-  This bill is not active in this session.
 

S02606 Summary:

BILL NO    S02606D

SAME AS    SAME AS UNI. A03006-D

SPONSOR    BUDGET

COSPNSR    

MLTSPNSR   

Amd Various Laws, generally

Relates to the cap on local Medicaid expenditures; relates to the determination
of rates of payments by certain state governmental agencies; relates to the
medical assistance information and payment system; relates to managed care
programs and managed long term care plans; relates to participation in the
state health insurance exchange; relates to liability for certain acts under
the false claims act; relates to civil actions pursuant to the false claims
act; relates to the delay of certain administrative costs; relates to the
preferred drug program; relates to antipsychotic therapeutic drugs; authorizes
the commissioner of health to implement an incontinence supply utilization
management program; relates to the funding of health home infrastructure
development; relates to general hospital inpatient reimbursement; relates to
managed care programs; relates to rates of payment for residential health care
facilities and rates of reimbursement for inpatient detoxification and
withdrawal services; relates to hospital inpatient base years; relates to the
Medicaid managed care inpatient psychiatric care default rate; relates to the
Medicaid managed care default rate; moves rate setting for child health plus to
the department of health; requires the use of an enrollment broker for counties
that are mandated Medicaid managed care and managed long term care; repeals the
twentieth day of the month enrollment cut-off for managed long term care
enrollees; relates to the nursing home financially disadvantaged program;
eliminates the recruitment and retention attestation requirement for certain
certified home health agencies; extends the office of the Medicaid inspector
general's power to audit rebasing rates; relates to rebasing transition
payments; relates to payment of claims; establishes the home and
community-based care work group; relates to critical access hospitals;
eliminates the bed hold requirement; relates to eligibility for Medicaid;
relates to treatment of income and resources of institutionalized persons;
relates to the people; repeals certain provisions of law relating to the
pharmacy and therapeutics committee; relates to payments to hospital
assessments; relates to the effectiveness of eligibility for medical assistance
and the family health plus program; extends various plans and programs; relates
to rates of payment by state governmental agencies; relates to reports on
chronic illness demonstration projects and reports by the commissioner of
health on health homes; relates to rates of payment for long term home health
care programs; extends a demonstration program for physicians suffering from
alcoholism, drug abuse or mental illness; relates to indigent care; relates to
permitting online and telephone Medicaid applications; allows administrative
renewals and self-attestation of residency; ends applications for family health
plus; establishes a methodology for modified adjusted gross income; centralizes
child health plus eligibility determinations; requires audit standards for
eligibility; relates to residency and income attestation and verification for
child health plus; eliminates temporary enrollment in child health plus;
expands the child health plus social security number requirement to lawfully
residing children; requires a status report on the health benefit exchange;
relates to health benefit exchange navigators and clarifies the identity of
persons to whom insurance licensing requirements apply; relates to coverage
limitations requirements and student accident and health insurance; relates to
standardization of individual enrollee direct payment contracts; ensures that
group and individual insurance policy provisions conform to applicable
requirements of federal law; relates to the general public health work program;
consolidates the excess medical malpractice liability coverage pool; relates to
the addition to the methadone registry of dosage and such other information as
is necessary to facilitate disaster management; relates to state aid funding
authorization of services funded by the office of alcoholism and substance
abuse services; vests all authority to appoint and remove officers and
employees of the office of mental health; creates mental health incident review
panels; relates to psychiatric emergency programs; relates to foregoing a
cost-of-living adjustment during the 2013-2014 state fiscal year; authorizes
the actions necessary to manage the loss of federal revenue and create the
mental hygiene stabilization fund; provides medical assistance to certain
retirees of the New York city off-track betting corporation; and relates to
funding to SUNY Downstate Medical Center and directing the restructuring of the
hospital.
Go to top

S02606 Actions:

BILL NO    S02606D

01/22/2013 REFERRED TO FINANCE
02/13/2013 AMEND AND RECOMMIT TO FINANCE
02/13/2013 PRINT NUMBER 2606A
02/22/2013 AMEND (T) AND RECOMMIT TO FINANCE
02/22/2013 PRINT NUMBER 2606B
03/10/2013 AMEND (T) AND RECOMMIT TO FINANCE
03/10/2013 PRINT NUMBER 2606C
03/23/2013 AMEND (T) AND RECOMMIT TO FINANCE
03/23/2013 PRINT NUMBER 2606D
03/26/2013 ORDERED TO THIRD READING CAL.276
03/26/2013 PASSED SENATE
03/26/2013 DELIVERED TO ASSEMBLY
03/27/2013 referred to ways and means
03/28/2013 substituted for a3006d
03/28/2013 ordered to third reading rules cal.45
03/28/2013 motion to amend lost
03/28/2013 motion to amend lost
03/28/2013 passed assembly
03/28/2013 returned to senate
03/28/2013 DELIVERED TO GOVERNOR
03/28/2013 SIGNED CHAP.56
Go to top

S02606 Votes:

S02606D03/28/2013 103/35
AbbateERClarkYGanttYKavanagYMcLaughNORamosYStecY
AbinantYColtonYGarbariNOKearnsYMillerYReilichNOSteckY
ArroyoYCookYGibsonYKellnerYMillmanNORiveraYStevensER
AubryYCorwinYGiglioNOKimYMontesaYRobertsYStirpeY
BarclayNOCrespoYGjonajERKolbNOMorelleYRobinsoERSweeneyY
BarrettYCrouchYGlickYLalorNOMosleyYRodriguYTediscoY
BarronERCurranNOGoldfedYLavineYMoyaYRosaYTenneyNO
BenedetYCusickYGoodellYLentolYNojayNORosenthYThieleY
BlankenNOCymbrowYGottfriYLiftonYNolanYRozicYTitoneY
BorelliNODenDekkYGrafNOLope PDNOOaksNORussellYTitusY
BoylandERDinowitERGuntherYLope VJNOO'DonneYRyanYWalterNO
BraunstYDiPietrNOHawleyNOLupardoYOrtizERSaladinNOWeinsteY
BrennanYDupreyYHeastieERLupinacNOOtisYSantabaYWeisenbY
BrindisYEnglebrYHennessYMageeYPalmesaNOScarborYWeprinY
BronsonYEspinalNOHevesiYMagnareYPaulinYSchimelYWrightY
Brook-KYFahyYHikindYMaiselNOPeoplesYSchimmiYZebrowsY
BuchwalYFarrellYHooperYMalliotNOPerryYSepulveYMr SpkrY
ButlerNOFinchNOJacobsYMarkeyYPretlowYSimanowY
CahillYFitzpatNOJaffeeYMayerYQuartYSimotasY
CamaraERFriendNOJohnsYMcDonalYRaNOSkartadY
CastroERGabryszYJordanYMcDonouNORabbittNOSkoufisY
CerettoYGalefYKatzNOMcKevitNORaiaYSolagesY

Go to top

S02606 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
            S. 2606--D                                            A. 3006--D
 
                SENATE - ASSEMBLY
 
                                    January 22, 2013
                                       ___________
 
        IN  SENATE -- A BUDGET BILL, submitted by the Governor pursuant to arti-
          cle seven of the Constitution -- read twice and ordered  printed,  and
          when  printed to be committed to the Committee on Finance -- committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee  --  committee  discharged,  bill  amended,  ordered

          reprinted  as  amended  and recommitted to said committee -- committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee  --  committee  discharged,  bill  amended,  ordered
          reprinted as amended and recommitted to said committee
 
        IN  ASSEMBLY  --  A  BUDGET  BILL, submitted by the Governor pursuant to
          article seven of the Constitution -- read once  and  referred  to  the
          Committee  on  Ways  and  Means -- committee discharged, bill amended,
          ordered reprinted as amended and  recommitted  to  said  committee  --
          again  reported from said committee with amendments, ordered reprinted
          as amended and recommitted to said committee --  again  reported  from
          said  committee  with  amendments,  ordered  reprinted  as amended and
          recommitted to said committee -- again reported  from  said  committee

          with  amendments, ordered reprinted as amended and recommitted to said
          committee
 
        AN ACT to amend chapter 59 of the laws  of  2011,  amending  the  public
          health  law  and other laws relating to general hospital reimbursement
          for annual rates, in relation to the cap on  local  Medicaid  expendi-
          tures;  in  relation  to  the  determination  of  rates of payments by
          certain state governmental agencies; to amend the social services law,
          in relation to the medical assistance information and payment  system;
          to  amend  the  social  services  law,  in  relation  to  managed care
          programs; to amend the public health law, in relation to managed  long
          term  care  plans;  to  amend  the  public  health law, in relation to
          participation in the state health insurance  exchange;  to  amend  the
          state finance law, in relation to liability for certain acts under the

          false claims act; to amend the state finance law, in relation to civil
          actions  pursuant  to the false claims act; to amend part C of chapter
          58 of the laws of 2005, amending the public health law and other  laws
          authorizing  reimbursements  for  expenditures made by social services
          districts for medical assistance, in  relation  to  delay  of  certain
          administrative  costs;  to amend the public health law, in relation to
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD12571-12-3

        S. 2606--D                          2                         A. 3006--D
 
          the preferred drug  program;  to  amend  the  public  health  law,  in

          relation  to  antipsychotic  therapeutic  drugs;  to  amend the social
          services law, in relation to reducing pharmacy reimbursement for  name
          brand  drugs; to amend the public health law, in relation to eliminat-
          ing the summary posting requirement for the pharmacy  and  therapeutic
          committee;  to  amend  the  social  services law, in relation to early
          refill of prescriptions; to amend the social services law, in relation
          to authorizing the commissioner of health to implement an incontinence
          supply utilization management program; to amend  the  social  services
          law, in relation to the funding of health home infrastructure develop-
          ment;  to amend the public health law, in relation to general hospital
          inpatient reimbursement; to amend the social services law, in relation
          to managed care programs; to amend section 2 of part H of chapter  111

          of  the  laws  of  2010,  relating  to increasing Medicaid payments to
          providers through managed care organizations and providing  equivalent
          fees  through  an ambulatory patient group methodology, in relation to
          the effectiveness thereof; to amend the public health law, in relation
          to rates of payment for residential  health  care  facilities  and  in
          relation  to  rates  of reimbursement for inpatient detoxification and
          withdrawal services; to amend the public health law,  in  relation  to
          hospital  inpatient  base  years;  to  amend the public health law, in
          relation to the  Medicaid  managed  care  inpatient  psychiatric  care
          default rate; to amend the public health law, in relation to the Medi-
          caid  managed  care  default  rate; to amend the public health law, in
          relation to moving rate setting for child health plus to  the  depart-

          ment of health; to amend the social services law and the public health
          law,  in  relation  to  requiring  the use of an enrollment broker for
          counties that are mandated Medicaid managed care and managed long term
          care; to amend the public health law, in  relation  to  repealing  the
          twentieth  day  of  the month enrollment cut-off for managed long term
          care enrollees; to amend the public health law,  in  relation  to  the
          nursing  home  financially  disadvantaged program; to amend the public
          health law, in relation to eliminating the recruitment  and  retention
          attestation requirement for certain certified home health agencies; to
          amend  the  public  health law, in relation to extending the office of
          the Medicaid inspector general's power to  audit  rebasing  rates;  to
          amend  the  public  health  law,  in  relation  to rebasing transition

          payments; to amend the public health law, in relation  to  payment  of
          claims; to amend the insurance law, in relation to health care provid-
          ers;  in  relation  to  establishing the home and community-based care
          work group; in relation to critical access  hospitals;  to  amend  the
          public  health  law,  in relation to eliminating the bed hold require-
          ment; to amend the social services law, in relation to eligibility for
          Medicaid; to amend the social services law, in relation  to  treatment
          of  income  and  resources  of institutionalized persons; to amend the
          public health law, in relation to certain payments  for  certain  home
          care  agencies  and  services;  to  amend  the social services law, in
          relation to Medicaid eligibility; to amend the mental hygiene law,  in
          relation  to  people first waiver program; to amend subdivision (a) of

          section 90 of part H of chapter 59 of the laws of 2011,  amending  the
          public  health  law  and other laws relating to general hospital inpa-
          tient reimbursement, in relation  to  the  effectiveness  thereof;  to
          amend  subdivision 1 of section 92 of part H of chapter 59 of the laws
          of 2011, amending the public health law and  other  laws  relating  to
          known and projected department of health state funds Medicaid expendi-
          tures, in relation to the effectiveness thereof; in relation to elimi-

        S. 2606--D                          3                         A. 3006--D
 
          nating  the  2013-2014  trend factor and thereafter; to repeal certain
          provisions of the social services law and the public health law relat-
          ing to managed care programs; and to repeal certain provisions of  the

          public health law and the social services law relating to the pharmacy
          and  therapeutics  committee;  providing  for  the  repeal  of certain
          provisions upon expiration thereof  (Part  A);  to  amend  the  public
          health  law, in relation to payments to hospital assessments; to amend
          part C of chapter 58 of the laws of 2009 amending  the  public  health
          law  relating to payment by governmental agencies for general hospital
          inpatient services, in relation to the  effectiveness  of  eligibility
          for  medical  assistance  and the family health plus program; to amend
          chapter 474 of the laws of 1996, amending the education law and  other
          laws  relating  to  rates  for  residential  healthcare facilities, in
          relation to reimbursements; to amend chapter 884 of the laws of  1990,
          amending  the  public  health law relating to authorizing bad debt and

          charity  care  allowances  for  certified  home  health  agencies,  in
          relation  to  the  effectiveness  thereof; to amend the long term care
          integration and finance act of 1997,  in  relation  to  extending  the
          expiration  of  operating demonstrations operating a managed long term
          care plan; to amend chapter 81 of  the  laws  of  1995,  amending  the
          public health law and other laws relating to medical reimbursement and
          welfare  reform,  in  relation to reimbursements and the effectiveness
          thereof; to amend the  public  health  law,  in  relation  to  capital
          related  inpatient expenses; to amend part C of chapter 58 of the laws
          of 2007, amending the social services law and other laws  relating  to
          enacting  the  major  components of legislation necessary to implement
          the health and mental hygiene budget for the  2007-2008  state  fiscal

          year,  in  relation to rates of payment by state governmental agencies
          and the effectiveness of certain provisions of such chapter; to  amend
          the  social  services  law,  in relation to reports on chronic illness
          demonstration projects and reports by the commissioner  of  health  on
          health  homes;  to amend chapter 451 of the laws of 2007, amending the
          public health law, the social services  law  and  the  insurance  law,
          relating  to  providing enhanced consumer and provider protections, in
          relation to extending the effectiveness of certain provisions thereof;
          to amend the public health law, in relation to rates  of  payment  for
          long  term home health care programs; to amend chapter 426 of the laws
          of 1983, amending the  public  health  law  relating  to  professional
          misconduct  proceedings  and chapter 582 of the laws of 1984, amending

          the public health law relating to regulating activities of physicians,
          in relation to the effectiveness of  certain  provisions  thereof;  to
          amend  the public health law, in relation to extending a demonstration
          program for physicians suffering from alcoholism, drug abuse or mental
          illness; to amend part X2 of chapter 62 of the laws of  2003  amending
          the  public  health  law  relating to allowing the use of funds of the
          office of professional medical conduct for activities of  the  patient
          health information and quality improvement act of 2000, in relation to
          the  effectiveness of certain provisions thereof; and to amend chapter
          906 of the laws of 1984, amending the social services law relating  to
          expanding  medical  assistance  eligibility  and the scope of services
          available to certain persons with disabilities,  in  relation  to  the

          effectiveness  thereof  (Part  B);  to amend the public health law, in
          relation to indigent care (Part C); to amend the social services  law,
          in  relation  to  eligibility conditions; to amend the social services
          law, in relation to permitting online and telephone Medicaid  applica-
          tions;  to  amend  the  social  services  law, in relation to allowing

        S. 2606--D                          4                         A. 3006--D
 
          administrative renewals and self-attestation of  residency;  to  amend
          the social services law, in relation to ending applications for family
          health plus; to amend the social services law, in relation to modified
          adjusted  gross  income  and Medicaid eligibility groups; to amend the
          public health law, in relation to establishing methodology  for  modi-

          fied  adjusted  gross  income;  to  amend  the  public  health law, in
          relation to centralizing child health plus eligibility determinations;
          to amend the public health law, in relation to requiring audit  stand-
          ards  for  eligibility; to amend the public health law, in relation to
          residency and income attestation and  verification  for  child  health
          plus;  to  amend  the  public  health  law, in relation to eliminating
          temporary enrollment in child health plus; to amend the public  health
          law,  in  relation  to expanding the child health plus social security
          number requirement to lawfully residing children; to amend the  public
          health  law, in relation to modified adjusted gross income under child
          health plus; to amend the public health law, in relation  to  personal
          interviews  under child health plus; to amend the social services law,

          in relation to amendment of contracts awarded by the  commissioner  of
          health;  to  amend  the  public health law, in relation to requiring a
          status report on the health benefit exchange; to amend  the  insurance
          law, in relation to health benefit exchange navigators and in relation
          to  clarifying  the  identity  of  persons to whom insurance licensing
          requirements apply; to amend the insurance law, in relation to  cover-
          age  limitations  requirements  and student accident and health insur-
          ance; to amend the insurance law, in relation  to  standardization  of
          individual  enrollee  direct  payment  contracts;  to amend the public
          health law, in relation to  HMOs;  to  amend  the  insurance  law,  in
          relation  to  ensuring  that  group  and  individual  insurance policy
          provisions conform to applicable requirements of federal  law  and  to

          make  conforming  changes; to repeal sections 369-ee and 369-ff of the
          social services law, relating to the family health  plus  program;  to
          repeal  certain  other  provisions of the social services law relating
          thereto; to repeal certain provisions of the  insurance  law  relating
          thereto;  providing  for the repeal of certain provisions upon expira-
          tion thereof (Part D); to amend the public health law, in relation  to
          the  general  public  health work program; to amend chapter 577 of the
          laws of 2008 amending the public health  law,  relating  to  expedited
          partner  therapy  for  persons infected with chlamydia trachomatis, in
          relation to the effectiveness of such chapter;  to  amend  the  public
          health  law  and  the mental hygiene law, in relation to consolidating
          the excess medical malpractice liability coverage pool; to amend  part

          C  of  chapter  58  of  the  laws  of  2005,  relating  to authorizing
          reimbursements for  expenditures  made  by  or  on  behalf  of  social
          services  districts  for  medical assistance for needy persons and the
          administration thereof, in relation to the use  of  Medicaid  recovery
          savings;  to repeal sections 602, 610 and 612 and subdivisions 5 and 7
          of section 613 of the public health law  relating  to  state  aid;  to
          repeal  sections  2300,  2301, 2302, 2303, 2309 and 2310 of the public
          health law relating to the control of sexually  transmitted  diseases;
          and  providing  for  the  repeal of certain provisions upon expiration
          thereof (Part E); to amend the mental hygiene law, in relation to  the
          addition  to  the methadone registry of dosage and such other informa-
          tion as is necessary to facilitate disaster management  (Part  F);  to

          amend the mental hygiene law, in relation to state aid funding author-
          ization  of  services funded by the office of alcoholism and substance
          abuse services; to repeal article 26  of  such  law  relating  thereto

        S. 2606--D                          5                         A. 3006--D
 
          (Part  G);  to amend the mental hygiene law and chapter 56 of the laws
          of 2012, amending the mental hygiene law relating to the  closure  and
          the  reduction  in  size  of  certain  facilities serving persons with
          mental illness, in relation to references to certain former children's
          psychiatric  centers  in  the city of New York, and in relation to the
          expiration and repeal of certain provisions thereof; to amend  chapter
          62  of the laws of 2003, amending the mental hygiene law and the state

          finance law relating to the community mental health support and  work-
          force reinvestment program, the membership of subcommittees for mental
          health  of community services boards and the duties of such subcommit-
          tees and creating the community mental health and workforce  reinvest-
          ment account, in relation to extending such provisions relating there-
          to  (Part H); to amend chapter 111 of the laws of 2010 relating to the
          recovery of exempt income by the office of mental health for community
          residences and family-based treatment programs,  in  relation  to  the
          effectiveness  thereof  (Part  I); to amend the mental hygiene law, in
          relation to vesting all authority to appoint and remove  officers  and
          employees of the office of mental health (Part J); intentionally omit-
          ted (Part K); to amend the mental hygiene law, in relation to creating

          mental  health  incident  review  panels (Part L); to amend the mental
          hygiene law, in relation to psychiatric  emergency  programs;  and  to
          repeal  certain  provisions  of  the  mental  hygiene  law and certain
          provisions of chapter 723 of the laws of  1989,  amending  the  mental
          hygiene law and other laws relating to the establishment of comprehen-
          sive psychiatric emergency programs, relating to eliminating the annu-
          al  reports on the comprehensive psychiatric emergency program; family
          care; and the confinement, care and treatment of persons with develop-
          mental disabilities (Part M); to amend chapter 57 of the laws of 2006,
          relating to establishing a cost of living  adjustment  for  designated
          human  services  programs,  in  relation  to foregoing such adjustment
          during the 2013-2014 state fiscal year  (Part  N);  to  authorize  the

          actions necessary to manage the loss of federal revenue and create the
          Mental Hygiene Stabilization Fund (Part O); to provide medical assist-
          ance to certain retirees of the New York city off-track betting corpo-
          ration  (Part P); and to amend the education law and the public health
          law, in relation to funding  to  SUNY  Downstate  Medical  Center  and
          directing the restructuring of hospital (Part Q)
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1. This act enacts into law major  components  of  legislation
     2  which are necessary to implement the state fiscal plan for the 2013-2014
     3  state  fiscal  year.  Each  component  is wholly contained within a Part
     4  identified as Parts A through Q. The effective date for each  particular

     5  provision contained within such Part is set forth in the last section of
     6  such Part. Any provision in any section contained within a Part, includ-
     7  ing the effective date of the Part, which makes a reference to a section
     8  "of  this  act", when used in connection with that particular component,
     9  shall be deemed to mean and refer to the corresponding  section  of  the
    10  Part  in  which  it  is  found. Section three of this act sets forth the
    11  general effective date of this act.
 
    12                                   PART A

        S. 2606--D                          6                         A. 3006--D
 
     1    Section 1. Subdivision (a) of section 90 of part H of  chapter  59  of
     2  the  laws of 2011, amending the public health law and other laws, relat-
     3  ing to general hospital inpatient reimbursement  for  annual  rates,  is
     4  amended to read as follows:

     5    (a)  Notwithstanding  any  other provision of law to the contrary, for
     6  the state fiscal years beginning April 1, 2011 and ending on  March  31,
     7  [2013]  2015,  all  Medicaid  payments made for services provided on and
     8  after April 1, 2011, shall, except as hereinafter provided,  be  subject
     9  to  a uniform two percent reduction and such reduction shall be applied,
    10  to the extent practicable, in equal  amounts  during  the  fiscal  year,
    11  provided,  however,  that an alternative method may be considered at the
    12  discretion of the commissioner of health and the director of the  budget
    13  based  upon consultation with the health care industry including but not
    14  limited to, a uniform reduction in Medicaid rates of payments  or  other
    15  reductions provided that any method selected achieves up to $345,000,000
    16  in  Medicaid  state share savings in state fiscal year 2011-12 and up to

    17  $357,000,000 annually in state fiscal [year] years 2012-13, 2013-14  and
    18  2014-15  except  as  hereinafter  provided, for services provided on and
    19  after April 1, 2011 through March 31,  [2013]  2015.    Any  alternative
    20  methods  to  achieve the reduction must be provided in writing and shall
    21  be filed with the senate finance committee and  the  assembly  ways  and
    22  means  committee  not  less  than  thirty  days before the date on which
    23  implementation is expected to begin. Nothing in this  section  shall  be
    24  deemed  to  prevent  all or part of such alternative reduction plan from
    25  taking effect retroactively, to the  extent  permitted  by  the  federal
    26  centers for medicare and medicaid services.
    27    §  2.  Subdivision 1 of section 91 of part H of chapter 59 of the laws

    28  of 2011, amending the public health  law  and  other  laws  relating  to
    29  general hospital reimbursement for annual rates, as amended by section 5
    30  of  part  F  of  chapter  56  of the laws of 2012, is amended to read as
    31  follows:
    32    1. Notwithstanding any inconsistent provision of state  law,  rule  or
    33  regulation  to  the  contrary,  subject to federal approval, the year to
    34  year rate of growth of department of health state funds Medicaid  spend-
    35  ing  shall not exceed the ten year rolling average of the medical compo-
    36  nent of the consumer price index  as  published  by  the  United  States
    37  department  of  labor, bureau of labor statistics, for the preceding ten
    38  years[.]; provided, however, that for state fiscal year 2013-14 and  for
    39  each  fiscal  year  thereafter, the maximum allowable annual increase in

    40  the amount of department of health state funds Medicaid  spending  shall
    41  be  calculated by multiplying the department of health state funds Medi-
    42  caid spending for the previous year, minus the amount of any  department
    43  of  health  state operations spending included therein, by such ten year
    44  rolling average.
    45    § 3.  Subdivisions 1 and 5 of section 92 of part H of   chapter 59  of
    46  the laws of 2011, amending the public health law and other laws relating
    47  to known and projected department of health state fund medicaid expendi-
    48  tures, subdivision 1 as amended by section 57 of part D of chapter 56 of
    49  the laws of 2012, are amended to read as follows:
    50    1.  For  state  fiscal  years  2011-12  through [2013-14] 2014-15, the
    51  director of the budget, in consultation with the commissioner of  health

    52  referenced  as "commissioner" for purposes of this section, shall assess
    53  on a monthly basis, as reflected in monthly reports pursuant to subdivi-
    54  sion five of this section known and projected department of health state
    55  funds medicaid expenditures by category of  service  and  by  geographic
    56  regions,  as  defined  by  the  commissioner, and if the director of the

        S. 2606--D                          7                         A. 3006--D
 
     1  budget determines that such expenditures are expected to cause  medicaid
     2  disbursements  for  such  period  to  exceed the projected department of
     3  health medicaid state funds disbursements in the enacted  budget  finan-
     4  cial  plan  pursuant to subdivision 3 of section 23 of the state finance
     5  law, the commissioner of health, in consultation with  the  director  of

     6  the  budget,  shall  develop a medicaid savings allocation plan to limit
     7  such spending to the aggregate limit  level  specified  in  the  enacted
     8  budget  financial  plan,  provided,  however,  such  projections  may be
     9  adjusted by the director of the budget to account for any changes in the
    10  New York state federal medical assistance percentage amount  established
    11  pursuant  to the federal social security act, changes in provider reven-
    12  ues, reductions to local social  services  district  medical  assistance
    13  administration, and beginning April 1, 2012 the operational costs of the
    14  New York state medical indemnity fund.  Such projections may be adjusted
    15  by  the  director  of  the  budget to account for increased or expedited
    16  department of health state funds medicaid expenditures as a result of  a

    17  natural  or other type of disaster, including a governmental declaration
    18  of emergency.
    19    5.  The department of health shall prepare a monthly report that  sets
    20  forth:    (a) known and projected department of health medicaid expendi-
    21  tures as described in subdivision one of this section, and factors  that
    22  could  result  in  medicaid  disbursements for the relevant state fiscal
    23  year to exceed the projected department of health state funds  disburse-
    24  ments  in the enacted budget financial plan pursuant to subdivision 3 of
    25  section 23 of the state finance law,  including  spending  increases  or
    26  decreases  due  to:  enrollment  fluctuations, rate changes, utilization
    27  changes, MRT investments, and shift of beneficiaries  to  managed  care;

    28  and  variations  in offline medicaid payments; and (b) the actions taken
    29  to implement any medicaid savings allocation plan  implemented  pursuant
    30  to  subdivision  four  of this section, including information concerning
    31  the impact of  such  actions  on  each  category  of  service  and  each
    32  geographic  region  of  the  state.  Each  such  monthly report shall be
    33  provided to the chairs of the senate finance and the assembly  ways  and
    34  means  committees  and  shall  be  posted  on the department of health's
    35  website in a timely manner.
    36    § 4. Notwithstanding paragraph (c) of subdivision 10 of section 2807-c
    37  of the public health law, section 21 of chapter 1 of the laws  of  1999,
    38  or any other contrary provision of law, in determining rates of payments
    39  by  state  governmental  agencies effective for services provided on and

    40  after April 1, 2013, for inpatient and outpatient services  provided  by
    41  general  hospitals,  for  inpatient  services  and adult day health care
    42  outpatient services  provided  by  residential  health  care  facilities
    43  pursuant  to article 28 of the public health law, except for residential
    44  health care facilities or units of such facilities  providing  inpatient
    45  services  primarily  to children under twenty-one years of age, for home
    46  health care services provided pursuant  to  article  36  of  the  public
    47  health law by certified home health agencies, long term home health care
    48  programs  and  AIDS  home  care programs, and for personal care services
    49  provided pursuant to section 365-a  of  the  social  services  law,  the
    50  commissioner  of  health  shall apply no greater than zero trend factors
    51  attributable to the 2013 and 2014  calendar  years  in  accordance  with

    52  paragraph  (c)  of subdivision 10 of section 2807-c of the public health
    53  law, provided, however, that such no greater  than  zero  trend  factors
    54  attributable  to such 2013 and 2014 calendar years shall also be applied
    55  to rates of payment for rate periods on and  after  April  1,  2013  for
    56  personal   care   services  provided  in  those  local  social  services

        S. 2606--D                          8                         A. 3006--D
 
     1  districts, including  New York city, whose rates  of  payment  for  such
     2  services  are established by such local social services districts pursu-
     3  ant to a rate-setting exemption issued by the commissioner of health  to
     4  such local social services districts in accordance with applicable regu-
     5  lations,  and  provided  further, however, that for rates of payment for

     6  assisted living program services provided on and after  April  1,  2013,
     7  such  trend  factors  attributable  to  the 2013 and 2014 calendar years
     8  shall be established at no greater than zero percent.
     9    § 4-a. Notwithstanding paragraph (c)  of  subdivision  10  of  section
    10  2807-c  of the public health law, section 21 of chapter 1 of the laws of
    11  1999, or any other contrary provision of law, in  determining  rates  of
    12  payments  by state governmental agencies effective for services provided
    13  on and after January 1, 2015 through March 31, 2015, for  inpatient  and
    14  outpatient   services  provided  by  general  hospitals,  for  inpatient
    15  services and adult day health care outpatient services provided by resi-
    16  dential health care facilities pursuant to  article  28  of  the  public
    17  health  law,  except  for residential health care facilities or units of

    18  such facilities providing services primarily to children  under  twenty-
    19  one  years  of  age,  for home health care services provided pursuant to
    20  article 36 of the public health law by certified home  health  agencies,
    21  long term home health care programs and AIDS home care programs, and for
    22  personal  care services provided pursuant to section 365-a of the social
    23  services law, the commissioner of health shall  apply  no  greater  than
    24  zero  trend factors attributable to the 2015 calendar year in accordance
    25  with paragraph (c) of subdivision 10 of section  2807-c  of  the  public
    26  health  law,  provided,  however,  that  such no greater than zero trend
    27  factors attributable to such 2015 calendar year shall also be applied to
    28  rates of payment provided on and after January 1, 2015 through March 31,
    29  2015 for personal care services provided in those local social  services

    30  districts,  including  New  York  city,  whose rates of payment for such
    31  services are established by such local social services districts  pursu-
    32  ant  to a rate-setting exemption issued by the commissioner of health to
    33  such local social services districts in accordance with applicable regu-
    34  lations, and provided further, however, that for rates  of  payment  for
    35  assisted  living  program services provided on and after January 1, 2015
    36  through March 31, 2015, such trend  factors  attributable  to  the  2015
    37  calendar year shall be established at no greater than zero percent.
    38    §  5.  Paragraph  (a)  of subdivision 8 of section 367-b of the social
    39  services law, as amended by chapter 109 of the laws of 2007, is  amended
    40  to read as follows:
    41    (a)  For  the  purpose  of  orderly  and  timely implementation of the
    42  medical assistance information and payment  system,  the  department  is

    43  hereby authorized to enter into agreements with fiscal intermediaries or
    44  fiscal  agents  for  the design, development, implementation, operation,
    45  processing, auditing and making of payments,  subject  to  audits  being
    46  conducted  by the state in accordance with the terms of such agreements,
    47  for medical assistance claims under the system described by this section
    48  in any social services  district.  Such  agreements  shall  specifically
    49  provide  that the state shall have complete oversight responsibility for
    50  the fiscal intermediaries' or fiscal agents' performance  and  shall  be
    51  solely responsible for establishing eligibility requirements for recipi-
    52  ents,  provider  qualifications,  rates  of  payment,  investigation  of
    53  suspected fraud and abuse, issuance of identification cards,  establish-
    54  ing  and maintaining recipient eligibility files, provider profiles, and

    55  conducting state audits of the  fiscal  intermediaries'  or  agents'  at
    56  least  once  annually. The system described in this subdivision shall be

        S. 2606--D                          9                         A. 3006--D
 
     1  operated by [a] one or  more  fiscal  [intermediary]  intermediaries  or
     2  fiscal  [agent]  agents  in  accordance with this subdivision unless the
     3  department is otherwise authorized by a law enacted  subsequent  to  the
     4  effective  date  of  this  subdivision  to operate the system in another
     5  manner. In no event shall such intermediary  or  agent  be  a  political
     6  subdivision  of  the  state  or any other governmental agency or entity.
     7  Notwithstanding the foregoing, the department may  make  payments  to  a

     8  provider  upon  the  commissioner's  determination  that the provider is
     9  temporarily unable to comply with billing requirements.  The  department
    10  shall  consult  with  the office of Medicaid inspector general regarding
    11  any activities undertaken by the fiscal intermediaries or fiscal  agents
    12  regarding investigation of suspected fraud and abuse.
    13    §  6.  Section 365-l of the social services law is amended by adding a
    14  new subdivision 9 to read as follows:
    15    9. Any contract or contracts  entered  into  by  the  commissioner  of
    16  health  prior to January first, two thousand thirteen pursuant to subdi-
    17  vision eight of this section may be amended or modified without the need
    18  for a competitive bid or  request  for  proposal  process,  and  without

    19  regard  to the provisions of sections one hundred twelve and one hundred
    20  sixty-three of the state finance law, section one hundred  forty-two  of
    21  the  economic  development  law, or any other provision of law, to allow
    22  the purchase of additional personnel and services, subject to  available
    23  funding,  for  the limited purpose of assisting the department of health
    24  with implementing the Balancing Incentive Program, the Fully  Integrated
    25  Duals Advantage Program, the Vital Access Provider Program, the Medicaid
    26  waiver amendment associated with the public hospital transformation, the
    27  addition  of  behavioral health services as a managed care plan benefit,
    28  and/or any workgroups required to be established by the chapter  of  the

    29  laws of two thousand thirteen that added this subdivision.
    30    §  7.  Section 364-j of the social services law is amended by adding a
    31  new subdivision 27 to read as follows:
    32    27. The commissioner of the department of health may make  any  neces-
    33  sary  amendments  to  a contract pursuant to this section with a managed
    34  care provider, as defined in paragraph (b) of subdivision  one  of  this
    35  section,  to allow such managed care provider to participate as a quali-
    36  fied health plan in a state health benefit exchange established pursuant
    37  to  the  federal  Patient  Protection  and  Affordable  Care  Act  (P.L.
    38  111-148),  as amended by the federal Health Care and Education Reconcil-
    39  iation Act of 2010 (P.L. 111-152).

    40    § 7-a. Section 4403-f of the public health law is amended by adding  a
    41  new subdivision 12 to read as follows:
    42    12.  The  commissioner may make any necessary amendments to a contract
    43  pursuant to this section with a managed long term care plan, as  defined
    44  in  paragraph  (a)  of  subdivision  one  of this section, to allow such
    45  managed long term care plan to participate as a qualified health plan in
    46  a state health benefit exchange  established  pursuant  to  the  federal
    47  Patient Protection and Affordable Care Act (P.L. 111-148), as amended by
    48  the  federal  Health Care and Education Reconciliation Act of 2010 (P.L.
    49  111-152).
    50    § 7-b. Section 2511 of the public health law is amended  by  adding  a
    51  new subdivision 21 to read as follows:

    52    21.   The commissioner may make any necessary amendments to a contract
    53  pursuant to this section with an approved organization,  as  defined  in
    54  subdivision  two  of  section twenty-five hundred ten of this title,  to
    55  allow such approved organization to participate as  a  qualified  health
    56  plan  in  a  state  health  benefit exchange established pursuant to the

        S. 2606--D                         10                         A. 3006--D
 
     1  federal Patient Protection and Affordable Care Act  (P.L.  111-148),  as
     2  amended  by  the federal Health Care and Education Reconciliation Act of
     3  2010 (P.L. 111-152).
     4    §  8. Subdivisions 1 and 4 of section 189 of the state finance law, as
     5  amended by chapter 379 of the laws of  2010,  are  amended  to  read  as

     6  follows:
     7    1.  Subject  to the provisions of subdivision two of this section, any
     8  person who:
     9    (a) knowingly presents, or causes to be presented a false  or  fraudu-
    10  lent claim for payment or approval;
    11    (b)  knowingly  makes,  uses,  or  causes  to be made or used, a false
    12  record or statement material to a false or fraudulent claim;
    13    (c) conspires to commit a violation of paragraph (a), (b),  (d),  (e),
    14  (f) or (g) of this subdivision;
    15    (d)  has possession, custody, or control of property or money used, or
    16  to be used, by the state or a local government and  knowingly  delivers,
    17  or causes to be delivered, less than all of that money or property;
    18    (e)  is authorized to make or deliver a document certifying receipt of
    19  property used, or to be used, by the state or a  local  government  and,
    20  intending  to defraud the state or a local government, makes or delivers

    21  the receipt without completely  knowing  that  the  information  on  the
    22  receipt is true;
    23    (f)  knowingly buys, or receives as a pledge of an obligation or debt,
    24  public property from an officer or employee of  the  state  or  a  local
    25  government  knowing that the officer or employee violates a provision of
    26  law when selling or pledging such property; [or]
    27    (g) knowingly makes, uses, or causes to  be  made  or  used,  a  false
    28  record  or  statement material to an obligation to pay or transmit money
    29  or property to the state or a local government; or
    30    (h) knowingly conceals or knowingly and improperly avoids or decreases
    31  an obligation to pay or transmit money or property to  the  state  or  a
    32  local  government,  or  conspires to do the same; shall be liable to the

    33  state or a local government, as applicable, for a civil penalty  of  not
    34  less  than  six  thousand  dollars  and  not  more  than twelve thousand
    35  dollars, plus three times the amount of all  damages,  including  conse-
    36  quential  damages,  which the state or local government sustains because
    37  of the act of that person.
    38    4. (a) This section shall apply to claims, records, or statements made
    39  under the tax law only if (i) the net income  or  sales  of  the  person
    40  against whom the action is brought equals or exceeds one million dollars
    41  for  any  taxable  year  subject  to any action brought pursuant to this
    42  article; [and] (ii) the damages pleaded  in  such  action  exceed  three
    43  hundred  and  fifty thousand dollars; and (iii) the person is alleged to
    44  have violated paragraph (a), (b), (c), (d), (e), (f) or (g) of  subdivi-

    45  sion  one  of  this  section;  provided,  however,  that nothing in this
    46  subparagraph shall be deemed to modify or restrict  the  application  of
    47  such  paragraphs  to  any act alleged that relates to a violation of the
    48  tax law.
    49    (b) The attorney general shall consult with the  commissioner  of  the
    50  department of taxation and finance prior to filing or intervening in any
    51  action  under  this article that is based on the filing of false claims,
    52  records or statements made under the tax law. If the state  declines  to
    53  participate  or to authorize participation by a local government in such
    54  an action pursuant to subdivision two of section one hundred  ninety  of
    55  this article, the qui tam plaintiff must obtain approval from the attor-


        S. 2606--D                         11                         A. 3006--D
 
     1  ney  general  before making any motion to compel the department of taxa-
     2  tion and finance to disclose tax records.
     3    §  9. Subparagraphs (d) and (e) of subdivision 2 of section 190 of the
     4  state finance law, paragraph (d) as amended by chapter 379 of  the  laws
     5  of  2010, paragraph (e) as amended by section 39 of part C of chapter 58
     6  of the laws of 2007, are amended to read as follows:
     7    (d) If the state  notifies  the  court  that  it  intends  to  file  a
     8  complaint against the defendant and thereby be substituted as the plain-
     9  tiff  in  the  action,  or  to  permit a local government to do so, such
    10  complaint, whether filed separately or as an amendment to  the  qui  tam
    11  plaintiff's  complaint,  must  be  filed  within  thirty  days after the

    12  notification to the court. For statute of limitations purposes, any such
    13  complaint filed by the state or a local government shall relate back  to
    14  the filing date of the complaint of the qui tam plaintiff, to the extent
    15  that  the cause of action of the state or local government arises out of
    16  the conduct, transactions, or occurrences set forth, or attempted to  be
    17  set forth, in the [prior] complaint of the qui tam plaintiff.
    18    (e)  If  the  state notifies the court that it intends to intervene in
    19  the action, or to permit a local government to do so, then  such  motion
    20  [for  intervention]  to  intervene,  whether  filed  separately or as an
    21  amendment to the qui tam plaintiff's complaint, shall  be  filed  within
    22  thirty  days after the notification to the court. For statute of limita-

    23  tions purposes, any complaint filed by the state or a local  government,
    24  whether  filed  separately or as an amendment to the qui tam plaintiff's
    25  complaint, shall relate back to the filing date of the complaint of  the
    26  qui  tam  plaintiff, to the extent that the cause of action of the state
    27  or local government arises out of the conduct, transactions,  or  occur-
    28  rences  set forth, or attempted to be set forth, in the complaint of the
    29  qui tam plaintiff.
    30    § 9-a. Subdivision 4 of section 190 of the state finance law, as added
    31  by section 39 of part C of chapter 58 of the laws of 2007, is amended to
    32  read as follows:
    33    4. Related actions. When a person brings a qui tam action  under  this
    34  section,  no  person other than the attorney general, or a local govern-

    35  ment attorney acting pursuant to subdivision  one  of  this  section  or
    36  paragraph (b) of subdivision two of this section, may intervene or bring
    37  a  related  civil  action  based  upon  the facts underlying the pending
    38  action[, unless such other person has first obtained the  permission  of
    39  the  attorney  general  to  intervene  or to bring such related action];
    40  provided, however, that nothing in this subdivision shall be  deemed  to
    41  deny persons the right, upon leave of court, to file briefs amicus curi-
    42  ae.
    43    §  9-b.  Subdivisions 6 and 7 of section 190 of the state finance law,
    44  as added by section 39 of part C of chapter 58 of the laws of 2007,  are
    45  amended to read as follows:
    46    6.  Awards to qui tam plaintiff. (a) If the attorney general elects to
    47  convert the qui tam civil action into an  attorney  general  enforcement

    48  action,  or  to  permit  a local government to convert the action into a
    49  civil enforcement action by such local government, or  if  the  attorney
    50  general  or  a local government elects to intervene in the qui tam civil
    51  action, then the person or persons  who  initiated  the  qui  tam  civil
    52  action  collectively  shall  be  entitled to receive between fifteen and
    53  twenty-five percent of the  proceeds  recovered  in  the  action  or  in
    54  settlement  of  the  action. The court shall determine the percentage of
    55  the proceeds to which a person commencing a  qui  tam  civil  action  is
    56  entitled, by considering the extent to which the plaintiff substantially

        S. 2606--D                         12                         A. 3006--D
 
     1  contributed to the prosecution of the action. Where the court finds that

     2  the  action  was  based primarily on disclosures of specific information
     3  (other than information provided by  the  person  bringing  the  action)
     4  relating to allegations or transactions in a criminal, civil or adminis-
     5  trative  hearing,  in  a  legislative or administrative report, hearing,
     6  audit or investigation, or from the news media, the court may award such
     7  sums as it considers appropriate, but in no case more than  ten  percent
     8  of the proceeds, taking into account the significance of the information
     9  and  the  role of the person or persons bringing the action in advancing
    10  the case to litigation. Any such person shall also receive an amount for
    11  reasonable expenses that  the  court  finds  to  have  been  necessarily
    12  incurred,  reasonable  attorneys'  fees,  and  costs pursuant to article

    13  eighty-one of the civil practice law and rules. All such expenses, fees,
    14  and costs shall be awarded against the defendant.
    15    (b) If the attorney general or a local government does  not  elect  to
    16  intervene  or convert the action, and the action is successful, then the
    17  person or persons  who  initiated  the  qui  tam  action  which  obtains
    18  proceeds  shall  be  entitled  to receive between twenty-five and thirty
    19  percent of the proceeds recovered in the action  or  settlement  of  the
    20  action.  The  court  shall  determine  the percentage of the proceeds to
    21  which a person commencing a qui tam civil action is entitled, by consid-
    22  ering the extent to which the plaintiff substantially contributed to the
    23  prosecution of the action. Such person shall also receive an amount  for

    24  reasonable  expenses  that  the  court  finds  to  have been necessarily
    25  incurred, reasonable attorneys' fees,  and  costs  pursuant  to  article
    26  eighty-one of the civil practice law and rules. All such expenses, fees,
    27  and costs shall be awarded against the defendant.
    28    (c)  With  the exception of a court award of costs, expenses or attor-
    29  neys' fees, any payment to a person pursuant to this paragraph shall  be
    30  made from the proceeds.
    31    (d)  If  the  attorney  general or a local government does not proceed
    32  with the action and the person bringing the action conducts the  action,
    33  the  court may award to the defendant its reasonable attorneys' fees and
    34  expenses if the defendant prevails in the action  and  the  court  finds

    35  that  the claim of the person bringing the action was clearly frivolous,
    36  clearly vexatious, or brought primarily for purposes of harassment.
    37    7. Costs, expenses, disbursements and attorneys' fees. In  any  action
    38  brought  pursuant  to  this  article,  the court may award [the attorney
    39  general, on behalf of the people of the state  of  New  York,  and]  any
    40  local  government  that  participates as a party in the action[, and any
    41  person who is a qui tam plaintiff,] an amount  for  reasonable  expenses
    42  which the court finds to have been necessarily incurred, plus reasonable
    43  attorneys'  fees, plus costs pursuant to article eighty-one of the civil
    44  practice law and rules. All such  expenses,  fees  and  costs  shall  be
    45  awarded directly against the defendant and shall not be charged from the

    46  proceeds, but shall only be awarded if [the state or] a local government
    47  [or the qui tam civil action plaintiff] prevails in the action.
    48    § 10. Paragraph (a) of section 4-a of part C of chapter 58 of the laws
    49  of  2005,  amending  the  public  health  law and other laws authorizing
    50  reimbursements for expenditures made by social  services  districts  for
    51  medical assistance, as added by section 4 of part F of chapter 56 of the
    52  laws of 2012, is amended to read as follows:
    53    (a)  For  state  fiscal  year  2012-13, and for each state fiscal year
    54  thereafter, a social services district will be reimbursed by  the  state
    55  for  the  full non-federal share of expenditures by the district for the
    56  administration of the medical assistance  program,  not  to  exceed  the


        S. 2606--D                         13                         A. 3006--D
 
     1  administrative  cap amount determined in accordance with subdivision (b)
     2  of this section. Any portion of the non-federal share of  such  expendi-
     3  tures  in excess of the administrative cap amount shall be the responsi-
     4  bility  of  the social services district and shall be in addition to the
     5  medical assistance expenditure  amount  calculated  in  accordance  with
     6  subdivisions (b), (c), (c-1), and (d) of section one of this act. Begin-
     7  ning  in  state  fiscal  year 2013-14, no reimbursement will be made for
     8  administrative expenditures in excess of such cap, with the exception of
     9  administrative costs from a prior fiscal year if reimbursement for  such
    10  expenditures  was  delayed due to a deferral of the federal share of the
    11  expenditures.

    12    § 11. Part C of chapter 58 of the laws of 2005,  amending  the  public
    13  health  law  and  other  laws relating to authorizing reimbursements for
    14  expenditures made by social services districts for  medical  assistance,
    15  is amended by adding a new section 7-a to read as follows:
    16    § 7-a. (a) The commissioner of health, with the approval of the direc-
    17  tor  of the division of budget, shall reduce the weekly amounts required
    18  by paragraph (f) of section one of this act to reflect increased federal
    19  reimbursement that is expected to be  received  in  the  first  calendar
    20  quarter  of  2014  as  the  result of an increase in the state's federal
    21  medical assistance percentage for care, services, and supplies  provided
    22  to certain recipients pursuant to 42 U.S.C. § 1396d(z), and that must be

    23  shared  with social services districts in accordance with the provisions
    24  of 42 U.S.C. § 1396(cc). The weekly reductions described in  this  para-
    25  graph will begin April 1, 2013 and continue through March 31, 2014.
    26    (b)  Amounts  advanced to social services districts through the weekly
    27  reductions described in paragraph (a) of this section  shall  be  recon-
    28  ciled  against  the  amount  of  increased  federal  assistance actually
    29  received pursuant to 42 U.S.C. § 1396d(z) for the first calendar quarter
    30  of 2014, and any excess amounts advanced to districts shall be recovered
    31  by the commissioner of  health  through  an  adjustment  to  the  weekly
    32  amounts  required from such districts by paragraph (f) of section one of

    33  this act for the period from April 1, 2014 through March 31, 2015.
    34    § 12. Paragraph (u) of subdivision 4 of section 364-j  of  the  social
    35  services  law,  as  amended by section 40 of part D of chapter 56 of the
    36  laws of 2012, is amended to read as follows:
    37    (u) A managed care provider that provides  coverage  for  prescription
    38  drugs  shall  permit  each  participant  to  fill any mail order covered
    39  prescription, at his or her option, at any mail order pharmacy  or  non-
    40  mail-order  retail pharmacy in the managed care provider network. If the
    41  managed care provider has designated one or more pharmacies for  filling
    42  prescriptions  for  a  particular drug or drugs, then such prescriptions
    43  may be filled, at the participant's option, at any other pharmacy in the

    44  network, if the [non-mail-order retail pharmacy] network pharmacy chosen
    45  by the participant offers to accept a price that is comparable  to  that
    46  of  the  [mail  order] pharmacy designated by the managed care provider.
    47  For the purposes of this section, "mail order pharmacy" means a pharmacy
    48  whose primary business is to receive prescriptions by mail,  telefax  or
    49  through  electronic  submissions, and to dispense medication to patients
    50  through the use of the United States mail or other  common  or  contract
    51  carrier  services, and provides any consultation with patients electron-
    52  ically rather than face to face. Every non-mail-order retail pharmacy in
    53  the managed care provider's network with  respect  to  any  prescription

    54  drug  shall  be  deemed to be in the managed care provider's network for
    55  every covered prescription drug[; provided, however,  that  the  managed
    56  care  provider  may limit its network of pharmacies for specified drugs,

        S. 2606--D                         14                         A. 3006--D

     1  approved by the commissioner, based on clinical,  professional  or  cost
     2  criteria. Such limitation shall not be based solely on cost].
     3    §  13. Section 364-j of the social services law is amended by adding a
     4  new subdivision 25-a to read as follows:
     5    25-a. Effective July first, two thousand thirteen, notwithstanding any
     6  provision of law to the contrary, managed  care  providers  shall  cover
     7  medically  necessary prescription drugs in the anti-depressant, anti-re-

     8  troviral, anti-rejection, seizure, epilepsy, endocrine, hematologic  and
     9  immunologic  therapeutic  classes,  including  non-formulary drugs, upon
    10  demonstration by the prescriber, after consulting with the managed  care
    11  provider,  that  such drugs, in the prescriber's reasonable professional
    12  judgment, are medically necessary and warranted.
    13    § 14. Section 271 of the public health law is REPEALED.
    14    § 15. Subdivision 3 of  section  270  of  the  public  health  law  is
    15  REPEALED,  subdivision  2 is renumbered subdivision 3 and a new subdivi-
    16  sion 2 is added to read as follows:
    17    2. "Board" shall mean the drug utilization review board.
    18    § 15-a. Subdivision 12 of section 270 of the  public  health  law,  as
    19  added  by  section  10  of  part C of chapter 58 of the laws of 2005, is

    20  amended to read as follows:
    21    12. "Supplemental rebate" means a supplemental rebate  under  subdivi-
    22  sion [ten] eleven of section two hundred seventy-two of this article.
    23    §  16. Section 272 of the public health law, as added by section 10 of
    24  part C of chapter 58 of the laws of 2005, subdivision 4  as  amended  by
    25  section 30 of part A of chapter 58 of the laws of 2008, subdivision 8 as
    26  amended by section 5 of part B of chapter 109 of the laws of 2010, para-
    27  graph  (d) of subdivision 10 as added by section 17 of part H of chapter
    28  59 of the laws of 2011, subdivision 11 as amended by section 36 of  part
    29  C  of chapter 58 of the laws of 2009, paragraph (b) of subdivision 11 as
    30  amended by section 9 of part H of chapter 59 of the  laws  of  2011,  is
    31  amended to read as follows:
    32    §  272.  Preferred  drug  program.  1.  There  is hereby established a

    33  preferred  drug  program  to  promote  access  to  the  most   effective
    34  prescription  drugs  while  reducing  the cost of prescription drugs for
    35  persons in state public health plans.
    36    2. When a prescriber prescribes a  non-preferred  drug,  state  public
    37  health  plan reimbursement shall be denied unless prior authorization is
    38  obtained, unless no prior authorization is required under this article.
    39    3. The commissioner shall  establish  performance  standards  for  the
    40  program  that,  at a minimum, ensure that the preferred drug program and
    41  the clinical drug review program provide  sufficient  technical  support
    42  and timely responses to consumers, prescribers and pharmacists.
    43    4.  Notwithstanding  any  other  provision  of law to the contrary, no
    44  preferred  drug  program  or   prior   authorization   requirement   for

    45  prescription  drugs,  except as created by this article, paragraph (a-1)
    46  or (a-2) of subdivision four of section three  hundred  sixty-five-a  of
    47  the  social  services  law,  paragraph (g) of subdivision two of section
    48  three hundred sixty-five-a of the social services law,  subdivision  one
    49  of section two hundred forty-one of the elder law and shall apply to the
    50  state public health plans.
    51    5.  The  [pharmacy and therapeutics committee] drug utilization review
    52  board shall consider and make recommendations to  the  commissioner  for
    53  the  adoption  of  a  preferred  drug  program.  (a)  In  developing the
    54  preferred drug program, the [committee] board shall, without limitation:
    55  (i) identify  therapeutic  classes  or  drugs  to  be  included  in  the
    56  preferred  drug  program;  (ii)  identify preferred drugs in each of the

        S. 2606--D                         15                         A. 3006--D
 
     1  chosen therapeutic classes; (iii) evaluate  the  clinical  effectiveness
     2  and  safety  of  drugs considering the latest peer-reviewed research and
     3  may consider studies submitted to the federal  food  and  drug  adminis-
     4  tration  in  connection with its drug approval system; (iv) consider the
     5  potential impact on patient care and the potential  fiscal  impact  that
     6  may result from making such a therapeutic class subject to prior author-
     7  ization;  and  (v)  consider  the potential impact of the preferred drug
     8  program on the health of  special  populations  such  as  children,  the
     9  elderly,  the  chronically  ill,  persons with HIV/AIDS and persons with
    10  mental health conditions.
    11    (b) In developing the preferred drug program,  the  [committee]  board

    12  may consider preferred drug programs or evidence based research operated
    13  or  conducted by or for other state governments, the federal government,
    14  or multi-state coalitions. Notwithstanding any inconsistent provision of
    15  section one hundred twelve or article eleven of the state finance law or
    16  section one hundred forty-two of the economic  development  law  or  any
    17  other law, the department may enter into contractual agreements with the
    18  Oregon  Health  and Science University Drug Effectiveness Review Project
    19  to provide technical and clinical support to the [committee]  board  and
    20  the department in researching and recommending drugs to be placed on the
    21  preferred drug list.
    22    (c) The [committee] board shall from time to time review all therapeu-
    23  tic  classes  included  in the preferred drug program, and may recommend

    24  that the commissioner add or delete drugs or classes of drugs to or from
    25  the preferred drug program, subject to this subdivision.
    26    (d) The [committee]  board  shall  establish  procedures  to  promptly
    27  review  prescription  drugs  newly approved by the federal food and drug
    28  administration.
    29    6. The [committee] board shall recommend a procedure and criteria  for
    30  the  approval  of non-preferred drugs as part of the prior authorization
    31  process. In developing  these  criteria,  the  [committee]  board  shall
    32  include consideration of the following:
    33    (a) the preferred drug has been tried by the patient and has failed to
    34  produce the desired health outcomes;
    35    (b) the patient has tried the preferred drug and has experienced unac-
    36  ceptable side effects;

    37    (c)  the patient has been stabilized on a non-preferred drug and tran-
    38  sition to the preferred drug would be medically contraindicated; and
    39    (d) other clinical indications for the use of the non-preferred  drug,
    40  which  shall include consideration of the medical needs of special popu-
    41  lations, including children, the elderly, the chronically  ill,  persons
    42  with mental health conditions, and persons affected by HIV/AIDS.
    43    7.  The  commissioner  shall  provide thirty days public notice on the
    44  department's website prior to any meeting of the  [committee]  board  to
    45  develop  recommendations  concerning  the  preferred  drug program. Such
    46  notice regarding meetings of  the  [committee]  board  shall  include  a
    47  description  of the proposed therapeutic class to be reviewed, a listing

    48  of drug products in the therapeutic  class,  and  the  proposals  to  be
    49  considered  by the [committee] board.  The [committee] board shall allow
    50  interested parties a reasonable opportunity to make an oral presentation
    51  to the [committee] board related to the prior authorization of the ther-
    52  apeutic class to be reviewed. The [committee] board shall  consider  any
    53  information provided by any interested party, including, but not limited
    54  to,  prescribers,  dispensers,  patients, consumers and manufacturers of
    55  the drug in developing their recommendations.

        S. 2606--D                         16                         A. 3006--D
 
     1    8. The commissioner shall provide notice of any recommendations devel-

     2  oped by the [committee] board regarding the preferred drug  program,  at
     3  least  five  days before any final determination by the commissioner, by
     4  making such information available  on  the  department's  website.  Such
     5  public notice [shall] may include: a summary of the deliberations of the
     6  [committee]  board;  a  summary  of the positions of those making public
     7  comments at meetings of the  [committee]  board;  the  response  of  the
     8  [committee] board to those comments, if any; and the findings and recom-
     9  mendations of the [committee] board.
    10    9.  Within  ten  days of a final determination regarding the preferred
    11  drug program, the  commissioner  shall  provide  public  notice  on  the

    12  department's  website  of  such determinations, including: the nature of
    13  the determination; and analysis of  the  impact  of  the  commissioner's
    14  determination on state public health plan populations and providers; and
    15  the  projected fiscal impact to the state public health plan programs of
    16  the commissioner's determination.
    17    10. The commissioner shall adopt a preferred drug program  and  amend-
    18  ments  after  considering the recommendations from the [committee] board
    19  and  any  comments  received  from  prescribers,  dispensers,  patients,
    20  consumers and manufacturers of the drug.
    21    (a)  The  preferred drug list in any therapeutic class included in the
    22  preferred drug program shall be developed based initially on  an  evalu-
    23  ation  of  the  clinical  effectiveness,  safety  and  patient outcomes,

    24  followed by consideration of the cost-effectiveness of the drugs.
    25    (b) In each therapeutic class included in the preferred drug  program,
    26  the [committee] board shall determine whether there is one drug which is
    27  significantly more clinically effective and safe, and that drug shall be
    28  included  on  the preferred drug list without consideration of cost. If,
    29  among two or more drugs in a therapeutic class, the difference in  clin-
    30  ical  effectiveness  and safety is not clinically significant, then cost
    31  effectiveness (including price and supplemental  rebates)  may  also  be
    32  considered  in  determining which drug or drugs shall be included on the
    33  preferred drug list.
    34    (c) In addition to drugs selected under paragraph (b) of this subdivi-
    35  sion, any prescription drug in the therapeutic class, whose cost to  the

    36  state public health plans (including net price and supplemental rebates)
    37  is  equal  to  or  less than the cost of another drug in the therapeutic
    38  class that is on the preferred drug list under  paragraph  (b)  of  this
    39  subdivision,  may be selected to be on the preferred drug list, based on
    40  clinical effectiveness, safety and cost-effectiveness.
    41    (d) Notwithstanding any provision of this section to the contrary, the
    42  commissioner may  designate  therapeutic  classes  of  drugs,  including
    43  classes  with  only  one drug, as all preferred prior to any review that
    44  may be conducted by the [committee] board pursuant to this section.
    45    11. (a) The commissioner shall provide an opportunity  for  pharmaceu-
    46  tical  manufacturers to provide supplemental rebates to the state public
    47  health plans for drugs within a  therapeutic  class;  such  supplemental

    48  rebates  shall  be taken into consideration by the [committee] board and
    49  the commissioner in determining the cost-effectiveness of drugs within a
    50  therapeutic class under the state public health plans.
    51    (b) The commissioner may designate a  pharmaceutical  manufacturer  as
    52  one  with  whom  the  commissioner  is  negotiating  or has negotiated a
    53  manufacturer agreement, and all of the drugs it manufactures or  markets
    54  shall  be  included  in the preferred drug program. The commissioner may
    55  negotiate directly with a pharmaceutical manufacturer for rebates relat-
    56  ing to any or all of the drugs it manufactures or markets. A manufactur-

        S. 2606--D                         17                         A. 3006--D
 
     1  er agreement shall designate any or all of  the  drugs  manufactured  or

     2  marketed  by  the  pharmaceutical manufacturer as being preferred or non
     3  preferred drugs. When a pharmaceutical manufacturer has been  designated
     4  by  the  commissioner  under this paragraph but the commissioner has not
     5  reached a manufacturer agreement with the  pharmaceutical  manufacturer,
     6  then  the  commissioner  may designate some or all of the drugs manufac-
     7  tured or marketed by the pharmaceutical manufacturer  as  non  preferred
     8  drugs.  However,  notwithstanding  this  paragraph,  any  drug  that  is
     9  selected to be on the preferred drug list under paragraph (b) of  subdi-
    10  vision  ten  of  this  section  on grounds that it is significantly more
    11  clinically effective and safer than other drugs in its therapeutic class
    12  shall be a preferred drug.
    13    (c) Supplemental rebates under this subdivision shall be  in  addition

    14  to  those  required  by  applicable federal law and subdivision seven of
    15  section three hundred sixty-seven-a of the social services law. In order
    16  to be considered in connection with the  preferred  drug  program,  such
    17  supplemental  rebates  shall  apply to the drug products dispensed under
    18  the Medicaid program and the EPIC program. The commissioner is prohibit-
    19  ed  from  approving  alternative  rebate  demonstrations,  value   added
    20  programs  or guaranteed savings from other program benefits as a substi-
    21  tution for supplemental rebates.
    22    13. The commissioner may implement all or a portion of  the  preferred
    23  drug  program  through  contracts  with administrators with expertise in
    24  management of pharmacy services, subject to applicable laws.
    25    14. For a period of eighteen  months,  commencing  with  the  date  of

    26  enactment  of  this  article,  and  without regard to the preferred drug
    27  program or the clinical drug review program requirements of  this  arti-
    28  cle,  the  commissioner is authorized to implement, or continue, a prior
    29  authorization requirement for a drug which may not be dispensed  without
    30  a  prescription  as  required  by section sixty-eight hundred ten of the
    31  education law, for which there is a non-prescription version within  the
    32  same  drug  class,  or  for which there is a comparable non-prescription
    33  version of the same drug. Any such prior authorization requirement shall
    34  be implemented in a manner that is consistent with the process  employed
    35  by  the  commissioner for such authorizations as of one day prior to the
    36  date of enactment of this article. At the  conclusion  of  the  eighteen
    37  month  period,  any  such  drug  or  drug  class shall be subject to the

    38  preferred drug program requirements of this article; provided,  however,
    39  that the commissioner is authorized to immediately subject any such drug
    40  to  prior authorization without regard to the provisions of subdivisions
    41  five through eleven of this section.
    42    § 17. Subdivisions 4, 5 and 6 of section 274 of the public health law,
    43  as added by section 10 of part C of chapter 58 of the laws of 2005,  are
    44  amended to read as follows:
    45    4.  The  commissioner  shall  obtain  an evaluation of the factors set
    46  forth in subdivision three of this section and a  recommendation  as  to
    47  the  establishment of a prior authorization requirement for a drug under
    48  the clinical drug review program from  the  [pharmacy  and  therapeutics
    49  committee]  drug utilization review board. For this purpose, the commis-

    50  sioner and the [committee] board, as applicable, shall comply  with  the
    51  following meeting and notice processes established by this article:
    52    (a) the open meetings law and freedom of information law provisions of
    53  subdivision six of section two hundred seventy-one of this article; and
    54    (b)  the public notice and interested party provisions of subdivisions
    55  seven, eight and nine of section two hundred seventy-two of  this  arti-
    56  cle.

        S. 2606--D                         18                         A. 3006--D
 
     1    5.  The [committee] board shall recommend a procedure and criteria for
     2  the approval of drugs subject to prior authorization under the  clinical
     3  drug  review  program. Such criteria shall include the specific approved
     4  clinical indications for use of the drug.

     5    6.  The  commissioner  shall  identify a drug for which prior authori-
     6  zation is required, as well as the procedures and criteria for  approval
     7  of use of the drug, under the clinical drug review program after consid-
     8  ering  the  recommendations  from the [committee] board and any comments
     9  received from prescribers, dispensers, consumers  and  manufacturers  of
    10  the  drug.  In  no  event  shall  the  prior  authorization criteria for
    11  approval pursuant to this subdivision result  in  denial  of  the  prior
    12  authorization  request based on the relative cost of the drug subject to
    13  prior authorization.
    14    § 18. Section 277 of the public health law, as added by section 10  of
    15  part C of chapter 58 of the laws of 2005, is amended to read as follows:
    16    §  277.  Review and reports. 1. The commissioner, in consultation with

    17  the [pharmacy and therapeutics committee] drug utilization review board,
    18  shall undertake periodic reviews, at least annually,  of  the  preferred
    19  drug program which shall include consideration of:
    20    (a)  the  volume of prior authorizations being handled, including data
    21  on the number and characteristics of prior  authorization  requests  for
    22  particular prescription drugs;
    23    (b) the quality of the program's responsiveness, including the quality
    24  of the administrator's responsiveness;
    25    (c) complaints received from patients and providers;
    26    (d)  the savings attributable to the state, and to each county and the
    27  city of New York, due to the provisions of this article;
    28    (e) the aggregate amount  of  supplemental  rebates  received  in  the
    29  previous  fiscal  year and in the current fiscal year, to date; and such

    30  amounts are to be broken out by fiscal year and by month;
    31    (f) the education and outreach  program  established  by  section  two
    32  hundred seventy-six of this article.
    33    2. The commissioner and the [panel] board shall, beginning March thir-
    34  ty-first,  two  thousand six and annually thereafter, submit a report to
    35  the governor and the legislature concerning each of the items subject to
    36  periodic review under subdivision one of this section.
    37    3. The commissioner and the [panel] board shall,  beginning  with  the
    38  commencement  of  the  preferred  drug  program  and monthly thereafter,
    39  submit a report to the  governor  and  the  legislature  concerning  the
    40  amount of supplemental rebates received.
    41    §  19.  Subdivision  5 of section 369-bb of the social services law is

    42  REPEALED and a new subdivision 5 is added to read as follows:
    43    5. (a) The functions, powers and duties of  the  former  pharmacy  and
    44  therapeutics  committee  as  established  in article two-A of the public
    45  health law shall now be considered a function of  the  drug  utilization
    46  review board, including but not limited to:
    47    (i)  conducting  an executive session for the purpose of receiving and
    48  evaluating drug pricing information related to supplemental rebates,  or
    49  receiving  and  evaluating trade secrets, or other information which, if
    50  disclosed, would cause substantial injury to the competitive position of
    51  the manufacturer; and
    52    (ii) evaluating and providing recommendations to the  commissioner  of

    53  health  on  other issues relating to pharmacy services under Medicaid or
    54  EPIC, including, but not limited to: therapeutic  comparisons;  enhanced
    55  use  of generic drug products; enhanced targeting of physician prescrib-
    56  ing patterns; and

        S. 2606--D                         19                         A. 3006--D
 
     1    (iii) collaborating with managed care organizations  to  address  drug
     2  utilization  concerns  and to implement consistent management strategies
     3  across the fee-for-service and managed care pharmacy benefits.
     4    (b)  Any business or other matter undertaken or commenced by the phar-
     5  macy and therapeutics committee pertaining  to  or  connected  with  the

     6  functions,  powers,  obligations  and  duties are hereby transferred and
     7  assigned to the drug utilization review board and pending on the  effec-
     8  tive  date  of  this  subdivision, may be conducted and completed by the
     9  drug utilization review board in the same  manner  and  under  the  same
    10  terms  and  conditions  and  with  the  same  effect as if conducted and
    11  completed by the pharmacy and therapeutics committee. All books, papers,
    12  and property of the pharmacy and therapeutics committee  shall  continue
    13  to be maintained by the drug utilization review board.
    14    (c)  All  rules,  regulations, acts, orders, determinations, and deci-
    15  sions of the pharmacy and therapeutics committee pertaining to the func-

    16  tions and powers herein transferred and assigned, in force at  the  time
    17  of such transfer and assumption, shall continue in full force and effect
    18  as rules, regulations, acts, orders, determinations and decisions of the
    19  drug  utilization  review  board until duly modified or abrogated by the
    20  commissioner of health.
    21    § 20. Subdivisions 1 and 2 of section 369-bb of  the  social  services
    22  law,  as  added  by  chapter  632  of the laws of 1992, paragraph (a) of
    23  subdivision 2 as amended by chapter 843 of the laws of 1992, are amended
    24  to read as follows:
    25    1. A [thirteen-member] nineteen-member drug utilization  review  board
    26  is  hereby  created in the department.  The board is responsible for the
    27  establishment and implementation of medical standards and  criteria  for

    28  the retrospective and prospective DUR program.
    29    2. The members of the DUR board shall be appointed by the commissioner
    30  and  shall serve a three-year term.  Members may be reappointed upon the
    31  completion of other terms.   The membership shall be  comprised  of  the
    32  following:
    33    (a)  [Five]  Six persons licensed and actively engaged in the practice
    34  of medicine in the state, [at least one of whom shall have expertise  in
    35  the area of mental health, who shall be selected from a list of nominees
    36  provided  by  the  medical  society  of  the state of New York and other
    37  medical associations] with expertise in  the  areas  of  mental  health,
    38  HIV/AIDS,  geriatrics,  pediatrics  or  internal medicine and who may be

    39  selected based on input from professional associations  and/or  advocacy
    40  groups in New York state.
    41    (b) [Five] Six persons licensed and actively practicing in [community]
    42  pharmacy  in the state who [shall] may be selected [from a list of nomi-
    43  nees provided by  pharmaceutical  societies/associations  of]  based  on
    44  input  from professional associations and/or advocacy groups in New York
    45  state.
    46    (c) Two persons with expertise in  drug  utilization  review  who  are
    47  [either]  health  care  professionals  licensed  under Title VIII of the
    48  education law [or who are pharmacologists] at least one  of  whom  is  a
    49  pharmacologist.

    50    (d)  [One  person from the department of social services (commissioner
    51  or designee).] Three persons that are consumers  or  consumer  represen-
    52  tatives  of  organizations with a regional or statewide constituency and
    53  who have been involved in activities related  to  health  care  consumer
    54  advocacy, including issues affecting Medicaid or EPIC recipients.
    55    (e) One person licensed and actively practicing as a nurse practition-
    56  er or midwife.

        S. 2606--D                         20                         A. 3006--D
 
     1    (f)  The  commissioner shall designate a person from the department to
     2  serve as chairperson of the board.
     3    §  21.  Paragraph  (g) of subdivision 2 of section 365-a of the social

     4  services law, as amended by section 7 of part D of  chapter  56  of  the
     5  laws of 2012, is amended to read as follows:
     6    (g)  sickroom  supplies,  eyeglasses, prosthetic appliances and dental
     7  prosthetic appliances furnished in accordance with  the  regulations  of
     8  the department; provided further that: (i) the commissioner of health is
     9  authorized  to implement a preferred diabetic supply program wherein the
    10  department of  health  will  receive  enhanced  rebates  from  preferred
    11  manufacturers  of  glucometers and test strips, and may subject non-pre-
    12  ferred manufacturers' glucometers and test strips to prior authorization
    13  under section two hundred seventy-three of the public health  law;  (ii)
    14  enteral  formula  therapy  and  nutritional  supplements  are limited to
    15  coverage only for nasogastric, jejunostomy, or gastrostomy tube feeding,

    16  for treatment of an inborn metabolic disorder, or to address growth  and
    17  development  problems  in children, or, subject to standards established
    18  by the commissioner, for persons with a diagnosis of HIV infection, AIDS
    19  or  HIV-related  illness  or  other  diseases  and   conditions;   (iii)
    20  prescription footwear and inserts are limited to coverage only when used
    21  as  an  integral  part  of a lower limb orthotic appliance, as part of a
    22  diabetic treatment plan, or to address growth and  development  problems
    23  in children; [and] (iv) compression and support stockings are limited to
    24  coverage  only  for  pregnancy or treatment of venous stasis ulcers; and
    25  (v) the commissioner of health is authorized to  implement  an  inconti-
    26  nence  supply  utilization  management  program  to reduce costs without

    27  limiting access through the existing provider network, including but not
    28  limited to single or multiple source contracts or, a preferred  inconti-
    29  nence  supply  program  wherein  the  department  of health will receive
    30  enhanced rebates from preferred manufacturers of incontinence  supplies,
    31  and  may  subject  non-preferred manufacturers' incontinence supplies to
    32  prior approval pursuant to regulations of the department,  provided  any
    33  necessary  approvals  under  federal  law  have been obtained to receive
    34  federal financial participation in the costs  of  incontinence  supplies
    35  provided pursuant to this subparagraph;
    36    § 22. Intentionally omitted.
    37    §  23. Section 365-l of the social services law is amended by adding a
    38  new subdivision 2-a to read as follows:

    39    2-a. Up to fifteen million dollars in state funding  may  be  used  to
    40  fund  health  home infrastructure development.  Such funds shall be used
    41  to develop enhanced systems to support Health Home operations  including
    42  assignments,  workflow,  and  transmission of data. Funding will also be
    43  disbursed pursuant to a formula established by the  commissioner  to  be
    44  designated health homes. Such formula may consider prior access to simi-
    45  lar funding opportunities, geographic and demographic factors, including
    46  the  population served, and prevalence of qualifying conditions, connec-
    47  tivity to providers, and other criteria as established  by  the  commis-
    48  sioner.
    49    §  24.  Paragraph  (c) of subdivision 2 of section 365-a of the social

    50  services law, as amended by chapter 778 of the laws of 1977, is  amended
    51  to read as follows:
    52    (c)  out-patient hospital or clinic services in facilities operated in
    53  compliance with applicable provisions of this chapter, the public health
    54  law, the mental hygiene law and other  laws,  including  any  provisions
    55  thereof requiring an operating certificate or license, including facili-
    56  ties  authorized by the appropriate licensing authority to provide inte-

        S. 2606--D                         21                         A. 3006--D
 
     1  grated mental health services, and/or  alcoholism  and  substance  abuse
     2  services,  and/or  physical  health services, and/or services to persons
     3  with developmental disabilities, when such services are  provided  at  a

     4  single  location  or  service  site,  or  where  such facilities are not
     5  conveniently accessible, in any hospital located without the  state  and
     6  care  and services in a day treatment program operated by the department
     7  of mental hygiene or by a voluntary agency under an agreement with  such
     8  department  in  that  part of a public institution operated and approved
     9  pursuant to law as an  intermediate  care  facility  for  [the  mentally
    10  retarded] persons with developmental disabilities;
    11    § 25. The opening paragraph of paragraph 1 of subdivision 4 of section
    12  2807-c  of  the public health law, as amended by section 11 of part C of
    13  chapter 58 of the laws of 2009, is amended to read as follows:
    14    Notwithstanding any inconsistent provision of this section and subject

    15  to the availability of federal financial participation, rates of payment
    16  by governmental agencies for general hospitals which  are  certified  by
    17  the  office  of alcoholism and substance abuse services to provide inpa-
    18  tient detoxification and withdrawal services and, with regard  to  inpa-
    19  tient  services  provided  to  patients discharged on and after December
    20  first, two thousand eight and who are determined to be in  diagnosis-re-
    21  lated  groups  [numbered seven hundred forty-three, seven hundred forty-
    22  four, seven hundred forty-five, seven hundred forty-six,  seven  hundred
    23  forty-seven,  seven hundred forty-eight, seven hundred forty-nine, seven
    24  hundred fifty, or seven hundred fifty-one] as defined by the commission-
    25  er and published on the New York state  department  of  health  website,

    26  shall be made on a per diem basis in accordance with the following:
    27    §  26. Paragraph (c) of subdivision 35 of section 2807-c of the public
    28  health law, as added by section 2 of part C of chapter 58 of the laws of
    29  2009, is amended to read as follows:
    30    (c) The base period reported costs and statistics used  for  rate-set-
    31  ting  for  operating  cost components, including the weights assigned to
    32  diagnostic related groups, shall be  updated  no  less  frequently  than
    33  every  four  years  and  the  new base period shall be no more than four
    34  years prior to the first applicable rate period that utilizes  such  new
    35  base  period provided, however, that the first updated base period shall
    36  begin on January first, two thousand fourteen.
    37    § 27. Intentionally omitted.
    38    § 28. Intentionally omitted.
    39    § 29. Intentionally omitted.

    40    § 30. Subparagraph (iv) of paragraph (e-2) of subdivision 4 of section
    41  2807-c of the public health law is amended by adding a new clause (D) to
    42  read as follows:
    43    (D) Notwithstanding any other provisions of law to  the  contrary  and
    44  subject  to the availability of federal financial participation, for all
    45  rate periods on and after April first, two thousand fourteen, the  oper-
    46  ating  component  of  outpatient specialty rates of hospitals subject to
    47  this subparagraph shall be determined by the  commissioner  pursuant  to
    48  regulations,  including  emergency regulations, and in consultation with
    49  such specialty outpatient facilities, provided  however,  that  for  the
    50  period  beginning October first, two thousand thirteen through September

    51  thirtieth, two thousand fourteen, services provided to patients enrolled
    52  in medicaid managed care shall be paid  by  the  medicaid  managed  care
    53  plans  at no less than the otherwise applicable medicaid fee-for-service
    54  rates, as computed in accordance with clause (B)  of  this  subparagraph
    55  for  the  period  beginning October first, two thousand thirteen through
    56  March thirty-first, two thousand fourteen and as computed in  accordance

        S. 2606--D                         22                         A. 3006--D
 
     1  with  this  clause  for  the  period beginning April first, two thousand
     2  fourteen through September thirtieth, two thousand fourteen.
     3    § 31. Intentionally omitted.
     4    § 32. Intentionally omitted.

