 1. Subdivisions 4 and 5 of section 2999-h of the public health
law, as added by section 52 of part H of chapter 59 of the laws of 2011,
are amended to read as follows:
4. "Qualified plaintiff" means every plaintiff or claimant who (i) has
been found by a jury or court to have sustained a birth-related neuro-
logical injury as the result of medical malpractice, or (ii) has
sustained a birth-related neurological injury as the result of alleged
medical malpractice, and has settled his or her lawsuit or claim there-
for; AND (III) HAS BEEN ORDERED TO BE ENROLLED IN THE FUND BY A COURT IN
NEW YORK STATE.
[5. Any reference to the "department of financial services" and the
"superintendent of financial services" in this title shall mean, prior
to October third, two thousand eleven, respectively, the "department of
insurance" and "superintendent of insurance."]
§ 2. Section 2999-i of the public health law, as added by section 52
of part H of chapter 59 of the laws of 2011, subdivision 1 as amended by
section 29 of part D of chapter 56 of the laws of 2012, is amended to
read as follows:
§ 2999-i. Custody and administration of the fund. 1. (a) The commis-
sioner of taxation and finance shall be the custodian of the fund and
the special account established pursuant to section ninety-nine-t of the
state finance law. All payments from the fund shall be made by the
commissioner of taxation and finance upon certificates signed by the
[superintendent of financial services] COMMISSIONER, or his or her
designee, as hereinafter provided. The fund shall be separate and apart
from any other fund and from all other state monies; provided, however,
that monies of the fund may be invested as set forth in paragraph (b) of
this subdivision. No monies from the fund shall be transferred to any
other fund, nor shall any such monies be applied to the making of any
payment for any purpose other than the purpose set forth in this title.
(b) Any monies of the fund not required for immediate use may, at the
discretion of the commissioner [of financial services] in consultation
with [the commissioner of health and] the director of the budget, be
invested by the commissioner of taxation and finance in obligations of
the United States or the state or obligations the principal and interest
of which are guaranteed by the United States or the state. The proceeds
of any such investment shall be retained by the fund as assets to be
used for the purposes of the fund.
S. 1507 79 A. 2007
2. (a) The fund shall be administered by the [superintendent of finan-
cial services] COMMISSIONER or his or her designee in accordance with
the provisions of this article.
(b) The [superintendent of financial services] COMMISSIONER shall have
all powers necessary and proper to carry out the purposes of the fund.
(c) Notwithstanding any contrary provision of this section, sections
one hundred twelve and one hundred sixty-three of the state finance law
or any other contrary provision of law, the superintendent of financial
services is authorized to [enter into a contract or contracts without a
competitive bid or request for proposal process for purposes of adminis-
tering the fund for the first year of its operation and in preparation
therefor] ASSIGN AND THE COMMISSIONER IS AUTHORIZED TO RECEIVE ASSIGN-
MENT OF ANY AND ALL CONTRACTS ENTERED INTO BY THE SUPERINTENDENT OF
FINANCIAL SERVICES TO ADMINISTER THE FUND FOR PERIODS PRIOR TO OCTOBER
FIRST, TWO THOUSAND NINETEEN.
(d) The department [of financial services and the department] shall
post on [their websites] ITS WEBSITE information about the fund[, eligi-
bility for enrollment in the fund,] and the process for enrollment in
the fund.
3. The expense of administering the fund[, including the expenses
incurred by the department,] shall be paid from the fund.
4. Monies for the fund will be provided pursuant to this chapter.
5. For the state fiscal year beginning April first, two thousand elev-
en and ending March thirty-first, two thousand twelve, the state fiscal
year beginning April first, two thousand twelve and ending March thir-
ty-first, two thousand thirteen, and the state fiscal year beginning
April first, two thousand thirteen and ending March thirty-first, two
thousand fourteen, the superintendent of financial services shall cause
to be deposited into the fund for each such fiscal year the amount
appropriated for such purpose. Beginning April first, two thousand four-
teen and annually thereafter, the superintendent of financial services
OR THE COMMISSIONER, WHOEVER IS ADMINISTERING THE FUND FOR THE APPLICA-
BLE PERIOD shall cause to be deposited into the fund, subject to avail-
able appropriations, an amount equal to the difference between the
amount appropriated to the fund in the preceding fiscal year, as
increased by the adjustment factor defined in subdivision seven of this
section, and the assets of the fund at the conclusion of that fiscal
year.
6. (a) Following the deposit referenced in subdivision five of this
section, the [superintendent of financial services] COMMISSIONER shall
conduct an actuarial calculation of the estimated liabilities of the
fund for the coming year resulting from the qualified plaintiffs
enrolled in the fund. The administrator shall from time to time adjust
such calculation IN ACCORDANCE WITH SUBDIVISION SEVEN OF THIS SECTION.
If the total of all estimates of current liabilities equals or exceeds
eighty percent of the fund's assets, then the fund shall not accept any
new enrollments until a new deposit has been made pursuant to subdivi-
sion five of this section. When, as a result of such new deposit, the
fund's liabilities no longer exceed eighty percent of the fund's assets,
the fund administrator shall enroll new qualified plaintiffs in the
order that an application for enrollment has been submitted in accord-
ance with subdivision seven of section twenty-nine hundred ninety-nine-j
of this title.
(b) Whenever enrollment is suspended pursuant to paragraph (a) of this
subdivision and until such time as enrollment resumes pursuant to such
paragraph: (i) notice of such suspension shall be promptly posted on the
S. 1507 80 A. 2007
department's website [and on the website of the department of financial
services]; (ii) the fund administrator shall deny each application for
enrollment that had been received but not accepted prior to the date of
suspension and each application for enrollment received after the date
of such suspension; and (iii) notification of each such denial shall be
made to the plaintiff or claimant or persons authorized to act on behalf
of such plaintiff or claimant and all defendants in regard to such
plaintiff or claimant, to the extent they are known to the fund adminis-
trator. Judgments and settlements for plaintiffs or claimants for whom
applications are denied under this paragraph or who are not eligible for
enrollment due to suspension pursuant to paragraph (a) of this subdivi-
sion shall be satisfied as if this title had not been enacted.
(c) Following a suspension, whenever enrollment resumes pursuant to
paragraph (a) of this subdivision, notice that enrollment has resumed
shall be promptly posted on the department's website [and on the website
of the department of financial services].
(d) The suspension of enrollment pursuant to paragraph (a) of this
subdivision shall not impact payment under the fund for any qualified
plaintiffs already enrolled in the fund.
7. For purposes of this section, the adjustment factor referenced in
this section shall be the ten year rolling average medical component of
the consumer price index as published by the United States department of
labor, bureau of labor statistics, for the preceding ten years.
§ 3. Subdivisions 2, 5, 6, 7, 9, 11, 12, 15 and 16 of section 2999-j
of the public health law, subdivision 2 as amended by chapter 517 of the
laws of 2016, paragraph (c) of subdivision 2 as amended by chapter 4 of
the laws of 2017, and subdivisions 5, 6, 7, 9, 11, 12, 15 and 16 as
added by section 52 of part H of chapter 59 of the laws of 2011, are
amended to read as follows:
2. The provision of qualifying health care costs to qualified plain-
tiffs shall not be subject to prior authorization, except as described
by the commissioner in regulation; provided, however:
(a) such regulation shall not prevent qualified plaintiffs from
receiving care or assistance that would, at a minimum, be authorized
under the medicaid program;
(b) if any prior authorization is required by such regulation, the
regulation shall require that requests for prior authorization be proc-
essed within a reasonably prompt period of time and[, subject to the
provisions of subdivision two-a of this section,] shall identify a proc-
ess for prompt administrative review of any denial of a request for
prior authorization; and
(c) such regulations shall not prohibit qualifying health care costs
on the grounds that the qualifying health care cost may incidentally
benefit other members of the household, provided that whether the quali-
fying health care cost primarily benefits the patient may be considered.
5. Claims for the payment or reimbursement from the fund of qualifying
health care costs shall be made upon forms prescribed and furnished by
the fund administrator [in consultation with the commissioner and] in
conjunction with regulations establishing a mechanism for submission of
claims by health care providers directly to the fund, where practicable.
6. (a) Every settlement agreement for claims arising out of a
plaintiff's or claimant's birth related neurological injury subject to
this title, and that provides for the payment of future medical expenses
for the plaintiff or claimant, shall provide that [in the event the
administrator of the fund determines that the plaintiff or claimant is a
qualified plaintiff,] all payments for future medical expenses shall be
S. 1507 81 A. 2007
paid in accordance with this title[,] in lieu of that portion of the
settlement agreement that provides for payment of such expenses. The
plaintiff's or claimant's future medical expenses shall be paid in
accordance with this title. When such a settlement agreement does not so
provide, the court shall direct the modification of the agreement to
include such term as a condition of court approval.
(b) In any case where the jury or court has made an award for future
medical expenses arising out of a birth related neurological injury, any
party to such action or person authorized to act on behalf of such party
may make application to the court that the judgment reflect that, in
lieu of that portion of the award that provides for payment of such
expenses, [and upon a determination by the fund administrator that the
plaintiff is a qualified plaintiff,] the future medical expenses of the
plaintiff shall be paid out of the fund in accordance with this title.
Upon a finding by the court that the applicant has made a prima facie
showing that the plaintiff is a qualified plaintiff, the court shall
ensure that the judgment so provides.
7. A qualified plaintiff shall be enrolled when (a) such plaintiff or
person authorized to act on behalf of such person, upon notice to all
defendants, or any of the defendants in regard to the plaintiff's claim,
upon notice to such plaintiff, makes an application for enrollment by
providing the fund administrator with a certified copy of the judgment
or of the court approved settlement agreement; and (b) the fund adminis-
trator determines [upon the basis of such judgment or settlement agree-
ment and any additional information the fund administrator shall
request] that the relevant provisions of subdivision six of this section
have been met [and that the plaintiff is a qualified plaintiff];
provided that no enrollment shall occur when the fund is closed to
enrollment pursuant to subdivision six of section twenty-nine hundred
ninety-nine-i of this title.
9. Payments from the fund shall be made by the commissioner of taxa-
tion and finance on the said certificate of the [superintendent of
financial services] COMMISSIONER. No payment shall be made by the
commissioner of taxation and finance in excess of the amount certified.
Promptly upon receipt of the said certificate of the [superintendent of
financial services] COMMISSIONER, the commissioner of taxation and
finance shall pay the qualified plaintiff's health care provider or
reimburse the qualified plaintiff the amount so certified for payment.
11. All health care providers shall accept from qualified plaintiff's
or persons authorized to act on behalf of such plaintiff's assignments
of the right to receive payments from the fund for qualifying health
care costs. SUCH PAYMENTS SHALL CONSTITUTE PAYMENT IN FULL FOR ANY
SERVICES PROVIDED TO A QUALIFIED PLAINTIFF IN ACCORDANCE WITH THIS ARTI-
CLE.
12. Health insurers (other than medicare and Medicaid) shall be the
primary payers of qualifying health care costs of qualified plaintiffs.
Such costs shall be paid from the fund only to the extent that health
insurers or other collateral sources or other persons are not otherwise
obligated to make payments therefor. Health insurers that make payments
for qualifying health care costs to or on behalf of qualified plaintiffs
shall have no right of recovery against and shall have no lien upon the
fund or any person or entity nor shall the fund constitute an additional
payment source to offset the payments otherwise contractually required
to be made by such health insurers. The superintendent of financial
services shall have the authority to enforce the provisions of this
subdivision UPON THE REFERRAL OF THE COMMISSIONER.
S. 1507 82 A. 2007
15. The commissioner[, in consultation with the superintendent of
financial services,] shall promulgate, amend and enforce all rules and
regulations necessary for the proper administration of the fund in
accordance with the provisions of this section, including, but not
limited to, those concerning the payment of claims and concerning the
actuarial calculations necessary to determine, annually, the total
amount to be paid into the fund as provided herein, and as otherwise
needed to implement this title.
[16. The commissioner shall convene a consumer advisory committee for
the purpose of providing information, as requested by the commissioner,
in the development of the regulations authorized by subdivision fifteen
of this section.]
§ 4. Section 5 of chapter 517 of the laws of 2016, amending the public
health law relating to payments from the New York state medical indem-
nity fund, as amended by chapter 4 of the laws of 2017, is amended to
read as follows:
§ 5. This act shall take effect on the forty-fifth day after it shall
have become a law, provided that the amendments to subdivision 4 of
section 2999-j of the public health law made by section two of this act
shall take effect on June 30, 2017 and shall expire and be deemed
repealed December 31, [2019] 2020.
§ 5. Section 99-t of the state finance law, as added by section 52-e
of part H of chapter 59 of the laws of 2011, is amended to read as
follows:
§ 99-t. New York state medical indemnity fund account. 1. There is
hereby established in the custody of the commissioner of taxation and
finance a special account to be known as the "New York state medical
indemnity fund account".
2. All moneys received by the New York state medical indemnity fund
pursuant to title four of article twenty-nine-D of the public health law
from whatever source derived shall be deposited to the exclusive credit
of such fund account. Said moneys shall be kept separate and shall not
be commingled with any other moneys in the custody of the commissioner
of taxation and finance.
3. The moneys in said account shall be retained by the fund and shall
be released by the commissioner of taxation and finance only upon
certificates signed by the [superintendent of financial services or the
head of any successor agency to the department of insurance] COMMISSION-
ER OF HEALTH or his or her designee and only for the purposes set forth
in title four of article twenty-nine-D of the public health law.
§ 6. This act shall take effect October 1, 2019; provided however, on
and after April 1, 2019, the commissioner of health may take any steps
necessary to implement this act on its effective date; and notwithstand-
ing any inconsistent provision of the state administrative procedure act
or any other provision of law, rule or regulation, the commissioner of
health is authorized to adopt or amend or promulgate on an emergency
basis any regulation he or she determines necessary to implement any
provision of this act on its effective date.
PART L
Section 1. Subparagraph (C) of paragraph 6 of subsection (k) of
section 3221 of the insurance law, as amended by section 1 of part K of
chapter 82 of the laws of 2002, is amended to read as follows:
(C) Coverage of diagnostic and treatment procedures, including
prescription drugs, used in the diagnosis and treatment of infertility
S. 1507 83 A. 2007
as required by subparagraphs (A) and (B) of this paragraph shall be
provided in accordance with the provisions of this subparagraph.
(i) [Coverage] EXCEPT AS PROVIDED IN ITEMS (VI) AND (VII) OF THIS
SUBPARAGRAPH, COVERAGE shall be provided for persons whose ages range
from twenty-one through forty-four years, provided that nothing herein
shall preclude the provision of coverage to persons whose age is below
or above such range.
(ii) Diagnosis and treatment of infertility shall be prescribed as
part of a physician's overall plan of care and consistent with the
guidelines for coverage as referenced in this subparagraph.
(iii) Coverage may be subject to co-payments, coinsurance and deduct-
ibles as may be deemed appropriate by the superintendent and as are
consistent with those established for other benefits within a given
policy.
(iv) [Coverage shall be limited to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this subparagraph "period of
not less than twelve months" shall be determined by calculating such
time from either the date the insured was first covered under the exist-
ing policy or from the date the insured was first covered by a previous-
ly in-force converted policy, whichever is earlier.
(v) Coverage] EXCEPT AS PROVIDED IN ITEMS (VI) AND (VII) OF THIS
SUBPARAGRAPH, COVERAGE shall not be required to include the diagnosis
and treatment of infertility in connection with: (I) in vitro fertiliza-
tion, gamete intrafallopian tube transfers or zygote intrafallopian tube
transfers; (II) the reversal of elective sterilizations; (III) sex
change procedures; (IV) cloning; or (V) medical or surgical services or
procedures that are deemed to be experimental in accordance with clin-
ical guidelines referenced in [clause (vi)] ITEM (V) of this subpara-
graph.
[(vi)] (V) The superintendent, in consultation with the commissioner
of health, shall promulgate regulations which shall stipulate the guide-
lines and standards which shall be used in carrying out the provisions
of this subparagraph, which shall include:
(I) The determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American College of
Obstetricians and Gynecologists and the American Society for Reproduc-
tive Medicine INCLUDING "IATROGENIC INFERTILITY", WHICH MEANS AN IMPAIR-
MENT OF FERTILITY BY SURGERY, RADIATION, CHEMOTHERAPY OR OTHER MEDICAL
TREATMENT AFFECTING REPRODUCTIVE ORGANS OR PROCESSES;
(II) The identification of experimental procedures and treatments not
covered for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine;
(III) The identification of the required training, experience and
other standards for health care providers for the provision of proce-
dures and treatments for the diagnosis and treatment of infertility
determined in accordance with the standards and guidelines established
and adopted by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
(IV) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the standards and guidelines estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.
S. 1507 84 A. 2007
(VI) COVERAGE SHALL ALSO INCLUDE STANDARD FERTILITY PRESERVATION
SERVICES WHEN A MEDICAL TREATMENT MAY DIRECTLY OR INDIRECTLY CAUSE
IATROGENIC INFERTILITY TO AN INSURED. COVERAGE MAY BE SUBJECT TO ANNUAL
DEDUCTIBLES AND COINSURANCE, INCLUDING COPAYMENTS, AS MAY BE DEEMED
APPROPRIATE BY THE SUPERINTENDENT AND AS ARE CONSISTENT WITH THOSE
ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN POLICY.
(VII) EVERY LARGE GROUP POLICY DELIVERED OR ISSUED FOR DELIVERY IN
THIS STATE THAT PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR COMPREHEN-
SIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE FOR THREE CYCLES OF IN-VITRO
FERTILIZATION USED IN THE TREATMENT OF INFERTILITY AS DEFINED IN CLAUSE
(I) OF ITEM (V) OF THIS SUBPARAGRAPH. COVERAGE MAY BE SUBJECT TO ANNUAL
DEDUCTIBLES AND COINSURANCE, INCLUDING COPAYMENTS, AS MAY BE DEEMED
APPROPRIATE BY THE SUPERINTENDENT AND AS ARE CONSISTENT WITH THOSE
ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN POLICY. FOR PURPOSES OF
THIS ITEM, A "CYCLE" IS DEFINED AS EITHER ALL TREATMENT THAT STARTS
WHEN: PREPARATORY MEDICATIONS ARE ADMINISTERED FOR OVARIAN STIMULATION
FOR OOCYTE RETRIEVAL WITH THE INTENT OF UNDERGOING IN-VITRO FERTILIZA-
TION USING A FRESH EMBRYO TRANSFER; OR MEDICATIONS ARE ADMINISTERED FOR
ENDOMETRIAL PREPARATION WITH THE INTENT OF UNDERGOING IN-VITRO FERTILI-
ZATION USING A FROZEN EMBRYO TRANSFER. NO INSURER PROVIDING COVERAGE
UNDER THIS ITEM OR ITEM (VI) OF THIS SUBPARAGRAPH SHALL DISCRIMINATE
BASED ON AN INSURED'S EXPECTED LENGTH OF LIFE, PRESENT OF PREDICTED
DISABILITY, DEGREE OF MEDICAL DEPENDENCY, PERCEIVED QUALITY OF LIFE, OR
OTHER HEALTH CONDITIONS, NOR BASED ON PERSONAL CHARACTERISTICS, INCLUD-
ING AGE, SEX, SEXUAL ORIENTATION, MARITAL STATUS OR GENDER IDENTITY.
§ 2. Paragraph 3 of subsection (s) of section 4303 of the insurance
law, as amended by section 2 of part K of chapter 82 of the laws of
2002, is amended to read as follows:
(3) Coverage of diagnostic and treatment procedures, including
prescription drugs used in the diagnosis and treatment of infertility as
required by paragraphs one and two of this subsection shall be provided
in accordance with this paragraph.
(A) [Coverage] EXCEPT AS PROVIDED IN SUBPARAGRAPHS (F) AND (G) OF THIS
PARAGRAPH, COVERAGE shall be provided for persons whose ages range from
twenty-one through forty-four years, provided that nothing herein shall
preclude the provision of coverage to persons whose age is below or
above such range.
(B) Diagnosis and treatment of infertility shall be prescribed as part
of a physician's overall plan of care and consistent with the guidelines
for coverage as referenced in this paragraph.
(C) Coverage may be subject to co-payments, coinsurance and deduct-
ibles as may be deemed appropriate by the superintendent and as are
consistent with those established for other benefits within a given
policy.
(D) [Coverage shall be limited to those individuals who have been
previously covered under the policy for a period of not less than twelve
months, provided that for the purposes of this paragraph "period of not
less than twelve months" shall be determined by calculating such time
from either the date the insured was first covered under the existing
policy or from the date the insured was first covered by a previously
in-force converted policy, whichever is earlier.
(E) Coverage] EXCEPT AS PROVIDED IN SUBPARAGRAPHS (F) AND (G) OF THIS
PARAGRAPH, COVERAGE shall not be required to include the diagnosis and
treatment of infertility in connection with: (i) in vitro fertilization,
gamete intrafallopian tube transfers or zygote intrafallopian tube
transfers; (ii) the reversal of elective sterilizations; (iii) sex
S. 1507 85 A. 2007
change procedures; (iv) cloning; or (v) medical or surgical services or
procedures that are deemed to be experimental in accordance with clin-
ical guidelines referenced in subparagraph [(F)] (E) of this paragraph.
[(F)] (E) The superintendent, in consultation with the commissioner of
health, shall promulgate regulations which shall stipulate the guide-
lines and standards which shall be used in carrying out the provisions
of this paragraph, which shall include:
(i) The determination of "infertility" in accordance with the stand-
ards and guidelines established and adopted by the American College of
Obstetricians and Gynecologists and the American Society for Reproduc-
tive Medicine;
(ii) The identification of experimental procedures and treatments not
covered for the diagnosis and treatment of infertility determined in
accordance with the standards and guidelines established and adopted by
the American College of Obstetricians and Gynecologists and the American
Society for Reproductive Medicine INCLUDING "IATROGENIC INFERTILITY",
WHICH MEANS AN IMPAIRMENT OF FERTILITY BY SURGERY, RADIATION, CHEMOTHER-
APY OR OTHER MEDICAL TREATMENT AFFECTING REPRODUCTIVE ORGANS OR PROC-
ESSES;
(iii) The identification of the required training, experience and
other standards for health care providers for the provision of proce-
dures and treatments for the diagnosis and treatment of infertility
determined in accordance with the standards and guidelines established
and adopted by the American College of Obstetricians and Gynecologists
and the American Society for Reproductive Medicine; and
(iv) The determination of appropriate medical candidates by the treat-
ing physician in accordance with the standards and guidelines estab-
lished and adopted by the American College of Obstetricians and Gynecol-
ogists and/or the American Society for Reproductive Medicine.
(F) COVERAGE SHALL ALSO INCLUDE STANDARD FERTILITY PRESERVATION
SERVICES WHEN A MEDICAL TREATMENT MAY DIRECTLY OR INDIRECTLY CAUSE
IATROGENIC INFERTILITY TO AN INSURED. COVERAGE MAY BE SUBJECT TO ANNUAL
DEDUCTIBLES AND COINSURANCE, INCLUDING COPAYMENTS, AS MAY BE DEEMED
APPROPRIATE BY THE SUPERINTENDENT AND AS ARE CONSISTENT WITH THOSE
ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN CONTRACT.
(G) EVERY LARGE GROUP CONTRACT THAT PROVIDES MEDICAL, MAJOR MEDICAL OR
SIMILAR COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE FOR THREE
CYCLES OF IN-VITRO FERTILIZATION USED IN THE TREATMENT OF INFERTILITY AS
DEFINED IN ITEM (I) OF SUBPARAGRAPH (E) OF THIS PARAGRAPH. COVERAGE MAY
BE SUBJECT TO ANNUAL DEDUCTIBLES AND COINSURANCE, INCLUDING COPAYMENTS,
AS MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND AS ARE CONSISTENT
WITH THOSE ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN CONTRACT. FOR
PURPOSES OF THIS SUBPARAGRAPH, A "CYCLE" IS DEFINED AS EITHER ALL TREAT-
MENT THAT STARTS WHEN: PREPARATORY MEDICATIONS ARE ADMINISTERED FOR
OVARIAN STIMULATION FOR OOCYTE RETRIEVAL WITH THE INTENT OF UNDERGOING
IN-VITRO FERTILIZATION USING A FRESH EMBRYO TRANSFER; OR MEDICATIONS ARE
ADMINISTERED FOR ENDOMETRIAL PREPARATION WITH THE INTENT OF UNDERGOING
IN-VITRO FERTILIZATION USING A FROZEN EMBRYO TRANSFER. NO CORPORATION
PROVIDING COVERAGE UNDER SUBPARAGRAPHS (F) OR (G) OF THIS PARAGRAPH
SHALL DISCRIMINATE BASED ON AN INSURED'S EXPECTED LENGTH OF LIFE, PRES-
ENT OR PREDICTED DISABILITY, DEGREE OF MEDICAL DEPENDENCY, PERCEIVED
QUALITY OF LIFE, OR OTHER HEALTH CONDITIONS, NOR BASED ON PERSONAL CHAR-
ACTERISTICS, INCLUDING AGE, SEX, SEXUAL ORIENTATION, MARITAL STATUS OR
GENDER IDENTITY.
§ 3. Paragraph 13 of subsection (i) of section 3216 of the insurance
law is amended by adding a new subparagraph (C) to read as follows:
S. 1507 86 A. 2007
(C) EVERY POLICY THAT PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR
COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE FOR STANDARD FERTILI-
TY PRESERVATION SERVICES WHEN A MEDICAL TREATMENT MAY DIRECTLY OR INDI-
RECTLY CAUSE IATROGENIC INFERTILITY TO AN INSURED. COVERAGE MAY BE
SUBJECT TO ANNUAL DEDUCTIBLES AND COINSURANCE, INCLUDING COPAYMENTS, AS
MAY BE DEEMED APPROPRIATE BY THE SUPERINTENDENT AND AS ARE CONSISTENT
WITH THOSE ESTABLISHED FOR OTHER BENEFITS WITHIN A GIVEN POLICY.
(I) FOR PURPOSES OF THIS SUBPARAGRAPH, "IATROGENIC INFERTILITY" MEANS
AN IMPAIRMENT OF FERTILITY BY SURGERY, RADIATION, CHEMOTHERAPY OR OTHER
MEDICAL TREATMENT AFFECTING REPRODUCTIVE ORGANS OR PROCESSES.
(II) NO INSURER PROVIDING COVERAGE UNDER THIS PARAGRAPH SHALL DISCRIM-
INATE BASED ON AN INSURED'S EXPECTED LENGTH OF LIFE, PRESENT OR
PREDICTED DISABILITY, DEGREE OF MEDICAL DEPENDENCY, PERCEIVED QUALITY OF
LIFE, OR OTHER HEALTH CONDITIONS, NOR BASED ON PERSONAL CHARACTERISTICS,
INCLUDING AGE, SEX, SEXUAL ORIENTATION, MARITAL STATUS OR GENDER IDENTI-
TY.
§ 4. This act shall take effect January 1, 2020 and shall apply to
policies and contracts issued, renewed, modified, altered or amended on
or after such date.
PART M
Section 1. This act shall be known and may be cited as the "comprehen-
sive contraception coverage act".
§ 2. Paragraph 16 of subsection (l) of section 3221 of the insurance
law, as added by chapter 554 of the laws of 2002, is amended to read as
follows:
(16) (A) Every group or blanket policy which [provides coverage for
prescription drugs shall include coverage for the cost of contraceptive
drugs or devices approved by the federal food and drug administration or
generic equivalents approved as substitutes by such food and drug admin-
istration under the prescription of a health care provider legally
authorized to prescribe under title eight of the education law. The
coverage required by this section shall be included in policies and
certificates only through the addition of a rider.
(A)] PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR COMPREHENSIVE-TYPE
COVERAGE SHALL PROVIDE COVERAGE FOR ALL OF THE FOLLOWING SERVICES AND
CONTRACEPTIVE METHODS:
(I) ALL FDA-APPROVED CONTRACEPTIVE DRUGS, DEVICES, AND OTHER PRODUCTS.
THIS INCLUDES ALL FDA-APPROVED OVER-THE-COUNTER CONTRACEPTIVE DRUGS,
DEVICES, AND PRODUCTS AS PRESCRIBED OR AS OTHERWISE AUTHORIZED UNDER
STATE OR FEDERAL LAW. NOTWITHSTANDING THIS PARAGRAPH, AN INSURER SHALL
NOT BE REQUIRED TO PROVIDE COVERAGE OF MALE CONDOMS. THE FOLLOWING
APPLIES TO THIS COVERAGE:
(I) WHERE THE FDA HAS APPROVED ONE OR MORE THERAPEUTIC AND PHARMACEU-
TICAL EQUIVALENT, AS DEFINED BY THE FDA, VERSIONS OF A CONTRACEPTIVE
DRUG, DEVICE, OR PRODUCT, AN INSURER IS NOT REQUIRED TO INCLUDE ALL SUCH
THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS IN ITS FORMULARY, SO
LONG AS AT LEAST ONE IS INCLUDED AND COVERED WITHOUT COST-SHARING AND IN
ACCORDANCE WITH THIS PARAGRAPH;
(II) IF THE COVERED THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS
OF A DRUG, DEVICE, OR PRODUCT ARE NOT AVAILABLE OR ARE DEEMED MEDICALLY
INADVISABLE, THE INSURER SHALL PROVIDE COVERAGE FOR AN ALTERNATE THERA-
PEUTIC AND PHARMACEUTICAL EQUIVALENT VERSION OF THE CONTRACEPTIVE DRUG,
DEVICE, OR PRODUCT WITHOUT COST-SHARING UPON THE RECOMMENDATION OF THE
INSURED'S ATTENDING HEALTH CARE PROVIDER. AN INSURER SHALL DEFER TO THE
S. 1507 87 A. 2007
ATTENDING HEALTH CARE PROVIDER'S DETERMINATION OF MEDICAL NECESSITY.
THE SUPERINTENDENT MAY DEVELOP A STANDARD EXCEPTION FORM WITH
INSTRUCTIONS THAT AN ATTENDING HEALTH CARE PROVIDER MAY USE TO RECOMMEND
A PARTICULAR CONTRACEPTIVE DRUG, DEVICE, OR PRODUCT BASED UPON A DETER-
MINATION OF MEDICAL NECESSITY FOR AN INSURED. THE INSURER SHALL ACCEPT
THE STANDARD EXCEPTION FORM SUBMITTED BY THE INSURED'S ATTENDING HEALTH
CARE PROVIDER;
(III) THIS COVERAGE SHALL INCLUDE EMERGENCY CONTRACEPTION WITHOUT
COST-SHARING WHEN PROVIDED PURSUANT TO PRESCRIPTION, ORDER UNDER SECTION
SIXTY-EIGHT HUNDRED THIRTY-ONE OF THE EDUCATION LAW, OVER-THE-COUNTER,
OR WHEN OTHERWISE LAWFULLY PROVIDED OTHER THAN PURSUANT TO A
PRESCRIPTION; AND
(IV) THIS COVERAGE SHALL ALLOW FOR THE DISPENSING OF TWELVE MONTHS-
WORTH OF A CONTRACEPTIVE AT ONE TIME;
(II) VOLUNTARY STERILIZATION PROCEDURES FOR WOMEN;
(III) PATIENT EDUCATION AND COUNSELING ON CONTRACEPTION; AND
(IV) FOLLOW-UP SERVICES RELATED TO THE DRUGS, DEVICES, PRODUCTS, AND
PROCEDURES COVERED UNDER THIS PARAGRAPH, INCLUDING, BUT NOT LIMITED TO,
MANAGEMENT OF SIDE EFFECTS, COUNSELING FOR CONTINUED ADHERENCE, AND
DEVICE INSERTION AND REMOVAL.
(B) AN INSURER SUBJECT TO THIS PARAGRAPH SHALL NOT IMPOSE A DEDUCT-
IBLE, COINSURANCE, COPAYMENT OR ANY OTHER COST-SHARING REQUIREMENT ON
THE COVERAGE PROVIDED PURSUANT TO THIS PARAGRAPH.
(C) EXCEPT AS OTHERWISE AUTHORIZED UNDER THIS PARAGRAPH, AN INSURER
SHALL NOT IMPOSE ANY RESTRICTIONS OR DELAYS ON THE COVERAGE REQUIRED
UNDER THIS PARAGRAPH.
(D) Notwithstanding any other provision of this subsection, a reli-
gious employer may request a contract without coverage for federal food
and drug administration approved contraceptive methods that are contrary
to the religious employer's religious tenets. If so requested, such
contract shall be provided without coverage for contraceptive methods.
This paragraph shall not be construed to deny an enrollee coverage of,
and timely access to, contraceptive methods.
(1) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:
(a) The inculcation of religious values is the purpose of the entity.
(b) The entity primarily employs persons who share the religious
tenets of the entity.
(c) The entity serves primarily persons who share the religious tenets
of the entity.
(d) The entity is a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(2) Every religious employer that invokes the exemption provided under
this paragraph shall provide written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
[(B) (i)] (E) (1) Where a group policyholder makes an election not to
purchase coverage for contraceptive drugs or devices in accordance with
subparagraph [(A)] (D) of this paragraph each certificateholder covered
under the policy issued to that group policyholder shall have the right
to directly purchase the rider required by this paragraph from the
insurer which issued the group policy at the prevailing small group
community rate for such rider whether or not the employee is part of a
small group.
[(ii)] (2) Where a group policyholder makes an election not to
purchase coverage for contraceptive drugs or devices in accordance with
S. 1507 88 A. 2007
subparagraph [(A)] (D) of this paragraph, the insurer that provides such
coverage shall provide written notice to certificateholders upon enroll-
ment with the insurer of their right to directly purchase a rider for
coverage for the cost of contraceptive drugs or devices. The notice
shall also advise the certificateholders of the additional premium for
such coverage.
[(C)] (F) Nothing in this paragraph shall be construed as authorizing
a group or blanket policy which provides coverage for prescription drugs
to exclude coverage for prescription drugs prescribed for reasons other
than contraceptive purposes.
[(D) Such coverage may be subject to reasonable annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other drugs or devices covered
under the policy.]
