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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.
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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
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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

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S02606 Text:

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

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

                             S E N A T E - A S S E M B L Y

                                   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    S  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    S 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    S 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    S 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    S  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    S  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    S  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    S 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    S 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    S  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    S  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    S 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    S  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    S 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    S 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    S 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. S 1396D(Z), AND THAT MUST BE
   23  SHARED  WITH SOCIAL SERVICES DISTRICTS IN ACCORDANCE WITH THE PROVISIONS
   24  OF 42 U.S.C. S 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. S 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    S 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    S  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    S 14. Section 271 of the public health law is REPEALED.
   14    S 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    S 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    S  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    S  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    S 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    S 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    S  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    S  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    S 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    S  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    S 22. Intentionally omitted.
   37    S  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    S  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    S 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    S  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    S 27. Intentionally omitted.
   38    S 28. Intentionally omitted.
   39    S 29. Intentionally omitted.
   40    S 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    S 31. Intentionally omitted.
    4    S 32. Intentionally omitted.
    5    S 33. Intentionally omitted.
    6    S  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    S  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    S 35. Intentionally omitted.
   39    S  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    S 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    S 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    S  37-a.   Paragraphs (b) and (c) of subdivision 3 of section 364-j of
   51  the social services law are REPEALED.
   52    S 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    S 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    S  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    S 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    S 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    S 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    S  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    S  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    S 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    S  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    S  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    S 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    S 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    S 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    S  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    S 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    S 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    S  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    S  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    S 50.  Intentionally omitted.
   43    S 51.  Intentionally omitted.
   44    S 52.  Intentionally omitted.
   45    S 53.  Intentionally omitted.
   46    S 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    S 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    S  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    S  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    S  57-a. The public health law is amended by adding a new section 3621
   20  to read as follows:
   21    S 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    S 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    S 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    S 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    S 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    S 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    S 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    S 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    S 62.  Intentionally omitted.
    4    S  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    S  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    S 65.  Intentionally omitted.
   45    S 66.  Intentionally omitted.
   46    S 67.  Intentionally omitted.
   47    S 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    S 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    S  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    S  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    S  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    S  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    S 72-b. The mental hygiene law is amended  by  adding  a  new  section
   14  13.40 to read as follows:
   15  S 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
   30  FORTY-FOUR  HUNDRED  THREE  OF  THE  PUBLIC HEALTH LAW, AND SUBDIVISIONS
   31  TWELVE, THIRTEEN AND FOURTEEN OF SECTION FORTY-FOUR HUNDRED  THREE-F  OF
   32  THE 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
   49  FORTY-FOUR HUNDRED THREE OF THE PUBLIC HEALTH LAW,  PARAGRAPH  A-TWO  OF
   50  SUBDIVISION  EIGHT  OF  SECTION  FORTY-FOUR  HUNDRED THREE OF THE PUBLIC
   51  HEALTH  LAW  OR  PARAGRAPH  A-TWO  OF  SUBDIVISION  TWELVE  OF   SECTION
   52  FORTY-FOUR  HUNDRED  THREE-F  OF  THE  PUBLIC HEALTH LAW; AND QUALITY OF
   53  LIFE, HEALTH, SAFETY  AND  COMMUNITY  INTEGRATION  OF  INDIVIDUALS  WITH
   54  DEVELOPMENTAL  DISABILITIES  ENROLLED IN MANAGED CARE.  THE COMMISSIONER
   55  AND COMMISSIONER OF THE OFFICE FOR PEOPLE WITH  DEVELOPMENTAL  DISABILI-
   56  TIES  OR THEIR DESIGNEES SHALL ATTEND ALL MEETINGS OF THE JOINT ADVISORY
       S. 2606--D                         45                         A. 3006--D

    1  COUNCIL. THE JOINT ADVISORY COUNCIL SHALL REPORT ITS FINDINGS, RECOMMEN-
    2  DATIONS, AND ANY PROPOSED AMENDMENTS TO PERTINENT SECTIONS OF THE LAW TO
    3  THE COMMISSIONER AND THE COMMISSIONER OF  HEALTH,  THE  SENATE  MAJORITY
    4  LEADER  AND  SPEAKER  OF  THE ASSEMBLY. THE JOINT ADVISORY COUNCIL SHALL
    5  HAVE ACCESS TO ANY AND ALL INFORMATION THAT MAY BE LAWFULLY DISCLOSED TO
    6  IT AND THAT IS NECESSARY 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
   12  FORTY-FOUR HUNDRED THREE-G OF THE PUBLIC HEALTH LAW,  SUBDIVISION  EIGHT
   13  OF SECTION FORTY-FOUR HUNDRED THREE OF THE PUBLIC HEALTH LAW, AND SUBDI-
   14  VISION 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
   33  FORTY-FOUR HUNDRED THREE-G OF THE PUBLIC HEALTH LAW, AND MEET THE STAND-
   34  ARDS 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    S 73.  The public health law is amended by adding a new section 4403-g
   40  to read as follows:
   41    S 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    S 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    S  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    S 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
   41  PERSON-CENTERED OUTCOMES AND SHALL BE CONSISTENT WITH  AND  HELP  INFORM
   42  ANY  OTHER PERSON-CENTERED PLAN REQUIRED FOR THE ENROLLEE BY THE COMMIS-
   43  SIONER OF THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL  DISABILITIES.    THE
   44  INITIAL ASSESSMENT SHALL BE COMPLETED BY SUCH OFFICE OR A DESIGNEE OTHER
   45  THAN  THE  PLAN AND SHALL BE COMPLETED IN CONSULTATION WITH THE PROSPEC-
   46  TIVE ENROLLEE'S HEALTH CARE PRACTITIONER AS  NECESSARY.    REASSESSMENTS
   47  SHALL  BE  COMPLETED  BY  SUCH  OFFICE OR ITS DESIGNEE, WHICH MAY BE THE
   48  MANAGED LONG TERM CARE PLAN IN WHICH THE PERSON IS ENROLLED OR  PROPOSES
   49  TO  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    S 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    S 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    S  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    S  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    S 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    S 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    S 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    S 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    S  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    S  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    S  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    S  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    S 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    S 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    S  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    S  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    S  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    S 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    S  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    S  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    S  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    S 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    S  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    S 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    S  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    S 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    S 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    S  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    S 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    S  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    S 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    S  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    S 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    S 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    S 19. Intentionally omitted.
   14    S 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    S 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    S  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    S 5. This act shall take effect June 1, 1983 and shall remain in  full
   43  force and effect until March 31, [2013] 2018.
   44    S  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    S 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    S 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    S 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    S 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    S 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    S  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    S 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    S 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    S  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
   24  SEVENTY-FOUR OF THE LAWS OF NINETEEN HUNDRED NINETY-SIX, IN A "FINANCIAL
   25  ASSISTANCE COMPLIANCE POOL" AND SHALL ESTABLISH  METHODOLOGIES  FOR  THE
   26  DISTRIBUTION  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    S 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
   10  TWENTY-EIGHT  HUNDRED  SEVEN-K  AND TWENTY-EIGHT HUNDRED SEVEN-W OF THIS
   11  ARTICLE. The adjustment may be made to rates of payment or as  aggregate
   12  payments to an eligible hospital.
   13    S  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
   25  THIRTY-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    S 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    S 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
   48  THIRTY-THREE  PERCENT  OF  THE  FEDERAL  POVERTY LINE FOR THE APPLICABLE
   49  FAMILY SIZE, WHICH SHALL  BE  CALCULATED  IN  ACCORDANCE  WITH  GUIDANCE
   50  ISSUED  BY  THE  SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND
   51  HUMAN SERVICES, OR A CHILD WHO IS AT LEAST ONE YEAR OF AGE  BUT  YOUNGER
   52  THAN  NINETEEN  YEARS  OF  AGE  WHO  MEETS  THE  PRESUMPTIVE ELIGIBILITY
   53  REQUIREMENTS OF SUBDIVISION FOUR OF SECTION THREE  HUNDRED  SIXTY-FOUR-I
   54  OF THIS TITLE.
   55    (4)  AN  INDIVIDUAL WHO IS A PREGNANT WOMAN OR IS A MEMBER OF A FAMILY
   56  THAT CONTAINS A DEPENDENT CHILD LIVING WITH A PARENT OR OTHER  CARETAKER
       S. 2606--D                         80                         A. 3006--D

    1  RELATIVE  IS ELIGIBLE FOR STANDARD COVERAGE IF HIS OR HER MAGI HOUSEHOLD
    2  INCOME DOES NOT EXCEED THE MAGI-EQUIVALENT OF ONE HUNDRED THIRTY PERCENT
    3  OF THE HIGHEST AMOUNT THAT ORDINARILY WOULD HAVE BEEN PAID TO  A  PERSON
    4  WITHOUT  ANY  INCOME OR RESOURCES UNDER THE FAMILY ASSISTANCE PROGRAM AS
    5  IT EXISTED ON THE FIRST DAY OF NOVEMBER, NINETEEN HUNDRED  NINETY-SEVEN,
    6  WHICH  SHALL  BE  CALCULATED  IN  ACCORDANCE WITH GUIDANCE ISSUED BY THE
    7  SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN  SERVICES;
    8  FOR  PURPOSES  OF  THIS  SUBPARAGRAPH,  THE TERM DEPENDENT CHILD MEANS A
    9  PERSON WHO IS UNDER EIGHTEEN YEARS OF AGE, OR IS EIGHTEEN YEARS  OF  AGE
   10  AND  A FULL-TIME STUDENT, WHO IS DEPRIVED OF PARENTAL SUPPORT OR CARE BY
   11  REASON OF THE DEATH, CONTINUED ABSENCE, OR PHYSICAL OR MENTAL INCAPACITY
   12  OF A PARENT, OR BY REASON OF THE UNEMPLOYMENT OF THE PARENT, AS  DEFINED
   13  BY THE DEPARTMENT OF HEALTH.
   14    (5) A CHILD WHO IS UNDER TWENTY-ONE YEARS OF AGE AND WHO WAS IN FOSTER
   15  CARE  UNDER  THE  RESPONSIBILITY  OF  THE STATE ON HIS OR HER EIGHTEENTH
   16  BIRTHDAY  IS  ELIGIBLE  FOR  STANDARD  COVERAGE;   NOTWITHSTANDING   ANY
   17  PROVISION  OF  LAW  TO THE CONTRARY, THE PROVISIONS OF THIS SUBPARAGRAPH
   18  SHALL BE EFFECTIVE ONLY IF AND FOR SO LONG AS FEDERAL FINANCIAL  PARTIC-
   19  IPATION  IS AVAILABLE IN THE COSTS OF MEDICAL ASSISTANCE FURNISHED HERE-
   20  UNDER.
   21    (6) AN INDIVIDUAL WHO IS NOT OTHERWISE ELIGIBLE FOR MEDICAL ASSISTANCE
   22  UNDER THIS SECTION IS ELIGIBLE FOR COVERAGE OF FAMILY PLANNING  SERVICES
   23  REIMBURSED  BY  THE  FEDERAL GOVERNMENT AT A RATE OF NINETY PERCENT, AND
   24  FOR COVERAGE OF THOSE SERVICES IDENTIFIED BY THE COMMISSIONER OF  HEALTH
   25  AS  SERVICES  GENERALLY  PERFORMED  AS  PART  OF  OR AS A FOLLOW-UP TO A
   26  SERVICE ELIGIBLE FOR SUCH NINETY PERCENT REIMBURSEMENT, INCLUDING TREAT-
   27  MENT FOR SEXUALLY TRANSMITTED DISEASES, IF HIS OR HER  INCOME  DOES  NOT
   28  EXCEED THE MAGI-EQUIVALENT OF TWO HUNDRED PERCENT OF THE FEDERAL POVERTY
   29  LINE  FOR  THE  APPLICABLE  FAMILY  SIZE,  WHICH  SHALL BE CALCULATED IN
   30  ACCORDANCE WITH GUIDANCE ISSUED BY THE SECRETARY OF  THE  UNITED  STATES
   31  DEPARTMENT OF HEALTH AND HUMAN SERVICES.
   32    (7)  A CHILD WHO IS NINETEEN OR TWENTY YEARS OF AGE LIVING WITH HIS OR
   33  HER PARENT WILL BE ELIGIBLE FOR STANDARD COVERAGE  IF  THE  SUM  OF  THE
   34  MAGI-BASED INCOME OF EVERY PERSON INCLUDED IN THE CHILD'S MAGI HOUSEHOLD
   35  EXCEEDS  ONE  HUNDRED  THIRTY-THREE  PERCENT,  BUT  DOES  NOT EXCEED ONE
   36  HUNDRED FIFTY PERCENT, OF THE FEDERAL POVERTY LINE  FOR  THE  APPLICABLE
   37  FAMILY SIZE.
   38    (7-A)  AN  INDIVIDUAL IS ELIGIBLE FOR BENCHMARK COVERAGE IF HIS OR HER
   39  MAGI HOUSEHOLD INCOME EXCEEDS ONE HUNDRED THIRTY-THREE  PERCENT  OF  THE
   40  FEDERAL POVERTY LINE FOR THE APPLICABLE FAMILY SIZE AND HE OR SHE:
   41    (I)  WAS  ELIGIBLE  OR  WOULD HAVE BEEN ELIGIBLE FOR THE FAMILY HEALTH
   42  PLUS PROGRAM WITHOUT FEDERAL FINANCIAL PARTICIPATION  IN  THE  COSTS  OF
   43  MEDICAL CARE AND SERVICES UNDER SUCH PROGRAM; AND
   44    (II)  IS  NOT  ELIGIBLE  TO  ENROLL IN A QUALIFIED HEALTH PLAN OFFERED
   45  THROUGH THE STATE HEALTH BENEFIT EXCHANGE ESTABLISHED  PURSUANT  TO  THE
   46  FEDERAL  PATIENT  PROTECTION  AND AFFORDABLE CARE ACT (P.L. 111-148), AS
   47  AMENDED BY THE FEDERAL HEALTH CARE AND EDUCATION RECONCILIATION  ACT  OF
   48  2010 (P.L. 111-152).
   49    (C)  NON-MAGI ELIGIBILITY GROUPS. INDIVIDUALS LISTED IN THIS PARAGRAPH
   50  ARE ELIGIBLE FOR STANDARD COVERAGE. WHERE A FINANCIAL ELIGIBILITY DETER-
   51  MINATION MUST BE MADE BY THE MEDICAL ASSISTANCE PROGRAM FOR  INDIVIDUALS
   52  IN  THESE  GROUPS,  SUCH  FINANCIAL  ELIGIBILITY  WILL  BE DETERMINED IN
   53  ACCORDANCE WITH SUBDIVISION TWO OF THIS SECTION.
   54    (1) AN INDIVIDUAL RECEIVING OR ELIGIBLE  TO  RECEIVE  FEDERAL  SUPPLE-
   55  MENTAL  SECURITY INCOME PAYMENTS AND/OR ADDITIONAL STATE PAYMENTS PURSU-
   56  ANT TO TITLE SIX OF THIS ARTICLE; ANY  INCONSISTENT  PROVISION  OF  THIS
       S. 2606--D                         81                         A. 3006--D

    1  CHAPTER  OR  OTHER LAW NOTWITHSTANDING, THE DEPARTMENT MAY DESIGNATE THE
    2  OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE AS ITS AGENT TO  DISCHARGE
    3  ITS  RESPONSIBILITY, OR SO MUCH OF ITS RESPONSIBILITY AS IS PERMITTED BY
    4  FEDERAL  LAW,  FOR  DETERMINING  ELIGIBILITY FOR MEDICAL ASSISTANCE WITH
    5  RESPECT TO PERSONS WHO ARE NOT ELIGIBLE TO RECEIVE FEDERAL  SUPPLEMENTAL
    6  SECURITY  INCOME  PAYMENTS  BUT  WHO  ARE RECEIVING A STATE ADMINISTERED
    7  SUPPLEMENTARY PAYMENT OR MANDATORY MINIMUM SUPPLEMENT IN ACCORDANCE WITH
    8  THE PROVISIONS OF SUBDIVISION ONE OF SECTION TWO HUNDRED TWELVE OF  THIS
    9  ARTICLE.
   10    (2)  AN  INDIVIDUAL  WHO,  ALTHOUGH NOT RECEIVING PUBLIC ASSISTANCE OR
   11  CARE FOR HIS OR HER MAINTENANCE UNDER OTHER PROVISIONS OF THIS  CHAPTER,
   12  HAS  INCOME  AND RESOURCES, INCLUDING AVAILABLE SUPPORT FROM RESPONSIBLE
   13  RELATIVES, THAT DOES NOT EXCEED THE AMOUNTS SET FORTH IN  PARAGRAPH  (A)
   14  OF  SUBDIVISION  TWO OF THIS SECTION, AND IS (I) SIXTY-FIVE YEARS OF AGE
   15  OR OLDER, OR CERTIFIED BLIND OR CERTIFIED DISABLED OR (II)  FOR  REASONS
   16  OTHER  THAN  INCOME  OR  RESOURCES, IS ELIGIBLE FOR FEDERAL SUPPLEMENTAL
   17  SECURITY INCOME BENEFITS AND/OR ADDITIONAL STATE PAYMENTS.
   18    (3) AN INDIVIDUAL WHO, ALTHOUGH NOT  RECEIVING  PUBLIC  ASSISTANCE  OR
   19  CARE  FOR HIS OR HER MAINTENANCE UNDER OTHER PROVISIONS OF THIS CHAPTER,
   20  HAS INCOME, INCLUDING AVAILABLE SUPPORT FROM RESPONSIBLE RELATIVES, THAT
   21  DOES NOT EXCEED THE AMOUNTS SET FORTH IN PARAGRAPH  (A)  OF  SUBDIVISION
   22  TWO  OF  THIS  SECTION, AND IS (I) UNDER THE AGE OF TWENTY-ONE YEARS, OR
   23  (II) A SPOUSE OF A CASH PUBLIC ASSISTANCE RECIPIENT LIVING WITH  HIM  OR
   24  HER AND ESSENTIAL OR NECESSARY TO HIS OR HER WELFARE AND WHOSE NEEDS ARE
   25  TAKEN INTO ACCOUNT IN DETERMINING THE AMOUNT OF HIS OR HER CASH PAYMENT,
   26  OR  (III)  FOR  REASONS  OTHER  THAN  INCOME, WOULD MEET THE ELIGIBILITY
   27  REQUIREMENTS OF THE AID TO DEPENDENT CHILDREN PROGRAM AS IT  EXISTED  ON
   28  THE SIXTEENTH DAY OF JULY, NINETEEN HUNDRED NINETY-SIX.
   29    (4)  A  CHILD  IN  FOSTER  CARE,  OR A CHILD DESCRIBED IN SECTION FOUR
   30  HUNDRED FIFTY-FOUR OR FOUR HUNDRED FIFTY-EIGHT-D OF THIS CHAPTER.
   31    (5) A DISABLED INDIVIDUAL AT LEAST SIXTEEN YEARS OF AGE, BUT UNDER THE
   32  AGE OF SIXTY-FIVE, WHO:   WOULD  BE  ELIGIBLE  FOR  BENEFITS  UNDER  THE
   33  SUPPLEMENTAL  SECURITY  INCOME PROGRAM BUT FOR EARNINGS IN EXCESS OF THE
   34  ALLOWABLE LIMIT; HAS NET AVAILABLE  INCOME  THAT  DOES  NOT  EXCEED  TWO
   35  HUNDRED  FIFTY PERCENT OF THE APPLICABLE FEDERAL INCOME OFFICIAL POVERTY
   36  LINE, AS DEFINED AND UPDATED BY THE UNITED STATES DEPARTMENT  OF  HEALTH
   37  AND HUMAN SERVICES, FOR A ONE-PERSON OR TWO-PERSON HOUSEHOLD, AS DEFINED
   38  BY  THE  COMMISSIONER IN REGULATION; HAS HOUSEHOLD RESOURCES, AS DEFINED
   39  IN PARAGRAPH (E) OF SUBDIVISION TWO OF SECTION THREE HUNDRED SIXTY-SIX-C
   40  OF THIS TITLE, OTHER THAN RETIREMENT ACCOUNTS, THAT DO NOT EXCEED TWENTY
   41  THOUSAND DOLLARS FOR A ONE-PERSON HOUSEHOLD OR THIRTY  THOUSAND  DOLLARS
   42  FOR  A  TWO-PERSON  HOUSEHOLD,  AS  DEFINED BY THE COMMISSIONER IN REGU-
   43  LATION; AND CONTRIBUTES TO  THE  COST  OF  MEDICAL  ASSISTANCE  PROVIDED
   44  PURSUANT  TO  THIS SUBPARAGRAPH IN ACCORDANCE WITH SUBDIVISION TWELVE OF
   45  SECTION THREE HUNDRED SIXTY-SEVEN-A OF THIS TITLE; FOR PURPOSES OF  THIS
   46  SUBPARAGRAPH,  DISABLED MEANS HAVING A MEDICALLY DETERMINABLE IMPAIRMENT
   47  OF SUFFICIENT SEVERITY  AND  DURATION  TO  QUALIFY  FOR  BENEFITS  UNDER
   48  SECTION 1902(A)(10)(A)(II)(XV) OF THE SOCIAL SECURITY ACT.
   49    (6)  AN INDIVIDUAL AT LEAST SIXTEEN YEARS OF AGE, BUT UNDER THE AGE OF
   50  SIXTY-FIVE, WHO: IS EMPLOYED; CEASES TO BE IN RECEIPT OF MEDICAL ASSIST-
   51  ANCE UNDER SUBPARAGRAPH FIVE OF THIS PARAGRAPH BECAUSE  THE  PERSON,  BY
   52  REASON  OF MEDICAL IMPROVEMENT, IS DETERMINED AT THE TIME OF A REGULARLY
   53  SCHEDULED CONTINUING DISABILITY REVIEW TO  NO  LONGER  BE  ELIGIBLE  FOR
   54  SUPPLEMENTAL  SECURITY  INCOME  PROGRAM BENEFITS OR DISABILITY INSURANCE
   55  BENEFITS UNDER THE SOCIAL SECURITY  ACT;  CONTINUES  TO  HAVE  A  SEVERE
   56  MEDICALLY  DETERMINABLE  IMPAIRMENT, TO BE DETERMINED IN ACCORDANCE WITH
       S. 2606--D                         82                         A. 3006--D

    1  APPLICABLE FEDERAL REGULATIONS; AND CONTRIBUTES TO THE COST  OF  MEDICAL
    2  ASSISTANCE  PROVIDED  PURSUANT  TO  THIS SUBPARAGRAPH IN ACCORDANCE WITH
    3  SUBDIVISION TWELVE OF SECTION THREE HUNDRED SIXTY-SEVEN-A OF THIS TITLE;
    4  FOR PURPOSES OF THIS SUBPARAGRAPH, A PERSON IS CONSIDERED TO BE EMPLOYED
    5  IF  THE  PERSON  IS  EARNING  AT LEAST THE APPLICABLE MINIMUM WAGE UNDER
    6  SECTION SIX OF THE FEDERAL FAIR LABOR STANDARDS ACT AND WORKING AT LEAST
    7  FORTY HOURS PER MONTH; OR
    8    (7) AN INDIVIDUAL RECEIVING TREATMENT FOR BREAST  OR  CERVICAL  CANCER
    9  WHO  MEETS  THE ELIGIBILITY REQUIREMENTS OF PARAGRAPH (D) OF SUBDIVISION
   10  FOUR OF THIS SECTION OR  THE  PRESUMPTIVE  ELIGIBILITY  REQUIREMENTS  OF
   11  SUBDIVISION FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE.
   12    (8) AN INDIVIDUAL RECEIVING TREATMENT FOR COLON OR PROSTATE CANCER WHO
   13  MEETS  THE ELIGIBILITY REQUIREMENTS OF PARAGRAPH (E) OF SUBDIVISION FOUR
   14  OF THIS SECTION OR THE PRESUMPTIVE ELIGIBILITY REQUIREMENTS OF  SUBDIVI-
   15  SION FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE.
   16    (9) AN INDIVIDUAL WHO:
   17    (I) IS UNDER TWENTY-SIX YEARS OF AGE; AND
   18    (II)  WAS  IN FOSTER CARE UNDER THE RESPONSIBILITY OF THE STATE ON HIS
   19  OR HER EIGHTEENTH BIRTHDAY; AND
   20    (III) WAS IN RECEIPT OF MEDICAL ASSISTANCE UNDER THIS TITLE  WHILE  IN
   21  FOSTER CARE; AND
   22    (IV)  IS  NOT  OTHERWISE  ELIGIBLE  FOR  MEDICAL ASSISTANCE UNDER THIS
   23  TITLE.
   24    (10) A RESIDENT OF A HOME FOR ADULTS OPERATED  BY  A  SOCIAL  SERVICES
   25  DISTRICT, OR A RESIDENTIAL CARE CENTER FOR ADULTS OR COMMUNITY RESIDENCE
   26  OPERATED  OR  CERTIFIED  BY  THE  OFFICE  OF MENTAL HEALTH, AND HAS NOT,
   27  ACCORDING TO CRITERIA PROMULGATED BY THE DEPARTMENT CONSISTENT WITH THIS
   28  TITLE, SUFFICIENT INCOME, OR IN THE CASE OF A PERSON SIXTY-FIVE YEARS OF
   29  AGE OR OLDER, CERTIFIED BLIND, OR CERTIFIED DISABLED, SUFFICIENT  INCOME
   30  AND  RESOURCES,  INCLUDING AVAILABLE SUPPORT FROM RESPONSIBLE RELATIVES,
   31  TO MEET ALL THE COSTS OF REQUIRED MEDICAL CARE  AND  SERVICES  AVAILABLE
   32  UNDER THIS TITLE.
   33    (D)  CONDITIONS  OF  ELIGIBILITY.  A  PERSON SHALL NOT BE ELIGIBLE FOR
   34  MEDICAL ASSISTANCE UNDER THIS TITLE UNLESS HE OR SHE:
   35    (1) IS A RESIDENT OF THE STATE, OR, WHILE TEMPORARILY  IN  THE  STATE,
   36  REQUIRES  IMMEDIATE  MEDICAL  CARE  WHICH  IS  NOT  OTHERWISE AVAILABLE,
   37  PROVIDED THAT SUCH PERSON DID NOT ENTER THE STATE  FOR  THE  PURPOSE  OF
   38  OBTAINING SUCH MEDICAL CARE; AND
   39    (2)  ASSIGNS  TO  THE  APPROPRIATE  SOCIAL SERVICES OFFICIAL OR TO THE
   40  DEPARTMENT, IN ACCORDANCE WITH DEPARTMENT REGULATIONS: (I) ANY  BENEFITS
   41  WHICH  ARE AVAILABLE TO HIM OR HER INDIVIDUALLY FROM ANY THIRD PARTY FOR
   42  CARE OR OTHER MEDICAL BENEFITS AVAILABLE UNDER THIS TITLE AND WHICH  ARE
   43  OTHERWISE  ASSIGNABLE  PURSUANT TO A CONTRACT OR ANY AGREEMENT WITH SUCH
   44  THIRD PARTY; OR (II) ANY RIGHTS, OF  THE  INDIVIDUAL  OR  OF  ANY  OTHER
   45  PERSON  WHO  IS  ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS TITLE AND ON
   46  WHOSE BEHALF THE INDIVIDUAL  HAS  THE  LEGAL  AUTHORITY  TO  EXECUTE  AN
   47  ASSIGNMENT  OF  SUCH  RIGHTS,  TO  SUPPORT  SPECIFIED AS SUPPORT FOR THE
   48  PURPOSE OF MEDICAL CARE BY A COURT OR ADMINISTRATIVE ORDER; AND
   49    (3) COOPERATES WITH THE APPROPRIATE SOCIAL SERVICES  OFFICIAL  OR  THE
   50  DEPARTMENT  IN  ESTABLISHING PATERNITY OR IN ESTABLISHING, MODIFYING, OR
   51  ENFORCING A SUPPORT ORDER WITH RESPECT TO HIS OR  HER  CHILD;  PROVIDED,
   52  HOWEVER,  THAT  NOTHING HEREIN CONTAINED SHALL BE CONSTRUED TO REQUIRE A
   53  PAYMENT UNDER THIS TITLE FOR CARE OR SERVICES, THE COST OF WHICH MAY  BE
   54  MET IN WHOLE OR IN PART BY A THIRD PARTY; NOTWITHSTANDING THE FOREGOING,
   55  A  SOCIAL  SERVICES  OFFICIAL  SHALL NOT REQUIRE SUCH COOPERATION IF THE
   56  SOCIAL SERVICES OFFICIAL OR THE DEPARTMENT DETERMINES THAT SUCH  ACTIONS
       S. 2606--D                         83                         A. 3006--D

    1  WOULD  BE  DETRIMENTAL  TO THE BEST INTEREST OF THE CHILD, APPLICANT, OR
    2  RECIPIENT, OR WITH RESPECT TO PREGNANT WOMEN DURING PREGNANCY AND DURING
    3  THE SIXTY-DAY PERIOD BEGINNING ON THE LAST DAY OF PREGNANCY, IN  ACCORD-
    4  ANCE  WITH  PROCEDURES  AND  CRITERIA  ESTABLISHED BY REGULATIONS OF THE
    5  DEPARTMENT CONSISTENT WITH FEDERAL LAW; AND
    6    (4) APPLIES FOR AND UTILIZES GROUP HEALTH INSURANCE BENEFITS AVAILABLE
    7  THROUGH A CURRENT OR FORMER EMPLOYER, INCLUDING BENEFITS  FOR  A  SPOUSE
    8  AND  DEPENDENT  CHILDREN,  IN  ACCORDANCE  WITH  THE  REGULATIONS OF THE
    9  DEPARTMENT.
   10    (E) CONDITIONS OF COVERAGE. AN OTHERWISE ELIGIBLE PERSON SHALL NOT  BE
   11  ENTITLED  TO MEDICAL ASSISTANCE COVERAGE OF CARE, SERVICES, AND SUPPLIES
   12  UNDER THIS TITLE WHILE HE OR SHE:
   13    (1) IS AN INMATE OR PATIENT IN  AN  INSTITUTION  OR  FACILITY  WHEREIN
   14  MEDICAL  ASSISTANCE  MAY  NOT  BE PROVIDED IN ACCORDANCE WITH APPLICABLE
   15  FEDERAL OR STATE REQUIREMENTS, EXCEPT FOR PERSONS DESCRIBED IN  SUBPARA-
   16  GRAPH  TEN  OF PARAGRAPH (C) OF THIS SUBDIVISION OR SUBDIVISION ONE-A OR
   17  SUBDIVISION ONE-B OF THIS SECTION; OR
   18    (2) IS A PATIENT IN A PUBLIC INSTITUTION OPERATED  PRIMARILY  FOR  THE
   19  TREATMENT  OF  TUBERCULOSIS  OR  CARE OF THE MENTALLY DISABLED, WITH THE
   20  EXCEPTION OF: (I) A PERSON SIXTY-FIVE  YEARS  OF  AGE  OR  OLDER  AND  A
   21  PATIENT IN ANY SUCH INSTITUTION; (II) A PERSON UNDER TWENTY-ONE YEARS OF
   22  AGE  AND  RECEIVING IN-PATIENT PSYCHIATRIC SERVICES IN A PUBLIC INSTITU-
   23  TION OPERATED PRIMARILY FOR THE CARE OF THE MENTALLY DISABLED;  (III)  A
   24  PATIENT  IN  A PUBLIC INSTITUTION OPERATED PRIMARILY FOR THE CARE OF THE
   25  MENTALLY RETARDED WHO IS RECEIVING MEDICAL CARE  OR  TREATMENT  IN  THAT
   26  PART  OF  SUCH  INSTITUTION  THAT HAS BEEN APPROVED PURSUANT TO LAW AS A
   27  HOSPITAL OR NURSING HOME; (IV) A PATIENT IN AN INSTITUTION  OPERATED  BY
   28  THE  STATE  DEPARTMENT OF MENTAL HYGIENE, WHILE UNDER CARE IN A HOSPITAL
   29  ON RELEASE FROM SUCH INSTITUTION FOR THE PURPOSE OF  RECEIVING  CARE  IN
   30  SUCH HOSPITAL; OR (V) IS A PERSON RESIDING IN A COMMUNITY RESIDENCE OR A
   31  RESIDENTIAL CARE CENTER FOR ADULTS.
   32    S  2.  Subdivision  4  of  section  366  of the social services law is
   33  REPEALED and a new subdivision 4 is added to read as follows:
   34    4. SPECIAL ELIGIBILITY PROVISIONS.
   35    (A) TRANSITIONAL MEDICAL ASSISTANCE.
   36    (1) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, EACH FAMILY WHICH  WAS
   37  ELIGIBLE  FOR  MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH FOUR OF PARA-
   38  GRAPH (B) OF SUBDIVISION ONE OF THIS SECTION IN AT LEAST ONE OF THE  SIX
   39  MONTHS IMMEDIATELY PRECEDING THE MONTH IN WHICH SUCH FAMILY BECAME INEL-
   40  IGIBLE  FOR SUCH ASSISTANCE BECAUSE OF INCOME FROM THE EMPLOYMENT OF THE
   41  CARETAKER RELATIVE SHALL, WHILE SUCH FAMILY INCLUDES A DEPENDENT  CHILD,
   42  REMAIN  ELIGIBLE FOR MEDICAL ASSISTANCE FOR TWELVE CALENDAR MONTHS IMME-
   43  DIATELY FOLLOWING THE MONTH IN WHICH  SUCH  FAMILY  WOULD  OTHERWISE  BE
   44  DETERMINED  TO  BE  INELIGIBLE  FOR  MEDICAL  ASSISTANCE PURSUANT TO THE
   45  PROVISIONS OF THIS TITLE AND THE REGULATIONS OF THE DEPARTMENT GOVERNING
   46  INCOME AND RESOURCE LIMITATIONS RELATING TO  ELIGIBILITY  DETERMINATIONS
   47  FOR FAMILIES DESCRIBED IN SUBPARAGRAPH FOUR OF PARAGRAPH (B) OF SUBDIVI-
   48  SION ONE OF THIS SECTION.
   49    (2)  (I)  UPON  GIVING  NOTICE  OF  TERMINATION  OF MEDICAL ASSISTANCE
   50  PROVIDED PURSUANT TO SUBPARAGRAPH FOUR OF PARAGRAPH (B)  OF  SUBDIVISION
   51  ONE OF THIS SECTION, THE DEPARTMENT SHALL NOTIFY EACH SUCH FAMILY OF ITS
   52  RIGHTS TO EXTENDED BENEFITS UNDER SUBPARAGRAPH ONE OF THIS PARAGRAPH AND
   53  DESCRIBE THE CONDITIONS UNDER WHICH SUCH EXTENSION MAY BE TERMINATED.
   54    (II)  THE  DEPARTMENT  SHALL  PROMULGATE  REGULATIONS IMPLEMENTING THE
   55  REQUIREMENTS OF THIS SUBPARAGRAPH AND SUBPARAGRAPH ONE OF THIS PARAGRAPH
   56  RELATING TO THE CONDITIONS UNDER WHICH EXTENDED COVERAGE  HEREUNDER  MAY
       S. 2606--D                         84                         A. 3006--D

    1  BE  TERMINATED,  THE  SCOPE  OF COVERAGE, AND THE CONDITIONS UNDER WHICH
    2  COVERAGE MAY BE EXTENDED PENDING A REDETERMINATION OF ELIGIBILITY.  SUCH
    3  REGULATIONS SHALL, AT A MINIMUM, PROVIDE FOR: TERMINATION OF SUCH COVER-
    4  AGE  AT  THE  CLOSE  OF  THE  FIRST  MONTH IN WHICH THE FAMILY CEASES TO
    5  INCLUDE A DEPENDENT CHILD; NOTICE OF TERMINATION PRIOR TO THE  EFFECTIVE
    6  DATE  OF  ANY  TERMINATIONS;  COVERAGE  UNDER  EMPLOYEE HEALTH PLANS AND
    7  HEALTH MAINTENANCE ORGANIZATIONS; AND DISQUALIFICATION  OF  PERSONS  FOR
    8  EXTENDED COVERAGE BENEFITS UNDER THIS PARAGRAPH FOR FRAUD.
    9    (3)  NOTWITHSTANDING  ANY  INCONSISTENT  PROVISION OF LAW, EACH FAMILY
   10  WHICH WAS ELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH  FOUR
   11  OF PARAGRAPH (B) OF SUBDIVISION ONE OF THIS SECTION IN AT LEAST THREE OF
   12  THE  SIX  MONTHS  IMMEDIATELY  PRECEDING  THE MONTH IN WHICH SUCH FAMILY
   13  BECAME INELIGIBLE FOR SUCH ASSISTANCE AS A RESULT, WHOLLY OR PARTLY,  OF
   14  THE  COLLECTION  OR  INCREASED COLLECTION OF SPOUSAL SUPPORT PURSUANT TO
   15  PART D OF TITLE IV OF  THE  FEDERAL  SOCIAL  SECURITY  ACT,  SHALL,  FOR
   16  PURPOSES OF MEDICAL ASSISTANCE ELIGIBILITY, BE CONSIDERED TO BE ELIGIBLE
   17  FOR MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH FOUR OF PARAGRAPH (B) OF
   18  SUBDIVISION  ONE  OF THIS SECTION FOR AN ADDITIONAL FOUR CALENDAR MONTHS
   19  BEGINNING WITH THE MONTH INELIGIBILITY FOR SUCH ASSISTANCE BEGINS.
   20    (B) PREGNANT WOMEN AND CHILDREN.
   21    (1) A PREGNANT WOMAN ELIGIBLE FOR MEDICAL  ASSISTANCE  UNDER  SUBPARA-
   22  GRAPH TWO OR FOUR OF PARAGRAPH (B) OF SUBDIVISION ONE OF THIS SECTION ON
   23  ANY  DAY OF HER PREGNANCY WILL CONTINUE TO BE ELIGIBLE FOR SUCH CARE AND
   24  SERVICES THROUGH THE END OF THE MONTH IN WHICH THE SIXTIETH DAY  FOLLOW-
   25  ING THE END OF THE PREGNANCY OCCURS, WITHOUT REGARD TO ANY CHANGE IN THE
   26  INCOME  OF  THE  FAMILY  THAT  INCLUDES THE PREGNANT WOMAN, EVEN IF SUCH
   27  CHANGE OTHERWISE WOULD HAVE RENDERED HER INELIGIBLE FOR MEDICAL  ASSIST-
   28  ANCE.
   29    (2) A CHILD BORN TO A WOMAN ELIGIBLE FOR AND RECEIVING MEDICAL ASSIST-
   30  ANCE  ON  THE  DATE OF THE CHILD'S BIRTH SHALL BE DEEMED TO HAVE APPLIED
   31  FOR MEDICAL ASSISTANCE AND TO HAVE BEEN FOUND ELIGIBLE FOR SUCH  ASSIST-
   32  ANCE  ON  THE DATE OF SUCH BIRTH AND TO REMAIN ELIGIBLE FOR SUCH ASSIST-
   33  ANCE FOR A PERIOD OF ONE YEAR, SO LONG AS THE CHILD IS A MEMBER  OF  THE
   34  WOMAN'S  HOUSEHOLD AND THE WOMAN REMAINS ELIGIBLE FOR SUCH ASSISTANCE OR
   35  WOULD REMAIN ELIGIBLE FOR SUCH ASSISTANCE IF SHE WERE PREGNANT.
   36    (3) A CHILD UNDER THE AGE OF NINETEEN WHO IS DETERMINED  ELIGIBLE  FOR
   37  MEDICAL ASSISTANCE UNDER THE PROVISIONS OF THIS SECTION, SHALL, CONSIST-
   38  ENT  WITH  APPLICABLE  FEDERAL  REQUIREMENTS,  REMAIN  ELIGIBLE FOR SUCH
   39  ASSISTANCE UNTIL THE EARLIER OF:
   40    (I) THE LAST DAY OF THE MONTH WHICH IS  TWELVE  MONTHS  FOLLOWING  THE
   41  DETERMINATION OR REDETERMINATION OF ELIGIBILITY FOR SUCH ASSISTANCE; OR
   42    (II)  THE  LAST DAY OF THE MONTH IN WHICH THE CHILD REACHES THE AGE OF
   43  NINETEEN.
   44    (4) AN INFANT ELIGIBLE UNDER SUBPARAGRAPH TWO OR FOUR OF PARAGRAPH (B)
   45  OF SUBDIVISION ONE OF THIS SECTION WHO IS RECEIVING MEDICALLY  NECESSARY
   46  IN-PATIENT SERVICES FOR WHICH MEDICAL ASSISTANCE IS PROVIDED ON THE DATE
   47  THE  CHILD ATTAINS ONE YEAR OF AGE, AND WHO, BUT FOR ATTAINING SUCH AGE,
   48  WOULD REMAIN ELIGIBLE FOR MEDICAL ASSISTANCE  UNDER  SUCH  SUBPARAGRAPH,
   49  SHALL  CONTINUE  TO  REMAIN ELIGIBLE UNTIL THE END OF THE STAY FOR WHICH
   50  IN-PATIENT SERVICES ARE BEING FURNISHED.
   51    (5) A CHILD ELIGIBLE UNDER SUBPARAGRAPH  THREE  OF  PARAGRAPH  (B)  OF
   52  SUBDIVISION  ONE  OF  THIS  SECTION WHO IS RECEIVING MEDICALLY NECESSARY
   53  IN-PATIENT SERVICES FOR WHICH MEDICAL ASSISTANCE IS PROVIDED ON THE DATE
   54  THE CHILD ATTAINS NINETEEN YEARS OF AGE, AND WHO, BUT FOR ATTAINING SUCH
   55  AGE, WOULD REMAIN ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS  PARAGRAPH,
       S. 2606--D                         85                         A. 3006--D

    1  SHALL  CONTINUE  TO  REMAIN ELIGIBLE UNTIL THE END OF THE STAY FOR WHICH
    2  IN-PATIENT SERVICES ARE BEING FURNISHED.
    3    (6)  A  WOMAN  WHO WAS PREGNANT WHILE IN RECEIPT OF MEDICAL ASSISTANCE
    4  WHO SUBSEQUENTLY LOSES HER ELIGIBILITY FOR MEDICAL ASSISTANCE SHALL HAVE
    5  HER ELIGIBILITY FOR MEDICAL ASSISTANCE CONTINUED FOR A PERIOD  OF  TWEN-
    6  TY-FOUR  MONTHS  FROM  THE  END  OF  THE MONTH IN WHICH THE SIXTIETH DAY
    7  FOLLOWING THE END OF HER PREGNANCY OCCURS, BUT ONLY FOR FEDERAL TITLE  X
    8  SERVICES  WHICH ARE ELIGIBLE FOR REIMBURSEMENT BY THE FEDERAL GOVERNMENT
    9  AT A RATE OF NINETY PERCENT; PROVIDED, HOWEVER, THAT SUCH NINETY PERCENT
   10  LIMITATION SHALL NOT APPLY TO THOSE SERVICES IDENTIFIED BY  THE  COMMIS-
   11  SIONER   AS  SERVICES,  INCLUDING  TREATMENT  FOR  SEXUALLY  TRANSMITTED
   12  DISEASES, GENERALLY PERFORMED AS PART OF OR AS A FOLLOW-UP TO A  SERVICE
   13  ELIGIBLE  FOR  SUCH  NINETY PERCENT REIMBURSEMENT; AND PROVIDED FURTHER,
   14  HOWEVER, THAT NOTHING IN  THIS  PARAGRAPH  SHALL  BE  DEEMED  TO  AFFECT
   15  PAYMENT  FOR SUCH TITLE X SERVICES IF FEDERAL FINANCIAL PARTICIPATION IS
   16  NOT AVAILABLE FOR SUCH CARE, SERVICES AND SUPPLIES.
   17    (C)  CONTINUOUS  COVERAGE  FOR  ADULTS.  NOTWITHSTANDING   ANY   OTHER
   18  PROVISION  OF  LAW, A PERSON WHOSE ELIGIBILITY FOR MEDICAL ASSISTANCE IS
   19  BASED ON THE MODIFIED  ADJUSTED  GROSS  INCOME  OF  THE  PERSON  OR  THE
   20  PERSON'S  HOUSEHOLD, AND WHO LOSES ELIGIBILITY FOR SUCH ASSISTANCE FOR A
   21  REASON OTHER THAN CITIZENSHIP STATUS, LACK OF STATE RESIDENCE, OR  FAIL-
   22  URE  TO  PROVIDE  A  VALID  SOCIAL  SECURITY NUMBER, BEFORE THE END OF A
   23  TWELVE MONTH PERIOD BEGINNING ON THE  EFFECTIVE  DATE  OF  THE  PERSON'S
   24  INITIAL  ELIGIBILITY  FOR SUCH ASSISTANCE, OR BEFORE THE END OF A TWELVE
   25  MONTH PERIOD BEGINNING ON THE DATE OF ANY  SUBSEQUENT  DETERMINATION  OF
   26  ELIGIBILITY  BASED  ON MODIFIED ADJUSTED GROSS INCOME, SHALL HAVE HIS OR
   27  HER ELIGIBILITY FOR SUCH ASSISTANCE CONTINUED  UNTIL  THE  END  OF  SUCH
   28  TWELVE  MONTH  PERIOD,  PROVIDED THAT FEDERAL FINANCIAL PARTICIPATION IN
   29  THE COSTS OF SUCH ASSISTANCE IS AVAILABLE.
   30    (D) BREAST AND CERVICAL CANCER TREATMENT.
   31    (1) PERSONS WHO ARE NOT ELIGIBLE  FOR  MEDICAL  ASSISTANCE  UNDER  THE
   32  TERMS  OF  SECTION  1902(A)(10)(A)(I) OF THE FEDERAL SOCIAL SECURITY ACT
   33  ARE ELIGIBLE FOR MEDICAL ASSISTANCE COVERAGE  DURING  THE  TREATMENT  OF
   34  BREAST OR CERVICAL CANCER, SUBJECT TO THE PROVISIONS OF THIS PARAGRAPH.
   35    (2)  (I)  MEDICAL  ASSISTANCE  IS  AVAILABLE  UNDER  THIS PARAGRAPH TO
   36  PERSONS WHO ARE UNDER SIXTY-FIVE YEARS OF AGE, HAVE  BEEN  SCREENED  FOR
   37  BREAST  AND/OR CERVICAL CANCER UNDER THE CENTERS FOR DISEASE CONTROL AND
   38  PREVENTION BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM  AND  NEED
   39  TREATMENT  FOR  BREAST OR CERVICAL CANCER, AND ARE NOT OTHERWISE COVERED
   40  UNDER CREDITABLE COVERAGE  AS  DEFINED  IN  THE  FEDERAL  PUBLIC  HEALTH
   41  SERVICE ACT; PROVIDED HOWEVER THAT MEDICAL ASSISTANCE SHALL BE FURNISHED
   42  PURSUANT  TO THIS CLAUSE ONLY TO THE EXTENT PERMITTED UNDER FEDERAL LAW,
   43  IF, FOR SO LONG AS, AND TO THE EXTENT  THAT  FEDERAL  FINANCIAL  PARTIC-
   44  IPATION IS AVAILABLE THEREFOR.
   45    (II)  MEDICAL  ASSISTANCE IS AVAILABLE UNDER THIS PARAGRAPH TO PERSONS
   46  WHO MEET THE REQUIREMENTS OF CLAUSE (I) OF  THIS  SUBPARAGRAPH  BUT  FOR
   47  THEIR AGE AND/OR GENDER, WHO HAVE BEEN SCREENED FOR BREAST AND/OR CERVI-
   48  CAL  CANCER  UNDER THE PROGRAM DESCRIBED IN TITLE ONE-A OF ARTICLE TWEN-
   49  TY-FOUR OF THE PUBLIC HEALTH LAW AND NEED TREATMENT FOR BREAST OR CERVI-
   50  CAL CANCER, AND ARE NOT OTHERWISE COVERED UNDER CREDITABLE  COVERAGE  AS
   51  DEFINED  IN THE FEDERAL PUBLIC HEALTH SERVICE ACT; PROVIDED HOWEVER THAT
   52  MEDICAL ASSISTANCE SHALL BE FURNISHED PURSUANT TO THIS  CLAUSE  ONLY  IF
   53  AND FOR SO LONG AS THE PROVISIONS OF CLAUSE (I) OF THIS SUBPARAGRAPH ARE
   54  IN EFFECT.
       S. 2606--D                         86                         A. 3006--D

