The New York State Senate

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

                                 5248--A

                       2019-2020 Regular Sessions

                          I N  A S S E M B L Y

                            February 8, 2019
                               ___________

Introduced  by M. of A. GOTTFRIED, ABINANTI, BARRETT, BARRON, BENEDETTO,
  BICHOTTE, BLAKE, BRONSON, BURKE, CAHILL, CARROLL, COLTON, COOK,  CRES-
  PO,  CRUZ,  CYMBROWITZ,  DE LA ROSA, DICKENS, DILAN, DINOWITZ, D'URSO,
  ENGLEBRIGHT, EPSTEIN,  FERNANDEZ,  FRONTUS,  GANTT,  HUNTER,  HYNDMAN,
  JAFFEE, JEAN-PIERRE, JOYNER, KIM, LAVINE, LIFTON, LUPARDO, M. G. MILL-
  ER, MOSLEY, NIOU, ORTIZ, PAULIN, PEOPLES-STOKES, PERRY, PHEFFER AMATO,
  PICHARDO,  RAMOS,  REYES, RICHARDSON, RIVERA, RODRIGUEZ, L. ROSENTHAL,
  SEAWRIGHT, SIMON, SIMOTAS, SOLAGES,  STECK,  STIRPE,  TAYLOR,  THIELE,
  VANEL,  WALKER,  WALLACE, WEINSTEIN, WEPRIN, WILLIAMS, WRIGHT, SAYEGH,
  FALL -- Multi-Sponsored by -- M. of A. ARROYO, AUBRY, DAVILA, DenDEKK-
  ER, FAHY, GALEF, GLICK, GUNTHER, LENTOL, MAGNARELLI, O'DONNELL,  PRET-
  LOW,  QUART,  D. ROSENTHAL,  ROZIC  --  read  once and referred to the
  Committee on Health -- recommitted  to  the  Committee  on  Health  in
  accordance  with Assembly Rule 3, sec. 2 -- committee discharged, bill
  amended, ordered reprinted as amended and recommitted to said  commit-
  tee

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

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

  Section  1.  Short  title. This act shall be known and may be cited as
the "New York health act".
  § 2. Legislative  findings  and  intent.  1.  The  state  constitution
states:  "The  protection and promotion of the health of the inhabitants
of the state are matters of public concern and provision therefor  shall
be made by the state and by such of its subdivisions and in such manner,
and by such means as the legislature shall from time to time determine."
(Article  XVII,  §3.)  The legislature finds and declares that all resi-
dents of the state have the right to health care.    While  the  federal
Affordable  Care Act brought many improvements in health care and health

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

                                                           LBD09777-06-0

A. 5248--A                          2

coverage, it still leaves many New  Yorkers  without  coverage  or  with
inadequate coverage.  Millions of New Yorkers do not get the health care
they  need  or face financial obstacles and hardships to get it. That is
not  acceptable.    There  is no plan other than the New York health act
that will enable New York state to meet that need.   New  Yorkers  -  as
individuals,  employers,  and taxpayers - have experienced a rise in the
cost of health care and  coverage  in  recent  years,  including  rising
premiums, deductibles and co-pays, restricted provider networks and high
out-of-network charges.  Many New Yorkers go without health care because
they  cannot  afford  it  or suffer financial hardship to get it.  Busi-
nesses have also experienced increases in the costs of health care bene-
fits for their employees, and many employers are shifting a larger share
of the cost of coverage to their employees or dropping coverage  entire-
ly.  Including long-term services and supports (LTSS) in New York Health
is  a major step forward for older adults, people with disabilities, and
their families. Older adults and people with disabilities  often  cannot
receive  the  services necessary to stay in the community or other LTSS.
Even when older adults and people with disabilities receive LTSS,  espe-
cially  services  in the community, it is often at the cost of unreason-
able demands on unpaid family caregivers, depleting their own or  family
resources,  or  impoverishing themselves to qualify for public coverage.
Health care providers are also affected by inadequate health coverage in
New York state. A large portion of hospitals, health centers  and  other
providers now experience substantial losses due to the provision of care
that  is  uncompensated.    Medicaid and Medicare often do not pay rates
that are reasonably related to the cost of efficiently providing  health
care services and sufficient to assure an adequate and accessible supply
of  health  care  services, as guaranteed under the New York Health Act.
Individuals often find that they are deprived  of  affordable  care  and
choice because of decisions by health plans guided by the plan's econom-
ic  interests rather than the individual's health care needs. To address
the fiscal crisis facing the health care system and  the  state  and  to
assure  New  Yorkers can exercise their right to health care, affordable
and comprehensive health coverage must  be  provided.  Pursuant  to  the
state constitution's charge to the legislature to provide for the health
of  New  Yorkers,  this legislation is an enactment of state concern for
the purpose of establishing a comprehensive universal guaranteed  health
care  coverage  program  and  a  health care cost control system for the
benefit of all residents of the state of New York.
  2. (a) It is the intent of the Legislature  to  create  the  New  York
Health program to provide a universal single payer health plan for every
New  Yorker, funded by broad-based revenue based on ability to pay.  The
legislature intends that federal waivers and approvals be  sought  where
they will improve the administration of the New York Health program, but
the  legislature  intends  that  the  program be implemented even in the
absence of such waivers or approvals.  The state shall  work  to  obtain
waivers  and  other  approvals  relating to Medicaid, Child Health Plus,
Medicare, the Affordable Care Act, and  any  other  appropriate  federal
programs,  under  which  federal  funds  and  other subsidies that would
otherwise be paid to New  York  State,  New  Yorkers,  and  health  care
providers  for  health  coverage that will be equaled or exceeded by New
York Health will be paid by the federal government to New York State and
deposited in the New York Health trust fund,  or  paid  to  health  care
providers and individuals in combination with New York Health trust fund
payments,  and for other program modifications (including elimination of
cost sharing and insurance premiums).  Under such waivers and approvals,

A. 5248--A                          3

health coverage under those programs will, to the maximum extent  possi-
ble,  be replaced and merged into New York Health, which will operate as
a true single-payer program.
  (b)  If  any  necessary  waiver or approval is not obtained, the state
shall use state plan amendments and seek waivers and approvals to  maxi-
mize,  and  make  as  seamless as possible, the use of federally-matched
health programs and federal health programs in New York Health.    Thus,
even where other programs such as Medicaid or Medicare may contribute to
paying  for  care,  it is the goal of this legislation that the coverage
will be delivered by New York Health  and,  as  much  as  possible,  the
multiple  sources  of  funding will be pooled with other New York Health
funds and not be apparent to New York Health  members  or  participating
providers.
  (c)  This  program  will  promote  movement  away from fee-for-service
payment, which tends to reward quantity and requires excessive  adminis-
trative  expense,  and  towards alternate payment methodologies, such as
global or capitated payments to providers or health care  organizations,
that  promote  quality, efficiency, investment in primary and preventive
care, and innovation and integration in the organizing of health care.
  (d) The program shall promote the use of clinical data to improve  the
quality  of health care and public health, consistent with protection of
patient confidentiality. The program shall maximize patient autonomy  in
choice  of  health care providers and health care decision making.  Care
coordination within the program shall ensure management and coordination
among a patient's health care services, consistent with patient autonomy
and person-centered service planning, rather than acting as a gatekeeper
to needed services.
  (e) The program shall operate with care, skill,  prudence,  diligence,
and professionalism, and for the best interests primarily of the members
and health care providers.
  3.  This  act  does  not create or relate to any employment benefit or
employment benefit plan, nor does it require,  prohibit,  or  limit  the
providing of any employment benefit or employment benefit plan.
  4. In order to promote improved quality of, and access to, health care
services and promote improved clinical outcomes, it is the policy of the
state  to  encourage cooperative, collaborative and integrative arrange-
ments among health care providers who might  otherwise  be  competitors,
under  the  active  supervision of the commissioner of health. It is the
intent of the state to supplant competition with such  arrangements  and
regulation  only  to  the extent necessary to accomplish the purposes of
this act, and to provide state  action  immunity  under  the  state  and
federal  antitrust  laws  to  health  care  providers, particularly with
respect to their relations with the single-payer New  York  Health  plan
created by this act.
  5.  There  have  been numerous professional economic analyses of state
and national single-payer  health  proposals,  including  the  New  York
Health Act, by noted consulting firms and academic economists. They have
almost  all  come  to  similar conclusions of net savings in the cost of
health coverage and health care. These savings are driven by (a)  elimi-
nating  the  administrative  bureaucracy costs, marketing, and profit of
multiple health plans and replacing that  with  the  dramatically  lower
costs  of  running a single-payer system; (b) substantially reducing the
administrative costs borne by health care providers dealing  with  those
health  plans; and (c) using the negotiating power of 20 million consum-
ers to achieve lower drug prices. These savings will  more  than  offset
costs primarily from (a) relieving patients of deductibles, co-pays, and

A. 5248--A                          4

out-of-network  charges;  (b)  covering  the  uninsured;  (c) increasing
provider payment rates  above  Medicare  and  Medicaid  rates;  and  (d)
replacing uncompensated home health care with paid care. Unlike premiums
and out-of-pocket spending, the New York Health Act tax will be progres-
sively  graduated  based  on  ability to pay.   The vast majority of New
Yorkers today spend dramatically more in premiums, deductibles and other
out-of-pocket costs than they will in New York Health Act taxes.    They
will  have  broader  coverage  (including long-term care), no restricted
provider networks or  out-of-network  charges,  and  no  deductibles  or
co-pays.
  §  3.  Article 50 and sections 5000, 5001, 5002 and 5003 of the public
health law are renumbered article 80 and sections 8000, 8001,  8002  and
8003, respectively, and a new article 51 is added to read as follows:
                               ARTICLE 51
                             NEW YORK HEALTH
SECTION 5100. DEFINITIONS.
        5101. PROGRAM CREATED.
        5102. BOARD OF TRUSTEES.
        5103. ELIGIBILITY AND ENROLLMENT.
        5104. BENEFITS.
        5105. HEALTH  CARE PROVIDERS; CARE COORDINATION; PAYMENT METHOD-
                OLOGIES.
        5106. HEALTH CARE ORGANIZATIONS.
        5107. PROGRAM STANDARDS.
        5108. REGULATIONS.
        5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS.
        5110. ADDITIONAL PROVISIONS.
        5111. REGIONAL ADVISORY COUNCILS.
  § 5100. DEFINITIONS. AS USED IN  THIS  ARTICLE,  THE  FOLLOWING  TERMS
SHALL  HAVE  THE FOLLOWING MEANINGS, UNLESS THE CONTEXT CLEARLY REQUIRES
OTHERWISE:
  1. "BOARD" MEANS THE BOARD OF TRUSTEES OF THE NEW YORK HEALTH  PROGRAM
CREATED  BY SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE, AND "TRUSTEE"
MEANS A TRUSTEE OF THE BOARD.
  2. "CARE COORDINATION" MEANS, BUT IS NOT LIMITED TO, MANAGING,  REFER-
RING TO, LOCATING, COORDINATING, AND MONITORING HEALTH CARE SERVICES FOR
THE  MEMBER  TO ASSURE THAT ALL MEDICALLY NECESSARY HEALTH CARE SERVICES
ARE MADE AVAILABLE TO AND ARE EFFECTIVELY USED BY THE MEMBER IN A TIMELY
MANNER, CONSISTENT WITH PATIENT AUTONOMY.  CARE  COORDINATION  DOES  NOT
INCLUDE  A  REQUIREMENT FOR PRIOR AUTHORIZATION FOR HEALTH CARE SERVICES
OR FOR REFERRAL FOR A MEMBER TO RECEIVE A HEALTH CARE SERVICE.
  3. "CARE COORDINATOR"  MEANS  AN  INDIVIDUAL  OR  ENTITY  APPROVED  TO
PROVIDE  CARE  COORDINATION  UNDER  SUBDIVISION TWO OF SECTION FIFTY-ONE
HUNDRED FIVE OF THIS ARTICLE.
  4. "FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM" MEANS THE MEDICAL ASSIST-
ANCE PROGRAM UNDER TITLE ELEVEN OF ARTICLE FIVE OF THE  SOCIAL  SERVICES
LAW,  THE BASIC HEALTH PROGRAM UNDER SECTION THREE HUNDRED SIXTY-NINE-GG
OF THE SOCIAL SERVICES LAW, AND THE  CHILD  HEALTH  PLUS  PROGRAM  UNDER
TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.
  5.  "HEALTH CARE ORGANIZATION" MEANS AN ENTITY THAT IS APPROVED BY THE
COMMISSIONER UNDER SECTION FIFTY-ONE HUNDRED  SIX  OF  THIS  ARTICLE  TO
PROVIDE HEALTH CARE SERVICES TO MEMBERS UNDER THE PROGRAM.
  6.  "HEALTH  CARE  PROVIDER"  MEANS  ANY  INDIVIDUAL OR ENTITY LEGALLY
AUTHORIZED TO PROVIDE A HEALTH CARE SERVICE UNDER MEDICAID  OR  MEDICARE
OR THIS ARTICLE. "HEALTH CARE PROFESSIONAL" MEANS A HEALTH CARE PROVIDER
THAT  IS  AN  INDIVIDUAL  LICENSED,  CERTIFIED,  REGISTERED OR OTHERWISE

A. 5248--A                          5

AUTHORIZED TO PRACTICE UNDER TITLE EIGHT OF THE EDUCATION LAW TO PROVIDE
SUCH HEALTH CARE SERVICE, ACTING WITHIN HIS OR HER LAWFUL SCOPE OF PRAC-
TICE.
  7. "HEALTH CARE SERVICE" MEANS ANY HEALTH CARE SERVICE, INCLUDING CARE
COORDINATION, INCLUDED AS A BENEFIT UNDER THE PROGRAM.
  8. "IMPLEMENTATION PERIOD" MEANS THE PERIOD UNDER SUBDIVISION THREE OF
SECTION  FIFTY-ONE  HUNDRED ONE OF THIS ARTICLE DURING WHICH THE PROGRAM
WILL BE SUBJECT TO SPECIAL ELIGIBILITY AND FINANCING PROVISIONS UNTIL IT
IS FULLY IMPLEMENTED UNDER THAT SECTION.
  9. "MEDICAID" OR "MEDICAL ASSISTANCE" MEANS TITLE  ELEVEN  OF  ARTICLE
FIVE  OF  THE  SOCIAL  SERVICES  LAW AND THE PROGRAM THEREUNDER.  "CHILD
HEALTH PLUS" MEANS TITLE ONE-A OF ARTICLE TWENTY-FIVE  OF  THIS  CHAPTER
AND  THE PROGRAM THEREUNDER. "MEDICARE" MEANS TITLE XVIII OF THE FEDERAL
SOCIAL SECURITY ACT AND THE PROGRAMS THEREUNDER.  "AFFORDABLE CARE  ACT"
MEANS THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT, PUBLIC LAW
111-148,  AS AMENDED BY THE HEALTH CARE AND EDUCATION RECONCILIATION ACT
OF 2010, PUBLIC LAW 111-152, AND AS  OTHERWISE  AMENDED  AND  ANY  REGU-
LATIONS  OR  GUIDANCE  ISSUED THEREUNDER.   "BASIC HEALTH PROGRAM" MEANS
SECTION THREE HUNDRED SIXTY-NINE-GG OF THE SOCIAL SERVICES LAW  AND  THE
PROGRAM THEREUNDER.
  10. "MEMBER" MEANS AN INDIVIDUAL WHO IS ENROLLED IN THE PROGRAM.
  11.  "NEW  YORK HEALTH", "NEW YORK HEALTH PROGRAM", AND "PROGRAM" MEAN
THE NEW YORK HEALTH PROGRAM CREATED BY SECTION FIFTY-ONE HUNDRED ONE  OF
THIS ARTICLE.
  12.  "NEW YORK HEALTH TRUST FUND" MEANS THE NEW YORK HEALTH TRUST FUND
ESTABLISHED UNDER SECTION EIGHTY-NINE-J OF THE STATE FINANCE LAW.
  13. "OUT-OF-STATE HEALTH CARE SERVICE" MEANS  A  HEALTH  CARE  SERVICE
PROVIDED  TO  A  MEMBER WHILE THE MEMBER IS TEMPORARILY OUT OF THE STATE
AND (A) IT IS MEDICALLY  NECESSARY  THAT  THE  HEALTH  CARE  SERVICE  BE
PROVIDED  WHILE  THE MEMBER IS OUT OF THE STATE, OR (B) IT IS CLINICALLY
APPROPRIATE THAT THE HEALTH CARE SERVICE BE  PROVIDED  BY  A  PARTICULAR
HEALTH  CARE PROVIDER LOCATED OUT OF THE STATE RATHER THAN IN THE STATE.
HOWEVER, ANY HEALTH CARE SERVICE PROVIDED TO A NEW YORK HEALTH  ENROLLEE
BY  A  HEALTH CARE PROVIDER QUALIFIED UNDER PARAGRAPH (A) OF SUBDIVISION
THREE OF SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE THAT IS  LOCATED
OUTSIDE  THE  STATE  SHALL NOT BE CONSIDERED AN OUT-OF-STATE SERVICE AND
SHALL BE COVERED AS OTHERWISE PROVIDED IN THIS ARTICLE.
  14. "PARTICIPATING PROVIDER" MEANS ANY INDIVIDUAL OR ENTITY THAT IS  A
HEALTH  CARE  PROVIDER  QUALIFIED  UNDER  SUBDIVISION  THREE  OF SECTION
FIFTY-ONE HUNDRED  FIVE  OF  THIS  ARTICLE  THAT  PROVIDES  HEALTH  CARE
SERVICES TO MEMBERS UNDER THE PROGRAM, OR A HEALTH CARE ORGANIZATION.
  15.  "PERSON"  MEANS ANY INDIVIDUAL OR NATURAL PERSON, TRUST, PARTNER-
SHIP, ASSOCIATION,  UNINCORPORATED  ASSOCIATION,  CORPORATION,  COMPANY,
LIMITED  LIABILITY  COMPANY,  PROPRIETORSHIP, JOINT VENTURE, FIRM, JOINT
STOCK ASSOCIATION, DEPARTMENT, AGENCY, AUTHORITY, OR OTHER LEGAL ENTITY,
WHETHER FOR-PROFIT, NOT-FOR-PROFIT OR GOVERNMENTAL.
  16. "PRESCRIPTION AND NON-PRESCRIPTION DRUGS" MEANS PRESCRIPTION DRUGS
AS DEFINED IN SECTION TWO HUNDRED SEVENTY OF THIS CHAPTER, AND NON-PRES-
CRIPTION SMOKING CESSATION PRODUCTS OR DEVICES.
  17. "RESIDENT" MEANS AN INDIVIDUAL WHOSE PRIMARY PLACE OF ABODE IS  IN
THE  STATE OR, IN THE CASE OF AN INDIVIDUAL WHOSE PRIMARY PLACE OF ABODE
IS NOT IN THE STATE, WHO IS EMPLOYED OR SELF-EMPLOYED FULL-TIME  IN  THE
STATE,  WITHOUT REGARD TO THE INDIVIDUAL'S IMMIGRATION STATUS, AS DETER-
MINED ACCORDING TO REGULATIONS OF THE COMMISSIONER.    SUCH  REGULATIONS
SHALL INCLUDE A PROCESS FOR APPEALING DENIALS OF RESIDENCY.