§ 3. Subsection (cc) of section 4303 of the insurance law, as added by
chapter 554 of the laws of 2002, is amended to read as follows:
(cc) (1) Every contract [which provides coverage for prescription
drugs shall include coverage for the cost of contraceptive drugs or
devices approved by the federal food and drug administration or generic
equivalents approved as substitutes by such food and drug administration
under the prescription of a health care provider legally authorized to
prescribe under title eight of the education law. The coverage required
by this section shall be included in contracts and certificates only
through the addition of a rider.
(1)] WHICH PROVIDES MEDICAL, MAJOR MEDICAL, OR SIMILAR COMPREHENSIVE-
TYPE COVERAGE SHALL PROVIDE COVERAGE FOR ALL OF THE FOLLOWING SERVICES
AND CONTRACEPTIVE METHODS:
(A) ALL FDA-APPROVED CONTRACEPTIVE DRUGS, DEVICES, AND OTHER PRODUCTS.
THIS INCLUDES ALL FDA-APPROVED OVER-THE-COUNTER CONTRACEPTIVE DRUGS,
DEVICES, AND PRODUCTS AS PRESCRIBED OR AS OTHERWISE AUTHORIZED UNDER
STATE OR FEDERAL LAW. NOTWITHSTANDING THIS PARAGRAPH, A CORPORATION
SHALL NOT BE REQUIRED TO PROVIDE COVERAGE OF MALE CONDOMS. THE FOLLOW-
ING APPLIES TO THIS COVERAGE:
(I) WHERE THE FDA HAS APPROVED ONE OR MORE THERAPEUTIC AND PHARMACEU-
TICAL EQUIVALENT, AS DEFINED BY THE FDA, VERSIONS OF A CONTRACEPTIVE
DRUG, DEVICE, OR PRODUCT, A CORPORATION IS NOT REQUIRED TO INCLUDE ALL
SUCH THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS IN ITS FORMU-
LARY, SO LONG AS AT LEAST ONE IS INCLUDED AND COVERED WITHOUT COST-SHAR-
ING AND IN ACCORDANCE WITH THIS SUBSECTION;
(II) IF THE COVERED THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS
OF A DRUG, DEVICE, OR PRODUCT ARE NOT AVAILABLE OR ARE DEEMED MEDICALLY
INADVISABLE, A CORPORATION SHALL PROVIDE COVERAGE FOR AN ALTERNATE THER-
APEUTIC AND PHARMACEUTICAL EQUIVALENT VERSION OF THE CONTRACEPTIVE DRUG,
DEVICE, OR PRODUCT WITHOUT COST-SHARING UPON THE RECOMMENDATION OF THE
INSURED'S ATTENDING HEALTH CARE PROVIDER. A CORPORATION SHALL DEFER TO
THE ATTENDING HEALTH CARE PROVIDER'S DETERMINATION OF MEDICAL NECESSITY.
THE SUPERINTENDENT MAY DEVELOP A STANDARD EXCEPTION FORM WITH
INSTRUCTIONS THAT AN ATTENDING HEALTH CARE PROVIDER MAY USE TO RECOMMEND
A PARTICULAR CONTRACEPTIVE DRUG, DEVICE, OR PRODUCT BASED UPON A DETER-
MINATION OF MEDICAL NECESSITY FOR AN INSURED. THE INSURER SHALL ACCEPT
THE STANDARD EXCEPTION FORM SUBMITTED BY THE INSURED'S ATTENDING HEALTH
CARE PROVIDER;
(III) THIS COVERAGE SHALL INCLUDE EMERGENCY CONTRACEPTION WITHOUT
COST-SHARING WHEN PROVIDED PURSUANT TO A PRESCRIPTION, ORDER UNDER
SECTION SIXTY-EIGHT HUNDRED THIRTY-ONE OF THE EDUCATION LAW, OVER-THE-
S. 1507 89 A. 2007
COUNTER, OR WHEN OTHERWISE LAWFULLY PROVIDED OTHER THAN THROUGH A
PRESCRIPTION; AND
(IV) THIS COVERAGE SHALL ALLOW FOR THE DISPENSING OF TWELVE MONTHS
WORTH OF A CONTRACEPTIVE AT ONE TIME;
(B) VOLUNTARY STERILIZATION PROCEDURES FOR WOMEN;
(C) PATIENT EDUCATION AND COUNSELING ON CONTRACEPTION; AND
(D) FOLLOW-UP SERVICES RELATED TO THE DRUGS, DEVICES, PRODUCTS, AND
PROCEDURES COVERED UNDER THIS SUBSECTION, INCLUDING, BUT NOT LIMITED TO,
MANAGEMENT OF SIDE EFFECTS, COUNSELING FOR CONTINUED ADHERENCE, AND
DEVICE INSERTION AND REMOVAL.
(2) A CORPORATION SUBJECT TO THIS PARAGRAPH SHALL NOT IMPOSE A DEDUCT-
IBLE, COINSURANCE, COPAYMENT OR ANY OTHER COST-SHARING REQUIREMENT ON
THE COVERAGE PROVIDED PURSUANT TO THIS SUBSECTION.
(3) EXCEPT AS OTHERWISE AUTHORIZED UNDER THIS SUBSECTION, A CORPO-
RATION SHALL NOT IMPOSE ANY RESTRICTIONS OR DELAYS ON THE COVERAGE
REQUIRED UNDER THIS SUBSECTION.
(4) Notwithstanding any other provision of this subsection, a reli-
gious employer may request a contract without coverage for federal food
and drug administration approved contraceptive methods that are contrary
to the religious employer's religious tenets. If so requested, such
contract shall be provided without coverage for contraceptive methods.
This paragraph shall not be construed to deny an enrollee coverage of,
and timely access to, contraceptive methods.
(A) For purposes of this subsection, a "religious employer" is an
entity for which each of the following is true:
(i) The inculcation of religious values is the purpose of the entity.
(ii) The entity primarily employs persons who share the religious
tenets of the entity.
(iii) The entity serves primarily persons who share the religious
tenets of the entity.
(iv) The entity is a nonprofit organization as described in Section
6033(a)(2)(A)i or iii, of the Internal Revenue Code of 1986, as amended.
(B) Every religious employer that invokes the exemption provided under
this paragraph shall provide written notice to prospective enrollees
prior to enrollment with the plan, listing the contraceptive health care
services the employer refuses to cover for religious reasons.
[(2)](5) (A) Where a group contractholder makes an election not to
purchase coverage for contraceptive drugs or devices in accordance with
paragraph [one] FOUR of this subsection, each enrollee covered under the
contract issued to that group contractholder shall have the right to
directly purchase the rider required by this subsection from the insurer
or health maintenance organization which issued the group contract at
the prevailing small group community rate for such rider whether or not
the employee is part of a small group.
(B) Where a group contractholder makes an election not to purchase
coverage for contraceptive drugs or devices in accordance with paragraph
[one] FOUR of this subsection, the insurer or health maintenance organ-
ization that provides such coverage shall provide written notice to
enrollees upon enrollment with the insurer or health maintenance organ-
ization of their right to directly purchase a rider for coverage for the
cost of contraceptive drugs or devices. The notice shall also advise the
enrollees of the additional premium for such coverage.
[(3)](6) Nothing in this subsection shall be construed as authorizing
a contract which provides coverage for prescription drugs to exclude
coverage for prescription drugs prescribed for reasons other than
contraceptive purposes.
S. 1507 90 A. 2007
[(4) Such coverage may be subject to reasonable annual deductibles and
coinsurance as may be deemed appropriate by the superintendent and as
are consistent with those established for other drugs or devices covered
under the policy.]
§ 4. Paragraph 17 of subsection (i) of section 3216 of the insurance
law is amended by adding a new subparagraph (G) to read as follows:
(G)(I) IN ADDITION TO SUBPARAGRAPHS (A), (B), (C), (D), OR (E) OF THIS
PARAGRAPH, EVERY POLICY THAT PROVIDES MEDICAL, MAJOR MEDICAL OR SIMILAR
COMPREHENSIVE-TYPE COVERAGE SHALL PROVIDE COVERAGE FOR ALL OF THE
FOLLOWING SERVICES AND CONTRACEPTIVE METHODS:
(I) ALL FDA-APPROVED CONTRACEPTIVE DRUGS, DEVICES, AND OTHER PRODUCTS.
THIS INCLUDES ALL FDA-APPROVED OVER-THE-COUNTER CONTRACEPTIVE DRUGS,
DEVICES, AND PRODUCTS AS PRESCRIBED OR AS OTHERWISE AUTHORIZED UNDER
STATE OR FEDERAL LAW. NOTWITHSTANDING THIS SUBPARAGRAPH, AN INSURER
SHALL NOT BE REQUIRED TO PROVIDE COVERAGE OF MALE CONDOMS. THE FOLLOWING
APPLIES TO THIS COVERAGE:
(AA) WHERE THE FDA HAS APPROVED ONE OR MORE THERAPEUTIC AND PHARMACEU-
TICAL EQUIVALENT, AS DEFINED BY THE FDA, VERSIONS OF A CONTRACEPTIVE
DRUG, DEVICE, OR PRODUCT, AN INSURER IS NOT REQUIRED TO INCLUDE ALL SUCH
THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS IN ITS FORMULARY, SO
LONG AS AT LEAST ONE IS INCLUDED AND COVERED WITHOUT COST-SHARING IN
ACCORDANCE WITH THIS SUBPARAGRAPH;
(BB) IF THE COVERED THERAPEUTIC AND PHARMACEUTICAL EQUIVALENT VERSIONS
OF A DRUG, DEVICE, OR PRODUCT ARE NOT AVAILABLE OR ARE DEEMED MEDICALLY
INADVISABLE, THE INSURER SHALL PROVIDE COVERAGE FOR AN ALTERNATE THERA-
PEUTIC AND PHARMACEUTICAL EQUIVALENT VERSION OF THE CONTRACEPTIVE DRUG,
DEVICE, OR PRODUCT WITHOUT COST-SHARING. AN INSURER SHALL DEFER TO THE
ATTENDING HEALTH CARE PROVIDER'S DETERMINATION OF MEDICAL NECESSITY.
THE SUPERINTENDENT MAY DEVELOP A STANDARD EXCEPTION FORM WITH
INSTRUCTIONS THAT AN ATTENDING HEALTH CARE PROVIDER MAY USE TO RECOMMEND
A PARTICULAR CONTRACEPTIVE DRUG, DEVICE, PROCEDURE, SERVICE, OR PRODUCT
BASED UPON A DETERMINATION OF MEDICAL NECESSITY FOR AN INSURED. THE
INSURER SHALL ACCEPT THE STANDARD EXCEPTION FORM SUBMITTED BY THE
INSURED'S ATTENDING HEALTH CARE PROVIDER;
(CC) THIS COVERAGE SHALL INCLUDE EMERGENCY CONTRACEPTION WITHOUT COST-
SHARING WHEN PROVIDED PURSUANT TO A PRESCRIPTION, ORDER UNDER SECTION
SIXTY-EIGHT HUNDRED THIRTY-ONE OF THE EDUCATION LAW, OVER-THE-COUNTER,
OR WHEN OTHERWISE LAWFULLY PROVIDED OTHER THAN PURSUANT TO A
PRESCRIPTION; AND
(DD) THIS COVERAGE SHALL ALLOW FOR THE DISPENSING OF TWELVE MONTHS-
WORTH OF A CONTRACEPTIVE AT ONE TIME:
(II) VOLUNTARY STERILIZATION PROCEDURES FOR WOMEN;
(III) PATIENT EDUCATION AND COUNSELING ON CONTRACEPTION; AND
(IV) FOLLOW-UP SERVICES RELATED TO THE DRUGS, DEVICES, PRODUCTS, AND
PROCEDURES COVERED UNDER THIS SUBPARAGRAPH, INCLUDING MANAGEMENT OF SIDE
EFFECTS, COUNSELING FOR CONTINUED ADHERENCE, AND DEVICE INSERTION AND
REMOVAL.
(II) AN INSURER SUBJECT TO THIS SUBPARAGRAPH SHALL NOT IMPOSE A DEDUC-
TIBLE, COINSURANCE, COPAYMENT OR ANY OTHER COST-SHARING REQUIREMENT ON
THE COVERAGE PROVIDED PURSUANT TO THIS SUBPARAGRAPH.
(III) EXCEPT AS OTHERWISE AUTHORIZED UNDER THIS SUBPARAGRAPH, AN
INSURER SHALL NOT IMPOSE ANY RESTRICTIONS OR DELAYS ON THE COVERAGE
REQUIRED UNDER THIS SUBPARAGRAPH.
§ 5. Paragraph (d) of subdivision 3 of section 365-a of the social
services law, as amended by chapter 909 of the laws of 1974 and as
S. 1507 91 A. 2007
relettered by chapter 82 of the laws of 1995, is amended to read as
follows:
(d) family planning services and supplies for eligible persons of
childbearing age, including children under twenty-one years of age who
can be considered sexually active, who desire such services and
supplies, in accordance with the requirements of federal law and regu-
lations and the regulations of the department. PRESCRIPTION CONTRACEP-
TIVES, WHEN PRESCRIBED BASED ON GENERALLY ACCEPTED MEDICAL PRACTICE, MAY
BE DISPENSED AT ONE TIME OR UP TO TWELVE TIMES WITHIN ONE YEAR FROM THE
DATE OF THE PRESCRIPTION. No person shall be compelled or coerced to
accept such services or supplies.
§ 6. This act shall take effect January 1, 2020; provided that
sections two, three and four of this act shall apply to policies and
contracts issued, renewed, modified, altered or amended on and after
such date.
PART N
Section 1. Universal access commission. 1. There is hereby created a
universal access commission, which shall consider and advise the commis-
sioner of health and the superintendent of financial services on options
for achieving universal access to health care in New York State.
2. The universal access commission shall consist of independent health
policy and insurance experts appointed by the commissioner and super-
intendent. The commission shall consult with the legislature and stake-
holder groups and convene at least one meeting for members of the public
to review and discuss options for achieving universal access to care.
3. The commissioner and superintendent shall select the chair of the
commission from among the members of such commission and shall designate
at least one employee from each department to assist the commission in
the performance of its duties under this section. The commissioner and
superintendent shall adopt rules for the governance of the commission,
which shall meet as frequently as its business may require and at such
other times as determined by the commissioner and superintendent to be
necessary.
4. Members of the commission shall serve without compensation for
their services as members, but each shall be allowed the necessary and
actual expenses incurred in the performance of his or her duties under
this section.
5. The commission shall provide a report to the Governor on the
options for achieving universal access to health care in New York State
by December 1, 2019.
§ 2. This act shall take effect immediately.
PART O
Section 1. Subdivision 2 of section 605 of the public health law, as
amended by section 20 of part E of chapter 56 of the laws of 2013, is
amended to read as follows:
2. State aid reimbursement for public health services provided by a
municipality under this title, shall be made if the municipality is
providing some or all of the core public health services identified in
section six hundred two of this title, pursuant to an approved applica-
tion for state aid, at a rate of no less than thirty-six per centum,
EXCEPT FOR THE CITY OF NEW YORK WHICH SHALL RECEIVE NO LESS THAN TWENTY
PER CENTUM, of the difference between the amount of moneys expended by
S. 1507 92 A. 2007
the municipality for public health services required by section six
hundred two of this title during the fiscal year and the base grant
provided pursuant to subdivision one of this section. No such reimburse-
ment shall be provided for services that are not eligible for state aid
pursuant to this article.
§ 2. Subdivision 1 of section 616 of the public health law, as amended
by section 27 of part E of chapter 56 of the laws of 2013, is amended to
read as follows:
1. The total amount of state aid provided pursuant to this article
shall be limited to the amount of the annual appropriation made by the
legislature. In no event, however, shall such state aid be less than an
amount to provide the full base grant and, as otherwise provided by
[paragraph (a) of] subdivision two of section six hundred five of this
article, [at least] NO LESS THAN thirty-six per centum, EXCEPT FOR THE
CITY OF NEW YORK WHICH SHALL RECEIVE NO LESS THAN TWENTY PER CENTUM, of
the difference between the amount of moneys expended by the municipality
for eligible public health services pursuant to an approved application
for state aid during the fiscal year and the base grant provided pursu-
ant to subdivision one of section six hundred five of this article.
§ 3. This act shall take effect July 1, 2019.
PART P
Section 1. Subdivision 6 of section 1370 of the public health law, as
amended by chapter 485 of the laws of 1992, is amended as follows:
6. "Elevated lead levels" means a blood lead level greater than or
equal to [ten] FIVE micrograms of lead per deciliter of whole blood or
such LOWER blood lead level as may be established by the department
pursuant to rule or regulation.
§ 2. The public health law is amended by adding a new section 1370-f
to read as follows:
§ 1370-F. LEAD SAFE RESIDENTIAL RENTAL PROPERTIES. 1. DEFINITIONS.
FOR THE PURPOSES OF THIS SECTION:
(A) "RESIDENTIAL RENTAL PROPERTY" SHALL MEAN A DWELLING WHICH IS
EITHER RENTED, LEASED, LET OR HIRED OUT, TO BE OCCUPIED, OR IS OCCUPIED
AS THE HOME, RESIDENCE OR SLEEPING PLACE OF ONE OR MORE PERSONS OTHER
THAN THE OWNER'S FAMILY. RESIDENTIAL RENTAL PROPERTY SHALL NOT INCLUDE
SHORT TERM RENTAL PROPERTIES DURING WHICH GUESTS DO NOT STAY IN EXCESS
OF TWENTY-EIGHT DAYS.
(B) "LEAD SAFE" SHALL MEAN ANY RESIDENTIAL RENTAL PROPERTY THAT:
(I) HAS BEEN DETERMINED THROUGH A LEAD-BASED PAINT INSPECTION
CONDUCTED IN ACCORDANCE WITH APPROPRIATE FEDERAL REGULATIONS NOT TO
CONTAIN LEAD-BASED PAINT; OR
(II) MEETS THE MINIMUM STANDARDS SET FORTH IN REGULATIONS PROMULGATED
BY THE COMMISSIONER PURSUANT TO THIS SECTION.
2. THE COMMISSIONER SHALL PROMULGATE RULES AND REGULATIONS ESTABLISH-
ING MINIMUM STANDARDS FOR THE MAINTENANCE OF LEAD SAFE RESIDENTIAL
RENTAL PROPERTIES. SUCH RULES AND REGULATIONS SHALL INCLUDE:
(A) MINIMUM STANDARDS FOR MAINTAINING INTERNAL AND EXTERNAL PAINTED
SURFACES THAT CONTAIN LEAD-BASED PAINT; AND
(B) A SCHEDULE BY WHICH OWNERS OF RESIDENTIAL RENTAL PROPERTY MUST
IMPLEMENT AND COMPLY WITH SUCH MINIMUM STANDARDS.
3. IT SHALL BE THE RESPONSIBILITY OF AN OWNER OF ANY RESIDENTIAL
RENTAL PROPERTY TO MAINTAIN SUCH PROPERTY IN A LEAD SAFE CONDITION IN
ACCORDANCE WITH RULES AND REGULATIONS PROMULGATED BY THE COMMISSIONER
PURSUANT TO THIS SECTION.
S. 1507 93 A. 2007
4. ALL PAINT ON ANY RESIDENTIAL RENTAL PROPERTY ON WHICH THE ORIGINAL
CONSTRUCTION WAS COMPLETED PRIOR TO JANUARY FIRST, NINETEEN HUNDRED
SEVENTY-EIGHT, SHALL BE PRESUMED TO BE LEAD-BASED PAINT. THIS PRESUMP-
TION MAY BE OVERCOME BY A CERTIFICATION ISSUED BY A FEDERALLY CERTIFIED
LEAD-BASED PAINT INSPECTOR OR RISK ASSESSOR THAT THE PROPERTY HAS BEEN
DETERMINED NOT TO CONTAIN LEAD-BASED PAINT, OR BY SUCH OTHER MEANS AS
MAY BE PRESCRIBED BY THE RULES AND REGULATIONS ADOPTED BY THE COMMIS-
SIONER PURSUANT TO THIS SECTION.
5. THE COMMISSIONER, LOCAL HEALTH OFFICER OF A COUNTY AND, IN THE CITY
OF NEW YORK, THE COMMISSIONER OF THE NEW YORK CITY DEPARTMENT OF HEALTH
AND MENTAL HYGIENE, MAY ENTER INTO AN AGREEMENT OR CONTRACT WITH A
MUNICIPAL GOVERNMENT REGARDING INSPECTION OF THE LEAD CONDITIONS IN
RESIDENTIAL RENTAL PROPERTIES AND SUCH HEALTH DEPARTMENT MAY DESIGNATE
THE LOCAL HOUSING MAINTENANCE CODE ENFORCEMENT AGENCY IN WHICH THE
RESIDENTIAL RENTAL PROPERTY IS LOCATED AS AN AGENCY AUTHORIZED TO
ADMINISTER AND ENSURE COMPLIANCE WITH THE PROVISIONS OF THIS SECTION
AND SUBSEQUENT REGULATIONS PURSUANT TO SUBDIVISION ONE OF SECTION THIR-
TEEN HUNDRED SEVENTY-FIVE OF THIS TITLE.
6. IF THE COMMISSIONER, OR OTHER OFFICER HAVING JURISDICTION, DETER-
MINES THAT AN OWNER OF RESIDENTIAL RENTAL PROPERTY IS IN VIOLATION OF
THIS SECTION OR ANY RULES OR REGULATIONS PROMULGATED PURSUANT TO THIS
SECTION, THE COMMISSIONER OR OTHER OFFICER HAVING JURISDICTION SHALL
HAVE THE AUTHORITY TO ORDER THE ABATEMENT OF ANY LEAD CONDITION PRESENT
AT THE RESIDENTIAL RENTAL PROPERTY AND ASSESS FINES NOT TO EXCEED TWO
THOUSAND DOLLARS FOR EACH VIOLATION.
§ 3. This act shall take effect immediately.
PART Q
Section 1. Section 2825-f of the public health law is amended by
adding two new subdivisions 4-a and 4-b to read as follows:
4-A. NOTWITHSTANDING SUBDIVISION TWO OF THIS SECTION OR ANY INCONSIST-
ENT PROVISION OF LAW TO THE CONTRARY, AND UPON APPROVAL OF THE DIRECTOR
OF THE BUDGET, THE COMMISSIONER MAY, SUBJECT TO THE AVAILABILITY OF
LAWFUL APPROPRIATION, AWARD UP TO THREE HUNDRED MILLION DOLLARS OF THE
FUNDS MADE AVAILABLE PURSUANT TO THIS SECTION FOR UNFUNDED PROJECT
APPLICATIONS SUBMITTED IN RESPONSE TO THE REQUEST FOR APPLICATIONS
NUMBER 17648 ISSUED BY THE DEPARTMENT ON JANUARY EIGHTH, TWO THOUSAND
EIGHTEEN PURSUANT TO SECTION TWENTY-EIGHT HUNDRED TWENTY-FIVE-E OF THIS
ARTICLE, PROVIDED HOWEVER THAT THE PROVISIONS OF SUBDIVISIONS THREE AND
FOUR OF THIS SECTION SHALL APPLY.
4-B. AUTHORIZED AMOUNTS TO BE AWARDED PURSUANT TO APPLICATIONS SUBMIT-
TED IN RESPONSE TO THE REQUEST FOR APPLICATION NUMBER 17648 SHALL BE
AWARDED NO LATER THAN MAY FIRST, TWO THOUSAND NINETEEN.
§ 2. This act shall take effect immediately.
PART R
Section 1. Legislative findings and intent. The legislature finds that
maternal mortality and morbidity is a serious public health concern and
has a serious family and societal impact. New York state has among the
highest maternal mortality rates in the country and racial disparities
remain significant. The U.S. Centers for Disease Control and Prevention
has determined that a regular process for professional, multi-discipli-
nary, confidential review of all maternal deaths can help identify the
causes of maternal mortality, and those findings can lead to clinical
S. 1507 94 A. 2007
and social change that can help prevent maternal mortality. The same is
true for severe maternal morbidity. Confidentiality is important to
ensure that full information is made available in the review process to
maximize protection of maternal health.
Section 3 of article 17 of 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." The
legislature finds that the creation of a state maternal mortality review
board, and recognition and protection of any maternal mortality review
board, including a New York city maternal mortality review board, are a
matter of state concern and an important exercise of the legislature's
constitutional mandate to protect the public health.
§ 2. The public health law is amended by adding a new section 2509 to
read as follows:
§ 2509. MATERNAL MORTALITY REVIEW BOARD. 1. (A) THERE IS HEREBY ESTAB-
LISHED IN THE DEPARTMENT THE MATERNAL MORTALITY REVIEW BOARD FOR THE
PURPOSE OF REVIEWING MATERNAL DEATHS AND SEVERE MATERNAL MORBIDITY AND
DEVELOPING FINDINGS, RECOMMENDATIONS, AND BEST PRACTICES TO THE COMMIS-
SIONER TO CONTRIBUTE TO THE PREVENTION OF MATERNAL MORTALITY AND SEVERE
MATERNAL MORBIDITY. THE BOARD SHALL ASSESS THE CAUSE OF DEATH, FACTORS
LEADING TO DEATH AND PREVENTABILITY FOR EACH MATERNAL DEATH REVIEWED
AND, AT THE DISCRETION OF THE BOARD, CASES OF SEVERE MATERNAL MORBIDITY,
AND SHALL DEVELOP STRATEGIES FOR REDUCING THE RISK OF MATERNAL MORTALITY
AND SEVERE MATERNAL MORBIDITY, WHERE CASES OF SEVERE MATERNAL MORBIDITY
WERE REVIEWED, TAKING INTO ACCOUNT FACTORS SUCH AS RACIAL, ECONOMIC, OR
OTHER DISPARITIES. THE BOARDS' FINDINGS, RECOMMENDATIONS AND BEST PRAC-
TICES SHALL BE GIVEN TO THE COMMISSIONER FOR DISSEMINATION.
(B) ANY MATERNAL MORALITY REVIEW BOARD, INCLUDING A NEW YORK CITY
MATERNAL MORTALITY REVIEW BOARD, SHALL PROVIDE TO THE COMMISSIONER THE
RESULTS AND THE FINDINGS OF ITS REVIEWS, INCLUDING RECOMMENDATIONS AND
BEST PRACTICES AND UPON REQUEST INFORMATION AND DATA, INCLUDING CASE
SUMMARIES, TO SUPPORT STATEWIDE SURVEILLANCE AND ENFORCEMENT.
2. AS USED IN THIS SECTION:
(A) "ADVISORY COUNCIL" AND "COUNCIL" MEAN THE ADVISORY COUNCIL ON
MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY, ESTABLISHED UNDER THIS
SECTION.
(B) "BOARD" MEANS A MATERNAL MORTALITY REVIEW BOARD ESTABLISHED BY
THIS SECTION, REFERRED TO IN THIS SECTION AS THE "STATE BOARD", OR ANY
BOARD OPERATING, INCLUDING A NEW YORK CITY MATERNAL MORTALITY REVIEW
BOARD, UNDER THIS SECTION.
(C) "MATERNAL DEATH" MEANS THE DEATH OF A WOMAN DURING PREGNANCY OR
WITHIN A YEAR FROM THE END OF PREGNANCY.
(D) "SEVERE MATERNAL MORBIDITY" MEANS UNEXPECTED OUTCOMES OF PREGNAN-
CY, LABOR, OR DELIVERY THAT RESULT IN SIGNIFICANT SHORT- OR LONG-TERM
CONSEQUENCES TO A WOMAN'S HEALTH.
3. (A) THE MEMBERS OF THE STATE BOARD SHALL BE COMPRISED OF MULTIDIS-
CIPLINARY EXPERTS IN THE FIELD OF MATERNAL MORTALITY, WOMEN'S HEALTH AND
PUBLIC HEALTH, AND SHALL INCLUDE HEALTH CARE PROFESSIONALS AND OTHER
EXPERTS WHO SERVE AND ARE REPRESENTATIVE OF THE RACIAL AND ETHNIC DIVER-
SITY OF THE WOMEN AND MOTHERS OF THE STATE.
(B) THE STATE BOARD SHALL BE COMPOSED OF AT LEAST FIFTEEN MEMBERS, ALL
OF WHOM SHALL BE APPOINTED BY THE COMMISSIONER.
S. 1507 95 A. 2007
(C) THE TERMS OF THE STATE BOARD MEMBERS SHALL BE THREE YEARS. THE
COMMISSIONER MAY CHOOSE TO REAPPOINT STATE BOARD MEMBERS TO ADDITIONAL
THREE YEAR TERMS.
(D) A MAJORITY OF THE APPOINTED MEMBERSHIP OF THE STATE BOARD, NO LESS
THAN THREE, SHALL CONSTITUTE A QUORUM.
(E) WHEN ANY MEMBER OF THE STATE BOARD FAILS TO ATTEND THREE CONSEC-
UTIVE REGULAR MEETINGS, UNLESS SUCH ABSENCE IS FOR GOOD CAUSE, THAT
MEMBERSHIP MAY BE DEEMED VACANT FOR PURPOSES OF THE APPOINTMENT OF A
SUCCESSOR.
(F) MEETINGS OF THE STATE BOARD SHALL BE HELD AT LEAST TWICE A YEAR
BUT MAY BE HELD MORE FREQUENTLY AS DEEMED NECESSARY, SUBJECT TO REQUEST
OF THE DEPARTMENT.
(G) MEMBERS OF THE STATE BOARD SHALL BE INDEMNIFIED UNDER SECTION
SEVENTEEN OF THE PUBLIC OFFICERS LAW.
(H) MEMBERS OF THE STATE BOARD SHALL NOT BE COMPENSATED FOR THEIR
PARTICIPATION ON THE BOARD BUT MAY RECEIVE REIMBURSEMENT FOR THEIR ORDI-
NARY AND NECESSARY EXPENSES OF PARTICIPATION.
(I) MEMBERSHIP ON A BOARD SHALL NOT DISQUALIFY ANY PERSON FROM HOLDING
ANY PUBLIC OFFICE OR EMPLOYMENT.
(J) THE BOARD IS NOT SUBJECT TO THE OPEN MEETINGS LAW.
4. (A) THE COMMISSIONER SHALL RECEIVE UPON REQUEST FROM ANY DEPART-
MENT, DIVISION, BOARD, BUREAU, COMMISSION, LOCAL HEALTH DEPARTMENTS OR
OTHER AGENCY OF THE STATE OR POLITICAL SUBDIVISION THEREOF OR ANY PUBLIC
AUTHORITY, AS WELL AS HOSPITALS ESTABLISHED PURSUANT TO ARTICLE TWENTY-
EIGHT OF THIS CHAPTER, BIRTHING FACILITIES, MEDICAL EXAMINERS, CORONERS
AND CORONER PHYSICIANS AND ANY OTHER FACILITY PROVIDING SERVICES ASSOCI-
ATED WITH MATERNAL MORTALITY, SUCH INFORMATION, INCLUDING, BUT NOT
LIMITED TO, DEATH RECORDS, MEDICAL RECORDS, AUTOPSY REPORTS, TOXICOLOGY
REPORTS, HOSPITAL DISCHARGE RECORDS, BIRTH RECORDS AND ANY OTHER INFOR-
MATION.
(B) THE COMMISSIONER SHALL RECEIVE INFORMATION, INCLUDING ORAL OR
WRITTEN STATEMENTS, RELATING TO ANY MATERNAL DEATH AND CASE OF SEVERE
MATERNAL MORBIDITY, FROM ANY FAMILY MEMBER OR OTHER INTERESTED PARTY
(INCLUDING THE PATIENT IN A CASE OF SEVERE MATERNAL MORBIDITY) RELATING
TO ANY CASE THAT MAY COME BEFORE THE BOARD. ORAL STATEMENTS RECEIVED
UNDER THIS PARAGRAPH SHALL BE TRANSCRIBED OR SUMMARIZED IN WRITING. THE
COMMISSIONER AND THE CITY COMMISSIONER SHALL TRANSMIT THAT INFORMATION
TO THE BOARD CONSIDERING THE CASE.
(C) BEFORE TRANSMITTING ANY INFORMATION TO THE BOARD, THE COMMISSION-
ER, OR THE CITY COMMISSIONER, SHALL REMOVE ALL PERSONAL IDENTIFYING
INFORMATION OF THE WOMAN, HEALTH CARE PRACTITIONER OR PRACTITIONERS OR
ANYONE ELSE INDIVIDUALLY NAMED IN SUCH INFORMATION, AS WELL AS THE
HOSPITAL OR FACILITY THAT TREATED THE WOMAN, AND ANY OTHER INFORMATION
SUCH AS GEOGRAPHIC LOCATION THAT MAY INADVERTENTLY IDENTIFY THE WOMAN,
PRACTITIONER OR FACILITY. THIS PARAGRAPH SHALL NOT PRECLUDE THE TRANS-
MITTING OF INFORMATION TO THE BOARD THAT IS REASONABLY NECESSARY TO
ENABLE THE BOARD TO PERFORM AN APPROPRIATE REVIEW UNDER THIS SECTION.