    1    (3) MEDICAL ASSISTANCE PROVIDED TO A PERSON UNDER THIS PARAGRAPH SHALL
    2  BE  LIMITED  TO  THE  PERIOD IN WHICH SUCH PERSON REQUIRES TREATMENT FOR
    3  BREAST OR CERVICAL CANCER.
    4    (4)  (I)  THE COMMISSIONER OF HEALTH SHALL PROMULGATE SUCH REGULATIONS
    5  AS MAY BE NECESSARY TO CARRY OUT THE PROVISIONS OF THIS PARAGRAPH.  SUCH
    6  REGULATIONS  SHALL  INCLUDE, BUT NOT BE LIMITED TO: ELIGIBILITY REQUIRE-
    7  MENTS; A DESCRIPTION OF THE MEDICAL SERVICES WHICH ARE  COVERED;  AND  A
    8  PROCESS  FOR  PROVIDING PRESUMPTIVE ELIGIBILITY WHEN A QUALIFIED ENTITY,
    9  AS DEFINED BY THE COMMISSIONER, DETERMINES ON THE BASIS  OF  PRELIMINARY
   10  INFORMATION  THAT  A PERSON MEETS THE REQUIREMENTS FOR ELIGIBILITY UNDER
   11  THIS PARAGRAPH.
   12    (II) FOR PURPOSES OF DETERMINING ELIGIBILITY  FOR  MEDICAL  ASSISTANCE
   13  UNDER  THIS  PARAGRAPH, RESOURCES AVAILABLE TO SUCH INDIVIDUAL SHALL NOT
   14  BE CONSIDERED NOR REQUIRED TO BE APPLIED  TOWARD  THE  PAYMENT  OR  PART
   15  PAYMENT  OF  THE  COST  OF MEDICAL CARE, SERVICES AND SUPPLIES AVAILABLE
   16  UNDER THIS PARAGRAPH.
   17    (III) AN INDIVIDUAL SHALL BE ELIGIBLE FOR PRESUMPTIVE ELIGIBILITY  FOR
   18  MEDICAL  ASSISTANCE  UNDER THIS PARAGRAPH IN ACCORDANCE WITH SUBDIVISION
   19  FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE.
   20    (5) THE COMMISSIONER OF HEALTH SHALL, CONSISTENT WITH THIS TITLE, MAKE
   21  ANY NECESSARY AMENDMENTS  TO  THE  STATE  PLAN  FOR  MEDICAL  ASSISTANCE
   22  SUBMITTED PURSUANT TO SECTION THREE HUNDRED SIXTY-THREE-A OF THIS TITLE,
   23  IN ORDER TO ENSURE FEDERAL FINANCIAL PARTICIPATION IN EXPENDITURES UNDER
   24  THIS  PARAGRAPH.  NOTWITHSTANDING  ANY PROVISION OF LAW TO THE CONTRARY,
   25  THE PROVISIONS OF CLAUSE (I) OF SUBPARAGRAPH TWO OF THIS PARAGRAPH SHALL
   26  BE EFFECTIVE ONLY IF AND FOR SO LONG AS FEDERAL FINANCIAL  PARTICIPATION
   27  IS AVAILABLE IN THE COSTS OF MEDICAL ASSISTANCE FURNISHED THEREUNDER.
   28    (E) COLON AND PROSTATE CANCER TREATMENT.
   29    (1)  NOTWITHSTANDING  ANY  OTHER  PROVISION  OF LAW TO THE CONTRARY, A
   30  PERSON WHO HAS BEEN SCREENED OR REFERRED  FOR  SCREENING  FOR  COLON  OR
   31  PROSTATE  CANCER  BY  THE CANCER SERVICES SCREENING PROGRAM, AS ADMINIS-
   32  TERED BY THE DEPARTMENT OF HEALTH, AND HAS BEEN DIAGNOSED WITH COLON  OR
   33  PROSTATE  CANCER  IS ELIGIBLE FOR MEDICAL ASSISTANCE FOR THE DURATION OF
   34  HIS OR HER TREATMENT FOR SUCH CANCER.
   35    (2) PERSONS ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS PARAGRAPH SHALL
   36  HAVE AN INCOME OF TWO HUNDRED FIFTY PERCENT OR LESS  OF  THE  COMPARABLE
   37  FEDERAL  INCOME OFFICIAL POVERTY LINE AS DEFINED AND ANNUALLY REVISED BY
   38  THE FEDERAL OFFICE OF MANAGEMENT AND BUDGET.
   39    (3) AN INDIVIDUAL SHALL BE ELIGIBLE FOR  PRESUMPTIVE  ELIGIBILITY  FOR
   40  MEDICAL  ASSISTANCE  UNDER THIS PARAGRAPH IN ACCORDANCE WITH SUBDIVISION
   41  FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE.
   42    (4) MEDICAL ASSISTANCE IS AVAILABLE UNDER THIS  PARAGRAPH  TO  PERSONS
   43  WHO  ARE  UNDER  SIXTY-FIVE  YEARS OF AGE, AND ARE NOT OTHERWISE COVERED
   44  UNDER CREDITABLE COVERAGE  AS  DEFINED  IN  THE  FEDERAL  PUBLIC  HEALTH
   45  SERVICE ACT.
   46    S  3.  Paragraph  (a)  of subdivision 4 of section 364-i of the social
   47  services law, as added by section 29-a of part A of chapter  58  of  the
   48  laws of 2007, is amended to read as follows:
   49    (a) Notwithstanding any inconsistent provision of law to the contrary,
   50  a  child  shall  be presumed to be eligible for medical assistance under
   51  this title beginning on the date that a qualified entity, as defined  in
   52  paragraph  (c)  of this subdivision, determine, on the basis of prelimi-
   53  nary information, that the [net] MAGI household income of the child does
   54  not exceed the applicable level for eligibility as provided for pursuant
   55  to SUBPARAGRAPH TWO OR THREE  OF  paragraph  [(u)]  (B)  of  subdivision
   56  [four] ONE of section three hundred sixty-six of this title.
       S. 2606--D                         87                         A. 3006--D

    1    S  4.  Paragraph  (a)  of subdivision 5 of section 364-i of the social
    2  services law, as added by chapter 176 of the laws of 2006, is amended to
    3  read as follows:
    4    (a) An individual shall be presumed to be eligible for medical assist-
    5  ance  under this title beginning on the date that a qualified entity, as
    6  defined in paragraph (c) of this subdivision, determines, on  the  basis
    7  of  preliminary  information, that the individual meets the requirements
    8  of paragraph [(v) or (v-1)] (D) OR (E) of subdivision  four  of  section
    9  three hundred sixty-six of this title.
   10    S  5.  Subdivision  6  of section 364-i of the social services law, as
   11  added by chapter 484 of the laws of 2009 and paragraph (a-2) as added by
   12  section 76 of part H of chapter 59 of the laws of 2011,  is  amended  to
   13  read as follows:
   14    6. (a) A pregnant woman shall be presumed to be eligible for [coverage
   15  of  services  described  in  paragraph  (c) of this subdivision] MEDICAL
   16  ASSISTANCE UNDER THIS TITLE, EXCLUDING INPATIENT SERVICES  AND  INSTITU-
   17  TIONAL  LONG  TERM  CARE,  beginning  on  the  date that a prenatal care
   18  provider, licensed under article twenty-eight of the public  health  law
   19  or  other  prenatal  care  provider approved by the department of health
   20  determines, on the basis of preliminary information, that  the  pregnant
   21  woman's  [family has: (i) subject to the approval of the federal Centers
   22  for Medicare and Medicaid Services, gross income that  does  not  exceed
   23  two  hundred  thirty percent of the federal poverty line (as defined and
   24  annually revised by the United States department  of  health  and  human
   25  services)  for a family of the same size, or (ii) in the absence of such
   26  approval, net income that does not exceed two  hundred  percent  of  the
   27  federal  poverty  line  (as  defined  and annually revised by the United
   28  States department of health and human services) for a family of the same
   29  size.] MAGI HOUSEHOLD INCOME DOES NOT EXCEED THE MAGI-EQUIVALENT OF  TWO
   30  HUNDRED  PERCENT  OF  THE FEDERAL POVERTY LINE FOR THE APPLICABLE FAMILY
   31  SIZE.
   32    (a-2) At the time of application for presumptive eligibility  pursuant
   33  to  this  subdivision, a pregnant woman who resides in a social services
   34  district that has implemented the state's managed care program  pursuant
   35  to  section  three  hundred  sixty-four-j  of  this  title must choose a
   36  managed care provider. If a managed care provider is not chosen  at  the
   37  time  of  application,  the pregnant woman will be assigned to a managed
   38  care provider in accordance with subparagraphs (ii), (iii), (iv) and (v)
   39  of paragraph (f) of subdivision four of  section  three  hundred  sixty-
   40  four-j of this title.
   41    (b)  Such  presumptive  eligibility shall continue through the earlier
   42  of:  the day on which eligibility is determined pursuant to this  title;
   43  or  the  last day of the month following the month in which the provider
   44  makes preliminary determination, in the case of  a  pregnant  woman  who
   45  does  not  file  an application for medical assistance on or before such
   46  day.
   47    (c) [A presumptively eligible pregnant woman is eligible for  coverage
   48  of:
   49    (i)  all  medical  care,  services,  and  supplies available under the
   50  medical assistance program, excluding inpatient  services  and  institu-
   51  tional  long  term  care,  if the woman's family has: (A) subject to the
   52  approval of the federal Centers  for  Medicare  and  Medicaid  Services,
   53  gross  income  that  does  not  exceed one hundred twenty percent of the
   54  federal poverty line (as defined and  annually  revised  by  the  United
   55  States department of health and human services) for a family of the same
   56  size,  or  (B) in the absence of such approval, net income that does not
       S. 2606--D                         88                         A. 3006--D

    1  exceed one hundred percent of the federal poverty line (as  defined  and
    2  annually  revised  by  the  United States department of health and human
    3  services) for a family of the same size; or
    4    (ii) prenatal care services as described in subparagraph four of para-
    5  graph (o) of subdivision four of section three hundred sixty-six of this
    6  title,  if  the  woman's  family has: (A) subject to the approval of the
    7  federal Centers for Medicare and Medicaid Services,  gross  income  that
    8  exceeds  one  hundred  twenty  percent  of  the federal poverty line (as
    9  defined and annually revised by the United States department  of  health
   10  and  human  services) for families of the same size, but does not exceed
   11  two hundred thirty percent of such federal poverty line, or (B)  in  the
   12  absence  of  such  approval, net income that exceeds one hundred percent
   13  but does not exceed two hundred percent of the federal poverty line  (as
   14  defined  and  annually revised by the United States department of health
   15  and human services) for a family of the same size.
   16    (d)] The department of health shall provide  prenatal  care  providers
   17  licensed  under  article twenty-eight of the public health law and other
   18  approved prenatal care providers with such forms as are necessary for  a
   19  pregnant  woman  to apply and information on how to assist such women in
   20  completing and filing such forms. A qualified provider which  determines
   21  that  a pregnant woman is presumptively eligible shall notify the social
   22  services district in which the pregnant woman resides  of  the  determi-
   23  nation  within  five  working days after the date on which such determi-
   24  nation is made and shall inform the woman at the time the  determination
   25  is  made that she is required to make application by the last day of the
   26  month following the month in which the determination is made.
   27    [(e)] (D) Notwithstanding any other provision of  law,  care  that  is
   28  furnished  to  a  pregnant  woman  pursuant to this subdivision during a
   29  presumptive eligibility period shall be deemed as medical assistance for
   30  purposes of payment and state reimbursement.
   31    [(f)] (E) Facilities licensed under article twenty-eight of the public
   32  health law providing prenatal care services  shall  perform  presumptive
   33  eligibility  determinations  and  assist women in submitting appropriate
   34  documentation to the social services district as required by the commis-
   35  sioner; provided, however, that a facility may apply to the commissioner
   36  for exemption from this requirement on the basis of undue hardship.
   37    [(g)] (F) All prenatal care providers enrolled in the medicaid program
   38  must provide prenatal  care  services  to  eligible  service  recipients
   39  determined  presumptively  eligible  for  medical assistance but not yet
   40  enrolled in the medical assistance program, and assist women in  submit-
   41  ting  appropriate  documentation  to  the  social  services  district as
   42  required by the commissioner.
   43    S 6. Subdivision 1 and the  opening  paragraph  of  subdivision  2  of
   44  section  365-a  of  the social services law, subdivision 1 as amended by
   45  chapter 110 of the laws of 1971 and the opening paragraph of subdivision
   46  2 as amended by chapter 41 of the laws of 1992, are amended to  read  as
   47  follows:
   48    [1.] The amount, nature and manner of providing medical assistance for
   49  needy  persons  shall  be determined by the public welfare official with
   50  the advice of a physician and in accordance with the local medical plan,
   51  this title, and the regulations of the department.
   52    1. "BENCHMARK COVERAGE" SHALL MEAN PAYMENT OF PART OR ALL OF THE  COST
   53  OF MEDICALLY NECESSARY MEDICAL, DENTAL, AND REMEDIAL CARE, SERVICES, AND
   54  SUPPLIES DESCRIBED IN SUBDIVISION TWO OF THIS SECTION, AND TO THE EXTENT
   55  NOT  INCLUDED  THEREIN,  ANY  ESSENTIAL BENEFITS AS DEFINED IN 42 U.S.C.
   56  18022(B), WITH THE EXCEPTION OF INSTITUTIONAL LONG TERM  CARE  SERVICES;
       S. 2606--D                         89                         A. 3006--D

    1  SUCH  CARE,  SERVICES AND SUPPLIES SHALL BE PROVIDED CONSISTENT WITH THE
    2  MANAGED CARE PROGRAM DESCRIBED IN SECTION THREE HUNDRED SIXTY-FOUR-J  OF
    3  THIS TITLE.
    4    ["Medical  assistance"] "STANDARD COVERAGE" shall mean payment of part
    5  or all of the cost of medically necessary medical, dental  and  remedial
    6  care,  services  and  supplies, as authorized in this title or the regu-
    7  lations of the department, which are  necessary  to  prevent,  diagnose,
    8  correct  or  cure  conditions  in the person that cause acute suffering,
    9  endanger life, result in  illness  or  infirmity,  interfere  with  such
   10  person's  capacity  for  normal  activity,  or threaten some significant
   11  handicap and which are furnished an eligible person in  accordance  with
   12  this  title  and  the regulations of the department. Such care, services
   13  and supplies shall include the  following  medical  care,  services  and
   14  supplies,  together  with  such  medical  care,  services  and  supplies
   15  provided for in subdivisions three, four and five of this  section,  and
   16  such  medical care, services and supplies as are authorized in the regu-
   17  lations of the department:
   18    S 7. Subdivision 1 of section 366-a of the  social  services  law,  as
   19  amended  by  section  60 of part C of chapter 58 of the laws of 2009, is
   20  amended to read as follows:
   21    1. Any person  requesting  medical  assistance  may  make  application
   22  therefor  [in  person,  through  another  in his behalf or by mail] BY A
   23  WRITTEN APPLICATION to the social services official of the county[, city
   24  or town, or to the service officer of the city or  town]  in  which  the
   25  applicant  resides  or  is  found  OR TO THE DEPARTMENT OF HEALTH OR ITS
   26  AGENT; A PHONE APPLICATION; OR AN ON-LINE APPLICATION.  [In addition, in
   27  the case of a person who is sixty-five years of age or older  and  is  a
   28  patient  in  a state hospital for tuberculosis or for the mentally disa-
   29  bled, applications may be made to the department or to a social services
   30  official designated as the agent of the department.] Notwithstanding any
   31  provision of law to the contrary, [a personal]  AN  IN-PERSON  interview
   32  with the applicant or with the person who made application on his or her
   33  behalf  shall  not  be required as part of a determination of initial or
   34  continuing eligibility pursuant to this title.
   35    S 8. Paragraph (a) of subdivision 2 of section  366-a  of  the  social
   36  services  law,  as  amended by section 60 of part C of chapter 58 of the
   37  laws of 2009, is amended to read as follows:
   38    (a) Upon receipt of such application, the appropriate social  services
   39  official,  or  the department of health or its agent [when the applicant
   40  is a patient in a state hospital for the mentally disabled,] shall veri-
   41  fy the eligibility of such applicant. In accordance with the regulations
   42  of the department of health, it  shall  be  the  responsibility  of  the
   43  applicant  to  provide  information  and documentation necessary for the
   44  determination of initial and ongoing eligibility for medical assistance.
   45  If an applicant or recipient is unable to provide  necessary  documenta-
   46  tion, the [public welfare] SOCIAL SERVICES official OR THE DEPARTMENT OF
   47  HEALTH  OR  ITS  AGENT shall promptly cause an investigation to be made.
   48  Where an investigation is necessary, sources of information  other  than
   49  public  records  will be consulted only with permission of the applicant
   50  or recipient. In the event that such permission is not  granted  by  the
   51  applicant  or  recipient, or necessary documentation cannot be obtained,
   52  the social services official or the department of health  or  its  agent
   53  may  suspend  or  deny  medical  assistance until such time as it may be
   54  satisfied as to the applicant's or recipient's eligibility therefor.
       S. 2606--D                         90                         A. 3006--D

    1    S 9. The opening paragraph of subdivision 3 of section  366-a  of  the
    2  social  services  law,  as  added by chapter 256 of the laws of 1966, is
    3  amended to read as follows:
    4    Upon  the receipt of such application, and after the completion of any
    5  investigation that shall be deemed necessary,  the  appropriate  [public
    6  welfare]  SOCIAL SERVICES official[,] or the department OF HEALTH or its
    7  agent [when the applicant is a patient in a state hospital for  tubercu-
    8  losis or for the mentally disabled,] shall
    9    S  10. Paragraphs (b) and (c) of subdivision 5 of section 366-a of the
   10  social services law, as added by section 52 of part A of  chapter  1  of
   11  the laws of 2002, are amended to read as follows:
   12    (b)  The  commissioner  shall develop a simplified statewide recertif-
   13  ication form for use in redetermining eligibility under this title.  The
   14  form [shall] MAY include requests only for such information that is:
   15    (i)  reasonably  necessary  to  determine  continued  eligibility  for
   16  medical assistance under this title; and
   17    (ii) subject to change since  the  date  of  the  recipient's  initial
   18  application.
   19    (c)  [A  personal]  THE  REGULATIONS REQUIRED BY PARAGRAPH (A) OF THIS
   20  SUBDIVISION SHALL PROVIDE THAT:
   21    (I) THE REDETERMINATION OF ELIGIBILITY WILL BE MADE BASED ON  RELIABLE
   22  INFORMATION  POSSESSED  OR  AVAILABLE TO THE DEPARTMENT OF HEALTH OR ITS
   23  AGENT, INCLUDING INFORMATION ACCESSED FROM DATABASES PURSUANT TO  SUBDI-
   24  VISION EIGHT OF THIS SECTION;
   25    (II)  IF  THE  DEPARTMENT  OF  HEALTH  OR ITS AGENT IS UNABLE TO RENEW
   26  ELIGIBILITY BASED  ON  AVAILABLE  INFORMATION,  THE  RECIPIENT  WILL  BE
   27  REQUESTED  TO  SUPPLY  ANY SUCH INFORMATION AS IS NECESSARY TO DETERMINE
   28  CONTINUED ELIGIBILITY FOR MEDICAL ASSISTANCE UNDER THIS TITLE; AND
   29    (III) FOR PERSONS WHOSE MEDICAL ASSISTANCE  ELIGIBILITY  IS  BASED  ON
   30  MODIFIED  ADJUSTED  GROSS  INCOME,  ELIGIBILITY MUST BE RENEWED AT LEAST
   31  ONCE EVERY TWELVE MONTHS, UNLESS THE DEPARTMENT OF HEALTH OR  ITS  AGENT
   32  RECEIVES  INFORMATION ABOUT A CHANGE IN A RECIPIENT'S CIRCUMSTANCES THAT
   33  MAY AFFECT ELIGIBILITY.
   34    (D) AN IN-PERSON interview with the recipient shall not  AUTOMATICALLY
   35  be required as part of a redetermination of eligibility pursuant to this
   36  subdivision UNLESS THE DEPARTMENT OF HEALTH DETERMINES OTHERWISE.
   37    S  11.  Paragraph  (d) of subdivision 5 of section 366-a of the social
   38  services law is REPEALED.
   39    S 12. Paragraph (e) of subdivision 5 of section 366-a  of  the  social
   40  services  law, as added by section 1 of part C of chapter 58 of the laws
   41  of 2007, is amended to read as follows:
   42    [(e)] (D) The commissioner of health shall verify the accuracy of  the
   43  information  provided  by  [the]  AN APPLICANT OR recipient [pursuant to
   44  paragraph (d) of this subdivision] by matching it against information to
   45  which the commissioner of health has access, including under subdivision
   46  eight of this section.  In the event [there is an inconsistency between]
   47  the information reported  by  the  recipient  [and]  IS  NOT  REASONABLY
   48  COMPATIBLE  WITH  any information obtained by the commissioner of health
   49  from other sources and such [inconsistency] INCOMPATIBILITY is  material
   50  to  medical  assistance  eligibility,  the  commissioner of health shall
   51  request that the recipient provide adequate documentation to verify  his
   52  or  her  place of residence or income, as applicable. In addition to the
   53  documentation of residence and income authorized by this paragraph,  the
   54  commissioner  of  health is authorized to periodically require a reason-
   55  able sample of recipients to  provide  documentation  of  residence  and
   56  income at recertification. The commissioner of health shall consult with
       S. 2606--D                         91                         A. 3006--D

    1  the  medicaid inspector general regarding income and residence verifica-
    2  tion practices and procedures necessary to  maintain  program  integrity
    3  and deter fraud and abuse.
    4    S  13.  Subdivision  11 of section 364-j of the social services law is
    5  REPEALED.
    6    S 14. Clause (D) of subparagraph (v) of paragraph (a) of subdivision 2
    7  of section 369-ee of the social services law, as amended by  section  67
    8  of  part  C  of  chapter  58  of the laws of 2009, is amended, and a new
    9  subparagraph (vi) is added to read as follows:
   10    (D) is not described in clause (A), (B) or (C)  of  this  subparagraph
   11  and has gross family income equal to or less than two hundred percent of
   12  the  federal income official poverty line (as defined and updated by the
   13  United States Department of Health and Human Services) for a  family  of
   14  the  same size; provided, however, that eligibility under this clause is
   15  subject to sources of federal and non-federal funding for  such  purpose
   16  described   in   section  sixty-seven-a  of  [the]  PART  C  OF  chapter
   17  FIFTY-EIGHT of the laws of two thousand nine [that added this clause] or
   18  as may be available under the waiver agreement  entered  into  with  the
   19  federal  government  under section eleven hundred fifteen of the federal
   20  social security act, as jointly determined by the commissioner  and  the
   21  director  of the division of the budget. In no case shall state funds be
   22  utilized to support the non-federal share of  expenditures  pursuant  to
   23  this  subparagraph,  provided  however  that the commissioner may demon-
   24  strate to the United States department of health and human services  the
   25  existence of non-federally participating state expenditures as necessary
   26  to secure federal funding under an eleven hundred fifteen waiver for the
   27  purposes  herein. Eligibility under this clause may be provided to resi-
   28  dents of all counties or, at the joint discretion  of  the  commissioner
   29  and  the director of the division of the budget, a subset of counties of
   30  the state[.]; AND
   31    (VI) MAKES APPLICATION FOR BENEFITS  PURSUANT  TO  THIS  TITLE  ON  OR
   32  BEFORE DECEMBER THIRTY-FIRST, TWO THOUSAND THIRTEEN.
   33    S  14-a. Subdivision 5 of section 369-ee of the social services law is
   34  amended by adding a new paragraph (d) to read as follows:
   35    (D) NOTWITHSTANDING THE PROVISIONS OF PARAGRAPH (A) OF  THIS  SUBDIVI-
   36  SION  OR  ANY  OTHER PROVISION OF LAW, IN THE CASE OF A PERSON RECEIVING
   37  HEALTH CARE SERVICES PURSUANT TO THIS TITLE ON JANUARY FIRST, TWO  THOU-
   38  SAND FOURTEEN, SUCH PERSON'S ELIGIBILITY SHALL BE RECERTIFIED AS SOON AS
   39  PRACTICABLE  THEREAFTER,  AND  SUCH  PERSON'S  COVERAGE UNDER THIS TITLE
   40  SHALL END ON THE EARLIEST OF: (I) THE DATE THE PERSON IS ENROLLED  IN  A
   41  QUALIFIED HEALTH PLAN OFFERED THROUGH A HEALTH INSURANCE EXCHANGE ESTAB-
   42  LISHED  IN  ACCORDANCE  WITH  THE  REQUIREMENTS  OF  THE FEDERAL PATIENT
   43  PROTECTION AND AFFORDABLE CARE ACT (P.L. 111-148),  AS  AMENDED  BY  THE
   44  FEDERAL  HEALTH  CARE  AND  EDUCATION  ACT  OF 2010 (P.L. 111-152); (II)
   45  DECEMBER THIRTY-FIRST, TWO THOUSAND FOURTEEN; OR (III) THE DATE ON WHICH
   46  THE DEPARTMENT OF HEALTH CEASES TO HAVE ALL  NECESSARY  APPROVALS  UNDER
   47  FEDERAL  LAW  AND REGULATION TO RECEIVE FEDERAL FINANCIAL PARTICIPATION,
   48  UNDER THE PROGRAM DESCRIBED IN TITLE ELEVEN  OF  THIS  ARTICLE,  IN  THE
   49  COSTS OF HEALTH SERVICES PROVIDED PURSUANT TO THIS SECTION.
   50    S 15. Section 369-ee of the social services law is REPEALED.
   51    S 15-a. Section 369-ff of the social services law is REPEALED.
   52    S  16.  Subdivision  3  of section 367-a of the social services law is
   53  amended by adding a new paragraph (e) to read as follows:
   54    (E) (1) PAYMENT OF PREMIUMS FOR  ENROLLING  INDIVIDUALS  IN  QUALIFIED
   55  HEALTH  PLANS  OFFERED  THROUGH  A HEALTH INSURANCE EXCHANGE ESTABLISHED
   56  PURSUANT TO THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT (P.L.
       S. 2606--D                         92                         A. 3006--D

    1  111-148), AS AMENDED BY THE FEDERAL HEALTH CARE AND EDUCATION  RECONCIL-
    2  IATION  ACT  OF  2010  (P.L. 111-152), SHALL BE AVAILABLE TO INDIVIDUALS
    3  WHO:
    4    (I)  IMMEDIATELY PRIOR TO BEING ENROLLED IN THE QUALIFIED HEALTH PLAN,
    5  WERE OR WOULD HAVE BEEN ELIGIBLE UNDER THE FAMILY HEALTH PLUS PROGRAM AS
    6  A PARENT OR STEPPARENT OF A CHILD UNDER THE AGE OF TWENTY-ONE, AND WHOSE
    7  MAGI HOUSEHOLD INCOME, AS DEFINED IN SUBPARAGRAPH EIGHT OF PARAGRAPH (A)
    8  OF SUBDIVISION ONE OF SECTION THREE HUNDRED  SIXTY-SIX  OF  THIS  TITLE,
    9  EXCEEDS ONE HUNDRED THIRTY-THREE PERCENT OF THE FEDERAL POVERTY LINE FOR
   10  THE APPLICABLE FAMILY SIZE;
   11    (II)  ARE  NOT  OTHERWISE  ELIGIBLE  FOR MEDICAL ASSISTANCE UNDER THIS
   12  TITLE; AND
   13    (III) ARE ENROLLED IN A STANDARD HEALTH PLAN IN THE SILVER  LEVEL,  AS
   14  DEFINED IN 42 U.S.C. 18022.
   15    (2)  PAYMENT  PURSUANT  TO  THIS  PARAGRAPH SHALL BE FOR PREMIUM OBLI-
   16  GATIONS OF THE INDIVIDUAL UNDER THE  QUALIFIED  HEALTH  PLAN  AND  SHALL
   17  CONTINUE  ONLY  IF  AND  FOR  SO LONG AS THE INDIVIDUAL'S MAGI HOUSEHOLD
   18  INCOME EXCEEDS ONE HUNDRED THIRTY-THREE PERCENT, BUT DOES NOT EXCEED ONE
   19  HUNDRED FIFTY PERCENT, OF THE FEDERAL POVERTY LINE  FOR  THE  APPLICABLE
   20  FAMILY SIZE.
   21    (3)  THE  COMMISSIONER  OF HEALTH SHALL SUBMIT AMENDMENTS TO THE STATE
   22  PLAN FOR MEDICAL ASSISTANCE AND/OR SUBMIT ONE OR MORE  APPLICATIONS  FOR
   23  WAIVERS  OF  THE  FEDERAL  SOCIAL  SECURITY  ACT  AS MAY BE NECESSARY TO
   24  RECEIVE FEDERAL FINANCIAL PARTICIPATION IN THE COSTS  OF  PAYMENTS  MADE
   25  PURSUANT  TO  THIS PARAGRAPH; PROVIDED FURTHER, HOWEVER, THAT NOTHING IN
   26  THIS SUBPARAGRAPH SHALL BE DEEMED TO AFFECT PAYMENTS FOR PREMIUMS PURSU-
   27  ANT TO THIS PARAGRAPH IF FEDERAL FINANCIAL PARTICIPATION IN THE COSTS OF
   28  SUCH PAYMENTS IS NOT AVAILABLE.
   29    S 16-a. (a) The commissioner of health shall convene  a  workgroup  to
   30  consider  issues  pertaining  to the federal option to establish a basic
   31  health program for individuals who are not eligible for medical  assist-
   32  ance under title eleven of article five of the social services law.
   33    (b)  The  workgroup  shall: evaluate federal guidance related to basic
   34  health programs; discuss fiscal, consumer, and health care impacts of  a
   35  basic  health  program;  and consider benefit package, premium and cost-
   36  sharing options for a basic health program.
   37    S 17. Section 2510 of the public health law is amended by adding a new
   38  subdivision 13 to read as follows:
   39    13. "HOUSEHOLD INCOME" MEANS THE SUM OF THE  MODIFIED  ADJUSTED  GROSS
   40  INCOME OF EVERY INDIVIDUAL INCLUDED IN A CHILD'S HOUSEHOLD CALCULATED IN
   41  ACCORDANCE  WITH  APPLICABLE  FEDERAL  LAW  AND  REGULATIONS,  AS MAY BE
   42  AMENDED.
   43    S 18. Section 2510 of the public health law is amended by  adding  two
   44  new subdivisions 14 and 15 to read as follows:
   45    14.  "STATE ENROLLMENT CENTER" MEANS THE CENTRALIZED SYSTEM AND OPERA-
   46  TION OF ELIGIBILITY DETERMINATIONS BY THE STATE OR  ITS  CONTRACTOR  FOR
   47  ALL  INSURANCE AFFORDABILITY PROGRAMS, INCLUDING THE CHILD HEALTH INSUR-
   48  ANCE PROGRAM ESTABLISHED PURSUANT TO THIS TITLE.
   49    15. "INSURANCE AFFORDABILITY PROGRAMS" MEANS THOSE PROGRAMS SET  FORTH
   50  IN SECTION 435.4 OF TITLE 42 OF THE CODE OF FEDERAL REGULATIONS.
   51    S 19. Subparagraphs (iv) and (vi) of paragraph (f) of subdivision 2 of
   52  section  2511  of  the  public health law, subparagraph (iv) as added by
   53  section 44 of part A of chapter 1 of the laws of 2002  and  subparagraph
   54  (vi)  as  added  by  section 45-b of part C of chapter 58 of the laws of
   55  2008, are amended to read as follows:
       S. 2606--D                         93                         A. 3006--D

    1    (iv) In the event a household does not  provide  income  documentation
    2  required  by  subparagraph  (iii) of this paragraph within two months of
    3  the approved organization's OR STATE ENROLLMENT CENTER'S request, WHICH-
    4  EVER IS APPLICABLE, the approved organization OR STATE ENROLLMENT CENTER
    5  shall disenroll the child at the end of such two month period. Except as
    6  provided  in  paragraph  (c)  of  subdivision  five-a  of  this section,
    7  approved organizations shall not be obligated to repay subsidy  payments
    8  made  by  the state on behalf of children enrolled during this two month
    9  period.
   10    (vi) Any income verification response by the  department  of  taxation
   11  and  finance  pursuant  to  subparagraphs (i) and (ii) of this paragraph
   12  shall not be a public record and shall not be released  by  the  commis-
   13  sioner,  the department of taxation and finance [or], an approved organ-
   14  ization, OR THE STATE ENROLLMENT CENTER, except pursuant to  this  para-
   15  graph. Information disclosed pursuant to this paragraph shall be limited
   16  to  information  necessary  for  verification.  Information so disclosed
   17  shall be kept confidential by the party receiving such information. Such
   18  information shall be expunged within a reasonable time to be  determined
   19  by the commissioner and the department of taxation and finance.
   20    S  20.  Paragraph  (j)  of subdivision 2 of section 2511 of the public
   21  health law, as added by section 45 of part A of chapter 1 of the laws of
   22  2002, is amended to read as follows:
   23    (j) Where an application for recertification of  coverage  under  this
   24  title  contains  insufficient  information  for a final determination of
   25  eligibility for continued coverage, a child shall be  presumed  eligible
   26  for  a period not to exceed the earlier of two months beyond the preced-
   27  ing period of eligibility or the date upon which a  final  determination
   28  of  eligibility  is  made based on the submission of additional data. In
   29  the event such additional information is not submitted within two months
   30  of the approved organization's OR  STATE  ENROLLMENT  CENTER'S  request,
   31  WHICHEVER  IS  APPLICABLE, the approved organization OR STATE ENROLLMENT
   32  CENTER shall disenroll the child following the expiration  of  such  two
   33  month  period. Except as provided in paragraph (c) of subdivision five-a
   34  of this section, approved organizations shall not be obligated to  repay
   35  subsidy payments received on behalf of children enrolled during this two
   36  month period.
   37    S  21.  Subdivision  4  of  section  2511 of the public health law, as
   38  amended by section 70 of part B of chapter 58 of the laws  of  2005,  is
   39  amended to read as follows:
   40    4.  Households  shall  report  to  the  approved organization OR STATE
   41  ENROLLMENT CENTER, WHICHEVER IS  APPLICABLE,  within  thirty  days,  any
   42  changes in New York state residency or health care coverage under insur-
   43  ance  that  may make a child ineligible for subsidy payments pursuant to
   44  this section. Any individual who, with the intent  to  obtain  benefits,
   45  willfully  misstates income or residence to establish eligibility pursu-
   46  ant to subdivision two of this section or willfully fails to  notify  an
   47  approved  organization  OR  STATE ENROLLMENT CENTER of a change in resi-
   48  dence or health care coverage pursuant to this subdivision  shall  repay
   49  such subsidy to the commissioner. Individuals seeking to enroll children
   50  for coverage shall be informed that such willful misstatement or failure
   51  to notify shall result in such liability.
   52    S  22.  The subdivision heading and paragraphs (a) and (b) of subdivi-
   53  sion 5-a of section 2511 of the public health law, the subdivision head-
   54  ing and paragraph (a) as added by chapter 170 of the laws  of  1994  and
   55  paragraph  (b)  as  amended by section 71 of part B of chapter 58 of the
   56  laws of 2005, are amended to read as follows:
       S. 2606--D                         94                         A. 3006--D

    1    Obligations of approved organizations OR THE STATE ENROLLMENT  CENTER.
    2  (a)  An  approved  organization OR STATE ENROLLMENT CENTER, WHICHEVER IS
    3  APPLICABLE, shall have the obligation to review all information provided
    4  pursuant to subdivision two of this section and  shall  not  certify  or
    5  recertify  a  child  as  eligible for a subsidy payment unless the child
    6  meets the eligibility criteria.
    7    (b) An approved organization OR STATE ENROLLMENT CENTER, WHICHEVER  IS
    8  APPLICABLE,  shall  promptly review all information relating to a poten-
    9  tial change in eligibility based on  information  provided  pursuant  to
   10  subdivision  four  of  this  section.  Within at least thirty days after
   11  receipt of such information, the approved organization OR STATE  ENROLL-
   12  MENT CENTER shall make a determination whether the child is still eligi-
   13  ble for a subsidy payment and shall notify the household and the commis-
   14  sioner if it determines the child is not eligible for a subsidy payment.
   15    S  23.  Paragraph  (a) of subdivision 11 of section 2511 of the public
   16  health law, as amended by section 37 of part A of chapter 58 of the laws
   17  of 2007, is amended to read as follows:
   18    (a) An approved organization shall submit required reports and  infor-
   19  mation to the commissioner in such form and at times, at least annually,
   20  as  may  be  required by the commissioner and specified in contracts and
   21  official department of health administrative guidance, in order to eval-
   22  uate the operations and results of the program and quality of care being
   23  provided by such  organizations.  Such  reports  and  information  shall
   24  include,  but  not be limited to, enrollee demographics (APPLICABLE ONLY
   25  UNTIL THE STATE ENROLLMENT CENTER IS IMPLEMENTED),  program  utilization
   26  and expense, patient care outcomes and patient specific medical informa-
   27  tion,  including  encounter  data maintained by an approved organization
   28  for purposes of quality assurance and oversight.    Any  information  or
   29  data  collected pursuant to this paragraph shall be kept confidential in
   30  accordance with Title XXI of the federal  social  security  act  or  any
   31  other applicable state or federal law.
   32    S  24.  Subdivision  12  of  section 2511 of the public health law, as
   33  amended by chapter 2 of the laws of 1998, is amended to read as follows:
   34    12. The commissioner shall, in consultation with  the  superintendent,
   35  establish  procedures to coordinate the child health insurance plan with
   36  the medical assistance program, including but not limited to, procedures
   37  to maximize enrollment of eligible  children  under  those  programs  by
   38  identification  and  transfer of children who are eligible or who become
   39  eligible to receive medical  assistance  and  procedures  to  facilitate
   40  changes  in enrollment status for children who are ineligible for subsi-
   41  dies under this section and for children who are no longer eligible  for
   42  medical  assistance  in  order  to  facilitate  and ensure continuity of
   43  coverage. The commissioner shall review, on an annual basis, the  eligi-
   44  bility verification and recertification procedures of approved organiza-
   45  tions under this title to insure the appropriate enrollment of children.
   46  Such  review shall include, but not be limited to, an audit of a statis-
   47  tically representative sample of cases from among all approved organiza-
   48  tions AND SHALL BE APPLICABLE TO ANY PERIOD  DURING  WHICH  AN  APPROVED
   49  ORGANIZATION'S RESPONSIBILITIES INCLUDE DETERMINING ELIGIBILITY.  In the
   50  event  such  review and audit reveals cases which do not meet the eligi-
   51  bility criteria for coverage set forth in this section, that information
   52  shall be forwarded to the approved organization and the commissioner for
   53  appropriate action.
   54    S 25. Paragraph (e) of subdivision 12-a of section 2511 of the  public
   55  health  law, as added by chapter 2 of the laws of 1998, is amended and a
   56  new paragraph (f) is added to read as follows:
       S. 2606--D                         95                         A. 3006--D

    1    (e) standards and procedures  for  the  imposition  of  penalties  for
    2  substantial  noncompliance,  which  may  include, but not be limited to,
    3  financial penalties in addition to penalties set forth in section twelve
    4  of this chapter and consistent with  applicable  federal  standards,  as
    5  specified in contracts, and contract termination[.]; PROVIDED HOWEVER
    6    (F)  AUDIT  STANDARDS  AND  PROCEDURES  ESTABLISHED  PURSUANT  TO THIS
    7  SECTION, INCLUDING PENALTIES, SHALL BE APPLICABLE TO ELIGIBILITY  DETER-
    8  MINATIONS  MADE  BY APPROVED ORGANIZATIONS ONLY FOR PERIODS DURING WHICH
    9  AN APPROVED ORGANIZATION'S RESPONSIBILITIES INCLUDE MAKING  SUCH  ELIGI-
   10  BILITY DETERMINATIONS.
   11    S  26.  Paragraph  (e)  and  subparagraphs (i), (ii), (iii) and (v) of
   12  paragraph (f) of subdivision 2 of section 2511 of the public health law,
   13  paragraph (e) as added by chapter 170 of the laws of 1994 and relettered
   14  by chapter 2 of the laws of 1998, and  subparagraphs  (i)  and  (ii)  of
   15  paragraph  (f)  as  amended  by section 6 of part B of chapter 58 of the
   16  laws of 2010, subparagraph (iii) of paragraph (f) as amended by  chapter
   17  535  of  the  laws  of  2010,  and  subparagraph (v) of paragraph (f) as
   18  amended by section 7 of part J of chapter 82 of the laws  of  2002,  are
   19  amended to read as follows:
   20    (e)  is  a resident of New York state. Such residency shall be [demon-
   21  strated by] ATTESTED TO BY THE APPLICANT FOR INSURANCE, PROVIDED  HOWEV-
   22  ER, THE COMMISSIONER SHALL REQUIRE adequate proof[, as determined by the
   23  commissioner,]  of a New York state street address IN CIRCUMSTANCES WHEN
   24  THERE IS AN INCONSISTENCY WITH RESIDENCY  INFORMATION  FROM  OTHER  DATA
   25  SOURCES.  [If  the  child has no street address, such proof may include,
   26  but not be limited to, school records or other documentation  determined
   27  by the commissioner.]
   28    (i) In order to establish income eligibility under this subdivision at
   29  initial application, a household shall provide [such documentation spec-
   30  ified  in  subparagraph (iii) of this paragraph, as necessary and suffi-
   31  cient to determine a child's financial eligibility for a subsidy payment
   32  under this title] THE SOCIAL SECURITY NUMBERS FOR EACH PARENT AND LEGAL-
   33  LY RESPONSIBLE ADULT WHO IS  A  MEMBER  OF  THE  HOUSEHOLD,  SUBJECT  TO
   34  SUBPARAGRAPH  (V)  OF  THIS  PARAGRAPH. The commissioner [may verify the
   35  accuracy of such income information provided by the household by  match-
   36  ing  it against] SHALL DETERMINE ELIGIBILITY BASED ON income information
   37  contained in databases to which the commissioner has  access,  including
   38  the  state's  wage  reporting  system  pursuant  to  subdivision five of
   39  section one hundred seventy-one-a of the tax law  and  by  means  of  an
   40  income  verification  performed pursuant to a cooperative agreement with
   41  the department of taxation and finance pursuant to subdivision  four  of
   42  section  one  hundred  seventy-one-b  of the tax law.   THE COMMISSIONER
   43  SHALL REQUIRE AN ATTESTATION BY THE HOUSEHOLD THAT THE  INCOME  INFORMA-
   44  TION OBTAINED FROM ELECTRONIC DATA SOURCES IS ACCURATE. SUCH ATTESTATION
   45  SHALL  INCLUDE  ANY OTHER HOUSEHOLD INCOME INFORMATION NOT OBTAINED FROM
   46  AN ELECTRONIC DATA SOURCE THAT  IS  NECESSARY  TO  DETERMINE  A  CHILD'S
   47  FINANCIAL  ELIGIBILITY  FOR  A  SUBSIDY PAYMENT UNDER THIS TITLE. IF THE
   48  ATTESTATION IS REASONABLY  COMPATIBLE  WITH  INFORMATION  OBTAINED  FROM
   49  AVAILABLE  DATA  SOURCES,  NO  FURTHER  INFORMATION  OR DOCUMENTATION IS
   50  REQUIRED. IF THE ATTESTATION IS NOT REASONABLY COMPATIBLE WITH  INFORMA-
   51  TION  OBTAINED  FROM  AVAILABLE  DATA  SOURCES,  DOCUMENTATION  SHALL BE
   52  REQUIRED AS SPECIFIED IN SUBPARAGRAPH (III) OF THIS PARAGRAPH.
   53    (ii) In order to establish income eligibility under  this  subdivision
   54  at recertification, [a household shall attest to all information regard-
   55  ing the household's income that is necessary and sufficient to determine
   56  a  child's  financial eligibility for a subsidy payment under this title
       S. 2606--D                         96                         A. 3006--D

    1  and shall provide the social security numbers for each parent and legal-
    2  ly responsible adult who is a member of the household and  whose  income
    3  is  available  to  the  child, subject to subparagraph (v) of this para-
    4  graph.    The]  THE commissioner [may verify the accuracy of such income
    5  information provided by the household by matching it against income] MAY
    6  MAKE A REDETERMINATION OF ELIGIBILITY WITHOUT REQUIRING INFORMATION FROM
    7  THE INDIVIDUAL IF ABLE TO DO SO BASED ON RELIABLE INFORMATION  CONTAINED
    8  IN  THE  INDIVIDUAL'S  ENROLLMENT FILE OR OTHER MORE CURRENT information
    9  contained in databases to which the commissioner has  access,  including
   10  the state's wage reporting system and by means of an income verification
   11  performed  pursuant  to  a  cooperative agreement with the department of
   12  taxation and finance pursuant to subdivision four of section one hundred
   13  seventy-one-b of the tax law.  THE COMMISSIONER SHALL REQUIRE AN  ATTES-
   14  TATION  BY  THE  HOUSEHOLD  THAT THE INCOME INFORMATION CONTAINED IN THE
   15  ENROLLMENT FILE OR OBTAINED FROM ELECTRONIC DATA  SOURCES  IS  ACCURATE.
   16  SUCH  ATTESTATION  SHALL  INCLUDE ANY OTHER HOUSEHOLD INCOME INFORMATION
   17  NOT OBTAINED FROM AN ELECTRONIC DATA SOURCE THAT IS NECESSARY  TO  REDE-
   18  TERMINE A CHILD'S FINANCIAL ELIGIBILITY FOR A SUBSIDY PAYMENT UNDER THIS
   19  TITLE.  In  the  event that there is an inconsistency between the income
   20  information attested to by the household and any information obtained by
   21  the commissioner from other sources pursuant to this  subparagraph,  and
   22  such  inconsistency  is  material  to  the household's eligibility for a
   23  subsidy payment under this title, the  commissioner  shall  require  the
   24  [approved organization to obtain] HOUSEHOLD TO PROVIDE income documenta-
   25  tion  [from  the  household]  as specified in subparagraph (iii) of this
   26  paragraph.
   27    (iii) IF THE ATTESTATION OF HOUSEHOLD INCOME REQUIRED BY SUBPARAGRAPHS
   28  (I) AND (II) OF THIS PARAGRAPH IS NOT REASONABLY COMPATIBLE WITH  INFOR-
   29  MATION  OBTAINED  FROM  DATA  SOURCES,  FURTHER  INFORMATION,  INCLUDING
   30  DOCUMENTATION, SHALL BE REQUIRED. Income  documentation  shall  include,
   31  but  not be limited to, one or more of the following for each parent and
   32  legally responsible adult who is a member of  the  household  and  whose
   33  income is available to the child;
   34    (A) current annual income tax returns;
   35    (B) paycheck stubs;
   36    (C) written documentation of income from all employers; or
   37    (D) written documentation of income eligibility of a child for free or
   38  reduced  breakfast or lunch through the school meal program certified by
   39  the child's school, provided that:
   40    (I) the commissioner  may  verify  the  accuracy  of  the  information
   41  provided in the same manner and way as provided for in subparagraph (ii)
   42  of this paragraph; and
   43    (II)  such  documentation  may  not be suitable proof of income in the
   44  event of a material inconsistency in income after the  commissioner  has
   45  performed  verification pursuant to subparagraph (ii) of this paragraph;
   46  or
   47    (E) other documentation of income (earned or unearned)  as  determined
   48  by  the  commissioner,  provided,  however, such documentation shall set
   49  forth the source of such income.
   50    (v) In the event a household chooses not to provide the social securi-
   51  ty numbers required by [subparagraph] SUBPARAGRAPHS (I) AND (ii) of this
   52  paragraph, such household shall provide income  documentation  specified
   53  in  subparagraph  (iii)  of this paragraph as a condition of the child's
   54  enrollment. Nothing in this paragraph shall be construed as obligating a
   55  household to provide social  security  numbers  of  parents  or  legally
       S. 2606--D                         97                         A. 3006--D

    1  responsible adults as a condition of a child's enrollment or eligibility
    2  for a subsidy payment under this title.
    3    S  27.  Subparagraph (ii) of paragraph (g) of subdivision 2 of section
    4  2511 of the public health law, as amended by section 29  of  part  A  of
    5  chapter 58 of the laws of 2007, is amended to read as follows:
    6    (ii) Effective September first two thousand seven, THROUGH MARCH THIR-
    7  TY-FIRST, TWO THOUSAND FOURTEEN temporary enrollment pursuant to subpar-
    8  agraph  (i)  of  this  paragraph  shall be provided only to children who
    9  apply for recertification of coverage under this title who appear to  be
   10  eligible  for  medical  assistance under title eleven of article five of
   11  the social services law.
   12    S 28. Paragraph (a) of subdivision 2-b of section 2511 of  the  public
   13  health law, as added by section 5 of part B of chapter 58 of the laws of
   14  2010, is amended to read as follows:
   15    (a)  [Effective  October first, two thousand ten, for] FOR purposes of
   16  claiming  federal  financial  participation  under  paragraph  nine   of
   17  subsection  (c) of section twenty-one hundred five of the federal social
   18  security act, [for individuals  declaring  to  be  citizens  at  initial
   19  application,] a household shall provide:
   20    (i) the social security number for the applicant to be verified by the
   21  commissioner  in  accordance  with  a  process established by the social
   22  security administration pursuant to federal law, or
   23    (ii) documentation  of  citizenship  and  identity  of  the  applicant
   24  consistent  with  requirements  under the medical assistance program, as
   25  specified by the commissioner on the initial application.
   26    S 29. Paragraph (d) of subdivision 9 of section  2510  of  the  public
   27  health law, as added by section 72-a of part C of chapter 58 of the laws
   28  of 2009, is amended to read as follows:
   29    (d)  for periods on or after July first, two thousand nine, amounts as
   30  follows:
   31    (i) no payments  are  required  for  eligible  children  whose  family
   32  [gross]  household  income is less than one hundred sixty percent of the
   33  non-farm federal poverty level and for eligible children who are  Ameri-
   34  can  Indians  or  Alaskan  Natives, as defined by the U.S. Department of
   35  Health and Human Services, whose family [gross] household income is less
   36  than two hundred fifty-one  percent  of  the  non-farm  federal  poverty
   37  level; and
   38    (ii)  nine  dollars  per  month  for  each eligible child whose family
   39  [gross] household income is between one hundred sixty  percent  and  two
   40  hundred twenty-two percent of the non-farm federal poverty level, but no
   41  more than twenty-seven dollars per month per family; and
   42    (iii)  fifteen  dollars per month for each eligible child whose family
   43  [gross] household income is between two hundred twenty-three percent and
   44  two hundred fifty percent of the non-farm federal poverty level, but  no
   45  more than forty-five dollars per month per family; and
   46    (iv)  thirty  dollars  per  month for each eligible child whose family
   47  [gross] household income is between two hundred  fifty-one  percent  and
   48  three hundred percent of the non-farm federal poverty level, but no more
   49  than ninety dollars per month per family;
   50    (v)  forty-five dollars per month for each eligible child whose family
   51  [gross] household income is between three hundred one percent and  three
   52  hundred fifty percent of the non-farm federal poverty level, but no more
   53  than one hundred thirty-five dollars per month per family; and
   54    (vi)  sixty  dollars  per  month  for each eligible child whose family
   55  [gross] household income is between three hundred fifty-one percent  and
       S. 2606--D                         98                         A. 3006--D

    1  four  hundred percent of the non-farm federal poverty level, but no more
    2  than one hundred eighty dollars per month per family.
    3    S  30. Subparagraph (iii) of paragraph (a) of subdivision 2 of section
    4  2511 of the public health law, as amended by section 32  of  part  B  of
    5  chapter 58 of the laws of 2008, is amended to read as follows:
    6    (iii)  effective  September  first,  two  thousand eight, resides in a
    7  household having a [gross] household income at  or  below  four  hundred
    8  percent of the non-farm federal poverty level (as defined and updated by
    9  the United States department of health and human services);
   10    S  31.  Subparagraph (ii) of paragraph (d) of subdivision 2 of section
   11  2511 of the public health law, as amended by section 33  of  part  A  of
   12  chapter  58  of  the laws of 2007, clause (B) as amended by section 3 of
   13  part OO of chapter 57 of the  laws  of  2008,  is  amended  to  read  as
   14  follows:
   15    (ii)  (A) The implementation of this paragraph for a child residing in
   16  a household having a [gross] household income at or  below  two  hundred
   17  fifty  percent  of  the  non-farm  federal poverty level (as defined and
   18  updated by the United States department of health  and  human  services)
   19  shall  take  effect  only upon the commissioner's finding that insurance
   20  provided under this title  is  substituting  for  coverage  under  group
   21  health plans in excess of a percentage specified by the secretary of the
   22  federal  department of health and human services. The commissioner shall
   23  notify the legislature prior to implementation of this paragraph.
   24    (B) The implementation of clauses (A), (B), (C), (D),  (E),  (F),  (G)
   25  and  (I) of subparagraph (i) of this paragraph for a child residing in a
   26  household having a [gross] household income between two  hundred  fifty-
   27  one  and  four hundred percent of the non-farm federal poverty level (as
   28  defined and updated by the United States department of health and  human
   29  services)  shall  take  effect  September  first,  two  thousand  eight;
   30  provided however, the entirety of subparagraph  (i)  of  this  paragraph
   31  shall  take  effect  and be applied to such children on the date federal
   32  financial participation becomes available for such population in accord-
   33  ance with the state's Title XXI  child  health  plan.  The  commissioner
   34  shall  monitor  the  number  of  children who are subject to the waiting
   35  period established pursuant to this clause.
   36    S 32. Clauses (A) and (B) of subparagraph  (i)  of  paragraph  (b)  of
   37  subdivision  18  of  section  2511 of the public health law, as added by
   38  section 31 of part A of chapter 58 of the laws of 2007, are  amended  to
   39  read as follows:
   40    (A)  participation  in the program for a child who resides in a house-
   41  hold having a [gross] household income at or  below  two  hundred  fifty
   42  percent of the non-farm federal poverty level (as defined and updated by
   43  the  United  States  department  of  health and human services) shall be
   44  voluntary and an eligible child may disenroll from the  premium  assist-
   45  ance  program  at  any time and enroll in individual coverage under this
   46  title; and
   47    (B) participation in the program for a child who resides in  a  house-
   48  hold having a [gross] household income between two hundred fifty-one and
   49  four  hundred  percent of the non-farm federal poverty level (as defined
   50  and updated  by  the  United  States  department  of  health  and  human
   51  services)  and  meets certain eligibility criteria shall be mandatory. A
   52  child in this income group who meets the criteria for enrollment in  the
   53  premium assistance program shall not be eligible for individual coverage
   54  under this title;
       S. 2606--D                         99                         A. 3006--D