     5    § 33. Intentionally omitted.
     6    §  33-a. Subparagraphs (ii) and (x) of paragraph (b) of subdivision 35
     7  of section 2807-c of the public health law, as added  by  section  2  of
     8  part  C  of  chapter  58  of  the  laws  of 2009, are amended to read as
     9  follows:
    10    (ii) Only those two thousand five base year costs which relate to  the
    11  cost  of  services provided to Medicaid inpatients, as determined by the
    12  applicable ratio of costs to charges methodology, shall be utilized  for
    13  rate-setting  purposes,  provided,  however,  that  the commissioner may
    14  utilize updated Medicaid inpatient related base year costs  and  statis-
    15  tics  as  necessary  to adjust inpatient rates in accordance with clause
    16  (C) of subparagraph (x) of this paragraph;
    17    (x) Such regulations shall provide for  administrative  rate  appeals,

    18  but  only  with regard to: (A) the correction of computational errors or
    19  omissions of data, including with regard to the hospital specific compu-
    20  tations pertaining to  graduate  medical  education,  wage  equalization
    21  factor  adjustments,  [and]  (B)  capital  cost  reimbursement, and, (C)
    22  changes to the base year statistics and  costs  used  to  determine  the
    23  direct  and  indirect graduate medical education components of the rates
    24  as a result of new teaching programs at new teaching hospitals and/or as
    25  a result of residents displaced and transferred as a result of  teaching
    26  hospital closures;
    27    §  34. Section 364-i of the social services law is amended by adding a
    28  new subdivision 7 to read as follows:
    29    7. Notwithstanding section one hundred thirty-three of  this  chapter,

    30  where  care or services are received prior to the date the individual is
    31  determined eligible for assistance under this title, medical  assistance
    32  reimbursement  shall  be available for such care or services only (a) if
    33  the care or services are received during the three month period  preced-
    34  ing the month of application for medical assistance and the recipient is
    35  determined  to  have  been  eligible  in  the month in which the care or
    36  service was received, or (b) as provided for in this  section  or  regu-
    37  lations of the department.
    38    § 35. Intentionally omitted.
    39    §  35-a. Subparagraph (i) of paragraph (b) of subdivision 1 of section
    40  364-j of the social services law, as amended by chapter 433 of the  laws
    41  of 1997, is amended to read as follows:

    42    (i)  is  authorized  to operate under article forty-four of the public
    43  health law or article forty-three of the insurance law and  provides  or
    44  arranges,  directly  or  indirectly  (including by referral) for covered
    45  comprehensive health services on a full capitation  basis,  including  a
    46  special needs managed care plan or comprehensive HIV special needs plan;
    47  or
    48    § 36. Paragraphs (c), (m) and (p) of subdivision 1 of section 364-j of
    49  the  social services law, paragraph (c) as amended by section 12 of part
    50  C of chapter 58 of the laws of 2004, paragraph (m) as amended by section
    51  42-b of part H of chapter 59 of the laws of 2011, and paragraph  (p)  as
    52  amended  by chapter 649 of the laws of 1996, are amended and a new para-
    53  graph (z) is added to read as follows:
    54    (c) "Managed care program".  A  statewide  program  in  which  medical

    55  assistance  recipients  enroll  on  a  voluntary  or  mandatory basis to
    56  receive medical assistance services, including case management, directly

        S. 2606--D                         23                         A. 3006--D
 
     1  and indirectly (including by referral) from  a  managed  care  provider,
     2  [and]  including  as  applicable,  a  [mental health special needs plan]
     3  special needs managed care plan or a  comprehensive  HIV  special  needs
     4  plan, under this section.
     5    (m)  "Special  needs managed care plan" [and "specialized managed care
     6  plan"] shall have the same meaning as in section forty-four hundred  one
     7  of the public health law.
     8    (p) "Grievance". Any complaint presented by a participant or a partic-

     9  ipant's representative for resolution through the grievance process of a
    10  managed care provider[, comprehensive HIV special needs plan or a mental
    11  health special needs plan].
    12    (z)  "Credentialed  alcoholism and substance abuse counselor (CASAC)".
    13  An individual credentialed by the office  of  alcoholism  and  substance
    14  abuse  services in accordance with applicable regulations of the commis-
    15  sioner of alcoholism and substance abuse services.
    16    § 37. Paragraph (c) of subdivision 2 of section 364-j  of  the  social
    17  services  law,  as  added by section 42-c of part H of chapter 59 of the
    18  laws of 2011, is amended to read as follows:
    19    (c) The commissioner of  health,  jointly  with  the  commissioner  of
    20  mental  health  and  the  commissioner of alcoholism and substance abuse

    21  services shall be authorized to establish  special  needs  managed  care
    22  [and  specialized  managed  care]  plans,  under  the medical assistance
    23  program, in accordance with applicable federal law and regulations.  The
    24  commissioner  of  health,  in  cooperation  with  such commissioners, is
    25  authorized, subject to the approval of the director of the  division  of
    26  the  budget,  to  apply  for  federal  waivers when such action would be
    27  necessary to assist in promoting the objectives of this section.    With
    28  regard  to  such  special  needs  managed care plans, in addition to the
    29  applicable requirements established in this section, such  commissioners
    30  shall jointly establish standards and requirements to:
    31    (i)  ensure  that  any  special  needs managed care plan shall have an

    32  adequate network of providers to meet the behavioral health  and  health
    33  needs  of  enrollees, and shall review the adequacy prior to approval of
    34  any special needs managed care plan, and upon contract renewal or expan-
    35  sion. To the extent that the network has been determined to meet  stand-
    36  ards set forth in subdivision five of section four thousand four hundred
    37  three of the public health law, such network shall be deemed adequate;
    38    (ii)  ensure that any special needs managed care plan shall make level
    39  of care and coverage determinations utilizing  evidence-based  tools  or
    40  guidelines designed to address the behavioral health needs of enrollees;
    41    (iii)  ensure  sufficient  access  to  behavioral  health  and  health

    42  services for eligible enrollees by  establishing  and  monitoring  pene-
    43  tration rates of special needs managed care plans; and
    44    (iv)  establish  standards  to encourage the use of services, products
    45  and care recommended, ordered or prescribed by a provider to sufficient-
    46  ly address the behavioral health and health services needs of enrollees;
    47  and monitor the application of such standards to ensure that they suffi-
    48  ciently address the behavioral  health  and  health  services  needs  of
    49  enrollees.
    50    §  37-a.   Paragraphs (b) and (c) of subdivision 3 of section 364-j of
    51  the social services law are REPEALED.
    52    § 38.  Paragraphs (a), (d) and (e) of subdivision 3 of  section  364-j
    53  of  the  social  services law, paragraph (a) as amended by section 13 of

    54  part C of chapter 58 of the laws of 2004, paragraph (d) as relettered by
    55  section 77 and paragraph (e) as amended by section 77-a  of  part  H  of
    56  chapter  59 of the laws of 2011, and paragraph (d) as amended by chapter

        S. 2606--D                         24                         A. 3006--D
 
     1  648 of the laws of 1999, are amended and a new paragraph (d-1) is  added
     2  to read as follows:
     3    (a)  Every  person  eligible for or receiving medical assistance under
     4  this article, who  resides  in  a  social  services  district  providing
     5  medical  assistance,  which  has  implemented  the  state's managed care
     6  program shall participate in the program  authorized  by  this  section.
     7  Provided,  however,  that  participation  in a comprehensive HIV special
     8  needs plan also shall be in accordance with article  forty-four  of  the

     9  public  health  law and participation in a [mental health special needs]
    10  special needs managed care plan shall also be in accordance with article
    11  forty-four of the public health law and article thirty-one of the mental
    12  hygiene law.
    13    (d) [The] Until such time as program features and reimbursement  rates
    14  are  approved  by  the  commissioner of health, in consultation with the
    15  commissioners of the office of mental health, the office for people with
    16  developmental disabilities, the office of children and family  services,
    17  and  the office of alcoholism and substance abuse services, as appropri-
    18  ate, the following services shall not be provided to medical  assistance
    19  recipients  through  managed  care programs established pursuant to this

    20  section, and shall continue to  be  provided  outside  of  managed  care
    21  programs  and in accordance with applicable reimbursement methodologies;
    22  provided,  however,  that  no  medical  assistance  recipient  shall  be
    23  required  to  obtain  services that are certified, funded, authorized or
    24  approved by the commissioner of the office for people with developmental
    25  disabilities through a managed care program until the  program  features
    26  approved by the commissioner of health, in consultation with the commis-
    27  sioner of the office for people with developmental disabilities, include
    28  features for habilitation services as defined in paragraph c of subdivi-
    29  sion one of section forty-four hundred three-g of the public health law:

    30    (i)  day treatment services provided to individuals with developmental
    31  disabilities;
    32    (ii) comprehensive medicaid case management services provided to indi-
    33  viduals with developmental disabilities;
    34    (iii) [services provided pursuant to title two-A  of  article  twenty-
    35  five of the public health law;
    36    (iv)]  services provided pursuant to article eighty-nine of the educa-
    37  tion law;
    38    [(v)] (iv) mental health services provided by  a  certified  voluntary
    39  free-standing  day treatment program where such services are provided in
    40  conjunction with educational services authorized  in  an  individualized
    41  education program in accordance with regulations promulgated pursuant to
    42  article eighty-nine of the education law;

    43    [(vi)]  (v)  long  term  services as determined by the commissioner of
    44  [mental retardation and]  the office for people with developmental disa-
    45  bilities, provided to individuals  with  developmental  disabilities  at
    46  facilities  licensed  pursuant  to article sixteen of the mental hygiene
    47  law or clinics serving individuals with  developmental  disabilities  at
    48  facilities  licensed  pursuant  to  article  twenty-eight  of the public
    49  health law;
    50    [(vii)] (vi) TB directly observed therapy;
    51    [(viii)] (vii) AIDS adult day health care;
    52    [(ix)] (viii) HIV COBRA case management; and
    53    [(x)] (ix) other services as determined by the commissioner of health.

    54    (d-1) Services provided pursuant to title two-A of article twenty-five
    55  of the public health law shall not be  provided  to  medical  assistance
    56  recipients  through  managed  care programs established pursuant to this

        S. 2606--D                         25                         A. 3006--D
 
     1  section, and shall continue to  be  provided  outside  of  managed  care
     2  programs and in accordance with applicable reimbursement methodologies.
     3    (e)  The following categories of individuals may be required to enroll
     4  with a managed care program  when  program  features  and  reimbursement
     5  rates  are  approved  by the commissioner of health and, as appropriate,
     6  the commissioners of the  [department]  office  of  mental  health,  the

     7  office  for [persons] people with developmental disabilities, the office
     8  of children and family services, and the office of [alcohol]  alcoholism
     9  and substance abuse services:
    10    (i)  an individual dually eligible for medical assistance and benefits
    11  under the federal Medicare program [and enrolled in a  Medicare  managed
    12  care  plan  offered  by  an entity that is also a managed care provider;
    13  provided that (notwithstanding paragraph (g) of subdivision four of this
    14  section):
    15    (a) if the individual changes his or her Medicare managed care plan as
    16  authorized by title XVIII  of  the  federal  social  security  act,  and
    17  enrolls  in  another  Medicare  managed care plan that is also a managed

    18  care provider, the individual shall be (if required by the  commissioner
    19  under this paragraph) enrolled in that managed care provider;
    20    (b) if the individual changes his or her Medicare managed care plan as
    21  authorized  by  title  XVIII  of  the  federal  social security act, but
    22  enrolls in another Medicare managed care plan that is not also a managed
    23  care provider, the individual shall be disenrolled from the managed care
    24  provider in which he or she was enrolled and withdraw from  the  managed
    25  care program;
    26    (c) if the individual disenrolls from his or her Medicare managed care
    27  plan  as  authorized  by title XVIII of the federal social security act,
    28  and does not enroll in another Medicare managed care plan, the  individ-

    29  ual  shall  be disenrolled from the managed care provider in which he or
    30  she was enrolled and withdraw from the managed care program;
    31    (d) nothing herein shall require an individual enrolled in  a  managed
    32  long  term  care plan, pursuant to section forty-four hundred three-f of
    33  the public health law,  to  disenroll  from  such  program.];  provided,
    34  however,  nothing  herein shall: (a) require an individual enrolled in a
    35  managed long term care plan,  pursuant  to  section  forty-four  hundred
    36  three-f of the public health law, to disenroll from such program; or (b)
    37  make enrollment in a Medicare managed care plan a condition of the indi-
    38  vidual's  participation  in  the  managed  care program pursuant to this

    39  section, or affect the individual's entitlement to payment of applicable
    40  Medicare managed care or fee for service coinsurance and deductibles  by
    41  the individual's managed care provider.
    42    (ii) an individual eligible for supplemental security income;
    43    (iii) HIV positive individuals;
    44    (iv)  persons with serious mental illness and children and adolescents
    45  with serious emotional disturbances, as defined  in  section  forty-four
    46  hundred one of the public health law;
    47    (v)  a  person receiving services provided by a residential alcohol or
    48  substance abuse program or facility for the [mentally retarded] develop-
    49  mentally disabled;
    50    (vi) a person receiving services  provided  by  an  intermediate  care
    51  facility for the [mentally retarded] developmentally disabled or who has

    52  characteristics and needs similar to such persons;
    53    (vii)  a  person  with  a  developmental  or  physical  disability who
    54  receives home and  community-based  services  or  care-at-home  services
    55  through  existing  waivers under section nineteen hundred fifteen (c) of

        S. 2606--D                         26                         A. 3006--D
 
     1  the federal social security act or who  has  characteristics  and  needs
     2  similar to such persons;
     3    (viii)  a  person  who  is eligible for medical assistance pursuant to
     4  subparagraph twelve or subparagraph thirteen of paragraph (a) of  subdi-
     5  vision one of section three hundred sixty-six of this title;
     6    (ix)  a  person receiving services provided by a long term home health
     7  care program, or a person receiving inpatient services in a  state-oper-

     8  ated  psychiatric facility or a residential treatment facility for chil-
     9  dren and youth;
    10    (x) certified blind or disabled children  living  or  expected  to  be
    11  living separate and apart from the parent for thirty days or more;
    12    (xi) residents of nursing facilities;
    13    (xii)  a foster child in the placement of a voluntary agency or in the
    14  direct care of the local social services district;
    15    (xiii) a person or family that is homeless; [and]
    16    (xiv) individuals for whom a managed care provider  is  not  geograph-
    17  ically  accessible so as to reasonably provide services to the person. A
    18  managed care provider is not geographically  accessible  if  the  person
    19  cannot  access  the  provider's  services  in  a  timely  fashion due to
    20  distance or travel time[.];

    21    (xv) a person eligible  for  Medicare  participating  in  a  capitated
    22  demonstration program for long term care;
    23    (xvi) an infant living with an incarcerated mother in a state or local
    24  correctional facility as defined in section two of the correction law;
    25    (xvii)  a person who is expected to be eligible for medical assistance
    26  for less than six months;
    27    (xviii) a person who is eligible for medical assistance benefits  only
    28  with respect to tuberculosis-related services;
    29    (xix)  individuals  receiving  hospice services at time of enrollment;
    30  provided, however, that this clause shall not be construed to require an
    31  individual enrolled in a managed long term care  plan  or  another  care

    32  coordination  model,  who subsequently elects hospice, to disenroll from
    33  such program;
    34    (xx) a person who has primary medical or health care  coverage  avail-
    35  able  from  or  under  a  third-party  payor  which may be maintained by
    36  payment, or part payment, of the premium or cost sharing  amounts,  when
    37  payment of such premium or cost sharing amounts would be cost-effective,
    38  as determined by the local social services district;
    39    (xxi) a person receiving family planning services pursuant to subpara-
    40  graph  six  of paragraph (b) of subdivision one of section three hundred
    41  sixty-six of this title;
    42    (xxii) a person who is eligible for  medical  assistance  pursuant  to

    43  paragraph  (d) of subdivision four of section three hundred sixty-six of
    44  this title;
    45    (xxiii) individuals with a chronic medical  condition  who  are  being
    46  treated  by a specialist physician that is not associated with a managed
    47  care provider in the individual's social services district; and
    48    (xxiv) Native Americans.
    49    § 39. Subparagraphs (ii), (iv) and (vii) of  paragraph  (e),  subpara-
    50  graphs  (i)  and (v) of paragraph (f) and paragraphs (g), (h), (i), (o),
    51  (p), (q) and (r) of  subdivision  4  of  section  364-j  of  the  social
    52  services  law,  subparagraphs  (ii),  (iv)  and  (vii) of paragraph (e),
    53  subparagraph (v) of paragraph  (f)  and  paragraph  (g)  as  amended  by
    54  section 14 of part C of chapter 58 of the laws of 2004, subparagraph (i)

    55  of paragraph (f) as amended by section 79 of part H of chapter 59 of the
    56  laws  of  2011,  paragraph  (h) as amended by chapter 433 of the laws of

        S. 2606--D                         27                         A. 3006--D
 
     1  1997, and paragraphs (i), (o), (p), (q) and (r) as  amended  by  chapter
     2  649 of the laws of 1996, are amended and a new paragraph (v) is added to
     3  read as follows:
     4    (ii) In any social services district which has implemented a mandatory
     5  managed  care program pursuant to this section, the requirements of this
     6  subparagraph shall apply to the extent consistent with federal  law  and
     7  regulations.  The  department  of  health, may contract with one or more
     8  independent organizations to provide enrollment counseling  and  enroll-
     9  ment  services,  for  participants  required  to  enroll in managed care

    10  programs, for each social services district requesting the  services  of
    11  an  enrollment  broker.  To select such organizations, the department of
    12  health shall  issue  a  request  for  proposals  (RFP),  shall  evaluate
    13  proposals  submitted  in response to such RFP and, pursuant to such RFP,
    14  shall award a contract to one or more qualified and responsive organiza-
    15  tions. Such organizations shall not be owned, operated, or controlled by
    16  any governmental  agency,  managed  care  provider,  [comprehensive  HIV
    17  special  needs  plan,  mental  health  special  needs  plan,] or medical
    18  services provider.
    19    (iv) Local  social  services  districts  or  enrollment  organizations
    20  through  their enrollment counselors shall provide participants with the
    21  opportunity for face to face counseling including individual  counseling

    22  upon  request  of  the  participant.  Local social services districts or
    23  enrollment organizations through their enrollment counselors shall  also
    24  provide participants with information in a culturally and linguistically
    25  appropriate  and  understandable  manner,  in light of the participant's
    26  needs, circumstances and language proficiency, sufficient to enable  the
    27  participant  to  make  an informed selection of a managed care provider.
    28  Such information shall include, but shall not  be  limited  to:  how  to
    29  access  care within the program; a description of the medical assistance
    30  services that can be obtained other than through a managed care  provid-
    31  er[, mental health special needs plan or comprehensive HIV special needs
    32  plan];  the  available  managed  care  providers[, mental health special

    33  needs plans and comprehensive HIV special needs plans] and the scope  of
    34  services  covered  by  each; a listing of the medical services providers
    35  associated with each managed care  provider;  the  participants'  rights
    36  within  the  managed  care  program;  and  how  to exercise such rights.
    37  Enrollment counselors shall inquire  into  each  participant's  existing
    38  relationships  with  medical  services providers and explain whether and
    39  how such  relationships  may  be  maintained  within  the  managed  care
    40  program.  For  enrollments  made  during face to face counseling, if the
    41  participant has a preference for particular medical services  providers,
    42  enrollment  counselors  shall verify with the medical services providers
    43  that such  medical  services  providers  whom  the  participant  prefers
    44  participate  in the managed care provider's network and are available to

    45  serve the participant.
    46    (vii) Any marketing materials developed by a managed  care  provider[,
    47  comprehensive  HIV  special  needs  plan  or mental health special needs
    48  plan] shall be approved by the department of health or the local  social
    49  services district, and the commissioner of mental health and the commis-
    50  sioner  of  alcoholism  and substance abuse services, where appropriate,
    51  within sixty days prior to distribution to recipients of medical assist-
    52  ance. All marketing materials shall be reviewed  within  sixty  days  of
    53  submission.
    54    (i)  Participants  shall choose a managed care provider at the time of
    55  application for medical assistance; if the participant does  not  choose
    56  such  a  provider  the  commissioner  shall assign such participant to a


        S. 2606--D                         28                         A. 3006--D
 
     1  managed care provider in accordance with subparagraphs (ii), (iii), (iv)
     2  and (v) of this paragraph. Participants already in  receipt  of  medical
     3  assistance shall have no less than thirty days from the date selected by
     4  the  district  to enroll in the managed care program to select a managed
     5  care provider[, and as appropriate, a mental health special needs plan,]
     6  and shall be provided with information to make an informed choice. Where
     7  a participant has not selected such a provider [or mental health special
     8  needs plan,] the commissioner of health shall assign such participant to
     9  a managed care provider[, and as] which, if appropriate, [to] may  be  a

    10  [mental  health  special  needs  plan]  special needs managed care plan,
    11  taking into account capacity and geographic accessibility.  The  commis-
    12  sioner  may after the period of time established in subparagraph (ii) of
    13  this paragraph assign participants to a  managed  care  provider  taking
    14  into  account  quality performance criteria and cost.  Provided however,
    15  cost criteria shall not be of greater value  than  quality  criteria  in
    16  assigning participants.
    17    (v)  The  commissioner  shall  assign  all  participants not otherwise
    18  assigned to a managed care plan pursuant to  subparagraphs  (ii),  (iii)
    19  and  (iv)  of  this  paragraph  equally  among  each of the managed care
    20  providers that meet the criteria established in subparagraph (i) of this
    21  paragraph; provided, however, that the commissioner shall  assign  indi-

    22  viduals  meeting  the criteria for enrollment in a special needs managed
    23  care plan to such plan or plans where available.
    24    (g) If another managed care provider[,  mental  health  special  needs
    25  plan or comprehensive HIV special needs plan] is available, participants
    26  may  change  such  provider  or plan without cause within thirty days of
    27  notification of enrollment or the effective date of enrollment, whichev-
    28  er is later with a managed care provider[, mental health  special  needs
    29  plan or comprehensive HIV special needs plan] by making a request of the
    30  local  social  services district except that such period shall be forty-
    31  five days for participants who have been assigned to a provider  by  the
    32  commissioner  of  health.  However,  after such thirty or forty-five day

    33  period, whichever is applicable, a participant may  be  prohibited  from
    34  changing  managed  care providers more frequently than once every twelve
    35  months, as permitted by federal law except for good cause as  determined
    36  by the commissioner of health through regulations.
    37    (h)  If  another medical services provider is available, a participant
    38  may change his or her provider of medical  services  (including  primary
    39  care  practitioners)  without  cause  within  thirty days of the partic-
    40  ipant's first appointment with a medical services provider by  making  a
    41  request  of the managed care provider[, mental health special needs plan
    42  or comprehensive HIV special needs plan]. However, after that thirty day
    43  period, no participant shall be permitted to change his or her  provider
    44  of  medical  services  other  than once every six months except for good

    45  cause as determined by the commissioner through regulations.
    46    (i) A managed care provider[, mental health special  needs  plan,  and
    47  comprehensive  HIV  special needs plan] requesting a disenrollment shall
    48  not disenroll a participant without the  prior  approval  of  the  local
    49  social services district in which the participant resides, provided that
    50  disenrollment  from  a  [mental health special needs plan] special needs
    51  managed care plan must comply with the standards of the commissioner  of
    52  health, the commissioner of alcoholism and substance abuse services, and
    53  the  commissioner  of  mental  health.  A managed care provider[, mental
    54  health special needs plan or comprehensive HIV special needs plan] shall
    55  not request disenrollment of  a  participant  based  on  any  diagnosis,

    56  condition,  or  perceived  diagnosis  or  condition,  or a participant's

        S. 2606--D                         29                         A. 3006--D
 
     1  efforts to exercise  his  or  her  rights  under  a  grievance  process,
     2  provided  however,  that  a  managed  care provider may, where medically
     3  appropriate, request permission  to  refer  participants  to  a  [mental
     4  health special needs plan] managed care provider that is a special needs
     5  managed  care  plan  or  a  comprehensive  HIV  special needs plan after
     6  consulting with such participant and upon obtaining his/her  consent  to
     7  such  referral,  and[,]  provided  further that a [mental health special
     8  needs plan] special needs managed care plan may, where clinically appro-

     9  priate, disenroll  individuals  who  no  longer  require  the  level  of
    10  services  provided by a [mental health special needs plan] special needs
    11  managed care plan.
    12    (o) A managed care provider shall  provide  or  arrange,  directly  or
    13  indirectly,  (including  by  referral)  for  the  full  range of covered
    14  services to all participants, notwithstanding that such participants may
    15  be eligible to be enrolled in a comprehensive HIV special needs plan  or
    16  [mental health special needs plan] special needs managed care plan.
    17    (p) A managed care provider[, comprehensive HIV special needs plan and
    18  mental health special needs plan] shall implement procedures to communi-
    19  cate  appropriately  with participants who have difficulty communicating

    20  in English and to communicate appropriately with  visually-impaired  and
    21  hearing-impaired participants.
    22    (q) A managed care provider[, comprehensive HIV special needs plan and
    23  mental health special needs plan] shall comply with applicable state and
    24  federal  law provisions prohibiting discrimination on the basis of disa-
    25  bility.
    26    (r) A managed care provider[, comprehensive HIV special needs plan and
    27  mental health special needs plan] shall provide services to participants
    28  pursuant to an order of a  court  of  competent  jurisdiction,  provided
    29  however,  that  such  services shall be within such provider's or plan's
    30  benefit package and are reimbursable under  title  xix  of  the  federal
    31  social security act.
    32    (v)  A  managed  care provider must allow enrollees to access chemical

    33  dependence treatment services from facilities certified by the office of
    34  alcoholism and substance abuse  services,  even  if  such  services  are
    35  rendered  by  a practitioner who would not otherwise be separately reim-
    36  bursed, including but not  limited  to  a  credentialed  alcoholism  and
    37  substance abuse counselor (CASAC).
    38    §  40.  Paragraph  (a) of subdivision 5 of section 364-j of the social
    39  services law, as amended by section 15 of part C of chapter  58  of  the
    40  laws of 2004, is amended to read as follows:
    41    (a) The managed care program shall provide for the selection of quali-
    42  fied  managed  care  providers  by  the  commissioner of health [and, as
    43  appropriate, mental health special needs  plans  and  comprehensive  HIV

    44  special needs plans] to participate in the program, including comprehen-
    45  sive  HIV  special  needs  plans and special needs managed care plans in
    46  accordance with the provisions of section three hundred sixty-five-m  of
    47  this  title;  provided,  however,  that  the  commissioner of health may
    48  contract directly with comprehensive HIV special needs plans  consistent
    49  with standards set forth in this section, and assure that such providers
    50  are  accessible  taking into account the needs of persons with disabili-
    51  ties and the differences between rural, suburban,  and  urban  settings,
    52  and in sufficient numbers to meet the health care needs of participants,
    53  and  shall  consider  the  extent  to  which  major public hospitals are
    54  included within such providers' networks.


        S. 2606--D                         30                         A. 3006--D
 
     1    § 41. The opening paragraph of subdivision 6 of section 364-j  of  the
     2  social  services  law,  as  added by chapter 649 of the laws of 1996, is
     3  amended to read as follows:
     4    A  managed care provider[, mental health special needs plan or compre-
     5  hensive HIV special needs plan provider] shall not engage in the follow-
     6  ing practices:
     7    § 42. Subdivision 17 of section 364-j of the social services  law,  as
     8  amended  by  section 94 of part B of chapter 436 of the laws of 1997, is
     9  amended to read as follows:
    10    17. (a) The provisions of  this  section  regarding  participation  of
    11  persons  receiving family assistance and supplemental security income in
    12  managed care programs shall be effective if, and  as  long  as,  federal

    13  financial  participation  is  available  for  expenditures  for services
    14  provided pursuant to this section.
    15    (b) The provisions of this section regarding the furnishing of  health
    16  and behavioral health services through a special needs managed care plan
    17  shall  be  effective if, and as long as, federal financial participation
    18  is available for expenditures for services provided by such plans pursu-
    19  ant to this section.
    20    § 43. Subdivision 20 of section 364-j of the social services  law,  as
    21  added by chapter 649 of the laws of 1996, is amended to read as follows:
    22    20. Upon a determination that a participant appears to be suitable for
    23  admission  to a comprehensive HIV special needs plan or a [mental health
    24  special needs plan] special needs managed  care  plan,  a  managed  care

    25  provider shall inform the participant of the availability of such plans,
    26  where available and appropriate.
    27    §  44.  Paragraph (a) of subdivision 23 of section 364-j of the social
    28  services law, as added by section 65 of part A of chapter 57 of the laws
    29  of 2006, is amended to read as follows:
    30    (a) As a means of protecting the health, safety and welfare of recipi-
    31  ents, in addition to any  other  sanctions  that  may  be  imposed,  the
    32  commissioner,  in  consultation  with the commissioners of the office of
    33  mental health and the office of alcoholism and substance abuse services,
    34  where appropriate, shall appoint temporary management of a managed  care
    35  provider  upon determining that the managed care provider has repeatedly
    36  failed to meet the substantive requirements of sections 1903(m) and 1932

    37  of the federal Social Security Act and regulations. A hearing shall  not
    38  be required prior to the appointment of temporary management.
    39    §  45.  The opening paragraph of subdivision 4 of section 365-m of the
    40  social services law, as added by section 42-d of part H of chapter 59 of
    41  the laws of 2011, is amended to read as follows:
    42    The commissioners of the office of mental health, the office of  alco-
    43  holism  and substance abuse services and the department of health, shall
    44  have the responsibility for jointly designating  on  a  regional  basis,
    45  after  consultation  with  the  local social services district and local
    46  governmental unit, as such term is defined in the mental hygiene law, of
    47  a city with a population of over one million persons, and after  consul-
    48  tation  of  other  affected  counties,  a limited number of [specialized

    49  managed care plans under section  three  hundred  sixty-four-j  of  this
    50  title,]  special  [need]  needs  managed  care plans under section three
    51  hundred sixty-four-j of this  title[,  and/or  integrated  physical  and
    52  behavioral health provider systems certified under article twenty-nine-E
    53  of  the  public health law] capable of managing the behavioral and phys-
    54  ical health needs  of  medical  assistance  enrollees  with  significant
    55  behavioral health needs. Initial designations of such plans [or provider
    56  systems]  should  be made no later than April first, two thousand [thir-

        S. 2606--D                         31                         A. 3006--D


     1  teen] fourteen, provided, however, such designations shall be contingent
     2  upon a determination by such state commissioners that the entities to be
     3  designated have the capacity and financial ability to  provide  services
     4  in  such  plans  [or provider systems], and that the region has a suffi-
     5  cient population and service base to support such plans  [and  systems].
     6  Once  designated,  the commissioner of health shall make arrangements to
     7  enroll such enrollees in such plans [or integrated provider systems] and
     8  to pay such plans [or provider systems] on a capitated or other basis to
     9  manage, coordinate, and pay for behavioral and physical  health  medical
    10  assistance services for such enrollees. Notwithstanding any inconsistent
    11  provision  of  section one hundred twelve and one hundred sixty-three of

    12  the state finance law, and section one hundred forty-two of the economic
    13  development law, or any other law to the contrary, the  designations  of
    14  such plans [and provider systems], and any resulting contracts with such
    15  plans[,] or providers [or provider systems] are authorized to be entered
    16  into  by  such  state commissioners without a competitive bid or request
    17  for proposal process, provided however that:
    18    § 45-a. Paragraph (c) of subdivision 3 of section 365-m of the  social
    19  services  law,  as  added by section 42-d of part H of chapter 59 of the
    20  laws of 2011, is amended to read as follows:
    21    (c) the commissioners of the office of mental health and the office of
    22  alcoholism and  substance  abuse  services,  in  consultation  with  the
    23  commissioner  of health and the impacted local governmental units, shall

    24  select such contractor or contractors that, in  their  discretion,  have
    25  demonstrated  the  ability to effectively, efficiently, and economically
    26  integrate behavioral health and  health  services;  have  the  requisite
    27  expertise  and  financial resources; have demonstrated that their direc-
    28  tors, sponsors, members, managers, partners or operators have the requi-
    29  site character, competence and standing in the community, and  are  best
    30  suited  to  serve  the  purposes  of  this  section.   In selecting such
    31  contractor or contractors, the commissioners shall:
    32    (i) ensure that any such contractor or contractors  have  an  adequate
    33  network  of  providers to meet the behavioral health and health needs of
    34  enrollees, and shall review the adequacy prior to approval of  any  such

    35  contract  or  contracts,  and upon contract renewal or expansion. To the
    36  extent that the network has been determined to meet standards set  forth
    37  in  subdivision  five of section four thousand four hundred three of the
    38  public health law, such network shall be deemed adequate.
    39    (ii) ensure that such contractor or contractors shall  make  level  of
    40  care  and  coverage  determinations  utilizing  evidence-based  tools or
    41  guidelines designated to address the behavioral health needs  of  enrol-
    42  lees.
    43    (iii)  ensure  sufficient  access  to  behavioral  health  and  health
    44  services for eligible enrollees by  establishing  and  monitoring  pene-
    45  tration rates of any such contractor or contractors.

    46    (iv)  establish  standards  to encourage the use of services, products
    47  and care recommended, ordered or prescribed by a provider to sufficient-
    48  ly address the behavioral health and health services needs of enrollees;
    49  and monitor the application of such standards to ensure that they suffi-
    50  ciently address the behavioral  health  and  health  services  needs  of
    51  enrollees.
    52    §  45-b. Paragraph (c) of subdivision 4 of section 365-m of the social
    53  services law, as added by section 42-d of part H of chapter  59  of  the
    54  laws of 2011, is amended to read as follows:
    55    (c) the commissioners of the office of mental health and the office of
    56  alcoholism  and  substance  abuse  services,  in  consultation  with the


        S. 2606--D                         32                         A. 3006--D
 
     1  commissioner of health, shall select such  plans  or  systems  that,  in
     2  their  discretion,  have  demonstrated the ability to effectively, effi-
     3  ciently, and economically manage  the  behavioral  and  physical  health
     4  needs of medical assistance enrollees with significant behavioral health
     5  needs; have the requisite expertise and financial resources; have demon-
     6  strated  that  their directors, sponsors, members, managers, partners or
     7  operators have the requisite character, competence and standing  in  the
     8  community,  and  are  best suited to serve the purposes of this section.
     9  Oversight of such contracts  with  such  plans,  providers  or  provider
    10  systems  shall  be the joint responsibility of such state commissioners,
    11  and for contracts affecting a city with a population of over one million

    12  persons, also with the city's local social services district  and  local
    13  governmental unit, as such term is defined in the mental hygiene law.
    14  In selecting such plans or systems, the commissioners shall:
    15    (i)  ensure that any such plans or systems have an adequate network of
    16  providers to meet the behavioral health and health needs  of  enrollees,
    17  and  shall  review  the  adequacy prior to approval of any such plans or
    18  systems, and upon contract renewal or expansion. To the extent that  the
    19  network  has  been determined to meet standards set forth in subdivision
    20  five of section four thousand four hundred three of  the  public  health
    21  law, such network shall be deemed adequate.
    22    (ii)  ensure  that  such plans or systems shall make level of care and

    23  coverage determinations utilizing  evidence-based  tools  or  guidelines
    24  designed to address the behavioral health needs of enrollees.
    25    (iii)  ensure  sufficient  access  to  behavioral  health  and  health
    26  services for eligible enrollees by  establishing  and  monitoring  pene-
    27  tration rates of any such plans or systems.
    28    (iv)  establish  standards  to encourage the use of services, products
    29  and care recommended, ordered or prescribed by a provider to sufficient-
    30  ly address the behavioral health and health services needs of enrollees;
    31  and monitor the application of such standards to ensure that they suffi-
    32  ciently address the behavioral  health  and  health  services  needs  of
    33  enrollees.

    34    §  45-c.  The  commissioner of health in consultation with the commis-
    35  sioners of the office of mental health and the office of alcoholism  and
    36  substance  abuse  shall prepare a report on the transition of behavioral
    37  health services as a managed care  benefit  in  the  medical  assistance
    38  program.   Such report shall examine (i) the adequacy of rates; (ii) the
    39  ability of managed care plans to arrange and manage covered services for
    40  eligible enrollees; (iii) the ability of managed care plans  to  provide
    41  an  adequate  network  of providers to meet the needs of enrollees; (iv)
    42  the use of evidence based tools or guidelines by managed care plans when
    43  determining the appropriate level of care or coverage for enrollees; (v)
    44  the ability of managed care plans to  provide  eligible  enrollees  with
    45  both  the  appropriate  amount  and  type  of services; (vi) the quality

    46  assurance mechanisms used by managed care plans, including processes  to
    47  ensure  enrollee  satisfaction;  (vii)  the manner in which managed care
    48  plans address the cultural and linguistic needs of enrollees; and (viii)
    49  any other quality of care criteria deemed appropriate by the commission-
    50  ers to ensure the adequacy of rates, continuity of care and the  quality
    51  of  life,  health,  and safety of enrollees during the transition of the
    52  behavioral health benefit. The report shall be submitted no  later  than
    53  April  first, two thousand sixteen to the governor, the temporary presi-
    54  dent of the senate, the speaker of the assembly, the minority leader  of
    55  the senate, and the minority leader of the assembly.

        S. 2606--D                         33                         A. 3006--D
 
     1    § 46. Subdivision 8 of section 4401 of the public health law, as added

     2  by section 42 of part H of chapter 59 of the laws of 2011, is amended to
     3  read as follows:
     4    8.  "Special  needs  managed  care plan" [or "specialized managed care
     5  plan"] shall mean a combination of persons natural or corporate, or  any
     6  groups  of  such  persons,  or  a  county or counties, who enter into an
     7  arrangement, agreement or plan, or combination of  arrangements,  agree-
     8  ments  or  plans,  to  provide  health and behavioral health services to
     9  enrollees with significant behavioral health needs.
    10    § 47. Section 4403-d of the public health law,  as  added  by  section
    11  42-a  of part H of chapter 59 of the laws of 2011, is amended to read as
    12  follows:
    13    § 4403-d. Special needs managed care plans  [and  specialized  managed
    14  care plans]. No person, group of persons, county or counties may operate

    15  a  special  needs  managed  care plan [or specialized managed care plan]
    16  without first obtaining a certificate of authority from the  commission-
    17  er,  issued jointly with the commissioner of the office of mental health
    18  and the commissioner of the office of  alcoholism  and  substance  abuse
    19  services.
    20    §  47-a.  Subparagraphs (iii) and (iv) of paragraph (b) of subdivision
    21  7 of section 4403-f of the public health law are REPEALED.
    22    § 48. Subparagraph (v) of paragraph (b) of subdivision  7  of  section
    23  4403-f of the public health law, as amended by section 41-b of part H of
    24  chapter 59 of the laws of 2011, is amended to read as follows:
    25    (v)  The following medical assistance recipients shall not be eligible
    26  to participate in a managed long term care program or other care coordi-
    27  nation model  established  pursuant  to  this  paragraph  until  program

    28  features  and  reimbursement rates are approved by the commissioner and,
    29  as applicable, the commissioner of developmental disabilities:
    30    (1) a person enrolled in a managed care plan pursuant to section three
    31  hundred sixty-four-j of the social services law;
    32    (2) a participant in the traumatic brain injury waiver program;
    33    (3) a participant in the nursing home transition and diversion  waiver
    34  program;
    35    (4) a person enrolled in the assisted living program;
    36    (5)  a  person  enrolled  in  home and community based waiver programs
    37  administered   by   the   office   for   people    with    developmental
    38  disabilities[.];
    39    (6) a person who is expected to be eligible for medical assistance for
    40  less  than six months, for a reason other than that the person is eligi-

    41  ble for medical assistance only through the application of excess income
    42  toward the cost of medical care and services;
    43    (7) a person who is eligible for medical assistance benefits only with
    44  respect to tuberculosis-related services;
    45    (8) a  person  receiving  hospice  services  at  time  of  enrollment;
    46  provided, however, that this clause shall not be construed to require an
    47  individual  enrolled  in  a  managed long term care plan or another care
    48  coordination model, who subsequently elects hospice, to  disenroll  from
    49  such program;
    50    (9) a person who has primary medical or health care coverage available
    51  from or under a third-party payor which may be maintained by payment, or

    52  part  payment,  of  the premium or cost sharing amounts, when payment of
    53  such premium or cost sharing amounts would be cost-effective, as  deter-
    54  mined by the social services district;

        S. 2606--D                         34                         A. 3006--D
 
     1    (10)  a person receiving family planning services pursuant to subpara-
     2  graph six of paragraph (b) of subdivision one of section  three  hundred
     3  sixty-six of the social services law;
     4    (11) a person who is eligible for medical assistance pursuant to para-
     5  graph  (b) of subdivision four of section three hundred sixty-six of the
     6  social services law; and
     7    (12) Native Americans.
     8    § 48-a. Notwithstanding any contrary provision of law, the commission-

     9  er of alcoholism and substance abuse services is authorized, subject  to
    10  the  approval  of the director of the budget, to transfer to the commis-
    11  sioner of health state funds to be utilized as the state share  for  the
    12  purpose  of  increasing  payments  under the medicaid program to managed
    13  care organizations licensed under article 44 of the public health law or
    14  under article 43 of the insurance law. Such managed  care  organizations
    15  shall  utilize  such funds for the purpose of reimbursing hospital-based
    16  and free-standing chemical dependence outpatient  and  opioid  treatment
    17  clinics  licensed  pursuant  to  article  28 of the public health law or
    18  article 32 of the mental hygiene law for chemical  dependency  services,
    19  as  determined  by  the commissioner of health, in consultation with the
    20  commissioner of alcoholism and substance  abuse  services,  provided  to

    21  medicaid  eligible  outpatients. Such reimbursement shall be in the form
    22  of fees for such services which are equivalent to  the  payments  estab-
    23  lished  for such services under the ambulatory patient group (APG) rate-
    24  setting methodology as utilized by the department of health  or  by  the
    25  office  of  alcoholism  and  substance  abuse  services for rate-setting
    26  purposes; provided, however, that the increase to such fees  that  shall
    27  result  from  the provisions of this section shall not, in the aggregate
    28  and as determined by the commissioner of health,  in  consultation  with
    29  the  commissioner of alcoholism and substance abuse services, be greater
    30  than the increased funds made available pursuant to  this  section.  The
    31  commissioner  of  health  may,  in consultation with the commissioner of
    32  alcoholism and substance abuse services, promulgate regulations, includ-

    33  ing emergency regulations, as are necessary to implement the  provisions
    34  of this section.
    35    §  49. Section 2 of part H of chapter 111 of the laws of 2010 relating
    36  to increasing Medicaid payments to providers through managed care organ-
    37  izations and providing equivalent fees  through  an  ambulatory  patient
    38  group methodology, is amended to read as follows:
    39    §  2.  This  act  shall take effect immediately and shall be deemed to
    40  have been in full force and effect on and after April 1, 2010, and shall
    41  expire on March 31, 2016.
    42    § 50.  Intentionally omitted.
    43    § 51.  Intentionally omitted.
    44    § 52.  Intentionally omitted.
    45    § 53.  Intentionally omitted.
    46    § 54. Subparagraph (iii) of paragraph (g) of subdivision 7 of  section
    47  4403-f of the public health law, as amended by section 41-b of part H of

    48  chapter 59 of the laws of 2011, is amended to read as follows:
    49    (iii)  The  enrollment  application  shall be submitted by the managed
    50  long term care plan or demonstration to the  entity  designated  by  the
    51  department  prior to the commencement of services under the managed long
    52  term care plan or demonstration. [For purposes of reimbursement  of  the
    53  managed long term care plan or demonstration, if the enrollment applica-
    54  tion  is  submitted  on  or  before  the twentieth day of the month, the
    55  enrollment shall commence on the first day of the  month  following  the
    56  completion and submission and if the enrollment application is submitted

        S. 2606--D                         35                         A. 3006--D


     1  after  the  twentieth day of the month, the enrollment shall commence on
     2  the first day of the second  month  following  submission.]  Enrollments
     3  conducted  by  a  plan  or  demonstration shall be subject to review and
     4  audit  by  the department or a contractor selected pursuant to paragraph
     5  (d) of this subdivision.
     6    § 55. Paragraph (a) of subdivision 8 of section  3614  of  the  public
     7  health  law,  as added by section 54 of part J of chapter 82 of the laws
     8  of 2002, is amended to read as follows:
     9    (a) Notwithstanding any inconsistent provision of law, rule  or  regu-
    10  lation  and  subject to the provisions of paragraph (b) of this subdivi-
    11  sion and to the availability of  federal  financial  participation,  the
    12  commissioner  shall  adjust  medical  assistance  rates  of  payment for

    13  services provided by certified home health agencies  for  such  services
    14  provided  to  children  under  eighteen  years  of  age and for services
    15  provided to a special needs population of medically complex and  fragile
    16  children,  adolescents  and  young  disabled  adults by a CHHA operating
    17  under a pilot program approved by the department, long term home  health
    18  care  programs and AIDS home care programs in accordance with this para-
    19  graph and paragraph (b) of this subdivision for  purposes  of  improving
    20  recruitment  and retention of non-supervisory home care services workers
    21  or any worker with direct patient care responsibility in  the  following
    22  amounts  for services provided on and after December first, two thousand
    23  two.
    24    (i) rates of payment  by  governmental  agencies  for  certified  home

    25  health  agency  services  for  such  services provided to children under
    26  eighteen years of age and for services provided to a special needs popu-
    27  lation of medically complex and fragile children, adolescents and  young
    28  disabled  adults  by  a CHHA operating under a pilot program approved by
    29  the department  (including  services  provided  through  contracts  with
    30  licensed  home  care  services  agencies)  shall  be  increased by three
    31  percent;
    32    (ii) rates of payment by governmental  agencies  for  long  term  home
    33  health  care  program  services  (including  services  provided  through
    34  contracts with licensed home care services agencies) shall be  increased
    35  by three percent; and
    36    (iii)  rates  of  payment  by governmental agencies for AIDS home care

    37  programs (including services provided through  contracts  with  licensed
    38  home care services agencies) shall be increased by three percent.
    39    §  56.  The  opening paragraph of subdivision 9 of section 3614 of the
    40  public health law, as amended by section 5 of part C of chapter  109  of
    41  the laws of 2006, is amended to read as follows:
    42    Notwithstanding  any  law  to  the  contrary,  the commissioner shall,
    43  subject to the availability of federal financial  participation,  adjust
    44  medical  assistance  rates of payment for certified home health agencies
    45  for such services provided to children under eighteen years of  age  and
    46  for services provided to a special needs population of medically complex
    47  and  fragile  children,  adolescents and young disabled adults by a CHHA

    48  operating under a pilot program approved by the  department,  long  term
    49  home  health care programs, AIDS home care programs established pursuant
    50  to this article, hospice programs established  under  article  forty  of
    51  this  chapter  and for managed long term care plans and approved managed
    52  long term care operating demonstrations as defined in section forty-four
    53  hundred three-f of this chapter. Such adjustments shall be for  purposes
    54  of improving recruitment, training and retention of home health aides or
    55  other personnel with direct patient care responsibility in the following
    56  aggregate amounts for the following periods:

        S. 2606--D                         36                         A. 3006--D
 
     1    §  57.  Paragraph  (a) of subdivision 10 of section 3614 of the public

     2  health law, as amended by section 24 of part C of chapter 59 of the laws
     3  of 2011, is amended to read as follows:
     4    (a)  Such  adjustments to rates of payments shall be allocated propor-
     5  tionally based on each certified home  health  [agency's]  agency,  long
     6  term home health care program, AIDS home care and hospice program's home
     7  health  aide or other direct care services total annual hours of service
     8  provided to medicaid patients, as reported in each  such  agency's  most
     9  recently available cost report as submitted to the department or for the
    10  purpose of the managed long term care program a suitable proxy developed
    11  by  the department in consultation with the interested parties. Payments
    12  made pursuant to this section shall not be subject to subsequent adjust-
    13  ment or reconciliation; provided  that  such  adjustments  to  rates  of

    14  payments  to  certified  home  health  agencies  shall  only be for that
    15  portion of services provided to children under eighteen years of age and
    16  for services provided to a special needs population of medically complex
    17  and fragile children, adolescents and young disabled adults  by  a  CHHA
    18  operating under a pilot program approved by the department.
    19    §  57-a. The public health law is amended by adding a new section 3621
    20  to read as follows:
    21    § 3621. Payment of claims. Notwithstanding any law  to  the  contrary,
    22  the provisions of section thirty-two hundred twenty-four-a of the insur-
    23  ance  law, and regulations thereunder, shall apply to claims for payment
    24  submitted by a licensed home care services agency, certified home health

    25  agency, long term home health care program, or fiscal intermediary oper-
    26  ating under section three hundred sixty-five-f of  the  social  services
    27  law,  pursuant  to  a  contract  with  a  payor under section forty-four
    28  hundred three-f of this chapter or section three hundred sixty-four-j of
    29  the social services law, and such claims shall be subject to and settled
    30  in compliance with the standards set forth in such section.
    31    § 57-b. Paragraph 2 of subsection (d) of section 3224-a of the  insur-
    32  ance  law,  as amended by chapter 666 of the laws of 1997, is amended to
    33  read as follows:
    34    (2) "health care provider" shall mean an entity licensed or  certified
    35  pursuant  to  article  twenty-eight,  thirty-six  or forty of the public

    36  health law, a facility licensed pursuant to article  nineteen[,  twenty-
    37  three]  or  thirty-one  of the mental hygiene law, a fiscal intermediary
    38  operating under  section  three  hundred  sixty  five-f  of  the  social
    39  services  law, a health care professional licensed, registered or certi-
    40  fied pursuant to title eight  of  the  education  law,  a  dispenser  or
    41  provider  of pharmaceutical products, services or durable medical equip-
    42  ment, or a representative designated by such entity or person.
    43    § 57-c. Home and community based care workgroup. The  commissioner  of
    44  health  shall convene a home and community based care workgroup to exam-
    45  ine and make recommendations on issues which include, but are not limit-
    46  ed to:
    47    a. State and federal regulatory requirements and related policy guide-

    48  lines (including the applicability of the federal conditions of  partic-
    49  ipation);
    50    b.  Efficient  home and community based care delivery, including tele-
    51  health and hospice services; and
    52    c. Alignment of functions between managed care entities and  home  and
    53  community based providers.
    54    The  workgroup shall be 11 members. The members of the workgroup shall
    55  including providers, plans and representatives of consumers  and  direct
    56  caregivers with relevant expertise.

        S. 2606--D                         37                         A. 3006--D
 
     1    The  commissioner  of  health,  or his or her designee shall chair the
     2  workgroup and department of health  and  other  executive  agencies  and
     3  offices  shall  provide relevant data and other information as is neces-
     4  sary for the group to perform its duties.

     5    The  commissioner  of  health  shall convene this workgroup by May 15,
     6  2013 and the group shall issue a report with recommendations by March 1,
     7  2014.
     8    § 58. Paragraph (h) of subdivision 21 of section 2808  of  the  public
     9  health  law, as amended by section 8 of part D of chapter 58 of the laws
    10  of 2009, is amended to read as follows:
    11    (h) The total amount of funds  to  be  allocated  and  distributed  as
    12  medical assistance for financially disadvantaged residential health care
    13  facility  rate  adjustments  to eligible facilities for a rate period in
    14  accordance with this subdivision shall be thirty million dollars for the
    15  period October first, two thousand four through  December  thirty-first,
    16  two  thousand four and thirty million dollars on an annualized basis for
    17  rate periods on and after  January  first,  two  thousand  five  through

    18  December  thirty-first, two thousand eight and thirty million dollars on
    19  an annualized basis on and  after  January  first,  two  thousand  nine,
    20  provided  that, subject to all necessary federal approvals, on and after
    21  January first, two thousand thirteen funds allocated  under  this  para-
    22  graph shall be distributed pursuant to 10 NYCRR 86-2.39.  The nonfederal
    23  share of such rate adjustments shall be paid by the state, with no local
    24  share,  from  allocations made pursuant to paragraph (hh) of subdivision
    25  one of section twenty-eight hundred seven-v of this  article.    In  the
    26  event  the  statewide  total  of  the annual rate adjustments determined
    27  pursuant to paragraph (g) of this subdivision varies  from  the  amounts
    28  set  forth in this paragraph, each qualifying facility's rate adjustment

    29  shall be proportionately increased or decreased such that the  total  of
    30  the  annual  rate adjustments made pursuant to this subdivision is equal
    31  to the amounts set forth in this paragraph on a statewide basis.
    32    § 58-a. Notwithstanding any law to the contrary, and  subject  to  the
    33  availability  of  federal  financial  participation,  general  hospitals
    34  defined as critical access hospitals pursuant  to  title  XVIII  of  the
    35  federal social security act shall be allocated no less than five million
    36  dollars  in accordance with the provisions of 10 NYCRR 86-1.31. In addi-
    37  tion, the department of health shall analyze the adequacy of  rates  for
    38  critical  access hospitals and develop recommendations for consideration
    39  in preparing the 2014-15 Executive Budget.
    40    § 59. Paragraph (d) of subdivision 2-b of section 2808 of  the  public

    41  health  law, as added by section 47 of part C of chapter 109 of the laws
    42  of 2006, is amended to read as follows:
    43    (d) Cost reports submitted by residential health care  facilities  for
    44  the  two  thousand two calendar year or any part thereof shall, notwith-
    45  standing any contrary provision of law,  be  subject  to  audit  through
    46  December  thirty-first,  two thousand [fourteen] eighteen and facilities
    47  shall retain for the purpose of such audits all fiscal  and  statistical
    48  records  relevant to such cost reports, provided, however, that any such
    49  audit commenced on or before December thirty-first, two thousand  [four-
    50  teen]  eighteen,  may be completed and used for the purpose of adjusting
    51  any Medicaid rates which utilize such costs.
    52    § 60. Subparagraph (ii) of paragraph (a) of subdivision 2-b of section

    53  2808 of the public health law, as added by section 47 of part C of chap-
    54  ter 109 of the laws of 2006, is amended to read as follows:
    55    (ii) Rates for the periods two thousand seven and two  thousand  eight
    56  shall  be further adjusted by a per diem add-on amount, as determined by

        S. 2606--D                         38                         A. 3006--D
 
     1  the commissioner, reflecting the proportional amount of each  facility's
     2  projected  Medicaid  benefit to the total projected Medicaid benefit for
     3  all facilities of the imputed use of the  rate-setting  methodology  set
     4  forth  in paragraph (b) of this subdivision, provided, however, that for
     5  those facilities that do not receive a per diem add-on adjustment pursu-
     6  ant to this subparagraph, rates shall be further adjusted to include the
     7  proportionate benefit, as determined by the commissioner, of the expira-

     8  tion of the opening paragraph and paragraph (a) of  subdivision  sixteen
     9  of  this  section  and  of paragraph (a) of subdivision fourteen of this
    10  section, provided, further, however, that the  aggregate  total  of  the
    11  rate adjustments made pursuant to this subparagraph shall not exceed one
    12  hundred  thirty-seven  million five hundred thousand dollars for the two
    13  thousand seven rate period and  one  hundred  sixty-seven  million  five
    14  hundred  thousand  dollars  for  the  two thousand eight rate period and
    15  provided further, however, that such rate adjustments as  made  pursuant
    16  to  this  subparagraph prior to two thousand twelve shall not be subject
    17  to subsequent adjustment or reconciliation.
    18    § 61. Subparagraph (i) of paragraph (b) of subdivision 2-b of  section

    19  2808  of  the  public  health law, as amended by section 94 of part H of
    20  chapter 59 of the laws of 2011, is amended to read as follows:
    21    (i) (A) Subject to the provisions of subparagraphs (ii) through  (xiv)
    22  of  this  paragraph,  for periods on and after April first, two thousand
    23  nine the operating cost component of  rates  of  payment  shall  reflect
    24  allowable operating costs as reported in each facility's cost report for
    25  the  two  thousand  two  calendar  year, as adjusted for inflation on an
    26  annual basis in accordance with the methodology set forth  in  paragraph
    27  (c)  of  subdivision ten of section twenty-eight hundred seven-c of this
    28  article, provided, however, that for  those  facilities  which  [do  not
    29  receive  a  per  diem add-on adjustment pursuant to subparagraph (ii) of

    30  paragraph (a) of this subdivision] are determined by the commissioner to
    31  be qualifying facilities in accordance with the provisions of clause (B)
    32  of this subparagraph, rates shall be further  adjusted  to  include  the
    33  proportionate benefit, as determined by the commissioner, of the expira-
    34  tion  of  the opening paragraph and paragraph (a) of subdivision sixteen
    35  of this section and of paragraph (a) of  subdivision  fourteen  of  this
    36  section, and provided further that the operating cost component of rates
    37  of  payment  for  those  facilities  which  [did  not receive a per diem
    38  adjustment in accordance with subparagraph (ii) of paragraph (a) of this
    39  subdivision] are determined by the commissioner to be qualifying facili-

    40  ties in accordance with the provisions of clause (B)  of  this  subpara-
    41  graph  shall  not  be  less than the operating component such facilities
    42  received in  the  two  thousand  eight  rate  period,  as  adjusted  for
    43  inflation  on  an  annual  basis  in accordance with the methodology set
    44  forth in paragraph  (c)  of  subdivision  ten  of  section  twenty-eight
    45  hundred  seven-c  of  this  article  and further provided, however, that
    46  rates for facilities whose operating cost component reflects  base  year
    47  costs  subsequent  to  January  first, two thousand two shall have rates
    48  computed in accordance with this paragraph, utilizing allowable  operat-
    49  ing  costs  as reported in such subsequent base year period, and trended
    50  forward to  the  rate  year  in  accordance  with  applicable  inflation
    51  factors.

    52    (B)  For  the  purposes of this subparagraph qualifying facilities are
    53  those facilities  for  which  the  commissioner  determines  that  their
    54  reported two thousand two base year operating cost component, as defined
    55  in  accordance with the regulations of the department as set forth in 10
    56  NYCRR 86-2.10(a)(7); is less than the operating component  such  facili-

        S. 2606--D                         39                         A. 3006--D
 
     1  ties  received  in  the  two  thousand eight rate period, as adjusted by
     2  applicable trend factors.
     3    § 62.  Intentionally omitted.
     4    §  63. Paragraph (e-1) of subdivision 12 of section 2808 of the public
     5  health law, as amended by section 1 of part D of chapter 59 of the  laws
     6  of 2011, is amended to read as follows:

     7    (e-1) Notwithstanding any inconsistent provision of law or regulation,
     8  the  commissioner  shall  provide,  in  addition to payments established
     9  pursuant to this article prior to application  of  this  section,  addi-
    10  tional  payments  under the medical assistance program pursuant to title
    11  eleven of article five of the social services law for non-state operated
    12  public residential health care facilities, including public  residential
    13  health  care  facilities  located in the county of Nassau, the county of
    14  Westchester and the county of Erie,  but  excluding  public  residential
    15  health  care  facilities  operated by a town or city within a county, in
    16  aggregate annual amounts of up to one hundred fifty million  dollars  in
    17  additional payments for the state fiscal year beginning April first, two
    18  thousand  six  and  for the state fiscal year beginning April first, two

    19  thousand seven and for the state fiscal year beginning April first,  two
    20  thousand eight and of up to three hundred million dollars in such aggre-
    21  gate  annual  additional  payments  for  the state fiscal year beginning
    22  April first, two thousand nine, and for the state fiscal year  beginning
    23  April  first,  two  thousand ten and for the state fiscal year beginning
    24  April first, two thousand eleven, and for the state fiscal years  begin-
    25  ning  April  first,  two  thousand  twelve and April first, two thousand
    26  thirteen. The amount  allocated  to  each  eligible  public  residential
    27  health  care  facility  for  this period shall be computed in accordance
    28  with the provisions of paragraph  (f)  of  this  subdivision,  provided,
    29  however,  that  patient  days  shall  be  utilized  for such computation
    30  reflecting actual reported data for two thousand three and  each  repre-

    31  sentative  succeeding year as applicable, and provided further, however,
    32  that, in consultation with impacted providers, of  the  funds  allocated
    33  for  distribution  in  the  state fiscal year beginning April first, two
    34  thousand thirteen, up to thirty-two million dollars may be allocated  in
    35  accordance with paragraph (f-1) of this subdivision.
    36    §  64.  Subdivision  12  of  section  2808 of the public health law is
    37  amended by adding a new paragraph (f-1) to read as follows:
    38    (f-1) Funds allocated by the provisions of  paragraph  (e-1)  of  this
    39  subdivision  for distribution pursuant to this paragraph, shall be allo-
    40  cated proportionally to those public residential health care  facilities
    41  which  were  subject to retroactive reductions in payments made pursuant

    42  to this subdivision for state fiscal year periods beginning April first,
    43  two thousand six.
    44    § 65.  Intentionally omitted.
    45    § 66.  Intentionally omitted.
    46    § 67.  Intentionally omitted.
    47    § 68. Paragraph (a) of subdivision 2 of section 366-c  of  the  social
    48  services law, as added by chapter 558 of the laws of 1989, is amended to
    49  read as follows:
    50    (a)  For  purposes  of this section an "institutionalized spouse" is a
    51  person (i) who is in a medical institution or nursing facility [(i)  who
    52  is]  and expected to remain in such facility or institution for at least
    53  thirty consecutive days[,]; or (ii) who is receiving care, services  and
    54  supplies  pursuant  to  a  waiver  pursuant to subsection (c) of section

    55  nineteen hundred fifteen of  the  federal  social  security  act  or  is
    56  receiving  care,  services and supplies in a managed long-term care plan

        S. 2606--D                         40                         A. 3006--D
 
     1  pursuant to section eleven hundred fifteen of the social  security  act;
     2  and  [(ii)]  (iii)  who  is  married to a person who is not in a medical
     3  institution or nursing facility or  is  not  receiving  waiver  services
     4  [pursuant  to  a  waiver  pursuant to subsection (c) of section nineteen
     5  hundred fifteen of the federal social security act] described in subpar-
     6  agraph (ii) of this paragraph; provided, however, that  medical  assist-

     7  ance  shall be furnished pursuant to this paragraph only if, for so long
     8  as, and to the extent that federal financial participation is  available
     9  therefor.  The  commissioner  of health shall make any amendments to the
    10  state plan for medical assistance, or apply for any waiver  or  approval
    11  under  the  federal  social security act that are necessary to carry out
    12  the provisions of this paragraph.
    13    § 69. Paragraph (b) of subdivision 6 of section  3614  of  the  public
    14  health  law,  as added by chapter 645 of the laws of 2003, is amended to
    15  read as follows:
    16    (b)  For  purposes  of  this  subdivision,   real   property   capital
    17  construction  costs  shall  only  be  included  in  rates of payment for
    18  assisted living programs if: the facility  houses  exclusively  assisted

    19  living  program beds authorized pursuant to paragraph (j) of subdivision
    20  three of section four hundred sixty-one-l of the social services law  or
    21  (i)  the  facility is operated by a not-for-profit corporation; (ii) the
    22  facility commenced operation after nineteen hundred ninety-eight and  at
    23  least ninety-five percent of the certified approved beds are provided to
    24  residents  who are subject to the assisted living program; and (iii) the
    25  assisted living program is in a county with a population of no less than
    26  two hundred eighty thousand persons.  The methodology used to  calculate
    27  the rate for such capital construction costs shall be the same methodol-
    28  ogy  used  to  calculate  the  capital construction costs at residential
    29  health care facilities for such costs, provided  that  the  commissioner

    30  may  adopt  rules and regulations which establish a cap on real property
    31  capital construction costs for those facilities that  house  exclusively
    32  assisted  living  program  beds  authorized pursuant to paragraph (j) of
    33  subdivision three of section four  hundred  sixty-one-l  of  the  social
    34  services law.
    35    §  70.  Subdivision  3  of section 461-l of the social services law is
    36  amended by adding a new paragraph (j) to read as follows:
    37    (j) The commissioner of health is authorized to add up to  four  thou-
    38  sand  five  hundred  assisted living program beds to the gross number of
    39  assisted living program beds having been determined to be  available  as
    40  of  April  first, two thousand twelve.  Applicants eligible to submit an

    41  application under this paragraph shall be limited to adult homes  estab-
    42  lished  pursuant  to  section  four  hundred sixty-one-b of this article
    43  with, as of September first, two thousand twelve, a  certified  capacity
    44  of eighty beds or more in which twenty-five percent or more of the resi-
    45  dent  population  are  persons with serious mental illness as defined in
    46  regulations promulgated by the commissioner of health. The  commissioner
    47  of  health shall not be required to review on a comparative basis appli-
    48  cations submitted for assisted living program beds made available  under
    49  this paragraph.
    50    §  71.  Subdivision  14  of section 366 of the social services law, as
    51  added by section 74 of part H of chapter 59 of  the  laws  of  2011,  is

    52  amended to read as follows:
    53    14.  The  commissioner  of health may make any available amendments to
    54  the state plan for medical  assistance  submitted  pursuant  to  section
    55  three  hundred  sixty-three-a  of this title, or, if an amendment is not
    56  possible, develop and submit an application for any waiver  or  approval

        S. 2606--D                         41                         A. 3006--D
 
     1  under the federal social security act that may be necessary to disregard
     2  or exempt an amount of income, for the purpose of assisting with housing
     3  costs,  for  individuals receiving coverage of nursing facility services
     4  under this title, other than short-term rehabilitation services, and for
     5  individuals  in receipt of medical assistance while in an adult home, as

     6  defined in subdivision twenty-five of section two of this  chapter,  who
     7  [are]:  are (i) discharged [from the nursing facility] to the community;
     8  and (ii) if eligible, enrolled in a plan certified pursuant  to  section
     9  forty-four hundred three-f of the public health law; and (iii) [while so
    10  enrolled,  not]  do  not meet the criteria to be considered an "institu-
    11  tionalized spouse" for purposes of section three hundred sixty-six-c  of
    12  this title.
    13    §  72. Section 364-j of the social services law is amended by adding a
    14  new subdivision 27 to read as follows:
    15    27. (a) The centers for medicare and medicaid services has established
    16  an initiative to align incentives between  medicare  and  medicaid.  The

    17  goal  of  the  initiative  is  to  increase  access to seamless, quality
    18  programs that integrate services for the dually eligible beneficiary  as
    19  well as to achieve both state and federal health care savings by improv-
    20  ing health care delivery and encouraging high-quality efficient care. In
    21  furtherance of this goal, the legislature authorizes the commissioner of
    22  health to establish a fully integrated dual advantage (FIDA) program.
    23    (b)   The   FIDA   program   shall  provide  targeted  populations  of
    24  medicare/medicaid dually  eligible  persons  with  comprehensive  health
    25  services  that  include  the full range of medicare and medicaid covered
    26  services,  including  but  not  limited  to  primary  and  acute   care,

    27  prescription   drugs,  behavioral  health  services,  care  coordination
    28  services,  and  long-term  supports  and  services,  as  well  as  other
    29  services,  through managed care providers, as defined in subdivision one
    30  of this section, including  managed  long  term  care  plans,  certified
    31  pursuant to section forty-four hundred three-f of the public health law.
    32    (c)  Under  the FIDA program established pursuant to this subdivision,
    33  up to three managed long term care plans may be authorized to exclusive-
    34  ly enroll individuals with developmental disabilities, as such  term  is
    35  defined  in  section 1.03 of the mental hygiene law. The commissioner of
    36  health may waive any of the department's regulations as such commission-

    37  er, in consultation with the commissioner of the office for people  with
    38  developmental  disabilities,  deems necessary to allow such managed long
    39  term care plans to provide or arrange for service for  individuals  with
    40  developmental disabilities that are adequate and appropriate to meet the
    41  needs  of such individuals and that will ensure their health and safety.
    42  The commissioner of the office for people with  developmental  disabili-
    43  ties may waive any of the office for people with developmental disabili-
    44  ties' regulations as such commissioner, in consultation with the commis-
    45  sioner  of  health, deems necessary to allow such managed long term care
    46  plans to provide or arrange for services for individuals  with  develop-

    47  mental  disabilities that are adequate and appropriate to meet the needs
    48  of such individuals and that will ensure their health and safety.
    49    (d) The provisions of this subdivision  shall  not  apply  unless  all
    50  necessary  approvals under federal law and regulation have been obtained
    51  to receive federal financial participation in the costs of  health  care
    52  services provided pursuant to this subdivision.
    53    (e)  The  commissioner of health is authorized to submit amendments to
    54  the state plan for medical assistance and/or submit one or more applica-
    55  tions for waivers of the federal social security act as may be necessary
    56  to obtain the federal approvals necessary to implement this subdivision.


        S. 2606--D                         42                         A. 3006--D
 
     1    (f) Notwithstanding any inconsistent provisions of  this  section  and
     2  sections  one  hundred  twelve  and one hundred sixty-three of the state
     3  finance law, or section one hundred forty-two of the  economic  develop-
     4  ment  law,  or any other law to the contrary, the commissioner of health
     5  and,  in the case of FIDAs authorized exclusively to enroll persons with
     6  developmental disabilities, the commissioner of health and  the  commis-
     7  sioner  of  the  office  for people with developmental disabilities, may
     8  contract with FIDAs approved under this section  without  a  competitive
     9  bid  or  request  for  proposal  process, are authorized to enter into a

    10  contract or contracts under this section, provided, however, that:
    11    (i) the department of health shall post on its website, for  a  period
    12  of no less than thirty days:
    13    (A)  a description of the proposed services to be provided pursuant to
    14  the contract or contracts;
    15    (B) the criteria for selection of a contractor or contractors;
    16    (C) the period of time during which a prospective contractor may  seek
    17  selection,  which  shall be no less than thirty days after such informa-
    18  tion is first posted on the website; and
    19    (D) the manner  by  which  a  prospective  contractor  may  seek  such
    20  selection, which may include submission by electronic means;
    21    (ii)  all reasonable and responsive submissions that are received from

    22  prospective contractors in a timely fashion shall  be  reviewed  by  the
    23  commissioner of health or commissioners, as applicable; and
    24    (iii) the commissioner or, in the case of FIDAs authorized exclusively
    25  to  enroll  persons with developmental disabilities, the commissioner of
    26  health and the commissioner of the office for people with  developmental
    27  disabilities,  may  select such contractor or contractors that, in their
    28  discretion, have demonstrated the ability  to  effectively,  efficiently
    29  and  economically integrate health and long term care services, and meet
    30  the standards for a certificate of authority under the public health law
    31  for the provision of services applicable to the  type  of  managed  long

    32  term care plan that such contractor proposes to operate.
    33    (g)  Nothing  in this section shall be construed as requiring an indi-
    34  vidual with a developmental disability to  enroll  in  a  FIDA  that  is
    35  authorized to exclusively enroll individuals with developmental disabil-
    36  ities.
    37    (h)  Nothing  in  this  section  shall  make  enrollment in a medicare
    38  managed care plan a condition of an individual's  participation  in  the
    39  FIDA  program,  or  affect  the  individual's  entitlement to payment of
    40  applicable medicare managed care or fee-for-service coinsurance  deduct-
    41  ibles by the individual's FIDA plan.
    42    §  72-a. Legislative intent of the people first waiver act. The legis-
    43  lature finds that persons receiving services operated, certified,  fund-

    44  ed,  authorized  or approved by the office for people with developmental
    45  disabilities can benefit from care coordination and integrated care that
    46  incorporates both long-term habilitation supports and health  care.  The
    47  legislature also finds that services provided to individuals with devel-
    48  opmental  disabilities  should  be  designed  to achieve person-centered
    49  outcomes and to enable the person to live in the most-integrated setting
    50  appropriate to that person's needs, and to enable that person to  inter-
    51  act  with  nondisabled persons to the fullest extent possible in social,
    52  workplace and other community settings,  consistent  with  the  person's
    53  needs  and  wishes,  to  the  extent such wishes are known. As such, the
    54  legislature hereby enacts sections 72-b, 73, 74, 75, 76, 77, 78, 79,  80
    55  and 80-a of this act, herein referred to as the people first waiver act.

    56  This  program shall include the use of developmental disability individ-

        S. 2606--D                         43                         A. 3006--D
 
     1  ual support and care  coordination  organizations  pursuant  to  section
     2  4403-g  of  the  public  health law, health maintenance organizations as
     3  provided for in subdivision 8 of section 4403 of the public health  law,
     4  and  managed  long term care plans providing services under subdivisions
     5  12, 13 and 14 of section 4403-f of the public  health  law.  It  is  the
     6  intent  of  the  legislature  that,  to the greatest extent possible and
     7  consistent with a person's needs and known wishes, all services provided
     8  should be in the most-integrated setting appropriate for such individual
     9  persons receiving services through this act, and that  such  individuals

    10  should  be able to make informed choices, either individually or through
    11  an authorized decision maker, regarding the development of a person-cen-
    12  tered plan of care.
    13    § 72-b. The mental hygiene law is amended  by  adding  a  new  section
    14  13.40 to read as follows:
    15  § 13.40 People first waiver program.
    16    (a)  The  commissioner  and  the  commissioner of health shall jointly
    17  establish a people first waiver program for  purposes  of  developing  a
    18  care  coordination  model that integrates various long-term habilitation
    19  supports and/or health care.  The  people  first  waiver  program  shall
    20  include  the use of developmental disability individual support and care
    21  coordination organizations, herein referred to as  DISCOs,  pursuant  to

    22  section  forty-four  hundred  three-g  of  the public health law, health
    23  maintenance  organizations,  herein  referred  to  as  HMOs,   providing
    24  services  under subdivision eight of section forty-four hundred three of
    25  the public health law, and managed long term care plans, herein referred
    26  to as MLTCs, providing services under subdivisions twelve, thirteen  and
    27  fourteen of section forty-four hundred three-f of the public health law.
    28  Services  shall  be  provided as described in section forty-four hundred
    29  three-g of the public health law, subdivision eight  of  section  forty-
    30  four  hundred  three  of the public health law, and subdivisions twelve,
    31  thirteen and fourteen of  section  forty-four  hundred  three-f  of  the
    32  public health law.

    33    (b) Entities providing services pursuant to this section shall provide
    34  health  and  long  term  care services as the term is defined in section
    35  forty-four hundred three-g of the public health law.
    36    (c) No person with a developmental  disability  who  is  receiving  or
    37  applying  for  medical  assistance  and who is receiving, or eligible to
    38  receive, services operated, funded, certified, authorized or approved by
    39  the office, shall be required to enroll in a DISCO, HMO or MLTC in order
    40  to receive such services until program features and reimbursement  rates
    41  are  approved  by  the  commissioner and the commissioner of health, and
    42  until such commissioners determine that a  sufficient  number  of  plans

    43  that  are authorized to coordinate care for individuals pursuant to this
    44  section or that are authorized to  operate  and  to  exclusively  enroll
    45  persons  with developmental disabilities pursuant to subdivision twenty-
    46  seven of section three hundred sixty-four-j of the social  services  law
    47  are  operating in such person's county of residence to meet the needs of
    48  persons with developmental disabilities, and that such entities meet the
    49  standards of this section. No person shall be required to  enroll  in  a
    50  DISCO, HMO or MLTC in order to receive services operated, funded, certi-
    51  fied,  authorized or approved by the office until there are at least two
    52  entities operating under this section in such person's county  of  resi-

    53  dence,  unless  federal  approval  is secured to require enrollment when
    54  there are less than two such entities operating in such county.
    55    (d) DISCOs, HMOs and MLTCs operating under this section shall  ensure,
    56  to the greatest extent practicable, that their assessment, services, and

        S. 2606--D                         44                         A. 3006--D
 
     1  the  grievance  and  appeals processes are culturally and linguistically
     2  competent.
     3    (e)  1. The commissioner and the commissioner of health shall identify
     4  one or more  valid  and  reliable  quality  assurance  instruments  that
     5  include  assessments of individual and family satisfaction, provision of
     6  services, and personal outcomes. The instruments shall:

     7    (1) provide nationally validated,  benchmarked,  consistent,  reliable
     8  and  measurable  data for a comprehensive quality improvement and review
     9  process, and
    10    (2) include outcome-based measures such as health, safety, well-being,
    11  relationships, interactions with people who do not  have  a  disability,
    12  employment,  quality  of life, integration, choice, service and consumer
    13  satisfaction.
    14    2. Within available appropriations, the instruments identified in this
    15  subdivision may be expanded to  collect  additional  data  requested  by
    16  other  offices,  departments  or agencies of the state, local or federal
    17  government.
    18    3. The commissioner may contract with an independent agency or  organ-

    19  ization  for  the  development  of  the  quality  assurance  instruments
    20  described in this subdivision.
    21    4. The commissioner shall establish the methodology by which the qual-
    22  ity assurance instruments shall be administered.
    23    5. The commissioner, in consultation with stakeholders, shall annually
    24  review  the  data  collected  from  the  quality  assurance  instruments
    25  described in this subdivision and shall review recommendations regarding
    26  additional  or  different criteria for the quality assurance instruments
    27  in order to assess the performance of the state's developmental disabil-
    28  ities services system and improve services for consumers.
    29    (f) There shall be a joint advisory council chaired by the commission-

    30  er and the commissioner of health that shall be  charged  with  advising
    31  both  commissioners in regard to the oversight of DISCOs, HMOs providing
    32  services under subdivision eight of section forty-four hundred three  of
    33  the  public  health law, and MLTCs providing services under subdivisions
    34  twelve, thirteen and fourteen of section forty-four hundred  three-f  of
    35  the  public  health  law. The joint advisory council may be comprised of
    36  the members of existing advisory councils or  similar  entities  serving
    37  the  office,  provided  that  it  shall  be comprised of twelve members,
    38  including individuals with developmental  disabilities,  family  members
    39  of,  advocates  for,  and  providers of services to people with develop-

    40  mental disabilities. Three members of the joint advisory  council  shall
    41  also be members of the special advisory review panel on medicaid managed
    42  care established under section three hundred sixty-four-jj of the social
    43  services  law.  The joint advisory council shall review all managed care
    44  options provided to individuals with developmental disabilities, includ-
    45  ing: the adequacy of habilitation services;  the  record  of  compliance
    46  with  person-centered  planning,  person-centered services and community
    47  integration; the adequacy of rates paid to providers in accordance  with
    48  the  provisions  of  paragraph one of subdivision four of section forty-
    49  four hundred three of the public health law, paragraph a-two of subdivi-

    50  sion eight of section forty-four hundred three of the public health  law
    51  or  paragraph  a-two of subdivision twelve of section forty-four hundred
    52  three-f of the public health law; and quality of  life,  health,  safety
    53  and community integration of individuals with developmental disabilities
    54  enrolled  in  managed  care.    The commissioner and commissioner of the
    55  office for people with developmental  disabilities  or  their  designees
    56  shall attend all meetings of the joint advisory council. The joint advi-

        S. 2606--D                         45                         A. 3006--D
 
     1  sory  council  shall  report  its  findings,  recommendations,  and  any
     2  proposed amendments to pertinent sections of the law to the commissioner

     3  and the commissioner of health, the senate majority leader  and  speaker
     4  of the assembly. The joint advisory council shall have access to any and
     5  all  information that may be lawfully disclosed to it and that is neces-
     6  sary to perform its functions under this section.
     7    (g) Notwithstanding any inconsistent provision of sections one hundred
     8  twelve and one hundred sixty-three of the state finance law, or  section
     9  one  hundred forty-two of the economic development law, or any other law
    10  to the contrary, the commissioner and the  commissioner  of  health  are
    11  authorized  to  enter  into a contract or contracts under section forty-
    12  four hundred three-g of the public  health  law,  subdivision  eight  of

    13  section  forty-four hundred three of the public health law, and subdivi-
    14  sion twelve of section forty-four hundred three-f of the  public  health
    15  law, provided, however, that:
    16    1.  the office shall post on its website, for a period of no less than
    17  thirty days:
    18    (1) a description of the proposed services to be provided pursuant  to
    19  the contract or contracts;
    20    (2) the criteria for selection of a contractor or contractors;
    21    (3)  the period of time during which a prospective contractor may seek
    22  selection, which shall be no less than thirty days after  such  informa-
    23  tion is first posted on the website; and
    24    (4)  the  manner  by  which  a  prospective  contractor  may seek such

    25  selection, which may include submission by electronic means;
    26    2. all reasonable and responsive submissions that  are  received  from
    27  prospective  contractors  in  a  timely fashion shall be reviewed by the
    28  commissioners; and
    29    3. the commissioner and the commissioner of health may jointly  select
    30  such  contractor  or  contractors that, in their discretion, have demon-
    31  strated the ability to effectively, efficiently and  economically  inte-
    32  grate  health  and  long term care services as defined in section forty-
    33  four hundred three-g of the public health law, and  meet  the  standards
    34  for  a  certificate  of  authority  in  the  public  health  law for the
    35  provision  of  services  operated,  funded,  certified,  authorized   or

    36  approved  by  the  office for people with developmental disabilities and
    37  applicable to the  type  of  managed  care  plan  that  such  contractor
    38  proposes to operate.
    39    § 73.  The public health law is amended by adding a new section 4403-g
    40  to read as follows:
    41    § 4403-g. Developmental disability individual support and care coordi-
    42  nation organizations. 1. Definitions. As used in this section:
    43    (a) "Developmental disability individual support and care coordination
    44  organization" or "DISCO" means an entity that has received a certificate
    45  of authority pursuant to this section to provide, or arrange for, health
    46  and  long  term care services, as determined by the commissioner and the

    47  commissioner of the office for people with  developmental  disabilities,
    48  on  a  capitated basis in accordance with this section, for a population
    49  of persons with developmental disabilities, as such term is  defined  in
    50  section  1.03  of  the  mental  hygiene  law,  which the organization is
    51  authorized to enroll.
    52    (b) "Eligible applicant" means an entity controlled  by  one  or  more
    53  non-profit organizations which have a history of providing or coordinat-
    54  ing  health  and  long  term care services to persons with developmental
    55  disabilities.