5. EACH BOARD:
(A) SHALL MAKE AND REPORT FINDINGS, RECOMMENDATIONS AND BEST PRACTICES
TO THE COMMISSIONER REGARDING THE CAUSE OF DEATH, FACTORS LEADING TO
DEATH, AND PREVENTABILITY OF EACH MATERNAL DEATH CASE, AND EACH CASE OF
SEVERE MATERNAL MORBIDITY REVIEWED BY THE BOARD, BY REVIEWING RELEVANT
INFORMATION FOR EACH CASE AND CONSULTING WITH EXPERTS AS NEEDED TO EVAL-
UATE THE INFORMATION FOR EACH DEATH; AND SHALL PROVIDE SUCH DE-IDENTI-
FIED FINDINGS AND RECOMMENDATIONS, INCLUDING BEST PRACTICES AND STRATE-
GIES FOR REDUCING THE RISK OF MATERNAL MORTALITY AND SEVERE MATERNAL
S. 1507 96 A. 2007
MORBIDITY, TO THE ADVISORY COUNCIL; PROVIDED THAT MATERIAL PROVIDED TO
THE ADVISORY COUNCIL SHALL NOT INCLUDE ANY INFORMATION THAT WOULD BE
CONFIDENTIAL UNDER THIS SECTION;
(B) SHALL DEVELOP RECOMMENDATIONS TO THE COMMISSIONER FOR AREAS OF
FOCUS, INCLUDING ISSUES OF SEVERE MATERNAL MORBIDITY AND ISSUES OF
RACIAL, ECONOMIC OR OTHER DISPARITIES IN MATERNAL OUTCOMES;
(C) MAY, IN ADDITION TO THE FINDINGS, RECOMMENDATIONS, AND BEST PRAC-
TICES MADE UNDER THIS SUBDIVISION, AND CONSISTENT WITH ALL APPLICABLE
CONFIDENTIALITY PROTECTIONS, BRING ANY PARTICULAR MATTER TO THE ATTEN-
TION OF THE COMMISSIONER;
(D) THE STATE BOARD SHALL ISSUE A REPORT EVERY OTHER YEAR TO THE
COMMISSIONER ON ITS FINDINGS, RECOMMENDATIONS, AND BEST PRACTICES, AND
IT SHALL BE A PUBLIC DOCUMENT.
6. THE COMMISSIONER AND BOARDS SHALL EACH KEEP CONFIDENTIAL ANY INFOR-
MATION COLLECTED OR RECEIVED UNDER THIS SECTION THAT INCLUDES PERSONAL
IDENTIFYING INFORMATION OF THE WOMAN, HEALTH CARE PRACTITIONER OR PRAC-
TITIONERS OR ANYONE ELSE INDIVIDUALLY NAMED IN SUCH INFORMATION, AS WELL
AS THE HOSPITAL OR FACILITY THAT TREATED THE WOMAN, AND ANY OTHER INFOR-
MATION SUCH AS GEOGRAPHIC LOCATION THAT MAY INADVERTENTLY IDENTIFY THE
WOMAN, PRACTITIONER OR FACILITY, AND SHALL USE THE INFORMATION PROVIDED
OR RECEIVED UNDER THIS SECTION SOLELY FOR THE PURPOSES OF IMPROVEMENT OF
THE QUALITY OF HEALTH CARE OF WOMEN AND TO PREVENT MATERNAL MORTALITY
AND SEVERE MATERNAL MORBIDITY. THIS SUBDIVISION SHALL NOT PRECLUDE THE
TRANSMITTING OF INFORMATION TO THE BOARD THAT IS REASONABLY NECESSARY TO
ENABLE THE BOARD TO PERFORM AN APPROPRIATE REVIEW UNDER THIS SECTION.
ALL INFORMATION AND RECORDS RECEIVED, MEETINGS CONDUCTED, REPORTS AND
RECORDS MADE AND MAINTAINED AND ALL BOOKS AND PAPERS OBTAINED BY THE
COMMISSIONER AS WELL AS THE BOARD SHALL BE CONFIDENTIAL AND SHALL NOT BE
MADE OPEN OR AVAILABLE, INCLUDING UNDER ARTICLE SIX OF THE PUBLIC OFFI-
CERS LAW, AND SHALL BE LIMITED TO BOARD MEMBERS AS WELL AS THOSE AUTHOR-
IZED BY THE COMMISSIONER. SUCH INFORMATION SHALL NOT BE DISCOVERABLE OR
ADMISSIBLE AS EVIDENCE IN ANY ACTION IN ANY COURT OR BEFORE ANY OTHER
TRIBUNAL, BOARD, AGENCY OR PERSON.
7. (A) THERE IS HEREBY ESTABLISHED IN THE DEPARTMENT AN ADVISORY COUN-
CIL ON MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY.
(B) THE ADVISORY COUNCIL:
(I) MAY REVIEW THE FINDINGS, RECOMMENDATIONS AND BEST PRACTICES OF THE
BOARDS;
(II) MAY USE THE BOARDS FINDINGS, RECOMMENDATIONS AND BEST PRACTICES
TO DEVELOP RECOMMENDATIONS ON POLICIES, BEST PRACTICES, AND STRATEGIES
TO PREVENT MATERNAL MORTALITY AND SEVERE MATERNAL MORBIDITY;
(III) MAY HOLD PUBLIC HEARINGS ON THOSE MATTERS; AND
(IV) MAY MAKE FINDINGS AND ISSUE REPORTS, INCLUDING AN ANNUAL REPORT,
ON SUCH MATTERS;
(C) THE ADVISORY COUNCIL SHALL CONSIST OF AT LEAST TWENTY MEMBERS,
REPRESENTATIVE OF THE RACIAL AND ETHNIC DIVERSITY OF THE WOMEN AND MOTH-
ERS OF THE STATE TO BE DETERMINED BY THE COMMISSIONER. TEN OF THE
MEMBERS OF THE COUNCIL SHALL BE REPRESENTATIVE OF THE POPULATION AND
HEALTH CARE SYSTEM OF THE CITY OF NEW YORK. THE COMMISSIONER SHALL
APPOINT THE CHAIR OF THE COUNCIL.
(D) THE MEMBERS OF THE COUNCIL SHALL BE COMPRISED OF MULTIDISCIPLINARY
EXPERTS AND LAY PERSONS KNOWLEDGEABLE IN THE FIELD OF MATERNAL MORTAL-
ITY, WOMEN'S HEALTH AND PUBLIC HEALTH AND SHALL INCLUDE MEMBERS WHO
SERVE AND ARE REPRESENTATIVE OF THE DIVERSITY OF THE WOMEN AND MOTHERS
IN MEDICALLY UNDERSERVED AREAS OF THE STATE OR AREAS OF THE STATE WITH
S. 1507 97 A. 2007
DISPROPORTIONATELY HIGH OCCURRENCES OF MATERNAL MORTALITY OR SEVERE
MATERNAL MORBIDITY.
(E) THE TERMS OF THE COUNCIL MEMBERS SHALL BE THREE YEARS. THE COMMIS-
SIONER MAY CHOOSE TO REAPPOINT COUNCIL MEMBERS TO ADDITIONAL THREE-YEAR
TERMS. VACANCIES ON THE COUNCIL SHALL BE FILLED BY APPOINTMENT BY THE
COMMISSIONER. A MAJORITY OF THE APPOINTED MEMBERSHIP OF THE COUNCIL
SHALL CONSTITUTE A QUORUM. WHEN ANY MEMBER OF THE COUNCIL FAILS TO
ATTEND THREE CONSECUTIVE REGULAR MEETINGS, UNLESS SUCH ABSENCE IS FOR
GOOD CAUSE, THAT MEMBERSHIP MAY BE DEEMED VACANT FOR PURPOSES OF THE
APPOINTMENT OF A SUCCESSOR.
(F) MEETINGS OF THE COUNCIL SHALL BE HELD AT LEAST TWICE A YEAR.
(G) MEMBERS OF THE COUNCIL SHALL BE INDEMNIFIED UNDER SECTION SEVEN-
TEEN OF THE PUBLIC OFFICERS LAW. MEMBERS OF THE COUNCIL SHALL NOT BE
COMPENSATED FOR THEIR PARTICIPATION ON THE COUNCIL BUT SHALL RECEIVE
REIMBURSEMENT FOR THEIR ORDINARY AND NECESSARY EXPENSES OF PARTIC-
IPATION. MEMBERSHIP ON THE COUNCIL SHALL NOT DISQUALIFY ANY PERSON FROM
HOLDING ANY PUBLIC OFFICE OR EMPLOYMENT.
§ 3. This act shall take effect immediately.
PART S
Section 1. Legislative intent. The legislature finds that comprehen-
sive reproductive health care, including contraception and abortion, is
a fundamental component of a woman's health, privacy and equality. The
New York Constitution and United States Constitution protect a woman's
fundamental right to access safe, legal abortion, courts have repeatedly
reaffirmed this right and further emphasized that states may not place
undue burdens on women seeking to access such right.
Moreover, the legislature finds, as with other medical procedures, the
safety of abortion is furthered by evidence-based practices developed
and supported by medical professionals. Abortion is one of the safest
medical procedures performed in the United States; the goal of medical
regulation should be to improve the quality and availability of health
care services.
Furthermore, the legislature declares that it is the public policy of
New York State that every individual possesses a fundamental right of
privacy and equality with respect to their personal reproductive deci-
sions and should be able to safely effectuate those decisions, including
by seeking and obtaining abortion care, free from discrimination in the
provision of health care.
Therefore, it is the intent of the legislature to prevent the enforce-
ment of laws or regulations that are not in furtherance of a legitimate
state interest in protecting a woman's health that burden abortion
access.
§ 2. The public health law is amended by adding a new article 25-A to
read as follows:
ARTICLE 25-A
REPRODUCTIVE HEALTH ACT
SECTION 2599-AA. POLICY AND PURPOSE.
2599-BB. ABORTION.
§ 2599-AA. POLICY AND PURPOSE. THE LEGISLATURE FINDS THAT COMPREHEN-
SIVE REPRODUCTIVE HEALTH CARE IS A FUNDAMENTAL COMPONENT OF EVERY INDI-
VIDUAL'S HEALTH, PRIVACY AND EQUALITY. THEREFORE, IT IS THE POLICY OF
THE STATE THAT:
1. EVERY INDIVIDUAL HAS THE FUNDAMENTAL RIGHT TO CHOOSE OR REFUSE
CONTRACEPTION OR STERILIZATION.
S. 1507 98 A. 2007
2. EVERY INDIVIDUAL WHO BECOMES PREGNANT HAS THE FUNDAMENTAL RIGHT TO
CHOOSE TO CARRY THE PREGNANCY TO TERM, TO GIVE BIRTH TO A CHILD, OR TO
HAVE AN ABORTION, PURSUANT TO THIS ARTICLE.
3. THE STATE SHALL NOT DISCRIMINATE AGAINST, DENY, OR INTERFERE WITH
THE EXERCISE OF THE RIGHTS SET FORTH IN THIS SECTION IN THE REGULATION
OR PROVISION OF BENEFITS, FACILITIES, SERVICES OR INFORMATION.
§ 2599-BB. ABORTION. 1. A HEALTH CARE PRACTITIONER LICENSED, CERTI-
FIED, OR AUTHORIZED UNDER TITLE EIGHT OF THE EDUCATION LAW, ACTING WITH-
IN HIS OR HER LAWFUL SCOPE OF PRACTICE, MAY PERFORM AN ABORTION WHEN,
ACCORDING TO THE PRACTITIONER'S REASONABLE AND GOOD FAITH PROFESSIONAL
JUDGMENT BASED ON THE FACTS OF THE PATIENT'S CASE: THE PATIENT IS WITHIN
TWENTY-FOUR WEEKS FROM THE COMMENCEMENT OF PREGNANCY, OR THERE IS AN
ABSENCE OF FETAL VIABILITY, OR THE ABORTION IS NECESSARY TO PROTECT THE
PATIENT'S LIFE OR HEALTH.
2. THIS ARTICLE SHALL BE CONSTRUED AND APPLIED CONSISTENT WITH AND
SUBJECT TO APPLICABLE LAWS AND APPLICABLE AND AUTHORIZED REGULATIONS
GOVERNING HEALTH CARE PROCEDURES.
§ 3. Section 4164 of the public health law is REPEALED.
§ 4. Subdivision 8 of section 6811 of the education law is REPEALED.
§ 5. Sections 125.40, 125.45, 125.50, 125.55 and 125.60 of the penal
law are REPEALED, and the article heading of article 125 of the penal
law is amended to read as follows:
HOMICIDE[, ABORTION] AND RELATED OFFENSES
§ 6. Section 125.00 of the penal law is amended to read as follows:
§ 125.00 Homicide defined.
Homicide means conduct which causes the death of a person [or an
unborn child with which a female has been pregnant for more than twen-
ty-four weeks] under circumstances constituting murder, manslaughter in
the first degree, manslaughter in the second degree, OR criminally
negligent homicide[, abortion in the first degree or self-abortion in
the first degree].
§ 7. The section heading, opening paragraph and subdivision 1 of
section 125.05 of the penal law are amended to read as follows:
Homicide[, abortion] and related offenses; [definitions of terms]
DEFINITION.
The following [definitions are] DEFINITION IS applicable to this arti-
cle:
[1.] "Person," when referring to the victim of a homicide, means a
human being who has been born and is alive.
§ 7-a. Subdivisions 2 and 3 of section 125.05 of the penal law are
REPEALED.
§ 8. Subdivision 2 of section 125.15 of the penal law is REPEALED.
§ 9. Subdivision 3 of section 125.20 of the penal law is REPEALED.
§ 10. Paragraph (b) of subdivision 8 of section 700.05 of the criminal
procedure law, as amended by chapter 189 of the laws of 2018, is amended
to read as follows:
(b) Any of the following felonies: assault in the second degree as
defined in section 120.05 of the penal law, assault in the first degree
as defined in section 120.10 of the penal law, reckless endangerment in
the first degree as defined in section 120.25 of the penal law, promot-
ing a suicide attempt as defined in section 120.30 of the penal law,
strangulation in the second degree as defined in section 121.12 of the
penal law, strangulation in the first degree as defined in section
121.13 of the penal law, criminally negligent homicide as defined in
section 125.10 of the penal law, manslaughter in the second degree as
defined in section 125.15 of the penal law, manslaughter in the first
S. 1507 99 A. 2007
degree as defined in section 125.20 of the penal law, murder in the
second degree as defined in section 125.25 of the penal law, murder in
the first degree as defined in section 125.27 of the penal law,
[abortion in the second degree as defined in section 125.40 of the penal
law, abortion in the first degree as defined in section 125.45 of the
penal law,] rape in the third degree as defined in section 130.25 of the
penal law, rape in the second degree as defined in section 130.30 of the
penal law, rape in the first degree as defined in section 130.35 of the
penal law, criminal sexual act in the third degree as defined in section
130.40 of the penal law, criminal sexual act in the second degree as
defined in section 130.45 of the penal law, criminal sexual act in the
first degree as defined in section 130.50 of the penal law, sexual abuse
in the first degree as defined in section 130.65 of the penal law,
unlawful imprisonment in the first degree as defined in section 135.10
of the penal law, kidnapping in the second degree as defined in section
135.20 of the penal law, kidnapping in the first degree as defined in
section 135.25 of the penal law, labor trafficking as defined in section
135.35 of the penal law, aggravated labor trafficking as defined in
section 135.37 of the penal law, custodial interference in the first
degree as defined in section 135.50 of the penal law, coercion in the
first degree as defined in section 135.65 of the penal law, criminal
trespass in the first degree as defined in section 140.17 of the penal
law, burglary in the third degree as defined in section 140.20 of the
penal law, burglary in the second degree as defined in section 140.25 of
the penal law, burglary in the first degree as defined in section 140.30
of the penal law, criminal mischief in the third degree as defined in
section 145.05 of the penal law, criminal mischief in the second degree
as defined in section 145.10 of the penal law, criminal mischief in the
first degree as defined in section 145.12 of the penal law, criminal
tampering in the first degree as defined in section 145.20 of the penal
law, arson in the fourth degree as defined in section 150.05 of the
penal law, arson in the third degree as defined in section 150.10 of the
penal law, arson in the second degree as defined in section 150.15 of
the penal law, arson in the first degree as defined in section 150.20 of
the penal law, grand larceny in the fourth degree as defined in section
155.30 of the penal law, grand larceny in the third degree as defined in
section 155.35 of the penal law, grand larceny in the second degree as
defined in section 155.40 of the penal law, grand larceny in the first
degree as defined in section 155.42 of the penal law, health care fraud
in the fourth degree as defined in section 177.10 of the penal law,
health care fraud in the third degree as defined in section 177.15 of
the penal law, health care fraud in the second degree as defined in
section 177.20 of the penal law, health care fraud in the first degree
as defined in section 177.25 of the penal law, robbery in the third
degree as defined in section 160.05 of the penal law, robbery in the
second degree as defined in section 160.10 of the penal law, robbery in
the first degree as defined in section 160.15 of the penal law, unlawful
use of secret scientific material as defined in section 165.07 of the
penal law, criminal possession of stolen property in the fourth degree
as defined in section 165.45 of the penal law, criminal possession of
stolen property in the third degree as defined in section 165.50 of the
penal law, criminal possession of stolen property in the second degree
as defined by section 165.52 of the penal law, criminal possession of
stolen property in the first degree as defined by section 165.54 of the
penal law, trademark counterfeiting in the second degree as defined in
section 165.72 of the penal law, trademark counterfeiting in the first
S. 1507 100 A. 2007
degree as defined in section 165.73 of the penal law, forgery in the
second degree as defined in section 170.10 of the penal law, forgery in
the first degree as defined in section 170.15 of the penal law, criminal
possession of a forged instrument in the second degree as defined in
section 170.25 of the penal law, criminal possession of a forged instru-
ment in the first degree as defined in section 170.30 of the penal law,
criminal possession of forgery devices as defined in section 170.40 of
the penal law, falsifying business records in the first degree as
defined in section 175.10 of the penal law, tampering with public
records in the first degree as defined in section 175.25 of the penal
law, offering a false instrument for filing in the first degree as
defined in section 175.35 of the penal law, issuing a false certificate
as defined in section 175.40 of the penal law, criminal diversion of
prescription medications and prescriptions in the second degree as
defined in section 178.20 of the penal law, criminal diversion of
prescription medications and prescriptions in the first degree as
defined in section 178.25 of the penal law, residential mortgage fraud
in the fourth degree as defined in section 187.10 of the penal law,
residential mortgage fraud in the third degree as defined in section
187.15 of the penal law, residential mortgage fraud in the second degree
as defined in section 187.20 of the penal law, residential mortgage
fraud in the first degree as defined in section 187.25 of the penal law,
escape in the second degree as defined in section 205.10 of the penal
law, escape in the first degree as defined in section 205.15 of the
penal law, absconding from temporary release in the first degree as
defined in section 205.17 of the penal law, promoting prison contraband
in the first degree as defined in section 205.25 of the penal law,
hindering prosecution in the second degree as defined in section 205.60
of the penal law, hindering prosecution in the first degree as defined
in section 205.65 of the penal law, sex trafficking as defined in
section 230.34 of the penal law, sex trafficking of a child as defined
in section 230.34-a of the penal law, criminal possession of a weapon in
the third degree as defined in subdivisions two, three and five of
section 265.02 of the penal law, criminal possession of a weapon in the
second degree as defined in section 265.03 of the penal law, criminal
possession of a weapon in the first degree as defined in section 265.04
of the penal law, manufacture, transport, disposition and defacement of
weapons and dangerous instruments and appliances defined as felonies in
subdivisions one, two, and three of section 265.10 of the penal law,
sections 265.11, 265.12 and 265.13 of the penal law, or prohibited use
of weapons as defined in subdivision two of section 265.35 of the penal
law, relating to firearms and other dangerous weapons, or failure to
disclose the origin of a recording in the first degree as defined in
section 275.40 of the penal law;
§ 11. Subdivision 1 of section 673 of the county law, as added by
chapter 545 of the laws of 1965, is amended to read as follows:
1. A coroner or medical examiner has jurisdiction and authority to
investigate the death of every person dying within his county, or whose
body is found within the county, which is or appears to be:
(a) A violent death, whether by criminal violence, suicide or casual-
ty;
(b) A death caused by unlawful act or criminal neglect;
(c) A death occurring in a suspicious, unusual or unexplained manner;
(d) [A death caused by suspected criminal abortion;
(e)] A death while unattended by a physician, so far as can be discov-
ered, or where no physician able to certify the cause of death as
S. 1507 101 A. 2007
provided in the public health law and in form as prescribed by the
commissioner of health can be found;
[(f)] (E) A death of a person confined in a public institution other
than a hospital, infirmary or nursing home.
§ 12. Section 4 of the judiciary law, as amended by chapter 264 of the
laws of 2003, is amended to read as follows:
§ 4. Sittings of courts to be public. The sittings of every court
within this state shall be public, and every citizen may freely attend
the same, except that in all proceedings and trials in cases for
divorce, seduction, [abortion,] rape, assault with intent to commit
rape, criminal sexual act, bastardy or filiation, the court may, in its
discretion, exclude therefrom all persons who are not directly inter-
ested therein, excepting jurors, witnesses, and officers of the court.
§ 13. Severability. If any provision of this act, or any application
of any provision of this act, is held to be invalid, that shall not
affect the validity or effectiveness of any other provision of this act,
or of any other application of any provision of this act, which can be
given effect without that provision or application; and to that end, the
provisions and applications of this act are severable.
§ 14. This act shall take effect immediately.
PART T
Section 1. This act shall be known and may be cited as the "NY State
of Health, The Official Health Plan Marketplace Act".
§ 2. Article 2 of the public health law is amended by adding a new
title VII to read as follows:
TITLE VII
NY STATE OF HEALTH
SECTION 268. STATEMENT OF POLICY AND PURPOSES.
268-A. DEFINITIONS.
268-B. ESTABLISHMENT OF NY STATE OF HEALTH, THE OFFICIAL HEALTH
PLAN MARKETPLACE.
268-C. FUNCTIONS OF THE MARKETPLACE.
268-D. SPECIAL FUNCTIONS OF THE MARKETPLACE RELATED TO HEALTH
PLAN CERTIFICATION AND QUALIFIED HEALTH PLAN OVERSIGHT.
268-E. APPEALS AND APPEAL HEARINGS; JUDICIAL REVIEW.
268-F. MARKETPLACE ADVISORY COMMITTEE.
268-G. FUNDING OF THE MARKETPLACE.
268-H. CONSTRUCTION.
§ 268. STATEMENT OF POLICY AND PURPOSES. THE PURPOSE OF THIS TITLE IS
TO CODIFY THE ESTABLISHMENT OF THE HEALTH BENEFIT EXCHANGE IN NEW YORK,
KNOWN AS NY STATE OF HEALTH, THE OFFICIAL HEALTH PLAN MARKETPLACE
(MARKETPLACE), IN CONFORMANCE WITH EXECUTIVE ORDER 42 (CUOMO) ISSUED
APRIL 12, 2012. THE MARKETPLACE SHALL CONTINUE TO PERFORM ELIGIBILITY
DETERMINATIONS FOR FEDERAL AND STATE INSURANCE AFFORDABILITY PROGRAMS
INCLUDING MEDICAL ASSISTANCE IN ACCORDANCE WITH SECTION THREE HUNDRED
SIXTY-SIX OF THE SOCIAL SERVICES LAW, CHILD HEALTH PLUS IN ACCORDANCE
WITH SECTION TWENTY-FIVE HUNDRED ELEVEN OF THIS CHAPTER, THE BASIC
HEALTH PROGRAM IN ACCORDANCE WITH SECTION THREE HUNDRED SIXTY-NINE-GG OF
THE SOCIAL SERVICES LAW, AND PREMIUM TAX CREDITS AND COST-SHARING
REDUCTIONS, TOGETHER WITH PERFORMING ELIGIBILITY DETERMINATIONS FOR
QUALIFIED HEALTH PLANS AND SUCH OTHER HEALTH INSURANCE PROGRAMS AS
DETERMINED BY THE COMMISSIONER. THE MARKETPLACE SHALL ALSO FACILITATE
ENROLLMENT IN INSURANCE AFFORDABILITY PROGRAMS, QUALIFIED HEALTH PLANS
AND OTHER HEALTH INSURANCE PROGRAMS AS DETERMINED BY THE COMMISSIONER,
S. 1507 102 A. 2007
THE PURCHASE AND SALE OF QUALIFIED HEALTH PLANS AND/OR OTHER OR ADDI-
TIONAL HEALTH PLANS CERTIFIED BY THE MARKETPLACE PURSUANT TO THIS TITLE,
AND SHALL CONTINUE TO HAVE THE AUTHORITY TO OPERATE A SMALL BUSINESS
HEALTH OPTIONS PROGRAM ("SHOP") TO ASSIST ELIGIBLE SMALL EMPLOYERS IN
SELECTING QUALIFIED HEALTH PLANS AND/OR OTHER OR ADDITIONAL HEALTH PLANS
CERTIFIED BY THE MARKETPLACE AND TO DETERMINE SMALL EMPLOYER ELIGIBILITY
FOR PURPOSES OF SMALL EMPLOYER TAX CREDITS. IT IS THE INTENT OF THE
LEGISLATURE, BY CODIFYING THE MARKETPLACE IN STATE STATUTE, TO CONTINUE
TO PROMOTE QUALITY AND AFFORDABLE HEALTH COVERAGE AND CARE, REDUCE THE
NUMBER OF UNINSURED PERSONS, PROVIDE A TRANSPARENT MARKETPLACE, EDUCATE
CONSUMERS AND ASSIST INDIVIDUALS WITH ACCESS TO COVERAGE, PREMIUM
ASSISTANCE TAX CREDITS AND COST-SHARING REDUCTIONS. IN ADDITION, THE
LEGISLATURE DECLARES THE INTENT THAT THE MARKETPLACE CONTINUE TO BE
PROPERLY INTEGRATED WITH INSURANCE AFFORDABILITY PROGRAMS, INCLUDING
MEDICAID, CHILD HEALTH PLUS AND THE BASIC HEALTH PROGRAM, AND SUCH OTHER
HEALTH INSURANCE PROGRAMS AS DETERMINED BY THE COMMISSIONER.
§ 268-A. DEFINITIONS. FOR PURPOSES OF THIS TITLE, THE FOLLOWING DEFI-
NITIONS SHALL APPLY:
1. "COMMISSIONER" MEANS THE COMMISSIONER OF HEALTH OF THE STATE OF NEW
YORK.
2. "MARKETPLACE" MEANS THE "NY STATE OF HEALTH, THE OFFICIAL HEALTH
PLAN MARKETPLACE" OR "MARKETPLACE" ESTABLISHED AS A HEALTH BENEFIT
EXCHANGE OR "MARKETPLACE" WITHIN THE DEPARTMENT OF HEALTH PURSUANT TO
EXECUTIVE ORDER 42 (CUOMO) ISSUED APRIL 12, 2012 AND THIS TITLE.
3. "FEDERAL ACT" MEANS THE PATIENT PROTECTION AND AFFORDABLE CARE ACT,
PUBLIC LAW 111-148, AS AMENDED BY THE HEALTH CARE AND EDUCATION RECON-
CILIATION ACT OF 2010, PUBLIC LAW 111-152, AND ANY REGULATIONS OR GUID-
ANCE ISSUED THEREUNDER.
4. "HEALTH PLAN" MEANS A POLICY, CONTRACT OR CERTIFICATE, OFFERED OR
ISSUED BY AN INSURER TO PROVIDE, DELIVER, ARRANGE FOR, PAY FOR OR REIM-
BURSE ANY OF THE COSTS OF HEALTH CARE SERVICES. HEALTH PLAN SHALL NOT
INCLUDE THE FOLLOWING:
(A) ACCIDENT INSURANCE OR DISABILITY INCOME INSURANCE, OR ANY COMBINA-
TION THEREOF;
(B) COVERAGE ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE;
(C) LIABILITY INSURANCE, INCLUDING GENERAL LIABILITY INSURANCE AND
AUTOMOBILE LIABILITY INSURANCE;
(D) WORKERS' COMPENSATION OR SIMILAR INSURANCE;
(E) AUTOMOBILE NO-FAULT INSURANCE;
(F) CREDIT INSURANCE;
(G) OTHER SIMILAR INSURANCE COVERAGE, AS SPECIFIED IN FEDERAL REGU-
LATIONS, UNDER WHICH BENEFITS FOR MEDICAL CARE ARE SECONDARY OR INCI-
DENTAL TO OTHER INSURANCE BENEFITS;
(H) LIMITED SCOPE DENTAL OR VISION BENEFITS, BENEFITS FOR LONG-TERM
CARE INSURANCE, NURSING HOME INSURANCE, HOME CARE INSURANCE, OR ANY
COMBINATION THEREOF, OR SUCH OTHER SIMILAR, LIMITED BENEFITS HEALTH
INSURANCE AS SPECIFIED IN FEDERAL REGULATIONS, IF THE BENEFITS ARE
PROVIDED UNDER A SEPARATE POLICY, CERTIFICATE OR CONTRACT OF INSURANCE
OR ARE OTHERWISE NOT AN INTEGRAL PART OF THE PLAN;
(I) COVERAGE ONLY FOR A SPECIFIED DISEASE OR ILLNESS, HOSPITAL INDEM-
NITY, OR OTHER FIXED INDEMNITY COVERAGE;
(J) MEDICARE SUPPLEMENTAL INSURANCE AS DEFINED IN SECTION 1882(G)(1)
OF THE FEDERAL SOCIAL SECURITY ACT, COVERAGE SUPPLEMENTAL TO THE COVER-
AGE PROVIDED UNDER CHAPTER 55 OF TITLE 10 OF THE UNITED STATES CODE, OR
SIMILAR SUPPLEMENTAL COVERAGE PROVIDED UNDER A GROUP HEALTH PLAN IF IT
S. 1507 103 A. 2007
IS OFFERED AS A SEPARATE POLICY, CERTIFICATE OR CONTRACT OF INSURANCE;
OR
(K) THE NEW YORK STATE MEDICAL INDEMNITY FUND ESTABLISHED PURSUANT TO
TITLE FOUR OF ARTICLE TWENTY-NINE-D OF THE PUBLIC HEALTH LAW.
5. "INSURER" MEANS AN INSURANCE COMPANY SUBJECT TO ARTICLE FORTY-TWO
OR A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THE INSURANCE LAW, OR
A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-
FOUR OF THE PUBLIC HEALTH LAW THAT CONTRACTS OR OFFERS TO CONTRACT TO
PROVIDE, DELIVER, ARRANGE, PAY OR REIMBURSE ANY OF THE COSTS OF HEALTH
CARE SERVICES.
6. "STAND-ALONE DENTAL PLAN" MEANS A DENTAL SERVICES PLAN THAT HAS
BEEN ISSUED PURSUANT TO APPLICABLE LAW AND CERTIFIED BY THE MARKETPLACE
IN ACCORDANCE WITH SECTION TWO HUNDRED SIXTY-EIGHT-D OF THIS TITLE.
7. "QUALIFIED HEALTH PLAN" MEANS A HEALTH PLAN THAT IS ISSUED PURSUANT
TO APPLICABLE LAW AND CERTIFIED BY THE MARKETPLACE IN ACCORDANCE WITH
SECTION TWO HUNDRED SIXTY-EIGHT-D OF THIS TITLE, INCLUDING A STAND-ALONE
DENTAL PLAN.
8. "INSURANCE AFFORDABILITY PROGRAM" MEANS MEDICAID, CHILD HEALTH
PLUS, THE BASIC HEALTH PROGRAM AND ANY OTHER HEALTH INSURANCE SUBSIDY
PROGRAM DESIGNATED AS SUCH BY THE COMMISSIONER.
9. "ELIGIBLE INDIVIDUAL" MEANS AN INDIVIDUAL, INCLUDING A MINOR, WHO
IS ELIGIBLE TO ENROLL IN AN INSURANCE AFFORDABILITY PROGRAM OR OTHER
HEALTH INSURANCE PROGRAM AS DETERMINED BY THE COMMISSIONER.
10. "QUALIFIED INDIVIDUAL" MEANS, WITH RESPECT TO QUALIFIED HEALTH
PLANS, AN INDIVIDUAL, INCLUDING A MINOR, WHO:
(A) IS ELIGIBLE TO ENROLL IN A QUALIFIED HEALTH PLAN OFFERED TO INDI-
VIDUALS THROUGH THE MARKETPLACE;
(B) RESIDES IN THIS STATE;
(C) AT THE TIME OF ENROLLMENT, IS NOT INCARCERATED, OTHER THAN INCAR-
CERATION PENDING THE DISPOSITION OF CHARGES; AND
(D) IS, AND IS REASONABLY EXPECTED TO BE, FOR THE ENTIRE PERIOD FOR
WHICH ENROLLMENT IS SOUGHT, A CITIZEN OR NATIONAL OF THE UNITED STATES
OR AN ALIEN LAWFULLY PRESENT IN THE UNITED STATES.
11. "SECRETARY" MEANS THE SECRETARY OF THE UNITED STATES DEPARTMENT OF
HEALTH AND HUMAN SERVICES.
12. "SHOP" MEANS THE SMALL BUSINESS HEALTH OPTIONS PROGRAM OPERATED BY
THE MARKETPLACE TO ASSIST ELIGIBLE SMALL EMPLOYERS IN THIS STATE IN
SELECTING QUALIFIED HEALTH PLANS AND/OR OTHER OR ADDITIONAL HEALTH PLANS
CERTIFIED BY THE MARKETPLACE AND TO DETERMINE SMALL EMPLOYER ELIGIBILITY
FOR PURPOSES OF SMALL EMPLOYER TAX CREDITS IN ACCORDANCE WITH APPLICABLE
FEDERAL AND STATE LAWS AND REGULATIONS.
13. "SMALL EMPLOYER" MEANS AN EMPLOYER WHICH OFFERS COVERAGE WHERE THE
COVERAGE SUCH EMPLOYER OFFERS WOULD BE CONSIDERED SMALL GROUP COVERAGE
UNDER THE INSURANCE LAW AND REGULATIONS PROMULGATED THEREUNDER, PROVIDED
THAT IT IS NOT OTHERWISE PROHIBITED UNDER THE FEDERAL ACT.
14. "SMALL GROUP MARKET" MEANS THE HEALTH INSURANCE MARKET UNDER WHICH
INDIVIDUALS RECEIVE HEALTH INSURANCE COVERAGE ON BEHALF OF THEMSELVES
AND THEIR DEPENDENTS THROUGH A GROUP HEALTH PLAN MAINTAINED BY A SMALL
EMPLOYER.
15. "SUPERINTENDENT" MEANS THE SUPERINTENDENT OF FINANCIAL SERVICES.
16. "ESSENTIAL HEALTH BENEFITS" SHALL MEAN THE CATEGORIES OF BENEFITS
DEFINED IN SUBSECTION (A) OF SECTION THREE THOUSAND TWO HUNDRED SEVEN-
TEEN-I AND SUBSECTION (A) OF SECTION FOUR THOUSAND THREE HUNDRED SIX-H
OF THE INSURANCE LAW.