A. 5248--A                          6

  §  5101.  PROGRAM  CREATED.  1.  THE NEW YORK HEALTH PROGRAM IS HEREBY
CREATED IN THE DEPARTMENT. THE COMMISSIONER SHALL ESTABLISH  AND  IMPLE-
MENT  THE  PROGRAM UNDER THIS ARTICLE. THE PROGRAM SHALL PROVIDE COMPRE-
HENSIVE HEALTH COVERAGE TO EVERY RESIDENT WHO ENROLLS IN THE PROGRAM.
  2.  THE  COMMISSIONER SHALL, TO THE MAXIMUM EXTENT POSSIBLE, ORGANIZE,
ADMINISTER AND MARKET THE PROGRAM AND SERVICES AS A SINGLE PROGRAM UNDER
THE NAME "NEW YORK HEALTH" OR SUCH OTHER NAME AS THE COMMISSIONER  SHALL
DETERMINE,  REGARDLESS  OF UNDER WHICH LAW OR SOURCE THE DEFINITION OF A
BENEFIT IS FOUND INCLUDING (ON A VOLUNTARY BASIS) RETIREE  HEALTH  BENE-
FITS.  IN  IMPLEMENTING THIS ARTICLE, THE COMMISSIONER SHALL AVOID JEOP-
ARDIZING FEDERAL FINANCIAL PARTICIPATION IN  THESE  PROGRAMS  AND  SHALL
TAKE  CARE  TO  PROMOTE  PUBLIC UNDERSTANDING AND AWARENESS OF AVAILABLE
BENEFITS AND PROGRAMS.
  3. THE COMMISSIONER SHALL DETERMINE WHEN INDIVIDUALS MAY BEGIN ENROLL-
ING IN THE PROGRAM. THERE SHALL BE AN IMPLEMENTATION PERIOD, WHICH SHALL
BEGIN ON THE DATE THAT INDIVIDUALS MAY BEGIN ENROLLING  IN  THE  PROGRAM
AND  SHALL  END  AS DETERMINED BY THE COMMISSIONER.  INDIVIDUALS MAY NOT
ENROLL IN THE NEW YORK HEALTH PROGRAM UNTIL THE LEGISLATURE HAS  ENACTED
THE  REVENUE  PROPOSAL, AS AMENDED, AND AS THE LEGISLATURE SHALL FURTHER
PROVIDE.
  4. AN INSURER AUTHORIZED TO PROVIDE COVERAGE PURSUANT TO THE INSURANCE
LAW OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED  UNDER  THIS  CHAPTER
MAY,  IF  OTHERWISE  AUTHORIZED,  OFFER  BENEFITS  THAT DO NOT COVER ANY
SERVICE FOR WHICH COVERAGE IS OFFERED TO INDIVIDUALS UNDER THE  PROGRAM,
BUT  MAY NOT OFFER BENEFITS THAT COVER ANY SERVICE FOR WHICH COVERAGE IS
OFFERED TO INDIVIDUALS UNDER THE PROGRAM. PROVIDED, HOWEVER,  THAT  THIS
SUBDIVISION  SHALL  NOT  PROHIBIT (A) THE OFFERING OF ANY BENEFITS TO OR
FOR INDIVIDUALS, INCLUDING THEIR FAMILIES, WHO ARE EMPLOYED OR  SELF-EM-
PLOYED  IN  THE STATE BUT WHO ARE NOT RESIDENTS OF THE STATE, OR (B) THE
OFFERING OF BENEFITS DURING THE IMPLEMENTATION PERIOD TO INDIVIDUALS WHO
ENROLLED OR MAY ENROLL AS MEMBERS OF THE PROGRAM, OR (C) THE OFFERING OF
RETIREE HEALTH BENEFITS.
  5. A COLLEGE, UNIVERSITY OR OTHER INSTITUTION OF HIGHER  EDUCATION  IN
THE  STATE  MAY  PURCHASE COVERAGE UNDER THE PROGRAM FOR ANY STUDENT, OR
STUDENT'S DEPENDENT, WHO IS NOT A RESIDENT OF THE STATE.
  6. TO THE EXTENT ANY PROVISION OF THIS CHAPTER,  THE  SOCIAL  SERVICES
LAW, THE INSURANCE LAW OR THE ELDER LAW:
  (A) IS INCONSISTENT WITH ANY PROVISION OF THIS ARTICLE OR THE LEGISLA-
TIVE  INTENT  OF  THE  NEW YORK HEALTH ACT, THIS ARTICLE SHALL APPLY AND
PREVAIL, EXCEPT WHERE EXPLICITLY PROVIDED OTHERWISE BY THIS ARTICLE;  OR
EXPLICITLY REQUIRED BY APPLICABLE FEDERAL LAW OR REGULATIONS AND
  (B) IS CONSISTENT WITH THE PROVISIONS OF THIS ARTICLE AND THE LEGISLA-
TIVE  INTENT OF THE NEW YORK HEALTH ACT, THE PROVISION OF THAT LAW SHALL
APPLY.
  7.  (A) (I) THE PROGRAM SHALL BE DEEMED TO BE A HEALTH CARE  PLAN  FOR
PURPOSES  OF  EXTERNAL  APPEAL  UNDER ARTICLE FORTY-NINE OF THIS CHAPTER
(REFERRED TO IN THIS SUBDIVISION AS "ARTICLE  FORTY-NINE"),  SUBJECT  TO
THIS SUBDIVISION AND ANY OTHER APPLICABLE PROVISION OF THIS ARTICLE.
  (II)    AN  EXTERNAL APPEAL SHALL NOT REQUIRE UTILIZATION REVIEW OR AN
ADVERSE DETERMINATION UNDER TITLE ONE  OF  ARTICLE  FORTY-NINE  OF  THIS
CHAPTER.  ANY REFERENCE IN ARTICLE FORTY-NINE TO UTILIZATION REVIEW OR A
UNIVERSAL  REVIEW AGENT SHALL MEAN THE PROGRAM.  WHERE THE PROGRAM MAKES
AN ADVERSE DETERMINATION, AN EXTERNAL APPEAL SHALL BE  AUTOMATIC  UNLESS
SPECIFICALLY WAIVED OR WITHDRAWN BY THE MEMBER OR THE MEMBER'S DESIGNEE.
SERVICES,  INCLUDING  SERVICES  PROVIDED  FOR  A CHRONIC CONDITION, WILL
CONTINUE UNCHANGED UNTIL THE OUTCOME OF THE EXTERNAL APPEAL DECISION  IS

A. 5248--A                          7

ISSUED.  WHERE  AN  EXTERNAL  APPEAL  IS  INITIATED  OR  PURSUED  BY THE
PATIENT'S HEALTH CARE PROVIDER, THE PROVIDER SHALL NOTIFY THE MEMBER  OR
THE  MEMBER'S  DESIGNEE,  AND  IT  SHALL  BE  SUBJECT TO THE MEMBER'S OR
MEMBER'S  DESIGNEE'S RIGHT TO WAIVE OR WITHDRAW THE EXTERNAL APPEAL.  NO
FEE SHALL BE REQUIRED TO BE PAID BY ANY PARTY  TO  AN  EXTERNAL  APPEAL,
INCLUDING THE MEMBER'S HEALTH CARE PROVIDER.
  (III)    WHERE AN EXTERNAL APPEAL IS DENIED, THE EXTERNAL APPEAL AGENT
SHALL NOTIFY THE MEMBER OR THE MEMBER'S DESIGNEE AND, WHERE APPROPRIATE,
THE MEMBER'S HEALTH CARE PROVIDER,  WITHIN  TWO  BUSINESS  DAYS  OF  THE
DETERMINATION.    THE  NOTICE SHALL INCLUDE A STATEMENT THAT THE MEMBER,
MEMBER'S DESIGNEE OR HEALTH CARE PROVIDER HAS THE RIGHT  TO  APPEAL  THE
DETERMINATION TO A FAIR HEARING UNDER THIS SUBDIVISION AND SEEK JUDICIAL
REVIEW.
  (IV)  AN ENROLLEE MAY DESIGNATE A PERSON OR ENTITY, INCLUDING, BUT NOT
LIMITED  TO,  THE  ENROLLEE'S  FAMILY MEMBER, CARE COORDINATOR, A HEALTH
CARE ORGANIZATION PROVIDING THE SERVICE UNDER REVIEW  OR  APPEAL,  OR  A
LABOR UNION OR AN ENTITY AFFILIATED WITH AND DESIGNATED BY A LABOR UNION
OF  WHICH THE ENROLLEE OR ENROLLEE'S FAMILY MEMBER IS A MEMBER, TO SERVE
AS THE ENROLLEE'S DESIGNEE FOR PURPOSES OF THAT ARTICLE, IF  THE  PERSON
OR ENTITY AGREES TO BE THE DESIGNEE.
  (B)  (I)  THIS PARAGRAPH APPLIES WHERE AN EXTERNAL APPEAL IS DENIED IN
WHOLE OR IN PART; OR THE PROGRAM  DENIES  COVERAGE  FOR  A  HEALTH  CARE
SERVICE  ON  ANY  GROUNDS  OTHER  THAN  UNDER ARTICLE FORTY-NINE; OR THE
PROGRAM MAKES ANY OTHER DETERMINATION AS TO A MEMBER OR INDIVIDUAL SEEK-
ING TO BECOME A MEMBER, CONTRARY TO THE INTEREST OF THE MEMBER OR  INDI-
VIDUAL (INCLUDING BUT NOT LIMITED TO A DENIAL OF ELIGIBILITY FOR LACK OF
RESIDENCE).
  (II)  THE  PROGRAM  SHALL  NOTIFY  THE  MEMBER OR INDIVIDUAL, MEMBER'S
DESIGNEE OR HEALTH CARE PROVIDER, AS APPROPRIATE, THAT  THE  PERSON  HAS
THE  RIGHT  TO  APPEAL  THE  DETERMINATION  TO A FAIR HEARING UNDER THIS
SUBDIVISION OR SEEK JUDICIAL REVIEW.
  (III)  THE COMMISSIONER SHALL ESTABLISH BY REGULATION  A  PROCESS  FOR
FAIR  HEARINGS  UNDER THIS SUBDIVISION.   THE PROCESS SHALL AT A MINIMUM
CONFORM TO THE STANDARDS FOR FAIR HEARINGS UNDER SECTION  TWENTY-TWO  OF
THE SOCIAL SERVICES LAW.
  (C)    ARTICLE SEVENTY-EIGHT OF THE CIVIL PRACTICE LAW AND RULES SHALL
APPLY TO ANY MATTER UNDER THIS ARTICLE.
  8. (A) NO MEMBER SHALL BE REQUIRED TO RECEIVE ANY HEALTH CARE  SERVICE
THROUGH  ANY  ENTITY  ORGANIZED, CERTIFIED OR OPERATING UNDER GUIDELINES
UNDER ARTICLE FORTY-FOUR OF THIS CHAPTER,  OR  SPECIFIED  UNDER  SECTION
THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW, THE INSURANCE LAW
OR  THE  ELDER LAW. NO SUCH ENTITY SHALL RECEIVE PAYMENT FOR HEALTH CARE
SERVICES (OTHER THAN CARE COORDINATION) FROM THE PROGRAM.
  (B) HOWEVER, THIS SUBDIVISION SHALL NOT PRECLUDE THE USE OF A MEDICARE
MANAGED CARE ("MEDICARE ADVANTAGE") ENTITY OR OTHER ENTITY CREATED BY OR
UNDER THE DIRECTION OF THE PROGRAM WHERE REASONABLY NECESSARY  TO  MAXI-
MIZE  FEDERAL FINANCIAL PARTICIPATION OR OTHER FEDERAL FINANCIAL SUPPORT
UNDER ANY FEDERALLY-MATCHED  PUBLIC  HEALTH  PROGRAM,  MEDICARE  OR  THE
AFFORDABLE CARE ACT. ANY ENTITY UNDER THIS PARAGRAPH SHALL, TO THE MAXI-
MUM  EXTENT  FEASIBLE,  OPERATE  IN THE BACKGROUND, WITHOUT BURDEN ON OR
INTERFERENCE WITH THE MEMBER AND HEALTH CARE PROVIDER, WITHOUT DEPRIVING
THE MEMBER OR HEALTH CARE PROVIDER OF ANY RIGHT  OR  BENEFIT  UNDER  THE
PROGRAM AND OTHERWISE CONSISTENT WITH THIS ARTICLE.
  9.  THE  PROGRAM  SHALL  INCLUDE PROVISIONS FOR AN APPROPRIATE RESERVE
FUND.

A. 5248--A                          8

  10. (A) THIS SUBDIVISION APPLIES TO EVERY PERSON WHO IS A RETIREE OF A
PUBLIC EMPLOYER, AS DEFINED IN SECTION TWO  HUNDRED  ONE  OF  THE  CIVIL
SERVICE LAW, AND ANY PERSON WHO IS A BENEFICIARY OF THE RETIREE'S PUBLIC
EMPLOYEE RETIREE HEALTH BENEFIT. ANY REFERENCE TO THE RETIREE SHALL MEAN
AND  INCLUDE  ANY  BENEFICIARY OF THE RETIREE. THIS SUBDIVISION DOES NOT
CREATE OR INCREASE ANY  ELIGIBILITY  FOR  ANY  PUBLIC  EMPLOYEE  RETIREE
HEALTH  BENEFIT THAT WOULD NOT OTHERWISE EXIST AND DOES NOT DIMINISH ANY
PUBLIC EMPLOYEE RETIREE HEALTH BENEFIT.
  (B) THIS PARAGRAPH APPLIES TO THE RETIREE WHILE HE OR SHE IS  A  RESI-
DENT OF NEW YORK STATE. THE RETIREE SHALL ENROLL IN THE PROGRAM.  IF, BY
THE  IMPLEMENTATION  DATE,  THE RETIREE HAS NOT ENROLLED IN THE PROGRAM,
THE APPROPRIATE PUBLIC EMPLOYEE RETIREE HEALTH BENEFIT PROGRAM  AND  THE
COMMISSIONER SHALL ENROLL THE RETIREE IN THE NEW YORK HEALTH PROGRAM. IF
THE  RETIREE'S  PUBLIC  EMPLOYEE  RETIREE  HEALTH  BENEFIT  INCLUDES ANY
SERVICE FOR WHICH COVERAGE IS NOT OFFERED  UNDER  THE  NEW  YORK  HEALTH
PROGRAM,  THE  RETIREE  SHALL  CONTINUE TO RECEIVE THAT BENEFIT FROM THE
APPROPRIATE PUBLIC EMPLOYEE RETIREE HEALTH BENEFIT PROGRAM.
  (C) FOR EVERY RETIREE, WHILE HE OR SHE IS NOT A RESIDENT OF  NEW  YORK
STATE,  THE  APPROPRIATE  PUBLIC EMPLOYEE RETIREE HEALTH BENEFIT PROGRAM
SHALL MAINTAIN THE RETIREE'S PUBLIC EMPLOYEE RETIREE HEALTH  BENEFIT  AS
IF THIS ARTICLE HAD NOT BEEN ENACTED.
  § 5102. BOARD OF TRUSTEES. 1. THE NEW YORK HEALTH BOARD OF TRUSTEES IS
HEREBY  CREATED  IN  THE DEPARTMENT. THE BOARD OF TRUSTEES SHALL, AT THE
REQUEST OF THE COMMISSIONER,  CONSIDER  ANY  MATTER  TO  EFFECTUATE  THE
PROVISIONS AND PURPOSES OF THIS ARTICLE, AND MAY ADVISE THE COMMISSIONER
THEREON;  AND  IT MAY, FROM TIME TO TIME, SUBMIT TO THE COMMISSIONER ANY
RECOMMENDATIONS TO EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS  ARTI-
CLE.  THE  COMMISSIONER  MAY  PROPOSE REGULATIONS UNDER THIS ARTICLE AND
AMENDMENTS THERETO FOR CONSIDERATION BY THE BOARD. THE BOARD OF TRUSTEES
SHALL HAVE NO EXECUTIVE, ADMINISTRATIVE OR APPOINTIVE DUTIES  EXCEPT  AS
OTHERWISE  PROVIDED  BY  LAW.  THE BOARD OF TRUSTEES SHALL HAVE POWER TO
ESTABLISH, AND FROM TIME TO TIME, AMEND REGULATIONS  TO  EFFECTUATE  THE
PROVISIONS  AND  PURPOSES  OF  THIS  ARTICLE, SUBJECT TO APPROVAL BY THE
COMMISSIONER.
  2. THE BOARD SHALL BE COMPOSED OF:
  (A) THE COMMISSIONER, THE SUPERINTENDENT OF  FINANCIAL  SERVICES,  AND
THE DIRECTOR OF THE BUDGET, OR THEIR DESIGNEES, AS EX OFFICIO MEMBERS:
  (B) TWENTY-NINE TRUSTEES APPOINTED BY THE GOVERNOR;
  (I) SIX OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE CONSUMER ADVO-
CACY  ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY, WHO
HAVE BEEN INVOLVED IN ISSUES OF INTEREST  TO  LOW-  AND  MODERATE-INCOME
INDIVIDUALS,  OLDER ADULTS, AND PEOPLE WITH DISABILITIES; AT LEAST THREE
OF WHOM SHALL REPRESENT ORGANIZATIONS LED BY CONSUMERS IN THOSE GROUPS;
  (II) THREE OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL  ORGANIZA-
TIONS REPRESENTING PHYSICIANS;
  (III) THREE OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
TIONS  REPRESENTING  LICENSED  OR  REGISTERED  HEALTH CARE PROFESSIONALS
OTHER THAN PHYSICIANS;
  (IV) THREE OF WHOM SHALL BE REPRESENTATIVES OF GENERAL HOSPITALS,  ONE
OF WHOM SHALL BE A REPRESENTATIVE OF PUBLIC GENERAL HOSPITALS;
  (V) ONE OF WHOM SHALL BE A REPRESENTATIVE OF COMMUNITY HEALTH CENTERS;
  (VI)  TWO  OF  WHOM SHALL BE REPRESENTATIVES OF REHABILITATION OR HOME
CARE PROVIDERS;
  (VII) TWO OF WHOM SHALL BE REPRESENTATIVES  OF  BEHAVIORAL  OR  MENTAL
HEALTH OR DISABILITY SERVICE PROVIDERS;

