The New York State Senate

 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   6027
 
                        2023-2024 Regular Sessions
 
                           I N  A S S E M B L Y
 
                              March 30, 2023
                                ___________
 
 Introduced  by M. of A. PAULIN, SEAWRIGHT, REYES, RAMOS, SIMON, EPSTEIN,
   BICHOTTE HERMELYN, STECK, MITAYNES, McDONOUGH, L. ROSENTHAL,  BENEDET-
   TO,  FORREST,  BURGOS,  GONZALEZ-ROJAS, RIVERA, GIBBS, KELLES, THIELE,
   ZINERMAN,  DE LOS SANTOS,  JACKSON,  JEAN-PIERRE  --  read  once   and
   referred to the Committee on Health

 AN ACT to amend the public health law, in relation to the general hospi-
   tal  indigent  care pool; and to repeal certain provisions of such law
   relating thereto
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.  Subdivision 9 of section 2807-k of the public health law,
 as amended by section 17 of part B of chapter 60 of the laws of 2014, is
 amended to read as follows:
   9. In order for a general hospital to participate in the  distribution
 of  funds  from  the  pool, the general hospital must [implement minimum
 collection policies and procedures approved] USE ONLY THE UNIFORM FINAN-
 CIAL ASSISTANCE POLICY AND FORM PROVIDED by the commissioner.
   § 2.  Subdivision 9-a of section 2807-k of the public health  law,  as
 added by section 39-a of part A of chapter 57 of the laws of 2006, para-
 graph  (k) as added by section 43 of part B of chapter 58 of the laws of
 2008, is amended to read as follows:
   9-a. (a) (I) As a condition for participation  in  pool  distributions
 authorized  pursuant  to  this  section and section twenty-eight hundred
 seven-w of this article for periods on  and  after  January  first,  two
 thousand  nine,  general  hospitals  shall, effective for periods on and
 after January first,  two  thousand  seven,  establish  financial  [aid]
 ASSISTANCE policies and procedures, in accordance with the provisions of
 this  subdivision, for reducing HOSPITAL charges otherwise applicable to
 low-income individuals without THIRD-PARTY health [insurance]  COVERAGE,
 or  who  have  [exhausted their] THIRD-PARTY health [insurance benefits]
 COVERAGE THAT DOES NOT COVER OR LIMITS COVERAGE OF THE SERVICE, and  who
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD02400-01-3

 A. 6027                             2
 
 can  demonstrate  an  inability  to  pay  full charges, and also, at the
 hospital's discretion, for reducing or  discounting  the  collection  of
 co-pays  and  deductible  payments from those individuals who can demon-
 strate an inability to pay such amounts. IMMIGRATION STATUS SHALL NOT BE
 AN  ELIGIBILITY  CRITERION  FOR  THE  PURPOSE  OF  DETERMINING FINANCIAL
 ASSISTANCE UNDER THIS SECTION.
   (II) A GENERAL HOSPITAL MAY USE THE NEW YORK STATE OF  HEALTH  MARKET-
 PLACE  ELIGIBILITY  DETERMINATION PAGE TO ESTABLISH THE PATIENT'S HOUSE-
 HOLD INCOME AND RESIDENCY IN LIEU OF  THE  FINANCIAL  APPLICATION  FORM,
 PROVIDED  IT  HAS SECURED THE CONSENT OF THE PATIENT. A GENERAL HOSPITAL
 SHALL NOT REQUIRE A PATIENT TO APPLY FOR COVERAGE THROUGH THE  NEW  YORK
 STATE  OF  HEALTH  MARKETPLACE  IN  ORDER  TO  RECEIVE CARE OR FINANCIAL
 ASSISTANCE.
   (III) UPON SUBMISSION OF A COMPLETED APPLICATION FORM, THE PATIENT  IS
 NOT LIABLE FOR ANY BILLS UNTIL THE GENERAL HOSPITAL HAS RENDERED A DECI-
 SION ON THE APPLICATION IN ACCORDANCE WITH THIS SUBDIVISION.
   (b)  [Such]  THE  reductions  from  charges  for  [uninsured] patients
 DESCRIBED IN PARAGRAPH (A) OF THIS SUBDIVISION with  incomes  below  [at
 least  three]  SIX  hundred  percent  of the federal poverty level shall
 result in a charge to such individuals that does not exceed [the greater
 of] the amount that would have been paid for the same services  [by  the
 "highest  volume payor" for such general hospital as defined in subpara-
 graph (v) of this paragraph, or for services provided pursuant to  title
 XVIII  of  the  federal social security act (medicare), or for services]
 provided pursuant to title [XIX] XVIII of the  federal  social  security
 act  [(medicaid)]  (MEDICARE),  and provided further that such [amounts]
 AMOUNT shall be adjusted according to income level as follows:
   (i) For patients with incomes at or below [at least one]  TWO  hundred
 percent of the federal poverty level, the hospital shall collect no more
 than a nominal payment amount, consistent with guidelines established by
 the commissioner[;].
   (ii)  For  patients  with  incomes  [between  at  least one] ABOVE TWO
 hundred [one] percent and [one] UP TO FOUR hundred  [fifty]  percent  of
 the  federal  poverty level, the hospital shall collect no more than the
 amount identified after application of a proportional sliding fee sched-
 ule under which patients with lower incomes shall pay the lowest amount.
 [Such] THE schedule shall provide  that  the  amount  the  hospital  may
 collect  for  [such  patients]  THE  PATIENT  increases from the nominal
 amount described in subparagraph (i) of this paragraph in  equal  incre-
 ments  as the income of the patient increases, up to a maximum of twenty
 percent of the [greater of the] amount that would have been paid for the
 same services [by the "highest volume payor" for such general  hospital,
 as  defined  in  subparagraph  (v)  of  this  paragraph, or for services
 provided pursuant to title XVIII of  the  federal  social  security  act
 (medicare)  or  for  services] provided pursuant to title [XIX] XVIII of
 the federal social security act [(medicaid);] (MEDICARE).
   (iii) [For patients with incomes between at least one  hundred  fifty-
 one  percent and two hundred fifty percent of the federal poverty level,
 the hospital shall collect no more  than  the  amount  identified  after
 application  of a proportional sliding fee schedule under which patients
 with lower income shall pay the  lowest  amounts.  Such  schedule  shall
 provide  that  the  amount  the  hospital  may collect for such patients
 increases from the twenty percent figure described in subparagraph  (ii)
 of  this  paragraph  in  equal  increments  as the income of the patient
 increases, up to a maximum of the greater of the amount that would  have
 been  paid  for the same services by the "highest volume payor" for such
 A. 6027                             3