    1    S 33. Subparagraph (iv) of paragraph (b) and paragraph (d) of subdivi-
    2  sion  9  of section 2511 of the public health law, as amended by section
    3  18-a of chapter 2 of the laws of 1998, are amended to read as follows:
    4    (iv) outstationing of persons who are authorized to provide assistance
    5  to  families in completing the enrollment application process under this
    6  title and title eleven of article  five  of  the  social  services  law,
    7  [including  the conduct of personal interviews pursuant to section three
    8  hundred sixty-six-a of the social services law and  personal  interviews
    9  required  upon recertification under such section of the social services
   10  law,] in locations, such as community settings, which are geographically
   11  accessible to large numbers of children who may be eligible for benefits
   12  under such titles, and at times, including evenings and  weekends,  when
   13  large  numbers  of  children who may be eligible for benefits under such
   14  titles are likely to be encountered. Persons outstationed in  accordance
   15  with  this  subparagraph  shall  be authorized to make determinations of
   16  presumptive eligibility in accordance with paragraph (g) of  subdivision
   17  two of section two thousand five hundred and eleven of this title; and
   18    (d)  Subject  to the availability of funds therefor, training shall be
   19  provided for outstationed persons and employees  of  approved  organiza-
   20  tions  to  enable  them  to  disseminate information, AND facilitate the
   21  completion of the  application  process  under  this  subdivision[,  and
   22  conduct   personal   interviews   required   by  section  three  hundred
   23  sixty-six-a of the social services law and personal interviews  required
   24  upon recertification under such section of the social services law].
   25    S  33-a.  Subdivision  1  of  section  206 of the public health law is
   26  amended by adding a new paragraph (s) to read as follows:
   27    (S) ISSUE A READINESS REPORT TO THE LEGISLATURE, DETAILING THE  STATUS
   28  OF  THE  STATEWIDE HEALTH BENEFIT EXCHANGE, STATE ENROLLMENT CENTER, AND
   29  STATE MEDICAID  ENROLLMENT  CENTER  ESTABLISHED  UNDER  EXECUTIVE  ORDER
   30  NUMBER  FORTY-TWO OF TWO THOUSAND TWELVE, BY AUGUST THIRTIETH, TWO THOU-
   31  SAND THIRTEEN. THE READINESS REPORT MAY BE PROVIDED IN ELECTRONIC FORMAT
   32  AND SHALL BE DISTRIBUTED TO THE TEMPORARY PRESIDENT OF THE  SENATE,  THE
   33  SPEAKER  OF  THE ASSEMBLY, THE CHAIR OF THE SENATE STANDING COMMITTEE ON
   34  HEALTH, AND THE CHAIR OF THE ASSEMBLY HEALTH  COMMITTEE.  THE  READINESS
   35  REPORT SHALL OUTLINE THE PROGRESS AND PREPAREDNESS OF THE HEALTH BENEFIT
   36  EXCHANGE,  STATE ENROLLMENT CENTER, AND STATE MEDICAID ENROLLMENT CENTER
   37  AND DETAIL HOW THE EXCHANGE, STATE ENROLLMENT CENTER, AND STATE MEDICAID
   38  ENROLLMENT CENTER WILL CARRY OUT THEIR  RESPECTIVE  FUNCTIONS  INCLUDING
   39  BUT NOT LIMITED TO:
   40    (I) THE PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE, STATE ENROLLMENT
   41  CENTER, AND STATE MEDICAID ENROLLMENT CENTER WILL BEGIN ACCEPTING APPLI-
   42  CATIONS ON OCTOBER FIRST, TWO THOUSAND THIRTEEN;
   43    (II)  THE  PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE, STATE ENROLL-
   44  MENT CENTER, AND STATE MEDICAID ENROLLMENT CENTER WILL CERTIFY QUALIFIED
   45  HEALTH PLANS;
   46    (III) THE ANTICIPATED COST OF INDIVIDUAL AND SMALL GROUP  PLANS  BEING
   47  OFFERED IN THE HEALTH BENEFIT EXCHANGE;
   48    (IV) THE NUMBER OF NAVIGATORS APPROVED;
   49    (V)  THE  PLAN FOR FULL OPERATION BY JANUARY FIRST, TWO THOUSAND FOUR-
   50  TEEN; AND
   51    (VI) THE PLAN TO BECOME FISCALLY SELF-SUSTAINING BY JANUARY FIRST, TWO
   52  THOUSAND FIFTEEN.
   53    S 34. Paragraphs 9 and 10 of subsection (a) of  section  2101  of  the
   54  insurance  law, as added by chapter 687 of the laws of 2003, are amended
   55  and a new paragraph 11 is added to read as follows:
       S. 2606--D                         100                        A. 3006--D

    1    (9) a person who is not a resident of this state who  sells,  solicits
    2  or  negotiates  a contract of insurance for commercial property/casualty
    3  risks to an insured with risks located in more than  one  state  insured
    4  under  that contract, provided that such person is otherwise licensed as
    5  an  insurance  producer  to sell, solicit or negotiate that insurance in
    6  the state where the insured maintains its principal  place  of  business
    7  and the contract of insurance insures risks located in that state; [or]
    8    (10)  any  salaried  full-time employee who counsels or advises his or
    9  her employer relative to the insurance interests of the employer  or  of
   10  the  subsidiaries  or  business affiliates of the employer provided that
   11  the employee does not sell or solicit insurance  or  receive  a  commis-
   12  sion[.]; OR
   13    (11)  ANY  PERSON WHO HAS RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED
   14  BY THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION  1311  OF
   15  THE  AFFORDABLE  CARE  ACT, 42 U.S.C. S 18031, TO ACT AS A NAVIGATOR, AS
   16  SUCH TERM IS USED IN 42 U.S.C. S 18031(I),  PROVIDED  THAT  THE  PERSON:
   17  (A)  HAS COMPLETED THE TRAINING REQUIRED BY THE HEALTH BENEFIT EXCHANGE;
   18  (B) DOES NOT SELL INSURANCE; (C) DOES NOT ENGAGE IN  ANY  ACTIVITY  WITH
   19  RESPECT   TO  INSURANCE  NOT  EXPRESSLY  PERMITTED  UNDER  42  U.S.C.  S
   20  18031(I)(3) AND REGULATIONS THEREUNDER; AND (D)  DOES  NOT  RECEIVE  ANY
   21  COMPENSATION  FOR  ACTING  AS A NAVIGATOR DIRECTLY OR INDIRECTLY FROM AN
   22  INSURED, INSURANCE PRODUCER, OR AN INSURER.
   23    S 35. Paragraphs 8 and 9 of subsection (c)  of  section  2101  of  the
   24  insurance  law,  paragraph  8  as  amended  and  paragraph 9 as added by
   25  section 5 of part I of chapter 61 of the laws of 2011, are amended and a
   26  new paragraph 10 is added to read as follows:
   27    (8) a person who is not a resident of this state who  sells,  solicits
   28  or  negotiates  a  contract for commercial property/casualty risks to an
   29  insured with risks located in more than one  state  insured  under  that
   30  contract,  provided  that such person is otherwise licensed as an insur-
   31  ance producer to sell, solicit or negotiate that insurance in the  state
   32  where  the  insured  maintains  its  principal place of business and the
   33  contract of insurance insures risks located in that state; [or]
   34    (9) a person who is not a resident of this state who  sells,  solicits
   35  or  negotiates  a contract of property/casualty insurance, as defined in
   36  paragraph six of subsection (x) of  this  section,  of  an  insurer  not
   37  authorized  to  do  business  in  this  state,  provided  that:  (A) the
   38  insured's home state is a state other than  this  state;  and  (B)  such
   39  person  is  otherwise licensed to sell, solicit or negotiate excess line
   40  insurance in the insured's home state[.]; OR
   41    (10) ANY PERSON WHO HAS RECEIVED A GRANT FROM AND HAS  BEEN  CERTIFIED
   42  BY  THE  HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF
   43  THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, TO ACT AS  A  NAVIGATOR,  AS
   44  SUCH TERM IS USED IN 42 U.S.C. S 18031(I), INCLUDING ANY PERSON EMPLOYED
   45  BY  A  CERTIFIED NAVIGATOR, PROVIDED THAT THE PERSON:  (A) HAS COMPLETED
   46  THE TRAINING REQUIRED BY THE HEALTH BENEFIT EXCHANGE; (B) DOES NOT  SELL
   47  INSURANCE; (C) DOES NOT ENGAGE IN ANY ACTIVITY WITH RESPECT TO INSURANCE
   48  NOT  EXPRESSLY  PERMITTED  UNDER 42 U.S.C. S 18031(I)(3) AND REGULATIONS
   49  THEREUNDER; AND (D) DOES NOT RECEIVE ANY COMPENSATION FOR  ACTING  AS  A
   50  NAVIGATOR DIRECTLY OR INDIRECTLY FROM AN INSURED, INSURANCE PRODUCER, OR
   51  AN INSURER.
   52    S  36.  Paragraphs  10 and 11 of subsection (k) of section 2101 of the
   53  insurance law, paragraph 10 as amended and  paragraph  11  as  added  by
   54  section 6 of part I of chapter 61 of the laws of 2011, are amended and a
   55  new paragraph 12 is added to read as follows:
       S. 2606--D                         101                        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 commission;
    5  [or]
    6    (11)  a person who is not a resident of this state who sells, solicits
    7  or negotiates a contract of property/casualty insurance, as  defined  in
    8  paragraph  six  of  subsection  (x)  of  this section, of an insurer not
    9  authorized to  do  business  in  this  state,  provided  that:  (A)  the
   10  insured's  home  state  is  a  state other than this state; and (B) such
   11  person is otherwise licensed to sell, solicit or negotiate  excess  line
   12  insurance in the insured's home state[.]; OR
   13    (12)  ANY  PERSON WHO HAS RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED
   14  BY THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION  1311  OF
   15  THE  AFFORDABLE  CARE  ACT,  42 U.S.C. S 18031 TO ACT AS A NAVIGATOR, AS
   16  SUCH TERM IS USED IN 42 U.S.C. S 18031(I), INCLUDING ANY PERSON EMPLOYED
   17  BY A CERTIFIED NAVIGATOR, PROVIDED THAT THE PERSON:  (A)  HAS  COMPLETED
   18  THE  TRAINING REQUIRED BY THE HEALTH BENEFIT EXCHANGE; (B) DOES NOT SELL
   19  INSURANCE; (C) DOES NOT ENGAGE IN ANY ACTIVITY WITH RESPECT TO INSURANCE
   20  NOT EXPRESSLY PERMITTED UNDER 42 U.S.C. S 18031 (I) (3) AND  REGULATIONS
   21  THEREUNDER;  AND  (D)  DOES NOT RECEIVE ANY COMPENSATION FOR ACTING AS A
   22  NAVIGATOR DIRECTLY OR INDIRECTLY FROM AN INSURED, INSURANCE PRODUCER, OR
   23  AN INSURER.
   24    S 37. Subsection (b) of section 2102 of the insurance law  is  amended
   25  by adding a new paragraph 5 to read as follows:
   26    (5) PARAGRAPHS ONE AND THREE OF THIS SUBSECTION SHALL NOT APPLY TO ANY
   27  PERSON  WHO  HAS  RECEIVED  A  GRANT  FROM AND HAS BEEN CERTIFIED BY THE
   28  HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT  TO  SECTION  1311  OF  THE
   29  AFFORDABLE  CARE  ACT, 42 U.S.C. S 18031 (I), INCLUDING PERSONS EMPLOYED
   30  BY CERTIFIED NAVIGATORS; PROVIDED THAT THE PERSON: (A) HAS COMPLETED THE
   31  TRAINING REQUIRED BY THE HEALTH BENEFIT  EXCHANGE;  (B)  DOES  NOT  SELL
   32  INSURANCE; (C) DOES NOT ENGAGE IN ANY ACTIVITY WITH RESPECT TO INSURANCE
   33  NOT  EXPRESSLY PERMITTED UNDER 42 U.S.C. S 18031 (I) (3) AND REGULATIONS
   34  THEREUNDER; AND (D) DOES NOT RECEIVE ANY COMPENSATION FOR  ACTING  AS  A
   35  NAVIGATOR DIRECTLY OR INDIRECTLY FROM AN INSURED, INSURANCE PRODUCER, OR
   36  AN INSURER.
   37    S  37-a. Subsections (a) and (d) of section 2123 of the insurance law,
   38  as amended by chapter 540 of the laws of 1996, paragraph 3 of subsection
   39  (a) as added by chapter 616 of the laws of 1997 and  the  opening  para-
   40  graph  of  paragraph 3 of subsection (a) as amended by chapter 13 of the
   41  laws of 2002, are amended to read as follows:
   42    (a) (1) No agent or representative of any insurer  or  health  mainte-
   43  nance  organization  authorized  to  transact  life,  accident or health
   44  insurance or health maintenance organization business in this state [and
   45  no], insurance broker, [and no] PERSON WHO HAS RECEIVED A GRANT FROM AND
   46  HAS BEEN CERTIFIED BY THE HEALTH BENEFIT EXCHANGE  ESTABLISHED  PURSUANT
   47  TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, TO ACT AS
   48  A  NAVIGATOR, INCLUDING ANY PERSON EMPLOYED BY A CERTIFIED NAVIGATOR, OR
   49  other person, firm, association or corporation, shall issue or circulate
   50  or cause or permit to be issued or circulated, any illustration,  circu-
   51  lar,  statement  or  memorandum  misrepresenting  the terms, benefits or
   52  advantages of any policy or contract of life, accident or health  insur-
   53  ance,  any  annuity  contract  or  any  health  maintenance organization
   54  contract, delivered or issued for delivery or to be delivered or  issued
   55  for delivery, in this state, or shall make any misleading estimate as to
   56  the  dividends  or share of surplus or additional amounts to be received
       S. 2606--D                         102                        A. 3006--D

    1  in the future on such policy or contract, or shall  make  any  false  or
    2  misleading  statement  as  to the dividends or share of surplus or addi-
    3  tional amounts previously paid by any such insurer or health maintenance
    4  organization  on  similar  policies  or  contracts,  or  shall  make any
    5  misleading representation, or any misrepresentation, as to the financial
    6  condition of any such insurer or health maintenance organization, or  as
    7  to  the  legal  reserve system upon which such insurer or health mainte-
    8  nance organization operates.
    9    (2) No such person, firm, association or corporation shall make to any
   10  person or persons any incomplete comparison  of  any  such  policies  or
   11  contracts  of any insurer, insurers, or health maintenance organization,
   12  for the purpose of inducing,  or  tending  to  induce,  such  person  or
   13  persons  to  lapse,  forfeit or surrender any insurance policy or health
   14  maintenance organization contract.
   15    (3) Any replacement of individual life insurance policies or  individ-
   16  ual  annuity  contracts of an insurer by an agent, representative of the
   17  same or different insurer or broker shall conform to  standards  promul-
   18  gated by regulation by the superintendent. Such regulation shall:
   19    (A) specify what constitutes the replacement of a life insurance poli-
   20  cy or annuity contract and the proper disclosure and notification proce-
   21  dures to replace a policy or contract;
   22    (B)  require  notification  of the proposed replacement to the insurer
   23  whose policies or contracts are intended to be replaced;
   24    (C) require the timely exchange of illustrative and  cost  information
   25  required  by section three thousand two hundred nine of this chapter and
   26  necessary for completion of a comparison of the  proposed  and  replaced
   27  coverage; and
   28    (D)  provide for a sixty-day period following issuance of the replace-
   29  ment policies or contracts during which the policy or contract owner may
   30  return the policies or contracts and reinstate the replaced policies  or
   31  contracts.
   32    (d)  Any  agent  or representative of an insurer or health maintenance
   33  organization, [any] insurance broker [and], PERSON WHO  HAS  RECEIVED  A
   34  GRANT  FROM AND HAS BEEN CERTIFIED BY THE HEALTH BENEFIT EXCHANGE ESTAB-
   35  LISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C.  S
   36  18031,  TO ACT AS A NAVIGATOR, INCLUDING ANY PERSON EMPLOYED BY A CERTI-
   37  FIED NAVIGATOR, OR any other person, firm,  association  or  corporation
   38  who,  or  which, shall violate any of the provisions of this section and
   39  shall knowingly receive any compensation or commission for the SOLICITA-
   40  TION, sale OR NEGOTIATION of any insurance  policy,  health  maintenance
   41  organization  or annuity contract induced by a violation of this section
   42  shall also be liable for a civil penalty in the amount received by  such
   43  violator  as  compensation  or commission, which penalty may be sued for
   44  and recovered for his, HER, OR ITS own use and  benefit  by  any  person
   45  induced to purchase an insurance policy, health maintenance organization
   46  or  annuity  contract by such violation. In addition, such agent, repre-
   47  sentative, broker, person, firm, association  or  corporation  violating
   48  this  section  shall  be liable for a civil penalty in the amount of any
   49  compensation or commission lost by any agent, representative  or  broker
   50  as  a  result of a violation of this section or the making of such false
   51  or misleading statement, which penalty may be sued for and recovered for
   52  his, HER, OR ITS own use and benefit by such  agent,  representative  or
   53  broker.
   54    S  37-b.  The insurance law is amended by adding a new section 2138 to
   55  read as follows:
       S. 2606--D                         103                        A. 3006--D

    1    S 2138. HEALTH BENEFIT EXCHANGE NAVIGATORS. A PERSON WHO HAS  RECEIVED
    2  A  GRANT  FROM  AND  HAS  BEEN  CERTIFIED BY THE HEALTH BENEFIT EXCHANGE
    3  ESTABLISHED PURSUANT TO SECTION 1311 OF  THE  AFFORDABLE  CARE  ACT,  42
    4  U.S.C.  S 18031, TO ACT AS A NAVIGATOR, INCLUDING ANY PERSON EMPLOYED BY
    5  A CERTIFIED NAVIGATOR, SHALL NOT RECEIVE, COLLECT OR HOLD ANY FUNDS THAT
    6  WOULD CONSTITUTE FIDUCIARY FUNDS WITHIN THE MEANING OF SECTION TWO THOU-
    7  SAND ONE HUNDRED TWENTY OF THIS ARTICLE.
    8    S  38.  Subparagraph  (B) of paragraph 25 of subsection (i) of section
    9  3216 of the insurance law, as amended by chapter  596  of  the  laws  of
   10  2011, is amended to read as follows:
   11    (B)  Every  policy  [which] THAT provides physician services, medical,
   12  major medical  or  similar  comprehensive-type  coverage  shall  provide
   13  coverage  for  the screening, diagnosis and treatment of autism spectrum
   14  disorder in accordance with this paragraph and shall not exclude  cover-
   15  age  for  the  screening,  diagnosis  or treatment of medical conditions
   16  otherwise covered by the policy because the individual is diagnosed with
   17  autism spectrum disorder. Such coverage may be subject to annual deduct-
   18  ibles, copayments and coinsurance as may be deemed  appropriate  by  the
   19  superintendent and shall be consistent with those imposed on other bene-
   20  fits  under  the policy. Coverage for applied behavior analysis shall be
   21  subject to a  maximum  benefit  of  [forty-five  thousand  dollars]  SIX
   22  HUNDRED  EIGHTY  HOURS  OF  TREATMENT  per  POLICY  OR CALENDAR year per
   23  covered individual [and such maximum annual benefit will increase by the
   24  amount calculated from the average ten year rolling average increase  of
   25  the medical component of the consumer price index]. This paragraph shall
   26  not  be  construed as limiting the benefits that are otherwise available
   27  to an individual under the policy, provided  however  that  such  policy
   28  shall  not  contain any limitations on visits that are solely applied to
   29  the treatment of autism spectrum disorder. No  insurer  shall  terminate
   30  coverage  or  refuse to deliver, execute, issue, amend, adjust, or renew
   31  coverage to an individual solely because  the  individual  is  diagnosed
   32  with autism spectrum disorder or has received treatment for autism spec-
   33  trum  disorder.  Coverage  shall  be  subject  to utilization review and
   34  external appeals of health care services pursuant to article  forty-nine
   35  of  this  chapter  as  well  as, case management, and other managed care
   36  provisions.
   37    S 39. Subparagraph (B) of paragraph 17 of subsection  (1)  of  section
   38  3221  of  the  insurance  law,  as amended by chapter 596 of the laws of
   39  2011, is amended to read as follows:
   40    (B) Every group or blanket  policy  [which]  THAT  provides  physician
   41  services,  medical, major medical or similar comprehensive-type coverage
   42  shall provide coverage for the screening,  diagnosis  and  treatment  of
   43  autism spectrum disorder in accordance with this paragraph and shall not
   44  exclude  coverage  for  the screening, diagnosis or treatment of medical
   45  conditions otherwise covered by the policy  because  the  individual  is
   46  diagnosed with autism spectrum disorder. Such coverage may be subject to
   47  annual  deductibles,  copayments and coinsurance as may be deemed appro-
   48  priate by the superintendent and shall be consistent with those  imposed
   49  on  other  benefits  under  the  group  or  blanket policy. Coverage for
   50  applied behavior analysis shall be  subject  to  a  maximum  benefit  of
   51  [forty-five  thousand dollars] SIX HUNDRED EIGHTY HOURS OF TREATMENT per
   52  POLICY OR CALENDAR year per covered individual [and such maximum  annual
   53  benefit will increase by the amount calculated from the average ten year
   54  rolling  average increase of the medical component of the consumer price
   55  index]. This paragraph shall not be construed as limiting  the  benefits
   56  that are otherwise available to an individual under the group or blanket
       S. 2606--D                         104                        A. 3006--D

    1  policy,  provided however that such policy shall not contain any limita-
    2  tions on visits that are solely applied to the treatment of autism spec-
    3  trum disorder. No insurer shall terminate coverage or refuse to deliver,
    4  execute, issue, amend, adjust, or renew coverage to an individual solely
    5  because the individual is diagnosed with autism spectrum disorder or has
    6  received  treatment  for  autism  spectrum  disorder.  Coverage shall be
    7  subject to utilization  review  and  external  appeals  of  health  care
    8  services pursuant to article forty-nine of this chapter as well as, case
    9  management, and other managed care provisions.
   10    S  40. Paragraph 2 of subsection (ee) of section 4303 of the insurance
   11  law, as amended by chapter 596 of the laws of 2011, is amended  to  read
   12  as follows:
   13    (2)  Every contract [which] THAT provides physician services, medical,
   14  major medical  or  similar  comprehensive-type  coverage  shall  provide
   15  coverage  for  the screening, diagnosis and treatment of autism spectrum
   16  disorder in accordance with this [subsection] PARAGRAPH  and  shall  not
   17  exclude  coverage  for  the screening, diagnosis or treatment of medical
   18  conditions otherwise covered by the contract because the  individual  is
   19  diagnosed with autism spectrum disorder. Such coverage may be subject to
   20  annual  deductibles,  copayments and coinsurance as may be deemed appro-
   21  priate by the superintendent and shall be consistent with those  imposed
   22  on  other  benefits  under  the  contract. Coverage for applied behavior
   23  analysis shall be subject to a maximum benefit of  [forty-five  thousand
   24  dollars]  SIX HUNDRED EIGHTY HOURS OF TREATMENT per CONTRACT OR CALENDAR
   25  year per covered  individual  [and  such  maximum  annual  benefit  will
   26  increase  by  the  amount  calculated  from the average ten year rolling
   27  average increase of the medical component of the consumer price  index].
   28  This  paragraph shall not be construed as limiting the benefits that are
   29  otherwise available to an individual under the contract, provided howev-
   30  er that such contract shall not contain any limitations on  visits  that
   31  are  solely  applied  to  the  treatment of autism spectrum disorder. No
   32  insurer shall terminate coverage or refuse to deliver,  execute,  issue,
   33  amend,  adjust,  or  renew  coverage to an individual solely because the
   34  individual is diagnosed with autism spectrum disorder  or  has  received
   35  treatment  for  autism  spectrum  disorder. Coverage shall be subject to
   36  utilization review and external appeals of health care services pursuant
   37  to article forty-nine of this chapter as well as, case  management,  and
   38  other managed care provisions.
   39    S 40-a. Paragraph 1 of subsection (d) of section 3221 of the insurance
   40  law is amended to read as follows:
   41    (1)  The  superintendent  may  approve  any  form of certificate to be
   42  issued under a blanket accident and health insurance policy  as  defined
   43  in section four thousand two hundred thirty-seven of this chapter, which
   44  omits  or  modifies any of the provisions hereinbefore required, if [he]
   45  THE SUPERINTENDENT deems such omission or modification suitable for  the
   46  character of such insurance and not unjust to the persons insured there-
   47  under.   CERTIFICATES ISSUED UNDER A POLICY OR CONTRACT OF STUDENT ACCI-
   48  DENT AND HEALTH INSURANCE AS  DEFINED  IN  SECTION  THREE  THOUSAND  TWO
   49  HUNDRED FORTY OF THIS ARTICLE SHALL COMPLY WITH SUCH SECTION.
   50    S  41.  The  insurance  law is amended by adding a new section 3240 to
   51  read as follows:
   52    S 3240. STUDENT ACCIDENT AND HEALTH INSURANCE.  (A) IN THIS SECTION:
   53    (1) "STUDENT ACCIDENT AND HEALTH INSURANCE" MEANS A POLICY OR CONTRACT
   54  OF HOSPITAL, MEDICAL, OR SURGICAL EXPENSE INSURANCE DELIVERED OR  ISSUED
   55  FOR  DELIVERY  IN  THIS  STATE  ON OR AFTER JANUARY FIRST, TWO  THOUSAND
   56  FOURTEEN, BY AN INSURER OR A CORPORATION, TO AN  INSTITUTION  OF  HIGHER
       S. 2606--D                         105                        A. 3006--D

    1  EDUCATION   COVERING  STUDENTS  ENROLLED  IN  THE  INSTITUTION  AND  THE
    2  STUDENTS' DEPENDENTS.
    3    (2)  "INSTITUTION OF HIGHER EDUCATION" OR "INSTITUTION" SHALL HAVE THE
    4  MEANING SET FORTH IN THE HIGHER EDUCATION ACT OF 1965, 20 U.S.C. S 1001.
    5    (3) "INSURER" MEANS AN INSURER LICENSED TO WRITE ACCIDENT  AND  HEALTH
    6  INSURANCE PURSUANT TO THIS CHAPTER.
    7    (4)  "CORPORATION"  MEANS  A  CORPORATION ORGANIZED IN ACCORDANCE WITH
    8  ARTICLE FORTY-THREE OF THIS CHAPTER.
    9    (B) AN INSURER OR CORPORATION SHALL NOT IMPOSE ANY PRE-EXISTING CONDI-
   10  TION EXCLUSION IN A STUDENT   ACCIDENT AND HEALTH  INSURANCE  POLICY  OR
   11  CONTRACT.    AN INSURER OR CORPORATION SHALL NOT CONDITION  ELIGIBILITY,
   12  INCLUDING CONTINUED ELIGIBILITY,  FOR  A  STUDENT  ACCIDENT  AND  HEALTH
   13  INSURANCE  POLICY  OR  CONTRACT  ON  HEALTH  STATUS,  MEDICAL CONDITION,
   14  INCLUDING BOTH PHYSICAL AND MENTAL ILLNESSES, CLAIMS EXPERIENCE, RECEIPT
   15  OF HEALTH CARE, MEDICAL HISTORY, GENETIC INFORMATION, EVIDENCE OF INSUR-
   16  ABILITY, INCLUDING CONDITIONS ARISING OUT OF ACTS OF DOMESTIC  VIOLENCE,
   17  OR DISABILITY.
   18    (C)  AN  INSURER  OR CORPORATION SHALL CONDITION ELIGIBILITY INCLUDING
   19  CONTINUING ELIGIBILITY, ON THE COVERED INDIVIDUAL BEING  ENROLLED  AS  A
   20  STUDENT IN AN INSTITUTION OF HIGHER EDUCATION TO WHICH THE STUDENT ACCI-
   21  DENT AND HEALTH INSURANCE POLICY OR CONTRACT IS ISSUED.
   22    (D)  A  STUDENT ACCIDENT AND HEALTH INSURANCE POLICY OR CONTRACT SHALL
   23  PROVIDE COVERAGE FOR ESSENTIAL HEALTH BENEFITS  AS  DEFINED  IN  SECTION
   24  1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B).
   25    (E)  AN  INSURER OR CORPORATION SHALL NOT REFUSE TO RENEW OR OTHERWISE
   26  TERMINATE A STUDENT ACCIDENT AND HEALTH  INSURANCE  POLICY  OR  CONTRACT
   27  EXCEPT FOR ONE OR MORE OF THE REASONS SET FORTH IN:
   28    (1)  SUBPARAGRAPHS (A), (B), (D) OR (G) OF PARAGRAPH TWO OF SUBSECTION
   29  (P) OF SECTION THREE THOUSAND TWO HUNDRED TWENTY-ONE OF THIS ARTICLE; OR
   30    (2) SUBPARAGRAPHS (A), (B), (D) OR (G) OF PARAGRAPH TWO OF  SUBSECTION
   31  (J) OF SECTION FOUR THOUSAND THREE HUNDRED FIVE OF THIS CHAPTER.
   32    (F)  OTHER  THAN  THE  PROVISIONS  HEREIN  ALSO  REQUIRED  BY  ARTICLE
   33  FORTY-THREE OF THIS CHAPTER, THIS SECTION SHALL NOT  APPLY  TO  COVERAGE
   34  UNDER  A STUDENT HEALTH PLAN ISSUED PURSUANT TO SECTION ONE THOUSAND ONE
   35  HUNDRED TWENTY-FOUR OF THIS CHAPTER.
   36    (G) THE SUPERINTENDENT MAY PROMULGATE  REGULATIONS  REGARDING  STUDENT
   37  ACCIDENT  AND  HEALTH INSURANCE, WHICH MAY INCLUDE MINIMUM STANDARDS FOR
   38  THE FORM, CONTENT AND SALE OF THE POLICIES AND CONTRACTS  AND,  NOTWITH-
   39  STANDING THE PROVISIONS OF SECTION THREE THOUSAND TWO HUNDRED THIRTY-ONE
   40  AND FOUR THOUSAND THREE HUNDRED EIGHT OF THIS CHAPTER, THE ESTABLISHMENT
   41  OF  RATING  METHODOLOGY  TO  BE  APPLIED  TO THE POLICIES AND CONTRACTS;
   42  PROVIDED THAT ANY SUCH REGULATIONS SHALL BE NO LESS FAVORABLE  TO    THE
   43  INSURED  THAN  THAT  WHICH  IS  PROVIDED UNDER FEDERAL LAW AND STATE LAW
   44  APPLICABLE TO INDIVIDUAL INSURANCE.
   45    (H) THE  RATIO  OF  BENEFITS  TO  PREMIUMS  SHALL  BE  NOT  LESS  THAN
   46  EIGHTY-TWO  PERCENT  AS  CALCULATED  IN A MANNER TO BE DETERMINED BY THE
   47  SUPERINTENDENT.
   48    (I) EVERY INSURER OR CORPORATION SHALL REPORT  TO  THE  SUPERINTENDENT
   49  ANNUALLY,  ON  A  DATE  SPECIFIED BY THE SUPERINTENDENT IN A REGULATION,
   50  CLAIMS EXPERIENCE AND OTHER DATA IN A MANNER ACCEPTABLE  TO  THE  SUPER-
   51  INTENDENT  THAT SHALL DEMONSTRATE THE INSURER'S OR CORPORATION'S COMPLI-
   52  ANCE WITH THE APPLICABLE  RULES AND REGULATIONS, INCLUDING  THE  MINIMUM
   53  LOSS RATIO REQUIRED BY SUBSECTION (H) OF THIS SECTION. FAILURE TO COMPLY
   54  WITH  SUBSECTION  (H)  OF  THIS SECTION IS SUBJECT TO CORRECTIVE ACTION,
   55  WHICH MAY INCLUDE THE SUBMISSION, TO THE SUPERINTENDENT, OF AN APPROPRI-
   56  ATE RATE FILING OR FORM AND  RATE  FILING  TO  REDUCE  FUTURE  PREMIUMS,
       S. 2606--D                         106                        A. 3006--D

    1  INCREASE BENEFITS, ISSUE DIVIDENDS, ISSUE PREMIUM REFUNDS OR CREDITS, OR
    2  ANY COMBINATION OF THESE SUCH THAT THE MINIMUM LOSS RATIO CAN REASONABLY
    3  BE EXPECTED TO BE ACHIEVED.
    4    S  42. Subsection (1) of section 3216 of the insurance law is REPEALED
    5  and a new subsection (l) is added to read as follows:
    6    (L) ON AND AFTER OCTOBER FIRST,  TWO  THOUSAND  THIRTEEN,  AN  INSURER
    7  SHALL  NOT OFFER INDIVIDUAL HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSUR-
    8  ANCE POLICIES UNLESS THE POLICIES MEET THE  REQUIREMENTS  OF  SUBSECTION
    9  (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF THIS CHAPTER.
   10  SUCH POLICIES THAT ARE OFFERED WITHIN THE HEALTH BENEFIT EXCHANGE ESTAB-
   11  LISHED  PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S
   12  18031, OR ANY REGULATIONS PROMULGATED THEREUNDER, ALSO  SHALL  MEET  ANY
   13  REQUIREMENTS ESTABLISHED BY THE HEALTH BENEFIT EXCHANGE.
   14    S  43. Subsection (1) of section 4304 of the insurance law is REPEALED
   15  and a new subsection (1) is added to read as follows:
   16    (1) ON AND AFTER OCTOBER FIRST, TWO THOUSAND THIRTEEN,  A  CORPORATION
   17  SHALL NOT OFFER INDIVIDUAL HOSPITAL, MEDICAL, OR SURGICAL EXPENSE INSUR-
   18  ANCE  CONTRACTS UNLESS THE CONTRACTS MEET THE REQUIREMENTS OF SUBSECTION
   19  (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF THIS ARTICLE.
   20  SUCH CONTRACTS THAT ARE  OFFERED  WITHIN  THE  HEALTH  BENEFIT  EXCHANGE
   21  ESTABLISHED  PURSUANT  TO  SECTION  1311  OF THE AFFORDABLE CARE ACT, 42
   22  U.S.C. S 18031, OR ANY REGULATIONS PROMULGATED  THEREUNDER,  ALSO  SHALL
   23  MEET ANY REQUIREMENTS ESTABLISHED BY THE HEALTH BENEFIT EXCHANGE. TO THE
   24  EXTENT  THAT  A  HOLDER  OF  A  SPECIAL PURPOSE CERTIFICATE OF AUTHORITY
   25  ISSUED PURSUANT TO SECTION FOUR THOUSAND FOUR  HUNDRED  THREE-A  OF  THE
   26  PUBLIC  HEALTH  LAW  OFFERS  INDIVIDUAL  HOSPITAL,  MEDICAL, OR SURGICAL
   27  EXPENSE INSURANCE CONTRACTS, THE CONTRACTS SHALL MEET  THE  REQUIREMENTS
   28  OF SUBSECTION (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF
   29  THIS ARTICLE.
   30    S  43-a. Item (i) of subparagraph (C) of paragraph 2 of subsection (c)
   31  of section 4304 of the insurance law, as amended by section 9 of part  A
   32  of chapter 1 of the laws of 2002, is amended to read as follows:
   33    (i)  Discontinuance  of  a  class  of contract upon not less than five
   34  months' prior written notice[, except  for  subscribers  to  direct  pay
   35  major  medical or similar comprehensive-type coverage issued by a corpo-
   36  ration organized pursuant to this article, or any successor  corporation
   37  organized  through  a  conversion  pursuant to subsection (j) of section
   38  four thousand three hundred one of this article, and in effect prior  to
   39  January  first,  nineteen  hundred  ninety-six  who  are  ineligible  to
   40  purchase policies offered after such date pursuant to section four thou-
   41  sand three hundred twenty-one or four thousand three hundred  twenty-two
   42  of  this  article due to the provisions of 42 U.S.C. 1395ss in effect on
   43  the effective date of this  item.  In  the  event  any  such  subscriber
   44  becomes  eligible  to purchase policies offered pursuant to section four
   45  thousand three hundred twenty-one or four thousand three  hundred  twen-
   46  ty-two  of  this  article, then such subscriber may be discontinued upon
   47  not less than five months' prior  written  notice].  In  exercising  the
   48  option  to  discontinue  coverage pursuant to this item, the corporation
   49  must act uniformly without regard to any health status-related factor of
   50  enrolled individuals or individuals who may  become  eligible  for  such
   51  coverage and must offer to subscribers or group remitting agents, as may
   52  be  appropriate,  the  option  to  purchase  all other individual health
   53  insurance coverage currently being offered by the corporation to  appli-
   54  cants in that market.
   55    S  44.  The  section heading and subsection (a) of section 4321 of the
   56  insurance law, the section heading as added by chapter 504 of  the  laws
       S. 2606--D                         107                        A. 3006--D

    1  of  1995  and  subsection  (a)  as amended by chapter 342 of the laws of
    2  2004, are amended to read as follows:
    3    Standardization   of  individual  enrollee  direct  payment  contracts
    4  offered by health maintenance organizations PRIOR TO OCTOBER FIRST,  TWO
    5  THOUSAND  THIRTEEN.  (a)  On  and  after January first, nineteen hundred
    6  ninety-six, AND UNTIL SEPTEMBER THIRTIETH,  TWO  THOUSAND  THIRTEEN  all
    7  health maintenance organizations issued a certificate of authority under
    8  article forty-four of the public health law or licensed under this arti-
    9  cle  shall  offer a standardized individual enrollee contract on an open
   10  enrollment basis as prescribed by section forty-three hundred  seventeen
   11  of  this article and section forty-four hundred six of the public health
   12  law, and regulations promulgated  thereunder,  provided,  however,  that
   13  such  requirements  shall not apply to a health maintenance organization
   14  exclusively serving individuals enrolled pursuant  to  title  eleven  of
   15  article  five of the social services law, title eleven-D of article five
   16  of the social services law, title one-A of article  twenty-five  of  the
   17  public health law or title eighteen of the federal Social Security Act[,
   18  and,  further  provided, that such health maintenance organization shall
   19  not discontinue a contract for an  individual  receiving  comprehensive-
   20  type coverage in effect prior to January first, two thousand four who is
   21  ineligible to purchase policies offered after such date pursuant to this
   22  section  or section four thousand three hundred twenty-two of this arti-
   23  cle due to the provision of 42 U.S.C. 1395ss in effect prior to  January
   24  first,  two thousand four]. On and after January first, nineteen hundred
   25  ninety-six, AND UNTIL SEPTEMBER THIRTIETH, TWO  THOUSAND  THIRTEEN,  the
   26  enrollee  contracts  issued  pursuant  to  this section and section four
   27  thousand three hundred twenty-two of this  article  shall  be  the  only
   28  contracts  offered  by  health maintenance organizations to individuals.
   29  The enrollee contracts issued by a health maintenance organization under
   30  this section and section four thousand three hundred twenty-two of  this
   31  article  shall  also  be the only contracts issued by health maintenance
   32  organizations for purposes of conversion pursuant to sections four thou-
   33  sand three hundred four and four thousand three  hundred  five  of  this
   34  article.  However,  nothing  in  this section shall be deemed to require
   35  health maintenance organizations to terminate individual direct  payment
   36  contracts  issued prior to January first, nineteen hundred ninety-six or
   37  prevent health maintenance  organizations  from  terminating  individual
   38  direct payment contracts issued prior to January first, nineteen hundred
   39  ninety-six.
   40    S  45.  The  section heading and subsection (a) of section 4322 of the
   41  insurance law, the section heading as added by chapter 504 of  the  laws
   42  of  1995  and  subsection  (a)  as amended by chapter 342 of the laws of
   43  2004, are amended and a new subsection (i) is added to read as follows:
   44    Standardization  of  individual  enrollee  direct  payment   contracts
   45  offered  by  health  maintenance organizations which provide out-of-plan
   46  benefits PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN. (a) On and after
   47  January first, nineteen hundred ninety-six, AND UNTIL SEPTEMBER  THIRTI-
   48  ETH,  TWO THOUSAND THIRTEEN, all health maintenance organizations issued
   49  a certificate of authority under article forty-four of the public health
   50  law or licensed under this article shall offer to individuals, in  addi-
   51  tion  to  the  standardized  contract  required by section four thousand
   52  three hundred twenty-one of  this  article,  a  standardized  individual
   53  enrollee  direct  payment  contract  on  an  open  enrollment  basis  as
   54  prescribed by section four thousand  three  hundred  seventeen  of  this
   55  article  and section four thousand four hundred six of the public health
   56  law, and regulations promulgated thereunder, with an out-of-plan benefit
       S. 2606--D                         108                        A. 3006--D

    1  system, provided, however, that such requirements shall not apply  to  a
    2  health maintenance organization exclusively serving individuals enrolled
    3  pursuant  to  title  eleven  of article five of the social services law,
    4  title  eleven-D  of article five of the social services law, title one-A
    5  of article twenty-five of the public health law or title eighteen of the
    6  federal Social Security Act[, and, further provided,  that  such  health
    7  maintenance  organization  shall not discontinue a contract for an indi-
    8  vidual receiving comprehensive-type coverage in effect prior to  January
    9  first,  two thousand four who is ineligible to purchase policies offered
   10  after such date pursuant to this section or section four thousand  three
   11  hundred  twenty-two  of  this  article due to the provision of 42 U.S.C.
   12  1395ss in effect prior to January first, two thousand four]. The out-of-
   13  plan benefit system shall either be provided by the  health  maintenance
   14  organization  pursuant  to subdivision two of section four thousand four
   15  hundred six of the public health law or through an  accompanying  insur-
   16  ance contract providing out-of-plan benefits offered by a company appro-
   17  priately  licensed pursuant to this chapter. On and after January first,
   18  nineteen hundred ninety-six, AND UNTIL SEPTEMBER THIRTIETH, TWO THOUSAND
   19  THIRTEEN, the contracts issued pursuant to this section and section four
   20  thousand three hundred twenty-one of this  article  shall  be  the  only
   21  contracts  offered  by  health maintenance organizations to individuals.
   22  The enrollee contracts issued by a health maintenance organization under
   23  this section and section four thousand three hundred twenty-one of  this
   24  article  shall  also  be the only contracts issued by the health mainte-
   25  nance organization for purposes of conversion pursuant to sections  four
   26  thousand three hundred four and four thousand three hundred five of this
   27  article.  However,  nothing  in  this section shall be deemed to require
   28  health maintenance organizations to terminate individual direct  payment
   29  contracts  issued prior to January first, nineteen hundred ninety-six or
   30  prohibit health maintenance organizations  from  terminating  individual
   31  direct payment contracts issued prior to January first, nineteen hundred
   32  ninety-six.
   33    (I)  ON  AND AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN, EACH CONTRACT
   34  THAT IS NOT A GRANDFATHERED HEALTH PLAN SHALL PROVIDE COVERAGE  FOR  THE
   35  ESSENTIAL HEALTH BENEFIT PACKAGE. FOR PURPOSES OF THIS SUBSECTION:
   36    (1)  "ESSENTIAL  HEALTH  BENEFITS  PACKAGE" SHALL HAVE THE MEANING SET
   37  FORTH IN SECTION 1302(A)  OF  THE  AFFORDABLE  CARE  ACT,  42  U.S.C.  S
   38  18022(A); AND
   39    (2)  "GRANDFATHERED  HEALTH  PLAN" MEANS COVERAGE PROVIDED BY A CORPO-
   40  RATION IN WHICH AN INDIVIDUAL WAS ENROLLED ON  MARCH  TWENTY-THIRD,  TWO
   41  THOUSAND  TEN FOR AS LONG AS THE COVERAGE MAINTAINS GRANDFATHERED STATUS
   42  IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
   43  S 18011(E).
   44    S 46. The insurance law is amended by adding a  new  section  4328  to
   45  read as follows:
   46    S 4328. INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACTS OFFERED BY HEALTH
   47  MAINTENANCE  ORGANIZATION ON AND AFTER OCTOBER FIRST, TWO THOUSAND THIR-
   48  TEEN. (A) ON AND AFTER  OCTOBER  FIRST,  TWO  THOUSAND  THIRTEEN,  EVERY
   49  HEALTH  MAINTENANCE ORGANIZATION ISSUED A CERTIFICATE OF AUTHORITY UNDER
   50  ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR LICENSED UNDER THIS ARTI-
   51  CLE SHALL OFFER  AN  INDIVIDUAL  ENROLLEE  DIRECT  PAYMENT  CONTRACT  IN
   52  ACCORDANCE  WITH  THE  REQUIREMENTS  OF THIS SECTION; PROVIDED, HOWEVER,
   53  THAT THIS REQUIREMENT SHALL NOT APPLY TO A HOLDER OF A  SPECIAL  PURPOSE
   54  CERTIFICATE  OF  AUTHORITY ISSUED PURSUANT TO SECTION FOUR THOUSAND FOUR
   55  HUNDRED THREE-A OF THE PUBLIC HEALTH LAW, EXCEPT AS  OTHERWISE  REQUIRED
   56  UNDER SUBSECTION (L) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR OF THIS
       S. 2606--D                         109                        A. 3006--D

    1  ARTICLE,  OR A HEALTH MAINTENANCE ORGANIZATION EXCLUSIVELY SERVING INDI-
    2  VIDUALS ENROLLED PURSUANT TO TITLE ELEVEN OF ARTICLE FIVE OF THE  SOCIAL
    3  SERVICES LAW, TITLE ELEVEN-D OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW,
    4  TITLE  ONE-A  OF  ARTICLE  TWENTY-FIVE OF THE PUBLIC HEALTH LAW OR TITLE
    5  EIGHTEEN OF THE FEDERAL SOCIAL SECURITY ACT.   THE  SUPERINTENDENT  MAY,
    6  AFTER GIVING CONSIDERATION TO THE PUBLIC INTEREST, EXEMPT A HEALTH MAIN-
    7  TENANCE ORGANIZATION FROM THE REQUIREMENTS OF THIS SECTION PROVIDED THAT
    8  ANOTHER  HEALTH  INSURER  OR  HEALTH MAINTENANCE ORGANIZATION WITHIN THE
    9  HEALTH  MAINTENANCE  ORGANIZATION'S  SAME  HOLDING  COMPANY  SYSTEM,  AS
   10  DEFINED  IN  ARTICLE FIFTEEN OF THIS CHAPTER, INCLUDING A HEALTH MAINTE-
   11  NANCE ORGANIZATION OPERATED AS A LINE OF BUSINESS OF  A  HEALTH  SERVICE
   12  CORPORATION  LICENSED  UNDER THIS ARTICLE, OFFERS AN INDIVIDUAL ENROLLEE
   13  DIRECT PAYMENT CONTRACT THAT, AT A MINIMUM, COMPLIES WITH  THIS  SECTION
   14  AND  PROVIDES ALL OF THE CONSUMER PROTECTIONS REQUIRED TO BE PROVIDED BY
   15  A HEALTH MAINTENANCE ORGANIZATION PURSUANT TO THE PUBLIC HEALTH LAW  AND
   16  REGULATIONS,  INCLUDING THOSE CONSUMER PROTECTIONS CONTAINED IN SECTIONS
   17  FOUR THOUSAND FOUR HUNDRED THREE AND FOUR THOUSAND FOUR HUNDRED  EIGHT-A
   18  OF  THE  PUBLIC HEALTH LAW.   THE ENROLLEE CONTRACTS ISSUED  BY A HEALTH
   19  MAINTENANCE ORGANIZATION UNDER THIS  SECTION  ALSO  SHALL  BE  THE  ONLY
   20  CONTRACTS  ISSUED BY THE HEALTH MAINTENANCE ORGANIZATION FOR PURPOSES OF
   21  CONVERSION PURSUANT TO SECTIONS FOUR THOUSAND  THREE  HUNDRED  FOUR  AND
   22  FOUR THOUSAND THREE HUNDRED FIVE OF THIS ARTICLE.
   23    (B) (1) THE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSU-
   24  ANT  TO  THIS  SECTION  SHALL  PROVIDE COVERAGE FOR THE ESSENTIAL HEALTH
   25  BENEFIT PACKAGE AS REQUIRED IN SECTION  2707(A)  OF  THE  PUBLIC  HEALTH
   26  SERVICE  ACT,  42  U.S.C.  S 300GG-6(A). FOR PURPOSES OF THIS PARAGRAPH,
   27  "ESSENTIAL HEALTH BENEFITS PACKAGE" SHALL HAVE THE MEANING SET FORTH  IN
   28  SECTION 1302(A) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(A).
   29    (2)  A  HEALTH MAINTENANCE ORGANIZATION SHALL OFFER AT LEAST ONE INDI-
   30  VIDUAL ENROLLEE DIRECT PAYMENT CONTRACT AT EACH  LEVEL  OF  COVERAGE  AS
   31  DEFINED  IN  SECTION  1302(D)  OF  THE  AFFORDABLE CARE ACT, 42 U.S.C. S
   32  18022(D). A HEALTH MAINTENANCE ORGANIZATION ALSO SHALL OFFER ONE  CHILD-
   33  ONLY  PLAN  AT  EACH LEVEL OF COVERAGE AS REQUIRED IN SECTION 2707(C) OF
   34  THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(C).
   35    (3) WITHIN THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION
   36  1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, A HEALTH MAINTENANCE
   37  ORGANIZATION MAY OFFER AN INDIVIDUAL ENROLLEE  DIRECT  PAYMENT  CONTRACT
   38  THAT  IS A CATASTROPHIC HEALTH PLAN AS DEFINED IN SECTION 1302(E) OF THE
   39  AFFORDABLE CARE ACT, 42 U.S.C. S 18022(E), OR ANY REGULATIONS PROMULGAT-
   40  ED THEREUNDER.
   41    (4) THE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT  OFFERED  PURSUANT
   42  TO  THIS  SECTION  SHALL  HAVE  THE  SAME  ENROLLMENT PERIODS, INCLUDING
   43  SPECIAL  ENROLLMENT  PERIODS,  AS  REQUIRED  FOR  AN  INDIVIDUAL  DIRECT
   44  PAYMENT  CONTRACT OFFERED WITHIN THE HEALTH BENEFIT EXCHANGE ESTABLISHED
   45  PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S  18031,
   46  OR ANY REGULATIONS PROMULGATED THEREUNDER.
   47    (5)  THE  INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSUANT
   48  TO THIS SECTION SHALL BE ISSUED WITHOUT REGARD TO EVIDENCE OF INSURABIL-
   49  ITY AND WITHOUT AN EXCLUSION FOR PRE-EXISTING CONDITIONS.
   50    (6) A HEALTH MAINTENANCE ORGANIZATION OFFERING AN INDIVIDUAL  ENROLLEE
   51  DIRECT  PAYMENT  CONTRACT  PURSUANT  TO THIS SECTION SHALL NOT ESTABLISH
   52  RULES FOR ELIGIBILITY, INCLUDING CONTINUED ELIGIBILITY, OF ANY  INDIVID-
   53  UAL OR DEPENDENT OF THE INDIVIDUAL TO ENROLL UNDER THE CONTRACT BASED ON
   54  ANY OF THE FOLLOWING HEALTH STATUS-RELATED FACTORS:
   55    (A) HEALTH STATUS;
   56    (B) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL ILLNESSES;
       S. 2606--D                         110                        A. 3006--D