        S. 2606--D                         46                         A. 3006--D
 
     1    (c) "Habilitation  services"  means  services  available  through  the

     2  state's home and community based services waiver for persons with devel-
     3  opmental  disabilities, state plan for medical assistance, and any other
     4  authorized federal funding for such services designed to assist  persons
     5  in acquiring, retaining, and improving the self-help, socialization, and
     6  adaptive  skills  necessary to reside successfully in home and community
     7  based settings.
     8    (d) "Health and long  term  care  services"  means  services,  whether
     9  provided  by state-operated programs or not-for-profit entities, includ-
    10  ing, but not limited to, habilitation services, home and community-based
    11  and institution-based long term care services, and  ancillary  services,
    12  that  shall  include  medical supplies and nutritional supplements, that

    13  are necessary to meet the needs of persons whom the plan  is  authorized
    14  to  enroll,  and may include primary care and acute care if the DISCO is
    15  authorized to provide  or  arrange  for  such  services.    Each  person
    16  enrolled  in  a  DISCO  shall receive health and long term care services
    17  designed to achieve person-centered outcomes, to enable that  person  to
    18  live  in the most integrated setting appropriate to that person's needs,
    19  and to enable that person to interact with nondisabled  persons  to  the
    20  fullest  extent  possible  in  social,  workplace  and  other  community
    21  settings, provided that all  such  services  are  consistent  with  such
    22  person's  wishes to the extent that such wishes are known and in accord-

    23  ance with such person's needs.
    24    2. Approval authority. An applicant shall be issued a  certificate  of
    25  authority  as  a DISCO for purposes of participating in the people first
    26  waiver program pursuant to section 13.40 of the mental hygiene law  upon
    27  a  determination  by the commissioner and the commissioner of the office
    28  for people with developmental disabilities that the  applicant  complies
    29  with the operating requirements for a DISCO under this section.
    30    3.  Application  for  certificate of authority; form. The commissioner
    31  and the commissioner of the office for people with  developmental  disa-
    32  bilities  shall  jointly  develop application forms for a certificate of
    33  authority to operate a DISCO. An  eligible  applicant  shall  submit  an

    34  application for a certificate of authority to operate a DISCO upon forms
    35  prescribed  by  such commissioners. Such eligible applicant shall submit
    36  information and documentation to the commissioner which  shall  include,
    37  but not be limited to:
    38    (a)  A  description  of  the service area proposed to be served by the
    39  DISCO with projections of enrollment that  will  result  in  a  fiscally
    40  sound plan;
    41    (b) A description of the services to be covered by such DISCO;
    42    (c)  A  description  of  the proposed marketing plan and how marketing
    43  materials will be presented to persons with  developmental  disabilities
    44  or their authorized decision makers for the purposes of enabling them to
    45  make an informed choice;

    46    (d) The names of the providers proposed to be in the DISCO's network;
    47    (e)  Evidence  of  the  character  and  competence  of the applicant's
    48  proposed operators, and of the incorporators, directors, stockholders or
    49  members of the applicant;
    50    (f) Adequate documentation of the appropriate licenses, certifications
    51  or approvals to provide care as planned, including affiliate  agreements
    52  or proposed contracts with such providers as may be necessary to provide
    53  the  full  complement  of  services  required  to be provided under this
    54  section;
    55    (g) A description of the proposed quality-assurance mechanisms, griev-
    56  ance procedures, mechanisms to protect the rights of enrollees and  care


        S. 2606--D                         47                         A. 3006--D
 
     1  coordination services to ensure continuity, quality, appropriateness and
     2  coordination of care;
     3    (h)  A  description of the proposed quality assessment and performance
     4  improvement program that includes performance and outcome based  quality
     5  standards   for  enrollee  health  status  and  satisfaction,  and  data
     6  collection and reporting for standard performance measures;
     7    (i) A description of the management systems  and  systems  to  process
     8  payment for covered services;
     9    (j)  A  description of how achievement of person-centered outcomes, as
    10  defined by the commissioner of the office for people with  developmental

    11  disabilities,  shall be assessed, as well as a description of how health
    12  and long term care services shall be used to meet such outcomes;
    13    (k) A description of the mechanism to maximize  reimbursement  of  and
    14  coordinate  services  reimbursed  pursuant to title XVIII of the federal
    15  social security act and all other applicable benefits, with such benefit
    16  coordination including, but not limited to, measures  to  support  sound
    17  clinical  decisions, reduce administrative complexity, coordinate access
    18  to services, maximize benefits available  pursuant  to  such  title  and
    19  ensure that necessary care is provided;
    20    (l)  A  description  of  the  systems for securing and integrating any

    21  potential sources of funding for services provided  by  or  through  the
    22  organization,  including,  but  not  limited to, funding available under
    23  titles XVI, XVIII, XIX and XX of the federal social security act and all
    24  other available sources of funding;
    25    (m) A description of the proposed contractual arrangements for provid-
    26  ers of health and long term care services in the benefit package; and
    27    (n) Information related to the financial condition of the applicant.
    28    4. Certificate of  authority  approval.  The  commissioner  shall  not
    29  approve  an application for a certificate of authority unless the appli-
    30  cant demonstrates to  the  satisfaction  of  the  commissioner  and  the

    31  commissioner of the office for people with developmental disabilities:
    32    (a)  That  it  will  have  in place acceptable quality assurance mech-
    33  anisms, grievance procedures and mechanisms to  protect  the  rights  of
    34  enrollees  and care coordination services to ensure continuity, quality,
    35  appropriateness and coordination of care;
    36    (b) That it will have in place a mechanism or  means  to  assure  that
    37  persons with developmental disabilities can make informed choices either
    38  individually  or  through  an  authorized  decision  maker regarding the
    39  development of a person-centered plan, as defined by the commissioner of
    40  the office for people with developmental disabilities;
    41    (c) That  it  has  developed  a  quality  assessment  and  performance

    42  improvement  program that includes performance and outcome based quality
    43  standards for enrollee health status and satisfaction,  which  shall  be
    44  reviewed  by  the  commissioner  and  the commissioner of the office for
    45  people with developmental disabilities. The program shall  include  data
    46  collection  and  reporting for standard performance measures as required
    47  by the commissioner and the commissioner of the office for  people  with
    48  developmental disabilities;
    49    (d)  That  an  otherwise  eligible enrollee shall not be involuntarily
    50  disenrolled without the prior approval of the commissioner of the office
    51  for people with developmental disabilities;
    52    (e) That the applicant shall not use deceptive or  coercive  marketing

    53  methods to encourage participants to enroll and that the applicant shall
    54  not  distribute  marketing  materials to potential enrollees before such
    55  materials have been approved by the commissioner and the commissioner of
    56  the office for people with developmental disabilities;

        S. 2606--D                         48                         A. 3006--D
 
     1    (f) Satisfactory evidence of  the  character  and  competence  of  the
     2  applicant's  proposed  operators, incorporators, directors, stockholders
     3  and members;
     4    (g)  Reasonable assurance that the applicant will provide high quality
     5  services to an enrolled population,  that  the  applicant's  network  of
     6  providers  is  adequate and that such providers have demonstrated suffi-

     7  cient competency to deliver high quality services to the enrolled  popu-
     8  lation  and that policies and procedures will be in place to address the
     9  cultural and linguistic needs of the enrolled population;
    10    (h) Sufficient management systems capacity to meet the requirements of
    11  this section and the ability to efficiently process payment for  covered
    12  services;
    13    (i)  Readiness and capability to maximize reimbursement of and coordi-
    14  nate services reimbursed pursuant to title XVIII of the  federal  social
    15  security  act and all other applicable benefits, with such benefit coor-
    16  dination including, but not limited to, measures to support sound  clin-
    17  ical  decisions,  reduce administrative complexity, coordinate access to

    18  services, maximize benefits available pursuant to such title and  ensure
    19  that necessary care is provided;
    20    (j) Readiness and capability to arrange and manage covered services;
    21    (k) Willingness and capability of taking, or cooperating in, all steps
    22  necessary  to  secure and integrate any potential sources of funding for
    23  services provided by or through the DISCO, including,  but  not  limited
    24  to, funding available under titles XVI, XVIII, XIX and XX of the federal
    25  social security act and all other available sources of funding;
    26    (l) That the contractual arrangements for providers of health and long
    27  term  care  services in the benefit package are sufficient to ensure the
    28  availability and accessibility of such services to the proposed enrolled

    29  population consistent with guidelines established  by  the  commissioner
    30  and  the  commissioner of the office for people with developmental disa-
    31  bilities. With respect to a person  receiving  non-residential  services
    32  operated,  certified,  funded,  authorized or approved by the office for
    33  people with developmental disabilities prior to enrollment in the DISCO,
    34  such guidelines shall require the DISCO to  contract  with  the  current
    35  provider  of  non-residential  services  at the rates established by the
    36  office for ninety days, in order to  ensure  continuity  of  care.  With
    37  respect  to a person living in a residential facility operated or certi-
    38  fied by the office for people with developmental disabilities  prior  to

    39  enrollment  in  the  DISCO,  such  guidelines shall require the DISCO to
    40  contract with the provider of residential services for that residence at
    41  the rates established by the office for so long as such individual lives
    42  in that residence pursuant to an approved plan of care;
    43    (m) That  the  applicant  is  financially  responsible  and  shall  be
    44  expected to meet its obligations to its enrolled members; and
    45    (n)  That  the  applicant  shall  assess  person-centered  outcomes as
    46  defined by the commissioner of the office for people with  developmental
    47  disabilities,  and  has  satisfactory mechanisms by which it will assess
    48  how health and long term  care  services  will  be  used  to  meet  such
    49  outcomes.

    50    5.  Enrollment.  (a)  Only persons with developmental disabilities, as
    51  determined by the office for  people  with  developmental  disabilities,
    52  shall be eligible to enroll in DISCOs.
    53    (b)  The  office  for  people  with  developmental disabilities or its
    54  designee shall enroll an eligible person in the DISCO chosen by  him  or
    55  her,  his  or  her guardian or other legal representative, provided that
    56  such DISCO is authorized to enroll such person.

        S. 2606--D                         49                         A. 3006--D
 
     1    (c) No person with a developmental  disability  who  is  receiving  or
     2  applying  for  medical  assistance  and who is receiving, or eligible to

     3  receive, services funded,  certified,  authorized  or  approved  by  the
     4  office  for people with developmental disabilities, shall be required to
     5  enroll  in  a  DISCO  in  order  to  receive such services until program
     6  features and reimbursement rates are approved by  the  commissioner  and
     7  the  commissioner  of the office for people with developmental disabili-
     8  ties, and until such commissioners determine that there are a sufficient
     9  number of plans authorized to coordinate care for persons with  develop-
    10  mental  disabilities pursuant to this article operating in such person's
    11  county of residence to meet the  needs  of  persons  with  developmental
    12  disabilities,  and  that such DISCOs meet the standards of this section.

    13  No person shall be required to enroll in a DISCO  in  order  to  receive
    14  services  operated,  funded,  certified,  authorized  or approved by the
    15  office for people with developmental disabilities  until  there  are  at
    16  least  two plans authorized to coordinate care for persons with develop-
    17  mental disabilities pursuant to this article in such person's county  of
    18  residence, unless federal approval is secured to require enrollment when
    19  there are less than two such entities operating in such county.
    20    (d)  Persons  required  to  enroll  in a DISCO shall have no less than
    21  sixty days to select a DISCO, and such persons and  their  guardians  or
    22  other  legal  representatives shall be provided with information to make

    23  an informed choice. Where a person, guardian or  other  legal  represen-
    24  tative  has  not  selected  a  DISCO, the commissioner of the office for
    25  people with developmental disabilities or its designee shall enroll such
    26  person in a DISCO chosen by such commissioner, taking into account qual-
    27  ity, capacity and geographic accessibility. The office for  people  with
    28  developmental disabilities or its designee shall automatically re-enroll
    29  a  person with the same DISCO if there is a loss of medicaid eligibility
    30  of two months or less.
    31    (e) Enrolled persons may change their enrollment at any  time  without
    32  cause, provided, however, that a person required to enroll in a DISCO in
    33  order  to  receive  services funded, licensed, authorized or approved by

    34  the office for people with developmental disabilities may only disenroll
    35  from a DISCO if he or she  enrolls in another DISCO authorized to enroll
    36  him or her. Such disenrollment shall be  effective  no  later  than  the
    37  first day of the second month following the request.
    38    (f)  A  DISCO may request the involuntary disenrollment of an enrolled
    39  person in writing to the office for people with developmental  disabili-
    40  ties.  Such  disenrollment  shall  not be effective until the request is
    41  reviewed and approved by such office. Notice shall be  provided  to  the
    42  enrollee  and  the  enrollee  may  request a fair hearing regarding such
    43  disenrollment. The department and the office for  people  with  develop-

    44  mental  disabilities  shall  adopt  rules and regulations governing this
    45  process.
    46    6. Assessments. The office for people with developmental disabilities,
    47  or its designee, shall complete a comprehensive  assessment  that  shall
    48  include,  but  not  be limited to, an evaluation of the medical, social,
    49  habilitative and environmental needs of each prospective enrollee  in  a
    50  DISCO  as  such needs relate to each individual's health, safety, living
    51  environment and wishes, to the extent that such wishes are  known.  This
    52  assessment  shall  also  serve  as  the  basis  for  the development and
    53  provision of an appropriate plan of care for the enrollee. Such plan  of
    54  care shall be focused on the achievement of person-centered outcomes and

    55  shall  be consistent with and help inform any other person-centered plan
    56  required for the enrollee by the commissioner of the office  for  people

        S. 2606--D                         50                         A. 3006--D
 
     1  with  developmental  disabilities.  The assessment shall be completed by
     2  the office for people with developmental disabilities or in consultation
     3  with the prospective enrollee's health care practitioner  as  necessary.
     4  The  commissioner  of the office for people with developmental disabili-
     5  ties shall prescribe the forms on which the assessment  shall  be  made.
     6  The  office for people with developmental disabilities may designate the
     7  DISCO to perform reassessments, but shall not  designate  the  DISCO  to

     8  perform the initial assessment of a prospective enrollee.
     9    7.  Program oversight and administration. (a) The commissioner and the
    10  commissioner of the office for people  with  developmental  disabilities
    11  shall  jointly  promulgate  regulations  to  implement  this section, to
    12  provide for oversight of DISCOs,  including  on  site  reviews,  and  to
    13  ensure  the  quality,  appropriateness  and  cost-effectiveness  of  the
    14  services provided by DISCOs.
    15    (b) The commissioner and the commissioner of  the  office  for  people
    16  with developmental disabilities may waive rules and regulations of their
    17  respective  department  or  office,  including but not limited to, those
    18  pertaining to duplicative requirements concerning record keeping, boards

    19  of directors, staffing and reporting, when such waiver shall promote the
    20  efficient delivery of appropriate, quality, cost-effective services  and
    21  when the health, safety and general welfare of DISCO enrollees shall not
    22  be  impaired  as a result of such waiver. The commissioners shall report
    23  annually to the legislature and to the  joint  advisory  council  estab-
    24  lished  pursuant to section 13.40 of the mental hygiene law on all rules
    25  and regulations waived pursuant to this paragraph. In order  to  achieve
    26  DISCO system efficiencies and coordination and to promote the objectives
    27  of  high  quality, integrated and cost effective care, the commissioners
    28  shall establish a single coordinated surveillance process, allow  for  a

    29  comprehensive  quality  improvement and review process to meet component
    30  quality requirements, and require a uniform cost report. The commission-
    31  ers shall require DISCOs to utilize quality improvement measures,  based
    32  on  the  achievement  of  personal  outcomes and quality of life, health
    33  outcomes data, and assessments of individual  and  family  satisfaction,
    34  for  internal quality assessment processes and may utilize such measures
    35  as part of the single coordinated surveillance process.
    36    (c) Notwithstanding any inconsistent provision of the social  services
    37  law  to  the contrary, the commissioner in consultation with the commis-
    38  sioner of the office for people with developmental  disabilities  shall,

    39  pursuant  to  regulation,  determine whether and the extent to which the
    40  applicable provisions of the social services law or regulations relating
    41  to approvals and authorizations  of,  and  utilization  limitations  on,
    42  health  and  long term care services reimbursed pursuant to title XIX of
    43  the federal social security act are inconsistent  with  the  flexibility
    44  necessary  for  the  efficient  administration of DISCOs, and such regu-
    45  lations shall provide that such provisions shall not  be  applicable  to
    46  enrollees  of  DISCOs,  provided that such determinations are consistent
    47  with applicable federal law and regulation.
    48    (d) The commissioner and the commissioner of  the  office  for  people

    49  with  developmental  disabilities shall ensure, through periodic reviews
    50  of DISCOs, that organization services are promptly available  to  enrol-
    51  lees  when appropriate. Such periodic reviews shall be made according to
    52  standards as determined by the commissioners in regulations.
    53    (e) The commissioner and the commissioner of  the  office  for  people
    54  with developmental disabilities shall have the authority to conduct both
    55  on  site  and  off site reviews of DISCOs. Such reviews may include, but
    56  not be limited to, the  following  components:  governance;  fiscal  and

        S. 2606--D                         51                         A. 3006--D
 
     1  financial   reporting;   recordkeeping;  internal  controls;  marketing;

     2  network contracting and adequacy; program integrity assurances; utiliza-
     3  tion control and review systems; grievance and appeals systems;  quality
     4  assessment and assurance systems; care management; enrollment and disen-
     5  rollment;  management  information  systems,  and  other operational and
     6  management components.
     7    8. Solvency. (a) The commissioner, in consultation  with  the  commis-
     8  sioner  of  the office for people with developmental disabilities, shall
     9  be responsible for evaluating,  approving  and  regulating  all  matters
    10  relating  to  fiscal  solvency, including reserves, surplus and provider
    11  contracts. The commissioner shall promulgate  regulations  to  implement
    12  this  section.  The commissioner, in the administration of this subdivi-

    13  sion:
    14    (i) shall be guided by the standards that govern the  fiscal  solvency
    15  of  a  health  maintenance  organization,  provided,  however,  that the
    16  commissioner shall recognize the specific  delivery  components,  opera-
    17  tional capacity and financial capability of the eligible applicant for a
    18  certificate of authority;
    19    (ii)  shall  not  apply financial solvency standards that exceed those
    20  required for a health maintenance organization; and
    21    (iii) shall establish reasonable capitalization and contingent reserve
    22  requirements.
    23    (b) Standards  established  pursuant  to  this  subdivision  shall  be
    24  adequate to protect the interests of enrollees in the DISCO. The commis-

    25  sioner  shall  be  satisfied  that the eligible applicant is financially
    26  sound, and has made adequate provisions to pay for quality services that
    27  are cost effective and  appropriate  to  needs  and  the  protection  of
    28  health, safety, welfare and satisfaction of those served.
    29    9.  Role  of  the superintendent of financial services. (a) The super-
    30  intendent of financial services shall determine and approve premiums  in
    31  accordance  with  the insurance law whenever any population of enrollees
    32  not eligible under title XIX of the federal social security act is to be
    33  covered. The determination and approval of the superintendent of  finan-
    34  cial  services  shall  relate  to premiums charged to such enrollees not

    35  eligible under title XIX of the federal social security act.
    36    (b) The  superintendent  of  financial  services  shall  evaluate  and
    37  approve  any  enrollee contracts whenever such enrollee contracts are to
    38  cover any population of enrollees not eligible under title  XIX  of  the
    39  federal social security act.
    40    10. Payment rates for DISCO enrollees eligible for medical assistance.
    41  The  commissioner shall establish payment rates for services provided to
    42  enrollees eligible under title XIX of the federal social  security  act.
    43  Such  payment  rates shall be subject to approval by the director of the
    44  division of the budget. Payment rates shall  be  actuarially  sound  for
    45  covered  services,  including  but not limited to habilitation services,

    46  and, when there is sufficient reliable data to permit, shall be risk-ad-
    47  justed to  take  into  account  the  characteristics  of  enrollees,  or
    48  proposed enrollees, which may include: frailty, disability level, health
    49  and  functional  status, age, gender, the nature of services provided to
    50  such enrollees, and other factors as determined by the commissioner  and
    51  the  commissioner  of the office for people with developmental disabili-
    52  ties. The risk adjusted premiums may also be combined with disincentives
    53  or requirements designed to mitigate any  incentives  to  obtain  higher
    54  payment categories.
    55    11.  Continuation  of  certificate  of  authority.  Continuation  of a
    56  certificate of authority issued under this section shall  be  contingent

        S. 2606--D                         52                         A. 3006--D
 
     1  upon  compliance by the DISCO with applicable provisions of this section
     2  and rules and regulations promulgated thereunder; the continuing  fiscal
     3  solvency  of  the DISCO; and federal financial participation in payments
     4  on  behalf of enrollees who are eligible to receive services under title
     5  XIX of the federal social security act.
     6    12. Protection of enrollees. The  commissioner  may,  in  his  or  her
     7  discretion  and  with  the concurrence of the commissioner of the office
     8  for people with developmental  disabilities,  for  the  purpose  of  the
     9  protection  of  enrollees, impose measures including, but not limited to

    10  bans on further enrollments until any identified problems  are  resolved
    11  to  the  satisfaction  of the commissioner, or fines upon a finding that
    12  the DISCO has failed to comply with the  provisions  of  any  applicable
    13  statute, rule or regulation.
    14    13.  Information sharing. The commissioner and the commissioner of the
    15  office for people with developmental disabilities  shall,  as  necessary
    16  and  consistent  with  federal  regulations  promulgated pursuant to the
    17  Health Insurance Portability and Accountability  Act,  share  with  such
    18  DISCO the following data if it is available:
    19    (a)  information  concerning  utilization of services and providers by
    20  each of its enrollees prior to and during enrollment.

    21    (b) Aggregate data concerning utilization and costs for enrollees  and
    22  for  comparable  cohorts  served  through  the  Medicaid fee-for-service
    23  program.
    24    14. Applicability of other  laws.  DISCOs  shall  be  subject  to  the
    25  provisions  of  the  insurance  law and regulations applicable to health
    26  maintenance organizations,  this  article  and  regulations  promulgated
    27  thereunder. To the extent that the provisions of this section are incon-
    28  sistent  with  the  provisions  of this chapter or the provisions of the
    29  insurance law, the provisions of this section shall prevail.
    30    15. Effectiveness. The provisions of this section shall only be effec-
    31  tive if, for so long as,  and  to  the  extent  that  federal  financial

    32  participation  is  available  for  the costs of services provided by the
    33  DISCOs to enrollees who are recipients of medical assistance pursuant to
    34  title eleven of article five of the social services law. The commission-
    35  er shall make any necessary amendments to the  state  plan  for  medical
    36  assistance  submitted pursuant to section three hundred sixty-three-a of
    37  the social services law, and/or submit  one  or  more  applications  for
    38  waivers  of  the  federal  social  security act, in order to ensure such
    39  federal financial participation.
    40    § 74. Section 4403 of the public health law is amended by adding a new
    41  subdivision 8 to read as follows:
    42    8. Notwithstanding any provision of law  to  the  contrary,  a  health

    43  maintenance  organization  may  expand its comprehensive health services
    44  plan to include services  operated,  certified,  funded,  authorized  or
    45  approved  by  the  office  for  people  with developmental disabilities,
    46  including habilitation services as defined in paragraph (c) of  subdivi-
    47  sion  one of section forty-four hundred three-g of this article, and may
    48  offer such expanded plan to a population of persons  with  developmental
    49  disabilities, as such term is defined in the mental hygiene law, subject
    50  to the following:
    51    (a)  Such  organization must have the ability to provide or coordinate
    52  services for persons with developmental disabilities, as demonstrated by
    53  criteria to be determined by the commissioner and  the  commissioner  of

    54  the  office  for  people  with developmental disabilities. Such criteria
    55  shall include, but not be limited to, adequate experience  providing  or
    56  coordinating services for persons with developmental disabilities.

        S. 2606--D                         53                         A. 3006--D
 
     1    (a-1)  If  the  commissioner  and  the  commissioner of the office for
     2  people with developmental disabilities determine that such  organization
     3  lacks  the experience required in paragraph (a) of this subdivision, the
     4  organization shall have an affiliation arrangement  with  an  entity  or
     5  entities with experience serving persons with developmental disabilities
     6  such  that the affiliated entity will coordinate and plan services oper-

     7  ated, certified, funded, authorized or approved by the office for people
     8  with developmental disabilities or will oversee and approve such coordi-
     9  nation and planning;
    10    (a-2)  Each  enrollee  shall  receive  services  designed  to  achieve
    11  person-centered  outcomes,  to  enable  that  person to live in the most
    12  integrated setting appropriate to that person's  needs,  and  to  enable
    13  that  person  to interact with nondisabled persons to the fullest extent
    14  possible in social, workplace and  other  community  settings,  provided
    15  that  all  such services are consistent with such person's wishes to the
    16  extent that such wishes are  known  and  the  individual's  needs.  With
    17  respect  to  an  individual receiving non-residential services operated,

    18  certified, funded, authorized or approved by the office for people  with
    19  developmental disabilities prior to enrollment in the organization, such
    20  guidelines  shall  require the organization to contract with the current
    21  provider of such non-residential services at the  rates  established  by
    22  the  office for ninety days, in order to ensure continuity of care. With
    23  respect to an individual living in a residential  facility  operated  or
    24  certified by the office for people with developmental disabilities prior
    25  to  enrollment in the organization, the organization shall contract with
    26  the provider of residential services for that  residence  at  the  rates
    27  established by the office for people with developmental disabilities for

    28  so  long  as such person lives in that residence pursuant to an approved
    29  plan of care;
    30    (b) The provision by such organization of  services  operated,  certi-
    31  fied,  funded,  authorized  or  approved  by  the office for people with
    32  developmental disabilities shall be subject to the joint  oversight  and
    33  review  of  both  the department and the office for people with develop-
    34  mental disabilities. The department and such office shall  require  such
    35  organization  to  provide  comprehensive  care planning, assess quality,
    36  meet quality assurance requirements and ensure the enrollee is  involved
    37  in care planning.
    38    (c)  Such organization shall not provide or arrange for services oper-

    39  ated, certified, funded, authorized or approved by the office for people
    40  with developmental disabilities until the commissioner and  the  commis-
    41  sioner  of the office for people with developmental disabilities approve
    42  program features and rates that include  such  services,  and  determine
    43  that  such organization meets the requirements of this paragraph and any
    44  other requirements set forth by  the  commissioner  of  the  office  for
    45  people with developmental disabilities;
    46    (d)  An  otherwise  eligible  enrollee  receiving services through the
    47  organization  that  are  operated,  certified,  funded,  authorized   or
    48  approved  by the office for people with developmental disabilities shall

    49  not be involuntarily disenrolled  from  such  organization  without  the
    50  prior  approval of the commissioner of the office for people with devel-
    51  opmental disabilities. Notice shall be provided to the enrollee and  the
    52  enrollee may request a fair hearing regarding such disenrollment;
    53    (e) The office for people with developmental disabilities shall deter-
    54  mine  the eligibility of individuals receiving services operated, certi-
    55  fied, funded, authorized or approved by such office to enroll in such  a

        S. 2606--D                         54                         A. 3006--D
 
     1  plan and shall enroll individuals it determines eligible in an organiza-
     2  tion chosen by such individual, guardian or other legal representative;

     3    (f)  The  office  for  people  with developmental disabilities, or its
     4  designee, shall complete a comprehensive assessment for  enrollees  that
     5  receive  services operated, certified, funded, authorized or approved by
     6  such office. This assessment shall include, but not be  limited  to,  an
     7  evaluation  of the medical, social, habilitative and environmental needs
     8  of each prospective enrollee as such needs  relate  to  such  enrollee's
     9  health, safety, living environment and wishes, to the extent such wishes
    10  are  known. This assessment shall also serve as the basis for the devel-
    11  opment and provision of an appropriate plan of care  for  the  enrollee.
    12  Such plan of care shall be focused on the achievement of person-centered

    13  outcomes  and shall be consistent with and help inform any other person-
    14  centered plan required for the  enrollee  by  the  commissioner  of  the
    15  office  for people with developmental disabilities.  The initial assess-
    16  ment shall be completed by such office or its designee  other  than  the
    17  organization  and  shall be completed, in consultation with the prospec-
    18  tive enrollee's health care practitioner as  necessary.    Reassessments
    19  shall  be  completed  by  the  office  or its designee, which may be the
    20  organization. The commissioner of the office for  people  with  develop-
    21  mental  disabilities  shall  prescribe the forms on which the assessment
    22  shall be made.
    23    (f-1) Such organization shall provide the department  and  the  office

    24  for  people  with  developmental  disabilities with a description of the
    25  proposed marketing plan and how marketing materials will be presented to
    26  persons with developmental disabilities  or  their  authorized  decision
    27  makers for the purposes of enabling them to make an informed choice.
    28    (g)  No  person  with  a developmental disability shall be required to
    29  enroll in a comprehensive health services plan as a condition of receiv-
    30  ing medical assistance and services operated, certified, funded, author-
    31  ized or approved by the office for people with  developmental  disabili-
    32  ties  until program features and reimbursement rates are approved by the
    33  commissioner and the commissioner of the office for people with develop-

    34  mental disabilities and until such commissioners  determine  that  there
    35  are  a  sufficient  number  of  plans  authorized to coordinate care for
    36  persons with developmental disabilities pursuant to this article operat-
    37  ing in the person's county of residence to meet  the  needs  of  persons
    38  with  developmental disabilities, and that such plans meet the standards
    39  of this section.
    40    (h) Organizations  providing  services  operated,  certified,  funded,
    41  authorized or approved by the office for people with developmental disa-
    42  bilities shall be subject to all requirements applicable to DISCOs oper-
    43  ating  under  section  forty-four  hundred  three-g of this article with
    44  respect to quality assurance, grievances and appeals,  informed  choice,

    45  participating  in  development  of  plans  of care and requirements with
    46  respect to marketing, to the  extent  that  such  requirements  are  not
    47  inconsistent with this section.
    48    (i) The provisions of this subdivision shall only be effective if, for
    49  so  long  as,  and to the extent that federal financial participation is
    50  available for the costs of services provided hereunder to recipients  of
    51  medical  assistance  pursuant  to  title  eleven  of article five of the
    52  social services law. The commissioner shall make  any  necessary  amend-
    53  ments  to  the  state  plan for medical assistance submitted pursuant to
    54  section three hundred sixty-three-a of the social services  law,  and/or

    55  submit  one or more applications for waivers of the federal social secu-
    56  rity act, as may be necessary to ensure such federal  financial  partic-

        S. 2606--D                         55                         A. 3006--D
 
     1  ipation.  To  the  extent  that  the  provisions of this subdivision are
     2  inconsistent  with  other  provisions  of  this  article  or  with   the
     3  provisions  of section three hundred sixty-four-j of the social services
     4  law, the provisions of this subdivision shall prevail.
     5    §  75.  The  opening  paragraph  of  paragraph (h) of subdivision 7 of
     6  section 4403-f of the public health law, as amended by section  41-b  of
     7  part H of chapter 59 of the laws of 2011, is amended to read as follows:

     8    The commissioner and, in the case of a plan arranging for or providing
     9  services  operated,  certified,  funded,  authorized  or approved by the
    10  office for people with developmental disabilities, the  commissioner  of
    11  the  office  for  people  with  developmental  disabilities, shall, upon
    12  request by a managed long term care plan or operating demonstration, and
    13  consistent with federal regulations promulgated pursuant to  the  Health
    14  Insurance  Portability  and  Accountability Act, share with such plan or
    15  demonstration the following data if it is available:
    16    § 76. Section 4403-f of the public health law  is  amended  by  adding
    17  three new subdivisions 12, 13 and 14 to read as follows:
    18    12. Notwithstanding any provision to the contrary, a managed long term

    19  care plan may expand the services it provides or arranges for to include
    20  services  operated,  certified,  funded,  authorized  or approved by the
    21  office for people with developmental disabilities for  a  population  of
    22  persons  with developmental disabilities, as such term is defined in the
    23  mental hygiene law, including habiltiation services as defined in  para-
    24  graph  (c)  of  subdivision one of section forty-four hundred three-g of
    25  this article, subject to the following:
    26    (a) Such plan must have the ability to provide or coordinate  services
    27  for  persons with developmental disabilities as demonstrated by criteria
    28  to be determined by the commissioner and the commissioner of the  office

    29  for people with developmental disabilities. Such criteria shall include,
    30  but  not  be  limited  to, adequate experience providing or coordinating
    31  services for persons with developmental disabilities;
    32    (a-1) If the commissioner and  the  commissioner  of  the  office  for
    33  people  with  developmental  disabilities determine that such plan lacks
    34  the experience required in paragraph (a) of this subdivision,  the  plan
    35  shall  have  an  affiliation arrangement with an entity or entities with
    36  experience serving persons with developmental disabilities such that the
    37  affiliated entity will coordinate and plan services operated, certified,
    38  funded, authorized or approved by the office for  people  with  develop-

    39  mental  disabilities  or  will oversee and approve such coordination and
    40  planning;
    41    (a-2)  Each  enrollee  shall  receive  services  designed  to  achieve
    42  person-centered  outcomes,  to  enable  that  person to live in the most
    43  integrated setting appropriate to that person's  needs,  and  to  enable
    44  that  person  to interact with nondisabled persons to the fullest extent
    45  possible in social, workplace and  other  community  settings,  provided
    46  that  all  such services are consistent with such person's wishes to the
    47  extent that such wishes are known. With respect to an individual receiv-
    48  ing non-residential services operated, certified, funded, authorized  or
    49  approved  by the office for people with developmental disabilities prior

    50  to enrollment in the plan, such guidelines shall  require  the  plan  to
    51  contract  with  the current provider of such non-residential services at
    52  the rates established by the office for ninety days in order  to  ensure
    53  continuity  of  care. With respect to an individual living in a residen-
    54  tial facility operated or certified by the office for people with devel-
    55  opmental disabilities prior to enrollment in the plan,  the  plan  shall
    56  contract with the provider of residential services for that residence at

        S. 2606--D                         56                         A. 3006--D
 
     1  the  rates established by the office for people with developmental disa-
     2  bilities for so long as such individual lives in that residence pursuant

     3  to an approved plan of care;
     4    (b)  The provision by such plan of services operated, certified, fund-
     5  ed, authorized or approved by the office for people  with  developmental
     6  disabilities shall be subject the joint oversight and review of both the
     7  department  and  the  office for people with developmental disabilities.
     8  The department and  such  office  shall  require  such  organization  to
     9  provide comprehensive care planning, assess quality, meet quality assur-
    10  ance requirements and ensure the enrollee is involved in care planning;
    11    (c)  Such  plan  shall  not  provide or arrange for services operated,
    12  certified, funded, authorized or approved by the office for people  with
    13  developmental  disabilities  until the commissioner and the commissioner

    14  of the office for people with developmental disabilities approve program
    15  features and rates that include such services, and determine  that  such
    16  organization  meets  the  requirements of this subdivision and any other
    17  requirements set forth by the commissioner of the office for people with
    18  developmental disabilities;
    19    (d) An otherwise eligible enrollee receiving services through the plan
    20  that are operated, certified, funded,  authorized  or  approved  by  the
    21  office  for people with developmental disabilities shall not be involun-
    22  tarily disenrolled from such plan without  the  prior  approval  of  the
    23  commissioner  of  the office for people with developmental disabilities.
    24  Notice shall be provided to the enrollee and the enrollee may request  a

    25  fair hearing regarding such disenrollment;
    26    (e) The office for people with developmental disabilities shall deter-
    27  mine  the eligibility of individuals receiving services operated, certi-
    28  fied, funded, authorized or approved by such office to  enroll  in  such
    29  plan  and  shall  enroll  individuals  it  determines eligible in a plan
    30  chosen by such individual, guardian or other legal representative;
    31    (f) The office for people  with  developmental  disabilities,  or  its
    32  designee,  shall  complete  a comprehensive assessment for enrollees who
    33  receive services operated, certified, funded, authorized or approved  by
    34  such  office.  This  assessment shall include, but not be limited to, an

    35  evaluation of the medical, social, habilitative and environmental  needs
    36  of  each  prospective enrollee as such needs relate to each individual's
    37  health, safety, living environment and wishes, to the extent  that  such
    38  wishes  are known. This assessment shall also serve as the basis for the
    39  development and provision of an appropriate plan of care for the  enrol-
    40  lee.  Such  plan  of care shall be focused on the achievement of person-
    41  centered outcomes and shall be consistent with and help inform any other
    42  person-centered plan required for the enrollee by  the  commissioner  of
    43  the  office  for  people  with developmental disabilities.   The initial
    44  assessment shall be completed by such office or a  designee  other  than

    45  the  plan  and  shall  be completed in consultation with the prospective
    46  enrollee's health care practitioner as necessary.   Reassessments  shall
    47  be  completed  by  such office or its designee, which may be the managed
    48  long term care plan in which the  person  is  enrolled  or  proposes  to
    49  enroll.  The  commissioner  of  the office for people with developmental
    50  disabilities shall prescribe the forms on which the assessment shall  be
    51  made.
    52    (f-1)  The plan shall provide the department and the office for people
    53  with developmental disabilities  with  a  description  of  the  proposed
    54  marketing  plan and how marketing materials will be presented to persons
    55  with developmental disabilities or their authorized decision makers  for

    56  the purposes of enabling them to make an informed choice.

        S. 2606--D                         57                         A. 3006--D
 
     1    (g)  Plans  providing services operated, certified, funded, authorized
     2  or approved by the office for  people  with  developmental  disabilities
     3  shall  be  subject  to  all requirements applicable to DISCOs  operating
     4  under section forty-four hundred three-g of this article with respect to
     5  quality  assurance,  grievances  and  appeals,  informed choice, partic-
     6  ipation in development of plans of care and requirements with respect to
     7  marketing, to the extent that such  requirements  are  not  inconsistent
     8  with this section.

     9    (h)  No  person  with  a developmental disability shall be required to
    10  enroll in a managed long term care plan  as  a  condition  of  receiving
    11  medical  assistance and services operated, certified, funded, authorized
    12  or approved by the office for  people  with  developmental  disabilities
    13  until  program  features  and  reimbursement  rates  are approved by the
    14  commissioner and the commissioner of the office for people with develop-
    15  mental disabilities and until such  commissioners determine  that  there
    16  are  a  sufficient  number  of  plans  authorized to coordinate care for
    17  persons with developmental disabilities pursuant to this article operat-
    18  ing in the person's county of residence to meet  the  needs  of  persons

    19  with  developmental disabilities, and that such plans meet the standards
    20  of this section.
    21    13.  Notwithstanding any inconsistent provision to the  contrary,  the
    22  commissioner  may issue a certificate of authority to no more than three
    23  eligible applicants who are eligible for Medicare and medical assistance
    24  to operate managed long term care plans that are  authorized  to  exclu-
    25  sively  enroll  persons with developmental disabilities, as such term is
    26  defined in section 1.03 of the mental hygiene law. The commissioner  may
    27  only  issue  certificates  of authority pursuant to this subdivision if,
    28  and to the extent that, the department has received federal approval  to
    29  operate  a  fully integrated duals advantage program for the integration

    30  of services for persons enrolled in Medicare and medical assistance. The
    31  commissioner may waive  any  of  the  department's  regulations  as  the
    32  commissioner,  in  consultation  with the commissioner of the office for
    33  people with developmental disabilities, deems necessary  to  allow  such
    34  managed  long  term  care  plans  to provide or arrange for services for
    35  persons with developmental disabilities that are adequate and  appropri-
    36  ate  to  meet  the  needs of such individuals and that will ensure their
    37  health and safety.
    38    14. The provisions of subdivisions twelve and thirteen of this section
    39  shall only be effective if, for so long  as,  and  to  the  extent  that
    40  federal  financial  participation is available for the costs of services

    41  provided thereunder to recipients  of  medical  assistance  pursuant  to
    42  title eleven of article five of the social services law. The commission-
    43  er  shall  make  any  necessary amendments to the state plan for medical
    44  assistance submitted pursuant to section three hundred sixty-three-a  of
    45  the  social  services  law,  and/or  submit one or more applications for
    46  waivers of the federal social security  act,  as  may  be  necessary  to
    47  ensure  such  federal  financial  participation.  To the extent that the
    48  provisions of subdivision twelve and thirteen of this section are incon-
    49  sistent with other provisions of this article or with the provisions  of
    50  section  three  hundred  sixty-four-j  of  the  social services law, the

    51  provisions of this subdivision shall prevail.
    52    § 77. Subparagraph (ii) of paragraph (b) of subdivision 1  of  section
    53  364-j  of the social services law, as amended by chapter 433 of the laws
    54  of 1997, is amended and a new subparagraph (iii) is  added  to  read  as
    55  follows:

        S. 2606--D                         58                         A. 3006--D
 
     1    (ii)  is  authorized  as  a  partially  capitated  program pursuant to
     2  section three hundred sixty-four-f of this title or  section  forty-four
     3  hundred  three-e of the public health law or section 1915b of the social
     4  security act[.]; or
     5    (iii)  is  authorized  to  operate  under  section  forty-four hundred
     6  three-g of the public health law.
     7    § 78. Section 364-j of the social services law is amended by adding  a

     8  new subdivision 28 to read as follows:
     9    28.  To  the extent that any provision of this section is inconsistent
    10  with any provision of section forty-four hundred three-g of  the  public
    11  health  law, such provision of this section shall not apply to an entity
    12  authorized to operate pursuant to section forty-four hundred three-g  of
    13  the public health law.
    14    §  79.  Subdivision  2  of section 365-a of the social services law is
    15  amended by adding a new paragraph (aa) to read as follows:
    16    (aa) care and services furnished by a developmental  disability  indi-
    17  vidual  support  and  care  coordination  organization  (DISCO) that has
    18  received a certificate  of  authority  pursuant  to  section  forty-four

    19  hundred  three-g of the public health law to eligible individuals resid-
    20  ing in the geographic area served by such entity, when such services are
    21  furnished in accordance with an agreement approved by the department  of
    22  health which meets the requirements of federal law and regulations.
    23    §  80.  The  commissioner  of  health  shall, to the extent necessary,
    24  submit the appropriate waivers, including, but  not  limited  to,  those
    25  authorized  pursuant  to  sections  eleven  hundred fifteen and nineteen
    26  hundred fifteen  of  the  federal  social  security  act,  or  successor
    27  provisions,  and  any other waivers necessary to achieve the purposes of
    28  high quality, integrated and cost effective care and  integrated  finan-
    29  cial eligibility policies under the medical assistance program or pursu-

    30  ant  to  title  XVIII  of the federal social security act and to require
    31  medical  assistance  recipients  with  developmental  disabilities   who
    32  require  home  and community-based services, as specified by the commis-
    33  sioner, to receive  such  services  through  an  available  organization
    34  certified  pursuant  to  article  44 of the public health law. Copies of
    35  such original  waiver  applications  and  amendments  thereto  shall  be
    36  provided  to  the  chairs  of the senate finance committee, the assembly
    37  ways and means committee and the senate and assembly  health  committees
    38  simultaneously with their submission to the federal government.
    39    § 80-a. Section 364-jj of the social services law, as added by chapter
    40  649 of the laws of 1996, is amended to read as follows:
    41    § 364-jj. Special advisory review panel on Medicaid managed care.  (a)

    42  There  is hereby established a special advisory review panel on Medicaid
    43  managed care.   The panel shall consist of  [nine]  twelve  members  who
    44  shall  be  appointed  as  follows:  [three] four by the governor, one of
    45  which shall serve as the chair; [two] three each by the temporary presi-
    46  dent of the senate and the speaker of the assembly; and one each by  the
    47  minority  leader  of the senate and the minority leader of the assembly.
    48  [All members shall be appointed no later than September first,  nineteen
    49  hundred  ninety-six.]  At  least  three  members  of such panel shall be
    50  members of the joint advisory panel established under section  13.40  of
    51  the  mental  hygiene  law.  Members shall serve without compensation but

    52  shall be reimbursed for appropriate  expenses.    The  department  shall
    53  provide  technical  assistance and access to data as is required for the
    54  panel to effectuate the mission and purposes established herein.
    55    (b) The panel shall:

        S. 2606--D                         59                         A. 3006--D
 
     1    (i) determine  whether  there  is  sufficient  managed  care  provider
     2  participation in the Medicaid managed care program;
     3    (ii)  determine  whether managed care providers meet proper enrollment
     4  targets that permit as many Medicaid  recipients  as  possible  to  make
     5  their own health plan decisions, thus minimizing the number of automatic
     6  assignments;
     7    (iii)  review  the  phase-in  schedule for enrollment, of managed care
     8  providers under both the voluntary and mandatory programs;

     9    (iv) assess the impact of managed care provider marketing and  enroll-
    10  ment strategies, and the public education campaign conducted in New York
    11  city, on enrollees participation in Medicaid managed care plans;
    12    (v) evaluate the adequacy of managed care provider capacity by review-
    13  ing  established  capacity  measurements and monitoring actual access to
    14  plan practitioners;
    15    (vi)  examine  the  cost  implications  of  populations  excluded  and
    16  exempted from Medicaid managed care; [and]
    17    (vii)  in  accordance  with  the recommendations of the joint advisory
    18  council established pursuant to section 13.40 of the mental hygiene law,
    19  advise the commissioners of health and developmental  disabilities  with
    20  respect  to  the oversight of DISCOs and of health maintenance organiza-

    21  tions and managed long term care plans  providing  services  authorized,
    22  funded,  approved  or  certified  by the office for people with develop-
    23  mental disabilities, and review all managed  care  options  provided  to
    24  persons  with  developmental  disabilities,  including:  the adequacy of
    25  support  for  habilitation  services;  the  record  of  compliance  with
    26  requirements  for person-centered planning, person-centered services and
    27  community integration; the  adequacy  of  rates  paid  to  providers  in
    28  accordance  with  the  provisions  of paragraph 1 of subdivision four of
    29  section forty-four hundred three of the  public  health  law,  paragraph
    30  (a-2)  of  subdivision  eight of section forty-four hundred three of the

    31  public health law or paragraph (a-2) of subdivision  twelve  of  section
    32  forty-four  hundred three-f of the public health law; and the quality of
    33  life, health, safety and community integration of persons with  develop-
    34  mental disabilities enrolled in managed care; and
    35    (viii) examine other issues as it deems appropriate.
    36    (c)  Commencing January first, nineteen hundred ninety-seven and quar-
    37  terly thereafter the panel shall  submit a report regarding  the  status
    38  of  Medicaid managed care in the state and provide recommendations if it
    39  deems appropriate to the  governor,  the  temporary  president  and  the
    40  minority  leader  of the senate, and the speaker and the minority leader
    41  of the assembly.
    42    § 81. Notwithstanding any inconsistent provision of law, rule or regu-

    43  lation, for purposes of implementing the provisions of the public health
    44  law and the social services law, references to titles XIX and XXI of the
    45  federal social security act in the public  health  law  and  the  social
    46  services  law  shall be deemed to include and also to mean any successor
    47  titles thereto under the federal social security act.
    48    § 82. Notwithstanding any inconsistent provision of law, rule or regu-
    49  lation, the effectiveness of the provisions of sections 2807 and 3614 of
    50  the public health law, section 18 of chapter 2 of the laws of 1988,  and
    51  18  NYCRR  505.14(h), as they relate to time frames for notice, approval
    52  or certification of rates of payment, are hereby suspended  and  without
    53  force or effect for purposes of implementing the provisions of this act.
    54    §  83. Severability clause. If any clause, sentence, paragraph, subdi-

    55  vision, section or part of this act shall be adjudged by  any  court  of
    56  competent  jurisdiction  to  be invalid, such judgment shall not affect,

        S. 2606--D                         60                         A. 3006--D
 
     1  impair or invalidate the remainder thereof, but shall be confined in its
     2  operation to the clause, sentence, paragraph,  subdivision,  section  or
     3  part thereof directly involved in the controversy in which such judgment
     4  shall  have been rendered. It is hereby declared to be the intent of the
     5  legislature that this act would have been enacted even if  such  invalid
     6  provisions had not been included herein.
     7    §  84.  This  act shall take effect immediately and shall be deemed to
     8  have been in full force and effect on and after April 1,  2013  provided
     9  that:
    10    1.  section  thirty-three-a  of  this act shall take effect January 1,

    11  2014;
    12    1-a. sections seventy-three  through  eighty-a  shall  expire  and  be
    13  deemed repealed September 30, 2019
    14    2.  any  rules or regulations necessary to implement the provisions of
    15  this act may be promulgated and any procedures, forms,  or  instructions
    16  necessary  for such implementation may be adopted and issued on or after
    17  the date this act shall have become a law;
    18    2-a. Notwithstanding any inconsistent provision of the state  adminis-
    19  trative  procedure  act, the commissioner of health and the commissioner
    20  of developmental disabilities are authorized to promulgate on  an  emer-
    21  gency  basis  any regulation he or she determines necessary to implement
    22  any provision of sections seventy-two through seventy-nine of  this  act
    23  upon its effective date;
    24    3. this act shall not be construed to alter, change, affect, impair or

    25  defeat any rights, obligations, duties or interests accrued, incurred or
    26  conferred prior to the effective date of this act;
    27    4.  the  commissioner  of  health  and the superintendent of financial
    28  services and any appropriate council may take  any  steps  necessary  to
    29  implement this act prior to its effective date;
    30    5. notwithstanding any inconsistent provision of the state administra-
    31  tive  procedure  act  or any other provision of law, rule or regulation,
    32  the commissioner of health and the superintendent of financial  services
    33  and  any  appropriate council is authorized to adopt or amend or promul-
    34  gate on an emergency basis any regulation he  or  she  or  such  council
    35  determines  necessary  to  implement  any  provision  of this act on its
    36  effective date;
    37    6. the provisions of this act shall become  effective  notwithstanding

    38  the  failure  of  the  commissioner  of  health or the superintendent of
    39  financial services or any council to adopt or amend or promulgate  regu-
    40  lations implementing this act;
    41    7.  the amendments to section 364-j of the social services law made by
    42  sections seven, twelve, thirteen, thirty-five-a, thirty-six, thirty-sev-
    43  en, thirty-eight, thirty-nine, forty, forty-one, forty-two, forty-three,
    44  forty-four, seventy-two, seventy-seven and  seventy-eight  of  this  act
    45  shall not affect the repeal of such section and shall be deemed repealed
    46  therewith;
    47    8.  section  forty-eight-a  of  this  act  shall  expire and be deemed
    48  repealed March 31, 2016;
    49    9. the amendments to section 4403-f of the public health law  made  by
    50  sections  seven-a, forty-eight, fifty-four, seventy-five and seventy-six
    51  of this act shall not affect the repeal of such  section  and  shall  be

    52  deemed repealed therewith; and
    53    10.  the  provisions  of  this act shall apply to any pending cause of
    54  action brought pursuant to article 13 of  the  state  finance  law,  and
    55  shall  further  apply  to claims, records, statements or obligations, as

        S. 2606--D                         61                         A. 3006--D
 
     1  defined by section 188 of the state finance law, that were  made,  used,
     2  or existing prior to, on or after April 1, 2007.
 
     3                                   PART B
 
     4    Section  1.  Subdivision (f) of section 129 of part C of chapter 58 of
     5  the laws of 2009, amending the public health law relating to payment  by
     6  governmental  agencies  for  general  hospital  inpatient  services,  is
     7  amended to read as follows:
     8    (f) section twenty-five  of  this  act  shall  expire  and  be  deemed

     9  repealed April 1, [2013] 2016;
    10    §  2.  Paragraph (a) of subdivision 1 of section 212 of chapter 474 of
    11  the laws of 1996, amending the education law and other laws relating  to
    12  rates  for residential healthcare facilities, as amended by section 2 of
    13  part D of chapter 59 of the laws of 2011, is amended to read as follows:
    14    (a) Notwithstanding any inconsistent provision of law or regulation to
    15  the contrary, effective beginning August 1, 1996, for the  period  April
    16  1,  1997  through  March 31, 1998, April 1, 1998 for the period April 1,
    17  1998 through March 31, 1999, August 1, 1999, for  the  period  April  1,
    18  1999 through March 31, 2000, April 1, 2000, for the period April 1, 2000
    19  through  March  31,  2001,  April  1, 2001, for the period April 1, 2001
    20  through March 31, 2002, April 1, 2002, for  the  period  April  1,  2002

    21  through March 31, 2003, and for the state fiscal year beginning April 1,
    22  2005  through  March  31,  2006, and for the state fiscal year beginning
    23  April 1, 2006 through March 31, 2007, and  for  the  state  fiscal  year
    24  beginning April 1, 2007 through March 31, 2008, and for the state fiscal
    25  year  beginning  April 1, 2008 through March 31, 2009, and for the state
    26  fiscal year beginning April 1, 2009 through March 31, 2010, and for  the
    27  state fiscal year beginning April 1, 2010 through March 31, [2013] 2016,
    28  the  department of health is authorized to pay public general hospitals,
    29  as defined in subdivision 10 of section 2801 of the public  health  law,
    30  operated by the state of New York or by the state university of New York
    31  or by a county, which shall not include a city with a population of over
    32  one  million,  of the state of New York, and those public general hospi-

    33  tals located in the county of Westchester, the county  of  Erie  or  the
    34  county of Nassau, additional payments for inpatient hospital services as
    35  medical  assistance  payments  pursuant  to title 11 of article 5 of the
    36  social services law for patients eligible for federal financial  partic-
    37  ipation  under  title  XIX of the federal social security act in medical
    38  assistance pursuant  to  the  federal  laws  and  regulations  governing
    39  disproportionate  share  payments to hospitals up to one hundred percent
    40  of each such public general hospital's medical assistance and  uninsured
    41  patient  losses after all other medical assistance, including dispropor-
    42  tionate share payments to such public general hospital for  1996,  1997,
    43  1998,  and  1999,  based  initially for 1996 on reported 1994 reconciled
    44  data as further reconciled to actual reported 1996 reconciled data,  and

    45  for  1997  based  initially  on reported 1995 reconciled data as further
    46  reconciled to actual reported  1997  reconciled  data,  for  1998  based
    47  initially  on  reported  1995  reconciled  data as further reconciled to
    48  actual reported 1998  reconciled  data,  for  1999  based  initially  on
    49  reported  1995  reconciled data as further reconciled to actual reported
    50  1999 reconciled data, for 2000 based initially on reported  1995  recon-
    51  ciled  data as further reconciled to actual reported 2000 data, for 2001
    52  based initially on reported 1995 reconciled data as  further  reconciled
    53  to  actual reported 2001 data, for 2002 based initially on reported 2000
    54  reconciled data as further reconciled to actual reported 2002 data,  and

        S. 2606--D                         62                         A. 3006--D
 

     1  for  state  fiscal  years beginning on April 1, 2005, based initially on
     2  reported 2000 reconciled data as further reconciled to  actual  reported
     3  data  for  2005,  and for state fiscal years beginning on April 1, 2006,
     4  based  initially  on reported 2000 reconciled data as further reconciled
     5  to actual reported data for 2006, for state fiscal  years  beginning  on
     6  and  after  April  1,  2007  through  March 31, 2009, based initially on
     7  reported 2000 reconciled data as further reconciled to  actual  reported
     8  data  for  2007 and 2008, respectively, for state fiscal years beginning
     9  on and after April 1, 2009, based initially on reported 2007  reconciled
    10  data,  adjusted  for  authorized Medicaid rate changes applicable to the
    11  state fiscal year, and as further reconciled to actual reported data for
    12  2009, for state fiscal years beginning on and after April 1, 2010, based

    13  initially on reported reconciled data from the base year two years prior
    14  to the payment year,  adjusted  for  authorized  Medicaid  rate  changes
    15  applicable  to  the  state fiscal year, and further reconciled to actual
    16  reported data from such payment year, and to actual  reported  data  for
    17  each  respective succeeding year.  The payments may be added to rates of
    18  payment or made as aggregate payments  to  an  eligible  public  general
    19  hospital.
    20    §  3.  Section  11  of  chapter  884 of the laws of 1990, amending the
    21  public health law relating to authorizing  bad  debt  and  charity  care
    22  allowances  for  certified home health agencies, as amended by section 3
    23  of part D of chapter 59 of the laws of  2011,  is  amended  to  read  as
    24  follows:
    25    § 11. This act shall take effect immediately and:
    26    (a) sections one and three shall expire on December 31, 1996,

    27    (b)  sections  four  through ten shall expire on June 30, [2013] 2015,
    28  and
    29    (c) provided that the amendment to section 2807-b of the public health
    30  law by section two of this act shall not affect the expiration  of  such
    31  section  2807-b  as  otherwise  provided  by  law and shall be deemed to
    32  expire therewith.
    33    § 4. Subdivision 2 of section 246 of chapter 81 of the laws  of  1995,
    34  amending  the  public  health  law  and  other  laws relating to medical
    35  reimbursement and welfare reform, as amended by section 4 of part  D  of
    36  chapter 59 of the laws of 2011, is amended to read as follows:
    37    2.  Sections  five,  seven  through nine, twelve through fourteen, and
    38  eighteen of this act shall be deemed to have  been  in  full  force  and
    39  effect  on  and  after  April  1, 1995 through March 31, 1999 and on and

    40  after July 1, 1999 through March 31, 2000 and on and after April 1, 2000
    41  through March 31, 2003 and on and after April 1, 2003 through March  31,
    42  2006  and  on  and after April 1, 2006 through March 31, 2007 and on and
    43  after April 1, 2007 through March 31, 2009 and on  and  after  April  1,
    44  2009  through  March 31, 2011 and sections twelve, thirteen and fourteen
    45  of this act shall be deemed to be in full force and effect on and  after
    46  April 1, 2011 through March 31, [2013] 2015;
    47    §  5.  Subparagraph  (vi) of paragraph (b) of subdivision 2 of section
    48  2807-d of the public health law, as amended by section 102 of part H  of
    49  chapter 59 of the laws of 2011, is amended to read as follows:
    50    (vi)  Notwithstanding  any contrary provision of this paragraph or any
    51  other provision of law or regulation to the  contrary,  for  residential

    52  health care facilities the assessment shall be six percent of each resi-
    53  dential  health care facility's gross receipts received from all patient
    54  care services and other operating income on a cash basis for the  period
    55  April  first,  two thousand two through March thirty-first, two thousand
    56  three for hospital  or  health-related  services,  including  adult  day

        S. 2606--D                         63                         A. 3006--D
 
     1  services;  provided,  however,  that residential health care facilities'
     2  gross receipts attributable to payments received pursuant to title XVIII
     3  of the federal social security act (medicare) shall be excluded from the
     4  assessment; provided, however, that for all such gross receipts received
     5  on  or after April first, two thousand three through March thirty-first,

     6  two thousand five, such assessment shall be five  percent,  and  further
     7  provided  that  for  all  such gross receipts received on or after April
     8  first, two thousand five through March thirty-first, two thousand  nine,
     9  and  on  or  after  April first, two thousand nine through March thirty-
    10  first, two thousand eleven such assessment shall  be  six  percent,  and
    11  further  provided  that for all such gross receipts received on or after
    12  April first, two thousand eleven through March thirty-first,  two  thou-
    13  sand thirteen such assessment shall be six percent, and further provided
    14  that  for  all such gross receipts received on or after April first, two
    15  thousand thirteen through March thirty-first, two thousand fifteen  such
    16  assessment shall be six percent.
    17    §  6.  Section 88 of chapter 659 of the laws of 1997, constituting the

    18  long term care integration and finance act of 1997, as amended by  chap-
    19  ter 446 of the laws of 2011, is amended to read as follows:
    20    §  88. Notwithstanding any provision of law to the contrary, all oper-
    21  ating demonstrations, as such term is defined in paragraph (c) of subdi-
    22  vision 1 of section 4403-f of the public health law as added by  section
    23  eighty-two  of this act, due to expire prior to January 1, 2001 shall be
    24  deemed to expire on December 31, [2013] 2015.
    25    § 7. Subparagraph (v) of paragraph (b) of subdivision  35  of  section
    26  2807-c  of  the  public health law, as amended by section 2 of part G of
    27  chapter 56 of the laws of 2012, is amended to read as follows:
    28    (v) such  regulations  shall  incorporate  quality  related  measures,
    29  including,  but  not  limited  to, potentially preventable re-admissions

    30  (PPRs) and provide for rate adjustments or payment disallowances related
    31  to PPRs and other potentially  preventable  negative  outcomes  (PPNOs),
    32  which shall be calculated in accordance with methodologies as determined
    33  by the commissioner, provided, however, that such methodologies shall be
    34  based on a comparison of the actual and risk adjusted expected number of
    35  PPRs and other PPNOs in a given hospital and with benchmarks established
    36  by  the  commissioner and provided further that such rate adjustments or
    37  payment disallowances shall result in an aggregate reduction in Medicaid
    38  payments of no less than thirty-five million dollars for the period July
    39  first, two thousand ten through March thirty-first, two thousand  eleven
    40  and  no less than fifty-one million dollars for annual periods beginning
    41  April first, two thousand eleven through March thirty-first,  two  thou-

    42  sand   [thirteen]   fourteen,   provided  further  that  such  aggregate
    43  reductions shall be offset by Medicaid payment reductions occurring as a
    44  result of decreased PPRs during the period July first, two thousand  ten
    45  through  March  thirty-first,  two  thousand eleven and the period April
    46  first, two thousand eleven  through  March  thirty-first,  two  thousand
    47  [thirteen] fourteen and as a result of decreased PPNOs during the period
    48  April  first,  two thousand eleven through March thirty-first, two thou-
    49  sand [thirteen] fourteen; and provided further that for the period  July
    50  first,  two thousand ten through March thirty-first, two thousand [thir-
    51  teen] fourteen, such rate adjustments or payment disallowances shall not

    52  apply to behavioral health PPRs; or to readmissions  that  occur  on  or
    53  after fifteen days following an initial admission. By no later than July
    54  first,  two  thousand eleven the commissioner shall enter into consulta-
    55  tions with representatives of the health care facilities subject to this
    56  section regarding potential prospective revisions to applicable  method-

        S. 2606--D                         64                         A. 3006--D
 
     1  ologies  and benchmarks set forth in regulations issued pursuant to this
     2  subparagraph;
     3    §  8.  Subdivision 2 of section 93 of part C of chapter 58 of the laws
     4  of 2007 amending the social services law  and  other  laws  relating  to
     5  enacting  the major components of legislation necessary to implement the
     6  health and mental hygiene budget  for  the  2007-2008  fiscal  year,  as

     7  amended  by  section  10 of part B of chapter 58 of the laws of 2009, is
     8  amended to read as follows:
     9    2. section two of this act shall expire  and  be  deemed  repealed  on
    10  March 31, [2013] 2014;
    11    §  8-a.  Subdivision 8 of section 364-l of the social services law, as
    12  added by section 2 of part C of chapter 58  of  the  laws  of  2007,  is
    13  amended to read as follows:
    14    8.  The  commissioner of health shall provide a report to the governor
    15  and the legislature no later than  January  first,  two  thousand  [ten]
    16  fourteen.    The  report  shall include findings as to the demonstration
    17  projects' effectiveness in managing the care  needs  and  improving  the
    18  health  of program participants, an evaluation as to the programs' cost-
    19  effectiveness as measured against traditional medicaid care models,  and

    20  recommendations as to whether the programs should be extended, modified,
    21  eliminated, or made permanent.
    22    §  9.  Section  194  of  chapter 474 of the laws of 1996, amending the
    23  education law and other laws relating to rates  for  residential  health
    24  care  facilities, as amended by section 9 of part D of chapter 59 of the
    25  laws of 2011, is amended to read as follows:
    26    § 194. 1. Notwithstanding any inconsistent provision of law  or  regu-
    27  lation,  the  trend factors used to project reimbursable operating costs
    28  to the rate period for purposes of determining rates of payment pursuant
    29  to article 28 of the public  health  law  for  residential  health  care
    30  facilities  for reimbursement of inpatient services provided to patients
    31  eligible for payments made by state governmental agencies on  and  after
    32  April  1, 1996 through March 31, 1999 and for payments made on and after

    33  July 1, 1999 through March 31, 2000 and  on  and  after  April  1,  2000
    34  through  March 31, 2003 and on and after April 1, 2003 through March 31,
    35  2007 and on and after April 1, 2007 through March 31, 2009  and  on  and
    36  after  April  1,  2009  through March 31, 2011 and on and after April 1,
    37  2011 through March 31, 2013 and on and after April 1, 2013 through March
    38  31, 2015 shall reflect no trend factor projections  or  adjustments  for
    39  the period April 1, 1996, through March 31, 1997.
    40    2.  The  commissioner  of health shall adjust such rates of payment to
    41  reflect the exclusion pursuant to this section of such  specified  trend
    42  factor projections or adjustments.
    43    §  10.  Subdivision  1  of section 89-a of part C of chapter 58 of the
    44  laws of 2007, amending the social services law and other  laws  relating

    45  to  enacting  the major components of legislation necessary to implement
    46  the health and mental hygiene budget  for  the  2007-2008  state  fiscal
    47  year,  as  amended  by section 10 of part D of chapter 59 of the laws of
    48  2011, is amended to read as follows:
    49    1. Notwithstanding paragraph (c) of subdivision 10 of  section  2807-c
    50  of  the  public  health  law  and section 21 of chapter 1 of the laws of
    51  1999, as amended, and any other inconsistent provision of law  or  regu-
    52  lation  to  the  contrary,  in  determining  rates  of payments by state
    53  governmental agencies effective for services provided beginning April 1,
    54  2006, through March 31, 2009, and on and after  April  1,  2009  through
    55  March  31,  2011, and on and after April 1, 2011 through March 31, 2013,
    56  and on and after April 1, 2013 through March 31, 2015 for inpatient  and

        S. 2606--D                         65                         A. 3006--D
 
     1  outpatient  services  provided  by  general  hospitals and for inpatient
     2  services and outpatient adult day health care services provided by resi-
     3  dential health care facilities pursuant to  article  28  of  the  public
     4  health  law,  the  commissioner  of  health  shall  apply a trend factor
     5  projection of two and twenty-five hundredths percent attributable to the
     6  period January 1, 2006 through December 31, 2006, and on and after Janu-
     7  ary 1, 2007, provided, however, that on  reconciliation  of  such  trend
     8  factor for the period January 1, 2006 through December 31, 2006 pursuant
     9  to  paragraph  (c)  of  subdivision  10  of section 2807-c of the public
    10  health law, such trend factor shall be the final US Consumer Price Index

    11  (CPI) for all urban consumers, as published  by  the  US  Department  of
    12  Labor,  Bureau  of  Labor  Statistics  less  twenty-five hundredths of a
    13  percentage point.
    14    § 11. Paragraph (f) of subdivision 1 of section 64 of  chapter  81  of
    15  the laws of 1995, amending the public health law and other laws relating
    16  to medical reimbursement and welfare reform, as amended by section 11 of
    17  part D of chapter 59 of the laws of 2011, is amended to read as follows:
    18    (f)  Prior  to  February  1, 2001, February 1, 2002, February 1, 2003,
    19  February 1, 2004, February 1, 2005, February 1, 2006, February 1,  2007,
    20  February  1, 2008, February 1, 2009, February 1, 2010, February 1, 2011,
    21  February 1, 2012, [and] February 1, 2013 and February 1, 2014 and Febru-
    22  ary 1, 2015 the commissioner of health shall calculate the result of the

    23  statewide total  of  residential  health  care  facility  days  of  care
    24  provided  to beneficiaries of title XVIII of the federal social security
    25  act (medicare), divided by the sum of such days of  care  plus  days  of
    26  care provided to residents eligible for payments pursuant to title 11 of
    27  article  5  of the social services law minus the number of days provided
    28  to residents receiving hospice care, expressed as a percentage, for  the
    29  period  commencing  January  1,  through  November 30, of the prior year
    30  respectively, based on such data for such period. This  value  shall  be
    31  called  the  2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009,
    32  2010, 2011, 2012, [and] 2013, 2014 and 2015 statewide target  percentage
    33  respectively.
    34    §  12.  Subparagraph (ii) of paragraph (b) of subdivision 3 of section

    35  64 of chapter 81 of the laws of 1995, amending the public health law and
    36  other laws relating to medical  reimbursement  and  welfare  reform,  as
    37  amended  by  section  12 of part D of chapter 59 of the laws of 2011, is
    38  amended to read as follows:
    39    (ii) If the 1997, 1998, 2000, 2001,  2002,  2003,  2004,  2005,  2006,
    40  2007,  2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 and 2015 statewide
    41  target percentages are not for  each  year  at  least  three  percentage
    42  points  higher  than  the statewide base percentage, the commissioner of
    43  health shall determine the percentage  by  which  the  statewide  target
    44  percentage  for each year is not at least three percentage points higher
    45  than the statewide base percentage. The percentage  calculated  pursuant
    46  to  this  paragraph  shall  be  called the 1997, 1998, 2000, 2001, 2002,

    47  2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and]  2013,
    48  2014  and 2015 statewide reduction percentage respectively. If the 1997,
    49  1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009,  2010,
    50  2011,  2012,  [and]  2013; 2014 and 2015 statewide target percentage for
    51  the respective year is at least three percentage points higher than  the
    52  statewide  base  percentage,  the statewide reduction percentage for the
    53  respective year shall be zero.
    54    § 13.  Subparagraph (iii) of paragraph (b) of subdivision 4 of section
    55  64 of chapter 81 of the laws of 1995, amending the public health law and
    56  other laws relating to medical  reimbursement  and  welfare  reform,  as

        S. 2606--D                         66                         A. 3006--D
 

     1  amended  by  section  13 of part D of chapter 59 of the laws of 2011, is
     2  amended to read as follows:
     3    (iii)  The 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008,
     4  2009, 2010, 2011, 2012, [and] 2013, 2014 and  2015  statewide  reduction
     5  percentage  shall  be  multiplied  by  one  hundred  two million dollars
     6  respectively to determine the 1998, 2000, 2001, 2002, 2003, 2004,  2005,
     7  2006,  2007,  2008,  2009,  2010,  2011, 2012, [and] 2013, 2014 and 2015
     8  statewide aggregate reduction amount. If the 1998 and  the  2000,  2001,
     9  2002,  2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and]
    10  2013, 2014 and 2015 statewide reduction percentage shall be zero respec-
    11  tively, there shall be no 1998, 2000,  2001,  2002,  2003,  2004,  2005,

    12  2006,  2007,  2008,  2009,  2010,  2011, 2012, [and] 2013, 2014 and 2015
    13  reduction amount.
    14    § 14. Paragraph (b) of subdivision 5 of section 64 of  chapter  81  of
    15  the laws of 1995, amending the public health law and other laws relating
    16  to medical reimbursement and welfare reform, as amended by section 14 of
    17  part D of chapter 59 of the laws of 2011, is amended to read as follows:
    18    (b)  The  1996,  1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005,
    19  2006, 2007, 2008, 2009, 2010, 2011, 2012,  [and]  2013,  2014  and  2015
    20  statewide  aggregate  reduction amounts shall for each year be allocated
    21  by the commissioner of health among residential health  care  facilities
    22  that are eligible to provide services to beneficiaries of title XVIII of
    23  the  federal  social  security act (medicare) and residents eligible for

    24  payments pursuant to title 11 of article 5 of the social services law on
    25  the basis of the extent of each facility's  failure  to  achieve  a  two
    26  percentage  points  increase  in  the  1996  target  percentage, a three
    27  percentage point increase in the 1997, 1998,  2000,  2001,  2002,  2003,
    28  2004,  2005,  2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014
    29  and 2015 target percentage and a two and  one-quarter  percentage  point
    30  increase  in  the  1999 target percentage for each year, compared to the
    31  base percentage, calculated  on  a  facility  specific  basis  for  this
    32  purpose,  compared  to the statewide total of the extent of each facili-
    33  ty's failure to achieve a two percentage points increase in the 1996 and
    34  a three percentage point increase in the 1997  and  a  three  percentage

    35  point  increase  in  the 1998 and a two and one-quarter percentage point
    36  increase in the 1999 target percentage  and  a  three  percentage  point
    37  increase  in  the  2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008,
    38  2009, 2010, 2011, 2012, [and] 2013,  2014  and  2015  target  percentage
    39  compared to the base percentage. These amounts shall be called the 1996,
    40  1997,  1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008,
    41  2009, 2010, 2011, 2012, [and] 2013,  2014  and  2015  facility  specific
    42  reduction amounts respectively.
    43    §  14-a.  Section 228 of chapter 474 of the laws of 1996, amending the
    44  education law and other laws relating to rates  for  residential  health
    45  care  facilities,  as amended by section 14-a of part D of chapter 59 of
    46  the laws of 2011, is amended to read as follows:

    47    § 228. 1. Definitions. (a) Regions,  for  purposes  of  this  section,
    48  shall  mean  a downstate region to consist of Kings, New York, Richmond,
    49  Queens, Bronx, Nassau and Suffolk counties  and  an  upstate  region  to
    50  consist  of  all  other New York state counties. A certified home health
    51  agency or long term home health care program shall  be  located  in  the
    52  same county utilized by the commissioner of health for the establishment
    53  of rates pursuant to article 36 of the public health law.
    54    (b)  Certified  home  health  agency  (CHHA)  shall  mean such term as
    55  defined in section 3602 of the public health law.

        S. 2606--D                         67                         A. 3006--D
 
     1    (c) Long term home health care program (LTHHCP) shall mean  such  term
     2  as defined in subdivision 8 of section 3602 of the public health law.

     3    (d) Regional group shall mean all those CHHAs and LTHHCPs, respective-
     4  ly, located within a region.
     5    (e)  Medicaid  revenue percentage, for purposes of this section, shall
     6  mean CHHA and LTHHCP  revenues  attributable  to  services  provided  to
     7  persons  eligible  for payments pursuant to title 11 of article 5 of the
     8  social services law divided by such revenues plus CHHA and LTHHCP reven-
     9  ues attributable to services provided to beneficiaries of Title XVIII of
    10  the federal social security act (medicare).
    11    (f) Base period, for purposes of this  section,  shall  mean  calendar
    12  year 1995.
    13    (g) Target period. For purposes of this section, the 1996 target peri-
    14  od  shall  mean  August  1, 1996 through March 31, 1997, the 1997 target
    15  period shall mean January 1, 1997 through November 30,  1997,  the  1998
    16  target  period shall mean January 1, 1998 through November 30, 1998, the

    17  1999 target period shall mean January 1, 1999 through November 30, 1999,
    18  the 2000 target period shall mean January 1, 2000 through  November  30,
    19  2000, the 2001 target period shall mean January 1, 2001 through November
    20  30,  2001,  the  2002  target  period shall mean January 1, 2002 through
    21  November 30, 2002, the 2003 target period shall  mean  January  1,  2003
    22  through  November 30, 2003, the 2004 target period shall mean January 1,
    23  2004 through November 30, 2004, and the 2005 target  period  shall  mean
    24  January  1, 2005 through November 30, 2005, the 2006 target period shall
    25  mean January 1, 2006 through November 30,  2006,  and  the  2007  target
    26  period shall mean January 1, 2007 through November 30, 2007 and the 2008
    27  target  period shall mean January 1, 2008 through November 30, 2008, and
    28  the 2009 target period shall mean January 1, 2009 through  November  30,

    29  2009  and  the  2010  target  period  shall mean January 1, 2010 through
    30  November 30, 2010 and the 2011 target period shall mean January 1,  2011
    31  through  November 30, 2011 and the 2012 target period shall mean January
    32  1, 2012 through November 30, 2012 and the 2013 target period shall  mean
    33  January  1,  2013  through November 30, 2013, and the 2014 target period
    34  shall mean January 1, 2014 through November 30, 2014 and the 2015 target
    35  period shall mean January 1, 2015 through November 30, 2015.
    36    2. (a) Prior to February 1, 1997, for each regional group the  commis-
    37  sioner  of  health shall calculate the 1996 medicaid revenue percentages
    38  for the period commencing August 1, 1996 to the last date for which such
    39  data is available and reasonably accurate.
    40    (b) Prior to February 1, 1998, prior to February  1,  1999,  prior  to

    41  February  1, 2000, prior to February 1, 2001, prior to February 1, 2002,
    42  prior to February 1, 2003, prior to February 1, 2004, prior to  February
    43  1,  2005, prior to February 1, 2006, prior to February 1, 2007, prior to
    44  February 1, 2008, prior to February 1, 2009, prior to February 1,  2010,
    45  prior  to  February  1,  2011, prior to February 1, 2012 [and], prior to
    46  February 1, 2013, prior to February 1, 2014 and  prior  to  February  1,
    47  2015  for each regional group the commissioner of health shall calculate
    48  the prior year's medicaid revenue percentages for the period  commencing
    49  January 1 through November 30 of such prior year.
    50    3.  By September 15, 1996, for each regional group the commissioner of
    51  health shall calculate the base period medicaid revenue percentage.
    52    4. (a) For each regional  group,  the  1996  target  medicaid  revenue

    53  percentage  shall be calculated by subtracting the 1996 medicaid revenue
    54  reduction percentages from the base period medicaid revenue percentages.
    55  The 1996 medicaid revenue  reduction  percentage,  taking  into  account

        S. 2606--D                         68                         A. 3006--D
 
     1  regional and program differences in utilization of medicaid and medicare
     2  services, for the following regional groups shall be equal to:
     3    (i)  one  and one-tenth percentage points for CHHAs located within the
     4  downstate region;
     5    (ii) six-tenths of one percentage point for CHHAs located  within  the
     6  upstate region;
     7    (iii) one and eight-tenths percentage points for LTHHCPs located with-
     8  in the downstate region; and
     9    (iv) one and seven-tenths percentage points for LTHHCPs located within
    10  the upstate region.