 general hospital, as defined in subparagraph (v) of this  paragraph,  or
 for  services  provided  pursuant  to  title XVIII of the federal social
 security act (medicare) or for services provided pursuant to  title  XIX
 of the federal social security act (medicaid); and
   (iv)]  For  patients with incomes [between at least two hundred fifty-
 one percent and three hundred] ABOVE FOUR HUNDRED PERCENT AND UP TO  SIX
 HUNDRED percent of the federal poverty level, the hospital shall collect
 no  more  than the [greater of the] amount that would have been paid for
 the same services [by the "highest volume payor" for such general hospi-
 tal as defined in subparagraph (v) of this paragraph,  or  for  services
 provided  pursuant  to  title  XVIII  of the federal social security act
 (medicare), or for services] provided pursuant to title [XIX]  XVIII  of
 the federal social security act [(medicaid)] (MEDICARE).
   [(v)  For the purposes of this paragraph, "highest volume payor" shall
 mean the insurer, corporation or  organization  licensed,  organized  or
 certified  pursuant  to  article thirty-two, forty-two or forty-three of
 the insurance law or article forty-four of this chapter, or other third-
 party payor, which has  a  contract  or  agreement  to  pay  claims  for
 services  provided  by  the  general  hospital  and incurred the highest
 volume of claims in the previous calendar year.
   (vi) A hospital may implement policies and procedures to  permit,  but
 not  require, consideration on a case-by-case basis of exceptions to the
 requirements described in subparagraphs (i) and (ii) of  this  paragraph
 based upon the existence of significant assets owned by the patient that
 should  be  taken  into  account  in determining the appropriate payment
 amount for that patient's care, provided, however,  that  such  proposed
 policies  and  procedures  shall  be  subject  to  the  prior review and
 approval of the commissioner and, if approved, shall be included in  the
 hospital's  financial  assistance  policy  established  pursuant to this
 section, and provided further that, if such  approval  is  granted,  the
 maximum amount that may be collected shall not exceed the greater of the
 amount  that  would have been paid for the same services by the "highest
 volume payor" for such general hospital as defined in  subparagraph  (v)
 of  this  paragraph, or for services provided pursuant to title XVIII of
 the federal social security act (medicare),  or  for  services  provided
 pursuant  to title XIX of the federal social security act (medicaid). In
 the event that a general hospital reviews a patient's assets  in  deter-
 mining  payment  adjustments  such  policies  and  procedures  shall not
 consider as assets a patient's primary residence, assets held in a  tax-
 deferred  or  comparable  retirement  savings  account,  college savings
 accounts, or cars used  regularly  by  a  patient  or  immediate  family
 members.
   (vii)]  (C) Nothing in this [paragraph] SUBDIVISION shall be construed
 to limit a hospital's  ability  to  establish  patient  eligibility  for
 payment  discounts  at  income levels higher than those specified herein
 and/or to provide greater payment discounts for eligible  patients  than
 those required by this [paragraph] SUBDIVISION.
   [(c)] (D) Such policies and procedures shall be clear, understandable,
 in  writing  and  publicly  available  in  summary form and each general
 hospital participating in the pool shall ensure that  every  patient  is
 made aware of the existence of [such] THE policies and procedures and is
 provided,  in  a timely manner, with a summary AND A COPY of [such poli-
 cies and procedures] THE POLICY  AND  FORM  upon  request.  Any  summary
 provided  to  patients shall, at a minimum, include specific information
 as to income levels used to  determine  eligibility  for  assistance,  a
 description of the primary service area of the hospital and the means of
 A. 6027                             4
 
 applying  for  assistance.  [For general hospitals with twenty-four hour
 emergency departments, such policies and procedures] A GENERAL  HOSPITAL
 shall  [require the notification of patients] NOTIFY PATIENTS BY PROVID-
 ING  WRITTEN  MATERIALS  TO PATIENTS OR THEIR AUTHORIZED REPRESENTATIVES
 during the intake and  registration  process,  through  the  conspicuous
 posting of language-appropriate information in the general hospital, and
 BY  INCLUDING information on bills and statements sent to patients, that
 financial [aid] ASSISTANCE may be available to  qualified  patients  and
 how  to  obtain  further  information.  [For specialty hospitals without
 twenty-four hour emergency departments,  such  notification  shall  take
 place  through  written materials provided to patients during the intake
 and registration process prior to  the  provision  of  any  health  care
 services  or procedures, and through information on bills and statements
 sent to patients, that financial  aid  may  be  available  to  qualified
 patients  and  how  to obtain further information. Application materials
 shall include a notice to patients that upon submission of  a  completed
 application, including any information or documentation needed to deter-
 mine  the  patient's  eligibility  pursuant  to the hospital's financial
 assistance policy, the patient may disregard any bills until the  hospi-
 tal  has  rendered a decision on the application in accordance with this
 paragraph] GENERAL HOSPITALS SHALL POST THE FINANCIAL ASSISTANCE  APPLI-
 CATION  POLICY,  PROCEDURES  AND  FORM,  AND A SUMMARY OF THE POLICY AND
 PROCEDURES, IN A CONSPICUOUS  LOCATION  AND  DOWNLOADABLE  FORM  ON  THE
 GENERAL HOSPITAL'S WEBSITE.
   [(d)  Such]  (E)  THE HOSPITAL'S APPLICATION MATERIALS SHALL INCLUDE A
 NOTICE TO PATIENTS THAT UPON SUBMISSION OF A COMPLETED APPLICATION FORM,
 THE PATIENT SHALL NOT BE LIABLE FOR ANY BILLS UNTIL THE GENERAL HOSPITAL
 HAS RENDERED A DECISION ON  THE  APPLICATION  IN  ACCORDANCE  WITH  THIS
 SUBDIVISION.   THE APPLICATION MATERIALS SHALL INCLUDE SPECIFIC INFORMA-
 TION AS THE INCOME LEVELS USED TO DETERMINE  ELIGIBILITY  FOR  FINANCIAL
 ASSISTANCE,  A  DESCRIPTION  OF THE PRIMARY SERVICE AREA OF THE HOSPITAL
 AND THE MEANS TO APPLY FOR ASSISTANCE. NOTHING IN THIS SUBDIVISION SHALL
 BE CONSTRUED AS PRECLUDING THE USE OF PRESUMPTIVE  ELIGIBILITY  DETERMI-
 NATIONS  BY HOSPITALS ON BEHALF OF PATIENTS. THE policies and procedures
 shall include clear, objective  criteria  for  determining  a  patient's
 ability  to  pay  and for providing such adjustments to payment require-
 ments as are necessary. In addition to  adjustment  mechanisms  such  as
 sliding  fee  schedules  and discounts to fixed standards, such policies
 and procedures shall also provide for the use of installment  plans  for
 the  payment  of  outstanding  balances  by  patients  pursuant  to  the
 provisions of the hospital's financial assistance  policy.  The  monthly
 payment  under  such  a  plan shall not exceed [ten] FIVE percent of the
 gross monthly income of the patient[, provided, however, that if patient
 assets are considered under such a policy, then patient assets which are
 not excluded assets pursuant to subparagraph (vi) of  paragraph  (b)  of
 this  subdivision  may be considered in addition to the limit on monthly
 payments]. INSTALLMENT PLAN PAYMENTS MAY NOT BE REQUIRED TO BEGIN BEFORE
 ONE HUNDRED EIGHTY DAYS AFTER THE DATE  OF  THE  SERVICE  OR  DISCHARGE,
 WHICHEVER  IS LATER. THE POLICY SHALL ALLOW THE PATIENT AND THE HOSPITAL
 TO MUTUALLY AGREE TO MODIFY THE TERMS OF AN INSTALLMENT PLAN.  The  rate
 of  interest charged to the patient on the unpaid balance, if any, shall
 not exceed [the rate for a ninety-day  security  issued  by  the  United
 States  Department of Treasury, plus .5 percent] TWO PERCENTUM PER ANNUM
 and no plan shall include an accelerator or similar clause under which a
 higher rate of interest is triggered upon a missed payment.   [If  such]
 THE policies and procedures SHALL NOT include a requirement of a deposit
 A. 6027                             5
 