    1    (C) CLAIMS EXPERIENCE;
    2    (D) RECEIPT OF HEALTH CARE;
    3    (E) MEDICAL HISTORY;
    4    (F) GENETIC INFORMATION;
    5    (G) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING OUT OF ACTS
    6  OF DOMESTIC VIOLENCE; OR
    7    (H) DISABILITY.
    8    (7)  THE  INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSUANT
    9  TO THIS SECTION SHALL BE COMMUNITY RATED. FOR  PURPOSES  OF  THIS  PARA-
   10  GRAPH, "COMMUNITY RATED" MEANS A RATING METHODOLOGY IN WHICH THE PREMIUM
   11  FOR  ALL  PERSONS  COVERED  BY A CONTRACT FORM IS THE SAME, BASED ON THE
   12  EXPERIENCE OF THE ENTIRE POOL OF RISKS,  WITHOUT  REGARD  TO  AGE,  SEX,
   13  HEALTH STATUS, TOBACCO USAGE, OR OCCUPATION.
   14    (8)  A  HEALTH  MAINTENANCE ORGANIZATION SHALL MAKE AVAILABLE AT LEAST
   15  ONE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT AT THE PLATINUM LEVEL OF
   16  COVERAGE, AS DEFINED IN SECTION 1302(D) OF THE AFFORDABLE CARE  ACT,  42
   17  USC  S  18022(D), THAT INCLUDES AN OUT-OF-PLAN BENEFITS OPTION TO ENROL-
   18  LEES COVERED PRIOR TO OCTOBER  FIRST,  TWO  THOUSAND  THIRTEEN,  BY  THE
   19  HEALTH  MAINTENANCE ORGANIZATION UNDER CONTRACTS SUBJECT TO SECTION FOUR
   20  THOUSAND THREE HUNDRED TWENTY-TWO OF THIS ARTICLE.  THE  HEALTH  MAINTE-
   21  NANCE  ORGANIZATION SHALL PROVIDE THE PLATINUM LEVEL OF COVERAGE WITH AN
   22  OUT-OF-PLAN BENEFIT RIDER TO ANY  ENROLLEE  THAT  ELECTS  THE  COVERAGE.
   23  ENROLLEES WHO TERMINATE THE RIDER OR ARE TERMINATED FOLLOWING THE EFFEC-
   24  TIVE  DATE  OF THIS PARAGRAPH SHALL BE INELIGIBLE TO PURCHASE SUCH RIDER
   25  FOLLOWING THE TERMINATION. NOTHING IN THIS  PARAGRAPH  SHALL  REQUIRE  A
   26  HEALTH  MAINTENANCE  ORGANIZATION TO OFFER AN OUT-OF-PLAN BENEFIT TO ANY
   27  OTHER ENROLLEE, INCLUDING THROUGH THE HEALTH BENEFIT EXCHANGE. A  HEALTH
   28  MAINTENANCE ORGANIZATION SHALL PROVIDE NOTICE OF THE AVAILABILITY OF THE
   29  OUT-OF-PLAN  BENEFITS  PRIOR  TO OCTOBER FIRST, TWO THOUSAND THIRTEEN OR
   30  SHALL  INCORPORATE  NOTICE  OF  SUCH  AVAILABILITY  INTO  DISCONTINUANCE
   31  NOTICES  ISSUED  PURSUANT TO SECTION FOUR THOUSAND THREE HUNDRED FOUR OF
   32  THIS ARTICLE.
   33    (C) IN ADDITION TO OR  IN  LIEU  OF  THE  INDIVIDUAL  ENROLLEE  DIRECT
   34  PAYMENT  CONTRACTS  REQUIRED  UNDER THIS SECTION, ALL HEALTH MAINTENANCE
   35  ORGANIZATIONS ISSUED A CERTIFICATE OF AUTHORITY UNDER ARTICLE FORTY-FOUR
   36  OF THE PUBLIC HEALTH LAW OR LICENSED UNDER THIS ARTICLE MAY OFFER  INDI-
   37  VIDUAL  ENROLLEE  DIRECT  PAYMENT  CONTRACTS  WITHIN  THE HEALTH BENEFIT
   38  EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311  OF  THE  AFFORDABLE  CARE
   39  ACT,  42  U.S.C.  S  18031,  OR  ANY REGULATIONS PROMULGATED THEREUNDER,
   40  SUBJECT TO ANY REQUIREMENTS ESTABLISHED BY THE HEALTH BENEFIT  EXCHANGE.
   41  IF  A  HEALTH  MAINTENANCE  ORGANIZATION  SATISFIES  THE REQUIREMENTS OF
   42  SUBSECTION (A) OF THIS SECTION BY OFFERING  INDIVIDUAL  ENROLLEE  DIRECT
   43  PAYMENT  CONTRACTS, ONLY WITHIN THE HEALTH  BENEFIT EXCHANGE, THE HEALTH
   44  MAINTENANCE ORGANIZATION, NOT INCLUDING A HOLDER OF  A  SPECIAL  PURPOSE
   45  CERTIFICATE  OF  AUTHORITY ISSUED PURSUANT TO SECTION FOUR THOUSAND FOUR
   46  HUNDRED THREE-A OF THE PUBLIC HEALTH LAW, SHALL ALSO OFFER AT LEAST  ONE
   47  INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT AT EACH LEVEL OF COVERAGE AS
   48  DEFINED  IN  SECTION  1302  (D)  OF THE AFFORDABLE CARE ACT, 42 U.S.C. S
   49  18022 (D), OUTSIDE THE HEALTH BENEFIT EXCHANGE.
   50    (D)(1) NOTHING IN THIS SECTION SHALL BE DEEMED TO REQUIRE HEALTH MAIN-
   51  TENANCE ORGANIZATIONS TO DISCONTINUE INDIVIDUAL DIRECT PAYMENT CONTRACTS
   52  ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN OR  PREVENT  HEALTH
   53  MAINTENANCE  ORGANIZATIONS  FROM DISCONTINUING INDIVIDUAL DIRECT PAYMENT
   54  CONTRACTS ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN.    IF  A
   55  HEALTH  MAINTENANCE  ORGANIZATION DISCONTINUES INDIVIDUAL DIRECT PAYMENT
   56  CONTRACTS ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN,  REGARD-
       S. 2606--D                         111                        A. 3006--D

    1  LESS OF WHETHER IT IS A GRANDFATHERED HEALTH PLAN, THEN THE HEALTH MAIN-
    2  TENANCE  ORGANIZATION  SHALL COMPLY WITH  THE REQUIREMENTS OF SUBSECTION
    3  (C) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR OF THIS ARTICLE.
    4    (2) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS
    5  COVERAGE  PROVIDED  BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED
    6  ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR  AS  LONG  AS  THE  COVERAGE
    7  MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE
    8  AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E).
    9    (E)  THE  SUPERINTENDENT  MAY  PROMULGATE REGULATIONS IMPLEMENTING THE
   10  REQUIREMENTS OF THIS  SECTION, INCLUDING REGULATIONS THAT MODIFY OR  ADD
   11  ADDITIONAL  STANDARDIZED INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACTS IF
   12  THE SUPERINTENDENT DETERMINES ADDITIONAL CONTRACTS WITH DIFFERENT LEVELS
   13  OF COVERAGE ARE NECESSARY TO MEET THE NEEDS OF THE PUBLIC.
   14    S 46-a. Subdivision 1 of section 4406 of the  public  health  law,  as
   15  amended by chapter 342 of the laws of 2004, is amended as follows:
   16    1.    The  contract  between  a health maintenance organization and an
   17  enrollee shall be subject to regulation by the superintendent as  if  it
   18  were  a health insurance subscriber contract, and shall include, but not
   19  be limited to, all mandated benefits required by article forty-three  of
   20  the insurance law. Such contract shall fully and clearly state the bene-
   21  fits  and  limitations  therein provided or imposed, so as to facilitate
   22  understanding and comparisons, and to exclude provisions  which  may  be
   23  misleading  or  unreasonably confusing. Such contract shall be issued to
   24  any individual and dependents of such individual and any group of  fifty
   25  or  fewer  employees or members, exclusive of spouses and dependents, or
   26  any employee or member of the group, including dependents, applying  for
   27  such contract at any time throughout the year, and may include a pre-ex-
   28  isting  condition  provision  as  provided  for in section four thousand
   29  three hundred eighteen of the insurance  law,  provided,  however,  that
   30  [such], THE SUPERINTENDENT MAY, AFTER GIVING CONSIDERATION TO THE PUBLIC
   31  INTEREST, EXEMPT A HEALTH MAINTENANCE ORGANIZATION FROM THE REQUIREMENTS
   32  OF  THIS  SECTION PROVIDED THAT ANOTHER HEALTH INSURER OR HEALTH MAINTE-
   33  NANCE ORGANIZATION WITHIN THE  HEALTH  MAINTENANCE  ORGANIZATION'S  SAME
   34  HOLDING  COMPANY  SYSTEM, AS DEFINED IN ARTICLE FIFTEEN OF THE INSURANCE
   35  LAW, INCLUDING A HEALTH MAINTENANCE ORGANIZATION OPERATED AS A  LINE  OF
   36  BUSINESS   OF  A  HEALTH  SERVICE  CORPORATION  LICENSED  UNDER  ARTICLE
   37  FORTY-THREE OF THE INSURANCE LAW, OFFERS COVERAGE THAT,  AT  A  MINIMUM,
   38  COMPLIES  WITH THIS SECTION AND PROVIDES ALL OF THE CONSUMER PROTECTIONS
   39  REQUIRED TO BE PROVIDED BY A HEALTH MAINTENANCE ORGANIZATION PURSUANT TO
   40  THIS CHAPTER  AND  REGULATIONS,  INCLUDING  THOSE  CONSUMER  PROTECTIONS
   41  CONTAINED IN SECTIONS FOUR THOUSAND FOUR HUNDRED THREE AND FOUR THOUSAND
   42  FOUR  HUNDRED  EIGHT-A OF THIS CHAPTER. THE requirements shall not apply
   43  to a health maintenance  organization  exclusively  serving  individuals
   44  enrolled pursuant to title eleven of article five of the social services
   45  law,  title  eleven-D  of article five of the social services law, title
   46  one-A of article twenty-five of the public health law or title  eighteen
   47  of  the  federal  Social  Security Act, and, further provided, that such
   48  health maintenance organization shall not discontinue a contract for  an
   49  individual  receiving  comprehensive-type  coverage  in  effect prior to
   50  January first, two thousand four who is ineligible to purchase  policies
   51  offered  after  such date pursuant to this section or section four thou-
   52  sand three hundred twenty-two of this article due to the provision of 42
   53  U.S.C.  1395ss in effect prior to  January  first,  two  thousand  four.
   54  Subject  to  the  creditable  coverage requirements of subsection (a) of
   55  section four thousand three hundred eighteen of the insurance  law,  the
   56  organization  may, as an alternative to the use of a pre-existing condi-
       S. 2606--D                         112                        A. 3006--D

    1  tion provision, elect to offer contracts without a  pre-existing  condi-
    2  tion  provision  to  such groups but may require that coverage shall not
    3  become effective until after a specified affiliation period of not  more
    4  than  sixty  days  after  the application for coverage is submitted. The
    5  organization is not required to provide health care services or benefits
    6  during such period and no premium shall  be  charged  for  any  coverage
    7  during  the  period.   After January first, nineteen hundred ninety-six,
    8  all individual direct payment contracts shall be issued only pursuant to
    9  sections four thousand three hundred twenty-one and four thousand  three
   10  hundred  twenty-two  of  the insurance law. Such contracts may not, with
   11  respect to an eligible individual (as defined in section 2741(b) of  the
   12  federal  Public  Health Service Act, 42 U.S.C. S 300gg-41(b), impose any
   13  pre-existing condition exclusion.
   14    S 46-b. Paragraph 5 of subsection (c) of section 3216 of the insurance
   15  law is amended to read as follows:
   16    (5) (A) Any family  policy  providing  hospital  or  surgical  expense
   17  insurance  (but  not  including such insurance against accidental injury
   18  only) shall provide that, in the event such  insurance  on  any  person,
   19  other  than  the  policyholder,  is  terminated because the person is no
   20  longer within the definition of the family as set forth  in  the  policy
   21  but before such person has attained the limiting age, if any, for cover-
   22  age  of adults specified in the policy, such person shall be entitled to
   23  have issued to [him] THAT PERSON by the  insurer,  without  evidence  of
   24  insurability,  upon application therefor and payment of the first premi-
   25  um, within [thirty-one] SIXTY  days  after  such  insurance  shall  have
   26  terminated,  an  individual conversion policy THAT CONTAINS THE BENEFITS
   27  DESCRIBED IN PARAGRAPH ONE OF SUBSECTION (B) OF  SECTION  FOUR  THOUSAND
   28  THREE  HUNDRED TWENTY-EIGHT OF THIS CHAPTER. THE INSURER SHALL OFFER ONE
   29  POLICY AT EACH LEVEL OF COVERAGE AS DEFINED IN SECTION  1302(D)  OF  THE
   30  AFFORDABLE CARE ACT, 42 U.S.C. S 18022(D). THE INDIVIDUAL MAY CHOOSE ANY
   31  SUCH  POLICY  OFFERED  BY THE INSURER. The conversion privilege afforded
   32  herein shall also be available upon the  divorce  or  annulment  of  the
   33  marriage of the policyholder to the former spouse of such policyholder.
   34    (B)  Written  notice  of  entitlement  to a conversion policy shall be
   35  given by the insurer to the policyholder at least fifteen and  not  more
   36  than  sixty days prior to the termination of coverage due to the initial
   37  limiting age of the covered dependent.  Such  notice  shall  include  an
   38  explanation  of  the  rights  of the dependent with respect to [his] THE
   39  DEPENDENT being enrolled in an accredited institution of learning or his
   40  incapacity for self-sustaining employment by reason of  mental  illness,
   41  developmental  disability or mental retardation as defined in the mental
   42  hygiene law or physical handicap.
   43    (C) Such individual conversion policy shall be subject to the  follow-
   44  ing terms and conditions:
   45    (i)  The  premium  shall  be  that applicable to the [class of risk to
   46  which such person belongs, to the age of such person and  to  the]  form
   47  and amount of insurance therefor.
   48    (ii)  [Such  policy  shall provide, on a basis specified in the family
   49  policy, the same or substantially the same benefits as those provided in
   50  the family policy or such benefits as are provided in a  policy  specif-
   51  ically  approved  as  an individual conversion policy by the superinten-
   52  dent.
   53    (iii)] The benefits provided under such policy shall become  effective
   54  upon  the  date that such person was no longer eligible under the family
   55  policy.
       S. 2606--D                         113                        A. 3006--D

    1    [(iv) The policy may exclude any  condition  excluded  by  the  family
    2  policy  for  such person at the time of the termination of his insurance
    3  thereunder. The policy shall not exclude any other  pre-existing  condi-
    4  tions,  but  the  benefits  paid under such policy may be reduced by the
    5  amount  of  any  such benefits payable under the family policy after the
    6  termination of such person's insurance thereunder and, during the  first
    7  policy  year  of  the  conversion policy, the benefits payable under the
    8  policy may be reduced so that they are not in excess of those that would
    9  have been payable had such person's insurance under  the  family  policy
   10  remained in force and effect.
   11    (v)]  (III)  No insurer shall be required to issue a conversion policy
   12  if it appears that the person applying for such  policy  shall  have  at
   13  that  time  in  force  another  insurance  policy or hospital service or
   14  medical expense indemnity contract  providing  similar  benefits  or  is
   15  covered  by  or  is eligible for coverage by a group insurance policy or
   16  contract providing similar benefits or shall be covered by similar bene-
   17  fits required by any statute or provided by any welfare plan or program,
   18  which together with the conversion policy would result in over insurance
   19  or duplication of benefits according  to  standards  on  file  with  the
   20  superintendent relating to individual policies.
   21    [(vi)  The  policy  may  include  a  provision whereby the insurer may
   22  request information at any premium due date of the policy of the  person
   23  covered thereunder as to whether he is then covered by another policy or
   24  hospital  service  or  medical  expense indemnity corporation subscriber
   25  contract providing similar benefits  or  is  then  covered  by  a  group
   26  contract  or  policy providing similar benefits or is then provided with
   27  similar benefits required by any statute or provided by any welfare plan
   28  or program. If any such person is so covered or so provided and fails to
   29  furnish the details of such coverage when requested, the benefits  paya-
   30  ble under the conversion policy may be based on the hospital surgical or
   31  medical  expenses  actually  incurred  after  excluding  expenses to the
   32  extent they are payable under such other coverage or provided under such
   33  statute, plan, or program.]
   34    S 47. Paragraphs 4, 6, 9 and 10 of subsection (e) of section  3221  of
   35  the insurance law are REPEALED, paragraphs 5, 7, 8, 11 and 12 are renum-
   36  bered paragraphs 4, 5, 6, 7 and 8 and paragraph 1, as amended by chapter
   37  306 of the laws of 1987, is amended to read as follows:
   38    (1)  A  group  policy  providing hospital, MEDICAL or surgical expense
   39  insurance for other than  specific  diseases  or  accident  only,  shall
   40  provide that if the insurance on an employee or member insured under the
   41  group policy ceases because of termination of [(I)] (A) employment or of
   42  membership in the class or classes eligible for coverage under the poli-
   43  cy or [(II)] (B) the policy, for any reason whatsoever, unless the poli-
   44  cyholder  has  replaced  the  group  policy  with similar and continuous
   45  coverage for the  same  group  whether  insured  or  self-insured,  such
   46  employee  or  member who has been insured under the group policy [for at
   47  least three months] shall be  entitled  to  have  issued  to  [him]  THE
   48  INSURED by the insurer without evidence of insurability upon application
   49  made  to  the  insurer  within [forty-five] SIXTY days after such termi-
   50  nation, and payment of the quarterly, or, at the option of the  employee
   51  or  member,  a less frequent premium applicable to the [class of risk to
   52  which the person belongs, the age of such  person,  and  the]  form  and
   53  amount of insurance, an individual policy of insurance. The insurer may,
   54  at  its  option  elect  to  provide the insurance coverage under a group
   55  insurance policy, delivered in this state, in lieu of the issuance of  a
   56  converted  individual  policy  of  insurance. Such individual policy, or
       S. 2606--D                         114                        A. 3006--D

    1  group policy, as the case  may  be  is  hereafter  referred  to  as  the
    2  converted policy. The benefits provided under the converted policy shall
    3  be  those  required by subsection (f)[,] AND (g)[, (h) or (i) hereof] OF
    4  THIS SECTION, [whichever is applicable and,] in the event of termination
    5  of  the  converted  group  policy  of insurance, each insured thereunder
    6  shall have a right of conversion to a  converted  individual  policy  of
    7  insurance.
    8    S  48.  Paragraph 3 of subsection (e) of section 3221 of the insurance
    9  law, as separately amended by chapters 370 and 869 of the laws of  1984,
   10  is amended to read as follows:
   11    (3)  The  converted  policy  shall,  at  the option of the employee or
   12  member, provide identical coverage for the dependents of  such  employee
   13  or  member  who  were covered under the group policy. Provided, however,
   14  that if the employee or member chooses the option of dependent  coverage
   15  then  dependents  acquired after the permitted time to convert stated in
   16  paragraph one of this subsection shall be added to the converted  family
   17  policy  in  accordance  with the provisions of subsection (c) of section
   18  thirty-two hundred sixteen of this article and any  regulations  promul-
   19  gated  or guidelines issued by the superintendent. [The converted policy
   20  need not provide benefits in excess of those provided for  such  persons
   21  under the group policy from which conversion is made and may contain any
   22  exclusion or benefit limitation contained in the group policy or custom-
   23  arily  used  in individual policies.] The effective date of the individ-
   24  ual's coverage under the converted policy  shall  be  the  date  of  the
   25  termination  of  the individual's insurance under the group policy as to
   26  those persons covered under the group policy.
   27    S 49. Subsections (f) and (g) of section 3221 of the insurance law are
   28  REPEALED and two new subsections (f)  and  (g)  are  added  to  read  as
   29  follows:
   30    (F)  IF  THE GROUP INSURANCE POLICY INSURES THE EMPLOYEE OR MEMBER FOR
   31  HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE, OR IF THE GROUP  INSUR-
   32  ANCE  POLICY INSURES THE EMPLOYEE OR MEMBER FOR MAJOR MEDICAL OR SIMILAR
   33  COMPREHENSIVE-TYPE COVERAGE, THEN THE CONVERSION PRIVILEGE SHALL ENTITLE
   34  THE EMPLOYEE OR MEMBER TO  OBTAIN  COVERAGE  UNDER  A  CONVERTED  POLICY
   35  PROVIDING,  AT THE INSURED'S OPTION, COVERAGE UNDER ANY ONE OF THE PLANS
   36  DESCRIBED IN SUBSECTION (G) OF  THIS  SECTION  ON  AN  EXPENSE  INCURRED
   37  BASIS.
   38    (G) FOR CONVERSION PURPOSES, AN INSURER SHALL OFFER TO THE EMPLOYEE OR
   39  MEMBER  A POLICY AT EACH LEVEL OF COVERAGE AS DEFINED IN SECTION 1302(D)
   40  OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(D) THAT CONTAINS THE BENE-
   41  FITS DESCRIBED IN PARAGRAPH ONE OF SUBSECTION (B) OF SECTION FOUR  THOU-
   42  SAND THREE HUNDRED TWENTY-EIGHT OF THIS CHAPTER.
   43    S  50.  Subparagraph  (D)  of paragraph 4 of subsection (l) of section
   44  3221 of the insurance law, as amended by chapter  230  of  the  laws  of
   45  2004, is amended to read as follows:
   46    (D)  In addition to the requirements of subparagraph (A) of this para-
   47  graph, every insurer issuing a group policy for delivery in  this  state
   48  [which]  WHERE THE policy provides reimbursement to insureds for psychi-
   49  atric or psychological services or for the diagnosis  and  treatment  of
   50  mental,  nervous or emotional disorders and ailments, however defined in
   51  such policy, by physicians, psychiatrists or psychologists, [must] SHALL
   52  provide the same coverage to insureds for such services  when  performed
   53  by  a licensed clinical social worker, within the lawful scope of his or
   54  her practice, who is licensed pursuant to  subdivision  two  of  section
   55  seven  thousand  seven hundred four of the education law and in addition
   56  shall have either: (i) three or  more  additional  years  experience  in
       S. 2606--D                         115                        A. 3006--D

    1  psychotherapy,  which  for  the purposes of this subparagraph shall mean
    2  the use of verbal methods in interpersonal relationships with the intent
    3  of assisting a person  or  persons  to  modify  attitudes  and  behavior
    4  [which]  THAT  are  intellectually, socially or emotionally maladaptive,
    5  under supervision, satisfactory to the state board for social work, in a
    6  facility,  licensed  or  incorporated  by  an  appropriate  governmental
    7  department,  providing  services  for  diagnosis or treatment of mental,
    8  nervous or emotional disorders or ailments[, or];  (ii)  three  or  more
    9  additional  years  experience  in  psychotherapy  under the supervision,
   10  satisfactory to the state board for social work, of  a  psychiatrist,  a
   11  licensed and registered psychologist or a licensed clinical social work-
   12  er  qualified for reimbursement pursuant to subsection [(h)] (E) of this
   13  section, or (iii) a combination of the experience specified in items (i)
   14  and (ii) OF THIS SUBPARAGRAPH totaling three years, satisfactory to  the
   15  state board for social work.
   16    (E)  The  state  board  for  social  work shall maintain a list of all
   17  licensed clinical  social  workers  qualified  for  reimbursement  under
   18  [this] subparagraph (D) OF THIS PARAGRAPH.
   19    S  51.  Paragraph 3 of subsection (e) of section 4304 of the insurance
   20  law is REPEALED and paragraphs 4 and 5 are renumbered paragraphs  3  and
   21  4, and paragraphs 1 and 2 of such subsection (e), paragraph 1 as amended
   22  by  chapter  661  of the laws of 1997, and as further amended by section
   23  104 of part A of chapter 62 of the laws of 2011, are amended to read  as
   24  follows:
   25    (1)  If  any  such  contract  is  terminated  in  accordance  with the
   26  provisions of paragraph one of subsection (c) [hereof] OF THIS  SECTION,
   27  or any such contract is terminated because of a default by the remitting
   28  agent  in  the payment of premiums not cured within the grace period and
   29  the remitting agent has not  replaced  the  contract  with  similar  and
   30  continuous  coverage for the same group whether insured or self-insured,
   31  or any such contract is terminated in accordance with the provisions  of
   32  subparagraph  (E)  of  paragraph  two of subsection (c) [hereof] OF THIS
   33  SECTION, or if an individual other than the contract holder is no longer
   34  covered under a "family contract" because  [he]  THE  INDIVIDUAL  is  no
   35  longer  within  the definition set forth in the contract, or a spouse is
   36  no longer covered  under  the  contract  because  of  divorce  from  the
   37  contract  holder  or  annulment of the marriage, or any such contract is
   38  terminated because of the death of the contract holder, then such  indi-
   39  vidual, former spouse, or in the case of the death of the contract hold-
   40  er  the  surviving  spouse  or other dependents of the deceased contract
   41  holder covered under the contract, as the case may be, shall be entitled
   42  to convert, without evidence of insurability, upon application  therefor
   43  and the making of the first payment thereunder within [thirty-one] SIXTY
   44  days after the date of termination of such contract, to a contract [of a
   45  type  which  provides  coverage  most  nearly  comparable to the type of
   46  coverage under the contract from which the individual  converted,  which
   47  coverage shall be no less than the minimum standards for basic hospital,
   48  basic  medical, or major medical as provided for in department of finan-
   49  cial services regulation; provided, however,  that  if  the  corporation
   50  does not issue such a major medical contract, then to a comprehensive or
   51  comparable  type  of coverage which is most commonly being sold to group
   52  remitting agents. Notwithstanding the previous sentence,  a  corporation
   53  may  elect to issue a standardized individual enrollee contract pursuant
   54  to section four thousand three hundred twenty-two  of  this  article  in
   55  lieu  of  a  major medical contract, comprehensive or comparable type of
   56  coverage required to  be  offered  upon  conversion  from  an  indemnity
       S. 2606--D                         116                        A. 3006--D

    1  contract]  THAT  CONTAINS  THE  BENEFITS  DESCRIBED  IN PARAGRAPH ONE OF
    2  SUBSECTION (B) OF SECTION FOUR THOUSAND THREE  HUNDRED  TWENTY-EIGHT  OF
    3  THIS  CHAPTER. THE CORPORATION SHALL OFFER ONE CONTRACT AT EACH LEVEL OF
    4  COVERAGE  AS  DEFINED  IN SECTION 1302(D) OF THE AFFORDABLE CARE ACT, 42
    5  U.S.C. S 18022(D). THE INDIVIDUAL MAY CHOOSE ANY SUCH  CONTRACT  OFFERED
    6  BY  THE CORPORATION.  The effective date of the coverage provided by the
    7  converted direct payment contract shall be the date of  the  termination
    8  of coverage under the contract from which conversion was made.
    9    (2)  The corporation shall not be required to issue any such converted
   10  individual direct payment contract if its issuance would result in over-
   11  insurance or duplication of benefits according to standards on file with
   12  the superintendent and approved by [him] THE SUPERINTENDENT with  regard
   13  to such contracts. [The individual direct payment contract may include a
   14  provision  whereby  the  corporation  may  request  information when any
   15  payment is due under the contract of the person covered thereunder as to
   16  whether he is then covered  by  another  individual  contract  providing
   17  similar benefits or is then covered by a group contract policy providing
   18  similar  benefits  or is then provided with similar benefits required by
   19  any statute or provided by any welfare plan or  program  which  together
   20  with  the  converted  individual direct payment contract would result in
   21  overinsurance or duplication of benefits according to the  standards  on
   22  file  with  the  superintendent relating to individual contracts. If any
   23  such person is so covered or  so  provided  and  fails  to  furnish  the
   24  details of such coverage when requested, the benefits provided under the
   25  converted  individual direct payment contract may be based on the hospi-
   26  tal, surgical or medical  expenses  actually  incurred  after  excluding
   27  expenses  to  the  extent  they are payable under such other coverage or
   28  provided under such statute, plan or program.]
   29    S 52. Paragraphs 1 and 2 of subsection (d)  of  section  4305  of  the
   30  insurance law, paragraph 1 as amended by chapter 504 of the laws of 1995
   31  and  paragraphs  1  and 2 as further amended by section 104 of part A of
   32  chapter 62 of the laws of 2011, are amended to read as follows:
   33    (1) (A) A group contract issued pursuant to this section shall contain
   34  a provision to the effect that in case  of  a  termination  of  coverage
   35  under  such  contract  of  any  member of the group because of [(I)] (I)
   36  termination for any reason whatsoever of [his] THE  MEMBER'S  employment
   37  or  membership,  [if he has been covered under the group contract for at
   38  least three months,] or [(II)] (II) termination for any reason whatsoev-
   39  er of the group contract itself unless the  group  contract  holder  has
   40  replaced the group contract with similar and continuous coverage for the
   41  same  group  whether  insured  or self-insured, [he] THE MEMBER shall be
   42  entitled to have issued to [him] THE MEMBER by the corporation,  without
   43  evidence  of  insurability, upon application therefor and payment of the
   44  first premium made to the corporation  within  [forty-five]  SIXTY  days
   45  after   termination  of  the  coverage,  an  individual  direct  payment
   46  contract, covering such member and [his] THE  MEMBER'S  eligible  depen-
   47  dents  who  were  covered by the group contract, which provides coverage
   48  [most nearly  comparable  to  the  type  of  coverage  under  the  group
   49  contract, which coverage shall be no less than the minimum standards for
   50  basic  hospital,  basic  medical,  or  major  medical as provided for in
   51  department of financial services regulation; provided, however, that  if
   52  the  corporation does not issue such a major medical contract, then to a
   53  comprehensive or comparable type of  coverage  which  is  most  commonly
   54  being  sold  to  group  remitting  agents.  Notwithstanding the previous
   55  sentence, a corporation may elect to  issue  a  standardized  individual
   56  enrollee contract pursuant to section four thousand three hundred twenty
       S. 2606--D                         117                        A. 3006--D

    1  two  of  this article in lieu of a major medical contract, comprehensive
    2  or comparable type of coverage required to be  offered  upon  conversion
    3  from  an  indemnity  contract]  THAT  CONTAINS THE BENEFITS DESCRIBED IN
    4  PARAGRAPH  ONE  OF SUBSECTION (B) OF SECTION FOUR THOUSAND THREE HUNDRED
    5  TWENTY-EIGHT OF THIS CHAPTER. THE CORPORATION SHALL OFFER  ONE  CONTRACT
    6  AT  EACH LEVEL OF COVERAGE AS DEFINED IN SECTION 1302(D) OF THE AFFORDA-
    7  BLE CARE ACT, 42 U.S.C. S 18022(D).  THE  MEMBER  MAY  CHOOSE  ANY  SUCH
    8  CONTRACT OFFERED BY THE CORPORATION.
    9    (B) The conversion privilege afforded [herein] IN THIS PARAGRAPH shall
   10  also  be  available:  [(A)]  (I)  upon  the  divorce or annulment of the
   11  marriage of a member, to the divorced spouse or former  spouse  of  such
   12  member[,  (B)];  (II)  upon  the  death  of the member, to the surviving
   13  spouse and other dependents covered under  the  contract[,];  and  [(C)]
   14  (III) to a dependent if no longer within the definition in the contract.
   15    (2)  The  effective  date  of  the coverage provided by the individual
   16  direct payment contract shall be the date  of  the  termination  of  the
   17  individual's  coverage  under the group contract. [The individual direct
   18  payment converted contract may exclude any  condition  excluded  by  the
   19  group contract. The individual direct payment contract shall not exclude
   20  any  other  pre-existing  conditions but the benefits provided under the
   21  individual direct payment converted  contract  may  be  reduced  by  the
   22  amount  of any such benefits provided under the group contract after the
   23  termination of the individual's coverage thereunder and during the first
   24  contract year of such individual direct payment converted  contract  the
   25  benefits provided under the contract may be reduced so that they are not
   26  in  excess  of  those that would have been provided had the individual's
   27  contract under the group contract remained in  force  and  effect.]  The
   28  corporation  shall  not  be  required  to  issue  such individual direct
   29  payment converted contract covering any person if it appears  that  such
   30  person  shall  then  be covered by another individual contract providing
   31  similar coverage or if it shall appear that such person is covered by or
   32  eligible to be covered by a group contract or policy  providing  similar
   33  benefits or is provided with similar benefits required by any statute or
   34  provided  by  any welfare plan or program, which together with the indi-
   35  vidual direct payment converted contract would result in  over-insurance
   36  or  duplication  of  benefits  according  to  standards on file with the
   37  superintendent of financial services relating to  individual  contracts.
   38  [The   individual  direct  payment  converted  contract  may  include  a
   39  provision whereby the  corporation  may  request  information  when  any
   40  payment is due under the contract of any person covered thereunder as to
   41  whether  he is then covered by another contract or by a policy providing
   42  similar benefits or is then  covered  by  a  group  contract  or  policy
   43  providing  similar  benefits  or  is then provided with similar benefits
   44  required by any statute or provided by any welfare plan or  program.  If
   45  any  such  person  is so covered or so provided and fails to furnish the
   46  details of such coverage when requested, the benefits payable under  the
   47  individual  direct payment converted contract may be based on the hospi-
   48  tal, surgical or medical  expenses  actually  incurred  after  excluding
   49  expenses  to  the  extent  they are payable under such other coverage or
   50  provided under such statute, plan or program.
   51    In the event the benefits provided or payable are reduced  in  accord-
   52  ance with the provisions of this subsection the corporation shall return
   53  such portion of the premium paid as shall exceed the pro rata portion of
   54  the benefits thus determined.]
   55    S  53.  Section  3216  of the insurance law is amended by adding a new
   56  subsection (m) to read as follows:
       S. 2606--D                         118                        A. 3006--D

    1    (M) AN INSURER SHALL NOT BE REQUIRED TO  OFFER  THE  POLICYHOLDER  ANY
    2  BENEFITS  THAT  MUST  BE  MADE AVAILABLE PURSUANT TO THIS SECTION IF THE
    3  BENEFITS MUST BE COVERED AS ESSENTIAL HEALTH BENEFITS.  FOR  ANY  POLICY
    4  ISSUED  WITHIN  THE  HEALTH  BENEFIT  EXCHANGE  ESTABLISHED  PURSUANT TO
    5  SECTION  1311  OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, AN INSURER
    6  SHALL NOT BE REQUIRED TO OFFER THE POLICYHOLDER ANY BENEFITS  THAT  MUST
    7  BE  MADE  AVAILABLE  PURSUANT  TO  THIS  SECTION.  FOR  PURPOSES OF THIS
    8  SUBSECTION, "ESSENTIAL HEALTH BENEFITS" SHALL HAVE THE MEANING SET FORTH
    9  IN SECTION 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B).
   10    S 54. Subsections (h) and (i) of section 3221 of the insurance law are
   11  REPEALED and two new subsections (h)  and  (i)  are  added  to  read  as
   12  follows:
   13    (H)  EVERY SMALL GROUP POLICY OR ASSOCIATION GROUP POLICY DELIVERED OR
   14  ISSUED FOR DELIVERY IN THIS STATE THAT PROVIDES  COVERAGE FOR  HOSPITAL,
   15  MEDICAL  OR SURGICAL EXPENSE INSURANCE AND IS NOT A GRANDFATHERED HEALTH
   16  PLAN SHALL PROVIDE COVERAGE FOR THE ESSENTIAL HEALTH BENEFIT PACKAGE  AS
   17  REQUIRED  IN SECTION 2707(A) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C.
   18  S 300GG-6(A). FOR PURPOSES OF THIS SUBSECTION:
   19    (1) "ESSENTIAL HEALTH BENEFITS PACKAGE" SHALL  HAVE  THE  MEANING  SET
   20  FORTH  IN  SECTION  1302(A)  OF  THE  AFFORDABLE  CARE  ACT, 42 U.S.C. S
   21  18022(A);
   22    (2) "GRANDFATHERED HEALTH PLAN" MEANS COVERAGE PROVIDED BY AN  INSURER
   23  IN WHICH AN INDIVIDUAL  WAS ENROLLED ON MARCH TWENTY-THIRD, TWO THOUSAND
   24  TEN  FOR  AS  LONG  AS  THE  COVERAGE  MAINTAINS GRANDFATHERED STATUS IN
   25  ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.  S
   26  18011(E);
   27    (3) "SMALL GROUP" MEANS A GROUP OF FIFTY OR FEWER EMPLOYEES OR MEMBERS
   28  EXCLUSIVE  OF SPOUSES  AND DEPENDENTS; PROVIDED, HOWEVER, THAT BEGINNING
   29  JANUARY FIRST, TWO THOUSAND SIXTEEN, "SMALL GROUP" MEANS A GROUP OF  ONE
   30  HUNDRED  OR  FEWER  EMPLOYEES OR MEMBERS EXCLUSIVE OF SPOUSES AND DEPEN-
   31  DENTS; AND
   32    (4) "ASSOCIATION GROUP" MEANS A GROUP DEFINED  IN  SUBPARAGRAPHS  (B),
   33  (D),  (H), (K), (L) OR (M) OF PARAGRAPH ONE OF SUBSECTION (C) OF SECTION
   34  FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER, PROVIDED THAT:
   35    (A) THE GROUP INCLUDES ONE OR MORE INDIVIDUAL MEMBERS; OR
   36    (B) THE GROUP INCLUDES ONE OR MORE MEMBER EMPLOYERS  OR  OTHER  MEMBER
   37  GROUPS THAT ARE SMALL GROUPS.
   38    (I)  AN  INSURER  SHALL  NOT BE REQUIRED TO OFFER THE POLICYHOLDER ANY
   39  BENEFITS THAT MUST BE MADE AVAILABLE PURSUANT TO  THIS  SECTION  IF  THE
   40  BENEFITS MUST BE COVERED PURSUANT TO SUBSECTION (H) OF THIS SECTION. FOR
   41  ANY  POLICY ISSUED WITHIN THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSU-
   42  ANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C.  S  18031,  AN
   43  INSURER  SHALL  NOT  BE  REQUIRED TO OFFER THE POLICYHOLDER ANY BENEFITS
   44  THAT MUST BE MADE AVAILABLE PURSUANT TO THIS SECTION.
   45    S 55. Subsection (gg) of section 4303 of the insurance law,  as  added
   46  by chapter 536 of the laws of 2010, is relettered to be subsection (jj),
   47  subsection  (hh), as added by chapter 597 of the laws of 2011, is relet-
   48  tered to be subsection (kk) and two new subsections (ll)  and  (mm)  are
   49  added to read as follows:
   50    (LL)  EVERY  SMALL GROUP CONTRACT OR ASSOCIATION GROUP CONTRACT DELIV-
   51  ERED OR ISSUED FOR DELIVERY IN THIS STATE  THAT  PROVIDES  COVERAGE  FOR
   52  HOSPITAL,  MEDICAL  OR  SURGICAL EXPENSE INSURANCE AND IS NOT A GRANDFA-
   53  THERED HEALTH PLAN SHALL PROVIDE COVERAGE FOR THE ESSENTIAL HEALTH BENE-
   54  FIT PACKAGE AS REQUIRED IN SECTION 2707(A) OF THE PUBLIC HEALTH  SERVICE
   55  ACT, 42 U.S.C. S 300GG-6(A). FOR PURPOSES OF THIS SUBSECTION:
       S. 2606--D                         119                        A. 3006--D

    1    (1)  "ESSENTIAL  HEALTH  BENEFITS  PACKAGE" SHALL HAVE THE MEANING SET
    2  FORTH IN SECTION 1302(A)  OF  THE  AFFORDABLE  CARE  ACT,  42  U.S.C.  S
    3  18022(A);
    4    (2)  "GRANDFATHERED  HEALTH  PLAN" MEANS COVERAGE PROVIDED BY A CORPO-
    5  RATION IN WHICH AN  INDIVIDUAL WAS ENROLLED ON MARCH  TWENTY-THIRD,  TWO
    6  THOUSAND TEN FOR AS LONG AS THE COVERAGE MAINTAINS  GRANDFATHERED STATUS
    7  IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
    8  S 18011(E); AND
    9    (3) "SMALL GROUP" MEANS A GROUP OF FIFTY OR FEWER EMPLOYEES OR MEMBERS
   10  EXCLUSIVE OF SPOUSES  AND DEPENDENTS. BEGINNING JANUARY FIRST, TWO THOU-
   11  SAND  SIXTEEN,  "SMALL  GROUP"  MEANS  A GROUP OF ONE   HUNDRED OR FEWER
   12  EMPLOYEES OR MEMBERS EXCLUSIVE OF SPOUSES AND DEPENDENTS; AND
   13    (4) "ASSOCIATION GROUP" MEANS A GROUP DEFINED  IN  SUBPARAGRAPHS  (B),
   14  (D),  (H), (K), (L) OR (M) OF PARAGRAPH ONE OF SUBSECTION (C) OF SECTION
   15  FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER, PROVIDED THAT:
   16    (A) THE GROUP INCLUDES ONE OR MORE INDIVIDUAL MEMBERS; OR
   17    (B) THE GROUP INCLUDES ONE OR MORE MEMBER EMPLOYERS  OR  OTHER  MEMBER
   18  GROUPS THAT ARE SMALL GROUPS.
   19    (MM)  A CORPORATION SHALL NOT BE REQUIRED TO OFFER THE CONTRACT HOLDER
   20  ANY BENEFITS THAT MUST BE MADE AVAILABLE PURSUANT  TO  THIS  SECTION  IF
   21  SUCH  BENEFITS  MUST  BE  COVERED  PURSUANT  TO  SUBSECTION (KK) OF THIS
   22  SECTION. FOR ANY CONTRACT ISSUED  WITHIN  THE  HEALTH  BENEFIT  EXCHANGE
   23  ESTABLISHED  PURSUANT  TO  SECTION  1311  OF THE AFFORDABLE CARE ACT, 42
   24  U.S.C. S 18031, A  CORPORATION  SHALL  NOT  BE  REQUIRED  TO  OFFER  THE
   25  CONTRACT  HOLDER  ANY  BENEFITS  THAT MUST BE MADE AVAILABLE PURSUANT TO
   26  THIS SECTION.
   27    S 55-a. Section 3221 of the insurance law is amended by adding  a  new
   28  subsection (s) to read as follows:
   29    (S)  AN INSURER SUBJECT TO THE PROVISIONS OF THIS ARTICLE OR AN INSUR-
   30  ANCE PRODUCER SUBJECT TO THIS CHAPTER SHALL NOT PERMIT THE RENEWAL OF  A
   31  SMALL  GROUP  POLICY THAT PROVIDES HOSPITAL, SURGICAL OR MEDICAL EXPENSE
   32  COVERAGE THAT RENEWS ON OR AFTER JANUARY FIRST, TWO  THOUSAND  FOURTEEN,
   33  BUT  BEFORE  JULY  FIRST, TWO THOUSAND FOURTEEN, SO AS TO RENEW THE SAME
   34  POLICY PRIOR TO THE POLICY'S ANNUAL RENEWAL DATE FOR THE SOLE PURPOSE OF
   35  EVADING THE REQUIREMENTS OF THE  AFFORDABLE  CARE  ACT  AND  REGULATIONS
   36  PROMULGATED  THEREUNDER  WITH RESPECT TO SUCH POLICY. AN ISOLATED, INAD-
   37  VERTENT RENEWAL DATE CHANGE WHICH WAS NOT MADE FOR THE SOLE  PURPOSE  OF
   38  EVADING  THE REQUIREMENTS OF THE AFFORDABLE CARE ACT SHALL NOT BE DEEMED
   39  A VIOLATION OF THIS SUBSECTION.
   40    S 55-b. Section 4303 of the insurance law is amended by adding  a  new
   41  subsection (nn) to read as follows:
   42    (NN)  A  CORPORATION  SUBJECT  TO THE PROVISIONS OF THIS ARTICLE OR AN
   43  INSURANCE PRODUCER SUBJECT TO THIS CHAPTER SHALL NOT PERMIT THE  RENEWAL
   44  OF  A  SMALL  GROUP  POLICY WHICH PROVIDES HOSPITAL, SURGICAL OR MEDICAL
   45  EXPENSE COVERAGE THAT RENEWS ON OR AFTER  JANUARY  FIRST,  TWO  THOUSAND
   46  FOURTEEN,  BUT  BEFORE JULY FIRST, TWO THOUSAND FOURTEEN, SO AS TO RENEW
   47  THE SAME POLICY PRIOR TO THE POLICY'S ANNUAL RENEWAL DATE FOR  THE  SOLE
   48  PURPOSE OF EVADING THE REQUIREMENTS OF THE AFFORDABLE CARE ACT AND REGU-
   49  LATIONS PROMULGATED THEREUNDER WITH RESPECT TO SUCH POLICY. AN ISOLATED,
   50  INADVERTENT  RENEWAL DATE CHANGE WHICH WAS NOT MADE FOR THE SOLE PURPOSE
   51  OF EVADING THE REQUIREMENTS OF THE AFFORDABLE  CARE  ACT  SHALL  NOT  BE
   52  DEEMED A VIOLATION OF THIS SUBSECTION.
   53    S  56. Section 4326 of the insurance law, as added by chapter 1 of the
   54  laws of 1999, subsection (b) as amended by chapter 342 of  the  laws  of
   55  2004,  subparagraph (A) of paragraph 1 and subparagraph (C) of paragraph
   56  3 of subsection (c) as amended by chapter 419 of the laws of 2000, para-
       S. 2606--D                         120                        A. 3006--D

    1  graphs 13 and 14 of subsection (d), paragraphs 6 and 7 of subsection (e)
    2  and subsection (k) as amended and paragraph  15  of  subsection  (d)  as
    3  added  by  chapter  219 of the laws of 2011 and subsections (d-1), (d-2)
    4  and  (d-3)  as  added  by chapter 645 of the laws of 2005, is amended to
    5  read as follows:
    6    S 4326. Standardized health insurance contracts for  qualifying  small
    7  employers  and  individuals. (a) A program is hereby established for the
    8  purpose of making standardized health insurance contracts  available  to
    9  qualifying  small  employers  [and qualifying individuals] as defined in
   10  this section. Such program is designed to encourage small  employers  to
   11  offer  health  insurance  coverage  to their employees [and to also make
   12  coverage available to uninsured employees whose employers do not provide
   13  group health insurance].
   14    (b) Participation in the  program  established  by  this  section  and
   15  section  four  thousand  three  hundred  twenty-seven of this article is
   16  limited to corporations or insurers organized  or  licensed  under  this
   17  article  or  article  forty-two  of  this chapter and health maintenance
   18  organizations issued a certificate of authority under article forty-four
   19  of the public health law or licensed under this  article.  Participation
   20  by all health maintenance organizations is mandatory, provided, however,
   21  that  such requirements shall not apply to a HOLDER OF A SPECIAL PURPOSE
   22  CERTIFICATE OF AUTHORITY ISSUED PURSUANT TO SECTION FOUR  THOUSAND  FOUR
   23  HUNDRED  THREE-A OF THE PUBLIC HEALTH LAW OR A health maintenance organ-
   24  ization exclusively serving individuals enrolled pursuant to title elev-
   25  en of article five of the social services law, title eleven-D of article
   26  five of the social services law, title one-A of article  twenty-five  of
   27  the  public  health law or title eighteen of the federal Social Security
   28  Act[, and, further provided, that such health  maintenance  organization
   29  shall  not discontinue a contract for an individual receiving comprehen-
   30  sive-type coverage in effect prior to January first, two  thousand  four
   31  who  is ineligible to purchase policies offered after such date pursuant
   32  to this section or section four thousand  three  hundred  twenty-two  of
   33  this article due to the provision of 42 U.S.C. 1395ss in effect prior to
   34  January first, two thousand four]. On and after January first, two thou-
   35  sand  one,  all  health maintenance organizations shall offer qualifying
   36  group health  insurance  contracts  [and  qualifying  individual  health
   37  insurance  contracts]  as  defined  in this section. For the purposes of
   38  this section and section four thousand  three  hundred  twenty-seven  of
   39  this  article,  article  forty-three  corporations  or article forty-two
   40  insurers which voluntarily participate in compliance with  the  require-
   41  ments  of this program shall be eligible for reimbursement from the stop
   42  loss funds created pursuant to section four thousand three hundred twen-
   43  ty-seven of this article under the same terms and conditions  as  health
   44  maintenance organizations.
   45    (c)  The  following  definitions  shall be applicable to the insurance
   46  contracts offered under the program established by this section:
   47    (1) (A) A qualifying small employer is [an employer that is either:
   48    (A) An individual proprietor who is the only employee of the business:
   49    (i) without health insurance which provides  benefits  on  an  expense
   50  reimbursed  or  prepaid  basis  in effect during the twelve month period
   51  prior to application for a qualifying group  health  insurance  contract
   52  under the program established by this section; and
   53    (ii)  resides in a household having a net household income at or below
   54  two hundred eight percent of the  non-farm  federal  poverty  level  (as
   55  defined  and  updated  by  the  federal  department  of health and human
   56  services) or the gross equivalent of such net income;
       S. 2606--D                         121                        A. 3006--D