§ 268-B. ESTABLISHMENT OF NY STATE OF HEALTH, THE OFFICIAL HEALTH PLAN
MARKETPLACE. 1. THERE IS HEREBY ESTABLISHED AN OFFICE WITHIN THE DEPART-
S. 1507 104 A. 2007
MENT OF HEALTH TO BE KNOWN AS THE "NY STATE OF HEALTH, THE OFFICIAL
HEALTH PLAN MARKETPLACE".
2. THE PURPOSE OF THE MARKETPLACE IS TO FACILITATE ENROLLMENT IN
HEALTH COVERAGE AND THE PURCHASE AND SALE OF QUALIFIED HEALTH PLANS AND
OTHER HEALTH PLANS CERTIFIED BY THE MARKETPLACE; ENROLL INDIVIDUALS IN
COVERAGE FOR WHICH THEY ARE ELIGIBLE IN ACCORDANCE WITH FEDERAL AND
STATE LAW; ENABLE ELIGIBLE INDIVIDUALS TO RECEIVE PREMIUM TAX CREDITS,
COST-SHARING REDUCTIONS, AND TO ACCESS INSURANCE AFFORDABILITY PROGRAMS
AND OTHER HEALTH INSURANCE PROGRAMS AS DETERMINED BY THE COMMISSIONER;
ASSIST ELIGIBLE SMALL EMPLOYERS IN SELECTING QUALIFIED HEALTH PLANS
AND/OR OTHER, OR ADDITIONAL HEALTH PLANS CERTIFIED BY THE MARKETPLACE
AND TO QUALIFY FOR SMALL EMPLOYER TAX CREDITS IN ACCORDANCE WITH APPLI-
CABLE LAW; AND TO CARRY OUT OTHER FUNCTIONS SET FORTH IN THIS TITLE.
§ 268-C. FUNCTIONS OF THE MARKETPLACE. THE MARKETPLACE SHALL:
1. (A) PERFORM ELIGIBILITY DETERMINATIONS FOR FEDERAL AND STATE INSUR-
ANCE AFFORDABILITY PROGRAMS INCLUDING MEDICAL ASSISTANCE IN ACCORDANCE
WITH SECTION THREE HUNDRED SIXTY-SIX OF THE SOCIAL SERVICES LAW, CHILD
HEALTH PLUS IN ACCORDANCE WITH SECTION TWENTY-FIVE HUNDRED ELEVEN OF
THIS CHAPTER, THE BASIC HEALTH PROGRAM IN ACCORDANCE WITH SECTION THREE
HUNDRED SIXTY-NINE-GG OF THE SOCIAL SERVICES LAW, PREMIUM TAX CREDITS
AND COST-SHARING REDUCTIONS AND QUALIFIED HEALTH PLANS IN ACCORDANCE
WITH APPLICABLE LAW AND OTHER HEALTH INSURANCE PROGRAMS AS DETERMINED BY
THE COMMISSIONER;
(B) CERTIFY AND MAKE AVAILABLE TO QUALIFIED INDIVIDUALS, QUALIFIED
HEALTH PLANS, INCLUDING DENTAL PLANS, CERTIFIED BY THE MARKETPLACE
PURSUANT TO APPLICABLE LAW, PROVIDED THAT COVERAGE UNDER SUCH PLANS
SHALL NOT BECOME EFFECTIVE PRIOR TO CERTIFICATION BY THE MARKETPLACE;
AND
(C) CERTIFY AND/OR MAKE AVAILABLE TO ELIGIBLE INDIVIDUALS, HEALTH
PLANS CERTIFIED BY THE MARKETPLACE PURSUANT TO APPLICABLE LAW, AND/OR
PARTICIPATING IN AN INSURANCE AFFORDABILITY PROGRAM PURSUANT TO APPLICA-
BLE LAW, PROVIDED THAT COVERAGE UNDER SUCH PLANS SHALL NOT BECOME EFFEC-
TIVE PRIOR TO CERTIFICATION BY THE MARKETPLACE, AND/OR APPROVAL BY THE
COMMISSIONER.
2. ASSIGN AN ACTUARIAL VALUE TO EACH MARKETPLACE CERTIFIED PLAN
OFFERED THROUGH THE MARKETPLACE IN ACCORDANCE WITH THE CRITERIA DEVEL-
OPED BY THE SECRETARY PURSUANT TO FEDERAL LAW OR THE SUPERINTENDENT
PURSUANT TO THE INSURANCE LAW AND/OR REQUIREMENTS DEVELOPED BY THE
MARKETPLACE, AND DETERMINE EACH HEALTH PLAN'S LEVEL OF COVERAGE IN
ACCORDANCE WITH REGULATIONS ISSUED BY THE SECRETARY PURSUANT TO FEDERAL
LAW OR THE SUPERINTENDENT PURSUANT TO THE INSURANCE LAW.
3. UTILIZE A STANDARDIZED FORMAT FOR PRESENTING HEALTH BENEFIT OPTIONS
IN THE MARKETPLACE, INCLUDING THE USE OF THE UNIFORM OUTLINE OF COVERAGE
ESTABLISHED UNDER SECTION 2715 OF THE FEDERAL PUBLIC HEALTH SERVICE ACT
OR THE INSURANCE LAW.
4. STANDARDIZE THE BENEFITS AVAILABLE THROUGH THE MARKETPLACE AT EACH
LEVEL OF COVERAGE DEFINED BY THE SUPERINTENDENT IN THE INSURANCE LAW.
5. MAINTAIN ENROLLMENT PERIODS IN THE BEST INTEREST OF QUALIFIED INDI-
VIDUALS CONSISTENT WITH FEDERAL AND STATE LAW.
6. IMPLEMENT PROCEDURES FOR THE CERTIFICATION, RECERTIFICATION AND
DECERTIFICATION OF HEALTH PLANS AS QUALIFIED HEALTH PLANS OR HEALTH
PLANS APPROVED FOR SALE BY THE DEPARTMENT OF FINANCIAL SERVICES OR
DEPARTMENT OF HEALTH AND CERTIFIED BY THE MARKETPLACE, CONSISTENT WITH
GUIDELINES DEVELOPED BY THE SECRETARY PURSUANT TO SECTION 1311(C) OF THE
FEDERAL ACT AND REQUIREMENTS DEVELOPED BY THE MARKETPLACE.
S. 1507 105 A. 2007
7. CONTRACT FOR HEALTH CARE COVERAGE OFFERED TO QUALIFIED INDIVIDUALS
THROUGH THE MARKETPLACE, AND IN DOING SO SHALL SEEK TO PROVIDE HEALTH
CARE COVERAGE CHOICES THAT OFFER THE OPTIMAL COMBINATION OF CHOICE,
VALUE, QUALITY, AND SERVICE.
8. CONTRACT FOR HEALTH CARE COVERAGE OFFERED TO CERTAIN ELIGIBLE INDI-
VIDUALS THROUGH THE MARKETPLACE, PURSUANT TO HEALTH INSURANCE PROGRAMS
AS DETERMINED BY THE COMMISSIONER, AND IN DOING SO SHALL SEEK TO PROVIDE
HEALTH CARE COVERAGE CHOICES THAT OFFER THE OPTIMAL COMBINATION OF
CHOICE, VALUE, QUALITY, AND SERVICE;
9. PROVIDE THE MINIMUM REQUIREMENTS AN INSURER SHALL MEET TO PARTIC-
IPATE IN THE MARKETPLACE, IN THE BEST INTEREST OF QUALIFIED INDIVIDUALS
OR ELIGIBLE INDIVIDUALS;
10. REQUIRE QUALIFIED HEALTH PLANS AND/OR OTHER HEALTH PLANS CERTIFIED
BY THE MARKETPLACE TO OFFER THOSE BENEFITS DETERMINED TO BE ESSENTIAL
HEALTH BENEFITS PURSUANT TO STATE LAW OR AS REQUIRED BY THE MARKETPLACE.
11. ENSURE THAT INSURERS OFFERING HEALTH PLANS THROUGH THE MARKETPLACE
DO NOT CHARGE AN INDIVIDUAL ENROLLEE A FEE OR PENALTY FOR TERMINATION OF
COVERAGE.
12. PROVIDE FOR THE OPERATION OF A TOLL-FREE TELEPHONE HOTLINE TO
RESPOND TO REQUESTS FOR ASSISTANCE.
13. MAINTAIN AN INTERNET WEBSITE THROUGH WHICH ENROLLEES AND PROSPEC-
TIVE ENROLLEES OF QUALIFIED HEALTH PLANS AND HEALTH PLANS CERTIFIED BY
THE MARKETPLACE MAY OBTAIN STANDARDIZED COMPARATIVE INFORMATION ON SUCH
PLANS AND INSURANCE AFFORDABILITY PROGRAMS.
14. MAKE AVAILABLE BY ELECTRONIC MEANS A CALCULATOR TO DETERMINE THE
ACTUAL COST OF COVERAGE AFTER THE APPLICATION OF ANY PREMIUM TAX CREDIT
UNDER SECTION 36B OF THE INTERNAL REVENUE CODE OF 1986 OR APPLICABLE
STATE LAW AND ANY COST-SHARING REDUCTION UNDER FEDERAL OR APPLICABLE
STATE LAW.
15. OPERATE A PROGRAM UNDER WHICH THE MARKETPLACE AWARDS GRANTS TO
ENTITIES TO SERVE AS NAVIGATORS IN ACCORDANCE WITH APPLICABLE FEDERAL
LAW AND REGULATIONS ADOPTED THEREUNDER, AND/OR A PROGRAM UNDER WHICH THE
MARKETPLACE AWARDS GRANTS TO ENTITIES TO PROVIDE COMMUNITY BASED ENROLL-
MENT ASSISTANCE IN ACCORDANCE WITH REQUIREMENTS DEVELOPED BY THE MARKET-
PLACE; AND/OR A PROGRAM UNDER WHICH THE MARKETPLACE CERTIFIES NEW YORK
STATE LICENSED PRODUCERS TO PROVIDE ASSISTANCE TO ELIGIBLE INDIVIDUALS
AND/OR SMALL EMPLOYERS PURSUANT TO FEDERAL OR STATE LAW.
16. IN ACCORDANCE WITH APPLICABLE FEDERAL AND STATE LAW, INFORM INDI-
VIDUALS OF ELIGIBILITY REQUIREMENTS FOR THE MEDICAID PROGRAM UNDER TITLE
XIX OF THE SOCIAL SECURITY ACT AND THE SOCIAL SERVICES LAW, THE CHIL-
DREN'S HEALTH INSURANCE PROGRAM (CHIP) UNDER TITLE XXI OF THE SOCIAL
SECURITY ACT AND THIS CHAPTER, THE BASIC HEALTH PROGRAM UNDER SECTION
THREE HUNDRED SIXTY-NINE-GG OF THE SOCIAL SERVICES LAW, OR ANY APPLICA-
BLE STATE OR LOCAL PUBLIC HEALTH INSURANCE PROGRAM AND IF, THROUGH
SCREENING OF THE APPLICATION BY THE MARKETPLACE, THE MARKETPLACE DETER-
MINES THAT SUCH INDIVIDUALS ARE ELIGIBLE FOR ANY SUCH PROGRAM, ENROLL
SUCH INDIVIDUALS IN SUCH PROGRAM.
17. GRANT A CERTIFICATION THAT AN INDIVIDUAL IS EXEMPT FROM THE
REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE PURSUANT TO FEDERAL
OR STATE LAW AND FROM ANY PENALTIES IMPOSED BY SUCH REQUIREMENTS
BECAUSE:
(A) THERE IS NO AFFORDABLE HEALTH PLAN AVAILABLE COVERING THE INDIVID-
UAL, AS DEFINED BY APPLICABLE LAW; OR
(B) THE INDIVIDUAL MEETS THE REQUIREMENTS FOR ANY OTHER SUCH EXEMPTION
FROM THE REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE OR TO PAY
THE PENALTY PURSUANT TO APPLICABLE FEDERAL OR STATE LAW.
S. 1507 106 A. 2007
18. OPERATE A SMALL BUSINESS HEALTH OPTIONS PROGRAM ("SHOP") PURSUANT
TO SECTION 1311 OF THE FEDERAL ACT AND APPLICABLE STATE LAW, THROUGH
WHICH ELIGIBLE SMALL EMPLOYERS MAY SELECT MARKETPLACE-CERTIFIED QUALI-
FIED HEALTH PLANS OFFERED IN THE SMALL GROUP MARKET, AND THROUGH WHICH
ELIGIBLE SMALL EMPLOYERS MAY RECEIVE ASSISTANCE IN QUALIFYING FOR SMALL
BUSINESS TAX CREDITS AVAILABLE PURSUANT TO FEDERAL AND STATE LAW.
19. ENTER INTO AGREEMENTS AS NECESSARY WITH FEDERAL AND STATE AGENCIES
AND OTHER STATE MARKETPLACES TO CARRY OUT ITS RESPONSIBILITIES UNDER
THIS TITLE, PROVIDED SUCH AGREEMENTS INCLUDE ADEQUATE PROTECTIONS WITH
RESPECT TO THE CONFIDENTIALITY OF ANY INFORMATION TO BE SHARED AND
COMPLY WITH ALL STATE AND FEDERAL LAWS AND REGULATIONS.
20. PERFORM DUTIES REQUIRED BY THE SECRETARY, THE SECRETARY OF THE
UNITED STATES DEPARTMENT OF THE TREASURY OR THE COMMISSIONER RELATED TO
DETERMINING ELIGIBILITY FOR PREMIUM TAX CREDITS OR REDUCED COST-SHARING
UNDER APPLICABLE FEDERAL OR STATE LAW.
21. MEET PROGRAM INTEGRITY REQUIREMENTS UNDER APPLICABLE LAW, INCLUD-
ING KEEPING AN ACCURATE ACCOUNTING OF RECEIPTS AND EXPENDITURES AND
PROVIDING REPORTS TO THE SECRETARY REGARDING MARKETPLACE RELATED ACTIV-
ITIES IN ACCORDANCE WITH APPLICABLE LAW.
22. SUBMIT INFORMATION PROVIDED BY MARKETPLACE APPLICANTS FOR VERIFI-
CATION AS REQUIRED BY SECTION 1411(C) OF THE FEDERAL ACT AND APPLICABLE
STATE LAW.
23. ESTABLISH RULES AND REGULATIONS THAT DO NOT CONFLICT WITH OR
PREVENT THE APPLICATION OF REGULATIONS PROMULGATED BY THE SECRETARY.
24. DETERMINE ELIGIBILITY, PROVIDE NOTICES, AND PROVIDE OPPORTUNITIES
FOR APPEAL AND REDETERMINATION IN ACCORDANCE WITH THE REQUIREMENTS OF
FEDERAL AND STATE LAW.
§ 268-D. SPECIAL FUNCTIONS OF THE MARKETPLACE RELATED TO HEALTH PLAN
CERTIFICATION AND QUALIFIED HEALTH PLAN OVERSIGHT. 1. HEALTH PLANS
CERTIFIED BY THE MARKETPLACE SHALL MEET THE FOLLOWING REQUIREMENTS:
(A) THE INSURER OFFERING THE HEALTH PLAN:
(I) IS LICENSED OR CERTIFIED BY THE SUPERINTENDENT OR COMMISSIONER, IN
GOOD STANDING TO OFFER HEALTH INSURANCE COVERAGE IN THIS STATE, AND
MEETS THE REQUIREMENTS ESTABLISHED BY THE MARKETPLACE;
(II) OFFERS AT LEAST ONE QUALIFIED HEALTH PLAN AND/OR OTHER OR ADDI-
TIONAL HEALTH PLANS AUTHORIZED FOR SALE BY THE DEPARTMENT OF FINANCIAL
SERVICES OR THE DEPARTMENT IN EACH OF THE SILVER AND GOLD LEVELS AS
REQUIRED BY STATE LAW, PROVIDED, HOWEVER, THAT THE MARKETPLACE MAY
REQUIRE ADDITIONAL BENEFIT LEVELS TO BE OFFERED BY ALL INSURERS PARTIC-
IPATING IN THE MARKETPLACE;
(III) HAS FILED WITH AND RECEIVED APPROVAL FROM THE SUPERINTENDENT OF
ITS PREMIUM RATES AND POLICY OR CONTRACT FORMS PURSUANT TO THE INSURANCE
LAW AND/OR THIS CHAPTER;
(IV) DOES NOT CHARGE ANY CANCELLATION FEES OR PENALTIES FOR TERMI-
NATION OF COVERAGE IN VIOLATION OF APPLICABLE LAW; AND
(V) COMPLIES WITH THE REGULATIONS DEVELOPED BY THE SECRETARY UNDER
SECTION 1311(C) OF THE FEDERAL ACT AND SUCH OTHER REQUIREMENTS AS THE
MARKETPLACE MAY ESTABLISH.
(B) THE HEALTH PLAN: (I) PROVIDES THE ESSENTIAL HEALTH BENEFITS PACK-
AGE DESCRIBED IN STATE LAW OR REQUIRED BY THE MARKETPLACE AND INCLUDES
SUCH ADDITIONAL BENEFITS AS ARE MANDATED BY STATE LAW, EXCEPT THAT THE
HEALTH PLAN SHALL NOT BE REQUIRED TO PROVIDE ESSENTIAL BENEFITS THAT
DUPLICATE THE MINIMUM BENEFITS OF QUALIFIED DENTAL PLANS IF:
(A) THE MARKETPLACE HAS DETERMINED THAT AT LEAST ONE QUALIFIED DENTAL
PLAN OR DENTAL PLAN APPROVED BY THE DEPARTMENT OF FINANCIAL SERVICES OR
S. 1507 107 A. 2007
THE DEPARTMENT IS AVAILABLE TO SUPPLEMENT THE HEALTH PLAN'S COVERAGE;
AND
(B) THE INSURER MAKES PROMINENT DISCLOSURE AT THE TIME IT OFFERS THE
HEALTH PLAN, IN A FORM APPROVED BY THE MARKETPLACE, THAT THE PLAN DOES
NOT PROVIDE THE FULL RANGE OF ESSENTIAL PEDIATRIC BENEFITS, AND THAT
QUALIFIED DENTAL PLANS OR DENTAL PLANS APPROVED BY THE DEPARTMENT OF
FINANCIAL SERVICES OR DEPARTMENT OF HEALTH PROVIDING THOSE BENEFITS AND
OTHER DENTAL BENEFITS NOT COVERED BY THE PLAN ARE OFFERED THROUGH THE
MARKETPLACE;
(II) PROVIDES AT LEAST A BRONZE LEVEL OF COVERAGE AS DEFINED BY STATE
LAW, UNLESS THE PLAN IS CERTIFIED AS A QUALIFIED CATASTROPHIC PLAN, AS
DEFINED IN SECTION 1302(E) OF THE FEDERAL ACT AND THE INSURANCE LAW, AND
SHALL ONLY BE OFFERED TO INDIVIDUALS ELIGIBLE FOR CATASTROPHIC COVERAGE;
(III) HAS COST-SHARING REQUIREMENTS, INCLUDING DEDUCTIBLES, WHICH DO
NOT EXCEED THE LIMITS ESTABLISHED UNDER SECTION 1302(C) OF THE FEDERAL
ACT, STATE LAW AND ANY REQUIREMENTS OF THE MARKETPLACE;
(IV) COMPLIES WITH REGULATIONS PROMULGATED BY THE SECRETARY PURSUANT
TO SECTION 1311(C) OF THE FEDERAL ACT AND APPLICABLE STATE LAW, WHICH
INCLUDE MINIMUM STANDARDS IN THE AREAS OF MARKETING PRACTICES, NETWORK
ADEQUACY, ESSENTIAL COMMUNITY PROVIDERS IN UNDERSERVED AREAS, ACCREDI-
TATION, QUALITY IMPROVEMENT, UNIFORM ENROLLMENT FORMS AND DESCRIPTIONS
OF COVERAGE AND INFORMATION ON QUALITY MEASURES FOR HEALTH BENEFIT PLAN
PERFORMANCE;
(V) MEETS STANDARDS SPECIFIED AND DETERMINED BY THE MARKETPLACE,
PROVIDED THAT THE STANDARDS DO NOT CONFLICT WITH OR PREVENT THE APPLICA-
TION OF FEDERAL REQUIREMENTS; AND
(VI) COMPLIES WITH THE INSURANCE LAW AND THIS CHAPTER REQUIREMENTS
APPLICABLE TO HEALTH INSURANCE ISSUED IN THIS STATE AND ANY REGULATIONS
PROMULGATED PURSUANT THERETO THAT DO NOT CONFLICT WITH OR PREVENT THE
APPLICATION OF FEDERAL REQUIREMENTS; AND
(C) THE MARKETPLACE DETERMINES THAT MAKING THE HEALTH PLAN AVAILABLE
THROUGH THE MARKETPLACE IS IN THE INTEREST OF QUALIFIED INDIVIDUALS IN
THIS STATE.
2. THE MARKETPLACE SHALL NOT EXCLUDE A HEALTH PLAN:
(A) ON THE BASIS THAT THE HEALTH PLAN IS A FEE-FOR-SERVICE PLAN;
(B) THROUGH THE IMPOSITION OF PREMIUM PRICE CONTROLS BY THE MARKET-
PLACE; OR
(C) ON THE BASIS THAT THE HEALTH PLAN PROVIDES TREATMENTS NECESSARY TO
PREVENT PATIENTS' DEATHS IN CIRCUMSTANCES THE MARKETPLACE DETERMINES ARE
INAPPROPRIATE OR TOO COSTLY.
3. THE MARKETPLACE SHALL REQUIRE EACH INSURER CERTIFIED OR SEEKING
CERTIFICATION OF A HEALTH PLAN AS A QUALIFIED HEALTH PLAN OR PLAN
APPROVED FOR SALE BY THE DEPARTMENT OF FINANCIAL SERVICES OR THE DEPART-
MENT TO:
(A) SUBMIT A JUSTIFICATION FOR ANY PREMIUM INCREASE PURSUANT TO APPLI-
CABLE LAW PRIOR TO IMPLEMENTATION OF SUCH INCREASE. THE INSURER SHALL
PROMINENTLY POST THE INFORMATION ON ITS INTERNET WEBSITE. SUCH RATE
INCREASES SHALL BE SUBJECT TO THE PRIOR APPROVAL OF THE SUPERINTENDENT
PURSUANT TO THE INSURANCE LAW;
(B)(I) MAKE AVAILABLE TO THE PUBLIC AND SUBMIT TO THE MARKETPLACE, THE
SECRETARY AND THE SUPERINTENDENT, ACCURATE AND TIMELY DISCLOSURE OF:
(A) CLAIMS PAYMENT POLICIES AND PRACTICES;
(B) PERIODIC FINANCIAL DISCLOSURES;
(C) DATA ON ENROLLMENT AND DISENROLLMENT;
(D) DATA ON THE NUMBER OF CLAIMS THAT ARE DENIED;
(E) DATA ON RATING PRACTICES;
S. 1507 108 A. 2007
(F) INFORMATION ON COST-SHARING AND PAYMENTS WITH RESPECT TO ANY OUT-
OF-NETWORK COVERAGE;
(G) INFORMATION ON ENROLLEE AND PARTICIPANT RIGHTS UNDER TITLE I OF
THE FEDERAL ACT; AND
(H) OTHER INFORMATION AS DETERMINED APPROPRIATE BY THE SECRETARY OR
OTHERWISE REQUIRED BY THE MARKETPLACE;
(II) THE INFORMATION SHALL BE PROVIDED IN PLAIN LANGUAGE, AS THAT TERM
IS DEFINED IN SECTION 1311(E)(3)(B) OF THE FEDERAL ACT AND STATE LAW,
AND IN GUIDANCE JOINTLY ISSUED THEREUNDER BY THE SECRETARY AND THE
FEDERAL SECRETARY OF LABOR; AND
(C) PROVIDE TO INDIVIDUALS, IN A TIMELY MANNER UPON THE REQUEST OF THE
INDIVIDUAL, THE AMOUNT OF COST-SHARING, INCLUDING DEDUCTIBLES, COPAY-
MENTS, AND COINSURANCE, UNDER THE INDIVIDUAL'S HEALTH PLAN OR COVERAGE
THAT THE INDIVIDUAL WOULD BE RESPONSIBLE FOR PAYING WITH RESPECT TO THE
FURNISHING OF A SPECIFIC ITEM OR SERVICE BY A PARTICIPATING PROVIDER. AT
A MINIMUM, THIS INFORMATION SHALL BE MADE AVAILABLE TO THE INDIVIDUAL
THROUGH AN INTERNET WEBSITE AND THROUGH OTHER MEANS FOR INDIVIDUALS
WITHOUT ACCESS TO THE INTERNET.
4. THE MARKETPLACE SHALL NOT EXEMPT ANY INSURER SEEKING CERTIFICATION
OF A HEALTH PLAN, REGARDLESS OF THE TYPE OR SIZE OF THE INSURER, FROM
LICENSING OR SOLVENCY REQUIREMENTS UNDER THE INSURANCE LAW OR THIS CHAP-
TER, AND SHALL APPLY THE CRITERIA OF THIS SECTION IN A MANNER THAT
ENSURES A LEVEL PLAYING FIELD FOR INSURERS PARTICIPATING IN THE MARKET-
PLACE.
5. (A) THE PROVISIONS OF THIS ARTICLE THAT APPLY TO QUALIFIED HEALTH
PLANS AND PLANS APPROVED FOR SALE BY THE DEPARTMENT OF FINANCIAL
SERVICES AND THE DEPARTMENT ALSO SHALL APPLY TO THE EXTENT RELEVANT TO
QUALIFIED DENTAL PLANS APPROVED FOR SALE BY THE DEPARTMENT OF FINANCIAL
SERVICES OR THE DEPARTMENT, EXCEPT AS MODIFIED IN ACCORDANCE WITH THE
PROVISIONS OF PARAGRAPHS (B) AND (C) OF THIS SUBDIVISION OR OTHERWISE
REQUIRED BY THE MARKETPLACE.
(B) THE QUALIFIED DENTAL PLAN OR DENTAL PLAN APPROVED FOR SALE BY THE
DEPARTMENT OF FINANCIAL SERVICES AND/OR THE DEPARTMENT SHALL BE LIMITED
TO DENTAL AND ORAL HEALTH BENEFITS, WITHOUT SUBSTANTIALLY DUPLICATING
THE BENEFITS TYPICALLY OFFERED BY HEALTH BENEFIT PLANS WITHOUT DENTAL
COVERAGE, AND SHALL INCLUDE, AT A MINIMUM, THE ESSENTIAL PEDIATRIC
DENTAL BENEFITS PRESCRIBED BY THE SECRETARY PURSUANT TO SECTION
1302(B)(1)(J) OF THE FEDERAL ACT, AND SUCH OTHER DENTAL BENEFITS AS THE
MARKETPLACE OR SECRETARY MAY SPECIFY IN REGULATIONS.
(C) INSURERS MAY JOINTLY OFFER A COMPREHENSIVE PLAN THROUGH THE
MARKETPLACE IN WHICH AN INSURER PROVIDES THE DENTAL BENEFITS THROUGH A
QUALIFIED DENTAL PLAN OR PLAN APPROVED BY THE DEPARTMENT OF FINANCIAL
SERVICES OR THE DEPARTMENT AND AN INSURER PROVIDES THE OTHER BENEFITS
THROUGH A QUALIFIED HEALTH PLAN, PROVIDED THAT THE PLANS ARE PRICED
SEPARATELY AND ALSO ARE MADE AVAILABLE FOR PURCHASE SEPARATELY AT THE
SAME PRICE.
§ 268-E. APPEALS AND APPEAL HEARINGS; JUDICIAL REVIEW. 1. ANY APPLI-
CANT OR ENROLLEE, OR ANY INDIVIDUAL AUTHORIZED TO ACT ON BEHALF OF ANY
SUCH APPLICANT OR ENROLLEE, MAY APPEAL TO THE DEPARTMENT FROM DETERMI-
NATIONS OF DEPARTMENT OFFICIALS OR FAILURES TO MAKE DETERMINATIONS UPON
GROUNDS SPECIFIED IN SUBDIVISION FOUR OF THIS SECTION. THE DEPARTMENT
MUST REVIEW THE APPEAL DE NOVO AND GIVE SUCH PERSON AN OPPORTUNITY FOR
AN APPEAL HEARING. THE DEPARTMENT MAY ALSO, ON ITS OWN MOTION, REVIEW
ANY DECISION MADE OR ANY CASE IN WHICH A DECISION HAS NOT BEEN MADE BY
THE MARKETPLACE OR A SOCIAL SERVICES OFFICIAL WITHIN THE TIME SPECIFIED
BY LAW OR REGULATIONS OF THE DEPARTMENT. THE DEPARTMENT MAY MAKE SUCH
S. 1507 109 A. 2007
ADDITIONAL INVESTIGATION AS IT MAY DEEM NECESSARY, AND THE COMMISSIONER
MUST MAKE SUCH DETERMINATION AS IS JUSTIFIED AND IN ACCORDANCE WITH
APPLICABLE LAW.
2. REGARDING ANY APPEAL PURSUANT TO THIS SECTION, WITH OR WITHOUT AN
APPEAL HEARING, THE COMMISSIONER MAY DESIGNATE AND AUTHORIZE ONE OR MORE
APPROPRIATE MEMBERS OF HIS STAFF TO CONSIDER AND DECIDE SUCH APPEALS.
ANY STAFF MEMBER SO DESIGNATED AND AUTHORIZED WILL HAVE AUTHORITY TO
DECIDE SUCH APPEALS ON BEHALF OF THE COMMISSIONER WITH THE SAME FORCE
AND EFFECT AS IF THE COMMISSIONER HAD MADE THE DECISIONS. APPEAL HEAR-
INGS MUST BE HELD ON BEHALF OF THE COMMISSIONER BY MEMBERS OF HIS STAFF
WHO ARE EMPLOYED FOR SUCH PURPOSES OR WHO HAVE BEEN DESIGNATED AND
AUTHORIZED BY THE COMMISSIONER.
3. PERSONS ENTITLED TO APPEAL TO THE DEPARTMENT PURSUANT TO THIS
SECTION MUST INCLUDE:
(A) APPLICANTS FOR OR ENROLLEES IN INSURANCE AFFORDABILITY PROGRAMS
AND QUALIFIED HEALTH PLANS; AND
(B) OTHER PERSONS ENTITLED TO AN OPPORTUNITY FOR AN APPEAL HEARING AS
DIRECTED BY THE COMMISSIONER.
4. AN APPLICANT OR ENROLLEE HAS THE RIGHT TO APPEAL AT LEAST THE
FOLLOWING ISSUES:
(A) AN ELIGIBILITY DETERMINATION MADE IN ACCORDANCE WITH THIS ARTICLE
AND APPLICABLE LAW, INCLUDING:
(I) AN INITIAL DETERMINATION OF ELIGIBILITY, INCLUDING:
(A) ELIGIBILITY TO ENROLL IN A QUALIFIED HEALTH PLAN;
(B) ELIGIBILITY FOR MEDICAID;
(C) ELIGIBILITY FOR CHILD HEALTH PLUS;
(D) ELIGIBILITY FOR THE BASIC HEALTH PROGRAM;
(E) THE AMOUNT OF ADVANCE PAYMENTS OF THE PREMIUM TAX CREDIT AND LEVEL
OF COST-SHARING REDUCTIONS;
(F) THE AMOUNT OF ANY OTHER SUBSIDY THAT MAY BE AVAILABLE UNDER LAW;
AND
(G) ELIGIBILITY FOR SUCH OTHER HEALTH INSURANCE PROGRAMS AS DETERMINED
BY THE COMMISSIONER; AND
(II) A RE-DETERMINATION OF ELIGIBILITY OF THE PROGRAMS UNDER THIS
SUBDIVISION.
(B) AN ELIGIBILITY DETERMINATION FOR AN EXEMPTION FOR ANY MANDATE TO
PURCHASE HEALTH INSURANCE.
(C) A FAILURE BY NY STATE OF HEALTH TO PROVIDE TIMELY WRITTEN NOTICE
OF AN ELIGIBILITY DETERMINATION MADE IN ACCORDANCE WITH APPLICABLE LAW.
5. THE DEPARTMENT MAY, SUBJECT TO THE DISCRETION OF THE COMMISSIONER,
PROMULGATE SUCH REGULATIONS, CONSISTENT WITH FEDERAL OR STATE LAW, AS
MAY BE NECESSARY TO IMPLEMENT THE PROVISIONS OF THIS SECTION.
6. REGARDING EVERY DECISION OF AN APPEAL PURSUANT TO THIS SECTION, THE
DEPARTMENT MUST INFORM EVERY PARTY, AND HIS OR HER REPRESENTATIVE, IF
ANY, OF THE AVAILABILITY OF JUDICIAL REVIEW AND THE TIME LIMITATION TO
PURSUE FUTURE REVIEW.
7. APPLICANTS AND ENROLLEES OF QUALIFIED HEALTH PLANS, WITH OR WITHOUT
ADVANCE PAYMENTS OF THE PREMIUM TAX CREDIT AND COST-SHARING REDUCTIONS,
ALSO HAVE THE RIGHT TO APPEAL TO THE UNITED STATES DEPARTMENT OF HEALTH
AND HUMAN SERVICES APPEAL ENTITY:
(A) APPEALS DECISIONS ISSUED BY NY STATE OF HEALTH UPON THE EXHAUSTION
OF THE NY STATE OF HEALTH APPEALS PROCESS; AND
(B) A DENIAL OF A REQUEST TO VACATE A DISMISSAL MADE BY THE NY STATE
OF HEALTH APPEALS ENTITY.
