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A07860 Summary:

BILL NOA07860A
 
SAME ASSAME AS UNI. S05425-A
 
SPONSORGottfried (MS)
 
COSPNSRBenedetto, Bronson, Brook-Krasny, Cymbrowitz, Englebright, Gantt, Hikind, Jaffee, Jacobs, Kellner, Lavine, Maisel, Peoples-Stokes, Sweeney, Titus, Kavanagh, Dinowitz, Abinanti, Lifton, Stevenson, Linares, Roberts, Schimel, Barron, Skartados
 
MLTSPNSRAbbate, Aubry, Boyland, Brennan, Cahill, Camara, Clark, Colton, Cook, Farrell, Glick, Gunther, Heastie, Hooper, Jeffries, Latimer, Lentol, Lopez V, Lupardo, Magee, Magnarelli, Markey, McEneny, Millman, O'Donnell, Ortiz, Paulin, Perry, Pretlow, Raia, Ramos, Reilly, Rivera J, Rivera N, Rivera P, Robinson, Rosenthal, Scarborough, Thiele, Titone, Weisenberg, Weprin, Wright
 
Ren Art 50 SS5000 - 5003 to be Art 80 SS8000 - 8003, add Art 51 SS5100 - 5110, add Art 49 Title 3 SS4920 - 4927, amd S270, Pub Health L; add S89-h, St Fin L
 
Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents: provides for administrative structure of the plan; provides for powers and duties of the board of trustees, the scope of benefits, payment methodologies and care coordination; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; enacts provisions relating to financing of New York Health, including a payroll assessment, similar to the Medicare tax; establishes a temporary commission on implementation of the plan; provides for collective negotiations by health care providers with New York Health.
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A07860 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
            S. 5425--A                                            A. 7860--A
 
                               2011-2012 Regular Sessions
 
                SENATE - ASSEMBLY
 
                                      May 19, 2011
                                       ___________
 
        IN  SENATE  --  Introduced  by  Sens.  DUANE, PERKINS, DILAN, ESPAILLAT,
          KRUEGER, MONTGOMERY, OPPENHEIMER, RIVERA, SERRANO --  read  twice  and
          ordered  printed, and when printed to be committed to the Committee on
          Finance -- recommitted to the Committee on Finance in accordance  with

          Senate  Rule  6, sec. 8 -- committee discharged, bill amended, ordered
          reprinted as amended and recommitted to said committee
 
        IN ASSEMBLY -- Introduced by M. of  A.  GOTTFRIED,  BENEDETTO,  BRONSON,
          BROOK-KRASNY,  CYMBROWITZ, ENGLEBRIGHT, GANTT, HIKIND, JAFFEE, JACOBS,
          KELLNER, LAVINE, MAISEL,  PEOPLES-STOKES,  SWEENEY,  TITUS,  KAVANAGH,
          DINOWITZ,  ABINANTI,  LIFTON,  STEVENSON,  LINARES,  ROBERTS, SCHIMEL,
          BARRON -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, BOYLAND, BREN-
          NAN, CAHILL, CAMARA, CLARK, COLTON,  COOK,  FARRELL,  GLICK,  GUNTHER,
          HEASTIE,  HOOPER, JEFFRIES, LATIMER, LENTOL, V. LOPEZ, LUPARDO, MAGEE,
          MAGNARELLI, MARKEY, McENENY, MILLMAN, O'DONNELL, ORTIZ, PAULIN, PERRY,
          PRETLOW, RAMOS, REILLY,  J. RIVERA,  N. RIVERA,  P. RIVERA,  ROBINSON,
          ROSENTHAL,  SCARBOROUGH,  THIELE,  WEISENBERG,  WEPRIN, WRIGHT -- read

          once and referred to the Committee on Health  --  recommitted  to  the
          Committee  on  Health  in  accordance  with Assembly Rule 3, sec. 2 --
          committee discharged, bill amended, ordered reprinted as  amended  and
          recommitted to said committee
 
        AN  ACT  to  amend  the  public health law and the state finance law, in
          relation to establishing New York Health
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1. Legislative findings and intent. 1. The state constitution
     2  states: "The protection and promotion of the health of  the  inhabitants
     3  of  the state are matters of public concern and provision therefor shall
     4  be made by the state and by such of its subdivisions and in such manner,
     5  and by such means as the legislature shall from time to time determine."

     6  (Article XVII, §3.) The legislature finds and declares  that  all  resi-
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD02490-03-2

        S. 5425--A                          2                         A. 7860--A
 
     1  dents of the state have the right to health care. New Yorkers - as indi-
     2  viduals, employers, and taxpayers - have experienced a rapid rise in the
     3  cost  of  health  care  and  coverage in recent years. This increase has
     4  resulted in a large number of people without health coverage. Businesses
     5  have  also  experienced  extraordinary  increases in the costs of health
     6  care benefits for their employees. An unacceptable number of New Yorkers

     7  have no health coverage, and many more are severely underinsured. Health
     8  care providers are also affected by inadequate health  coverage  in  New
     9  York  state.  A  large portion of voluntary and public hospitals, health
    10  centers and other providers now experience substantial losses due to the
    11  provision of care that is uncompensated.  Individuals  often  find  that
    12  they  are deprived of affordable care and choice because of decisions by
    13  health plans guided by the  plan's  economic  needs  rather  than  their
    14  health  care  needs. To address the fiscal crisis facing the health care
    15  system and the state and to assure New Yorkers can exercise their  right
    16  to  health  care,  affordable  and comprehensive health coverage must be
    17  provided. Pursuant to the state constitution's charge to the legislature
    18  to provide for the health of New Yorkers, this legislation is an  enact-

    19  ment  of  state  concern for the purpose of establishing a comprehensive
    20  universal single-payer health care coverage program and  a  health  care
    21  cost control system for the benefit of all residents of the state of New
    22  York.
    23    2.  It  is the intent of the Legislature to create the New York Health
    24  program to provide a universal health plan for every New Yorker,  funded
    25  by broad-based revenue based on ability to pay.  The state shall work to
    26  obtain  waivers  relating  to Medicaid, Family Health Plus, Child Health
    27  Plus, Medicare, the Patient Protection and Affordable Care Act, and  any
    28  other  appropriate federal programs, under which federal funds and other
    29  subsidies that would otherwise be paid to New York State and New Yorkers
    30  for health coverage that will be equaled or exceeded by New York  Health
    31  will  be  paid by the federal government to New York State and deposited

    32  in the New York Health trust fund. Under such a waiver, health  coverage
    33  under  those  programs will be replaced and merged into New York Health,
    34  which will operate as a true single-payer program.
    35    If such a waiver is not obtained,  the  state  shall  use  state  plan
    36  amendments  and seek waivers to maximize, and make as seamless as possi-
    37  ble, the use of federally-matched health  programs  and  federal  health
    38  programs  in  New York Health.   Thus, even where other programs such as
    39  Medicaid or Medicare may contribute to paying for care, it is  the  goal
    40  of  this  legislation  that  the  coverage will be delivered by New York
    41  Health and, as much as possible, the multiple sources of funding will be
    42  pooled with other New York Health funds and not be apparent to New  York
    43  Health  members  or participating providers.   This program will promote

    44  movement away from fee-for-service payment, which tends to reward  quan-
    45  tity  and  requires excessive administrative expense, and towards alter-
    46  nate payment methodologies, such as  global  or  capitated  payments  to
    47  providers  or health care organizations, that promote quality, efficien-
    48  cy, investment in primary and preventive care, and innovation and  inte-
    49  gration in the organizing of health care.
    50    3.  This  act  does  not  create  any  employment benefit, nor does is
    51  require, prohibit, or limit the providing of any employment benefit.
    52    4. In order to promote improved quality of, and access to, health care
    53  services and promote improved clinical outcomes, it is the policy of the
    54  state to encourage cooperative, collaborative and  integrative  arrange-
    55  ments  among  health  care providers who might otherwise be competitors,