 prior to [non-emergent,] medically-necessary care[, such deposit must be
 included  as  part  of  any financial aid consideration].   THE HOSPITAL
 SHALL REFUND ANY PAYMENTS MADE BY THE PATIENT BEFORE  THE  DETERMINATION
 OF  ELIGIBILITY  FOR  FINANCIAL  ASSISTANCE  THAT  EXCEEDS THE PATIENT'S
 LIABILITY AFTER DISCOUNTS ARE  APPLIED.  Such  policies  and  procedures
 shall be applied consistently to all eligible patients.
   [(e) Such policies and procedures shall permit patients to] (F) IN ANY
 LEGAL  ACTION  BY  OR ON BEHALF OF A HOSPITAL TO COLLECT A MEDICAL DEBT,
 THE COMPLAINT SHALL BE ACCOMPANIED BY AN  AFFIDAVIT  BY  THE  HOSPITAL'S
 CHIEF  FINANCIAL  OFFICER  STATING  THAT  ON  INFORMATION AND BELIEF THE
 PATIENT DOES NOT MEET THE INCOME OR  RESIDENCY  CRITERIA  FOR  FINANCIAL
 ASSISTANCE. PATIENTS MAY apply for FINANCIAL assistance [within at least
 ninety  days  of the date of discharge or date of service and provide at
 least twenty days for patients to submit a completed application] AT ANY
 TIME DURING THE COLLECTION PROCESS, INCLUDING AFTER THE COMMENCEMENT  OF
 A  MEDICAL  DEBT  COURT ACTION OR UPON THE PLAINTIFF OBTAINING A DEFAULT
 JUDGMENT. A HOSPITAL MAY USE CREDIT SCORING SOFTWARE FOR THE PURPOSES OF
 ESTABLISHING INCOME ELIGIBILITY AND APPROVING FINANCIAL ASSISTANCE,  BUT
 ONLY  IF THE HOSPITAL MAKES CLEAR TO THE PATIENT THAT PROVIDING A SOCIAL
 SECURITY NUMBER IS NOT MANDATORY AND THE  SCORING  DOES  NOT  NEGATIVELY
 IMPACT  THE  PATIENT'S  CREDIT SCORE.   HOWEVER, CREDIT SCORING SOFTWARE
 SHALL NOT BE SOLELY RELIED UPON BY THE HOSPITAL IN DENYING  A  PATIENT'S
 APPLICATION  FOR  FINANCIAL ASSISTANCE.   [Such] THE policies and proce-
 dures [may require that] SHALL ALLOW patients seeking  [payment  adjust-
 ments]  FINANCIAL  ASSISTANCE  TO  provide  [appropriate]  THE FOLLOWING
 financial information and documentation in  support  of  their  applica-
 tion[,  provided,  however,  that  such application process shall not be
 unduly burdensome or complex]: PAY CHECKS  OR  PAY  STUBS;  UNEMPLOYMENT
 DOCUMENTATION;  SOCIAL SECURITY INCOME; RENT RECEIPTS; A LETTER FROM THE
 PATIENT'S EMPLOYER ATTESTING TO THE PATIENT'S GROSS INCOME; OR, IF  NONE
 OF  THE  AFOREMENTIONED  INFORMATION  AND DOCUMENTATION ARE AVAILABLE, A
 WRITTEN SELF-ATTESTATION OF THE PATIENT'S INCOME MAY  BE  USED.  General
 hospitals  shall,  upon  request,  assist  patients in understanding the
 hospital's APPLICATION AND FORM, policies and procedures and in applying
 for payment adjustments. Application forms shall be printed  AND  POSTED
 TO  ITS  WEBSITE  in  the  "primary languages" of patients served by the
 general  hospital.  For  the  purposes  of  this   paragraph,   "primary
 languages"  shall include any language that is either (i) used to commu-
 nicate, during at least five percent of patient visits  in  a  year,  by
 patients  who  cannot  speak,  read,  write  or  understand  the English
 language at the level of proficiency necessary  for  effective  communi-
 cation  with health care providers, or (ii) spoken by non-English speak-
 ing individuals comprising more than one percent of the primary hospital
 service area population, as  calculated  using  demographic  information
 available  from  the United States Bureau of the Census, supplemented by
 data from school systems. Decisions regarding such applications shall be
 made within thirty days of receipt of a  completed  application.  [Such]
 THE  policies  and  procedures shall require that the hospital issue any
 [denial/approval] DENIAL OR APPROVAL of [such] THE application in  writ-
 ing  with  information on how to appeal the denial and shall require the
 hospital to establish an appeals process under which  it  will  evaluate
 the  denial  of  an  application.  [Nothing in this subdivision shall be
 interpreted as prohibiting a hospital from making  the  availability  of
 financial  assistance  contingent  upon  the  patient first applying for
 coverage under title XIX of the social security act (medicaid) or anoth-
 er insurance program if, in the judgment of the  hospital,  the  patient
 A. 6027                             6