A. 5248--A                          9

  (VIII)  TWO  OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE ORGANIZA-
TIONS;
  (IX) THREE OF WHOM SHALL BE REPRESENTATIVES OF ORGANIZED LABOR;
  (X)  TWO  OF  WHOM  SHALL  HAVE  DEMONSTRATED EXPERTISE IN HEALTH CARE
FINANCE; AND
  (XI) TWO OF WHOM SHALL BE EMPLOYERS OR  REPRESENTATIVES  OF  EMPLOYERS
WHO  PAY THE PAYROLL TAX UNDER THIS ARTICLE, OR, PRIOR TO THE TAX BECOM-
ING EFFECTIVE, WILL PAY THE TAX; AND
  (C) SIXTEEN TRUSTEES APPOINTED BY THE GOVERNOR;  SIX  OF  WHOM  TO  BE
APPOINTED  ON  THE RECOMMENDATION OF THE SPEAKER OF THE ASSEMBLY; SIX OF
WHOM TO BE APPOINTED ON THE RECOMMENDATION OF THE TEMPORARY PRESIDENT OF
THE SENATE; TWO OF WHOM TO BE APPOINTED ON  THE  RECOMMENDATION  OF  THE
MINORITY  LEADER OF THE ASSEMBLY; AND TWO OF WHOM TO BE APPOINTED ON THE
RECOMMENDATION OF THE MINORITY LEADER OF THE SENATE.
  3. (A) AFTER THE END OF THE IMPLEMENTATION PERIOD, NO PERSON SHALL  BE
A TRUSTEE UNLESS HE OR SHE IS A MEMBER OF THE PROGRAM.
  (B)  EACH  TRUSTEE SHALL SERVE AT THE PLEASURE OF THE APPOINTING OFFI-
CER, EXCEPT THE EX OFFICIO TRUSTEES.
  4. THE CHAIR OF THE BOARD SHALL BE APPOINTED, AND MAY  BE  REMOVED  AS
CHAIR,  BY THE GOVERNOR FROM AMONG THE TRUSTEES. THE BOARD SHALL MEET AT
LEAST FOUR TIMES EACH CALENDAR YEAR. MEETINGS SHALL  BE  HELD  UPON  THE
CALL  OF  THE  CHAIR  AND  AS  PROVIDED  BY THE BOARD. A MAJORITY OF THE
APPOINTED TRUSTEES SHALL BE A QUORUM OF THE BOARD, AND  THE  AFFIRMATIVE
VOTE  OF  A  MAJORITY  OF THE TRUSTEES VOTING, BUT NOT LESS THAN TWELVE,
SHALL BE NECESSARY FOR ANY ACTION TO BE TAKEN BY THE  BOARD.  THE  BOARD
MAY ESTABLISH AN EXECUTIVE COMMITTEE TO EXERCISE ANY POWERS OR DUTIES OF
THE BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO ASSIST THE BOARD OR
THE  EXECUTIVE  COMMITTEE. THE CHAIR OF THE BOARD SHALL CHAIR THE EXECU-
TIVE COMMITTEE AND SHALL APPOINT THE CHAIR  AND  MEMBERS  OF  ALL  OTHER
COMMITTEES.  THE  BOARD  OF  TRUSTEES  MAY  APPOINT ONE OR MORE ADVISORY
COMMITTEES. MEMBERS OF ADVISORY COMMITTEES NEED NOT BE  MEMBERS  OF  THE
BOARD OF TRUSTEES.
  5.  TRUSTEES  SHALL SERVE WITHOUT COMPENSATION BUT SHALL BE REIMBURSED
FOR THEIR NECESSARY AND ACTUAL EXPENSES INCURRED WHILE  ENGAGED  IN  THE
BUSINESS OF THE BOARD.
  6. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, NO OFFICER OR
EMPLOYEE OF THE STATE OR ANY LOCAL GOVERNMENT SHALL FORFEIT OR BE DEEMED
TO  HAVE  FORFEITED HIS OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A
TRUSTEE.
  7. THE BOARD AND ITS COMMITTEES AND ADVISORY  COMMITTEES  MAY  REQUEST
AND  RECEIVE  THE  ASSISTANCE  OF  THE DEPARTMENT AND ANY OTHER STATE OR
LOCAL GOVERNMENTAL ENTITY IN EXERCISING ITS POWERS AND DUTIES.
  8. NO LATER THAN TWO YEARS AFTER THE EFFECTIVE DATE OF THIS ARTICLE:
  (A) THE BOARD SHALL DEVELOP PROPOSALS FOR: (I)  INCORPORATING  RETIREE
HEALTH  BENEFITS INTO NEW YORK HEALTH; (II) ACCOMMODATING EMPLOYER RETI-
REE HEALTH BENEFITS FOR PEOPLE WHO HAVE BEEN MEMBERS OF NEW YORK  HEALTH
BUT  LIVE AS RETIREES OUT OF THE STATE; AND (III) ACCOMMODATING EMPLOYER
RETIREE HEALTH BENEFITS FOR PEOPLE WHO EARNED OR ACCRUED  SUCH  BENEFITS
WHILE  RESIDING  IN  THE  STATE  PRIOR TO THE IMPLEMENTATION OF NEW YORK
HEALTH AND LIVE AS RETIREES OUT OF THE STATE.  THE BOARD  SHALL  PRESENT
ITS PROPOSALS TO THE GOVERNOR AND THE LEGISLATURE.
  (B) THE BOARD SHALL DEVELOP A PROPOSAL FOR NEW YORK HEALTH COVERAGE OF
HEALTH  CARE  SERVICES  COVERED  UNDER  THE  WORKERS'  COMPENSATION LAW,
INCLUDING WHETHER AND HOW TO CONTINUE FUNDING FOR THOSE  SERVICES  UNDER
THAT  LAW  AND  WHETHER  AND HOW TO INCORPORATE AN ELEMENT OF EXPERIENCE
RATING.

A. 5248--A                         10

  (C) THE BOARD SHALL DEVELOP A PROPOSAL FOR NEW YORK  HEALTH  COVERAGE,
FOR  MEMBERS,  OF  HEALTH  CARE  SERVICES COVERED UNDER PARAGRAPH ONE OF
SUBSECTION (A) OF SECTION FIFTY-ONE HUNDRED TWO  OF  THE  INSURANCE  LAW
RELATING  TO  MOTOR VEHICLE INSURANCE REPARATIONS, INCLUDING WHETHER AND
HOW TO CONTINUE FUNDING FOR THOSE SERVICES.
  (D)  THE  BOARD  SHALL  DEVELOP  A PROPOSAL FOR INTEGRATION OF FEDERAL
VETERANS HEALTH ADMINISTRATION PROGRAMS WITH NEW YORK HEALTH COVERAGE OF
HEALTH CARE SERVICES; PROVIDED HOWEVER THAT ENROLLMENT IN OR ELIGIBILITY
FOR FEDERAL VETERANS HEALTH ADMINISTRATION PROGRAMS SHALL NOT  AFFECT  A
RESIDENT'S ELIGIBILITY FOR NEW YORK HEALTH COVERAGE.
  §  5103.  ELIGIBILITY  AND  ENROLLMENT. 1. EVERY RESIDENT OF THE STATE
SHALL BE ELIGIBLE AND ENTITLED TO ENROLL AS A MEMBER UNDER THE PROGRAM.
  2. NO INDIVIDUAL SHALL BE REQUIRED TO PAY ANY PREMIUM OR OTHER  CHARGE
FOR ENROLLING IN OR BEING A MEMBER UNDER THE PROGRAM.
  3.  A  NEWBORN  CHILD  SHALL BE ENROLLED AS OF THE DATE OF THE CHILD'S
BIRTH IF ENROLLMENT IS DONE PRIOR TO THE CHILD'S BIRTH OR  WITHIN  SIXTY
DAYS AFTER THE CHILD'S BIRTH.
  §  5104.  BENEFITS.  1. THE PROGRAM SHALL PROVIDE COMPREHENSIVE HEALTH
COVERAGE TO EVERY MEMBER, WHICH SHALL INCLUDE ALL HEALTH  CARE  SERVICES
REQUIRED  TO  BE  COVERED  UNDER ANY OF THE FOLLOWING, WITHOUT REGARD TO
WHETHER THE MEMBER WOULD OTHERWISE BE ELIGIBLE FOR  OR  COVERED  BY  THE
PROGRAM OR SOURCE REFERRED TO:
  (A) CHILD HEALTH PLUS;
  (B)  MEDICAID,  INCLUDING  BUT  NOT LIMITED TO SERVICES PROVIDED UNDER
MEDICAID WAIVER PROGRAMS, INCLUDING BUT NOT  LIMITED  TO  THOSE  GRANTED
UNDER  SECTION  1915  OF THE FEDERAL SOCIAL SECURITY ACT TO PERSONS WITH
TRAUMATIC BRAIN INJURIES OR QUALIFYING FOR NURSING  HOME  DIVERSION  AND
TRANSITION SERVICES;
  (C) MEDICARE;
  (D)  ARTICLE  FORTY-FOUR  OF  THIS  CHAPTER  OR  ARTICLE THIRTY-TWO OR
FORTY-THREE OF THE INSURANCE LAW;
  (E) ARTICLE ELEVEN OF THE CIVIL SERVICE LAW, AS OF THE DATE  ONE  YEAR
BEFORE THE BEGINNING OF THE IMPLEMENTATION PERIOD;
  (F)  ANY  COST  INCURRED DEFINED IN PARAGRAPH ONE OF SUBSECTION (A) OF
SECTION FIFTY-ONE HUNDRED TWO OF THE INSURANCE LAW, PROVIDED  THAT  THIS
COVERAGE  SHALL  NOT  REPLACE  COVERAGE  UNDER  ARTICLE FIFTY-ONE OF THE
INSURANCE LAW;
  (G) ANY ADDITIONAL HEALTH CARE SERVICE AUTHORIZED TO BE ADDED  TO  THE
PROGRAM'S BENEFITS BY THE PROGRAM; AND
  (H)  PROVIDED  THAT  WHERE  ANY STATE LAW OR REGULATION RELATED TO ANY
FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM STATES THAT A BENEFIT IS CONTIN-
GENT ON FEDERAL FINANCIAL PARTICIPATION, OR WORDS TO  THAT  EFFECT,  THE
BENEFIT  SHALL  BE  INCLUDED  UNDER  THE NEW YORK HEALTH PROGRAM WITHOUT
REGARD TO FEDERAL FINANCIAL PARTICIPATION.
  2. NO MEMBER SHALL BE REQUIRED TO PAY ANY PREMIUM, DEDUCTIBLE, CO-PAY-
MENT OR CO-INSURANCE UNDER THE PROGRAM.
  3. THE PROGRAM SHALL PROVIDE FOR PAYMENT UNDER THE PROGRAM FOR:
  (A) EMERGENCY AND TEMPORARY HEALTH CARE SERVICES PROVIDED TO A  MEMBER
OR  INDIVIDUAL  ENTITLED TO BECOME A MEMBER WHO HAS NOT HAD A REASONABLE
OPPORTUNITY TO BECOME A MEMBER OR TO ENROLL WITH A CARE COORDINATOR; AND
  (B) HEALTH CARE SERVICES PROVIDED IN AN EMERGENCY TO AN INDIVIDUAL WHO
IS ENTITLED TO BECOME A MEMBER OR  ENROLLED  WITH  A  CARE  COORDINATOR,
REGARDLESS OF HAVING HAD AN OPPORTUNITY TO DO SO.
  §  5105.  HEALTH  CARE PROVIDERS; CARE COORDINATION; PAYMENT METHODOL-
OGIES.  1. CHOICE OF HEALTH CARE PROVIDER. (A) ANY HEALTH CARE  PROVIDER
QUALIFIED  TO  PARTICIPATE  UNDER  THIS  SECTION MAY PROVIDE HEALTH CARE

A. 5248--A                         11

SERVICES UNDER THE PROGRAM, PROVIDED THAT THE HEALTH  CARE  PROVIDER  IS
OTHERWISE  LEGALLY AUTHORIZED TO PERFORM THE HEALTH CARE SERVICE FOR THE
INDIVIDUAL AND UNDER THE CIRCUMSTANCES INVOLVED.
  (B)  A  MEMBER  MAY  CHOOSE  TO RECEIVE HEALTH CARE SERVICES UNDER THE
PROGRAM FROM ANY PARTICIPATING PROVIDER, CONSISTENT WITH  PROVISIONS  OF
THIS  ARTICLE  RELATING  TO  CARE COORDINATION AND HEALTH CARE ORGANIZA-
TIONS, THE WILLINGNESS OR  AVAILABILITY  OF  THE  PROVIDER  (SUBJECT  TO
PROVISIONS  OF  THIS ARTICLE RELATING TO DISCRIMINATION), AND THE APPRO-
PRIATE CLINICALLY-RELEVANT CIRCUMSTANCES.
  2. CARE COORDINATION. (A) A CARE COORDINATOR MAY BE AN  INDIVIDUAL  OR
ENTITY THAT IS APPROVED BY THE PROGRAM THAT IS:
  (I)  A  HEALTH CARE PRACTITIONER WHO IS: (A) THE MEMBER'S PRIMARY CARE
PRACTITIONER; (B) AT THE OPTION OF A FEMALE MEMBER, THE MEMBER'S PROVID-
ER OF PRIMARY GYNECOLOGICAL CARE; OR (C) AT THE OPTION OF A  MEMBER  WHO
HAS  A  CHRONIC  CONDITION  THAT  REQUIRES  SPECIALTY CARE, A SPECIALIST
HEALTH CARE PRACTITIONER WHO REGULARLY AND CONTINUALLY  PROVIDES  TREAT-
MENT FOR THAT CONDITION TO THE MEMBER;
  (II)  AN ENTITY LICENSED UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR
CERTIFIED UNDER ARTICLE THIRTY-SIX OF THIS CHAPTER, OR, WITH RESPECT  TO
A  MEMBER  WHO  RECEIVES  CHRONIC MENTAL HEALTH CARE SERVICES, AN ENTITY
LICENSED UNDER ARTICLE THIRTY-ONE OF THE MENTAL  HYGIENE  LAW  OR  OTHER
ENTITY APPROVED BY THE COMMISSIONER IN CONSULTATION WITH THE COMMISSION-
ER OF MENTAL HEALTH;
  (III) A HEALTH CARE ORGANIZATION;
  (IV)  A  LABOR  UNION OR AN ENTITY AFFILIATED WITH AND DESIGNATED BY A
LABOR UNION OF WHICH THE ENROLLEE  OR  ENROLLEE'S  FAMILY  MEMBER  IS  A
MEMBER,  WITH  RESPECT TO ITS MEMBERS AND THEIR FAMILY MEMBERS; PROVIDED
THAT THIS PROVISION SHALL NOT PRECLUDE SUCH AN ENTITY  FROM  BECOMING  A
CARE  COORDINATOR  UNDER  SUBPARAGRAPH (V) OF THIS PARAGRAPH OR A HEALTH
CARE ORGANIZATION UNDER SECTION FIFTY-ONE HUNDRED SIX OF  THIS  ARTICLE;
OR
  (V) ANY NOT-FOR-PROFIT OR GOVERNMENTAL ENTITY APPROVED BY THE PROGRAM.
  (B)(I)  EVERY  MEMBER SHALL ENROLL WITH A CARE COORDINATOR THAT AGREES
TO PROVIDE CARE COORDINATION TO THE MEMBER  PRIOR  TO  RECEIVING  HEALTH
CARE  SERVICES  TO  BE PAID FOR UNDER THE PROGRAM.  HEALTH CARE SERVICES
PROVIDED TO A MEMBER SHALL NOT BE SUBJECT TO PAYMENT UNDER  THE  PROGRAM
UNLESS  THE  MEMBER  IS ENROLLED WITH A CARE COORDINATOR AT THE TIME THE
HEALTH CARE SERVICE IS PROVIDED.
  (II) THIS PARAGRAPH SHALL NOT APPLY TO HEALTH CARE  SERVICES  PROVIDED
UNDER  SUBDIVISION THREE OF SECTION FIFTY-ONE HUNDRED FOUR OF THIS ARTI-
CLE (CERTAIN EMERGENCY OR TEMPORARY SERVICES).
  (III) THE MEMBER SHALL REMAIN  ENROLLED  WITH  THAT  CARE  COORDINATOR
UNTIL  THE  MEMBER BECOMES ENROLLED WITH A DIFFERENT CARE COORDINATOR OR
CEASES TO BE A MEMBER. MEMBERS HAVE THE RIGHT TO CHANGE THEIR CARE COOR-
DINATOR ON TERMS AT LEAST AS PERMISSIVE AS  THE  PROVISIONS  OF  SECTION
THREE  HUNDRED  SIXTY-FOUR-J  OF  THE SOCIAL SERVICES LAW RELATING TO AN
INDIVIDUAL CHANGING HIS OR HER PRIMARY CARE  PROVIDER  OR  MANAGED  CARE
PROVIDER.
  (C)  CARE COORDINATION SHALL BE PROVIDED TO THE MEMBER BY THE MEMBER'S
CARE COORDINATOR.  A CARE COORDINATOR MAY EMPLOY OR UTILIZE THE SERVICES
OF OTHER INDIVIDUALS OR ENTITIES TO ASSIST  IN  PROVIDING  CARE  COORDI-
NATION FOR THE MEMBER, CONSISTENT WITH REGULATIONS OF THE COMMISSIONER.
  (D)  A  HEALTH  CARE ORGANIZATION MAY ESTABLISH RULES RELATING TO CARE
COORDINATION FOR MEMBERS IN THE HEALTH CARE ORGANIZATION, DIFFERENT FROM
THIS SUBDIVISION BUT OTHERWISE CONSISTENT WITH THIS  ARTICLE  AND  OTHER
APPLICABLE LAWS.