    11    (b)  For  1997,  1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007,
    12  2008, 2009, 2010, 2011,  2012,  [and]  2013,  2014  and  2015  for  each
    13  regional  group,  the target medicaid revenue percentage for the respec-
    14  tive year shall be calculated by subtracting the respective year's medi-
    15  caid revenue reduction percentage from the base period medicaid  revenue
    16  percentage.  The  medicaid revenue reduction percentages for 1997, 1998,
    17  2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010,  2011,
    18  2012, [and] 2013, 2014 and 2015 taking into account regional and program
    19  differences  in  utilization  of medicaid and medicare services, for the
    20  following regional groups shall be equal to for each such year:
    21    (i) one and one-tenth percentage points for CHHAs located  within  the
    22  downstate region;

    23    (ii)  six-tenths  of one percentage point for CHHAs located within the
    24  upstate region;
    25    (iii) one and eight-tenths percentage points for LTHHCPs located with-
    26  in the downstate region; and
    27    (iv) one and seven-tenths percentage points for LTHHCPs located within
    28  the upstate region.
    29    (c) For each regional group, the 1999 target medicaid revenue percent-
    30  age shall  be  calculated  by  subtracting  the  1999  medicaid  revenue
    31  reduction  percentage  from the base period medicaid revenue percentage.
    32  The 1999 medicaid revenue reduction  percentages,  taking  into  account
    33  regional and program differences in utilization of medicaid and medicare
    34  services, for the following regional groups shall be equal to:
    35    (i)  eight  hundred  twenty-five  thousandths (.825) of one percentage
    36  point for CHHAs located within the downstate region;

    37    (ii) forty-five hundredths (.45) of one  percentage  point  for  CHHAs
    38  located within the upstate region;
    39    (iii)  one  and  thirty-five  hundredths  percentage points (1.35) for
    40  LTHHCPs located within the downstate region; and
    41    (iv) one and two hundred seventy-five  thousandths  percentage  points
    42  (1.275) for LTHHCPs located within the upstate region.
    43    5.  (a) For each regional group, if the 1996 medicaid revenue percent-
    44  age is not equal to or  less  than  the  1996  target  medicaid  revenue
    45  percentage,  the  commissioner of health shall compare the 1996 medicaid
    46  revenue percentage to the 1996 target  medicaid  revenue  percentage  to
    47  determine  the  amount  of the shortfall which, when divided by the 1996
    48  medicaid  revenue  reduction  percentage,  shall  be  called  the   1996
    49  reduction  factor.  These  amounts, expressed as a percentage, shall not

    50  exceed one hundred percent. If the 1996 medicaid revenue  percentage  is
    51  equal  to  or less than the 1996 target medicaid revenue percentage, the
    52  1996 reduction factor shall be zero.
    53    (b) For 1997, 1998, 1999, 2000, 2001, 2002, 2003,  2004,  2005,  2006,
    54  2007,  2008,  2009, 2010, 2011, 2012, [and] 2013, 2014 and 2015 for each
    55  regional group, if the medicaid revenue percentage  for  the  respective
    56  year is not equal to or less than the target medicaid revenue percentage

        S. 2606--D                         69                         A. 3006--D
 
     1  for  such respective year, the commissioner of health shall compare such
     2  respective year's medicaid revenue percentage to such respective  year's
     3  target medicaid revenue percentage to determine the amount of the short-

     4  fall  which,  when  divided  by  the  respective year's medicaid revenue
     5  reduction percentage, shall be called  the  reduction  factor  for  such
     6  respective  year.  These  amounts,  expressed as a percentage, shall not
     7  exceed one hundred percent. If the medicaid  revenue  percentage  for  a
     8  particular  year  is  equal  to or less than the target medicaid revenue
     9  percentage for that year, the reduction factor for that  year  shall  be
    10  zero.
    11    6.  (a)  For  each  regional group, the 1996 reduction factor shall be
    12  multiplied by the following amounts to determine each  regional  group's
    13  applicable 1996 state share reduction amount:
    14    (i) two million three hundred ninety thousand dollars ($2,390,000) for
    15  CHHAs located within the downstate region;
    16    (ii) seven hundred fifty thousand dollars ($750,000) for CHHAs located
    17  within the upstate region;

    18    (iii)  one  million  two hundred seventy thousand dollars ($1,270,000)
    19  for LTHHCPs located within the downstate region; and
    20    (iv) five hundred  ninety  thousand  dollars  ($590,000)  for  LTHHCPs
    21  located within the upstate region.
    22    For  each regional group reduction, if the 1996 reduction factor shall
    23  be zero, there shall be no 1996 state share reduction amount.
    24    (b) For 1997, 1998, 2000, 2001, 2002, 2003, 2004,  2005,  2006,  2007,
    25  2008,  2009,  2010,  2011,  2012,  [and]  2013,  2014  and 2015 for each
    26  regional group, the reduction factor for the respective  year  shall  be
    27  multiplied  by  the following amounts to determine each regional group's
    28  applicable state share reduction amount for such respective year:
    29    (i) two million three hundred ninety thousand dollars ($2,390,000) for
    30  CHHAs located within the downstate region;

    31    (ii) seven hundred fifty thousand dollars ($750,000) for CHHAs located
    32  within the upstate region;
    33    (iii) one million two hundred seventy  thousand  dollars  ($1,270,000)
    34  for LTHHCPs located within the downstate region; and
    35    (iv)  five  hundred  ninety  thousand  dollars  ($590,000) for LTHHCPs
    36  located within the upstate region.
    37    For each regional group reduction,  if  the  reduction  factor  for  a
    38  particular  year  shall be zero, there shall be no state share reduction
    39  amount for such year.
    40    (c) For each regional group, the 1999 reduction factor shall be multi-
    41  plied by the following amounts to determine each regional group's appli-
    42  cable 1999 state share reduction amount:
    43    (i) one million seven hundred ninety-two thousand five hundred dollars
    44  ($1,792,500) for CHHAs located within the downstate region;

    45    (ii) five hundred sixty-two thousand five hundred  dollars  ($562,500)
    46  for CHHAs located within the upstate region;
    47    (iii)  nine hundred fifty-two thousand five hundred dollars ($952,500)
    48  for LTHHCPs located within the downstate region; and
    49    (iv) four hundred forty-two thousand five hundred  dollars  ($442,500)
    50  for LTHHCPs located within the upstate region.
    51    For  each regional group reduction, if the 1999 reduction factor shall
    52  be zero, there shall be no 1999 state share reduction amount.
    53    7. (a) For each regional group, the 1996 state share reduction  amount
    54  shall be allocated by the commissioner of health among CHHAs and LTHHCPs
    55  on  the  basis  of  the  extent  of  each CHHA's and LTHHCP's failure to
    56  achieve the 1996 target medicaid revenue  percentage,  calculated  on  a


        S. 2606--D                         70                         A. 3006--D
 
     1  provider  specific  basis utilizing revenues for this purpose, expressed
     2  as a proportion of the total of each  CHHA's  and  LTHHCP's  failure  to
     3  achieve  the 1996 target medicaid revenue percentage within the applica-
     4  ble  regional group. This proportion shall be multiplied by the applica-
     5  ble 1996 state share reduction amount calculation pursuant to  paragraph
     6  (a)  of  subdivision  6 of this section. This amount shall be called the
     7  1996 provider specific state share reduction amount.
     8    (b) For 1997, 1998, 1999, 2000, 2001, 2002, 2003,  2004,  2005,  2006,
     9  2007,  2008,  2009, 2010, 2011, 2012, [and] 2013, 2014 and 2015 for each
    10  regional group, the state share reduction amount for the respective year
    11  shall be allocated by the commissioner of health among CHHAs and LTHHCPs

    12  on the basis of the extent  of  each  CHHA's  and  LTHHCP's  failure  to
    13  achieve  the target medicaid revenue percentage for the applicable year,
    14  calculated on a provider specific  basis  utilizing  revenues  for  this
    15  purpose,  expressed  as  a  proportion  of  the total of each CHHA's and
    16  LTHHCP's failure to achieve the target medicaid revenue  percentage  for
    17  the  applicable  year within the applicable regional group. This propor-
    18  tion shall be multiplied by the applicable year's state share  reduction
    19  amount  calculation pursuant to paragraph (b) or (c) of subdivision 6 of
    20  this section. This amount shall be called the  provider  specific  state
    21  share reduction amount for the applicable year.
    22    8.  (a)  The 1996 provider specific state share reduction amount shall
    23  be due to the state from each CHHA and LTHHCP and may be recouped by the

    24  state by March 31, 1997 in a lump sum amount or  amounts  from  payments
    25  due  to  the  CHHA  and  LTHHCP pursuant to title 11 of article 5 of the
    26  social services law.
    27    (b) The provider specific state share reduction amount for 1997, 1998,
    28  1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009,  2010,
    29  2011,  2012, [and] 2013, 2014 and 2015 respectively, shall be due to the
    30  state from each CHHA and LTHHCP and each year the amount  due  for  such
    31  year may be recouped by the state by March 31 of the following year in a
    32  lump  sum  amount  or  amounts  from payments due to the CHHA and LTHHCP
    33  pursuant to title 11 of article 5 of the social services law.
    34    9. CHHAs and LTHHCPs shall submit such data and  information  at  such
    35  times  as  the  commissioner  of health may require for purposes of this

    36  section. The commissioner of health may use data available  from  third-
    37  party payors.
    38    10. On or about June 1, 1997, for each regional group the commissioner
    39  of  health  shall  calculate for the period August 1, 1996 through March
    40  31, 1997 a medicaid revenue percentage,  a  reduction  factor,  a  state
    41  share  reduction  amount,  and a provider specific state share reduction
    42  amount in accordance with the methodology provided in paragraph  (a)  of
    43  subdivision 2, paragraph (a) of subdivision 5, paragraph (a) of subdivi-
    44  sion  6 and paragraph (a) of subdivision 7 of this section. The provider
    45  specific state share reduction amount calculated in accordance with this
    46  subdivision shall be compared to the 1996 provider specific state  share
    47  reduction amount calculated in accordance with paragraph (a) of subdivi-
    48  sion 7 of this section. Any amount in excess of the amount determined in

    49  accordance  with paragraph (a) of subdivision 7 of this section shall be
    50  due to the state from each CHHA  and  LTHHCP  and  may  be  recouped  in
    51  accordance  with  paragraph (a) of subdivision 8 of this section. If the
    52  amount is less than the amount determined in accordance  with  paragraph
    53  (a)  of  subdivision 7 of this section, the difference shall be refunded
    54  to the CHHA and LTHHCP by the state no later than July 15,  1997.  CHHAs
    55  and  LTHHCPs  shall  submit  data  for the period August 1, 1996 through
    56  March 31, 1997 to the commissioner of health by April 15, 1997.

        S. 2606--D                         71                         A. 3006--D
 
     1    11. If a CHHA or LTHHCP  fails  to  submit  data  and  information  as
     2  required for purposes of this section:
     3    (a) such CHHA or LTHHCP shall be presumed to have no decrease in medi-

     4  caid  revenue  percentage  between  the  applicable  base period and the
     5  applicable target period for purposes of the  calculations  pursuant  to
     6  this section; and
     7    (b)  the  commissioner of health shall reduce the current rate paid to
     8  such CHHA and such LTHHCP by state  governmental  agencies  pursuant  to
     9  article  36  of the public health law by one percent for a period begin-
    10  ning on the first day of the calendar month following the applicable due
    11  date as established by the commissioner of health and  continuing  until
    12  the last day of the calendar month in which the required data and infor-
    13  mation are submitted.
    14    12. The commissioner of health shall inform in writing the director of
    15  the  budget  and the chair of the senate finance committee and the chair
    16  of the assembly ways and means committee of the results  of  the  calcu-
    17  lations pursuant to this section.

    18    §  15.  Subdivision  5-a  of  section 246 of chapter 81 of the laws of
    19  1995, amending the public health law and other laws relating to  medical
    20  reimbursement  and welfare reform, as amended by section 15 of part D of
    21  chapter 59 of the laws of 2011, is amended to read as follows:
    22    5-a. Section sixty-four-a of this act shall be deemed to have been  in
    23  full  force and effect on and after April 1, 1995 through March 31, 1999
    24  and on and after July 1, 1999 through March 31, 2000 and  on  and  after
    25  April  1,  2000  through  March  31, 2003 and on and after April 1, 2003
    26  through March 31, 2007, and on and after April 1, 2007 through March 31,
    27  2009, and on and after April 1, 2009 through March 31, 2011, and on  and
    28  after  April  1,  2011 through March 31, 2013, and on and after April 1,
    29  2013 through March 31, 2015;

    30    § 16. Section 64-b of chapter 81 of the laws  of  1995,  amending  the
    31  public  health  law and other laws relating to medical reimbursement and
    32  welfare reform, as amended by section 16 of part D of chapter 59 of  the
    33  laws of 2011, is amended to read as follows:
    34    §  64-b.  Notwithstanding  any  inconsistent  provision  of  law,  the
    35  provisions of subdivision 7 of section 3614 of the public health law, as
    36  amended, shall remain and be in full force and effect on April  1,  1995
    37  through March 31, 1999 and on July 1, 1999 through March 31, 2000 and on
    38  and after April 1, 2000 through March 31, 2003 and on and after April 1,
    39  2003  through  March  31,  2007,  and on and after April 1, 2007 through
    40  March 31, 2009, and on and after April 1, 2009 through March  31,  2011,
    41  and  on and after April 1, 2011 through March 31, 2013, and on and after

    42  April 1, 2013 through March 31, 2015.
    43    § 17. Subdivision 1 of section 20 of chapter 451 of the laws of  2007,
    44  amending  the  public health law, the social services law and the insur-
    45  ance  law,  relating  to  providing  enhanced  consumer   and   provider
    46  protections,  as  amended  by  section 17 of part D of chapter 59 of the
    47  laws of 2011, is amended to read as follows:
    48    1. sections four, eleven and thirteen  of this act shall  take  effect
    49  immediately  and  shall  expire  and  be deemed repealed June 30, [2013]
    50  2015;
    51    § 18. The opening paragraph of subdivision 7-a of section 3614 of  the
    52  public  health  law, as amended by section 18 of part D of chapter 59 of
    53  the laws of 2011, is amended to read as follows:
    54    Notwithstanding any inconsistent provision of law or  regulation,  for

    55  the  purposes  of establishing rates of payment by governmental agencies
    56  for long term home health care programs for the period April first,  two

        S. 2606--D                         72                         A. 3006--D
 
     1  thousand five, through December thirty-first, two thousand five, and for
     2  the  period  January first, two thousand six through March thirty-first,
     3  two thousand seven, and on and after April  first,  two  thousand  seven
     4  through  March  thirty-first,  two thousand nine, and on and after April
     5  first, two thousand nine through March thirty-first, two thousand  elev-
     6  en,  and  on  and  after  April first, two thousand eleven through March
     7  thirty-first, two thousand thirteen and on and after  April  first,  two
     8  thousand  thirteen through March thirty-first, two thousand fifteen, the

     9  reimbursable base year administrative and general costs of a provider of
    10  services shall not exceed the statewide average  of  total  reimbursable
    11  base  year  administrative  and  general  costs  of  such  providers  of
    12  services.
    13    § 19. Intentionally omitted.
    14    § 20.  Subdivision 6-a of section 93 of part C of chapter  58  of  the
    15  laws  of 2007 amending the social services law and the public health law
    16  relating to adjustments of rates, as amended by section 40 of part D  of
    17  chapter 58 of the laws of 2009, is amended to read as follows:
    18    6-a.  section  fifty-seven  of  this  act  shall  expire and be deemed
    19  repealed on December 31, [2013] 2018; provided that the amendments  made
    20  by such section to subdivision 4 of section 366-c of the social services
    21  law  shall  apply  with  respect  to  determining initial and continuing

    22  eligibility for medical assistance, including the continued  eligibility
    23  of recipients originally determined eligible prior to the effective date
    24  of  this  act, and provided further that such amendments shall not apply
    25  to any person or group of persons if it is  subsequently  determined  by
    26  the  Centers  for Medicare and Medicaid services or by a court of compe-
    27  tent jurisdiction that medical assistance with federal financial partic-
    28  ipation is available for the costs of services provided to  such  person
    29  or persons under the provisions of subdivision 4 of section 366-c of the
    30  social services law in effect immediately prior to the effective date of
    31  this act.
    32    § 21. Subdivision 12 of section 246 of chapter 81 of the laws of 1995,
    33  amending  the  public  health  law  and  other  laws relating to medical
    34  reimbursement and welfare reform, as amended by section 23 of part D  of

    35  chapter 59 of the laws of 2011, is amended to read as follows:
    36    12. Sections one hundred five-b through one hundred five-f of this act
    37  shall expire March 31, [2013] 2015.
    38    §  22.  Section  5  of  chapter  426 of the laws of 1983, amending the
    39  public health law relating to professional  misconduct  proceedings,  as
    40  amended  by  chapter  36  of  the  laws  of  2008, is amended to read as
    41  follows:
    42    § 5. This act shall take effect June 1, 1983 and shall remain in  full
    43  force and effect until March 31, [2013] 2018.
    44    §  23.  Section  5  of  chapter  582 of the laws of 1984, amending the
    45  public health law relating to regulating activities  of  physicians,  as
    46  amended  by  chapter  36  of  the  laws  of  2008, is amended to read as
    47  follows:

    48    § 5. This act shall take effect immediately, provided however that the
    49  provisions of this act shall remain in full force and effect until March
    50  31, [2013] 2018 at which time the provisions of this act shall be deemed
    51  to be repealed.
    52    § 24. Subparagraph (ii) of paragraph (c) of subdivision 11 of  section
    53  230  of  the  public health law, as amended by chapter 36 of the laws of
    54  2008, is amended to read as follows:
    55    (ii) Participation and membership during a  three  year  demonstration
    56  period  in  a physician committee of the Medical Society of the State of

        S. 2606--D                         73                         A. 3006--D
 
     1  New York or the New York State Osteopathic Society whose purpose  is  to
     2  confront and refer to treatment physicians who are thought to be suffer-

     3  ing  from  alcoholism,  drug abuse or mental illness. Such demonstration
     4  period shall commence on April first, nineteen hundred eighty and termi-
     5  nate  on May thirty-first, nineteen hundred eighty-three.  An additional
     6  demonstration period shall commence  on  June  first,  nineteen  hundred
     7  eighty-three  and  terminate  on  March  thirty-first,  nineteen hundred
     8  eighty-six. An additional demonstration period shall commence  on  April
     9  first,  nineteen hundred eighty-six and terminate on March thirty-first,
    10  nineteen hundred eighty-nine. An additional demonstration  period  shall
    11  commence  April  first, nineteen hundred eighty-nine and terminate March
    12  thirty-first, nineteen hundred ninety-two. An  additional  demonstration
    13  period  shall  commence  April  first,  nineteen  hundred ninety-two and
    14  terminate March thirty-first, nineteen  hundred  ninety-five.  An  addi-

    15  tional  demonstration  period  shall  commence  on April first, nineteen
    16  hundred  ninety-five  and  terminate  on  March  thirty-first,  nineteen
    17  hundred  ninety-eight. An additional demonstration period shall commence
    18  on April first, nineteen hundred ninety-eight  and  terminate  on  March
    19  thirty-first,  two  thousand  three.  An additional demonstration period
    20  shall commence on April first, two thousand three and terminate on March
    21  thirty-first, two  thousand  thirteen[;].  An  additional  demonstration
    22  period  shall  commence April first, two thousand thirteen and terminate
    23  on March thirty-first, two thousand eighteen provided, however, that the
    24  commissioner may prescribe requirements for  the  continuation  of  such
    25  demonstration  program,  including periodic reviews of such programs and

    26  submission of any reports and data necessary  to  permit  such  reviews.
    27  During  these  additional  periods,  the provisions of this subparagraph
    28  shall also apply to a physician committee of a county medical society.
    29    § 25. Section 4 of part X2 of chapter 62 of the laws of 2003, amending
    30  the public health law relating to allowing for the use of funds  of  the
    31  office  of  professional  medical  conduct for activities of the patient
    32  health information and quality improvement act of 2000,  as  amended  by
    33  section  27  of  part A of chapter 59 of the laws of 2011, is amended to
    34  read as follows:
    35    § 4. This  act  shall  take  effect  immediately;  provided  that  the
    36  provisions  of  section  one of this act shall be deemed to have been in
    37  full force and effect on and after April 1, 2003, and shall expire March

    38  31, [2013] 2015 when upon such date the provisions of such section shall
    39  be deemed repealed.
    40    § 25-a. Section 3 of chapter 906 of the laws  of  1984,  amending  the
    41  social services law relating to expanding medical assistance eligibility
    42  and  the  scope  of services available to certain persons with disabili-
    43  ties, as amended by section 69-a of part C of chapter 58 of the laws  of
    44  2008, is amended to read as follows:
    45    §  3.  This  act shall take effect on the thirtieth day after it shall
    46  have become a law and shall be of no  further  force  and  effect  after
    47  December 31, [2013] 2018, at which time the provisions of this act shall
    48  be deemed to be repealed.
    49    § 26. Notwithstanding any inconsistent provision of law, rule or regu-
    50  lation, the effectiveness of the provisions of sections 2807 and 3614 of

    51  the  public health law, section 18 of chapter 2 of the laws of 1988, and
    52  18 NYCRR 505.14(h), as they relate to time frames for  notice,  approval
    53  or  certification  of rates of payment, are hereby suspended and without
    54  force or effect for purposes of implementing the provisions of this act.
    55    § 27. Severability clause. If any clause, sentence, paragraph,  subdi-
    56  vision,  section  or  part of this act shall be adjudged by any court of

        S. 2606--D                         74                         A. 3006--D
 
     1  competent jurisdiction to be invalid, such judgment  shall  not  affect,
     2  impair or invalidate the remainder thereof, but shall be confined in its
     3  operation  to  the  clause, sentence, paragraph, subdivision, section or
     4  part  thereof  directly involved in the controversy in which such judge-

     5  ment shall have been rendered. It is hereby declared to be the intent of
     6  the legislature that this act would  have  been  enacted  even  if  such
     7  invalid provisions had not been included herein.
     8    §  28.  This  act shall take effect immediately and shall be deemed to
     9  have been in full force and effect on and after April 1, 2013;  provided
    10  that the amendments to subparagraph (ii) of paragraph (c) of subdivision
    11  11  of  section 230 of the public health law made by section twenty-four
    12  of this act shall not affect the expiration  of  such  subparagraph  and
    13  shall expire therewith.
 
    14                                   PART C
 
    15    Section  1.  Section  2807-k  of  the  public health law is amended by
    16  adding a new subdivision 5-d to read as follows:
    17    5-d. (a) Notwithstanding any inconsistent provision of  this  section,

    18  section  twenty-eight  hundred  seven-w  of  this  article  or any other
    19  contrary provision of law, and subject to the  availability  of  federal
    20  financial  participation,  for  periods  on and after January first, two
    21  thousand thirteen, through December thirty-first, two thousand  fifteen,
    22  all  funds  available  for distribution pursuant to this section, except
    23  for funds distributed pursuant to subparagraph (v) of paragraph  (b)  of
    24  subdivision five-b of this section, and all funds available for distrib-
    25  ution  pursuant to section twenty-eight hundred seven-w of this article,
    26  shall be reserved and set aside and distributed in accordance  with  the
    27  provisions of this subdivision.

    28    (b)  The commissioner shall promulgate regulations, and may promulgate
    29  emergency regulations, establishing methodologies for  the  distribution
    30  of  funds  as  described  in  paragraph (a) of this subdivision and such
    31  regulations shall include, but not be limited to, the following:
    32    (i) Such regulations shall  establish  methodologies  for  determining
    33  each  facility's  relative uncompensated care need amount based on unin-
    34  sured inpatient and outpatient units of service from the cost  reporting
    35  year  two years prior to the distribution year, multiplied by the appli-
    36  cable medicaid rates in effect January first of the  distribution  year,
    37  as summed and adjusted by a statewide cost adjustment factor and reduced

    38  by  the  sum  of  all  payment  amounts  collected  from  such uninsured
    39  patients, and as further adjusted  by  application  of  a  nominal  need
    40  computation  that shall take into account each facility's medicaid inpa-
    41  tient share.
    42    (ii) Annual distributions pursuant to such  regulations  for  the  two
    43  thousand  thirteen  through two thousand fifteen calendar years shall be
    44  in accord with the following:
    45    (A) one hundred thirty-nine  million  four  hundred  thousand  dollars
    46  shall be distributed as Medicaid Disproportionate Share Hospital ("DSH")
    47  payments to major public general hospitals; and
    48    (B)  nine hundred ninety-four million nine hundred thousand dollars as

    49  Medicaid DSH payments to eligible general hospitals,  other  than  major
    50  public general hospitals.
    51    (iii)(A)  Such  regulations  shall establish transition adjustments to
    52  the distributions made pursuant to clauses (A) and (B)  of  subparagraph
    53  (ii)  of this paragraph such that no facility experiences a reduction in
    54  indigent care pool payments pursuant to this subdivision that is greater

        S. 2606--D                         75                         A. 3006--D
 
     1  than the percentages, as specified in clause (C) of this subparagraph as
     2  compared to the average distribution that each  such  facility  received
     3  for  the three calendar years prior to two thousand thirteen pursuant to

     4  this section and section twenty-eight hundred seven-w of this article.
     5    (B)  Such  regulations  shall  also establish adjustments limiting the
     6  increases in indigent  care  pool  payments  experienced  by  facilities
     7  pursuant to this subdivision by an amount that will be, as determined by
     8  the  commissioner  and  in conjunction with such other funding as may be
     9  available for this purpose, sufficient to ensure full  funding  for  the
    10  transition adjustment payments authorized by clause (A) of this subpara-
    11  graph.
    12    (C)  No  facility  shall  experience a reduction in indigent care pool
    13  payments pursuant to this subdivision that: for the calendar year begin-
    14  ning January first, two thousand thirteen, is greater than two and  one-

    15  half  percent;  for the calendar year beginning January first, two thou-
    16  sand fourteen, is greater than five percent; and, for the calendar  year
    17  beginning  on January first, two thousand fifteen, is greater than seven
    18  and one-half percent.
    19    (iv) Such regulations shall reserve one percent of the funds available
    20  for distribution in the two thousand fourteen and two  thousand  fifteen
    21  calendar  years  pursuant to this subdivision, subdivision fourteen-f of
    22  section twenty-eight hundred seven-c of this article, and  sections  two
    23  hundred  eleven  and two hundred twelve of chapter four hundred seventy-
    24  four of the laws of nineteen hundred ninety-six, in a "financial assist-
    25  ance compliance pool" and shall establish methodologies for the distrib-

    26  ution of  such  pool  funds  to  facilities  based  on  their  level  of
    27  compliance,  as  determined  by the commissioner, with the provisions of
    28  subdivision nine-a of this section.
    29    (c) The commissioner shall annually report to  the  governor  and  the
    30  legislature  on the distribution of funds under this subdivision includ-
    31  ing, but not limited to:
    32    (i) the impact on safety net providers, including community providers,
    33  rural general hospitals and major public general hospitals;
    34    (ii) the provision of indigent care by units  of  services  and  funds
    35  distributed by general hospitals; and
    36    (iii) the extent to which access to care has been enhanced.
    37    §  2.  Subdivision 14-f of section 2807-c of the public health law, as

    38  amended by chapter 1 of the laws of 1999, is amended to read as follows:
    39    14-f. Public general hospital indigent care adjustment.  Notwithstand-
    40  ing any inconsistent provision of this section and subject to the avail-
    41  ability of federal financial participation, payment for inpatient hospi-
    42  tal   services   for   persons  eligible  for  payments  made  by  state
    43  governmental agencies for the period  January  first,  nineteen  hundred
    44  ninety-seven through December thirty-first, nineteen hundred ninety-nine
    45  and  periods  on  and  after  January  first, two thousand applicable to
    46  patients eligible for federal financial participation under title XIX of
    47  the federal social security act in medical assistance provided  pursuant
    48  to title eleven of article five of the social services law determined in
    49  accordance  with  this section shall include for eligible public general

    50  hospitals a public general hospital indigent care  adjustment  equal  to
    51  the aggregate amount of the adjustments provided for such public general
    52  hospital  for  the  period  January  first,  nineteen hundred ninety-six
    53  through December thirty-first, nineteen hundred ninety-six  pursuant  to
    54  subdivisions  fourteen-a and fourteen-d of this section on an annualized
    55  basis, [provided all federal approvals  necessary  by  federal  law  and
    56  regulation  for  federal  financial  participation  in payments made for

        S. 2606--D                         76                         A. 3006--D

     1  beneficiaries eligible for medical assistance under  title  XIX  of  the
     2  federal social security act based upon the adjustment provided herein as

     3  a  component  of  such payments are granted] provided, however, that for
     4  periods  on  and  after  January  first, two thousand thirteen an annual
     5  amount of four hundred twelve million  dollars  shall  be  allocated  to
     6  eligible  major  public hospitals based on each hospital's proportionate
     7  share of medicaid and uninsured losses to total medicaid  and  uninsured
     8  losses  for  all  eligible major public hospitals, net of any dispropor-
     9  tionate share hospital payments received pursuant  to  sections  twenty-
    10  eight  hundred seven-k and twenty-eight hundred seven-w of this article.
    11  The adjustment may be made to rates of payment or as aggregate  payments
    12  to an eligible hospital.
    13    §  3.  Paragraph  (i) of subdivision 2-a of section 2807 of the public

    14  health law, as amended by section 16 of part C of chapter 58 of the laws
    15  of 2009, is amended to read as follows:
    16    (i) Notwithstanding any provision of law to  the  contrary,  rates  of
    17  payment   by  governmental  agencies  for  general  hospital  outpatient
    18  services, general hospital emergency services  and  ambulatory  surgical
    19  services  provided  by  a general hospital established pursuant to para-
    20  graphs (a), (c) and (d) of this subdivision shall result in an aggregate
    21  increase in such rates of payment of fifty-six million dollars  for  the
    22  period  December  first,  two thousand eight through March thirty-first,
    23  two thousand nine and one  hundred  seventy-eight  million  dollars  for
    24  periods  after  April  first,  two  thousand nine, through March thirty-
    25  first, two  thousand  thirteen,  and  one  hundred  fifty-three  million

    26  dollars  for  state  fiscal  year  periods on and after April first, two
    27  thousand thirteen, provided, however, that  for  periods  on  and  after
    28  April  first, two thousand nine, such amounts may be adjusted to reflect
    29  projected decreases in fee-for-service Medicaid utilization and  changes
    30  in  case-mix  with  regard  to such services from the two thousand seven
    31  calendar year to the applicable rate year, and provided further,  howev-
    32  er,  that  funds made available as a result of any such decreases may be
    33  utilized by the commissioner to increase capitation rates paid to  Medi-
    34  caid  managed care plans and family health plus plans to cover increased
    35  payments to health care providers for ambulatory care  services  and  to
    36  increase  such  other  ambulatory care payment rates as the commissioner
    37  determines necessary to facilitate access  to  quality  ambulatory  care

    38  services.
    39    §  4.  The  opening  paragraph of subparagraph (i) of paragraph (i) of
    40  subdivision 35 of section 2807-c of the public health law, as  added  by
    41  section  3-a of part B of chapter 109 of the laws of 2010, is amended to
    42  read as follows:
    43    Notwithstanding any inconsistent provision of this subdivision or  any
    44  other  contrary  provision  of  law  and  subject to the availability of
    45  federal financial participation, for the period July first, two thousand
    46  ten through March thirty-first, two  thousand  eleven,  and  each  state
    47  fiscal  year  period  thereafter, the commissioner shall make additional
    48  inpatient hospital payments up to the aggregate upper payment limit  for
    49  inpatient hospital services after all other medical assistance payments,
    50  but  not to exceed two hundred thirty-five million five hundred thousand

    51  dollars for the period July first, two thousand ten through March  thir-
    52  ty-first,  two  thousand  eleven  [and],  three hundred fourteen million
    53  dollars for each state fiscal year beginning April first,  two  thousand
    54  eleven,  through  March thirty-first, two thousand thirteen, and no less
    55  than three hundred thirty-nine million dollars  for  each  state  fiscal
    56  year  thereafter,  to general hospitals, other than major public general

        S. 2606--D                         77                         A. 3006--D
 
     1  hospitals, providing emergency room services and  including  safety  net
     2  hospitals, which shall, for the purpose of this paragraph, be defined as
     3  having  either:  a Medicaid share of total inpatient hospital discharges

     4  of  at  least  thirty-five  percent,  including both fee-for-service and
     5  managed care discharges for acute and exempt  services;  or  a  Medicaid
     6  share  of  total  discharges  of at least thirty percent, including both
     7  fee-for-service  and  managed  care  discharges  for  acute  and  exempt
     8  services,  and  also  providing  obstetrical  services.  Eligibility  to
     9  receive such additional payments shall be based on data from the  period
    10  two  years prior to the rate year, as reported on the institutional cost
    11  report submitted to the department as of October first of the prior rate
    12  year. Such payments shall be made as  medical  assistance  payments  for
    13  fee-for-service  inpatient hospital services pursuant to title eleven of
    14  article five of the social services law for patients eligible for feder-
    15  al financial participation under title XIX of the federal social securi-

    16  ty act and in accordance with the following:
    17    § 5. This act shall take effect immediately and  shall  be  deemed  to
    18  have  been  in full force and effect on and after April 1, 2013 provided
    19  that:
    20    a. sections one, two and four of this act shall be deemed to have been
    21  in full force and effect on and after January 1, 2013; and
    22    b. the amendments to subdivision 14-f of section 2807-c of the  public
    23  health  law made by section two of this act shall not affect the expira-
    24  tion of such subdivision and shall be deemed to expire therewith.
 
    25                                   PART D
 
    26    Section 1. Subdivision 1 of section 366 of the social services law  is
    27  REPEALED and a new subdivision 1 is added to read as follows:
    28    1. (a) Definitions. For purposes of this section:
    29    (1) "benchmark coverage" refers to medical assistance coverage defined

    30  in subdivision one of section three hundred sixty-five-a of this title;
    31    (2)  "caretaker  relative"  means  a  relative of a dependent child by
    32  blood, adoption, or marriage with whom the child is living, who  assumes
    33  primary  responsibility  for  the  child's  care  and  who is one of the
    34  following:
    35    (i) the child's father,  mother,  grandfather,  grandmother,  brother,
    36  sister,  stepfather,  stepmother,  stepbrother, stepsister, uncle, aunt,
    37  first cousin, nephew, or niece; or
    38    (ii) the spouse of such parent or relative, even after the marriage is
    39  terminated by death or divorce;
    40    (3) "family size" means the number of persons counted as members of an
    41  individual's  household;  with  respect  to  individuals  whose  medical

    42  assistance  eligibility  is  based on modified adjusted gross income, in
    43  determining the family size of a pregnant woman, or of other individuals
    44  who have a pregnant woman in their  household,  the  pregnant  woman  is
    45  counted as herself plus the number of children she is expected to deliv-
    46  er;
    47    (4) "federal poverty line" means the poverty line defined and annually
    48  revised by the United States department of health and human services;
    49    (5) "household", for purposes of determining the financial eligibility
    50  of individuals whose medical assistance eligibility is based on modified
    51  adjusted gross income, shall mean:
    52    (i)  Basic  rule  for taxpayers not claimed as a tax dependent. In the

    53  case of an individual who expects to file a tax return for  the  taxable
    54  year  in  which  an  initial  determination or renewal of eligibility is

        S. 2606--D                         78                         A. 3006--D
 
     1  being made, and who does not expect to be claimed as a tax dependent  by
     2  another taxpayer, the household consists of the taxpayer and, subject to
     3  clause  (v)  of  this  subparagraph,  all  persons  whom such individual
     4  expects to claim as a tax dependent;
     5    (ii)  Basic  rule  for  individuals claimed as a tax dependent. In the
     6  case of an individual who expects to be claimed as a  tax  dependent  by
     7  another  taxpayer for the taxable year in which an initial determination

     8  or renewal of eligibility is being made, the household is the  household
     9  of the taxpayer claiming such individual as a tax dependent, except that
    10  the household must be determined in accordance with clause (iii) of this
    11  subparagraph in the case of:
    12    (A)  Individuals other than a spouse or child who expect to be claimed
    13  as a tax dependent by another taxpayer; and
    14    (B) Individuals under nineteen years of age, or under twenty-one years
    15  of age if a full-time student, who expect to be claimed by one parent as
    16  a tax dependent and are living with both parents but  whose  parents  do
    17  not expect to file a joint tax return; and
    18    (C) Individuals under nineteen years of age, or under twenty-one years

    19  of age if a full-time student, who expect to be claimed as a tax depend-
    20  ent by a non-custodial parent. For purposes of this subclause:
    21    (1) A court order or binding separation, divorce, or custody agreement
    22  establishing physical custody controls; or
    23    (2) If there is no such order or agreement or in the event of a shared
    24  custody  agreement,  the  custodial  parent  is the parent with whom the
    25  child spends most nights;
    26    (iii) Rules for individuals who neither file  a  tax  return  nor  are
    27  claimed as a tax dependent. In the case of individuals who do not expect
    28  to  file  a  Federal tax return and do not expect to be claimed as a tax
    29  dependent for the taxable year in  which  an  initial  determination  or

    30  renewal of eligibility is being made, or who are described in subclauses
    31  (A),  (B),  or  (C)  of  clause (ii) of this subparagraph, the household
    32  consists of the individual and, if living with the individual:
    33    (A) The individual's spouse;
    34    (B) The individual's children under nineteen years of  age,  or  under
    35  twenty-one years of age if a full-time student; and
    36    (C) In the case of an individual under nineteen years of age, or under
    37  twenty-one years of age if a full-time student, the individual's parents
    38  and  the  individual's  siblings  under  nineteen years of age, or under
    39  twenty-one years of age if a full-time student;
    40    (iv) Married couples. In the case of a married couple living together,

    41  each spouse will be included in  the  household  of  the  other  spouse,
    42  regardless  of  whether  they  expect  to  file a joint tax return under
    43  section six thousand thirteen of the internal revenue  code  or  whether
    44  one spouse expects to be claimed as a tax dependent by the other spouse.
    45    (v)  For  purposes  of  clause (i) of this subparagraph, if a taxpayer
    46  cannot reasonably establish that another individual is a  tax  dependent
    47  of the taxpayer for the tax year in which Medicaid is sought, the inclu-
    48  sion  of  such individual in the household of the taxpayer is determined
    49  in accordance with clause (iii) of this subparagraph.
    50    (6) "MAGI" means modified adjusted gross income;

    51    (7) "MAGI-based income" means income calculated using the same method-
    52  ologies used to determine MAGI under section 36B(d)(2)(B) of the  Inter-
    53  nal  Revenue  Code,  with  the   exception of lump sum payments, certain
    54  educational scholarships, and certain American Indian and Alaska  Native
    55  income,  as  specified  by  the  commissioner  of health consistent with
    56  federal regulation at 42 CFR 435.603 or any successor regulation;

        S. 2606--D                         79                         A. 3006--D
 
     1    (8) "MAGI household income" means, with respect to an individual whose
     2  medical assistance eligibility  is  based  on  modified  adjusted  gross
     3  income, the sum of the MAGI-based income of every person included in the

     4  individual's  MAGI household, except that it shall not include the MAGI-
     5  based  income  of the following persons if such persons are not expected
     6  to be required to file a tax return in the taxable year in which  eligi-
     7  bility for medical assistance is being determined:
     8    (i)  a biological, adopted, or step child who is included in the indi-
     9  vidual's MAGI household; or
    10    (ii) a person, other than a spouse or a biological, adopted,  or  step
    11  child,  who is expected to be claimed as a tax dependent by the individ-
    12  ual;
    13    (9) "standard coverage" refers to medical assistance coverage  defined
    14  in subdivision two of section three hundred sixty-five-a of this title.

    15    (b)  MAGI eligibility groups. Individuals listed in this paragraph are
    16  eligible for medical assistance based on modified adjusted gross income.
    17  In determining the eligibility of an individual for the MAGI eligibility
    18  group with the highest income standard under which  the  individual  may
    19  qualify,  an  amount equivalent to five percentage points of the federal
    20  poverty level for the applicable family size will be deducted  from  the
    21  household income.
    22    (1)  An  individual  is  eligible for benchmark coverage if his or her
    23  MAGI household income does not exceed one hundred  thirty-three  percent
    24  of the federal poverty line for the applicable family size and he or she
    25  is:

    26    (i) age nineteen or older and under age sixty-five; and
    27    (ii) not pregnant; and
    28    (iii)  not  entitled to or enrolled for benefits under parts A or B of
    29  title XVIII of the federal social security act; and
    30    (iv) not otherwise eligible for and receiving coverage under  subpara-
    31  graphs two and three of this paragraph; and
    32    (v)  not  a  parent  or  other caretaker relative of a dependent child
    33  under twenty-one years of age and living with such  child,  unless  such
    34  child is receiving benefits under this title or under title 1-A of arti-
    35  cle  twenty-five  of  the public health law, or otherwise is enrolled in
    36  minimum essential coverage.
    37    (2) A pregnant woman or an infant younger than  one  year  of  age  is

    38  eligible  for standard coverage if his or her MAGI household income does
    39  not exceed the MAGI-equivalent of two hundred  percent  of  the  federal
    40  poverty  line  for the applicable family size, which shall be calculated
    41  in accordance with guidance issued by the secretary of the United States
    42  department of health and human services, or an infant younger  than  one
    43  year of age who meets the presumptive eligibility requirements of subdi-
    44  vision four of section three hundred sixty-four-i of this title.
    45    (3)  A child who is at least one year of age but younger than nineteen
    46  years of age is eligible for standard coverage if his or her MAGI house-
    47  hold income does not exceed the MAGI-equivalent of one  hundred  thirty-

    48  three  percent  of  the  federal  poverty line for the applicable family
    49  size, which shall be calculated in accordance with  guidance  issued  by
    50  the  Secretary  of  the  United  States  department  of health and human
    51  services, or a child who is at least one year of age  but  younger  than
    52  nineteen years of age who meets the presumptive eligibility requirements
    53  of subdivision four of section three hundred sixty-four-i of this title.
    54    (4)  An  individual who is a pregnant woman or is a member of a family
    55  that contains a dependent child living with a parent or other  caretaker
    56  relative  is eligible for standard coverage if his or her MAGI household

        S. 2606--D                         80                         A. 3006--D
 

     1  income does not exceed the MAGI-equivalent of one hundred thirty percent
     2  of the highest amount that ordinarily would have been paid to  a  person
     3  without  any  income or resources under the family assistance program as
     4  it  existed on the first day of November, nineteen hundred ninety-seven,
     5  which shall be calculated in accordance  with  guidance  issued  by  the
     6  Secretary  of the United States department of health and human services;
     7  for purposes of this subparagraph, the  term  dependent  child  means  a
     8  person  who  is under eighteen years of age, or is eighteen years of age
     9  and a full-time student, who is deprived of parental support or care  by
    10  reason of the death, continued absence, or physical or mental incapacity

    11  of  a parent, or by reason of the unemployment of the parent, as defined
    12  by the department of health.
    13    (5) A child who is under twenty-one years of age and who was in foster
    14  care under the responsibility of the state  on  his  or  her  eighteenth
    15  birthday   is   eligible  for  standard  coverage;  notwithstanding  any
    16  provision of law to the contrary, the provisions  of  this  subparagraph
    17  shall  be effective only if and for so long as federal financial partic-
    18  ipation is available in the costs of medical assistance furnished  here-
    19  under.
    20    (6) An individual who is not otherwise eligible for medical assistance
    21  under  this section is eligible for coverage of family planning services

    22  reimbursed by the federal government at a rate of  ninety  percent,  and
    23  for  coverage of those services identified by the commissioner of health
    24  as services generally performed as part  of  or  as  a  follow-up  to  a
    25  service eligible for such ninety percent reimbursement, including treat-
    26  ment  for  sexually  transmitted diseases, if his or her income does not
    27  exceed the MAGI-equivalent of two hundred percent of the federal poverty
    28  line for the applicable  family  size,  which  shall  be  calculated  in
    29  accordance  with  guidance  issued by the secretary of the United States
    30  department of health and human services.
    31    (7) A child who is nineteen or twenty years of age living with his  or

    32  her  parent  will  be  eligible  for standard coverage if the sum of the
    33  MAGI-based income of every person included in the child's MAGI household
    34  exceeds one hundred  thirty-three  percent,  but  does  not  exceed  one
    35  hundred  fifty  percent,  of the federal poverty line for the applicable
    36  family size.
    37    (7-a) An individual is eligible for benchmark coverage if his  or  her
    38  MAGI  household  income  exceeds one hundred thirty-three percent of the
    39  federal poverty line for the applicable family size and he or she:
    40    (i) was eligible or would have been eligible  for  the  family  health
    41  plus  program  without  federal  financial participation in the costs of
    42  medical care and services under such program; and

    43    (ii) is not eligible to enroll in  a  qualified  health  plan  offered
    44  through  the  state  health benefit exchange established pursuant to the
    45  federal Patient Protection and Affordable Care Act  (P.L.  111-148),  as
    46  amended  by  the federal Health Care and Education Reconciliation Act of
    47  2010 (P.L. 111-152).
    48    (c) Non-MAGI eligibility groups. Individuals listed in this  paragraph
    49  are eligible for standard coverage. Where a financial eligibility deter-
    50  mination  must be made by the medical assistance program for individuals
    51  in these groups,  such  financial  eligibility  will  be  determined  in
    52  accordance with subdivision two of this section.
    53    (1)  An  individual  receiving  or eligible to receive federal supple-

    54  mental security income payments and/or additional state payments  pursu-
    55  ant  to  title  six  of this article; any inconsistent provision of this
    56  chapter or other law notwithstanding, the department may  designate  the

        S. 2606--D                         81                         A. 3006--D
 
     1  office  of temporary and disability assistance as its agent to discharge
     2  its responsibility, or so much of its responsibility as is permitted  by
     3  federal  law,  for  determining  eligibility for medical assistance with
     4  respect  to persons who are not eligible to receive federal supplemental
     5  security income payments but who  are  receiving  a  state  administered
     6  supplementary payment or mandatory minimum supplement in accordance with

     7  the  provisions of subdivision one of section two hundred twelve of this
     8  article.
     9    (2) An individual who, although not  receiving  public  assistance  or
    10  care  for his or her maintenance under other provisions of this chapter,
    11  has income and resources, including available support  from  responsible
    12  relatives,  that  does not exceed the amounts set forth in paragraph (a)
    13  of subdivision two of this section, and is (i) sixty-five years  of  age
    14  or  older,  or certified blind or certified disabled or (ii) for reasons
    15  other than income or resources, is  eligible  for  federal  supplemental
    16  security income benefits and/or additional state payments.
    17    (3)  An  individual  who,  although not receiving public assistance or

    18  care for his or her maintenance under other provisions of this  chapter,
    19  has income, including available support from responsible relatives, that
    20  does  not  exceed  the amounts set forth in paragraph (a) of subdivision
    21  two of this section, and is (i) under the age of  twenty-one  years,  or
    22  (ii)  a  spouse of a cash public assistance recipient living with him or
    23  her and essential or necessary to his or her welfare and whose needs are
    24  taken into account in determining the amount of his or her cash payment,
    25  or (iii) for reasons other  than  income,  would  meet  the  eligibility
    26  requirements  of  the aid to dependent children program as it existed on
    27  the sixteenth day of July, nineteen hundred ninety-six.

    28    (4) A child in foster care, or  a  child  described  in  section  four
    29  hundred fifty-four or four hundred fifty-eight-d of this chapter.
    30    (5) A disabled individual at least sixteen years of age, but under the
    31  age  of  sixty-five,  who:    would  be  eligible for benefits under the
    32  supplemental security income program but for earnings in excess  of  the
    33  allowable  limit;  has  net  available  income  that does not exceed two
    34  hundred fifty percent of the applicable federal income official  poverty
    35  line,  as  defined and updated by the United States department of health
    36  and human services, for a one-person or two-person household, as defined
    37  by the commissioner in regulation; has household resources,  as  defined

    38  in paragraph (e) of subdivision two of section three hundred sixty-six-c
    39  of this title, other than retirement accounts, that do not exceed twenty
    40  thousand  dollars  for a one-person household or thirty thousand dollars
    41  for a two-person household, as defined  by  the  commissioner  in  regu-
    42  lation;  and  contributes  to  the  cost  of medical assistance provided
    43  pursuant to this subparagraph in accordance with subdivision  twelve  of
    44  section  three hundred sixty-seven-a of this title; for purposes of this
    45  subparagraph, disabled means having a medically determinable  impairment
    46  of  sufficient  severity  and  duration  to  qualify  for benefits under
    47  section 1902(a)(10)(A)(ii)(xv) of the social security act.

    48    (6) An individual at least sixteen years of age, but under the age  of
    49  sixty-five, who: is employed; ceases to be in receipt of medical assist-
    50  ance  under  subparagraph  five of this paragraph because the person, by
    51  reason of medical improvement, is determined at the time of a  regularly
    52  scheduled  continuing  disability  review  to  no longer be eligible for
    53  supplemental security income program benefits  or  disability  insurance
    54  benefits  under  the  social  security  act;  continues to have a severe
    55  medically determinable impairment, to be determined in  accordance  with
    56  applicable  federal  regulations; and contributes to the cost of medical

        S. 2606--D                         82                         A. 3006--D
 

     1  assistance provided pursuant to this  subparagraph  in  accordance  with
     2  subdivision twelve of section three hundred sixty-seven-a of this title;
     3  for purposes of this subparagraph, a person is considered to be employed
     4  if  the  person  is  earning  at least the applicable minimum wage under
     5  section six of the federal fair labor standards act and working at least
     6  forty hours per month; or
     7    (7) An individual receiving treatment for breast  or  cervical  cancer
     8  who  meets  the eligibility requirements of paragraph (d) of subdivision
     9  four of this section or  the  presumptive  eligibility  requirements  of
    10  subdivision five of section three hundred sixty-four-i of this title.
    11    (8) An individual receiving treatment for colon or prostate cancer who

    12  meets  the eligibility requirements of paragraph (e) of subdivision four
    13  of this section or the presumptive eligibility requirements of  subdivi-
    14  sion five of section three hundred sixty-four-i of this title.
    15    (9) An individual who:
    16    (i) is under twenty-six years of age; and
    17    (ii)  was  in foster care under the responsibility of the state on his
    18  or her eighteenth birthday; and
    19    (iii) was in receipt of medical assistance under this title  while  in
    20  foster care; and
    21    (iv)  is  not  otherwise  eligible  for  medical assistance under this
    22  title.
    23    (10) A resident of a home for adults operated  by  a  social  services
    24  district, or a residential care center for adults or community residence

    25  operated  or  certified  by  the  office  of mental health, and has not,
    26  according to criteria promulgated by the department consistent with this
    27  title, sufficient income, or in the case of a person sixty-five years of
    28  age or older, certified blind, or certified disabled, sufficient  income
    29  and  resources,  including available support from responsible relatives,
    30  to meet all the costs of required medical care  and  services  available
    31  under this title.
    32    (d)  Conditions  of  eligibility.  A  person shall not be eligible for
    33  medical assistance under this title unless he or she:
    34    (1) is a resident of the state, or, while temporarily  in  the  state,
    35  requires  immediate  medical  care  which  is  not  otherwise available,

    36  provided that such person did not enter the state  for  the  purpose  of
    37  obtaining such medical care; and
    38    (2)  assigns  to  the  appropriate  social services official or to the
    39  department, in accordance with department regulations: (i) any  benefits
    40  which  are available to him or her individually from any third party for
    41  care or other medical benefits available under this title and which  are
    42  otherwise  assignable  pursuant to a contract or any agreement with such
    43  third party; or (ii) any rights, of  the  individual  or  of  any  other
    44  person  who  is  eligible for medical assistance under this title and on
    45  whose behalf the individual  has  the  legal  authority  to  execute  an

    46  assignment  of  such  rights,  to  support  specified as support for the
    47  purpose of medical care by a court or administrative order; and
    48    (3) cooperates with the appropriate social services  official  or  the
    49  department  in  establishing paternity or in establishing, modifying, or
    50  enforcing a support order with respect to his or  her  child;  provided,
    51  however,  that  nothing herein contained shall be construed to require a
    52  payment under this title for care or services, the cost of which may  be
    53  met in whole or in part by a third party; notwithstanding the foregoing,
    54  a  social  services  official  shall not require such cooperation if the
    55  social services official or the department determines that such  actions

    56  would  be  detrimental  to the best interest of the child, applicant, or

        S. 2606--D                         83                         A. 3006--D
 
     1  recipient, or with respect to pregnant women during pregnancy and during
     2  the sixty-day period beginning on the last day of pregnancy, in  accord-
     3  ance  with  procedures  and  criteria  established by regulations of the
     4  department consistent with federal law; and
     5    (4) applies for and utilizes group health insurance benefits available
     6  through  a  current  or former employer, including benefits for a spouse
     7  and dependent children,  in  accordance  with  the  regulations  of  the
     8  department.
     9    (e)  Conditions of coverage. An otherwise eligible person shall not be

    10  entitled to medical assistance coverage of care, services, and  supplies
    11  under this title while he or she:
    12    (1)  is  an  inmate  or  patient in an institution or facility wherein
    13  medical assistance may not be provided  in  accordance  with  applicable
    14  federal  or state requirements, except for persons described in subpara-
    15  graph ten of paragraph (c) of this subdivision or subdivision  one-a  or
    16  subdivision one-b of this section; or
    17    (2)  is  a  patient in a public institution operated primarily for the
    18  treatment of tuberculosis or care of the  mentally  disabled,  with  the
    19  exception  of:  (i)  a  person  sixty-five  years  of age or older and a
    20  patient in any such institution; (ii) a person under twenty-one years of

    21  age and receiving in-patient psychiatric services in a  public  institu-
    22  tion  operated  primarily for the care of the mentally disabled; (iii) a
    23  patient in a public institution operated primarily for the care  of  the
    24  mentally  retarded  who  is  receiving medical care or treatment in that
    25  part of such institution that has been approved pursuant  to  law  as  a
    26  hospital  or  nursing home; (iv) a patient in an institution operated by
    27  the state department of mental hygiene, while under care in  a  hospital
    28  on  release  from  such institution for the purpose of receiving care in
    29  such hospital; or (v) is a person residing in a community residence or a
    30  residential care center for adults.
    31    § 2. Subdivision 4 of section  366  of  the  social  services  law  is

    32  REPEALED and a new subdivision 4 is added to read as follows:
    33    4. Special eligibility provisions.
    34    (a) Transitional medical assistance.
    35    (1)  Notwithstanding any other provision of law, each family which was
    36  eligible for medical assistance pursuant to subparagraph four  of  para-
    37  graph  (b) of subdivision one of this section in at least one of the six
    38  months immediately preceding the month in which such family became inel-
    39  igible for such assistance because of income from the employment of  the
    40  caretaker  relative shall, while such family includes a dependent child,
    41  remain eligible for medical assistance for twelve calendar months  imme-
    42  diately  following  the  month  in  which such family would otherwise be

    43  determined to be ineligible  for  medical  assistance  pursuant  to  the
    44  provisions of this title and the regulations of the department governing
    45  income  and  resource limitations relating to eligibility determinations
    46  for families described in subparagraph four of paragraph (b) of subdivi-
    47  sion one of this section.
    48    (2) (i) Upon  giving  notice  of  termination  of  medical  assistance
    49  provided  pursuant  to subparagraph four of paragraph (b) of subdivision
    50  one of this section, the department shall notify each such family of its
    51  rights to extended benefits under subparagraph one of this paragraph and
    52  describe the conditions under which such extension may be terminated.
    53    (ii) The department  shall  promulgate  regulations  implementing  the

    54  requirements of this subparagraph and subparagraph one of this paragraph
    55  relating  to  the conditions under which extended coverage hereunder may
    56  be terminated, the scope of coverage, and  the  conditions  under  which

        S. 2606--D                         84                         A. 3006--D
 
     1  coverage  may be extended pending a redetermination of eligibility. Such
     2  regulations shall, at a minimum, provide for: termination of such cover-
     3  age at the close of the first  month  in  which  the  family  ceases  to
     4  include  a dependent child; notice of termination prior to the effective
     5  date of any terminations;  coverage  under  employee  health  plans  and
     6  health  maintenance  organizations;  and disqualification of persons for

     7  extended coverage benefits under this paragraph for fraud.
     8    (3) Notwithstanding any inconsistent provision  of  law,  each  family
     9  which  was eligible for medical assistance pursuant to subparagraph four
    10  of paragraph (b) of subdivision one of this section in at least three of
    11  the six months immediately preceding the  month  in  which  such  family
    12  became  ineligible for such assistance as a result, wholly or partly, of
    13  the collection or increased collection of spousal  support  pursuant  to
    14  part  D  of  title  IV  of  the  federal social security act, shall, for
    15  purposes of medical assistance eligibility, be considered to be eligible
    16  for medical assistance pursuant to subparagraph four of paragraph (b) of

    17  subdivision one of this section for an additional four  calendar  months
    18  beginning with the month ineligibility for such assistance begins.
    19    (b) Pregnant women and children.
    20    (1)  A  pregnant  woman eligible for medical assistance under subpara-
    21  graph two or four of paragraph (b) of subdivision one of this section on
    22  any day of her pregnancy will continue to be eligible for such care  and
    23  services  through the end of the month in which the sixtieth day follow-
    24  ing the end of the pregnancy occurs, without regard to any change in the
    25  income of the family that includes the  pregnant  woman,  even  if  such
    26  change  otherwise would have rendered her ineligible for medical assist-
    27  ance.

    28    (2) A child born to a woman eligible for and receiving medical assist-
    29  ance on the date of the child's birth shall be deemed  to  have  applied
    30  for  medical assistance and to have been found eligible for such assist-
    31  ance on the date of such birth and to remain eligible for  such  assist-
    32  ance  for  a period of one year, so long as the child is a member of the
    33  woman's household and the woman remains eligible for such assistance  or
    34  would remain eligible for such assistance if she were pregnant.
    35    (3)  A  child under the age of nineteen who is determined eligible for
    36  medical assistance under the provisions of this section, shall, consist-
    37  ent with applicable  federal  requirements,  remain  eligible  for  such
    38  assistance until the earlier of:

    39    (i)  the  last  day  of the month which is twelve months following the
    40  determination or redetermination of eligibility for such assistance; or
    41    (ii) the last day of the month in which the child reaches the  age  of
    42  nineteen.
    43    (4) An infant eligible under subparagraph two or four of paragraph (b)
    44  of  subdivision one of this section who is receiving medically necessary
    45  in-patient services for which medical assistance is provided on the date
    46  the child attains one year of age, and who, but for attaining such  age,
    47  would  remain  eligible  for medical assistance under such subparagraph,
    48  shall continue to remain eligible until the end of the  stay  for  which
    49  in-patient services are being furnished.

    50    (5)  A  child  eligible  under  subparagraph three of paragraph (b) of
    51  subdivision one of this section who  is  receiving  medically  necessary
    52  in-patient services for which medical assistance is provided on the date
    53  the child attains nineteen years of age, and who, but for attaining such
    54  age,  would remain eligible for medical assistance under this paragraph,
    55  shall continue to remain eligible until the end of the  stay  for  which
    56  in-patient services are being furnished.

        S. 2606--D                         85                         A. 3006--D
 
     1    (6)  A  woman  who was pregnant while in receipt of medical assistance
     2  who subsequently loses her eligibility for medical assistance shall have

     3  her eligibility for medical assistance continued for a period  of  twen-
     4  ty-four  months  from  the  end  of  the month in which the sixtieth day
     5  following  the end of her pregnancy occurs, but only for Federal Title X
     6  services which are eligible for reimbursement by the federal  government
     7  at a rate of ninety percent; provided, however, that such ninety percent
     8  limitation  shall  not apply to those services identified by the commis-
     9  sioner  as  services,  including  treatment  for  sexually   transmitted
    10  diseases,  generally performed as part of or as a follow-up to a service
    11  eligible for such ninety percent reimbursement;  and  provided  further,
    12  however,  that  nothing  in  this  paragraph  shall  be deemed to affect

    13  payment for such Title X services if federal financial participation  is
    14  not available for such care, services and supplies.
    15    (c)   Continuous   coverage  for  adults.  Notwithstanding  any  other
    16  provision of law, a person whose eligibility for medical  assistance  is
    17  based  on  the  modified  adjusted  gross  income  of  the person or the
    18  person's household, and who loses eligibility for such assistance for  a
    19  reason  other than citizenship status, lack of state residence, or fail-
    20  ure to provide a valid social security  number,  before  the  end  of  a
    21  twelve  month  period  beginning  on  the effective date of the person's
    22  initial eligibility for such assistance, or before the end of  a  twelve

    23  month  period  beginning  on the date of any subsequent determination of
    24  eligibility based on modified adjusted gross income, shall have  his  or
    25  her  eligibility  for  such  assistance  continued until the end of such
    26  twelve month period, provided that federal  financial  participation  in
    27  the costs of such assistance is available.
    28    (d) Breast and cervical cancer treatment.
    29    (1)  Persons  who  are  not  eligible for medical assistance under the
    30  terms of section 1902(a)(10)(A)(i) of the federal  social  security  act
    31  are  eligible  for  medical  assistance coverage during the treatment of
    32  breast or cervical cancer, subject to the provisions of this paragraph.
    33    (2) (i) Medical  assistance  is  available  under  this  paragraph  to

    34  persons  who  are  under sixty-five years of age, have been screened for
    35  breast and/or cervical cancer under the Centers for Disease Control  and
    36  Prevention  breast  and cervical cancer early detection program and need
    37  treatment for breast or cervical cancer, and are not  otherwise  covered
    38  under  creditable  coverage  as  defined  in  the  federal public health
    39  service act; provided however that medical assistance shall be furnished
    40  pursuant to this clause only to the extent permitted under federal  law,
    41  if,  for  so  long  as, and to the extent that federal financial partic-
    42  ipation is available therefor.
    43    (ii) Medical assistance is available under this paragraph  to  persons

    44  who  meet  the  requirements  of clause (i) of this subparagraph but for
    45  their age and/or gender, who have been screened for breast and/or cervi-
    46  cal cancer under the program described in title one-A of  article  twen-
    47  ty-four of the public health law and need treatment for breast or cervi-
    48  cal  cancer,  and are not otherwise covered under creditable coverage as
    49  defined in the federal public health service act; provided however  that
    50  medical  assistance  shall  be furnished pursuant to this clause only if
    51  and for so long as the provisions of clause (i) of this subparagraph are
    52  in effect.
    53    (3) Medical assistance provided to a person under this paragraph shall
    54  be limited to the period in which such  person  requires  treatment  for

    55  breast or cervical cancer.

        S. 2606--D                         86                         A. 3006--D
 
     1    (4)  (i)  The commissioner of health shall promulgate such regulations
     2  as may be necessary to carry out the provisions of this paragraph.  Such
     3  regulations  shall  include, but not be limited to: eligibility require-
     4  ments; a description of the medical services which are  covered;  and  a
     5  process  for  providing presumptive eligibility when a qualified entity,
     6  as defined by the commissioner, determines on the basis  of  preliminary
     7  information  that  a person meets the requirements for eligibility under
     8  this paragraph.
     9    (ii) For purposes of determining eligibility  for  medical  assistance

    10  under  this  paragraph, resources available to such individual shall not
    11  be considered nor required to be applied  toward  the  payment  or  part
    12  payment  of  the  cost  of medical care, services and supplies available
    13  under this paragraph.
    14    (iii) An individual shall be eligible for presumptive eligibility  for
    15  medical  assistance  under this paragraph in accordance with subdivision
    16  five of section three hundred sixty-four-i of this title.
    17    (5) The commissioner of health shall, consistent with this title, make
    18  any necessary amendments  to  the  state  plan  for  medical  assistance
    19  submitted pursuant to section three hundred sixty-three-a of this title,
    20  in order to ensure federal financial participation in expenditures under

    21  this  paragraph.  Notwithstanding  any provision of law to the contrary,
    22  the provisions of clause (i) of subparagraph two of this paragraph shall
    23  be effective only if and for so long as federal financial  participation
    24  is available in the costs of medical assistance furnished thereunder.
    25    (e) Colon and prostate cancer treatment.
    26    (1)  Notwithstanding  any  other  provision  of law to the contrary, a
    27  person who has been screened or referred  for  screening  for  colon  or
    28  prostate  cancer  by  the cancer services screening program, as adminis-
    29  tered by the department of health, and has been diagnosed with colon  or
    30  prostate  cancer  is eligible for medical assistance for the duration of
    31  his or her treatment for such cancer.

    32    (2) Persons eligible for medical assistance under this paragraph shall
    33  have an income of two hundred fifty percent or less  of  the  comparable
    34  federal  income official poverty line as defined and annually revised by
    35  the federal office of management and budget.
    36    (3) An individual shall be eligible for  presumptive  eligibility  for
    37  medical  assistance  under this paragraph in accordance with subdivision
    38  five of section three hundred sixty-four-i of this title.
    39    (4) Medical assistance is available under this  paragraph  to  persons
    40  who  are  under  sixty-five  years of age, and are not otherwise covered
    41  under creditable coverage  as  defined  in  the  federal  Public  Health
    42  Service Act.

    43    §  3.  Paragraph  (a)  of subdivision 4 of section 364-i of the social
    44  services law, as added by section 29-a of part A of chapter  58  of  the
    45  laws of 2007, is amended to read as follows:
    46    (a) Notwithstanding any inconsistent provision of law to the contrary,
    47  a  child  shall  be presumed to be eligible for medical assistance under
    48  this title beginning on the date that a qualified entity, as defined  in
    49  paragraph  (c)  of this subdivision, determine, on the basis of prelimi-
    50  nary information, that the [net] MAGI household income of the child does
    51  not exceed the applicable level for eligibility as provided for pursuant
    52  to subparagraph two or three  of  paragraph  [(u)]  (b)  of  subdivision
    53  [four] one of section three hundred sixty-six of this title.

    54    §  4.  Paragraph  (a)  of subdivision 5 of section 364-i of the social
    55  services law, as added by chapter 176 of the laws of 2006, is amended to
    56  read as follows:

        S. 2606--D                         87                         A. 3006--D
 
     1    (a) An individual shall be presumed to be eligible for medical assist-
     2  ance under this title beginning on the date that a qualified entity,  as
     3  defined  in  paragraph (c) of this subdivision, determines, on the basis
     4  of preliminary information, that the individual meets  the  requirements
     5  of  paragraph  [(v)  or (v-1)] (d) or (e) of subdivision four of section
     6  three hundred sixty-six of this title.
     7    § 5. Subdivision 6 of section 364-i of the  social  services  law,  as
     8  added by chapter 484 of the laws of 2009 and paragraph (a-2) as added by

     9  section  76  of  part H of chapter 59 of the laws of 2011, is amended to
    10  read as follows:
    11    6. (a) A pregnant woman shall be presumed to be eligible for [coverage
    12  of services described in paragraph  (c)  of  this  subdivision]  medical
    13  assistance  under  this title, excluding inpatient services and institu-
    14  tional long term care, beginning  on  the  date  that  a  prenatal  care
    15  provider,  licensed  under article twenty-eight of the public health law
    16  or other prenatal care provider approved by  the  department  of  health
    17  determines,  on  the basis of preliminary information, that the pregnant
    18  woman's [family has: (i) subject to the approval of the federal  Centers
    19  for  Medicare  and  Medicaid Services, gross income that does not exceed

    20  two hundred thirty percent of the federal poverty line (as  defined  and
    21  annually  revised  by  the  United States department of health and human
    22  services) for a family of the same size, or (ii) in the absence of  such
    23  approval,  net  income  that  does not exceed two hundred percent of the
    24  federal poverty line (as defined and  annually  revised  by  the  United
    25  States department of health and human services) for a family of the same
    26  size.]  MAGI household income does not exceed the MAGI-equivalent of two
    27  hundred percent of the federal poverty line for  the  applicable  family
    28  size.
    29    (a-2)  At the time of application for presumptive eligibility pursuant
    30  to this subdivision, a pregnant woman who resides in a  social  services

    31  district  that has implemented the state's managed care program pursuant
    32  to section three hundred  sixty-four-j  of  this  title  must  choose  a
    33  managed  care  provider. If a managed care provider is not chosen at the
    34  time of application, the pregnant woman will be assigned  to  a  managed
    35  care provider in accordance with subparagraphs (ii), (iii), (iv) and (v)
    36  of  paragraph  (f)  of  subdivision four of section three hundred sixty-
    37  four-j of this title.
    38    (b) Such presumptive eligibility shall continue  through  the  earlier
    39  of:   the day on which eligibility is determined pursuant to this title;
    40  or the last day of the month following the month in which  the  provider
    41  makes  preliminary  determination,  in  the case of a pregnant woman who
    42  does not file an application for medical assistance on  or  before  such
    43  day.

    44    (c)  [A presumptively eligible pregnant woman is eligible for coverage
    45  of:
    46    (i) all medical care,  services,  and  supplies  available  under  the
    47  medical  assistance  program,  excluding inpatient services and institu-
    48  tional long term care, if the woman's family has:  (A)  subject  to  the
    49  approval  of  the  federal  Centers  for Medicare and Medicaid Services,
    50  gross income that does not exceed one  hundred  twenty  percent  of  the
    51  federal  poverty  line  (as  defined  and annually revised by the United
    52  States department of health and human services) for a family of the same
    53  size, or (B) in the absence of such approval, net income that  does  not
    54  exceed  one  hundred percent of the federal poverty line (as defined and

    55  annually revised by the United States department  of  health  and  human
    56  services) for a family of the same size; or

        S. 2606--D                         88                         A. 3006--D

     1    (ii) prenatal care services as described in subparagraph four of para-
     2  graph (o) of subdivision four of section three hundred sixty-six of this
     3  title,  if  the  woman's  family has: (A) subject to the approval of the
     4  federal Centers for Medicare and Medicaid Services,  gross  income  that
     5  exceeds  one  hundred  twenty  percent  of  the federal poverty line (as
     6  defined and annually revised by the United States department  of  health
     7  and  human  services) for families of the same size, but does not exceed

     8  two hundred thirty percent of such federal poverty line, or (B)  in  the
     9  absence  of  such  approval, net income that exceeds one hundred percent
    10  but does not exceed two hundred percent of the federal poverty line  (as
    11  defined  and  annually revised by the United States department of health
    12  and human services) for a family of the same size.
    13    (d)] The department of health shall provide  prenatal  care  providers
    14  licensed  under  article twenty-eight of the public health law and other
    15  approved prenatal care providers with such forms as are necessary for  a
    16  pregnant  woman  to apply and information on how to assist such women in
    17  completing and filing such forms. A qualified provider which  determines
    18  that  a pregnant woman is presumptively eligible shall notify the social

    19  services district in which the pregnant woman resides  of  the  determi-
    20  nation  within  five  working days after the date on which such determi-
    21  nation is made and shall inform the woman at the time the  determination
    22  is  made that she is required to make application by the last day of the
    23  month following the month in which the determination is made.
    24    [(e)] (d) Notwithstanding any other provision of  law,  care  that  is
    25  furnished  to  a  pregnant  woman  pursuant to this subdivision during a
    26  presumptive eligibility period shall be deemed as medical assistance for
    27  purposes of payment and state reimbursement.
    28    [(f)] (e) Facilities licensed under article twenty-eight of the public
    29  health law providing prenatal care services  shall  perform  presumptive
    30  eligibility  determinations  and  assist women in submitting appropriate

    31  documentation to the social services district as required by the commis-
    32  sioner; provided, however, that a facility may apply to the commissioner
    33  for exemption from this requirement on the basis of undue hardship.
    34    [(g)] (f) All prenatal care providers enrolled in the medicaid program
    35  must provide prenatal  care  services  to  eligible  service  recipients
    36  determined  presumptively  eligible  for  medical assistance but not yet
    37  enrolled in the medical assistance program, and assist women in  submit-
    38  ting  appropriate  documentation  to  the  social  services  district as
    39  required by the commissioner.
    40    § 6. Subdivision 1 and the  opening  paragraph  of  subdivision  2  of
    41  section  365-a  of  the social services law, subdivision 1 as amended by
    42  chapter 110 of the laws of 1971 and the opening paragraph of subdivision

    43  2 as amended by chapter 41 of the laws of 1992, are amended to  read  as
    44  follows:
    45    [1.] The amount, nature and manner of providing medical assistance for
    46  needy  persons  shall  be determined by the public welfare official with
    47  the advice of a physician and in accordance with the local medical plan,
    48  this title, and the regulations of the department.
    49    1. "Benchmark coverage" shall mean payment of part or all of the  cost
    50  of medically necessary medical, dental, and remedial care, services, and
    51  supplies described in subdivision two of this section, and to the extent
    52  not  included  therein,  any  essential benefits as defined in 42 U.S.C.
    53  18022(b), with the exception of institutional long term  care  services;
    54  such  care,  services and supplies shall be provided consistent with the

    55  managed care program described in section three hundred sixty-four-j  of
    56  this title.

        S. 2606--D                         89                         A. 3006--D
 
     1    ["Medical  assistance"] "Standard coverage" shall mean payment of part
     2  or all of the cost of medically necessary medical, dental  and  remedial
     3  care,  services  and  supplies, as authorized in this title or the regu-
     4  lations of the department, which are  necessary  to  prevent,  diagnose,
     5  correct  or  cure  conditions  in the person that cause acute suffering,
     6  endanger life, result in  illness  or  infirmity,  interfere  with  such
     7  person's  capacity  for  normal  activity,  or threaten some significant
     8  handicap and which are furnished an eligible person in  accordance  with

     9  this  title  and  the regulations of the department. Such care, services
    10  and supplies shall include the  following  medical  care,  services  and
    11  supplies,  together  with  such  medical  care,  services  and  supplies
    12  provided for in subdivisions three, four and five of this  section,  and
    13  such  medical care, services and supplies as are authorized in the regu-
    14  lations of the department:
    15    § 7. Subdivision 1 of section 366-a of the  social  services  law,  as
    16  amended  by  section  60 of part C of chapter 58 of the laws of 2009, is
    17  amended to read as follows:
    18    1. Any person  requesting  medical  assistance  may  make  application
    19  therefor  [in  person,  through  another  in his behalf or by mail] by a
    20  written application to the social services official of the county[, city

    21  or town, or to the service officer of the city or  town]  in  which  the
    22  applicant  resides  or  is  found  or to the department of health or its
    23  agent; a phone application; or an on-line application.  [In addition, in
    24  the case of a person who is sixty-five years of age or older  and  is  a
    25  patient  in  a state hospital for tuberculosis or for the mentally disa-
    26  bled, applications may be made to the department or to a social services
    27  official designated as the agent of the department.] Notwithstanding any
    28  provision of law to the contrary, [a personal]  an  in-person  interview
    29  with the applicant or with the person who made application on his or her
    30  behalf  shall  not  be required as part of a determination of initial or

    31  continuing eligibility pursuant to this title.
    32    § 8. Paragraph (a) of subdivision 2 of section  366-a  of  the  social
    33  services  law,  as  amended by section 60 of part C of chapter 58 of the
    34  laws of 2009, is amended to read as follows:
    35    (a) Upon receipt of such application, the appropriate social  services
    36  official,  or  the department of health or its agent [when the applicant
    37  is a patient in a state hospital for the mentally disabled,] shall veri-
    38  fy the eligibility of such applicant. In accordance with the regulations
    39  of the department of health, it  shall  be  the  responsibility  of  the
    40  applicant  to  provide  information  and documentation necessary for the
    41  determination of initial and ongoing eligibility for medical assistance.
    42  If an applicant or recipient is unable to provide  necessary  documenta-

    43  tion, the [public welfare] social services official or the department of
    44  health  or  its  agent shall promptly cause an investigation to be made.
    45  Where an investigation is necessary, sources of information  other  than
    46  public  records  will be consulted only with permission of the applicant
    47  or recipient. In the event that such permission is not  granted  by  the
    48  applicant  or  recipient, or necessary documentation cannot be obtained,
    49  the social services official or the department of health  or  its  agent
    50  may  suspend  or  deny  medical  assistance until such time as it may be
    51  satisfied as to the applicant's or recipient's eligibility therefor.
    52    § 9. The opening paragraph of subdivision 3 of section  366-a  of  the
    53  social  services  law,  as  added by chapter 256 of the laws of 1966, is
    54  amended to read as follows:

    55    Upon the receipt of such application, and after the completion of  any
    56  investigation  that  shall  be deemed necessary, the appropriate [public

        S. 2606--D                         90                         A. 3006--D

     1  welfare] social services official[,] or the department of health or  its
     2  agent  [when the applicant is a patient in a state hospital for tubercu-
     3  losis or for the mentally disabled,] shall
     4    §  10. Paragraphs (b) and (c) of subdivision 5 of section 366-a of the
     5  social services law, as added by section 52 of part A of  chapter  1  of
     6  the laws of 2002, are amended to read as follows:
     7    (b)  The  commissioner  shall develop a simplified statewide recertif-
     8  ication form for use in redetermining eligibility under this title.  The

     9  form [shall] may include requests only for such information that is:
    10    (i)  reasonably  necessary  to  determine  continued  eligibility  for
    11  medical assistance under this title; and
    12    (ii) subject to change since  the  date  of  the  recipient's  initial
    13  application.
    14    (c)  [A  personal]  The  regulations required by paragraph (a) of this
    15  subdivision shall provide that:
    16    (i) the redetermination of eligibility will be made based on  reliable
    17  information  possessed  or  available to the department of health or its
    18  agent, including information accessed from databases pursuant to  subdi-
    19  vision eight of this section;
    20    (ii)  if  the  department  of  health  or its agent is unable to renew

    21  eligibility based  on  available  information,  the  recipient  will  be
    22  requested  to  supply  any such information as is necessary to determine
    23  continued eligibility for medical assistance under this title; and
    24    (iii) for persons whose medical assistance  eligibility  is  based  on
    25  modified  adjusted  gross  income,  eligibility must be renewed at least
    26  once every twelve months, unless the department of health or  its  agent
    27  receives  information about a change in a recipient's circumstances that
    28  may affect eligibility.
    29    (d) An in-person interview with the recipient shall not  automatically
    30  be required as part of a redetermination of eligibility pursuant to this
    31  subdivision unless the department of health determines otherwise.

    32    §  11.  Paragraph  (d) of subdivision 5 of section 366-a of the social
    33  services law is REPEALED.
    34    § 12. Paragraph (e) of subdivision 5 of section 366-a  of  the  social
    35  services  law, as added by section 1 of part C of chapter 58 of the laws
    36  of 2007, is amended to read as follows:
    37    [(e)] (d) The commissioner of health shall verify the accuracy of  the
    38  information  provided  by  [the]  an applicant or recipient [pursuant to
    39  paragraph (d) of this subdivision] by matching it against information to
    40  which the commissioner of health has access, including under subdivision
    41  eight of this section.  In the event [there is an inconsistency between]
    42  the information reported  by  the  recipient  [and]  is  not  reasonably

    43  compatible  with  any information obtained by the commissioner of health
    44  from other sources and such [inconsistency] incompatibility is  material
    45  to  medical  assistance  eligibility,  the  commissioner of health shall
    46  request that the recipient provide adequate documentation to verify  his
    47  or  her  place of residence or income, as applicable. In addition to the
    48  documentation of residence and income authorized by this paragraph,  the
    49  commissioner  of  health is authorized to periodically require a reason-
    50  able sample of recipients to  provide  documentation  of  residence  and
    51  income at recertification. The commissioner of health shall consult with
    52  the  medicaid inspector general regarding income and residence verifica-
    53  tion practices and procedures necessary to  maintain  program  integrity
    54  and deter fraud and abuse.

    55    §  13.  Subdivision  11 of section 364-j of the social services law is
    56  REPEALED.

        S. 2606--D                         91                         A. 3006--D
 
     1    § 14. Clause (D) of subparagraph (v) of paragraph (a) of subdivision 2
     2  of section 369-ee of the social services law, as amended by  section  67
     3  of  part  C  of  chapter  58  of the laws of 2009, is amended, and a new
     4  subparagraph (vi) is added to read as follows:
     5    (D)  is  not  described in clause (A), (B) or (C) of this subparagraph
     6  and has gross family income equal to or less than two hundred percent of
     7  the federal income official poverty line (as defined and updated by  the
     8  United  States  Department of Health and Human Services) for a family of
     9  the same size; provided, however, that eligibility under this clause  is

    10  subject  to  sources of federal and non-federal funding for such purpose
    11  described in section sixty-seven-a of [the] part  C  of  chapter  fifty-
    12  eight  of  the  laws of two thousand nine [that added this clause] or as
    13  may be available under the waiver agreement entered into with the feder-
    14  al government under section eleven hundred fifteen of the federal social
    15  security act, as jointly determined by the commissioner and the director
    16  of the division of the budget. In no case shall state funds be  utilized
    17  to  support  the  non-federal  share  of  expenditures  pursuant to this
    18  subparagraph, provided however that the commissioner may demonstrate  to
    19  the  United States department of health and human services the existence
    20  of non-federally participating state expenditures as necessary to secure

    21  federal funding under an eleven hundred fifteen waiver for the  purposes
    22  herein.  Eligibility  under  this clause may be provided to residents of
    23  all counties or, at the joint discretion of  the  commissioner  and  the
    24  director  of  the  division  of  the budget, a subset of counties of the
    25  state[.]; and
    26    (vi) makes application for benefits  pursuant  to  this  title  on  or
    27  before December thirty-first, two thousand thirteen.
    28    §  14-a. Subdivision 5 of section 369-ee of the social services law is
    29  amended by adding a new paragraph (d) to read as follows:
    30    (d) Notwithstanding the provisions of paragraph (a) of  this  subdivi-
    31  sion  or  any  other provision of law, in the case of a person receiving
    32  health care services pursuant to this title on January first, two  thou-

    33  sand fourteen, such person's eligibility shall be recertified as soon as
    34  practicable  thereafter,  and  such  person's  coverage under this title
    35  shall end on the earliest of: (i) the date the person is enrolled  in  a
    36  qualified health plan offered through a health insurance exchange estab-
    37  lished  in  accordance  with  the  requirements  of  the federal Patient
    38  Protection and Affordable Care Act (P.L. 111-148),  as  amended  by  the
    39  federal  Health  Care  and  Education  Act  of 2010 (P.L. 111-152); (ii)
    40  December thirty-first, two thousand fourteen; or (iii) the date on which
    41  the department of health ceases to have all  necessary  approvals  under
    42  federal  law  and regulation to receive federal financial participation,

    43  under the program described in title eleven  of  this  article,  in  the
    44  costs of health services provided pursuant to this section.
    45    § 15. Section 369-ee of the social services law is REPEALED.
    46    § 15-a. Section 369-ff of the social services law is REPEALED.
    47    §  16.  Subdivision  3  of section 367-a of the social services law is
    48  amended by adding a new paragraph (e) to read as follows:
    49    (e) (1) Payment of premiums for  enrolling  individuals  in  qualified
    50  health  plans  offered  through  a health insurance exchange established
    51  pursuant to the federal Patient Protection and Affordable Care Act (P.L.
    52  111-148), as amended by the federal Health Care and Education  Reconcil-
    53  iation  Act  of  2010  (P.L. 111-152), shall be available to individuals
    54  who:

    55    (i) immediately prior to being enrolled in the qualified health  plan,
    56  were or would have been eligible under the family health plus program as

        S. 2606--D                         92                         A. 3006--D
 
     1  a parent or stepparent of a child under the age of twenty-one, and whose
     2  MAGI household income, as defined in subparagraph eight of paragraph (a)
     3  of  subdivision  one  of  section three hundred sixty-six of this title,
     4  exceeds one hundred thirty-three percent of the federal poverty line for
     5  the applicable family size;
     6    (ii)  are  not  otherwise  eligible  for medical assistance under this
     7  title; and
     8    (iii) are enrolled in a standard health plan in the silver  level,  as

     9  defined in 42 U.S.C. 18022.
    10    (2)  Payment  pursuant  to  this  paragraph shall be for premium obli-
    11  gations of the individual under the  qualified  health  plan  and  shall
    12  continue  only  if  and  for  so long as the individual's MAGI household
    13  income exceeds one hundred thirty-three percent, but does not exceed one
    14  hundred fifty percent, of the federal poverty line  for  the  applicable
    15  family size.
    16    (3)  The  commissioner  of health shall submit amendments to the state
    17  plan for medical assistance and/or submit one or more  applications  for
    18  waivers  of  the  federal  social  security  act  as may be necessary to
    19  receive federal financial participation in the costs  of  payments  made

    20  pursuant  to  this paragraph; provided further, however, that nothing in
    21  this subparagraph shall be deemed to affect payments for premiums pursu-
    22  ant to this paragraph if federal financial participation in the costs of
    23  such payments is not available.
    24    § 16-a. (a) The commissioner of health shall convene  a  workgroup  to
    25  consider  issues  pertaining  to the federal option to establish a basic
    26  health program for individuals who are not eligible for medical  assist-
    27  ance under title eleven of article five of the social services law.
    28    (b)  The  workgroup  shall: evaluate federal guidance related to basic
    29  health programs; discuss fiscal, consumer, and health care impacts of  a
    30  basic  health  program;  and consider benefit package, premium and cost-
    31  sharing options for a basic health program.