8. THE DEPARTMENT MUST INCLUDE NOTICE OF THE RIGHT TO APPEAL AS
PROVIDED BY SUBDIVISION FOUR OF THIS SECTION AND INSTRUCTIONS REGARDING
S. 1507 110 A. 2007
HOW TO FILE AN APPEAL IN ANY ELIGIBILITY DETERMINATION ISSUED TO THE
APPLICANT OR ENROLLEE IN ACCORDANCE WITH APPLICABLE LAW. SUCH NOTICE
SHALL INCLUDE:
(A) AN EXPLANATION OF THE APPLICANT OR ENROLLEE'S APPEAL RIGHTS;
(B) A DESCRIPTION OF THE PROCEDURES BY WHICH THE APPLICANT OR ENROLLEE
MAY REQUEST AN APPEAL;
(C) INFORMATION ON THE APPLICANT OR ENROLLEE'S RIGHT TO REPRESENT
HIMSELF OR HERSELF, OR TO BE REPRESENTED BY LEGAL COUNSEL OR ANOTHER
REPRESENTATIVE;
(D) AN EXPLANATION OF THE CIRCUMSTANCES UNDER WHICH THE APPELLANT'S
ELIGIBILITY MAY BE MAINTAINED OR REINSTATED PENDING AN APPEAL DECISION;
AND
(E) AN EXPLANATION THAT AN APPEAL DECISION FOR ONE HOUSEHOLD MEMBER
MAY RESULT IN A CHANGE IN ELIGIBILITY FOR OTHER HOUSEHOLD MEMBERS AND
THAT SUCH A CHANGE WILL BE HANDLED AS A REDETERMINATION OF ELIGIBILITY
FOR ALL HOUSEHOLD MEMBERS IN ACCORDANCE WITH THE STANDARDS SPECIFIED IN
APPLICABLE LAW.
§ 268-F. MARKETPLACE ADVISORY COMMITTEE. 1. THERE IS HEREBY CREATED
THE MARKETPLACE ADVISORY COMMITTEE, WHICH SHALL CONSIDER AND ADVISE THE
DEPARTMENT AND COMMISSIONER ON MATTERS CONCERNING THE PROVISION OF
HEALTH CARE COVERAGE THROUGH THE NY STATE OF HEALTH OR MARKETPLACE.
2. THE MARKETPLACE ADVISORY COMMITTEE SHALL CONSIST OF UP TO TWENTY-
EIGHT MEMBERS APPOINTED BY THE COMMISSIONER, REPRESENTATIVE OF EACH
GEOGRAPHIC AREA OF THE STATE AND INCLUDING:
(A) REPRESENTATIVES FROM THE FOLLOWING CATEGORIES, BUT NOT MORE THAN
SIX FROM ANY SINGLE CATEGORY:
(I) HEALTH PLAN CONSUMER ADVOCATES;
(II) SMALL BUSINESS CONSUMER REPRESENTATIVES;
(III) HEALTH CARE PROVIDER REPRESENTATIVES;
(IV) REPRESENTATIVES OF THE HEALTH INSURANCE INDUSTRY;
(B) REPRESENTATIVES FROM THE FOLLOWING CATEGORIES, BUT NOT MORE THAN
TWO FROM EITHER CATEGORY:
(I) LICENSED INSURANCE PRODUCERS; AND
(II) REPRESENTATIVES OF LABOR ORGANIZATIONS.
3. THE MARKETPLACE SHALL SELECT THE CHAIR OF THE ADVISORY COMMITTEE
FROM AMONG THE MEMBERS OF SUCH COMMITTEE AND SHALL DESIGNATE AN OFFICER
OR EMPLOYEE OF THE DEPARTMENT TO ASSIST THE MARKETPLACE ADVISORY COMMIT-
TEE IN THE PERFORMANCE OF ITS DUTIES UNDER THIS SECTION. THE MARKETPLACE
SHALL ADOPT RULES FOR THE GOVERNANCE OF THE ADVISORY COMMITTEE, WHICH
SHALL MEET AS FREQUENTLY AS ITS BUSINESS MAY REQUIRE AND AT SUCH OTHER
TIMES AS DETERMINED BY THE MARKETPLACE TO BE NECESSARY.
4. MEMBERS OF THE ADVISORY COMMITTEE SHALL SERVE WITHOUT COMPENSATION
FOR THEIR SERVICES AS MEMBERS, BUT EACH SHALL BE ALLOWED THE NECESSARY
AND ACTUAL EXPENSES INCURRED IN THE PERFORMANCE OF HIS OR HER DUTIES
UNDER THIS SECTION.
§ 268-G. FUNDING OF THE MARKETPLACE. 1. THE MARKETPLACE SHALL BE FUND-
ED BY STATE AND FEDERAL SOURCES AS AUTHORIZED BY APPLICABLE LAW, INCLUD-
ING BUT NOT LIMITED TO APPLICABLE LAW AUTHORIZING THE RESPECTIVE INSUR-
ANCE AFFORDABILITY PROGRAMS AVAILABLE THROUGH THE MARKETPLACE.
2. THE ACCOUNTS OF THE MARKETPLACE SHALL BE SUBJECT TO SUPERVISION OF
THE COMPTROLLER AND SUCH ACCOUNTS SHALL INCLUDE RECEIPTS, EXPENDITURES,
CONTRACTS AND OTHER MATTERS WHICH PERTAIN TO THE FISCAL SOUNDNESS OF THE
MARKETPLACE.
3. NOTWITHSTANDING ANY LAW TO THE CONTRARY, AND IN ACCORDANCE WITH
SECTION FOUR OF THE STATE FINANCE LAW, UPON REQUEST OF THE DIRECTOR OF
THE BUDGET, IN CONSULTATION WITH THE COMMISSIONER, THE SUPERINTENDENT
S. 1507 111 A. 2007
AND THE EXECUTIVE DIRECTOR OF THE MARKETPLACE, THE COMPTROLLER IS HEREBY
AUTHORIZED AND DIRECTED TO SUB-ALLOCATE OR TRANSFER SPECIAL REVENUE
FEDERAL FUNDS APPROPRIATED TO THE DEPARTMENT FOR PLANNING AND IMPLEMENT-
ING VARIOUS HEALTHCARE AND INSURANCE REFORM INITIATIVES AUTHORIZED BY
APPLICABLE LAW. MARKETPLACE MONEYS SUB-ALLOCATED OR TRANSFERRED PURSU-
ANT TO THIS SECTION SHALL BE PAID OUT OF THE FUND UPON AUDIT AND WARRANT
OF THE STATE COMPTROLLER ON VOUCHERS CERTIFIED OR APPROVED BY THE
MARKETPLACE.
§ 268-H. CONSTRUCTION. NOTHING IN THIS ARTICLE, AND NO ACTION TAKEN BY
THE MARKETPLACE PURSUANT HERETO, SHALL BE CONSTRUED TO:
1. PREEMPT OR SUPERSEDE THE AUTHORITY OF THE SUPERINTENDENT OR THE
COMMISSIONER; OR
2. EXEMPT INSURERS, INSURANCE PRODUCERS OR QUALIFIED HEALTH PLANS FROM
THIS CHAPTER OR THE INSURANCE LAW AND ANY REGULATIONS PROMULGATED THERE-
UNDER.
§ 3. Severability. If any provision of this article, or the applica-
tion thereof to any person or circumstances is held invalid or unconsti-
tutional, that invalidity or unconstitutionality shall not affect other
provisions or applications of this article that can be given effect
without the invalid or unconstitutional provision or application, and to
this end the provisions and application of this article are severable.
§ 4. This act shall take effect immediately.
PART U
Section 1. Section 203 of the elder law is amended by adding a new
subdivision 12 to read as follows:
12. THE DIRECTOR IS HEREBY AUTHORIZED TO IMPLEMENT PRIVATE PAY PROTO-
COLS FOR ALL PROGRAMS ADMINISTERED BY THE OFFICE. THESE PROTOCOLS MAY BE
IMPLEMENTED BY AREA AGENCIES ON AGING AT THEIR OPTION AND SUCH PROTOCOLS
MAY NOT BE APPLIED TO CLIENTS WHOSE SERVICES ARE PAID FOR WITH FEDERAL
FUNDS OR FUNDS DESIGNATED AS FEDERAL MATCH. ALL PRIVATE PAYMENTS
RECEIVED DIRECTLY BY AN AREA AGENCY ON AGING OR INDIRECTLY BY ONE OF ITS
CONTRACTORS SHALL BE USED TO SUPPLEMENT, NOT SUPPLANT, FUNDS BY STATE,
FEDERAL, OR COUNTY APPROPRIATIONS. PRIVATE PAY PAYMENTS RECEIVED UNDER
THIS SUBDIVISION SHALL BE USED BY THE AREA AGENCY ON AGING TO SUPPORT
AND ENHANCE SERVICES OR PROGRAMS PROVIDED BY THE AREA AGENCY ON AGING.
PARTICIPANT PAYMENTS UNDER THIS SUBDIVISION SHALL NOT BE REQUIRED OF
INDIVIDUALS WITH INCOMES BELOW FOUR HUNDRED PERCENT OF THE FEDERAL
POVERTY LEVEL. NO PARTICIPANT, REGARDLESS OF INCOME, SHALL BE REQUIRED
TO PAY FOR ANY SERVICE THAT THEY ARE RECEIVING AT THE TIME THESE PROTO-
COLS ARE IMPLEMENTED BY THE AREA AGENCY ON AGING. THIS SUBDIVISION SHALL
NOT PREVENT COST SHARING FOR THE PROGRAMS ESTABLISHED PURSUANT TO
SECTION TWO HUNDRED FOURTEEN OF THIS TITLE FOR INDIVIDUALS BELOW FOUR
HUNDRED PERCENT OF THE FEDERAL POVERTY LEVEL.
§ 2. This act shall take effect immediately.
PART V
Section 1. Paragraph (d) of subdivision 32 of section 364-j of the
social services law, as amended by section 15 of part B of chapter 59 of
the laws of 2016, is amended to read as follows:
(d) (I) Penalties under this subdivision may be applied to any and all
circumstances described in paragraph (b) of this subdivision until the
managed care organization complies with the requirements for submission
of encounter data.
S. 1507 112 A. 2007
(II) No penalties for late, incomplete or inaccurate encounter data
shall be assessed against managed care organizations in addition to
those provided for in this subdivision, PROVIDED, HOWEVER, THAT NOTHING
IN THIS PARAGRAPH SHALL PROHIBIT THE IMPOSITION OF PENALTIES, IN CASES
OF FRAUD OR ABUSE, OTHERWISE AUTHORIZED BY LAW.
§ 2. Section 364-j of the social services law is amended by adding a
new subdivision 34 read as follows:
34. ANY PAYMENT MADE PURSUANT TO THE STATE'S MANAGED CARE PROGRAM,
INCLUDING PAYMENTS MADE BY MANAGED LONG TERM CARE PLANS, SHALL BE DEEMED
A PAYMENT BY THE STATE'S MEDICAL ASSISTANCE PROGRAM.
§ 3. Section 364-j of the social services law is amended by adding a
new subdivision 36 to read as follows:
36. MEDICAID PROGRAM INTEGRITY REVIEWS. (A) FOR PURPOSES OF THIS
SUBDIVISION, MANAGED CARE PROVIDER SHALL ALSO INCLUDE MANAGED LONG TERM
CARE PLANS.
(B) THE MEDICAID INSPECTOR GENERAL SHALL CONDUCT PERIODIC REVIEWS OF
THE CONTRACTUAL PERFORMANCE OF EACH MANAGED CARE PROVIDER AS IT RELATES
TO THE MANAGED CARE PROVIDER'S PROGRAM INTEGRITY OBLIGATIONS UNDER ITS
CONTRACT WITH THE DEPARTMENT. THE MEDICAID INSPECTOR GENERAL, IN CONSUL-
TATION WITH THE COMMISSIONER, SHALL PUBLISH A LIST OF THOSE CONTRACTUAL
OBLIGATIONS WHICH MAY BE SUBJECT TO REVIEW AND HOW THEY SHALL BE EVALU-
ATED, INCLUDING BENCHMARKS, PRIOR TO COMMENCING ANY REVIEW.
(C) IF, AS A RESULT OF HIS OR HER REVIEW, THE MEDICAID INSPECTOR
GENERAL DETERMINES THAT A MANAGED CARE PROVIDER IS NOT MEETING ITS
PROGRAM INTEGRITY OBLIGATIONS, THE MEDICAID INSPECTOR GENERAL MAY
RECOVER FROM THE MANAGED CARE PROVIDER UP TO TWO PERCENT OF THE MEDICAID
PREMIUMS PAID TO THE MANAGED CARE PROVIDER FOR THE PERIOD UNDER REVIEW.
ANY PREMIUM RECOVERY UNDER THIS SUBDIVISION SHALL BE A PERCENTAGE OF THE
ADMINISTRATIVE COMPONENT OF THE MEDICAID PREMIUM CALCULATED BY THE
DEPARTMENT AND MAY BE RECOVERED BY THE DEPARTMENT IN THE SAME MANNER IT
RECOVERS OVERPAYMENTS.
(D) THE MANAGED CARE PROVIDER SHALL BE ENTITLED TO RECEIVE A DRAFT
AUDIT REPORT AND FINAL AUDIT REPORT CONTAINING THE RESULTS OF THE MEDI-
CAID INSPECTOR GENERAL'S REVIEW. IF THE MEDICAID INSPECTOR GENERAL
DETERMINES TO RECOVER A PERCENTAGE OF THE PREMIUM AS DESCRIBED IN PARA-
GRAPH (C) OF THIS SUBDIVISION, THE MANAGED CARE PROVIDER SHALL HAVE AN
OPPORTUNITY TO BE HEARD IN ACCORDANCE WITH SECTION TWENTY-TWO OF THIS
CHAPTER.
§ 4. Subdivision 3 of section 363-d of the social services law, as
amended by section 44 of part C of chapter 58 of the laws of 2007, is
amended to read as follows:
3. Upon enrollment in the medical assistance program, a provider shall
certify to the department that the provider satisfactorily meets the
requirements of this section. Additionally, the commissioner of health
and Medicaid inspector general shall have the authority to determine at
any time if a provider has a compliance program that satisfactorily
meets the requirements of this section.
(a) A compliance program that is accepted by the federal department of
health and human services office of inspector general and remains in
compliance with the standards promulgated by such office shall be deemed
in compliance with the provisions of this section, so long as such plans
adequately address medical assistance program risk areas and compliance
issues.
(b) A COMPLIANCE PROGRAM THAT MEETS FEDERAL REQUIREMENTS FOR MANAGED
CARE PROVIDER COMPLIANCE PROGRAMS, AS SPECIFIED IN THE CONTRACT OR
CONTRACTS BETWEEN THE DEPARTMENT AND THE MEDICAID MANAGED CARE PROVIDER
S. 1507 113 A. 2007
SHALL BE DEEMED IN COMPLIANCE WITH THE PROVISIONS IN THIS SECTION, SO
LONG AS SUCH PROGRAMS ADEQUATELY ADDRESS MEDICAL ASSISTANCE PROGRAM RISK
AREAS AND COMPLIANCE ISSUES. FOR PURPOSES OF THIS SECTION, A MANAGED
CARE PROVIDER IS AS DEFINED IN PARAGRAPH (C) OF SUBDIVISION ONE OF
SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS CHAPTER, AND INCLUDES MANAGED
LONG TERM CARE PLANS.
(C) In the event that the commissioner of health or the Medicaid
inspector general finds that the provider does not have a satisfactory
program within ninety days after the effective date of the regulations
issued pursuant to subdivision four of this section, the provider may be
subject to any sanctions or penalties permitted by federal or state laws
and regulations, including revocation of the provider's agreement to
participate in the medical assistance program.
§ 5. Section 3613 of the public health law is amended by adding a new
subdivision 1-a to read as follows:
1-A. EACH HOME CARE SERVICES WORKER SHALL OBTAIN AN INDIVIDUAL
NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER FROM THE NATIONAL PROVIDER
PLAN AND PROVIDER ENUMERATION SYSTEM (NPPES).
§ 6. Section 364-j of the social services law is amended by adding a
new subdivision 35 to read as follows:
35. RECOVERY OF OVERPAYMENTS FROM NETWORK PROVIDERS. (A) WHERE THE
MEDICAID INSPECTOR GENERAL DURING THE COURSE OF AN AUDIT, INVESTIGATION,
OR REVIEW, OR THE DEPUTY ATTORNEY GENERAL FOR THE MEDICAID FRAUD CONTROL
UNIT DURING THE COURSE OF AN INVESTIGATION OR PROSECUTION FOR MEDICAID
FRAUD, IDENTIFIES MEDICAL ASSISTANCE OVERPAYMENTS MADE BY A MANAGED CARE
PROVIDER OR MANAGED LONG TERM CARE PLAN TO ITS SUBCONTRACTOR OR SUBCON-
TRACTORS OR PROVIDER OR PROVIDERS, THE STATE SHALL HAVE THE RIGHT TO
RECOVER THE OVERPAYMENT FROM THE SUBCONTRACTOR OR SUBCONTRACTORS,
PROVIDER OR PROVIDERS, OR THE MANAGED CARE PROVIDER OR MANAGED LONG TERM
CARE PLAN.
(B) WHERE THE STATE IS UNSUCCESSFUL IN RECOVERING AN OVERPAYMENT FROM
THE SUBCONTRACTOR OR SUBCONTRACTORS OR PROVIDER OR PROVIDERS, THE MEDI-
CAID INSPECTOR GENERAL MAY REQUIRE THE MANAGED CARE PROVIDER OR MANAGED
LONG TERM CARE PLAN TO RECOVER THE MEDICAL ASSISTANCE OVERPAYMENT IDEN-
TIFIED IN PARAGRAPH (A) OF THIS SUBDIVISION ON BEHALF OF THE STATE. THE
MANAGED CARE PROVIDER OR MANAGED LONG TERM CARE PLAN SHALL REMIT TO THE
STATE THE FULL AMOUNT OF THE IDENTIFIED OVERPAYMENT NO LATER THAN SIX
MONTHS AFTER RECEIVING NOTICE OF THE OVERPAYMENT FROM THE STATE.
§ 7. This act shall take effect immediately; provided, however, that
the amendments to section 364-j of the social services law made by
sections one, two, three, and six of this act shall not affect the
repeal of such section and shall be deemed repealed therewith; provided
further, that section three of this act shall apply to a contract or
contracts in effect as of January 1, 2015 and any review period in
section three of this act shall not begin before January 1, 2018.
PART W
Section 1. Section 1 of part D of chapter 111 of the laws of 2010
relating to the recovery of exempt income by the office of mental health
for community residences and family-based treatment programs, as amended
by section 1 of part H of chapter 59 of the laws of 2016, is amended to
read as follows:
Section 1. The office of mental health is authorized to recover fund-
ing from community residences and family-based treatment providers
licensed by the office of mental health, consistent with contractual
S. 1507 114 A. 2007
obligations of such providers, and notwithstanding any other inconsist-
ent provision of law to the contrary, in an amount equal to 50 percent
of the income received by such providers which exceeds the fixed amount
of annual Medicaid revenue limitations, as established by the commis-
sioner of mental health. Recovery of such excess income shall be for the
following fiscal periods: for programs in counties located outside of
the city of New York, the applicable fiscal periods shall be January 1,
2003 through December 31, 2009 and January 1, 2011 through December 31,
[2019] 2022; and for programs located within the city of New York, the
applicable fiscal periods shall be July 1, 2003 through June 30, 2010
and July 1, 2011 through June 30, [2019] 2022.
§ 2. This act shall take effect immediately.
PART X
Section 1. Subdivision 9 of section 730.10 of the criminal procedure
law, as added by section 1 of part Q of chapter 56 of the laws of 2012,
is amended to read as follows:
9. "Appropriate institution" means: (a) a hospital operated by the
office of mental health or a developmental center operated by the office
for people with developmental disabilities; [or] (b) a hospital licensed
by the department of health which operates a psychiatric unit licensed
by the office of mental health, as determined by the commissioner
provided, however, that any such hospital that is not operated by the
state shall qualify as an "appropriate institution" only pursuant to the
terms of an agreement between the commissioner and the hospital; OR (C)
A MENTAL HEALTH UNIT OPERATING WITHIN A LOCAL CORRECTIONAL FACILITY
EXCEPT THOSE LOCATED WITHIN A CITY WITH A POPULATION OF ONE MILLION OR
MORE; PROVIDED HOWEVER, THAT ANY SUCH MENTAL HEALTH UNIT OPERATING WITH-
IN A LOCAL CORRECTIONAL FACILITY SHALL QUALIFY AS AN "APPROPRIATE INSTI-
TUTION" ONLY PURSUANT TO THE TERMS OF AN AGREEMENT BETWEEN THE COMMIS-
SIONER OF MENTAL HEALTH, DIRECTOR OF COMMUNITY SERVICES AND THE SHERIFF
FOR THE RESPECTIVE LOCALITY. Nothing in this article shall be construed
as requiring a hospital OR LOCAL CORRECTIONAL FACILITY to consent to
providing care and treatment to an incapacitated person at such hospital
OR LOCAL CORRECTIONAL FACILITY. THE COMMISSIONER OF MENTAL HEALTH SHALL
PROMULGATE REGULATIONS FOR DEMONSTRATION PROGRAMS AT NO MORE THAN TWO
COUNTIES TO IMPLEMENT RESTORATION TO COMPETENCY WITHIN A LOCAL CORREC-
TIONAL FACILITY. SUBJECT TO ANNUAL APPROPRIATION, THE COMMISSIONER OF
MENTAL HEALTH MAY, AT SUCH COMMISSIONER'S DISCRETION, MAKE FUNDS AVAIL-
ABLE FOR STATE AID GRANTS TO ANY COUNTY THAT DEVELOPS AND OPERATES A
MENTAL HEALTH UNIT WITHIN A LOCAL CORRECTIONAL FACILITY PURSUANT TO THIS
SECTION. NOTHING IN THIS ARTICLE SHALL BE CONSTRUED AS REQUIRING A
HOSPITAL OR LOCAL CORRECTIONAL FACILITY TO CONSENT TO PROVIDING CARE AND
TREATMENT TO AN INCAPACITATED PERSON AT SUCH HOSPITAL OR LOCAL CORREC-
TIONAL FACILITY.
§ 2. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019; provided,
however, that this act shall expire and be deemed repealed March 31,
2024; effective immediately, the addition, amendment and/or repeal of
any rule or regulation necessary for the implementation of this act on
its effective date are authorized to be made and completed on or before
such effective date.
PART Y
S. 1507 115 A. 2007
Section 1. Subdivisions 3-b and 3-c of section 1 of part C of chapter
57 of the laws of 2006, relating to establishing a cost of living
adjustment for designated human services programs, as amended by section
1 of part AA of chapter 57 of the laws of 2018, are amended to read as
follows:
3-b. Notwithstanding any inconsistent provision of law, beginning
April 1, 2009 and ending March 31, 2016 and beginning April 1, 2017 and
ending March 31, [2019] 2020, the commissioners shall not include a COLA
for the purpose of establishing rates of payments, contracts or any
other form of reimbursement[, provided that the commissioners of the
office for people with developmental disabilities, the office of mental
health, and the office of alcoholism and substance abuse services shall
not include a COLA beginning April 1, 2017 and ending March 31, 2019].
3-c. Notwithstanding any inconsistent provision of law, beginning
April 1, [2019] 2020 and ending March 31, [2022] 2023, the commissioners
shall develop the COLA under this section using the actual U.S. consumer
price index for all urban consumers (CPI-U) published by the United
States department of labor, bureau of labor statistics for the twelve
month period ending in July of the budget year prior to such state
fiscal year, for the purpose of establishing rates of payments,
contracts or any other form of reimbursement.
§ 2. This act shall take effect immediately and shall be deemed to
have been in full force and effect on and after April 1, 2019; provided,
however, that the amendments to section 1 of part C of chapter 57 of the
laws of 2006 made by section one of this act shall not affect the repeal
of such section and shall be deemed repealed therewith.
PART Z
Section 1. Subdivision 1 of section 2801 of the public health law, as
amended by section 1 of subpart B of part S of chapter 57 of the laws of
2018, is amended to read as follows:
1. "Hospital" means a facility or institution engaged principally in
providing services by or under the supervision of a physician or, in the
case of a dental clinic or dental dispensary, of a dentist, or, in the
case of a midwifery birth center, of a midwife, for the prevention,
diagnosis or treatment of human disease, pain, injury, deformity or
physical condition, including, but not limited to, a general hospital,
public health center, diagnostic center, treatment center, dental clin-
ic, dental dispensary, rehabilitation center other than a facility used
solely for vocational rehabilitation, nursing home, tuberculosis hospi-
tal, chronic disease hospital, maternity hospital, midwifery birth
center, lying-in-asylum, out-patient department, out-patient lodge,
dispensary and a laboratory or central service facility serving one or
more such institutions, but the term hospital shall not include an
institution, sanitarium or other facility engaged principally in provid-
ing services for the prevention, diagnosis or treatment of mental disa-
bility and which is subject to the powers of visitation, examination,
inspection and investigation of the department of mental hygiene except
for those distinct parts of such a facility which provide hospital
service. The provisions of this article shall not apply to a facility or
institution engaged principally in providing services by or under the
supervision of the bona fide members and adherents of a recognized reli-
gious organization whose teachings include reliance on spiritual means
through prayer alone for healing in the practice of the religion of such
organization and where services are provided in accordance with those
S. 1507 116 A. 2007
teachings. No provision of this article or any other provision of law
shall be construed to: (a) limit the volume of mental health [or],
substance use disorder services OR DEVELOPMENTAL DISABILITY SERVICES
that can be provided by a provider of primary care services licensed
under this article and authorized to provide integrated services in
accordance with regulations issued by the commissioner in consultation
with the commissioner of the office of mental health [and], the commis-
sioner of the office of alcoholism and substance abuse services AND THE
COMMISSIONER OF THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES,
including regulations issued pursuant to subdivision seven of section
three hundred sixty-five-l of the social services law or part L of chap-
ter fifty-six of the laws of two thousand twelve; (b) require a provider
licensed pursuant to article thirty-one of the mental hygiene law or
certified pursuant to ARTICLE SIXTEEN OR article thirty-two of the
mental hygiene law to obtain an operating certificate from the depart-
ment if such provider has been authorized to provide integrated services
in accordance with regulations issued by the commissioner in consulta-
tion with the commissioner of the office of mental health [and], the
commissioner of the office of alcoholism and substance abuse services
AND THE COMMISSIONER OF THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISA-
BILITIES, including regulations issued pursuant to subdivision seven of
section three hundred sixty-five-l of the social services law or part L
of chapter fifty-six of the laws of two thousand twelve.
§ 2. Subdivision (f) of section 31.02 of the mental hygiene law, as
added by section 2 of subpart B of part S of chapter 57 of the laws of
2018, is amended to read as follows:
(f) No provision of this article or any other provision of law shall
be construed to require a provider licensed pursuant to article twenty-
eight of the public health law or certified pursuant to ARTICLE SIXTEEN
OR article thirty-two of this chapter to obtain an operating certificate
from the office of mental health if such provider has been authorized to
provide integrated services in accordance with regulations issued by the
commissioner of the office of mental health in consultation with the
commissioner of the department of health [and], the commissioner of the
office of alcoholism and substance abuse services AND THE COMMISSIONER
OF THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, including
regulations issued pursuant to subdivision seven of section three
hundred sixty-five-l of the social services law or part L of chapter
fifty-six of the laws of two thousand twelve.
§ 3. Subdivision (b) of section 32.05 of the mental hygiene law, as
amended by section 3 of subpart B of part S of chapter 57 of the laws of
2018, is amended to read as follow:
(b) (i) Methadone, or such other controlled substance designated by
the commissioner of health as appropriate for such use, may be adminis-
tered to an addict, as defined in section thirty-three hundred two of
the public health law, by individual physicians, groups of physicians
and public or private medical facilities certified pursuant to article
twenty-eight or thirty-three of the public health law as part of a chem-
ical dependence program which has been issued an operating certificate
by the commissioner pursuant to subdivision (b) of section 32.09 of this
article, provided, however, that such administration must be done in
accordance with all applicable federal and state laws and regulations.
Individual physicians or groups of physicians who have obtained authori-
zation from the federal government to administer buprenorphine to
addicts may do so without obtaining an operating certificate from the
commissioner. (ii) No provision of this article or any other provision
S. 1507 117 A. 2007
of law shall be construed to require a provider licensed pursuant to
article twenty-eight of the public health law or article thirty-one of
this chapter to obtain an operating certificate from the office of alco-
holism and substance abuse services if such provider has been authorized
to provide integrated services in accordance with regulations issued by
the commissioner of alcoholism and substance abuse services in consulta-
tion with the commissioner of the department of health [and], the
commissioner of the office of mental health AND THE COMMISSIONER OF THE
OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, including regulations
issued pursuant to subdivision seven of section three hundred sixty-
five-l of the social services law or part L of chapter fifty-six of the
laws of two thousand twelve.
§ 4. Section 16.03 of the mental hygiene law is amended by adding a
new subdivision (g) to read as follows:
(G) NO PROVISION OF THIS ARTICLE OR ANY OTHER PROVISION OF LAW SHALL
BE CONSTRUED TO REQUIRE A PROVIDER LICENSED PURSUANT TO ARTICLE TWENTY-
EIGHT OF THE PUBLIC HEALTH LAW OR CERTIFIED PURSUANT TO ARTICLE THIRTY-
ONE OR THIRTY-TWO OF THIS CHAPTER TO OBTAIN AN OPERATING CERTIFICATE
FROM THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES IF SUCH
PROVIDER HAS BEEN AUTHORIZED TO PROVIDE INTEGRATED SERVICES IN ACCORD-
ANCE WITH REGULATIONS ISSUED BY THE COMMISSIONER OF THE OFFICE FOR
PEOPLE WITH DEVELOPMENTAL DISABILITIES, IN CONSULTATION WITH THE COMMIS-
SIONER OF THE DEPARTMENT OF HEALTH, THE COMMISSIONER AND THE COMMISSION-
ER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, INCLUDING
REGULATIONS ISSUED PURSUANT TO SUBDIVISION SEVEN OF SECTION THREE
HUNDRED SIXTY-FIVE-L OF THE SOCIAL SERVICES LAW OR PART L OF CHAPTER
FIFTY-SIX OF THE LAWS OF TWO THOUSAND TWELVE.
§ 5. This act shall take effect October 1, 2019; provided, however,
that the commissioner of the department of health, the commissioner of
the office of mental health, the commissioner of the office of alcohol-
ism and substance abuse services, and the commissioner of the office for
people with developmental disabilities are authorized to issue any rule
or regulation necessary for the implementation of this act on or before
its effective date.
PART AA
Section 1. Paragraph (a) of subdivision 4 of section 488 of the social
services law, as amended by section 2 of part MM of chapter 58 of the
laws of 2015, is amended to read as follows:
(a) a facility or program in which services are provided and which is
operated, licensed or certified by the office of mental health, the
office for people with developmental disabilities or the office of alco-
holism and substance abuse services, including but not limited to
psychiatric centers, [inpatient psychiatric units of a general hospi-
tal,] developmental centers, intermediate care facilities, community
residences, group homes and family care homes, provided, however, that
such term shall not include a secure treatment facility as defined in
section 10.03 of the mental hygiene law, services defined in subpara-
graph four of subdivision (a) of section 16.03 of the mental hygiene
law, [or] services provided in programs or facilities that are operated
by the office of mental health and located in state correctional facili-
ties under the jurisdiction of the department of corrections and commu-
nity supervision OR SERVICES PROVIDED IN A UNIT OF A HOSPITAL, AS
DEFINED IN SUBDIVISION ONE OF SECTION TWENTY-EIGHT HUNDRED ONE OF THE
S. 1507 118 A. 2007
PUBLIC HEALTH LAW THAT IS LICENSED OR CERTIFIED BY THE OFFICE OF MENTAL
HEALTH OR THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES;
§ 2. Paragraphs (c), (d) and (e) of subdivision 4 of section 488 of
the social services law, as added by section 1 of part B of chapter 501
of the laws of 2012, paragraph (d) as amended by chapter 126 of the laws
of 2014, and paragraph (e) as amended by chapter 83 of the laws of 2013,
are amended to read as follows:
(c) adult care facilities, which shall mean adult homes or enriched
housing programs licensed pursuant to article seven of this chapter: (i)
(A) that have a licensed capacity of eighty or more beds; and (B) in
which at least twenty-five percent of the residents are persons with
serious mental illness as defined by subdivision fifty-two of section
1.03 of the mental hygiene law; (ii) but not including an adult home or
enriched housing program which is authorized to operate fifty-five
percent or more of its total licensed capacity of beds as assisted
living program beds pursuant to section four hundred sixty-one-l of this
chapter; OR
(d) [any overnight, summer day and traveling summer day camps for
children with developmental disabilities as defined in regulations
promulgated by the commissioner of health; or
(e)] the New York state school for the blind and the New York state
school for the deaf, which operate pursuant to articles eighty-seven and
eighty-eight of the education law; an institution for the instruction of
the deaf and the blind which has a residential component and is subject
to the visitation of the commissioner of education pursuant to article
eighty-five of the education law with respect to its day and residential
components; special act school districts serving students with disabili-
ties; or in-state private schools which have been approved by the
commissioner of education for special education services or programs,
and which have a residential program.
§ 3. This act shall take effect August 1, 2019 and shall apply to
reports of abuse or neglect made on or after such date; provided that,
any reports of abuse or neglect reported to the justice center prior to
the effective date of this act shall be completed by the justice center.
PART BB
Section 1. This part enacts into law major components of legislation
which are necessary to effectuate provisions relating to mental health
and substance use disorder treatment. Each component is wholly
contained within a Subpart identified as Subparts A through E. The
effective date for each particular provision contained within such
Subpart is set forth in the last section of such Subpart. Any provision
in any section contained within a Subpart, including the effective date
of the Subpart, which makes a reference to a section "of this act", when
used in connection with that particular component, shall be deemed to
mean and refer to the corresponding section of the Subpart in which it
is found. Section three of this Part sets forth the general effective
date of this Part.
SUBPART A
Section 1. Paragraph 4 of subsection (i) of section 3216 of the insur-
ance law is amended to read as follows:
(4) If a policy provides for reimbursement for psychiatric or psycho-
logical services or for diagnosis and treatment of mental[,nervous, or
S. 1507 119 A. 2007
emotional disorders or ailments,] HEALTH CONDITIONS however defined in
the policy, the insured shall be entitled to reimbursement for such
services, diagnosis or treatment whether performed by a physician,
psychiatrist [or], a certified and registered psychologist, OR A NURSE
PRACTITIONER when the services rendered are within the lawful scope of
their practice.