A. 5248--A                         12

  (E) THE COMMISSIONER SHALL DEVELOP AND IMPLEMENT PROCEDURES AND STAND-
ARDS FOR AN INDIVIDUAL OR ENTITY TO BE APPROVED TO BE A CARE COORDINATOR
IN  THE  PROGRAM,  INCLUDING BUT NOT LIMITED TO PROCEDURES AND STANDARDS
RELATING TO THE REVOCATION,  SUSPENSION,  LIMITATION,  OR  ANNULMENT  OF
APPROVAL  ON A DETERMINATION THAT THE INDIVIDUAL OR ENTITY IS NOT QUALI-
FIED OR COMPETENT TO BE A CARE COORDINATOR OR HAS EXHIBITED A COURSE  OF
CONDUCT  WHICH  IS  EITHER INCONSISTENT WITH PROGRAM STANDARDS AND REGU-
LATIONS OR WHICH EXHIBITS AN UNWILLINGNESS TO MEET  SUCH  STANDARDS  AND
REGULATIONS,  OR  IS  A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY.
SUCH PROCEDURES AND STANDARDS SHALL NOT LIMIT  APPROVAL  TO  BE  A  CARE
COORDINATOR  IN  THE  PROGRAM  FOR  CRITERIA OTHER THAN THOSE UNDER THIS
SECTION AND SHALL BE CONSISTENT  WITH  GOOD  PROFESSIONAL  PRACTICE.  IN
DEVELOPING  THE  PROCEDURES  AND  STANDARDS, THE COMMISSIONER SHALL: (I)
CONSIDER  EXISTING  STANDARDS  DEVELOPED  BY  NATIONAL  ACCREDITING  AND
PROFESSIONAL  ORGANIZATIONS;  AND  (II)  CONSULT WITH NATIONAL AND LOCAL
ORGANIZATIONS WORKING ON CARE COORDINATION OR SIMILAR MODELS,  INCLUDING
HEALTH  CARE  PRACTITIONERS, HOSPITALS, CLINICS, AND CONSUMERS AND THEIR
REPRESENTATIVES. WHEN DEVELOPING AND IMPLEMENTING STANDARDS OF  APPROVAL
OF  CARE  COORDINATORS  FOR  INDIVIDUALS RECEIVING CHRONIC MENTAL HEALTH
CARE SERVICES, THE COMMISSIONER SHALL CONSULT WITH THE  COMMISSIONER  OF
MENTAL  HEALTH.  AN  INDIVIDUAL  OR ENTITY MAY NOT BE A CARE COORDINATOR
UNLESS THE SERVICES INCLUDED IN CARE COORDINATION ARE WITHIN  THE  INDI-
VIDUAL'S PROFESSIONAL SCOPE OF PRACTICE OR THE ENTITY'S LEGAL AUTHORITY.
  (F)  TO  MAINTAIN APPROVAL UNDER THE PROGRAM, A CARE COORDINATOR MUST:
(I) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE COMMISSIONER;  AND
(II)  PROVIDE  DATA TO THE DEPARTMENT AS REQUIRED BY THE COMMISSIONER TO
ENABLE THE COMMISSIONER TO EVALUATE THE IMPACT OF CARE  COORDINATORS  ON
QUALITY, OUTCOMES, COST, AND PATIENT AND PROVIDER SATISFACTION.
  (G)  NOTHING  IN  THIS  SUBDIVISION  SHALL AUTHORIZE ANY INDIVIDUAL TO
ENGAGE IN ANY ACT IN VIOLATION OF TITLE EIGHT OF THE EDUCATION LAW.
  3. HEALTH CARE PROVIDERS. (A) THE  COMMISSIONER  SHALL  ESTABLISH  AND
MAINTAIN PROCEDURES AND STANDARDS FOR HEALTH CARE PROVIDERS TO BE QUALI-
FIED  TO PARTICIPATE IN THE PROGRAM, INCLUDING BUT NOT LIMITED TO PROCE-
DURES AND STANDARDS RELATING TO THE REVOCATION, SUSPENSION,  LIMITATION,
OR ANNULMENT OF QUALIFICATION TO PARTICIPATE ON A DETERMINATION THAT THE
HEALTH  CARE  PROVIDER IS NOT QUALIFIED OR COMPETENT TO BE A PROVIDER OF
SPECIFIC HEALTH CARE SERVICES OR HAS EXHIBITED A COURSE OF CONDUCT WHICH
IS EITHER INCONSISTENT WITH PROGRAM STANDARDS AND REGULATIONS  OR  WHICH
EXHIBITS  AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR IS
A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH  PROCEDURES  AND
STANDARDS  SHALL  NOT  LIMIT  HEALTH  CARE PROVIDER PARTICIPATION IN THE
PROGRAM FOR CRITERIA OTHER THAN THOSE UNDER THIS SECTION  AND  SHALL  BE
CONSISTENT  WITH GOOD PROFESSIONAL PRACTICE.  SUCH PROCEDURES AND STAND-
ARDS MAY BE DIFFERENT FOR DIFFERENT TYPES OF HEALTH CARE  PROVIDERS  AND
HEALTH  CARE  PROFESSIONALS.    THE COMMISSIONER MAY REQUIRE THAT HEALTH
CARE PROVIDERS AND HEALTH CARE PROFESSIONALS  PARTICIPATE  IN  MEDICAID,
CHILD HEALTH PLUS, OR MEDICARE TO QUALIFY TO PARTICIPATE IN THE PROGRAM.
ANY  HEALTH  CARE  PROVIDER THAT IS QUALIFIED TO PARTICIPATE UNDER MEDI-
CAID, CHILD HEALTH PLUS OR MEDICARE SHALL BE DEEMED TO BE  QUALIFIED  TO
PARTICIPATE  IN  THE PROGRAM, AND ANY HEALTH CARE PROVIDER'S REVOCATION,
SUSPENSION, LIMITATION, OR ANNULMENT OF QUALIFICATION TO PARTICIPATE  IN
ANY  OF  THOSE PROGRAMS SHALL APPLY TO THE HEALTH CARE PROVIDER'S QUALI-
FICATION TO PARTICIPATE IN THE PROGRAM;  PROVIDED  THAT  A  HEALTH  CARE
PROVIDER  QUALIFIED  UNDER  THIS SENTENCE SHALL FOLLOW THE PROCEDURES TO
BECOME QUALIFIED UNDER THE PROGRAM BY  THE  END  OF  THE  IMPLEMENTATION
PERIOD.

A. 5248--A                         13

  (B) THE COMMISSIONER SHALL ESTABLISH AND MAINTAIN PROCEDURES AND STAN-
DARDS FOR RECOGNIZING HEALTH CARE PROVIDERS LOCATED OUT OF THE STATE FOR
PURPOSES OF PROVIDING COVERAGE UNDER THE PROGRAM FOR OUT-OF-STATE HEALTH
CARE SERVICES.
  (C)  PROCEDURES  AND  STANDARDS  UNDER  THIS SUBDIVISION SHALL INCLUDE
PROVISIONS FOR EXPEDITED TEMPORARY QUALIFICATION TO PARTICIPATE  IN  THE
PROGRAM FOR HEALTH CARE PROFESSIONALS WHO ARE (I) TEMPORARILY AUTHORIZED
TO  PRACTICE  IN  THE STATE OR (II) ARE RECENTLY ARRIVED IN THE STATE OR
RECENTLY AUTHORIZED TO PRACTICE IN THE STATE.
  4. PAYMENT FOR HEALTH CARE SERVICES.  (A)  (I)  THE  COMMISSIONER  MAY
ESTABLISH  BY  REGULATION PAYMENT METHODOLOGIES FOR HEALTH CARE SERVICES
AND CARE COORDINATION PROVIDED TO MEMBERS UNDER THE PROGRAM  BY  PARTIC-
IPATING  PROVIDERS,  CARE  COORDINATORS,  AND HEALTH CARE ORGANIZATIONS.
THERE MAY BE A VARIETY OF  DIFFERENT  PAYMENT  METHODOLOGIES,  INCLUDING
THOSE ESTABLISHED ON A DEMONSTRATION BASIS.
  (II)  ALL  PAYMENT  METHODOLOGIES AND RATES UNDER THE PROGRAM SHALL BE
REASONABLE AND REASONABLY RELATED TO THE COST OF  EFFICIENTLY  PROVIDING
THE  HEALTH  CARE SERVICE AND ASSURING AN ADEQUATE AND ACCESSIBLE SUPPLY
OF THE HEALTH CARE SERVICE.
  (III) IN DETERMINING SUCH PAYMENT METHODOLOGIES AND RATES, THE COMMIS-
SIONER SHALL CONSIDER FACTORS INCLUDING USUAL AND CUSTOMARY RATES  IMME-
DIATELY PRIOR TO THE IMPLEMENTATION OF THE PROGRAM, REPORTED IN A BENCH-
MARKING DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE
SUPERINTENDENT OF FINANCIAL SERVICES, UNDER SECTION SIX HUNDRED THREE OF
THE  FINANCIAL SERVICES LAW; THE LEVEL OF TRAINING, EDUCATION, AND EXPE-
RIENCE OF THE HEALTH CARE PROVIDER OR PROVIDERS INVOLVED; AND THE  SCOPE
OF  SERVICES, COMPLEXITY, AND CIRCUMSTANCES OF CARE INCLUDING GEOGRAPHIC
FACTORS. UNTIL AND UNLESS OTHER  APPLICABLE  PAYMENT  METHODOLOGIES  ARE
ESTABLISHED,  HEALTH CARE SERVICES PROVIDED TO MEMBERS UNDER THE PROGRAM
SHALL BE PAID FOR ON A FEE-FOR-SERVICE BASIS, EXCEPT  FOR  CARE  COORDI-
NATION.
  (B)  THE  PROGRAM  SHALL ENGAGE IN GOOD FAITH NEGOTIATIONS WITH HEALTH
CARE PROVIDERS' REPRESENTATIVES UNDER TITLE III OF ARTICLE FORTY-NINE OF
THIS CHAPTER, INCLUDING, BUT NOT LIMITED TO, IN  RELATION  TO  RATES  OF
PAYMENT AND PAYMENT METHODOLOGIES.
  (C) (I) PRESCRIPTION DRUGS ELIGIBLE FOR REIMBURSEMENT UNDER THIS ARTI-
CLE AND DISPENSED BY A PHARMACY SHALL BE PROVIDED AND PAID FOR UNDER THE
PREFERRED  DRUG PROGRAM AND THE CLINICAL DRUG REVIEW PROGRAM UNDER TITLE
ONE OF ARTICLE TWO-A OF THIS CHAPTER, EXCEPT AS  OTHERWISE  PROVIDED  IN
THIS  PARAGRAPH.    AS  USED  IN THIS PARAGRAPH, "MANAGED CARE PROVIDER"
MEANS AN ENTITY UNDER PARAGRAPH (B)  OF  SUBDIVISION  EIGHT  OF  SECTION
FIFTY-ONE  HUNDRED  ONE OF THIS ARTICLE THAT QUALIFIES UNDER THE FEDERAL
PUBLIC HEALTH SERVICES ACT (THE "340B PROGRAM").
  (II) WHERE THE MEMBER IS ENROLLED IN A MANAGED  CARE  PROVIDER  AND  A
PRESCRIPTION  FOR  THE  MEMBER IS MADE UNDER SECTION 340B OF THE FEDERAL
PUBLIC HEALTH SERVICE ACT (THE "340B PROGRAM") AND UNDER A MEMORANDUM OF
UNDERSTANDING RELATING TO THE 340B PROGRAM BETWEEN THE NEW  YORK  HEALTH
PROGRAM  AND  THE RELEVANT 340B PROGRAM COVERED ENTITY, THE MANAGED CARE
PROVIDER SHALL PURCHASE, PAY FOR AND PROVIDE FOR  THE  DRUGS  UNDER  THE
340B  PROGRAM. HOWEVER, THE PRESCRIPTION SHALL BE SUBJECT TO SECTION TWO
HUNDRED SEVENTY-THREE (PREFERRED DRUG PROGRAM PRIOR  AUTHORIZATION)  AND
SECTION  TWO HUNDRED SEVENTY-FOUR (CLINICAL DRUG REVIEW PROGRAM) OF THIS
CHAPTER.
  (III) THE NEW YORK HEALTH PROGRAM SHALL  ENTER  INTO  AND  MAINTAIN  A
MEMORANDUM  OF UNDERSTANDING RELATING TO THE 340B PROGRAM WITH EACH 340B
COVERED ENTITY IN THE STATE THAT AGREES TO DO SO.

A. 5248--A                         14

  (IV) WHERE PRESCRIPTION DRUGS ARE NOT DISPENSED  THROUGH  A  PHARMACY,
PAYMENT  SHALL  BE MADE AS OTHERWISE PROVIDED IN THIS ARTICLE, INCLUDING
USE OF THE 340B PROGRAM AS APPROPRIATE.
  (D)  PAYMENT  FOR  HEALTH CARE SERVICES ESTABLISHED UNDER THIS ARTICLE
SHALL BE CONSIDERED PAYMENT IN FULL. A PARTICIPATING PROVIDER SHALL  NOT
CHARGE  ANY RATE IN EXCESS OF THE PAYMENT ESTABLISHED UNDER THIS ARTICLE
FOR ANY HEALTH CARE SERVICE PROVIDED UNDER THE  PROGRAM  AND  SHALL  NOT
SOLICIT  OR  ACCEPT  PAYMENT FROM ANY MEMBER OR THIRD PARTY FOR ANY SUCH
SERVICE EXCEPT AS PROVIDED UNDER SECTION FIFTY-ONE HUNDRED NINE OF  THIS
ARTICLE.    HOWEVER,  THIS PARAGRAPH SHALL NOT PRECLUDE THE PROGRAM FROM
ACTING AS A PRIMARY OR  SECONDARY  PAYER  IN  CONJUNCTION  WITH  ANOTHER
THIRD-PARTY  PAYER  WHERE PERMITTED UNDER SECTION FIFTY-ONE HUNDRED NINE
OF THIS ARTICLE.
  (E) THE PROGRAM MAY PROVIDE IN PAYMENT METHODOLOGIES FOR  PAYMENT  FOR
CAPITAL  RELATED  EXPENSES  FOR SPECIFICALLY IDENTIFIED CAPITAL EXPENDI-
TURES INCURRED BY  NOT-FOR-PROFIT  OR  GOVERNMENTAL  ENTITIES  CERTIFIED
UNDER  ARTICLE TWENTY-EIGHT OF THIS CHAPTER. ANY CAPITAL RELATED EXPENSE
GENERATED BY A CAPITAL EXPENDITURE THAT REQUIRES  OR  REQUIRED  APPROVAL
UNDER  ARTICLE  TWENTY-EIGHT  OF  THIS  CHAPTER  MUST HAVE RECEIVED THAT
APPROVAL FOR THE CAPITAL RELATED  EXPENSE  TO  BE  PAID  FOR  UNDER  THE
PROGRAM.
  (F) PAYMENT METHODOLOGIES AND RATES SHALL INCLUDE A DISTINCT COMPONENT
OF  REIMBURSEMENT  FOR DIRECT AND INDIRECT GRADUATE MEDICAL EDUCATION AS
DEFINED, CALCULATED AND IMPLEMENTED  PURSUANT  TO  SECTION  TWENTY-EIGHT
HUNDRED SEVEN-C OF THIS CHAPTER.
  (G)  THE COMMISSIONER SHALL PROVIDE BY  REGULATION FOR PAYMENT METHOD-
OLOGIES AND PROCEDURES FOR PAYING FOR OUT-OF-STATE HEALTH CARE SERVICES.
  5. PRIOR AUTHORIZATION. THE PROGRAM SHALL NOT REQUIRE  PRIOR  AUTHORI-
ZATION  FOR  ANY  HEALTH  CARE SERVICE IN ANY MANNER MORE RESTRICTIVE OF
ACCESS TO OR PAYMENT FOR THE SERVICE THAN  WOULD  BE  REQUIRED  FOR  THE
SERVICE  UNDER  MEDICARE  PART  A  OR  PART  B.  PRIOR AUTHORIZATION FOR
PRESCRIPTION DRUGS PROVIDED BY PHARMACIES UNDER  THE  PROGRAM  SHALL  BE
UNDER TITLE ONE OF ARTICLE TWO-A OF THIS CHAPTER.
  §  5106.  HEALTH  CARE ORGANIZATIONS. 1. A MEMBER MAY CHOOSE TO ENROLL
WITH AND RECEIVE HEALTH CARE SERVICES UNDER THE PROGRAM  FROM  A  HEALTH
CARE ORGANIZATION.
  2.  A  HEALTH  CARE  ORGANIZATION SHALL BE A NOT-FOR-PROFIT OR GOVERN-
MENTAL ENTITY THAT IS APPROVED BY THE COMMISSIONER THAT IS:
  (A) AN ACCOUNTABLE CARE ORGANIZATION UNDER  ARTICLE  TWENTY-NINE-E  OF
THIS CHAPTER; OR
  (B)  A  LABOR  UNION  OR AN ENTITY AFFILIATED WITH AND DESIGNATED BY A
LABOR UNION OF WHICH THE ENROLLEE  OR  ENROLLEE'S  FAMILY  MEMBER  IS  A
MEMBER  (I)  WITH  RESPECT  TO ITS MEMBERS AND THEIR FAMILY MEMBERS, AND
(II) IF ALLOWED BY APPLICABLE LAW AND APPROVED BY THE COMMISSIONER,  FOR
OTHER MEMBERS OF THE PROGRAM.
  3.  A HEALTH CARE ORGANIZATION MAY BE RESPONSIBLE FOR PROVIDING ALL OR
PART OF THE HEALTH CARE SERVICES TO WHICH ITS MEMBERS ARE ENTITLED UNDER
THE PROGRAM, CONSISTENT WITH THE TERMS OF ITS APPROVAL  BY  THE  COMMIS-
SIONER.
  4.  (A)  THE  COMMISSIONER  SHALL DEVELOP AND IMPLEMENT PROCEDURES AND
STANDARDS FOR AN ENTITY TO BE APPROVED TO BE A HEALTH CARE  ORGANIZATION
IN  THE  PROGRAM,  INCLUDING BUT NOT LIMITED TO PROCEDURES AND STANDARDS
RELATING TO THE REVOCATION,  SUSPENSION,  LIMITATION,  OR  ANNULMENT  OF
APPROVAL  ON  A  DETERMINATION  THAT THE ENTITY IS NOT COMPETENT TO BE A
HEALTH CARE ORGANIZATION OR HAS EXHIBITED A COURSE OF CONDUCT  WHICH  IS
EITHER  INCONSISTENT  WITH  PROGRAM  STANDARDS  AND REGULATIONS OR WHICH