    56  under the active supervision of the commissioner of health.  It  is  the

        S. 5425--A                          3                         A. 7860--A
 
     1  intent  of  the state to supplant competition with such arrangements and
     2  regulation only to the extent necessary to accomplish  the  purposes  of
     3  this  act,  and  to  provide  state  action immunity under the state and
     4  federal  antitrust  laws  to  health  care  providers, particularly with
     5  respect to their relations with the single-payer New  York  Health  plan
     6  created by this act.
     7    §  2.  Article 50 and sections 5000, 5001, 5002 and 5003 of the public
     8  health law are renumbered article 80 and sections 8000, 8001,  8002  and
     9  8003, respectively, and a new article 51 is added to read as follows:
    10                                  ARTICLE 51

    11                               NEW YORK HEALTH
    12  Section 5100. Definitions.
    13          5101. Program created.
    14          5102. Board of trustees.
    15          5103. Eligibility and enrollment.
    16          5104. Benefits.
    17          5105. Health  care providers; care coordination; payment method-
    18                  ologies.
    19          5106. Health care organizations.
    20          5107. Program standards.
    21          5108. Regulations.
    22          5109. Provisions relating to federal health programs.
    23          5110. Additional provisions.
    24    § 5100. Definitions. As used in  this  article,  the  following  terms
    25  shall  have  the following meanings, unless the context clearly requires

    26  otherwise:
    27    1. "Board" means the board of trustees of the New York Health  program
    28  created  by section fifty-one hundred two of this article, and "trustee"
    29  means a trustee of the board.
    30    2. "Care coordination" means services provided by a  care  coordinator
    31  under paragraph (b) of subdivision two of section fifty-one hundred five
    32  of this article.
    33    3.  "Care  coordinator"  means  an  individual  or  entity approved to
    34  provide care coordination under paragraph  (b)  of  subdivision  two  of
    35  section fifty-one hundred five of this article.
    36    4. "Federally-matched public health program" means the medical assist-
    37  ance  program  under title eleven of article five of the social services

    38  law, the family health plus program under title eleven-D of article five
    39  of the social services law, and the  child  health  plus  program  under
    40  title one-A of article twenty-five of this chapter.
    41    5.  "Health care organization" means an entity that is approved by the
    42  commissioner under section fifty-one hundred  six  of  this  article  to
    43  provide health care services to members under the program.
    44    6. "Health care service" means any health care service, including care
    45  coordination, included as a benefit under the program.
    46    7. "Implementation period" means the period under subdivision three of
    47  section  fifty-one  hundred one of this article during which the program
    48  will be subject to special eligibility and financing provisions until it

    49  is fully implemented under that section.
    50    8. "Long term care" means long term care, treatment,  maintenance,  or
    51  services  not  covered under family health plus or child health plus, as
    52  appropriate, with the exception of short term rehabilitation, as defined
    53  by the commissioner.
    54    9. "Medicaid" or "medical assistance" means title  eleven  of  article
    55  five  of  the  social  services law and the program thereunder.  "Family
    56  health plus" means title eleven-D of the social  services  law  and  the

        S. 5425--A                          4                         A. 7860--A
 
     1  program  thereunder.  "Child  health  plus" means title one-A of article
     2  twenty-five of this chapter and the program thereunder. "Medicare" means

     3  title XVIII of the federal social security act and the  programs  there-
     4  under.
     5    10. "Member" means an individual who is enrolled in the program.
     6    11.  "New York Health trust fund" means the New York Health trust fund
     7  established under section eighty-nine-h of the state finance law.
     8    12. "Participating provider" means any individual or entity that is  a
     9  health care provider that provides health care services to members under
    10  the program, or a health care organization.
    11    13.  "Patient  protection  and  affordable care act" means the federal
    12  patient protection and affordable  care  act,  public  law  111-148,  as
    13  amended  by  the  health  care and education reconciliation act of 2010,

    14  public law 111-152, and any regulations or guidance issued thereunder.
    15    14. "Person" means any individual or natural person,  trust,  partner-
    16  ship,  association,  unincorporated  association,  corporation, company,
    17  limited liability company, proprietorship, joint  venture,  firm,  joint
    18  stock association, department, agency, authority, or other legal entity,
    19  whether for-profit, not-for-profit or governmental.
    20    15.  "Program"  means  the  New York Health program created by section
    21  fifty-one hundred one of this article.
    22    16. "Prescription and non-prescription drugs" shall mean  prescription
    23  drugs  as  defined  in  section two hundred seventy of this chapter, and
    24  non-prescription smoking cessation products or devices.

    25    17. "Resident" means an individual whose primary place of abode is  in
    26  the state, as determined according to regulations of the commissioner.
    27    §  5101.  Program  created.  1.  The New York Health program is hereby
    28  created in the department. The commissioner shall establish  and  imple-
    29  ment  the  program under this article. The program shall provide compre-
    30  hensive health coverage to every resident who enrolls in the program.
    31    2. The commissioner shall, to the maximum extent  possible,  organize,
    32  administer and market the program and services as a single program under
    33  the  name "New York Health" or such other name as the commissioner shall
    34  determine, regardless of under which law or source the definition  of  a

    35  benefit  is  found including (on a voluntary basis) retiree health bene-
    36  fits.  In implementing this subdivision, the  commissioner  shall  avoid
    37  jeopardizing federal financial participation in these programs and shall
    38  take  care  to  promote  public understanding and awareness of available
    39  benefits and programs.
    40    3. The commissioner shall determine when individuals may begin enroll-
    41  ing in the program. There shall be an implementation period, which shall
    42  begin on the date that individuals may begin enrolling  in  the  program
    43  and shall end as determined by the commissioner.
    44    4. An insurer authorized to provide coverage pursuant to the insurance
    45  law  or  a  health maintenance organization certified under this chapter

    46  may, if otherwise authorized,  offer  benefits  that  do  not  duplicate
    47  coverage  offered  to an individual under the program, but may not offer
    48  benefits that duplicate coverage offered  to  an  individual  under  the
    49  program. Provided, however, that this subdivision shall not prohibit (a)
    50  the  offering  of  any  benefits  to or for individuals, including their
    51  families, who are employed or self-employed in the state but who are not
    52  residents of the state, or (b)  the  offering  of  benefits  during  the
    53  implementation  period  to  individuals  who  enrolled as members of the
    54  program, or (c) the offering of retiree health benefits.

        S. 5425--A                          5                         A. 7860--A
 

     1    5. A college, university or other institution of higher  education  in
     2  the  state  may  purchase coverage under the program for any student, or
     3  student's dependent, who is not a resident of the state.
     4    § 5102. Board of trustees. 1. The New York Health board of trustees is
     5  hereby  created  in  the department. The board of trustees shall, at the
     6  request of the commissioner,  consider  any  matter  to  effectuate  the
     7  provisions and purposes of this article, and may advise the commissioner
     8  thereon;  and  it may, from time to time, submit to the commissioner any
     9  recommendations to effectuate the provisions and purposes of this  arti-
    10  cle.  The  commissioner  may  propose regulations under this article and

    11  amendments thereto for consideration by the board. The board of trustees
    12  shall have no executive, administrative or appointive duties  except  as
    13  otherwise  provided  by  law.  The board of trustees shall have power to
    14  establish, and from time to time, amend regulations  to  effectuate  the
    15  provisions  and  purposes  of  this  article, subject to approval by the
    16  commissioner.
    17    2. The board shall be composed of:
    18    (a) the commissioner, the superintendent of  financial  services,  and
    19  the director of the budget, or their designees, as ex officio members;
    20    (b) seventeen trustees appointed by the governor;
    21    (i)  five  of  whom  shall  be representatives of health care consumer

    22  advocacy organizations which have a statewide or regional  constituency,
    23  who  have  been  involved  in activities related to health care consumer
    24  advocacy, including issues of interest to low- and moderate-income indi-
    25  viduals;
    26    (ii) two of whom shall be representatives  of  professional  organiza-
    27  tions representing physicians;
    28    (iii)  two  of whom shall be representatives of professional organiza-
    29  tions representing licensed  or  registered  health  care  professionals
    30  other than physicians;
    31    (iv)  three of whom shall be representatives of hospitals, one of whom
    32  shall be a representative of public hospitals;
    33    (v) one of whom shall be representative of community health centers;

    34    (vi) two of whom shall be representatives  of  health  care  organiza-
    35  tions; and
    36    (viii) two of whom shall be representatives of organized labor;
    37    (c)  three  trustees  appointed  by the speaker of the assembly; three
    38  trustees appointed by the temporary president of the senate; one trustee
    39  appointed by the minority  leader  of  the  assembly;  and  one  trustee
    40  appointed by the minority leader of the senate.
    41    After the end of the implementation period, no person shall be a trus-
    42  tee  unless  he or she is a member of the program, except the ex officio
    43  trustees. Each trustee shall serve at the  pleasure  of  the  appointing
    44  officer, except the ex officio trustees.