§ 2. Subparagraph (B) of paragraph 25 of subsection (i) of section
3216 of the insurance law, as amended by section 38 of part D of chapter
56 of the laws of 2013, is amended to read as follows:
(B) Every policy that provides physician services, medical, major
medical or similar comprehensive-type coverage shall provide coverage
for the screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening, diagnosis or treatment of medical conditions otherwise
covered by the policy because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the super-
intendent and shall be consistent with those imposed on other benefits
under the policy. [Coverage for applied behavior analysis shall be
subject to a maximum benefit of six hundred eighty hours of treatment
per policy or calendar year per covered individual.] This paragraph
shall not be construed as limiting the benefits that are otherwise
available to an individual under the policy, provided however that such
policy shall not contain any limitations on visits that are solely
applied to the treatment of autism spectrum disorder. No insurer shall
terminate coverage or refuse to deliver, execute, issue, amend, adjust,
or renew coverage to an individual solely because the individual is
diagnosed with autism spectrum disorder or has received treatment for
autism spectrum disorder. Coverage shall be subject to utilization
review and external appeals of health care services pursuant to article
forty-nine of this chapter as well as[,] case management[,] and other
managed care provisions.
§ 3. Items (i) and (iii) of subparagraph (C) of paragraph 25 of
subsection (i) of section 3216 of the insurance law, as amended by chap-
ter 596 of the laws of 2011, are amended to read as follows:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders[, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS)].
(iii) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided [or supervised] by a [behavior analyst certified
pursuant to the behavior analyst certification board] PERSON LICENSED,
CERTIFIED OR OTHERWISE AUTHORIZED TO PROVIDE APPLIED BEHAVIOR ANALYSIS,
that are necessary to develop, maintain, or restore, to the maximum
extent practicable, the functioning of an individual. [Individuals that
provide behavioral health treatment under the supervision of a certified
behavior analyst pursuant to this paragraph shall be subject to stand-
ards of professionalism, supervision and relevant experience pursuant to
regulations promulgated by the superintendent in consultation with the
commissioners of health and education.]
§ 4. Paragraph 25 of subsection (i) of section 3216 of the insurance
law is amended by adding four new subparagraphs (H), (I), (J), and (K)
to read as follows:
S. 1507 120 A. 2007
(H) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO AUTISM SPECTRUM DISORDER BENEFITS THAT
ARE MORE RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND
TREATMENT LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL
BENEFITS COVERED BY THE POLICY.
(I) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO AUTISM SPECTRUM DISORDER BENEFITS SHALL BE MADE AVAIL-
ABLE BY THE INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NETWORK
PROVIDER UPON REQUEST.
(J) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT; AND
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETER-
MINING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP
THERAPY PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF
TREATMENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY.
(K) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
§ 5. Paragraph 30 of subsection (i) of section 3216 of the insurance
law, as amended by section 1 of part B of chapter 71 of the laws of
2016, is amended to read as follows:
(30)(A) Every policy that provides hospital, major medical or similar
comprehensive coverage [must] SHALL provide inpatient coverage for the
diagnosis and treatment of substance use disorder, including detoxifica-
tion and rehabilitation services. Such inpatient coverage shall include
unlimited medically necessary treatment for substance use disorder
treatment services provided in residential settings [as required by the
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a)]. Further, such inpatient coverage shall not apply financial
requirements or treatment limitations, including utilization review
requirements, to inpatient substance use disorder benefits that are more
restrictive than the predominant financial requirements and treatment
limitations applied to substantially all medical and surgical benefits
covered by the policy. [Further, such coverage shall be provided
consistent with the federal Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
(B) Coverage provided under this paragraph may be limited to facili-
ties in New York state [which are certified] THAT ARE LICENSED, CERTI-
FIED OR OTHERWISE AUTHORIZED by the office of alcoholism and substance
abuse services and, in other states, to those which are accredited by
the joint commission as alcoholism, substance abuse, or chemical depend-
ence treatment programs AND ARE SIMILARLY LICENSED, CERTIFIED OR OTHER-
WISE AUTHORIZED IN THE STATE IN WHICH THE FACILITY IS LOCATED.
S. 1507 121 A. 2007
(C) Coverage provided under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other benefits within a
given policy.
(D) This subparagraph shall apply to facilities in this state THAT ARE
LICENSED, certified OR OTHERWISE AUTHORIZED by the office of alcoholism
and substance abuse services that are participating in the insurer's
provider network. Coverage provided under this paragraph shall not be
subject to preauthorization. Coverage provided under this paragraph
shall also not be subject to concurrent utilization review during the
first [fourteen] TWENTY-ONE days of the inpatient admission provided
that the facility notifies the insurer of both the admission and the
initial treatment plan within [forty-eight hours] TWO BUSINESS DAYS of
the admission. The facility shall perform daily clinical review of the
patient, including the periodic consultation with the insurer to ensure
that the facility is using the evidence-based and peer reviewed clinical
review tool utilized by the insurer which is designated by the office of
alcoholism and substance abuse services and appropriate to the age of
the patient, to ensure that the inpatient treatment is medically neces-
sary for the patient. Any utilization review of treatment provided under
this subparagraph may include a review of all services provided during
such inpatient treatment, including all services provided during the
first [fourteen] TWENTY-ONE days of such inpatient treatment. Provided,
however, the insurer shall only deny coverage for any portion of the
initial [fourteen] TWENTY-ONE day inpatient treatment on the basis that
such treatment was not medically necessary if such inpatient treatment
was contrary to the evidence-based and peer reviewed clinical review
tool utilized by the insurer which is designated by the office of alco-
holism and substance abuse services. An insured shall not have any
financial obligation to the facility for any treatment under this
subparagraph other than any copayment, coinsurance, or deductible other-
wise required under the policy.
(E) AN INSURER SHALL MAKE AVAILABLE TO ANY INSURED, PROSPECTIVE
INSURED, OR IN-NETWORK PROVIDER, UPON REQUEST, THE CRITERIA FOR MEDICAL
NECESSITY DETERMINATIONS UNDER THE POLICY WITH RESPECT TO INPATIENT
SUBSTANCE USE DISORDER BENEFITS.
(F) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
S. 1507 122 A. 2007
(IV) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE, SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
(G) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
§ 6. Paragraph 31 of subsection (i) of section 3216 of the insurance
law, as added by chapter 41 of the laws of 2014 and subparagraph (E) as
added by section 3 of part MM of chapter 57 of the laws of 2018, is
amended to read as follows:
(31) (A) Every policy that provides medical, major medical or similar
comprehensive-type coverage [must] SHALL provide outpatient coverage for
the diagnosis and treatment of substance use disorder, including detoxi-
fication and rehabilitation services. Such coverage shall not apply
financial requirements or treatment limitations to outpatient substance
use disorder benefits that are more restrictive than the predominant
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the policy. [Further,
such coverage shall be provided consistent with the federal Paul Well-
stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 (29 U.S.C. § 1185a).]
(B) Coverage under this paragraph may be limited to facilities in New
York state [certified] THAT ARE LICENSED, CERTIFIED OR OTHERWISE AUTHOR-
IZED by the office of alcoholism and substance abuse services [or
licensed by such office as outpatient clinics or medically supervised
ambulatory] TO PROVIDE OUTPATIENT substance [abuse programs] USE DISOR-
DER SERVICES and, in other states, to those which are accredited by the
joint commission as alcoholism or chemical dependence substance abuse
treatment programs AND ARE SIMILARLY LICENSED, CERTIFIED, OR OTHERWISE
AUTHORIZED IN THE STATE IN WHICH THE FACILITY IS LOCATED.
(C) Coverage provided under this paragraph may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other benefits within a
given policy.
(D) A policy providing coverage for substance use disorder services
pursuant to this paragraph shall provide up to twenty outpatient visits
per policy or calendar year to an individual who identifies him or
herself as a family member of a person suffering from substance use
disorder and who seeks treatment as a family member who is otherwise
covered by the applicable policy pursuant to this paragraph. The cover-
age required by this paragraph shall include treatment as a family
member pursuant to such family member's own policy provided such family
member:
(i) does not exceed the allowable number of family visits provided by
the applicable policy pursuant to this paragraph; and
(ii) is otherwise entitled to coverage pursuant to this paragraph and
such family member's applicable policy.
(E) This subparagraph shall apply to facilities in this state THAT ARE
LICENSED, certified OR OTHERWISE AUTHORIZED by the office of alcoholism
and substance abuse services for the provision of outpatient, intensive
outpatient, outpatient rehabilitation and opioid treatment that are
participating in the insurer's provider network. Coverage provided under
this paragraph shall not be subject to preauthorization. Coverage
provided under this paragraph shall not be subject to concurrent review
S. 1507 123 A. 2007
for the first [two] THREE weeks of continuous treatment, not to exceed
[fourteen] TWENTY-ONE visits, provided the facility notifies the insurer
of both the start of treatment and the initial treatment plan within
[forty-eight hours] TWO BUSINESS DAYS. The facility shall perform clin-
ical assessment of the patient at each visit, including the periodic
consultation with the insurer to ensure that the facility is using the
evidence-based and peer reviewed clinical review tool utilized by the
insurer which is designated by the office of alcoholism and substance
abuse services and appropriate to the age of the patient, to ensure that
the outpatient treatment is medically necessary for the patient. Any
utilization review of the treatment provided under this subparagraph may
include a review of all services provided during such outpatient treat-
ment, including all services provided during the first [two] THREE weeks
of continuous treatment, not to exceed [fourteen] TWENTY-ONE visits, of
such outpatient treatment. Provided, however, the insurer shall only
deny coverage for any portion of the initial [two] THREE weeks of
continuous treatment, not to exceed [fourteen] TWENTY-ONE visits, for
outpatient treatment on the basis that such treatment was not medically
necessary if such outpatient treatment was contrary to the evidence-
based and peer reviewed clinical review tool utilized by the insurer
which is designated by the office of alcoholism and substance abuse
services. An insured shall not have any financial obligation to the
facility for any treatment under this subparagraph other than any copay-
ment, coinsurance, or deductible otherwise required under the policy.
(F) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO OUTPATIENT SUBSTANCE USE DISORDER BENEFITS SHALL BE MADE
AVAILABLE BY THE INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NET-
WORK PROVIDER UPON REQUEST.
(G) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
(IV) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
(H) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
S. 1507 124 A. 2007
§ 7. Paragraph 31-a of subsection (i) of section 3216 of the insurance
law, as added by section 1 of part B of chapter 69 of the laws of 2016,
is amended to read as follows:
(31-a) [(A)] Every policy that provides medical, major medical or
similar comprehensive-type coverage and provides coverage for
prescription drugs for medication for the treatment of a substance use
disorder shall include immediate access, without prior authorization, to
[a five day emergency supply] THE FORMULARY FORMS of prescribed medica-
tions covered under the policy for the treatment of substance use disor-
der [where an emergency condition exists], including a prescribed drug
or medication associated with the management of opioid withdrawal and/or
stabilization, except where otherwise prohibited by law. Further, cover-
age [of an emergency supply] WITHOUT PRIOR AUTHORIZATION shall include
FORMULARY FORMS OF medication for opioid overdose reversal otherwise
covered under the policy prescribed OR DISPENSED to an individual
covered by the policy.
[(B) For purposes of this paragraph, an "emergency condition" means a
substance use disorder condition that manifests itself by acute symptoms
of sufficient severity, including severe pain or the expectation of
severe pain, such that a prudent layperson, possessing an average know-
ledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in:
(i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition, placing the
health of such person or others in serious jeopardy;
(ii) serious impairment to such person's bodily functions;
(iii) serious dysfunction of any bodily organ or part of such person;
(iv) serious disfigurement of such person; or
(v) a condition described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
(C) Coverage provided under this paragraph may be subject to copay-
ments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the policy; provided, however, no
policy shall impose an additional copayment or coinsurance on an insured
who received an emergency supply of medication and then received up to a
thirty day supply of the same medication in the same thirty day period
in which the emergency supply of medication was dispensed. This subpara-
graph shall not preclude the imposition of a copayment or coinsurance on
the initial emergency supply of medication in an amount that is less
than the copayment or coinsurance otherwise applicable to a thirty day
supply of such medication, provided that the total sum of the copayments
or coinsurance for an entire thirty day supply of the medication does
not exceed the copayment or coinsurance otherwise applicable to a thirty
day supply of such medication.]
§ 8. Subsection (i) of section 3216 of the insurance law is amended by
adding a new paragraph 35 to read as follows:
(35) (A) EVERY POLICY DELIVERED OR ISSUED FOR DELIVERY IN THIS STATE
THAT PROVIDES COVERAGE FOR INPATIENT HOSPITAL CARE OR COVERAGE FOR
PHYSICIAN SERVICES SHALL PROVIDE COVERAGE FOR THE DIAGNOSIS AND TREAT-
MENT OF MENTAL HEALTH CONDITIONS AS FOLLOWS:
(I) WHERE THE POLICY PROVIDES COVERAGE FOR INPATIENT HOSPITAL CARE,
BENEFITS FOR INPATIENT CARE IN A HOSPITAL AS DEFINED BY SUBDIVISION TEN
OF SECTION 1.03 OF THE MENTAL HYGIENE LAW AND BENEFITS FOR OUTPATIENT
CARE PROVIDED IN A FACILITY ISSUED AN OPERATING CERTIFICATE BY THE
COMMISSIONER OF MENTAL HEALTH PURSUANT TO THE PROVISIONS OF ARTICLE
THIRTY-ONE OF THE MENTAL HYGIENE LAW, OR IN A FACILITY OPERATED BY THE
S. 1507 125 A. 2007
OFFICE OF MENTAL HEALTH, OR, FOR CARE PROVIDED IN OTHER STATES, TO SIMI-
LARLY LICENSED OR CERTIFIED HOSPITALS OR FACILITIES; AND
(II) WHERE THE POLICY PROVIDES COVERAGE FOR PHYSICIAN SERVICES, BENE-
FITS FOR OUTPATIENT CARE PROVIDED BY A PSYCHIATRIST OR PSYCHOLOGIST
LICENSED TO PRACTICE IN THIS STATE, A LICENSED CLINICAL SOCIAL WORKER
WHO MEETS THE REQUIREMENTS OF SUBPARAGRAPH (D) OF PARAGRAPH FOUR OF
SUBSECTION (1) OF SECTION THREE THOUSAND TWO HUNDRED TWENTY-ONE OF THIS
ARTICLE, A NURSE PRACTITIONER LICENSED TO PRACTICE IN THIS STATE, OR A
PROFESSIONAL CORPORATION OR UNIVERSITY FACULTY PRACTICE CORPORATION
THEREOF.
(B) COVERAGE REQUIRED BY THIS PARAGRAPH MAY BE SUBJECT TO ANNUAL
DEDUCTIBLES, COPAYMENTS AND COINSURANCE AS MAY BE DEEMED APPROPRIATE BY
THE SUPERINTENDENT AND SHALL BE CONSISTENT WITH THOSE IMPOSED ON OTHER
BENEFITS UNDER THE POLICY.
(C) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO MENTAL HEALTH BENEFITS THAT ARE MORE
RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND TREATMENT
LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL BENEFITS
COVERED BY THE POLICY.
(D) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO MENTAL HEALTH BENEFITS SHALL BE MADE AVAILABLE BY THE
INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NETWORK PROVIDER UPON
REQUEST.
(E) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
(IV) "MENTAL HEALTH CONDITION" MEANS ANY MENTAL HEALTH DISORDER AS
DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENER-
ALLY RECOGNIZED INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS
THE INTERNATIONAL CLASSIFICATION OF DISEASES.
(F) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
(G) THIS SUBPARAGRAPH SHALL APPLY TO HOSPITALS IN THIS STATE THAT ARE
LICENSED BY THE OFFICE OF MENTAL HEALTH THAT ARE PARTICIPATING IN THE
INSURER'S PROVIDER NETWORK. WHERE THE POLICY PROVIDES COVERAGE FOR INPA-
TIENT HOSPITAL CARE, BENEFITS FOR INPATIENT HOSPITAL CARE IN A HOSPITAL
AS DEFINED BY SUBDIVISION TEN OF SECTION 1.03 OF THE MENTAL HYGIENE LAW
PROVIDED TO INDIVIDUALS WHO HAVE NOT ATTAINED THE AGE OF EIGHTEEN SHALL
S. 1507 126 A. 2007
NOT BE SUBJECT TO PREAUTHORIZATION. COVERAGE PROVIDED UNDER THIS PARA-
GRAPH SHALL ALSO NOT BE SUBJECT TO CONCURRENT UTILIZATION REVIEW DURING
THE FIRST FOURTEEN DAYS OF THE INPATIENT ADMISSION, PROVIDED THE FACILI-
TY NOTIFIES THE INSURER OF BOTH THE ADMISSION AND THE INITIAL TREATMENT
PLAN WITHIN TWO BUSINESS DAYS OF THE ADMISSION, PERFORMS DAILY CLINICAL
REVIEW OF THE PATIENT, AND PARTICIPATES IN PERIODIC CONSULTATION WITH
THE INSURER TO ENSURE THAT THE FACILITY IS USING THE EVIDENCE-BASED AND
PEER REVIEWED CLINICAL REVIEW CRITERIA UTILIZED BY THE INSURER WHICH IS
APPROVED BY THE OFFICE OF MENTAL HEALTH AND APPROPRIATE TO THE AGE OF
THE PATIENT, TO ENSURE THAT THE INPATIENT CARE IS MEDICALLY NECESSARY
FOR THE PATIENT. ALL TREATMENT PROVIDED UNDER THIS SUBPARAGRAPH MAY BE
REVIEWED RETROSPECTIVELY. WHERE CARE IS DENIED RETROSPECTIVELY, AN
INSURED SHALL NOT HAVE ANY FINANCIAL OBLIGATION TO THE FACILITY FOR ANY
TREATMENT UNDER THIS SUBPARAGRAPH OTHER THAN ANY COPAYMENT, COINSURANCE,
OR DEDUCTIBLE OTHERWISE REQUIRED UNDER THE POLICY.
§ 9. Paragraphs 17, 19 and 20 of subsection 2 of section 3217-a of the
insurance law, paragraph 17 as amended and paragraphs 19 and 20 as added
by section 1 of part H of chapter 60 of the laws of 2014, are amended
and a new paragraph 21 is added to read as follows:
(17) where applicable, a listing by specialty, which may be in a sepa-
rate document that is updated annually, of the name, address, and tele-
phone number of all participating providers, including facilities, AND:
(A) WHETHER THE PROVIDER IS ACCEPTING NEW PATIENTS; (B) IN THE CASE OF
MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES PROVIDERS, ANY AFFIL-
IATIONS WITH PARTICIPATING FACILITIES CERTIFIED OR AUTHORIZED BY THE
OFFICE OF MENTAL HEALTH OR THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
SERVICES, AND ANY RESTRICTIONS REGARDING THE AVAILABILITY OF THE INDI-
VIDUAL PROVIDER'S SERVICES; and [in addition,] (C) in the case of physi-
cians, board certification, languages spoken and any affiliations with
participating hospitals. The listing shall also be posted on the insur-
er's website and the insurer shall update the website within fifteen
days of the addition or termination of a provider from the insurer's
network or a change in a physician's hospital affiliation;
(19) with respect to out-of-network coverage:
(A) a clear description of the methodology used by the insurer to
determine reimbursement for out-of-network health care services;
(B) the amount that the insurer will reimburse under the methodology
for out-of-network health care services set forth as a percentage of the
usual and customary cost for out-of-network health care services; and
(C) examples of anticipated out-of-pocket costs for frequently billed
out-of-network health care services; [and]
(20) information in writing and through an internet website that
reasonably permits an insured or prospective insured to estimate the
anticipated out-of-pocket cost for out-of-network health care services
in a geographical area or zip code based upon the difference between
what the insurer will reimburse for out-of-network health care services
and the usual and customary cost for out-of-network health care
services[.]; AND
(21) THE MOST RECENT COMPARATIVE ANALYSIS PERFORMED BY THE INSURER TO
ASSESS THE PROVISION OF ITS COVERED SERVICES IN ACCORDANCE WITH THE PAUL
WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY
ACT OF 2008, 42 U.S.C. 18031(J), AND ANY AMENDMENTS TO, AND FEDERAL
GUIDANCE OR REGULATIONS ISSUED UNDER THOSE ACTS.
§ 10. Subsection (b) of section 3217-b of the insurance law, as added
by chapter 705 of the laws of 1996, is amended to read as follows:
S. 1507 127 A. 2007
(b) No insurer subject to this article shall by contract, written
policy [or], written procedure OR PRACTICE prohibit or restrict any
health care provider from filing a complaint, making a report or
commenting to an appropriate governmental body regarding the policies or
practices of such insurer which the provider believes may negatively
impact upon the quality of, or access to, patient care. NOR SHALL AN
INSURER SUBJECT TO THIS ARTICLE TAKE ANY ADVERSE ACTION, INCLUDING BUT
NOT LIMITED TO REFUSING TO RENEW OR EXECUTE A CONTRACT OR AGREEMENT WITH
A HEALTH CARE PROVIDER AS RETALIATION AGAINST A HEALTH CARE PROVIDER FOR
FILING A COMPLAINT, MAKING A REPORT OR COMMENTING TO AN APPROPRIATE
GOVERNMENTAL BODY REGARDING POLICIES OR PRACTICES OF SUCH INSURER WHICH
MAY VIOLATE THIS CHAPTER INCLUDING PARAGRAPHS THIRTY, AS ADDED BY CHAP-
TER FORTY-ONE OF THE LAWS OF 2014, THIRTY-ONE, THIRTY-ONE-A AND THIRTY-
FIVE OF SUBSECTION (I) OF SECTION THIRTY-TWO HUNDRED SIXTEEN AND PARA-
GRAPHS FIVE, SIX, SEVEN, SEVEN-A AND SEVEN-B OF SUBSECTION (L) OF
SECTION THIRTY-TWO HUNDRED TWENTY-ONE OF THIS ARTICLE.
§ 11. Subparagraph (A) of paragraph 4 of subsection (l) of section
3221 of the insurance law, as amended by chapter 230 of the laws of
2004, is amended to read as follows:
(A) Every insurer delivering a group policy or issuing a group policy
for delivery, in this state, [which] THAT provides reimbursement for
psychiatric or psychological services or for the diagnosis and treatment
of mental[, nervous or emotional disorders and ailments] HEALTH CONDI-
TIONS, however defined in such policy, by physicians, psychiatrists or
psychologists, [must] SHALL make available and if requested by the poli-
cyholder provide the same coverage to insureds for such services when
performed by a licensed clinical social worker, within the lawful scope
of his or her practice, who is licensed pursuant to article one hundred
fifty-four of the education law. Written notice of the availability of
such coverage shall be delivered to the policyholder prior to inception
of such group policy and annually thereafter, except that this notice
shall not be required where a policy covers two hundred or more employ-
ees or where the benefit structure was the subject of collective
bargaining affecting persons who are employed in more than one state.
§ 12. Subparagraph (D) of paragraph 4 of subsection (l) of section
3221 of the insurance law, as amended by section 50 of part D of chapter
56 of the laws of 2013, is amended to read as follows:
(D) In addition to the requirements of subparagraph (A) of this para-
graph, every insurer issuing a group policy for delivery in this state
where the policy provides reimbursement to insureds for psychiatric or
psychological services or for the diagnosis and treatment of mental[,
nervous or emotional disorders and ailments] HEALTH CONDITIONS, however
defined in such policy, by physicians, psychiatrists or psychologists,
shall provide the same coverage to insureds for such services when
performed by a licensed clinical social worker, within the lawful scope
of his or her practice, who is licensed pursuant to subdivision two of
section seven thousand seven hundred four of the education law and in
addition shall have either: (i) three or more additional years experi-
ence in psychotherapy, which for the purposes of this subparagraph shall
mean the use of verbal methods in interpersonal relationships with the
intent of assisting a person or persons to modify attitudes and behavior
that are intellectually, socially or emotionally maladaptive, under
supervision, satisfactory to the state board for social work, in a
facility, licensed or incorporated by an appropriate governmental
department, providing services for diagnosis or treatment of mental[,
nervous or emotional disorders or ailments] HEALTH CONDITIONS; (ii)
S. 1507 128 A. 2007
three or more additional years experience in psychotherapy under the
supervision, satisfactory to the state board for social work, of a
psychiatrist, a licensed and registered psychologist or a licensed clin-
ical social worker qualified for reimbursement pursuant to subsection
(e) of this section, or (iii) a combination of the experience specified
in items (i) and (ii) of this subparagraph totaling three years, satis-
factory to the state board for social work.
§ 13. Subparagraphs (A) and (B) of paragraph 5 of subsection (l) of
section 3221 of the insurance law, as amended by chapter 502 of the laws
of 2007, are amended to read as follows:
(A) Every insurer delivering a group or school blanket policy or issu-
ing a group or school blanket policy for delivery, in this state, which
provides coverage for inpatient hospital care or coverage for physician
services shall provide [as part of such policy broad-based] coverage for
the diagnosis and treatment of mental[, nervous or emotional disorders
or ailments, however defined in such policy, at least equal to the
coverage provided for other] health conditions and:
(i) where the policy provides coverage for inpatient hospital care,
benefits for inpatient care in a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law[, which benefits may be limit-
ed to not less than thirty days of active treatment in any contract
year, plan year or calendar year,] and benefits for outpatient care
provided in a facility issued an operating certificate by the commis-
sioner of mental health pursuant to the provisions of article thirty-one
of the mental hygiene law, or in a facility operated by the office of
mental health[, which benefits may be limited to not less than twenty
visits in any contract year, plan year or calendar year. Benefits for
partial hospitalization program services shall be provided as an offset
to covered inpatient days at a ratio of two partial hospitalization
visits to one inpatient day of treatment.] OR, FOR CARE PROVIDED IN
OTHER STATES, TO SIMILARLY LICENSED OR CERTIFIED HOSPITALS OR FACILI-
TIES; AND
(ii) where the policy provides coverage for physician services, it
shall include benefits for outpatient care provided by a psychiatrist or
psychologist licensed to practice in this state, a licensed clinical
social worker who meets the requirements of subparagraph (D) of para-
graph four of this subsection, A NURSE PRACTITIONER LICENSED TO PRACTICE
IN THIS STATE, or a professional corporation or university faculty prac-
tice corporation thereof. [Such benefits may be limited to not less than
twenty visits in any contract year, plan year, or calendar year.]
[(iii)] (B) Coverage required by this paragraph may be [provided on a
contract year, plan year or calendar year basis and shall be consistent
with the provision of other benefits under the policy. Such coverage may
be] subject to annual deductibles, co-pays and coinsurance as may be
deemed appropriate by the superintendent and shall be consistent with
those imposed on other benefits under the policy. [In the event that a
policy provides coverage for both inpatient hospital care and physician
services, the aggregate of the benefits for outpatient care obtained
under this paragraph may be limited to not less than twenty visits in
any contract year, plan year or calendar year.
(iv) In this paragraph, "active treatment" means treatment furnished
in conjunction with inpatient confinement for mental, nervous or
emotional disorders or ailments that meet standards prescribed pursuant
to the regulations of the commissioner of mental health.
(B) (i) Every insurer delivering a group or school blanket policy or
issuing a group or school blanket policy for delivery, in this state,
S. 1507 129 A. 2007
which provides coverage for inpatient hospital care or coverage for
physician services, shall provide comparable coverage for adults and
children with biologically based mental illness. Such group policies
issued or delivered in this state shall also provide such comparable
coverage for children with serious emotional disturbances. Such coverage
shall be provided under the terms and conditions otherwise applicable
under the policy, including network limitations or variations, exclu-
sions, co-pays, coinsurance, deductibles or other specific cost sharing
mechanisms. Provided further, where a policy provides both in-network
and out-of-network benefits, the out-of-network benefits may have
different coinsurance, co-pays, or deductibles, than the in-network
benefits, regardless of whether the policy is written under one license
or two licenses.
(ii) For purposes of this paragraph, the term "biologically based
mental illness" means a mental, nervous, or emotional condition that is
caused by a biological disorder of the brain and results in a clinically
significant, psychological syndrome or pattern that substantially limits
the functioning of the person with the illness. Such biologically based
mental illnesses are defined as schizophrenia/psychotic disorders, major
depression, bipolar disorder, delusional disorders, panic disorder,
obsessive compulsive disorders, bulimia, and anorexia.] PROVIDED THAT NO
COPAYMENT OR COINSURANCE IMPOSED FOR OUTPATIENT MENTAL HEALTH SERVICES
PROVIDED IN A FACILITY LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY
THE OFFICE OF MENTAL HEALTH SHALL EXCEED THE COPAYMENTS OR COINSURANCE
IMPOSED FOR A PRIMARY CARE OFFICE VISIT UNDER THE POLICY.
§ 14. Subparagraphs (C), (D) and (E) of paragraph 5 of subsection (l)
of section 3221 of the insurance law are REPEALED and five new subpara-
graphs (C), (D), (E), (F) and (G) are added to read as follows:
(C) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO MENTAL HEALTH BENEFITS THAT ARE MORE
RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND TREATMENT
LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL BENEFITS
COVERED BY THE POLICY.
(D) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO MENTAL HEALTH BENEFITS SHALL BE MADE AVAILABLE BY THE
INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NETWORK PROVIDER UPON
REQUEST.
(E) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
S. 1507 130 A. 2007
(IV) "MENTAL HEALTH CONDITION" MEANS ANY MENTAL HEALTH DISORDER AS
DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENER-
ALLY RECOGNIZED INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS
THE INTERNATIONAL CLASSIFICATION OF DISEASES.
(F) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
(G) THIS SUBPARAGRAPH SHALL APPLY TO HOSPITALS IN THIS STATE THAT ARE
LICENSED BY THE OFFICE OF MENTAL HEALTH THAT ARE PARTICIPATING IN THE
INSURER'S PROVIDER NETWORK. WHERE THE POLICY PROVIDES COVERAGE FOR INPA-
TIENT HOSPITAL CARE, BENEFITS FOR INPATIENT HOSPITAL CARE IN A HOSPITAL
AS DEFINED BY SUBDIVISION TEN OF SECTION 1.03 OF THE MENTAL HYGIENE LAW
PROVIDED TO INDIVIDUALS WHO HAVE NOT ATTAINED THE AGE OF EIGHTEEN SHALL
NOT BE SUBJECT TO PREAUTHORIZATION. COVERAGE PROVIDED UNDER THIS PARA-
GRAPH SHALL ALSO NOT BE SUBJECT TO CONCURRENT UTILIZATION REVIEW DURING
THE FIRST FOURTEEN DAYS OF THE INPATIENT ADMISSION, PROVIDED THE FACILI-
TY NOTIFIES THE INSURER OF BOTH THE ADMISSION AND THE INITIAL TREATMENT
PLAN WITHIN TWO BUSINESS DAYS OF THE ADMISSION, PERFORMS DAILY CLINICAL
REVIEW OF THE PATIENT, AND PARTICIPATES IN PERIODIC CONSULTATION WITH
THE INSURER TO ENSURE THAT THE FACILITY IS USING THE EVIDENCE-BASED AND
PEER REVIEWED CLINICAL REVIEW CRITERIA UTILIZED BY THE INSURER WHICH IS
APPROVED BY THE OFFICE OF MENTAL HEALTH AND APPROPRIATE TO THE AGE OF
THE PATIENT, TO ENSURE THAT THE INPATIENT CARE IS MEDICALLY NECESSARY
FOR THE PATIENT. ALL TREATMENT PROVIDED UNDER THIS SUBPARAGRAPH MAY BE
REVIEWED RETROSPECTIVELY. WHERE CARE IS DENIED RETROSPECTIVELY, AN
INSURED SHALL NOT HAVE ANY FINANCIAL OBLIGATION TO THE FACILITY FOR ANY
TREATMENT UNDER THIS SUBPARAGRAPH OTHER THAN ANY COPAYMENT, COINSURANCE,
OR DEDUCTIBLE OTHERWISE REQUIRED UNDER THE POLICY.
§ 15. Subparagraphs (A), (B) and (D) of paragraph 6 of subsection (l)
of section 3221 of the insurance law, as amended by section 2 of part B
of chapter 71 of the laws of 2016, are amended and three new subpara-
graphs (E), (F) and (G) are added to read as follows:
(A) Every policy that provides hospital, major medical or similar
comprehensive coverage [must] SHALL provide inpatient coverage for the
diagnosis and treatment of substance use disorder, including detoxifica-
tion and rehabilitation services. Such inpatient coverage shall include
unlimited medically necessary treatment for substance use disorder
treatment services provided in residential settings [as required by the
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a)]. Further, such inpatient coverage shall not apply financial
requirements or treatment limitations, including utilization review
requirements, to inpatient substance use disorder benefits that are more
restrictive than the predominant financial requirements and treatment
limitations applied to substantially all medical and surgical benefits
covered by the policy. [Further, such coverage shall be provided
consistent with the federal Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
(B) Coverage provided under this paragraph may be limited to facili-
ties in New York state [which are certified] THAT ARE LICENSED, certi-
fied OR OTHERWISE AUTHORIZED by the office of alcoholism and substance
abuse services and, in other states, to those which are accredited by
the joint commission as alcoholism, substance abuse or chemical depend-
ence treatment programs AND ARE SIMILARLY LICENSED, CERTIFIED, OR OTHER-
WISE AUTHORIZED IN THE STATE IN WHICH THE FACILITY IS LOCATED.