A. 5248--A                         15

EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS, OR  IS
A  POTENTIAL  THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES AND
STANDARDS SHALL NOT LIMIT APPROVAL TO BE A HEALTH CARE  ORGANIZATION  IN
THE  PROGRAM  FOR CRITERIA OTHER THAN THOSE UNDER THIS SECTION AND SHALL
BE CONSISTENT WITH GOOD PROFESSIONAL PRACTICE. IN DEVELOPING THE  PROCE-
DURES AND STANDARDS, THE COMMISSIONER SHALL: (I) CONSIDER EXISTING STAN-
DARDS  DEVELOPED BY NATIONAL ACCREDITING AND PROFESSIONAL ORGANIZATIONS;
AND (II) CONSULT WITH NATIONAL AND LOCAL ORGANIZATIONS  WORKING  IN  THE
FIELD OF HEALTH CARE ORGANIZATIONS, INCLUDING HEALTH CARE PRACTITIONERS,
HOSPITALS,  CLINICS, LONG-TERM SUPPORTS AND SERVICE PROVIDERS, CONSUMERS
AND THEIR REPRESENTATIVES AND LABOR  ORGANIZATIONS  REPRESENTING  HEALTH
CARE  WORKERS. WHEN DEVELOPING AND IMPLEMENTING STANDARDS OF APPROVAL OF
HEALTH CARE ORGANIZATIONS,  THE  COMMISSIONER  SHALL  CONSULT  WITH  THE
COMMISSIONER  OF  MENTAL HEALTH, THE COMMISSIONER OF DEVELOPMENTAL DISA-
BILITIES, THE DIRECTOR OF THE STATE OFFICE FOR THE AGING AND THE COMMIS-
SIONER OF THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES.
  (B) TO MAINTAIN APPROVAL UNDER THE PROGRAM, A HEALTH CARE ORGANIZATION
MUST: (I) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE  COMMISSION-
ER;  AND  (II) PROVIDE DATA TO THE DEPARTMENT AS REQUIRED BY THE COMMIS-
SIONER TO ENABLE THE COMMISSIONER TO EVALUATE THE HEALTH CARE  ORGANIZA-
TION  IN  RELATION  TO  QUALITY  OF  HEALTH  CARE  SERVICES, HEALTH CARE
OUTCOMES, COST, AND PATIENT AND PROVIDER SATISFACTION.
  5. THE COMMISSIONER SHALL MAKE REGULATIONS  RELATING  TO  HEALTH  CARE
ORGANIZATIONS  CONSISTENT  WITH AND TO ENSURE COMPLIANCE WITH THIS ARTI-
CLE.
  6. THE PROVISION OF HEALTH CARE SERVICES DIRECTLY OR INDIRECTLY  BY  A
HEALTH  CARE  ORGANIZATION  THROUGH  HEALTH  CARE PROVIDERS SHALL NOT BE
CONSIDERED THE PRACTICE OF A PROFESSION UNDER TITLE EIGHT OF THE  EDUCA-
TION LAW BY THE HEALTH CARE ORGANIZATION.
  §  5107.  PROGRAM  STANDARDS.  1.  THE  COMMISSIONER  SHALL  ESTABLISH
REQUIREMENTS AND STANDARDS FOR THE PROGRAM AND FOR HEALTH CARE ORGANIZA-
TIONS, CARE COORDINATORS, AND HEALTH  CARE  PROVIDERS,  CONSISTENT  WITH
THIS ARTICLE, INCLUDING REQUIREMENTS AND STANDARDS FOR, AS APPLICABLE:
  (A) THE SCOPE, QUALITY AND ACCESSIBILITY OF HEALTH CARE SERVICES;
  (B) RELATIONS BETWEEN HEALTH CARE ORGANIZATIONS OR HEALTH CARE PROVID-
ERS AND MEMBERS; AND
  (C)  RELATIONS  BETWEEN  HEALTH  CARE  ORGANIZATIONS  AND  HEALTH CARE
PROVIDERS, INCLUDING (I) CREDENTIALING AND PARTICIPATION IN  THE  HEALTH
CARE ORGANIZATION; AND (II) TERMS, METHODS AND RATES OF PAYMENT.
  2. REQUIREMENTS AND STANDARDS UNDER THE PROGRAM SHALL INCLUDE, BUT NOT
BE LIMITED TO, PROVISIONS TO PROMOTE THE FOLLOWING:
  (A)  SIMPLIFICATION,  TRANSPARENCY, UNIFORMITY, AND FAIRNESS IN HEALTH
CARE PROVIDER CREDENTIALING AND PARTICIPATION IN HEALTH  CARE  ORGANIZA-
TION  NETWORKS, REFERRALS, PAYMENT PROCEDURES AND RATES, CLAIMS PROCESS-
ING, AND APPROVAL OF HEALTH CARE SERVICES, AS APPLICABLE;
  (B) PRIMARY AND PREVENTIVE  CARE,  CARE  COORDINATION,  EFFICIENT  AND
EFFECTIVE  HEALTH  CARE  SERVICES,  QUALITY  ASSURANCE, COORDINATION AND
INTEGRATION OF HEALTH CARE SERVICES, INCLUDING USE OF APPROPRIATE  TECH-
NOLOGY, AND PROMOTION OF PUBLIC, ENVIRONMENTAL AND OCCUPATIONAL HEALTH;
  (C) ELIMINATION OF HEALTH CARE DISPARITIES;
  (D) NON-DISCRIMINATION WITH RESPECT TO MEMBERS AND HEALTH CARE PROVID-
ERS ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, RELIGION, DISABIL-
ITY,  AGE,  SEX,  SEXUAL  ORIENTATION, GENDER IDENTITY OR EXPRESSION, OR
ECONOMIC CIRCUMSTANCES; PROVIDED  THAT  HEALTH  CARE  SERVICES  PROVIDED
UNDER THE PROGRAM SHALL BE APPROPRIATE TO THE PATIENT'S CLINICALLY-RELE-
VANT CIRCUMSTANCES;

A. 5248--A                         16

  (E)  ACCESSIBILITY  OF  CARE  COORDINATION,  HEALTH  CARE ORGANIZATION
SERVICES AND HEALTH CARE SERVICES, INCLUDING  ACCESSIBILITY  FOR  PEOPLE
WITH DISABILITIES AND PEOPLE WITH LIMITED ABILITY TO SPEAK OR UNDERSTAND
ENGLISH,  AND  THE PROVIDING OF CARE COORDINATION, HEALTH CARE ORGANIZA-
TION SERVICES AND HEALTH CARE SERVICES IN A CULTURALLY COMPETENT MANNER;
AND
  (F)  ESPECIALLY  IN  RELATION  TO LONG-TERM SUPPORTS AND SERVICES, THE
MAXIMIZATION AND PRIORITIZATION OF THE MOST  INTEGRATED  COMMUNITY-BASED
SUPPORTS AND SERVICES.
  3. ANY PARTICIPATING PROVIDER OR CARE COORDINATOR THAT IS ORGANIZED AS
A  FOR-PROFIT  ENTITY (OTHER THAN A PROFESSIONAL PRACTICE OF ONE OR MORE
HEALTH CARE PROFESSIONALS) SHALL BE REQUIRED TO MEET THE  SAME  REQUIRE-
MENTS  AND  STANDARDS  AS ENTITIES ORGANIZED AS NOT-FOR-PROFIT ENTITIES,
AND PAYMENTS UNDER THE PROGRAM PAID TO SUCH ENTITIES SHALL NOT BE CALCU-
LATED TO ACCOMMODATE THE GENERATION OF PROFIT OR REVENUE  FOR  DIVIDENDS
OR  OTHER RETURN ON INVESTMENT OR THE PAYMENT OF TAXES THAT WOULD NOT BE
PAID BY A NOT-FOR-PROFIT ENTITY.
  4. EVERY PARTICIPATING PROVIDER SHALL  FURNISH  TO  THE  PROGRAM  SUCH
INFORMATION  TO,  AND PERMIT EXAMINATION OF ITS RECORDS BY, THE PROGRAM,
AS MAY BE REASONABLY REQUIRED FOR PURPOSES  OF  REVIEWING  ACCESSIBILITY
AND  UTILIZATION  OF  HEALTH CARE SERVICES, QUALITY ASSURANCE, PROMOTING
IMPROVED PATIENT OUTCOMES AND COST CONTAINMENT, THE MAKING OF  PAYMENTS,
AND  STATISTICAL OR OTHER STUDIES OF THE OPERATION OF THE PROGRAM OR FOR
PROTECTION AND  PROMOTION  OF  PUBLIC,  ENVIRONMENTAL  AND  OCCUPATIONAL
HEALTH.
  5.  IN  DEVELOPING  REQUIREMENTS AND STANDARDS AND MAKING OTHER POLICY
DETERMINATIONS UNDER THIS ARTICLE, THE COMMISSIONER SHALL  CONSULT  WITH
REPRESENTATIVES  OF  MEMBERS,  HEALTH CARE PROVIDERS, CARE COORDINATORS,
HEALTH CARE ORGANIZATIONS  EMPLOYERS, ORGANIZED LABOR  INCLUDING  REPRE-
SENTATIVES OF HEALTH CARE WORKERS, AND OTHER INTERESTED PARTIES.
  6.  THE PROGRAM SHALL MAINTAIN THE SECURITY AND CONFIDENTIALITY OF ALL
DATA AND OTHER INFORMATION COLLECTED UNDER THE PROGRAM  WHEN  SUCH  DATA
WOULD  BE NORMALLY CONSIDERED CONFIDENTIAL PATIENT DATA.  AGGREGATE DATA
OF THE PROGRAM WHICH IS DERIVED FROM  CONFIDENTIAL  DATA  BUT  DOES  NOT
VIOLATE  PATIENT  CONFIDENTIALITY  SHALL BE PUBLIC INFORMATION INCLUDING
FOR PURPOSES OF ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  § 5108. REGULATIONS. THE COMMISSIONER  SHALL  MAKE  REGULATIONS  UNDER
THIS  ARTICLE  BY  APPROVING  REGULATIONS  AND AMENDMENTS THERETO, UNDER
SUBDIVISION ONE OF SECTION FIFTY-ONE HUNDRED TWO OF  THIS  ARTICLE.  THE
COMMISSIONER MAY MAKE REGULATIONS OR AMENDMENTS THERETO UNDER THIS ARTI-
CLE  ON  AN  EMERGENCY  BASIS UNDER SECTION TWO HUNDRED TWO OF THE STATE
ADMINISTRATIVE PROCEDURE ACT, PROVIDED THAT SUCH REGULATIONS  OR  AMEND-
MENTS SHALL NOT BECOME PERMANENT UNLESS ADOPTED UNDER SUBDIVISION ONE OF
SECTION FIFTY-ONE HUNDRED TWO OF THIS ARTICLE.
  § 5109. PROVISIONS RELATING TO FEDERAL HEALTH PROGRAMS. 1. THE COMMIS-
SIONER  SHALL  SEEK  ALL FEDERAL WAIVERS AND OTHER FEDERAL APPROVALS AND
ARRANGEMENTS AND SUBMIT STATE PLAN AMENDMENTS NECESSARY TO  OPERATE  THE
PROGRAM CONSISTENT WITH THIS ARTICLE TO THE MAXIMUM EXTENT POSSIBLE.  NO
PROVISION OF THIS ARTICLE AND NO ACTION UNDER THE PROGRAM SHALL DIMINISH
ANY  RIGHT OR BENEFIT THE MEMBER WOULD OTHERWISE HAVE UNDER ANY FEDERAL-
LY-MATCHED PROGRAM OR MEDICARE.
  2. (A) THE COMMISSIONER SHALL APPLY TO THE  SECRETARY  OF  HEALTH  AND
HUMAN  SERVICES OR OTHER APPROPRIATE FEDERAL OFFICIAL FOR ALL WAIVERS OF
REQUIREMENTS, AND MAKE OTHER ARRANGEMENTS, UNDER MEDICARE, ANY  FEDERAL-
LY-MATCHED PUBLIC HEALTH PROGRAM, THE AFFORDABLE CARE ACT, AND ANY OTHER
FEDERAL  PROGRAMS THAT PROVIDE FEDERAL FUNDS FOR PAYMENT FOR HEALTH CARE

A. 5248--A                         17

SERVICES, THAT ARE NECESSARY TO ENABLE ALL NEW YORK  HEALTH  MEMBERS  TO
RECEIVE ALL BENEFITS UNDER THE PROGRAM THROUGH THE PROGRAM TO ENABLE THE
STATE  TO  IMPLEMENT THIS ARTICLE AND TO RECEIVE AND DEPOSIT ALL FEDERAL
PAYMENTS  UNDER  THOSE PROGRAMS (INCLUDING FUNDS THAT MAY BE PROVIDED IN
LIEU OF PREMIUM TAX CREDITS, COST-SHARING SUBSIDIES, AND SMALL  BUSINESS
TAX  CREDITS) IN THE STATE TREASURY TO THE CREDIT OF THE NEW YORK HEALTH
TRUST FUND AND TO USE THOSE FUNDS FOR THE NEW YORK  HEALTH  PROGRAM  AND
OTHER PROVISIONS UNDER THIS ARTICLE. TO THE EXTENT POSSIBLE, THE COMMIS-
SIONER SHALL NEGOTIATE ARRANGEMENTS WITH THE FEDERAL GOVERNMENT IN WHICH
BULK  OR  LUMP-SUM FEDERAL PAYMENTS ARE PAID TO NEW YORK HEALTH IN PLACE
OF  FEDERAL  SPENDING  OR  TAX  BENEFITS  FOR  FEDERALLY-MATCHED  HEALTH
PROGRAMS  OR  FEDERAL  HEALTH  PROGRAMS.    THE  COMMISSIONER SHALL TAKE
ACTIONS UNDER PARAGRAPH (B) OF SUBDIVISION EIGHT  OF  SECTION  FIFTY-ONE
HUNDRED ONE OF THIS ARTICLE AS REASONABLY NECESSARY.
  (B)  THE  COMMISSIONER MAY REQUIRE MEMBERS OR APPLICANTS TO BE MEMBERS
TO PROVIDE INFORMATION NECESSARY FOR THE  PROGRAM  TO  COMPLY  WITH  ANY
WAIVER OR ARRANGEMENT UNDER THIS SUBDIVISION.
  3.  (A) THE COMMISSIONER MAY TAKE ACTIONS CONSISTENT WITH THIS ARTICLE
TO ENABLE NEW YORK HEALTH TO ADMINISTER MEDICARE IN NEW YORK  STATE,  TO
CREATE  A  MEDICARE  MANAGED CARE PLAN ("MEDICARE ADVANTAGE") THAT WOULD
OPERATE CONSISTENT WITH THIS ARTICLE, AND  TO  BE  A  PROVIDER  OF  DRUG
COVERAGE UNDER MEDICARE PART D FOR ELIGIBLE MEMBERS OF NEW YORK HEALTH.
  (B)  THE  COMMISSIONER  MAY  WAIVE  OR  MODIFY  THE  APPLICABILITY  OF
PROVISIONS OF THIS SECTION  RELATING  TO  ANY  FEDERALLY-MATCHED  PUBLIC
HEALTH  PROGRAM  OR  MEDICARE  AS  NECESSARY  TO IMPLEMENT ANY WAIVER OR
ARRANGEMENT UNDER THIS SECTION OR TO MAXIMIZE THE  BENEFIT  TO  THE  NEW
YORK  HEALTH PROGRAM UNDER THIS SECTION, PROVIDED THAT THE COMMISSIONER,
IN CONSULTATION WITH THE DIRECTOR OF THE BUDGET,  SHALL  DETERMINE  THAT
SUCH  WAIVER  OR  MODIFICATION  IS  IN THE BEST INTERESTS OF THE MEMBERS
AFFECTED BY THE ACTION AND THE  STATE,  AND  PROVIDED  FURTHER  THAT  NO
ACTION  UNDER  THIS  PARAGRAPH  SHALL  DIMINISH ANY RIGHT OR BENEFIT THE
MEMBER WOULD OTHERWISE HAVE UNDER THE PROGRAM OR  ANY  FEDERALLY-MATCHED
PUBLIC HEALTH PROGRAM OR MEDICARE.
  (C)  THE  COMMISSIONER  MAY  APPLY  FOR  COVERAGE UNDER ANY FEDERALLY-
MATCHED PUBLIC HEALTH PROGRAM ON BEHALF OF ANY  MEMBER  AND  ENROLL  THE
MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM OR MEDICARE IF THE
MEMBER  IS  ELIGIBLE  FOR IT.   ENROLLMENT IN A FEDERALLY-MATCHED PUBLIC
HEALTH PROGRAM OR MEDICARE SHALL NOT CAUSE ANY MEMBER TO LOSE ANY HEALTH
CARE SERVICE PROVIDED BY THE PROGRAM OR DIMINISH ANY  RIGHT  OR  BENEFIT
THE MEMBER WOULD OTHERWISE HAVE.
  (D) THE COMMISSIONER SHALL BY REGULATION INCREASE THE INCOME ELIGIBIL-
ITY  LEVEL,  INCREASE  OR  ELIMINATE  THE RESOURCE TEST FOR ELIGIBILITY,
SIMPLIFY ANY PROCEDURAL OR DOCUMENTATION REQUIREMENT FOR ENROLLMENT, AND
INCREASE THE BENEFITS FOR ANY FEDERALLY-MATCHED PUBLIC  HEALTH  PROGRAM,
AND  FOR ANY PROGRAM TO REDUCE OR ELIMINATE AN INDIVIDUAL'S COINSURANCE,
COST-SHARING OR PREMIUM OBLIGATIONS OR INCREASE AN  INDIVIDUAL'S  ELIGI-
BILITY  FOR  ANY  FEDERAL  FINANCIAL  SUPPORT RELATED TO MEDICARE OR THE
AFFORDABLE CARE ACT NOTWITHSTANDING ANY LAW OR REGULATION TO THE CONTRA-
RY. THE COMMISSIONER MAY  ACT  UNDER  THIS  PARAGRAPH  UPON  A  FINDING,
APPROVED BY THE DIRECTOR OF THE BUDGET, THAT THE ACTION (I) WILL HELP TO
INCREASE  THE  NUMBER  OF  MEMBERS  WHO ARE ELIGIBLE FOR AND ENROLLED IN
FEDERALLY-MATCHED PUBLIC HEALTH PROGRAMS, OR FOR ANY PROGRAM  TO  REDUCE
OR  ELIMINATE AN INDIVIDUAL'S COINSURANCE, COST-SHARING OR PREMIUM OBLI-
GATIONS OR INCREASE AN INDIVIDUAL'S ELIGIBILITY FOR ANY  FEDERAL  FINAN-
CIAL  SUPPORT  RELATED TO MEDICARE OR THE AFFORDABLE CARE ACT; (II) WILL
NOT DIMINISH ANY INDIVIDUAL'S ACCESS TO ANY HEALTH CARE SERVICE, BENEFIT