    45    3.  The  chair  of the board shall be appointed, and may be removed as
    46  chair, by the governor from among the trustees. The board shall meet  at
    47  least  four  times  each  calendar year. Meetings shall be held upon the
    48  call of the chair and as provided  by  the  board.  A  majority  of  the
    49  appointed  trustees  shall be a quorum of the board, and the affirmative
    50  vote of a majority of the trustees voting, but not less than ten,  shall
    51  be  necessary  for  any  action  to be taken by the board. The board may
    52  establish an executive committee to exercise any powers or duties of the
    53  board as it may provide, and other committees to assist the board or the
    54  executive committee. The chair of the board shall  chair  the  executive

    55  committee  and  shall appoint the chair and members of all other commit-
    56  tees. The board of trustees may appoint one or more advisory committees.

        S. 5425--A                          6                         A. 7860--A
 
     1  Members of advisory committees need not be members of the board of trus-
     2  tees.
     3    4.  Trustees  shall serve without compensation but shall be reimbursed
     4  for their necessary and actual expenses incurred while  engaged  in  the
     5  business of the board.
     6    5. Notwithstanding any provision of law to the contrary, no officer or
     7  employee of the state or any local government shall forfeit or be deemed
     8  to  have  forfeited his or her office or employment by reason of being a
     9  trustee.

    10    6. The board and its committees and advisory  committees  may  request
    11  and  receive  the  assistance  of  the department and any other state or
    12  local governmental entity in exercising its powers and duties.
    13    7. No later than five years after the effective date of this article:
    14    (a) The board shall develop a proposal, consistent with the principles
    15  of this article, for provision by the program of long-term  care  cover-
    16  age,  including the development of a proposal, consistent with the prin-
    17  ciples of this article, for its funding.   In developing  the  proposal,
    18  the  board  shall  consult  with an advisory committee, appointed by the
    19  chair of the board, including representatives of consumers and potential

    20  consumers of long-term care, providers of  long-term  care,  labor,  and
    21  other  interested  parties.  The board shall present its proposal to the
    22  governor and the legislature.
    23    (b) The board shall  develop  a  proposal  for  incorporating  retiree
    24  health benefits into New York Health.
    25    §  5103.  Eligibility  and  enrollment. 1. Every resident of the state
    26  shall be eligible and entitled to enroll as a member under the program.
    27    2. No member shall be required to pay any premium or other charge  for
    28  enrolling in or being a member under the program.
    29    §  5104.  Benefits.  1. The program shall provide comprehensive health
    30  coverage to every member, which shall include all health  care  services

    31  required  to  be  covered  under any of the following, without regard to
    32  whether the member would otherwise be eligible for  or  covered  by  the
    33  program or source referred to:
    34    (a) family health plus;
    35    (b) for every member under the age of twenty-one, child health plus;
    36    (c) Medicaid;
    37    (d) Medicare;
    38    (e)  article  forty-four  of  this  chapter  or  article thirty-two or
    39  forty-three of the insurance law;
    40    (f) article eleven of the civil service law, as of the date  one  year
    41  before the beginning of the implementation period;
    42    (g)  any  additional health care service authorized to be added to the
    43  program's benefits by the program; and

    44    (h) provided that none of the above  shall  include  long  term  care,
    45  until  a  proposal  under  paragraph (a) of subdivision seven of section
    46  fifty-one hundred two of this article is enacted into law.
    47    2. No member shall be required to pay any  deductible,  co-payment  or
    48  co-insurance under the program.
    49    3.  The  program shall provide for payment under the program for emer-
    50  gency and temporary health care services provided to members or individ-
    51  uals entitled to become members who have not had a  reasonable  opportu-
    52  nity to become a member or to enroll with a care coordinator.
    53    §  5105.  Health  care providers; care coordination; payment methodol-
    54  ogies.  1. Choice of health care provider. (a) Any health care  provider

    55  qualified  to  participate  under  this  section may provide health care
    56  services under the program, provided that the health  care  provider  is

        S. 5425--A                          7                         A. 7860--A
 
     1  otherwise  legally authorized to perform the health care service for the
     2  individual and under the circumstances involved.
     3    (b)  A  member  may  choose  to receive health care services under the
     4  program from any participating provider, consistent with  provisions  of
     5  this  article  relating  to  care coordination and health care organiza-
     6  tions, the willingness or  availability  of  the  provider  (subject  to
     7  provisions  of  this article relating to discrimination), and the appro-

     8  priate clinically-relevant circumstances.
     9    2. Care coordination.  (a) Health care services provided to  a  member
    10  shall  not  be subject to payment under the program unless the member is
    11  enrolled with a care coordinator at the time the health care service  is
    12  provided,  except  where  provided  under  subdivision  three of section
    13  fifty-one hundred four of this article. Every member shall enroll with a
    14  care coordinator that agrees to provide care coordination to the  member
    15  prior  to  receiving  health  care  services  to  be  paid for under the
    16  program. The member shall remain enrolled  with  that  care  coordinator
    17  until  the  member becomes enrolled with a different care coordinator or

    18  ceases to be a member. The commissioner shall  provide,  by  regulation,
    19  that members have the right to change their care coordinator on terms at
    20  least  as  permissive  as the provisions of section three hundred sixty-
    21  four-j of the social services law relating to an individual changing his
    22  or her primary care provider or managed care provider.
    23    (b) Care coordination shall be provided to the member by the  member's
    24  care coordinator.  A care coordinator may employ or utilize the services
    25  of  other  individuals  or  entities to assist in providing care coordi-
    26  nation for the member, consistent with regulations of the  commissioner.
    27  Care coordination shall include, but not be limited to, managing, refer-

    28  ring to, locating, coordinating, and monitoring health care services for
    29  the  member  to assure that all medically necessary health care services
    30  are made available to and are effectively used by the member in a timely
    31  manner, consistent with patient autonomy. Care  coordination  is  not  a
    32  requirement  for prior authorization for health care services and refer-
    33  ral shall not be required for a member to receive a health care service.
    34  However: (i) a health care organization may establish rules relating  to
    35  care coordination for members in the health care organization, different
    36  from  this  subdivision  but  otherwise consistent with this article and
    37  other applicable laws;  and  (ii)  nothing  in  this  subdivision  shall

    38  authorize  any  individual  to  engage  in any act in violation of title
    39  eight of the education law.
    40    (c) Where a member receives chronic mental health  care  services,  at
    41  the  option of the member, the member may enroll with a care coordinator
    42  for his or her mental health care services and another care  coordinator
    43  approved  for  his  or  her  other health care services, consistent with
    44  standards established by  the  commissioner  in  consultation  with  the
    45  commissioner of mental health. In such a case, the two care coordinators
    46  shall work in close consultation with each other.
    47    (d) A care coordinator may be an individual or entity that is approved
    48  by the program that is:

    49    (i)  a  health care practitioner who is: (A) the member's primary care
    50  practitioner; (B) at the option of a female member, the member's provid-
    51  er of primary gynecological care; or (C) at the option of a  member  who
    52  has  a  chronic  condition  that  requires  specialty care, a specialist
    53  health care practitioner who regularly and continually  provides  treat-
    54  ment for that condition to the member;
    55    (ii)  an entity licensed under article twenty-eight of this chapter or
    56  certified under article thirty-six of this chapter, a managed long  term