    32    § 17. Section 2510 of the public health law is amended by adding a new
    33  subdivision 13 to read as follows:
    34    13. "Household income" means the sum of the  modified  adjusted  gross
    35  income of every individual included in a child's household calculated in
    36  accordance  with  applicable  federal  law  and  regulations,  as may be
    37  amended.
    38    § 18. Section 2510 of the public health law is amended by  adding  two
    39  new subdivisions 14 and 15 to read as follows:
    40    14.  "State enrollment center" means the centralized system and opera-
    41  tion of eligibility determinations by the state or  its  contractor  for
    42  all  insurance affordability programs, including the child health insur-
    43  ance program established pursuant to this title.

    44    15. "Insurance affordability programs" means those programs set  forth
    45  in section 435.4 of title 42 of the code of federal regulations.
    46    § 19. Subparagraphs (iv) and (vi) of paragraph (f) of subdivision 2 of
    47  section  2511  of  the  public health law, subparagraph (iv) as added by
    48  section 44 of part A of chapter 1 of the laws of 2002  and  subparagraph
    49  (vi)  as  added  by  section 45-b of part C of chapter 58 of the laws of
    50  2008, are amended to read as follows:
    51    (iv) In the event a household does not  provide  income  documentation
    52  required  by  subparagraph  (iii) of this paragraph within two months of
    53  the approved organization's or state enrollment center's request, which-
    54  ever is applicable, the approved organization or state enrollment center

    55  shall disenroll the child at the end of such two month period. Except as
    56  provided in  paragraph  (c)  of  subdivision  five-a  of  this  section,

        S. 2606--D                         93                         A. 3006--D
 
     1  approved  organizations shall not be obligated to repay subsidy payments
     2  made by the state on behalf of children enrolled during this  two  month
     3  period.
     4    (vi)  Any  income  verification response by the department of taxation
     5  and finance pursuant to subparagraphs (i) and  (ii)  of  this  paragraph
     6  shall  not  be  a public record and shall not be released by the commis-
     7  sioner, the department of taxation and finance [or], an approved  organ-
     8  ization,  or  the state enrollment center, except pursuant to this para-
     9  graph. Information disclosed pursuant to this paragraph shall be limited

    10  to information necessary  for  verification.  Information  so  disclosed
    11  shall be kept confidential by the party receiving such information. Such
    12  information  shall be expunged within a reasonable time to be determined
    13  by the commissioner and the department of taxation and finance.
    14    § 20. Paragraph (j) of subdivision 2 of section  2511  of  the  public
    15  health law, as added by section 45 of part A of chapter 1 of the laws of
    16  2002, is amended to read as follows:
    17    (j)  Where  an  application for recertification of coverage under this
    18  title contains insufficient information for  a  final  determination  of
    19  eligibility  for  continued coverage, a child shall be presumed eligible
    20  for a period not to exceed the earlier of two months beyond the  preced-
    21  ing  period  of eligibility or the date upon which a final determination

    22  of eligibility is made based on the submission of  additional  data.  In
    23  the event such additional information is not submitted within two months
    24  of  the  approved  organization's  or state enrollment center's request,
    25  whichever is applicable, the approved organization or  state  enrollment
    26  center  shall  disenroll  the child following the expiration of such two
    27  month period. Except as provided in paragraph (c) of subdivision  five-a
    28  of  this section, approved organizations shall not be obligated to repay
    29  subsidy payments received on behalf of children enrolled during this two
    30  month period.
    31    § 21. Subdivision 4 of section 2511  of  the  public  health  law,  as
    32  amended  by  section  70 of part B of chapter 58 of the laws of 2005, is
    33  amended to read as follows:

    34    4. Households shall report  to  the  approved  organization  or  state
    35  enrollment  center,  whichever  is  applicable,  within thirty days, any
    36  changes in New York state residency or health care coverage under insur-
    37  ance that may make a child ineligible for subsidy payments  pursuant  to
    38  this  section.  Any  individual who, with the intent to obtain benefits,
    39  willfully misstates income or residence to establish eligibility  pursu-
    40  ant  to  subdivision two of this section or willfully fails to notify an
    41  approved organization or state enrollment center of a  change  in  resi-
    42  dence  or  health care coverage pursuant to this subdivision shall repay
    43  such subsidy to the commissioner. Individuals seeking to enroll children
    44  for coverage shall be informed that such willful misstatement or failure
    45  to notify shall result in such liability.

    46    § 22. The subdivision heading and paragraphs (a) and (b)  of  subdivi-
    47  sion 5-a of section 2511 of the public health law, the subdivision head-
    48  ing  and  paragraph  (a) as added by chapter 170 of the laws of 1994 and
    49  paragraph (b) as amended by section 71 of part B of chapter  58  of  the
    50  laws of 2005, are amended to read as follows:
    51    Obligations  of approved organizations or the state enrollment center.
    52  (a) An approved organization or state enrollment  center,  whichever  is
    53  applicable, shall have the obligation to review all information provided
    54  pursuant  to  subdivision  two  of this section and shall not certify or
    55  recertify a child as eligible for a subsidy  payment  unless  the  child
    56  meets the eligibility criteria.

        S. 2606--D                         94                         A. 3006--D
 

     1    (b)  An approved organization or state enrollment center, whichever is
     2  applicable, shall promptly review all information relating to  a  poten-
     3  tial  change  in  eligibility  based on information provided pursuant to
     4  subdivision four of this section. Within  at  least  thirty  days  after
     5  receipt  of such information, the approved organization or state enroll-
     6  ment center shall make a determination whether the child is still eligi-
     7  ble for a subsidy payment and shall notify the household and the commis-
     8  sioner if it determines the child is not eligible for a subsidy payment.
     9    § 23. Paragraph (a) of subdivision 11 of section 2511  of  the  public
    10  health law, as amended by section 37 of part A of chapter 58 of the laws
    11  of 2007, is amended to read as follows:
    12    (a)  An approved organization shall submit required reports and infor-

    13  mation to the commissioner in such form and at times, at least annually,
    14  as may be required by the commissioner and specified  in  contracts  and
    15  official department of health administrative guidance, in order to eval-
    16  uate the operations and results of the program and quality of care being
    17  provided  by  such  organizations.  Such  reports  and information shall
    18  include, but not be limited to, enrollee demographics  (applicable  only
    19  until  the  state enrollment center is implemented), program utilization
    20  and expense, patient care outcomes and patient specific medical informa-
    21  tion, including encounter data maintained by  an  approved  organization
    22  for  purposes  of  quality assurance and oversight.   Any information or
    23  data collected pursuant to this paragraph shall be kept confidential  in
    24  accordance  with  Title  XXI  of  the federal social security act or any

    25  other applicable state or federal law.
    26    § 24. Subdivision 12 of section 2511 of  the  public  health  law,  as
    27  amended by chapter 2 of the laws of 1998, is amended to read as follows:
    28    12.  The  commissioner shall, in consultation with the superintendent,
    29  establish procedures to coordinate the child health insurance plan  with
    30  the medical assistance program, including but not limited to, procedures
    31  to  maximize  enrollment  of  eligible  children under those programs by
    32  identification and transfer of children who are eligible or  who  become
    33  eligible  to  receive  medical  assistance  and procedures to facilitate
    34  changes in enrollment status for children who are ineligible for  subsi-
    35  dies  under this section and for children who are no longer eligible for
    36  medical assistance in order  to  facilitate  and  ensure  continuity  of

    37  coverage.  The commissioner shall review, on an annual basis, the eligi-
    38  bility verification and recertification procedures of approved organiza-
    39  tions under this title to insure the appropriate enrollment of children.
    40  Such review shall include, but not be limited to, an audit of a  statis-
    41  tically representative sample of cases from among all approved organiza-
    42  tions  and  shall  be  applicable to any period during which an approved
    43  organization's responsibilities include determining eligibility.  In the
    44  event such review and audit reveals cases which do not meet  the  eligi-
    45  bility criteria for coverage set forth in this section, that information
    46  shall be forwarded to the approved organization and the commissioner for
    47  appropriate action.
    48    §  25. Paragraph (e) of subdivision 12-a of section 2511 of the public

    49  health law, as added by chapter 2 of the laws of 1998, is amended and  a
    50  new paragraph (f) is added to read as follows:
    51    (e)  standards  and  procedures  for  the  imposition of penalties for
    52  substantial noncompliance, which may include, but  not  be  limited  to,
    53  financial penalties in addition to penalties set forth in section twelve
    54  of  this  chapter  and  consistent with applicable federal standards, as
    55  specified in contracts, and contract termination[.]; provided however

        S. 2606--D                         95                         A. 3006--D
 
     1    (f) audit  standards  and  procedures  established  pursuant  to  this
     2  section,  including penalties, shall be applicable to eligibility deter-
     3  minations made by approved organizations only for periods  during  which

     4  an  approved  organization's responsibilities include making such eligi-
     5  bility determinations.
     6    §  26.  Paragraph  (e)  and  subparagraphs (i), (ii), (iii) and (v) of
     7  paragraph (f) of subdivision 2 of section 2511 of the public health law,
     8  paragraph (e) as added by chapter 170 of the laws of 1994 and relettered
     9  by chapter 2 of the laws of 1998, and  subparagraphs  (i)  and  (ii)  of
    10  paragraph  (f)  as  amended  by section 6 of part B of chapter 58 of the
    11  laws of 2010, subparagraph (iii) of paragraph (f) as amended by  chapter
    12  535  of  the  laws  of  2010,  and  subparagraph (v) of paragraph (f) as
    13  amended by section 7 of part J of chapter 82 of the laws  of  2002,  are
    14  amended to read as follows:
    15    (e)  is  a resident of New York state. Such residency shall be [demon-

    16  strated by] attested to by the applicant for insurance, provided  howev-
    17  er, the commissioner shall require adequate proof[, as determined by the
    18  commissioner,]  of a New York state street address in circumstances when
    19  there is an inconsistency with residency  information  from  other  data
    20  sources.  [If  the  child has no street address, such proof may include,
    21  but not be limited to, school records or other documentation  determined
    22  by the commissioner.]
    23    (i) In order to establish income eligibility under this subdivision at
    24  initial application, a household shall provide [such documentation spec-
    25  ified  in  subparagraph (iii) of this paragraph, as necessary and suffi-

    26  cient to determine a child's financial eligibility for a subsidy payment
    27  under this title] the social security numbers for each parent and legal-
    28  ly responsible adult who is  a  member  of  the  household,  subject  to
    29  subparagraph  (v)  of  this  paragraph. The commissioner [may verify the
    30  accuracy of such income information provided by the household by  match-
    31  ing  it against] shall determine eligibility based on income information
    32  contained in databases to which the commissioner has  access,  including
    33  the  state's  wage  reporting  system  pursuant  to  subdivision five of
    34  section one hundred seventy-one-a of the tax law  and  by  means  of  an
    35  income  verification  performed pursuant to a cooperative agreement with

    36  the department of taxation and finance pursuant to subdivision  four  of
    37  section  one  hundred  seventy-one-b  of the tax law.   The commissioner
    38  shall require an attestation by the household that the  income  informa-
    39  tion obtained from electronic data sources is accurate. Such attestation
    40  shall  include  any other household income information not obtained from
    41  an electronic data source that  is  necessary  to  determine  a  child's
    42  financial  eligibility  for  a  subsidy payment under this title. If the
    43  attestation is reasonably  compatible  with  information  obtained  from
    44  available  data  sources,  no  further  information  or documentation is
    45  required. If the attestation is not reasonably compatible with  informa-

    46  tion  obtained  from  available  data  sources,  documentation  shall be
    47  required as specified in subparagraph (iii) of this paragraph.
    48    (ii) In order to establish income eligibility under  this  subdivision
    49  at recertification, [a household shall attest to all information regard-
    50  ing the household's income that is necessary and sufficient to determine
    51  a  child's  financial eligibility for a subsidy payment under this title
    52  and shall provide the social security numbers for each parent and legal-
    53  ly responsible adult who is a member of the household and  whose  income
    54  is  available  to  the  child, subject to subparagraph (v) of this para-
    55  graph.  The] the commissioner [may verify the accuracy  of  such  income

    56  information provided by the household by matching it against income] may

        S. 2606--D                         96                         A. 3006--D
 
     1  make a redetermination of eligibility without requiring information from
     2  the  individual if able to do so based on reliable information contained
     3  in the individual's enrollment file or other  more  current  information
     4  contained  in  databases to which the commissioner has access, including
     5  the state's wage reporting system and by means of an income verification
     6  performed pursuant to a cooperative agreement  with  the  department  of
     7  taxation and finance pursuant to subdivision four of section one hundred
     8  seventy-one-b  of the tax law.  The commissioner shall require an attes-

     9  tation by the household that the income  information  contained  in  the
    10  enrollment  file  or  obtained from electronic data sources is accurate.
    11  Such attestation shall include any other  household  income  information
    12  not  obtained  from an electronic data source that is necessary to rede-
    13  termine a child's financial eligibility for a subsidy payment under this
    14  title. In the event that there is an inconsistency  between  the  income
    15  information attested to by the household and any information obtained by
    16  the  commissioner  from other sources pursuant to this subparagraph, and
    17  such inconsistency is material to  the  household's  eligibility  for  a
    18  subsidy  payment  under  this  title, the commissioner shall require the

    19  [approved organization to obtain] household to provide income documenta-
    20  tion [from the household] as specified in  subparagraph  (iii)  of  this
    21  paragraph.
    22    (iii) If the attestation of household income required by subparagraphs
    23  (i)  and (ii) of this paragraph is not reasonably compatible with infor-
    24  mation  obtained  from  data  sources,  further  information,  including
    25  documentation,  shall  be  required. Income documentation shall include,
    26  but not be limited to, one or more of the following for each parent  and
    27  legally  responsible  adult  who  is a member of the household and whose
    28  income is available to the child;
    29    (A) current annual income tax returns;
    30    (B) paycheck stubs;
    31    (C) written documentation of income from all employers; or

    32    (D) written documentation of income eligibility of a child for free or
    33  reduced breakfast or lunch through the school meal program certified  by
    34  the child's school, provided that:
    35    (I)  the  commissioner  may  verify  the  accuracy  of the information
    36  provided in the same manner and way as provided for in subparagraph (ii)
    37  of this paragraph; and
    38    (II) such documentation may not be suitable proof  of  income  in  the
    39  event  of  a material inconsistency in income after the commissioner has
    40  performed verification pursuant to subparagraph (ii) of this  paragraph;
    41  or
    42    (E)  other  documentation of income (earned or unearned) as determined
    43  by the commissioner, provided, however,  such  documentation  shall  set
    44  forth the source of such income.
    45    (v) In the event a household chooses not to provide the social securi-

    46  ty numbers required by [subparagraph] subparagraphs (i) and (ii) of this
    47  paragraph,  such  household shall provide income documentation specified
    48  in subparagraph (iii) of this paragraph as a condition  of  the  child's
    49  enrollment. Nothing in this paragraph shall be construed as obligating a
    50  household  to  provide  social  security  numbers  of parents or legally
    51  responsible adults as a condition of a child's enrollment or eligibility
    52  for a subsidy payment under this title.
    53    § 27. Subparagraph (ii) of paragraph (g) of subdivision 2  of  section
    54  2511  of  the  public  health law, as amended by section 29 of part A of
    55  chapter 58 of the laws of 2007, is amended to read as follows:

        S. 2606--D                         97                         A. 3006--D
 

     1    (ii) Effective September first two thousand seven, through March thir-
     2  ty-first, two thousand fourteen temporary enrollment pursuant to subpar-
     3  agraph (i) of this paragraph shall be  provided  only  to  children  who
     4  apply  for recertification of coverage under this title who appear to be
     5  eligible  for  medical  assistance under title eleven of article five of
     6  the social services law.
     7    § 28. Paragraph (a) of subdivision 2-b of section 2511 of  the  public
     8  health law, as added by section 5 of part B of chapter 58 of the laws of
     9  2010, is amended to read as follows:
    10    (a)  [Effective  October first, two thousand ten, for] For purposes of
    11  claiming  federal  financial  participation  under  paragraph  nine   of
    12  subsection  (c) of section twenty-one hundred five of the federal social

    13  security act, [for individuals  declaring  to  be  citizens  at  initial
    14  application,] a household shall provide:
    15    (i) the social security number for the applicant to be verified by the
    16  commissioner  in  accordance  with  a  process established by the social
    17  security administration pursuant to federal law, or
    18    (ii) documentation  of  citizenship  and  identity  of  the  applicant
    19  consistent  with  requirements  under the medical assistance program, as
    20  specified by the commissioner on the initial application.
    21    § 29. Paragraph (d) of subdivision 9 of section  2510  of  the  public
    22  health law, as added by section 72-a of part C of chapter 58 of the laws
    23  of 2009, is amended to read as follows:
    24    (d)  for periods on or after July first, two thousand nine, amounts as
    25  follows:

    26    (i) no payments  are  required  for  eligible  children  whose  family
    27  [gross]  household  income is less than one hundred sixty percent of the
    28  non-farm federal poverty level and for eligible children who are  Ameri-
    29  can  Indians  or  Alaskan  Natives, as defined by the U.S. Department of
    30  Health and Human Services, whose family [gross] household income is less
    31  than two hundred fifty-one  percent  of  the  non-farm  federal  poverty
    32  level; and
    33    (ii)  nine  dollars  per  month  for  each eligible child whose family
    34  [gross] household income is between one hundred sixty  percent  and  two
    35  hundred twenty-two percent of the non-farm federal poverty level, but no
    36  more than twenty-seven dollars per month per family; and
    37    (iii)  fifteen  dollars per month for each eligible child whose family

    38  [gross] household income is between two hundred twenty-three percent and
    39  two hundred fifty percent of the non-farm federal poverty level, but  no
    40  more than forty-five dollars per month per family; and
    41    (iv)  thirty  dollars  per  month for each eligible child whose family
    42  [gross] household income is between two hundred  fifty-one  percent  and
    43  three hundred percent of the non-farm federal poverty level, but no more
    44  than ninety dollars per month per family;
    45    (v)  forty-five dollars per month for each eligible child whose family
    46  [gross] household income is between three hundred one percent and  three
    47  hundred fifty percent of the non-farm federal poverty level, but no more
    48  than one hundred thirty-five dollars per month per family; and
    49    (vi)  sixty  dollars  per  month  for each eligible child whose family

    50  [gross] household income is between three hundred fifty-one percent  and
    51  four  hundred percent of the non-farm federal poverty level, but no more
    52  than one hundred eighty dollars per month per family.
    53    § 30. Subparagraph (iii) of paragraph (a) of subdivision 2 of  section
    54  2511  of  the  public  health law, as amended by section 32 of part B of
    55  chapter 58 of the laws of 2008, is amended to read as follows:

        S. 2606--D                         98                         A. 3006--D
 
     1    (iii) effective September first, two  thousand  eight,  resides  in  a
     2  household  having  a  [gross]  household income at or below four hundred
     3  percent of the non-farm federal poverty level (as defined and updated by
     4  the United States department of health and human services);

     5    §  31.  Subparagraph (ii) of paragraph (d) of subdivision 2 of section
     6  2511 of the public health law, as amended by section 33  of  part  A  of
     7  chapter  58  of  the laws of 2007, clause (B) as amended by section 3 of
     8  part OO of chapter 57 of the  laws  of  2008,  is  amended  to  read  as
     9  follows:
    10    (ii)  (A) The implementation of this paragraph for a child residing in
    11  a household having a [gross] household income at or  below  two  hundred
    12  fifty  percent  of  the  non-farm  federal poverty level (as defined and
    13  updated by the United States department of health  and  human  services)
    14  shall  take  effect  only upon the commissioner's finding that insurance
    15  provided under this title  is  substituting  for  coverage  under  group
    16  health plans in excess of a percentage specified by the secretary of the

    17  federal  department of health and human services. The commissioner shall
    18  notify the legislature prior to implementation of this paragraph.
    19    (B) The implementation of clauses (A), (B), (C), (D),  (E),  (F),  (G)
    20  and  (I) of subparagraph (i) of this paragraph for a child residing in a
    21  household having a [gross] household income between two  hundred  fifty-
    22  one  and  four hundred percent of the non-farm federal poverty level (as
    23  defined and updated by the United States department of health and  human
    24  services)  shall  take  effect  September  first,  two  thousand  eight;
    25  provided however, the entirety of subparagraph  (i)  of  this  paragraph
    26  shall  take  effect  and be applied to such children on the date federal
    27  financial participation becomes available for such population in accord-
    28  ance with the state's Title XXI  child  health  plan.  The  commissioner

    29  shall  monitor  the  number  of  children who are subject to the waiting
    30  period established pursuant to this clause.
    31    § 32. Clauses (A) and (B) of subparagraph  (i)  of  paragraph  (b)  of
    32  subdivision  18  of  section  2511 of the public health law, as added by
    33  section 31 of part A of chapter 58 of the laws of 2007, are  amended  to
    34  read as follows:
    35    (A)  participation  in the program for a child who resides in a house-
    36  hold having a [gross] household income at or  below  two  hundred  fifty
    37  percent of the non-farm federal poverty level (as defined and updated by
    38  the  United  States  department  of  health and human services) shall be
    39  voluntary and an eligible child may disenroll from the  premium  assist-
    40  ance  program  at  any time and enroll in individual coverage under this
    41  title; and

    42    (B) participation in the program for a child who resides in  a  house-
    43  hold having a [gross] household income between two hundred fifty-one and
    44  four  hundred  percent of the non-farm federal poverty level (as defined
    45  and updated  by  the  United  States  department  of  health  and  human
    46  services)  and  meets certain eligibility criteria shall be mandatory. A
    47  child in this income group who meets the criteria for enrollment in  the
    48  premium assistance program shall not be eligible for individual coverage
    49  under this title;
    50    § 33. Subparagraph (iv) of paragraph (b) and paragraph (d) of subdivi-
    51  sion  9  of section 2511 of the public health law, as amended by section
    52  18-a of chapter 2 of the laws of 1998, are amended to read as follows:
    53    (iv) outstationing of persons who are authorized to provide assistance

    54  to families in completing the enrollment application process under  this
    55  title  and  title  eleven  of  article  five of the social services law,
    56  [including the conduct of personal interviews pursuant to section  three

        S. 2606--D                         99                         A. 3006--D

     1  hundred  sixty-six-a  of the social services law and personal interviews
     2  required upon recertification under such section of the social  services
     3  law,] in locations, such as community settings, which are geographically
     4  accessible to large numbers of children who may be eligible for benefits
     5  under  such  titles, and at times, including evenings and weekends, when
     6  large numbers of children who may be eligible for  benefits  under  such
     7  titles  are likely to be encountered. Persons outstationed in accordance

     8  with this subparagraph shall be authorized  to  make  determinations  of
     9  presumptive  eligibility in accordance with paragraph (g) of subdivision
    10  two of section two thousand five hundred and eleven of this title; and
    11    (d) Subject to the availability of funds therefor, training  shall  be
    12  provided  for  outstationed  persons and employees of approved organiza-
    13  tions to enable them to  disseminate  information,  and  facilitate  the
    14  completion  of  the  application  process  under  this subdivision[, and
    15  conduct  personal  interviews  required   by   section   three   hundred
    16  sixty-six-a  of the social services law and personal interviews required
    17  upon recertification under such section of the social services law].
    18    § 33-a. Subdivision 1 of section 206  of  the  public  health  law  is

    19  amended by adding a new paragraph (s) to read as follows:
    20    (s)  issue a readiness report to the legislature, detailing the status
    21  of the statewide health benefit exchange, state enrollment  center,  and
    22  state  Medicaid  enrollment  center  established  under  executive order
    23  number forty-two of two thousand twelve, by August thirtieth, two  thou-
    24  sand thirteen. The readiness report may be provided in electronic format
    25  and  shall  be distributed to the temporary president of the senate, the
    26  speaker of the assembly, the chair of the senate standing  committee  on
    27  health,  and  the  chair of the assembly health committee. The readiness
    28  report shall outline the progress and preparedness of the health benefit

    29  exchange, state enrollment center, and state Medicaid enrollment  center
    30  and detail how the exchange, state enrollment center, and state Medicaid
    31  enrollment  center  will  carry out their respective functions including
    32  but not limited to:
    33    (i) the process by which the health benefit exchange, state enrollment
    34  center, and state Medicaid enrollment center will begin accepting appli-
    35  cations on October first, two thousand thirteen;
    36    (ii) the process by which the health benefit exchange,  state  enroll-
    37  ment center, and state Medicaid enrollment center will certify qualified
    38  health plans;
    39    (iii)  the  anticipated cost of individual and small group plans being
    40  offered in the health benefit exchange;

    41    (iv) the number of navigators approved;
    42    (v) the plan for full operation by January first, two  thousand  four-
    43  teen; and
    44    (vi) the plan to become fiscally self-sustaining by January first, two
    45  thousand fifteen.
    46    §  34.  Paragraphs  9  and 10 of subsection (a) of section 2101 of the
    47  insurance law, as added by chapter 687 of the laws of 2003, are  amended
    48  and a new paragraph 11 is added to read as follows:
    49    (9)  a  person who is not a resident of this state who sells, solicits
    50  or negotiates a contract of insurance for  commercial  property/casualty
    51  risks  to  an  insured with risks located in more than one state insured
    52  under that contract, provided that such person is otherwise licensed  as
    53  an  insurance  producer  to sell, solicit or negotiate that insurance in

    54  the state where the insured maintains its principal  place  of  business
    55  and the contract of insurance insures risks located in that state; [or]

        S. 2606--D                         100                        A. 3006--D
 
     1    (10)  any  salaried  full-time employee who counsels or advises his or
     2  her employer relative to the insurance interests of the employer  or  of
     3  the  subsidiaries  or  business affiliates of the employer provided that
     4  the employee does not sell or solicit insurance  or  receive  a  commis-
     5  sion[.]; or
     6    (11)  any  person who has received a grant from and has been certified
     7  by the health benefit exchange established pursuant to section  1311  of
     8  the  affordable  care  act, 42 U.S.C. § 18031, to act as a navigator, as

     9  such term is used in 42 U.S.C. § 18031(i),  provided  that  the  person:
    10  (A)  has completed the training required by the health benefit exchange;
    11  (B) does not sell insurance; (C) does not engage in  any  activity  with
    12  respect   to  insurance  not  expressly  permitted  under  42  U.S.C.  §
    13  18031(i)(3) and regulations thereunder; and (D)  does  not  receive  any
    14  compensation  for  acting  as a navigator directly or indirectly from an
    15  insured, insurance producer, or an insurer.
    16    § 35. Paragraphs 8 and 9 of subsection (c)  of  section  2101  of  the
    17  insurance  law,  paragraph  8  as  amended  and  paragraph 9 as added by
    18  section 5 of part I of chapter 61 of the laws of 2011, are amended and a
    19  new paragraph 10 is added to read as follows:

    20    (8) a person who is not a resident of this state who  sells,  solicits
    21  or  negotiates  a  contract for commercial property/casualty risks to an
    22  insured with risks located in more than one  state  insured  under  that
    23  contract,  provided  that such person is otherwise licensed as an insur-
    24  ance producer to sell, solicit or negotiate that insurance in the  state
    25  where  the  insured  maintains  its  principal place of business and the
    26  contract of insurance insures risks located in that state; [or]
    27    (9) a person who is not a resident of this state who  sells,  solicits
    28  or  negotiates  a contract of property/casualty insurance, as defined in
    29  paragraph six of subsection (x) of  this  section,  of  an  insurer  not
    30  authorized  to  do  business  in  this  state,  provided  that:  (A) the
    31  insured's home state is a state other than  this  state;  and  (B)  such

    32  person  is  otherwise licensed to sell, solicit or negotiate excess line
    33  insurance in the insured's home state[.]; or
    34    (10) any person who has received a grant from and has  been  certified
    35  by  the  health benefit exchange established pursuant to section 1311 of
    36  the affordable care act, 42 U.S.C. § 18031, to act as  a  navigator,  as
    37  such term is used in 42 U.S.C. § 18031(i), including any person employed
    38  by  a  certified navigator, provided that the person:  (A) has completed
    39  the training required by the health benefit exchange; (B) does not  sell
    40  insurance; (C) does not engage in any activity with respect to insurance
    41  not  expressly  permitted  under 42 U.S.C. § 18031(i)(3) and regulations

    42  thereunder; and (D) does not receive any compensation for  acting  as  a
    43  navigator directly or indirectly from an insured, insurance producer, or
    44  an insurer.
    45    §  36.  Paragraphs  10 and 11 of subsection (k) of section 2101 of the
    46  insurance law, paragraph 10 as amended and  paragraph  11  as  added  by
    47  section 6 of part I of chapter 61 of the laws of 2011, are amended and a
    48  new paragraph 12 is added to read as follows:
    49    (10)  any  salaried  full-time employee who counsels or advises his or
    50  her employer relative to the insurance interests of the employer  or  of
    51  the  subsidiaries  or business affiliates of the employer, provided that
    52  the employee does not sell or solicit insurance or receive a commission;
    53  [or]
    54    (11) a person who is not a resident of this state who sells,  solicits

    55  or  negotiates  a contract of property/casualty insurance, as defined in
    56  paragraph six of subsection (x) of  this  section,  of  an  insurer  not

        S. 2606--D                         101                        A. 3006--D
 
     1  authorized  to  do  business  in  this  state,  provided  that:  (A) the
     2  insured's home state is a state other than  this  state;  and  (B)  such
     3  person  is  otherwise licensed to sell, solicit or negotiate excess line
     4  insurance in the insured's home state[.]; or
     5    (12)  any  person who has received a grant from and has been certified
     6  by the health benefit exchange established pursuant to section  1311  of
     7  the  affordable  care  act,  42 U.S.C. § 18031 to act as a navigator, as
     8  such term is used in 42 U.S.C. § 18031(i), including any person employed

     9  by a certified navigator, provided that the person:  (A)  has  completed
    10  the  training required by the health benefit exchange; (B) does not sell
    11  insurance; (C) does not engage in any activity with respect to insurance
    12  not expressly permitted under 42 U.S.C. § 18031 (i) (3) and  regulations
    13  thereunder;  and  (D)  does not receive any compensation for acting as a
    14  navigator directly or indirectly from an insured, insurance producer, or
    15  an insurer.
    16    § 37. Subsection (b) of section 2102 of the insurance law  is  amended
    17  by adding a new paragraph 5 to read as follows:
    18    (5) Paragraphs one and three of this subsection shall not apply to any
    19  person  who  has  received  a  grant  from and has been certified by the

    20  health benefit exchange established pursuant  to  section  1311  of  the
    21  Affordable  Care  Act, 42 U.S.C. § 18031 (i), including persons employed
    22  by certified navigators; provided that the person: (A) has completed the
    23  training required by the health benefit  exchange;  (B)  does  not  sell
    24  insurance; (C) does not engage in any activity with respect to insurance
    25  not  expressly permitted under 42 U.S.C. § 18031 (i) (3) and regulations
    26  thereunder; and (D) does not receive any compensation for  acting  as  a
    27  navigator directly or indirectly from an insured, insurance producer, or
    28  an insurer.
    29    §  37-a. Subsections (a) and (d) of section 2123 of the insurance law,
    30  as amended by chapter 540 of the laws of 1996, paragraph 3 of subsection

    31  (a) as added by chapter 616 of the laws of 1997 and  the  opening  para-
    32  graph  of  paragraph 3 of subsection (a) as amended by chapter 13 of the
    33  laws of 2002, are amended to read as follows:
    34    (a) (1) No agent or representative of any insurer  or  health  mainte-
    35  nance  organization  authorized  to  transact  life,  accident or health
    36  insurance or health maintenance organization business in this state [and
    37  no], insurance broker, [and no] person who has received a grant from and
    38  has been certified by the health benefit exchange  established  pursuant
    39  to section 1311 of the Affordable Care Act, 42 U.S.C. § 18031, to act as
    40  a  navigator, including any person employed by a certified navigator, or
    41  other person, firm, association or corporation, shall issue or circulate

    42  or cause or permit to be issued or circulated, any illustration,  circu-
    43  lar,  statement  or  memorandum  misrepresenting  the terms, benefits or
    44  advantages of any policy or contract of life, accident or health  insur-
    45  ance,  any  annuity  contract  or  any  health  maintenance organization
    46  contract, delivered or issued for delivery or to be delivered or  issued
    47  for delivery, in this state, or shall make any misleading estimate as to
    48  the  dividends  or share of surplus or additional amounts to be received
    49  in the future on such policy or contract, or shall  make  any  false  or
    50  misleading  statement  as  to the dividends or share of surplus or addi-
    51  tional amounts previously paid by any such insurer or health maintenance
    52  organization on  similar  policies  or  contracts,  or  shall  make  any
    53  misleading representation, or any misrepresentation, as to the financial

    54  condition  of any such insurer or health maintenance organization, or as
    55  to the legal reserve system upon which such insurer  or  health  mainte-
    56  nance organization operates.

        S. 2606--D                         102                        A. 3006--D
 
     1    (2) No such person, firm, association or corporation shall make to any
     2  person  or  persons  any  incomplete  comparison of any such policies or
     3  contracts of any insurer, insurers, or health maintenance  organization,
     4  for  the  purpose  of  inducing,  or  tending  to induce, such person or
     5  persons  to  lapse,  forfeit or surrender any insurance policy or health
     6  maintenance organization contract.
     7    (3) Any replacement of individual life insurance policies or  individ-
     8  ual  annuity  contracts of an insurer by an agent, representative of the

     9  same or different insurer or broker shall conform to  standards  promul-
    10  gated by regulation by the superintendent. Such regulation shall:
    11    (A) specify what constitutes the replacement of a life insurance poli-
    12  cy or annuity contract and the proper disclosure and notification proce-
    13  dures to replace a policy or contract;
    14    (B)  require  notification  of the proposed replacement to the insurer
    15  whose policies or contracts are intended to be replaced;
    16    (C) require the timely exchange of illustrative and  cost  information
    17  required  by section three thousand two hundred nine of this chapter and
    18  necessary for completion of a comparison of the  proposed  and  replaced
    19  coverage; and
    20    (D)  provide for a sixty-day period following issuance of the replace-
    21  ment policies or contracts during which the policy or contract owner may

    22  return the policies or contracts and reinstate the replaced policies  or
    23  contracts.
    24    (d)  Any  agent  or representative of an insurer or health maintenance
    25  organization, [any] insurance broker [and], person who  has  received  a
    26  grant  from and has been certified by the health benefit exchange estab-
    27  lished pursuant to section 1311 of the affordable care act, 42 U.S.C.  §
    28  18031,  to act as a navigator, including any person employed by a certi-
    29  fied navigator, or any other person, firm,  association  or  corporation
    30  who,  or  which, shall violate any of the provisions of this section and
    31  shall knowingly receive any compensation or commission for the solicita-
    32  tion, sale or negotiation of any insurance  policy,  health  maintenance

    33  organization  or annuity contract induced by a violation of this section
    34  shall also be liable for a civil penalty in the amount received by  such
    35  violator  as  compensation  or commission, which penalty may be sued for
    36  and recovered for his, her, or its own use and  benefit  by  any  person
    37  induced to purchase an insurance policy, health maintenance organization
    38  or  annuity  contract by such violation. In addition, such agent, repre-
    39  sentative, broker, person, firm, association  or  corporation  violating
    40  this  section  shall  be liable for a civil penalty in the amount of any
    41  compensation or commission lost by any agent, representative  or  broker
    42  as  a  result of a violation of this section or the making of such false
    43  or misleading statement, which penalty may be sued for and recovered for
    44  his, her, or its own use and benefit by such  agent,  representative  or

    45  broker.
    46    §  37-b.  The insurance law is amended by adding a new section 2138 to
    47  read as follows:
    48    § 2138. Health benefit exchange navigators. A person who has  received
    49  a  grant  from  and  has  been  certified by the health benefit exchange
    50  established pursuant to section 1311 of  the  affordable  care  act,  42
    51  U.S.C.  § 18031, to act as a navigator, including any person employed by
    52  a certified navigator, shall not receive, collect or hold any funds that
    53  would constitute fiduciary funds within the meaning of section two thou-
    54  sand one hundred twenty of this article.

        S. 2606--D                         103                        A. 3006--D
 
     1    § 38. Subparagraph (B) of paragraph 25 of subsection  (i)  of  section

     2  3216  of  the  insurance  law,  as amended by chapter 596 of the laws of
     3  2011, is amended to read as follows:
     4    (B)  Every  policy  [which] that provides physician services, medical,
     5  major medical  or  similar  comprehensive-type  coverage  shall  provide
     6  coverage  for  the screening, diagnosis and treatment of autism spectrum
     7  disorder in accordance with this paragraph and shall not exclude  cover-
     8  age  for  the  screening,  diagnosis  or treatment of medical conditions
     9  otherwise covered by the policy because the individual is diagnosed with
    10  autism spectrum disorder. Such coverage may be subject to annual deduct-
    11  ibles, copayments and coinsurance as may be deemed  appropriate  by  the
    12  superintendent and shall be consistent with those imposed on other bene-
    13  fits  under  the policy. Coverage for applied behavior analysis shall be

    14  subject to a  maximum  benefit  of  [forty-five  thousand  dollars]  six
    15  hundred  eighty  hours  of  treatment  per  policy  or calendar year per
    16  covered individual [and such maximum annual benefit will increase by the
    17  amount calculated from the average ten year rolling average increase  of
    18  the medical component of the consumer price index]. This paragraph shall
    19  not  be  construed as limiting the benefits that are otherwise available
    20  to an individual under the policy, provided  however  that  such  policy
    21  shall  not  contain any limitations on visits that are solely applied to
    22  the treatment of autism spectrum disorder. No  insurer  shall  terminate
    23  coverage  or  refuse to deliver, execute, issue, amend, adjust, or renew
    24  coverage to an individual solely because  the  individual  is  diagnosed

    25  with autism spectrum disorder or has received treatment for autism spec-
    26  trum  disorder.  Coverage  shall  be  subject  to utilization review and
    27  external appeals of health care services pursuant to article  forty-nine
    28  of  this  chapter  as  well  as, case management, and other managed care
    29  provisions.
    30    § 39. Subparagraph (B) of paragraph 17 of subsection  (1)  of  section
    31  3221  of  the  insurance  law,  as amended by chapter 596 of the laws of
    32  2011, is amended to read as follows:
    33    (B) Every group or blanket  policy  [which]  that  provides  physician
    34  services,  medical, major medical or similar comprehensive-type coverage
    35  shall provide coverage for the screening,  diagnosis  and  treatment  of
    36  autism spectrum disorder in accordance with this paragraph and shall not
    37  exclude  coverage  for  the screening, diagnosis or treatment of medical

    38  conditions otherwise covered by the policy  because  the  individual  is
    39  diagnosed with autism spectrum disorder. Such coverage may be subject to
    40  annual  deductibles,  copayments and coinsurance as may be deemed appro-
    41  priate by the superintendent and shall be consistent with those  imposed
    42  on  other  benefits  under  the  group  or  blanket policy. Coverage for
    43  applied behavior analysis shall be  subject  to  a  maximum  benefit  of
    44  [forty-five  thousand dollars] six hundred eighty hours of treatment per
    45  policy or calendar year per covered individual [and such maximum  annual
    46  benefit will increase by the amount calculated from the average ten year
    47  rolling  average increase of the medical component of the consumer price
    48  index]. This paragraph shall not be construed as limiting  the  benefits

    49  that are otherwise available to an individual under the group or blanket
    50  policy,  provided however that such policy shall not contain any limita-
    51  tions on visits that are solely applied to the treatment of autism spec-
    52  trum disorder. No insurer shall terminate coverage or refuse to deliver,
    53  execute, issue, amend, adjust, or renew coverage to an individual solely
    54  because the individual is diagnosed with autism spectrum disorder or has
    55  received treatment for  autism  spectrum  disorder.  Coverage  shall  be
    56  subject  to  utilization  review  and  external  appeals  of health care

        S. 2606--D                         104                        A. 3006--D
 
     1  services pursuant to article forty-nine of this chapter as well as, case
     2  management, and other managed care provisions.
     3    §  40. Paragraph 2 of subsection (ee) of section 4303 of the insurance

     4  law, as amended by chapter 596 of the laws of 2011, is amended  to  read
     5  as follows:
     6    (2)  Every contract [which] that provides physician services, medical,
     7  major medical  or  similar  comprehensive-type  coverage  shall  provide
     8  coverage  for  the screening, diagnosis and treatment of autism spectrum
     9  disorder in accordance with this [subsection] paragraph  and  shall  not
    10  exclude  coverage  for  the screening, diagnosis or treatment of medical
    11  conditions otherwise covered by the contract because the  individual  is
    12  diagnosed with autism spectrum disorder. Such coverage may be subject to
    13  annual  deductibles,  copayments and coinsurance as may be deemed appro-
    14  priate by the superintendent and shall be consistent with those  imposed
    15  on  other  benefits  under  the  contract. Coverage for applied behavior

    16  analysis shall be subject to a maximum benefit of  [forty-five  thousand
    17  dollars]  six hundred eighty hours of treatment per contract or calendar
    18  year per covered  individual  [and  such  maximum  annual  benefit  will
    19  increase  by  the  amount  calculated  from the average ten year rolling
    20  average increase of the medical component of the consumer price  index].
    21  This  paragraph shall not be construed as limiting the benefits that are
    22  otherwise available to an individual under the contract, provided howev-
    23  er that such contract shall not contain any limitations on  visits  that
    24  are  solely  applied  to  the  treatment of autism spectrum disorder. No
    25  insurer shall terminate coverage or refuse to deliver,  execute,  issue,
    26  amend,  adjust,  or  renew  coverage to an individual solely because the

    27  individual is diagnosed with autism spectrum disorder  or  has  received
    28  treatment  for  autism  spectrum  disorder. Coverage shall be subject to
    29  utilization review and external appeals of health care services pursuant
    30  to article forty-nine of this chapter as well as, case  management,  and
    31  other managed care provisions.
    32    § 40-a. Paragraph 1 of subsection (d) of section 3221 of the insurance
    33  law is amended to read as follows:
    34    (1)  The  superintendent  may  approve  any  form of certificate to be
    35  issued under a blanket accident and health insurance policy  as  defined
    36  in section four thousand two hundred thirty-seven of this chapter, which
    37  omits  or  modifies any of the provisions hereinbefore required, if [he]
    38  the superintendent deems such omission or modification suitable for  the

    39  character of such insurance and not unjust to the persons insured there-
    40  under.   Certificates issued under a policy or contract of student acci-
    41  dent and health insurance as  defined  in  section  three  thousand  two
    42  hundred forty of this article shall comply with such section.
    43    §  41.  The  insurance  law is amended by adding a new section 3240 to
    44  read as follows:
    45    § 3240. Student accident and health insurance.  (a) In this section:
    46    (1) "Student accident and health insurance" means a policy or contract
    47  of hospital, medical, or surgical expense insurance delivered or  issued
    48  for  delivery  in  this  state  on or after January first, two  thousand
    49  fourteen, by an insurer or a corporation, to an  institution  of  higher

    50  education   covering  students  enrolled  in  the  institution  and  the
    51  students' dependents.
    52    (2) "Institution of higher education" or "institution" shall have  the
    53  meaning set forth in the higher education act of 1965, 20 U.S.C. § 1001.
    54    (3)  "Insurer"  means an insurer licensed to write accident and health
    55  insurance pursuant to this chapter.

        S. 2606--D                         105                        A. 3006--D
 
     1    (4) "Corporation" means a corporation  organized  in  accordance  with
     2  article forty-three of this chapter.
     3    (b) An insurer or corporation shall not impose any pre-existing condi-
     4  tion  exclusion  in  a student   accident and health insurance policy or

     5  contract.  An insurer or corporation shall not condition    eligibility,
     6  including  continued  eligibility,  for  a  student  accident and health
     7  insurance policy  or  contract  on  health  status,  medical  condition,
     8  including both physical and mental illnesses, claims experience, receipt
     9  of health care, medical history, genetic information, evidence of insur-
    10  ability,  including conditions arising out of acts of domestic violence,
    11  or disability.
    12    (c) An insurer or corporation shall  condition  eligibility  including
    13  continuing  eligibility,  on  the covered individual being enrolled as a
    14  student in an institution of higher education to which the student acci-
    15  dent and health insurance policy or contract is issued.

    16    (d) A student accident and health insurance policy or  contract  shall
    17  provide  coverage  for  essential  health benefits as defined in section
    18  1302(b) of the affordable care act, 42 U.S.C. § 18022(b).
    19    (e) An insurer or corporation shall not refuse to renew  or  otherwise
    20  terminate  a  student  accident  and health insurance policy or contract
    21  except for one or more of the reasons set forth in:
    22    (1) subparagraphs (A), (B), (D) or (G) of paragraph two of  subsection
    23  (p) of section three thousand two hundred twenty-one of this article; or
    24    (2)  subparagraphs (A), (B), (D) or (G) of paragraph two of subsection
    25  (j) of section four thousand three hundred five of this chapter.

    26    (f) Other than the provisions herein also required by  article  forty-
    27  three  of this chapter, this section shall not apply to coverage under a
    28  student health plan issued pursuant to section one thousand one  hundred
    29  twenty-four of this chapter.
    30    (g)  The  superintendent  may promulgate regulations regarding student
    31  accident and health insurance, which may include minimum  standards  for
    32  the  form,  content and sale of the policies and contracts and, notwith-
    33  standing the provisions of section three thousand two hundred thirty-one
    34  and four thousand three hundred eight of this chapter, the establishment
    35  of rating methodology to be  applied  to  the  policies  and  contracts;

    36  provided  that  any  such regulations shall be no less favorable to  the
    37  insured than that which is provided under  federal  law  and  state  law
    38  applicable to individual insurance.
    39    (h)  The  ratio of benefits to premiums shall be not less than eighty-
    40  two percent as calculated in a manner to be  determined  by  the  super-
    41  intendent.
    42    (i)  Every  insurer  or corporation shall report to the superintendent
    43  annually, on a date specified by the  superintendent  in  a  regulation,
    44  claims  experience  and  other data in a manner acceptable to the super-
    45  intendent that shall demonstrate the insurer's or corporation's  compli-
    46  ance  with  the applicable  rules and regulations, including the minimum

    47  loss ratio required by subsection (h) of this section. Failure to comply
    48  with subsection (h) of this section is  subject  to  corrective  action,
    49  which may include the submission, to the superintendent, of an appropri-
    50  ate  rate  filing  or  form  and  rate filing to reduce future premiums,
    51  increase benefits, issue dividends, issue premium refunds or credits, or
    52  any combination of these such that the minimum loss ratio can reasonably
    53  be expected to be achieved.
    54    § 42. Subsection (1) of section 3216 of the insurance law is  REPEALED
    55  and a new subsection (l) is added to read as follows:

        S. 2606--D                         106                        A. 3006--D
 
     1    (l)  On  and  after  October  first, two thousand thirteen, an insurer

     2  shall not offer individual hospital, medical or surgical expense  insur-
     3  ance  policies  unless  the policies meet the requirements of subsection
     4  (b) of section four thousand three hundred twenty-eight of this chapter.
     5  Such policies that are offered within the health benefit exchange estab-
     6  lished  pursuant to section 1311 of the affordable care act, 42 U.S.C. §
     7  18031, or any regulations promulgated thereunder, also  shall  meet  any
     8  requirements established by the health benefit exchange.
     9    §  43. Subsection (1) of section 4304 of the insurance law is REPEALED
    10  and a new subsection (1) is added to read as follows:
    11    (1) On and after October first, two thousand thirteen,  a  corporation
    12  shall not offer individual hospital, medical, or surgical expense insur-

    13  ance  contracts unless the contracts meet the requirements of subsection
    14  (b) of section four thousand three hundred twenty-eight of this article.
    15  Such contracts that are  offered  within  the  health  benefit  exchange
    16  established  pursuant  to  section  1311  of the affordable care act, 42
    17  U.S.C. § 18031, or any regulations promulgated  thereunder,  also  shall
    18  meet any requirements established by the health benefit exchange. To the
    19  extent  that  a  holder  of  a  special purpose certificate of authority
    20  issued pursuant to section four thousand four  hundred  three-a  of  the
    21  public  health  law  offers  individual  hospital,  medical, or surgical
    22  expense insurance contracts, the contracts shall meet  the  requirements

    23  of subsection (b) of section four thousand three hundred twenty-eight of
    24  this article.
    25    §  43-a. Item (i) of subparagraph (C) of paragraph 2 of subsection (c)
    26  of section 4304 of the insurance law, as amended by section 9 of part  A
    27  of chapter 1 of the laws of 2002, is amended to read as follows:
    28    (i)  Discontinuance  of  a  class  of contract upon not less than five
    29  months' prior written notice[, except  for  subscribers  to  direct  pay
    30  major  medical or similar comprehensive-type coverage issued by a corpo-
    31  ration organized pursuant to this article, or any successor  corporation
    32  organized  through  a  conversion  pursuant to subsection (j) of section
    33  four thousand three hundred one of this article, and in effect prior  to

    34  January  first,  nineteen  hundred  ninety-six  who  are  ineligible  to
    35  purchase policies offered after such date pursuant to section four thou-
    36  sand three hundred twenty-one or four thousand three hundred  twenty-two
    37  of  this  article due to the provisions of 42 U.S.C. 1395ss in effect on
    38  the effective date of this  item.  In  the  event  any  such  subscriber
    39  becomes  eligible  to purchase policies offered pursuant to section four
    40  thousand three hundred twenty-one or four thousand three  hundred  twen-
    41  ty-two  of  this  article, then such subscriber may be discontinued upon
    42  not less than five months' prior  written  notice].  In  exercising  the
    43  option  to  discontinue  coverage pursuant to this item, the corporation

    44  must act uniformly without regard to any health status-related factor of
    45  enrolled individuals or individuals who may  become  eligible  for  such
    46  coverage and must offer to subscribers or group remitting agents, as may
    47  be  appropriate,  the  option  to  purchase  all other individual health
    48  insurance coverage currently being offered by the corporation to  appli-
    49  cants in that market.
    50    §  44.  The  section heading and subsection (a) of section 4321 of the
    51  insurance law, the section heading as added by chapter 504 of  the  laws
    52  of  1995  and  subsection  (a)  as amended by chapter 342 of the laws of
    53  2004, are amended to read as follows:
    54    Standardization  of  individual  enrollee  direct  payment   contracts
    55  offered  by health maintenance organizations prior to October first, two
    56  thousand thirteen. (a) On and  after  January  first,  nineteen  hundred

        S. 2606--D                         107                        A. 3006--D
 
     1  ninety-six,  and  until  September  thirtieth, two thousand thirteen all
     2  health maintenance organizations issued a certificate of authority under
     3  article forty-four of the public health law or licensed under this arti-
     4  cle  shall  offer a standardized individual enrollee contract on an open
     5  enrollment basis as prescribed by section forty-three hundred  seventeen
     6  of  this article and section forty-four hundred six of the public health
     7  law, and regulations promulgated  thereunder,  provided,  however,  that
     8  such  requirements  shall not apply to a health maintenance organization
     9  exclusively serving individuals enrolled pursuant  to  title  eleven  of
    10  article  five of the social services law, title eleven-D of article five

    11  of the social services law, title one-A of article  twenty-five  of  the
    12  public health law or title eighteen of the federal Social Security Act[,
    13  and,  further  provided, that such health maintenance organization shall
    14  not discontinue a contract for an  individual  receiving  comprehensive-
    15  type coverage in effect prior to January first, two thousand four who is
    16  ineligible to purchase policies offered after such date pursuant to this
    17  section  or section four thousand three hundred twenty-two of this arti-
    18  cle due to the provision of 42 U.S.C. 1395ss in effect prior to  January
    19  first,  two thousand four]. On and after January first, nineteen hundred
    20  ninety-six, and until September thirtieth, two  thousand  thirteen,  the

    21  enrollee  contracts  issued  pursuant  to  this section and section four
    22  thousand three hundred twenty-two of this  article  shall  be  the  only
    23  contracts  offered  by  health maintenance organizations to individuals.
    24  The enrollee contracts issued by a health maintenance organization under
    25  this section and section four thousand three hundred twenty-two of  this
    26  article  shall  also  be the only contracts issued by health maintenance
    27  organizations for purposes of conversion pursuant to sections four thou-
    28  sand three hundred four and four thousand three  hundred  five  of  this
    29  article.  However,  nothing  in  this section shall be deemed to require
    30  health maintenance organizations to terminate individual direct  payment
    31  contracts  issued prior to January first, nineteen hundred ninety-six or
    32  prevent health maintenance  organizations  from  terminating  individual

    33  direct payment contracts issued prior to January first, nineteen hundred
    34  ninety-six.
    35    §  45.  The  section heading and subsection (a) of section 4322 of the
    36  insurance law, the section heading as added by chapter 504 of  the  laws
    37  of  1995  and  subsection  (a)  as amended by chapter 342 of the laws of
    38  2004, are amended and a new subsection (i) is added to read as follows:
    39    Standardization  of  individual  enrollee  direct  payment   contracts
    40  offered  by  health  maintenance organizations which provide out-of-plan
    41  benefits prior to October first, two thousand thirteen. (a) On and after
    42  January first, nineteen hundred ninety-six, and until September  thirti-
    43  eth,  two thousand thirteen, all health maintenance organizations issued
    44  a certificate of authority under article forty-four of the public health

    45  law or licensed under this article shall offer to individuals, in  addi-
    46  tion  to  the  standardized  contract  required by section four thousand
    47  three hundred twenty-one of  this  article,  a  standardized  individual
    48  enrollee  direct  payment  contract  on  an  open  enrollment  basis  as
    49  prescribed by section four thousand  three  hundred  seventeen  of  this
    50  article  and section four thousand four hundred six of the public health
    51  law, and regulations promulgated thereunder, with an out-of-plan benefit
    52  system, provided, however, that such requirements shall not apply  to  a
    53  health maintenance organization exclusively serving individuals enrolled
    54  pursuant  to  title  eleven  of article five of the social services law,
    55  title eleven-D of article five of the social services law,  title  one-A
    56  of article twenty-five of the public health law or title eighteen of the

        S. 2606--D                         108                        A. 3006--D
 
     1  federal  Social  Security  Act[, and, further provided, that such health
     2  maintenance organization shall not discontinue a contract for  an  indi-
     3  vidual  receiving comprehensive-type coverage in effect prior to January
     4  first,  two thousand four who is ineligible to purchase policies offered
     5  after such date pursuant to this section or section four thousand  three
     6  hundred  twenty-two  of  this  article due to the provision of 42 U.S.C.
     7  1395ss in effect prior to January first, two thousand four]. The out-of-
     8  plan benefit system shall either be provided by the  health  maintenance
     9  organization  pursuant  to subdivision two of section four thousand four

    10  hundred six of the public health law or through an  accompanying  insur-
    11  ance contract providing out-of-plan benefits offered by a company appro-
    12  priately  licensed pursuant to this chapter. On and after January first,
    13  nineteen hundred ninety-six, and until September thirtieth, two thousand
    14  thirteen, the contracts issued pursuant to this section and section four
    15  thousand three hundred twenty-one of this  article  shall  be  the  only
    16  contracts  offered  by  health maintenance organizations to individuals.
    17  The enrollee contracts issued by a health maintenance organization under
    18  this section and section four thousand three hundred twenty-one of  this
    19  article  shall  also  be the only contracts issued by the health mainte-
    20  nance organization for purposes of conversion pursuant to sections  four
    21  thousand three hundred four and four thousand three hundred five of this

    22  article.  However,  nothing  in  this section shall be deemed to require
    23  health maintenance organizations to terminate individual direct  payment
    24  contracts  issued prior to January first, nineteen hundred ninety-six or
    25  prohibit health maintenance organizations  from  terminating  individual
    26  direct payment contracts issued prior to January first, nineteen hundred
    27  ninety-six.
    28    (i)  On  and after January first, two thousand fourteen, each contract
    29  that is not a grandfathered health plan shall provide coverage  for  the
    30  essential health benefit package. For purposes of this subsection:
    31    (1)  "essential  health  benefits  package" shall have the meaning set
    32  forth in section 1302(a)  of  the  affordable  care  act,  42  U.S.C.  §
    33  18022(a); and

    34    (2)  "grandfathered  health  plan" means coverage provided by a corpo-
    35  ration in which an individual was enrolled on  March  twenty-third,  two
    36  thousand  ten for as long as the coverage maintains grandfathered status
    37  in accordance with section 1251(e) of the affordable care act, 42 U.S.C.
    38  § 18011(e).
    39    § 46. The insurance law is amended by adding a  new  section  4328  to
    40  read as follows:
    41    § 4328. Individual enrollee direct payment contracts offered by health
    42  maintenance  organization on and after October first, two thousand thir-
    43  teen. (a) On and after  October  first,  two  thousand  thirteen,  every
    44  health  maintenance organization issued a certificate of authority under

    45  article forty-four of the public health law or licensed under this arti-
    46  cle shall offer  an  individual  enrollee  direct  payment  contract  in
    47  accordance  with  the  requirements  of this section; provided, however,
    48  that this requirement shall not apply to a holder of a  special  purpose
    49  certificate  of  authority issued pursuant to section four thousand four
    50  hundred three-a of the public health law, except as  otherwise  required
    51  under subsection (l) of section four thousand three hundred four of this
    52  article,  or a health maintenance organization exclusively serving indi-
    53  viduals enrolled pursuant to title eleven of article five of the  social
    54  services law, title eleven-D of article five of the social services law,

    55  title  one-A  of  article  twenty-five of the public health law or title
    56  eighteen of the federal social security act.   The  superintendent  may,

        S. 2606--D                         109                        A. 3006--D
 
     1  after giving consideration to the public interest, exempt a health main-
     2  tenance organization from the requirements of this section provided that
     3  another  health  insurer  or  health maintenance organization within the
     4  health  maintenance  organization's  same  holding  company  system,  as
     5  defined in article fifteen of this chapter, including a  health  mainte-
     6  nance  organization  operated  as a line of business of a health service
     7  corporation licensed under this article, offers an  individual  enrollee

     8  direct  payment  contract that, at a minimum, complies with this section
     9  and provides all of the consumer protections required to be provided  by
    10  a  health maintenance organization pursuant to the public health law and
    11  regulations, including those consumer protections contained in  sections
    12  four  thousand four hundred three and four thousand four hundred eight-a
    13  of the public health law.  The enrollee contracts issued   by  a  health
    14  maintenance  organization  under  this  section  also  shall be the only
    15  contracts issued by the health maintenance organization for purposes  of
    16  conversion  pursuant  to  sections  four thousand three hundred four and
    17  four thousand three hundred five of this article.

    18    (b) (1) The individual enrollee direct payment contract offered pursu-
    19  ant to this section shall provide  coverage  for  the  essential  health
    20  benefit  package  as  required  in  section 2707(a) of the public health
    21  service act, 42 U.S.C. § 300gg-6(a). For  purposes  of  this  paragraph,
    22  "essential  health benefits package" shall have the meaning set forth in
    23  section 1302(a) of the affordable care act, 42 U.S.C. § 18022(a).
    24    (2) A health maintenance organization shall offer at least  one  indi-
    25  vidual  enrollee  direct  payment  contract at each level of coverage as
    26  defined in section 1302(d) of the  affordable  care  act,  42  U.S.C.  §
    27  18022(d).  A health maintenance organization also shall offer one child-

    28  only plan at each level of coverage as required in  section  2707(c)  of
    29  the public health service act, 42 U.S.C. § 300gg-6(c).
    30    (3) Within the health benefit exchange established pursuant to section
    31  1311 of the affordable care act, 42 U.S.C. § 18031, a health maintenance
    32  organization  may  offer  an individual enrollee direct payment contract
    33  that is a catastrophic health plan as defined in section 1302(e) of  the
    34  affordable care act, 42 U.S.C. § 18022(e), or any regulations promulgat-
    35  ed thereunder.
    36    (4)  The  individual enrollee direct payment contract offered pursuant
    37  to this section  shall  have  the  same  enrollment  periods,  including
    38  special  enrollment  periods,  as  required  for  an  individual  direct

    39  payment contract offered within the health benefit exchange  established
    40  pursuant  to section 1311 of the affordable care act, 42 U.S.C. § 18031,
    41  or any regulations promulgated thereunder.
    42    (5) The individual enrollee direct payment contract  offered  pursuant
    43  to this section shall be issued without regard to evidence of insurabil-
    44  ity and without an exclusion for pre-existing conditions.
    45    (6)  A health maintenance organization offering an individual enrollee
    46  direct payment contract pursuant to this  section  shall  not  establish
    47  rules  for eligibility, including continued eligibility, of any individ-
    48  ual or dependent of the individual to enroll under the contract based on
    49  any of the following health status-related factors:

    50    (A) health status;
    51    (B) medical condition, including both physical and mental illnesses;
    52    (C) claims experience;
    53    (D) receipt of health care;
    54    (E) medical history;
    55    (F) genetic information;

        S. 2606--D                         110                        A. 3006--D
 
     1    (G) evidence of insurability, including conditions arising out of acts
     2  of domestic violence; or
     3    (H) disability.
     4    (7)  The  individual enrollee direct payment contract offered pursuant
     5  to this section shall be community rated. For  purposes  of  this  para-
     6  graph, "community rated" means a rating methodology in which the premium

     7  for  all  persons  covered  by a contract form is the same, based on the
     8  experience of the entire pool of risks,  without  regard  to  age,  sex,
     9  health status, tobacco usage, or occupation.
    10    (8)  A  health  maintenance organization shall make available at least
    11  one individual enrollee direct payment contract at the platinum level of
    12  coverage, as defined in section 1302(d) of the affordable care  act,  42
    13  USC  §  18022(d), that includes an out-of-plan benefits option to enrol-
    14  lees covered prior to October  first,  two  thousand  thirteen,  by  the
    15  health  maintenance organization under contracts subject to section four
    16  thousand three hundred twenty-two of this article.  The  health  mainte-

    17  nance  organization shall provide the platinum level of coverage with an
    18  out-of-plan benefit rider to any  enrollee  that  elects  the  coverage.
    19  Enrollees who terminate the rider or are terminated following the effec-
    20  tive  date  of this paragraph shall be ineligible to purchase such rider
    21  following the termination. Nothing in this  paragraph  shall  require  a
    22  health  maintenance  organization to offer an out-of-plan benefit to any
    23  other enrollee, including through the health benefit exchange. A  health
    24  maintenance organization shall provide notice of the availability of the
    25  out-of-plan  benefits  prior  to October first, two thousand thirteen or
    26  shall  incorporate  notice  of  such  availability  into  discontinuance

    27  notices  issued  pursuant to section four thousand three hundred four of
    28  this article.
    29    (c) In addition to or  in  lieu  of  the  individual  enrollee  direct
    30  payment  contracts  required  under this section, all health maintenance
    31  organizations issued a certificate of authority under article forty-four
    32  of the public health law or licensed under this article may offer  indi-
    33  vidual  enrollee  direct  payment  contracts  within  the health benefit
    34  exchange established pursuant to section 1311  of  the  affordable  care
    35  act,  42  U.S.C.  §  18031,  or  any regulations promulgated thereunder,
    36  subject to any requirements established by the health benefit  exchange.
    37  If  a  health  maintenance  organization  satisfies  the requirements of

    38  subsection (a) of this section by offering  individual  enrollee  direct
    39  payment  contracts, only within the health  benefit exchange, the health
    40  maintenance organization, not including a holder of  a  special  purpose
    41  certificate  of  authority issued pursuant to section four thousand four
    42  hundred three-a of the public health law, shall also offer at least  one
    43  individual enrollee direct payment contract at each level of coverage as
    44  defined  in  section  1302  (d)  of the affordable care act, 42 U.S.C. §
    45  18022 (d), outside the health benefit exchange.
    46    (d)(1) Nothing in this section shall be deemed to require health main-
    47  tenance organizations to discontinue individual direct payment contracts

    48  issued prior to October first, two thousand thirteen or  prevent  health
    49  maintenance  organizations  from discontinuing individual direct payment
    50  contracts issued prior to October first, two thousand thirteen.    If  a
    51  health  maintenance  organization discontinues individual direct payment
    52  contracts issued prior to October first, two thousand thirteen,  regard-
    53  less of whether it is a grandfathered health plan, then the health main-
    54  tenance  organization  shall comply with  the requirements of subsection
    55  (c) of section four thousand three hundred four of this article.

        S. 2606--D                         111                        A. 3006--D
 
     1    (2) For purposes of this subsection, "grandfathered health plan" means

     2  coverage provided by a corporation in which an individual  was  enrolled
     3  on  March  twenty-third,  two  thousand  ten for as long as the coverage
     4  maintains grandfathered status in accordance with section 1251(e) of the
     5  affordable care act, 42 U.S.C. § 18011(e).
     6    (e)  The  superintendent  may  promulgate regulations implementing the
     7  requirements of this  section, including regulations that modify or  add
     8  additional  standardized individual enrollee direct payment contracts if
     9  the superintendent determines additional contracts with different levels
    10  of coverage are necessary to meet the needs of the public.
    11    § 46-a. Subdivision 1 of section 4406 of the  public  health  law,  as
    12  amended by chapter 342 of the laws of 2004, is amended as follows:

    13    1.    The  contract  between  a health maintenance organization and an
    14  enrollee shall be subject to regulation by the superintendent as  if  it
    15  were  a health insurance subscriber contract, and shall include, but not
    16  be limited to, all mandated benefits required by article forty-three  of
    17  the insurance law. Such contract shall fully and clearly state the bene-
    18  fits  and  limitations  therein provided or imposed, so as to facilitate
    19  understanding and comparisons, and to exclude provisions  which  may  be
    20  misleading  or  unreasonably confusing. Such contract shall be issued to
    21  any individual and dependents of such individual and any group of  fifty
    22  or  fewer  employees or members, exclusive of spouses and dependents, or
    23  any employee or member of the group, including dependents, applying  for
    24  such contract at any time throughout the year, and may include a pre-ex-

    25  isting  condition  provision  as  provided  for in section four thousand
    26  three hundred eighteen of the insurance  law,  provided,  however,  that
    27  [such], the superintendent may, after giving consideration to the public
    28  interest, exempt a health maintenance organization from the requirements
    29  of  this  section provided that another health insurer or health mainte-
    30  nance organization within the  health  maintenance  organization's  same
    31  holding  company  system, as defined in article fifteen of the insurance
    32  law, including a health maintenance organization operated as a  line  of
    33  business  of  a health service corporation licensed under article forty-
    34  three of the insurance law, offers coverage that, at a minimum, complies

    35  with this section and provides all of the consumer protections  required
    36  to  be  provided  by  a health maintenance organization pursuant to this
    37  chapter and regulations, including those consumer protections  contained
    38  in  sections  four  thousand  four  hundred three and four thousand four
    39  hundred eight-a of this chapter. The requirements shall not apply  to  a
    40  health maintenance organization exclusively serving individuals enrolled
    41  pursuant  to  title  eleven  of article five of the social services law,
    42  title eleven-D of article five of the social services law,  title  one-A
    43  of article twenty-five of the public health law or title eighteen of the
    44  federal  Social  Security  Act,  and, further provided, that such health
    45  maintenance organization shall not discontinue a contract for  an  indi-

    46  vidual  receiving comprehensive-type coverage in effect prior to January
    47  first, two thousand four who is ineligible to purchase policies  offered
    48  after  such date pursuant to this section or section four thousand three
    49  hundred twenty-two of this article due to the  provision  of  42  U.S.C.
    50  1395ss  in  effect prior to January first, two thousand four. Subject to
    51  the creditable coverage requirements of subsection (a) of  section  four
    52  thousand  three  hundred eighteen of the insurance law, the organization
    53  may, as an alternative to the use of a pre-existing condition provision,
    54  elect to offer contracts without a pre-existing condition  provision  to
    55  such  groups  but  may  require that coverage shall not become effective
    56  until after a specified affiliation period of not more than  sixty  days


        S. 2606--D                         112                        A. 3006--D
 
     1  after the application for coverage is submitted. The organization is not
     2  required  to provide health care services or benefits during such period
     3  and no premium shall be charged for  any  coverage  during  the  period.
     4  After  January first, nineteen hundred ninety-six, all individual direct
     5  payment contracts shall be issued only pursuant to sections  four  thou-
     6  sand three hundred twenty-one and four thousand three hundred twenty-two
     7  of  the insurance law. Such contracts may not, with respect to an eligi-
     8  ble individual (as defined in section  2741(b)  of  the  federal  Public
     9  Health  Service  Act,  42  U.S.C. § 300gg-41(b), impose any pre-existing
    10  condition exclusion.
    11    § 46-b. Paragraph 5 of subsection (c) of section 3216 of the insurance
    12  law is amended to read as follows:

    13    (5) (A) Any family  policy  providing  hospital  or  surgical  expense
    14  insurance  (but  not  including such insurance against accidental injury
    15  only) shall provide that, in the event such  insurance  on  any  person,
    16  other  than  the  policyholder,  is  terminated because the person is no
    17  longer within the definition of the family as set forth  in  the  policy
    18  but before such person has attained the limiting age, if any, for cover-
    19  age  of adults specified in the policy, such person shall be entitled to
    20  have issued to [him] that person by the  insurer,  without  evidence  of
    21  insurability,  upon application therefor and payment of the first premi-
    22  um, within [thirty-one] sixty  days  after  such  insurance  shall  have
    23  terminated,  an  individual conversion policy that contains the benefits

    24  described in paragraph one of subsection (b) of  section  four  thousand
    25  three  hundred twenty-eight of this chapter. The insurer shall offer one
    26  policy at each level of coverage as defined in section  1302(d)  of  the
    27  affordable care act, 42 U.S.C. § 18022(d). The individual may choose any
    28  such  policy  offered  by the insurer. The conversion privilege afforded
    29  herein shall also be available upon the  divorce  or  annulment  of  the
    30  marriage of the policyholder to the former spouse of such policyholder.
    31    (B)  Written  notice  of  entitlement  to a conversion policy shall be
    32  given by the insurer to the policyholder at least fifteen and  not  more
    33  than  sixty days prior to the termination of coverage due to the initial
    34  limiting age of the covered dependent.  Such  notice  shall  include  an

    35  explanation  of  the  rights  of the dependent with respect to [his] the
    36  dependent being enrolled in an accredited institution of learning or his
    37  incapacity for self-sustaining employment by reason of  mental  illness,
    38  developmental  disability or mental retardation as defined in the mental
    39  hygiene law or physical handicap.
    40    (C) Such individual conversion policy shall be subject to the  follow-
    41  ing terms and conditions:
    42    (i)  The  premium  shall  be  that applicable to the [class of risk to
    43  which such person belongs, to the age of such person and  to  the]  form
    44  and amount of insurance therefor.
    45    (ii)  [Such  policy  shall provide, on a basis specified in the family
    46  policy, the same or substantially the same benefits as those provided in

    47  the family policy or such benefits as are provided in a  policy  specif-
    48  ically  approved  as  an individual conversion policy by the superinten-
    49  dent.
    50    (iii)] The benefits provided under such policy shall become  effective
    51  upon  the  date that such person was no longer eligible under the family
    52  policy.
    53    [(iv) The policy may exclude any  condition  excluded  by  the  family
    54  policy  for  such person at the time of the termination of his insurance
    55  thereunder. The policy shall not exclude any other  pre-existing  condi-
    56  tions,  but  the  benefits  paid under such policy may be reduced by the

        S. 2606--D                         113                        A. 3006--D


     1  amount of any such benefits payable under the family  policy  after  the
     2  termination  of such person's insurance thereunder and, during the first
     3  policy year of the conversion policy, the  benefits  payable  under  the
     4  policy may be reduced so that they are not in excess of those that would
     5  have  been  payable  had such person's insurance under the family policy
     6  remained in force and effect.
     7    (v)] (iii) No insurer shall be required to issue a  conversion  policy
     8  if  it  appears  that  the person applying for such policy shall have at
     9  that time in force another  insurance  policy  or  hospital  service  or
    10  medical  expense  indemnity  contract  providing  similar benefits or is
    11  covered by or is eligible for coverage by a group  insurance  policy  or

    12  contract providing similar benefits or shall be covered by similar bene-
    13  fits required by any statute or provided by any welfare plan or program,
    14  which together with the conversion policy would result in over insurance
    15  or  duplication  of  benefits  according  to  standards on file with the
    16  superintendent relating to individual policies.
    17    [(vi) The policy may include  a  provision  whereby  the  insurer  may
    18  request  information at any premium due date of the policy of the person
    19  covered thereunder as to whether he is then covered by another policy or
    20  hospital service or medical  expense  indemnity  corporation  subscriber
    21  contract  providing  similar  benefits  or  is  then  covered by a group
    22  contract or policy providing similar benefits or is then  provided  with

    23  similar benefits required by any statute or provided by any welfare plan
    24  or program. If any such person is so covered or so provided and fails to
    25  furnish  the details of such coverage when requested, the benefits paya-
    26  ble under the conversion policy may be based on the hospital surgical or
    27  medical expenses actually  incurred  after  excluding  expenses  to  the
    28  extent they are payable under such other coverage or provided under such
    29  statute, plan, or program.]
    30    §  47.  Paragraphs 4, 6, 9 and 10 of subsection (e) of section 3221 of
    31  the insurance law are REPEALED, paragraphs 5, 7, 8, 11 and 12 are renum-
    32  bered paragraphs 4, 5, 6, 7 and 8 and paragraph 1, as amended by chapter
    33  306 of the laws of 1987, is amended to read as follows:

    34    (1) A group policy providing hospital,  medical  or  surgical  expense
    35  insurance  for  other  than  specific  diseases  or accident only, shall
    36  provide that if the insurance on an employee or member insured under the
    37  group policy ceases because of termination of [(I)] (A) employment or of
    38  membership in the class or classes eligible for coverage under the poli-
    39  cy or [(II)] (B) the policy, for any reason whatsoever, unless the poli-
    40  cyholder has replaced the  group  policy  with  similar  and  continuous
    41  coverage  for  the  same  group  whether  insured  or self-insured, such
    42  employee or member who has been insured under the group policy  [for  at
    43  least  three  months]  shall  be  entitled  to  have issued to [him] the

    44  insured by the insurer without evidence of insurability upon application
    45  made to the insurer within [forty-five] sixty  days  after  such  termi-
    46  nation,  and payment of the quarterly, or, at the option of the employee
    47  or member, a less frequent premium applicable to the [class of  risk  to
    48  which  the  person  belongs,  the  age of such person, and the] form and
    49  amount of insurance, an individual policy of insurance. The insurer may,
    50  at its option elect to provide the  insurance  coverage  under  a  group
    51  insurance  policy, delivered in this state, in lieu of the issuance of a
    52  converted individual policy of insurance.  Such  individual  policy,  or
    53  group  policy,  as  the  case  may  be  is  hereafter referred to as the
    54  converted policy. The benefits provided under the converted policy shall

    55  be those required by subsection (f)[,] and (g)[, (h) or (i)  hereof]  of
    56  this section, [whichever is applicable and,] in the event of termination

        S. 2606--D                         114                        A. 3006--D
 
     1  of  the  converted  group  policy  of insurance, each insured thereunder
     2  shall have a right of conversion to a  converted  individual  policy  of
     3  insurance.
     4    §  48.  Paragraph 3 of subsection (e) of section 3221 of the insurance
     5  law, as separately amended by chapters 370 and 869 of the laws of  1984,
     6  is amended to read as follows:
     7    (3)  The  converted  policy  shall,  at  the option of the employee or
     8  member, provide identical coverage for the dependents of  such  employee
     9  or  member  who  were covered under the group policy. Provided, however,

    10  that if the employee or member chooses the option of dependent  coverage
    11  then  dependents  acquired after the permitted time to convert stated in
    12  paragraph one of this subsection shall be added to the converted  family
    13  policy  in  accordance  with the provisions of subsection (c) of section
    14  thirty-two hundred sixteen of this article and any  regulations  promul-
    15  gated  or guidelines issued by the superintendent. [The converted policy
    16  need not provide benefits in excess of those provided for  such  persons
    17  under the group policy from which conversion is made and may contain any
    18  exclusion or benefit limitation contained in the group policy or custom-
    19  arily  used  in individual policies.] The effective date of the individ-
    20  ual's coverage under the converted policy  shall  be  the  date  of  the

    21  termination  of  the individual's insurance under the group policy as to
    22  those persons covered under the group policy.
    23    § 49. Subsections (f) and (g) of section 3221 of the insurance law are
    24  REPEALED and two new subsections (f)  and  (g)  are  added  to  read  as
    25  follows:
    26    (f)  If  the group insurance policy insures the employee or member for
    27  hospital, medical or surgical expense insurance, or if the group  insur-
    28  ance  policy insures the employee or member for major medical or similar
    29  comprehensive-type coverage, then the conversion privilege shall entitle
    30  the employee or member to  obtain  coverage  under  a  converted  policy
    31  providing,  at the insured's option, coverage under any one of the plans
    32  described in subsection (g) of  this  section  on  an  expense  incurred

    33  basis.
    34    (g) For conversion purposes, an insurer shall offer to the employee or
    35  member  a policy at each level of coverage as defined in section 1302(d)
    36  of the affordable care act, 42 U.S.C. § 18022(d) that contains the bene-
    37  fits described in paragraph one of subsection (b) of section four  thou-
    38  sand three hundred twenty-eight of this chapter.
    39    §  50.  Subparagraph  (D)  of paragraph 4 of subsection (l) of section
    40  3221 of the insurance law, as amended by chapter  230  of  the  laws  of
    41  2004, is amended to read as follows:
    42    (D)  In addition to the requirements of subparagraph (A) of this para-
    43  graph, every insurer issuing a group policy for delivery in  this  state
    44  [which]  where the policy provides reimbursement to insureds for psychi-

    45  atric or psychological services or for the diagnosis  and  treatment  of
    46  mental,  nervous or emotional disorders and ailments, however defined in
    47  such policy, by physicians, psychiatrists or psychologists, [must] shall
    48  provide the same coverage to insureds for such services  when  performed
    49  by  a licensed clinical social worker, within the lawful scope of his or
    50  her practice, who is licensed pursuant to  subdivision  two  of  section
    51  seven  thousand  seven hundred four of the education law and in addition
    52  shall have either: (i) three or  more  additional  years  experience  in
    53  psychotherapy,  which  for  the purposes of this subparagraph shall mean
    54  the use of verbal methods in interpersonal relationships with the intent
    55  of assisting a person  or  persons  to  modify  attitudes  and  behavior

    56  [which]  that  are  intellectually, socially or emotionally maladaptive,

        S. 2606--D                         115                        A. 3006--D
 
     1  under supervision, satisfactory to the state board for social work, in a
     2  facility,  licensed  or  incorporated  by  an  appropriate  governmental
     3  department,  providing  services  for  diagnosis or treatment of mental,
     4  nervous  or  emotional  disorders  or ailments[, or]; (ii) three or more
     5  additional years experience  in  psychotherapy  under  the  supervision,
     6  satisfactory  to  the  state board for social work, of a psychiatrist, a
     7  licensed and registered psychologist or a licensed clinical social work-
     8  er qualified for reimbursement pursuant to subsection [(h)] (e) of  this

     9  section, or (iii) a combination of the experience specified in items (i)
    10  and  (ii) of this subparagraph totaling three years, satisfactory to the
    11  state board for social work.
    12    (E) The state board for social work  shall  maintain  a  list  of  all
    13  licensed  clinical  social  workers  qualified  for  reimbursement under
    14  [this] subparagraph (D) of this paragraph.
    15    § 51. Paragraph 3 of subsection (e) of section 4304 of  the  insurance
    16  law  is  REPEALED and paragraphs 4 and 5 are renumbered paragraphs 3 and
    17  4, and paragraphs 1 and 2 of such subsection (e), paragraph 1 as amended
    18  by chapter 661 of the laws of 1997, and as further  amended  by  section
    19  104  of part A of chapter 62 of the laws of 2011, are amended to read as
    20  follows:
    21    (1) If  any  such  contract  is  terminated  in  accordance  with  the

    22  provisions  of paragraph one of subsection (c) [hereof] of this section,
    23  or any such contract is terminated because of a default by the remitting
    24  agent in the payment of premiums not cured within the grace  period  and
    25  the  remitting  agent  has  not  replaced  the contract with similar and
    26  continuous coverage for the same group whether insured or  self-insured,
    27  or  any such contract is terminated in accordance with the provisions of
    28  subparagraph (E) of paragraph two of subsection  (c)  [hereof]  of  this
    29  section, or if an individual other than the contract holder is no longer
    30  covered  under  a  "family  contract"  because [he] the individual is no
    31  longer within the definition set forth in the contract, or a  spouse  is
    32  no  longer  covered  under  the  contract  because  of  divorce from the

    33  contract holder or annulment of the marriage, or any  such  contract  is
    34  terminated  because of the death of the contract holder, then such indi-
    35  vidual, former spouse, or in the case of the death of the contract hold-
    36  er the surviving spouse or other dependents  of  the  deceased  contract
    37  holder covered under the contract, as the case may be, shall be entitled
    38  to  convert, without evidence of insurability, upon application therefor
    39  and the making of the first payment thereunder within [thirty-one] sixty
    40  days after the date of termination of such contract, to a contract [of a
    41  type which provides coverage most  nearly  comparable  to  the  type  of
    42  coverage  under  the contract from which the individual converted, which
    43  coverage shall be no less than the minimum standards for basic hospital,

    44  basic medical, or major medical as provided for in department of  finan-
    45  cial  services  regulation;  provided,  however, that if the corporation
    46  does not issue such a major medical contract, then to a comprehensive or
    47  comparable type of coverage which is most commonly being sold  to  group
    48  remitting  agents.  Notwithstanding the previous sentence, a corporation
    49  may elect to issue a standardized individual enrollee contract  pursuant
    50  to  section  four  thousand  three hundred twenty-two of this article in
    51  lieu of a major medical contract, comprehensive or  comparable  type  of
    52  coverage  required  to  be  offered  upon  conversion  from an indemnity
    53  contract] that contains the  benefits  described  in  paragraph  one  of

    54  subsection  (b)  of  section four thousand three hundred twenty-eight of
    55  this chapter. The corporation shall offer one contract at each level  of
    56  coverage  as  defined  in section 1302(d) of the affordable care act, 42

        S. 2606--D                         116                        A. 3006--D
 
     1  U.S.C. § 18022(d). The individual may choose any such  contract  offered
     2  by  the corporation.  The effective date of the coverage provided by the
     3  converted direct payment contract shall be the date of  the  termination
     4  of coverage under the contract from which conversion was made.
     5    (2)  The corporation shall not be required to issue any such converted
     6  individual direct payment contract if its issuance would result in over-
     7  insurance or duplication of benefits according to standards on file with

     8  the superintendent and approved by [him] the superintendent with  regard
     9  to such contracts. [The individual direct payment contract may include a
    10  provision  whereby  the  corporation  may  request  information when any
    11  payment is due under the contract of the person covered thereunder as to
    12  whether he is then covered  by  another  individual  contract  providing
    13  similar benefits or is then covered by a group contract policy providing
    14  similar  benefits  or is then provided with similar benefits required by
    15  any statute or provided by any welfare plan or  program  which  together
    16  with  the  converted  individual direct payment contract would result in
    17  overinsurance or duplication of benefits according to the  standards  on

    18  file  with  the  superintendent relating to individual contracts. If any
    19  such person is so covered or  so  provided  and  fails  to  furnish  the
    20  details of such coverage when requested, the benefits provided under the
    21  converted  individual direct payment contract may be based on the hospi-
    22  tal, surgical or medical  expenses  actually  incurred  after  excluding
    23  expenses  to  the  extent  they are payable under such other coverage or
    24  provided under such statute, plan or program.]
    25    § 52. Paragraphs 1 and 2 of subsection (d)  of  section  4305  of  the
    26  insurance law, paragraph 1 as amended by chapter 504 of the laws of 1995
    27  and  paragraphs  1  and 2 as further amended by section 104 of part A of
    28  chapter 62 of the laws of 2011, are amended to read as follows:

    29    (1) (A) A group contract issued pursuant to this section shall contain
    30  a provision to the effect that in case  of  a  termination  of  coverage
    31  under  such  contract  of  any  member of the group because of [(I)] (i)
    32  termination for any reason whatsoever of [his] the  member's  employment
    33  or  membership,  [if he has been covered under the group contract for at
    34  least three months,] or [(II)] (ii) termination for any reason whatsoev-
    35  er of the group contract itself unless the  group  contract  holder  has
    36  replaced the group contract with similar and continuous coverage for the
    37  same  group  whether  insured  or self-insured, [he] the member shall be
    38  entitled to have issued to [him] the member by the corporation,  without

    39  evidence  of  insurability, upon application therefor and payment of the
    40  first premium made to the corporation  within  [forty-five]  sixty  days
    41  after   termination  of  the  coverage,  an  individual  direct  payment
    42  contract, covering such member and [his] the  member's  eligible  depen-
    43  dents  who  were  covered by the group contract, which provides coverage
    44  [most nearly  comparable  to  the  type  of  coverage  under  the  group
    45  contract, which coverage shall be no less than the minimum standards for
    46  basic  hospital,  basic  medical,  or  major  medical as provided for in
    47  department of financial services regulation; provided, however, that  if
    48  the  corporation does not issue such a major medical contract, then to a

    49  comprehensive or comparable type of  coverage  which  is  most  commonly
    50  being  sold  to  group  remitting  agents.  Notwithstanding the previous
    51  sentence, a corporation may elect to  issue  a  standardized  individual
    52  enrollee contract pursuant to section four thousand three hundred twenty
    53  two  of  this article in lieu of a major medical contract, comprehensive
    54  or comparable type of coverage required to be  offered  upon  conversion
    55  from  an  indemnity  contract]  that  contains the benefits described in
    56  paragraph one of subsection (b) of section four thousand  three  hundred

        S. 2606--D                         117                        A. 3006--D
 
     1  twenty-eight  of  this chapter. The corporation shall offer one contract

     2  at each level of coverage as defined in section 1302(d) of the  afforda-
     3  ble  care  act,  42  U.S.C.  §  18022(d). The member may choose any such
     4  contract offered by the corporation.
     5    (B) The conversion privilege afforded [herein] in this paragraph shall
     6  also  be  available:  [(A)]  (i)  upon  the  divorce or annulment of the
     7  marriage of a member, to the divorced spouse or former  spouse  of  such
     8  member[,  (B)];  (ii)  upon  the  death  of the member, to the surviving
     9  spouse and other dependents covered under  the  contract[,];  and  [(C)]
    10  (iii) to a dependent if no longer within the definition in the contract.
    11    (2)  The  effective  date  of  the coverage provided by the individual

    12  direct payment contract shall be the date  of  the  termination  of  the
    13  individual's  coverage  under the group contract. [The individual direct
    14  payment converted contract may exclude any  condition  excluded  by  the
    15  group contract. The individual direct payment contract shall not exclude
    16  any  other  pre-existing  conditions but the benefits provided under the
    17  individual direct payment converted  contract  may  be  reduced  by  the
    18  amount  of any such benefits provided under the group contract after the
    19  termination of the individual's coverage thereunder and during the first
    20  contract year of such individual direct payment converted  contract  the
    21  benefits provided under the contract may be reduced so that they are not

    22  in  excess  of  those that would have been provided had the individual's
    23  contract under the group contract remained in  force  and  effect.]  The
    24  corporation  shall  not  be  required  to  issue  such individual direct
    25  payment converted contract covering any person if it appears  that  such
    26  person  shall  then  be covered by another individual contract providing
    27  similar coverage or if it shall appear that such person is covered by or
    28  eligible to be covered by a group contract or policy  providing  similar
    29  benefits or is provided with similar benefits required by any statute or
    30  provided  by  any welfare plan or program, which together with the indi-
    31  vidual direct payment converted contract would result in  over-insurance
    32  or  duplication  of  benefits  according  to  standards on file with the
    33  superintendent of financial services relating to  individual  contracts.