A. 5248--A                         18

OR RIGHT THE INDIVIDUAL WOULD OTHERWISE HAVE; (III) IS IN  THE  INTEREST
OF  THE PROGRAM; AND (IV) DOES NOT REQUIRE OR HAS RECEIVED ANY NECESSARY
FEDERAL WAIVERS OR APPROVALS TO ENSURE FEDERAL FINANCIAL PARTICIPATION.
  (E)  TO  ENABLE  THE  COMMISSIONER  TO APPLY FOR COVERAGE OR FINANCIAL
SUPPORT UNDER ANY FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM, THE  AFFORDA-
BLE  CARE ACT, OR MEDICARE ON BEHALF OF ANY MEMBER AND ENROLL THE MEMBER
IN ANY SUCH PROGRAM, INCLUDING AN ENTITY UNDER PARAGRAPH (B) OF SUBDIVI-
SION EIGHT OF SECTION FIFTY-ONE HUNDRED  ONE  OF  THIS  ARTICLE  IF  THE
MEMBER  IS  ELIGIBLE  FOR  IT,  THE  COMMISSIONER MAY REQUIRE THAT EVERY
MEMBER OR APPLICANT TO BE A MEMBER SHALL PROVIDE INFORMATION  TO  ENABLE
THE COMMISSIONER TO DETERMINE WHETHER THE APPLICANT IS ELIGIBLE FOR SUCH
PROGRAM.    THE PROGRAM SHALL MAKE A REASONABLE EFFORT TO NOTIFY MEMBERS
OF THEIR OBLIGATIONS UNDER THIS PARAGRAPH. AFTER A REASONABLE EFFORT HAS
BEEN MADE TO CONTACT THE MEMBER, THE MEMBER SHALL BE NOTIFIED IN WRITING
THAT HE OR SHE HAS SIXTY DAYS TO PROVIDE SUCH REQUIRED  INFORMATION.  IF
SUCH  INFORMATION  IS  NOT  PROVIDED  WITHIN  THE  SIXTY DAY PERIOD, THE
MEMBER'S COVERAGE UNDER THE PROGRAM MAY BE TERMINATED.
  (F) TO THE EXTENT NECESSARY FOR PURPOSES OF THIS SECTION, AS A  CONDI-
TION  OF  CONTINUED  ELIGIBILITY  FOR  HEALTH  CARE  SERVICES  UNDER THE
PROGRAM, A MEMBER WHO IS ELIGIBLE  FOR  BENEFITS  UNDER  MEDICARE  SHALL
ENROLL IN MEDICARE, INCLUDING PARTS A, B AND D.
  (G)  THE  PROGRAM  SHALL  PROVIDE  PREMIUM  ASSISTANCE FOR ALL MEMBERS
ENROLLING IN A MEDICARE PART D DRUG  COVERAGE  UNDER  SECTION  1860D  OF
TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT LIMITED TO THE LOW-INCOME
BENCHMARK PREMIUM AMOUNT ESTABLISHED BY THE FEDERAL CENTERS FOR MEDICARE
AND MEDICAID SERVICES AND ANY OTHER AMOUNT WHICH SUCH AGENCY ESTABLISHES
UNDER  ITS  DE MINIMIS PREMIUM POLICY, EXCEPT THAT SUCH PAYMENTS MADE ON
BEHALF OF MEMBERS ENROLLED IN A MEDICARE ADVANTAGE PLAN MAY  EXCEED  THE
LOW-INCOME  BENCHMARK  PREMIUM AMOUNT IF DETERMINED TO BE COST EFFECTIVE
TO THE PROGRAM.
  (H) IF THE COMMISSIONER HAS  REASONABLE  GROUNDS  TO  BELIEVE  THAT  A
MEMBER  COULD  BE  ELIGIBLE  FOR AN INCOME-RELATED SUBSIDY UNDER SECTION
1860D-14 OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT,  THE  MEMBER
SHALL  PROVIDE,  AND AUTHORIZE THE PROGRAM TO OBTAIN, ANY INFORMATION OR
DOCUMENTATION REQUIRED TO ESTABLISH THE MEMBER'S  ELIGIBILITY  FOR  SUCH
SUBSIDY,  PROVIDED THAT THE COMMISSIONER SHALL ATTEMPT TO OBTAIN AS MUCH
OF THE INFORMATION AND DOCUMENTATION AS POSSIBLE FROM RECORDS  THAT  ARE
AVAILABLE TO HIM OR HER.
  (I)  THE  PROGRAM  SHALL MAKE A REASONABLE EFFORT TO NOTIFY MEMBERS OF
THEIR OBLIGATIONS UNDER THIS SUBDIVISION. AFTER A REASONABLE EFFORT  HAS
BEEN MADE TO CONTACT THE MEMBER, THE MEMBER SHALL BE NOTIFIED IN WRITING
THAT  HE  OR SHE HAS SIXTY DAYS TO PROVIDE SUCH REQUIRED INFORMATION. IF
SUCH INFORMATION IS NOT  PROVIDED  WITHIN  THE  SIXTY  DAY  PERIOD,  THE
MEMBER'S COVERAGE UNDER THE PROGRAM MAY BE TERMINATED.
  §  5110.  ADDITIONAL  PROVISIONS.   1. THE COMMISSIONER SHALL CONTRACT
WITH NOT-FOR-PROFIT ORGANIZATIONS TO PROVIDE:
  (A) CONSUMER ASSISTANCE TO INDIVIDUALS WITH RESPECT TO  SELECTION  AND
CHANGING  SELECTION  OF  A CARE COORDINATOR OR HEALTH CARE ORGANIZATION,
ENROLLING, OBTAINING HEALTH CARE SERVICES, AND OTHER MATTERS RELATING TO
THE PROGRAM;
  (B) HEALTH CARE PROVIDER ASSISTANCE TO HEALTH CARE PROVIDERS PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  HEALTH  CARE  SERVICES
UNDER THE PROGRAM, WITH RESPECT TO PARTICIPATING IN A HEALTH CARE ORGAN-
IZATION AND DEALING WITH A HEALTH CARE ORGANIZATION; AND

A. 5248--A                         19

  (C)  CARE COORDINATOR ASSISTANCE TO INDIVIDUALS AND ENTITIES PROVIDING
AND SEEKING OR CONSIDERING WHETHER  TO  PROVIDE,  CARE  COORDINATION  TO
MEMBERS.
  2.  THE  COMMISSIONER  SHALL PROVIDE GRANTS FROM FUNDS IN THE NEW YORK
HEALTH TRUST FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE, TO  HEALTH
SYSTEMS  AGENCIES UNDER SECTION TWENTY-NINE HUNDRED FOUR-B OF THIS CHAP-
TER TO SUPPORT THE OPERATION OF SUCH HEALTH SYSTEMS AGENCIES.
  3. RETRAINING AND RE-EMPLOYMENT OF IMPACTED EMPLOYEES. (A) AS USED  IN
THIS SUBDIVISION:
  (I)  "THIRD  PARTY  PAYER"  HAS  ITS ORDINARY MEANING AND INCLUDES ANY
ENTITY THAT PROVIDES OR ARRANGES REIMBURSEMENT IN WHOLE OR IN  PART  FOR
THE PURCHASE OF HEALTH CARE SERVICES.
  (II)  "HEALTH CARE PROVIDER ADMINISTRATIVE EMPLOYEE" MEANS AN EMPLOYEE
OF A HEALTH CARE PROVIDER PRIMARILY ENGAGED  IN  RELATIONS  OR  DEALINGS
WITH  THIRD  PARTY PAYERS OR SEEKING PAYMENT OR REIMBURSEMENT FOR HEALTH
CARE SERVICES FROM THIRD PARTY PAYERS.
  (III) "IMPACTED EMPLOYEE" MEANS AN INDIVIDUAL WHO, AT  ANY  TIME  FROM
THE DATE THIS SECTION BECOMES A LAW UNTIL TWO YEARS AFTER THE END OF THE
IMPLEMENTATION PERIOD, IS EMPLOYED BY A THIRD PARTY PAYER OR IS A HEALTH
CARE  PROVIDER  ADMINISTRATIVE EMPLOYEE, AND WHOSE EMPLOYMENT ENDS OR IS
REASONABLY ANTICIPATED TO END AS A RESULT OF THE IMPLEMENTATION  OF  THE
NEW YORK HEALTH PROGRAM.
  (B)  WITHIN  NINETY  DAYS  AFTER  THIS SECTION SHALL BECOME A LAW, THE
COMMISSIONER OF LABOR SHALL CONVENE A RETRAINING AND RE-EMPLOYMENT  TASK
FORCE  INCLUDING  BUT  NOT  LIMITED  TO:  REPRESENTATIVES  OF  POTENTIAL
IMPACTED EMPLOYEES, HUMAN RESOURCE DEPARTMENTS OF THIRD PARTY PAYERS AND
HEALTH CARE PROVIDERS, INDIVIDUALS  WITH  EXPERIENCE  AND  EXPERTISE  IN
RETRAINING  AND  RE-EMPLOYMENT PROGRAMS RELEVANT TO THE CIRCUMSTANCES OF
IMPACTED EMPLOYEES, AND REPRESENTATIVES OF THE  COMMISSIONER  OF  LABOR.
THE COMMISSIONER OF LABOR AND THE TASK FORCE SHALL REVIEW AND PROVIDE:
  (I)  ANALYSIS  OF  POTENTIAL  IMPACTED  EMPLOYEES  BY  JOB  TITLE  AND
GEOGRAPHY;
  (II) COMPETENCY MAPPING AND LABOR MARKET ANALYSIS OF IMPACTED EMPLOYEE
OCCUPATIONS WITH JOB OPENINGS; AND
  (III) ESTABLISHMENT OF REGIONAL RETRAINING AND RE-EMPLOYMENT  SYSTEMS,
INCLUDING  BUT  NOT  LIMITED  TO  JOB BOARDS, OUTPLACEMENT SERVICES, JOB
SEARCH SERVICES, CAREER ADVISEMENT SERVICES, AND RETRAINING  ADVISEMENT,
TO  BE COORDINATED WITH THE REGIONAL ADVISORY COUNCILS ESTABLISHED UNDER
SECTION FIFTY-ONE HUNDRED ELEVEN OF THIS ARTICLE.
  (C) (I) THREE OR MORE IMPACTED EMPLOYEES, A RECOGNIZED UNION OF  WORK-
ERS  INCLUDING  IMPACTED EMPLOYEES, OR AN EMPLOYER OF IMPACTED EMPLOYEES
MAY FILE A PETITION WITH THE  COMMISSIONER  OF  LABOR  TO  CERTIFY  SUCH
EMPLOYEES AS BEING IMPACTED EMPLOYEES.
  (II) IMPACTED EMPLOYEES SHALL BE ELIGIBLE FOR:
  (A) UP TO TWO YEARS OF RETRAINING AT ANY TRAINING PROVIDER APPROVED BY
THE COMMISSIONER OF LABOR; AND
  (B)  UP  TO  TWO  YEARS  OF  UNEMPLOYMENT  BENEFITS, PROVIDED THAT THE
IMPACTED EMPLOYEE IS ENROLLED IN A DEPARTMENT OF LABOR APPROVED TRAINING
PROGRAM, IS ACTIVELY SEEKING EMPLOYMENT, AND IS NOT  CURRENTLY  EMPLOYED
FULL  TIME;  PROVIDED, HOWEVER, THAT SUCH IMPACTED EMPLOYEE MAY MAINTAIN
UNEMPLOYMENT BENEFITS FOR UP TO TWO YEARS EVEN IF HE  OR  SHE  DOES  NOT
MEET  THE  CRITERIA SET FORTH IN THIS CLAUSE BUT IS SIXTY-THREE YEARS OF
AGE OR OLDER AT THE TIME OF LOSS OF EMPLOYMENT AS AN IMPACTED EMPLOYEE.
  (D) THE COMMISSIONER SHALL PROVIDE FUNDS  FROM  THE  NEW  YORK  HEALTH
TRUST FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE TO THE COMMISSION-