        S. 5425--A                          8                         A. 7860--A
 
     1  care  plan  under  section forty-four hundred three-f of this chapter or

     2  other program model under paragraph (b) of  subdivision  seven  of  such
     3  section, or, with respect to a member who receives chronic mental health
     4  care services, an entity licensed under article thirty-one of the mental
     5  hygiene law or other entity approved by the commissioner in consultation
     6  with the commissioner of mental health;
     7    (iii) a health care organization;
     8    (iv) a Taft-Hartley fund, with respect to its members and their family
     9  members;  provided that this provision shall not preclude a Taft-Hartley
    10  fund from becoming a care coordinator under  subparagraph  (v)  of  this
    11  paragraph  or a health care organization under section fifty-one hundred
    12  six of this article; or

    13    (v) any not-for-profit or governmental entity approved by the program.
    14    (e) The commissioner shall develop and implement procedures and stand-
    15  ards for an individual or entity to be approved to be a care coordinator
    16  in the program, including but not limited to  procedures  and  standards
    17  relating  to  the  revocation,  suspension,  limitation, or annulment of
    18  approval on a determination that the individual or entity is incompetent
    19  to be a care coordinator or has exhibited a course of conduct  which  is
    20  either  inconsistent  with  program  standards  and regulations or which
    21  exhibits an unwillingness to meet such standards and regulations, or  is
    22  a  potential  threat to the public health or safety. Such procedures and

    23  standards shall not limit approval to  be  a  care  coordinator  in  the
    24  program  for economic purposes and shall be consistent with good profes-
    25  sional practice. In developing the procedures and standards, the commis-
    26  sioner shall: (i) consider  existing  standards  developed  by  national
    27  accrediting  and  professional  organizations;  and  (ii)  consult  with
    28  national and local organizations working on care coordination or similar
    29  models, including health care  practitioners,  hospitals,  clinics,  and
    30  consumers  and  their  representatives. When developing and implementing
    31  standards of approval of care  coordinators  for  individuals  receiving
    32  chronic mental health care services, the commissioner shall consult with

    33  the  commissioner of mental health. An individual or entity may not be a
    34  care coordinator unless the services included in care  coordination  are
    35  within  the  individual's professional scope of practice or the entity's
    36  legal authority.
    37    (f) To maintain approval under the program, a care  coordinator  must:
    38  (i)  renew its status at a frequency determined by the commissioner; and
    39  (ii) provide data to the department as required by the  commissioner  to
    40  enable  the  commissioner to evaluate the impact of care coordinators on
    41  quality, outcomes and cost.
    42    3. Health care providers. The commissioner shall establish  and  main-
    43  tain  procedures and standards for health care providers to be qualified

    44  to participate in the program, including but not limited  to  procedures
    45  and  standards  relating  to  the revocation, suspension, limitation, or
    46  annulment of qualification to participate on a  determination  that  the
    47  health  care provider is an incompetent provider of specific health care
    48  services or has exhibited a course of conduct which is either inconsist-
    49  ent with program standards and regulations or which exhibits an  unwill-
    50  ingness to meet such standards and regulations, or is a potential threat
    51  to  the public health or safety. Such procedures and standards shall not
    52  limit health care provider participation in  the  program  for  economic
    53  purposes  and  shall  be consistent with good professional practice. Any

    54  health care provider who is qualified  to  participate  under  Medicaid,
    55  family  health plus, child health plus or Medicare shall be deemed to be
    56  qualified to participate in the program, and any health care  provider's

        S. 5425--A                          9                         A. 7860--A
 
     1  revocation,  suspension,  limitation,  or  annulment of qualification to
     2  participate in any of those programs shall  apply  to  the  health  care
     3  provider's  qualification to participate in the program; provided that a
     4  health  care  provider  qualified  under  this sentence shall follow the
     5  procedures to become qualified under the  program  by  the  end  of  the
     6  implementation period.

     7    4. Payment for health care services. (a) Health care services provided
     8  to  members  under  the  program  shall be paid for on a fee-for-service
     9  basis, except for  care  coordination.  However,  the  commissioner  may
    10  establish  by  regulation  other  payment  methodologies for health care
    11  services and care coordination provided to members under the program  by
    12  participating  providers,  care  coordinators, and health care organiza-
    13  tions.   There may be a  variety  of  different  payment  methodologies,
    14  including  those established on a demonstration basis. All payment rates
    15  under the program shall be reasonable and reasonably related to the cost
    16  of efficiently  providing  the  health  care  service  and  assuring  an

    17  adequate and accessible supply of health care service.
    18    (b)  The  program  shall engage in good faith negotiations with health
    19  care providers' representatives under title III of article forty-nine of
    20  this chapter, including, but not limited to, in  relation  to  rates  of
    21  payment and payment methodologies.
    22    (c)  Notwithstanding any provision of law to the contrary, payment for
    23  drugs provided by pharmacies under the program shall be made pursuant to
    24  article two-A of this chapter and  subdivision  four  of  section  three
    25  hundred  sixty-five-a  of  the social services law. However, the program
    26  shall provide for payment for prescription drugs under section  340B  of
    27  the   federal   public   service   act  where  applicable.  Payment  for

    28  prescription drugs provided by health care providers other than  pharma-
    29  cies shall be pursuant to other provisions of this article.
    30    (d)  Payment  for  health care services established under this article
    31  shall be considered payment in full. A participating provider shall  not
    32  charge  any rate in excess of the payment established under this article
    33  for any health care service under the program provided to a  member  and
    34  shall  not  solicit or accept payment from any member or third party for
    35  any such service except as provided under this article.   However,  this
    36  paragraph  shall  not  preclude  the program from acting as a primary or
    37  secondary payer in conjunction  with  another  third-party  payer  where
    38  permitted under this article.

    39    (e)  The  program may provide in payment methodologies for payment for
    40  capital related expenses for specifically  identified  capital  expendi-
    41  tures  incurred  by  not-for-profit  or  governmental entities certified
    42  under article twenty-eight of this chapter. Any capital related  expense
    43  generated  by  a  capital expenditure that requires or required approval
    44  under article twenty-eight of  this  chapter  must  have  received  that
    45  approval  for  the  capital  related  expense  to  be paid for under the
    46  program.
    47    5. (a) For purposes  of  this  subdivision,  "income-eligible  member"
    48  means  a  member  who  is  enrolled in a federally-matched public health
    49  program and (i) there is federal financial participation in the individ-

    50  ual's health coverage, or (ii) the member is eligible to enroll  in  the
    51  federally-matched  public  health  program by reason of income, age, and
    52  resources (where applicable) under state law in effect on the  effective
    53  date of this section, but there is no federal financial participation in
    54  the  individual's health coverage. A person who is eligible to enroll in
    55  a federally-matched public health program solely by  reason  of  section

        S. 5425--A                         10                         A. 7860--A
 
     1  three  hundred  sixty-nine-ff of the social services law (employer part-
     2  nerships for family health plus) is not an income-eligible member.
     3    (b)  The  program,  with  respect to income-eligible members, shall be

     4  considered a federally-matched public health program or government payor
     5  under article twenty-eight of this chapter with respect to the following
     6  provisions, and with respect to those members who are not  income-eligi-
     7  ble  members,  shall not be considered a federally-matched public health
     8  program or governmental payor under article twenty-eight of this chapter
     9  with respect to the following provisions:
    10    (i) patient services payments in accordance with section  twenty-eight
    11  hundred seven-j of this chapter;
    12    (ii)  professional  education  pool funding under section twenty-eight
    13  hundred seven-s of this chapter; or
    14    (iii) assessments on covered lives under section twenty-eight  hundred
    15  seven-t of this chapter.