 may  be eligible for medicaid or another insurance program, and upon the
 patient's cooperation in following the hospital's  financial  assistance
 application  requirements, including the provision of information needed
 to  make a determination on the patient's application in accordance with
 the hospital's financial assistance policy] THE  HOSPITAL  SHALL  INFORM
 PATIENTS  ON  HOW  TO  FILE  A  COMPLAINT AGAINST THE HOSPITAL OR A DEBT
 COLLECTOR THAT IS CONTRACTED ON BEHALF OF  THE  HOSPITAL  REGARDING  THE
 PATIENT'S BILL.
   [(f) Such] (G) THE policies and procedures shall provide that patients
 with  incomes  below  [three] SIX hundred percent of the federal poverty
 level are deemed [presumptively] eligible for  payment  adjustments  and
 shall  conform  to  the  requirements set forth in paragraph (b) of this
 subdivision, provided, however, that nothing in this  subdivision  shall
 be  interpreted  as  precluding  hospitals  from  extending such payment
 adjustments to other patients, either generally  or  on  a  case-by-case
 basis.  [Such] THE policies and procedures shall provide financial [aid]
 ASSISTANCE for emergency hospital services, including  emergency  trans-
 fers  pursuant  to  the  federal  emergency medical treatment and active
 labor act (42 USC 1395dd), to patients who reside in New York state  and
 for medically necessary hospital services for patients who reside in the
 hospital's  primary  service  area  as  determined according to criteria
 established by the commissioner. In developing [such] THE criteria,  the
 commissioner  shall  consult with representatives of the hospital indus-
 try, health care consumer advocates and local public  health  officials.
 [Such]  THE  criteria shall be made available to the public no less than
 thirty days prior to the date of implementation and shall, at a minimum:
   (i) prohibit a  hospital  from  developing  or  altering  its  primary
 service  area in a manner designed to avoid medically underserved commu-
 nities or communities with high percentages of uninsured residents;
   (ii) ensure that every geographic area of the state is included in  at
 least  one  general  hospital's  primary  service  area so that eligible
 patients may access care and financial assistance; and
   (iii) require the hospital to notify the commissioner upon making  any
 change  to its primary service area, and to include a description of its
 primary service area in  the  hospital's  annual  implementation  report
 filed  pursuant  to  subdivision  three  of section twenty-eight hundred
 three-l of this article.
   [(g)] (H) Nothing in this subdivision shall be interpreted as preclud-
 ing hospitals from extending payment adjustments for medically necessary
 non-emergency hospital services to patients outside  of  the  hospital's
 primary  service area. For patients determined to be eligible for finan-
 cial [aid] ASSISTANCE under the terms of a  hospital's  financial  [aid]
 ASSISTANCE policy, [such] THE policies and procedures shall prohibit any
 limitations  on  financial  [aid]  ASSISTANCE  for services based on the
 medical condition of the applicant, other than  typical  limitations  or
 exclusions  based  on  medical  necessity or the clinical or therapeutic
 benefit of a procedure or treatment.
   [(h) Such policies and procedures shall not permit the forced]  (I)  A
 HOSPITAL  OR  ITS  AGENT  SHALL NOT ISSUE, AUTHORIZE OR PERMIT AN INCOME
 EXECUTION OF A PATIENT'S WAGES, SECURE A LIEN OR FORCE A sale  or  fore-
 closure  of  a  patient's  primary  residence  in  order  to  collect an
 outstanding medical bill and shall [require the hospital to refrain from
 sending] NOT SEND an account to collection if the patient has  submitted
 a  completed  application  for  financial  [aid,  including any required
 supporting documentation] ASSISTANCE, while the hospital determines  the
 patient's  eligibility  for [such aid] FINANCIAL ASSISTANCE.  [Such] THE
 A. 6027                             7
 
 policies and procedures shall provide for  written  notification,  which
 shall include notification on a patient bill, to a patient not less than
 thirty  days  prior  to  the  referral of debts for collection and shall
 require that the collection agency obtain the hospital's written consent
 prior  to  commencing a legal action. [Such] THE policies and procedures
 shall require all general hospital staff who interact with  patients  or
 have  responsibility for billing and collections to be trained in [such]
 THE policies and procedures, and require the implementation of  a  mech-
 anism for the general hospital to measure its compliance with [such] THE
 policies  and  procedures.    [Such]  THE  policies and procedures shall
 require that any collection agency, LAWYER OR FIRM under contract with a
 general hospital for the  collection  of  debts  follow  the  hospital's
 financial assistance policy, including providing information to patients
 on  how  to apply for financial assistance where appropriate. [Such] THE
 policies and procedures shall prohibit collections from a patient who is
 determined to be eligible for medical assistance [pursuant to title  XIX
 of  the  federal social security act] UNDER TITLE ELEVEN OF ARTICLE FIVE
 OF THE SOCIAL SERVICES LAW at the time services were  rendered  and  for
 which services medicaid payment is available.
   [(i)]  (J)  Reports required to be submitted to the department by each
 general hospital as a condition for participation  in  the  pools[,  and
 which   contain,  in  accordance  with  applicable  regulations,]  SHALL
 CONTAIN: (I)  a  certification  from  an  independent  certified  public
 accountant  or  independent licensed public accountant or an attestation
 from a senior official of the hospital that the hospital is  in  compli-
 ance with conditions of participation in the pools[, shall also contain,
 for reporting periods on and after January first, two thousand seven:];
   [(i)] (II) a report on hospital costs incurred and uncollected amounts
 in  providing  services to [eligible] patients [without insurance] FOUND
 ELIGIBLE FOR FINANCIAL ASSISTANCE, including the amount of care provided
 for a nominal payment amount, during the period covered by the report;
   [(ii)] (III) hospital  costs  incurred  and  uncollected  amounts  for
 deductibles  and  coinsurance  for  eligible  patients with insurance or
 other third-party payor coverage;
   [(iii)] (IV) the number of patients,  organized  according  to  United
 States  postal service zip code, RACE, ETHNICITY AND GENDER, who applied
 for financial assistance [pursuant to] UNDER  the  hospital's  financial
 assistance  policy, and the number, organized according to United States
 postal service zip code, RACE, ETHNICITY AND GENDER, whose  applications
 were approved and whose applications were denied;
   [(iv)]  (V) the reimbursement received for indigent care from the pool
 established [pursuant to] UNDER this section;
   [(v)] (VI) the amount of funds that have  been  expended  on  [charity
 care]  FINANCIAL  ASSISTANCE  from  charitable  bequests  made or trusts
 established  for  the  purpose  of  providing  financial  assistance  to
 patients  who  are  eligible  in accordance with the terms of [such] THE
 bequests or trusts;
   [(vi)] (VII) for hospitals located in  social  services  districts  in
 which  the district allows hospitals to assist patients with such appli-
 cations, the number of applications for eligibility FOR  MEDICAID  under
 title [XIX of the social security act (medicaid)] ELEVEN OF ARTICLE FIVE
 OF  THE  SOCIAL  SERVICES  LAW  that  the  hospital assisted patients in
 completing and the number denied and approved;
   [(vii)] (VIII) the hospital's financial losses resulting from services
 provided under medicaid; and
 A. 6027                             8