    34  [The   individual  direct  payment  converted  contract  may  include  a
    35  provision whereby the  corporation  may  request  information  when  any
    36  payment is due under the contract of any person covered thereunder as to
    37  whether  he is then covered by another contract or by a policy providing
    38  similar benefits or is then  covered  by  a  group  contract  or  policy
    39  providing  similar  benefits  or  is then provided with similar benefits
    40  required by any statute or provided by any welfare plan or  program.  If
    41  any  such  person  is so covered or so provided and fails to furnish the
    42  details of such coverage when requested, the benefits payable under  the
    43  individual  direct payment converted contract may be based on the hospi-

    44  tal, surgical or medical  expenses  actually  incurred  after  excluding
    45  expenses  to  the  extent  they are payable under such other coverage or
    46  provided under such statute, plan or program.
    47    In the event the benefits provided or payable are reduced  in  accord-
    48  ance with the provisions of this subsection the corporation shall return
    49  such portion of the premium paid as shall exceed the pro rata portion of
    50  the benefits thus determined.]
    51    §  53.  Section  3216  of the insurance law is amended by adding a new
    52  subsection (m) to read as follows:
    53    (m) An insurer shall not be required to  offer  the  policyholder  any
    54  benefits  that  must  be  made available pursuant to this section if the

    55  benefits must be covered as essential health benefits.  For  any  policy
    56  issued  within  the  health  benefit  exchange  established  pursuant to

        S. 2606--D                         118                        A. 3006--D
 
     1  section 1311 of the affordable care act, 42 U.S.C. § 18031,  an  insurer
     2  shall  not  be required to offer the policyholder any benefits that must
     3  be made available  pursuant  to  this  section.  For  purposes  of  this
     4  subsection, "essential health benefits" shall have the meaning set forth
     5  in section 1302(b) of the affordable care act, 42 U.S.C. § 18022(b).
     6    § 54. Subsections (h) and (i) of section 3221 of the insurance law are
     7  REPEALED  and  two  new  subsections  (h)  and  (i) are added to read as
     8  follows:

     9    (h) Every small group policy or association group policy delivered  or
    10  issued  for delivery in this state that provides  coverage for hospital,
    11  medical or surgical expense insurance and is not a grandfathered  health
    12  plan  shall provide coverage for the essential health benefit package as
    13  required in section 2707(a) of the public health service act, 42  U.S.C.
    14  § 300gg-6(a). For purposes of this subsection:
    15    (1)  "essential  health  benefits  package" shall have the meaning set
    16  forth in section 1302(a)  of  the  affordable  care  act,  42  U.S.C.  §
    17  18022(a);
    18    (2)  "grandfathered health plan" means coverage provided by an insurer
    19  in which an individual  was enrolled on March twenty-third, two thousand

    20  ten for as long  as  the  coverage  maintains  grandfathered  status  in
    21  accordance  with section 1251(e) of the affordable care act, 42 U.S.C. §
    22  18011(e);
    23    (3) "small group" means a group of fifty or fewer employees or members
    24  exclusive of spouses  and dependents; provided, however, that  beginning
    25  January  first, two thousand sixteen, "small group" means a group of one
    26  hundred or fewer employees or members exclusive of  spouses  and  depen-
    27  dents; and
    28    (4)  "association  group"  means a group defined in subparagraphs (B),
    29  (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of  section
    30  four thousand two hundred thirty-five of this chapter, provided that:

    31    (A) the group includes one or more individual members; or
    32    (B)  the  group  includes one or more member employers or other member
    33  groups that are small groups.
    34    (i) An insurer shall not be required to  offer  the  policyholder  any
    35  benefits  that  must  be  made available pursuant to this section if the
    36  benefits must be covered pursuant to subsection (h) of this section. For
    37  any policy issued within the health benefit exchange established  pursu-
    38  ant  to  section  1311 of the affordable care act, 42 U.S.C. § 18031, an
    39  insurer shall not be required to offer  the  policyholder  any  benefits
    40  that must be made available pursuant to this section.
    41    §  55.  Subsection (gg) of section 4303 of the insurance law, as added

    42  by chapter 536 of the laws of 2010, is relettered to be subsection (jj),
    43  subsection (hh), as added by chapter 597 of the laws of 2011, is  relet-
    44  tered  to  be  subsection (kk) and two new subsections (ll) and (mm) are
    45  added to read as follows:
    46    (ll) Every small group contract or association group  contract  deliv-
    47  ered  or  issued  for  delivery in this state that provides coverage for
    48  hospital, medical or surgical expense insurance and is  not  a  grandfa-
    49  thered health plan shall provide coverage for the essential health bene-
    50  fit  package as required in section 2707(a) of the public health service
    51  act, 42 U.S.C. § 300gg-6(a). For purposes of this subsection:
    52    (1) "essential health benefits package" shall  have  the  meaning  set

    53  forth  in  section  1302(a)  of  the  affordable  care  act, 42 U.S.C. §
    54  18022(a);
    55    (2) "grandfathered health plan" means coverage provided  by  a  corpo-
    56  ration  in  which an  individual was enrolled on March twenty-third, two

        S. 2606--D                         119                        A. 3006--D
 
     1  thousand ten for as long as the coverage maintains  grandfathered status
     2  in accordance with section 1251(e) of the affordable care act, 42 U.S.C.
     3  § 18011(e); and
     4    (3) "small group" means a group of fifty or fewer employees or members
     5  exclusive of spouses  and dependents. Beginning January first, two thou-
     6  sand  sixteen,  "small  group"  means  a group of one   hundred or fewer

     7  employees or members exclusive of spouses and dependents; and
     8    (4) "association group" means a group defined  in  subparagraphs  (B),
     9  (D),  (H), (K), (L) or (M) of paragraph one of subsection (c) of section
    10  four thousand two hundred thirty-five of this chapter, provided that:
    11    (A) the group includes one or more individual members; or
    12    (B) the group includes one or more member employers  or  other  member
    13  groups that are small groups.
    14    (mm)  A corporation shall not be required to offer the contract holder
    15  any benefits that must be made available pursuant  to  this  section  if
    16  such  benefits  must  be  covered  pursuant  to  subsection (kk) of this
    17  section. For any contract issued  within  the  health  benefit  exchange

    18  established  pursuant  to  section  1311  of the affordable care act, 42
    19  U.S.C. § 18031, a  corporation  shall  not  be  required  to  offer  the
    20  contract  holder  any  benefits  that must be made available pursuant to
    21  this section.
    22    § 55-a. Section 3221 of the insurance law is amended by adding  a  new
    23  subsection (s) to read as follows:
    24    (s)  An insurer subject to the provisions of this article or an insur-
    25  ance producer subject to this chapter shall not permit the renewal of  a
    26  small  group  policy that provides hospital, surgical or medical expense
    27  coverage that renews on or after January first, two  thousand  fourteen,
    28  but  before  July  first, two thousand fourteen, so as to renew the same

    29  policy prior to the policy's annual renewal date for the sole purpose of
    30  evading the requirements of the  affordable  care  act  and  regulations
    31  promulgated  thereunder  with respect to such policy. An isolated, inad-
    32  vertent renewal date change which was not made for the sole  purpose  of
    33  evading  the requirements of the affordable care act shall not be deemed
    34  a violation of this subsection.
    35    § 55-b. Section 4303 of the insurance law is amended by adding  a  new
    36  subsection (nn) to read as follows:
    37    (nn)  A  corporation  subject  to the provisions of this article or an
    38  insurance producer subject to this chapter shall not permit the  renewal
    39  of  a  small  group  policy which provides hospital, surgical or medical

    40  expense coverage that renews on or after  January  first,  two  thousand
    41  fourteen,  but  before July first, two thousand fourteen, so as to renew
    42  the same policy prior to the policy's annual renewal date for  the  sole
    43  purpose of evading the requirements of the affordable care act and regu-
    44  lations promulgated thereunder with respect to such policy. An isolated,
    45  inadvertent  renewal date change which was not made for the sole purpose
    46  of evading the requirements of the affordable  care  act  shall  not  be
    47  deemed a violation of this subsection.
    48    §  56. Section 4326 of the insurance law, as added by chapter 1 of the
    49  laws of 1999, subsection (b) as amended by chapter 342 of  the  laws  of
    50  2004,  subparagraph (A) of paragraph 1 and subparagraph (C) of paragraph

    51  3 of subsection (c) as amended by chapter 419 of the laws of 2000, para-
    52  graphs 13 and 14 of subsection (d), paragraphs 6 and 7 of subsection (e)
    53  and subsection (k) as amended and paragraph  15  of  subsection  (d)  as
    54  added  by  chapter  219 of the laws of 2011 and subsections (d-1), (d-2)
    55  and (d-3) as added by chapter 645 of the laws of  2005,  is  amended  to
    56  read as follows:

        S. 2606--D                         120                        A. 3006--D
 
     1    §  4326.  Standardized health insurance contracts for qualifying small
     2  employers and individuals. (a) A program is hereby established  for  the
     3  purpose  of  making standardized health insurance contracts available to
     4  qualifying small employers [and qualifying individuals]  as  defined  in
     5  this  section.  Such program is designed to encourage small employers to

     6  offer health insurance coverage to their employees  [and  to  also  make
     7  coverage available to uninsured employees whose employers do not provide
     8  group health insurance].
     9    (b)  Participation  in  the  program  established  by this section and
    10  section four thousand three hundred  twenty-seven  of  this  article  is
    11  limited  to  corporations  or  insurers organized or licensed under this
    12  article or article forty-two of  this  chapter  and  health  maintenance
    13  organizations issued a certificate of authority under article forty-four
    14  of  the  public health law or licensed under this article. Participation
    15  by all health maintenance organizations is mandatory, provided, however,
    16  that such requirements shall not apply to a holder of a special  purpose
    17  certificate  of  authority issued pursuant to section four thousand four

    18  hundred three-a of the public health law or a health maintenance  organ-
    19  ization exclusively serving individuals enrolled pursuant to title elev-
    20  en of article five of the social services law, title eleven-D of article
    21  five  of  the social services law, title one-A of article twenty-five of
    22  the public health law or title eighteen of the federal  Social  Security
    23  Act[,  and,  further provided, that such health maintenance organization
    24  shall not discontinue a contract for an individual receiving  comprehen-
    25  sive-type  coverage  in effect prior to January first, two thousand four
    26  who is ineligible to purchase policies offered after such date  pursuant
    27  to  this  section  or  section four thousand three hundred twenty-two of
    28  this article due to the provision of 42 U.S.C. 1395ss in effect prior to

    29  January first, two thousand four]. On and after January first, two thou-
    30  sand one, all health maintenance organizations  shall  offer  qualifying
    31  group  health  insurance  contracts  [and  qualifying  individual health
    32  insurance contracts] as defined in this section.  For  the  purposes  of
    33  this  section  and  section  four thousand three hundred twenty-seven of
    34  this article, article  forty-three  corporations  or  article  forty-two
    35  insurers  which  voluntarily participate in compliance with the require-
    36  ments of this program shall be eligible for reimbursement from the  stop
    37  loss funds created pursuant to section four thousand three hundred twen-
    38  ty-seven  of  this article under the same terms and conditions as health
    39  maintenance organizations.
    40    (c) The following definitions shall be  applicable  to  the  insurance

    41  contracts offered under the program established by this section:
    42    (1) (A) A qualifying small employer is [an employer that is either:
    43    (A) An individual proprietor who is the only employee of the business:
    44    (i)  without  health  insurance  which provides benefits on an expense
    45  reimbursed or prepaid basis in effect during  the  twelve  month  period
    46  prior  to  application  for a qualifying group health insurance contract
    47  under the program established by this section; and
    48    (ii) resides in a household having a net household income at or  below
    49  two  hundred  eight  percent  of  the non-farm federal poverty level (as
    50  defined and updated by  the  federal  department  of  health  and  human
    51  services) or the gross equivalent of such net income;

    52    (iii)  except  that  the  requirements  set  forth in item (i) of this
    53  subparagraph shall not be applicable where an individual proprietor  had
    54  health  insurance  coverage  during  the previous twelve months and such
    55  coverage terminated due to one of the reasons set  forth  in  items  (i)

        S. 2606--D                         121                        A. 3006--D

     1  through  (viii) of subparagraph (C) of paragraph three of subsection (c)
     2  of this section; or
     3    (B) An] an employer with:
     4    (i) not more than fifty [eligible] employees;
     5    (ii)  no  group  health insurance [which] that provides benefits on an
     6  expense reimbursed or prepaid basis covering employees in effect  during

     7  the  twelve  month  period  prior  to application for a qualifying group
     8  health insurance contract under the program established by this section;
     9  and
    10    (iii) at least thirty percent of its  [eligible]  employees  receiving
    11  annual  wages  from the employer at a level equal to or less than thirty
    12  thousand dollars. The thirty thousand dollar figure  shall  be  adjusted
    13  periodically pursuant to subparagraph [(F)] (D) of this paragraph.
    14    [(C)  The  requirements  set  forth in item (i) of subparagraph (A) of
    15  this paragraph and in item (ii) of subparagraph (B)  of  this  paragraph
    16  shall  not  be  applicable where an individual proprietor or employer is
    17  transferring from a health insurance contract issued pursuant to the New

    18  York state small business health insurance  partnership  program  estab-
    19  lished  by  section  nine hundred twenty-two of the public health law or
    20  from health care coverage issued pursuant to a  regional  pilot  project
    21  for  the uninsured established by section one thousand one hundred eigh-
    22  teen of this chapter.
    23    (D)] (B) The twelve month period set forth [in item  (i)  of  subpara-
    24  graph  (A) of this paragraph and] in item (ii) of subparagraph [(B)] (A)
    25  of this paragraph may be adjusted  by  the  superintendent  from  twelve
    26  months  to eighteen months if he determines that the twelve month period
    27  is insufficient to prevent inappropriate substitution of  [other  health

    28  insurance contracts for] qualifying group health insurance contracts for
    29  other health insurance contracts.
    30    [(E)]  (C)  An [individual proprietor or] employer shall cease to be a
    31  qualifying small employer if any health insurance [which] that  provides
    32  benefits  on  an expense reimbursed or prepaid basis covering [the indi-
    33  vidual proprietor or] an employer's  employees,  other  than  qualifying
    34  group  health insurance purchased pursuant to this section, is purchased
    35  or otherwise takes effect subsequent to  purchase  of  qualifying  group
    36  health insurance under the program established by this section.
    37    [(F)]  (D)  The wage levels utilized in subparagraph [(B)] (A) of this

    38  paragraph shall be adjusted annually, beginning in two thousand two. The
    39  adjustment shall take effect on July first of each year. For July first,
    40  two thousand two, the adjustment shall be a  percentage  of  the  annual
    41  wage  figure  specified in subparagraph [(B)] (A) of this paragraph. For
    42  subsequent years, the adjustment shall be a  percentage  of  the  annual
    43  wage  figure  [which]  that took effect on July first of the prior year.
    44  The percentage adjustment shall be the  same  percentage  by  which  the
    45  current year's non-farm federal poverty level, as defined and updated by
    46  the  federal  department of health and human services, for a family unit
    47  of four persons for the forty-eight contiguous  states  and  Washington,
    48  D.C., changed from the same level established for the prior year.

    49    (2)  A  qualifying group health insurance contract is a group contract
    50  purchased from a health maintenance organization, corporation or insurer
    51  by a qualifying small employer [which] that provides  the  benefits  set
    52  forth  in  subsection  (d) of this section. The contract must insure not
    53  less than fifty percent of the employees [eligible for coverage].
    54    [(3)(A) A qualifying individual is an employed person:
    55    (i) who does not have and has not had health insurance  with  benefits
    56  on an expense reimbursed or prepaid basis during the twelve month period

        S. 2606--D                         122                        A. 3006--D

     1  prior  to  the  individual's  application for health insurance under the
     2  program established by this section;

     3    (ii)  whose  employer  does not provide group health insurance and has
     4  not provided group health insurance with benefits on  an  expense  reim-
     5  bursed  or  prepaid basis covering employees in effect during the twelve
     6  month period prior to the individual's application for health  insurance
     7  under the program established by this section;
     8    (iii) resides in a household having a net household income at or below
     9  two  hundred  eight  percent  of  the non-farm federal poverty level (as
    10  defined and updated by  the  federal  department  of  health  and  human
    11  services) or the gross equivalent of such net income; and
    12    (iv) is ineligible for Medicare.
    13    (B)  The  requirements set forth in items (i) and (ii) of subparagraph

    14  (A) of this paragraph shall not be applicable  where  an  individual  is
    15  transferring  from  a  health  insurance contract issued pursuant to the
    16  voucher insurance  program  established  by  section  one  thousand  one
    17  hundred  twenty-one  of this chapter, a health insurance contract issued
    18  pursuant to the New York state small business health insurance  partner-
    19  ship  program  established  by  section  nine  hundred twenty-two of the
    20  public health law or health care coverage issued pursuant to a  regional
    21  pilot  project for the uninsured established by section one thousand one
    22  hundred eighteen of this chapter.
    23    (C) The requirements set forth in items (i) and (ii)  of  subparagraph

    24  (A)  of  this  paragraph shall not be applicable where an individual had
    25  health insurance coverage during the previous  twelve  months  and  such
    26  coverage terminated due to:
    27    (i) loss of employment due to factors other than voluntary separation;
    28    (ii) death of a family member which results in termination of coverage
    29  under a health insurance contract under which the individual is covered;
    30    (iii)  change  to  a  new  employer that does not provide group health
    31  insurance with benefits on an expense reimbursed or prepaid basis;
    32    (iv) change of residence so that no  employer-based  health  insurance
    33  with benefits on an expense reimbursed or prepaid basis is available;
    34    (v) discontinuation of a group health insurance contract with benefits

    35  on  an expense reimbursed or prepaid basis covering the qualifying indi-
    36  vidual as an employee or dependent;
    37    (vi) expiration of the coverage periods established by  the  continua-
    38  tion  provisions  of  the  Employee  Retirement  Income Security Act, 29
    39  U.S.C.   section 1161 et seq. and the  Public  Health  Service  Act,  42
    40  U.S.C.   section 300bb-1 et seq. established by the Consolidated Omnibus
    41  Budget Reconciliation Act of  1985,  as  amended,  or  the  continuation
    42  provisions of subsection (m) of section three thousand two hundred twen-
    43  ty-one,  subsection  (k) of section four thousand three hundred four and
    44  subsection (e) of section four thousand three hundred five of this chap-
    45  ter;

    46    (vii) legal separation, divorce or annulment which results  in  termi-
    47  nation  of  coverage  under  a health insurance contract under which the
    48  individual is covered; or
    49    (viii) loss of eligibility under a group health plan.
    50    (D) The twelve month period set forth in items (i) and (ii) of subpar-
    51  agraph (A) of this paragraph may be adjusted by the superintendent  from
    52  twelve  months to eighteen months if he determines that the twelve month
    53  period is insufficient to prevent inappropriate  substitution  of  other
    54  health  insurance  contracts  for qualifying individual health insurance
    55  contracts.

        S. 2606--D                         123                        A. 3006--D


     1    (4) A qualifying individual health insurance contract is an individual
     2  contract issued directly to a qualifying individual and  which  provides
     3  the  benefits set forth in subsection (d) of this section. At the option
     4  of the qualifying individual, such contract  may  include  coverage  for
     5  dependents of the qualifying individual.]
     6    (d)  [The  contracts issued pursuant to this section by health mainte-
     7  nance organizations, corporations or insurers and approved by the super-
     8  intendent shall only provide in-plan benefits, except for emergency care
     9  or where services are not available through a plan  provider.    Covered
    10  services shall include only the following:
    11    (1)  inpatient  hospital  services consisting of daily room and board,

    12  general nursing care, special diets and miscellaneous hospital  services
    13  and supplies;
    14    (2)  outpatient  hospital services consisting of diagnostic and treat-
    15  ment services;
    16    (3)  physician  services  consisting  of  diagnostic   and   treatment
    17  services, consultant and referral services, surgical services (including
    18  breast  reconstruction surgery after a mastectomy), anesthesia services,
    19  second surgical opinion, and a second opinion for cancer treatment;
    20    (4) outpatient surgical facility charges related to a covered surgical
    21  procedure;
    22    (5) preadmission testing;
    23    (6) maternity care;
    24    (7) adult preventive health services consisting of mammography screen-

    25  ing; cervical cytology screening; periodic physical examinations no more
    26  than once every three years; and adult immunizations;
    27    (8) preventive and primary health care services for dependent children
    28  including routine well-child visits and necessary immunizations;
    29    (9) equipment, supplies and self-management education for  the  treat-
    30  ment of diabetes;
    31    (10) diagnostic x-ray and laboratory services;
    32    (11) emergency services;
    33    (12)  therapeutic services consisting of radiologic services, chemoth-
    34  erapy and hemodialysis;
    35    (13) blood and blood products furnished in connection with surgery  or
    36  inpatient hospital services;
    37    (14) prescription drugs obtained at a participating pharmacy. In addi-

    38  tion  to  providing coverage at a participating pharmacy, health mainte-
    39  nance organizations may utilize a mail order prescription drug  program.
    40  Health maintenance organizations may provide prescription drugs pursuant
    41  to  a  drug  formulary;  however,  health maintenance organizations must
    42  implement  an  appeals  process  so  that  the  use   of   non-formulary
    43  prescription drugs may be requested by a physician; and
    44    (15)  for  a  contract  that  is  not a grandfathered health plan, the
    45  following additional preventive health services:
    46    (A) evidence-based items or services that have in effect a  rating  of
    47  'A'  or  'B' in the current recommendations of the United States preven-
    48  tive services task force;

    49    (B) immunizations that have in effect a recommendation from the  advi-
    50  sory  committee  on  immunization  practices  of the centers for disease
    51  control and prevention with respect to the individual involved;
    52    (C) with respect  to  children,  including  infants  and  adolescents,
    53  evidence-informed  preventive  care  and  screenings provided for in the
    54  comprehensive guidelines supported by the health resources and  services
    55  administration; and

        S. 2606--D                         124                        A. 3006--D

     1    (D) with respect to women, such additional preventive care and screen-
     2  ings not described in subparagraph (A) of this paragraph as provided for

     3  in  comprehensive  guidelines  supported  by  the  health  resources and
     4  services administration.
     5    (E)  For purposes of this paragraph, "grandfathered health plan" means
     6  coverage provided by a corporation in which an individual  was  enrolled
     7  on  March  twenty-third,  two  thousand  ten for as long as the coverage
     8  maintains grandfathered status in accordance with section 1251(e) of the
     9  Affordable Care Act, 42 U.S.C. § 18011(e)]  A  qualifying  group  health
    10  insurance contract shall provide coverage for the essential health bene-
    11  fit  package as required in section 2707(a) of the public health service
    12  act, 42 U.S.C. § 300gg-6(a). For purposes of this subsection  "essential

    13  health  benefits  package"  shall  have the meaning set forth in section
    14  1302(a) of the affordable care act, 42 U.S.C. § 18022(a).
    15    (d-1)  Covered  services  shall  not  include  drugs,  procedures  and
    16  supplies  for the treatment of erectile dysfunction when provided to, or
    17  prescribed for use by, a person who is required to  register  as  a  sex
    18  offender pursuant to article six-C of the correction law, provided that:
    19  (1) any denial of coverage pursuant to this subsection shall provide the
    20  enrollee  with  the means of obtaining additional information concerning
    21  both the denial and the means of challenging such denial; (2) all drugs,
    22  procedures and supplies for the treatment of erectile dysfunction may be
    23  subject to prior authorization by corporations, insurers or health main-
    24  tenance organizations for the purposes of implementing this  subsection;

    25  and (3) the superintendent shall promulgate regulations to implement the
    26  denial of coverage pursuant to this subsection giving health maintenance
    27  organizations,  corporations  and insurers at least sixty days following
    28  promulgation of the regulations to  implement  their  denial  procedures
    29  pursuant to this subsection.
    30    (d-2)  No  person  or entity authorized to provide coverage under this
    31  section shall be subject to any civil or criminal liability for  damages
    32  for any decision or action pursuant to subsection (d-1) of this section,
    33  made  in  the  ordinary  course of business if that authorized person or
    34  entity acted reasonably and in good faith with respect to such  informa-
    35  tion.
    36    (d-3)  Notwithstanding any other provision of law, if the commissioner
    37  of health makes  a  finding  pursuant  to  subdivision  twenty-three  of

    38  section  two hundred six of the public health law, the superintendent is
    39  authorized to remove a drug,  procedure  or  supply  from  the  services
    40  covered  by  the  standardized  health insurance contract established by
    41  this section for those persons required to  register  as  sex  offenders
    42  pursuant to article six-C of the correction law.
    43    (e)  [The  benefits  provided in the contracts described in subsection
    44  (d) of this section shall be subject to the  following  deductibles  and
    45  copayments:
    46    (1)  in-patient  hospital  services  shall  have a five hundred dollar
    47  copayment for each continuous hospital confinement;
    48    (2) surgical services shall be subject to a copayment of the lesser of
    49  twenty percent of the cost of such services or two hundred  dollars  per
    50  occurrence;

    51    (3) outpatient surgical facility charges shall be subject to a facili-
    52  ty copayment charge of seventy-five dollars per occurrence;
    53    (4)  emergency services shall have a fifty dollar copayment which must
    54  be waived if hospital admission results from the emergency room visit;
    55    (5) prescription drugs shall have a one hundred dollar  calendar  year
    56  deductible per individual. After the deductible is satisfied, each thir-

        S. 2606--D                         125                        A. 3006--D

     1  ty-four  day  supply  of a prescription drug will be subject to a copay-
     2  ment. The copayment will be ten dollars if  the  drug  is  generic.  The
     3  copayment  for a brand name drug will be twenty dollars plus the differ-

     4  ence  in  cost  between  the  brand name drug and the equivalent generic
     5  drug. If a mail order drug program is utilized, a twenty  dollar  copay-
     6  ment  shall  be  imposed  on a ninety day supply of generic prescription
     7  drugs. A forty dollar copayment plus the difference in cost between  the
     8  brand  name  drug  and the equivalent generic drug shall be imposed on a
     9  ninety day supply of brand name prescription drugs. In  no  event  shall
    10  the copayment exceed the cost of the prescribed drug;
    11    (6)  (A)  the maximum coverage for prescription drugs in an individual
    12  contract that is a grandfathered health plan  shall  be  three  thousand
    13  dollars per individual in a calendar year; and
    14    (B) the maximum dollar amount on coverage for prescription drugs in an

    15  individual  contract  that  is not a grandfathered health plan or in any
    16  group contract shall be consistent  with  section  2711  of  the  Public
    17  Health Service Act, 42 U.S.C. § 300gg-11 or any regulations thereunder.
    18    (C)  For purposes of this paragraph, "grandfathered health plan" means
    19  coverage provided by a corporation in which an individual  was  enrolled
    20  on  March  twenty-third,  two  thousand  ten for as long as the coverage
    21  maintains grandfathered status in accordance with section 1251(e) of the
    22  Affordable Care Act, 42 U.S.C. § 18011(e); and
    23    (7) all other services shall have a twenty dollar copayment  with  the
    24  exception  of  prenatal  care which shall have a ten dollar copayment or

    25  preventive health services provided pursuant  to  paragraph  fifteen  of
    26  subsection  (d)  of  this section, for which no copayment shall apply] A
    27  qualifying group health insurance contract issued to a qualifying  small
    28  employer  prior  to  January  first, two thousand fourteen that does not
    29  include all essential  health  benefits  required  pursuant  to  section
    30  2707(a)  of the public health service act, 42 U.S.C. § 300gg-6(a), shall
    31  be discontinued, including grandfathered health plans. For the  purposes
    32  of  this paragraph, "grandfathered health plans" means coverage provided
    33  by a corporation to individuals who were enrolled on March twenty-third,
    34  two thousand ten for as long as  the  coverage  maintains  grandfathered

    35  status in accordance with section 1251(e) of the affordable care act, 42
    36  U.S.C.  § 18011(e). A qualifying small employer shall be transitioned to
    37  a plan that provides: (1) a  level  of  coverage  that  is  designed  to
    38  provide  benefits  that  are actuarially equivalent to eighty percent of
    39  the full actuarial value of the benefits provided under  the  plan;  and
    40  (2)  coverage  for  the  essential health benefit package as required in
    41  section  2707(a)  of  the  public  health  service  act,  42  U.S.C.   §
    42  300gg-6(a). The superintendent shall standardize the benefit package and
    43  cost  sharing requirements of qualified group health insurance contracts
    44  consistent with coverage offered through  the  health  benefit  exchange

    45  established  pursuant  to  section  1311  of the affordable care act, 42
    46  U.S.C. § 18031.
    47    (f) [Except as included in the list of covered services in  subsection
    48  (d)  of  this section, the] The mandated and make-available benefits set
    49  forth in sections [three thousand two hundred sixteen,]  three  thousand
    50  two  hundred  twenty-one of this chapter and four thousand three hundred
    51  three of this article shall not be applicable to  the  contracts  issued
    52  pursuant  to this section. [Mandated benefits included in such contracts
    53  shall be  subject  to  the  deductibles  and  copayments  set  forth  in
    54  subsection (e) of this section.]
    55    (g)  [The superintendent shall be authorized to modify, by regulation,

    56  the copayment and deductible amounts described in this  section  if  the

        S. 2606--D                         126                        A. 3006--D

     1  superintendent  determines  such  amendments are necessary to facilitate
     2  implementation of this section. On or after January first, two  thousand
     3  two, the superintendent shall be authorized to establish, by regulation,
     4  one or more additional standardized health insurance benefit packages if
     5  the superintendent determines additional benefit packages with different
     6  levels of benefits are necessary to meet the needs of the public.
     7    (h)]  A  health  maintenance organization, corporation or insurer must
     8  offer the benefit package without change or additional benefits. [Quali-

     9  fying] A qualifying small [employers] employer shall be issued the bene-
    10  fit package in a qualifying group health insurance contract. [Qualifying
    11  individuals shall be issued the benefit package in a qualifying individ-
    12  ual health insurance contract.
    13    (i)] (h) A health maintenance  organization,  corporation  or  insurer
    14  shall  obtain from the employer [or individual] written certification at
    15  the time of initial application  and  annually  thereafter  ninety  days
    16  prior  to  the  contract renewal date that such employer [or individual]
    17  meets the requirements of a qualifying small employer [or  a  qualifying
    18  individual] pursuant to this section. A health maintenance organization,

    19  corporation  or  insurer  may  require  the  submission  of  appropriate
    20  documentation in support of the certification.
    21    [(j)] (i) Applications for qualifying group health insurance contracts
    22  [and qualifying individual health insurance contracts] must be  accepted
    23  from  [any  qualifying  individual and] any qualifying small employer at
    24  all times throughout the year. The superintendent,  by  regulation,  may
    25  require  health  maintenance  organizations, corporations or insurers to
    26  give preference to qualifying small employers whose [eligible] employees
    27  have the lowest average salaries.
    28    [(k) (1) All  coverage  under  a  qualifying  group  health  insurance
    29  contract  or  a  qualifying individual health insurance contract must be

    30  subject to a pre-existing condition limitation provision as set forth in
    31  sections three thousand two hundred thirty-two of this chapter and  four
    32  thousand three hundred eighteen of this article, including the crediting
    33  requirements  thereunder.  The  underwriting  of  such contracts may not
    34  involve more than the imposition of a pre-existing condition limitation.
    35  However, as provided in sections three thousand two  hundred  thirty-two
    36  of  this  chapter and four thousand three hundred eighteen of this arti-
    37  cle, a corporation shall not impose a pre-existing condition  limitation
    38  provision  on  any  person  under age nineteen, except may impose such a
    39  limitation on those persons covered by a  qualifying  individual  health

    40  insurance contract that is a grandfathered health plan.
    41    (2)]  (j)  Beginning January first, two thousand fourteen, pursuant to
    42  section 2704 of the Public Health Service Act, 42 U.S.C.  §  300gg-3,  a
    43  corporation  shall not impose any pre-existing condition limitation in a
    44  qualifying group health insurance contract [or a  qualifying  individual
    45  health insurance contract except may impose such a limitation in a qual-
    46  ifying  individual  health  insurance  contract  that is a grandfathered
    47  health plan].
    48    [(3) For purposes of  paragraphs  one  and  two  of  this  subsection,
    49  "grandfathered  health plan" means coverage provided by a corporation in
    50  which an individual was enrolled on March twenty-third, two thousand ten

    51  for as long as the coverage maintains grandfathered status in accordance
    52  with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 18011(e).
    53    (l)] (k) A qualifying small  employer  shall  elect  whether  to  make
    54  coverage  under the qualifying group health insurance contract available
    55  to dependents of employees. Any employee or dependent who is enrolled in
    56  Medicare is ineligible for coverage, unless  required  by  federal  law.

        S. 2606--D                         127                        A. 3006--D
 
     1  Dependents  of  an employee who is enrolled in Medicare will be eligible
     2  for dependent coverage provided the dependent is not  also  enrolled  in
     3  Medicare.
     4    [(m)]  (l) A qualifying small employer must pay at least fifty percent

     5  of the premium for employees covered under  a  qualifying  group  health
     6  insurance  contract  and  must offer coverage to all employees receiving
     7  annual wages at a level of thirty thousand dollars or less, and at least
     8  one such employee shall accept such coverage. The thirty thousand dollar
     9  wage level shall be adjusted periodically in  accordance  with  subpara-
    10  graph  [(F)] (D) of paragraph one of subsection (c) of this section. The
    11  employer premium contribution  must  be  the  same  percentage  for  all
    12  covered employees.
    13    [(n)] (m) Premium rate calculations for qualifying group health insur-
    14  ance  contracts  [and  qualifying individual health insurance contracts]
    15  shall be subject to the following:
    16    (1) coverage must be community rated and [include rate tiers for indi-

    17  viduals, two adult families and at least one other family tier. The rate
    18  differences must be based upon the cost differences  for  the  different
    19  family units and the rate tiers must be uniformly applied. The rate tier
    20  structure  used  by  a  health  maintenance organization, corporation or
    21  insurer for the contracts issued to qualifying small  employers  and  to
    22  qualifying  individuals  must  be the same] the superintendent shall set
    23  standard rating tiers for family units and standard rating  relativities
    24  between tiers applicable to all contracts subject to this section; and
    25    (2)  [if  geographic  rating areas are utilized, such geographic areas
    26  must be reasonable and in a given case may include a single county.  The

    27  geographic  areas  utilized must be the same for the contracts issued to
    28  qualifying small employers and to  qualifying  individuals.  The  super-
    29  intendent  shall  not  require  the inclusion of any specific geographic
    30  region within the proposed community rated region selected by the health
    31  maintenance organization, corporation or insurer so long as  the  health
    32  maintenance  organization,  corporation or insurer's proposed regions do
    33  not contain configurations designed to  avoid  or  segregate  particular
    34  areas  within  a  county covered by the health maintenance organization,
    35  corporation or insurer's community rates.] beginning January first,  two
    36  thousand fourteen, every policy subject to this section shall use stand-

    37  ardized regions established by the superintendent; and
    38    (3)  claims  experience  under  contracts  issued  to qualifying small
    39  employers [and to qualifying individuals] must be pooled with the health
    40  maintenance organization, corporation or insurer's small group  business
    41  for  rate  setting  purposes.  [The  premium  rates for qualifying group
    42  health insurance contracts and qualifying  individual  health  insurance
    43  contracts must be the same.
    44    (o)]  (n)  A  health  maintenance organization, corporation or insurer
    45  shall submit reports to the superintendent in such form and at times  as
    46  may  be  reasonably  required  in  order  to evaluate the operations and
    47  results of the standardized health insurance program established by this
    48  section.

    49    [(p) Notwithstanding any other provision of law, all  individuals  and
    50  small  businesses  that  are  participating  in  or covered by insurance
    51  contracts or policies issued pursuant to the New York state small  busi-
    52  ness  health  insurance  partnership program established by section nine
    53  hundred twenty-two of the  public  health  law,  the  voucher  insurance
    54  program  established  by  section one thousand one hundred twenty-one of
    55  this chapter, or uninsured pilot programs established pursuant to  chap-
    56  ter  seven  hundred  three  of the laws of nineteen hundred eighty-eight

        S. 2606--D                         128                        A. 3006--D

     1  shall be eligible for participation in the standardized health insurance

     2  contracts established by this section, regardless of any of  the  eligi-
     3  bility  requirements  established  pursuant  to  subsection  (c) of this
     4  section.]
     5    §  57.  The insurance law is amended by adding a new section 4326-a to
     6  read as follows:
     7    § 4326-a. Transition of healthy New York enrollees.  (a)  On  December
     8  thirty-first, two thousand thirteen, coverage issued to qualifying indi-
     9  viduals  and  qualifying  small  employers  who  are sole proprietors as
    10  defined in section four thousand  three  hundred  twenty-six  shall  end
    11  contingent  upon  the  availability  of coverage for individual and sole
    12  proprietors through the health benefit exchange.
    13    (b) A health maintenance organization, corporation, or  insurer  shall

    14  provide  written  notice  of the program discontinuance to each enrolled
    15  individual and individual proprietor at least  one  hundred  and  eighty
    16  days  prior  to  the  date  of  program  discontinuance. Every notice of
    17  program discontinuance shall be in such form and contain  such  informa-
    18  tion as the superintendent requires.
    19    (c)  Qualifying  group health insurance contracts issued to qualifying
    20  small employers prior to January first, two thousand  fourteen  that  do
    21  not  include  all essential health benefits required pursuant to section
    22  2707(a) of the public health service act, 42 U.S.C. § 300gg-6(a);  shall
    23  be  discontinued.    Qualifying small employers that are impacted by the

    24  discontinuance shall be transitioned to a plan that meets  the  require-
    25  ments  of  subsection (e) of section four thousand three hundred twenty-
    26  six of this chapter. A health maintenance organization, corporation,  or
    27  insurer  shall  provide  written notice of the program discontinuance to
    28  each enrolled qualifying small employer at least one hundred eighty days
    29  prior to the date of program discontinuance.  Every  notice  of  program
    30  discontinuance  shall  be  in  such form and contain such information as
    31  required by the superintendent.
    32    § 58. Section 4327 of the insurance law, as added by chapter 1 of  the
    33  laws  of  1999,  subsection (h) as amended by chapter 419 of the laws of
    34  2000, subsection (m-1) as added by section 12 of part B of chapter 58 of

    35  the laws of 2010, subsection (s) as amended and subsection (t) as  added
    36  by chapter 441 of the laws of 2006, is amended to read as follows:
    37    §  4327.  Stop  loss funds for standardized health insurance contracts
    38  issued to qualifying small employers and qualifying individuals. (a) The
    39  superintendent shall establish a  fund  from  which  health  maintenance
    40  organizations,  corporations  or  insurers may receive reimbursement, to
    41  the extent of funds available therefor, for claims paid by  such  health
    42  maintenance  organizations, corporations or insurers for members covered
    43  under qualifying group health insurance  contracts  issued  pursuant  to
    44  section  four  thousand  three  hundred twenty-six of this article. This
    45  fund shall be known as the "small employer stop loss fund". [The  super-
    46  intendent shall establish a separate and distinct fund from which health

    47  maintenance   organizations,   corporations   or  insurers  may  receive
    48  reimbursement, to the extent of funds  available  therefor,  for  claims
    49  paid  by such health maintenance organizations, corporations or insurers
    50  for  members  covered  under  qualifying  individual  health   insurance
    51  contracts  issued  pursuant to section four thousand three hundred twen-
    52  ty-six of this article. This fund shall  be  known  as  the  "qualifying
    53  individual stop loss fund".]
    54    (b)  [Commencing  on  January  first, two thousand one, health] Health
    55  maintenance organizations, corporations or insurers shall be eligible to
    56  receive reimbursement for ninety percent of claims paid between [thirty]


        S. 2606--D                         129                        A. 3006--D
 
     1  five thousand and [one  hundred]  seventy-five  thousand  dollars  in  a
     2  calendar  year  for  any  member  covered  under a standardized contract
     3  issued pursuant to section four thousand  three  hundred  twenty-six  of
     4  this  article.  Claims  paid  for members covered under qualifying group
     5  health insurance contracts shall be reimbursable from the small employer
     6  stop loss fund. [Claims paid for members covered under qualifying  indi-
     7  vidual  health insurance contracts shall be reimbursable from the quali-
     8  fying individual stop loss fund.] For  the  purposes  of  this  section,
     9  claims  shall  include  health  care claims paid by a health maintenance
    10  organization on behalf of a covered member pursuant to such standardized
    11  contracts.

    12    (c) The superintendent shall promulgate  regulations  that  set  forth
    13  procedures  for  the operation of the small employer stop loss fund [and
    14  the qualifying individual stop loss fund]  and  distribution  of  monies
    15  therefrom.
    16    (d)  [The  small employer stop loss fund shall operate separately from
    17  the qualifying  individual  stop  loss  fund.  Except  as  specified  in
    18  subsection  (b)  of this section with respect to calendar year two thou-
    19  sand one, the level of stop  loss  coverage  for  the  qualifying  group
    20  health  insurance  contracts and the qualifying individual health insur-
    21  ance contracts need not be the same. The two stop loss funds need not be
    22  structured or operated in the same manner, except as specified  in  this

    23  section.  The monies available for distribution from the stop loss funds
    24  may be reallocated between the small employer stop  loss  fund  and  the
    25  qualifying  individual  stop  loss fund if the superintendent determines
    26  that such reallocation is  warranted  due  to  enrollment  trends.]  The
    27  superintendent  may  adjust the level of stop loss coverage specified in
    28  subsection (b) of this section.
    29    (e) Claims shall be reported and funds shall be distributed  from  the
    30  small  employer  stop loss fund [and from the qualifying individual stop
    31  loss fund] on a calendar  year  basis.  Claims  shall  be  eligible  for
    32  reimbursement  only  for the calendar year in which the claims are paid.
    33  Once claims paid on behalf of a  covered  member  reach  or  exceed  one

    34  hundred  thousand  dollars  in  a given calendar year, no further claims
    35  paid on behalf of such member in that calendar year  shall  be  eligible
    36  for reimbursement.
    37    (f) Each health maintenance organization, corporation or insurer shall
    38  submit  a request for reimbursement from [each of] the stop loss [funds]
    39  fund on forms prescribed by the  superintendent.    [Each  of  the]  The
    40  requests  for reimbursement shall be submitted no later than April first
    41  following the end of the  calendar  year  for  which  the  reimbursement
    42  requests  are  being made. The superintendent may require health mainte-
    43  nance organizations, corporations or insurers to submit such claims data
    44  in connection with the reimbursement requests as he deems  necessary  to
    45  enable  him  to distribute monies and oversee the operation of the small

    46  employer [and qualifying individual] stop loss [funds] fund.  The super-
    47  intendent may require that such data  be  submitted  on  a  per  member,
    48  aggregate  and/or  categorical basis. [Data shall be reported separately
    49  for qualifying group health insurance contracts and qualifying  individ-
    50  ual  health insurance contracts issued pursuant to section four thousand
    51  three hundred twenty-six of this article.]
    52    (g) For [each] the stop loss fund, the superintendent shall  calculate
    53  the  total claims reimbursement amount for all health maintenance organ-
    54  izations, corporations or insurers  for  the  calendar  year  for  which
    55  claims are being reported.

        S. 2606--D                         130                        A. 3006--D
 

     1    (1) In the event that the total amount requested for reimbursement for
     2  a calendar year exceeds funds available for distribution for claims paid
     3  during that same calendar year, the superintendent shall provide for the
     4  pro-rata  distribution  of  the available funds. Each health maintenance
     5  organization,  corporation  or insurer shall be eligible to receive only
     6  such proportionate amount of  the  available  funds  as  the  individual
     7  health  maintenance  organization's,  corporation's  or  insurer's total
     8  eligible claims paid bears to the total  eligible  claims  paid  by  all
     9  health maintenance organizations, corporations or insurers.
    10    (2) In the event that funds available for distribution for claims paid
    11  by all health maintenance organizations, corporations or insurers during
    12  a  calendar year exceeds the total amount requested for reimbursement by

    13  all health maintenance organizations, corporations  or  insurers  during
    14  that  same  calendar year, any excess funds shall be carried forward and
    15  made available for distribution in the next calendar year.  Such  excess
    16  funds  shall be in addition to the monies appropriated for the stop loss
    17  fund in the next calendar year.
    18    (h) Upon the request of the superintendent,  each  health  maintenance
    19  organization  shall  be required to furnish such data as the superinten-
    20  dent deems necessary to oversee the operation of the small employer [and
    21  qualifying individual] stop  loss  [funds]  fund.  Such  data  shall  be
    22  furnished  in a form prescribed by the superintendent. Each health main-
    23  tenance organization, corporation or insurer shall  provide  the  super-
    24  intendent  with monthly reports of the total enrollment under the quali-

    25  fying group health insurance contracts [and  the  qualifying  individual
    26  health  insurance  contracts]  issued  pursuant to section four thousand
    27  three hundred twenty-six of this article. The reports shall be in a form
    28  prescribed by the superintendent.
    29    (i) The superintendent shall separately estimate the per member annual
    30  cost of total claims reimbursement from each stop loss fund for  [quali-
    31  fying  individual  health  insurance contracts and for] qualifying group
    32  health insurance contracts based upon  available  data  and  appropriate
    33  actuarial  assumptions.  Upon request, each health maintenance organiza-
    34  tion, corporation or insurer shall furnish to the superintendent  claims
    35  experience data for use in such estimations.
    36    (j) The superintendent shall determine total eligible enrollment under

    37  qualifying  group  health insurance contracts [and qualifying individual
    38  health insurance contracts].  [For  qualifying  group  health  insurance
    39  contracts,  the]  The  total  eligible enrollment shall be determined by
    40  dividing the total funds  available  for  distribution  from  the  small
    41  employer stop loss fund by the estimated per member annual cost of total
    42  claims reimbursement from the small employer stop loss fund. [For quali-
    43  fying  individual health insurance contracts, the total eligible enroll-
    44  ment shall be determined by  dividing  the  total  funds  available  for
    45  distribution  from the qualifying individual stop loss fund by the esti-
    46  mated per member annual cost of  total  claims  reimbursement  from  the

    47  qualifying individual stop loss fund.]
    48    (k)  The  superintendent shall suspend the enrollment of new employers
    49  under qualifying group health insurance contracts  if  [he]  the  super-
    50  intendent  determines  that  the total enrollment reported by all health
    51  maintenance organizations, corporations or insurers under such contracts
    52  exceeds the total eligible enrollment, thereby resulting in  anticipated
    53  annual  expenditures from the small employer stop loss fund in excess of
    54  the total funds available for distribution from  such  stop  loss  fund.
    55  [The  superintendent  shall  suspend  the  enrollment of new individuals
    56  under qualifying individual health insurance contracts if he  determines

        S. 2606--D                         131                        A. 3006--D


     1  that  the  total enrollment reported by all health maintenance organiza-
     2  tions, corporations or insurers under such contracts exceeds  the  total
     3  eligible  enrollment,  thereby  resulting in anticipated annual expendi-
     4  tures  from  the  qualifying  individual stop loss fund in excess of the
     5  total funds available for distribution from such stop loss fund.]
     6    (l) The superintendent shall provide the health maintenance  organiza-
     7  tions,  corporations  or  insurers  with  notification of any enrollment
     8  suspensions as soon as practicable after receipt of all enrollment data.
     9  [The superintendent's determination and notification shall be made sepa-
    10  rately for the qualifying group health insurance contracts and  for  the
    11  qualifying individual health insurance contracts.]

    12    (m)  If at any point during a suspension of enrollment of new qualify-
    13  ing small employers [and/or qualifying individuals], the  superintendent
    14  determines  that funds are sufficient to provide for the addition of new
    15  enrollments, the superintendent shall be authorized  to  reactivate  new
    16  enrollments  and  to notify all health maintenance organizations, corpo-
    17  rations or insurers that enrollment of new  employers  [and/or  individ-
    18  uals]  may  again  commence.  [The  superintendent's  determination  and
    19  notification shall be made separately for the  qualifying  group  health
    20  insurance  contracts  and for the qualifying individual health insurance
    21  contracts.]
    22    (m-1) In the event that the superintendent suspends the enrollment  of

    23  new  individuals  for  qualifying  group  health insurance contracts [or
    24  qualifying individual health insurance  contracts],  the  superintendent
    25  shall  ensure  that  small  employers  [or  sole proprietors] seeking to
    26  enroll in a qualified group [or individual]  health  insurance  contract
    27  pursuant  to  section forty-three hundred twenty-six of this article are
    28  provided information on and directed to [the family health plus employer
    29  partnership program under section three  hundred  sixty-nine-ff  of  the
    30  social services law] coverage options available through the health bene-
    31  fit exchange established pursuant to section 1311 of the affordable care
    32  act, 42 U.S.C. § 18031.
    33    (n)  The  suspension  of issuance of qualifying group health insurance

    34  contracts to new qualifying small employers shall not preclude the addi-
    35  tion of new employees of  an  employer  already  covered  under  such  a
    36  contract  or  new  dependents  of  employees  already covered under such
    37  contracts.
    38    (o) [The suspension of issuance of qualifying individual health insur-
    39  ance contracts to new qualifying  individuals  shall  not  preclude  the
    40  addition  of  new dependents to an existing qualifying individual health
    41  insurance contract.
    42    (p)] The premiums for qualifying group health insurance contracts must
    43  factor in the availability of reimbursement from the small employer stop
    44  loss fund. [The premiums  for  qualifying  individual  health  insurance
    45  contracts  must  factor  in  the  availability of reimbursement from the

    46  qualifying individual stop loss funds.
    47    (q)] (p) The superintendent may obtain the services of an organization
    48  to administer the stop loss funds established by this section.  [If  the
    49  superintendent  deems  it  appropriate, he or she may utilize a separate
    50  organization for administration of the small employer stop loss fund and
    51  the qualifying individual stop  loss  fund.]  The  superintendent  shall
    52  establish  guidelines  for  the submission of proposals by organizations
    53  for the purposes of administering the funds.  The  superintendent  shall
    54  make a determination whether to approve, disapprove or recommend modifi-
    55  cation  to  the  proposal  of  an  applicant to administer the funds. An
    56  organization approved to administer the funds shall  submit  reports  to


        S. 2606--D                         132                        A. 3006--D
 
     1  the  superintendent  in such form and at times as may be required by the
     2  superintendent in order to  facilitate  evaluation  and  ensure  orderly
     3  operation  of  the  funds,  including[,  but  not limited to,] an annual
     4  report  of  the  affairs  and  operations of the fund, such report to be
     5  delivered to the superintendent and to the chairs of the senate  finance
     6  committee  and  the  assembly  ways and means committee. An organization
     7  approved to administer the  funds  shall  maintain  records  in  a  form
     8  prescribed  by  the  superintendent  and  which  shall  be available for
     9  inspection by or at the request of the superintendent.  The  superinten-
    10  dent  shall  determine  the amount of compensation to be allocated to an
    11  approved organization as payment for fund  administration.  Compensation

    12  shall  be  payable  from  the  stop loss coverage funds. An organization
    13  approved to administer the funds may be removed  by  the  superintendent
    14  and  must  cooperate  in  the  orderly transition of services to another
    15  approved organization or to the superintendent.
    16    [(r)] (q) If the superintendent deems it appropriate  for  the  proper
    17  administration of the small employer stop loss fund [and/or the qualify-
    18  ing individual stop loss fund], the administrator of the fund, on behalf
    19  of  and  with the prior approval of the superintendent, shall be author-
    20  ized to purchase stop loss insurance and/or reinsurance from  an  insur-
    21  ance  company  licensed  to  write such type of insurance in this state.
    22  Such stop loss insurance and/or reinsurance  may  be  purchased  to  the

    23  extent of funds available therefor within such funds which are available
    24  for purposes of the stop loss funds established by this section.
    25    [(s)] (r) The superintendent may access funding from the small employ-
    26  er  stop loss fund [and/or the qualifying individual stop loss fund] for
    27  the purposes of developing and implementing public  education,  outreach
    28  and  facilitated  enrollment strategies targeted to small employers [and
    29  working  adults]  without  health  insurance.  The  superintendent   may
    30  contract  with  marketing organizations to perform or provide assistance
    31  with such education, outreach, and  enrollment  strategies.  The  super-
    32  intendent  shall  determine  the  amount  of  funding  available for the
    33  purposes of this subsection which in no event shall exceed eight percent

    34  of the annual funding amounts for the small employer stop loss fund [and
    35  the qualifying individual stop loss fund].
    36    [(t)] (s) Brooklyn healthworks pilot program and  upstate  healthworks
    37  pilot  program.  Commencing  on July first, two thousand six, the super-
    38  intendent shall access funding from the small employer  stop  loss  fund
    39  [and  the  qualifying  individual  stop  loss  fund]  for the purpose of
    40  support and expansion of the existing pilot program Brooklyn healthworks
    41  approved by the superintendent and for the establishment  and  operation
    42  of a pilot program to be located in upstate New York. For the purpose of
    43  this  subsection,  in  no  event  shall  the amount of funding available
    44  exceed two percent of the annual funding [amounts] amount for the  small

    45  employer stop loss fund [and the qualifying individual stop loss fund].
    46    §  59.  Paragraph 1 of subsection (d) of section 4235 of the insurance
    47  law is amended to read as follows:
    48    (1) In this section, for the purpose of insurance other than for group
    49  hospital, medical,  major  medical  or  similar  comprehensive-types  of
    50  expense  reimbursed insurance hereunder:  "employees" includes the offi-
    51  cers, managers, employees and retired employees of the employer  and  of
    52  subsidiary  or  affiliated corporations of a corporate employer, and the
    53  individual proprietors, partners, employees  and  retired  employees  of
    54  affiliated  individuals  and  firms  controlled  by the insured employer
    55  through stock ownership,  contract  or  otherwise;  "employees"  may  be
    56  deemed  to include the individual proprietor or partners if the employer

        S. 2606--D                         133                        A. 3006--D
 
     1  is an individual proprietor or a partnership; and "employees" as used in
     2  subparagraph (A) of paragraph one of  subsection  (c)  hereof  may  also
     3  include  the  directors  of the employer and of subsidiary or affiliated
     4  corporations of a corporate employer.
     5    §  60.  Subsection (d) of section 4235 of the insurance law is amended
     6  by adding a new paragraph 3 to read as follows:
     7    (3) In this section, for the purpose of group hospital, medical, major
     8  medical or similar comprehensive-types of expense  reimbursed  insurance
     9  hereunder:
    10    (A) "employee" shall have the meaning set forth in section 2791 of the
    11  public health service act, 42 U.S.C. § 300gg-91(d)(5) or any regulations

    12  promulgated thereunder; and
    13    (B)  "full-time employee" means with respect to any month, an employee
    14  who is employed on average for at least thirty hours of service per week
    15  as set forth in section 4980H(c)(4) of the  internal  revenue  code,  26
    16  U.S.C. § 4980H(c)(4), or any regulations promulgated thereunder.
    17    §  61.  Subparagraph  (B)  of paragraph 1 of subsection (e) of section
    18  3231 of the insurance law, as amended by chapter  107  of  the  laws  of
    19  2010, is amended to read as follows:
    20    (B)  The expected minimum loss ratio for a policy form subject to this
    21  section, for which a rate filing or application is made pursuant to this
    22  paragraph, other than a medicare supplemental insurance policy, or, with
    23  the approval of the superintendent, an aggregation of policy forms  that

    24  are  combined  into  one  community  rating  experience  pool  and rated
    25  consistent with community rating requirements, shall not  be  less  than
    26  eighty-two  percent.  In  reviewing  a  rate  filing or application, the
    27  superintendent may modify the eighty-two percent expected  minimum  loss
    28  ratio  requirement  if the superintendent determines the modification to
    29  be in the interests of the people of this state or if the superintendent
    30  determines that a modification is necessary to maintain insurer  solven-
    31  cy. No later than [June thirtieth] July thirty-first of each year, every
    32  insurer  subject  to  this subparagraph shall annually report the actual
    33  loss ratio for the previous calendar year in a format acceptable to  the
    34  superintendent. If an expected loss ratio is not met, the superintendent
    35  may  direct the insurer to take corrective action, which may include the

    36  submission of a rate filing to reduce future premiums, or to issue divi-
    37  dends, premium refunds or credits, or any combination of these.
    38    § 62. Subparagraph (A) of paragraph 3 of  subsection  (c)  of  section
    39  4308  of the insurance law, as added by chapter 107 of the laws of 2010,
    40  is amended to read as follows:
    41    (A) The expected minimum loss ratio for a  contract  form  subject  to
    42  this  subsection for which a rate filing or application is made pursuant
    43  to  this  paragraph,  other  than  a  medicare  supplemental   insurance
    44  contract, or, with the approval of the superintendent, an aggregation of
    45  contract  forms  that  are combined into one community rating experience
    46  pool and rated consistent with community rating requirements, shall  not
    47  be  less than eighty-two percent. In reviewing a rate filing or applica-

    48  tion, the superintendent may  modify  the  eighty-two  percent  expected
    49  minimum  loss  ratio  requirement  if  the superintendent determines the
    50  modification to be in the interests of the people of this  state  or  if
    51  the  superintendent determines that a modification is necessary to main-
    52  tain insurer solvency. No later than [June thirtieth] July  thirty-first
    53  of each year, every corporation subject to this subparagraph shall annu-
    54  ally  report  the  actual loss ratio for the previous calendar year in a
    55  format acceptable to the superintendent. If an expected  loss  ratio  is
    56  not  met,  the superintendent may direct the corporation to take correc-

        S. 2606--D                         134                        A. 3006--D
 
     1  tive action, which may include the submission of a rate filing to reduce

     2  future premiums, or to issue dividends, premium refunds or  credits,  or
     3  any combination of these.
     4    §  63.  Section  3233  of the insurance law is amended by adding a new
     5  subsection (d) to read as follows:
     6    (d) Notwithstanding any provision of this chapter or any  other  chap-
     7  ter,  the  superintendent  may  suspend or terminate, by regulation, the
     8  operation, in whole or in part, of any mechanism established and operat-
     9  ing pursuant to the authority of this section provided that  the  super-
    10  intendent  determines  that  the  objectives stated in subsection (a) of
    11  this section are met by the  operation  of  a  mechanism  or  mechanisms
    12  established  by  the  federal government pursuant to section 1343 of the

    13  affordable care act, 42 U.S.C. § 18063. Notwithstanding  subsection  (b)
    14  of  this section, the superintendent may exercise this authority without
    15  convening a technical advisory committee.
    16    § 64. Subparagraph (D) of paragraph 2 of  subsection  (p)  of  section
    17  3221  of the insurance law, as added by chapter 661 of the laws of 1997,
    18  is amended to read as follows:
    19    (D) The insurer is ceasing to offer group or  blanket  policies  in  a
    20  market in accordance with paragraph three or seven of this subsection.
    21    §  65.  Subsection (p) of section 3221 of the insurance law is amended
    22  by adding a new paragraph 7 to read as follows:
    23    (7) Notwithstanding paragraph three of this subsection, an insurer may
    24  discontinue offering a particular class of group or  blanket  policy  of

    25  hospital,  surgical or medical expense insurance offered in the small or
    26  large group market, and instead offer  a  group  or  blanket  policy  of
    27  hospital,  surgical  or medical expense insurance that complies with the
    28  requirements of section 2707 of the public  health  service  act,  §  42
    29  U.S.C.  300gg-6  that  become  applicable  to  such policy as of January
    30  first, two thousand fourteen, provided that the insurer:
    31    (A) discontinues the existing class of policy in  such  market  as  of
    32  either  December  thirty-first,  two  thousand  thirteen  or  the policy
    33  renewal date occurring in two thousand fourteen in accordance with  this
    34  chapter;
    35    (B)  provides written notice to each policyholder provided coverage of

    36  the class in the market  (and  to  all  employees  and  member  insureds
    37  covered  under such coverage) of the discontinuance at least ninety days
    38  prior to the date of discontinuance of such coverage. The written notice
    39  shall be in a form satisfactory to the superintendent;
    40    (C) offers to each policyholder provided coverage of the class in  the
    41  market,  the  option to purchase all (or, in the case of the large group
    42  market, any) other hospital, surgical and medical expense coverage  that
    43  complies  with  the  requirements  of  section 2707 of the public health
    44  service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage
    45  as of January first, two thousand fourteen, currently being  offered  by
    46  the insurer to a group in that market;

    47    (D)  in exercising the option to discontinue coverage of the class and
    48  in offering the option of coverage under subparagraph (C) of this  para-
    49  graph,  acts  uniformly without regard to the claims experience of those
    50  policyholders or  any  health  status-related  factor  relating  to  any
    51  particular  covered employee, member insured or dependent, or particular
    52  new employee, member insured, or dependent who may become  eligible  for
    53  such  coverage,  and does not discontinue the coverage of the class with
    54  the intent or as a pretext to discontinuing the  coverage  of  any  such
    55  employee, member insured, or dependent; and

        S. 2606--D                         135                        A. 3006--D
 

     1    (E)  at least one hundred twenty days prior to the date of the discon-
     2  tinuance of such coverage, provides written notice to the superintendent
     3  of the discontinuance, including certification by an officer or director
     4  of the insurer that the reason for the discontinuance is to replace  the
     5  coverage  with  new  coverage  that  complies  with  the requirements of
     6  section 2707 of the public health service act, § 42 U.S.C. 300gg-6  that
     7  become  effective  January  first,  two  thousand  fourteen. The written
     8  notice shall be in such form and contain  such  information  the  super-
     9  intendent requires.
    10    §  66. Item (iii) of subparagraph (C) of paragraph 2 of subsection (c)
    11  of section 4304 of the insurance law, as amended by chapter 661  of  the

    12  laws of 1997, is amended to read as follows:
    13    (iii)  Discontinuance  of all individual hospital, surgical or medical
    14  expense insurance contracts for which the premiums are paid by a  remit-
    15  ting  agent  of  a  group, in the small group market, or the large group
    16  market, or both markets, in this state, in conjunction with a withdrawal
    17  from the small group market, or the large group market, or both markets,
    18  in this state. Withdrawal from the small  group  market,  or  the  large
    19  group  market, or both markets, shall be governed by the requirements of
    20  subparagraphs [(B)] (E) and [(C)] (F) of paragraph three  of  subsection
    21  (j)  of  section  four  thousand three hundred five of this article. For
    22  purposes of this item, "withdrawal" from a market means that no coverage
    23  is offered or maintained in such market under contracts issued  pursuant

    24  to  this  section  or contracts issued pursuant to section four thousand
    25  three hundred five of this article.
    26    § 67. Subparagraph (D) of paragraph 2 of  subsection  (j)  of  section
    27  4305  of the insurance law, as added by chapter 661 of the laws of 1997,
    28  is amended to read as follows:
    29    (D) The corporation is ceasing to offer group or blanket contracts  in
    30  a  market  in  accordance  with paragraph three or paragraph six of this
    31  subsection.
    32    § 68. Subsection (j) of section 4305 of the insurance law  is  amended
    33  by adding a new paragraph 6 to read as follows:
    34    (6)  Notwithstanding paragraph three of this subsection, a corporation
    35  may discontinue offering a particular class of group or blanket contract
    36  of hospital, surgical or medical expense insurance offered in the  small

    37  or  large group market, and instead offer a group or blanket contract of
    38  hospital, surgical or medical expense insurance that complies  with  the
    39  requirements of section 2707 of the public health service act, 42 U.S.C.
    40  §  300gg-6  that become applicable to such contract as of January first,
    41  two thousand fourteen, provided that the corporation:
    42    (A) discontinues the existing class of contract in such market  as  of
    43  either  December  thirty-first,  two  thousand  thirteen or the contract
    44  renewal date occurring in two thousand fourteen in accordance with  this
    45  chapter;
    46    (B)  provides written notice to each contract holder provided coverage
    47  of the class in the market (and to all  employees  and  member  insureds

    48  covered  under such coverage) of the discontinuance at least ninety days
    49  prior to the date of discontinuance of such coverage. The written notice
    50  shall be in a form satisfactory to the superintendent;
    51    (C) offers to each contract holder provided coverage of the  class  in
    52  the  market,  the  option  to purchase all (or, in the case of the large
    53  group market, any) other hospital, surgical and medical expense coverage
    54  that complies with the requirements of section 2707 of the public health
    55  service act, 42 U.S.C. § 300gg-6 that become applicable to such coverage

        S. 2606--D                         136                        A. 3006--D
 
     1  as of January first, two thousand fourteen, currently being  offered  by

     2  the corporation to a group in that market;
     3    (D)  in exercising the option to discontinue coverage of the class and
     4  in offering the option of coverage under subparagraph (C) of this  para-
     5  graph,  acts uniformly without regard to the claims  experience of those
     6  contract holders or any health status-related  factor  relating  to  any
     7  particular  covered employee, member insured or dependent, or particular
     8  new employee, member insured, or dependent who may become  eligible  for
     9  such  coverage, and does not discontinue the coverage of the  class with
    10  the intent or as a pretext to discontinuing the  coverage  of  any  such
    11  employee, member insured, or dependent; and
    12    (E)  at least one hundred twenty days prior to the date of the discon-

    13  tinuance of such coverage, provides written notice to the superintendent
    14  of the discontinuance, including certification by an officer or director
    15  of the corporation that the reason for the discontinuance is to  replace
    16  the  coverage  with  new coverage that complies with the requirements of
    17  section 2707 of the public health service act, 42  U.S.C. § 300gg-6 that
    18  become effective January  first,  two  thousand  fourteen.  The  written
    19  notice  shall  be  in  such form and contain such information the super-
    20  intendent requires.
    21    § 69. Subsections (a), (b) and (c) of section 3231  of  the  insurance
    22  law,  subsection  (a)  as  amended  by  chapter 661 of the laws of 1997,
    23  subsection (b) as amended by chapter 557 of the laws of 2002, subsection

    24  (c) as added by chapter 501 of the laws of 1992, are amended to read  as
    25  follows:
    26    (a)  (1)  No  individual  health  insurance policy and no group health
    27  insurance policy covering between  [two]  one  and  fifty  employees  or
    28  members of the group or between one and one hundred employees or members
    29  of  the  group for policies issued or renewed on or after January first,
    30  two thousand sixteen exclusive of spouses  and  dependents,  hereinafter
    31  referred  to  as  a small group, providing hospital and/or medical bene-
    32  fits, including medicare supplemental insurance, shall be issued in this
    33  state unless such policy is community  rated  and,  notwithstanding  any
    34  other  provisions  of  law,  the underwriting of such policy involves no

    35  more than the imposition of a pre-existing condition limitation [as]  if
    36  otherwise  permitted by this article. (2) Any individual, and dependents
    37  of such individual, and any small  group,  including  all  employees  or
    38  group members and dependents of employees or members, applying for indi-
    39  vidual health insurance coverage, including medicare supplemental cover-
    40  age,  [or  small  group  health  insurance  coverage, including medicare
    41  supplemental insurance,]  or  small  group  health  insurance  coverage,
    42  including  medicare  supplemental  insurance, but not including coverage
    43  issued on or after January first, two thousand  fourteen,  specified  in
    44  subsection  (l)  of  section three thousand two hundred sixteen, of this

    45  article must be accepted at all times throughout the year for any hospi-
    46  tal and/or medical coverage offered by the  insurer  to  individuals  or
    47  small  groups in this state. (3) Once accepted for coverage, an individ-
    48  ual or small group cannot be terminated by the  insurer  due  to  claims
    49  experience.  Termination  of an individual or small group shall be based
    50  only on one or more of the  reasons  set  forth  in  subsection  (g)  of
    51  section  three thousand two hundred sixteen or subsection (p) of section
    52  three thousand two hundred twenty-one of this  article.  Group  hospital
    53  and/or  medical  coverage,  including  medicare  supplemental insurance,
    54  obtained through an out-of-state trust covering  a  group  of  fifty  or
    55  fewer  employees,  or between one and one hundred employees for policies

    56  issued or renewed on or after January first, two  thousand  sixteen,  or

        S. 2606--D                         137                        A. 3006--D
 
     1  participating  persons who are residents of this state must be community
     2  rated regardless of the situs of delivery of the policy. Notwithstanding
     3  any other provisions of law, the underwriting of such policy may involve
     4  no  more than the imposition of a pre-existing condition limitation [as]
     5  if permitted by this article, and once accepted for coverage,  an  indi-
     6  vidual  or  small  group  cannot be terminated due to claims experience.
     7  Termination of an individual or small group shall be based only  on  one
     8  or  more  of  the  reasons  set forth in subsection (p) of section three
     9  thousand two hundred twenty-one of this article.  (4) For  the  purposes

    10  of  this  section, "community rated" means a rating methodology in which
    11  the premium for all persons covered by a policy [or  contract]  form  is
    12  the same based on the experience of the entire pool of risks [covered by
    13  that policy or contract form] of all individuals or small groups covered
    14  by  the insurer without regard to age, sex, health status, tobacco usage
    15  or occupation, excluding those individuals or small  groups  covered  by
    16  medicare  supplemental  insurance.   For medicare supplemental insurance
    17  coverage, "community rated" means a  rating  methodology  in  which  the
    18  premiums  for  all  persons  covered by a policy or contract form is the
    19  same based on the experience of the entire pool of risks covered by that

    20  policy or contract form without  regard  to  age,  sex,  health  status,
    21  tobacco  usage  or  occupation.  Catastrophic  health insurance policies
    22  issued pursuant to section 1302(e) of the affordable care act, 42 U.S.C.
    23  § 18022(e), shall be classified in a distinct community rating pool.
    24    (b) [Nothing herein shall prohibit the use of premium rate  structures
    25  to establish different premium rates for individuals as opposed to fami-
    26  ly  units  or] (1) The superintendent may set standard premium tiers and
    27  standard rating relativities between tiers applicable  to  all  policies
    28  subject to this section. The superintendent may set a standard relativi-
    29  ty  applicable to child-only policies issued pursuant to section 1302(f)

    30  of the affordable care act, 42 U.S.C.   § 18022(f). The  relativity  for
    31  child-only policies shall be actuarially justifiable using the aggregate
    32  experience  of insurers to prevent the charging of unjustified premiums.
    33  The superintendent may adjust such premium tiers and relativities  peri-
    34  odically based upon the aggregate experience of insurers.  (2) An insur-
    35  er  shall  establish separate community rates for individuals as opposed
    36  to small groups. (3) If an insurer is required  to  issue  a  [contract]
    37  policy  to  individual  proprietors  pursuant  to subsection (i) of this
    38  section, such policy shall be subject to subsection (a) of this section.
    39    (c) (1) The superintendent shall permit the use of separate  community

    40  rates  for  reasonable  geographic  regions, which may, in a given case,
    41  include a single county. The regions shall be  approved  by  the  super-
    42  intendent  as  part  of  the  rate  filing. The superintendent shall not
    43  require the inclusion of any  specific  geographic  regions  within  the
    44  proposed  community  rated  regions  selected by the insurer in its rate
    45  filing so long as the insurer's proposed regions do not contain  config-
    46  urations designed to avoid or segregate particular areas within a county
    47  covered  by  the  insurer's  community rates.   (2) Beginning on January
    48  first, two thousand fourteen, for every policy subject to  this  section
    49  that  provides  physician  services,  medical,  major medical or similar
    50  comprehensive-type  coverage,  except  for  medicare  supplement  plans,

    51  insurers  shall  use standardized regions established by the superinten-
    52  dent.
    53    § 70. Subsection (g) of section 3231 of the insurance law, as added by
    54  chapter 501 of the laws of 1992, is amended to read as follows:
    55    (g) (1) This section shall also apply to policies issued  to  a  group
    56  defined  in  subsection (c) of section four thousand two hundred thirty-

        S. 2606--D                         138                        A. 3006--D
 
     1  five, including but not limited to an association or trust of employers,
     2  if the group includes one or  more  member  employers  or  other  member
     3  groups  which  have  fifty  or  fewer  employees or members exclusive of
     4  spouses and dependents. For policies issued or renewed on or after Janu-

     5  ary  first,  two  thousand  fourteen,  if the group includes one or more
     6  member small group employers  eligible  for  coverage  subject  to  this
     7  section,  then such member employers shall be classified as small groups
     8  for rating purposes and the remaining members shall be rated  consistent
     9  with  the  rating rules applicable to such remaining members pursuant to
    10  paragraph two of this subsection.
    11    (2) If a policy is issued to a group  defined  in  subsection  (c)  of
    12  section four thousand two hundred thirty-five of this chapter, including
    13  an association group, that includes one or more individual or individual
    14  proprietor  members,  for rating purposes the insurer shall include such

    15  members in its individual pool of risks in  establishing  premium  rates
    16  for such members.
    17    §  71.  Paragraph 2 of subsection (i) of section 3231 of the insurance
    18  law, as amended by chapter 183 of the laws of 2011, is amended  to  read
    19  as follows:
    20    (2) For coverage purchased pursuant to this subsection, through Decem-
    21  ber thirty-first, two thousand thirteen, individual proprietors shall be
    22  classified  in their own community rating category, provided however, up
    23  to  and  including  December  thirty-first,  two   thousand   [fourteen]
    24  thirteen,  the  premium  rate  established  for  individual  proprietors
    25  purchased pursuant to paragraph one of  this  subsection  shall  not  be
    26  greater than one hundred fifteen percent of the rate established for the

    27  same  coverage issued to groups.  Coverage purchased or renewed pursuant
    28  to this subsection on or after  January  first,  two  thousand  fourteen
    29  shall be classified in the individual rating category.
    30    §  72.  Section  4317 of the insurance law, as added by chapter 501 of
    31  the laws of 1992, subsection (a) as amended by chapter 661 of  the  laws
    32  of  1997, subsection (b) as amended and subsection (f) as added by chap-
    33  ter 557 of the laws of 2002, subsection (d) as amended by section  2  of
    34  part A of chapter 494 of the laws of 2009, paragraph 2 of subsection (f)
    35  as  amended  by  chapter  183 of the laws of 2011, is amended to read as
    36  follows:
    37    §  4317.  Rating  of  individual  and  small  group  health  insurance
    38  contracts.  (a) (1) No individual health insurance contract and no group

    39  health insurance contract covering between [two] one and fifty employees
    40  or  members  of  the  group, or between one and one hundred employees or
    41  members of the group for policies issued or renewed on or after  January
    42  first, two thousand sixteen exclusive of spouses and dependents, includ-
    43  ing contracts for which the premiums are paid by a remitting agent for a
    44  group,  hereinafter  referred  to  as  a small group, providing hospital
    45  and/or medical  benefits,  including  Medicare  supplemental  insurance,
    46  shall  be  issued  in this state unless such contract is community rated
    47  and, notwithstanding any other provisions of law,  the  underwriting  of
    48  such  contract  involves  no  more than the imposition of a pre-existing

    49  condition limitation [as] if otherwise permitted by  this  article.  (2)
    50  Any  individual, and dependents of such individual, and any small group,
    51  including all employees or group members and dependents of employees  or
    52  members,  applying for individual or small group health insurance cover-
    53  age including Medicare supplemental insurance, but not including  cover-
    54  age issued on or after January first, two thousand fourteen specified in
    55  subsection  (l) of section four thousand three hundred four, and section
    56  four thousand three  hundred  twenty-eight  of  this  chapter,  must  be

        S. 2606--D                         139                        A. 3006--D
 
     1  accepted  at  all  times  throughout  the  year  for any hospital and/or

     2  medical coverage[, including Medicare supplemental  insurance,]  offered
     3  by  the  corporation  to individuals or small groups in this state.  (3)
     4  Once  accepted  for  coverage,  an  individual  or small group cannot be
     5  terminated by the insurer  due  to  claims  experience.  Termination  of
     6  coverage  for  individuals  or  small groups may be based only on one or
     7  more of the reasons set forth in subsection (c) of section four thousand
     8  three hundred four or subsection (j)  of  section  four  thousand  three
     9  hundred  five  of  this  article.  (4) For the purposes of this section,
    10  "community rated" means a rating methodology in which  the  premium  for
    11  all  persons  covered by a policy or contract form is the same, based on
    12  the experience of the entire pool of risks [covered by  that  policy  or

    13  contract  form] of all individuals or small groups covered by the corpo-
    14  ration without regard to age, sex, health status, tobacco usage or occu-
    15  pation excluding those individuals of small groups covered  by  Medicare
    16  supplemental  insurance.   For medicare supplemental insurance coverage,
    17  "community rated" means a rating methodology in which the  premiums  for
    18  all  persons  covered  by a policy or contract form is the same based on
    19  the experience of the entire pool of risks covered  by  that  policy  or
    20  contract  form  without regard to age, sex, health status, tobacco usage
    21  or occupation.  Catastrophic health insurance contracts issued  pursuant
    22  to  section  1302(e)  of  the affordable care act, 42 U.S.C. § 18022(e),

    23  shall be classified in a distinct community rating pool.
    24    (b) [Nothing herein shall prohibit the use of premium rate  structures
    25  to establish different premium rates for individuals as opposed to fami-
    26  ly  units  or] (1) The superintendent may set standard premium tiers and
    27  standard rating relativities between tiers applicable to  all  contracts
    28  subject  to  this  section.  The  superintendent may also set a standard
    29  relativity applicable to child-only contracts issued pursuant to section
    30  1302(f) of the affordable care act, 42 U.S.C. § 18022(f).  The relativi-
    31  ty for child-only contracts must be actuarially  justifiable  using  the
    32  aggregate experience of corporations to prevent the charging of unjusti-

    33  fied  premiums.    The  superintendent may adjust such premium tiers and
    34  relativities periodically based upon the aggregate experience of  corpo-
    35  rations  issuing  contract  forms subject to this section.  (2) A corpo-
    36  ration shall establish  separate  community  rates  for  individuals  as
    37  opposed  to  small  groups.  (3) If a corporation is required to issue a
    38  contract to individual proprietors pursuant to subsection  (f)  of  this
    39  section,   such  contract  shall  be  subject  to  the  requirements  of
    40  subsection (a) of this section.
    41    (c) (1) The superintendent shall permit the use of separate  community
    42  rates  for  reasonable  geographic  regions, which may, in a given case,
    43  include a single county. The regions shall be  approved  by  the  super-

    44  intendent  as  part  of  the  rate  filing. The superintendent shall not
    45  require the inclusion of any  specific  geographic  regions  within  the
    46  proposed community rated regions selected by the corporation in its rate
    47  filing  so  long  as  the  corporation's proposed regions do not contain
    48  configurations designed to avoid or segregate particular areas within  a
    49  county  covered  by the corporation's community rates.  (2) Beginning on
    50  January first, two thousand fourteen, for every contract subject to this
    51  section that provides physician  services,  medical,  major  medical  or
    52  similar  comprehensive-type  coverage,  except for Medicare supplemental
    53  insurance, corporations shall use standardized  regions  established  by
    54  the superintendent.