    1    (iii) except that the requirements set  forth  in  item  (i)  of  this
    2  subparagraph  shall not be applicable where an individual proprietor had
    3  health insurance coverage during the previous  twelve  months  and  such
    4  coverage  terminated  due  to  one of the reasons set forth in items (i)
    5  through  (viii) of subparagraph (C) of paragraph three of subsection (c)
    6  of this section; or
    7    (B) An] AN employer with:
    8    (i) not more than fifty [eligible] employees;
    9    (ii) no group health insurance [which] THAT provides  benefits  on  an
   10  expense  reimbursed or prepaid basis covering employees in effect during
   11  the twelve month period prior to  application  for  a  qualifying  group
   12  health insurance contract under the program established by this section;
   13  and
   14    (iii)  at  least  thirty percent of its [eligible] employees receiving
   15  annual wages from the employer at a level equal to or less  than  thirty
   16  thousand  dollars.  The  thirty thousand dollar figure shall be adjusted
   17  periodically pursuant to subparagraph [(F)] (D) of this paragraph.
   18    [(C) The requirements set forth in item (i)  of  subparagraph  (A)  of
   19  this  paragraph  and  in item (ii) of subparagraph (B) of this paragraph
   20  shall not be applicable where an individual proprietor  or  employer  is
   21  transferring from a health insurance contract issued pursuant to the New
   22  York  state  small  business health insurance partnership program estab-
   23  lished by section nine hundred twenty-two of the public  health  law  or
   24  from  health  care  coverage issued pursuant to a regional pilot project
   25  for the uninsured established by section one thousand one hundred  eigh-
   26  teen of this chapter.
   27    (D)]  (B)  The  twelve month period set forth [in item (i) of subpara-
   28  graph (A) of this paragraph and] in item (ii) of subparagraph [(B)]  (A)
   29  of  this  paragraph  may  be  adjusted by the superintendent from twelve
   30  months to eighteen months if he determines that the twelve month  period
   31  is  insufficient  to prevent inappropriate substitution of [other health
   32  insurance contracts for] qualifying group health insurance contracts FOR
   33  OTHER HEALTH INSURANCE CONTRACTS.
   34    [(E)] (C) An [individual proprietor or] employer shall cease to  be  a
   35  qualifying  small employer if any health insurance [which] THAT provides
   36  benefits on an expense reimbursed or prepaid basis covering  [the  indi-
   37  vidual  proprietor  or]  an  employer's employees, other than qualifying
   38  group health insurance purchased pursuant to this section, is  purchased
   39  or  otherwise  takes  effect  subsequent to purchase of qualifying group
   40  health insurance under the program established by this section.
   41    [(F)] (D) The wage levels utilized in subparagraph [(B)] (A)  of  this
   42  paragraph shall be adjusted annually, beginning in two thousand two. The
   43  adjustment shall take effect on July first of each year. For July first,
   44  two  thousand  two,  the  adjustment shall be a percentage of the annual
   45  wage figure specified in subparagraph [(B)] (A) of this  paragraph.  For
   46  subsequent  years,  the  adjustment  shall be a percentage of the annual
   47  wage figure [which] THAT took effect on July first of  the  prior  year.
   48  The  percentage  adjustment  shall  be  the same percentage by which the
   49  current year's non-farm federal poverty level, as defined and updated by
   50  the federal department of health and human services, for a  family  unit
   51  of  four  persons  for the forty-eight contiguous states and Washington,
   52  D.C., changed from the same level established for the prior year.
   53    (2) A qualifying group health insurance contract is a  group  contract
   54  purchased from a health maintenance organization, corporation or insurer
   55  by  a  qualifying  small employer [which] THAT provides the benefits set
       S. 2606--D                         122                        A. 3006--D

    1  forth in subsection (d) of this section. The contract  must  insure  not
    2  less than fifty percent of the employees [eligible for coverage].
    3    [(3)(A) A qualifying individual is an employed person:
    4    (i)  who  does not have and has not had health insurance with benefits
    5  on an expense reimbursed or prepaid basis during the twelve month period
    6  prior to the individual's application for  health  insurance  under  the
    7  program established by this section;
    8    (ii)  whose  employer  does not provide group health insurance and has
    9  not provided group health insurance with benefits on  an  expense  reim-
   10  bursed  or  prepaid basis covering employees in effect during the twelve
   11  month period prior to the individual's application for health  insurance
   12  under the program established by this section;
   13    (iii) resides in a household having a net household income at or below
   14  two  hundred  eight  percent  of  the non-farm federal poverty level (as
   15  defined and updated by  the  federal  department  of  health  and  human
   16  services) or the gross equivalent of such net income; and
   17    (iv) is ineligible for Medicare.
   18    (B)  The  requirements set forth in items (i) and (ii) of subparagraph
   19  (A) of this paragraph shall not be applicable  where  an  individual  is
   20  transferring  from  a  health  insurance contract issued pursuant to the
   21  voucher insurance  program  established  by  section  one  thousand  one
   22  hundred  twenty-one  of this chapter, a health insurance contract issued
   23  pursuant to the New York state small business health insurance  partner-
   24  ship  program  established  by  section  nine  hundred twenty-two of the
   25  public health law or health care coverage issued pursuant to a  regional
   26  pilot  project for the uninsured established by section one thousand one
   27  hundred eighteen of this chapter.
   28    (C) The requirements set forth in items (i) and (ii)  of  subparagraph
   29  (A)  of  this  paragraph shall not be applicable where an individual had
   30  health insurance coverage during the previous  twelve  months  and  such
   31  coverage terminated due to:
   32    (i) loss of employment due to factors other than voluntary separation;
   33    (ii) death of a family member which results in termination of coverage
   34  under a health insurance contract under which the individual is covered;
   35    (iii)  change  to  a  new  employer that does not provide group health
   36  insurance with benefits on an expense reimbursed or prepaid basis;
   37    (iv) change of residence so that no  employer-based  health  insurance
   38  with benefits on an expense reimbursed or prepaid basis is available;
   39    (v) discontinuation of a group health insurance contract with benefits
   40  on  an expense reimbursed or prepaid basis covering the qualifying indi-
   41  vidual as an employee or dependent;
   42    (vi) expiration of the coverage periods established by  the  continua-
   43  tion  provisions  of  the  Employee  Retirement  Income Security Act, 29
   44  U.S.C.   section 1161 et seq. and the  Public  Health  Service  Act,  42
   45  U.S.C.   section 300bb-1 et seq. established by the Consolidated Omnibus
   46  Budget Reconciliation Act of  1985,  as  amended,  or  the  continuation
   47  provisions of subsection (m) of section three thousand two hundred twen-
   48  ty-one,  subsection  (k) of section four thousand three hundred four and
   49  subsection (e) of section four thousand three hundred five of this chap-
   50  ter;
   51    (vii) legal separation, divorce or annulment which results  in  termi-
   52  nation  of  coverage  under  a health insurance contract under which the
   53  individual is covered; or
   54    (viii) loss of eligibility under a group health plan.
   55    (D) The twelve month period set forth in items (i) and (ii) of subpar-
   56  agraph (A) of this paragraph may be adjusted by the superintendent  from
       S. 2606--D                         123                        A. 3006--D

    1  twelve  months to eighteen months if he determines that the twelve month
    2  period is insufficient to prevent inappropriate  substitution  of  other
    3  health  insurance  contracts  for qualifying individual health insurance
    4  contracts.
    5    (4) A qualifying individual health insurance contract is an individual
    6  contract  issued  directly to a qualifying individual and which provides
    7  the benefits set forth in subsection (d) of this section. At the  option
    8  of  the  qualifying  individual,  such contract may include coverage for
    9  dependents of the qualifying individual.]
   10    (d) [The contracts issued pursuant to this section by  health  mainte-
   11  nance organizations, corporations or insurers and approved by the super-
   12  intendent shall only provide in-plan benefits, except for emergency care
   13  or  where  services  are not available through a plan provider.  Covered
   14  services shall include only the following:
   15    (1) inpatient hospital services consisting of daily  room  and  board,
   16  general  nursing care, special diets and miscellaneous hospital services
   17  and supplies;
   18    (2) outpatient hospital services consisting of diagnostic  and  treat-
   19  ment services;
   20    (3)   physician   services  consisting  of  diagnostic  and  treatment
   21  services, consultant and referral services, surgical services (including
   22  breast reconstruction surgery after a mastectomy), anesthesia  services,
   23  second surgical opinion, and a second opinion for cancer treatment;
   24    (4) outpatient surgical facility charges related to a covered surgical
   25  procedure;
   26    (5) preadmission testing;
   27    (6) maternity care;
   28    (7) adult preventive health services consisting of mammography screen-
   29  ing; cervical cytology screening; periodic physical examinations no more
   30  than once every three years; and adult immunizations;
   31    (8) preventive and primary health care services for dependent children
   32  including routine well-child visits and necessary immunizations;
   33    (9)  equipment,  supplies and self-management education for the treat-
   34  ment of diabetes;
   35    (10) diagnostic x-ray and laboratory services;
   36    (11) emergency services;
   37    (12) therapeutic services consisting of radiologic services,  chemoth-
   38  erapy and hemodialysis;
   39    (13)  blood and blood products furnished in connection with surgery or
   40  inpatient hospital services;
   41    (14) prescription drugs obtained at a participating pharmacy. In addi-
   42  tion to providing coverage at a participating pharmacy,  health  mainte-
   43  nance  organizations may utilize a mail order prescription drug program.
   44  Health maintenance organizations may provide prescription drugs pursuant
   45  to a drug formulary;  however,  health  maintenance  organizations  must
   46  implement   an   appeals  process  so  that  the  use  of  non-formulary
   47  prescription drugs may be requested by a physician; and
   48    (15) for a contract that is  not  a  grandfathered  health  plan,  the
   49  following additional preventive health services:
   50    (A)  evidence-based  items or services that have in effect a rating of
   51  'A' or 'B' in the current recommendations of the United  States  preven-
   52  tive services task force;
   53    (B)  immunizations that have in effect a recommendation from the advi-
   54  sory committee on immunization practices  of  the  centers  for  disease
   55  control and prevention with respect to the individual involved;
       S. 2606--D                         124                        A. 3006--D

    1    (C)  with  respect  to  children,  including  infants and adolescents,
    2  evidence-informed preventive care and screenings  provided  for  in  the
    3  comprehensive  guidelines supported by the health resources and services
    4  administration; and
    5    (D) with respect to women, such additional preventive care and screen-
    6  ings not described in subparagraph (A) of this paragraph as provided for
    7  in  comprehensive  guidelines  supported  by  the  health  resources and
    8  services administration.
    9    (E) For purposes of this paragraph, "grandfathered health plan"  means
   10  coverage  provided  by a corporation in which an individual was enrolled
   11  on March twenty-third, two thousand ten for  as  long  as  the  coverage
   12  maintains grandfathered status in accordance with section 1251(e) of the
   13  Affordable  Care  Act,  42  U.S.C. S 18011(e)] A QUALIFYING GROUP HEALTH
   14  INSURANCE CONTRACT SHALL PROVIDE COVERAGE FOR THE ESSENTIAL HEALTH BENE-
   15  FIT PACKAGE AS REQUIRED IN SECTION 2707(A) OF THE PUBLIC HEALTH  SERVICE
   16  ACT,  42 U.S.C. S 300GG-6(A). FOR PURPOSES OF THIS SUBSECTION "ESSENTIAL
   17  HEALTH BENEFITS PACKAGE" SHALL HAVE THE MEANING  SET  FORTH  IN  SECTION
   18  1302(A) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(A).
   19    (d-1)  Covered  services  shall  not  include  drugs,  procedures  and
   20  supplies for the treatment of erectile dysfunction when provided to,  or
   21  prescribed  for  use  by,  a person who is required to register as a sex
   22  offender pursuant to article six-C of the correction law, provided that:
   23  (1) any denial of coverage pursuant to this subsection shall provide the
   24  enrollee with the means of obtaining additional  information  concerning
   25  both the denial and the means of challenging such denial; (2) all drugs,
   26  procedures and supplies for the treatment of erectile dysfunction may be
   27  subject to prior authorization by corporations, insurers or health main-
   28  tenance  organizations for the purposes of implementing this subsection;
   29  and (3) the superintendent shall promulgate regulations to implement the
   30  denial of coverage pursuant to this subsection giving health maintenance
   31  organizations, corporations and insurers at least sixty  days  following
   32  promulgation  of  the  regulations  to implement their denial procedures
   33  pursuant to this subsection.
   34    (d-2) No person or entity authorized to provide  coverage  under  this
   35  section  shall be subject to any civil or criminal liability for damages
   36  for any decision or action pursuant to subsection (d-1) of this section,
   37  made in the ordinary course of business if  that  authorized  person  or
   38  entity  acted reasonably and in good faith with respect to such informa-
   39  tion.
   40    (d-3) Notwithstanding any other provision of law, if the  commissioner
   41  of  health  makes  a  finding  pursuant  to  subdivision twenty-three of
   42  section two hundred six of the public health law, the superintendent  is
   43  authorized  to  remove  a  drug,  procedure  or supply from the services
   44  covered by the standardized health  insurance  contract  established  by
   45  this  section  for  those  persons required to register as sex offenders
   46  pursuant to article six-C of the correction law.
   47    (e) [The benefits provided in the contracts  described  in  subsection
   48  (d)  of  this  section shall be subject to the following deductibles and
   49  copayments:
   50    (1) in-patient hospital services shall  have  a  five  hundred  dollar
   51  copayment for each continuous hospital confinement;
   52    (2) surgical services shall be subject to a copayment of the lesser of
   53  twenty  percent  of the cost of such services or two hundred dollars per
   54  occurrence;
   55    (3) outpatient surgical facility charges shall be subject to a facili-
   56  ty copayment charge of seventy-five dollars per occurrence;
       S. 2606--D                         125                        A. 3006--D

    1    (4) emergency services shall have a fifty dollar copayment which  must
    2  be waived if hospital admission results from the emergency room visit;
    3    (5)  prescription  drugs shall have a one hundred dollar calendar year
    4  deductible per individual. After the deductible is satisfied, each thir-
    5  ty-four day supply of a prescription drug will be subject  to  a  copay-
    6  ment.  The  copayment  will  be  ten dollars if the drug is generic. The
    7  copayment for a brand name drug will be twenty dollars plus the  differ-
    8  ence  in  cost  between  the  brand name drug and the equivalent generic
    9  drug. If a mail order drug program is utilized, a twenty  dollar  copay-
   10  ment  shall  be  imposed  on a ninety day supply of generic prescription
   11  drugs. A forty dollar copayment plus the difference in cost between  the
   12  brand  name  drug  and the equivalent generic drug shall be imposed on a
   13  ninety day supply of brand name prescription drugs. In  no  event  shall
   14  the copayment exceed the cost of the prescribed drug;
   15    (6)  (A)  the maximum coverage for prescription drugs in an individual
   16  contract that is a grandfathered health plan  shall  be  three  thousand
   17  dollars per individual in a calendar year; and
   18    (B) the maximum dollar amount on coverage for prescription drugs in an
   19  individual  contract  that  is not a grandfathered health plan or in any
   20  group contract shall be consistent  with  section  2711  of  the  Public
   21  Health Service Act, 42 U.S.C. S 300gg-11 or any regulations thereunder.
   22    (C)  For purposes of this paragraph, "grandfathered health plan" means
   23  coverage provided by a corporation in which an individual  was  enrolled
   24  on  March  twenty-third,  two  thousand  ten for as long as the coverage
   25  maintains grandfathered status in accordance with section 1251(e) of the
   26  Affordable Care Act, 42 U.S.C. S 18011(e); and
   27    (7) all other services shall have a twenty dollar copayment  with  the
   28  exception  of  prenatal  care which shall have a ten dollar copayment or
   29  preventive health services provided pursuant  to  paragraph  fifteen  of
   30  subsection  (d)  of  this section, for which no copayment shall apply] A
   31  QUALIFYING GROUP HEALTH INSURANCE CONTRACT ISSUED TO A QUALIFYING  SMALL
   32  EMPLOYER  PRIOR  TO  JANUARY  FIRST, TWO THOUSAND FOURTEEN THAT DOES NOT
   33  INCLUDE ALL ESSENTIAL  HEALTH  BENEFITS  REQUIRED  PURSUANT  TO  SECTION
   34  2707(A)  OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(A), SHALL
   35  BE DISCONTINUED, INCLUDING GRANDFATHERED HEALTH PLANS. FOR THE  PURPOSES
   36  OF  THIS PARAGRAPH, "GRANDFATHERED HEALTH PLANS" MEANS COVERAGE PROVIDED
   37  BY A CORPORATION TO INDIVIDUALS WHO WERE ENROLLED ON MARCH TWENTY-THIRD,
   38  TWO THOUSAND TEN FOR AS LONG AS  THE  COVERAGE  MAINTAINS  GRANDFATHERED
   39  STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE AFFORDABLE CARE ACT, 42
   40  U.S.C.  S 18011(E). A QUALIFYING SMALL EMPLOYER SHALL BE TRANSITIONED TO
   41  A PLAN THAT PROVIDES: (1) A  LEVEL  OF  COVERAGE  THAT  IS  DESIGNED  TO
   42  PROVIDE  BENEFITS  THAT  ARE ACTUARIALLY EQUIVALENT TO EIGHTY PERCENT OF
   43  THE FULL ACTUARIAL VALUE OF THE BENEFITS PROVIDED UNDER  THE  PLAN;  AND
   44  (2)  COVERAGE  FOR  THE  ESSENTIAL HEALTH BENEFIT PACKAGE AS REQUIRED IN
   45  SECTION  2707(A)  OF  THE  PUBLIC  HEALTH  SERVICE  ACT,  42  U.S.C.   S
   46  300GG-6(A). THE SUPERINTENDENT SHALL STANDARDIZE THE BENEFIT PACKAGE AND
   47  COST  SHARING REQUIREMENTS OF QUALIFIED GROUP HEALTH INSURANCE CONTRACTS
   48  CONSISTENT WITH COVERAGE OFFERED THROUGH  THE  HEALTH  BENEFIT  EXCHANGE
   49  ESTABLISHED  PURSUANT  TO  SECTION  1311  OF THE AFFORDABLE CARE ACT, 42
   50  U.S.C. S 18031.
   51    (f) [Except as included in the list of covered services in  subsection
   52  (d)  of  this section, the] THE mandated and make-available benefits set
   53  forth in sections [three thousand two hundred sixteen,]  three  thousand
   54  two  hundred  twenty-one of this chapter and four thousand three hundred
   55  three of this article shall not be applicable to  the  contracts  issued
   56  pursuant  to this section. [Mandated benefits included in such contracts
       S. 2606--D                         126                        A. 3006--D

    1  shall be  subject  to  the  deductibles  and  copayments  set  forth  in
    2  subsection (e) of this section.]
    3    (g)  [The superintendent shall be authorized to modify, by regulation,
    4  the copayment and deductible amounts described in this  section  if  the
    5  superintendent  determines  such  amendments are necessary to facilitate
    6  implementation of this section. On or after January first, two  thousand
    7  two, the superintendent shall be authorized to establish, by regulation,
    8  one or more additional standardized health insurance benefit packages if
    9  the superintendent determines additional benefit packages with different
   10  levels of benefits are necessary to meet the needs of the public.
   11    (h)]  A  health  maintenance organization, corporation or insurer must
   12  offer the benefit package without change or additional benefits. [Quali-
   13  fying] A QUALIFYING small [employers] EMPLOYER shall be issued the bene-
   14  fit package in a qualifying group health insurance contract. [Qualifying
   15  individuals shall be issued the benefit package in a qualifying individ-
   16  ual health insurance contract.
   17    (i)] (H) A health maintenance  organization,  corporation  or  insurer
   18  shall  obtain from the employer [or individual] written certification at
   19  the time of initial application  and  annually  thereafter  ninety  days
   20  prior  to  the  contract renewal date that such employer [or individual]
   21  meets the requirements of a qualifying small employer [or  a  qualifying
   22  individual] pursuant to this section. A health maintenance organization,
   23  corporation  or  insurer  may  require  the  submission  of  appropriate
   24  documentation in support of the certification.
   25    [(j)] (I) Applications for qualifying group health insurance contracts
   26  [and qualifying individual health insurance contracts] must be  accepted
   27  from  [any  qualifying  individual and] any qualifying small employer at
   28  all times throughout the year. The superintendent,  by  regulation,  may
   29  require  health  maintenance  organizations, corporations or insurers to
   30  give preference to qualifying small employers whose [eligible] employees
   31  have the lowest average salaries.
   32    [(k) (1) All  coverage  under  a  qualifying  group  health  insurance
   33  contract  or  a  qualifying individual health insurance contract must be
   34  subject to a pre-existing condition limitation provision as set forth in
   35  sections three thousand two hundred thirty-two of this chapter and  four
   36  thousand three hundred eighteen of this article, including the crediting
   37  requirements  thereunder.  The  underwriting  of  such contracts may not
   38  involve more than the imposition of a pre-existing condition limitation.
   39  However, as provided in sections three thousand two  hundred  thirty-two
   40  of  this  chapter and four thousand three hundred eighteen of this arti-
   41  cle, a corporation shall not impose a pre-existing condition  limitation
   42  provision  on  any  person  under age nineteen, except may impose such a
   43  limitation on those persons covered by a  qualifying  individual  health
   44  insurance contract that is a grandfathered health plan.
   45    (2)]  (J)  Beginning January first, two thousand fourteen, pursuant to
   46  section 2704 of the Public Health Service Act, 42 U.S.C.  S  300gg-3,  a
   47  corporation  shall not impose any pre-existing condition limitation in a
   48  qualifying group health insurance contract [or a  qualifying  individual
   49  health insurance contract except may impose such a limitation in a qual-
   50  ifying  individual  health  insurance  contract  that is a grandfathered
   51  health plan].
   52    [(3) For purposes of  paragraphs  one  and  two  of  this  subsection,
   53  "grandfathered  health plan" means coverage provided by a corporation in
   54  which an individual was enrolled on March twenty-third, two thousand ten
   55  for as long as the coverage maintains grandfathered status in accordance
   56  with section 1251(e) of the Affordable Care Act, 42 U.S.C. S 18011(e).
       S. 2606--D                         127                        A. 3006--D

    1    (l)] (K) A qualifying small  employer  shall  elect  whether  to  make
    2  coverage  under the qualifying group health insurance contract available
    3  to dependents of employees. Any employee or dependent who is enrolled in
    4  Medicare is ineligible for coverage, unless  required  by  federal  law.
    5  Dependents  of  an employee who is enrolled in Medicare will be eligible
    6  for dependent coverage provided the dependent is not  also  enrolled  in
    7  Medicare.
    8    [(m)]  (L) A qualifying small employer must pay at least fifty percent
    9  of the premium for employees covered under  a  qualifying  group  health
   10  insurance  contract  and  must offer coverage to all employees receiving
   11  annual wages at a level of thirty thousand dollars or less, and at least
   12  one such employee shall accept such coverage. The thirty thousand dollar
   13  wage level shall be adjusted periodically in  accordance  with  subpara-
   14  graph  [(F)] (D) of paragraph one of subsection (c) of this section. The
   15  employer premium contribution  must  be  the  same  percentage  for  all
   16  covered employees.
   17    [(n)] (M) Premium rate calculations for qualifying group health insur-
   18  ance  contracts  [and  qualifying individual health insurance contracts]
   19  shall be subject to the following:
   20    (1) coverage must be community rated and [include rate tiers for indi-
   21  viduals, two adult families and at least one other family tier. The rate
   22  differences must be based upon the cost differences  for  the  different
   23  family units and the rate tiers must be uniformly applied. The rate tier
   24  structure  used  by  a  health  maintenance organization, corporation or
   25  insurer for the contracts issued to qualifying small  employers  and  to
   26  qualifying  individuals  must  be the same] THE SUPERINTENDENT SHALL SET
   27  STANDARD RATING TIERS FOR FAMILY UNITS AND STANDARD RATING  RELATIVITIES
   28  BETWEEN TIERS APPLICABLE TO ALL CONTRACTS SUBJECT TO THIS SECTION; AND
   29    (2)  [if  geographic  rating areas are utilized, such geographic areas
   30  must be reasonable and in a given case may include a single county.  The
   31  geographic  areas  utilized must be the same for the contracts issued to
   32  qualifying small employers and to  qualifying  individuals.  The  super-
   33  intendent  shall  not  require  the inclusion of any specific geographic
   34  region within the proposed community rated region selected by the health
   35  maintenance organization, corporation or insurer so long as  the  health
   36  maintenance  organization,  corporation or insurer's proposed regions do
   37  not contain configurations designed to  avoid  or  segregate  particular
   38  areas  within  a  county covered by the health maintenance organization,
   39  corporation or insurer's community rates.] BEGINNING JANUARY FIRST,  TWO
   40  THOUSAND FOURTEEN, EVERY POLICY SUBJECT TO THIS SECTION SHALL USE STAND-
   41  ARDIZED REGIONS ESTABLISHED BY THE SUPERINTENDENT; AND
   42    (3)  claims  experience  under  contracts  issued  to qualifying small
   43  employers [and to qualifying individuals] must be pooled WITH THE HEALTH
   44  MAINTENANCE ORGANIZATION, CORPORATION OR INSURER'S SMALL GROUP  BUSINESS
   45  for  rate  setting  purposes.  [The  premium  rates for qualifying group
   46  health insurance contracts and qualifying  individual  health  insurance
   47  contracts must be the same.
   48    (o)]  (N)  A  health  maintenance organization, corporation or insurer
   49  shall submit reports to the superintendent in such form and at times  as
   50  may  be  reasonably  required  in  order  to evaluate the operations and
   51  results of the standardized health insurance program established by this
   52  section.
   53    [(p) Notwithstanding any other provision of law, all  individuals  and
   54  small  businesses  that  are  participating  in  or covered by insurance
   55  contracts or policies issued pursuant to the New York state small  busi-
   56  ness  health  insurance  partnership program established by section nine
       S. 2606--D                         128                        A. 3006--D

    1  hundred twenty-two of the  public  health  law,  the  voucher  insurance
    2  program  established  by  section one thousand one hundred twenty-one of
    3  this chapter, or uninsured pilot programs established pursuant to  chap-
    4  ter  seven  hundred  three  of the laws of nineteen hundred eighty-eight
    5  shall be eligible for participation in the standardized health insurance
    6  contracts established by this section, regardless of any of  the  eligi-
    7  bility  requirements  established  pursuant  to  subsection  (c) of this
    8  section.]
    9    S 57. The insurance law is amended by adding a new section  4326-a  to
   10  read as follows:
   11    S  4326-A.  TRANSITION  OF HEALTHY NEW YORK ENROLLEES. (A) ON DECEMBER
   12  THIRTY-FIRST, TWO THOUSAND THIRTEEN, COVERAGE ISSUED TO QUALIFYING INDI-
   13  VIDUALS AND QUALIFYING SMALL  EMPLOYERS  WHO  ARE  SOLE  PROPRIETORS  AS
   14  DEFINED  IN  SECTION  FOUR  THOUSAND  THREE HUNDRED TWENTY-SIX SHALL END
   15  CONTINGENT UPON THE AVAILABILITY OF COVERAGE  FOR  INDIVIDUAL  AND  SOLE
   16  PROPRIETORS THROUGH THE HEALTH BENEFIT EXCHANGE.
   17    (B)  A  HEALTH MAINTENANCE ORGANIZATION, CORPORATION, OR INSURER SHALL
   18  PROVIDE WRITTEN NOTICE OF THE PROGRAM DISCONTINUANCE  TO  EACH  ENROLLED
   19  INDIVIDUAL  AND  INDIVIDUAL  PROPRIETOR  AT LEAST ONE HUNDRED AND EIGHTY
   20  DAYS PRIOR TO THE  DATE  OF  PROGRAM  DISCONTINUANCE.  EVERY  NOTICE  OF
   21  PROGRAM  DISCONTINUANCE  SHALL BE IN SUCH FORM AND CONTAIN SUCH INFORMA-
   22  TION AS THE SUPERINTENDENT REQUIRES.
   23    (C) QUALIFYING GROUP HEALTH INSURANCE CONTRACTS ISSUED  TO  QUALIFYING
   24  SMALL  EMPLOYERS  PRIOR  TO JANUARY FIRST, TWO THOUSAND FOURTEEN THAT DO
   25  NOT INCLUDE ALL ESSENTIAL HEALTH BENEFITS REQUIRED PURSUANT  TO  SECTION
   26  2707(A)  OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(A); SHALL
   27  BE DISCONTINUED.  QUALIFYING SMALL EMPLOYERS THAT ARE  IMPACTED  BY  THE
   28  DISCONTINUANCE  SHALL  BE TRANSITIONED TO A PLAN THAT MEETS THE REQUIRE-
   29  MENTS  OF  SUBSECTION  (E)  OF  SECTION  FOUR  THOUSAND  THREE   HUNDRED
   30  TWENTY-SIX  OF  THIS  CHAPTER. A HEALTH MAINTENANCE ORGANIZATION, CORPO-
   31  RATION, OR INSURER SHALL PROVIDE WRITTEN NOTICE OF THE  PROGRAM  DISCON-
   32  TINUANCE TO EACH ENROLLED QUALIFYING SMALL EMPLOYER AT LEAST ONE HUNDRED
   33  EIGHTY DAYS PRIOR TO THE DATE OF PROGRAM DISCONTINUANCE. EVERY NOTICE OF
   34  PROGRAM  DISCONTINUANCE  SHALL BE IN SUCH FORM AND CONTAIN SUCH INFORMA-
   35  TION AS REQUIRED BY THE SUPERINTENDENT.
   36    S 58. Section 4327 of the insurance law, as added by chapter 1 of  the
   37  laws  of  1999,  subsection (h) as amended by chapter 419 of the laws of
   38  2000, subsection (m-1) as added by section 12 of part B of chapter 58 of
   39  the laws of 2010, subsection (s) as amended and subsection (t) as  added
   40  by chapter 441 of the laws of 2006, is amended to read as follows:
   41    S  4327.  Stop  loss funds for standardized health insurance contracts
   42  issued to qualifying small employers and qualifying individuals. (a) The
   43  superintendent shall establish a  fund  from  which  health  maintenance
   44  organizations,  corporations  or  insurers may receive reimbursement, to
   45  the extent of funds available therefor, for claims paid by  such  health
   46  maintenance  organizations, corporations or insurers for members covered
   47  under qualifying group health insurance  contracts  issued  pursuant  to
   48  section  four  thousand  three  hundred twenty-six of this article. This
   49  fund shall be known as the "small employer stop loss fund". [The  super-
   50  intendent shall establish a separate and distinct fund from which health
   51  maintenance   organizations,   corporations   or  insurers  may  receive
   52  reimbursement, to the extent of funds  available  therefor,  for  claims
   53  paid  by such health maintenance organizations, corporations or insurers
   54  for  members  covered  under  qualifying  individual  health   insurance
   55  contracts  issued  pursuant to section four thousand three hundred twen-
       S. 2606--D                         129                        A. 3006--D

    1  ty-six of this article. This fund shall  be  known  as  the  "qualifying
    2  individual stop loss fund".]
    3    (b)  [Commencing  on  January  first, two thousand one, health] HEALTH
    4  maintenance organizations, corporations or insurers shall be eligible to
    5  receive reimbursement for ninety percent of claims paid between [thirty]
    6  FIVE thousand and [one  hundred]  SEVENTY-FIVE  thousand  dollars  in  a
    7  calendar  year  for  any  member  covered  under a standardized contract
    8  issued pursuant to section four thousand  three  hundred  twenty-six  of
    9  this  article.  Claims  paid  for members covered under qualifying group
   10  health insurance contracts shall be reimbursable from the small employer
   11  stop loss fund. [Claims paid for members covered under qualifying  indi-
   12  vidual  health insurance contracts shall be reimbursable from the quali-
   13  fying individual stop loss fund.] For  the  purposes  of  this  section,
   14  claims  shall  include  health  care claims paid by a health maintenance
   15  organization on behalf of a covered member pursuant to such standardized
   16  contracts.
   17    (c) The superintendent shall promulgate  regulations  that  set  forth
   18  procedures  for  the operation of the small employer stop loss fund [and
   19  the qualifying individual stop loss fund]  and  distribution  of  monies
   20  therefrom.
   21    (d)  [The  small employer stop loss fund shall operate separately from
   22  the qualifying  individual  stop  loss  fund.  Except  as  specified  in
   23  subsection  (b)  of this section with respect to calendar year two thou-
   24  sand one, the level of stop  loss  coverage  for  the  qualifying  group
   25  health  insurance  contracts and the qualifying individual health insur-
   26  ance contracts need not be the same. The two stop loss funds need not be
   27  structured or operated in the same manner, except as specified  in  this
   28  section.  The monies available for distribution from the stop loss funds
   29  may be reallocated between the small employer stop  loss  fund  and  the
   30  qualifying  individual  stop  loss fund if the superintendent determines
   31  that such reallocation is  warranted  due  to  enrollment  trends.]  THE
   32  SUPERINTENDENT  MAY  ADJUST THE LEVEL OF STOP LOSS COVERAGE SPECIFIED IN
   33  SUBSECTION (B) OF THIS SECTION.
   34    (e) Claims shall be reported and funds shall be distributed  from  the
   35  small  employer  stop loss fund [and from the qualifying individual stop
   36  loss fund] on a calendar  year  basis.  Claims  shall  be  eligible  for
   37  reimbursement  only  for the calendar year in which the claims are paid.
   38  Once claims paid on behalf of a  covered  member  reach  or  exceed  one
   39  hundred  thousand  dollars  in  a given calendar year, no further claims
   40  paid on behalf of such member in that calendar year  shall  be  eligible
   41  for reimbursement.
   42    (f) Each health maintenance organization, corporation or insurer shall
   43  submit  a request for reimbursement from [each of] the stop loss [funds]
   44  FUND on forms prescribed by the  superintendent.    [Each  of  the]  THE
   45  requests  for reimbursement shall be submitted no later than April first
   46  following the end of the  calendar  year  for  which  the  reimbursement
   47  requests  are  being made. The superintendent may require health mainte-
   48  nance organizations, corporations or insurers to submit such claims data
   49  in connection with the reimbursement requests as he deems  necessary  to
   50  enable  him  to distribute monies and oversee the operation of the small
   51  employer [and qualifying individual] stop loss [funds] FUND.  The super-
   52  intendent may require that such data  be  submitted  on  a  per  member,
   53  aggregate  and/or  categorical basis. [Data shall be reported separately
   54  for qualifying group health insurance contracts and qualifying  individ-
   55  ual  health insurance contracts issued pursuant to section four thousand
   56  three hundred twenty-six of this article.]
       S. 2606--D                         130                        A. 3006--D

    1    (g) For [each] THE stop loss fund, the superintendent shall  calculate
    2  the  total claims reimbursement amount for all health maintenance organ-
    3  izations, corporations or insurers  for  the  calendar  year  for  which
    4  claims are being reported.
    5    (1) In the event that the total amount requested for reimbursement for
    6  a calendar year exceeds funds available for distribution for claims paid
    7  during that same calendar year, the superintendent shall provide for the
    8  pro-rata  distribution  of  the available funds. Each health maintenance
    9  organization, corporation or insurer shall be eligible to  receive  only
   10  such  proportionate  amount  of  the  available  funds as the individual
   11  health maintenance  organization's,  corporation's  or  insurer's  total
   12  eligible  claims  paid  bears  to  the total eligible claims paid by all
   13  health maintenance organizations, corporations or insurers.
   14    (2) In the event that funds available for distribution for claims paid
   15  by all health maintenance organizations, corporations or insurers during
   16  a calendar year exceeds the total amount requested for reimbursement  by
   17  all  health  maintenance  organizations, corporations or insurers during
   18  that same calendar year, any excess funds shall be carried  forward  and
   19  made  available  for distribution in the next calendar year. Such excess
   20  funds shall be in addition to the monies appropriated for the stop  loss
   21  fund in the next calendar year.
   22    (h)  Upon  the  request of the superintendent, each health maintenance
   23  organization shall be required to furnish such data as  the  superinten-
   24  dent deems necessary to oversee the operation of the small employer [and
   25  qualifying  individual]  stop  loss  [funds]  FUND.  Such  data shall be
   26  furnished in a form prescribed by the superintendent. Each health  main-
   27  tenance  organization,  corporation  or insurer shall provide the super-
   28  intendent with monthly reports of the total enrollment under the  quali-
   29  fying  group  health  insurance contracts [and the qualifying individual
   30  health insurance contracts] issued pursuant  to  section  four  thousand
   31  three hundred twenty-six of this article. The reports shall be in a form
   32  prescribed by the superintendent.
   33    (i) The superintendent shall separately estimate the per member annual
   34  cost  of total claims reimbursement from each stop loss fund for [quali-
   35  fying individual health insurance contracts and  for]  qualifying  group
   36  health  insurance  contracts  based  upon available data and appropriate
   37  actuarial assumptions. Upon request, each health  maintenance  organiza-
   38  tion,  corporation or insurer shall furnish to the superintendent claims
   39  experience data for use in such estimations.
   40    (j) The superintendent shall determine total eligible enrollment under
   41  qualifying group health insurance contracts [and  qualifying  individual
   42  health  insurance  contracts].  [For  qualifying  group health insurance
   43  contracts, the] THE total eligible enrollment  shall  be  determined  by
   44  dividing  the  total  funds  available  for  distribution from the small
   45  employer stop loss fund by the estimated per member annual cost of total
   46  claims reimbursement from the small employer stop loss fund. [For quali-
   47  fying individual health insurance contracts, the total eligible  enroll-
   48  ment  shall  be  determined  by  dividing  the total funds available for
   49  distribution from the qualifying individual stop loss fund by the  esti-
   50  mated  per  member  annual  cost  of total claims reimbursement from the
   51  qualifying individual stop loss fund.]
   52    (k) The superintendent shall suspend the enrollment of  new  employers
   53  under  qualifying  group  health  insurance contracts if [he] THE SUPER-
   54  INTENDENT determines that the total enrollment reported  by  all  health
   55  maintenance organizations, corporations or insurers under such contracts
   56  exceeds  the total eligible enrollment, thereby resulting in anticipated
       S. 2606--D                         131                        A. 3006--D

    1  annual expenditures from the small employer stop loss fund in excess  of
    2  the  total  funds  available  for distribution from such stop loss fund.
    3  [The superintendent shall suspend  the  enrollment  of  new  individuals
    4  under  qualifying individual health insurance contracts if he determines
    5  that the total enrollment reported by all health  maintenance  organiza-
    6  tions,  corporations  or insurers under such contracts exceeds the total
    7  eligible enrollment, thereby resulting in  anticipated  annual  expendi-
    8  tures  from  the  qualifying  individual stop loss fund in excess of the
    9  total funds available for distribution from such stop loss fund.]
   10    (l) The superintendent shall provide the health maintenance  organiza-
   11  tions,  corporations  or  insurers  with  notification of any enrollment
   12  suspensions as soon as practicable after receipt of all enrollment data.
   13  [The superintendent's determination and notification shall be made sepa-
   14  rately for the qualifying group health insurance contracts and  for  the
   15  qualifying individual health insurance contracts.]
   16    (m)  If at any point during a suspension of enrollment of new qualify-
   17  ing small employers [and/or qualifying individuals], the  superintendent
   18  determines  that funds are sufficient to provide for the addition of new
   19  enrollments, the superintendent shall be authorized  to  reactivate  new
   20  enrollments  and  to notify all health maintenance organizations, corpo-
   21  rations or insurers that enrollment of new  employers  [and/or  individ-
   22  uals]  may  again  commence.  [The  superintendent's  determination  and
   23  notification shall be made separately for the  qualifying  group  health
   24  insurance  contracts  and for the qualifying individual health insurance
   25  contracts.]
   26    (m-1) In the event that the superintendent suspends the enrollment  of
   27  new  individuals  for  qualifying  group  health insurance contracts [or
   28  qualifying individual health insurance  contracts],  the  superintendent
   29  shall  ensure  that  small  employers  [or  sole proprietors] seeking to
   30  enroll in a qualified group [or individual]  health  insurance  contract
   31  pursuant  to  section forty-three hundred twenty-six of this article are
   32  provided information on and directed to [the family health plus employer
   33  partnership program under section three  hundred  sixty-nine-ff  of  the
   34  social services law] COVERAGE OPTIONS AVAILABLE THROUGH THE HEALTH BENE-
   35  FIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE
   36  ACT, 42 U.S.C. S 18031.
   37    (n)  The  suspension  of issuance of qualifying group health insurance
   38  contracts to new qualifying small employers shall not preclude the addi-
   39  tion of new employees of  an  employer  already  covered  under  such  a
   40  contract  or  new  dependents  of  employees  already covered under such
   41  contracts.
   42    (o) [The suspension of issuance of qualifying individual health insur-
   43  ance contracts to new qualifying  individuals  shall  not  preclude  the
   44  addition  of  new dependents to an existing qualifying individual health
   45  insurance contract.
   46    (p)] The premiums for qualifying group health insurance contracts must
   47  factor in the availability of reimbursement from the small employer stop
   48  loss fund. [The premiums  for  qualifying  individual  health  insurance
   49  contracts  must  factor  in  the  availability of reimbursement from the
   50  qualifying individual stop loss funds.
   51    (q)] (P) The superintendent may obtain the services of an organization
   52  to administer the stop loss funds established by this section.  [If  the
   53  superintendent  deems  it  appropriate, he or she may utilize a separate
   54  organization for administration of the small employer stop loss fund and
   55  the qualifying individual stop  loss  fund.]  The  superintendent  shall
   56  establish  guidelines  for  the submission of proposals by organizations
       S. 2606--D                         132                        A. 3006--D

    1  for the purposes of administering the funds.  The  superintendent  shall
    2  make a determination whether to approve, disapprove or recommend modifi-
    3  cation  to  the  proposal  of  an  applicant to administer the funds. An
    4  organization  approved  to  administer the funds shall submit reports to
    5  the superintendent in such form and at times as may be required  by  the
    6  superintendent  in  order  to  facilitate  evaluation and ensure orderly
    7  operation of the funds, including[,  but  not  limited  to,]  an  annual
    8  report  of  the  affairs  and  operations of the fund, such report to be
    9  delivered to the superintendent and to the chairs of the senate  finance
   10  committee  and  the  assembly  ways and means committee. An organization
   11  approved to administer the  funds  shall  maintain  records  in  a  form
   12  prescribed  by  the  superintendent  and  which  shall  be available for
   13  inspection by or at the request of the superintendent.  The  superinten-
   14  dent  shall  determine  the amount of compensation to be allocated to an
   15  approved organization as payment for fund  administration.  Compensation
   16  shall  be  payable  from  the  stop loss coverage funds. An organization
   17  approved to administer the funds may be removed  by  the  superintendent
   18  and  must  cooperate  in  the  orderly transition of services to another
   19  approved organization or to the superintendent.
   20    [(r)] (Q) If the superintendent deems it appropriate  for  the  proper
   21  administration of the small employer stop loss fund [and/or the qualify-
   22  ing individual stop loss fund], the administrator of the fund, on behalf
   23  of  and  with the prior approval of the superintendent, shall be author-
   24  ized to purchase stop loss insurance and/or reinsurance from  an  insur-
   25  ance  company  licensed  to  write such type of insurance in this state.
   26  Such stop loss insurance and/or reinsurance  may  be  purchased  to  the
   27  extent of funds available therefor within such funds which are available
   28  for purposes of the stop loss funds established by this section.
   29    [(s)] (R) The superintendent may access funding from the small employ-
   30  er  stop loss fund [and/or the qualifying individual stop loss fund] for
   31  the purposes of developing and implementing public  education,  outreach
   32  and  facilitated  enrollment strategies targeted to small employers [and
   33  working  adults]  without  health  insurance.  The  superintendent   may
   34  contract  with  marketing organizations to perform or provide assistance
   35  with such education, outreach, and  enrollment  strategies.  The  super-
   36  intendent  shall  determine  the  amount  of  funding  available for the
   37  purposes of this subsection which in no event shall exceed eight percent
   38  of the annual funding amounts for the small employer stop loss fund [and
   39  the qualifying individual stop loss fund].
   40    [(t)] (S) Brooklyn healthworks pilot program and  upstate  healthworks
   41  pilot  program.  Commencing  on July first, two thousand six, the super-
   42  intendent shall access funding from the small employer  stop  loss  fund
   43  [and  the  qualifying  individual  stop  loss  fund]  for the purpose of
   44  support and expansion of the existing pilot program Brooklyn healthworks
   45  approved by the superintendent and for the establishment  and  operation
   46  of a pilot program to be located in upstate New York. For the purpose of
   47  this  subsection,  in  no  event  shall  the amount of funding available
   48  exceed two percent of the annual funding [amounts] AMOUNT for the  small
   49  employer stop loss fund [and the qualifying individual stop loss fund].
   50    S  59.  Paragraph 1 of subsection (d) of section 4235 of the insurance
   51  law is amended to read as follows:
   52    (1) In this section, for the purpose of insurance OTHER THAN FOR GROUP
   53  HOSPITAL, MEDICAL,  MAJOR  MEDICAL  OR  SIMILAR  COMPREHENSIVE-TYPES  OF
   54  EXPENSE  REIMBURSED INSURANCE hereunder:  "employees" includes the offi-
   55  cers, managers, employees and retired employees of the employer  and  of
   56  subsidiary  or  affiliated corporations of a corporate employer, and the
       S. 2606--D                         133                        A. 3006--D

    1  individual proprietors, partners, employees  and  retired  employees  of
    2  affiliated  individuals  and  firms  controlled  by the insured employer
    3  through stock ownership,  contract  or  otherwise;  "employees"  may  be
    4  deemed  to include the individual proprietor or partners if the employer
    5  is an individual proprietor or a partnership; and "employees" as used in
    6  subparagraph (A) of paragraph one of  subsection  (c)  hereof  may  also
    7  include  the  directors  of the employer and of subsidiary or affiliated
    8  corporations of a corporate employer.
    9    S 60. Subsection (d) of section 4235 of the insurance law  is  amended
   10  by adding a new paragraph 3 to read as follows:
   11    (3) IN THIS SECTION, FOR THE PURPOSE OF GROUP HOSPITAL, MEDICAL, MAJOR
   12  MEDICAL  OR  SIMILAR COMPREHENSIVE-TYPES OF EXPENSE REIMBURSED INSURANCE
   13  HEREUNDER:
   14    (A) "EMPLOYEE" SHALL HAVE THE MEANING SET FORTH IN SECTION 2791 OF THE
   15  PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-91(D)(5) OR ANY REGULATIONS
   16  PROMULGATED THEREUNDER; AND
   17    (B) "FULL-TIME EMPLOYEE" MEANS WITH RESPECT TO ANY MONTH, AN  EMPLOYEE
   18  WHO IS EMPLOYED ON AVERAGE FOR AT LEAST THIRTY HOURS OF SERVICE PER WEEK
   19  AS  SET  FORTH  IN  SECTION 4980H(C)(4) OF THE INTERNAL REVENUE CODE, 26
   20  U.S.C. S 4980H(C)(4), OR ANY REGULATIONS PROMULGATED THEREUNDER.
   21    S 61. Subparagraph (B) of paragraph 1 of  subsection  (e)  of  section
   22  3231  of  the  insurance  law,  as amended by chapter 107 of the laws of
   23  2010, is amended to read as follows:
   24    (B) The expected minimum loss ratio for a policy form subject to  this
   25  section, for which a rate filing or application is made pursuant to this
   26  paragraph, other than a medicare supplemental insurance policy, or, with
   27  the  approval of the superintendent, an aggregation of policy forms that
   28  are combined  into  one  community  rating  experience  pool  and  rated
   29  consistent  with  community  rating requirements, shall not be less than
   30  eighty-two percent. In reviewing  a  rate  filing  or  application,  the
   31  superintendent  may  modify the eighty-two percent expected minimum loss
   32  ratio requirement if the superintendent determines the  modification  to
   33  be in the interests of the people of this state or if the superintendent
   34  determines  that a modification is necessary to maintain insurer solven-
   35  cy. No later than [June thirtieth] JULY THIRTY-FIRST of each year, every
   36  insurer subject to this subparagraph shall annually  report  the  actual
   37  loss  ratio for the previous calendar year in a format acceptable to the
   38  superintendent. If an expected loss ratio is not met, the superintendent
   39  may direct the insurer to take corrective action, which may include  the
   40  submission of a rate filing to reduce future premiums, or to issue divi-
   41  dends, premium refunds or credits, or any combination of these.
   42    S  62.  Subparagraph  (A)  of paragraph 3 of subsection (c) of section
   43  4308 of the insurance law, as added by chapter 107 of the laws of  2010,
   44  is amended to read as follows:
   45    (A)  The  expected  minimum  loss ratio for a contract form subject to
   46  this subsection for which a rate filing or application is made  pursuant
   47  to   this  paragraph,  other  than  a  medicare  supplemental  insurance
   48  contract, or, with the approval of the superintendent, an aggregation of
   49  contract forms that are combined into one  community  rating  experience
   50  pool  and rated consistent with community rating requirements, shall not
   51  be less than eighty-two percent. In reviewing a rate filing or  applica-
   52  tion,  the  superintendent  may  modify  the eighty-two percent expected
   53  minimum loss ratio requirement  if  the  superintendent  determines  the
   54  modification  to  be  in the interests of the people of this state or if
   55  the superintendent determines that a modification is necessary to  main-
   56  tain  insurer solvency. No later than [June thirtieth] JULY THIRTY-FIRST
       S. 2606--D                         134                        A. 3006--D