   [(viii)]  (IX)  the  number  of  REFERRALS  TO  COLLECTION  AGENTS  OR
 CONTRACTED  EXTERNAL COLLECTION VENDORS, COURT CASES AND liens placed on
 [the primary] ANY residences of patients through the collection  process
 used by a hospital.
   [(j)]  (K)  Within ninety days of the effective date of THE CHAPTER OF
 THE LAWS OF TWO THOUSAND TWENTY-THREE  WHICH  AMENDED  this  subdivision
 each  hospital  shall submit to the commissioner a written report on its
 policies and procedures for financial assistance to patients  which  are
 used  by the hospital [on the] AS OF SUCH effective date [of this subdi-
 vision]. Such report shall include copies of  its  policies  and  proce-
 dures,  including  material  which  is  distributed  to  patients, and a
 description of the hospital's financial  aid  policies  and  procedures.
 Such  description  shall  include the income levels of patients on which
 eligibility is based, the financial aid eligible  patients  receive  and
 the means of calculating such aid, and the service area, if any, used by
 the hospital to determine eligibility.
   [(k)]  (L)  THE  COMMISSIONER  SHALL  INCLUDE THE DATA COLLECTED UNDER
 PARAGRAPH (J) OF THIS SUBDIVISION IN REGULAR AUDITS OF THE ANNUAL GENER-
 AL HOSPITAL INSTITUTIONAL COST REPORT.
   (M) In the event [it is determined by the commissioner that] the state
 [will be] IS  unable  to  secure  all  necessary  federal  approvals  to
 include, as part of the state's approved state plan under title nineteen
 of  the  federal  social  security  act, a requirement[, as set forth in
 paragraph one of this subdivision,] that compliance with  this  subdivi-
 sion  is  a  condition of participation in pool distributions authorized
 pursuant to this section and section  twenty-eight  hundred  seven-w  of
 this  article, then such condition of participation shall be deemed null
 and void [and, notwithstanding]. NOTWITHSTANDING section twelve of  this
 chapter,  failure to comply with [the provisions of] this subdivision by
 a GENERAL hospital [on and after the date of such  determination]  shall
 make  [such]  THE  hospital liable for a civil penalty not to exceed ten
 thousand dollars for each [such] violation. The imposition of [such] THE
 civil penalties shall be subject to [the provisions of] section twelve-a
 of this chapter.
   (N) A HOSPITAL OR ITS  COLLECTION  AGENTS  SHALL  NOT  REPORT  ADVERSE
 INFORMATION ABOUT A PATIENT TO A CONSUMER OR FINANCIAL REPORTING ENTITY,
 OR  COMMENCE  CIVIL  ACTION  AGAINST  A PATIENT OR DELEGATE A COLLECTION
 ACTIVITY TO A DEBT COLLECTOR FOR NONPAYMENT FOR ONE HUNDRED EIGHTY  DAYS
 AFTER  THE  FIRST  POST-SERVICE BILL IS ISSUED; AND A HOSPITAL SHALL NOT
 REPORT ADVERSE INFORMATION TO A CONSUMER REPORTING AGENCY, OR COMMENCE A
 CIVIL ACTION AGAINST A PATIENT OR DELEGATE A COLLECTION  ACTIVITY  TO  A
 DEBT COLLECTOR, IF: THE HOSPITAL WAS NOTIFIED THAT AN APPEAL OR A REVIEW
 OF A HEALTH INSURANCE DECISION IS PENDING WITHIN THE IMMEDIATELY PRECED-
 ING  SIXTY  DAYS; OR THE PATIENT HAS A PENDING APPLICATION FOR OR QUALI-
 FIED FOR FINANCIAL ASSISTANCE.  A HOSPITAL SHALL REPORT THE  FULFILLMENT
 OF  A  PATIENT'S  PAYMENT  OBLIGATION WITHIN THIRTY DAYS AFTER THE OBLI-
 GATION IS FULFILLED TO A CONSUMER OR FINANCIAL REPORTING ENTITY TO WHICH
 THE HOSPITAL HAD REPORTED ADVERSE INFORMATION ABOUT THE PATIENT.
   § 3. Subdivision 9-a of section 2807-k of the  public  health  law  as
 amended by section two of this act, is amended to read as follows:
   9-a.  (a)  (i)  As a condition for participation in pool distributions
 authorized pursuant to this section  and  section  twenty-eight  hundred
 seven-w  of  this  article  for  periods on and after January first, two
 thousand nine, general hospitals shall, effective  for  periods  on  and
 after  January first, two thousand [seven, establish] TWENTY-FIVE, ADOPT
 AND IMPLEMENT THE UNIFORM financial assistance [policies and procedures,
 A. 6027                             9