A. 5248--A                         20

ER  OF  LABOR  FOR  RETRAINING  AND  RE-EMPLOYMENT PROGRAMS FOR IMPACTED
EMPLOYEES UNDER THIS SUBDIVISION.
  (E)  THE  COMMISSIONER  OF LABOR SHALL MAKE REGULATIONS AND TAKE OTHER
ACTIONS REASONABLY NECESSARY TO IMPLEMENT THIS SUBDIVISION. THIS  SUBDI-
VISION  SHALL  BE  IMPLEMENTED  CONSISTENT WITH APPLICABLE LAW AND REGU-
LATIONS.
  4. THE COMMISSIONER SHALL, DIRECTLY AND THROUGH GRANTS TO NOT-FOR-PRO-
FIT ENTITIES, CONDUCT PROGRAMS USING DATA COLLECTED THROUGH THE NEW YORK
HEALTH PROGRAM, TO PROMOTE  AND  PROTECT  THE  QUALITY  OF  HEALTH  CARE
SERVICES,  PATIENT  OUTCOMES, AND PUBLIC, ENVIRONMENTAL AND OCCUPATIONAL
HEALTH, INCLUDING COOPERATION WITH OTHER DATA  COLLECTION  AND  RESEARCH
PROGRAMS OF THE DEPARTMENT, CONSISTENT WITH THIS ARTICLE, THE PROTECTION
OF THE SECURITY AND CONFIDENTIALITY OF INDIVIDUALLY IDENTIFIABLE PATIENT
INFORMATION, AND OTHERWISE APPLICABLE LAW.
  5.  SETTLEMENTS  AND  JUDGMENTS.  THIS  SUBDIVISION  APPLIES WHERE ANY
SETTLEMENT, JUDGMENT OR ORDER  IN  THE  COURSE  OF  LITIGATION,  OR  ANY
CONTRACT  OR  AGREEMENT  MADE  AS AN ALTERNATIVE TO LITIGATION, PROVIDES
THAT ONE PARTY SHALL PAY FOR HEALTH CARE COVERAGE FOR ANOTHER PARTY  WHO
IS ENTITLED TO ENROLL IN THE PROGRAM. ANY PARTY TO THE SETTLEMENT, JUDG-
MENT, ORDER, CONTRACT OR AGREEMENT MAY APPLY TO AN APPROPRIATE COURT FOR
MODIFICATION  OF THE JUDGMENT, ORDER, CONTRACT OR AGREEMENT. THE MODIFI-
CATION MAY PROVIDE THAT THE PAYING PARTY, INSTEAD OF PAYING  FOR  HEALTH
CARE  COVERAGE, SHALL PAY ALL OR PART OF THE NEW YORK HEALTH TAX THAT IS
OWED BY THE OTHER PARTY, AND MAY INCLUDE OTHER  OR  FURTHER  PROVISIONS.
THE MODIFICATIONS SHALL BE APPROPRIATE, CONSISTENT WITH THE PROGRAM, AND
IN  THE  INTEREST  OF  JUSTICE.  AS  USED IN THIS SUBDIVISION, "NEW YORK
HEALTH TAX" MEANS THE TAX OR TAXES ENACTED BY THE LEGISLATURE AS PART OF
THE REVENUE PROPOSAL, AS AMENDED, TO FUND THE PROGRAM.
  § 5111. REGIONAL ADVISORY COUNCILS.  1. THE NEW YORK  HEALTH  REGIONAL
ADVISORY COUNCILS (EACH REFERRED TO IN THIS ARTICLE AS A "REGIONAL ADVI-
SORY COUNCIL") ARE HEREBY CREATED IN THE DEPARTMENT.
  2.  THERE  SHALL BE A REGIONAL ADVISORY COUNCIL ESTABLISHED IN EACH OF
THE FOLLOWING REGIONS:
  (A) LONG ISLAND, CONSISTING OF NASSAU AND SUFFOLK COUNTIES;
  (B) NEW YORK CITY;
  (C) HUDSON VALLEY, CONSISTING OF DELAWARE, DUTCHESS,  ORANGE,  PUTNAM,
ROCKLAND, SULLIVAN, ULSTER, WESTCHESTER COUNTIES;
  (D)  NORTHERN,  CONSISTING OF ALBANY, CLINTON, COLUMBIA, ESSEX, FRANK-
LIN, FULTON, GREENE, HAMILTON, HERKIMER, JEFFERSON,  LEWIS,  MONTGOMERY,
OTSEGO,  RENSSELAER,  SARATOGA,  SCHENECTADY,  SCHOHARIE,  ST. LAWRENCE,
WARREN, WASHINGTON COUNTIES;
  (E) CENTRAL, CONSISTING OF BROOME, CAYUGA,  CHEMUNG,  CHENANGO,  CORT-
LAND,  LIVINGSTON,  MADISON,  MONROE, ONEIDA, ONONDAGA, ONTARIO, OSWEGO,
SCHUYLER, SENECA, STEUBEN, TIOGA, TOMPKINS, WAYNE, YATES COUNTIES; AND
  (F) WESTERN, CONSISTING OF ALLEGANY,  CATTARAUGUS,  CHAUTAUQUA,  ERIE,
GENESEE, NIAGARA, ORLEANS, WYOMING COUNTIES.
  3.  EACH REGIONAL ADVISORY COUNCIL SHALL BE COMPOSED OF NOT FEWER THAN
TWENTY-SEVEN MEMBERS, AS DETERMINED BY THE COMMISSIONER AND  THE  BOARD,
AS  NECESSARY  TO APPROPRIATELY REPRESENT THE DIVERSE NEEDS AND CONCERNS
OF THE REGION. MEMBERS OF A REGIONAL ADVISORY COUNCIL SHALL BE RESIDENTS
OF OR HAVE THEIR PRINCIPAL PLACE OF BUSINESS IN THE REGION SERVED BY THE
REGIONAL ADVISORY COUNCIL.
  4. APPOINTMENT OF MEMBERS OF THE REGIONAL ADVISORY COUNCILS.
  (A) THE TWENTY-SEVEN MEMBERS SHALL BE APPOINTED AS FOLLOWS:
  (I) NINE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR;

A. 5248--A                         21

  (II) SIX MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMENDA-
TION OF THE SPEAKER OF THE ASSEMBLY;
  (III)  SIX MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMEN-
DATION OF THE TEMPORARY PRESIDENT OF THE SENATE;
  (IV) THREE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE RECOMMEN-
DATION OF THE MINORITY LEADER OF THE ASSEMBLY; AND
  (V) THREE MEMBERS SHALL BE APPOINTED BY THE GOVERNOR ON THE  RECOMMEN-
DATION OF THE MINORITY LEADER OF THE SENATE.
  WHERE  A REGIONAL ADVISORY COUNCIL HAS MORE THAN TWENTY-SEVEN MEMBERS,
ADDITIONAL MEMBERS SHALL BE APPOINTED AND RECOMMENDED BY THESE OFFICIALS
IN THE SAME PROPORTION AS THE TWENTY-SEVEN MEMBERS.
  (B) REGIONAL ADVISORY COUNCIL MEMBERSHIP  SHALL  INCLUDE  BUT  NOT  BE
LIMITED TO:
  (I) REPRESENTATIVES OF ORGANIZATIONS WITH A REGIONAL CONSTITUENCY THAT
ADVOCATE  FOR HEALTH CARE CONSUMERS, OLDER ADULTS, AND PEOPLE WITH DISA-
BILITIES INCLUDING ORGANIZATIONS LED BY MEMBERS  OF  THOSE  GROUPS,  WHO
SHALL  CONSTITUTE  AT LEAST ONE THIRD OF THE MEMBERSHIP OF EACH REGIONAL
COUNCIL;
  (II) REPRESENTATIVES OF PROFESSIONAL ORGANIZATIONS REPRESENTING PHYSI-
CIANS;
  (III)  REPRESENTATIVES  OF  PROFESSIONAL  ORGANIZATIONS   REPRESENTING
HEALTH CARE PROFESSIONALS OTHER THAN PHYSICIANS;
  (IV) REPRESENTATIVES OF GENERAL HOSPITALS, INCLUDING PUBLIC HOSPITALS;
  (V) REPRESENTATIVES OF COMMUNITY HEALTH CENTERS;
  (VI)  REPRESENTATIVES  OF  MENTAL HEALTH, BEHAVIORAL HEALTH (INCLUDING
SUBSTANCE USE), PHYSICAL DISABILITY, DEVELOPMENTAL DISABILITY, REHABILI-
TATION, HOME CARE AND OTHER SERVICE PROVIDERS;
  (VII) REPRESENTATIVES OF WOMEN'S HEALTH SERVICE PROVIDERS;
  (VIII) REPRESENTATIVES OF HEALTH CARE ORGANIZATIONS;
  (IX) REPRESENTATIVES OF ORGANIZED LABOR INCLUDING  REPRESENTATIVES  OF
HEALTH CARE WORKERS;
  (X) REPRESENTATIVES OF EMPLOYERS; AND
  (XI) REPRESENTATIVES OF MUNICIPAL AND COUNTY GOVERNMENT.
  5. MEMBERS OF A REGIONAL ADVISORY COUNCIL SHALL BE APPOINTED FOR TERMS
OF  THREE  YEARS PROVIDED, HOWEVER, THAT OF THE MEMBERS FIRST APPOINTED,
ONE-THIRD SHALL BE APPOINTED FOR ONE YEAR TERMS AND ONE-THIRD  SHALL  BE
APPOINTED  FOR  TWO  YEAR  TERMS.  VACANCIES SHALL BE FILLED IN THE SAME
MANNER AS ORIGINAL APPOINTMENTS FOR THE REMAINDER OF ANY UNEXPIRED TERM.
NO PERSON SHALL BE A MEMBER OF A REGIONAL ADVISORY COUNCIL FOR MORE THAN
SIX YEARS IN ANY PERIOD OF TWELVE CONSECUTIVE YEARS.
  6. MEMBERS OF THE  REGIONAL  ADVISORY  COUNCILS  SHALL  SERVE  WITHOUT
COMPENSATION  BUT  SHALL  BE  REIMBURSED  FOR THEIR NECESSARY AND ACTUAL
EXPENSES INCURRED WHILE ENGAGED IN THE BUSINESS OF  THE  ADVISORY  COUN-
CILS.  THE PROGRAM SHALL PROVIDE FINANCIAL SUPPORT FOR SUCH EXPENSES AND
OTHER EXPENSES OF THE REGIONAL ADVISORY COUNCILS.
  7. EACH REGIONAL ADVISORY COUNCIL SHALL MEET AT LEAST QUARTERLY.  EACH
REGIONAL  ADVISORY COUNCIL MAY FORM COMMITTEES TO ASSIST IT IN ITS WORK.
MEMBERS OF A COMMITTEE NEED NOT BE  MEMBERS  OF  THE  REGIONAL  ADVISORY
COUNCIL.    THE  NEW  YORK  CITY  REGIONAL ADVISORY COUNCIL SHALL FORM A
COMMITTEE FOR EACH BOROUGH OF NEW YORK  CITY,  TO  ASSIST  THE  REGIONAL
ADVISORY COUNCIL IN ITS WORK AS IT RELATES PARTICULARLY TO THAT BOROUGH.
  8.  EACH  REGIONAL ADVISORY COUNCIL SHALL ADVISE THE COMMISSIONER, THE
BOARD, THE GOVERNOR AND THE LEGISLATURE ON ALL MATTERS RELATING  TO  THE
DEVELOPMENT AND IMPLEMENTATION OF THE NEW YORK HEALTH PROGRAM.

A. 5248--A                         22

  9.  EACH  REGIONAL ADVISORY COUNCIL SHALL ADOPT, AND FROM TIME TO TIME
REVISE, A COMMUNITY HEALTH IMPROVEMENT  PLAN  FOR  ITS  REGION  FOR  THE
PURPOSE OF:
  (A)  PROMOTING  THE  DELIVERY  OF  HEALTH CARE SERVICES IN THE REGION,
IMPROVING THE QUALITY AND  ACCESSIBILITY  OF  CARE,  INCLUDING  CULTURAL
COMPETENCY,  CLINICAL  INTEGRATION  OF  CARE  BETWEEN  SERVICE PROVIDERS
INCLUDING BUT NOT LIMITED TO PHYSICAL, MENTAL,  AND  BEHAVIORAL  HEALTH,
PHYSICAL  AND  DEVELOPMENTAL DISABILITY SERVICES, AND LONG-TERM SUPPORTS
AND SERVICES;
  (B) FACILITY AND HEALTH SERVICES PLANNING IN THE REGION;
  (C) IDENTIFYING GAPS IN REGIONAL HEALTH CARE SERVICES;
  (D) PROMOTING INCREASED PUBLIC KNOWLEDGE AND RESPONSIBILITY  REGARDING
THE  AVAILABILITY  AND  APPROPRIATE UTILIZATION OF HEALTH CARE SERVICES.
EACH COMMUNITY HEALTH IMPROVEMENT PLAN SHALL BE SUBMITTED TO THE COMMIS-
SIONER AND THE BOARD AND SHALL BE POSTED ON THE DEPARTMENT'S WEBSITE;
  (E) IDENTIFYING NEEDS IN PROFESSIONAL AND SERVICE  PERSONNEL  REQUIRED
TO DELIVER HEALTH CARE SERVICES; AND
  (F)  COORDINATING REGIONAL IMPLEMENTATION OF RETRAINING AND RE-EMPLOY-
MENT PROGRAMS FOR IMPACTED EMPLOYEES UNDER SUBDIVISION THREE OF  SECTION
FIFTY-ONE HUNDRED TEN OF THIS ARTICLE.
  10.  EACH  REGIONAL  ADVISORY  COUNCIL SHALL HOLD AT LEAST FOUR PUBLIC
HEARINGS ANNUALLY ON MATTERS RELATING TO THE NEW YORK HEALTH PROGRAM AND
THE DEVELOPMENT AND IMPLEMENTATION OF THE COMMUNITY  HEALTH  IMPROVEMENT
PLAN.
  11.  EACH  REGIONAL ADVISORY COUNCIL SHALL PUBLISH AN ANNUAL REPORT TO
THE COMMISSIONER AND THE BOARD ON THE PROGRESS OF THE  COMMUNITY  HEALTH
IMPROVEMENT  PLAN.  THESE  REPORTS  SHALL  BE POSTED ON THE DEPARTMENT'S
WEBSITE.
  12. ALL MEETINGS OF THE  REGIONAL  ADVISORY  COUNCILS  AND  COMMITTEES
SHALL BE SUBJECT TO ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  §  4.  Financing  of New York Health. 1.  (a) As used in this section,
unless the context clearly requires otherwise:
  (i) "New York Health program" and the  "program"  mean  the  New  York
Health  program,  as  created by article 51 of the public health law and
all provisions of that article.
  (ii) "Revenue proposal" means the revenue plan and legislative  bills,
as  proposed  and  enacted  under  this  section, to provide the revenue
necessary to finance the New York Health program.
  (iii) "Tax" means the payroll tax or non-payroll  tax  to  be  enacted
under  the  revenue  proposal.  "Payroll  tax"  means the tax on payroll
income and self-employed income subject to  the  Medicare  Part  A  tax,
provided for in subdivision two of this section. "Non-payroll tax" means
the  tax  on  taxable  income  (such as interest, dividends, and capital
gains) not subject to the payroll tax, provided for in  subdivision  two
of this section.
  (b)  The  governor shall submit to the legislature a revenue proposal.
The revenue proposal shall be submitted to the legislature  as  part  of
the  executive  budget  under article VII of the state constitution, for
the fiscal year commencing on the first day of  April  in  the  calendar
year  after  this  act  shall  become  a  law. In developing the revenue
proposal, the governor shall consult with appropriate officials  of  the
executive  branch; the temporary president of the senate; the speaker of
the assembly; the chairs of the fiscal  and  health  committees  of  the
senate  and  assembly; and representatives of business, labor, consumers
and local government.

A. 5248--A                         23

  2. (a) Basic structure. The basic structure of  the  revenue  proposal
shall  be as follows: Revenue for the program shall come from two taxes.
First, there shall be a progressively graduated tax on all  payroll  and
self-employed  income,  paid  by  employers, employees and self-employed
individuals.    Second,  there shall be a progressively graduated tax on
taxable income (such as interest,  dividends,  and  capital  gains)  not
subject  to  the  payroll tax.   Income in the bracket below twenty-five
thousand dollars per year shall be exempt from the taxes; provided  that
for  individuals  enrolled in Medicare as defined in the program, income
in the bracket below fifty thousand dollars per  year  shall  be  exempt
from the taxes.  Higher brackets of income subject to the taxes shall be
assessed at a higher marginal rate than lower brackets.  The taxes shall
be  set  at  levels anticipated to produce sufficient revenue to finance
the program, to be scaled up as enrollment grows, taking into  consider-
ation  anticipated  federal revenue available for the program. Provision
shall be made for state residents who  are  employed  out-of-state,  and
non-residents  who  are  employed in the state (including those employed
less than full-time).
  (b) Payroll tax. The income to be subject to the payroll tax shall  be
all  income subject to the Medicare Part A tax. The payroll tax shall be
set at a percentage of that income, which shall be progressively  gradu-
ated,  so  the  percentage  is  higher on higher brackets of income. For
employed individuals, the employer  shall  pay  eighty  percent  of  the
payroll tax and the employee shall pay twenty percent of the tax, except
that  an  employer may agree to pay all or part of the employee's share.
A self-employed individual shall pay the full tax.
  (c) Non-payroll income tax. There shall be a tax  on  income  that  is
subject  to  the personal income tax under article 22 of the tax law and
is not subject to the payroll tax. It shall be set at  a  percentage  of
that  income,  which shall be progressively graduated, so the percentage
is higher on higher brackets of income.
  (d) Phased-in rates. Early in the program, when enrollment is growing,
the amount of the taxes shall be at an appropriate level, and  shall  be
changed as anticipated enrollment grows, to cover the actual cost of the
program.  The revenue proposal shall include a mechanism for determining
the rates of the taxes.
  (e) Cross-border employees. (i) State residents employed out-of-state.
If an individual is employed out-of-state by an employer that is subject
to New York state law, the employer and employee shall  be  required  to
pay the payroll tax as to that employee as if the employment were in the
state.  If an individual is employed out-of-state by an employer that is
not subject to New York state law, either (A) the employer and  employee
shall  voluntarily comply with the tax or (B) the employee shall pay the
tax as if he or she were self-employed.
  (ii) Out-of-state residents employed in the state.   The  payroll  tax
shall  apply  to  any  out-of-state resident who is employed or self-em-
ployed in the state.  Such individual and individual's employer shall be
able to take a credit against the payroll taxes each would otherwise pay
as to that individual for amounts  they  spend  respectively  on  health
benefits (A) for the individual, if the individual is not eligible to be
a  member  of  the  program,  and (B) for any member of the individual's
immediate family.   For the employer,  the  credit  shall  be  available
regardless  of the form of the health benefit (e.g., health insurance, a
self-insured plan, direct services, or reimbursement for  services),  to
make  sure that the revenue proposal does not relate to employment bene-
fits in violation of any federal law. For non-employment-based  spending