S. 1507 131 A. 2007
(D) This subparagraph shall apply to facilities in this state THAT ARE
LICENSED, certified OR OTHERWISE AUTHORIZED by the office of alcoholism
and substance abuse services that are participating in the insurer's
provider network. Coverage provided under this paragraph shall not be
subject to preauthorization. Coverage provided under this paragraph
shall also not be subject to concurrent utilization review during the
first [fourteen] TWENTY-ONE days of the inpatient admission provided
that the facility notifies the insurer of both the admission and the
initial treatment plan within [forty-eight hours] TWO BUSINESS DAYS of
the admission. The facility shall perform daily clinical review of the
patient, including the periodic consultation with the insurer to ensure
that the facility is using the evidence-based and peer reviewed clinical
review tool utilized by the insurer which is designated by the office of
alcoholism and substance abuse services and appropriate to the age of
the patient, to ensure that the inpatient treatment is medically neces-
sary for the patient. Any utilization review of treatment provided under
this subparagraph may include a review of all services provided during
such inpatient treatment, including all services provided during the
first [fourteen] TWENTY-ONE days of such inpatient treatment. Provided,
however, the insurer shall only deny coverage for any portion of the
initial [fourteen] TWENTY-ONE day inpatient treatment on the basis that
such treatment was not medically necessary if such inpatient treatment
was contrary to the evidence-based and peer reviewed clinical review
tool utilized by the insurer which is designated by the office of alco-
holism and substance abuse services. An insured shall not have any
financial obligation to the facility for any treatment under this
subparagraph other than any copayment, coinsurance, or deductible other-
wise required under the policy.
(E) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO INPATIENT SUBSTANCE USE DISORDER BENEFITS SHALL BE MADE
AVAILABLE BY THE INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NET-
WORK PROVIDER UPON REQUEST.
(F) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
(IV) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
S. 1507 132 A. 2007
(G) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
§ 16. Subparagraphs (A) and (B) of paragraph 7 of subsection (l) of
section 3221 of the insurance law, as amended by chapter 41 of the laws
of 2014, are amended and a new subparagraph (C-1) is added to read as
follows:
(A) Every policy that provides medical, major medical or similar
comprehensive-type coverage [must] SHALL provide outpatient coverage for
the diagnosis and treatment of substance use disorder, including detoxi-
fication and rehabilitation services. Such coverage shall not apply
financial requirements or treatment limitations to outpatient substance
use disorder benefits that are more restrictive than the predominant
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the policy. [Further,
such coverage shall be provided consistent with the federal Paul Well-
stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 (29 U.S.C. § 1185a).]
(B) Coverage under this paragraph may be limited to facilities in New
York state THAT ARE LICENSED, certified OR OTHERWISE AUTHORIZED by the
office of alcoholism and substance abuse services [or licensed by such
office as outpatient clinics or medically supervised ambulatory
substance abuse programs] TO PROVIDE OUTPATIENT SUBSTANCE USE DISORDER
SERVICES and, in other states, to those which are accredited by the
joint commission as alcoholism or chemical dependence treatment programs
AND SIMILARLY LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED IN THE STATE
IN WHICH THE FACILITY IS LOCATED.
(C-1) A LARGE GROUP POLICY THAT PROVIDES COVERAGE UNDER THIS PARAGRAPH
MAY NOT IMPOSE COPAYMENTS OR COINSURANCE FOR OUTPATIENT SUBSTANCE USE
DISORDER SERVICES THAT EXCEEDS THE COPAYMENT OR COINSURANCE IMPOSED FOR
A PRIMARY CARE OFFICE VISIT. PROVIDED THAT ONLY ONE SUCH COPAYMENT MAY
BE IMPOSED FOR ALL SERVICES PROVIDED IN A SINGLE DAY BY A FACILITY
LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY THE OFFICE OF ALCOHOLISM
AND SUBSTANCE ABUSE SERVICES TO PROVIDE OUTPATIENT SUBSTANCE USE DISOR-
DER SERVICES.
§ 17. Subparagraph (E) of paragraph 7 of subsection (l) of section
3221 of the insurance law, as added by section 4 of part MM of chapter
57 of the laws of 2018, is amended and three new subparagraphs (F), (G)
and (H) are added to read as follows:
(E) This subparagraph shall apply to facilities in this state THAT ARE
LICENSED, certified OR OTHERWISE AUTHORIZED by the office of alcoholism
and substance abuse services for the provision of outpatient, intensive
outpatient, outpatient rehabilitation and opioid treatment that are
participating in the insurer's provider network. Coverage provided under
this paragraph shall not be subject to preauthorization. Coverage
provided under this paragraph shall not be subject to concurrent review
for the first [two] THREE weeks of continuous treatment, not to exceed
[fourteen] TWENTY-ONE visits, provided the facility notifies the insurer
of both the start of treatment and the initial treatment plan within
[forty-eight hours] TWO BUSINESS DAYS. The facility shall perform clin-
ical assessment of the patient at each visit, including the periodic
consultation with the insurer to ensure that the facility is using the
evidence-based and peer reviewed clinical review tool utilized by the
insurer which is designated by the office of alcoholism and substance
abuse services and appropriate to the age of the patient, to ensure that
the outpatient treatment is medically necessary for the patient. Any
S. 1507 133 A. 2007
utilization review of the treatment provided under this subparagraph may
include a review of all services provided during such outpatient treat-
ment, including all services provided during the first [two] THREE weeks
of continuous treatment, not to exceed [fourteen] TWENTY-ONE visits, of
such outpatient treatment. Provided, however, the insurer shall only
deny coverage for any portion of the initial [two] THREE weeks of
continuous treatment, not to exceed [fourteen] TWENTY-ONE visits, for
outpatient treatment on the basis that such treatment was not medically
necessary if such outpatient treatment was contrary to the evidence-
based and peer reviewed clinical review tool utilized by the insurer
which is designated by the office of alcoholism and substance abuse
services. An insured shall not have any financial obligation to the
facility for any treatment under this subparagraph other than any copay-
ment, coinsurance, or deductible otherwise required under the policy.
(F) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO OUTPATIENT SUBSTANCE USE DISORDER BENEFITS SHALL BE MADE
AVAILABLE BY THE INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NET-
WORK PROVIDER UPON REQUEST.
(G) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY; AND
(IV) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
(H) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
§ 18. Paragraph 7-b of subsection (l) of section 3221 of the insurance
law, as added by section 2 of part B of chapter 69 of the laws of 2016,
is amended to read as follows:
(7-b) [(A)] Every policy that provides medical, major medical or simi-
lar comprehensive-type coverage and provides coverage for prescription
drugs for medication for the treatment of a substance use disorder shall
include immediate access, without prior authorization, [to a five day
emergency supply] TO THE FORMULARY FORMS of prescribed medications
covered under the policy for the treatment of substance use disorder
[where an emergency condition exists], including a prescribed drug or
medication associated with the management of opioid withdrawal and/or
S. 1507 134 A. 2007
stabilization, except where otherwise prohibited by law. Further, cover-
age [of an emergency supply] WITHOUT PRIOR AUTHORIZATION shall include
FORMULARY FORMS medication for opioid overdose reversal otherwise
covered under the policy prescribed OR DISPENSED to an individual
covered by the policy.
[(B) For purposes of this paragraph, an "emergency condition" means a
substance use disorder condition that manifests itself by acute symptoms
of sufficient severity, including severe pain or the expectation of
severe pain, such that a prudent layperson, possessing an average know-
ledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in:
(i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition, placing the
health of such person or others in serious jeopardy;
(ii) serious impairment to such person's bodily functions;
(iii) serious dysfunction of any bodily organ or part of such person;
(iv) serious disfigurement of such person; or
(v) a condition described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
(C) Coverage provided under this paragraph may be subject to copay-
ments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the policy; provided, however, no
policy shall impose an additional copayment or coinsurance on an insured
who received an emergency supply of medication and then received up to a
thirty day supply of the same medication in the same thirty day period
in which the emergency supply of medication was dispensed. This subpara-
graph shall not preclude the imposition of a copayment or coinsurance on
the initial emergency supply of medication in an amount that is less
than the copayment or coinsurance otherwise applicable to a thirty day
supply of such medication, provided that the total sum of the copayments
or coinsurance for an entire thirty day supply of the medication does
not exceed the copayment or coinsurance otherwise applicable to a thirty
day supply of such medication.]
§ 19. Subparagraph (B) of paragraph 17 of subsection (l) of section
3221 of the insurance law, as amended by section 39 of part D of chapter
56 of the laws of 2013, is amended to read as follows:
(B) Every group or blanket policy that provides physician services,
medical, major medical or similar comprehensive-type coverage shall
provide coverage for the screening, diagnosis and treatment of autism
spectrum disorder in accordance with this paragraph and shall not
exclude coverage for the screening, diagnosis or treatment of medical
conditions otherwise covered by the policy because the individual is
diagnosed with autism spectrum disorder. Such coverage may be subject to
annual deductibles, copayments and coinsurance as may be deemed appro-
priate by the superintendent and shall be consistent with those imposed
on other benefits under the group or blanket policy. [Coverage for
applied behavior analysis shall be subject to a maximum benefit of six
hundred eighty hours of treatment per policy or calendar year per
covered individual.] This paragraph shall not be construed as limiting
the benefits that are otherwise available to an individual under the
group or blanket policy, provided however that such policy shall not
contain any limitations on visits that are solely applied to the treat-
ment of autism spectrum disorder. No insurer shall terminate coverage or
refuse to deliver, execute, issue, amend, adjust, or renew coverage to
an individual solely because the individual is diagnosed with autism
spectrum disorder or has received treatment for autism spectrum disor-
S. 1507 135 A. 2007
der. Coverage shall be subject to utilization review and external
appeals of health care services pursuant to article forty-nine of this
chapter as well as[,] case management[,] and other managed care
provisions.
§ 20. Items (i) and (iii) of subparagraph (C) of paragraph 17 of
subsection (l) of section 3221 of the insurance law, as amended by chap-
ter 596 of the laws of 2011, are amended to read as follows:
(i) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders[, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS)].
(iii) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided [or supervised] by a [behavior analyst] PERSON
LICENSED, certified [pursuant to the behavior analyst certification
board,] OR OTHERWISE AUTHORIZED TO PROVIDE APPLIED BEHAVIOR ANALYSIS,
that are necessary to develop, maintain, or restore, to the maximum
extent practicable, the functioning of an individual. [Individuals that
provide behavioral health treatment under the supervision of a certified
behavior analyst pursuant to this paragraph shall be subject to stand-
ards of professionalism, supervision and relevant experience pursuant to
regulations promulgated by the superintendent in consultation with the
commissioners of health and education.]
§ 21. Paragraph 17 of subsection (l) of section 3221 of the insurance
law is amended by adding four new subparagraphs (H), (I), (J) and (K) to
read as follows:
(H) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO AUTISM SPECTRUM DISORDER BENEFITS THAT
ARE MORE RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND
TREATMENT LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL
BENEFITS COVERED BY THE POLICY.
(I) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE POLICY
WITH RESPECT TO OUTPATIENT SUBSTANCE USE DISORDER BENEFITS SHALL BE
MADE AVAILABLE BY THE INSURER TO ANY INSURED, PROSPECTIVE INSURED, OR
IN-NETWORK PROVIDER UPON REQUEST.
(J) FOR PURPOSES OF THIS PARAGRAPH:
(I) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(II) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT; AND
(III) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREAT-
MENT, NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON
THE SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREAT-
MENT LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR
EXCLUDING BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE
TREATMENT IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR
PRESCRIPTION DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMIS-
SION TO PARTICIPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS
FOR DETERMINING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR
STEP THERAPY PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE
OF TREATMENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY
TYPE, PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR
DURATION OF BENEFITS FOR SERVICES PROVIDED UNDER THE POLICY.
S. 1507 136 A. 2007
(K) AN INSURER SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A MINI-
MUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI MENTAL
HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. § 1185A).
§ 22. Paragraphs 1, 2, and 3 of subsection (g) of section 4303 of the
insurance law, as amended by chapter 502 of the laws of 2007, are
amended to read as follows:
[(1)] A MEDICAL EXPENSE INDEMNITY CORPORATION, hospital service corpo-
ration or a health service corporation, [which] THAT provides group,
group remittance or school blanket coverage for inpatient hospital
care[,] OR COVERAGE FOR PHYSICIAN SERVICES shall provide as part of its
contract [broad-based] coverage for the diagnosis and treatment of
mental[, nervous or emotional disorders or ailments, however defined in
such contract, at least equal to the coverage provided for other] health
conditions and [shall include]:
[(A)]
(1) WHERE THE CONTRACT PROVIDES COVERAGE FOR INPATIENT HOSPITAL CARE,
benefits for in-patient care in a hospital as defined by subdivision ten
of section 1.03 of the mental hygiene law[, which benefits may be limit-
ed to not less than thirty days of active treatment in any contract
year, plan year or calendar year.
(B)] OR FOR INPATIENT CARE PROVIDED IN OTHER STATES, TO SIMILARLY
LICENSED HOSPITALS, AND benefits for out-patient care provided in a
facility issued an operating certificate by the commissioner of mental
health pursuant to the provisions of article thirty-one of the mental
hygiene law or in a facility operated by the office of mental health[,
which benefits may be limited to not less than twenty visits in any
contract year, plan year or calendar year. Benefits for partial hospi-
talization program services shall be provided as an offset to covered
inpatient days at a ratio of two partial hospitalization visits to one
inpatient day of treatment.
(C) Such coverage may be provided on a contract year, plan year or
calendar year basis and shall be consistent with the provision of other
benefits under the contract.] OR FOR OUT-PATIENT CARE PROVIDED IN OTHER
STATES, TO SIMILARLY CERTIFIED FACILITIES; AND
(2) WHERE THE CONTRACT PROVIDES COVERAGE FOR PHYSICIAN SERVICES BENE-
FITS FOR OUTPATIENT CARE PROVIDED BY A PSYCHIATRIST OR PSYCHOLOGIST
LICENSED TO PRACTICE IN THIS STATE, A LICENSED CLINICAL SOCIAL WORKER
WHO MEETS THE REQUIREMENTS OF SUBSECTION (N) OF THIS SECTION, A NURSE
PRACTITIONER LICENSED TO PRACTICE ON THIS STATE, OR PROFESSIONAL CORPO-
RATION OR UNIVERSITY FACULTY PRACTICE CORPORATION THEREOF.
(3) Such coverage may be subject to annual deductibles, co-pays and
coinsurance as may be deemed appropriate by the superintendent and shall
be consistent with those imposed on other benefits under the contract.
PROVIDED THAT NO COPAYMENT OR COINSURANCE IMPOSED FOR OUTPATIENT MENTAL
HEALTH SERVICES PROVIDED IN A FACILITY LICENSED, CERTIFIED OR OTHERWISE
AUTHORIZED BY THE OFFICE OF MENTAL HEALTH SHALL EXCEED THE COPAYMENTS OR
COINSURANCE IMPOSED FOR A PRIMARY CARE OFFICE VISIT UNDER THE CONTRACT.
[(D) For the purpose of this subsection, "active treatment" means
treatment furnished in conjunction with in-patient confinement for
mental, nervous or emotional disorders or ailments that meet such stand-
ards as shall be prescribed pursuant to the regulations of the commis-
sioner of mental health.
(E) In the event the group remittance group or contract holder is
provided coverage under this subsection and under paragraph one of
subsection (h) of this section from the same health service corporation,
or under a contract that is jointly underwritten by two health service
S. 1507 137 A. 2007
corporations or by a health service corporation and a medical expense
indemnity corporation, the aggregate of the benefits for outpatient care
obtained under subparagraph (B) of this paragraph and paragraph one of
subsection (h) of this section may be limited to not less than twenty
visits in any contract year, plan year or calendar year.
(2) (A) A hospital service corporation or a health service corpo-
ration, which provides group, group remittance or school blanket cover-
age for inpatient hospital care, shall provide comparable coverage for
adults and children with biologically based mental illness. Such hospi-
tal service corporation or health service corporation shall also provide
such comparable coverage for children with serious emotional disturb-
ances. Such coverage shall be provided under the terms and conditions
otherwise applicable under the contract, including network limitations
or variations, exclusions, co-pays, coinsurance, deductibles or other
specific cost sharing mechanisms. Provided further, where a contract
provides both in-network and out-of-network benefits, the out-of-network
benefits may have different coinsurance, co-pays, or deductibles, than
the in-network benefits, regardless of whether the contract is written
under one license or two licenses.
(B) For purposes of this subsection, the term "biologically based
mental illness" means a mental, nervous, or emotional condition that is
caused by a biological disorder of the brain and results in a clinically
significant, psychological syndrome or pattern that substantially limits
the functioning of the person with the illness. Such biologically based
mental illnesses are defined as schizophrenia/psychotic disorders, major
depression, bipolar disorder, delusional disorders, panic disorder,
obsessive compulsive disorders, anorexia, and bulimia.
(3) For purposes of this subsection, the term "children with serious
emotional disturbances" means persons under the age of eighteen years
who have diagnoses of attention deficit disorders, disruptive behavior
disorders, or pervasive development disorders, and where there are one
or more of the following:
(A) serious suicidal symptoms or other life-threatening self-destruc-
tive behaviors;
(B) significant psychotic symptoms (hallucinations, delusion, bizarre
behaviors);
(C) behavior caused by emotional disturbances that placed the child at
risk of causing personal injury or significant property damage; or
(D) behavior caused by emotional disturbances that placed the child at
substantial risk of removal from the household.]
§ 23. Paragraphs 4 and 5 of subsection (g) of section 4303 of the
insurance law are REPEALED and five new paragraphs 4, 5, 6, 7 and 8 are
added to read as follows:
(4) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO MENTAL HEALTH BENEFITS THAT ARE MORE
RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND TREATMENT
LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL BENEFITS
COVERED BY THE CONTRACT.
(5) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE
CONTRACT WITH RESPECT TO MENTAL HEALTH BENEFITS SHALL BE MADE AVAILABLE
BY THE CORPORATION TO ANY INSURED, PROSPECTIVE INSURED, OR IN-NETWORK
PROVIDER UPON REQUEST.
(6) FOR PURPOSES OF THIS SUBSECTION:
(A) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
S. 1507 138 A. 2007
(B) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(C) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREATMENT,
NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETER-
MINING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP
THERAPY PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF
TREATMENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE CONTRACT; AND
(D) "MENTAL HEALTH CONDITION" MEANS ANY MENTAL HEALTH DISORDER AS
DEFINED IN THE MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL
MANUAL OF MENTAL DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENER-
ALLY RECOGNIZED INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS
THE INTERNATIONAL CLASSIFICATION OF DISEASES.
(7) A CORPORATION SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A
MINIMUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. §
1185A).
(8) THIS SUBPARAGRAPH SHALL APPLY TO HOSPITALS IN THIS STATE THAT ARE
LICENSED BY THE OFFICE OF MENTAL HEALTH THAT ARE PARTICIPATING IN THE
CORPORATION'S PROVIDER NETWORK. WHERE THE CONTRACT PROVIDES COVERAGE FOR
INPATIENT HOSPITAL CARE, BENEFITS FOR INPATIENT HOSPITAL CARE IN A
HOSPITAL AS DEFINED BY SUBDIVISION TEN OF SECTION 1.03 OF THE MENTAL
HYGIENE LAW PROVIDED TO INDIVIDUALS WHO HAVE NOT ATTAINED THE AGE OF
EIGHTEEN SHALL NOT BE SUBJECT TO PREAUTHORIZATION. COVERAGE PROVIDED
UNDER THIS PARAGRAPH SHALL ALSO NOT BE SUBJECT TO CONCURRENT UTILIZA-
TION REVIEW DURING THE FIRST FOURTEEN DAYS OF THE INPATIENT ADMISSION,
PROVIDED THE FACILITY NOTIFIES THE CORPORATION OF BOTH THE ADMISSION AND
THE INITIAL TREATMENT PLAN WITHIN TWO BUSINESS DAYS OF THE ADMISSION,
PERFORMS DAILY CLINICAL REVIEW OF THE PATIENT, AND PARTICIPATES IN PERI-
ODIC CONSULTATION WITH THE CORPORATION TO ENSURE THAT THE FACILITY IS
USING THE EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW CRITERIA
UTILIZED BY THE CORPORATION WHICH IS APPROVED BY THE OFFICE OF MENTAL
HEALTH AND APPROPRIATE TO THE AGE OF THE PATIENT, TO ENSURE THAT THE
INPATIENT CARE IS MEDICALLY NECESSARY FOR THE PATIENT. ALL TREATMENT
PROVIDED UNDER THIS SUBPARAGRAPH MAY BE REVIEWED RETROSPECTIVELY. WHERE
CARE IS DENIED RETROSPECTIVELY, AN INSURED SHALL NOT HAVE ANY FINANCIAL
OBLIGATION TO THE FACILITY FOR ANY TREATMENT UNDER THIS SUBPARAGRAPH
OTHER THAN ANY COPAYMENT, COINSURANCE, OR DEDUCTIBLE OTHERWISE REQUIRED
UNDER THE CONTRACT.
§ 24. Subsection (h) of section 4303 of the insurance law is REPEALED.
§ 25. Subsection (i) of section 4303 of the insurance law, as amended
by chapter 230 of the laws of 2004, is amended to read as follows:
(i) A medical expense indemnity corporation or health service corpo-
ration [which] THAT provides coverage for physicians, psychiatrists or
psychologists for psychiatric or psychological services or for the diag-
nosis and treatment of [mental, nervous or emotional disorders and
ailments] MENTAL HEALTH CONDITIONS, however defined in such contract,
[must] SHALL make available and if requested by all persons holding
S. 1507 139 A. 2007
individual contracts in a group whose premiums are paid by a remitting
agent or by the contract holder in the case of a group contract issued
pursuant to section four thousand three hundred five of this article,
provide the same coverage for such services when performed by a licensed
clinical social worker, within the lawful scope of his or her practice,
who is licensed pursuant to article one hundred fifty-four of the educa-
tion law. The state board for social work shall maintain a list of all
licensed clinical social workers qualified for reimbursement under this
subsection. Such coverage shall be made available at the inception of
all new contracts and, with respect to all other contracts, at any anni-
versary date subject to evidence of insurability. Written notice of the
availability of such coverage shall be delivered to the group remitting
agent or group contract holder prior to inception of such contract and
annually thereafter, except that this notice shall not be required where
a [policy] CONTRACT covers two hundred or more employees or where the
benefit structure was the subject of collective bargaining affecting
persons who are employed in more than one state.
§ 26. Subsection (k) of section 4303 of the insurance law, as amended
by section 3 of part B of chapter 71 of the laws of 2016, is amended to
read as follows:
(k)(1) Every contract that provides hospital, major medical or similar
comprehensive coverage [must] SHALL provide inpatient coverage for the
diagnosis and treatment of substance use disorder, including detoxifica-
tion and rehabilitation services. Such inpatient coverage shall include
unlimited medically necessary treatment for substance use disorder
treatment services provided in residential settings [as required by the
Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §
1185a)]. Further, such inpatient coverage shall not apply financial
requirements or treatment limitations, including utilization review
requirements, to inpatient substance use disorder benefits that are more
restrictive than the predominant financial requirements and treatment
limitations applied to substantially all medical and surgical benefits
covered by the contract. [Further, such coverage shall be provided
consistent with the federal Paul Wellstone and Pete Domenici Mental
Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
(2) Coverage provided under this subsection may be limited to facili-
ties in New York state [which are certified] THAT ARE LICENSED, CERTI-
FIED OR OTHERWISE AUTHORIZED by the office of alcoholism and substance
abuse services and, in other states, to those which are accredited by
the joint commission as alcoholism, substance abuse, or chemical depend-
ence treatment programs AND ARE SIMILARLY LICENSED, CERTIFIED OR OTHER-
WISE AUTHORIZED IN THE STATE IN WHICH THE FACILITY IS LOCATED.
(3) Coverage provided under this subsection may be subject to annual
deductibles and co-insurance as deemed appropriate by the superintendent
and that are consistent with those imposed on other benefits within a
given contract.
(4) This paragraph shall apply to facilities in this state [certified]
THAT ARE LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED by the office of
alcoholism and substance abuse services that are participating in the
corporation's provider network. Coverage provided under this subsection
shall not be subject to preauthorization. Coverage provided under this
subsection shall also not be subject to concurrent utilization review
during the first [fourteen] TWENTY-ONE days of the inpatient admission
provided that the facility notifies the corporation of both the admis-
sion and the initial treatment plan within [forty-eight hours] TWO BUSI-
NESS DAYS of the admission. The facility shall perform daily clinical
S. 1507 140 A. 2007
review of the patient, including the periodic consultation with the
corporation to ensure that the facility is using the evidence-based and
peer reviewed clinical review tool utilized by the corporation which is
designated by the office of alcoholism and substance abuse services and
appropriate to the age of the patient, to ensure that the inpatient
treatment is medically necessary for the patient. Any utilization review
of treatment provided under this paragraph may include a review of all
services provided during such inpatient treatment, including all
services provided during the first [fourteen] TWENTY-ONE days of such
inpatient treatment. Provided, however, the corporation shall only deny
coverage for any portion of the initial [fourteen] TWENTY-ONE day inpa-
tient treatment on the basis that such treatment was not medically
necessary if such inpatient treatment was contrary to the evidence-based
and peer reviewed clinical review tool utilized by the corporation which
is designated by the office of alcoholism and substance abuse services.
An insured shall not have any financial obligation to the facility for
any treatment under this paragraph other than any copayment, coinsu-
rance, or deductible otherwise required under the contract.
(5) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE
CONTRACT WITH RESPECT TO INPATIENT SUBSTANCE USE DISORDER BENEFITS
SHALL BE MADE AVAILABLE BY THE CORPORATION TO ANY INSURED, PROSPECTIVE
INSURED OR IN-NETWORK PROVIDER UPON REQUEST.
(6) FOR PURPOSES OF THIS SUBSECTION:
(A) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(B) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT;
(C) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREATMENT,
NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE
SCOPE OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT
LIMITATIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING
BENEFITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT
IS EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETER-
MINING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP
THERAPY PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF
TREATMENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE CONTRACT; AND
(D) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
(7) A CORPORATION SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A
MINIMUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. §
1185A).
§ 27. Paragraphs 1 and 2 of subsection (l) of section 4303 of the
insurance law, as amended by chapter 41 of the laws of 2014, are amended
and a new paragraph 3-a is added to read as follows:
(1) Every contract that provides medical, major medical or similar
comprehensive-type coverage [must] SHALL provide outpatient coverage for
the diagnosis and treatment of substance use disorder, including detoxi-
S. 1507 141 A. 2007
fication and rehabilitation services. Such coverage shall not apply
financial requirements or treatment limitations to outpatient substance
use disorder benefits that are more restrictive than the predominant
financial requirements and treatment limitations applied to substantial-
ly all medical and surgical benefits covered by the contract. [Further,
such coverage shall be provided consistent with the federal Paul Well-
stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
2008 (29 U.S.C. § 1185a).]
(2) Coverage under this subsection may be limited to facilities in New
York state THAT ARE LICENSED, certified OR OTHERWISE AUTHORIZED by the
office of alcoholism and substance abuse services [or licensed by such
office as outpatient clinics or medically supervised ambulatory] TO
PROVIDE OUTPATIENT substance [abuse programs] USE DISORDER SERVICES and,
in other states, to those which are accredited by the joint commission
as alcoholism or chemical dependence substance abuse treatment programs
AND ARE SIMILARLY LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED IN THE
STATE IN WHICH THE FACILITY IS LOCATED.
(3-A) A CONTRACT THAT PROVIDES LARGE GROUP COVERAGE THAT PROVIDES
COVERAGE FOR OUTPATIENT SUBSTANCE USE DISORDER SERVICES UNDER THIS
SUBSECTION MAY NOT IMPOSE COPAYMENTS OR COINSURANCE FOR OUTPATIENT
SUBSTANCE USE DISORDER SERVICES THAT EXCEED THE COPAYMENT OR COINSURANCE
IMPOSED FOR A PRIMARY CARE OFFICE VISIT. PROVIDED THAT ONLY ONE SUCH
COPAYMENT MAY BE IMPOSED FOR ALL SERVICES PROVIDED IN A SINGLE DAY BY A
FACILITY LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED BY THE OFFICE OF
ALCOHOLISM AND SUBSTANCE ABUSE SERVICES TO PROVIDE OUTPATIENT SUBSTANCE
USE DISORDER SERVICES.
§ 28. Paragraph 5 of subsection (l) of section 4303 of the insurance
law, as added by section 5 of part MM of chapter 57 of the laws of 2018,
is amended and three new paragraphs 6, 7 and 8 are added to read as
follows:
(5) This paragraph shall apply to facilities in this state [certified]
THAT ARE LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED by the office of
alcoholism and substance abuse services for the provision of outpatient,
intensive outpatient, outpatient rehabilitation and opioid treatment
that are participating in the corporation's provider network. Coverage
provided under this subsection shall not be subject to preauthorization.
Coverage provided under this subsection shall not be subject to concur-
rent review for the first [two] THREE weeks of continuous treatment, not
to exceed [fourteen] TWENTY-ONE visits, provided the facility notifies
the corporation of both the start of treatment and the initial treatment
plan within [forty-eight hours] TWO BUSINESS DAYS. The facility shall
perform clinical assessment of the patient at each visit, including the
periodic consultation with the corporation to ensure that the facility
is using the evidence-based and peer reviewed clinical review tool
utilized by the corporation which is designated by the office of alco-
holism and substance abuse services and appropriate to the age of the
patient, to ensure that the outpatient treatment is medically necessary
for the patient. Any utilization review of the treatment provided under
this paragraph may include a review of all services provided during such
outpatient treatment, including all services provided during the first
[two] THREE weeks of continuous treatment, not to exceed [fourteen]
TWENTY-ONE visits, of such outpatient treatment. Provided, however, the
corporation shall only deny coverage for any portion of the initial
[two] THREE weeks of continuous treatment, not to exceed [fourteen]
TWENTY-ONE visits, for outpatient treatment on the basis that such
treatment was not medically necessary if such outpatient treatment was
S. 1507 142 A. 2007
contrary to the evidence-based and peer reviewed clinical review tool
utilized by the corporation which is designated by the office of alco-
holism and substance abuse services. A subscriber shall not have any
financial obligation to the facility for any treatment under this para-
graph other than any copayment, coinsurance, or deductible otherwise
required under the contract.
(6) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE
CONTRACT WITH RESPECT TO OUTPATIENT SUBSTANCE USE DISORDER BENEFITS
SHALL BE MADE AVAILABLE BY THE CORPORATION TO ANY INSURED, PROSPECTIVE
INSURED, OR IN-NETWORK PROVIDER UPON REQUEST.
(7) FOR PURPOSES OF THIS SUBSECTION:
(A) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(B) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT.
(C) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREATMENT,
NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE SCOPE
OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT LIMITA-
TIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING BENE-
FITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT IS
EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE CONTRACT; AND
(D) "SUBSTANCE USE DISORDER" SHALL HAVE THE MEANING SET FORTH IN THE
MOST RECENT EDITION OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL
DISORDERS OR THE MOST RECENT EDITION OF ANOTHER GENERALLY RECOGNIZED
INDEPENDENT STANDARD OF CURRENT MEDICAL PRACTICE SUCH AS THE INTERNA-
TIONAL CLASSIFICATION OF DISEASES.
(8) A CORPORATION SHALL PROVIDE COVERAGE UNDER THIS PARAGRAPH, AT A
MINIMUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. §
1185A).
§ 29. Subsection (l-2) of section 4303 of the insurance law, as added
by section 3 of part B of chapter 69 of the laws of 2016, is amended to
read as follows:
(l-2) [(1)] Every contract that provides medical, major medical or
similar comprehensive-type coverage and provides coverage for
prescription drugs for medication for the treatment of a substance use
disorder shall include immediate access, without prior authorization, to
[a five day emergency supply] THE FORMULARY FORMS of prescribed medica-
tions covered under the contract for the treatment of substance use
disorder [where an emergency condition exists], including a prescribed
drug or medication associated with the management of opioid withdrawal
and/or stabilization, except where otherwise prohibited by law. Further,
coverage [of an emergency supply] WITHOUT PRIOR AUTHORIZATION shall
include FORMULARY FORMS OF medication for opioid overdose reversal
otherwise covered under the contract prescribed OR DISPENSED to an indi-
vidual covered by the contract.
[(2) For purposes of this paragraph, an "emergency condition" means a
substance use disorder condition that manifests itself by acute symptoms
S. 1507 143 A. 2007
of sufficient severity, including severe pain or the expectation of
severe pain, such that a prudent layperson, possessing an average know-
ledge of medicine and health, could reasonably expect the absence of
immediate medical attention to result in:
(i) placing the health of the person afflicted with such condition in
serious jeopardy, or in the case of a behavioral condition, placing the
health of such person or others in serious jeopardy;
(ii) serious impairment to such person's bodily functions;
(iii) serious dysfunction of any bodily organ or part of such person;
(iv) serious disfigurement of such person; or
(v) a condition described in clause (i), (ii) or (iii) of section
1867(e)(1)(A) of the Social Security Act.
(3) Coverage provided under this subsection may be subject to copay-
ments, coinsurance, and annual deductibles that are consistent with
those imposed on other benefits within the contract; provided, however,
no contract shall impose an additional copayment or coinsurance on an
insured who received an emergency supply of medication and then received
up to a thirty day supply of the same medication in the same thirty day
period in which the emergency supply of medication was dispensed. This
paragraph shall not preclude the imposition of a copayment or coinsu-
rance on the initial limited supply of medication in an amount that is
less than the copayment or coinsurance otherwise applicable to a thirty
day supply of such medication, provided that the total sum of the copay-
ments or coinsurance for an entire thirty day supply of the medication
does not exceed the copayment or coinsurance otherwise applicable to a
thirty day supply of such medication.]