    1  of each year, every corporation subject to this subparagraph shall annu-
    2  ally report the actual loss ratio for the previous calendar  year  in  a
    3  format  acceptable  to  the superintendent. If an expected loss ratio is
    4  not  met,  the superintendent may direct the corporation to take correc-
    5  tive action, which may include the submission of a rate filing to reduce
    6  future premiums, or to issue dividends, premium refunds or  credits,  or
    7  any combination of these.
    8    S  63.  Section  3233  of the insurance law is amended by adding a new
    9  subsection (d) to read as follows:
   10    (D) NOTWITHSTANDING ANY PROVISION OF THIS CHAPTER OR ANY  OTHER  CHAP-
   11  TER,  THE  SUPERINTENDENT  MAY  SUSPEND OR TERMINATE, BY REGULATION, THE
   12  OPERATION, IN WHOLE OR IN PART, OF ANY MECHANISM ESTABLISHED AND OPERAT-
   13  ING PURSUANT TO THE AUTHORITY OF THIS SECTION PROVIDED THAT  THE  SUPER-
   14  INTENDENT  DETERMINES  THAT  THE  OBJECTIVES STATED IN SUBSECTION (A) OF
   15  THIS SECTION ARE MET BY THE  OPERATION  OF  A  MECHANISM  OR  MECHANISMS
   16  ESTABLISHED  BY  THE  FEDERAL GOVERNMENT PURSUANT TO SECTION 1343 OF THE
   17  AFFORDABLE CARE ACT, 42 U.S.C. S 18063. NOTWITHSTANDING  SUBSECTION  (B)
   18  OF  THIS SECTION, THE SUPERINTENDENT MAY EXERCISE THIS AUTHORITY WITHOUT
   19  CONVENING A TECHNICAL ADVISORY COMMITTEE.
   20    S 64. Subparagraph (D) of paragraph 2 of  subsection  (p)  of  section
   21  3221  of the insurance law, as added by chapter 661 of the laws of 1997,
   22  is amended to read as follows:
   23    (D) The insurer is ceasing to offer group or  blanket  policies  in  a
   24  market in accordance with paragraph three OR SEVEN of this subsection.
   25    S  65.  Subsection (p) of section 3221 of the insurance law is amended
   26  by adding a new paragraph 7 to read as follows:
   27    (7) NOTWITHSTANDING PARAGRAPH THREE OF THIS SUBSECTION, AN INSURER MAY
   28  DISCONTINUE OFFERING A PARTICULAR CLASS OF GROUP OR  BLANKET  POLICY  OF
   29  HOSPITAL,  SURGICAL OR MEDICAL EXPENSE INSURANCE OFFERED IN THE SMALL OR
   30  LARGE GROUP MARKET, AND INSTEAD OFFER  A  GROUP  OR  BLANKET  POLICY  OF
   31  HOSPITAL,  SURGICAL  OR MEDICAL EXPENSE INSURANCE THAT COMPLIES WITH THE
   32  REQUIREMENTS OF SECTION 2707 OF THE PUBLIC  HEALTH  SERVICE  ACT,  S  42
   33  U.S.C.  300GG-6  THAT  BECOME  APPLICABLE  TO  SUCH POLICY AS OF JANUARY
   34  FIRST, TWO THOUSAND FOURTEEN, PROVIDED THAT THE INSURER:
   35    (A) DISCONTINUES THE EXISTING CLASS OF POLICY IN  SUCH  MARKET  AS  OF
   36  EITHER  DECEMBER  THIRTY-FIRST,  TWO  THOUSAND  THIRTEEN  OR  THE POLICY
   37  RENEWAL DATE OCCURRING IN TWO THOUSAND FOURTEEN IN ACCORDANCE WITH  THIS
   38  CHAPTER;
   39    (B)  PROVIDES WRITTEN NOTICE TO EACH POLICYHOLDER PROVIDED COVERAGE OF
   40  THE CLASS IN THE MARKET  (AND  TO  ALL  EMPLOYEES  AND  MEMBER  INSUREDS
   41  COVERED  UNDER SUCH COVERAGE) OF THE DISCONTINUANCE AT LEAST NINETY DAYS
   42  PRIOR TO THE DATE OF DISCONTINUANCE OF SUCH COVERAGE. THE WRITTEN NOTICE
   43  SHALL BE IN A FORM SATISFACTORY TO THE SUPERINTENDENT;
   44    (C) OFFERS TO EACH POLICYHOLDER PROVIDED COVERAGE OF THE CLASS IN  THE
   45  MARKET,  THE  OPTION TO PURCHASE ALL (OR, IN THE CASE OF THE LARGE GROUP
   46  MARKET, ANY) OTHER HOSPITAL, SURGICAL AND MEDICAL EXPENSE COVERAGE  THAT
   47  COMPLIES  WITH  THE  REQUIREMENTS  OF  SECTION 2707 OF THE PUBLIC HEALTH
   48  SERVICE ACT, 42 U.S.C. S 300GG-6 THAT BECOME APPLICABLE TO SUCH COVERAGE
   49  AS OF JANUARY FIRST, TWO THOUSAND FOURTEEN, CURRENTLY BEING  OFFERED  BY
   50  THE INSURER TO A GROUP IN THAT MARKET;
   51    (D)  IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF THE CLASS AND
   52  IN OFFERING THE OPTION OF COVERAGE UNDER SUBPARAGRAPH (C) OF THIS  PARA-
   53  GRAPH,  ACTS  UNIFORMLY WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE
   54  POLICYHOLDERS OR  ANY  HEALTH  STATUS-RELATED  FACTOR  RELATING  TO  ANY
   55  PARTICULAR  COVERED EMPLOYEE, MEMBER INSURED OR DEPENDENT, OR PARTICULAR
   56  NEW EMPLOYEE, MEMBER INSURED, OR DEPENDENT WHO MAY BECOME  ELIGIBLE  FOR
       S. 2606--D                         135                        A. 3006--D

    1  SUCH  COVERAGE,  AND DOES NOT DISCONTINUE THE COVERAGE OF THE CLASS WITH
    2  THE INTENT OR AS A PRETEXT TO DISCONTINUING THE  COVERAGE  OF  ANY  SUCH
    3  EMPLOYEE, MEMBER INSURED, OR DEPENDENT; AND
    4    (E)  AT LEAST ONE HUNDRED TWENTY DAYS PRIOR TO THE DATE OF THE DISCON-
    5  TINUANCE OF SUCH COVERAGE, PROVIDES WRITTEN NOTICE TO THE SUPERINTENDENT
    6  OF THE DISCONTINUANCE, INCLUDING CERTIFICATION BY AN OFFICER OR DIRECTOR
    7  OF THE INSURER THAT THE REASON FOR THE DISCONTINUANCE IS TO REPLACE  THE
    8  COVERAGE  WITH  NEW  COVERAGE  THAT  COMPLIES  WITH  THE REQUIREMENTS OF
    9  SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, S 42 U.S.C. 300GG-6  THAT
   10  BECOME  EFFECTIVE  JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN. THE WRITTEN
   11  NOTICE SHALL BE IN SUCH FORM AND CONTAIN  SUCH  INFORMATION  THE  SUPER-
   12  INTENDENT REQUIRES.
   13    S  66. Item (iii) of subparagraph (C) of paragraph 2 of subsection (c)
   14  of section 4304 of the insurance law, as amended by chapter 661  of  the
   15  laws of 1997, is amended to read as follows:
   16    (iii)  Discontinuance  of all individual hospital, surgical or medical
   17  expense insurance contracts for which the premiums are paid by a  remit-
   18  ting  agent  of  a  group, in the small group market, or the large group
   19  market, or both markets, in this state, in conjunction with a withdrawal
   20  from the small group market, or the large group market, or both markets,
   21  in this state. Withdrawal from the small  group  market,  or  the  large
   22  group  market, or both markets, shall be governed by the requirements of
   23  subparagraphs [(B)] (E) and [(C)] (F) of paragraph three  of  subsection
   24  (j)  of  section  four  thousand three hundred five of this article. For
   25  purposes of this item, "withdrawal" from a market means that no coverage
   26  is offered or maintained in such market under contracts issued  pursuant
   27  to  this  section  or contracts issued pursuant to section four thousand
   28  three hundred five of this article.
   29    S 67. Subparagraph (D) of paragraph 2 of  subsection  (j)  of  section
   30  4305  of the insurance law, as added by chapter 661 of the laws of 1997,
   31  is amended to read as follows:
   32    (D) The corporation is ceasing to offer group or blanket contracts  in
   33  a  market  in  accordance  with paragraph three OR PARAGRAPH SIX of this
   34  subsection.
   35    S 68. Subsection (j) of section 4305 of the insurance law  is  amended
   36  by adding a new paragraph 6 to read as follows:
   37    (6)  NOTWITHSTANDING PARAGRAPH THREE OF THIS SUBSECTION, A CORPORATION
   38  MAY DISCONTINUE OFFERING A PARTICULAR CLASS OF GROUP OR BLANKET CONTRACT
   39  OF HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE OFFERED IN THE  SMALL
   40  OR  LARGE GROUP MARKET, AND INSTEAD OFFER A GROUP OR BLANKET CONTRACT OF
   41  HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE THAT COMPLIES  WITH  THE
   42  REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C.
   43  S  300GG-6  THAT BECOME APPLICABLE TO SUCH CONTRACT AS OF JANUARY FIRST,
   44  TWO THOUSAND FOURTEEN, PROVIDED THAT THE CORPORATION:
   45    (A) DISCONTINUES THE EXISTING CLASS OF CONTRACT IN SUCH MARKET  AS  OF
   46  EITHER  DECEMBER  THIRTY-FIRST,  TWO  THOUSAND  THIRTEEN OR THE CONTRACT
   47  RENEWAL DATE OCCURRING IN TWO THOUSAND FOURTEEN IN ACCORDANCE WITH  THIS
   48  CHAPTER;
   49    (B)  PROVIDES WRITTEN NOTICE TO EACH CONTRACT HOLDER PROVIDED COVERAGE
   50  OF THE CLASS IN THE MARKET (AND TO ALL  EMPLOYEES  AND  MEMBER  INSUREDS
   51  COVERED  UNDER SUCH COVERAGE) OF THE DISCONTINUANCE AT LEAST NINETY DAYS
   52  PRIOR TO THE DATE OF DISCONTINUANCE OF SUCH COVERAGE. THE WRITTEN NOTICE
   53  SHALL BE IN A FORM SATISFACTORY TO THE SUPERINTENDENT;
   54    (C) OFFERS TO EACH CONTRACT HOLDER PROVIDED COVERAGE OF THE  CLASS  IN
   55  THE  MARKET,  THE  OPTION  TO PURCHASE ALL (OR, IN THE CASE OF THE LARGE
   56  GROUP MARKET, ANY) OTHER HOSPITAL, SURGICAL AND MEDICAL EXPENSE COVERAGE
       S. 2606--D                         136                        A. 3006--D

    1  THAT COMPLIES WITH THE REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH
    2  SERVICE ACT, 42 U.S.C. S 300GG-6 THAT BECOME APPLICABLE TO SUCH COVERAGE
    3  AS OF JANUARY FIRST, TWO THOUSAND FOURTEEN, CURRENTLY BEING  OFFERED  BY
    4  THE CORPORATION TO A GROUP IN THAT MARKET;
    5    (D)  IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF THE CLASS AND
    6  IN OFFERING THE OPTION OF COVERAGE UNDER SUBPARAGRAPH (C) OF THIS  PARA-
    7  GRAPH,  ACTS UNIFORMLY WITHOUT REGARD TO THE CLAIMS  EXPERIENCE OF THOSE
    8  CONTRACT HOLDERS OR ANY HEALTH STATUS-RELATED  FACTOR  RELATING  TO  ANY
    9  PARTICULAR  COVERED EMPLOYEE, MEMBER INSURED OR DEPENDENT, OR PARTICULAR
   10  NEW EMPLOYEE, MEMBER INSURED, OR DEPENDENT WHO MAY BECOME  ELIGIBLE  FOR
   11  SUCH  COVERAGE, AND DOES NOT DISCONTINUE THE COVERAGE OF THE  CLASS WITH
   12  THE INTENT OR AS A PRETEXT TO DISCONTINUING THE  COVERAGE  OF  ANY  SUCH
   13  EMPLOYEE, MEMBER INSURED, OR DEPENDENT; AND
   14    (E)  AT LEAST ONE HUNDRED TWENTY DAYS PRIOR TO THE DATE OF THE DISCON-
   15  TINUANCE OF SUCH COVERAGE, PROVIDES WRITTEN NOTICE TO THE SUPERINTENDENT
   16  OF THE DISCONTINUANCE, INCLUDING CERTIFICATION BY AN OFFICER OR DIRECTOR
   17  OF THE CORPORATION THAT THE REASON FOR THE DISCONTINUANCE IS TO  REPLACE
   18  THE  COVERAGE  WITH  NEW COVERAGE THAT COMPLIES WITH THE REQUIREMENTS OF
   19  SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, 42  U.S.C. S 300GG-6 THAT
   20  BECOME EFFECTIVE JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN.  THE  WRITTEN
   21  NOTICE  SHALL  BE  IN  SUCH FORM AND CONTAIN SUCH INFORMATION THE SUPER-
   22  INTENDENT REQUIRES.
   23    S 69. Subsections (a), (b) and (c) of section 3231  of  the  insurance
   24  law,  subsection  (a)  as  amended  by  chapter 661 of the laws of 1997,
   25  subsection (b) as amended by chapter 557 of the laws of 2002, subsection
   26  (c) as added by chapter 501 of the laws of 1992, are amended to read  as
   27  follows:
   28    (a)  (1)  No  individual  health  insurance policy and no group health
   29  insurance policy covering between  [two]  ONE  and  fifty  employees  or
   30  members of the group OR BETWEEN ONE AND ONE HUNDRED EMPLOYEES OR MEMBERS
   31  OF  THE  GROUP FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANUARY FIRST,
   32  TWO THOUSAND SIXTEEN exclusive of spouses  and  dependents,  hereinafter
   33  referred  to  as  a small group, providing hospital and/or medical bene-
   34  fits, including medicare supplemental insurance, shall be issued in this
   35  state unless such policy is community  rated  and,  notwithstanding  any
   36  other  provisions  of  law,  the underwriting of such policy involves no
   37  more than the imposition of a pre-existing condition limitation [as]  IF
   38  OTHERWISE  permitted by this article. (2) Any individual, and dependents
   39  of such individual, and any small  group,  including  all  employees  or
   40  group members and dependents of employees or members, applying for indi-
   41  vidual health insurance coverage, including medicare supplemental cover-
   42  age,  [or  small  group  health  insurance  coverage, including medicare
   43  supplemental insurance,]  OR  SMALL  GROUP  HEALTH  INSURANCE  COVERAGE,
   44  INCLUDING  MEDICARE  SUPPLEMENTAL  INSURANCE, BUT NOT INCLUDING COVERAGE
   45  ISSUED ON OR AFTER JANUARY FIRST, TWO THOUSAND  FOURTEEN,  SPECIFIED  IN
   46  SUBSECTION  (L)  OF  SECTION THREE THOUSAND TWO HUNDRED SIXTEEN, OF THIS
   47  ARTICLE must be accepted at all times throughout the year for any hospi-
   48  tal and/or medical coverage offered by the  insurer  to  individuals  or
   49  small  groups in this state. (3) Once accepted for coverage, an individ-
   50  ual or small group cannot be terminated by the  insurer  due  to  claims
   51  experience.  Termination  of an individual or small group shall be based
   52  only on one or more of the  reasons  set  forth  in  subsection  (g)  of
   53  section  three thousand two hundred sixteen or subsection (p) of section
   54  three thousand two hundred twenty-one of this  article.  Group  hospital
   55  and/or  medical  coverage,  including  medicare  supplemental insurance,
   56  obtained through an out-of-state trust covering  a  group  of  fifty  or
       S. 2606--D                         137                        A. 3006--D

    1  fewer  employees,  OR BETWEEN ONE AND ONE HUNDRED EMPLOYEES FOR POLICIES
    2  ISSUED OR RENEWED ON OR AFTER JANUARY FIRST, TWO  THOUSAND  SIXTEEN,  or
    3  participating  persons who are residents of this state must be community
    4  rated regardless of the situs of delivery of the policy. Notwithstanding
    5  any other provisions of law, the underwriting of such policy may involve
    6  no  more than the imposition of a pre-existing condition limitation [as]
    7  IF permitted by this article, and once accepted for coverage,  an  indi-
    8  vidual  or  small  group  cannot be terminated due to claims experience.
    9  Termination of an individual or small group shall be based only  on  one
   10  or  more  of  the  reasons  set forth in subsection (p) of section three
   11  thousand two hundred twenty-one of this article.  (4) For  the  purposes
   12  of  this  section, "community rated" means a rating methodology in which
   13  the premium for all persons covered by a policy [or  contract]  form  is
   14  the same based on the experience of the entire pool of risks [covered by
   15  that policy or contract form] OF ALL INDIVIDUALS OR SMALL GROUPS COVERED
   16  BY  THE INSURER without regard to age, sex, health status, TOBACCO USAGE
   17  or occupation, EXCLUDING THOSE INDIVIDUALS OR SMALL  GROUPS  COVERED  BY
   18  MEDICARE  SUPPLEMENTAL  INSURANCE.   FOR MEDICARE SUPPLEMENTAL INSURANCE
   19  COVERAGE, "COMMUNITY RATED" MEANS A  RATING  METHODOLOGY  IN  WHICH  THE
   20  PREMIUMS  FOR  ALL  PERSONS  COVERED BY A POLICY OR CONTRACT FORM IS THE
   21  SAME BASED ON THE EXPERIENCE OF THE ENTIRE POOL OF RISKS COVERED BY THAT
   22  POLICY OR CONTRACT FORM WITHOUT  REGARD  TO  AGE,  SEX,  HEALTH  STATUS,
   23  TOBACCO  USAGE  OR  OCCUPATION.  CATASTROPHIC  HEALTH INSURANCE POLICIES
   24  ISSUED PURSUANT TO SECTION 1302(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C.
   25  S 18022(E), SHALL BE CLASSIFIED IN A DISTINCT COMMUNITY RATING POOL.
   26    (b) [Nothing herein shall prohibit the use of premium rate  structures
   27  to establish different premium rates for individuals as opposed to fami-
   28  ly  units  or] (1) THE SUPERINTENDENT MAY SET STANDARD PREMIUM TIERS AND
   29  STANDARD RATING RELATIVITIES BETWEEN TIERS APPLICABLE  TO  ALL  POLICIES
   30  SUBJECT TO THIS SECTION. THE SUPERINTENDENT MAY SET A STANDARD RELATIVI-
   31  TY  APPLICABLE TO CHILD-ONLY POLICIES ISSUED PURSUANT TO SECTION 1302(F)
   32  OF THE AFFORDABLE CARE ACT, 42 U.S.C.   S 18022(F). THE  RELATIVITY  FOR
   33  CHILD-ONLY POLICIES SHALL BE ACTUARIALLY JUSTIFIABLE USING THE AGGREGATE
   34  EXPERIENCE  OF INSURERS TO PREVENT THE CHARGING OF UNJUSTIFIED PREMIUMS.
   35  THE SUPERINTENDENT MAY ADJUST SUCH PREMIUM TIERS AND RELATIVITIES  PERI-
   36  ODICALLY BASED UPON THE AGGREGATE EXPERIENCE OF INSURERS.  (2) AN INSUR-
   37  ER  SHALL  ESTABLISH separate community rates for individuals as opposed
   38  to small groups. (3) If an insurer is required  to  issue  a  [contract]
   39  POLICY  to  individual  proprietors  pursuant  to subsection (i) of this
   40  section, such policy shall be subject to 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 insurer in its rate
   47  filing so long as the insurer's proposed regions do not contain  config-
   48  urations designed to avoid or segregate particular areas within a county
   49  covered  by  the  insurer's  community rates.   (2) BEGINNING ON JANUARY
   50  FIRST, TWO THOUSAND FOURTEEN, FOR EVERY POLICY SUBJECT TO  THIS  SECTION
   51  THAT  PROVIDES  PHYSICIAN  SERVICES,  MEDICAL,  MAJOR MEDICAL OR SIMILAR
   52  COMPREHENSIVE-TYPE  COVERAGE,  EXCEPT  FOR  MEDICARE  SUPPLEMENT  PLANS,
   53  INSURERS  SHALL  USE STANDARDIZED REGIONS ESTABLISHED BY THE SUPERINTEN-
   54  DENT.
   55    S 70. Subsection (g) of section 3231 of the insurance law, as added by
   56  chapter 501 of the laws of 1992, is amended to read as follows:
       S. 2606--D                         138                        A. 3006--D

    1    (g) (1) This section shall also apply to policies issued  to  a  group
    2  defined  in  subsection (c) of section four thousand two hundred thirty-
    3  five, including but not limited to an association or trust of employers,
    4  if the group includes one or  more  member  employers  or  other  member
    5  groups  which  have  fifty  or  fewer  employees or members exclusive of
    6  spouses and dependents. FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANU-
    7  ARY FIRST, TWO THOUSAND FOURTEEN, IF THE  GROUP  INCLUDES  ONE  OR  MORE
    8  MEMBER  SMALL  GROUP  EMPLOYERS  ELIGIBLE  FOR  COVERAGE SUBJECT TO THIS
    9  SECTION, THEN SUCH MEMBER EMPLOYERS SHALL BE CLASSIFIED AS SMALL  GROUPS
   10  FOR  RATING PURPOSES AND THE REMAINING MEMBERS SHALL BE RATED CONSISTENT
   11  WITH THE RATING RULES APPLICABLE TO SUCH REMAINING MEMBERS  PURSUANT  TO
   12  PARAGRAPH TWO OF THIS SUBSECTION.
   13    (2)  IF  A  POLICY  IS  ISSUED TO A GROUP DEFINED IN SUBSECTION (C) OF
   14  SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER, INCLUDING
   15  AN ASSOCIATION GROUP, THAT INCLUDES ONE OR MORE INDIVIDUAL OR INDIVIDUAL
   16  PROPRIETOR MEMBERS, FOR RATING PURPOSES THE INSURER SHALL  INCLUDE  SUCH
   17  MEMBERS  IN  ITS  INDIVIDUAL POOL OF RISKS IN ESTABLISHING PREMIUM RATES
   18  FOR SUCH MEMBERS.
   19    S 71. Paragraph 2 of subsection (i) of section 3231 of  the  insurance
   20  law,  as  amended by chapter 183 of the laws of 2011, is amended to read
   21  as follows:
   22    (2) For coverage purchased pursuant to this subsection, THROUGH DECEM-
   23  BER THIRTY-FIRST, TWO THOUSAND THIRTEEN, individual proprietors shall be
   24  classified in their own community rating category, provided however,  up
   25  to   and   including  December  thirty-first,  two  thousand  [fourteen]
   26  THIRTEEN,  the  premium  rate  established  for  individual  proprietors
   27  purchased  pursuant  to  paragraph  one  of this subsection shall not be
   28  greater than one hundred fifteen percent of the rate established for the
   29  same coverage issued to groups.  COVERAGE PURCHASED OR RENEWED  PURSUANT
   30  TO  THIS  SUBSECTION  ON  OR  AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN
   31  SHALL BE CLASSIFIED IN THE INDIVIDUAL RATING CATEGORY.
   32    S 72. Section 4317 of the insurance law, as added by  chapter  501  of
   33  the  laws  of 1992, subsection (a) as amended by chapter 661 of the laws
   34  of 1997, subsection (b) as amended and subsection (f) as added by  chap-
   35  ter  557  of the laws of 2002, subsection (d) as amended by section 2 of
   36  part A of chapter 494 of the laws of 2009, paragraph 2 of subsection (f)
   37  as amended by chapter 183 of the laws of 2011, is  amended  to  read  as
   38  follows:
   39    S  4317.  Rating  of  individual  and  small  group  health  insurance
   40  contracts.  (a) (1) No individual health insurance contract and no group
   41  health insurance contract covering between [two] ONE and fifty employees
   42  or members of the group, OR BETWEEN ONE AND  ONE  HUNDRED  EMPLOYEES  OR
   43  MEMBERS  OF THE GROUP FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANUARY
   44  FIRST, TWO THOUSAND SIXTEEN exclusive of spouses and dependents, includ-
   45  ing contracts for which the premiums are paid by a remitting agent for a
   46  group, hereinafter referred to as  a  small  group,  providing  hospital
   47  and/or  medical  benefits,  including  Medicare  supplemental insurance,
   48  shall be issued in this state unless such contract  is  community  rated
   49  and,  notwithstanding  any  other provisions of law, the underwriting of
   50  such contract involves no more than the  imposition  of  a  pre-existing
   51  condition  limitation  [as]  IF OTHERWISE permitted by this article. (2)
   52  Any individual, and dependents of such individual, and any small  group,
   53  including  all employees or group members and dependents of employees or
   54  members, applying for individual or small group health insurance  cover-
   55  age  INCLUDING MEDICARE SUPPLEMENTAL INSURANCE, BUT NOT INCLUDING COVER-
   56  AGE ISSUED ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN SPECIFIED IN
       S. 2606--D                         139                        A. 3006--D

    1  SUBSECTION (L) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR, AND  SECTION
    2  FOUR  THOUSAND  THREE  HUNDRED  TWENTY-EIGHT  OF  THIS  CHAPTER, must be
    3  accepted at all times  throughout  the  year  for  any  hospital  and/or
    4  medical  coverage[,  including Medicare supplemental insurance,] offered
    5  by the corporation to individuals or small groups in this  state.    (3)
    6  Once  accepted  for  coverage,  an  individual  or small group cannot be
    7  terminated by the insurer  due  to  claims  experience.  Termination  of
    8  coverage  for  individuals  or  small groups may be based only on one or
    9  more of the reasons set forth in subsection (c) of section four thousand
   10  three hundred four or subsection (j)  of  section  four  thousand  three
   11  hundred  five  of  this  article.  (4) For the purposes of this section,
   12  "community rated" means a rating methodology in which  the  premium  for
   13  all  persons  covered by a policy or contract form is the same, based on
   14  the experience of the entire pool of risks [covered by  that  policy  or
   15  contract  form] OF ALL INDIVIDUALS OR SMALL GROUPS COVERED BY THE CORPO-
   16  RATION without regard to age, sex, health status, TOBACCO USAGE or occu-
   17  pation EXCLUDING THOSE INDIVIDUALS OF SMALL GROUPS COVERED  BY  MEDICARE
   18  SUPPLEMENTAL  INSURANCE.   FOR MEDICARE SUPPLEMENTAL INSURANCE COVERAGE,
   19  "COMMUNITY RATED" MEANS A RATING METHODOLOGY IN WHICH THE  PREMIUMS  FOR
   20  ALL  PERSONS  COVERED  BY A POLICY OR CONTRACT FORM IS THE SAME BASED ON
   21  THE EXPERIENCE OF THE ENTIRE POOL OF RISKS COVERED  BY  THAT  POLICY  OR
   22  CONTRACT  FORM  WITHOUT REGARD TO AGE, SEX, HEALTH STATUS, TOBACCO USAGE
   23  OR OCCUPATION.  CATASTROPHIC HEALTH INSURANCE CONTRACTS ISSUED  PURSUANT
   24  TO  SECTION  1302(E)  OF  THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(E),
   25  SHALL BE CLASSIFIED IN A DISTINCT COMMUNITY RATING POOL.
   26    (b) [Nothing herein shall prohibit the use of premium rate  structures
   27  to establish different premium rates for individuals as opposed to fami-
   28  ly  units  or] (1) THE SUPERINTENDENT MAY SET STANDARD PREMIUM TIERS AND
   29  STANDARD RATING RELATIVITIES BETWEEN TIERS APPLICABLE TO  ALL  CONTRACTS
   30  SUBJECT  TO  THIS  SECTION.  THE  SUPERINTENDENT MAY ALSO SET A STANDARD
   31  RELATIVITY APPLICABLE TO CHILD-ONLY CONTRACTS ISSUED PURSUANT TO SECTION
   32  1302(F) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(F).  THE RELATIVI-
   33  TY FOR CHILD-ONLY CONTRACTS MUST BE ACTUARIALLY  JUSTIFIABLE  USING  THE
   34  AGGREGATE EXPERIENCE OF CORPORATIONS TO PREVENT THE CHARGING OF UNJUSTI-
   35  FIED  PREMIUMS.    THE  SUPERINTENDENT MAY ADJUST SUCH PREMIUM TIERS AND
   36  RELATIVITIES PERIODICALLY BASED UPON THE AGGREGATE EXPERIENCE OF  CORPO-
   37  RATIONS  ISSUING  CONTRACT  FORMS SUBJECT TO THIS SECTION.  (2) A CORPO-
   38  RATION SHALL ESTABLISH  separate  community  rates  for  individuals  as
   39  opposed  to  small  groups.  (3) If a corporation is required to issue a
   40  contract to individual proprietors pursuant to subsection  (f)  of  this
   41  section,   such  contract  shall  be  subject  to  the  requirements  of
   42  subsection (a) of this section.
   43    (c) (1) The superintendent shall permit the use of separate  community
   44  rates  for  reasonable  geographic  regions, which may, in a given case,
   45  include a single county. The regions shall be  approved  by  the  super-
   46  intendent  as  part  of  the  rate  filing. The superintendent shall not
   47  require the inclusion of any  specific  geographic  regions  within  the
   48  proposed community rated regions selected by the corporation in its rate
   49  filing  so  long  as  the  corporation's proposed regions do not contain
   50  configurations designed to avoid or segregate particular areas within  a
   51  county  covered  by the corporation's community rates.  (2) BEGINNING ON
   52  JANUARY FIRST, TWO THOUSAND FOURTEEN, FOR EVERY CONTRACT SUBJECT TO THIS
   53  SECTION THAT PROVIDES PHYSICIAN  SERVICES,  MEDICAL,  MAJOR  MEDICAL  OR
   54  SIMILAR  COMPREHENSIVE-TYPE  COVERAGE,  EXCEPT FOR MEDICARE SUPPLEMENTAL
   55  INSURANCE, CORPORATIONS SHALL USE STANDARDIZED  REGIONS  ESTABLISHED  BY
   56  THE SUPERINTENDENT.
       S. 2606--D                         140                        A. 3006--D

    1    (d) (1) This section shall also apply to [contracts] A CONTRACT issued
    2  to  a  group  defined  in  subsection  (c)  of section four thousand two
    3  hundred thirty-five of this chapter, including but  not  limited  to  an
    4  association  or  trust  of  employers, if the group includes one or more
    5  member  employers  or  other  member  groups  which  have fifty or fewer
    6  employees or members exclusive of spouses and dependents.  FOR CONTRACTS
    7  ISSUED OR RENEWED ON OR AFTER JANUARY FIRST, TWO THOUSAND  FOURTEEN,  IF
    8  THE GROUP INCLUDES ONE OR MORE MEMBER SMALL GROUP EMPLOYERS ELIGIBLE FOR
    9  COVERAGE  SUBJECT  TO  THIS SECTION, THEN SUCH MEMBER EMPLOYERS SHALL BE
   10  CLASSIFIED AS SMALL GROUPS FOR RATING PURPOSES AND THE REMAINING MEMBERS
   11  SHALL BE RATED CONSISTENT WITH  THE  RATING  RULES  APPLICABLE  TO  SUCH
   12  REMAINING MEMBERS PURSUANT TO PARAGRAPH TWO OF THIS SUBSECTION.
   13    (2)  IF  A  CONTRACT IS ISSUED TO A GROUP DEFINED IN SUBSECTION (C) OF
   14  SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER  INCLUDING
   15  ASSOCIATION  GROUPS,  THAT INCLUDES ONE OR MORE INDIVIDUAL OR INDIVIDUAL
   16  PROPRIETOR MEMBERS, THEN  FOR  RATING  PURPOSES  THE  CORPORATION  SHALL
   17  INCLUDE  SUCH  MEMBERS  IN  ITS INDIVIDUAL POOL OF RISKS IN ESTABLISHING
   18  PREMIUM RATES FOR SUCH MEMBERS.
   19    (3) A corporation shall provide specific claims experience to a munic-
   20  ipal corporation, as defined in subsection (f) of section four  thousand
   21  seven  hundred  two  of this chapter, covered by the corporation under a
   22  community rated contract when the  municipal  corporation  requests  its
   23  claims experience for purposes of forming or joining a municipal cooper-
   24  ative  health  benefit plan certified pursuant to article forty-seven of
   25  this chapter. Notwithstanding the foregoing provisions,  no  corporation
   26  shall be required to provide more than three years' claims experience to
   27  a municipal corporation making this request.
   28    (e) (1) Notwithstanding any other provision of this chapter, no insur-
   29  er,  subsidiary of an insurer, or controlled person of a holding company
   30  system may act as an administrator or claims paying agent, as opposed to
   31  an insurer, on behalf of small groups which, if  they  purchased  insur-
   32  ance,  would  be  subject  to this section. No insurer, subsidiary of an
   33  insurer, or controlled person of a  holding  company  may  provide  stop
   34  loss,  catastrophic  or  reinsurance  coverage to small groups which, if
   35  they purchased insurance, would be subject to this section.
   36    (2) This subsection shall  not  apply  to  coverage  insuring  a  plan
   37  [which]  THAT was in effect on or before December thirty-first, nineteen
   38  hundred ninety-one and was issued  to  a  group  [which]  THAT  includes
   39  member  small  employers or other member small groups, including but not
   40  limited to association groups, provided that  (A)  acceptance  of  addi-
   41  tional small member employers (or other member groups comprised of fifty
   42  or fewer employees or members, exclusive of spouses and dependents) into
   43  the group on or after June first, nineteen hundred ninety-two and before
   44  April  first,  nineteen  hundred  ninety-four  does not exceed an amount
   45  equal to ten percent per year of the total  number  of  persons  covered
   46  under the group as of June first, nineteen hundred ninety-two, but noth-
   47  ing  in  this  subparagraph  shall  limit  the addition of larger member
   48  employers; (B) (i) after April first, nineteen hundred ninety-four,  the
   49  group  thereafter accepts member small employers and member small groups
   50  without underwriting by any more than the imposition of  a  pre-existing
   51  condition  limitation  as  permitted  by  this  article and the cost for
   52  participation in the group for all persons covered  shall  be  the  same
   53  based  on  the  experience of the entire pool of risks covered under the
   54  entire group, without regard to age, sex, health status  or  occupation;
   55  and;  (ii)  once  accepted  for  coverage,  an individual or small group
   56  cannot be terminated due to claims experience; (C) the [insurer]  CORPO-
       S. 2606--D                         141                        A. 3006--D

    1  RATION  has  registered  the  names  of such groups, including the total
    2  number of persons covered as of June first, nineteen hundred ninety-two,
    3  with the superintendent, in a form prescribed by the superintendent,  on
    4  or  before  April  first, nineteen hundred ninety-three and shall report
    5  annually thereafter until such groups  comply  with  the  provisions  of
    6  subparagraph  (B)  of this paragraph; and (D) the types or categories of
    7  employers or groups eligible to join the association are not altered  or
    8  expanded after June first, nineteen hundred ninety-two.
    9    (3)  A corporation may apply to the superintendent for an extension or
   10  extensions of time beyond April first, nineteen hundred  ninety-four  in
   11  which  to  implement the provisions of this subsection as they relate to
   12  groups registered with the superintendent pursuant to  subparagraph  (C)
   13  of  paragraph  two  of this subsection; any such extension or extensions
   14  may not exceed two years in aggregate duration, and the ten percent  per
   15  year  limitation of subparagraph (A) of paragraph two of this subsection
   16  shall be reduced to five percent per year during the period of any  such
   17  extension  or  extensions. Any application for an extension shall demon-
   18  strate that a significant financial hardship to such group would  result
   19  from such implementation.
   20    (f)(1)  If the [insurer] CORPORATION issues coverage to an association
   21  group (including chambers of commerce), as defined in  subparagraph  (K)
   22  of  paragraph one of subsection (c) of section four thousand two hundred
   23  thirty-five of this chapter, THEN the [insurer must]  CORPORATION  SHALL
   24  issue  the  same coverage to individual proprietors [which] WHO purchase
   25  coverage through the association  group  as  the  [insurer]  CORPORATION
   26  issues  to groups [which] THAT purchase coverage through the association
   27  group; provided, however, that [an insurer which] A CORPORATION THAT, on
   28  the effective date of this subsection, is issuing coverage to individual
   29  proprietors not connected with an association  group,  may  continue  to
   30  issue  such  coverage provided that the coverage is otherwise in accord-
   31  ance with this subsection and all other applicable provisions of law.
   32    (2) For coverage purchased pursuant to this subsection THROUGH  DECEM-
   33  BER THIRTY-FIRST, TWO THOUSAND THIRTEEN, individual proprietors shall be
   34  classified  in their own community rating category, provided however, up
   35  to  and  including  December  thirty-first,  two   thousand   [fourteen]
   36  THIRTEEN,  the  premium  rate  established  for  individual  proprietors
   37  purchased pursuant to paragraph one of  this  subsection  shall  not  be
   38  greater than one hundred fifteen percent of the rate established for the
   39  same  coverage issued to groups.  COVERAGE PURCHASED OR RENEWED PURSUANT
   40  TO THIS SUBSECTION ON OR AFTER  JANUARY  FIRST,  TWO  THOUSAND  FOURTEEN
   41  SHALL BE CLASSIFIED IN THE INDIVIDUAL RATING CATEGORY.
   42    (3)  The  [insurer] CORPORATION may require members of the association
   43  purchasing health insurance to verify that all employees electing health
   44  insurance are legitimate employees of the employers,  as  documented  on
   45  New  York  state  tax form NYS-45-ATT-MN or comparable documentation. In
   46  order to be eligible to  purchase  health  insurance  pursuant  to  this
   47  subsection  and  obtain the same group insurance products as are offered
   48  to groups, a sole employee of a corporation or a sole proprietor  of  an
   49  unincorporated  business  or  entity must (A) work at least twenty hours
   50  per week, (B) if purchasing the coverage through an  association  group,
   51  be  a  member  of  the  association for at least sixty days prior to the
   52  effective date of the insurance [policy] CONTRACT,  and  (C)  present  a
   53  copy  of  the  following  documentation  to the [insurer] CORPORATION or
   54  health plan administrator on an annual basis:
   55    (i) NYS tax form 45-ATT, or comparable documentation of active employ-
   56  ee status;
       S. 2606--D                         142                        A. 3006--D

    1    (ii) for an unincorporated business, the prior year's  federal  income
    2  tax Schedule C for an incorporated business subject to Subchapter S with
    3  a  sole  employee,  federal income tax Schedule E for other incorporated
    4  businesses with a sole employee, a W-2 annual wage statement, or federal
    5  tax form 1099 with federal income tax Schedule F; or
    6    (iii)  for  a business in business for less than one year, a cancelled
    7  business check, a certificate of  doing  business,  or  appropriate  tax
    8  documentation; and
    9    (iv)  such  other  documentation  as may be reasonably required by the
   10  insurer as approved by the superintendent to verify  eligibility  of  an
   11  individual to purchase health insurance pursuant to this subsection.
   12    (4)  Notwithstanding  the  provisions  of  item  (I)  of clause (i) of
   13  subparagraph (K) of paragraph one of  subsection  (c)  of  section  four
   14  thousand  two  hundred thirty-five of this chapter, for purposes of this
   15  section, an association group shall include chambers  of  commerce  with
   16  less  than  two  hundred  members and which are 501C3 or 501C6 organiza-
   17  tions.
   18    S 73. Notwithstanding any inconsistent provision of law, rule or regu-
   19  lation, for purposes of implementing the provisions of the public health
   20  law and the social services law, references to titles XIX and XXI of the
   21  federal social security act in the public  health  law  and  the  social
   22  services  law  shall be deemed to include and also to mean any successor
   23  titles thereto under the federal social security act.
   24    S 74. Notwithstanding any inconsistent provision of law, rule or regu-
   25  lation, the effectiveness of the provisions of sections 2807 and 3614 of
   26  the public health law, section 18 of chapter 2 of the laws of 1988,  and
   27  18  NYCRR  505.14(h), as they relate to time frames for notice, approval
   28  or certification of rates of payment, are hereby suspended  and  without
   29  force or effect for purposes of implementing the provisions of this act.
   30    S  75. Severability clause. If any clause, sentence, paragraph, subdi-
   31  vision, section or part of this act shall be adjudged by  any  court  of
   32  competent  jurisdiction  to  be invalid, such judgment shall not affect,
   33  impair or invalidate the remainder thereof, but shall be confined in its
   34  operation to the clause, sentence, paragraph,  subdivision,  section  or
   35  part thereof directly involved in the controversy in which such judgment
   36  shall  have been rendered. It is hereby declared to be the intent of the
   37  legislature that this act would have been enacted even if  such  invalid
   38  provisions had not been included herein.
   39    S  76.  This  act shall take effect immediately and shall be deemed to
   40  have been in full force  and  effect  on  and  after  January  1,  2013;
   41  provided that:
   42    a.  sections  seventeen,  thirty-eight,  thirty-nine,  forty, forty-a,
   43  forty-one, forty-six-a,  forty-six-b  forty-seven,  forty-eight,  forty-
   44  nine,  fifty,  fifty-one,  fifty-two, fifty-three, fifty-four and fifty-
   45  five of this act shall take effect January 1, 2014, and shall  apply  to
   46  all policies and contracts issued, renewed, modified, altered or amended
   47  on or after such date.
   48    b.  sections forty-two, forty-three, forty-three-a, forty-four, forty-
   49  five and forty-six of this act shall apply to all policies and contracts
   50  issued, renewed, modified, altered or amended on  or  after  October  1,
   51  2013;
   52    b-1  paragraph  8  of  subsection (b) of section 4328 of the insurance
   53  law, as added by section forty-six of  this  act  shall  expire  and  be
   54  deemed repealed on December 31, 2015;
   55    c. section fifty-six of this act shall take effect January 1, 2014;
       S. 2606--D                         143                        A. 3006--D

    1    d. section fifty-seven of this act shall be deemed repealed January 1,
    2  2014;
    3    e.  sections fifteen, fifty-eight, sixty-one and sixty-two of this act
    4  shall take effect January 1, 2015;
    5    e-1.  section fifteen-a of this act shall take effect January 1, 2014;
    6    f. sections fifty-nine and sixty of this act shall take effect January
    7  1, 2016 and shall apply to all policies and contracts  issued,  renewed,
    8  modified, altered, or amended on or after such date;
    9    g.  sections  fourteen  and  fourteen-a  of this act shall take effect
   10  immediately and shall be deemed to have been in full force and effect on
   11  and after April 1, 2013;
   12    h. the amendments to paragraphs  (e)  and  (f)  of  subdivision  2  of
   13  section  2511  of  the  public  health law made by sections nineteen and
   14  twenty-six of this act shall take effect January 1, 2014 or a later date
   15  to be determined by the  commissioner  of  health  contingent  upon  the
   16  requirements  of  the Patient Protection and Affordable Care Act of 2010
   17  being fully implemented by the state and as approved by the secretary of
   18  the department of health and human services; provided that  the  commis-
   19  sioner  of  health shall notify the legislative bill drafting commission
   20  upon the occurrence of the enactment of the legislation provided for  in
   21  sections  nineteen  and twenty-six of this act in order that the commis-
   22  sion may maintain an accurate and timely  effective  data  base  of  the
   23  official  text  of  the  laws of the state of New York in furtherance of
   24  effectuating the provisions of section 44 of  the  legislative  law  and
   25  section 70-b of the public officers law;
   26    h-1.  provided  however,  the amendments to subparagraph (ii) of para-
   27  graph (f) of subdivision 2 of section 2511 of the public health law made
   28  by section twenty-six of this act shall take effect April 1, 2014;
   29    i. the amendments to subdivision 4  of  section  2511  of  the  public
   30  health  law  made by section twenty-one of this act shall not affect the
   31  expiration and reversion of such subdivision  and  shall  be  deemed  to
   32  expire therewith;
   33    j. the amendments to subparagraph (ii) of paragraph (g) of subdivision
   34  2  of section 2511 of the public health law made by section twenty-seven
   35  of this act shall not affect the expiration of such paragraph and  shall
   36  be deemed to expire therewith;
   37    j-1. the amendments to subparagraph (iii) of paragraph (a) of subdivi-
   38  sion  2  of section 2511 of the public health law made by section thirty
   39  of this act shall not affect the expiration of such paragraph and  shall
   40  be deemed to expire therewith;
   41    j-2.  the  amendments  to subparagraph (iv) of paragraph (b) and para-
   42  graph (d) of subdivision 9 of section 2511 of the public health law made
   43  by section thirty-three of this act shall not affect the  expiration  of
   44  such subdivision and shall be deemed to expire therewith;
   45    j-3.  the  amendments  to subdivision 5 of section 365-n of the social
   46  services law made by section thirty-three-a of this act shall not affect
   47  the repeal of such subdivision and shall be deemed repealed therewith;
   48    k. any rules or regulations necessary to implement the  provisions  of
   49  this  act  may be promulgated and any procedures, forms, or instructions
   50  necessary for implementation may be adopted and issued on or  after  the
   51  date this act shall have become a law;
   52    l. this act shall not be construed to alter, change, affect, impair or
   53  defeat any rights, obligations, duties or interests accrued, incurred or
   54  conferred prior to the effective date of this act;
       S. 2606--D                         144                        A. 3006--D

    1    m.  the  commissioner  of  health  and the superintendent of financial
    2  services and any appropriate council may take  any  steps  necessary  to
    3  implement this act prior to its effective date;
    4    n. notwithstanding any inconsistent provision of the state administra-
    5  tive  procedure  act  or any other provision of law, rule or regulation,
    6  the commissioner of health and the superintendent of financial  services
    7  and  any  appropriate council is authorized to adopt or amend or promul-
    8  gate on an emergency basis any regulation he  or  she  or  such  council
    9  determines  necessary  to  implement  any  provision  of this act on its
   10  effective date;
   11    o. the provisions of this act shall become  effective  notwithstanding
   12  the  failure  of  the  commissioner  of  health or the superintendent of
   13  financial services or any council to adopt or amend or promulgate  regu-
   14  lations implementing this act; and
   15    p.  the amendments made to subparagraph (7) of paragraph (b) of subdi-
   16  vision 1 of section 366 of the social services law made by  section  one
   17  of this act shall expire and be deemed repealed October 1, 2019.