 in accordance with the provisions of this subdivision,] FORM AND POLICY,
 TO BE DEVELOPED AND ISSUED BY THE COMMISSIONER. GENERAL HOSPITALS  SHALL
 IMPLEMENT  THE UNIFORM POLICY AND FORM for reducing hospital charges AND
 CHARGES  FOR  AFFILIATED  PROVIDERS  otherwise  applicable to low-income
 individuals without third-party health coverage, or who have third-party
 health coverage that does not cover or limits coverage of  the  service,
 and  who  can demonstrate an inability to pay full charges, and also, at
 the hospital's discretion, for reducing or discounting the collection of
 co-pays and deductible payments from those individuals  who  can  demon-
 strate an inability to pay such amounts. Immigration status shall not be
 an  eligibility  criterion  for  the  purpose  of  determining financial
 assistance under this section. AS  USED  IN  THIS  SECTION,  "AFFILIATED
 PROVIDER"  MEANS  A  PROVIDER THAT IS: (A) EMPLOYED BY THE HOSPITAL; (B)
 UNDER A PROFESSIONAL SERVICES AGREEMENT WITH  THE  HOSPITAL;  OR  (C)  A
 CLINICAL  FACULTY MEMBER OF A MEDICAL SCHOOL OR OTHER SCHOOL THAT TRAINS
 INDIVIDUALS TO BE PROVIDERS AND THAT IS AFFILIATED WITH THE HOSPITAL  OR
 HEALTH SYSTEM.
   (ii)  A  general hospital may use the New York state of health market-
 place eligibility determination page to establish the  patient's  house-
 hold  income  and  residency  in lieu of the financial application form,
 provided it has secured the consent of the patient. A  general  hospital
 shall  not  require a patient to apply for coverage through the New York
 state of health marketplace  in  order  to  receive  care  or  financial
 assistance.
   (iii)  Upon submission of a completed application form, the patient is
 not liable for any bills until the general hospital has rendered a deci-
 sion on the application in accordance with this subdivision.
   (b) The reductions from charges for patients  described  in  paragraph
 (a)  of  this  subdivision with incomes below six hundred percent of the
 federal poverty level shall result in a charge to such individuals  that
 does  not  exceed  the  amount  that  would  have been paid for the same
 services provided pursuant to title XVIII of the federal social security
 act (medicare), and provided further that such amount shall be  adjusted
 according to income level as follows:
   (i)  For  patients with incomes at or below two hundred percent of the
 federal poverty level, the hospital shall collect no more than a nominal
 payment amount, consistent with guidelines established  by  the  commis-
 sioner.
   (ii)  For  patients  with  incomes above two hundred percent and up to
 four hundred percent of the federal poverty level,  the  hospital  shall
 collect  no  more  than  the  amount  identified  after application of a
 proportional sliding  fee  schedule  under  which  patients  with  lower
 incomes shall pay the lowest amount. The schedule shall provide that the
 amount the hospital may collect for the patient increases from the nomi-
 nal  amount  described  in  subparagraph  (i) of this paragraph in equal
 increments as the income of the patient increases, up to  a  maximum  of
 twenty  percent  of  the  amount  that would have been paid for the same
 services provided pursuant to title XVIII of the federal social security
 act (medicare).
   (iii) For patients with incomes above four hundred percent and  up  to
 six  hundred  percent  of  the federal poverty level, the hospital shall
 collect no more than the amount that would have been paid for  the  same
 services provided pursuant to title XVIII of the federal social security
 act (medicare).
   (c)  Nothing  in this subdivision shall be construed to limit a hospi-
 tal's ability to establish patient eligibility for payment discounts  at
 A. 6027                            10
 
 income  levels  higher  than  those  specified  herein and/or to provide
 greater payment discounts for eligible patients than those  required  by
 this subdivision.
   (d)  [Such  policies and procedures shall be clear, understandable, in
 writing and publicly available in summary form and  each]  EACH  general
 hospital  participating  in  the pool shall ensure that every patient is
 made aware of the existence of [the policies and procedures] THE UNIFORM
 FINANCIAL ASSISTANCE FORM AND  POLICY  and  is  provided,  in  a  timely
 manner, with [a summary and] a copy of the policy and form upon request.
 [Any  summary provided to patients shall, at a minimum, include specific
 information as to  income  levels  used  to  determine  eligibility  for
 assistance,  a  description  of the primary service area of the hospital
 and the means of applying for  assistance.]  A  general  hospital  shall
 notify  patients  by  providing  written  materials to patients or their
 authorized representatives during the intake and  registration  process,
 through  the  conspicuous posting of language-appropriate information in
 the general hospital, and by including information on bills  and  state-
 ments  sent  to  patients, that financial assistance may be available to
 qualified patients and how to obtain further information. General hospi-
 tals shall post the UNIFORM financial  assistance  application  policy[,
 procedures] and form, and a summary of the policy [and procedures], in a
 conspicuous  location  and  downloadable  form on the general hospital's
 website. THE COMMISSIONER SHALL POST THE  UNIFORM  FINANCIAL  ASSISTANCE
 FORM  AND  POLICY  IN  DOWNLOADABLE  FORM  ON  THE DEPARTMENT'S HOSPITAL
 PROFILE PAGE OR ANY SUCCESSOR WEBSITE.
   (e) The [hospital's] COMMISSIONER SHALL PROVIDE APPLICATION  MATERIALS
 TO  GENERAL HOSPITALS, INCLUDING THE UNIFORM FINANCIAL ASSISTANCE APPLI-
 CATION FORM AND POLICY. THESE  application  materials  shall  include  a
 notice to patients that upon submission of a completed application form,
 the patient shall not be liable for any bills until the general hospital
 has  rendered  a  decision  on  the  application in accordance with this
 subdivision.  The application materials shall include specific  informa-
 tion  as  the  income levels used to determine eligibility for financial
 assistance, a description of the primary service area  of  the  hospital
 and the means to apply for assistance. Nothing in this subdivision shall
 be  construed  as precluding the use of presumptive eligibility determi-
 nations by hospitals on behalf of patients.  The  [policies  and  proce-
 dures]  UNIFORM  APPLICATION FORM AND POLICY shall include clear, objec-
 tive criteria for  determining  a  patient's  ability  to  pay  and  for
 providing  such adjustments to payment requirements as are necessary. In
 addition to adjustment mechanisms such  as  sliding  fee  schedules  and
 discounts to fixed standards, [such policies and procedures] THE UNIFORM
 POLICY  shall  also  provide  for  the  use of installment plans for the
 payment of outstanding balances by patients [pursuant to the  provisions
 of  the  hospital's  financial  assistance  policy]. The monthly payment
 under such a plan shall not exceed five percent  of  the  gross  monthly
 income  of the patient. Installment plan payments may not be required to
 begin before one hundred eighty days after the date of  the  service  or
 discharge,  whichever  is  later. The policy shall allow the patient and
 the hospital to mutually agree to modify the  terms  of  an  installment
 plan.    The  rate  of  interest  charged  to  the patient on the unpaid
 balance, if any, shall not exceed two percentum per annum  and  no  plan
 shall include an accelerator or similar clause under which a higher rate
 of interest is triggered upon a missed payment. The [policies and proce-
 dures] UNIFORM POLICY shall not include a requirement of a deposit prior
 to medically-necessary care. The hospital shall refund any payments made
 A. 6027                            11
 