    55    (d) (1) This section shall also apply to [contracts] a contract issued
    56  to  a  group  defined  in  subsection  (c)  of section four thousand two

        S. 2606--D                         140                        A. 3006--D
 
     1  hundred thirty-five of this chapter, including but  not  limited  to  an
     2  association  or  trust  of  employers, if the group includes one or more
     3  member employers or other  member  groups  which  have  fifty  or  fewer
     4  employees or members exclusive of spouses and dependents.  For contracts
     5  issued  or  renewed on or after January first, two thousand fourteen, if
     6  the group includes one or more member small group employers eligible for
     7  coverage subject to this section, then such member  employers  shall  be

     8  classified as small groups for rating purposes and the remaining members
     9  shall  be  rated  consistent  with  the  rating rules applicable to such
    10  remaining members pursuant to paragraph two of this subsection.
    11    (2) If a contract is issued to a group defined in  subsection  (c)  of
    12  section  four thousand two hundred thirty-five of this chapter including
    13  association groups, that includes one or more individual  or  individual
    14  proprietor  members,  then  for  rating  purposes  the corporation shall
    15  include such members in its individual pool  of  risks  in  establishing
    16  premium rates for such members.
    17    (3) A corporation shall provide specific claims experience to a munic-
    18  ipal  corporation, as defined in subsection (f) of section four thousand

    19  seven hundred two of this chapter, covered by the  corporation  under  a
    20  community  rated  contract  when  the municipal corporation requests its
    21  claims experience for purposes of forming or joining a municipal cooper-
    22  ative health benefit plan certified pursuant to article  forty-seven  of
    23  this  chapter.  Notwithstanding the foregoing provisions, no corporation
    24  shall be required to provide more than three years' claims experience to
    25  a municipal corporation making this request.
    26    (e) (1) Notwithstanding any other provision of this chapter, no insur-
    27  er, subsidiary of an insurer, or controlled person of a holding  company
    28  system may act as an administrator or claims paying agent, as opposed to
    29  an  insurer,  on  behalf of small groups which, if they purchased insur-
    30  ance, would be subject to this section. No  insurer,  subsidiary  of  an

    31  insurer,  or  controlled  person  of  a holding company may provide stop
    32  loss, catastrophic or reinsurance coverage to  small  groups  which,  if
    33  they purchased insurance, would be subject to this section.
    34    (2)  This  subsection  shall  not  apply  to  coverage insuring a plan
    35  [which] that was in effect on or before December thirty-first,  nineteen
    36  hundred  ninety-one  and  was  issued  to  a group [which] that includes
    37  member small employers or other member small groups, including  but  not
    38  limited  to  association  groups,  provided that (A) acceptance of addi-
    39  tional small member employers (or other member groups comprised of fifty
    40  or fewer employees or members, exclusive of spouses and dependents) into
    41  the group on or after June first, nineteen hundred ninety-two and before

    42  April first, nineteen hundred ninety-four  does  not  exceed  an  amount
    43  equal  to  ten  percent  per year of the total number of persons covered
    44  under the group as of June first, nineteen hundred ninety-two, but noth-
    45  ing in this subparagraph shall  limit  the  addition  of  larger  member
    46  employers;  (B) (i) after April first, nineteen hundred ninety-four, the
    47  group thereafter accepts member small employers and member small  groups
    48  without  underwriting  by any more than the imposition of a pre-existing
    49  condition limitation as permitted by  this  article  and  the  cost  for
    50  participation  in  the  group  for all persons covered shall be the same
    51  based on the experience of the entire pool of risks  covered  under  the
    52  entire  group,  without regard to age, sex, health status or occupation;
    53  and; (ii) once accepted for  coverage,  an  individual  or  small  group

    54  cannot  be terminated due to claims experience; (C) the [insurer] corpo-
    55  ration has registered the names of  such  groups,  including  the  total
    56  number of persons covered as of June first, nineteen hundred ninety-two,

        S. 2606--D                         141                        A. 3006--D
 
     1  with  the superintendent, in a form prescribed by the superintendent, on
     2  or before April first, nineteen hundred ninety-three  and  shall  report
     3  annually  thereafter  until  such  groups  comply with the provisions of
     4  subparagraph  (B)  of this paragraph; and (D) the types or categories of
     5  employers or groups eligible to join the association are not altered  or
     6  expanded after June first, nineteen hundred ninety-two.
     7    (3)  A corporation may apply to the superintendent for an extension or

     8  extensions of time beyond April first, nineteen hundred  ninety-four  in
     9  which  to  implement the provisions of this subsection as they relate to
    10  groups registered with the superintendent pursuant to  subparagraph  (C)
    11  of  paragraph  two  of this subsection; any such extension or extensions
    12  may not exceed two years in aggregate duration, and the ten percent  per
    13  year  limitation of subparagraph (A) of paragraph two of this subsection
    14  shall be reduced to five percent per year during the period of any  such
    15  extension  or  extensions. Any application for an extension shall demon-
    16  strate that a significant financial hardship to such group would  result
    17  from such implementation.
    18    (f)(1)  If the [insurer] corporation issues coverage to an association
    19  group (including chambers of commerce), as defined in  subparagraph  (K)

    20  of  paragraph one of subsection (c) of section four thousand two hundred
    21  thirty-five of this chapter, then the [insurer must]  corporation  shall
    22  issue  the  same coverage to individual proprietors [which] who purchase
    23  coverage through the association  group  as  the  [insurer]  corporation
    24  issues  to groups [which] that purchase coverage through the association
    25  group; provided, however, that [an insurer which] a corporation that, on
    26  the effective date of this subsection, is issuing coverage to individual
    27  proprietors not connected with an association  group,  may  continue  to
    28  issue  such  coverage provided that the coverage is otherwise in accord-
    29  ance with this subsection and all other applicable provisions of law.

    30    (2) For coverage purchased pursuant to this subsection through  Decem-
    31  ber thirty-first, two thousand thirteen, individual proprietors shall be
    32  classified  in their own community rating category, provided however, up
    33  to  and  including  December  thirty-first,  two   thousand   [fourteen]
    34  thirteen,  the  premium  rate  established  for  individual  proprietors
    35  purchased pursuant to paragraph one of  this  subsection  shall  not  be
    36  greater than one hundred fifteen percent of the rate established for the
    37  same  coverage issued to groups.  Coverage purchased or renewed pursuant
    38  to this subsection on or after  January  first,  two  thousand  fourteen
    39  shall be classified in the individual rating category.
    40    (3)  The  [insurer] corporation may require members of the association

    41  purchasing health insurance to verify that all employees electing health
    42  insurance are legitimate employees of the employers,  as  documented  on
    43  New  York  state  tax form NYS-45-ATT-MN or comparable documentation. In
    44  order to be eligible to  purchase  health  insurance  pursuant  to  this
    45  subsection  and  obtain the same group insurance products as are offered
    46  to groups, a sole employee of a corporation or a sole proprietor  of  an
    47  unincorporated  business  or  entity must (A) work at least twenty hours
    48  per week, (B) if purchasing the coverage through an  association  group,
    49  be  a  member  of  the  association for at least sixty days prior to the
    50  effective date of the insurance [policy] contract,  and  (C)  present  a
    51  copy  of  the  following  documentation  to the [insurer] corporation or

    52  health plan administrator on an annual basis:
    53    (i) NYS tax form 45-ATT, or comparable documentation of active employ-
    54  ee status;
    55    (ii) for an unincorporated business, the prior year's  federal  income
    56  tax Schedule C for an incorporated business subject to Subchapter S with

        S. 2606--D                         142                        A. 3006--D
 
     1  a  sole  employee,  federal income tax Schedule E for other incorporated
     2  businesses with a sole employee, a W-2 annual wage statement, or federal
     3  tax form 1099 with federal income tax Schedule F; or
     4    (iii)  for  a business in business for less than one year, a cancelled
     5  business check, a certificate of  doing  business,  or  appropriate  tax
     6  documentation; and
     7    (iv)  such  other  documentation  as may be reasonably required by the

     8  insurer as approved by the superintendent to verify  eligibility  of  an
     9  individual to purchase health insurance pursuant to this subsection.
    10    (4)  Notwithstanding  the  provisions  of  item  (I)  of clause (i) of
    11  subparagraph (K) of paragraph one of  subsection  (c)  of  section  four
    12  thousand  two  hundred thirty-five of this chapter, for purposes of this
    13  section, an association group shall include chambers  of  commerce  with
    14  less  than  two  hundred  members and which are 501C3 or 501C6 organiza-
    15  tions.
    16    § 73. Notwithstanding any inconsistent provision of law, rule or regu-
    17  lation, for purposes of implementing the provisions of the public health
    18  law and the social services law, references to titles XIX and XXI of the
    19  federal social security act in the public  health  law  and  the  social
    20  services  law  shall be deemed to include and also to mean any successor

    21  titles thereto under the federal social security act.
    22    § 74. Notwithstanding any inconsistent provision of law, rule or regu-
    23  lation, the effectiveness of the provisions of sections 2807 and 3614 of
    24  the public health law, section 18 of chapter 2 of the laws of 1988,  and
    25  18  NYCRR  505.14(h), as they relate to time frames for notice, approval
    26  or certification of rates of payment, are hereby suspended  and  without
    27  force or effect for purposes of implementing the provisions of this act.
    28    §  75. Severability clause. If any clause, sentence, paragraph, subdi-
    29  vision, section or part of this act shall be adjudged by  any  court  of
    30  competent  jurisdiction  to  be invalid, such judgment shall not affect,
    31  impair or invalidate the remainder thereof, but shall be confined in its
    32  operation to the clause, sentence, paragraph,  subdivision,  section  or

    33  part thereof directly involved in the controversy in which such judgment
    34  shall  have been rendered. It is hereby declared to be the intent of the
    35  legislature that this act would have been enacted even if  such  invalid
    36  provisions had not been included herein.
    37    §  76.  This  act shall take effect immediately and shall be deemed to
    38  have been in full force  and  effect  on  and  after  January  1,  2013;
    39  provided that:
    40    a.  sections  seventeen,  thirty-eight,  thirty-nine,  forty, forty-a,
    41  forty-one, forty-six-a,  forty-six-b  forty-seven,  forty-eight,  forty-
    42  nine,  fifty,  fifty-one,  fifty-two, fifty-three, fifty-four and fifty-
    43  five of this act shall take effect January 1, 2014, and shall  apply  to
    44  all policies and contracts issued, renewed, modified, altered or amended
    45  on or after such date.
    46    b.  sections forty-two, forty-three, forty-three-a, forty-four, forty-

    47  five and forty-six of this act shall apply to all policies and contracts
    48  issued, renewed, modified, altered or amended on  or  after  October  1,
    49  2013;
    50    b-1  paragraph  8  of  subsection (b) of section 4328 of the insurance
    51  law, as added by section forty-six of  this  act  shall  expire  and  be
    52  deemed repealed on December 31, 2015;
    53    c. section fifty-six of this act shall take effect January 1, 2014;
    54    d. section fifty-seven of this act shall be deemed repealed January 1,
    55  2014;

        S. 2606--D                         143                        A. 3006--D
 
     1    e.  sections fifteen, fifty-eight, sixty-one and sixty-two of this act
     2  shall take effect January 1, 2015;
     3    e-1.  section fifteen-a of this act shall take effect January 1, 2014;
     4    f. sections fifty-nine and sixty of this act shall take effect January

     5  1,  2016  and shall apply to all policies and contracts issued, renewed,
     6  modified, altered, or amended on or after such date;
     7    g. sections fourteen and fourteen-a of  this  act  shall  take  effect
     8  immediately and shall be deemed to have been in full force and effect on
     9  and after April 1, 2013;
    10    h.  the  amendments  to  paragraphs  (e)  and  (f) of subdivision 2 of
    11  section 2511 of the public health law  made  by  sections  nineteen  and
    12  twenty-six of this act shall take effect January 1, 2014 or a later date
    13  to  be  determined  by  the  commissioner  of health contingent upon the
    14  requirements of the Patient Protection and Affordable Care Act  of  2010
    15  being fully implemented by the state and as approved by the secretary of
    16  the  department  of health and human services; provided that the commis-
    17  sioner of health shall notify the legislative bill  drafting  commission

    18  upon  the occurrence of the enactment of the legislation provided for in
    19  sections nineteen and twenty-six of this act in order that  the  commis-
    20  sion  may  maintain  an  accurate  and timely effective data base of the
    21  official text of the laws of the state of New  York  in  furtherance  of
    22  effectuating  the  provisions  of  section 44 of the legislative law and
    23  section 70-b of the public officers law;
    24    h-1. provided however, the amendments to subparagraph  (ii)  of  para-
    25  graph (f) of subdivision 2 of section 2511 of the public health law made
    26  by section twenty-six of this act shall take effect April 1, 2014;
    27    i.  the  amendments  to  subdivision  4  of section 2511 of the public
    28  health law made by section twenty-one of this act shall not  affect  the
    29  expiration  and  reversion  of  such  subdivision and shall be deemed to
    30  expire therewith;

    31    j. the amendments to subparagraph (ii) of paragraph (g) of subdivision
    32  2 of section 2511 of the public health law made by section  twenty-seven
    33  of  this act shall not affect the expiration of such paragraph and shall
    34  be deemed to expire therewith;
    35    j-1. the amendments to subparagraph (iii) of paragraph (a) of subdivi-
    36  sion 2 of section 2511 of the public health law made by  section  thirty
    37  of  this act shall not affect the expiration of such paragraph and shall
    38  be deemed to expire therewith;
    39    j-2. the amendments to subparagraph (iv) of paragraph  (b)  and  para-
    40  graph (d) of subdivision 9 of section 2511 of the public health law made
    41  by  section  thirty-three of this act shall not affect the expiration of
    42  such subdivision and shall be deemed to expire therewith;
    43    j-3. the amendments to subdivision 5 of section 365-n  of  the  social

    44  services law made by section thirty-three-a of this act shall not affect
    45  the repeal of such subdivision and shall be deemed repealed therewith;
    46    k.  any  rules or regulations necessary to implement the provisions of
    47  this act may be promulgated and any procedures, forms,  or  instructions
    48  necessary  for  implementation may be adopted and issued on or after the
    49  date this act shall have become a law;
    50    l. this act shall not be construed to alter, change, affect, impair or
    51  defeat any rights, obligations, duties or interests accrued, incurred or
    52  conferred prior to the effective date of this act;
    53    m. the commissioner of health  and  the  superintendent  of  financial
    54  services  and  any  appropriate  council may take any steps necessary to
    55  implement this act prior to its effective date;


        S. 2606--D                         144                        A. 3006--D
 
     1    n. notwithstanding any inconsistent provision of the state administra-
     2  tive procedure act or any other provision of law,  rule  or  regulation,
     3  the  commissioner of health and the superintendent of financial services
     4  and any appropriate council is authorized to adopt or amend  or  promul-
     5  gate  on  an  emergency  basis  any regulation he or she or such council
     6  determines necessary to implement any  provision  of  this  act  on  its
     7  effective date;
     8    o.  the  provisions of this act shall become effective notwithstanding
     9  the failure of the commissioner  of  health  or  the  superintendent  of
    10  financial  services or any council to adopt or amend or promulgate regu-
    11  lations implementing this act; and
    12    p. the amendments made to subparagraph (7) of paragraph (b) of  subdi-

    13  vision  1  of section 366 of the social services law made by section one
    14  of this act shall expire and be deemed repealed October 1, 2019.
 
    15                                   PART E
 
    16    Section 1. Intentionally omitted.
    17    § 2. Intentionally omitted.
    18    § 3. Intentionally omitted.
    19    § 4. Intentionally omitted.
    20    § 5. Intentionally omitted.
    21    § 6. Intentionally omitted.
    22    § 7. Intentionally omitted.
    23    § 8. Intentionally omitted.
    24    § 9. Intentionally omitted.
    25    § 10. Intentionally omitted.
    26    § 11. Intentionally omitted.
    27    § 12. Intentionally omitted.
    28    § 13. Intentionally omitted.
    29    § 14. Section 600 of the public health law, as added by chapter 901 of
    30  the laws of 1986, is amended to read as follows:
    31    § 600. State aid; general requirements. In order to  be  eligible  for

    32  state  aid  under this title, a municipality shall be required to do the
    33  following in accordance with the provisions of this article:
    34    1. submit an application to the department  for  state  aid  which  is
    35  approved  by the commissioner in accordance with section six hundred one
    36  of this title;
    37    [2. submit a municipal public health services plan to  the  department
    38  for approval;
    39    3.  implement and adhere to the municipal public health services plan,
    40  as approved;
    41    4. submit a detailed report to the department of all  expenditures  on
    42  services  funded by this title for the immediately preceding fiscal year
    43  of such municipality;
    44    5. employ a  person  to  supervise  the  provision  of  public  health

    45  services  in  accordance with the provisions of section six hundred four
    46  of this chapter; and
    47    6.] 2. provide core public health services, as defined in section  six
    48  hundred  two  of this title, in accordance with an application for state
    49  aid submitted by the municipality and approved by the commissioner;
    50    3. submit a community health assessment in accordance with section six
    51  hundred two-a of this title;
    52    4. establish,  collect  and  report  fees  and  revenue  for  services
    53  provided by the municipality, in accordance with section six hundred six
    54  of this title; and

        S. 2606--D                         145                        A. 3006--D
 

     1    5.  appropriate  or  otherwise  make  funds  available  to  finance  a
     2  prescribed share of the cost of public health services.
     3    § 15. Section 601 of the public health law, as added by chapter 901 of
     4  the laws of 1986, is amended to read as follows:
     5    §  601. Application for state aid. 1. The governing body of each muni-
     6  cipality desiring to make application for state  aid  under  this  title
     7  shall  annually,  on  such  dates  as  may be fixed by the commissioner,
     8  submit an application for such aid.
     9    2. The application shall be in such form  as  the  commissioner  shall
    10  prescribe, and shall include, but not be limited to:
    11    (a)  an  organizational  chart  of  the municipal health agency, and a
    12  statement providing the number of employees, by job title,  proposed  to

    13  provide public health services funded by this title;
    14    (b)  a  [detailed] budget of proposed expenditures for services funded
    15  by this title;
    16    [(c) a description of proposed program activities for services  funded
    17  by this title;
    18    (d)  a  copy of the municipal public health services plan prepared and
    19  submitted pursuant to section six hundred two of this title;
    20    (e) a certification by the chief  executive  officer  of  the  munici-
    21  pality,  or  in those municipalities with no chief executive officer the
    22  chairman of the county legislature, that the proposed  expenditures  and
    23  program  activities are consistent with the public health services plan;
    24  and

    25    (f)] (c) a description of how the  municipality  will  provide  public
    26  health services;
    27    (d)  an attestation by the chief executive officer of the municipality
    28  that sufficient funds have  been  appropriated  to  provide  the  public
    29  health services for which the municipality is seeking state aid;
    30    (e) an attestation by the municipal officer in charge of administering
    31  public  health  that  the municipality has diligently reviewed its state
    32  aid application and that the application seeks state aid only for eligi-
    33  ble public health services;
    34    (f) a list of public health services provided by the municipality that
    35  are not eligible for state aid, and the cost of each service;

    36    (g) a projection of fees and revenue to be collected for public health
    37  services eligible for state aid, in accordance with section six  hundred
    38  six of this title; and
    39    (h) such other information as the commissioner may require.
    40    3.  The  commissioner  shall  approve the state aid application to the
    41  extent that it is consistent with this section and any other  conditions
    42  or  limitations  established in, or regulations promulgated pursuant to,
    43  this article.
    44    4. A municipality  may  amend  its  state  aid  application  with  the
    45  approval  of  the commissioner, and subject to any rules and regulations
    46  that the commissioner may adopt.
    47    § 16. Section 602 of the public health  law  is  REPEALED  and  a  new

    48  section 602 is added to read as follows:
    49    §  602. Core public health services.  1. To be eligible for state aid,
    50  a municipality must provide the following core public health services:
    51    (a) Family health, which shall include activities designed  to  reduce
    52  perinatal,  infant  and  maternal mortality and morbidity and to promote
    53  the health of infants, children, adolescents, and people of childbearing
    54  age. Such activities shall include family  centered  perinatal  services
    55  and other services appropriate to promote the birth of a healthy baby to
    56  a  healthy  mother, and services to assure that infants, young children,

        S. 2606--D                         146                        A. 3006--D
 

     1  and school age children are enrolled  in  appropriate  health  insurance
     2  programs  and other health benefit programs for which they are eligible,
     3  and that the parents or guardians of such  children  are  provided  with
     4  information  concerning  health  care  providers  in their area that are
     5  willing and able to provide health services to such children.  Provision
     6  of primary and preventive clinical health care services shall be  eligi-
     7  ble  for  state  aid  for uninsured persons under the age of twenty-one,
     8  provided that the municipality makes good faith efforts to  assist  such
     9  persons with insurance enrollment and only until such time as enrollment
    10  becomes effective.
    11    (b)  Communicable  disease  control, which shall include activities to

    12  control and mitigate the extent of infectious diseases. Such  activities
    13  shall  include,  but not be limited to, surveillance and epidemiological
    14  programs, programs to detect diseases in their early  stages,  immuniza-
    15  tions   against  infectious  diseases,  investigation  of  diseases  and
    16  prevention of transmission, prevention and treatment of  sexually  tran-
    17  smissible diseases, and arthropod vector-borne disease prevention.
    18    (c)  Chronic disease prevention, which shall include promoting public,
    19  health care provider and other  community  service  provider  activities
    20  that  encourage  chronic disease prevention, early detection and quality
    21  care delivery. Such activities include, but are not  limited  to,  those

    22  that promote healthy communities and reduce risk factors such as tobacco
    23  use,  poor  nutrition  and  physical  inactivity.  Provision of clinical
    24  services shall not be eligible for state aid, subject to such exceptions
    25  as the commissioner may deem appropriate.
    26    (d) Community health assessment, as described in section  six  hundred
    27  two-a of this article.
    28    (e)  Environmental health, which shall include activities that promote
    29  health and prevent illness and injury by assuring that safe and sanitary
    30  conditions are  maintained  at  public  drinking  water  supplies,  food
    31  service  establishments,  and  other regulated facilities; investigating
    32  public health nuisances to  assure  abatement  by  responsible  parties;

    33  protecting the public from unnecessary exposure to radiation, chemicals,
    34  and  other  harmful contaminants; and conducting investigations of inci-
    35  dents that result in illness, injury or death in order to  identify  and
    36  mitigate  the  environmental  causes to prevent additional morbidity and
    37  mortality.
    38    (f) Public health emergency preparedness and response, including plan-
    39  ning, training, and maintaining readiness for public health emergencies.
    40    2. The municipality must incorporate  into  each  core  public  health
    41  service the following general activities:
    42    (a) ongoing assessment of community health needs;
    43    (b) education on public health issues;
    44    (c) development of policies and plans to address health needs; and

    45    (d)  actions  to assure that services necessary to achieve agreed upon
    46  goals are provided.
    47    3.  The commissioner may approve a state aid application in which  the
    48  municipality  actually  provides  fewer services than those set forth in
    49  subdivision one of this section as long as  the  application  identifies
    50  the  availability of other services, who will provide those services and
    51  the manner in which the services will be provided and financed.
    52    4. The commissioner shall consult with the county  health  commission-
    53  ers,  public  health directors, and boards of public health when promul-
    54  gating rules and regulations to effectuate the provisions  and  purposes
    55  of  this article. The commissioner shall not have the power to prescribe

    56  the number of persons to be employed by any municipality.

        S. 2606--D                         147                        A. 3006--D
 
     1    § 17. The public health law is amended by adding a new  section  602-a
     2  to read as follows:
     3    §  602-a.  Community  health assessment.   1. Every municipality shall
     4  submit to the department no more frequently  than  every  two  years,  a
     5  community health assessment.
     6    2.  The  community  health  assessment  shall  be  in such form as the
     7  commissioner shall prescribe, and shall include, but not be limited to:
     8    (a) an estimate and description of the health status of the population
     9  and factors that contribute to health issues;

    10    (b) identification  of  priority  areas  for  health  improvement,  in
    11  conjunction with the state health improvement plan;
    12    (c)  identification  of public health services in the municipality and
    13  in the community and other resources that can be  mobilized  to  improve
    14  population  health,  particularly  in those priority areas identified in
    15  paragraph (b) of this subdivision; and
    16    (d) a community health improvement plan consisting of  actions,  poli-
    17  cies,  strategies  and  measurable  objectives through which the munici-
    18  pality and its community partners will address areas for health improve-
    19  ment and track progress toward improvement of public health outcomes.
    20    § 18. Section 603 of the public health law, as added by chapter 901 of

    21  the laws of 1986, is amended to read as follows:
    22    § 603. [Municipal public health  services  plan]  Core  public  health
    23  services; implementation. 1. In order to be eligible for state aid under
    24  this  title,  each  municipality shall administer its core public health
    25  [programs] services in accordance with [its  approved  municipal  public
    26  health  services  plan  and] the standards of performance established by
    27  the commissioner through rules and regulations [and] pursuant to section
    28  six hundred nineteen  of  this  article.  Each  municipality  shall,  in
    29  particular,  ensure that public health services are provided in an effi-
    30  cient and effective manner to all persons in the municipality.

    31    2. The commissioner may withhold state aid  reimbursement  under  this
    32  title  for  the appropriate services if, on any audit [and], review of a
    33  state aid application or periodic claim for state aid, or other informa-
    34  tion available to the  department,  the  commissioner  finds  that  such
    35  services are not furnished or rendered in conformance with the rules and
    36  regulations  established  by the commissioner, including but not limited
    37  to the standards of performance  established  pursuant  to  section  six
    38  hundred  nineteen  of  this  article,  or that the expenditures were not
    39  [made according to the approved public health services plan required by]
    40  for an activity set forth in section six hundred two of this  title.  In

    41  such  cases, the commissioner, in order to ensure that the public health
    42  is promoted as defined  in  [paragraph  (b)  of  subdivision  three  of]
    43  section  six  hundred two of this title, may use any proportionate share
    44  of a municipality's per  capita  or  base  grant  that  is  withheld  to
    45  contract  with  agencies,  associations,  or  organizations.  The health
    46  department may use any such withheld  share  to  provide  services  upon
    47  approval  of  the director of the division of the budget. Copies of such
    48  transactions shall be filed with the fiscal committees of  the  legisla-
    49  ture.
    50    3.  Consistent  with  paragraph  (h) of subdivision two of section six
    51  hundred one of this title, when determining whether to approve  a  state
    52  aid  application or periodic claim for state aid, the commissioner shall

    53  have authority to request any and  all  financial  and  other  documents
    54  necessary or relevant to verify that the claimed expenditures are eligi-
    55  ble for state aid under this article.

        S. 2606--D                         148                        A. 3006--D
 
     1    § 19. Section 604 of the public health law, as added by chapter 901 of
     2  the laws of 1986, is amended to read as follows:
     3    §  604. Supervision of public health programs. In order to be eligible
     4  for state aid, under this title, each municipality shall employ a  full-
     5  time local commissioner of health or public health director to supervise
     6  the  provision  of public health services [and to implement the approved
     7  public health services plan]  for  that  municipality,  subject  to  the

     8  following exceptions:
     9    1.  such  person  may serve as the head of a merged agency or multiple
    10  agencies, if the approval of the commissioner is obtained; and
    11    2. such person may serve as the local commissioner of health or public
    12  health director of additional  counties,  when  authorized  pursuant  to
    13  section three hundred fifty-one of this chapter.
    14    § 20. Section 605 of the public health law, as added by chapter 901 of
    15  the  laws  of  1986,  subdivision 1 as amended by section 6 of part B of
    16  chapter 57 of the laws of 2006, subdivision 2 as amended by  section  13
    17  of  part  A  of  chapter  59  of the laws of 2011, is amended to read as
    18  follows:
    19    § 605. State aid; amount of reimbursement. 1. A state aid  base  grant

    20  shall  be reimbursed to municipalities for the [base] core public health
    21  services identified in [paragraph (b) of subdivision three  of]  section
    22  six  hundred  two  of this title, in an amount of the greater of [fifty-
    23  five] sixty-five cents per capita, for each person in the  municipality,
    24  or  [five]  six hundred fifty thousand dollars provided that the munici-
    25  pality expends at least [five] six hundred fifty  thousand  dollars  for
    26  such [base] core public health services. A municipality must provide all
    27  the  [basic] core public health services identified in [paragraph (b) of
    28  subdivision three of] section six hundred two of this title  to  qualify

    29  for  such  base  grant  unless  the municipality has the approval of the
    30  commissioner to expend the base grant on a portion of such  [base]  core
    31  public  health services. If any services in such [paragraph (b)] section
    32  are not [approved in the plan or  if  no  plan  is  submitted  for  such
    33  services]  provided,  the  commissioner may limit the municipality's per
    34  capita or base grant to [that proportionate share which will fund  those
    35  services that are submitted in a plan and subsequently approved] reflect
    36  the scope of the reduced services. The commissioner may use the [propor-
    37  tionate  share]  amount  that  is not granted to contract with agencies,

    38  associations, or organizations to provide such services; or  the  health
    39  department may use such proportionate share to provide the services upon
    40  approval of the director of the division of the budget.
    41    2.  State  aid  reimbursement for public health services provided by a
    42  municipality under this title, shall be  made  if  the  municipality  is
    43  providing some or all of the [basic] core public health services identi-
    44  fied  in [paragraph (b) of subdivision three of] section six hundred two
    45  of this title, pursuant to an approved [plan] application for state aid,
    46  at a rate of no less  than  thirty-six  per  centum  of  the  difference
    47  between  the  amount  of  moneys expended by the municipality for public
    48  health services required by [paragraph  (b)  of  subdivision  three  of]

    49  section  six  hundred  two  of this title during the fiscal year and the
    50  base grant provided pursuant to subdivision one of this section. No such
    51  reimbursement shall be provided for services [if they are  not  approved
    52  in  a  plan  or  if no plan is submitted for such services] that are not
    53  eligible for state aid pursuant to this article.
    54    3. Municipalities  shall  make  every  reasonable  effort  to  collect
    55  payments for public health services provided. All such revenues shall be
    56  reported to the commissioner pursuant to section six hundred six of this

        S. 2606--D                         149                        A. 3006--D
 
     1  title  and  will be deducted from expenditures identified under subdivi-
     2  sion two of this section to produce a net cost eligible for state aid.

     3    § 21. Section 606 of the public health law, as added by chapter 901 of
     4  the laws of 1986, is amended to read as follows:
     5    §  606.  Assessment  of fees; third-party coverage or indemnification.
     6  1. Assessment of fees  by  municipalities.    [Each  municipality  shall
     7  assess  fees  for  services  provided by such municipality in accordance
     8  with a fee and revenue plan which shall include a schedule of fees  that
     9  the  municipality  proposes to charge for each service identified by the
    10  commissioner and each additional service identified by the  municipality
    11  for  which  a fee is to be charged. In accordance with the provisions of
    12  subdivision four of section six hundred two of this chapter, the commis-

    13  sioner shall review each fee and revenue plan submitted to him  and,  on
    14  the  basis  of  such  review, issue a notice of intent to disapprove the
    15  plan or approve the plan, with or without conditions, within ninety days
    16  of his receipt of the plan. In determining whether to approve or  disap-
    17  prove  a  plan,  the commissioner shall consider the extent to which the
    18  plan, once implemented, will satisfy standards  which  the  commissioner
    19  has  promulgated through rules and regulations after consulting with the
    20  public health council and county health commissioners, boards and public
    21  health directors. Such standards shall include a list of those  environ-
    22  mental,  personal  health  and  other  services  for which fees shall be

    23  charged, the calculation of cost by each municipality and the  relation-
    24  ship  of  cost to fees, and provisions for prohibiting the assessment of
    25  fees which would impede the delivery of services deemed essential to the
    26  protection of the health of the public.] Each municipality shall  estab-
    27  lish a schedule of fees for public health services provided by the muni-
    28  cipality  and  shall  make every reasonable effort to collect such fees.
    29  Fees for personal health services shall be reflective of an individual's
    30  ability to pay and shall not  be  inconsistent  with  the  reimbursement
    31  guidelines  of  articles twenty-eight and thirty-six of this chapter and
    32  applicable federal laws and regulations. To the extent possible revenues

    33  generated shall be used to enhance or expand public health services.  In
    34  its state aid application, each municipality shall provide  the  depart-
    35  ment  with  a  projection  of  fees and revenue to be collected for that
    36  year. Each municipality shall periodically report to the department fees
    37  and revenue actually collected.
    38    2. Assessment of fees by the commissioner. In each  municipality,  the
    39  commissioner  shall  establish  a  fee  and  revenue  plan  for services
    40  provided by the department in a manner consistent with the standards and
    41  regulations established pursuant to subdivision one of this section.
    42    3. Third party coverage or  indemnification.  For  any  public  health
    43  service  for  which  coverage  or  indemnification from a third party is

    44  available, the municipality must seek such coverage  or  indemnification
    45  and  report  any  associated  revenue to the department in its state aid
    46  application.
    47    § 22. Subdivisions 1 and 2 of section 609 of the public health law, as
    48  amended by chapter 474 of the laws of  1996,  are  amended  to  read  as
    49  follows:
    50    1.  Where  a  laboratory  shall  have been or is hereafter established
    51  pursuant to article five of this chapter, the state, through the  legis-
    52  lature and within the limits to be prescribed by the commissioner, shall
    53  provide  aid  at  a  per  centum,  determined  in  accordance  with  the
    54  provisions of [paragraph (b) of] subdivision two of section six  hundred
    55  five  of  this  article,  of  the actual cost of [installation,] repair,

    56  relocation, equipment and maintenance of the laboratory or  laboratories

        S. 2606--D                         150                        A. 3006--D
 
     1  for  services associated with a core public health service, as described
     2  in section six hundred two of this  title.    Such  cost  shall  be  the
     3  excess,  if  any,  of  such  expenditures over available revenues of all
     4  types, including adequate and reasonable fees, derived from or attribut-
     5  able to the performance of laboratory services.
     6    2.  Where a county or city provides or shall have provided for labora-
     7  tory service by contracting with an established laboratory for  services
     8  associated  with  a core public health service, as described in subdivi-
     9  sion three of section six hundred two of this title, with  the  approval

    10  of  the commissioner, it shall be entitled to state aid at a per centum,
    11  determined in accordance with  the  provisions  of  [paragraph  (b)  of]
    12  subdivision two of section six hundred five of this article, of the cost
    13  of the contracts. [State aid shall be available for a district laborato-
    14  ry  supply  station  maintained  and operated in accordance with article
    15  five of this chapter in the same manner and to the same  extent  as  for
    16  laboratory services.]
    17    § 23. Sections 610 and 612 of the public health law are REPEALED.
    18    §  24.  Paragraphs  (a)  and (c) of subdivision 1 and subdivision 4 of
    19  section 613 of the public health law, paragraphs (a) and (c) of subdivi-
    20  sion 1 as amended by chapter 36 of the laws of 2010,  subdivision  4  as
    21  amended  by  chapter  207  of  the  laws of 2004, are amended to read as

    22  follows:
    23    (a) The commissioner shall develop and supervise the  execution  of  a
    24  program of immunization, surveillance and testing, to raise to the high-
    25  est  reasonable  level the immunity of the children of the state against
    26  communicable diseases including, but not limited to, influenza,  poliom-
    27  yelitis,  measles,  mumps, rubella, haemophilus influenzae type b (Hib),
    28  diphtheria, pertussis, tetanus,  varicella,  hepatitis  B,  pneumococcal
    29  disease,  and the immunity of adults of the state against diseases iden-
    30  tified by the commissioner, including  but  not  limited  to  influenza,
    31  smallpox,  [and]  hepatitis  and such other diseases as the commissioner
    32  may designate through regulation.  [The commissioner shall encourage the

    33  municipalities] Municipalities in  the  state  [to  develop  and]  shall
    34  [assist  them  in  the  development and the execution of] maintain local
    35  programs of [inoculation] immunization to  raise  the  immunity  of  the
    36  children  and  adults  of  each  municipality  to the highest reasonable
    37  level, in accordance with an application for state aid submitted by  the
    38  municipality  and  approved  by  the commissioner.   Such programs shall
    39  include assurance of provision  of  vaccine,  [surveillance  of  vaccine
    40  effectiveness  by  means  of  laboratory  tests,] serological testing of
    41  individuals and educational efforts to inform health care providers  and
    42  target  populations  or  their parents, if they are minors, of the facts

    43  relative to these diseases and [inoculation]  immunizations  to  prevent
    44  their occurrence.
    45    (c)  The commissioner shall invite and encourage the active assistance
    46  and cooperation in such education activities of: the medical  societies,
    47  organizations  of  other  licensed  health  personnel, hospitals, corpo-
    48  rations subject to article  forty-three  of  the  insurance  law,  trade
    49  unions, trade associations, parents and teachers and their associations,
    50  organizations of child care resource and referral agencies, the media of
    51  mass communication, and such other voluntary groups and organizations of
    52  citizens  as  he  or  she  shall deem appropriate. The public health and
    53  health planning council, the department of education, the department  of
    54  family  assistance,  and  the department of mental hygiene shall provide

    55  the commissioner with such assistance in carrying out the program as  he
    56  or  she  shall request.  All other state agencies shall also render such

        S. 2606--D                         151                        A. 3006--D
 
     1  assistance as the commissioner may reasonably require for this  program.
     2  Nothing  in  this  subdivision shall authorize mandatory immunization of
     3  adults or children, except as provided in  sections  twenty-one  hundred
     4  sixty-four and twenty-one hundred sixty-five of this chapter.
     5    4.  The  commissioner shall expend such funds as the legislature shall
     6  make available for the purchase of the vaccines described in subdivision
     7  one of this section. [All  immunization  vaccines  purchased  with  such
     8  funds  shall  be  purchased by sealed competitive state bids through the

     9  office of general services.  Immunization  vaccine]  Vaccines  purchased
    10  with  funds  made  available  under this section shall be made available
    11  without charge to licensed private physicians,  hospitals,  clinics  and
    12  such  others  as  the  commissioner  shall determine [in accordance with
    13  regulations to be promulgated by the commissioner], and no charge  shall
    14  be made to any patient for such vaccines.
    15    § 25. Subdivisions 5 and 7 of section 613 of the public health law are
    16  REPEALED,  and  subdivision  6,  as  added by chapter 901 of the laws of
    17  1986, is amended to read as follows:
    18    [6.] 5. The commissioner shall submit to the governor and the legisla-
    19  ture an annual report on the progress of the immunization program.  Such
    20  reports  shall  include  specific  information  on  the  steps taken and

    21  planned by the department [and by each  participating  municipality]  to
    22  carry  out the program[, statistical information on immunization vaccine
    23  purchased for each municipality, the number of inoculations administered
    24  to children of various ages  by  municipal  agencies,  private  clinics,
    25  private  physicians  and  others,  the  cost  of  the  several  vaccines
    26  purchased, information on the results of the  immunization  program  and
    27  research on the effects of the vaccine, cooperative education efforts by
    28  public  and  private  agencies,  special  information and administrative
    29  measures to reach parents and children in population groups which  pres-
    30  ent  special  educational  problems,  the  actual and planned use of any

    31  federal funds available to meet any part of the cost of the program, and
    32  actual and planned expenditure  by  municipalities  to  meet  costs  not
    33  provided for by state and federal funds].
    34    §  26. Subdivision 2 of section 614 of the public health law, as added
    35  by chapter 901 of the laws of 1986, is amended to read as follows:
    36    2. "City", each city of the state having a population of [fifty  thou-
    37  sand]  one  million  or  more,  according  to the last preceding federal
    38  census[, but does not include any such city which is included as a  part
    39  of a county health district pursuant to this chapter].
    40    §  27.  Subdivision  1  of  section  616  of the public health law, as
    41  amended by section 9 of part B of chapter 57 of the  laws  of  2006,  is
    42  amended to read as follows:

    43    1.  The  total  amount  of state aid provided pursuant to this article
    44  shall be limited to the amount of the annual appropriation made  by  the
    45  legislature.  In no event, however, shall such state aid be less than an
    46  amount to provide the full base grant  and,  as  otherwise  provided  by
    47  paragraph  (a)  of  subdivision  two of section six hundred five of this
    48  article, at least thirty-six per centum of the  difference  between  the
    49  amount of moneys expended by the municipality for eligible public health
    50  services  [required by paragraph (b) of subdivision three of section six
    51  hundred two of this article] pursuant to  an  approved  application  for
    52  state aid during the fiscal year and the base grant provided pursuant to
    53  subdivision  one of section six hundred five of this article. [A munici-

    54  pality shall also receive not less than thirty-six  per  centum  of  the
    55  moneys  expended  for other public health services pursuant to paragraph
    56  (b) of subdivision two of section six hundred five of this article, and,

        S. 2606--D                         152                        A. 3006--D

     1  at least the minimum amount so required for the services  identified  in
     2  title two of this article.]
     3    § 28. Section 617 of the public health law, as added by chapter 901 of
     4  the laws of 1986, is amended to read as follows:
     5    §  617.  Maintenance of effort. Such amount of state aid provided will
     6  be used to support and to the extent practicable, to increase the  level
     7  of  funds  that  would otherwise be made available for such purposes and

     8  not to supplant the amount to be provided by the  municipalities.  If  a
     9  municipality  that  is  provided state aid pursuant to title one of this
    10  article reduces its expenditures beneath the amount expended in its base
    11  year, which is [the greater of  its  expenditures  in  its  fiscal  year
    12  ending in either nineteen hundred eighty-five or] the most recent fiscal
    13  year  for  which  the municipality has filed [an annual] all expenditure
    14  [report] reports to the department,  state  aid  reimbursement  provided
    15  pursuant  to subdivision one of section six hundred five of this article
    16  will be reduced by  the  [difference  between  the  reduction  in  local
    17  expenditures  between  its base year and its current fiscal year and the

    18  reduction in state aid between the base year and the current fiscal year
    19  pursuant to paragraphs (a) and (b) of subdivision  two  of  section  six
    20  hundred  five  of  this  article.  A  municipality  may include revenue,
    21  excluding third party  reimbursement,  raised  by  the  municipality  in
    22  calculating  its maintenance of effort] percentage reduction in expendi-
    23  tures between its base year and its current fiscal year. For purposes of
    24  this section, reductions in  expenditures  shall  be  adjusted  for:  an
    25  absence  of  extraordinary  expenditures  of a temporary nature, such as
    26  disaster relief; unavoidable or justifiable program reductions, such  as
    27  a  program  being  subsumed by another agency; or in circumstances where

    28  the municipality can demonstrate, to the department's satisfaction, that
    29  the need for the expenditure no longer exists.
    30    § 29. Section 618 of the public health law, as added by chapter 901 of
    31  the laws of 1986, is amended to read as follows:
    32    § 618. Performance and accountability.  The commissioner shall  estab-
    33  lish,   in  consultation  with  the  municipalities,  uniform  statewide
    34  performance standards for the services funded pursuant to this  article;
    35  provided, however, the commissioner may modify a specific standard for a
    36  municipality  if  such municipality demonstrates adequate justification.
    37  The commissioner shall recognize the particular needs  and  capabilities
    38  of  the  various  municipalities.  The  commissioner  shall  monitor the
    39  performance and expenditures of each municipality to  ensure  that  each

    40  one  satisfies  the  performance  standards. Any municipality failing to
    41  satisfy its standards may be subject to a reduction or loss of aid until
    42  such municipality can demonstrate that it has the  capacity  to  satisfy
    43  such  standards.  The  commissioner shall establish a uniform accounting
    44  system for monitoring the expenditures for services of each municipality
    45  to which aid is granted[, and for determining the appropriateness of the
    46  costs of such services. The commissioner shall also establish a  uniform
    47  reporting  system  to  determine  the  appropriateness of the amount and
    48  types of services provided, and the  number  of  people  receiving  such
    49  services.]  and  the amount of state aid received including any perform-
    50  ance payments pursuant to section six hundred nineteen-a of  this  arti-

    51  cle.  Such  reporting  system  shall  [also]  require information on the
    52  amount of public health moneys received from the federal government, the
    53  private sector, grants, and fees. Each such  municipality  shall  comply
    54  with  the  regulations  of  such  accounting and reporting systems. [The
    55  commissioner shall determine the extent to which the services maintained
    56  and improved the health status of a municipality's residents  and  main-

        S. 2606--D                         153                        A. 3006--D

     1  tained   and  improved  the  accessibility  and  quality  of  care,  and
     2  controlled costs of the health care system.]
     3    § 30. Section 619 of the public health law, as added by chapter 901 of
     4  the laws of 1986, is amended to read as follows:

     5    §  619.  Commissioner; regulatory powers. The commissioner shall adopt
     6  regulations to effectuate the provisions and purposes of  this  article,
     7  including, but not limited to:
     8    1.  setting  standards  of  performance [and reasonable costs] for the
     9  provision of [basic] core public health  services  which  shall  include
    10  performance  criteria  to  ensure  that reimbursable health services are
    11  delivered in an efficient and effective manner by a municipality; and
    12    2. monitoring, collecting data and evaluating the provision of [basic]
    13  core public health  services  by  the  municipalities  and  the  amounts
    14  expended by the municipalities for such services.
    15    §  31.  The public health law is amended by adding a new section 619-a
    16  to read as follows:

    17    § 619-a. Incentive standards of performance. 1. The  commissioner  may
    18  establish  statewide incentive performance standards for the delivery of
    19  core public health services.
    20    2. Within amounts appropriated, and subject to  the  approval  of  the
    21  director  of  the budget, the commissioner may increase state aid to any
    22  municipality that meets or exceeds statewide incentive performance stan-
    23  dards established under this section, provided that the  total  of  such
    24  payments  to all municipalities may not exceed one million dollars annu-
    25  ally.
    26    § 32. The article heading of article 23 of the public health  law,  as
    27  amended  by  chapter  878  of  the  laws  of 1980, is amended to read as
    28  follows:

    29          CONTROL OF SEXUALLY [TRANSMISSIBLE] TRANSMITTED DISEASES
    30    § 33. Sections 2300, 2301, 2302 and 2303 of the public health law  are
    31  REPEALED.
    32    §  34. The section heading and subdivisions 1 and 2 of section 2304 of
    33  the public health law, as amended by chapter 878 of the  laws  of  1980,
    34  are  amended  and  two  new  subdivisions  4  and 5 are added to read as
    35  follows:
    36    Sexually [transmissible] transmitted diseases;  treatment  facilities;
    37  administration.  1.  It  shall  be  the  responsibility of each board of
    38  health of a health district  to  provide  adequate  facilities  for  the
    39  [free] diagnosis and treatment of persons living within its jurisdiction
    40  who  are  suspected  of  being  infected or are infected with a sexually
    41  [transmissible] transmitted disease.

    42    2. The health officer of said health district shall  administer  these
    43  facilities  directly  or  through contract and shall promptly examine or
    44  arrange for the examination of persons suspected of being infected  with
    45  a  sexually  [transmissible]  transmitted  disease,  and  shall promptly
    46  institute treatment or arrange for  the  treatment  of  those  found  or
    47  otherwise known to be infected with a sexually [transmissible] transmit-
    48  ted  disease, provided that any person may, at his option, be treated at
    49  his own expense by a licensed physician of his choice.
    50    4. Each board of health and local health  officer  shall  ensure  that
    51  diagnosis  and  treatment  services  are  available and, to the greatest
    52  extent practicable, seek third party  coverage  or  indemnification  for

    53  such  services; provided, however, that no board of health, local health
    54  officer, or other municipal officer or entity shall request  or  require
    55  that  such  coverage  or  indemnification  be utilized as a condition of
    56  providing diagnosis or treatment services.

        S. 2606--D                         154                        A. 3006--D
 
     1    5. The term "health officer" as used in  this  article  shall  mean  a
     2  county  health  officer, a city health officer, a town health officer, a
     3  village health officer, the health  officer  of  a  consolidated  health
     4  district or a state district health officer.
     5    §  35. The section heading and subdivisions 1 and 2 of section 2305 of
     6  the public health law, as amended by chapter 878 of the  laws  of  1980,

     7  are amended to read as follows:
     8    Sexually  [transmissible]  transmitted diseases; treatment by licensed
     9  physician or staff physician  of  a  hospital;  prescriptions.    1.  No
    10  person,  other  than  a  licensed  physician, or, in a hospital, a staff
    11  physician, shall diagnose, treat  or  prescribe  for  a  person  who  is
    12  infected with a sexually [transmissible] transmitted disease, or who has
    13  been  exposed  to  infection with a sexually [transmissible] transmitted
    14  disease, or dispense or sell a drug, medicine or remedy for  the  treat-
    15  ment of such person except on prescription of a duly licensed physician.
    16    2.  A  licensed  physician,  or  in a hospital, a staff physician, may
    17  diagnose, treat or prescribe for a person under the  age  of  twenty-one

    18  years  without  the  consent  or knowledge of the parents or guardian of
    19  said person, where such person is infected with a sexually  [transmissi-
    20  ble]  transmitted disease, or has been exposed to infection with a sexu-
    21  ally [transmissible] transmitted disease.
    22    § 36. Section 2306 of the public health law, as amended by chapter  41
    23  of the laws of 2010, is amended to read as follows:
    24    §  2306.  Sexually  [transmissible]  transmitted diseases; reports and
    25  information, confidential. All reports or information secured by a board
    26  of health or health officer under the provisions of this  article  shall
    27  be  confidential  except  in  so  far  as  is necessary to carry out the
    28  purposes of this article. Such report or information may be disclosed by

    29  court order in a criminal proceeding in which it is otherwise admissible
    30  or in a proceeding pursuant to article ten of the family  court  act  in
    31  which it is otherwise admissible, to the prosecution and to the defense,
    32  or  in  a  proceeding pursuant to article ten of the family court act in
    33  which it is otherwise admissible,  to  the  petitioner,  respondent  and
    34  attorney  for  the  child,  provided  that  the subject of the report or
    35  information has waived the confidentiality provided for by this  section
    36  except  insofar  as is necessary to carry out the purposes of this arti-
    37  cle. Information may be disclosed to third party  reimbursers  or  their
    38  agents  to  the  extent necessary to reimburse health care providers for
    39  health services; provided that, when necessary, an otherwise appropriate

    40  authorization for such disclosure has been secured by  the  provider.  A
    41  person  waives  the confidentiality provided for by this section if such
    42  person voluntarily discloses or consents to disclosure of such report or
    43  information or a portion thereof. If such person lacks the  capacity  to
    44  consent to such a waiver, his or her parent, guardian or attorney may so
    45  consent.  An  order  directing disclosure pursuant to this section shall
    46  specify that no report or information shall  be  disclosed  pursuant  to
    47  such  order  which  identifies  or  relates to any person other than the
    48  subject of the report or information. Reports  and  information  may  be
    49  used  in  the aggregate in programs approved by the commissioner for the
    50  improvement of the quality of medical  care  provided  to  persons  with

    51  sexually  transmitted  diseases;  or  with patient identifiers when used
    52  within the state or local health department  by  public  health  disease
    53  programs  to  assess  co-morbidity  or  completeness of reporting and to
    54  direct program needs, in which case patient  identifiers  shall  not  be
    55  disclosed  outside the state or local health department except as other-
    56  wise provided for in this section.

        S. 2606--D                         155                        A. 3006--D
 
     1    § 37. The section heading of section 2308 of the public health law  is
     2  amended to read as follows:
     3    [Venereal]  Sexually  transmitted  disease; pregnant women; blood test
     4  for syphilis.
     5    § 38. Section 2308-a of the public health law, as amended  by  chapter

     6  878 of the laws of 1980, is amended to read as follows:
     7    §  2308-a.  Sexually  [transmissible]  transmitted diseases; tests for
     8  sexually [transmissible] transmitted diseases.   1.  The  administrative
     9  officer  or other person in charge of a clinic or other facility provid-
    10  ing gynecological, obstetrical, genito-urological, contraceptive, steri-
    11  lization or termination of pregnancy services or treatment shall require
    12  the staff of such clinic or facility to offer  to  administer  to  every
    13  resident  of the state of New York coming to such clinic or facility for
    14  such services or treatment, appropriate examinations or  tests  for  the
    15  detection of sexually [transmissible] transmitted diseases.
    16    2. Each physician providing gynecological, obstetrical, genito-urolog-

    17  ical, contraceptive, sterilization, or termination of pregnancy services
    18  or treatment shall offer to administer to every resident of the state of
    19  New York coming to such physician for such services or treatment, appro-
    20  priate  examinations or tests for the detection of sexually [transmissi-
    21  ble] transmitted diseases.
    22    § 39. Sections 2309 and 2310 of the public health law are REPEALED.
    23    § 40. Section 2311 of the public health law, as added by  chapter  878
    24  of the laws of 1980, is amended to read as follows:
    25    § 2311. Sexually [transmissible] transmitted disease list. The commis-
    26  sioner  shall  promulgate a list of sexually [transmissible] transmitted
    27  diseases, such as gonorrhea and syphilis, for the purposes of this arti-

    28  cle. The commissioner, in determining the diseases  to  be  included  in
    29  such  list,  shall  consider those conditions principally transmitted by
    30  sexual contact, other sections of this chapter  addressing  communicable
    31  diseases  and  the impact of particular diseases on individual morbidity
    32  and the health of newborns.
    33    § 41. Section 2 of chapter 577 of  the  laws  of  2008,  amending  the
    34  public  health  law  relating  to  expedited partner therapy for persons
    35  infected with chlamydia trachomatis, is amended to read as follows:
    36    § 2. This act shall take effect on the one hundred twentieth day after
    37  it shall have become a law [and shall  expire  and  be  deemed  repealed
    38  January 1, 2014].
    39    § 42. Intentionally omitted.
    40    § 43. Intentionally omitted.
    41    § 44. Intentionally omitted.

    42    § 45. Intentionally omitted.
    43    § 46. Intentionally omitted.
    44    § 47. Intentionally omitted.
    45    § 48. Intentionally omitted
    46    § 49. Intentionally omitted.
    47    §  50. The public health law is amended by adding a new section 2806-a
    48  to read as follows:
    49    § 2806-a. Temporary operator. 1. For the purposes of this section:
    50    (a) "adult care facility" shall mean an adult home or enriched housing
    51  program licensed pursuant to article seven of the social services law or
    52  an assisted living residence licensed pursuant to article forty-six-B of
    53  this chapter;
    54    (b) "established operator" shall mean the operator of  an  adult  care
    55  facility,  a  general hospital or a diagnostic and treatment center that


        S. 2606--D                         156                        A. 3006--D
 
     1  has been established and issued an operating certificate as such  pursu-
     2  ant to this article;
     3    (c)  "facility"  shall mean (i) a general hospital or a diagnostic and
     4  treatment center that has been issued an operating certificate  as  such
     5  pursuant to this article; or (ii) an adult care facility;
     6    (d) "temporary operator" shall mean any person or entity that:
     7    (i)  agrees  to  operate  a  facility on a temporary basis in the best
     8  interests of its residents or patients and the community served  by  the
     9  facility; and
    10    (ii) has demonstrated that he or she has the character, competence and
    11  financial  ability to operate the facility in compliance with applicable

    12  standards;
    13    (e) "serious financial instability" shall include but not  be  limited
    14  to  defaulting  or  violating key covenants of loans, or missed mortgage
    15  payments, or general untimely payment of obligations, including but  not
    16  limited  to  employee  benefit  fund, payroll tax, and insurance premium
    17  obligations, or failure  to  maintain  required  debt  service  coverage
    18  ratios or, as applicable, factors that have triggered a written event of
    19  default notice to the department by the dormitory authority of the state
    20  of New York; and
    21    (f)  "extraordinary  financial  assistance"  shall  mean  state  funds
    22  provided to a facility upon such facility's request for the  purpose  of

    23  assisting  the  facility to address serious financial instability.  Such
    24  funds may be derived  from  existing  programs  within  the  department,
    25  special appropriations, or other funds.
    26    2.(a)  In the event that: (i) a facility seeks extraordinary financial
    27  assistance and the commissioner finds that the facility is  experiencing
    28  serious financial instability that is jeopardizing existing or continued
    29  access  to  essential services within the community, or (ii) the commis-
    30  sioner finds that there are conditions within the facility that serious-
    31  ly endanger the life, health or safety of  residents  or  patients,  the
    32  commissioner may appoint a temporary operator to assume sole control and

    33  sole responsibility for the operations of that facility. The appointment
    34  of  the temporary operator shall be effectuated pursuant to this section
    35  and shall be in addition to any other remedies provided by law.
    36    (b) The established operator of a facility may at any time request the
    37  commissioner to appoint a temporary  operator.  Upon  receiving  such  a
    38  request,  the  commissioner  may,  if  he or she determines that such an
    39  action is necessary to restore or maintain the provision of quality care
    40  to the residents or  patients  or  alleviate  the  facility's  financial
    41  instability,  enter  into an agreement with the established operator for
    42  the appointment of a temporary operator to assume sole control and  sole

    43  responsibility for the operations of that facility.
    44    3.  (a) A temporary operator appointed pursuant to this section shall,
    45  prior to his or her  appointment  as  temporary  operator,  provide  the
    46  commissioner  with  a  work  plan  satisfactory  to  the commissioner to
    47  address the facility's deficiencies and  serious  financial  instability
    48  and a schedule for implementation of such plan. A work plan shall not be
    49  required  prior to the appointment of the temporary operator pursuant to
    50  clause (ii) of paragraph (a) of subdivision two of this section  if  the
    51  commissioner  has  determined that the immediate appointment of a tempo-
    52  rary operator is necessary because public health or safety is  in  immi-

    53  nent  danger  or  there exists any condition or practice or a continuing
    54  pattern of conditions or practices which poses imminent  danger  to  the
    55  health  or safety of any patient or resident of the facility. Where such
    56  immediate appointment has been found  to  be  necessary,  the  temporary

        S. 2606--D                         157                        A. 3006--D
 
     1  operator shall provide the commissioner with a work plan satisfactory to
     2  the commissioner as soon as practicable.
     3    (b) The temporary operator shall use his or her best efforts to imple-
     4  ment  the  work plan provided to the commissioner, if applicable, and to
     5  correct or eliminate any deficiencies or financial  instability  in  the

     6  facility  and  to  promote  the quality and accessibility of health care
     7  services in the community served by the  facility.  Such  correction  or
     8  elimination  of  deficiencies or serious financial instability shall not
     9  include major alterations of the physical  structure  of  the  facility.
    10  During  the term of his or her appointment, the temporary operator shall
    11  have the sole authority to direct the management of the facility in  all
    12  aspects  of  operation and shall be afforded full access to the accounts
    13  and records of the facility. The temporary operator shall,  during  this
    14  period,  operate  the facility in such a manner as to promote safety and
    15  the quality and accessibility of health  care  services  or  residential

    16  care  in  the  community  served by the facility. The temporary operator
    17  shall have the power to let contracts  therefor  or  incur  expenses  on
    18  behalf of the facility, provided that where individual items of repairs,
    19  improvements  or  supplies  exceed  ten  thousand dollars, the temporary
    20  operator shall obtain price quotations from  at  least  three  reputable
    21  sources.  The temporary operator shall not be required to file any bond.
    22  No security interest in any real or  personal  property  comprising  the
    23  facility  or  contained  within  the  facility, or in any fixture of the
    24  facility, shall be impaired or diminished in priority by  the  temporary
    25  operator. Neither the temporary operator nor the department shall engage

    26  in  any activity that constitutes a confiscation of property without the
    27  payment of fair compensation.
    28    4. The temporary operator shall be entitled to a  reasonable  fee,  as
    29  determined  by  the commissioner, and necessary expenses incurred during
    30  his or her performance as temporary operator, to be paid from the reven-
    31  ue of the  facility.  The  temporary  operator  shall  collect  incoming
    32  payments  from  all  sources and apply them to the reasonable fee and to
    33  costs incurred in the performance of his or her functions  as  temporary
    34  operator  in  correcting  deficiencies  and  causes of serious financial
    35  instability.  The temporary operator shall be liable only in his or  her

    36  capacity  as  temporary  operator  for  injury to person and property by
    37  reason of conditions of the facility in  a  case  where  an  established
    38  operator  would have been liable; he or she shall not have any liability
    39  in his or her personal capacity, except for gross negligence and  inten-
    40  tional acts.
    41    5.  (a)  The initial term of the appointment of the temporary operator
    42  shall not exceed one hundred eighty days. After one hundred eighty days,
    43  if the commissioner determines that termination of the temporary  opera-
    44  tor  would  cause significant deterioration of the quality of, or access
    45  to, health care or residential care in the community or that  reappoint-
    46  ment  is  necessary  to  correct the conditions within the facility that

    47  seriously endanger the life, health or safety of residents or  patients,
    48  or the financial instability that required the appointment of the tempo-
    49  rary operator, the commissioner may authorize up to two additional nine-
    50  ty-day terms.
    51    (b)  Upon  the  completion  of  the two ninety-day terms referenced in
    52  paragraph (a) of this subdivision,
    53    (i) if the established operator is the debtor in a bankruptcy proceed-
    54  ing,  and  the  commissioner  determines  that  the  temporary  operator
    55  requires additional terms to operate the facility during the pendency of
    56  the  bankruptcy  proceeding and to carry out any plan resulting from the

        S. 2606--D                         158                        A. 3006--D
 

     1  proceeding, the commissioner may reappoint the  temporary  operator  for
     2  additional  ninety-day  terms  until  the  termination of the bankruptcy
     3  proceeding, provided that the commissioner shall provide for notice  and
     4  a hearing as set forth in subdivision six of this section; or
     5    (ii)  if  the  established  operator requests the reappointment of the
     6  temporary operator, the commissioner may reappoint the temporary  opera-
     7  tor for one additional ninety-day term, pursuant to an agreement between
     8  the established operator, the temporary operator and the department.
     9    (c)  Within fourteen days prior to the termination of each term of the
    10  appointment of the temporary  operator,  the  temporary  operator  shall

    11  submit  to  the  commissioner  and  to the established operator a report
    12  describing:
    13    (i) the actions taken during the appointment to address such deficien-
    14  cies and financial instability,
    15    (ii) objectives for the continuation of the temporary operatorship  if
    16  necessary and a schedule for satisfaction of such objectives,
    17    (iii)  recommended  actions  for the ongoing operation of the facility
    18  subsequent to the term of the temporary operator; and
    19    (iv) with respect to the first ninety-day term referenced in paragraph
    20  (a) of this subdivision, a  plan  for  sustainable  operation  to  avoid
    21  closure,  or transformation of the facility which may include any option

    22  permissible under this chapter or the social services law and implement-
    23  ing regulations thereof.   The report  shall  reflect  best  efforts  to
    24  produce a full and complete accounting.
    25    (d)  The  term  of the initial appointment and of any subsequent reap-
    26  pointment may be terminated prior to the expiration  of  the  designated
    27  term,  if  the established operator and the commissioner agree on a plan
    28  of correction and the implementation of such plan.
    29    6. (a) The commissioner, upon making  a  determination  to  appoint  a
    30  temporary  operator pursuant to paragraph (a) of subdivision two of this
    31  section shall, prior to the commencement of the appointment,  cause  the
    32  established operator of the facility to be notified of the determination

    33  by registered or certified mail addressed to the principal office of the
    34  established   operator.  Such  notification  shall  include  a  detailed
    35  description of the findings underlying the determination  to  appoint  a
    36  temporary operator, and the date and time of a required meeting with the
    37  commissioner  and/or his or her designee within ten business days of the
    38  date of such notice. At such meeting,  the  established  operator  shall
    39  have  the  opportunity  to  review and discuss all relevant findings. At
    40  such meeting or within ten additional business  days,  the  commissioner
    41  and  the established operator shall attempt to develop a mutually satis-
    42  factory plan of correction and schedule for implementation. In the event

    43  such plan of correction is agreed upon, the  commissioner  shall  notify
    44  the  established  operator  that  the  commissioner no longer intends to
    45  appoint a temporary operator. A meeting shall not be required  prior  to
    46  the  appointment  of  the  temporary operator pursuant to clause (ii) of
    47  paragraph (a) of subdivision two of this section if the commissioner has
    48  determined that the immediate appointment of  a  temporary  operator  is
    49  necessary because public health or safety is in imminent danger or there
    50  exists  any  condition or practice or a continuing pattern of conditions
    51  or practices which poses imminent danger to the health or safety of  any
    52  patient  or  resident  of the facility. Where such immediate appointment

    53  has been found to be  necessary,  the  commissioner  shall  provide  the
    54  established  operator  with a notice as required under this paragraph on
    55  the date of the appointment of the temporary operator.

        S. 2606--D                         159                        A. 3006--D
 
     1    (b) Should the commissioner and the established operator be unable  to
     2  establish  a plan of correction pursuant to paragraph (a) of this subdi-
     3  vision, or should the  established  operator  fail  to  respond  to  the
     4  commissioner's  initial  notification,  a  temporary  operator  shall be
     5  appointed  as  soon  as is practicable and shall operate pursuant to the
     6  provisions of this section.

     7    (c) The established operator shall be afforded an opportunity  for  an
     8  administrative  hearing on the commissioner's determination to appoint a
     9  temporary operator. Such administrative hearing  shall  occur  prior  to
    10  such appointment, except that the hearing shall not be required prior to
    11  the  appointment  of  the  temporary operator pursuant to clause (ii) of
    12  paragraph (a) of subdivision two of this section if the commissioner has
    13  determined that the immediate appointment of  a  temporary  operator  is
    14  necessary because public health or safety is in imminent danger or there
    15  exists  any  condition or practice or a continuing pattern of conditions
    16  or practices which poses imminent danger to the health or safety of  any

    17  patient  or  resident  of  the  facility.  An  administrative hearing as
    18  provided for under this paragraph shall begin no later than  sixty  days
    19  from the date of the notice to the established operator and shall not be
    20  extended  without the consent of both parties. Any such hearing shall be
    21  strictly limited to the  issue  of  whether  the  determination  of  the
    22  commissioner to appoint a temporary operator is supported by substantial
    23  evidence. A copy of the decision shall be sent to the established opera-
    24  tor.
    25    (d) The commissioner shall, upon making a determination to reappoint a
    26  temporary operator for the first of an additional ninety-day term pursu-
    27  ant  to  paragraph  (a)  of  subdivision five of this section, cause the

    28  established operator of the facility to be notified of the determination
    29  by registered or certified mail addressed to the principal office of the
    30  established operator. If the  commissioner  determines  that  additional
    31  reappointments pursuant to subparagraph (i) of paragraph (b) of subdivi-
    32  sion  five  of  this  section are required, the commissioner shall again
    33  cause the established operator of the facility to be  notified  of  such
    34  determination by registered or certified mail addressed to the principal
    35  office  of  the established operator at the commencement of the first of
    36  every two additional terms. Upon receipt of  such  notification  at  the
    37  principal  office  of the established operator and before the expiration

    38  of ten days thereafter, the established operator may request an adminis-
    39  trative hearing on the determination to begin no later than  sixty  days
    40  from  the  date of the reappointment of the temporary operator. Any such
    41  hearing shall be strictly limited to the issue of whether  the  determi-
    42  nation  of  the  commissioner  to  reappoint  the  temporary operator is
    43  supported by substantial evidence.
    44    7. No provision contained in this section shall be deemed  to  relieve
    45  the  established  operator  or any other person of any civil or criminal
    46  liability incurred, or any duty imposed by law, by  reason  of  acts  or
    47  omissions  of  the established operator or any other person prior to the

    48  appointment of any temporary  operator  hereunder;  nor  shall  anything
    49  contained in this section be construed to suspend during the term of the
    50  appointment  of the temporary operator any obligation of the established
    51  operator or any other person for the payment of taxes or other operating
    52  and maintenance expenses of the facility nor of the established operator
    53  or any other person for the payment of mortgages or liens.
    54    § 51. The mental hygiene law is amended by adding a new section  32.20
    55  to read as follows:
    56  § 32.20 Temporary operator.  1. For the purposes of this section:

        S. 2606--D                         160                        A. 3006--D
 
     1    (a)  "chemical  dependence  treatment  program"  shall  mean a program

     2  certified pursuant to section 32.05 of this article;
     3    (b)  "established  operator"  shall  mean  the  operator of a chemical
     4  dependence treatment program that has been  established  and  issued  an
     5  operating certificate pursuant to section 32.05 of this article;
     6    (c)  "temporary operator" shall mean any OASAS staff member, person or
     7  entity that:
     8    (i) agrees to operate a program on  a  temporary  basis  in  the  best
     9  interests of its patients and the community served by the program;
    10    (ii) has demonstrated that he or she has the character, competence and
    11  ability  to operate an OASAS-certified program in compliance with appli-
    12  cable standards; and
    13    (iii) prior to his or her appointment as temporary operator,  develops

    14  with  guidance  from the commissioner a satisfactory plan to address the
    15  program's deficiencies;
    16    (d) "serious financial instability" shall include but not  be  limited
    17  to defaulting or violating key covenants of bond issues, missed mortgage
    18  payments,  general untimely payment of debts, failure to pay its employ-
    19  ees or  vendors,  insufficient  funds  to  meet  the  general  operating
    20  expenses  of  the  program and/or facility, failure to maintain required
    21  debt service coverage ratios and/or, as applicable,  factors  that  have
    22  triggered  a written event of default notice to the office by the dormi-
    23  tory authority of the state of New York; and
    24    (e)  "extraordinary  financial  assistance"  shall  mean  state  funds

    25  provided  to,  or  requested  by,  a  program for the express purpose of
    26  preventing the closure  of  the  program  that  the  commissioner  finds
    27  provides essential and necessary services within the community.
    28    2.  (a)  In  the event that:  (i) the program is seeking extraordinary
    29  financial assistance; (ii) office  collected  data  indicates  that  the
    30  program  is  experiencing  serious  financial  instability issues; (iii)
    31  office collected data indicates that the program's board of directors or
    32  administration are unable or unwilling to ensure the proper operation of
    33  the program; or (iv) office collected data indicates  there  are  condi-
    34  tions  that  seriously endanger or jeopardize continued access to neces-

    35  sary chemical dependence treatment services within  the  community,  the
    36  commissioner  shall notify the established operator of his or her inten-
    37  tion to appoint a temporary operator to assume sole  responsibility  for
    38  the program's treatment operations of that facility for a limited period
    39  of  time.  The  appointment of a temporary operator shall be effectuated
    40  pursuant to this section, and shall be in addition to any other remedies
    41  provided by law.
    42    (b) The established operator of a program may at any time request  the
    43  commissioner  to  appoint  a  temporary  operator. Upon receiving such a
    44  request, the commissioner may, if he or  she  determines  that  such  an
    45  action is necessary, enter into an agreement with the established opera-

    46  tor  for  the appointment of a temporary operator to restore or maintain
    47  the provision of quality care to  the  patients  until  the  established
    48  operator  can  resume  operations within the designated time period; the
    49  patients may be transferred to other OASAS-certified providers;  or  the
    50  program operations of that facility should be completely discontinued.
    51    3.  (a)  A temporary operator appointed pursuant to this section shall
    52  use his or her best efforts to implement the  plan  developed  with  the
    53  guidance of the commissioner to correct or eliminate any deficiencies in
    54  the  program  and  to  promote the quality and accessibility of chemical
    55  dependence treatment services in the community served by the program.


        S. 2606--D                         161                        A. 3006--D
 
     1    (b) If the identified program deficiencies cannot be addressed in  the
     2  time period designated in the plan, the patients shall be transferred to
     3  other OASAS-certified providers.
     4    (c)  During the term of his or her appointment, the temporary operator
     5  shall have the authority to direct the program staff of the facility  in
     6  all  aspects  necessary  to  appropriately  treat  and/or  transfer  the
     7  patients. The temporary operator shall, during this period, operate  the
     8  program in such a manner as to promote safety and the quality and acces-
     9  sibility  of  chemical  dependence  treatment  services in the community
    10  served by the facility until either the established operator can  resume

    11  program  operations  or until the patients are appropriately transferred
    12  to other OASAS-certified providers.
    13    (d) The  temporary  operator  shall  also  be  afforded  access  to  a
    14  program's  accounts  and  records  in  order to address any deficiencies
    15  related to a program experiencing serious  financial  instability  or  a
    16  program requesting financial assistance in accordance with this section.
    17  The temporary operator shall approve any financial decision related to a
    18  program's day to day operations or program's ability to provide chemical
    19  dependence services.
    20    (e)  The temporary operator shall not be required to file any bond. No
    21  security interest in any real or personal property comprising the facil-

    22  ity or contained within the facility or in any fixture of the  facility,
    23  shall  be  impaired or diminished in priority by the temporary operator.
    24  Neither the temporary operator nor the office shall engage in any activ-
    25  ity that constitutes a confiscation of property.
    26    4. The temporary operator shall be entitled to a  reasonable  fee,  as
    27  determined  by  the commissioner, and necessary expenses incurred during
    28  his or her performance as temporary  operator.  The  temporary  operator
    29  shall be liable only in his or her capacity as temporary operator of the
    30  program for injury to person and property by reason of his or her opera-
    31  tion  of  such program; he or she shall not have any liability in his or

    32  her personal capacity, except for gross negligence and intentional acts.
    33    5. (a) The initial term of the appointment of the  temporary  operator
    34  shall  not  exceed  ninety  days. After ninety days, if the commissioner
    35  determines that  termination  of  the  temporary  operator  would  cause
    36  significant  deterioration  of the quality of, or access to, health care
    37  in the community or that reappointment is necessary to correct the defi-
    38  ciencies that required the appointment of the  temporary  operator,  the
    39  commissioner  may authorize an additional ninety-day term. However, such
    40  authorization shall include the commissioner's requirements for  conclu-
    41  sion of the temporary operatorship to be satisfied within the additional
    42  term.