   18                                   PART E

   19    Section 1. Intentionally omitted.
   20    S 2. Intentionally omitted.
   21    S 3. Intentionally omitted.
   22    S 4. Intentionally omitted.
   23    S 5. Intentionally omitted.
   24    S 6. Intentionally omitted.
   25    S 7. Intentionally omitted.
   26    S 8. Intentionally omitted.
   27    S 9. Intentionally omitted.
   28    S 10. Intentionally omitted.
   29    S 11. Intentionally omitted.
   30    S 12. Intentionally omitted.
   31    S 13. Intentionally omitted.
   32    S 14. Section 600 of the public health law, as added by chapter 901 of
   33  the laws of 1986, is amended to read as follows:
   34    S  600.  State  aid; general requirements. In order to be eligible for
   35  state aid under this title, a municipality shall be required to  do  the
   36  following in accordance with the provisions of this article:
   37    1.  submit  an  application  to  the department for state aid WHICH IS
   38  APPROVED BY THE COMMISSIONER IN ACCORDANCE WITH SECTION SIX HUNDRED  ONE
   39  OF THIS TITLE;
   40    [2.  submit  a municipal public health services plan to the department
   41  for approval;
   42    3. implement and adhere to the municipal public health services  plan,
   43  as approved;
   44    4.  submit  a detailed report to the department of all expenditures on
   45  services funded by this title for the immediately preceding fiscal  year
   46  of such municipality;
   47    5.  employ  a  person  to  supervise  the  provision  of public health
   48  services in accordance with the provisions of section six  hundred  four
   49  of this chapter; and
   50    6.]  2. PROVIDE CORE PUBLIC HEALTH SERVICES, AS DEFINED IN SECTION SIX
   51  HUNDRED TWO OF THIS TITLE, IN ACCORDANCE WITH AN APPLICATION  FOR  STATE
   52  AID SUBMITTED BY THE MUNICIPALITY AND APPROVED BY THE COMMISSIONER;
   53    3. SUBMIT A COMMUNITY HEALTH ASSESSMENT IN ACCORDANCE WITH SECTION SIX
   54  HUNDRED TWO-A OF THIS TITLE;
       S. 2606--D                         145                        A. 3006--D

    1    4.  ESTABLISH,  COLLECT  AND  REPORT  FEES  AND  REVENUE  FOR SERVICES
    2  PROVIDED BY THE MUNICIPALITY, IN ACCORDANCE WITH SECTION SIX HUNDRED SIX
    3  OF THIS TITLE; AND
    4    5.  appropriate  or  otherwise  make  funds  available  to  finance  a
    5  prescribed share of the cost of public health services.
    6    S 15. Section 601 of the public health law, as added by chapter 901 of
    7  the laws of 1986, is amended to read as follows:
    8    S 601. Application for state aid. 1. The governing body of each  muni-
    9  cipality  desiring  to  make  application for state aid under this title
   10  shall annually, on such dates as  may  be  fixed  by  the  commissioner,
   11  submit an application for such aid.
   12    2.  The  application  shall  be in such form as the commissioner shall
   13  prescribe, and shall include, but not be limited to:
   14    (a) an organizational chart of the  municipal  health  agency,  AND  A
   15  STATEMENT  PROVIDING  THE NUMBER OF EMPLOYEES, BY JOB TITLE, PROPOSED TO
   16  PROVIDE PUBLIC HEALTH SERVICES FUNDED BY THIS TITLE;
   17    (b) a [detailed] budget of proposed expenditures for  services  funded
   18  by this title;
   19    [(c)  a description of proposed program activities for services funded
   20  by this title;
   21    (d) a copy of the municipal public health services plan  prepared  and
   22  submitted pursuant to section six hundred two of this title;
   23    (e)  a  certification  by  the  chief executive officer of the munici-
   24  pality, or in those municipalities with no chief executive  officer  the
   25  chairman  of  the county legislature, that the proposed expenditures and
   26  program activities are consistent with the public health services  plan;
   27  and
   28    (f)]  (C)  A  DESCRIPTION  OF HOW THE MUNICIPALITY WILL PROVIDE PUBLIC
   29  HEALTH SERVICES;
   30    (D) AN ATTESTATION BY THE CHIEF EXECUTIVE OFFICER OF THE  MUNICIPALITY
   31  THAT  SUFFICIENT  FUNDS  HAVE  BEEN  APPROPRIATED  TO PROVIDE THE PUBLIC
   32  HEALTH SERVICES FOR WHICH THE MUNICIPALITY IS SEEKING STATE AID;
   33    (E) AN ATTESTATION BY THE MUNICIPAL OFFICER IN CHARGE OF ADMINISTERING
   34  PUBLIC HEALTH THAT THE MUNICIPALITY HAS DILIGENTLY  REVIEWED  ITS  STATE
   35  AID APPLICATION AND THAT THE APPLICATION SEEKS STATE AID ONLY FOR ELIGI-
   36  BLE PUBLIC HEALTH SERVICES;
   37    (F) A LIST OF PUBLIC HEALTH SERVICES PROVIDED BY THE MUNICIPALITY THAT
   38  ARE NOT ELIGIBLE FOR STATE AID, AND THE COST OF EACH SERVICE;
   39    (G) A PROJECTION OF FEES AND REVENUE TO BE COLLECTED FOR PUBLIC HEALTH
   40  SERVICES  ELIGIBLE FOR STATE AID, IN ACCORDANCE WITH SECTION SIX HUNDRED
   41  SIX OF THIS TITLE; AND
   42    (H) such other information as the commissioner may require.
   43    3. THE COMMISSIONER SHALL APPROVE THE STATE  AID  APPLICATION  TO  THE
   44  EXTENT  THAT IT IS CONSISTENT WITH THIS SECTION AND ANY OTHER CONDITIONS
   45  OR LIMITATIONS ESTABLISHED IN, OR REGULATIONS PROMULGATED  PURSUANT  TO,
   46  THIS ARTICLE.
   47    4.  A  MUNICIPALITY  MAY  AMEND  ITS  STATE  AID  APPLICATION WITH THE
   48  APPROVAL OF THE COMMISSIONER, AND SUBJECT TO ANY RULES  AND  REGULATIONS
   49  THAT THE COMMISSIONER MAY ADOPT.
   50    S  16.  Section  602  of  the  public health law is REPEALED and a new
   51  section 602 is added to read as follows:
   52    S 602. CORE PUBLIC HEALTH SERVICES.  1. TO BE ELIGIBLE FOR STATE  AID,
   53  A MUNICIPALITY MUST PROVIDE THE FOLLOWING CORE PUBLIC HEALTH SERVICES:
   54    (A)  FAMILY  HEALTH, WHICH SHALL INCLUDE ACTIVITIES DESIGNED TO REDUCE
   55  PERINATAL, INFANT AND MATERNAL MORTALITY AND MORBIDITY  AND  TO  PROMOTE
   56  THE HEALTH OF INFANTS, CHILDREN, ADOLESCENTS, AND PEOPLE OF CHILDBEARING
       S. 2606--D                         146                        A. 3006--D

    1  AGE.  SUCH  ACTIVITIES  SHALL INCLUDE FAMILY CENTERED PERINATAL SERVICES
    2  AND OTHER SERVICES APPROPRIATE TO PROMOTE THE BIRTH OF A HEALTHY BABY TO
    3  A HEALTHY MOTHER, AND SERVICES TO ASSURE THAT INFANTS,  YOUNG  CHILDREN,
    4  AND  SCHOOL  AGE  CHILDREN  ARE ENROLLED IN APPROPRIATE HEALTH INSURANCE
    5  PROGRAMS AND OTHER HEALTH BENEFIT PROGRAMS FOR WHICH THEY ARE  ELIGIBLE,
    6  AND  THAT  THE  PARENTS  OR GUARDIANS OF SUCH CHILDREN ARE PROVIDED WITH
    7  INFORMATION CONCERNING HEALTH CARE PROVIDERS  IN  THEIR  AREA  THAT  ARE
    8  WILLING AND ABLE TO PROVIDE HEALTH SERVICES TO SUCH CHILDREN.  PROVISION
    9  OF  PRIMARY AND PREVENTIVE CLINICAL HEALTH CARE SERVICES SHALL BE ELIGI-
   10  BLE FOR STATE AID FOR UNINSURED PERSONS UNDER  THE  AGE  OF  TWENTY-ONE,
   11  PROVIDED  THAT  THE MUNICIPALITY MAKES GOOD FAITH EFFORTS TO ASSIST SUCH
   12  PERSONS WITH INSURANCE ENROLLMENT AND ONLY UNTIL SUCH TIME AS ENROLLMENT
   13  BECOMES EFFECTIVE.
   14    (B) COMMUNICABLE DISEASE CONTROL, WHICH SHALL  INCLUDE  ACTIVITIES  TO
   15  CONTROL  AND MITIGATE THE EXTENT OF INFECTIOUS DISEASES. SUCH ACTIVITIES
   16  SHALL INCLUDE, BUT NOT BE LIMITED TO, SURVEILLANCE  AND  EPIDEMIOLOGICAL
   17  PROGRAMS,  PROGRAMS  TO DETECT DISEASES IN THEIR EARLY STAGES, IMMUNIZA-
   18  TIONS  AGAINST  INFECTIOUS  DISEASES,  INVESTIGATION  OF  DISEASES   AND
   19  PREVENTION  OF  TRANSMISSION, PREVENTION AND TREATMENT OF SEXUALLY TRAN-
   20  SMISSIBLE DISEASES, AND ARTHROPOD VECTOR-BORNE DISEASE PREVENTION.
   21    (C) CHRONIC DISEASE PREVENTION, WHICH SHALL INCLUDE PROMOTING  PUBLIC,
   22  HEALTH  CARE  PROVIDER  AND  OTHER COMMUNITY SERVICE PROVIDER ACTIVITIES
   23  THAT ENCOURAGE CHRONIC DISEASE PREVENTION, EARLY DETECTION  AND  QUALITY
   24  CARE  DELIVERY.  SUCH  ACTIVITIES INCLUDE, BUT ARE NOT LIMITED TO, THOSE
   25  THAT PROMOTE HEALTHY COMMUNITIES AND REDUCE RISK FACTORS SUCH AS TOBACCO
   26  USE, POOR NUTRITION  AND  PHYSICAL  INACTIVITY.  PROVISION  OF  CLINICAL
   27  SERVICES SHALL NOT BE ELIGIBLE FOR STATE AID, SUBJECT TO SUCH EXCEPTIONS
   28  AS THE COMMISSIONER MAY DEEM APPROPRIATE.
   29    (D)  COMMUNITY  HEALTH ASSESSMENT, AS DESCRIBED IN SECTION SIX HUNDRED
   30  TWO-A OF THIS ARTICLE.
   31    (E) ENVIRONMENTAL HEALTH, WHICH SHALL INCLUDE ACTIVITIES THAT  PROMOTE
   32  HEALTH AND PREVENT ILLNESS AND INJURY BY ASSURING THAT SAFE AND SANITARY
   33  CONDITIONS  ARE  MAINTAINED  AT  PUBLIC  DRINKING  WATER  SUPPLIES, FOOD
   34  SERVICE ESTABLISHMENTS, AND OTHER  REGULATED  FACILITIES;  INVESTIGATING
   35  PUBLIC  HEALTH  NUISANCES  TO  ASSURE  ABATEMENT BY RESPONSIBLE PARTIES;
   36  PROTECTING THE PUBLIC FROM UNNECESSARY EXPOSURE TO RADIATION, CHEMICALS,
   37  AND OTHER HARMFUL CONTAMINANTS; AND CONDUCTING INVESTIGATIONS  OF  INCI-
   38  DENTS  THAT  RESULT IN ILLNESS, INJURY OR DEATH IN ORDER TO IDENTIFY AND
   39  MITIGATE THE ENVIRONMENTAL CAUSES TO PREVENT  ADDITIONAL  MORBIDITY  AND
   40  MORTALITY.
   41    (F) PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE, INCLUDING PLAN-
   42  NING, TRAINING, AND MAINTAINING READINESS FOR PUBLIC HEALTH EMERGENCIES.
   43    2.  THE  MUNICIPALITY  MUST  INCORPORATE  INTO EACH CORE PUBLIC HEALTH
   44  SERVICE THE FOLLOWING GENERAL ACTIVITIES:
   45    (A) ONGOING ASSESSMENT OF COMMUNITY HEALTH NEEDS;
   46    (B) EDUCATION ON PUBLIC HEALTH ISSUES;
   47    (C) DEVELOPMENT OF POLICIES AND PLANS TO ADDRESS HEALTH NEEDS; AND
   48    (D) ACTIONS TO ASSURE THAT SERVICES NECESSARY TO ACHIEVE  AGREED  UPON
   49  GOALS ARE PROVIDED.
   50    3.   THE COMMISSIONER MAY APPROVE A STATE AID APPLICATION IN WHICH THE
   51  MUNICIPALITY ACTUALLY PROVIDES FEWER SERVICES THAN THOSE  SET  FORTH  IN
   52  SUBDIVISION  ONE  OF  THIS SECTION AS LONG AS THE APPLICATION IDENTIFIES
   53  THE AVAILABILITY OF OTHER SERVICES, WHO WILL PROVIDE THOSE SERVICES  AND
   54  THE MANNER IN WHICH THE SERVICES WILL BE PROVIDED AND FINANCED.
   55    4.  THE  COMMISSIONER SHALL CONSULT WITH THE COUNTY HEALTH COMMISSION-
   56  ERS, PUBLIC HEALTH DIRECTORS, AND BOARDS OF PUBLIC HEALTH  WHEN  PROMUL-
       S. 2606--D                         147                        A. 3006--D

    1  GATING  RULES  AND REGULATIONS TO EFFECTUATE THE PROVISIONS AND PURPOSES
    2  OF THIS ARTICLE. THE COMMISSIONER SHALL NOT HAVE THE POWER TO  PRESCRIBE
    3  THE NUMBER OF PERSONS TO BE EMPLOYED BY ANY MUNICIPALITY.
    4    S  17.  The public health law is amended by adding a new section 602-a
    5  to read as follows:
    6    S 602-A. COMMUNITY HEALTH ASSESSMENT.   1.  EVERY  MUNICIPALITY  SHALL
    7  SUBMIT  TO  THE  DEPARTMENT  NO  MORE FREQUENTLY THAN EVERY TWO YEARS, A
    8  COMMUNITY HEALTH ASSESSMENT.
    9    2. THE COMMUNITY HEALTH ASSESSMENT  SHALL  BE  IN  SUCH  FORM  AS  THE
   10  COMMISSIONER SHALL PRESCRIBE, AND SHALL INCLUDE, BUT NOT BE LIMITED TO:
   11    (A) AN ESTIMATE AND DESCRIPTION OF THE HEALTH STATUS OF THE POPULATION
   12  AND FACTORS THAT CONTRIBUTE TO HEALTH ISSUES;
   13    (B)  IDENTIFICATION  OF  PRIORITY  AREAS  FOR  HEALTH  IMPROVEMENT, IN
   14  CONJUNCTION WITH THE STATE HEALTH IMPROVEMENT PLAN;
   15    (C) IDENTIFICATION OF PUBLIC HEALTH SERVICES IN THE  MUNICIPALITY  AND
   16  IN  THE  COMMUNITY  AND OTHER RESOURCES THAT CAN BE MOBILIZED TO IMPROVE
   17  POPULATION HEALTH, PARTICULARLY IN THOSE PRIORITY  AREAS  IDENTIFIED  IN
   18  PARAGRAPH (B) OF THIS SUBDIVISION; AND
   19    (D)  A  COMMUNITY HEALTH IMPROVEMENT PLAN CONSISTING OF ACTIONS, POLI-
   20  CIES, STRATEGIES AND MEASURABLE OBJECTIVES  THROUGH  WHICH  THE  MUNICI-
   21  PALITY AND ITS COMMUNITY PARTNERS WILL ADDRESS AREAS FOR HEALTH IMPROVE-
   22  MENT AND TRACK PROGRESS TOWARD IMPROVEMENT OF PUBLIC HEALTH OUTCOMES.
   23    S 18. Section 603 of the public health law, as added by chapter 901 of
   24  the laws of 1986, is amended to read as follows:
   25    S  603.  [Municipal  public  health  services plan] CORE PUBLIC HEALTH
   26  SERVICES; implementation. 1. In order to be eligible for state aid under
   27  this title, each municipality shall administer its  CORE  public  health
   28  [programs]  SERVICES  in  accordance with [its approved municipal public
   29  health services plan and] THE standards of  performance  established  by
   30  the commissioner through rules and regulations [and] PURSUANT TO SECTION
   31  SIX  HUNDRED  NINETEEN  OF  THIS  ARTICLE.  EACH  MUNICIPALITY shall, in
   32  particular, ensure that public health services are provided in an  effi-
   33  cient and effective manner to all persons in the municipality.
   34    2.  The  commissioner  may withhold state aid reimbursement under this
   35  title for the appropriate services if, on ANY audit [and], review  OF  A
   36  STATE AID APPLICATION OR PERIODIC CLAIM FOR STATE AID, OR OTHER INFORMA-
   37  TION  AVAILABLE  TO  THE  DEPARTMENT,  the  commissioner finds that such
   38  services are not furnished or rendered in conformance with the rules and
   39  regulations established by the commissioner, INCLUDING BUT  NOT  LIMITED
   40  TO  THE  STANDARDS  OF  PERFORMANCE  ESTABLISHED PURSUANT TO SECTION SIX
   41  HUNDRED NINETEEN OF THIS ARTICLE, or  that  the  expenditures  were  not
   42  [made according to the approved public health services plan required by]
   43  FOR  AN  ACTIVITY SET FORTH IN section six hundred two of this title. In
   44  such cases, the commissioner, in order to ensure that the public  health
   45  is  promoted  as  defined  in  [paragraph  (b)  of subdivision three of]
   46  section six hundred two of this title, may use any  proportionate  share
   47  of  a  municipality's  per  capita  or  base  grant  that is withheld to
   48  contract with  agencies,  associations,  or  organizations.  The  health
   49  department  may  use  any  such  withheld share to provide services upon
   50  approval of the director of the division of the budget. Copies  of  such
   51  transactions  shall  be filed with the fiscal committees of the legisla-
   52  ture.
   53    3. CONSISTENT WITH PARAGRAPH (H) OF SUBDIVISION  TWO  OF  SECTION  SIX
   54  HUNDRED  ONE  OF THIS TITLE, WHEN DETERMINING WHETHER TO APPROVE A STATE
   55  AID APPLICATION OR PERIODIC CLAIM FOR STATE AID, THE COMMISSIONER  SHALL
   56  HAVE  AUTHORITY  TO  REQUEST  ANY  AND ALL FINANCIAL AND OTHER DOCUMENTS
       S. 2606--D                         148                        A. 3006--D

    1  NECESSARY OR RELEVANT TO VERIFY THAT THE CLAIMED EXPENDITURES ARE ELIGI-
    2  BLE FOR STATE AID UNDER THIS ARTICLE.
    3    S 19. Section 604 of the public health law, as added by chapter 901 of
    4  the laws of 1986, is amended to read as follows:
    5    S  604. Supervision of public health programs. In order to be eligible
    6  for state aid, under this title, each municipality shall employ a  full-
    7  time local commissioner of health or public health director to supervise
    8  the  provision  of public health services [and to implement the approved
    9  public health services plan]  for  that  municipality,  SUBJECT  TO  THE
   10  FOLLOWING EXCEPTIONS:
   11    1.  SUCH  PERSON  MAY SERVE AS THE HEAD OF A MERGED AGENCY OR MULTIPLE
   12  AGENCIES, IF THE APPROVAL OF THE COMMISSIONER IS OBTAINED; AND
   13    2. SUCH PERSON MAY SERVE AS THE LOCAL COMMISSIONER OF HEALTH OR PUBLIC
   14  HEALTH DIRECTOR OF ADDITIONAL  COUNTIES,  WHEN  AUTHORIZED  PURSUANT  TO
   15  SECTION THREE HUNDRED FIFTY-ONE OF THIS CHAPTER.
   16    S 20. Section 605 of the public health law, as added by chapter 901 of
   17  the  laws  of  1986,  subdivision 1 as amended by section 6 of part B of
   18  chapter 57 of the laws of 2006, subdivision 2 as amended by  section  13
   19  of  part  A  of  chapter  59  of the laws of 2011, is amended to read as
   20  follows:
   21    S 605. State aid; amount of reimbursement. 1. A state aid  base  grant
   22  shall  be reimbursed to municipalities for the [base] CORE public health
   23  services identified in [paragraph (b) of subdivision three  of]  section
   24  six  hundred  two  of this title, in an amount of the greater of [fifty-
   25  five] SIXTY-FIVE cents per capita, for each person in the  municipality,
   26  or  [five]  SIX hundred fifty thousand dollars provided that the munici-
   27  pality expends at least [five] SIX hundred fifty  thousand  dollars  for
   28  such [base] CORE public health services. A municipality must provide all
   29  the  [basic] CORE public health services identified in [paragraph (b) of
   30  subdivision three of] section six hundred two of this title  to  qualify
   31  for  such  base  grant  unless  the municipality has the approval of the
   32  commissioner to expend the base grant on a portion of such  [base]  CORE
   33  public  health services. If any services in such [paragraph (b)] SECTION
   34  are not [approved in the plan or  if  no  plan  is  submitted  for  such
   35  services]  PROVIDED,  the  commissioner may limit the municipality's per
   36  capita or base grant to [that proportionate share which will fund  those
   37  services that are submitted in a plan and subsequently approved] REFLECT
   38  THE SCOPE OF THE REDUCED SERVICES. The commissioner may use the [propor-
   39  tionate  share]  AMOUNT  that  is not granted to contract with agencies,
   40  associations, or organizations to provide such services; or  the  health
   41  department may use such proportionate share to provide the services upon
   42  approval of the director of the division of the budget.
   43    2.  State  aid  reimbursement for public health services provided by a
   44  municipality under this title, shall be  made  if  the  municipality  is
   45  providing some or all of the [basic] CORE public health services identi-
   46  fied  in [paragraph (b) of subdivision three of] section six hundred two
   47  of this title, pursuant to an approved [plan] APPLICATION FOR STATE AID,
   48  at a rate of no less  than  thirty-six  per  centum  of  the  difference
   49  between  the  amount  of  moneys expended by the municipality for public
   50  health services required by [paragraph  (b)  of  subdivision  three  of]
   51  section  six  hundred  two  of this title during the fiscal year and the
   52  base grant provided pursuant to subdivision one of this section. No such
   53  reimbursement shall be provided for services [if they are  not  approved
   54  in  a  plan  or  if no plan is submitted for such services] THAT ARE NOT
   55  ELIGIBLE FOR STATE AID PURSUANT TO THIS ARTICLE.
       S. 2606--D                         149                        A. 3006--D

    1    3. Municipalities  shall  make  every  reasonable  effort  to  collect
    2  payments for public health services provided. All such revenues shall be
    3  reported to the commissioner PURSUANT TO SECTION SIX HUNDRED SIX OF THIS
    4  TITLE  and  will be deducted from expenditures identified under subdivi-
    5  sion two of this section to produce a net cost eligible for state aid.
    6    S 21. Section 606 of the public health law, as added by chapter 901 of
    7  the laws of 1986, is amended to read as follows:
    8    S  606.  Assessment  of fees; THIRD-PARTY COVERAGE OR INDEMNIFICATION.
    9  1. Assessment of fees  by  municipalities.    [Each  municipality  shall
   10  assess  fees  for  services  provided by such municipality in accordance
   11  with a fee and revenue plan which shall include a schedule of fees  that
   12  the  municipality  proposes to charge for each service identified by the
   13  commissioner and each additional service identified by the  municipality
   14  for  which  a fee is to be charged. In accordance with the provisions of
   15  subdivision four of section six hundred two of this chapter, the commis-
   16  sioner shall review each fee and revenue plan submitted to him  and,  on
   17  the  basis  of  such  review, issue a notice of intent to disapprove the
   18  plan or approve the plan, with or without conditions, within ninety days
   19  of his receipt of the plan. In determining whether to approve or  disap-
   20  prove  a  plan,  the commissioner shall consider the extent to which the
   21  plan, once implemented, will satisfy standards  which  the  commissioner
   22  has  promulgated through rules and regulations after consulting with the
   23  public health council and county health commissioners, boards and public
   24  health directors. Such standards shall include a list of those  environ-
   25  mental,  personal  health  and  other  services  for which fees shall be
   26  charged, the calculation of cost by each municipality and the  relation-
   27  ship  of  cost to fees, and provisions for prohibiting the assessment of
   28  fees which would impede the delivery of services deemed essential to the
   29  protection of the health of the public.] EACH MUNICIPALITY SHALL  ESTAB-
   30  LISH A SCHEDULE OF FEES FOR PUBLIC HEALTH SERVICES PROVIDED BY THE MUNI-
   31  CIPALITY  AND  SHALL  MAKE EVERY REASONABLE EFFORT TO COLLECT SUCH FEES.
   32  Fees for personal health services shall be reflective of an individual's
   33  ability to pay and shall not  be  inconsistent  with  the  reimbursement
   34  guidelines  of  articles twenty-eight and thirty-six of this chapter and
   35  applicable federal laws and regulations. To the extent possible revenues
   36  generated shall be used to enhance or expand public health services.  IN
   37  ITS STATE AID APPLICATION, EACH MUNICIPALITY SHALL PROVIDE  THE  DEPART-
   38  MENT  WITH  A  PROJECTION  OF  FEES AND REVENUE TO BE COLLECTED FOR THAT
   39  YEAR. EACH MUNICIPALITY SHALL PERIODICALLY REPORT TO THE DEPARTMENT FEES
   40  AND REVENUE ACTUALLY COLLECTED.
   41    2. Assessment of fees by the commissioner. In each  municipality,  the
   42  commissioner  shall  establish  a  fee  and  revenue  plan  for services
   43  provided by the department in a manner consistent with the standards and
   44  regulations established pursuant to subdivision one of this section.
   45    3. THIRD PARTY COVERAGE OR  INDEMNIFICATION.  FOR  ANY  PUBLIC  HEALTH
   46  SERVICE  FOR  WHICH  COVERAGE  OR  INDEMNIFICATION FROM A THIRD PARTY IS
   47  AVAILABLE, THE MUNICIPALITY MUST SEEK SUCH COVERAGE  OR  INDEMNIFICATION
   48  AND  REPORT  ANY  ASSOCIATED  REVENUE TO THE DEPARTMENT IN ITS STATE AID
   49  APPLICATION.
   50    S 22. Subdivisions 1 and 2 of section 609 of the public health law, as
   51  amended by chapter 474 of the laws of  1996,  are  amended  to  read  as
   52  follows:
   53    1.  Where  a  laboratory  shall  have been or is hereafter established
   54  pursuant to article five of this chapter, the state, through the  legis-
   55  lature and within the limits to be prescribed by the commissioner, shall
   56  provide  aid  at  a  per  centum,  determined  in  accordance  with  the
       S. 2606--D                         150                        A. 3006--D

    1  provisions of [paragraph (b) of] subdivision two of section six  hundred
    2  five  of  this  article,  of  the actual cost of [installation,] REPAIR,
    3  RELOCATION, equipment and maintenance of the laboratory or  laboratories
    4  FOR  SERVICES ASSOCIATED WITH A CORE PUBLIC HEALTH SERVICE, AS DESCRIBED
    5  IN SECTION SIX HUNDRED TWO OF THIS  TITLE.    Such  cost  shall  be  the
    6  excess,  if  any,  of  such  expenditures over available revenues of all
    7  types, including adequate and reasonable fees, derived from or attribut-
    8  able to the performance of laboratory services.
    9    2. Where a county or city provides or shall have provided for  labora-
   10  tory  service by contracting with an established laboratory FOR SERVICES
   11  ASSOCIATED WITH A CORE PUBLIC HEALTH SERVICE, AS DESCRIBED  IN  SUBDIVI-
   12  SION  THREE  OF SECTION SIX HUNDRED TWO OF THIS TITLE, with the approval
   13  of the commissioner, it shall be entitled to state aid at a per  centum,
   14  determined  in  accordance  with  the  provisions  of [paragraph (b) of]
   15  subdivision two of section six hundred five of this article, of the cost
   16  of the contracts. [State aid shall be available for a district laborato-
   17  ry supply station maintained and operated  in  accordance  with  article
   18  five  of  this  chapter in the same manner and to the same extent as for
   19  laboratory services.]
   20    S 23. Sections 610 and 612 of the public health law are REPEALED.
   21    S 24. Paragraphs (a) and (c) of subdivision 1  and  subdivision  4  of
   22  section 613 of the public health law, paragraphs (a) and (c) of subdivi-
   23  sion  1  as  amended by chapter 36 of the laws of 2010, subdivision 4 as
   24  amended by chapter 207 of the laws of  2004,  are  amended  to  read  as
   25  follows:
   26    (a)  The  commissioner  shall develop and supervise the execution of a
   27  program of immunization, surveillance and testing, to raise to the high-
   28  est reasonable level the immunity of the children of the  state  against
   29  communicable  diseases including, but not limited to, influenza, poliom-
   30  yelitis, measles, mumps, rubella, haemophilus influenzae type  b  (Hib),
   31  diphtheria,  pertussis,  tetanus,  varicella,  hepatitis B, pneumococcal
   32  disease, and the immunity of adults of the state against diseases  iden-
   33  tified  by  the  commissioner,  including  but not limited to influenza,
   34  smallpox, [and] hepatitis AND SUCH OTHER DISEASES  AS  THE  COMMISSIONER
   35  MAY DESIGNATE THROUGH REGULATION.  [The commissioner shall encourage the
   36  municipalities]  MUNICIPALITIES  in  the  state  [to  develop and] shall
   37  [assist them in the development and the  execution  of]  MAINTAIN  local
   38  programs  of  [inoculation]  IMMUNIZATION  to  raise the immunity of the
   39  children and adults of  each  municipality  to  the  highest  reasonable
   40  level,  IN ACCORDANCE WITH AN APPLICATION FOR STATE AID SUBMITTED BY THE
   41  MUNICIPALITY AND APPROVED BY THE  COMMISSIONER.    Such  programs  shall
   42  include  ASSURANCE  OF  provision  of  vaccine, [surveillance of vaccine
   43  effectiveness by means of  laboratory  tests,]  serological  testing  of
   44  individuals  and educational efforts to inform health care providers and
   45  target populations or their parents, if they are minors,  of  the  facts
   46  relative  to  these  diseases and [inoculation] IMMUNIZATIONS to prevent
   47  their occurrence.
   48    (c) The commissioner shall invite and encourage the active  assistance
   49  and  cooperation in such education activities of: the medical societies,
   50  organizations of other  licensed  health  personnel,  hospitals,  corpo-
   51  rations  subject  to  article  forty-three  of  the insurance law, trade
   52  unions, trade associations, parents and teachers and their associations,
   53  organizations of child care resource and referral agencies, the media of
   54  mass communication, and such other voluntary groups and organizations of
   55  citizens as he or she shall deem  appropriate.  The  public  health  AND
   56  HEALTH  PLANNING council, the department of education, the department of
       S. 2606--D                         151                        A. 3006--D

    1  family assistance, and the department of mental  hygiene  shall  provide
    2  the  commissioner with such assistance in carrying out the program as he
    3  or she shall request.  All other state agencies shall also  render  such
    4  assistance  as the commissioner may reasonably require for this program.
    5  Nothing in this subdivision shall authorize  mandatory  immunization  of
    6  adults  or  children,  except as provided in sections twenty-one hundred
    7  sixty-four and twenty-one hundred sixty-five of this chapter.
    8    4. The commissioner shall expend such funds as the  legislature  shall
    9  make available for the purchase of the vaccines described in subdivision
   10  one  of  this  section.  [All  immunization vaccines purchased with such
   11  funds shall be purchased by sealed competitive state  bids  through  the
   12  office  of  general  services.  Immunization vaccine] VACCINES purchased
   13  with funds made available under this section  shall  be  made  available
   14  without  charge  to  licensed private physicians, hospitals, clinics and
   15  such others as the commissioner  shall  determine  [in  accordance  with
   16  regulations  to be promulgated by the commissioner], and no charge shall
   17  be made to any patient for such vaccines.
   18    S 25. Subdivisions 5 and 7 of section 613 of the public health law are
   19  REPEALED, and subdivision 6, as added by chapter  901  of  the  laws  of
   20  1986, is amended to read as follows:
   21    [6.] 5. The commissioner shall submit to the governor and the legisla-
   22  ture  an annual report on the progress of the immunization program. Such
   23  reports shall include  specific  information  on  the  steps  taken  and
   24  planned  by  the  department [and by each participating municipality] to
   25  carry out the program[, statistical information on immunization  vaccine
   26  purchased for each municipality, the number of inoculations administered
   27  to  children  of  various  ages  by municipal agencies, private clinics,
   28  private  physicians  and  others,  the  cost  of  the  several  vaccines
   29  purchased,  information  on  the results of the immunization program and
   30  research on the effects of the vaccine, cooperative education efforts by
   31  public and private  agencies,  special  information  and  administrative
   32  measures  to reach parents and children in population groups which pres-
   33  ent special educational problems, the actual  and  planned  use  of  any
   34  federal funds available to meet any part of the cost of the program, and
   35  actual  and  planned  expenditure  by  municipalities  to meet costs not
   36  provided for by state and federal funds].
   37    S 26. Subdivision 2 of section 614 of the public health law, as  added
   38  by chapter 901 of the laws of 1986, is amended to read as follows:
   39    2.  "City", each city of the state having a population of [fifty thou-
   40  sand] ONE MILLION or more,  according  to  the  last  preceding  federal
   41  census[,  but does not include any such city which is included as a part
   42  of a county health district pursuant to this chapter].
   43    S 27. Subdivision 1 of section  616  of  the  public  health  law,  as
   44  amended  by  section  9  of part B of chapter 57 of the laws of 2006, is
   45  amended to read as follows:
   46    1. The total amount of state aid provided  pursuant  to  this  article
   47  shall  be  limited to the amount of the annual appropriation made by the
   48  legislature. In no event, however, shall such state aid be less than  an
   49  amount  to  provide  the  full  base grant and, as otherwise provided by
   50  paragraph (a) of subdivision two of section six  hundred  five  of  this
   51  article,  at  least  thirty-six per centum of the difference between the
   52  amount of moneys expended by the municipality for ELIGIBLE public health
   53  services [required by paragraph (b) of subdivision three of section  six
   54  hundred  two  of  this  article] PURSUANT TO AN APPROVED APPLICATION FOR
   55  STATE AID during the fiscal year and the base grant provided pursuant to
   56  subdivision one of section six hundred five of this article. [A  munici-
       S. 2606--D                         152                        A. 3006--D

    1  pality  shall  also  receive  not less than thirty-six per centum of the
    2  moneys expended for other public health services pursuant  to  paragraph
    3  (b) of subdivision two of section six hundred five of this article, and,
    4  at  least  the minimum amount so required for the services identified in
    5  title two of this article.]
    6    S 28. Section 617 of the public health law, as added by chapter 901 of
    7  the laws of 1986, is amended to read as follows:
    8    S 617. Maintenance of effort. Such amount of state aid  provided  will
    9  be  used to support and to the extent practicable, to increase the level
   10  of funds that would otherwise be made available for  such  purposes  and
   11  not  to  supplant  the amount to be provided by the municipalities. If a
   12  municipality that is provided state aid pursuant to title  one  of  this
   13  article reduces its expenditures beneath the amount expended in its base
   14  year,  which  is  [the  greater  of  its expenditures in its fiscal year
   15  ending in either nineteen hundred eighty-five or] the most recent fiscal
   16  year for which the municipality has filed [an  annual]  ALL  expenditure
   17  [report]  REPORTS  to  the  department, state aid reimbursement provided
   18  pursuant to subdivision one of section six hundred five of this  article
   19  will  be  reduced  by  the  [difference  between  the reduction in local
   20  expenditures between its base year and its current fiscal year  and  the
   21  reduction in state aid between the base year and the current fiscal year
   22  pursuant  to  paragraphs  (a)  and (b) of subdivision two of section six
   23  hundred five of  this  article.  A  municipality  may  include  revenue,
   24  excluding  third  party  reimbursement,  raised  by  the municipality in
   25  calculating its maintenance of effort] PERCENTAGE REDUCTION IN  EXPENDI-
   26  TURES BETWEEN ITS BASE YEAR AND ITS CURRENT FISCAL YEAR. FOR PURPOSES OF
   27  THIS  SECTION,  REDUCTIONS  IN  EXPENDITURES  SHALL  BE ADJUSTED FOR: AN
   28  ABSENCE OF EXTRAORDINARY EXPENDITURES OF A  TEMPORARY  NATURE,  SUCH  AS
   29  DISASTER  RELIEF; UNAVOIDABLE OR JUSTIFIABLE PROGRAM REDUCTIONS, SUCH AS
   30  A PROGRAM BEING SUBSUMED BY ANOTHER AGENCY; OR  IN  CIRCUMSTANCES  WHERE
   31  THE MUNICIPALITY CAN DEMONSTRATE, TO THE DEPARTMENT'S SATISFACTION, THAT
   32  THE NEED FOR THE EXPENDITURE NO LONGER EXISTS.
   33    S 29. Section 618 of the public health law, as added by chapter 901 of
   34  the laws of 1986, is amended to read as follows:
   35    S  618. Performance and accountability.  The commissioner shall estab-
   36  lish,  in  consultation  with  the  municipalities,  uniform   statewide
   37  performance  standards for the services funded pursuant to this article;
   38  provided, however, the commissioner may modify a specific standard for a
   39  municipality if such municipality demonstrates  adequate  justification.
   40  The  commissioner  shall recognize the particular needs and capabilities
   41  of the  various  municipalities.  The  commissioner  shall  monitor  the
   42  PERFORMANCE  AND  expenditures  of each municipality to ensure that each
   43  one satisfies the performance standards.  Any  municipality  failing  to
   44  satisfy its standards may be subject to a reduction or loss of aid until
   45  such  municipality  can  demonstrate that it has the capacity to satisfy
   46  such standards. The commissioner shall establish  a  uniform  accounting
   47  system for monitoring the expenditures for services of each municipality
   48  to which aid is granted[, and for determining the appropriateness of the
   49  costs  of such services. The commissioner shall also establish a uniform
   50  reporting system to determine the  appropriateness  of  the  amount  and
   51  types  of  services  provided,  and  the number of people receiving such
   52  services.] AND THE AMOUNT OF STATE AID RECEIVED INCLUDING  ANY  PERFORM-
   53  ANCE  PAYMENTS  PURSUANT TO SECTION SIX HUNDRED NINETEEN-A OF THIS ARTI-
   54  CLE. Such reporting system  shall  [also]  require  information  on  the
   55  amount of public health moneys received from the federal government, the
   56  private  sector,  grants,  and fees. Each such municipality shall comply
       S. 2606--D                         153                        A. 3006--D

    1  with the regulations of such  accounting  and  reporting  systems.  [The
    2  commissioner shall determine the extent to which the services maintained
    3  and  improved  the health status of a municipality's residents and main-
    4  tained   and  improved  the  accessibility  and  quality  of  care,  and
    5  controlled costs of the health care system.]
    6    S 30. Section 619 of the public health law, as added by chapter 901 of
    7  the laws of 1986, is amended to read as follows:
    8    S 619. Commissioner; regulatory powers. The commissioner  shall  adopt
    9  regulations  to  effectuate the provisions and purposes of this article,
   10  including, but not limited to:
   11    1. setting standards of performance [and  reasonable  costs]  for  the
   12  provision  of  [basic]  CORE  public health services which shall include
   13  performance criteria to ensure that  reimbursable  health  services  are
   14  delivered in an efficient and effective manner by a municipality; and
   15    2. monitoring, COLLECTING DATA and evaluating the provision of [basic]
   16  CORE  public  health  services  by  the  municipalities  and the amounts
   17  expended by the municipalities for such services.
   18    S 31. The public health law is amended by adding a new  section  619-a
   19  to read as follows:
   20    S  619-A.  INCENTIVE STANDARDS OF PERFORMANCE. 1. THE COMMISSIONER MAY
   21  ESTABLISH STATEWIDE INCENTIVE PERFORMANCE STANDARDS FOR THE DELIVERY  OF
   22  CORE PUBLIC HEALTH SERVICES.
   23    2.  WITHIN  AMOUNTS  APPROPRIATED,  AND SUBJECT TO THE APPROVAL OF THE
   24  DIRECTOR OF THE BUDGET, THE COMMISSIONER MAY INCREASE STATE AID  TO  ANY
   25  MUNICIPALITY THAT MEETS OR EXCEEDS STATEWIDE INCENTIVE PERFORMANCE STAN-
   26  DARDS  ESTABLISHED  UNDER  THIS SECTION, PROVIDED THAT THE TOTAL OF SUCH
   27  PAYMENTS TO ALL MUNICIPALITIES MAY NOT EXCEED ONE MILLION DOLLARS  ANNU-
   28  ALLY.
   29    S  32.  The article heading of article 23 of the public health law, as
   30  amended by chapter 878 of the laws  of  1980,  is  amended  to  read  as
   31  follows:
   32          CONTROL OF SEXUALLY [TRANSMISSIBLE] TRANSMITTED DISEASES
   33    S  33. Sections 2300, 2301, 2302 and 2303 of the public health law are
   34  REPEALED.
   35    S 34. The section heading and subdivisions 1 and 2 of section 2304  of
   36  the  public  health  law, as amended by chapter 878 of the laws of 1980,
   37  are amended and two new subdivisions 4  and  5  are  added  to  read  as
   38  follows:
   39    Sexually  [transmissible]  TRANSMITTED diseases; treatment facilities;
   40  administration. 1. It shall be  the  responsibility  of  each  board  of
   41  health  of  a  health  district  to  provide adequate facilities for the
   42  [free] diagnosis and treatment of persons living within its jurisdiction
   43  who are suspected of being infected or  are  infected  with  a  sexually
   44  [transmissible] TRANSMITTED disease.
   45    2.  The  health officer of said health district shall administer these
   46  facilities DIRECTLY OR THROUGH CONTRACT and shall  promptly  examine  or
   47  arrange  for the examination of persons suspected of being infected with
   48  a sexually  [transmissible]  TRANSMITTED  disease,  and  shall  promptly
   49  institute  treatment  or  arrange  for  the  treatment of those found or
   50  otherwise known to be infected with a sexually [transmissible] TRANSMIT-
   51  TED disease, provided that any person may, at his option, be treated  at
   52  his own expense by a licensed physician of his choice.
   53    4.  EACH  BOARD  OF  HEALTH AND LOCAL HEALTH OFFICER SHALL ENSURE THAT
   54  DIAGNOSIS AND TREATMENT SERVICES ARE  AVAILABLE  AND,  TO  THE  GREATEST
   55  EXTENT  PRACTICABLE,  SEEK  THIRD  PARTY COVERAGE OR INDEMNIFICATION FOR
   56  SUCH SERVICES; PROVIDED, HOWEVER, THAT NO BOARD OF HEALTH, LOCAL  HEALTH
       S. 2606--D                         154                        A. 3006--D

    1  OFFICER,  OR  OTHER MUNICIPAL OFFICER OR ENTITY SHALL REQUEST OR REQUIRE
    2  THAT SUCH COVERAGE OR INDEMNIFICATION BE  UTILIZED  AS  A  CONDITION  OF
    3  PROVIDING DIAGNOSIS OR TREATMENT SERVICES.
    4    5.  THE  TERM  "HEALTH  OFFICER"  AS USED IN THIS ARTICLE SHALL MEAN A
    5  COUNTY HEALTH OFFICER, A CITY HEALTH OFFICER, A TOWN HEALTH  OFFICER,  A
    6  VILLAGE  HEALTH  OFFICER,  THE  HEALTH  OFFICER OF A CONSOLIDATED HEALTH
    7  DISTRICT OR A STATE DISTRICT HEALTH OFFICER.
    8    S 35. The section heading and subdivisions 1 and 2 of section 2305  of
    9  the  public  health  law, as amended by chapter 878 of the laws of 1980,
   10  are amended to read as follows:
   11    Sexually [transmissible] TRANSMITTED diseases; treatment  by  licensed
   12  physician  or  staff  physician  of  a  hospital; prescriptions.   1. No
   13  person, other than a licensed physician, or,  in  a  hospital,  a  staff
   14  physician,  shall  diagnose,  treat  or  prescribe  for  a person who is
   15  infected with a sexually [transmissible] TRANSMITTED disease, or who has
   16  been exposed to infection with a  sexually  [transmissible]  TRANSMITTED
   17  disease,  or  dispense or sell a drug, medicine or remedy for the treat-
   18  ment of such person except on prescription of a duly licensed physician.
   19    2. A licensed physician, or in a  hospital,  a  staff  physician,  may
   20  diagnose,  treat  or  prescribe for a person under the age of twenty-one
   21  years without the consent or knowledge of the  parents  or  guardian  of
   22  said  person, where such person is infected with a sexually [transmissi-
   23  ble] TRANSMITTED disease, or has been exposed to infection with a  sexu-
   24  ally [transmissible] TRANSMITTED disease.
   25    S  36. Section 2306 of the public health law, as amended by chapter 41
   26  of the laws of 2010, is amended to read as follows:
   27    S 2306. Sexually [transmissible]  TRANSMITTED  diseases;  reports  and
   28  information, confidential. All reports or information secured by a board
   29  of  health  or health officer under the provisions of this article shall
   30  be confidential except in so far  as  is  necessary  to  carry  out  the
   31  purposes of this article. Such report or information may be disclosed by
   32  court order in a criminal proceeding in which it is otherwise admissible
   33  or  in  a  proceeding pursuant to article ten of the family court act in
   34  which it is otherwise admissible, to the prosecution and to the defense,
   35  or in a proceeding pursuant to article ten of the family  court  act  in
   36  which  it  is  otherwise  admissible,  to the petitioner, respondent and
   37  attorney for the child, provided that  the  subject  of  the  report  or
   38  information  has waived the confidentiality provided for by this section
   39  EXCEPT INSOFAR AS IS NECESSARY TO CARRY OUT THE PURPOSES OF  THIS  ARTI-
   40  CLE.  INFORMATION  MAY  BE DISCLOSED TO THIRD PARTY REIMBURSERS OR THEIR
   41  AGENTS TO THE EXTENT NECESSARY TO REIMBURSE HEALTH  CARE  PROVIDERS  FOR
   42  HEALTH SERVICES; PROVIDED THAT, WHEN NECESSARY, AN OTHERWISE APPROPRIATE
   43  AUTHORIZATION  FOR  SUCH  DISCLOSURE HAS BEEN SECURED BY THE PROVIDER. A
   44  person waives the confidentiality provided for by this section  if  such
   45  person voluntarily discloses or consents to disclosure of such report or
   46  information  or  a portion thereof. If such person lacks the capacity to
   47  consent to such a waiver, his or her parent, guardian or attorney may so
   48  consent. An order directing disclosure pursuant to  this  section  shall
   49  specify  that  no  report  or information shall be disclosed pursuant to
   50  such order which identifies or relates to  any  person  other  than  the
   51  subject  of  the  report  or information. REPORTS AND INFORMATION MAY BE
   52  USED IN THE AGGREGATE IN PROGRAMS APPROVED BY THE COMMISSIONER  FOR  THE
   53  IMPROVEMENT  OF  THE  QUALITY  OF  MEDICAL CARE PROVIDED TO PERSONS WITH
   54  SEXUALLY TRANSMITTED DISEASES; OR WITH  PATIENT  IDENTIFIERS  WHEN  USED
   55  WITHIN  THE  STATE  OR  LOCAL HEALTH DEPARTMENT BY PUBLIC HEALTH DISEASE
   56  PROGRAMS TO ASSESS CO-MORBIDITY OR  COMPLETENESS  OF  REPORTING  AND  TO
       S. 2606--D                         155                        A. 3006--D

    1  DIRECT  PROGRAM  NEEDS,  IN  WHICH CASE PATIENT IDENTIFIERS SHALL NOT BE
    2  DISCLOSED OUTSIDE THE STATE OR LOCAL HEALTH DEPARTMENT EXCEPT AS  OTHER-
    3  WISE PROVIDED FOR IN THIS SECTION.
    4    S  37. The section heading of section 2308 of the public health law is
    5  amended to read as follows:
    6    [Venereal] SEXUALLY TRANSMITTED disease; pregnant  women;  blood  test
    7  for syphilis.
    8    S  38.  Section 2308-a of the public health law, as amended by chapter
    9  878 of the laws of 1980, is amended to read as follows:
   10    S 2308-a. Sexually [transmissible]  TRANSMITTED  diseases;  tests  for
   11  sexually  [transmissible]  TRANSMITTED diseases.   1. The administrative
   12  officer or other person in charge of a clinic or other facility  provid-
   13  ing gynecological, obstetrical, genito-urological, contraceptive, steri-
   14  lization or termination of pregnancy services or treatment shall require
   15  the  staff  of  such  clinic or facility to offer to administer to every
   16  resident of the state of New York coming to such clinic or facility  for
   17  such  services  or  treatment, appropriate examinations or tests for the
   18  detection of sexually [transmissible] TRANSMITTED diseases.
   19    2. Each physician providing gynecological, obstetrical, genito-urolog-
   20  ical, contraceptive, sterilization, or termination of pregnancy services
   21  or treatment shall offer to administer to every resident of the state of
   22  New York coming to such physician for such services or treatment, appro-
   23  priate examinations or tests for the detection of sexually  [transmissi-
   24  ble] TRANSMITTED diseases.
   25    S 39. Sections 2309 and 2310 of the public health law are REPEALED.
   26    S  40.  Section 2311 of the public health law, as added by chapter 878
   27  of the laws of 1980, is amended to read as follows:
   28    S 2311. Sexually [transmissible] TRANSMITTED disease list. The commis-
   29  sioner shall promulgate a list of sexually  [transmissible]  TRANSMITTED
   30  diseases, such as gonorrhea and syphilis, for the purposes of this arti-
   31  cle.  The  commissioner,  in  determining the diseases to be included in
   32  such list, shall consider those conditions  principally  transmitted  by
   33  sexual  contact,  OTHER SECTIONS OF THIS CHAPTER ADDRESSING COMMUNICABLE
   34  DISEASES and the impact of particular diseases on  individual  morbidity
   35  and the health of newborns.
   36    S  41.  Section  2  of  chapter  577 of the laws of 2008, amending the
   37  public health law relating to  expedited  partner  therapy  for  persons
   38  infected with chlamydia trachomatis, is amended to read as follows:
   39    S 2. This act shall take effect on the one hundred twentieth day after
   40  it  shall  have  become  a  law [and shall expire and be deemed repealed
   41  January 1, 2014].
   42    S 42. Intentionally omitted.
   43    S 43. Intentionally omitted.
   44    S 44. Intentionally omitted.
   45    S 45. Intentionally omitted.
   46    S 46. Intentionally omitted.
   47    S 47. Intentionally omitted.
   48    S 48. Intentionally omitted
   49    S 49. Intentionally omitted.
   50    S 50. The public health law is amended by adding a new section  2806-a
   51  to read as follows:
   52    S 2806-A. TEMPORARY OPERATOR. 1. FOR THE PURPOSES OF THIS SECTION:
   53    (A) "ADULT CARE FACILITY" SHALL MEAN AN ADULT HOME OR ENRICHED HOUSING
   54  PROGRAM LICENSED PURSUANT TO ARTICLE SEVEN OF THE SOCIAL SERVICES LAW OR
   55  AN ASSISTED LIVING RESIDENCE LICENSED PURSUANT TO ARTICLE FORTY-SIX-B OF
   56  THIS CHAPTER;
       S. 2606--D                         156                        A. 3006--D

    1    (B)  "ESTABLISHED  OPERATOR"  SHALL MEAN THE OPERATOR OF AN ADULT CARE
    2  FACILITY, A GENERAL HOSPITAL OR A DIAGNOSTIC AND TREATMENT  CENTER  THAT
    3  HAS  BEEN ESTABLISHED AND ISSUED AN OPERATING CERTIFICATE AS SUCH PURSU-
    4  ANT TO THIS ARTICLE;
    5    (C)  "FACILITY"  SHALL MEAN (I) A GENERAL HOSPITAL OR A DIAGNOSTIC AND
    6  TREATMENT CENTER THAT HAS BEEN ISSUED AN OPERATING CERTIFICATE  AS  SUCH
    7  PURSUANT TO THIS ARTICLE; OR (II) AN ADULT CARE FACILITY;
    8    (D) "TEMPORARY OPERATOR" SHALL MEAN ANY PERSON OR ENTITY THAT:
    9    (I)  AGREES  TO  OPERATE  A  FACILITY ON A TEMPORARY BASIS IN THE BEST
   10  INTERESTS OF ITS RESIDENTS OR PATIENTS AND THE COMMUNITY SERVED  BY  THE
   11  FACILITY; AND
   12    (II) HAS DEMONSTRATED THAT HE OR SHE HAS THE CHARACTER, COMPETENCE AND
   13  FINANCIAL  ABILITY TO OPERATE THE FACILITY IN COMPLIANCE WITH APPLICABLE
   14  STANDARDS;
   15    (E) "SERIOUS FINANCIAL INSTABILITY" SHALL INCLUDE BUT NOT  BE  LIMITED
   16  TO  DEFAULTING  OR  VIOLATING KEY COVENANTS OF LOANS, OR MISSED MORTGAGE
   17  PAYMENTS, OR GENERAL UNTIMELY PAYMENT OF OBLIGATIONS, INCLUDING BUT  NOT
   18  LIMITED  TO  EMPLOYEE  BENEFIT  FUND, PAYROLL TAX, AND INSURANCE PREMIUM
   19  OBLIGATIONS, OR FAILURE  TO  MAINTAIN  REQUIRED  DEBT  SERVICE  COVERAGE
   20  RATIOS OR, AS APPLICABLE, FACTORS THAT HAVE TRIGGERED A WRITTEN EVENT OF
   21  DEFAULT NOTICE TO THE DEPARTMENT BY THE DORMITORY AUTHORITY OF THE STATE
   22  OF NEW YORK; AND
   23    (F)  "EXTRAORDINARY  FINANCIAL  ASSISTANCE"  SHALL  MEAN  STATE  FUNDS
   24  PROVIDED TO A FACILITY UPON SUCH FACILITY'S REQUEST FOR THE  PURPOSE  OF
   25  ASSISTING  THE  FACILITY TO ADDRESS SERIOUS FINANCIAL INSTABILITY.  SUCH
   26  FUNDS MAY BE DERIVED  FROM  EXISTING  PROGRAMS  WITHIN  THE  DEPARTMENT,
   27  SPECIAL APPROPRIATIONS, OR OTHER FUNDS.
   28    2.(A)  IN THE EVENT THAT: (I) A FACILITY SEEKS EXTRAORDINARY FINANCIAL
   29  ASSISTANCE AND THE COMMISSIONER FINDS THAT THE FACILITY IS  EXPERIENCING
   30  SERIOUS FINANCIAL INSTABILITY THAT IS JEOPARDIZING EXISTING OR CONTINUED
   31  ACCESS  TO  ESSENTIAL SERVICES WITHIN THE COMMUNITY, OR (II) THE COMMIS-
   32  SIONER FINDS THAT THERE ARE CONDITIONS WITHIN THE FACILITY THAT SERIOUS-
   33  LY ENDANGER THE LIFE, HEALTH OR SAFETY OF  RESIDENTS  OR  PATIENTS,  THE
   34  COMMISSIONER MAY APPOINT A TEMPORARY OPERATOR TO ASSUME SOLE CONTROL AND
   35  SOLE RESPONSIBILITY FOR THE OPERATIONS OF THAT FACILITY. THE APPOINTMENT
   36  OF  THE TEMPORARY OPERATOR SHALL BE EFFECTUATED PURSUANT TO THIS SECTION
   37  AND SHALL BE IN ADDITION TO ANY OTHER REMEDIES PROVIDED BY LAW.
   38    (B) THE ESTABLISHED OPERATOR OF A FACILITY MAY AT ANY TIME REQUEST THE
   39  COMMISSIONER TO APPOINT A TEMPORARY  OPERATOR.  UPON  RECEIVING  SUCH  A
   40  REQUEST,  THE  COMMISSIONER  MAY,  IF  HE OR SHE DETERMINES THAT SUCH AN
   41  ACTION IS NECESSARY TO RESTORE OR MAINTAIN THE PROVISION OF QUALITY CARE
   42  TO THE RESIDENTS OR  PATIENTS  OR  ALLEVIATE  THE  FACILITY'S  FINANCIAL
   43  INSTABILITY,  ENTER  INTO AN AGREEMENT WITH THE ESTABLISHED OPERATOR FOR
   44  THE APPOINTMENT OF A TEMPORARY OPERATOR TO ASSUME SOLE CONTROL AND  SOLE
   45  RESPONSIBILITY FOR THE OPERATIONS OF THAT FACILITY.
   46    3.  (A) A TEMPORARY OPERATOR APPOINTED PURSUANT TO THIS SECTION SHALL,
   47  PRIOR TO HIS OR HER  APPOINTMENT  AS  TEMPORARY  OPERATOR,  PROVIDE  THE
   48  COMMISSIONER  WITH  A  WORK  PLAN  SATISFACTORY  TO  THE COMMISSIONER TO
   49  ADDRESS THE FACILITY'S DEFICIENCIES AND  SERIOUS  FINANCIAL  INSTABILITY
   50  AND A SCHEDULE FOR IMPLEMENTATION OF SUCH PLAN. A WORK PLAN SHALL NOT BE
   51  REQUIRED  PRIOR TO THE APPOINTMENT OF THE TEMPORARY OPERATOR PURSUANT TO
   52  CLAUSE (II) OF PARAGRAPH (A) OF SUBDIVISION TWO OF THIS SECTION  IF  THE
   53  COMMISSIONER  HAS  DETERMINED THAT THE IMMEDIATE APPOINTMENT OF A TEMPO-
   54  RARY OPERATOR IS NECESSARY BECAUSE PUBLIC HEALTH OR SAFETY IS  IN  IMMI-
   55  NENT  DANGER  OR  THERE EXISTS ANY CONDITION OR PRACTICE OR A CONTINUING
   56  PATTERN OF CONDITIONS OR PRACTICES WHICH POSES IMMINENT  DANGER  TO  THE
       S. 2606--D                         157                        A. 3006--D