A. 5248--A                         24

by  the  individual,  the  credit  shall be available for and limited to
spending for health coverage (not out-of-pocket  health  spending).  The
credit  shall  be available without regard to how little is spent or how
sparse  the  benefit.  The  credit may only be taken against the payroll
tax. Any excess amount may not be applied to other  tax  liability.  The
credit  shall  be  distributed  between the employer and employee in the
same proportion as the spending by each  for  the  benefit  and  may  be
applied to their respective portion of the tax. If any provision of this
subparagraph  or any application of it shall be ruled to violate federal
law, the provision or the application of it shall be null and  void  and
the  ruling  shall not affect any other provision or application of this
section or the act that enacted it.
  3. (a) The revenue proposal  shall  include  a  plan  and  legislative
provisions   for  ending  the  requirement  for  local  social  services
districts to pay part of  the  cost  of  Medicaid  and  replacing  those
payments with revenue from the taxes under the revenue proposal.
  (b)  The  taxes  under this section shall not supplant the spending of
other state revenue to pay for the Medicaid program as it exists  as  of
the  enactment  of  the  revenue proposal as amended, unless the revenue
proposal as amended provides otherwise.
  4. To the extent that the revenue proposal differs from the  terms  of
subdivision  two  or paragraph (b) of subdivision three of this section,
the revenue proposal shall state how it differs  from  those  terms  and
reasons for and the effects of the differences.
  5.  All  revenue  from  the  taxes  shall be deposited in the New York
Health trust fund account under section 89-j of the state finance law.
  § 5.  Article 49 of the public health law is amended by adding  a  new
title 3 to read as follows:
                                TITLE III
          COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
                             NEW YORK HEALTH
SECTION 4920. DEFINITIONS.
        4921. COLLECTIVE NEGOTIATION AUTHORIZED.
        4922. COLLECTIVE NEGOTIATION REQUIREMENTS.
        4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE.
        4924. MEDIATION.
        4925. CERTAIN COLLECTIVE ACTION PROHIBITED.
        4926. FEES.
        4927. CONFIDENTIALITY.
        4928. SEVERABILITY AND CONSTRUCTION.
  § 4920. DEFINITIONS. FOR PURPOSES OF THIS TITLE:
  1. "NEW YORK HEALTH" MEANS THE PROGRAM UNDER ARTICLE FIFTY-ONE OF THIS
CHAPTER.
  2.  "PERSON"  MEANS  AN  INDIVIDUAL,  ASSOCIATION, CORPORATION, OR ANY
OTHER LEGAL ENTITY.
  3. "HEALTH CARE PROVIDERS' REPRESENTATIVE" MEANS A THIRD PARTY THAT IS
AUTHORIZED BY HEALTH CARE PROVIDERS TO NEGOTIATE ON  THEIR  BEHALF  WITH
NEW  YORK  HEALTH  OVER TERMS AND CONDITIONS AFFECTING THOSE HEALTH CARE
PROVIDERS.
  4. "STRIKE" MEANS A WORK STOPPAGE IN PART OR IN WHOLE, DIRECT OR INDI-
RECT, BY A BODY OF WORKERS TO GAIN COMPLIANCE WITH DEMANDS  MADE  ON  AN
EMPLOYER.
  5.  "HEALTH  CARE PROVIDER" MEANS A HEALTH CARE PROVIDER UNDER ARTICLE
FIFTY-ONE OF THIS CHAPTER. A HEALTH  CARE  PROFESSIONAL  AS  DEFINED  IN
ARTICLE  FIFTY-ONE OF THIS CHAPTER WHO PRACTICES AS AN EMPLOYEE OR INDE-

A. 5248--A                         25

PENDENT CONTRACTOR OF ANOTHER HEALTH CARE PROVIDER SHALL NOT BE DEEMED A
HEALTH CARE PROVIDER FOR PURPOSES OF THIS TITLE.
  §  4921.  COLLECTIVE  NEGOTIATION AUTHORIZED. 1. HEALTH CARE PROVIDERS
MAY MEET AND COMMUNICATE FOR THE  PURPOSE  OF  COLLECTIVELY  NEGOTIATING
WITH  NEW YORK HEALTH ON ANY MATTER RELATING TO NEW YORK HEALTH, INCLUD-
ING BUT NOT LIMITED TO RATES OF PAYMENT AND PAYMENT METHODOLOGIES.
  2. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE AN
ALTERATION OF THE TERMS OF THE INTERNAL AND EXTERNAL  REVIEW  PROCEDURES
SET FORTH IN LAW.
  3. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW A STRIKE OF NEW
YORK HEALTH BY HEALTH CARE PROVIDERS.
  4.  NOTHING  IN  THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE
TERMS OR CONDITIONS WHICH WOULD IMPEDE THE ABILITY OF NEW YORK HEALTH TO
OBTAIN OR RETAIN ACCREDITATION BY THE  NATIONAL  COMMITTEE  FOR  QUALITY
ASSURANCE OR A SIMILAR BODY OR TO COMPLY WITH APPLICABLE STATE OR FEDER-
AL LAW.
  § 4922. COLLECTIVE NEGOTIATION REQUIREMENTS. 1. COLLECTIVE NEGOTIATION
RIGHTS GRANTED BY THIS TITLE MUST CONFORM TO THE FOLLOWING REQUIREMENTS:
  (A)  HEALTH  CARE  PROVIDERS  MAY  COMMUNICATE  WITH OTHER HEALTH CARE
PROVIDERS REGARDING THE TERMS AND CONDITIONS TO BE NEGOTIATED  WITH  NEW
YORK HEALTH;
  (B)  HEALTH CARE PROVIDERS MAY COMMUNICATE WITH HEALTH CARE PROVIDERS'
REPRESENTATIVES;
  (C) A HEALTH CARE PROVIDERS' REPRESENTATIVE IS THE ONLY PARTY  AUTHOR-
IZED  TO  NEGOTIATE  WITH  NEW  YORK HEALTH ON BEHALF OF THE HEALTH CARE
PROVIDERS AS A GROUP;
  (D) A HEALTH CARE PROVIDER CAN BE BOUND BY THE  TERMS  AND  CONDITIONS
NEGOTIATED BY THE HEALTH CARE PROVIDERS' REPRESENTATIVES; AND
  (E)  IN  COMMUNICATING  OR NEGOTIATING WITH THE HEALTH CARE PROVIDERS'
REPRESENTATIVE, NEW YORK HEALTH IS ENTITLED TO OFFER AND PROVIDE DIFFER-
ENT TERMS AND CONDITIONS TO INDIVIDUAL COMPETING HEALTH CARE PROVIDERS.
  2. NOTHING IN THIS TITLE SHALL AFFECT OR LIMIT THE RIGHT OF  A  HEALTH
CARE PROVIDER OR GROUP OF HEALTH CARE PROVIDERS TO COLLECTIVELY PETITION
A GOVERNMENT ENTITY FOR A CHANGE IN A LAW, RULE, OR REGULATION.
  3.  NOTHING  IN  THIS TITLE SHALL AFFECT OR LIMIT COLLECTIVE ACTION OR
COLLECTIVE BARGAINING ON THE PART OF ANY HEALTH CARE PROVIDER  WITH  HIS
OR  HER  EMPLOYER  OR  ANY  OTHER LAWFUL COLLECTIVE ACTION OR COLLECTIVE
BARGAINING.
  § 4923. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE. BEFORE
ENGAGING IN COLLECTIVE NEGOTIATIONS WITH NEW YORK HEALTH  ON  BEHALF  OF
HEALTH  CARE  PROVIDERS,  A  HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL
FILE WITH THE COMMISSIONER, IN THE MANNER PRESCRIBED BY THE  COMMISSION-
ER,  INFORMATION  IDENTIFYING  THE  REPRESENTATIVE, THE REPRESENTATIVE'S
PLAN OF OPERATION, AND THE REPRESENTATIVE'S PROCEDURES TO ENSURE COMPLI-
ANCE WITH THIS TITLE.
  § 4924. MEDIATION. 1. IN THE EVENT THE COMMISSIONER DETERMINES THAT AN
IMPASSE EXISTS  IN  THE  NEGOTIATIONS,  THE  COMMISSIONER  SHALL  RENDER
ASSISTANCE AS FOLLOWS:
  (A)  TO  ASSIST  THE  PARTIES  TO EFFECT A VOLUNTARY RESOLUTION OF THE
NEGOTIATIONS, THE COMMISSIONER SHALL APPOINT A MEDIATOR WHO IS  MUTUALLY
ACCEPTABLE  TO  BOTH  THE  HEALTH CARE PROVIDERS' REPRESENTATIVE AND THE
REPRESENTATIVE OF NEW YORK HEALTH. IF  THE  MEDIATOR  IS  SUCCESSFUL  IN
RESOLVING  THE  IMPASSE,  THEN THE HEALTH CARE PROVIDERS' REPRESENTATIVE
SHALL PROCEED AS SET FORTH IN THIS ARTICLE;
  (B) IF AN IMPASSE CONTINUES, THE COMMISSIONER SHALL  APPOINT  A  FACT-
FINDING  BOARD OF NOT MORE THAN THREE MEMBERS, WHO ARE MUTUALLY ACCEPTA-

A. 5248--A                         26

BLE TO BOTH THE HEALTH CARE PROVIDERS' REPRESENTATIVE AND THE  REPRESEN-
TATIVE  OF  NEW  YORK  HEALTH.  THE  FACT-FINDING  BOARD  SHALL HAVE, IN
ADDITION TO THE POWERS DELEGATED TO IT BY THE BOARD, THE POWER  TO  MAKE
RECOMMENDATIONS FOR THE RESOLUTION OF THE DISPUTE;
  (C) THE FACT-FINDING BOARD, ACTING BY A MAJORITY OF ITS MEMBERS, SHALL
TRANSMIT  ITS FINDINGS OF FACT AND RECOMMENDATIONS FOR RESOLUTION OF THE
DISPUTE TO THE COMMISSIONER, AND MAY THEREAFTER ASSIST  THE  PARTIES  TO
EFFECT  A  VOLUNTARY  RESOLUTION  OF THE DISPUTE. THE FACT-FINDING BOARD
SHALL ALSO SHARE ITS FINDINGS  OF  FACT  AND  RECOMMENDATIONS  WITH  THE
HEALTH CARE PROVIDERS' REPRESENTATIVE AND THE REPRESENTATIVE OF NEW YORK
HEALTH.  IF  WITHIN  TWENTY DAYS AFTER THE SUBMISSION OF THE FINDINGS OF
FACT AND RECOMMENDATIONS, THE IMPASSE CONTINUES, THE COMMISSIONER  SHALL
ORDER  A  RESOLUTION TO THE NEGOTIATIONS BASED UPON THE FINDINGS OF FACT
AND RECOMMENDATIONS SUBMITTED BY THE FACT-FINDING BOARD.
  § 4925. CERTAIN COLLECTIVE ACTION PROHIBITED. 1.  THIS  TITLE  IS  NOT
INTENDED  TO AUTHORIZE COMPETING HEALTH CARE PROVIDERS TO ACT IN CONCERT
IN RESPONSE TO A HEALTH CARE PROVIDERS' REPRESENTATIVE'S DISCUSSIONS  OR
NEGOTIATIONS WITH NEW YORK HEALTH EXCEPT AS AUTHORIZED BY OTHER LAW.
  2. NO HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL NEGOTIATE ANY AGREE-
MENT  THAT  EXCLUDES,  LIMITS  THE PARTICIPATION OR REIMBURSEMENT OF, OR
OTHERWISE LIMITS THE SCOPE OF SERVICES TO BE PROVIDED BY ANY HEALTH CARE
PROVIDER OR GROUP OF HEALTH CARE PROVIDERS WITH RESPECT TO THE  PERFORM-
ANCE OF SERVICES THAT ARE WITHIN THE HEALTH CARE PROVIDER'S LAWFUL SCOPE
OR TERMS OF PRACTICE, LICENSE, REGISTRATION, OR CERTIFICATE.
  §  4926. FEES. EACH PERSON WHO ACTS AS THE REPRESENTATIVE OF NEGOTIAT-
ING PARTIES UNDER THIS TITLE SHALL PAY TO THE DEPARTMENT A FEE TO ACT AS
A REPRESENTATIVE. THE COMMISSIONER, BY REGULATION,  SHALL  SET  FEES  IN
AMOUNTS  DEEMED  REASONABLE AND NECESSARY TO COVER THE COSTS INCURRED BY
THE DEPARTMENT IN ADMINISTERING THIS TITLE.
  § 4927. CONFIDENTIALITY. ALL REPORTS AND OTHER INFORMATION REQUIRED TO
BE REPORTED TO THE DEPARTMENT UNDER THIS TITLE SHALL NOT BE  SUBJECT  TO
DISCLOSURE UNDER ARTICLE SIX OF THE PUBLIC OFFICERS LAW.
  § 4928. SEVERABILITY AND CONSTRUCTION. IF ANY PROVISION OR APPLICATION
OF  THIS  TITLE  SHALL BE HELD TO BE INVALID, OR TO VIOLATE OR BE INCON-
SISTENT WITH ANY APPLICABLE FEDERAL LAW OR REGULATION,  THAT  SHALL  NOT
AFFECT OTHER PROVISIONS OR APPLICATIONS OF THIS TITLE WHICH CAN BE GIVEN
EFFECT  WITHOUT  THAT  PROVISION  OR  APPLICATION;  AND TO THAT END, THE
PROVISIONS AND APPLICATIONS OF THIS TITLE ARE SEVERABLE. THE  PROVISIONS
OF  THIS  TITLE  SHALL  BE  LIBERALLY  CONSTRUED  TO  GIVE EFFECT TO THE
PURPOSES THEREOF.
  § 6. Subdivision 11 of section  270  of  the  public  health  law,  as
amended  by  section 2-a of part C of chapter 58 of the laws of 2008, is
amended to read as follows:
  11. "State public health plan" means the  medical  assistance  program
established  by  title eleven of article five of the social services law
(referred to in this article as "Medicaid"), the elderly  pharmaceutical
insurance  coverage program established by title three of article two of
the elder law (referred to in this article as "EPIC"), and  the  [family
health  plus  program established by section three hundred sixty-nine-ee
of the social services law to the extent that section provides that  the
program shall be subject to this article] NEW YORK HEALTH PROGRAM ESTAB-
LISHED BY ARTICLE FIFTY-ONE OF THIS CHAPTER.
  §  7. The state finance law is amended by adding a new section 89-j to
read as follows:
  § 89-J. NEW YORK HEALTH TRUST FUND. 1. THERE IS HEREBY ESTABLISHED  IN
THE JOINT CUSTODY OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXA-

A. 5248--A                         27

TION  AND  FINANCE  A  SPECIAL REVENUE FUND TO BE KNOWN AS THE "NEW YORK
HEALTH TRUST FUND", REFERRED TO IN THIS SECTION AS "THE FUND". THE DEFI-
NITIONS IN SECTION FIFTY-ONE HUNDRED OF  THE  PUBLIC  HEALTH  LAW  SHALL
APPLY TO THIS SECTION.
  2. THE FUND SHALL CONSIST OF:
  (A)  ALL MONIES OBTAINED FROM TAXES PURSUANT TO LEGISLATION ENACTED AS
PROPOSED UNDER SECTION THREE OF THE NEW YORK HEALTH ACT;
  (B) FEDERAL PAYMENTS RECEIVED AS A  RESULT  OF  ANY  WAIVER  OR  OTHER
ARRANGEMENTS  AGREED  TO  BY  THE  UNITED STATES SECRETARY OF HEALTH AND
HUMAN SERVICES OR OTHER APPROPRIATE FEDERAL OFFICIALS  FOR  HEALTH  CARE
PROGRAMS ESTABLISHED UNDER MEDICARE, ANY FEDERALLY-MATCHED PUBLIC HEALTH
PROGRAM, OR THE AFFORDABLE CARE ACT;
  (C)  THE  AMOUNTS PAID BY THE DEPARTMENT OF HEALTH THAT ARE EQUIVALENT
TO THOSE AMOUNTS THAT ARE PAID ON BEHALF  OF  RESIDENTS  OF  THIS  STATE
UNDER  MEDICARE,  ANY  FEDERALLY-MATCHED  PUBLIC  HEALTH PROGRAM, OR THE
AFFORDABLE CARE ACT FOR HEALTH BENEFITS WHICH ARE EQUIVALENT  TO  HEALTH
BENEFITS COVERED UNDER NEW YORK HEALTH;
  (D)  FEDERAL AND STATE FUNDS FOR PURPOSES OF THE PROVISION OF SERVICES
AUTHORIZED UNDER TITLE XX OF THE FEDERAL SOCIAL SECURITY ACT THAT  WOULD
OTHERWISE  BE  COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW;
AND
  (E) STATE MONIES THAT WOULD OTHERWISE BE APPROPRIATED TO  ANY  GOVERN-
MENTAL  AGENCY,  OFFICE,  PROGRAM,  INSTRUMENTALITY OR INSTITUTION WHICH
PROVIDES HEALTH SERVICES, FOR SERVICES AND BENEFITS  COVERED  UNDER  NEW
YORK HEALTH. PAYMENTS TO THE FUND PURSUANT TO THIS PARAGRAPH SHALL BE IN
AN  AMOUNT  EQUAL  TO  THE  MONEY  APPROPRIATED FOR SUCH PURPOSES IN THE
FISCAL YEAR BEGINNING IMMEDIATELY PRECEDING THE EFFECTIVE  DATE  OF  THE
NEW YORK HEALTH ACT.
  3.  MONIES  IN  THE  FUND  SHALL ONLY BE USED FOR PURPOSES ESTABLISHED
UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
  § 8. Temporary commission on implementation. 1. There is hereby estab-
lished a temporary commission on implementation of the New  York  Health
program,  referred  to  in this section as the commission, consisting of
fifteen members: five members, including the chair, shall  be  appointed
by the governor; four members shall be appointed by the temporary presi-
dent of the senate, one member shall be appointed by the senate minority
leader;  four members shall be appointed by the speaker of the assembly,
and one member shall be appointed by the assembly minority  leader.  The
commissioner  of  health,  the superintendent of financial services, and
the commissioner of taxation and finance, or their designees shall serve
as non-voting ex-officio members of the commission.
  2. Members of the commission shall receive such assistance as  may  be
necessary  from  other  state  agencies  and entities, and shall receive
reasonable and necessary expenses incurred in the performance  of  their
duties.  The  commission  may  employ  staff  as needed, prescribe their
duties, and fix their compensation within amounts appropriated  for  the
commission.
  3.  The commission shall examine the laws and regulations of the state
and consult with health care providers, consumers, and other  stakehold-
ers  and  make such recommendations as are necessary to conform the laws
and regulations of the state and article 51 of  the  public  health  law
establishing  the  New  York  Health program and other provisions of law
relating to the New York Health program, and to  improve  and  implement
the  program.  The  commission  shall  report its recommendations to the
governor and the legislature.   The commission shall  immediately  begin
development of proposals consistent with the principles of article 51 of

A. 5248--A                         28

the  public  health  law  for  provision of health care services covered
under the workers' compensation law; and incorporation of retiree health
benefits, as described in paragraphs (a), (b) and (c) of  subdivision  8
of  section 5102 of the public health law.  The commission shall provide
its work product and assistance to the  board  established  pursuant  to
section 5102 of the public health law upon completion of the appointment
of the board.
  §  9.  Severability. If any provision or application of this act shall
be held to be invalid, or to violate or be inconsistent with any  appli-
cable  federal law or regulation, that shall not affect other provisions
or applications of this act which  can  be  given  effect  without  that
provision  or  application; and to that end, the provisions and applica-
tions of this act are severable.
  § 10. This act shall take effect immediately.