§ 30. Subsection (n) of section 4303 of the insurance law, as amended
by chapter 230 of the laws of 2004, is amended to read as follows:
(n) In addition to the requirements of subsection (i) of this section,
every health service or medical expense indemnity corporation issuing a
group contract pursuant to this section or a group remittance contract
for delivery in this state which contract provides reimbursement to
subscribers or physicians, psychiatrists or psychologists for psychiat-
ric or psychological services or for the diagnosis and treatment of
[mental, nervous or emotional disorders and ailments,] MENTAL HEALTH
CONDITIONS, however defined in such contract, must provide the same
coverage to persons covered under the group contract for such services
when performed by a licensed clinical social worker, within the lawful
scope of his or her practice, who is licensed pursuant to subdivision
two of section seven thousand seven hundred four of the education law
and in addition shall have either (i) three or more additional years
experience in psychotherapy, which for the purposes of this subsection
shall mean the use of verbal methods in interpersonal relationships with
the intent of assisting a person or persons to modify attitudes and
behavior which are intellectually, socially or emotionally maladaptive,
under supervision, satisfactory to the state board for social work, in a
facility, licensed or incorporated by an appropriate governmental
department, providing services for diagnosis or treatment of [mental,
nervous or emotional disorders or ailments,] MENTAL HEALTH CONDITIONS,
or (ii) three or more additional years experience in psychotherapy under
the supervision, satisfactory to the state board for social work, of a
psychiatrist, a licensed and registered psychologist or a licensed clin-
ical social worker qualified for reimbursement pursuant to subsection
(i) of this section, or (iii) a combination of the experience specified
in paragraphs (i) and (ii) totaling three years, satisfactory to the
state board for social work. The state board for social work shall
S. 1507 144 A. 2007
maintain a list of all licensed clinical social workers qualified for
reimbursement under this subsection.
§ 31. Paragraph 2 of subsection (ee) of section 4303 of the insurance
law, as amended by section 40 of part D of chapter 56 of the laws of
2013, is amended to read as follows:
(2) Every contract that provides physician services, medical, major
medical or similar comprehensive-type coverage shall provide coverage
for the screening, diagnosis and treatment of autism spectrum disorder
in accordance with this paragraph and shall not exclude coverage for the
screening, diagnosis or treatment of medical conditions otherwise
covered by the contract because the individual is diagnosed with autism
spectrum disorder. Such coverage may be subject to annual deductibles,
copayments and coinsurance as may be deemed appropriate by the super-
intendent and shall be consistent with those imposed on other benefits
under the contract. [Coverage for applied behavior analysis shall be
subject to a maximum benefit of six hundred eighty hours of treatment
per contract or calendar year per covered individual.] This paragraph
shall not be construed as limiting the benefits that are otherwise
available to an individual under the contract, provided however that
such contract shall not contain any limitations on visits that are sole-
ly applied to the treatment of autism spectrum disorder. No insurer
shall terminate coverage or refuse to deliver, execute, issue, amend,
adjust, or renew coverage to an individual solely because the individual
is diagnosed with autism spectrum disorder or has received treatment for
autism spectrum disorder. Coverage shall be subject to utilization
review and external appeals of health care services pursuant to article
forty-nine of this chapter as well as[,] case management[,] and other
managed care provisions.
§ 32. Subparagraphs (A) and (C) of paragraph 3 of subsection (ee) of
section 4303 of the insurance law, as amended by chapter 596 of the laws
of 2011, are amended to read as follows:
(A) "autism spectrum disorder" means any pervasive developmental
disorder as defined in the most recent edition of the diagnostic and
statistical manual of mental disorders[, including autistic disorder,
Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
or pervasive developmental disorder not otherwise specified (PDD-NOS)].
(C) "behavioral health treatment" means counseling and treatment
programs, when provided by a licensed provider, and applied behavior
analysis, when provided [or supervised] by a [behavior analyst certified
pursuant to the behavior analyst certification board] PERSON THAT IS
LICENSED, CERTIFIED OR OTHERWISE AUTHORIZED TO PROVIDE APPLIED BEHAVIOR
ANALYSIS, that are necessary to develop, maintain, or restore, to the
maximum extent practicable, the functioning of an individual. [Individ-
uals that provide behavioral health treatment under the supervision of a
certified behavior analyst pursuant to this subsection shall be subject
to standards of professionalism, supervision and relevant experience
pursuant to regulations promulgated by the superintendent in consulta-
tion with the commissioners of health and education.]
§ 33. Subsection (ee) of section 4303 of the insurance law is amended
by adding four new paragraphs 8, 9, 10, and 11 to read as follows:
(8) COVERAGE UNDER THIS PARAGRAPH SHALL NOT APPLY FINANCIAL REQUIRE-
MENTS OR TREATMENT LIMITATIONS TO AUTISM SPECTRUM DISORDER BENEFITS THAT
ARE MORE RESTRICTIVE THAN THE PREDOMINANT FINANCIAL REQUIREMENTS AND
TREATMENT LIMITATIONS APPLIED TO SUBSTANTIALLY ALL MEDICAL AND SURGICAL
BENEFITS COVERED BY THE POLICY.
S. 1507 145 A. 2007
(9) THE CRITERIA FOR MEDICAL NECESSITY DETERMINATIONS UNDER THE
CONTRACT WITH RESPECT TO AUTISM SPECTRUM DISORDER BENEFITS SHALL BE MADE
AVAILABLE BY THE CORPORATION TO ANY INSURED, PROSPECTIVE INSURED, OR
IN-NETWORK PROVIDER UPON REQUEST.
(10) FOR PURPOSES OF THIS SUBSECTION:
(A) "FINANCIAL REQUIREMENT" MEANS DEDUCTIBLE, COPAYMENTS, COINSURANCE
AND OUT-OF-POCKET EXPENSES;
(B) "PREDOMINANT" MEANS THAT A FINANCIAL REQUIREMENT OR TREATMENT
LIMITATION IS THE MOST COMMON OR FREQUENT OF SUCH TYPE OF LIMIT OR
REQUIREMENT; AND
(C) "TREATMENT LIMITATION" MEANS LIMITS ON THE FREQUENCY OF TREATMENT,
NUMBER OF VISITS, DAYS OF COVERAGE, OR OTHER SIMILAR LIMITS ON THE SCOPE
OR DURATION OF TREATMENT AND INCLUDES NONQUANTITATIVE TREATMENT LIMITA-
TIONS SUCH AS: MEDICAL MANAGEMENT STANDARDS LIMITING OR EXCLUDING BENE-
FITS BASED ON MEDICAL NECESSITY, OR BASED ON WHETHER THE TREATMENT IS
EXPERIMENTAL OR INVESTIGATIONAL; FORMULARY DESIGN FOR PRESCRIPTION
DRUGS; NETWORK TIER DESIGN; STANDARDS FOR PROVIDER ADMISSION TO PARTIC-
IPATE IN A NETWORK, INCLUDING REIMBURSEMENT RATES; METHODS FOR DETERMIN-
ING USUAL, CUSTOMARY, AND REASONABLE CHARGES; FAIL-FIRST OR STEP THERAPY
PROTOCOLS; EXCLUSIONS BASED ON FAILURE TO COMPLETE A COURSE OF TREAT-
MENT; AND RESTRICTIONS BASED ON GEOGRAPHIC LOCATION, FACILITY TYPE,
PROVIDER SPECIALTY, AND OTHER CRITERIA THAT LIMIT THE SCOPE OR DURATION
OF BENEFITS FOR SERVICES PROVIDED UNDER THE CONTRACT.
(11) A CORPORATION SHALL PROVIDE COVERAGE UNDER THIS SUBSECTION, AT A
MINIMUM, CONSISTENT WITH THE FEDERAL PAUL WELLSTONE AND PETE DOMENICI
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (29 U.S.C. §
1185A).
§ 34. Paragraphs 17, 20 and 21 of subsection (a) of section 4324 of
the insurance law, paragraph 17 as amended and paragraphs 20 and 21 as
added by section 8 of part H of chapter 60 of the laws of 2014, are
amended and a new paragraph 22 is added to read as follows:
(17) where applicable, a listing by specialty, which may be in a sepa-
rate document that is updated annually, of the name, address, and tele-
phone number of all participating providers, including facilities, [and
in addition,] AND: (A) WHETHER THE PROVIDER IS ACCEPTING NEW PATIENTS;
(B) IN THE CASE OF MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES
PROVIDERS, ANY AFFILIATIONS WITH PARTICIPATING FACILITIES CERTIFIED OR
AUTHORIZED BY THE OFFICE OF MENTAL HEALTH OR THE OFFICE OF ALCOHOLISM
AND SUBSTANCE ABUSE SERVICES, AND ANY RESTRICTIONS REGARDING THE AVAIL-
ABILITY OF THE INDIVIDUAL PROVIDER'S SERVICES; (C) in the case of physi-
cians, board certification, languages spoken and any affiliations with
participating hospitals. The listing shall also be posted on the corpo-
ration's website and the corporation shall update the website within
fifteen days of the addition or termination of a provider from the
corporation's network or a change in a physician's hospital affiliation;
(20) with respect to out-of-network coverage:
(A) a clear description of the methodology used by the corporation to
determine reimbursement for out-of-network health care services;
(B) a description of the amount that the corporation will reimburse
under the methodology for out-of-network health care services set forth
as a percentage of the usual and customary cost for out-of-network
health care services; and
(C) examples of anticipated out-of-pocket costs for frequently billed
out-of-network health care services; [and]
(21) information in writing and through an internet website that
reasonably permits a subscriber or prospective subscriber to estimate
S. 1507 146 A. 2007
the anticipated out-of-pocket cost for out-of-network health care
services in a geographical area or zip code based upon the difference
between what the corporation will reimburse for out-of-network health
care services and the usual and customary cost for out-of-network health
care services[.]; AND
(22) THE MOST RECENT COMPARATIVE ANALYSIS PERFORMED BY THE CORPORATION
TO ASSESS THE PROVISION OF ITS COVERED SERVICES IN ACCORDANCE WITH THE
PAUL WELLSTONE AND PETE DOMENICI MENTAL HEALTH PARITY AND ADDICTION
EQUITY ACT OF 2008, 42 U.S.C. 18031 (J), AND ANY AMENDMENTS TO, AND
FEDERAL GUIDANCE OR REGULATIONS ISSUED UNDER, THOSE ACTS.
§ 35. Subsection (b) of section 4325 of the insurance law, as added by
chapter 705 of the laws of 1996, is amended to read as follows:
(b) No corporation organized under this article shall by contract,
written policy [or], written procedure OR PRACTICE prohibit or restrict
any health care provider from filing a complaint, making a report or
commenting to an appropriate governmental body regarding the policies or
practices of such corporation which the provider believes may negatively
impact upon the quality of or access to patient care. NOR SHALL A CORPO-
RATION ORGANIZED UNDER THIS ARTICLE TAKE ANY ADVERSE ACTION, INCLUDING
BUT NOT LIMITED TO REFUSING TO RENEW OR EXECUTE A CONTRACT OR AGREEMENT
WITH A HEALTH CARE PROVIDER AS RETALIATION AGAINST A HEALTH CARE PROVID-
ER FOR FILING A COMPLAINT, MAKING A REPORT OR COMMENTING TO AN APPROPRI-
ATE GOVERNMENTAL BODY REGARDING POLICIES OR PRACTICES OF SUCH CORPO-
RATION WHICH MAY VIOLATE THIS CHAPTER INCLUDING SUBSECTION (G), (K),
(1), (1-1) OR (1-2) OF SECTION FORTY-THREE HUNDRED THREE OF THIS ARTI-
CLE.
§ 36. Subparagraph (C) of paragraph 1 of subsection (b) of section
4900 of the insurance law, as added by chapter 41 of the laws of 2014,
is amended and a new subparagraph (D) is added to read as follows:
(C) for purposes of a determination involving substance use disorder
treatment:
(i) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of substance use disorder courses of
treatment; or
(ii) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of
substance use disorder courses of treatment and, where applicable,
possesses a current and valid non-restricted license, certificate or
registration or, where no provision for a license, certificate or regis-
tration exists, is credentialed by the national accrediting body appro-
priate to the profession; [and] OR
(D) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION:
(I) A PHYSICIAN WHO POSSESSES A CURRENT AND VALID NON-RESTRICTED
LICENSE TO PRACTICE MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH
AND HAS EXPERIENCE IN THE DELIVERY OF MENTAL HEALTH COURSES OR TREAT-
MENT; OR
(II) A HEALTH CARE PROFESSIONAL OTHER THAN A LICENSED PHYSICIAN WHO
SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN THE DELIVERY OF
MENTAL HEALTH COURSES OF TREATMENT AND, WHERE APPLICABLE, POSSESSES A
CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE, OR REGISTRATION
OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR REGISTRATION
EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY APPROPRIATE TO
THE PROFESSION; AND
S. 1507 147 A. 2007
§ 37. Paragraph 9 of subsection (a) of section 4902 of the insurance
law, as amended by section 1 of part A of chapter 69 of the laws of
2016, is amended to read as follows:
(9) When conducting utilization review for purposes of determining
health care coverage for substance use disorder treatment, a utilization
review agent shall utilize AN evidence-based and peer reviewed clinical
review [tools designated by the office of alcoholism and substance abuse
services that are appropriate to the age of the patient and consistent
with the treatment service levels within the office of alcoholism and
substance abuse services system] TOOL THAT IS APPROPRIATE TO THE AGE OF
THE PATIENT. WHEN CONDUCTING SUCH UTILIZATION REVIEW FOR TREATMENT
PROVIDED IN THIS STATE, A UTILIZATION REVIEW AGENT SHALL UTILIZE AN
EVIDENCE-BASED AND PEER REVIEWED CLINICAL TOOL DESIGNATED BY THE OFFICE
OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES THAT IS CONSISTENT WITH THE
TREATMENT SERVICE LEVELS WITHIN THE OFFICE OF ALCOHOLISM AND SUBSTANCE
ABUSE SERVICES SYSTEM. All approved tools shall have inter rater reli-
ability testing completed by December thirty-first, two thousand
sixteen.
§ 38. Subsection (a) of section 4902 of the insurance law is amended
by adding a new paragraph 12 to read as follows:
(12) WHEN CONDUCTING UTILIZATION REVIEW FOR PURPOSES OF DETERMINING
HEALTH CARE COVERAGE FOR A MENTAL HEALTH CONDITION, A UTILIZATION REVIEW
AGENT SHALL UTILIZE EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW
CRITERIA THAT IS APPROPRIATE TO THE AGE OF THE PATIENT. THE UTILIZATION
REVIEW AGENT SHALL USE CLINICAL REVIEW CRITERIA DEEMED APPROPRIATE AND
APPROVED FOR SUCH USE BY THE COMMISSIONER OF THE OFFICE OF MENTAL
HEALTH, IN CONSULTATION WITH THE COMMISSIONER OF HEALTH AND THE SUPER-
INTENDENT. APPROVED CLINICAL REVIEW CRITERIA SHALL HAVE INTER RATER
RELIABILITY TESTING COMPLETED BY DECEMBER THIRTY-FIRST, TWO THOUSAND
NINETEEN.
§ 39. Paragraph (b) of subsection 5 of section 4403 of the public
health law, as added by chapter 705 of the laws of 1996, is amended to
read as follows:
(b) The following criteria shall be considered by the commissioner at
the time of a review: (i) the availability of appropriate and timely
care that is provided in compliance with the standards of the Federal
Americans with Disability Act to assure access to health care for the
enrollee population; (ii) the network's ability to provide culturally
and linguistically competent care to meet the needs of the enrollee
population; [and] (iii) THE AVAILABILITY OF APPROPRIATE AND TIMELY CARE
THAT IS IN COMPLIANCE WITH THE STANDARDS OF THE PAUL WELLSTONE AND PETE
DOMENICI MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008, 42
U.S.C. 18031(J), AND ANY AMENDMENTS TO, AND FEDERAL GUIDANCE AND REGU-
LATIONS ISSUED UNDER THOSE ACTS, WHICH SHALL INCLUDE AN ANALYSIS OF THE
RATE OF OUT-OF-NETWORK UTILIZATION FOR COVERED MENTAL HEALTH AND
SUBSTANCE USE DISORDER SERVICES AS COMPARED TO THE RATE OF OUT-OF-NET-
WORK UTILIZATION FOR THE RESPECTIVE CATEGORY OF MEDICAL SERVICES; AND
(IV) with the exception of initial licensure, the number of grievances
filed by enrollees relating to waiting times for appointments, appropri-
ateness of referrals and other indicators of plan capacity.
§ 40. Subdivision 3 of section 4406-c of the public health law, as
added by chapter 705 of the laws of 1996, is amended to read as follows:
3. No health care plan shall by contract, written policy [or], written
procedure OR PRACTICE prohibit or restrict any health care provider from
filing a complaint, making a report or commenting to an appropriate
governmental body regarding the policies or practices of such health
S. 1507 148 A. 2007
care plan which the provider believes may negatively impact upon the
quality of, or access to, patient care. NOR SHALL A HEALTH CARE PLAN
TAKE ANY ADVERSE ACTION, INCLUDING BUT NOT LIMITED TO REFUSING TO RENEW
OR EXECUTE A CONTRACT OR AGREEMENT WITH A HEALTH CARE PROVIDER AS RETAL-
IATION AGAINST A HEALTH CARE PROVIDER FOR FILING A COMPLAINT, MAKING A
REPORT OR COMMENTING TO AN APPROPRIATE GOVERNMENTAL BODY REGARDING POLI-
CIES OR PRACTICES OF SUCH HEALTH CARE PLAN WHICH MAY VIOLATE THIS CHAP-
TER OR THE INSURANCE LAW INCLUDING SUBSECTION (G), (K), (L), (L-1) OR
(1-2) OF SECTION FORTY-THREE HUNDRED THREE OF THE INSURANCE LAW.
§ 41. Paragraphs (r), (t) and (u) of subdivision 1 of section 4408 of
the public health law, paragraph (r) as amended and paragraphs (t) and
(u) as added by section 18 of part H of chapter 60 of the laws of 2014,
are amended and a new paragraph (v) is added to read as follows:
(r) a listing by specialty, which may be in a separate document that
is updated annually, of the name, address and telephone number of all
participating providers, including facilities, [and, in addition,] AND:
(I) WHETHER THE PROVIDER IS ACCEPTING NEW PATIENTS; (II) IN THE CASE OF
MENTAL HEALTH OR SUBSTANCE USE DISORDER SERVICES PROVIDERS, ANY AFFIL-
IATIONS WITH PARTICIPATING FACILITIES CERTIFIED OR AUTHORIZED BY THE
OFFICE OF MENTAL HEALTH OR THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE
SERVICES, AND ANY RESTRICTIONS REGARDING THE AVAILABILITY OF THE INDI-
VIDUAL PROVIDER'S SERVICES; AND (III) in the case of physicians, board
certification, languages spoken and any affiliations with participating
hospitals. The listing shall also be posted on the health maintenance
organization's website and the health maintenance organization shall
update the website within fifteen days of the addition or termination of
a provider from the health maintenance organization's network or a
change in a physician's hospital affiliation;
(t) with respect to out-of-network coverage:
(i) a clear description of the methodology used by the health mainte-
nance organization to determine reimbursement for out-of-network health
care services;
(ii) the amount that the health maintenance organization will reim-
burse under the methodology for out-of-network health care services set
forth as a percentage of the usual and customary cost for out-of-network
health care services;
(iii) examples of anticipated out-of-pocket costs for frequently
billed out-of-network health care services; [and]
(u) information in writing and through an internet website that
reasonably permits an enrollee or prospective enrollee to estimate the
anticipated out-of-pocket cost for out-of-network health care services
in a geographical area or zip code based upon the difference between
what the health maintenance organization will reimburse for out-of-net-
work health care services and the usual and customary cost for out-of-
network health care services[.]; AND
(V) THE MOST RECENT COMPARATIVE ANALYSIS PERFORMED BY THE HEALTH MAIN-
TENANCE ORGANIZATION TO ASSESS THE PROVISION OF ITS COVERED SERVICES IN
ACCORDANCE WITH THE PAUL WELLSTONE AND PETE DOMINICI MENTAL HEALTH PARI-
TY AND ADDICTION EQUITY ACT OF 2008, 42 U.S.C. 18031(J) AND ANY AMEND-
MENTS TO, AND FEDERAL GUIDANCE AND REGULATIONS ISSUED UNDER, THOSE ACTS.
§ 42. Subparagraph (iii) of paragraph (a) of subdivision 2 of section
4900 of the public health law, as added by chapter 41 of the laws of
2014, is amended and a new subparagraph (iv) is added to read as
follows:
(iii) for purposes of a determination involving substance use disorder
treatment:
S. 1507 149 A. 2007
(A) a physician who possesses a current and valid non-restricted
license to practice medicine and who specializes in behavioral health
and has experience in the delivery of substance use disorder courses of
treatment; or
(B) a health care professional other than a licensed physician who
specializes in behavioral health and has experience in the delivery of
substance use disorder courses of treatment and, where applicable,
possesses a current and valid non-restricted license, certificate or
registration or, where no provision for a license, certificate or regis-
tration exists, is credentialed by the national accrediting body appro-
priate to the profession; [and] OR
(IV) FOR PURPOSES OF A DETERMINATION INVOLVING TREATMENT FOR A MENTAL
HEALTH CONDITION:
(A) A PHYSICIAN WHO POSSESSES A CURRENT AND VALID NON-RESTRICTED
LICENSE TO PRACTICE MEDICINE AND WHO SPECIALIZES IN BEHAVIORAL HEALTH
AND HAS EXPERIENCE IN THE DELIVERY OF MENTAL HEALTH COURSES OF TREAT-
MENT; OR
(B) A HEALTH CARE PROFESSIONAL OTHER THAN A LICENSED PHYSICIAN WHO
SPECIALIZES IN BEHAVIORAL HEALTH AND HAS EXPERIENCE IN THE DELIVERY OF A
MENTAL HEALTH COURSES OF TREATMENT AND, WHERE APPLICABLE, POSSESSES A
CURRENT AND VALID NON-RESTRICTED LICENSE, CERTIFICATE, OR REGISTRATION
OR, WHERE NO PROVISION FOR A LICENSE, CERTIFICATE OR REGISTRATION
EXISTS, IS CREDENTIALED BY THE NATIONAL ACCREDITING BODY APPROPRIATE TO
THE PROFESSION; AND
§ 43. Paragraph (i) of subdivision 1 of section 4902 of the public
health law, as amended by section 2 of part A of chapter 69 of the laws
of 2016, is amended and a new paragraph (j) is added to read as follows:
(i) When conducting utilization review for purposes of determining
health care coverage for substance use disorder treatment, a utilization
review agent shall utilize AN evidence-based and peer reviewed clinical
review [tools designated by the office of alcoholism and substance abuse
services that are appropriate to the age of the patient and consistent
with the treatment service levels within the office of alcoholism and
substance abuse services system] TOOL THAT IS APPROPRIATE TO THE AGE OF
THE PATIENT. WHEN CONDUCTING SUCH UTILIZATION REVIEW FOR TREATMENT
PROVIDED IN THIS STATE, A UTILIZATION REVIEW AGENT SHALL UTILIZE AN
EVIDENCE-BASED AND PEER REVIEWED CLINICAL TOOL DESIGNATED BY THE OFFICE
OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES THAT IS CONSISTENT WITH THE
TREATMENT SERVICE LEVELS WITHIN THE OFFICE OF ALCOHOLISM AND SUBSTANCE
ABUSE SERVICES SYSTEM. All approved tools shall have inter rater reli-
ability testing completed by December thirty-first, two thousand
sixteen.
(J) WHEN CONDUCTING UTILIZATION REVIEW FOR PURPOSES OF DETERMINING
HEALTH CARE COVERAGE FOR A MENTAL HEALTH CONDITION, A UTILIZATION REVIEW
AGENT SHALL UTILIZE EVIDENCE-BASED AND PEER REVIEWED CLINICAL REVIEW
CRITERIA THAT IS APPROPRIATE TO THE AGE OF THE PATIENT. THE UTILIZATION
REVIEW AGENT SHALL USE CLINICAL REVIEW CRITERIA DEEMED APPROPRIATE AND
APPROVED FOR SUCH USE BY THE COMMISSIONER OF THE OFFICE OF MENTAL
HEALTH, IN CONSULTATION WITH THE COMMISSIONER AND THE SUPERINTENDENT OF
FINANCIAL SERVICES. APPROVED CLINICAL REVIEW CRITERIA SHALL HAVE INTER
RATER RELIABILITY TESTING COMPLETED BY DECEMBER THIRTY-FIRST, TWO THOU-
SAND NINETEEN.
§ 44. This act shall take effect on the first of January next succeed-
ing the date on which it shall have become a law and shall apply to all
policies and contracts issued, renewed, modified, altered or amended on
or after such date; provided, however, notwithstanding any provision of
S. 1507 150 A. 2007
law to the contrary, nothing in this act shall limit the rights accruing
to employees pursuant to a collective bargaining agreement with any
state or local government employer for the unexpired term of such agree-
ment where such agreement is in effect on the effective date of this act
and so long as such agreement remains in effect thereafter or the eligi-
bility of any member of an employee organization to join a health insur-
ance plan open to him or her pursuant to such a collectively negotiated
agreement.
SUBPART B
Section 1. Subdivision 1 of section 2803-u of the public health law,
as added by section 1 of part C of chapter 70 of the laws of 2016, is
amended to read as follows:
1. The office of alcoholism and substance abuse services, in consulta-
tion with the department, shall develop or utilize existing educational
materials to be provided to general hospitals to disseminate to individ-
uals with a documented substance use disorder or who appear to have or
be at risk for a substance use disorder during discharge planning pursu-
ant to section twenty-eight hundred three-i of this [chapter] ARTICLE.
Such materials shall include information regarding the various types of
treatment and recovery services, including but not limited to: inpa-
tient, outpatient, and medication-assisted treatment; how to recognize
the need for treatment services; information for individuals to deter-
mine what type and level of treatment is most appropriate and what
resources are available to them; and any other information the commis-
sioner deems appropriate. GENERAL HOSPITALS SHALL INCLUDE IN THEIR POLI-
CIES AND PROCEDURES TREATMENT PROTOCOLS, CONSISTENT WITH MEDICAL STAND-
ARDS, TO BE UTILIZED BY THE EMERGENCY DEPARTMENTS IN GENERAL HOSPITALS
FOR THE APPROPRIATE USE OF MEDICATION-ASSISTED TREATMENT, INCLUDING
BUPRENORPHINE, PRIOR TO DISCHARGE, OR REFERRAL PROTOCOLS FOR EVALUATION
OF MEDICATION-ASSISTED TREATMENT WHEN INITIATION IN AN EMERGENCY DEPART-
MENT OF A GENERAL HOSPITAL IS NOT FEASIBLE.
§ 2. This act shall take effect immediately.
SUBPART C
Section 1. Subparagraph (v) of paragraph (a) of subdivision 2 of
section 3343-a of the public health law is REPEALED and subparagraphs
(vi), (vii), (viii), (ix) and (x) are renumbered subparagraphs (v),
(vi), (vii), (viii) and (ix).
§ 2. This act shall take effect immediately.
SUBPART D
Section 1. Paragraph (r) of subdivision 4 of section 364-j of the
social services law, as amended by section 39 of part A of chapter 56 of
the laws of 2013, is amended to read as follows:
(r) A managed care provider shall provide services to participants
pursuant to an order of a court of competent jurisdiction, provided
however, that such services shall be within such provider's or plan's
benefit package and are reimbursable under title xix of the federal
social security act, PROVIDED THAT SERVICES FOR A SUBSTANCE USE DISORDER
SHALL BE PROVIDED BY A PROGRAM LICENSED, CERTIFIED OR OTHERWISE AUTHOR-
IZED BY THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES.
S. 1507 151 A. 2007
§ 2. This act shall take effect immediately; provided, however that
the amendments to paragraph (r) of subdivision 4 of section 364-j of the
social services law made by section one of this act shall not affect the
repeal of such section and shall be deemed to be repealed therewith.
SUBPART E
Section 1. Subdivision (b) of schedule I of section 3306 of the public
health law is amended by adding nineteen new paragraphs 58, 59, 60, 61,
62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75 and 76 to read as
follows:
(58) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLBUTYRAMIDE. OTHER NAME:
BUTYRYL FENTANYL.
(59) N-[1-[2-hydroxy-2-(thiophen-2-yl)ethyl]PIPERIDIN-4-Y1]-N-PHENYLPRO-
PIONAMIDE. OTHER NAME: BETA-HYDROXYTHIOFENTANYL.
(60) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLFURAN-2-CARBOXAMIDE. OTHER
NAME: FURANYL FENTANYL.
(61) 3,4-DICHLORO-N-[2-(dimethylamino)cyclohexyl]-N-METHYLBENZAMIDE.
OTHER NAME: U-47700.
(62) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLACRYLAMIDE. OTHER NAMES:
ACRYL FENTANYL OR ACRYLOYLFENTANYL.
(63) N-(4-FLUOROPHENY1)-N-(1-PHENETHYLPIPERIDIN-4-YL)ISOBUTYRAMIDE.
OTHER NAMES: 4-FLUOROISOBUTYRYL FENTANYL, PARA-FLUOROISOBUTYRYL FENTA-
NYL.
(64) N-(2-FLUOROPHENY1)-N-(1-PHENETHYLPIPERIDIN-4-YL)PROPIONAMIDE.
OTHER NAMES: ORTHO-FLUOROFENTANYL OR 2-FLUOROFENTANYL.
(65) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLTETRAHYDROFURAN-2-CARBOXAMIDE.
OTHER NAME: TETRAHYDROFURANYL FENTANYL.
(66) 2-METHOXY-N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLACETAMIDE. OTHER
NAME: METHOXYACETYL FENTANYL.
(67) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLCYCLOPROPANECARBOXAMIDE.
OTHER NAME: CYCLOPROPYL FENTANYL.
(68) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLPENTANAMIDE. OTHER NAME:
VALERYL FENTANYL.
(69) N-(4-FLUOROPHENY1)-N-(1-PHENETHYLPIPERIDIN-4-YL)BUTYRAMIDE. OTHER
NAME: PARA-FLUOROBUTYRYLFENTANYL.
(70) N-(4-METHOXYPHENY1)-N-(1-PHENETHYLPIPERIDIN-4-YL)BUTYRAMIDE.
OTHER NAME: PARA-METHOXYBUTYRYL FENTANYL.
(71) N-(4-CHLOROPHENY1)-N-(1-PHENETHYLPIPERIDIN-4-YL)ISOBUTYRAMIDE.
OTHER NAME: PARA-CHLOROISOBUTYRYL FENTANYL.
(72) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLISOBUTYRAMIDE. OTHER NAME:
ISOBUTYRYL FENTANYL.
(73) N-(1-PHENETHYLPIPERIDIN-4-Y1)-N-PHENYLCYCLOPENTANECARBOXAMIDE.
OTHER NAME: CYCLOPENTYL FENTANYL.
(74) N-(2-FLUOROPHENY1)-2-METHOXY-N-(1-PHENETHYLPIPERIDIN-4-YL)
ACETAMIDE. OTHER NAME: OCFENTANIL.
(75) 1-CYCLOHEXY1-4-(1,2-DIPHENYLETHYL)PIPERAZINE. OTHER NAME: MT-45.
(76) FENTANYL-RELATED SUBSTANCES, THEIR ISOMERS, ESTERS, ETHERS, SALTS
AND SALTS OF ISOMERS, ESTERS AND ETHERS.
(I) FENTANYL-RELATED SUBSTANCE MEANS ANY SUBSTANCE NOT OTHERWISE LIST-
ED IN THIS SECTION, THAT IS STRUCTURALLY RELATED TO FENTANYL BY ONE OR
MORE OF THE FOLLOWING MODIFICATIONS:
(A) REPLACEMENT OF THE PHENYL PORTION OF THE PHENETHYL GROUP BY ANY
MONOCYCLE, WHETHER OR NOT FURTHER SUBSTITUTED IN OR ON THE MONOCYCLE;
(B) SUBSTITUTION IN OR ON THE PHENETHYL GROUP WITH ALKYL, ALKENYL,
ALKOXYL, HYDROXYL, HALO, HALOALKYL, AMINO OR NITRO GROUPS;
S. 1507 152 A. 2007
(C) SUBSTITUTION IN OR ON THE PIPERIDINE RING WITH ALKYL, ALKENYL,
ALKOXYL, ESTER, ETHER, HYDROXYL, HALO, HALOALKYL, AMINO OR NITRO GROUPS;
(D) REPLACEMENT OF THE ANILINE RING WITH ANY AROMATIC MONOCYCLE WHETH-
ER OR NOT FURTHER SUBSTITUTED IN OR ON THE AROMATIC MONOCYCLE; AND/OR
(E) REPLACEMENT OF THE N-PROPIONYL GROUP BY ANOTHER ACYL GROUP.
§ 2. Section 3308 of the public health law is amended by adding a new
subdivision 7 to read as follows:
7. THE COMMISSIONER MAY, BY REGULATION, CLASSIFY AS A SCHEDULE I
CONTROLLED SUBSTANCE IN SECTION THREE THOUSAND THREE HUNDRED SIX OF THIS
ARTICLE ANY SUBSTANCE LISTED IN SCHEDULE I OF THE FEDERAL SCHEDULES OF
CONTROLLED SUBSTANCES IN 21 USC §812 OR 21 CFR §1308.11.
§ 3. This act shall take effect on the ninetieth day after it shall
have become a law.
§ 2. Severability clause. If any clause, sentence, paragraph, subdivi-
sion, section or part of this act shall be adjudged by any court of
competent jurisdiction to be invalid, such judgment shall not affect,
impair, or invalidate the remainder thereof, but shall be confined in
its operation to the clause, sentence, paragraph, subdivision, section
or part thereof directly involved in the controversy in which such judg-
ment shall have been rendered. It has hereby declared to be the intent
of the legislature that this act would have been enacted even if such
invalid provisions had not been included herein.
§ 3. This act shall take effect immediately provided, however, that
the applicable effective date of Subparts A through E of this act shall
be as specifically set forth in the last section of such Subparts.
§ 2. Severability clause. If any clause, sentence, paragraph, subdivi-
sion, section or part of this act shall be adjudged by any court of
competent jurisdiction to be invalid, such judgment shall not affect,
impair, or invalidate the remainder thereof, but shall be confined in
its operation to the clause, sentence, paragraph, subdivision, section
or part thereof directly involved in the controversy in which such judg-
ment shall have been rendered. It is hereby declared to be the intent of
the legislature that this act would have been enacted even if such
invalid provisions had not been included herein.
§ 3. This act shall take effect immediately provided, however, that
the applicable effective date of Parts A through BB of this act shall be
as specifically set forth in the last section of such Parts.