 by  the  patient  before  the determination of eligibility for financial
 assistance that exceeds the  patient's  liability  after  discounts  are
 applied.   Such policies and procedures shall be applied consistently to
 all eligible patients.
   (f)  In  any  legal  action by or on behalf of a hospital to collect a
 medical debt, the complaint shall be accompanied by an affidavit by  the
 hospital's  chief  financial  officer  stating  that  on information and
 belief the patient does not meet the income or  residency  criteria  for
 financial assistance. Patients may apply for financial assistance at any
 time  during the collection process, including after the commencement of
 a medical debt court action or upon the plaintiff  obtaining  a  default
 judgment. A hospital may use credit scoring software for the purposes of
 establishing  income eligibility and approving financial assistance, but
 only if the hospital makes clear to the patient that providing a  social
 security  number  is  not  mandatory and the scoring does not negatively
 impact the patient's credit score.   However,  credit  scoring  software
 shall  not  be solely relied upon by the hospital in denying a patient's
 application for financial  assistance.  The  [policies  and  procedures]
 UNIFORM  POLICY  AND FORM shall allow patients seeking financial assist-
 ance to provide the following financial information and documentation in
 support of their application:   pay checks or  pay  stubs;  unemployment
 documentation;  social security income; rent receipts; a letter from the
 patient's employer attesting to the patient's gross income; or, if  none
 of  the  aforementioned  information  and documentation are available, a
 written self-attestation of the patient's income may  be  used.  General
 hospitals  shall,  upon  request,  assist  patients in understanding the
 [hospital's application  and  form,  policies  and  procedures]  UNIFORM
 FINANCIAL  ASSISTANCE  APPLICATION  FORM  AND POLICY and in applying for
 payment adjustments. [Application forms shall be printed and posted] THE
 COMMISSIONER SHALL TRANSLATE THE UNIFORM FINANCIAL  ASSISTANCE  APPLICA-
 TION FORM AND POLICY INTO THE "PRIMARY LANGUAGES" OF EACH GENERAL HOSPI-
 TAL.  EACH  GENERAL HOSPITAL SHALL PRINT AND POST THESE MATERIALS to its
 website in the "primary languages" of patients  served  by  the  general
 hospital.  For the purposes of this paragraph, "primary languages" shall
 include any language that is either (i) used to communicate,  during  at
 least  five  percent of patient visits in a year, by patients who cannot
 speak, read, write or understand the English language at  the  level  of
 proficiency  necessary  for  effective  communication  with  health care
 providers, or (ii) spoken by non-English speaking individuals comprising
 more than one percent of the primary hospital service  area  population,
 as  calculated  using  demographic information available from the United
 States Bureau of the Census, supplemented by data from  school  systems.
 Decisions  regarding  such applications shall be made within thirty days
 of receipt of a completed application.  The  [policies  and  procedures]
 UNIFORM  FINANCIAL  ASSISTANCE  POLICY  shall  require that the hospital
 issue any denial or approval of the application in writing with informa-
 tion on how to appeal the denial  and  shall  require  the  hospital  to
 establish  an appeals process under which it will evaluate the denial of
 an application. The hospital shall inform patients  on  how  to  file  a
 complaint against the hospital or a debt collector that is contracted on
 behalf of the hospital regarding the patient's bill.
   (g)  The [policies and procedures] UNIFORM FINANCIAL ASSISTANCE POLICY
 shall provide that patients with incomes below six  hundred  percent  of
 the  federal  poverty  level are deemed eligible for payment adjustments
 and shall conform to the requirements set forth in paragraph (b) of this
 subdivision, provided, however, that nothing in this  subdivision  shall
 A. 6027                            12
 
 be  interpreted  as  precluding  hospitals  from  extending such payment
 adjustments to other patients, either generally  or  on  a  case-by-case
 basis. The [policies and procedures] UNIFORM POLICY shall provide finan-
 cial  assistance  for  emergency  hospital services, including emergency
 transfers pursuant to the federal emergency medical treatment and active
 labor act (42 USC 1395dd), to patients who reside in New York state  and
 for medically necessary hospital services for patients who reside in the
 hospital's  primary  service  area  as  determined according to criteria
 established by the commissioner. In developing the criteria, the commis-
 sioner shall consult with  representatives  of  the  hospital  industry,
 health  care  consumer  advocates and local public health officials. The
 criteria shall be made available to the public no less than thirty  days
 prior to the date of implementation and shall, at a minimum:
   (i)  prohibit  a  hospital  from  developing  or  altering its primary
 service area in a manner designed to avoid medically underserved  commu-
 nities or communities with high percentages of uninsured residents;
   (ii)  ensure that every geographic area of the state is included in at
 least one general hospital's  primary  service  area  so  that  eligible
 patients may access care and financial assistance; and
   (iii)  require the hospital to notify the commissioner upon making any
 change to its primary service area, and to include a description of  its
 primary  service  area  in  the  hospital's annual implementation report
 filed pursuant to subdivision  three  of  section  twenty-eight  hundred
 three-l of this article.
   (h)  Nothing  in  this  subdivision shall be interpreted as precluding
 hospitals from extending payment  adjustments  for  medically  necessary
 non-emergency  hospital  services  to patients outside of the hospital's
 primary service area. For patients determined to be eligible for  finan-
 cial  assistance under the terms of [a hospital's] THE UNIFORM financial
 assistance policy, the [policies and  procedures]  FINANCIAL  ASSISTANCE
 POLICY  shall  prohibit  any  limitations  on  financial  assistance for
 services based on the medical condition of  the  applicant,  other  than
 typical  limitations  or  exclusions  based  on medical necessity or the
 clinical or therapeutic benefit of a procedure or treatment.
   (i) A hospital or its agent shall not issue, authorize  or  permit  an
 income  execution of a patient's wages, secure a lien or force a sale or
 foreclosure of a patient's primary residence  in  order  to  collect  an
 outstanding  medical bill and shall not send an account to collection if
 the patient has submitted a completed application for financial  assist-
 ance, while the hospital determines the patient's eligibility for finan-
 cial  assistance.    The  [policies and procedures] UNIFORM POLICY shall
 provide for written notification, which shall include notification on  a
 patient bill, to a patient not less than thirty days prior to the refer-
 ral of debts for collection and shall require that the collection agency
 obtain  the  hospital's  written  consent  prior  to  commencing a legal
 action.  The [policies and procedures] UNIFORM POLICY shall require  all
 general hospital staff who interact with patients or have responsibility
 for  billing  and  collections to be trained in the [policies and proce-
 dures] POLICY, and require the implementation of  a  mechanism  for  the
 general hospital to measure its compliance with the [policies and proce-
 dures]  POLICY.  The  [policies  and  procedures]  UNIFORM  POLICY shall
 require that any collection agency, lawyer or firm under contract with a
 general hospital for the collection of  debts  follow  the  [hospital's]
 UNIFORM  financial assistance policy, including providing information to
 patients on how to apply for  financial  assistance  where  appropriate.
 The  [policies and procedures] UNIFORM POLICY shall prohibit collections
 A. 6027                            13
 
