The New York State Senate

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

                                 3577--A

                       2019-2020 Regular Sessions

                            I N  S E N A T E

                            February 11, 2019
                               ___________

Introduced  by  Sens.  RIVERA, RAMOS, ADDABBO, BAILEY, BENJAMIN, BIAGGI,
  BRESLIN, CARLUCCI, COMRIE,  GIANARIS,  GOUNARDES,  HARCKHAM,  HOYLMAN,
  JACKSON,  KAVANAGH,  KENNEDY, KRUEGER, LIU, MAY, MAYER, METZGER, MONT-
  GOMERY, MYRIE, PARKER, PERSAUD, SALAZAR, SANDERS, SEPULVEDA,  SERRANO,
  STAVISKY,  THOMAS  -- read twice and ordered printed, and when printed
  to be committed to the Committee  on  Health  --  recommitted  to  the
  Committee  on  Health  in  accordance  with  Senate  Rule 6, sec. 8 --
  committee discharged, bill amended, ordered reprinted as  amended  and
  recommitted to said committee

AN  ACT  to  amend  the  public health law and the state finance law, in
  relation to 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
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

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

                                                           LBD09777-07-0

S. 3577--A                          2

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,
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,

S. 3577--A                          3

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
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

S. 3577--A                          4

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
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

S. 3577--A                          5

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.
  § 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

S. 3577--A                          6

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
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,

S. 3577--A                          7

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.
  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.

S. 3577--A                          8

  (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;
  (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

S. 3577--A                          9

  (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.
  (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

S. 3577--A                         10

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
SERVICES UNDER THE PROGRAM, PROVIDED THAT THE HEALTH  CARE  PROVIDER  IS
OTHERWISE  LEGALLY AUTHORIZED TO PERFORM THE HEALTH CARE SERVICE FOR THE
INDIVIDUAL AND UNDER THE CIRCUMSTANCES INVOLVED.
  (B) A MEMBER MAY CHOOSE TO RECEIVE  HEALTH  CARE  SERVICES  UNDER  THE
PROGRAM  FROM  ANY PARTICIPATING PROVIDER, CONSISTENT WITH PROVISIONS OF
THIS ARTICLE RELATING TO CARE COORDINATION  AND  HEALTH  CARE  ORGANIZA-
TIONS,  THE  WILLINGNESS  OR  AVAILABILITY  OF  THE PROVIDER (SUBJECT TO

S. 3577--A                         11

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.
  (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-

S. 3577--A                         12

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.
  (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

S. 3577--A                         13

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.
  (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

S. 3577--A                         14

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
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;

S. 3577--A                         15

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;
  (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

S. 3577--A                         16

  (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
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

S. 3577--A                         17

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
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

S. 3577--A                         18

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
  (C) CARE COORDINATOR ASSISTANCE TO INDIVIDUALS AND ENTITIES  PROVIDING
AND  SEEKING  OR  CONSIDERING  WHETHER  TO PROVIDE, CARE COORDINATION TO
MEMBERS.
  2. THE COMMISSIONER SHALL PROVIDE GRANTS FROM FUNDS IN  THE  NEW  YORK
HEALTH  TRUST FUND OR OTHERWISE APPROPRIATED FOR THIS PURPOSE, TO HEALTH
SYSTEMS AGENCIES UNDER SECTION TWENTY-NINE HUNDRED FOUR-B OF THIS  CHAP-
TER TO SUPPORT THE OPERATION OF SUCH HEALTH SYSTEMS AGENCIES.

S. 3577--A                         19

  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-
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

S. 3577--A                         20

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;
  (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.

S. 3577--A                         21

  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.
  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;

S. 3577--A                         22

  (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.
  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

S. 3577--A                         23

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
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

S. 3577--A                         24

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-
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.

S. 3577--A                         25

  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-
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

S. 3577--A                         26

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-
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

S. 3577--A                         27

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
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

S. 3577--A                         28

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.