    16    §  5106.  Health  care organizations. 1. A member may choose to enroll
    17  with and receive health care services under the program  from  a  health
    18  care organization.
    19    2.  A  health  care  organization shall be a not-for-profit or govern-
    20  mental entity that is approved by the commissioner that is:
    21    (a) an accountable care organization under  article  twenty-nine-E  of
    22  this chapter; or
    23    (b)  a  Taft-Hartley  fund  (i)  with respect to its members and their
    24  family members, and (ii) if allowed by applicable law  and  approved  by
    25  the  commissioner,  for  other members of the program; provided that the
    26  commissioner shall provide by regulation that where a Taft-Hartley  fund

    27  is  acting under this subparagraph there are protections for health care
    28  providers and patients comparable to  those  applicable  to  accountable
    29  care organizations.
    30    3.  A  health  care organization may be responsible for all or part of
    31  the health care services to which its members  are  entitled  under  the
    32  program, consistent with the terms of its approval by the commissioner.
    33    4.  (a)  The  commissioner  shall develop and implement procedures and
    34  standards for an entity to be approved to be a health care  organization
    35  in  the  program,  including but not limited to procedures and standards
    36  relating to the revocation,  suspension,  limitation,  or  annulment  of
    37  approval  on  a  determination  that  the  entity is incompetent to be a

    38  health care organization or has exhibited a course of conduct  which  is
    39  either  inconsistent  with  program  standards  and regulations or which
    40  exhibits an unwillingness to meet such standards and regulations, or  is
    41  a  potential  threat to the public health or safety. Such procedures and
    42  standards shall not limit approval to be a health care  organization  in
    43  the  program  for  economic  purposes  and shall be consistent with good
    44  professional practice. In developing the procedures and  standards,  the
    45  commissioner   shall:  (i)  consider  existing  standards  developed  by
    46  national accrediting and professional organizations;  and  (ii)  consult
    47  with  national  and  local  organizations working in the field of health

    48  care organizations,  including  health  care  practitioners,  hospitals,
    49  clinics,  and  consumers  and their representatives. When developing and
    50  implementing standards of approval of  health  care  organizations,  the
    51  commissioner  shall  consult  with the commissioner of mental health and
    52  the commissioner of developmental disabilities.
    53    (b) To maintain approval under the program, a health care organization
    54  must: (i) renew its status at a frequency determined by the  commission-
    55  er;  and  (ii) provide data to the department as required by the commis-
    56  sioner to enable the commissioner to evaluate the health care  organiza-

        S. 5425--A                         11                         A. 7860--A
 

     1  tion  in  relation  to  quality  of  health  care  services, health care
     2  outcomes, and cost.
     3    5.  The  commissioner  shall  make regulations relating to health care
     4  organizations consistent with and to ensure compliance with  this  arti-
     5  cle.
     6    6.  The  provision of health care services directly or indirectly by a
     7  health care organization through health  care  providers  shall  not  be
     8  considered  the practice of a profession under title eight of the educa-
     9  tion law by the health care organization.
    10    §  5107.  Program  standards.  1.  The  commissioner  shall  establish
    11  requirements and standards for the program and for health care organiza-
    12  tions,  care coordinators, and health care providers, including require-

    13  ments and standards for, as applicable:
    14    (a) the scope, quality and accessibility of health care services;
    15    (b) relations between health care organizations or health care provid-
    16  ers and members, including approval of health care services; and
    17    (c) relations  between  health  care  organizations  and  health  care
    18  providers,  including (i) credentialing and participation in health care
    19  organization networks; and (ii) terms, methods and rates of payment.
    20    2. Requirements and standards under the program shall include, but not
    21  be limited to, provisions to promote the following:
    22    (a) simplification, transparency, uniformity, and fairness  in  health
    23  care  provider  credentialing and participation in health care organiza-

    24  tion networks, referrals, payment procedures and rates, claims  process-
    25  ing, and approval of health care services, as applicable;
    26    (b)  primary  and  preventive  care,  care coordination, efficient and
    27  effective health care services, quality assurance, and coordination  and
    28  integration  of health care services, including use of appropriate tech-
    29  nology;
    30    (c) elimination of health care disparities;
    31    (d) non-discrimination with respect to members and health care provid-
    32  ers on the basis of race, ethnicity, national origin, religion, disabil-
    33  ity, age, sex, sexual orientation, gender  identity  or  expression,  or
    34  economic  circumstances;  provided  that  health  care services provided

    35  under the program shall be appropriate to the patient's clinically-rele-
    36  vant circumstances; and
    37    (e) accessibility  of  care  coordination,  health  care  organization
    38  services  and  health  care services, including accessibility for people
    39  with disabilities and people with limited ability to speak or understand
    40  English, and the providing of  health  care  organization  services  and
    41  health care services in a culturally competent manner.
    42    3. Any participating provider or care coordinator that is organized as
    43  a  for-profit entity shall be required to meet the same requirements and
    44  standards as entities organized as not-for-profit entities, and payments
    45  under the program paid to such  entities  shall  not  be  calculated  to

    46  accommodate  the  generation of profit or revenue for dividends or other
    47  return on investment or the payment of taxes that would not be paid by a
    48  not-for-profit entity.
    49    4. Every participating provider shall  furnish  to  the  program  such
    50  information  to,  and permit examination of its records by, the program,
    51  as may be reasonably required for purposes of utilization review, quali-
    52  ty assurance, and cost containment, for the making of payments, and  for
    53  statistical or other studies of the operation of the program.
    54    5.  In  developing  requirements and standards and making other policy
    55  determinations under this article, the commissioner shall  consult  with


        S. 5425--A                         12                         A. 7860--A
 
     1  representatives of members, health care providers, health care organiza-
     2  tions and other interested parties.
     3    6.    The  program  shall maintain the confidentiality of all data and
     4  other information collected under the program when such  data  would  be
     5  normally  considered confidential data between a patient and health care
     6  provider.  Aggregate data of the program which is derived from confiden-
     7  tial data but does not violate patient confidentiality shall  be  public
     8  information.
     9    §  5108.  Regulations.  The  commissioner  may approve regulations and
    10  amendments thereto, under subdivision one of section  fifty-one  hundred

    11  two of this article. The commissioner may make regulations or amendments
    12  thereto  to effectuate the provisions and purposes of this article on an
    13  emergency basis under section two hundred two of the  state  administra-
    14  tive  procedure  act, provided that such regulations or amendments shall
    15  not become permanent unless adopted under  subdivision  one  of  section
    16  fifty-one hundred two of this article.
    17    § 5109. Provisions relating to federal health programs. 1. The commis-
    18  sioner  shall  seek  all federal waivers and other federal approvals and
    19  arrangements and submit state plan amendments necessary to  operate  the
    20  program consistent with this article.
    21    2.  (a)  The  commissioner  shall apply to the secretary of health and

    22  human services or other appropriate federal official for all waivers  of
    23  requirements,  and make other arrangements, under Medicare, any federal-
    24  ly-matched public health program, the patient protection and  affordable
    25  care  act, and any other federal programs that provide federal funds for
    26  payment for health care services, that are necessary to enable  all  New
    27  York  Health  members  to receive all benefits under the program through
    28  the program to enable the state to implement this article and to receive
    29  and deposit all federal payments under those programs  (including  funds
    30  that may be provided in lieu of premium tax credits, cost-sharing subsi-
    31  dies, and small business tax credits) in the state treasury to the cred-

    32  it of the New York Health trust fund created under section eighty-nine-h
    33  of  the state finance law and to use those funds for the New York Health
    34  program and other provisions under this article. To the extent possible,
    35  the commissioner shall negotiate arrangements with the  federal  govern-
    36  ment  in  which  bulk  or lump-sum federal payments are paid to New York
    37  Health in place of federal  spending  or  tax  benefits  for  federally-
    38  matched health programs or federal health programs.
    39    (b)  The  commissioner may require members or applicants to be members
    40  to provide information necessary for the  program  to  comply  with  any
    41  waiver or arrangement under this subdivision.
    42    3.  (a)  If actions taken under subdivision two of this section do not