    43    (b)  Within fourteen days prior to the termination of each term of the
    44  appointment of the temporary  operator,  the  temporary  operator  shall
    45  submit  to  the  commissioner  and  to the established operator a report
    46  describing:
    47    (i) the actions taken during the appointment to address:  the  identi-
    48  fied  program  deficiencies; the resumption of program operations by the
    49  established  operator;  or  the  transfer  of  the  patients  to   other
    50  OASAS-certified providers;
    51    (ii)  objectives for the continuation of the temporary operatorship if
    52  necessary and a schedule for satisfaction of such objectives; and
    53    (iii) if applicable, the recommended actions for the ongoing operation

    54  of the program subsequent to the temporary operatorship.
    55    (c) The term of the initial appointment and of  any  subsequent  reap-
    56  pointment  may  be  terminated prior to the expiration of the designated

        S. 2606--D                         162                        A. 3006--D
 
     1  term, if the established operator and the commissioner agree on  a  plan
     2  of correction and the implementation of such plan.
     3    6.  (a)  The  commissioner  shall,  upon  making a determination of an
     4  intention to appoint a temporary operator pursuant to paragraph  (a)  of
     5  subdivision  two  of  this section cause the established operator of the
     6  facility to be notified of the intention by registered or certified mail

     7  addressed to the principal office  of  the  established  operator.  Such
     8  notification shall include a detailed description of the findings under-
     9  lying  the  intention  to appoint a temporary operator, and the date and
    10  time of a required meeting with  the  commissioner  and/or  his  or  her
    11  designee within ten business days of the receipt of such notice. At such
    12  meeting,  the  established operator shall have the opportunity to review
    13  and discuss all relevant findings. At such meeting, the commissioner and
    14  the established operator shall attempt to develop a  mutually  satisfac-
    15  tory  plan of correction and schedule for implementation. In such event,
    16  the commissioner shall notify the established operator that the  commis-

    17  sioner will abstain from appointing a temporary operator contingent upon
    18  the  established operator remediating the identified deficiencies within
    19  the agreed upon timeframe.
    20    (b) Should the commissioner and the established operator be unable  to
    21  establish  a plan of correction pursuant to paragraph (a) of this subdi-
    22  vision, or should the  established  operator  fail  to  respond  to  the
    23  commissioner's  initial  notification,  there shall be an administrative
    24  hearing on the commissioner's determination to appoint a temporary oper-
    25  ator to begin no later than thirty days from the date of the  notice  to
    26  the  established operator. Any such hearing shall be strictly limited to
    27  the issue of whether the determination of the commissioner to appoint  a

    28  temporary  operator  is supported by substantial evidence. A copy of the
    29  decision shall be sent to the established operator.
    30    (c) If the decision to appoint a temporary  operator  is  upheld  such
    31  temporary  operator  shall  be  appointed  as soon as is practicable and
    32  shall operate the program pursuant to the provisions of this section.
    33    7. Notwithstanding the appointment of a temporary operator, the estab-
    34  lished operator remains obligated for the  continued  operation  of  the
    35  facility  so  that  the  program  can  function  in  a normal manner. No
    36  provision contained in this section  shall  be  deemed  to  relieve  the
    37  established  operator  or  any  other  person  of  any civil or criminal

    38  liability incurred, or any duty imposed by law, by  reason  of  acts  or
    39  omissions  of  the established operator or any other person prior to the
    40  appointment of any temporary operator  of  the  program  hereunder;  nor
    41  shall  anything contained in this section be construed to suspend during
    42  the term of the appointment of the temporary operator of the program any
    43  obligation of the established operator or any other person for the main-
    44  tenance and repair of  the  facility,  provision  of  utility  services,
    45  payment  of  taxes  or  other  operating and maintenance expenses of the
    46  facility, nor of the established operator or any other  person  for  the
    47  payment of mortgages or liens.
    48    § 52. Intentionally omitted.
    49    § 53. Intentionally omitted.

    50    § 54. Intentionally omitted.
    51    § 55. Intentionally omitted.
    52    § 56. Intentionally omitted.
    53    § 57. Intentionally omitted.
    54    § 58. Intentionally omitted.
    55    § 59. Intentionally omitted.
    56    § 60. Intentionally omitted.

        S. 2606--D                         163                        A. 3006--D
 
     1    § 61. Intentionally omitted.
     2    § 62. Intentionally omitted.
     3    § 63. Intentionally omitted.
     4    § 64. Intentionally omitted.
     5    § 65. Intentionally omitted.
     6    § 66. Intentionally omitted.
     7    § 67. Intentionally omitted.
     8    § 68. Intentionally omitted.
     9    § 69. Intentionally omitted.
    10    § 70. Intentionally omitted.
    11    § 71. Intentionally omitted.
    12    § 72. Intentionally omitted.

    13    § 73. Intentionally omitted.
    14    § 74. Intentionally omitted.
    15    § 75. Intentionally omitted.
    16    § 76. Intentionally omitted.
    17    § 77. Intentionally omitted.
    18    § 78. Intentionally omitted.
    19    § 79. Intentionally omitted.
    20    § 80. Intentionally omitted.
    21    § 81. Intentionally omitted.
    22    § 82. Intentionally omitted.
    23    § 83. Intentionally omitted.
    24    § 84. Intentionally omitted.
    25    § 85. Intentionally omitted.
    26    § 86. Intentionally omitted.
    27    § 87. Intentionally omitted.
    28    § 88. Intentionally omitted.
    29    § 89. Intentionally omitted.
    30    § 90. Intentionally omitted.
    31    § 91. Intentionally omitted.
    32    § 92. Intentionally omitted.
    33    § 93. Intentionally omitted.
    34    § 94. Intentionally omitted.

    35    § 95. Intentionally omitted.
    36    § 96. Intentionally omitted.
    37    § 97. The opening paragraph, and paragraphs (k) and (l) of subdivision
    38  1  of  section 3510 of the public health law, as added by chapter 175 of
    39  the laws of 2006, are amended and four new paragraphs (m), (n), (o)  and
    40  (p) are added to read as follows:
    41    The  license,  registration  or  intravenous  contrast  administration
    42  certificate of a [radiological] radiologic technologist may be suspended
    43  for a fixed period, revoked or  annulled,  or  such  licensee  censured,
    44  reprimanded,  subject  to  a  civil  penalty  not to exceed two thousand
    45  dollars for every such violation, or otherwise disciplined,  in  accord-
    46  ance  with  the  provisions  and  procedures  defined  in  this article,
    47  provided that no civil penalty  shall  be  assessed  for  any  crime  or

    48  misconduct that occurred outside the jurisdiction of New York state upon
    49  decision  after due hearing that the individual is guilty of the follow-
    50  ing misconduct:
    51    (k) using the prefix "Dr.", the word "doctor" or any suffix  or  affix
    52  to  indicate  or imply that the licensee is a duly licensed practitioner
    53  as defined in this article when not so licensed; [or]
    54    (l) incompetence or negligence[.];
    55    (m) being convicted of a crime which has a direct relationship to  the
    56  employment or licensure at issue or poses an unreasonable risk to public

        S. 2606--D                         164                        A. 3006--D
 
     1  safety pursuant to article twenty-three-a of the correction law and is a

     2  conviction  under (i) New York state law; (ii) federal law; or (iii) the
     3  law of another jurisdiction which, if committed within this state, would
     4  have constituted professional misconduct under New York state law;
     5    (n)  having  been  found  guilty  of improper professional practice or
     6  professional misconduct by a duly authorized  professional  disciplinary
     7  agency  of  another  state  where the conduct upon which the finding was
     8  based, if committed in New York  state,  would  constitute  professional
     9  misconduct under the laws of New York state;
    10    (o)  having been found guilty in an adjudicatory proceeding of violat-
    11  ing a state or federal statute or regulation, pursuant to a final  deci-

    12  sion  or  determination,  and when no appeal is pending, or after resol-
    13  ution of the proceeding  by  stipulation  or  agreement,  and  when  the
    14  violation would constitute professional misconduct under the laws of New
    15  York state; or
    16    (p) having his or her license to practice as a radiologic technologist
    17  revoked,  suspended or having other disciplinary action taken, or having
    18  his or her application for a license refused, revoked  or  suspended  or
    19  having  voluntarily  or otherwise surrendered his or her license after a
    20  disciplinary action was instituted by  a  duly  authorized  professional
    21  disciplinary agency of another state, where the conduct resulting in the
    22  revocation,  suspension  or  other  disciplinary  action  involving  the

    23  license or refusal, revocation or suspension of  an  application  for  a
    24  license  or the surrender of the license would, if committed in New York
    25  state, constitute professional misconduct under the  laws  of  New  York
    26  state.  A radiologic technologist licensed in New York state who is also
    27  licensed or seeking licensure in another state must  immediately  report
    28  to  the  department  any  revocation,  suspension  or other disciplinary
    29  action involving the out-of-state  license  or  refusal,  revocation  or
    30  suspension  of an application for an out-of-state license or the surren-
    31  der of the out-of-state license.
    32    § 98. Intentionally omitted.
    33    § 99. Intentionally omitted.
    34    § 100. Intentionally omitted.
    35    § 101. Intentionally omitted.

    36    § 102. Intentionally omitted.
    37    § 103. Intentionally omitted.
    38    § 104. Intentionally omitted.
    39    § 105. Intentionally omitted.
    40    § 105-a. Intentionally omitted.
    41    § 106. Intentionally omitted.
    42    § 107. Intentionally omitted.
    43    § 108. 1. Notwithstanding any law, rule or regulation to the contrary,
    44  only physicians or dentists who were eligible, and for whom  the  super-
    45  intendent of financial services and the commissioner of health, or their
    46  designee, purchased, with funds available in the hospital excess liabil-
    47  ity  pool,  a  full  or partial policy for excess coverage or equivalent
    48  excess coverage for the coverage periods ending the thirtieth  of  June,
    49  two  thousand thirteen, shall be eligible to apply for such coverage for
    50  the coverage period beginning the first of July, two thousand  thirteen.

    51  For  the coverage period beginning the first of July, two thousand thir-
    52  teen, the superintendent of financial services and the  commissioner  of
    53  health,  or  their  designee, shall purchase up to one thousand policies
    54  for excess coverage or equivalent excess coverage  in  addition  to  the
    55  number  of  policies  purchased for excess coverage or equivalent excess
    56  coverage for the coverage period ending the thirtieth of June, two thou-

        S. 2606--D                         165                        A. 3006--D
 
     1  sand thirteen. A general hospital may certify additional eligible physi-
     2  cians or dentists in a number equal to such general  hospital's  propor-
     3  tional  share  of  the  total  number of physicians or dentists for whom
     4  excess  coverage  or equivalent excess coverage was purchased with funds

     5  available in the hospital excess liability pool as of the  thirtieth  of
     6  June,  two  thousand thirteen, as applied to the greater of one thousand
     7  or the difference between the number of eligible physicians or  dentists
     8  for  whom a policy for excess coverage or equivalent excess coverage was
     9  purchased for the coverage period ending  the  thirtieth  of  June,  two
    10  thousand thirteen and the number of such eligible physicians or dentists
    11  who  have  applied for excess coverage or equivalent excess coverage for
    12  the coverage period beginning the first of July, two  thousand  thirteen
    13  plus one thousand.
    14    2.  Notwithstanding any inconsistent provision of sections one hundred
    15  twelve and one hundred sixty-three of the state finance law, or sections
    16  one hundred forty-two and one hundred forty-three of the economic devel-
    17  opment law, or any other contrary provision of law,  the  superintendent

    18  of  financial services may enter into a contract or contracts under this
    19  subdivision for the purpose of retaining an  entity  to  administer  the
    20  hospital  excess liability pool without a competitive bid or request for
    21  proposal process, provided, however, that:
    22    (a) The department of financial services shall post  on  its  website,
    23  for a period of no less than thirty days:
    24    (i)  A description of the proposed services to be provided pursuant to
    25  the contract or contracts;
    26    (ii) The criteria for selection of a contractor or contractors;
    27    (iii) The period of time during which  a  prospective  contractor  may
    28  seek  selection,  which  shall  be  no  less than thirty days after such
    29  information is first posted on the website; and
    30    (iv) The manner by  which  a  prospective  contractor  may  seek  such
    31  selection, which may include submission by electronic means;

    32    (b)  All  reasonable and responsive submissions that are received from
    33  prospective contractors in timely  fashion  shall  be  reviewed  by  the
    34  superintendent of financial services; and
    35    (c)  The  superintendent  of  financial  services  shall  select  such
    36  contractor or contractors  that,  in  the  superintendent  of  financial
    37  services'  discretion,  are  best  suited  to serve the purposes of this
    38  subdivision.
    39    § 109. Section 5-a of part C of chapter 58 of the laws of 2005, relat-
    40  ing to authorizing reimbursements for expenditures made by or on  behalf
    41  of  social  services  districts for medical assistance for needy persons
    42  and the administration thereof, in  relation  to  the  use  of  Medicaid
    43  recovery  savings,  as  added by section 52-f of part H of chapter 59 of
    44  the laws of 2011, is amended to read as follows:

    45    § 5-a. Notwithstanding any provision  of  law  to  the  contrary,  the
    46  commissioner of health is authorized to approve social services district
    47  demonstration  programs  for  the  purpose of maximizing Medicaid recov-
    48  eries. The commissioner shall evaluate the results of any such programs,
    49  including any savings resulting therefrom.  [Ten] Twenty percent of  any
    50  such savings, after certification by the director of the division of the
    51  budget,  shall be shared with the applicable social services district in
    52  a manner to be determined jointly by the commissioner of health and  the
    53  director of the division of the budget.
    54    §  110.  Subdivisions  5, 23 and 24 of section 32 of the public health
    55  law, as added by chapter 442 of the laws of 2006, are amended and 2  new
    56  subdivisions 25 and 26 are added to read as follows:


        S. 2606--D                         166                        A. 3006--D
 
     1    5.  to  keep the governor, attorney general, state comptroller, tempo-
     2  rary president and minority leader of the senate, the  speaker  and  the
     3  minority  leader of the assembly, and the heads of agencies with respon-
     4  sibility for  the  administration  of  the  medical  assistance  program
     5  apprised of efforts to prevent, detect, investigate, and prosecute fraud
     6  and  abuse within the medical assistance program, and to provide a quar-
     7  terly briefing to the legislature on activities of the office;
     8    23. to annually submit a budget request, for the ensuing state  fiscal
     9  year,  to  the division of the budget, provided that the office's budget
    10  request shall not be subject to review, alteration  or  modification  by

    11  the  commissioner  or any other entity or person prior to its submission
    12  to the division of the budget; [and]
    13    24.   to  meet  quarterly  with  representatives  of  social  services
    14  districts  to  discuss the status of ongoing cooperative efforts between
    15  the office of Medicaid inspector general and districts, including demon-
    16  stration programs authorized pursuant to section five-a  of  part  C  of
    17  chapter  fifty-eight of the laws of two thousand five, the potential for
    18  additional collaboration and/or for improved or innovative techniques to
    19  be employed, and any issues of concern to such districts with respect to
    20  the prevention and detection of fraud and abuse in the  medical  assist-
    21  ance program;

    22    25.  to  request submission of social services districts annual budget
    23  and audit workplans for purposes of planning for and executing the coun-
    24  ty demonstration program and for the creation  of  the  office's  annual
    25  workplan and to include in the office's annual workplan a description of
    26  activities  that will be conducted in collaboration with social services
    27  districts;
    28    26. to develop training materials with respect to the  office's  audit
    29  standards and criteria for identifying fraud or waste, for use by social
    30  services  districts  who  are  engaged  with the office in demonstration
    31  programs or other collaborative efforts; and
    32    27. to perform any other functions that are necessary  or  appropriate

    33  to  fulfill  the duties and responsibilities of the office in accordance
    34  with federal and state law.
    35    § 111. Paragraphs (e) and (f) of subdivision 1 of section  35  of  the
    36  public  health  law,  as  added  by chapter 442 of the laws of 2006, are
    37  amended and a new paragraph (g) is added to read as follows:
    38    (e) the number, subject and other relevant  characteristics  of  civil
    39  actions  initiated  by  the  office  related  to  improper payments, the
    40  resulting civil settlements entered and overpayments identified and  the
    41  total dollar value both identified and collected; [and]
    42    (f) a narrative that evaluates the office's performance, describes any
    43  specific  problems  and  connection  with  the procedures and agreements
    44  required under this section, discusses any other matters that  may  have
    45  impaired  its  effectiveness  and  summarizes  the  total savings to the

    46  state's medical assistance program[.]; and
    47    (g) a narrative, provided by  the  department  in  its  annual  report
    48  pursuant  to paragraph (t) of subdivision one of section two hundred six
    49  of this chapter that summarizes the department's activities to  mitigate
    50  fraud, waste and abuse during the preceding calendar year.
    51    §  112.    Subdivision  1  of  section 206 of the public health law is
    52  amended by adding a new paragraph (t) to read as follows:
    53    (t) The department shall submit as part of its annual report  prepared
    54  pursuant  to  section one hundred sixty-four of the executive law, which
    55  may be submitted in electronic format, comprehensive information includ-
    56  ing, but not limited to, a  detailed  description  of  the  department's

        S. 2606--D                         167                        A. 3006--D
 
     1  mission, priorities and goals for the upcoming year, achievements of the
     2  past year, and any relevant data and statistics.
     3    §  113. Section 2500-a of the public health law is amended by adding a
     4  new subdivision (c) to read as follows:
     5    (c) By regulation, the  commissioner  shall  add  adrenoleukodystrophy
     6  ("ALD")  to  the list of diseases and conditions for which testing shall
     7  be performed pursuant to subdivision (a) of this section upon validation
     8  by the Wadsworth Center of a test for ALD. The  Wadsworth  Center  shall
     9  undertake  the  process  for  validation upon the development of a test.
    10  This subdivision shall be known and may be cited as "Aidan's Law."

    11    § 114. Intentionally omitted.
    12    § 115. Intentionally omitted.
    13    § 116. Intentionally omitted.
    14    § 117. Intentionally omitted.
    15    § 118. Intentionally omitted.
    16    § 119. Notwithstanding any inconsistent  provision  of  law,  rule  or
    17  regulation,  for  purposes  of implementing the provisions of the public
    18  health law and the social services law, references to titles XIX and XXI
    19  of the federal social security act in the  public  health  law  and  the
    20  social  services  law  shall  be  deemed to include and also to mean any
    21  successor titles thereto under the federal social security act.
    22    § 120. Notwithstanding any inconsistent  provision  of  law,  rule  or
    23  regulation,  the  effectiveness  of  the provisions of sections 2807 and
    24  3614 of the public health law, section 18 of chapter 2 of  the  laws  of

    25  1988,  and 18 NYCRR 505.14(h), as they relate to time frames for notice,
    26  approval or certification of rates of payment, are hereby suspended  and
    27  without  force  or effect for purposes of implementing the provisions of
    28  this act.
    29    § 121. Severability. If any clause, sentence, paragraph,  subdivision,
    30  section  or part of this act shall be adjudged by any court of competent
    31  jurisdiction to be invalid, such judgment shall not  affect,  impair  or
    32  invalidate the remainder thereof, but shall be confined in its operation
    33  to the clause, sentence, paragraph, subdivision, section or part thereof
    34  directly  involved  in  the controversy in which the judgment shall have
    35  been rendered. It is hereby declared to be the intent of the legislature
    36  that this act would have been enacted even if  such  invalid  provisions
    37  had not been included herein.

    38    §  122.  This act shall take effect immediately and shall be deemed to
    39  have been in full force and effect on and after April 1, 2013; provided,
    40  however, that the provisions of this act shall apply only to actions and
    41  proceedings  commenced  on  or  after  such  effective  date;  provided,
    42  further, that:
    43    (a) sections thirty-two, thirty-three, thirty-four, thirty-five, thir-
    44  ty-six,  thirty-seven,  thirty-nine,  forty,  forty-one, and one hundred
    45  eight of this act shall take effect immediately;
    46    (b) sections fourteen, fifteen, sixteen,  seventeen,  eighteen,  nine-
    47  teen,  twenty,  twenty-one, twenty-two, twenty-three, twenty-four, twen-
    48  ty-six, twenty-seven, twenty-eight,  twenty-nine,  thirty,  one  hundred
    49  twelve,  and  one hundred thirteen of this act shall take effect January
    50  1, 2014;
    51    (c) section fifty of this act shall take effect immediately and  shall

    52  expire three years after it becomes law;
    53    (d)  any rules or regulations necessary to implement the provisions of
    54  this act may be promulgated and any procedures, forms,  or  instructions
    55  necessary  for such implementation may be adopted and issued on or after
    56  the date this act shall have become a law;

        S. 2606--D                         168                        A. 3006--D
 
     1    (e) this act shall not be construed to alter, change,  affect,  impair
     2  or defeat any rights, obligations, duties or interests accrued, incurred
     3  or conferred prior to the effective date of this act;
     4    (f)  the  commissioner  of  health and the superintendent of financial
     5  services and any appropriate council may take  any  steps  necessary  to
     6  implement this act prior to its effective date;
     7    (g)  notwithstanding  any inconsistent provision of the state adminis-

     8  trative procedure act or any other provision of law, rule or regulation,
     9  the commissioner of health and the superintendent of financial  services
    10  and  any  appropriate council is authorized to adopt or amend or promul-
    11  gate on an emergency basis any regulation he  or  she  or  such  council
    12  determines  necessary  to  implement  any  provision  of this act on its
    13  effective date; and
    14    (h) the provisions of this act shall become effective  notwithstanding
    15  the  failure  of  the  commissioner  of  health or the superintendent of
    16  financial services or any council to adopt or amend or promulgate  regu-
    17  lations implementing this act.
 
    18                                   PART F
 
    19    Section  1. Section 19.16 of the mental hygiene law, as added by chap-
    20  ter 223 of the laws of 1992, is amended to read as follows:
    21  § 19.16 Methadone Registry.

    22    The office shall establish and maintain, either  directly  or  through
    23  contract, a central registry for purposes of preventing multiple enroll-
    24  ment,  ensuring  accurate  dosage  delivery  and  facilitating  disaster
    25  management in methadone programs. The office shall require all methadone
    26  programs to utilize such registry and shall have  the  power  to  assess
    27  methadone programs such fees as are necessary and appropriate.
    28    §  2.  The  office  of  alcoholism  and substance abuse services shall
    29  ensure that accurate dosage delivery and facilitating  disaster  manage-
    30  ment  shall  not  result  in  any new material expenditures by methadone
    31  programs.
    32    § 3. This act shall take effect April 1, 2013.
 
    33                                   PART G
 
    34    Section 1. Article 26 of the mental hygiene law is REPEALED.

    35    § 2. The article heading of article 25 of the mental hygiene  law,  as
    36  added by chapter 471 of the laws of 1980, is amended to read as follows:
    37                   [FUNDING FOR SUBSTANCE ABUSE SERVICES]
    38            FUNDING FOR SERVICES OF THE OFFICE OF ALCOHOLISM AND
    39                          SUBSTANCE ABUSE SERVICES
    40    §  3.  Paragraphs 1, 2, 3 and 4 of subdivision (a) of section 25.01 of
    41  the mental hygiene law, paragraph 1 as added by chapter 471 of the  laws
    42  of 1980, and paragraphs 2, 3 and 4 as amended by chapter 223 of the laws
    43  of 1992, are amended, and four new paragraphs 5, 6, 7 and 8 are added to
    44  read as follows:
    45    1. ["Local  agency" shall mean a county governmental unit for a county
    46  not wholly within a city, and a city governmental unit for a city having

    47  a population of one million or more, designated by such county  or  city
    48  as  responsible  for  substance  abuse services in such county or city.]
    49  "Local governmental unit" shall have the same meaning as that  contained
    50  in article forty-one of this chapter.
    51    2. "Operating  [costs]  expenses"  shall mean expenditures[, excluding
    52  capital costs and debt service, subject to the approval of the  office,]

        S. 2606--D                         169                        A. 3006--D
 
     1  approved by the office and incurred for the maintenance and operation of
     2  substance  [abuse]  use  disorder  and/or  compulsive gambling programs,
     3  including but not limited to expenditures for treatment, administration,

     4  personnel,  and contractual services[, rental, depreciation and interest
     5  expenses incurred, in connection with the design, construction, acquisi-
     6  tion, reconstruction, rehabilitation or improvement of a substance abuse
     7  program facility, and payments made to the facilities development corpo-
     8  ration for substance abuse program facilities; provided that where the].
     9  Operating expenses do not include capital costs and debt service  unless
    10  such  expenses  are related to the rent, financing or refinancing of the
    11  design, construction,  acquisition,  reconstruction,  rehabilitation  or
    12  improvement of a substance [abuse] use disorder and/or compulsive gambl-
    13  ing program facility [is through the facilities development corporation,

    14  operating  costs  shall  include the debt service to be paid to amortize
    15  obligations, including principal and interest, issued by  the  New  York
    16  State medical care facilities finance agency to finance or refinance the
    17  capital costs of such facilities] pursuant to the mental hygiene facili-
    18  ties finance program through the dormitory authority of the state of New
    19  York  (DASNY;  successor  to the Facilities Development Corporation), or
    20  otherwise approved by the office.
    21    3. "Debt service" shall mean amounts, subject to the approval  of  the
    22  office,  [as  shall  be]  required  to  be  paid to amortize obligations
    23  including principal and interest [issued by the New York  state  housing

    24  finance agency, the New York State medical care facilities finance agen-
    25  cy or], assumed by or on behalf of a [substance abuse program] voluntary
    26  agency or a program operated by a local [agency to finance capital costs
    27  for substance abuse program facilities] governmental unit.
    28    4. "Capital  costs"  shall mean [expenditures, subject to the approval
    29  of the office, as shall be obligated to acquire, construct, reconstruct,
    30  rehabilitate or improve a substance abuse program facility.]  the  costs
    31  of a program operated by a local governmental unit or a voluntary agency
    32  with respect to the acquisition of real property estates, interests, and

    33  cooperative  interests  in  realty,  their  design, construction, recon-
    34  struction, rehabilitation  and  improvement,  original  furnishings  and
    35  equipment, site development, and appurtenances of a facility.
    36    5. "State aid" shall mean financial support provided through appropri-
    37  ations  of the office to support the provision of substance use disorder
    38  treatment, compulsive gambling, prevention or other authorized services,
    39  with the exclusion of appropriations for the purpose of medical  assist-
    40  ance.
    41    6.  "Voluntary  agency  contributions"  shall  mean revenue sources of
    42  voluntary agencies exclusive of state aid and local tax levy.
    43    7. "Approved net operating cost" shall mean  the  remainder  of  total

    44  operating  expenses approved by the office, less all sources of revenue,
    45  including voluntary agency contributions and local tax levy.
    46    8. "Voluntary agency" shall mean a corporation organized  or  existing
    47  pursuant  to  the  not-for-profit  corporation  law  for  the purpose of
    48  providing  substance  use  disorder,  treatment,  compulsive   gambling,
    49  prevention or other authorized services.
    50    §  4.  Subdivisions (a) and (b) of section 25.03 of the mental hygiene
    51  law, subdivision (a) as amended by chapter 558 of the laws of  1999  and
    52  subdivision  (b)  as  amended  by  chapter  223 of the laws of 1992, are
    53  amended and a new subdivision (d) is added to read as follows:
    54    (a) In accordance with the provisions  of  this  article,  and  within

    55  appropriations   made  available,  the  office  may  provide  [financial
    56  support] state aid to a [substance abuse program or a] program  operated

        S. 2606--D                         170                        A. 3006--D
 
     1  by  a  local  [agency]  governmental  unit or voluntary agency up to one
     2  hundred per centum of the approved net operating costs of such [program]
     3  program operated by a local governmental unit or voluntary  agency,  and
     4  [either  fifty per centum of the capital cost or fifty per centum of the
     5  debt service,] state aid may also be granted to a program operated by  a

     6  local  governmental unit or a voluntary agency for capital costs associ-
     7  ated with the provision of services at a  rate  of  up  to  one  hundred
     8  percent  of  approved capital costs. Such state aid shall not be granted
     9  unless and until such program operated by a local governmental  unit  or
    10  voluntary  agency  is  in compliance with all regulations promulgated by
    11  the commissioner regarding the financing of capital projects. Such state
    12  aid for approved [services] net operating costs shall be made  available
    13  by  way  of  advance  or reimbursement, through either contracts entered
    14  into between the office and such [program or]  voluntary  agency[,  upon

    15  such  terms  and conditions as the office shall deem appropriate, except
    16  as provided in section 25.07 of this article, provided,  however,  that,
    17  upon  issuance  of  an  operating certificate in accordance with article
    18  thirty-two of this chapter, if required, the office shall provide finan-
    19  cial support for approved chemical  dependence  services  in  accordance
    20  with article twenty-six of this title.] or by distribution of such state
    21  aid  to  local  governmental  units  through a grant process pursuant to
    22  section 25.11 of this article.
    23    (b) Financial support by the office shall be subject to  the  approval
    24  of the director of the budget and within available appropriations.
    25    (d) Nothing in this section shall be construed to require the state to

    26  increase  such  state  aid  should  a  local governmental unit choose to
    27  remove any portion of its local tax levy support of voluntary  agencies,
    28  although the state may choose to do so to address an urgent public need,
    29  or  conversely,  may  choose  to  reduce  its  state  aid up to the same
    30  percentage as the reduction in local tax levy.
    31    § 5. Section 25.05 of the mental hygiene law, as  amended  by  chapter
    32  223 of the laws of 1992, is amended to read as follows:
    33  § 25.05 Reimbursement from other sources.
    34    The  office  shall  not  provide a [substance abuse program] voluntary
    35  agency or a program operated by a local [agency] governmental unit  with
    36  financial  support  for  obligations  incurred  by  or on behalf of such

    37  program or agency for substance [abuse] use disorder  and/or  compulsive
    38  gambling services for which reimbursement is or may be claimed under any
    39  provision of law other than this article.
    40    § 6. The section heading and subdivisions (a) and (c) of section 25.06
    41  of  the  mental  hygiene  law,  as amended by chapter 223 of the laws of
    42  1992, are amended to read as follows:
    43  Disclosures by closely allied entities of [substance abuse  programs]  a
    44            voluntary agency.
    45    (a)  A  closely allied entity of a [substance abuse program] voluntary
    46  agency that is funded or has applied for funding from the  office  shall
    47  provide the office with the following information:
    48    1.  A  schedule  of the dates, nature and amounts of all fiscal trans-

    49  actions between the closely  allied  entity  and  the  [substance  abuse
    50  program] voluntary agency that is funded or has applied for funding from
    51  the office.
    52    2.  A  copy  of the closely allied entity's certified annual financial
    53  statements.
    54    3. With respect to any lease  agreement  between  the  closely  allied
    55  entity,  as  lessor,  and the [substance abuse program] voluntary agency

        S. 2606--D                         171                        A. 3006--D
 
     1  that is funded or has applied for funding from the office, as lessee, of
     2  real or personal property:
     3    (i) A certified statement by an independent outside entity providing a
     4  fair  market  appraisal of the real property space to be rented, as well
     5  as of any rental of personal property.

     6    (ii) A statement of projected operating costs  of  the  allied  entity
     7  relative  to any such leased property for the budget period. The closely
     8  allied entity must furnish the office with a certified statement of  its
     9  actual operating costs relative to the leased property.
    10    4.  A  statement of the funds received by the closely allied entity in
    11  connection with its fund raising activities conducted on behalf  of  the
    12  substance  [abuse]  use disorder and/or compulsive gambling program that
    13  is funded or has applied for funding from the office which clearly iden-
    14  tifies how such funds were and will be distributed or  applied  to  such
    15  program.
    16    5.  Any  other data or information which the office may deem necessary
    17  for purposes of making a funding decision.
    18    (c) For purposes of this section,  a  "closely  allied  entity"  shall

    19  mean, but not be limited to, a corporation, partnership or unincorporat-
    20  ed  association  or  other  body that has been formed or is organized to
    21  provide financial assistance and aid for the  benefit  of  a  [substance
    22  abuse  program] voluntary agency that is funded or has applied for fund-
    23  ing from the  office  and  which  financial  assistance  and  aid  shall
    24  include,  but  not  be  limited to, engaging in fund raising activities,
    25  administering funds, holding title to real property, having an  interest
    26  in personal property of any nature whatsoever, and engaging in any other
    27  activities  for  the  benefit  of any such program.  Moreover, an entity
    28  shall be deemed closely allied to a [substance abuse program]  voluntary

    29  agency  that is funded or has applied for funding from the office to the
    30  extent that such entity and applicable fiscal transactions are  required
    31  to be disclosed within the annual financial statements of the [substance
    32  abuse  program] voluntary agency that is funded or has applied for fund-
    33  ing from the office, under the category of related  party  transactions,
    34  as defined by and in accordance with generally accepted accounting prin-
    35  ciples  (GAAP)  and  generally  accepted  auditing  standards (GAAS), as
    36  promulgated by the American institute of  certified  public  accountants
    37  (AICPA).
    38    §  7. Section 25.07 of the mental hygiene law, as added by chapter 471
    39  of the laws of 1980, is amended to read as follows:
    40  § 25.07 Non-substitution.

    41    A [substance abuse program] voluntary agency or a program operated  by
    42  a local [agency] governmental unit shall not substitute state monies for
    43  cash  contributions,  federal aid otherwise committed to or intended for
    44  use in such program or by such agency, revenues derived from the  opera-
    45  tion of such program or agency, or the other resources available for use
    46  in the operation of the program or agency.
    47    §  8.  Section  25.09 of the mental hygiene law, as amended by chapter
    48  223 of the laws of 1992, is amended to read as follows:
    49  § 25.09 Administrative costs.
    50    Subject to the approval of the director  of  the  budget,  the  office
    51  shall  establish a limit on the amount of financial support which may be

    52  advanced or reimbursed to a [substance abuse program]  voluntary  agency
    53  or  a  program  operated  by  a local [agency] governmental unit for the
    54  administration of a [substance abuse] program.

        S. 2606--D                         172                        A. 3006--D
 
     1    § 9. Section 25.11 of the mental hygiene law, as added by chapter  471
     2  of  the  laws  of 1980, subdivision (a) as amended by chapter 223 of the
     3  laws of 1992, is amended to read as follows:
     4  § 25.11 [Comprehensive  plan]  Distribution  of  state  aid  to  a local
     5            governmental unit.
     6    [(a) A local agency intending  to  seek  financial  support  from  the
     7  office  shall no later than July first of each year submit to the office

     8  a comprehensive substance abuse services plan, which shall describe  the
     9  programs  and  activities planned for its ensuing fiscal year. Such plan
    10  shall indicate to the extent possible, the nature of the services to  be
    11  provided,  whether  such  services  are to be provided directly, through
    12  subcontract, or through the utilization of  existing  public  resources,
    13  the  area  or  areas  to  be served, and an estimate of the cost of such
    14  services, including amounts to be provided other than by  office  finan-
    15  cial  support, specifically identifying the amount of local governmental
    16  funds committed to substance abuse programs during  its  current  fiscal
    17  year,  and  a  commitment  that no less than such an amount will be used

    18  from such funds for the operation  of  such  programs  during  the  next
    19  fiscal  year.  Such  plan shall make provisions for all needed substance
    20  abuse services and for the  evaluation  of  the  effectiveness  of  such
    21  services.
    22    (b)  When  a comprehensive plan includes a local school district based
    23  substance abuse program such  plan  shall  include  the  details  of  an
    24  adequate  distribution of in-school and community-wide preventive educa-
    25  tion services, including, but not limited to, services to be provided by
    26  local drug abuse prevention councils, and shall  emphasize  the  use  of
    27  other  volunteer agency services as may be available. The description of
    28  the program and activities thereunder shall be  separately  stated,  and

    29  the  data  and  information required to be provided shall conform to the
    30  provisions of subdivision (a) of this section except that the period  to
    31  be  covered  may,  notwithstanding  the fiscal year of the local agency,
    32  conform to the school year.] Notwithstanding section one hundred  twelve
    33  of  the  state  finance law, the office is authorized to grant state aid
    34  annually to local governmental units in the following manner:
    35    (a) Local governmental units shall be granted state aid by a state aid
    36  funding authorization letter issued by the office for approved net oper-
    37  ating costs for voluntary agencies to support the base amount  of  state
    38  aid provided to such voluntary agencies for the prior year provided that

    39  the  local  governmental unit has approved and submitted budgets for the
    40  voluntary agencies to the office. The  voluntary  agency  budgets  shall
    41  identify  the  nature  of  the  services  to  be  provided which must be
    42  consistent with the local services plan submitted by the  local  govern-
    43  mental  unit pursuant to article forty-one of this chapter, the areas to
    44  be served and include a description of  the  voluntary  agency  contrib-
    45  utions  and  local governmental unit funding provided. The local govern-
    46  mental unit shall enter  into  contracts  with  the  voluntary  agencies
    47  receiving  such state aid. Such contracts shall include funding require-
    48  ments set by the office including but not limited to responsibilities of

    49  voluntary agencies relating to  work  scopes,  program  performance  and
    50  operations,  application  of  program  income,  prohibited use of funds,
    51  recordkeeping and audit obligations. Upon  designation  by  the  office,
    52  local  governmental  units  shall  notify  voluntary  agencies as to the
    53  source of funding received by such voluntary agencies.
    54    (b) State aid made available to a local governmental unit for approved
    55  net operating costs for a program operated by a voluntary  agency  or  a

        S. 2606--D                         173                        A. 3006--D
 
     1  local  governmental unit may be reduced where a review of such voluntary
     2  agency's prior year's budget and/or performance indicates:

     3    (1)  that  the program operated by a local governmental unit or volun-
     4  tary agency  has  failed  to  meet  minimum  performance  standards  and
     5  requirements  of  the  office including, but not limited to, maintaining
     6  service utilization rates and  productivity  standards  as  set  by  the
     7  office provided however, that upon determination that the program is not
     8  meeting  the minimum standards and requirements, the office shall notify
     9  such program operated by a local governmental unit or  voluntary  agency
    10  of their deficiencies, and if appropriate, a corrective action plan that
    11  includes  specific  actions  to address any deficiencies and a timetable
    12  for implementation shall be developed. State aid may  be  reduced  if  a

    13  corrective  action  plan  is not approved by the office or is not imple-
    14  mented in a timely and satisfactory manner;
    15    (2) that the voluntary agency has had an increase in voluntary  agency
    16  contributions  that  reduces the approved net operating costs necessary,
    17  except where the office has approved an alternative use of  such  volun-
    18  tary  agency  contributions  or  such voluntary agency contributions are
    19  necessary to ensure financial viability.
    20    § 10. Section 25.13 of the mental hygiene law, as amended  by  chapter
    21  223 of the laws of 1992, is amended to read as follows:
    22  § 25.13 Office is authorized state agency.
    23    (a)  The  office  when designated by the governor is the agency of the
    24  state to administer and/or supervise the state plan or plans  concerning

    25  substance [abuse] use disorder and/or compulsive gambling services spec-
    26  ified  in  the  federal  drug abuse office and treatment act of nineteen
    27  hundred seventy-two and to cooperate with the  duly  designated  federal
    28  authorities charged with the administration thereof.
    29    (b) The office and all entities to which it provides financial support
    30  shall  do all that is required and shall render necessary cooperation to
    31  ensure optimum use of federal aid for  substance  [abuse]  use  disorder
    32  and/or compulsive gambling services.
    33    (c)  The  commissioner is authorized and empowered to take such steps,
    34  not inconsistent with law, as  may  be  necessary  for  the  purpose  of
    35  procuring  for  the people of this state all of the benefits and assist-
    36  ance, financial and otherwise, provided, or to be provided  for,  by  or

    37  pursuant to any act of congress relating to substance [abuse] use disor-
    38  der and/or compulsive gambling services.
    39    §  11.  Section 25.15 of the mental hygiene law, as amended by chapter
    40  223 of the laws of 1992, is amended to read as follows:
    41  § 25.15 Optimizing federal aid.
    42    (a) A program operated  by  a  local  [agency]  governmental  unit  or
    43  [substance  abuse  program]  voluntary  agency  shall, unless a specific
    44  written waiver of this requirement is made by the office, cause applica-
    45  tions to be completed on such forms and in such manner  as  directed  by
    46  the  office and submit the same to the office for the purpose of causing
    47  a determination to be made whether the cost  of  the  services  provided

    48  individuals  and  groups  qualify for federal aid which may be available
    49  for services provided pursuant to titles IV, XVI,  XIX  and  XX  of  the
    50  federal  social  security act, or any other federal law. A program oper-
    51  ated by a  local  [agency]  governmental  unit  or  a  [substance  abuse
    52  program] voluntary agency shall furnish to the office such other data as
    53  may be required and shall render such cooperation as may be necessary to
    54  maximize  such  potential  federal  aid.  All information concerning the
    55  identity of individuals obtained and provided pursuant to this  subdivi-
    56  sion shall be kept confidential.

        S. 2606--D                         174                        A. 3006--D
 
     1    (b)  To the extent that federal aid may be available for any substance

     2  [abuse] use disorder and/or compulsive gambling  services,  the  office,
     3  notwithstanding  any  other  inconsistent provision of law, and with the
     4  approval of the director of the budget, is  hereby  authorized  to  seek
     5  such federal aid on behalf of [substance abuse programs] voluntary agen-
     6  cies  and  a  program  operated  by a local [agencies] governmental unit
     7  either directly or through the submission of  claims  to  another  state
     8  agency  authorized  to submit the same to an appropriate federal agency.
     9  The office is further authorized to certify for  payment  to  [substance
    10  abuse  programs]  voluntary  agencies  and a program operated by a local

    11  [agencies] governmental unit any federal aid received by the state which
    12  is attributable to the activities financed by such  programs  and  agen-
    13  cies.
    14    §  12.  Section 25.17 of the mental hygiene law, as amended by chapter
    15  223 of the laws of 1992, is amended to read as follows:
    16  § 25.17 Fees for services.
    17    [Local agencies governments and substance  abuse  treatment  programs]
    18  Voluntary  agencies  and  programs  operated by local governmental units
    19  funded in whole or in part by the office shall establish, subject to the
    20  approval of the office, fee schedules for substance [abuse] use disorder
    21  and/or compulsive gambling services, not  specifically  covered  by  the
    22  rates  established pursuant to article twenty-eight of the public health

    23  law or title two of article five of the social services law.  Such  fees
    24  shall  be  charged  for substance [abuse] use disorder and/or compulsive
    25  gambling services furnished to persons who are financially able  to  pay
    26  the  same,  provided,  that  such  services  shall not be refused to any
    27  person because of his inability to pay therefor.
    28    § 13. Subdivision (d) of section 41.18 of the mental hygiene  law,  as
    29  amended  by  chapter  558  of  the  laws  of 1999, is amended to read as
    30  follows:
    31    (d) The liability of the state in any state fiscal year for state  aid
    32  pursuant  to  this  section  shall exclude chemical dependence services,
    33  which are subject to article [twenty-six] twenty-five of  this  chapter,
    34  and  shall  be limited to the amounts appropriated for such state aid by

    35  the legislature for such state fiscal year.
    36    § 14. This act shall take effect April  1,  2013;  provided,  however,
    37  that  effective  immediately,  any  rule or regulation necessary for the
    38  implementation of this act on  its  effective  date  is  authorized  and
    39  directed to be made and completed on or before such effective date.
 
    40                                   PART H
 
    41    Section  1. Subdivision (b) of section 7.17 of the mental hygiene law,
    42  as amended by section 1 of part O of chapter 56 of the laws of 2012,  is
    43  amended to read as follows:
    44    (b)  There  shall  be  in the office the hospitals named below for the
    45  care, treatment and rehabilitation of persons with  mental  illness  and
    46  for  research  and  teaching  in the science and skills required for the
    47  care, treatment and rehabilitation of such persons with mental illness.
    48    Greater Binghamton Health Center

    49    Bronx Psychiatric Center
    50    Buffalo Psychiatric Center
    51    Capital District Psychiatric Center
    52    Central New York Psychiatric Center
    53    Creedmoor Psychiatric Center
    54    Elmira Psychiatric Center

        S. 2606--D                         175                        A. 3006--D
 
     1    Kingsboro Psychiatric Center
     2    Kirby Forensic Psychiatric Center
     3    Manhattan Psychiatric Center
     4    Mid-Hudson Forensic Psychiatric Center
     5    Mohawk Valley Psychiatric Center
     6    Nathan S. Kline Institute for Psychiatric Research
     7    New York State Psychiatric Institute
     8    Pilgrim Psychiatric Center
     9    Richard H. Hutchings Psychiatric Center
    10    Rochester Psychiatric Center
    11    Rockland Psychiatric Center
    12    St. Lawrence Psychiatric Center
    13    South Beach Psychiatric Center
    14    New York City Children's Center

    15    Rockland Children's Psychiatric Center
    16    Sagamore Children's Psychiatric Center
    17    Western New York Children's Psychiatric Center
    18    The  New  York  State  Psychiatric  Institute  and The Nathan S. Kline
    19  Institute for Psychiatric Research are designated as institutes for  the
    20  conduct  of medical research and other scientific investigation directed
    21  towards furthering knowledge of the etiology, diagnosis,  treatment  and
    22  prevention  of  mental  illness.  [Whenever  the  term  Bronx Children's
    23  Psychiatric Center, Brooklyn Children's Psychiatric  Center  and  Queens
    24  Children's  Psychiatric Center is referred to or designated in any regu-
    25  lation, contract or document pertaining to the functions, powers,  obli-
    26  gations  and  duties  hereby transferred and assigned, such reference or

    27  designation shall be deemed to refer to the  New  York  City  Children's
    28  Center.]
    29    §  2.  Section 4 of part O of chapter 56 of the laws of 2012, amending
    30  the mental hygiene law relating to the closure and the reduction in size
    31  of certain facilities serving persons with mental  illness,  is  amended
    32  and a new section 1-a is added to read as follows:
    33    § 1-a. Whenever the term Bronx Children's Psychiatric Center, Brooklyn
    34  Children's Psychiatric Center or Queens Children's Psychiatric Center is
    35  referred  to  or  designated  in  any  regulation,  contract or document
    36  pertaining to the  functions,  powers,  obligations  and  duties  hereby
    37  transferred  and assigned pursuant to this act, such reference or desig-

    38  nation shall be deemed to refer to the New York City Children's Center.
    39    § 4. This act shall take effect immediately and  shall  be  deemed  to
    40  have  been in full force and effect on and after April 1, 2012; provided
    41  that the date for any closure or  consolidation  pursuant  to  this  act
    42  shall  be  on a date certified by the commissioner of mental health; and
    43  provided further, however, that section two of this act shall expire and
    44  be deemed repealed March 31, 2013.
    45    § 3. Section 7 of part R2 of chapter 62 of the laws of 2003,  amending
    46  the  mental hygiene law and the state finance law relating to the commu-
    47  nity mental health  support  and  workforce  reinvestment  program,  the
    48  membership  of  subcommittees  for  mental  health of community services
    49  boards and the duties of such subcommittees and creating  the  community

    50  mental  health and workforce reinvestment account, as amended by section
    51  2 of part C of chapter 111 of the laws of 2010, is amended  to  read  as
    52  follows:
    53    § 7. This act shall take effect immediately and shall expire March 31,
    54  [2013]  2015  when  upon  such  date the provisions of this act shall be
    55  deemed repealed.

        S. 2606--D                         176                        A. 3006--D
 
     1    § 4. Severability clause. If any clause, sentence, paragraph, subdivi-
     2  sion, section or part of this act shall be  adjudged  by  any  court  of
     3  competent  jurisdiction  to  be invalid, such judgment shall not affect,
     4  impair, or invalidate the remainder thereof, but shall  be  confined  in
     5  its  operation  to the clause, sentence, paragraph, subdivision, section

     6  or part thereof directly involved in the controversy in which such judg-
     7  ment shall have been rendered. It is hereby declared to be the intent of
     8  the legislature that this act would  have  been  enacted  even  if  such
     9  invalid provisions had not been included herein.
    10    §  5. This act shall take effect April 1, 2013; provided, however that
    11  if this act shall become a law after April 1, 2013, this act shall  take
    12  effect  immediately  and  shall be deemed to have been in full force and
    13  effect on and after April 1, 2013.
 
    14                                   PART I
 
    15    Section 1. Section 1 of part D of chapter 111  of  the  laws  of  2010
    16  relating to the recovery of exempt income by the office of mental health
    17  for  community residences and family-based treatment programs as amended
    18  by section 1 of part R of chapter 56 of the laws of 2012, is amended  to
    19  read as follows:

    20    Section  1. The office of mental health is authorized to recover fund-
    21  ing from  community  residences  and  family-based  treatment  providers
    22  licensed  by  the  office  of mental health, consistent with contractual
    23  obligations of such providers, and notwithstanding any other  inconsist-
    24  ent  provision  of law to the contrary, in an amount equal to 50 percent
    25  of the income received by such providers which exceeds the fixed  amount
    26  of  annual  Medicaid  revenue limitations, as established by the commis-
    27  sioner of mental health. Recovery of such excess income shall be for the
    28  following fiscal periods: for programs in counties  located  outside  of
    29  the  city of New York, the applicable fiscal periods shall be January 1,
    30  2003 through December 31, 2009 and January 1, 2011 through December  31,
    31  [2013]  2014;  and for programs located within the city of New York, the

    32  applicable fiscal periods shall be July 1, 2003 through  June  30,  2010
    33  and July 1, 2011 through June 30, [2013] 2014.
    34    § 2. This act shall take effect immediately.
 
    35                                   PART J
 
    36    Section  1. Subdivision (a) of section 7.19 of the mental hygiene law,
    37  as amended by chapter 307 of the laws of 1979, is  amended  to  read  as
    38  follows:
    39    (a)  The  commissioner  or his or her designee may, within the amounts
    40  appropriated therefor, appoint and remove in  accordance  with  law  and
    41  applicable  rules  of  the state civil service commission, such officers
    42  and employees of the office of mental health [and facility officers  and
    43  employees  who  are  designated  managerial  or confidential pursuant to
    44  article fourteen of the civil service law] as are  necessary  for  effi-

    45  cient  administration and shall administer the office's personnel system
    46  in accordance with such law and  rules.  In  exercising  the  appointing
    47  authority,  the  commissioner  shall  take  all reasonable and necessary
    48  steps, consistent with article twenty-three-A of the correction law,  to
    49  ensure  that  any such person so appointed has not previously engaged in
    50  any act in violation of any law which could compromise  the  health  and
    51  safety of patients.

        S. 2606--D                         177                        A. 3006--D
 
     1    §  2.  Subdivision  (a)  of section 7.21 of the mental hygiene law, as
     2  amended by chapter 434 of the laws  of  1980,  is  amended  to  read  as
     3  follows:
     4    (a) The director of a facility under the jurisdiction of the office of

     5  mental  health  shall be its chief executive officer. Each such director
     6  shall be in the noncompetitive class and designated as  confidential  as
     7  defined  by  subdivision two-a of section forty-two of the civil service
     8  law and shall be appointed by and serve at the pleasure of  the  commis-
     9  sioner.  [Except  for facility officers and employees for which subdivi-
    10  sion (a) of section 7.19 of this  article  makes  the  commissioner  the
    11  appointing and removing authority, the director of a facility shall have
    12  the  power,  within amounts appropriated therefor, to appoint and remove
    13  in accordance with law and applicable rules of the state  civil  service
    14  commission  such  officers  and employees of the facility of which he is
    15  director as are necessary for its efficient administration. He shall  in

    16  exercising this appointing authority take, consistent with article twen-
    17  ty-three-A  of the correction law, all reasonable and necessary steps to
    18  insure that any such person so appointed has not previously  engaged  in
    19  any  act  in  violation of any law which could compromise the health and
    20  safety of patients in the facility of which he is director.] He  or  she
    21  shall  manage the facility [and administer its personnel system] subject
    22  to applicable law and the regulations  of  the  commissioner  of  mental
    23  health  [and  the  rules of the state civil service commission].  Before
    24  the commissioner shall issue any such regulation  or  any  amendment  or
    25  revision  thereof,  he  or she shall consult with the facility directors

    26  [of the office's hospitals]  regarding  its  suitability.  The  director
    27  shall  maintain  effective  supervision of all parts of the facility and
    28  over all persons employed therein or coming thereon and shall  generally
    29  direct  the  care and treatment of patients. Directors presently serving
    30  at office of mental health facilities shall continue to serve under  the
    31  terms of their original appointment.
    32    §  3.  The  amendments to sections 7.19 and 7.21 of the mental hygiene
    33  law pursuant to Part J of a chapter of the laws of two thousand thirteen
    34  shall not authorize the commissioner of mental health to make any  deci-
    35  sions  with  respect  to employees in contradiction of the civil service
    36  law and regulations, and applicable  collective  bargaining  agreements,
    37  nor otherwise alter any geographically discrete layoff unit structures.

    38    § 4. This act shall take effect April 1, 2013.
 
    39                                   PART K
    40                            Intentionally omitted
 
    41                                   PART L
 
    42    Section  1.  The mental hygiene law is amended by adding a new section
    43  31.37 to read as follows:
    44  § 31.37 Mental health incident review panels.
    45    (a) The commissioner is authorized to establish, on  his  or  her  own
    46  accord  or  pursuant to a request by a local governmental unit, a mental
    47  health incident review panel for the purposes of reviewing  in  conjunc-
    48  tion  with local representation, the circumstances and events related to
    49  a serious incident involving a person with mental illness.  For purposes
    50  of this section, a "serious incident  involving  a  person  with  mental

    51  illness"  means an incident occurring in the community in which a person
    52  with a serious mental illness suffers  physical  injury  as  defined  in

        S. 2606--D                         178                        A. 3006--D
 
     1  subdivision  nine of section 10.00 of the penal law or causes such phys-
     2  ical injury to another person, or  suffers  a  serious  and  preventable
     3  medical  complication or becomes involved in a criminal incident involv-
     4  ing  violence.  A  panel shall be authorized to conduct a review of such
     5  serious incident in an attempt to identify problems or  gaps  in  mental
     6  health  delivery  systems  and  to  make  recommendations for corrective
     7  actions to improve the provision of mental health or  related  services,

     8  to  improve  the coordination, integration and accountability of care in
     9  the mental health service system, and to enhance individual  and  public
    10  safety.
    11    (b)  A  mental  health  incident  review panel shall include represen-
    12  tatives from the office of mental health and the chief executive officer
    13  or designee of the local governmental unit where  the  serious  incident
    14  involving a person with a mental illness occurred. A mental health inci-
    15  dent review panel may also include, if deemed appropriate by the commis-
    16  sioner  based  on the nature of the serious incident being reviewed, one
    17  or more representatives from mental health providers, local  departments
    18  of  social  services, human services programs, hospitals, local schools,

    19  emergency medical or mental health services, the office  of  the  county
    20  attorney,  state  or  local  police  agencies, the office of the medical
    21  examiner or the office of the coroner, the judiciary, or other appropri-
    22  ate state or local  officials;  provided,  however,  that  a  local  law
    23  enforcement official may not serve as a member of such a review panel if
    24  his or her office or agency is directly involved in any ongoing investi-
    25  gation  or  prosecution  of  a  crime  under review by the panel, or any
    26  appeal of a criminal conviction for such crime.
    27    (c) (i) Notwithstanding any other provision of law to the contrary and
    28  to the extent consistent with federal  law,  a  mental  health  incident

    29  review  panel  shall  have  access to those relevant client-identifiable
    30  mental health records, as well as all records, documentation and reports
    31  relating to the investigation of an  incident  by  the  justice  center,
    32  pursuant  to  article  twenty  of the executive law and an incident by a
    33  facility in accordance with regulations of the commissioner,  which  are
    34  necessary  for  the  investigation  of  the serious incident involving a
    35  person with mental illness and the preparation of a report of such inci-
    36  dent, as provided  in subdivision (e) of this section. A  mental  health
    37  incident  review  panel  investigating  a  serious  incident involving a
    38  person with a mental illness pursuant to this section shall be  provided

    39  with access to all relevant, non-privileged records in the possession of
    40  state  or local officials or agencies, within twenty-one days of receipt
    41  of a request, except: (A) those records protected by section  190.25  of
    42  the  criminal procedure law; (B) where providing law enforcement records
    43  would interfere with an ongoing law enforcement investigation  or  judi-
    44  cial proceeding, identify a confidential source or disclose confidential
    45  information relating to an ongoing criminal investigation, highly sensi-
    46  tive  criminal  investigative  techniques or procedures, or endanger the
    47  safety or welfare of an individual; (C) with respect to any such  record
    48  that is privileged, where the privilege is held by the official or agen-

    49  cy  and  no separate privilege held by an individual applies, such offi-
    50  cial or agency shall be authorized to waive such official's or  agency's
    51  privilege,  as  applicable, and provide such record; and (D) whenever an
    52  agency, director or unit believes pursuant to subparagraph (B)  of  this
    53  paragraph  that  release  of  records  would  interfere  with a judicial
    54  proceeding, it shall identify that proceeding,  and  the  mental  health
    55  incident  review  panel shall be authorized, upon notice to such agency,
    56  director or unit, to request in writing to the judge  before  whom  such

        S. 2606--D                         179                        A. 3006--D
 
     1  judicial proceeding is pending, that such judge determine whether access

     2  to  such  records  should  be  denied on the ground that release of such
     3  records would interfere with the pending  proceeding.  Upon  receipt  of
     4  such  a  request, the judge shall offer the agency, director or unit and
     5  the panel a reasonable opportunity to  be  heard,  and  may  review  the
     6  disputed  records in camera. The judge shall submit its determination to
     7  the agency, director or unit  and  the  mental  health  incident  review
     8  panel, and the agency, director or unit shall then proceed in accordance
     9  with the judge's determination.
    10    (ii) In any case in which access to records is denied pursuant to this
    11  subdivision, the appropriate agency shall inform the panel in writing of
    12  the reasoning for such denial.

    13    (d)  Mental  health  incident  review panels and members of the review
    14  panels shall have immunity from civil and  criminal  liability  for  all
    15  reasonable  and  good  faith actions taken pursuant to this section, and
    16  shall not be questioned in any civil or  criminal  proceeding  regarding
    17  any  discussions,  deliberations  or  findings  relating to the official
    18  duties of such review panel. Nothing in this section shall be  construed
    19  to prevent a person from testifying as to information obtained independ-
    20  ently  of a mental health incident review panel, or information which is
    21  public.
    22    (d-1) Persons who present information to the panel shall have immunity
    23  from civil and criminal liability for  all  reasonable  and  good  faith

    24  actions  taken  pursuant to this section, and shall not be questioned in
    25  any civil or criminal  proceeding  regarding  their  authorized  partic-
    26  ipation  at  a  meeting  of  the  panel. Neither information nor records
    27  relating to the performance of a review panel function, nor  a  person's
    28  participation  in a review panel shall be subject to disclosure pursuant
    29  to article thirty-one of the civil practice law and  rules.  Nothing  in
    30  this  section shall be construed to prevent the disclosure of, or testi-
    31  mony regarding, information that exists or is obtained independently  of
    32  the panel or information that is public.
    33    (e)  Notwithstanding  any  other provision of law to the contrary, all

    34  meetings conducted, all reports and records made and maintained and  all
    35  books and papers obtained by a mental health incident review panel shall
    36  be  confidential,  and  shall  not  be open or made available, except by
    37  court order for good cause shown or as set forth in subdivision  (g)  of
    38  this  section.  Each mental health incident review panel shall develop a
    39  report of the incident investigated. Such report shall not  contain  any
    40  individually  identifiable  information  and  shall  be  provided to the
    41  office of mental health upon completion. Records,  reports,  information
    42  regarding  testimony  and  other information gathered by the panel shall
    43  not be further disseminated by a panel member.

    44    (f) If quality problems of particular mental health programs are iden-
    45  tified based on such reviews, the commissioner is  authorized,  pursuant
    46  to  the relevant provisions of this chapter, to take appropriate actions
    47  regarding the licensure of particular providers, to refer the  issue  to
    48  other  responsible parties for investigation, or to take other appropri-
    49  ate action within the scope of his or her authority.
    50    (g) In his or her discretion, the commissioner shall be authorized  to
    51  provide  the  final  report of a review panel or portions thereof to any
    52  individual or entity for  whom  the  report  makes  recommendations  for
    53  corrective  or other appropriate actions that should be taken. Any final

    54  report or portion thereof shall not be further disseminated by the indi-
    55  vidual or entity receiving such report.  Further, the commissioner shall
    56  submit the final report of a review panel to the governor, the temporary

        S. 2606--D                         180                        A. 3006--D
 
     1  president of the senate and the speaker of the assembly, consistent with
     2  federal and state confidentiality protections.
     3    (h)  The  commissioner shall submit an annual cumulative report to the
     4  governor and the legislature incorporating the data in the mental health
     5  incident review panel reports and including a summary  of  the  findings
     6  and  recommendations made by such review panels and, to the extent prac-

     7  ticable, any  recommendations  that  have  been  implemented,  including
     8  recommendations  from  prior year reports, and the impact of such imple-
     9  mentations.   The annual cumulative reports  shall  thereafter  be  made
    10  available to the public consistent with federal and state confidentiali-
    11  ty protections.
    12    §  2.  Subdivision  (c)  of section 33.13 of the mental hygiene law is
    13  amended by adding a new paragraph 16 to read as follows:
    14    16. to a mental health incident  review  panel,  or  members  thereof,
    15  established by the commissioner pursuant to section 31.37 of this title,
    16  in connection with incident reviews conducted by such panel.
    17    §  3.  This  act  shall take effect on the sixtieth day after it shall
    18  have become a law.
 

    19                                   PART M
 
    20    Section 1. Section 20 of chapter 723 of the laws of 1989, amending the
    21  mental hygiene law and other  laws  relating  to  the  establishment  of
    22  comprehensive psychiatric emergency programs, is REPEALED.
    23    §  2.  Subdivision  (c)  of  section 7.15 of the mental hygiene law is
    24  REPEALED.
    25    § 3.  Subdivision (c) of section 13.15 of the mental  hygiene  law  is
    26  REPEALED.
    27    §  4.  Paragraph  3  of subdivision (d) of section 16.19 of the mental
    28  hygiene law is REPEALED.
    29    § 5. Subparagraph e of paragraph 2 of subdivision (b) of section  5.07
    30  of  the mental hygiene law, as added by chapter 322 of the laws of 1992,
    31  is amended to read as follows:
    32    e. a description of the  available  community-based  acute  inpatient,

    33  out-patient,  [emergency,  and  community support] community support and
    34  emergency services, which shall include comprehensive psychiatric  emer-
    35  gency  programs licensed pursuant to section 31.27 of this chapter. Such
    36  description should include  the  extent  to  which  these  services  are
    37  currently  utilized  by  persons  with mental illness and, as available,
    38  compare estimates of utilization with estimates  of  the  prevalence  of
    39  mental  illness  among persons residing in the service area to determine
    40  unmet need;
    41    § 6. This act shall take effect April 1, 2013.
 
    42                                   PART N
 
    43    Section 1.  Subdivisions 3-b and 3-c of section 1  and  section  4  of
    44  part  C  of  chapter  57 of the laws of 2006, relating to establishing a

    45  cost of living adjustment for designated  human  services  programs,  as
    46  amended  by  section  1  of part H of chapter 56 of the laws of 2012, is
    47  amended to read as follows:
    48    3-b. Notwithstanding any  inconsistent  provision  of  law,  beginning
    49  April  1, 2009 and ending March 31, [2013] 2014, the commissioners shall
    50  not include a COLA for the purpose of establishing  rates  of  payments,
    51  contracts or any other form of reimbursement.

        S. 2606--D                         181                        A. 3006--D
 
     1    3-c.  Notwithstanding  any  inconsistent  provision  of law, beginning
     2  April 1, [2013] 2014 and ending March 31, [2016] 2017, the commissioners
     3  shall develop the COLA under this section using the actual U.S. consumer

     4  price index for all urban consumers  (CPI-U)  published  by  the  United
     5  States  department  of  labor, bureau of labor statistics for the twelve
     6  month period ending in July of the  budget  year  prior  to  such  state
     7  fiscal  year,  for  the  purpose  of  establishing  rates  of  payments,
     8  contracts or any other form of reimbursement.
     9    § 4. This act shall take effect immediately and  shall  be  deemed  to
    10  have  been in full force and effect on and after April 1, 2006; provided
    11  section one of this act shall expire and be  deemed  repealed  April  1,
    12  [2016]  2017; provided, further, that sections two and three of this act
    13  shall expire and be deemed repealed December 31, 2009.
    14    § 2. This act shall take effect immediately and  shall  be  deemed  to
    15  have been in full force and effect on and after April 1, 2013; provided,

    16  however, that the amendments to section 1 of part C of chapter 57 of the
    17  laws of 2006 made by section one of this act shall not affect the repeal
    18  of such section and shall be deemed repealed therewith.
 
    19                                   PART O
 
    20    Section  1.  Legislative  findings  and purpose. Recent actions by the
    21  United States Center for  Medicare  and  Medicaid  Services  impact  the
    22  stability  of  New  York  state's mental hygiene system. While the state
    23  must embark on a deliberate path to replace the existing,  long-standing
    24  financing  system  for developmental disability services, replacement of
    25  the sudden loss of $1.1 billion in federal revenue is too significant to
    26  be solved solely by actions within the mental hygiene system. A partner-
    27  ship with the entire health care community is needed to manage this loss

    28  over time. Accordingly, this part authorizes the actions  necessary  and
    29  creates  the Mental Hygiene Stabilization Fund that will be supported by
    30  department of health medicaid resources under the Global Cap  in  annual
    31  amounts  not  to  exceed  $730,000,000  in  state  fiscal  year 2013-14,
    32  $445,000,000 in 2014-15, $267,000,000 in 2015-16,  and  $267,000,000  in
    33  2016-17.
    34    §  2.  Notwithstanding any contrary provision of law, the commissioner
    35  of health may, in consultation with the director of  the  budget,  annul
    36  implementation of the reimbursement reductions authorized by section one
    37  of  part  A  of this act with regard to any period between April 1, 2013
    38  and March 31, 2015 if it is determined by the commissioner of health, in
    39  consultation with the director of the budget, that such annulment may be
    40  accomplished consistent with the implementation  of  the  provisions  of

    41  section 92 of part H of chapter 59 of the laws of 2011, as amended.
    42    §  3. Notwithstanding any contrary provision of law, implementation of
    43  the provisions of sections twenty-two, twenty-three, and/or  twenty-four
    44  of  part  A of this act shall be delayed to the state fiscal year begin-
    45  ning April 1, 2014, provided, however, that the commissioner  of  health
    46  may,  in  consultation with the director of the budget, implement one or
    47  more of such provisions during the 2013-14 state fiscal year  if  it  is
    48  determined  that such implementation may be accomplished consistent with
    49  the implementation of the provisions of section 92 of part H of  chapter
    50  59 of the laws of 2011, as amended.
    51    §  4. Notwithstanding any inconsistent provision of law, rule or regu-
    52  lation, for purposes of implementing the provisions of the public health

    53  law and the social services law, references to titles XIX and XXI of the
    54  federal social security act in the public  health  law  and  the  social

        S. 2606--D                         182                        A. 3006--D
 
     1  services  law  shall be deemed to include and also to mean any successor
     2  titles thereto under the federal social security act.
     3    §  5. Notwithstanding any inconsistent provision of law, rule or regu-
     4  lation, the effectiveness of the provisions of sections 2807 and 3614 of
     5  the public health law, section 18 of chapter 2 of the laws of  1988,  as
     6  amended,  and  18  NYCRR  505.14(h),  as  they relate to time frames for
     7  notice, approval or  certification  of  rates  of  payment,  are  hereby
     8  suspended  and  without force or effect for purposes of implementing the
     9  provisions of this act.

    10    § 6. Severability clause. If any clause, sentence, paragraph, subdivi-
    11  sion, section or part of this act shall be  adjudged  by  any  court  of
    12  competent  jurisdiction  to  be invalid, such judgment shall not affect,
    13  impair or invalidate the remainder thereof, but shall be confined in its
    14  operation to the clause, sentence, paragraph,  subdivision,  section  or
    15  part thereof directly involved in the controversy in which such judgment
    16  shall  have been rendered. It is hereby declared to be the intent of the
    17  legislature that this act would have been enacted even if  such  invalid
    18  provisions had not been included herein.
    19    §  7.  This  act  shall take effect immediately and shall be deemed to
    20  have been in full force and effect on and after April 1, 2013.
 
    21                                   PART P
 
    22    Section 1. Notwithstanding any  other  provision  of  law,  for  state

    23  fiscal  year  2013-14,  and for each state fiscal year thereafter, up to
    24  five million dollars shall be  available  annually  to  provide  medical
    25  assistance for individuals who reside in New York state and are retirees
    26  of  the  New  York  city  off-track  betting  corporation or were active
    27  employees of such corporation with vested pension time or credit  as  of
    28  December 7, 2010, and for the dependents of such individuals, in accord-
    29  ance with the provisions of this section. Such individuals who are Medi-
    30  care  beneficiaries under title XVIII of the federal social security act
    31  shall be eligible for assistance under title 11  of  article  5  of  the
    32  social services law with the cost of Medicare premiums and/or cost shar-
    33  ing obligations, as determined in accordance with guidelines established
    34  by  the  commissioner  of  health.  For the period from April 1, 2013 to

    35  December 31, 2013, such individuals who are not  Medicare  beneficiaries
    36  under  title  XVIII of the federal social security act shall be eligible
    37  for standard fee-for-service coverage under title 11 of article 5 of the
    38  social services law, as determined in accordance with guidelines  estab-
    39  lished  by  the  commissioner of health.   Prior to October 1, 2013, the
    40  state enrollment center  shall  provide  a  written  notice  of  program
    41  discontinuance  that  will  become effective as of December 31, 2013, to
    42  each individual eligible by a Medicaid fee-for-service plan  established
    43  pursuant  to  this section. The notice shall be in such form and contain
    44  such information as the commissioner of health may require. In  addition
    45  to  any  other  information  required  by such commissioner, the written
    46  notice shall include  a  conspicuous  explanation,  in  plain  language,

    47  informing such individual of available health insurance options, includ-
    48  ing coverage through the health benefit exchange established pursuant to
    49  section  1311  of  the federal affordable care act, (42 USC § 18031) and
    50  information on the process by which application therefore  may  be  made
    51  through the state enrollment center in order to effectuate health cover-
    52  age  under the health benefit exchange for such individuals beginning on
    53  January 1, 2014. Such commissioner shall  direct  the  state  enrollment
    54  center  to facilitate the enrollment of such individuals into the health

        S. 2606--D                         183                        A. 3006--D
 
     1  benefit exchange established in accordance with the requirements of  the
     2  federal  patient  protection  and affordable care act (P.L. 111-148), as

     3  amended by the federal health care and education act of 2010 (P.L.  111-
     4  152).  Upon  notice  to participating individuals, the size and scope of
     5  program benefits in a given fiscal year may be reduced  by  the  commis-
     6  sioner of health to remain within program funding levels.
     7    § 2. This act shall take effect immediately.
 
     8                                   PART Q
 
     9    Section  1.  Legislative  findings.  The  legislature hereby finds and
    10  declares that it is necessary  to  restructure  University  Hospital  of
    11  Brooklyn ("Downstate Hospital") in order to achieve its continued fiscal
    12  viability.
    13    § 2. On or before June 1, 2013, the chancellor of the state university
    14  of New York shall submit to the governor, the chair of the assembly ways
    15  and  means  committee,  the  chair  of the senate finance committee, the

    16  chair of the senate health committee, the chair of the  assembly  health
    17  committee,  the  chair  of the senate higher education committee and the
    18  chair of the assembly higher education committee, a sustainability  plan
    19  achieving the fiscal viability of Downstate Hospital.
    20    §  3. Such sustainability plan shall be subject to the approval of the
    21  commissioner of health and the director of the division  of  the  budget
    22  and  shall set forth recommendations for accomplishing the restructuring
    23  of Downstate Hospital for the  purpose  of  achieving  fiscal  viability
    24  while  preserving its status as a teaching hospital. Such sustainability
    25  plan shall include the elimination and/or reduction of acute, ambulatory
    26  and support services that are not necessary or  financially  sustainable
    27  and  any additional measures necessary to achieve such restructuring and
    28  achieve financial stability.

    29    § 4. In the development of the  sustainability  plan,  the  chancellor
    30  shall consult with labor representatives, community representatives, and
    31  other regional stakeholders. The chancellor shall, to the maximum extent
    32  practicable, allow for public comment and input from consumers of health
    33  care services in the development of the plan.
    34    §  5.  Notwithstanding  any  contrary  provision  of law, the approved
    35  sustainability plan for Downstate Hospital shall be deemed final and the
    36  chancellor shall initiate implementation of such sustainability plan  by
    37  June 15, 2013.
    38    §  6.  Notwithstanding  any inconsistent provision of sections 112 and
    39  163 of the state finance law, section  355  of  the  education  law,  or
    40  section  142  of  the  economic  development  law,  or any other law, in
    41  academic fiscal year 2013-14 the chancellor, for the purpose  of  imple-

    42  menting  a  sustainability plan for Downstate Hospital is hereby author-
    43  ized to enter into a contract or contracts under this section  without a
    44  competitive bid or request for proposal  process  and  provided  further
    45  that such contract or contracts shall not be subject to the requirements
    46  set  forth  in  subdivisions 2 and 3 of section 112 of the state finance
    47  law, provided, however, that:
    48    (a) (i) such contracts are  limited  to  the  purchase  of  goods  and
    49  supplies  where exigencies require an expedited process, and may also be
    50  authorized for restructuring consultant services, revenue collection and
    51  billing services, electronic and medical health records,  and  insurance
    52  eligibility  and  verification  services;  and  (ii)  due  to the unique
    53  circumstances facing Downstate Hospital, such contracts may also include

    54  clinical services pursuant to the sustainability plan, provided,  howev-

        S. 2606--D                         184                        A. 3006--D
 
     1  er, that such contracts shall not be of such scope or nature as to alter
     2  the  character  of Downstate Hospital as a public hospital, and shall be
     3  limited to fifteen percent of clinical services unless the  commissioner
     4  of  health determines that additional actions are necessary for the full
     5  implementation of the sustainability plan, in which case, up  to  twenty
     6  percent of such clinical services may be authorized; and
     7    (b)  Downstate  Hospital shall post on its website, for a period of no
     8  less than fifteen days:
     9    (i) a description of the proposed goods or  services  to  be  provided
    10  pursuant to the contract or contracts;
    11    (ii) the criteria for contractor selection;

    12    (iii)  the  period  of  time during which a prospective contractor may
    13  seek selection, which shall be no less  than  fifteen  days  after  such
    14  information is first posted on the website; and
    15    (iv)  the  manner  by  which  a  prospective  contractor may seek such
    16  selection, which may include submission by electronic means; and
    17    (c) all reasonable and responsive submissions that are  received  from
    18  prospective  contractors  in  a  timely fashion shall be reviewed by the
    19  chancellor or his or her designee.
    20    § 7.  Paragraph a of subdivision 16 of section 355  of  the  education
    21  law,  as added by chapter 363 of the laws of 1998, is amended to read as
    22  follows:
    23    a. Notwithstanding  section  one  hundred  sixty-three  of  the  state
    24  finance  law,  authorize  contracts  for  a state university health care

    25  facility for participation in managed care networks and other joint  and
    26  cooperative  arrangements  with  public, non-profit or business entities
    27  including entering into a maximum of  twenty  network  arrangements  per
    28  year,  as partners, joint ventures, sole member or members of non-profit
    29  or for-profit corporations, sole member  or  members  of  non-profit  or
    30  for-profit  limited liability companies, as lessor or lessee, as partic-
    31  ipants in joint  operating  agreements,  and  shareholders  of  business
    32  corporations,   and  the  provision  of  management  and  administrative
    33  services by or for state university; provided, however,  that  any  such
    34  contracts  with  for-profit  entities  shall  be  authorized  only  upon

    35  approval by the commissioner of health and the director of the  division
    36  of  the  budget  of  a request by the chancellor demonstrating financial
    37  need of a state university health care facility. Any  contract  for  the
    38  provision  of  management  services shall be subject to any provision of
    39  the public health law and health regulations  applicable  to  the  state
    40  university  as  a  health  care  provider,  including  any review by the
    41  commissioner of health pursuant to 10 NYCRR section 405.3(f).  In  addi-
    42  tion, the commissioner of health shall provide for public comment within
    43  thirty  days  of  a submission of any management contract required to be
    44  reviewed  pursuant  to  regulation.  The  trustees  may  also  authorize
    45  contracts, including capitation contracts, for a state university health

    46  care  facility  for the provision of general comprehensive and specialty
    47  health care services, directly or through contract  with  other  service
    48  providers  or entities, including state university employees or entities
    49  comprised thereof. Contracts authorized hereunder shall be:
    50    (1) consistent with trustee guidelines respecting all terms and condi-
    51  tions necessary and appropriate for  managed  care  and  other  network,
    52  joint  or cooperative arrangements, including guidelines for comparative
    53  review where appropriate;
    54    (2) subject to laws and regulations applicable to the state university
    55  as a health care provider, including with respect to rates  and  certif-
    56  icates of need; and

        S. 2606--D                         185                        A. 3006--D
 
     1    (3)  subject  to  article  fourteen  of  the civil service law and the

     2  applicable provisions of  agreements  between  the  state  and  employee
     3  organizations pursuant to article fourteen of the civil service law.
     4    §  8. Subdivision 8-a of section 355 of the education law, as added by
     5  chapter 363 of the laws of 1998, is amended to read as follows:
     6    8-a. All monies received by state university  health  care  facilities
     7  from  fees,  charges, and reimbursement and from all other sources shall
     8  be credited to a state university health care account in a  fund  to  be
     9  designated  by  the state comptroller.  Notwithstanding the provision of
    10  any law, rule or regulation to the contrary, a portion  of  such  monies
    11  credited  may  be transferred to a state university account as requested
    12  by the state university chancellor or his or  her  designee.  Monies  to

    13  establish  reserves  for  long-term  expenses of state university health
    14  care facilities and to fulfill obligations required for any contract for
    15  health care services authorized pursuant to subdivision sixteen of  this
    16  section  may  be  designated  by  the  state university as a reserve and
    17  transferred to a separate contractual reserve account.  The  amounts  in
    18  such  accounts shall be available for use in accordance with paragraph b
    19  of subdivision four and subdivision eight of this section. Monies  shall
    20  only  be  expended from the state university health care account and the
    21  contractual reserve account pursuant to  appropriation.  Notwithstanding
    22  any provision of this chapter, the state finance law or any other law to
    23  the  contrary, such appropriations shall remain in full force and effect
    24  for two years from the effective date of the  appropriation  act  making

    25  the  appropriation.  Monies  so transferred may be returned to the state
    26  university health care account; provided, however, that  funds  in  such
    27  contractual  reserve  account must be sufficient to meet the obligations
    28  of all such contracts.
    29    § 9. Section 2807 of the public health law is amended by adding a  new
    30  subdivision 20 to read as follows:
    31    20.  Notwithstanding  any contrary provision of law and subject to the
    32  receipt of all necessary  federal  approvals  and  the  availability  of
    33  federal financial participation, the commissioner is authorized to enter
    34  into agreements with SUNY downstate medical center, other public general
    35  hospitals,  and/or  with  the sponsoring local governments of such other
    36  public general hospitals, under which such facilities and/or such  local

    37  government  shall,  by  intergovernmental transfer, fund the non-federal
    38  share of Medicaid funds made available for Delivery System Reform Incen-
    39  tive Payments ("DSRIPS") to  such  facilities.  Such  non-federal  share
    40  payments  shall be deemed voluntary and, further, such payments shall be
    41  excluded from computations made pursuant to section one  of  part  C  of
    42  chapter  fifty-eight  of  the laws of two thousand five, as amended.  In
    43  addition, the facilities, and/or the  sponsoring  local  governments  of
    44  such  facilities  or the state may, by written notification to the other
    45  parties to the agreement, cancel such agreement at any time prior to the
    46  payment of the DSRIP funds.
    47    § 10. Section 2807 of the public health law is amended by adding a new

    48  subdivision 21 to read as follows:
    49    21. Notwithstanding any contrary provision of law and subject  to  the
    50  receipt  of  all  necessary  federal  approvals  and the availability of
    51  federal financial participation, the commissioner is authorized to enter
    52  into agreements with SUNY downstate medical center, other public general
    53  hospitals, and/or with the sponsoring local governments  of  such  other
    54  public  general hospitals, under which such facilities and/or such local
    55  government shall, by intergovernmental transfer,  fund  the  non-federal
    56  share  of  Medicaid  funds made available for implementation of Medicaid

        S. 2606--D                         186                        A. 3006--D
 

     1  Redesign Team initiatives. Such  non-federal  share  payments  shall  be
     2  deemed  voluntary  and,  further,  such  payments shall be excluded from
     3  computations made pursuant to section one of part C  of  chapter  fifty-
     4  eight  of  the  laws  of two thousand five, as amended. In addition, the
     5  facilities, and/or the sponsoring local governments of  such  facilities
     6  or  the  state  may, by written notification to the other parties to the
     7  agreement, cancel such agreement at any time prior to the payment of the
     8  Medicaid Redesign Team initiatives funds.
     9    § 11. This act shall take effect immediately.
    10    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    11  sion, section or part of this act shall be  adjudged  by  any  court  of

    12  competent  jurisdiction  to  be invalid, such judgment shall not affect,
    13  impair, or invalidate the remainder thereof, but shall  be  confined  in
    14  its  operation  to the clause, sentence, paragraph, subdivision, section
    15  or part thereof directly involved in the controversy in which such judg-
    16  ment shall have been rendered. It is hereby declared to be the intent of
    17  the legislature that this act would  have  been  enacted  even  if  such
    18  invalid provisions had not been included herein.
    19    §  3.  This  act shall take effect immediately provided, however, that
    20  the applicable effective date of Parts A through Q of this act shall  be
    21  as specifically set forth in the last section of such Parts.
Go to top
Page display time = 0.4443 sec