 from a patient who is determined to be eligible for  medical  assistance
 under  title  eleven  of  article five of the social services law at the
 time services were rendered and for which services medicaid  payment  is
 available.
   (j) Reports required to be submitted to the department by each general
 hospital as a condition for participation in the pools shall contain:
   (i) a certification from an independent certified public accountant or
 independent  licensed  public accountant or an attestation from a senior
 official of the hospital that the hospital is in compliance with  condi-
 tions of participation in the pools;
   (ii)  a  report  on hospital costs incurred and uncollected amounts in
 providing services to patients found eligible for financial  assistance,
 including  the  amount  of  care  provided for a nominal payment amount,
 during the period covered by the report;
   (iii) hospital costs incurred and uncollected amounts for  deductibles
 and coinsurance for eligible patients with insurance or other third-par-
 ty payor coverage;
   (iv)  the  number  of  patients,  organized according to United States
 postal service zip code, race, ethnicity and  gender,  who  applied  for
 financial assistance under the [hospital's] UNIFORM financial assistance
 policy,  and  the  number,  organized  according to United States postal
 service zip code, race, ethnicity and gender,  whose  applications  were
 approved and whose applications were denied;
   (v)  the reimbursement received for indigent care from the pool estab-
 lished under this section;
   (vi) the amount of funds that have been expended on financial  assist-
 ance from charitable bequests made or trusts established for the purpose
 of  providing  financial  assistance  to  patients  who  are eligible in
 accordance with the terms of the bequests or trusts;
   (vii) for hospitals located in social services districts in which  the
 district allows hospitals to assist patients with such applications, the
 number  of  applications for eligibility for medicaid under title eleven
 of article five of the social services law that  the  hospital  assisted
 patients in completing and the number denied and approved;
   (viii)   the  hospital's  financial  losses  resulting  from  services
 provided under medicaid; and
   (ix) the number  of  referrals  to  collection  agents  or  contracted
 external  collection  vendors, court cases and liens placed on any resi-
 dences of patients through the collection process used by a hospital.
   (k) [Within ninety days of the effective date of the  chapter  of  the
 laws  of  two  thousand twenty-three which amended this subdivision each
 hospital shall submit to the commissioner a written report on its  poli-
 cies  and procedures for financial assistance to patients which are used
 by the hospital as of such effective date.  Such  report  shall  include
 copies  of  its  policies  and  procedures,  including material which is
 distributed to patients, and a description of the  hospital's  financial
 aid  policies  and procedures. Such description shall include the income
 levels of patients on which eligibility  is  based,  the  financial  aid
 eligible patients receive and the means of calculating such aid, and the
 service area, if any, used by the hospital to determine eligibility.
   (l)] The commissioner shall include the data collected under paragraph
 (j) of this subdivision in regular audits of the annual general hospital
 institutional cost report.
   [(m)]  (L)  In  the  event the state is unable to secure all necessary
 federal approvals to include, as part of the state's approved state plan
 under title nineteen of the federal social security act,  a  requirement
 A. 6027                            14
 
 that compliance with this subdivision is a condition of participation in
 pool distributions authorized pursuant to this section and section twen-
 ty-eight hundred seven-w of this article, then such condition of partic-
 ipation shall be deemed null and void. Notwithstanding section twelve of
 this  chapter,  failure  to  comply  with  this subdivision by a general
 hospital shall make the hospital liable  for  a  civil  penalty  not  to
 exceed  ten  thousand  dollars for each violation. The imposition of the
 civil penalties shall be subject to section twelve-a of this chapter.
   [(n)] (M) A hospital or its collection agents shall not report adverse
 information about a patient to a consumer or financial reporting entity,
 or commence civil action against a  patient  or  delegate  a  collection
 activity  to a debt collector for nonpayment for one hundred eighty days
 after the first post-service bill is issued; and a  hospital  shall  not
 report adverse information to a consumer reporting agency, or commence a
 civil  action  against  a patient or delegate a collection activity to a
 debt collector, if: the hospital was notified that an appeal or a review
 of a health insurance decision is pending within the immediately preced-
 ing sixty days; or the patient has a pending application for  or  quali-
 fied  for financial assistance.  A hospital shall report the fulfillment
 of a patient's payment obligation within thirty  days  after  the  obli-
 gation is fulfilled to a consumer or financial reporting entity to which
 the hospital had reported adverse information about the patient.
   §  4.  Subdivision  14  of  section 2807-k of the public health law is
 REPEALED and subdivisions 15, 16 and 17 are renumbered subdivisions  14,
 15 and 16.
   §  5.  This  act  shall  take  effect immediately; provided   that (a)
 section two of this act shall take effect on the one  hundred  twentieth
 day  after it shall have become a law; and (b) sections one and three of
 this act shall take effect October 1, 2024 and apply to funding distrib-
 utions made on or after January 1, 2025.    Effective  immediately,  the
 commissioner  of  health  may  make  regulations  and take other actions
 reasonably necessary to implement sections one, two and  three  of  this
 act on their respective effective dates.