    43  accomplish all results intended under that subdivision, then this subdi-
    44  vision shall apply and shall authorize additional actions to effectively
    45  implement New York Health to the maximum extent possible  as  a  single-
    46  payer program consistent with this article.
    47    (b)  The commissioner may take actions consistent with this article to
    48  enable New York Health to administer Medicare in New York state  and  to
    49  be  a  provider  of  drug  coverage  under  Medicare part D for eligible
    50  members of New York Health.
    51    (c)  The  commissioner  may  waive  or  modify  the  applicability  of
    52  provisions  of  this  section  relating  to any federally-matched public
    53  health program or Medicare as  necessary  to  implement  any  waiver  or

    54  arrangement  under  this  section  or to maximize the benefit to the New
    55  York Health program under this section, provided that the  commissioner,
    56  in  consultation  with  the director of the budget, shall determine that

        S. 5425--A                         13                         A. 7860--A
 
     1  such waiver or modification is in the  best  interests  of  the  members
     2  affected by the action and the state.
     3    (d)  The  commissioner  may  apply  for  coverage under any federally-
     4  matched public health program on behalf of any  member  and  enroll  the
     5  member  in  the federally-matched public health program if the member is
     6  eligible for it.    Enrollment  in  a  federally-matched  public  health

     7  program  shall  not  cause  any  member  to lose any health care service
     8  provided by the program.
     9    (e) The commissioner shall by regulation increase the income eligibil-
    10  ity level, increase or eliminate  the  resource  test  for  eligibility,
    11  simplify any procedural or documentation requirement for enrollment, and
    12  increase  the  benefits for any federally-matched public health program,
    13  notwithstanding any law or regulation to the contrary. The  commissioner
    14  may act under this paragraph upon a finding, approved by the director of
    15  the  budget,  that  the  action  (i) will help to increase the number of
    16  members who are eligible for and enrolled  in  federally-matched  public
    17  health  programs;  (ii) will not diminish any individual's access to any

    18  health care service; and (iii) does not  require  or  has  received  any
    19  necessary  federal  waivers  or  approvals  to  ensure federal financial
    20  participation. Actions under this paragraph shall not apply to eligibil-
    21  ity for payment for long term care.
    22    (f) To enable the commissioner to apply for coverage under any  feder-
    23  ally-matched  public  health  program on behalf of any member and enroll
    24  the member in the federally-matched public health program if the  member
    25  is  eligible  for  it, the commissioner may require that every member or
    26  applicant to be a member shall provide information to enable the commis-
    27  sioner to determine whether the applicant is eligible for  a  federally-

    28  matched public health program and for Medicare (and any program or bene-
    29  fit  under  Medicare).  The  program  shall  make a reasonable effort to
    30  notify members of  their  obligations  under  this  paragraph.  After  a
    31  reasonable  effort has been made to contact the member, the member shall
    32  be notified in writing that he or she has sixty  days  to  provide  such
    33  required  information.  If  such  information is not provided within the
    34  sixty day period, the member's coverage under the program may be  termi-
    35  nated.
    36    (g)  As  a condition of continued eligibility for health care services
    37  under the program, a member who is eligible for benefits under  Medicare
    38  shall enroll in Medicare, including parts A, B and D.

    39    (h)  The  program  shall  provide  premium  assistance for all members
    40  enrolling in a Medicare part D drug  coverage  under  section  1860D  of
    41  Title XVIII of the federal social security act limited to the low-income
    42  benchmark premium amount established by the federal centers for Medicare
    43  and Medicaid services and any other amount which such agency establishes
    44  under  its  de minimus premium policy, except that such payments made on
    45  behalf of members enrolled in a Medicare advantage plan may  exceed  the
    46  low-income  benchmark  premium amount if determined to be cost effective
    47  to the program.
    48    (i) If the commissioner has  reasonable  grounds  to  believe  that  a
    49  member  could  be  eligible  for an income-related subsidy under section

    50  1860D-14 of Title XVIII of the federal social security act,  the  member
    51  shall  provide,  and authorize the program to obtain, any information or
    52  documentation required to establish the member's  eligibility  for  such
    53  subsidy,  provided that the commissioner shall attempt to obtain as much
    54  of the information and documentation as possible from records  that  are
    55  available to him or her.

        S. 5425--A                         14                         A. 7860--A
 
     1    (j)  The  program  shall make a reasonable effort to notify members of
     2  their obligations under this subdivision. After a reasonable effort  has
     3  been made to contact the member, the member shall be notified in writing

     4  that  he  or she has sixty days to provide such required information. If
     5  such  information  is  not  provided  within  the  sixty day period, the
     6  member's coverage under the program may be terminated.
     7    § 5110. Additional provisions.   1. The  commissioner  shall  contract
     8  with not-for-profit organizations to provide:
     9    (a)  consumer assistance to individuals with respect to selection of a
    10  care coordinator  or  health  care  organization,  enrolling,  obtaining
    11  health  care  services,  disenrolling, and other matters relating to the
    12  program;
    13    (b) health care provider assistance to health care providers providing
    14  and seeking or considering whether  to  provide,  health  care  services

    15  under the program, with respect to participating in a health care organ-
    16  ization and dealing with a health care organization; and
    17    (c)  care coordinator assistance to individuals and entities providing
    18  and seeking or considering whether  to  provide,  care  coordination  to
    19  members.
    20    2.  The  commissioner  shall provide grants from funds in the New York
    21  Health trust fund or otherwise appropriated for this purpose, to  health
    22  systems  agencies under section twenty-nine hundred four-b of this chap-
    23  ter to support the operation of such health systems agencies.
    24    § 3. Financing of New York Health. 1. The governor shall submit to the
    25  legislature a plan and legislative bills to implement the plan (referred

    26  to collectively in this section as the "revenue  proposal")  to  provide
    27  the revenue necessary to finance the New York Health program, as created
    28  by  article  51 of the public health law (referred to in this section as
    29  the "program"), taking into consideration  anticipated  federal  revenue
    30  available  for  the  program. The revenue proposal shall be submitted to
    31  the legislature as part of the executive budget under article VII of the
    32  state constitution, for the fiscal year commencing on the first  day  of
    33  April  in the calendar year after this act shall become a law. In devel-
    34  oping the revenue proposal, the governor shall consult with  appropriate
    35  officials  of  the  executive  branch;  the  temporary  president of the
    36  senate; the speaker of the assembly; the chairs of the fiscal and health
    37  committees of the senate and assembly; and representatives of  business,

    38  labor, consumers and local government.
    39    2.  (a)  Basic  structure. The basic structure of the revenue proposal
    40  shall be as follows: Revenue for the program shall come from two assess-
    41  ments (referred to collectively in this section as  the  "assessments").
    42  First,  there  shall  be  an assessment on all payroll and self-employed
    43  income (referred to in this section as the "payroll  assessment"),  paid
    44  by  employers, employees and self-employed, similar to the Medicare tax.
    45  Higher brackets of income subject to this assessment shall  be  assessed
    46  at a higher marginal rate than lower brackets.  Second, there shall be a
    47  progressively-graduated  assessment on taxable income (such as interest,
    48  dividends, and capital gains) not  subject  to  the  payroll  assessment
    49  (referred  to  in  this  section  as  the "non-payroll assessment"). The

    50  assessments will be set at  levels  anticipated  to  produce  sufficient
    51  revenue to finance the program and other provisions of article 51 of the
    52  public  health  law,  to  be  scaled up as enrollment grows, taking into
    53  consideration anticipated federal revenue  available  for  the  program.
    54  Provision  shall  be  made for state residents (who are eligible for the
    55  program) who are employed out-of-state, and non-residents (who  are  not
    56  eligible for the program) who are employed in the state.

        S. 5425--A                         15                         A. 7860--A
 
     1    (b)  Payroll  assessment.  The  income  to  be  subject to the payroll
     2  assessment shall be all income subject to the Medicare tax. The  assess-
     3  ment shall be set at a particular percentage of that income, which shall
     4  be progressively graduated, so the percentage is higher on higher brack-

     5  ets  of  income. For employed individuals, the employer shall pay eighty
     6  percent of the assessment and the  employee  shall  pay  twenty  percent
     7  (unless the employer agrees to pay a higher percentage). A self-employed
     8  individual shall pay the full assessment.
     9    (c) Non-payroll income assessment. There shall be a second assessment,
    10  on  upper-bracket  taxable  income  that  is  not subject to the payroll
    11  assessment. It shall be progressively  graduated  and  structured  as  a
    12  percentage of the personal income tax on that income.
    13    (d) Phased-in rates. Early in the program, when enrollment is growing,
    14  the  amount  of  the  assessments  shall be at an appropriate level, and
    15  shall be raised as anticipated enrollment grows,  to  cover  the  actual
    16  cost  of  the  program  and other provisions of article 51 of the public

    17  health law. The revenue proposal shall include a mechanism for determin-
    18  ing the rates of the assessments.
    19    (e) Cross-border employees. (i) State residents employed out-of-state.
    20  If an individual is employed out-of-state by an employer that is subject
    21  to New York state law, the employer and employee shall  be  required  to
    22  pay the payroll assessment as if the employment were in the state. If an
    23  individual  is  employed out-of-state by an employer that is not subject
    24  to New York state law, either (A) the employer and employee shall volun-
    25  tarily comply with the assessment or (B)  the  employee  shall  pay  the
    26  assessment as if he or she were self-employed.
    27    (ii)  Out-of-state  residents  employed in the state.  (A) The payroll
    28  assessment shall apply to any out-of-state resident who is  employed  or
    29  self-employed in the state.  (B) In the case of an out-of-state resident

    30  who is employed or self-employed in the state, such individual's employ-
    31  er  (which term shall include a Taft-Hartley fund) shall be able to take
    32  a credit against the payroll assessments they would otherwise  pay,  for
    33  amounts they spend on health benefits that would otherwise be covered by
    34  the  program. For employers, the credit shall be available regardless of
    35  the form of the health benefit (e.g., health insurance,  a  self-insured
    36  plan, direct services, or reimbursement for services), to make sure that
    37  the revenue proposal does not relate to employment benefits in violation
    38  of  the  federal  ERISA.  An employee may take the credit for his or her
    39  contribution to an employment-based health benefit. For  non-employment-
    40  based  spending  by  individuals,  the credit shall be available for and
    41  limited to spending for health coverage (not out-of-pocket health spend-

    42  ing). The credit shall be available without  regard  to  how  little  is
    43  spent  or  how  sparse the benefit. The credit may only be taken against
    44  the payroll assessments. Any excess amount may not be applied  to  other
    45  tax liability. For employment-based health benefits, the credit shall be
    46  distributed  between the employer and employee in the same proportion as
    47  the spending by each for the benefit. The employer and employee may each
    48  apply their respective portion of the credit to their respective portion
    49  of the assessment. If any provision of this clause (B) or  any  applica-
    50  tion of it shall be ruled to violate federal ERISA, the provision or the
    51  application of it shall be null and void and the ruling shall not affect
    52  any  other  provision  or  application  of  this section or the act that
    53  enacted it.
    54    3.  The  revenue  proposal  shall  include  a  plan  and   legislative

    55  provisions   for  ending  the  requirement  for  local  social  services

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     1  districts to pay part of  the  cost  of  Medicaid  and  replacing  those
     2  payments with revenue from the assessments under the revenue proposal.
     3    4.  To  the extent that the revenue proposal differs from the terms of
     4  subdivision 2 of this section, the revenue proposal shall state  how  it
     5  differs  from those terms and reasons for and the effects of the differ-
     6  ences.
     7    5. All revenue from the assessments shall be deposited in the New York
     8  Health trust fund account under section 89-h of the state finance law.
     9    § 4.  Article 49 of the public health law is amended by adding  a  new
    10  title 3 to read as follows:
    11                                  TITLE III

    12            COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
    13                               NEW YORK HEALTH
    14  Section 4920. Definitions.
    15          4921. Collective negotiation authorized.
    16          4922. Collective negotiation requirements.
    17          4923. Requirements for health care providers' representative.
    18          4924. Certain collective action prohibited.
    19          4925. Fees.
    20          4926. Confidentiality.
    21          4927. Severability and construction.
    22    § 4920. Definitions. For purposes of this title:
    23    1. "New York Health" means the program under article fifty-one of this
    24  chapter.
    25    2.  "Person"  means  an  individual,  association, corporation, or any

    26  other legal entity.
    27    3. "Health care providers' representative" means a third party who  is
    28  authorized  by  health  care providers to negotiate on their behalf with
    29  New York Health over terms and conditions affecting  those  health  care
    30  providers.
    31    4. "Strike" means a work stoppage in part or in whole, direct or indi-
    32  rect,  by  a  body of workers to gain compliance with demands made on an
    33  employer.
    34    5. "Health care provider" means a person who is  licensed,  certified,
    35  or registered pursuant to title eight of the education law and who prac-
    36  tices  as  a health care provider as an independent contractor or who is
    37  an owner, officer, shareholder, or proprietor of a health care provider;

    38  or an entity that employs or utilizes health care providers  to  provide
    39  health  care  services, including but not limited to a hospital licensed
    40  under article twenty-eight of this chapter or an accountable care organ-
    41  ization under article twenty-nine-E  of  this  chapter.  A  health  care
    42  provider  under  title  eight  of  the education law who practices as an
    43  employee of a health care provider shall not be  deemed  a  health  care
    44  provider for purposes of this title.
    45    §  4921.  Collective  negotiation authorized. 1. Health care providers
    46  may meet and communicate for the purpose of collectively negotiating the
    47  following terms and conditions  of  provider  contracts  with  New  York
    48  Health:

    49    (a)  the details of the utilization review plan as defined pursuant to
    50  subdivision ten of section forty-nine hundred of this article;
    51    (b) the definition of medical necessity;
    52    (c) the clinical practice guidelines used to  make  medical  necessity
    53  and utilization review determinations;
    54    (d) preventive care and other medical coordination practices;
    55    (e)  drug  formularies  and  standards  and procedures for prescribing
    56  off-formulary drugs;

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     1    (f) the details of risk transfer arrangements with providers;
     2    (g) administrative procedures;
     3    (h)  procedures  to  be  utilized to resolve disputes between New York

     4  Health and health care providers;
     5    (i) patient referral procedures;
     6    (j) the formulation and application of health care provider reimburse-
     7  ment procedures;
     8    (k) quality assurance programs;
     9    (l)  the  process  for  rendering  utilization  review  determinations
    10  including:  establishment  of a process for rendering utilization review
    11  determinations which shall, at a minimum, include: written procedures to
    12  assure that utilization reviews and determinations are conducted  within
    13  the  timeframes  established  in  this  article; procedures to notify an
    14  enrollee, an  enrollee's  designee  and/or  an  enrollee's  health  care
    15  provider of adverse determinations; and procedures for appeal of adverse

    16  determinations,  including  the  establishment  of  an expedited appeals
    17  process for denials of continued inpatient care or where there is  immi-
    18  nent or serious threat to the health of the enrollee;
    19    (m)  health  care  provider selection and termination criteria used by
    20  New York Health;
    21    (n) the fees assessed by New York Health for services, including  fees
    22  established through the application of reimbursement procedures;
    23    (o) the conversion factors used by New York Health in a resource-based
    24  relative  value scale reimbursement methodology or other similar method-
    25  ology; provided the same are  not  otherwise  established  by  state  or
    26  federal law or regulation;

    27    (p)  the  amount of any discount granted by New York Health on the fee
    28  of health care services to be rendered by health care providers;
    29    (q) the dollar amount of capitation or fixed payment for  health  care
    30  services rendered by health care providers to New York Health members;
    31    (r)  the  procedure code or other description of a health care service
    32  covered by a payment and  the  appropriate  grouping  of  the  procedure
    33  codes; and
    34    (s) the amount of any other component of the reimbursement methodology
    35  for a health care service.
    36    2. Nothing in this section shall be construed to allow or authorize an
    37  alteration  of  the terms of the internal and external review procedures
    38  set forth in law.

    39    3. Nothing in this section shall be construed to allow a strike of New
    40  York Health by health care providers.
    41    4. Nothing in this section shall be construed to  allow  or  authorize
    42  terms or conditions which would impede the ability of New York Health to
    43  obtain  or  retain  accreditation  by the national committee for quality
    44  assurance or a similar body or to comply with applicable state or feder-
    45  al law.
    46    5. Nothing in this section shall be deemed  to  affect  or  limit  the
    47  right  of  a  health  care provider or group of health care providers to
    48  collectively petition a government entity for a change in a  law,  rule,
    49  or regulation.
    50    § 4922. Collective negotiation requirements. 1. Collective negotiation

    51  rights granted by this title must conform to the following requirements:
    52    (a)  health  care  providers  may  communicate  with other health care
    53  providers regarding the terms and conditions to be negotiated  with  New
    54  York Health;
    55    (b)  health care providers may communicate with health care providers'
    56  representatives;

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     1    (c) a health care providers' representative is the only party  author-
     2  ized  to  negotiate  with  New  York Health on behalf of the health care
     3  providers as a group;
     4    (d)  a  health  care provider can be bound by the terms and conditions
     5  negotiated by the health care providers' representatives; and

     6    (e) in communicating or negotiating with the  health  care  providers'
     7  representative, New York Health is entitled to offer and provide differ-
     8  ent terms and conditions to individual competing health care providers.
     9    2.  Nothing  in  this  title  shall  be construed to prohibit or limit
    10  collective action or collective bargaining on the  part  of  any  health
    11  care  provider  with  his or her employer or any other lawful collective
    12  action or collective bargaining.
    13    § 4923. Requirements for health care providers' representative. Before
    14  engaging in collective negotiations with New York Health  on  behalf  of
    15  health  care  providers,  a  health care providers' representative shall

    16  file with the commissioner, in the manner prescribed by the  commission-
    17  er,  information  identifying  the  representative, the representative's
    18  plan of operation, and the representative's procedures to ensure compli-
    19  ance with this title.
    20    § 4924. Certain collective action prohibited. 1.  This  title  is  not
    21  intended  to authorize competing health care providers to act in concert
    22  in response to a health care providers' representative's discussions  or
    23  negotiations with New York Health.
    24    2. No health care providers' representative shall negotiate any agree-
    25  ment  that  excludes,  limits  the participation or reimbursement of, or
    26  otherwise limits the scope of services to be provided by any health care

    27  provider or group of health care providers with respect to the  perform-
    28  ance  of  services  that  are within the health care provider's scope of
    29  practice, license, registration, or certificate.
    30    § 4925. Fees. Each person who acts as the representative or  negotiat-
    31  ing parties under this title shall pay to the department a fee to act as
    32  a  representative.  The commissioner, by rule, shall set fees in amounts
    33  deemed reasonable and necessary to  cover  the  costs  incurred  by  the
    34  department in administering this title.
    35    § 4926. Confidentiality. All reports and other information required to
    36  be  reported  to the department under this title shall not be subject to
    37  disclosure under article six of the public officers law or article thir-

    38  ty-one of the civil practice law and rules.
    39    § 4927. Severability and construction. If any provision or application
    40  of this title shall be held to be invalid, or to violate  or  be  incon-
    41  sistent  with  any  applicable federal law or regulation, that shall not
    42  affect other provisions or applications of this title which can be given
    43  effect without that provision or  application;  and  to  that  end,  the
    44  provisions  and applications of this title are severable. The provisions
    45  of this title shall  be  liberally  construed  to  give  effect  to  the
    46  purposes thereof.
    47    §  5.  Subdivision  11  of  section  270  of the public health law, as
    48  amended by section 2-a of part C of chapter 58 of the laws of  2008,  is
    49  amended to read as follows:

    50    11.  "State  public  health plan" means the medical assistance program
    51  established by title eleven of article five of the social  services  law
    52  (referred  to in this article as "Medicaid"), the elderly pharmaceutical
    53  insurance coverage program established by title three of article two  of
    54  the  elder law (referred to in this article as "EPIC"), [and] the family
    55  health plus program established by section three  hundred  sixty-nine-ee
    56  of  the social services law to the extent that section provides that the

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     1  program shall be subject to  this  article,  and  the  New  York  Health
     2  program established by article fifty-one of this chapter.
     3    §  6. The state finance law is amended by adding a new section 89-h to
     4  read as follows:

     5    § 89-h. New York Health trust fund. 1. There is hereby established  in
     6  the joint custody of the state comptroller and the commissioner of taxa-
     7  tion  and  finance  a  special revenue fund to be known as the "New York
     8  Health trust fund", hereinafter known as "the fund". The definitions  in
     9  section  fifty-one  hundred of the public health law shall apply to this
    10  section.
    11    2. The fund shall consist of:
    12    (a) all monies  obtained  from  assessments  pursuant  to  legislation
    13  enacted  as  proposed  under  section  three  of the act that added this
    14  section;
    15    (b) federal payments received as a result of any  waiver  of  require-
    16  ments  granted  or  other  arrangements  agreed  to by the United States

    17  secretary of health and human  services  or  other  appropriate  federal
    18  officials  for  health  care  programs  established  under Medicare, any
    19  federally-matched public health program, or the patient  protection  and
    20  affordable care act;
    21    (c)  the  amounts paid by the department of health and by local social
    22  services districts that are equivalent to those amounts that are paid on
    23  behalf of residents of this state under Medicare, any  federally-matched
    24  public health program, or the patient protection and affordable care act
    25  for  health  benefits  which  are  equivalent to health benefits covered
    26  under New York Health;
    27    (d) all surcharges that are imposed on  residents  of  this  state  to

    28  replace payments made by the residents under the cost-sharing provisions
    29  of Medicare;
    30    (e)  federal,  state  and local funds for purposes of the provision of
    31  services authorized under title XX of the federal  social  security  act
    32  that  would  otherwise  be covered under article fifty-one of the public
    33  health law; and
    34    (f) state and local government monies that would otherwise  be  appro-
    35  priated  to any governmental agency, office, program, instrumentality or
    36  institution which provides health services, for  services  and  benefits
    37  covered  under  New  York  Health. Payments to the fund pursuant to this
    38  paragraph shall be in an amount equal to the money appropriated for such

    39  purposes in the fiscal year immediately preceding the effective date  of
    40  article fifty-one of the public health law.
    41    3.  Monies  in  the  fund  shall only be used for purposes established
    42  under article fifty-one of the public health law.
    43    § 7. Temporary commission on implementation. 1. There is hereby estab-
    44  lished a temporary commission on implementation of the New  York  Health
    45  program,  hereinafter  to  be  known  as  the  commission, consisting of
    46  fifteen members: five members, including the chair, shall  be  appointed
    47  by the governor; four members shall be appointed by the temporary presi-
    48  dent of the senate, one member shall be appointed by the senate minority
    49  leader;  four members shall be appointed by the speaker of the assembly,
    50  and one member shall be appointed by the assembly minority  leader.  The

    51  commissioner  of  health,  the superintendent of financial services, and
    52  the commissioner of taxation and finance, or their designees shall serve
    53  as non-voting ex-officio members of the commission.
    54    2. Members of the commission shall receive such assistance as  may  be
    55  necessary  from  other  state  agencies  and entities, and shall receive
    56  necessary expenses incurred in the  performance  of  their  duties.  The

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     1  commission  may  employ staff as needed, prescribe their duties, and fix
     2  their compensation within amounts appropriate for the commission.
     3    3.  The commission shall examine the laws and regulations of the state
     4  and make such recommendations as are necessary to conform the  laws  and
     5  regulations  of the state and article 51 of the public health law estab-

     6  lishing the New York Health program and other provisions of law relating
     7  to the New York  Health  program,  and  to  improve  and  implement  the
     8  program. The commission shall report its recommendations to the governor
     9  and the legislature.
    10    §  8.  Severability. If any provision or application of this act shall
    11  be held to be invalid, or to violate or be inconsistent with any  appli-
    12  cable  federal law or regulation, that shall not affect other provisions
    13  or applications of this act which  can  be  given  effect  without  that
    14  provision  or  application; and to that end, the provisions and applica-
    15  tions of this act are severable.
    16    § 9. This act shall take effect immediately.
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