    1  HEALTH  OR SAFETY OF ANY PATIENT OR RESIDENT OF THE FACILITY. WHERE SUCH
    2  IMMEDIATE APPOINTMENT HAS BEEN FOUND  TO  BE  NECESSARY,  THE  TEMPORARY
    3  OPERATOR SHALL PROVIDE THE COMMISSIONER WITH A WORK PLAN SATISFACTORY TO
    4  THE COMMISSIONER AS SOON AS PRACTICABLE.
    5    (B) THE TEMPORARY OPERATOR SHALL USE HIS OR HER BEST EFFORTS TO IMPLE-
    6  MENT  THE  WORK PLAN PROVIDED TO THE COMMISSIONER, IF APPLICABLE, AND TO
    7  CORRECT OR ELIMINATE ANY DEFICIENCIES OR FINANCIAL  INSTABILITY  IN  THE
    8  FACILITY  AND  TO  PROMOTE  THE QUALITY AND ACCESSIBILITY OF HEALTH CARE
    9  SERVICES IN THE COMMUNITY SERVED BY THE  FACILITY.  SUCH  CORRECTION  OR
   10  ELIMINATION  OF  DEFICIENCIES OR SERIOUS FINANCIAL INSTABILITY SHALL NOT
   11  INCLUDE MAJOR ALTERATIONS OF THE PHYSICAL  STRUCTURE  OF  THE  FACILITY.
   12  DURING  THE TERM OF HIS OR HER APPOINTMENT, THE TEMPORARY OPERATOR SHALL
   13  HAVE THE SOLE AUTHORITY TO DIRECT THE MANAGEMENT OF THE FACILITY IN  ALL
   14  ASPECTS  OF  OPERATION AND SHALL BE AFFORDED FULL ACCESS TO THE ACCOUNTS
   15  AND RECORDS OF THE FACILITY. THE TEMPORARY OPERATOR SHALL,  DURING  THIS
   16  PERIOD,  OPERATE  THE FACILITY IN SUCH A MANNER AS TO PROMOTE SAFETY AND
   17  THE QUALITY AND ACCESSIBILITY OF HEALTH  CARE  SERVICES  OR  RESIDENTIAL
   18  CARE  IN  THE  COMMUNITY  SERVED BY THE FACILITY. THE TEMPORARY OPERATOR
   19  SHALL HAVE THE POWER TO LET CONTRACTS  THEREFOR  OR  INCUR  EXPENSES  ON
   20  BEHALF OF THE FACILITY, PROVIDED THAT WHERE INDIVIDUAL ITEMS OF REPAIRS,
   21  IMPROVEMENTS  OR  SUPPLIES  EXCEED  TEN  THOUSAND DOLLARS, THE TEMPORARY
   22  OPERATOR SHALL OBTAIN PRICE QUOTATIONS FROM  AT  LEAST  THREE  REPUTABLE
   23  SOURCES.  THE TEMPORARY OPERATOR SHALL NOT BE REQUIRED TO FILE ANY BOND.
   24  NO SECURITY INTEREST IN ANY REAL OR  PERSONAL  PROPERTY  COMPRISING  THE
   25  FACILITY  OR  CONTAINED  WITHIN  THE  FACILITY, OR IN ANY FIXTURE OF THE
   26  FACILITY, SHALL BE IMPAIRED OR DIMINISHED IN PRIORITY BY  THE  TEMPORARY
   27  OPERATOR. NEITHER THE TEMPORARY OPERATOR NOR THE DEPARTMENT SHALL ENGAGE
   28  IN  ANY ACTIVITY THAT CONSTITUTES A CONFISCATION OF PROPERTY WITHOUT THE
   29  PAYMENT OF FAIR COMPENSATION.
   30    4. THE TEMPORARY OPERATOR SHALL BE ENTITLED TO A  REASONABLE  FEE,  AS
   31  DETERMINED  BY  THE COMMISSIONER, AND NECESSARY EXPENSES INCURRED DURING
   32  HIS OR HER PERFORMANCE AS TEMPORARY OPERATOR, TO BE PAID FROM THE REVEN-
   33  UE OF THE  FACILITY.  THE  TEMPORARY  OPERATOR  SHALL  COLLECT  INCOMING
   34  PAYMENTS  FROM  ALL  SOURCES AND APPLY THEM TO THE REASONABLE FEE AND TO
   35  COSTS INCURRED IN THE PERFORMANCE OF HIS OR HER FUNCTIONS  AS  TEMPORARY
   36  OPERATOR  IN  CORRECTING  DEFICIENCIES  AND  CAUSES OF SERIOUS FINANCIAL
   37  INSTABILITY.  THE TEMPORARY OPERATOR SHALL BE LIABLE ONLY IN HIS OR  HER
   38  CAPACITY  AS  TEMPORARY  OPERATOR  FOR  INJURY TO PERSON AND PROPERTY BY
   39  REASON OF CONDITIONS OF THE FACILITY IN  A  CASE  WHERE  AN  ESTABLISHED
   40  OPERATOR  WOULD HAVE BEEN LIABLE; HE OR SHE SHALL NOT HAVE ANY LIABILITY
   41  IN HIS OR HER PERSONAL CAPACITY, EXCEPT FOR GROSS NEGLIGENCE AND  INTEN-
   42  TIONAL ACTS.
   43    5.  (A)  THE INITIAL TERM OF THE APPOINTMENT OF THE TEMPORARY OPERATOR
   44  SHALL NOT EXCEED ONE HUNDRED EIGHTY DAYS. AFTER ONE HUNDRED EIGHTY DAYS,
   45  IF THE COMMISSIONER DETERMINES THAT TERMINATION OF THE TEMPORARY  OPERA-
   46  TOR  WOULD  CAUSE SIGNIFICANT DETERIORATION OF THE QUALITY OF, OR ACCESS
   47  TO, HEALTH CARE OR RESIDENTIAL CARE IN THE COMMUNITY OR THAT  REAPPOINT-
   48  MENT  IS  NECESSARY  TO  CORRECT THE CONDITIONS WITHIN THE FACILITY THAT
   49  SERIOUSLY ENDANGER THE LIFE, HEALTH OR SAFETY OF RESIDENTS OR  PATIENTS,
   50  OR THE FINANCIAL INSTABILITY THAT REQUIRED THE APPOINTMENT OF THE TEMPO-
   51  RARY OPERATOR, THE COMMISSIONER MAY AUTHORIZE UP TO TWO ADDITIONAL NINE-
   52  TY-DAY TERMS.
   53    (B)  UPON  THE  COMPLETION  OF  THE TWO NINETY-DAY TERMS REFERENCED IN
   54  PARAGRAPH (A) OF THIS SUBDIVISION,
   55    (I) IF THE ESTABLISHED OPERATOR IS THE DEBTOR IN A BANKRUPTCY PROCEED-
   56  ING,  AND  THE  COMMISSIONER  DETERMINES  THAT  THE  TEMPORARY  OPERATOR
       S. 2606--D                         158                        A. 3006--D

    1  REQUIRES ADDITIONAL TERMS TO OPERATE THE FACILITY DURING THE PENDENCY OF
    2  THE  BANKRUPTCY  PROCEEDING AND TO CARRY OUT ANY PLAN RESULTING FROM THE
    3  PROCEEDING, THE COMMISSIONER MAY REAPPOINT THE  TEMPORARY  OPERATOR  FOR
    4  ADDITIONAL  NINETY-DAY  TERMS  UNTIL  THE  TERMINATION OF THE BANKRUPTCY
    5  PROCEEDING, PROVIDED THAT THE COMMISSIONER SHALL PROVIDE FOR NOTICE  AND
    6  A HEARING AS SET FORTH IN SUBDIVISION SIX OF THIS SECTION; OR
    7    (II)  IF  THE  ESTABLISHED  OPERATOR REQUESTS THE REAPPOINTMENT OF THE
    8  TEMPORARY OPERATOR, THE COMMISSIONER MAY REAPPOINT THE TEMPORARY  OPERA-
    9  TOR FOR ONE ADDITIONAL NINETY-DAY TERM, PURSUANT TO AN AGREEMENT BETWEEN
   10  THE ESTABLISHED OPERATOR, THE TEMPORARY OPERATOR AND THE DEPARTMENT.
   11    (C)  WITHIN FOURTEEN DAYS PRIOR TO THE TERMINATION OF EACH TERM OF THE
   12  APPOINTMENT OF THE TEMPORARY  OPERATOR,  THE  TEMPORARY  OPERATOR  SHALL
   13  SUBMIT  TO  THE  COMMISSIONER  AND  TO THE ESTABLISHED OPERATOR A REPORT
   14  DESCRIBING:
   15    (I) THE ACTIONS TAKEN DURING THE APPOINTMENT TO ADDRESS SUCH DEFICIEN-
   16  CIES AND FINANCIAL INSTABILITY,
   17    (II) OBJECTIVES FOR THE CONTINUATION OF THE TEMPORARY OPERATORSHIP  IF
   18  NECESSARY AND A SCHEDULE FOR SATISFACTION OF SUCH OBJECTIVES,
   19    (III)  RECOMMENDED  ACTIONS  FOR THE ONGOING OPERATION OF THE FACILITY
   20  SUBSEQUENT TO THE TERM OF THE TEMPORARY OPERATOR; AND
   21    (IV) WITH RESPECT TO THE FIRST NINETY-DAY TERM REFERENCED IN PARAGRAPH
   22  (A) OF THIS SUBDIVISION, A  PLAN  FOR  SUSTAINABLE  OPERATION  TO  AVOID
   23  CLOSURE,  OR TRANSFORMATION OF THE FACILITY WHICH MAY INCLUDE ANY OPTION
   24  PERMISSIBLE UNDER THIS CHAPTER OR THE SOCIAL SERVICES LAW AND IMPLEMENT-
   25  ING REGULATIONS THEREOF.   THE REPORT  SHALL  REFLECT  BEST  EFFORTS  TO
   26  PRODUCE A FULL AND COMPLETE ACCOUNTING.
   27    (D)  THE  TERM  OF THE INITIAL APPOINTMENT AND OF ANY SUBSEQUENT REAP-
   28  POINTMENT MAY BE TERMINATED PRIOR TO THE EXPIRATION  OF  THE  DESIGNATED
   29  TERM,  IF  THE ESTABLISHED OPERATOR AND THE COMMISSIONER AGREE ON A PLAN
   30  OF CORRECTION AND THE IMPLEMENTATION OF SUCH PLAN.
   31    6. (A) THE COMMISSIONER, UPON MAKING  A  DETERMINATION  TO  APPOINT  A
   32  TEMPORARY  OPERATOR PURSUANT TO PARAGRAPH (A) OF SUBDIVISION TWO OF THIS
   33  SECTION SHALL, PRIOR TO THE COMMENCEMENT OF THE APPOINTMENT,  CAUSE  THE
   34  ESTABLISHED OPERATOR OF THE FACILITY TO BE NOTIFIED OF THE DETERMINATION
   35  BY REGISTERED OR CERTIFIED MAIL ADDRESSED TO THE PRINCIPAL OFFICE OF THE
   36  ESTABLISHED   OPERATOR.  SUCH  NOTIFICATION  SHALL  INCLUDE  A  DETAILED
   37  DESCRIPTION OF THE FINDINGS UNDERLYING THE DETERMINATION  TO  APPOINT  A
   38  TEMPORARY OPERATOR, AND THE DATE AND TIME OF A REQUIRED MEETING WITH THE
   39  COMMISSIONER  AND/OR HIS OR HER DESIGNEE WITHIN TEN BUSINESS DAYS OF THE
   40  DATE OF SUCH NOTICE. AT SUCH MEETING,  THE  ESTABLISHED  OPERATOR  SHALL
   41  HAVE  THE  OPPORTUNITY  TO  REVIEW AND DISCUSS ALL RELEVANT FINDINGS. AT
   42  SUCH MEETING OR WITHIN TEN ADDITIONAL BUSINESS  DAYS,  THE  COMMISSIONER
   43  AND  THE ESTABLISHED OPERATOR SHALL ATTEMPT TO DEVELOP A MUTUALLY SATIS-
   44  FACTORY PLAN OF CORRECTION AND SCHEDULE FOR IMPLEMENTATION. IN THE EVENT
   45  SUCH PLAN OF CORRECTION IS AGREED UPON, THE  COMMISSIONER  SHALL  NOTIFY
   46  THE  ESTABLISHED  OPERATOR  THAT  THE  COMMISSIONER NO LONGER INTENDS TO
   47  APPOINT A TEMPORARY OPERATOR. A MEETING SHALL NOT BE REQUIRED  PRIOR  TO
   48  THE  APPOINTMENT  OF  THE  TEMPORARY OPERATOR PURSUANT TO CLAUSE (II) OF
   49  PARAGRAPH (A) OF SUBDIVISION TWO OF THIS SECTION IF THE COMMISSIONER HAS
   50  DETERMINED THAT THE IMMEDIATE APPOINTMENT OF  A  TEMPORARY  OPERATOR  IS
   51  NECESSARY BECAUSE PUBLIC HEALTH OR SAFETY IS IN IMMINENT DANGER OR THERE
   52  EXISTS  ANY  CONDITION OR PRACTICE OR A CONTINUING PATTERN OF CONDITIONS
   53  OR PRACTICES WHICH POSES IMMINENT DANGER TO THE HEALTH OR SAFETY OF  ANY
   54  PATIENT  OR  RESIDENT  OF THE FACILITY. WHERE SUCH IMMEDIATE APPOINTMENT
   55  HAS BEEN FOUND TO BE  NECESSARY,  THE  COMMISSIONER  SHALL  PROVIDE  THE
       S. 2606--D                         159                        A. 3006--D

    1  ESTABLISHED  OPERATOR  WITH A NOTICE AS REQUIRED UNDER THIS PARAGRAPH ON
    2  THE DATE OF THE APPOINTMENT OF THE TEMPORARY OPERATOR.
    3    (B)  SHOULD THE COMMISSIONER AND THE ESTABLISHED OPERATOR BE UNABLE TO
    4  ESTABLISH A PLAN OF CORRECTION PURSUANT TO PARAGRAPH (A) OF THIS  SUBDI-
    5  VISION,  OR  SHOULD  THE  ESTABLISHED  OPERATOR  FAIL  TO RESPOND TO THE
    6  COMMISSIONER'S INITIAL  NOTIFICATION,  A  TEMPORARY  OPERATOR  SHALL  BE
    7  APPOINTED  AS  SOON  AS IS PRACTICABLE AND SHALL OPERATE PURSUANT TO THE
    8  PROVISIONS OF THIS SECTION.
    9    (C) THE ESTABLISHED OPERATOR SHALL BE AFFORDED AN OPPORTUNITY  FOR  AN
   10  ADMINISTRATIVE  HEARING ON THE COMMISSIONER'S DETERMINATION TO APPOINT A
   11  TEMPORARY OPERATOR. SUCH ADMINISTRATIVE HEARING  SHALL  OCCUR  PRIOR  TO
   12  SUCH APPOINTMENT, EXCEPT THAT THE HEARING SHALL NOT BE REQUIRED PRIOR TO
   13  THE  APPOINTMENT  OF  THE  TEMPORARY OPERATOR PURSUANT TO CLAUSE (II) OF
   14  PARAGRAPH (A) OF SUBDIVISION TWO OF THIS SECTION IF THE COMMISSIONER HAS
   15  DETERMINED THAT THE IMMEDIATE APPOINTMENT OF  A  TEMPORARY  OPERATOR  IS
   16  NECESSARY BECAUSE PUBLIC HEALTH OR SAFETY IS IN IMMINENT DANGER OR THERE
   17  EXISTS  ANY  CONDITION OR PRACTICE OR A CONTINUING PATTERN OF CONDITIONS
   18  OR PRACTICES WHICH POSES IMMINENT DANGER TO THE HEALTH OR SAFETY OF  ANY
   19  PATIENT  OR  RESIDENT  OF  THE  FACILITY.  AN  ADMINISTRATIVE HEARING AS
   20  PROVIDED FOR UNDER THIS PARAGRAPH SHALL BEGIN NO LATER THAN  SIXTY  DAYS
   21  FROM THE DATE OF THE NOTICE TO THE ESTABLISHED OPERATOR AND SHALL NOT BE
   22  EXTENDED  WITHOUT THE CONSENT OF BOTH PARTIES. ANY SUCH HEARING SHALL BE
   23  STRICTLY LIMITED TO THE  ISSUE  OF  WHETHER  THE  DETERMINATION  OF  THE
   24  COMMISSIONER TO APPOINT A TEMPORARY OPERATOR IS SUPPORTED BY SUBSTANTIAL
   25  EVIDENCE. A COPY OF THE DECISION SHALL BE SENT TO THE ESTABLISHED OPERA-
   26  TOR.
   27    (D) THE COMMISSIONER SHALL, UPON MAKING A DETERMINATION TO REAPPOINT A
   28  TEMPORARY OPERATOR FOR THE FIRST OF AN ADDITIONAL NINETY-DAY TERM PURSU-
   29  ANT  TO  PARAGRAPH  (A)  OF  SUBDIVISION FIVE OF THIS SECTION, CAUSE THE
   30  ESTABLISHED OPERATOR OF THE FACILITY TO BE NOTIFIED OF THE DETERMINATION
   31  BY REGISTERED OR CERTIFIED MAIL ADDRESSED TO THE PRINCIPAL OFFICE OF THE
   32  ESTABLISHED OPERATOR. IF THE  COMMISSIONER  DETERMINES  THAT  ADDITIONAL
   33  REAPPOINTMENTS PURSUANT TO SUBPARAGRAPH (I) OF PARAGRAPH (B) OF SUBDIVI-
   34  SION  FIVE  OF  THIS  SECTION ARE REQUIRED, THE COMMISSIONER SHALL AGAIN
   35  CAUSE THE ESTABLISHED OPERATOR OF THE FACILITY TO BE  NOTIFIED  OF  SUCH
   36  DETERMINATION BY REGISTERED OR CERTIFIED MAIL ADDRESSED TO THE PRINCIPAL
   37  OFFICE  OF  THE ESTABLISHED OPERATOR AT THE COMMENCEMENT OF THE FIRST OF
   38  EVERY TWO ADDITIONAL TERMS. UPON RECEIPT OF  SUCH  NOTIFICATION  AT  THE
   39  PRINCIPAL  OFFICE  OF THE ESTABLISHED OPERATOR AND BEFORE THE EXPIRATION
   40  OF TEN DAYS THEREAFTER, THE ESTABLISHED OPERATOR MAY REQUEST AN ADMINIS-
   41  TRATIVE HEARING ON THE DETERMINATION TO BEGIN NO LATER THAN  SIXTY  DAYS
   42  FROM  THE  DATE OF THE REAPPOINTMENT OF THE TEMPORARY OPERATOR. ANY SUCH
   43  HEARING SHALL BE STRICTLY LIMITED TO THE ISSUE OF WHETHER  THE  DETERMI-
   44  NATION  OF  THE  COMMISSIONER  TO  REAPPOINT  THE  TEMPORARY OPERATOR IS
   45  SUPPORTED BY SUBSTANTIAL EVIDENCE.
   46    7. NO PROVISION CONTAINED IN THIS SECTION SHALL BE DEEMED  TO  RELIEVE
   47  THE  ESTABLISHED  OPERATOR  OR ANY OTHER PERSON OF ANY CIVIL OR CRIMINAL
   48  LIABILITY INCURRED, OR ANY DUTY IMPOSED BY LAW, BY  REASON  OF  ACTS  OR
   49  OMISSIONS  OF  THE ESTABLISHED OPERATOR OR ANY OTHER PERSON PRIOR TO THE
   50  APPOINTMENT OF ANY TEMPORARY  OPERATOR  HEREUNDER;  NOR  SHALL  ANYTHING
   51  CONTAINED IN THIS SECTION BE CONSTRUED TO SUSPEND DURING THE TERM OF THE
   52  APPOINTMENT  OF THE TEMPORARY OPERATOR ANY OBLIGATION OF THE ESTABLISHED
   53  OPERATOR OR ANY OTHER PERSON FOR THE PAYMENT OF TAXES OR OTHER OPERATING
   54  AND MAINTENANCE EXPENSES OF THE FACILITY NOR OF THE ESTABLISHED OPERATOR
   55  OR ANY OTHER PERSON FOR THE PAYMENT OF MORTGAGES OR LIENS.
       S. 2606--D                         160                        A. 3006--D

    1    S 51. The mental hygiene law is amended by adding a new section  32.20
    2  to read as follows:
    3  S 32.20 TEMPORARY OPERATOR.  1. FOR THE PURPOSES OF THIS SECTION:
    4    (A)  "CHEMICAL  DEPENDENCE  TREATMENT  PROGRAM"  SHALL  MEAN A PROGRAM
    5  CERTIFIED PURSUANT TO SECTION 32.05 OF THIS ARTICLE;
    6    (B) "ESTABLISHED OPERATOR" SHALL  MEAN  THE  OPERATOR  OF  A  CHEMICAL
    7  DEPENDENCE  TREATMENT  PROGRAM  THAT  HAS BEEN ESTABLISHED AND ISSUED AN
    8  OPERATING CERTIFICATE PURSUANT TO SECTION 32.05 OF THIS ARTICLE;
    9    (C) "TEMPORARY OPERATOR" SHALL MEAN ANY OASAS STAFF MEMBER, PERSON  OR
   10  ENTITY THAT:
   11    (I)  AGREES  TO  OPERATE  A  PROGRAM  ON A TEMPORARY BASIS IN THE BEST
   12  INTERESTS OF ITS PATIENTS AND THE COMMUNITY SERVED BY THE PROGRAM;
   13    (II) HAS DEMONSTRATED THAT HE OR SHE HAS THE CHARACTER, COMPETENCE AND
   14  ABILITY TO OPERATE AN OASAS-CERTIFIED PROGRAM IN COMPLIANCE WITH  APPLI-
   15  CABLE STANDARDS; AND
   16    (III)  PRIOR TO HIS OR HER APPOINTMENT AS TEMPORARY OPERATOR, DEVELOPS
   17  WITH GUIDANCE FROM THE COMMISSIONER A SATISFACTORY PLAN TO  ADDRESS  THE
   18  PROGRAM'S DEFICIENCIES;
   19    (D)  "SERIOUS  FINANCIAL INSTABILITY" SHALL INCLUDE BUT NOT BE LIMITED
   20  TO DEFAULTING OR VIOLATING KEY COVENANTS OF BOND ISSUES, MISSED MORTGAGE
   21  PAYMENTS, GENERAL UNTIMELY PAYMENT OF DEBTS, FAILURE TO PAY ITS  EMPLOY-
   22  EES  OR  VENDORS,  INSUFFICIENT  FUNDS  TO  MEET  THE  GENERAL OPERATING
   23  EXPENSES OF THE PROGRAM AND/OR FACILITY, FAILURE  TO  MAINTAIN  REQUIRED
   24  DEBT  SERVICE  COVERAGE  RATIOS AND/OR, AS APPLICABLE, FACTORS THAT HAVE
   25  TRIGGERED A WRITTEN EVENT OF DEFAULT NOTICE TO THE OFFICE BY THE  DORMI-
   26  TORY AUTHORITY OF THE STATE OF NEW YORK; AND
   27    (E)  "EXTRAORDINARY  FINANCIAL  ASSISTANCE"  SHALL  MEAN  STATE  FUNDS
   28  PROVIDED TO, OR REQUESTED BY, A  PROGRAM  FOR  THE  EXPRESS  PURPOSE  OF
   29  PREVENTING  THE  CLOSURE  OF  THE  PROGRAM  THAT  THE COMMISSIONER FINDS
   30  PROVIDES ESSENTIAL AND NECESSARY SERVICES WITHIN THE COMMUNITY.
   31    2. (A) IN THE EVENT THAT:  (I) THE PROGRAM  IS  SEEKING  EXTRAORDINARY
   32  FINANCIAL  ASSISTANCE;  (II)  OFFICE  COLLECTED  DATA INDICATES THAT THE
   33  PROGRAM IS EXPERIENCING  SERIOUS  FINANCIAL  INSTABILITY  ISSUES;  (III)
   34  OFFICE COLLECTED DATA INDICATES THAT THE PROGRAM'S BOARD OF DIRECTORS OR
   35  ADMINISTRATION ARE UNABLE OR UNWILLING TO ENSURE THE PROPER OPERATION OF
   36  THE  PROGRAM;  OR  (IV) OFFICE COLLECTED DATA INDICATES THERE ARE CONDI-
   37  TIONS THAT SERIOUSLY ENDANGER OR JEOPARDIZE CONTINUED ACCESS  TO  NECES-
   38  SARY  CHEMICAL  DEPENDENCE  TREATMENT SERVICES WITHIN THE COMMUNITY, THE
   39  COMMISSIONER SHALL NOTIFY THE ESTABLISHED OPERATOR OF HIS OR HER  INTEN-
   40  TION  TO  APPOINT A TEMPORARY OPERATOR TO ASSUME SOLE RESPONSIBILITY FOR
   41  THE PROGRAM'S TREATMENT OPERATIONS OF THAT FACILITY FOR A LIMITED PERIOD
   42  OF TIME. THE APPOINTMENT OF A TEMPORARY OPERATOR  SHALL  BE  EFFECTUATED
   43  PURSUANT TO THIS SECTION, AND SHALL BE IN ADDITION TO ANY OTHER REMEDIES
   44  PROVIDED BY LAW.
   45    (B)  THE ESTABLISHED OPERATOR OF A PROGRAM MAY AT ANY TIME REQUEST THE
   46  COMMISSIONER TO APPOINT A TEMPORARY  OPERATOR.  UPON  RECEIVING  SUCH  A
   47  REQUEST,  THE  COMMISSIONER  MAY,  IF  HE OR SHE DETERMINES THAT SUCH AN
   48  ACTION IS NECESSARY, ENTER INTO AN AGREEMENT WITH THE ESTABLISHED OPERA-
   49  TOR FOR THE APPOINTMENT OF A TEMPORARY OPERATOR TO RESTORE  OR  MAINTAIN
   50  THE  PROVISION  OF  QUALITY  CARE  TO THE PATIENTS UNTIL THE ESTABLISHED
   51  OPERATOR CAN RESUME OPERATIONS WITHIN THE DESIGNATED  TIME  PERIOD;  THE
   52  PATIENTS  MAY  BE TRANSFERRED TO OTHER OASAS-CERTIFIED PROVIDERS; OR THE
   53  PROGRAM OPERATIONS OF THAT FACILITY SHOULD BE COMPLETELY DISCONTINUED.
   54    3. (A) A TEMPORARY OPERATOR APPOINTED PURSUANT TO THIS  SECTION  SHALL
   55  USE  HIS  OR  HER  BEST EFFORTS TO IMPLEMENT THE PLAN DEVELOPED WITH THE
   56  GUIDANCE OF THE COMMISSIONER TO CORRECT OR ELIMINATE ANY DEFICIENCIES IN
       S. 2606--D                         161                        A. 3006--D

    1  THE PROGRAM AND TO PROMOTE THE QUALITY  AND  ACCESSIBILITY  OF  CHEMICAL
    2  DEPENDENCE TREATMENT SERVICES IN THE COMMUNITY SERVED BY THE PROGRAM.
    3    (B)  IF THE IDENTIFIED PROGRAM DEFICIENCIES CANNOT BE ADDRESSED IN THE
    4  TIME PERIOD DESIGNATED IN THE PLAN, THE PATIENTS SHALL BE TRANSFERRED TO
    5  OTHER OASAS-CERTIFIED PROVIDERS.
    6    (C) DURING THE TERM OF HIS OR HER APPOINTMENT, THE TEMPORARY  OPERATOR
    7  SHALL  HAVE THE AUTHORITY TO DIRECT THE PROGRAM STAFF OF THE FACILITY IN
    8  ALL  ASPECTS  NECESSARY  TO  APPROPRIATELY  TREAT  AND/OR  TRANSFER  THE
    9  PATIENTS.  THE TEMPORARY OPERATOR SHALL, DURING THIS PERIOD, OPERATE THE
   10  PROGRAM IN SUCH A MANNER AS TO PROMOTE SAFETY AND THE QUALITY AND ACCES-
   11  SIBILITY OF CHEMICAL DEPENDENCE  TREATMENT  SERVICES  IN  THE  COMMUNITY
   12  SERVED  BY THE FACILITY UNTIL EITHER THE ESTABLISHED OPERATOR CAN RESUME
   13  PROGRAM OPERATIONS OR UNTIL THE PATIENTS ARE  APPROPRIATELY  TRANSFERRED
   14  TO OTHER OASAS-CERTIFIED PROVIDERS.
   15    (D)  THE  TEMPORARY  OPERATOR  SHALL  ALSO  BE  AFFORDED  ACCESS  TO A
   16  PROGRAM'S ACCOUNTS AND RECORDS IN  ORDER  TO  ADDRESS  ANY  DEFICIENCIES
   17  RELATED  TO  A  PROGRAM  EXPERIENCING SERIOUS FINANCIAL INSTABILITY OR A
   18  PROGRAM REQUESTING FINANCIAL ASSISTANCE IN ACCORDANCE WITH THIS SECTION.
   19  THE TEMPORARY OPERATOR SHALL APPROVE ANY FINANCIAL DECISION RELATED TO A
   20  PROGRAM'S DAY TO DAY OPERATIONS OR PROGRAM'S ABILITY TO PROVIDE CHEMICAL
   21  DEPENDENCE SERVICES.
   22    (E) THE TEMPORARY OPERATOR SHALL NOT BE REQUIRED TO FILE ANY BOND.  NO
   23  SECURITY INTEREST IN ANY REAL OR PERSONAL PROPERTY COMPRISING THE FACIL-
   24  ITY  OR CONTAINED WITHIN THE FACILITY OR IN ANY FIXTURE OF THE FACILITY,
   25  SHALL BE IMPAIRED OR DIMINISHED IN PRIORITY BY THE  TEMPORARY  OPERATOR.
   26  NEITHER THE TEMPORARY OPERATOR NOR THE OFFICE SHALL ENGAGE IN ANY ACTIV-
   27  ITY THAT CONSTITUTES A CONFISCATION OF PROPERTY.
   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. THE TEMPORARY OPERATOR
   31  SHALL BE LIABLE ONLY IN HIS OR HER CAPACITY AS TEMPORARY OPERATOR OF THE
   32  PROGRAM FOR INJURY TO PERSON AND PROPERTY BY REASON OF HIS OR HER OPERA-
   33  TION OF SUCH PROGRAM; HE OR SHE SHALL NOT HAVE ANY LIABILITY IN  HIS  OR
   34  HER PERSONAL CAPACITY, EXCEPT FOR GROSS NEGLIGENCE AND INTENTIONAL ACTS.
   35    5.  (A)  THE INITIAL TERM OF THE APPOINTMENT OF THE TEMPORARY OPERATOR
   36  SHALL NOT EXCEED NINETY DAYS. AFTER NINETY  DAYS,  IF  THE  COMMISSIONER
   37  DETERMINES  THAT  TERMINATION  OF  THE  TEMPORARY  OPERATOR  WOULD CAUSE
   38  SIGNIFICANT DETERIORATION OF THE QUALITY OF, OR ACCESS TO,  HEALTH  CARE
   39  IN THE COMMUNITY OR THAT REAPPOINTMENT IS NECESSARY TO CORRECT THE DEFI-
   40  CIENCIES  THAT  REQUIRED  THE APPOINTMENT OF THE TEMPORARY OPERATOR, THE
   41  COMMISSIONER MAY AUTHORIZE AN ADDITIONAL NINETY-DAY TERM. HOWEVER,  SUCH
   42  AUTHORIZATION  SHALL INCLUDE THE COMMISSIONER'S REQUIREMENTS FOR CONCLU-
   43  SION OF THE TEMPORARY OPERATORSHIP TO BE SATISFIED WITHIN THE ADDITIONAL
   44  TERM.
   45    (B) WITHIN FOURTEEN DAYS PRIOR TO THE TERMINATION OF EACH TERM OF  THE
   46  APPOINTMENT  OF  THE  TEMPORARY  OPERATOR,  THE TEMPORARY OPERATOR SHALL
   47  SUBMIT TO THE COMMISSIONER AND TO  THE  ESTABLISHED  OPERATOR  A  REPORT
   48  DESCRIBING:
   49    (I)  THE  ACTIONS TAKEN DURING THE APPOINTMENT TO ADDRESS: THE IDENTI-
   50  FIED PROGRAM DEFICIENCIES; THE RESUMPTION OF PROGRAM OPERATIONS  BY  THE
   51  ESTABLISHED   OPERATOR;  OR  THE  TRANSFER  OF  THE  PATIENTS  TO  OTHER
   52  OASAS-CERTIFIED PROVIDERS;
   53    (II) OBJECTIVES FOR THE CONTINUATION OF THE TEMPORARY OPERATORSHIP  IF
   54  NECESSARY AND A SCHEDULE FOR SATISFACTION OF SUCH OBJECTIVES; AND
   55    (III) IF APPLICABLE, THE RECOMMENDED ACTIONS FOR THE ONGOING OPERATION
   56  OF THE PROGRAM SUBSEQUENT TO THE TEMPORARY OPERATORSHIP.
       S. 2606--D                         162                        A. 3006--D

    1    (C)  THE  TERM  OF THE INITIAL APPOINTMENT AND OF ANY SUBSEQUENT REAP-
    2  POINTMENT MAY BE TERMINATED PRIOR TO THE EXPIRATION  OF  THE  DESIGNATED
    3  TERM,  IF  THE ESTABLISHED OPERATOR AND THE COMMISSIONER AGREE ON A PLAN
    4  OF CORRECTION AND THE IMPLEMENTATION OF SUCH PLAN.
    5    6.  (A)  THE  COMMISSIONER  SHALL,  UPON  MAKING A DETERMINATION OF AN
    6  INTENTION TO APPOINT A TEMPORARY OPERATOR PURSUANT TO PARAGRAPH  (A)  OF
    7  SUBDIVISION  TWO  OF  THIS SECTION CAUSE THE ESTABLISHED OPERATOR OF THE
    8  FACILITY TO BE NOTIFIED OF THE INTENTION BY REGISTERED OR CERTIFIED MAIL
    9  ADDRESSED TO THE PRINCIPAL OFFICE  OF  THE  ESTABLISHED  OPERATOR.  SUCH
   10  NOTIFICATION SHALL INCLUDE A DETAILED DESCRIPTION OF THE FINDINGS UNDER-
   11  LYING  THE  INTENTION  TO APPOINT A TEMPORARY OPERATOR, AND THE DATE AND
   12  TIME OF A REQUIRED MEETING WITH  THE  COMMISSIONER  AND/OR  HIS  OR  HER
   13  DESIGNEE WITHIN TEN BUSINESS DAYS OF THE RECEIPT OF SUCH NOTICE. AT SUCH
   14  MEETING,  THE  ESTABLISHED OPERATOR SHALL HAVE THE OPPORTUNITY TO REVIEW
   15  AND DISCUSS ALL RELEVANT FINDINGS. AT SUCH MEETING, THE COMMISSIONER AND
   16  THE ESTABLISHED OPERATOR SHALL ATTEMPT TO DEVELOP A  MUTUALLY  SATISFAC-
   17  TORY  PLAN OF CORRECTION AND SCHEDULE FOR IMPLEMENTATION. IN SUCH EVENT,
   18  THE COMMISSIONER SHALL NOTIFY THE ESTABLISHED OPERATOR THAT THE  COMMIS-
   19  SIONER WILL ABSTAIN FROM APPOINTING A TEMPORARY OPERATOR CONTINGENT UPON
   20  THE  ESTABLISHED OPERATOR REMEDIATING THE IDENTIFIED DEFICIENCIES WITHIN
   21  THE AGREED UPON TIMEFRAME.
   22    (B) SHOULD THE COMMISSIONER AND THE ESTABLISHED OPERATOR BE UNABLE  TO
   23  ESTABLISH  A PLAN OF CORRECTION PURSUANT TO PARAGRAPH (A) OF THIS SUBDI-
   24  VISION, OR SHOULD THE  ESTABLISHED  OPERATOR  FAIL  TO  RESPOND  TO  THE
   25  COMMISSIONER'S  INITIAL  NOTIFICATION,  THERE SHALL BE AN ADMINISTRATIVE
   26  HEARING ON THE COMMISSIONER'S DETERMINATION TO APPOINT A TEMPORARY OPER-
   27  ATOR TO BEGIN NO LATER THAN THIRTY DAYS FROM THE DATE OF THE  NOTICE  TO
   28  THE  ESTABLISHED OPERATOR. ANY SUCH HEARING SHALL BE STRICTLY LIMITED TO
   29  THE ISSUE OF WHETHER THE DETERMINATION OF THE COMMISSIONER TO APPOINT  A
   30  TEMPORARY  OPERATOR  IS SUPPORTED BY SUBSTANTIAL EVIDENCE. A COPY OF THE
   31  DECISION SHALL BE SENT TO THE ESTABLISHED OPERATOR.
   32    (C) IF THE DECISION TO APPOINT A TEMPORARY  OPERATOR  IS  UPHELD  SUCH
   33  TEMPORARY  OPERATOR  SHALL  BE  APPOINTED  AS SOON AS IS PRACTICABLE AND
   34  SHALL OPERATE THE PROGRAM PURSUANT TO THE PROVISIONS OF THIS SECTION.
   35    7. NOTWITHSTANDING THE APPOINTMENT OF A TEMPORARY OPERATOR, THE ESTAB-
   36  LISHED OPERATOR REMAINS OBLIGATED FOR THE  CONTINUED  OPERATION  OF  THE
   37  FACILITY  SO  THAT  THE  PROGRAM  CAN  FUNCTION  IN  A NORMAL MANNER. NO
   38  PROVISION CONTAINED IN THIS SECTION  SHALL  BE  DEEMED  TO  RELIEVE  THE
   39  ESTABLISHED  OPERATOR  OR  ANY  OTHER  PERSON  OF  ANY CIVIL OR CRIMINAL
   40  LIABILITY INCURRED, OR ANY DUTY IMPOSED BY LAW, BY  REASON  OF  ACTS  OR
   41  OMISSIONS  OF  THE ESTABLISHED OPERATOR OR ANY OTHER PERSON PRIOR TO THE
   42  APPOINTMENT OF ANY TEMPORARY OPERATOR  OF  THE  PROGRAM  HEREUNDER;  NOR
   43  SHALL  ANYTHING CONTAINED IN THIS SECTION BE CONSTRUED TO SUSPEND DURING
   44  THE TERM OF THE APPOINTMENT OF THE TEMPORARY OPERATOR OF THE PROGRAM ANY
   45  OBLIGATION OF THE ESTABLISHED OPERATOR OR ANY OTHER PERSON FOR THE MAIN-
   46  TENANCE AND REPAIR OF  THE  FACILITY,  PROVISION  OF  UTILITY  SERVICES,
   47  PAYMENT  OF  TAXES  OR  OTHER  OPERATING AND MAINTENANCE EXPENSES OF THE
   48  FACILITY, NOR OF THE ESTABLISHED OPERATOR OR ANY OTHER  PERSON  FOR  THE
   49  PAYMENT OF MORTGAGES OR LIENS.
   50    S 52. Intentionally omitted.
   51    S 53. Intentionally omitted.
   52    S 54. Intentionally omitted.
   53    S 55. Intentionally omitted.
   54    S 56. Intentionally omitted.
   55    S 57. Intentionally omitted.
   56    S 58. Intentionally omitted.
       S. 2606--D                         163                        A. 3006--D

    1    S 59. Intentionally omitted.
    2    S 60. Intentionally omitted.
    3    S 61. Intentionally omitted.
    4    S 62. Intentionally omitted.
    5    S 63. Intentionally omitted.
    6    S 64. Intentionally omitted.
    7    S 65. Intentionally omitted.
    8    S 66. Intentionally omitted.
    9    S 67. Intentionally omitted.
   10    S 68. Intentionally omitted.
   11    S 69. Intentionally omitted.
   12    S 70. Intentionally omitted.
   13    S 71. Intentionally omitted.
   14    S 72. Intentionally omitted.
   15    S 73. Intentionally omitted.
   16    S 74. Intentionally omitted.
   17    S 75. Intentionally omitted.
   18    S 76. Intentionally omitted.
   19    S 77. Intentionally omitted.
   20    S 78. Intentionally omitted.
   21    S 79. Intentionally omitted.
   22    S 80. Intentionally omitted.
   23    S 81. Intentionally omitted.
   24    S 82. Intentionally omitted.
   25    S 83. Intentionally omitted.
   26    S 84. Intentionally omitted.
   27    S 85. Intentionally omitted.
   28    S 86. Intentionally omitted.
   29    S 87. Intentionally omitted.
   30    S 88. Intentionally omitted.
   31    S 89. Intentionally omitted.
   32    S 90. Intentionally omitted.
   33    S 91. Intentionally omitted.
   34    S 92. Intentionally omitted.
   35    S 93. Intentionally omitted.
   36    S 94. Intentionally omitted.
   37    S 95. Intentionally omitted.
   38    S 96. Intentionally omitted.
   39    S 97. The opening paragraph, and paragraphs (k) and (l) of subdivision
   40  1  of  section 3510 of the public health law, as added by chapter 175 of
   41  the laws of 2006, are amended and four new paragraphs (m), (n), (o)  and
   42  (p) are added to read as follows:
   43    The  license,  registration  or  intravenous  contrast  administration
   44  certificate of a [radiological] RADIOLOGIC technologist may be suspended
   45  for a fixed period, revoked or  annulled,  or  such  licensee  censured,
   46  reprimanded,  subject  to  a  civil  penalty  not to exceed two thousand
   47  dollars for every such violation, or otherwise disciplined,  in  accord-
   48  ance  with  the  provisions  and  procedures  defined  in  this article,
   49  PROVIDED THAT NO CIVIL PENALTY  SHALL  BE  ASSESSED  FOR  ANY  CRIME  OR
   50  MISCONDUCT THAT OCCURRED OUTSIDE THE JURISDICTION OF NEW YORK STATE upon
   51  decision  after due hearing that the individual is guilty of the follow-
   52  ing misconduct:
   53    (k) using the prefix "Dr.", the word "doctor" or any suffix  or  affix
   54  to  indicate  or imply that the licensee is a duly licensed practitioner
   55  as defined in this article when not so licensed; [or]
   56    (l) incompetence or negligence[.];
       S. 2606--D                         164                        A. 3006--D

    1    (M) BEING CONVICTED OF A CRIME WHICH HAS A DIRECT RELATIONSHIP TO  THE
    2  EMPLOYMENT OR LICENSURE AT ISSUE OR POSES AN UNREASONABLE RISK TO PUBLIC
    3  SAFETY PURSUANT TO ARTICLE TWENTY-THREE-A OF THE CORRECTION LAW AND IS A
    4  CONVICTION  UNDER (I) NEW YORK STATE LAW; (II) FEDERAL LAW; OR (III) THE
    5  LAW OF ANOTHER JURISDICTION WHICH, IF COMMITTED WITHIN THIS STATE, WOULD
    6  HAVE CONSTITUTED PROFESSIONAL MISCONDUCT UNDER NEW YORK STATE LAW;
    7    (N)  HAVING  BEEN  FOUND  GUILTY  OF IMPROPER PROFESSIONAL PRACTICE OR
    8  PROFESSIONAL MISCONDUCT BY A DULY AUTHORIZED  PROFESSIONAL  DISCIPLINARY
    9  AGENCY  OF  ANOTHER  STATE  WHERE THE CONDUCT UPON WHICH THE FINDING WAS
   10  BASED, IF COMMITTED IN NEW YORK  STATE,  WOULD  CONSTITUTE  PROFESSIONAL
   11  MISCONDUCT UNDER THE LAWS OF NEW YORK STATE;
   12    (O)  HAVING BEEN FOUND GUILTY IN AN ADJUDICATORY PROCEEDING OF VIOLAT-
   13  ING A STATE OR FEDERAL STATUTE OR REGULATION, PURSUANT TO A FINAL  DECI-
   14  SION  OR  DETERMINATION,  AND WHEN NO APPEAL IS PENDING, OR AFTER RESOL-
   15  UTION OF THE PROCEEDING  BY  STIPULATION  OR  AGREEMENT,  AND  WHEN  THE
   16  VIOLATION WOULD CONSTITUTE PROFESSIONAL MISCONDUCT UNDER THE LAWS OF NEW
   17  YORK STATE; OR
   18    (P) HAVING HIS OR HER LICENSE TO PRACTICE AS A RADIOLOGIC TECHNOLOGIST
   19  REVOKED,  SUSPENDED OR HAVING OTHER DISCIPLINARY ACTION TAKEN, OR HAVING
   20  HIS OR HER APPLICATION FOR A LICENSE REFUSED, REVOKED  OR  SUSPENDED  OR
   21  HAVING  VOLUNTARILY  OR OTHERWISE SURRENDERED HIS OR HER LICENSE AFTER A
   22  DISCIPLINARY ACTION WAS INSTITUTED BY  A  DULY  AUTHORIZED  PROFESSIONAL
   23  DISCIPLINARY AGENCY OF ANOTHER STATE, WHERE THE CONDUCT RESULTING IN THE
   24  REVOCATION,  SUSPENSION  OR  OTHER  DISCIPLINARY  ACTION  INVOLVING  THE
   25  LICENSE OR REFUSAL, REVOCATION OR SUSPENSION OF  AN  APPLICATION  FOR  A
   26  LICENSE  OR THE SURRENDER OF THE LICENSE WOULD, IF COMMITTED IN NEW YORK
   27  STATE, CONSTITUTE PROFESSIONAL MISCONDUCT UNDER THE  LAWS  OF  NEW  YORK
   28  STATE.  A RADIOLOGIC TECHNOLOGIST LICENSED IN NEW YORK STATE WHO IS ALSO
   29  LICENSED OR SEEKING LICENSURE IN ANOTHER STATE MUST  IMMEDIATELY  REPORT
   30  TO  THE  DEPARTMENT  ANY  REVOCATION,  SUSPENSION  OR OTHER DISCIPLINARY
   31  ACTION INVOLVING THE OUT-OF-STATE  LICENSE  OR  REFUSAL,  REVOCATION  OR
   32  SUSPENSION  OF AN APPLICATION FOR AN OUT-OF-STATE LICENSE OR THE SURREN-
   33  DER OF THE OUT-OF-STATE LICENSE.
   34    S 98. Intentionally omitted.
   35    S 99. Intentionally omitted.
   36    S 100. Intentionally omitted.
   37    S 101. Intentionally omitted.
   38    S 102. Intentionally omitted.
   39    S 103. Intentionally omitted.
   40    S 104. Intentionally omitted.
   41    S 105. Intentionally omitted.
   42    S 105-a. Intentionally omitted.
   43    S 106. Intentionally omitted.
   44    S 107. Intentionally omitted.
   45    S 108. 1. Notwithstanding any law, rule or regulation to the contrary,
   46  only physicians or dentists who were eligible, and for whom  the  super-
   47  intendent of financial services and the commissioner of health, or their
   48  designee, purchased, with funds available in the hospital excess liabil-
   49  ity  pool,  a  full  or partial policy for excess coverage or equivalent
   50  excess coverage for the coverage periods ending the thirtieth  of  June,
   51  two  thousand thirteen, shall be eligible to apply for such coverage for
   52  the coverage period beginning the first of July, two thousand  thirteen.
   53  For  the coverage period beginning the first of July, two thousand thir-
   54  teen, the superintendent of financial services and the  commissioner  of
   55  health,  or  their  designee, shall purchase up to one thousand policies
   56  for excess coverage or equivalent excess coverage  in  addition  to  the
       S. 2606--D                         165                        A. 3006--D

    1  number  of  policies  purchased for excess coverage or equivalent excess
    2  coverage for the coverage period ending the thirtieth of June, two thou-
    3  sand thirteen. A general hospital may certify additional eligible physi-
    4  cians  or  dentists in a number equal to such general hospital's propor-
    5  tional share of the total number of  physicians  or  dentists  for  whom
    6  excess  coverage  or equivalent excess coverage was purchased with funds
    7  available in the hospital excess liability pool as of the  thirtieth  of
    8  June,  two  thousand thirteen, as applied to the greater of one thousand
    9  or the difference between the number of eligible physicians or  dentists
   10  for  whom a policy for excess coverage or equivalent excess coverage was
   11  purchased for the coverage period ending  the  thirtieth  of  June,  two
   12  thousand thirteen and the number of such eligible physicians or dentists
   13  who  have  applied for excess coverage or equivalent excess coverage for
   14  the coverage period beginning the first of July, two  thousand  thirteen
   15  plus one thousand.
   16    2.  Notwithstanding any inconsistent provision of sections one hundred
   17  twelve and one hundred sixty-three of the state finance law, or sections
   18  one hundred forty-two and one hundred forty-three of the economic devel-
   19  opment law, or any other contrary provision of law,  the  superintendent
   20  of  financial services may enter into a contract or contracts under this
   21  subdivision for the purpose of retaining an  entity  to  administer  the
   22  hospital  excess liability pool without a competitive bid or request for
   23  proposal process, provided, however, that:
   24    (a) The department of financial services shall post  on  its  website,
   25  for a period of no less than thirty days:
   26    (i)  A description of the proposed services to be provided pursuant to
   27  the contract or contracts;
   28    (ii) The criteria for selection of a contractor or contractors;
   29    (iii) The period of time during which  a  prospective  contractor  may
   30  seek  selection,  which  shall  be  no  less than thirty days after such
   31  information is first posted on the website; and
   32    (iv) The manner by  which  a  prospective  contractor  may  seek  such
   33  selection, which may include submission by electronic means;
   34    (b)  All  reasonable and responsive submissions that are received from
   35  prospective contractors in timely  fashion  shall  be  reviewed  by  the
   36  superintendent of financial services; and
   37    (c)  The  superintendent  of  financial  services  shall  select  such
   38  contractor or contractors  that,  in  the  superintendent  of  financial
   39  services'  discretion,  are  best  suited  to serve the purposes of this
   40  subdivision.
   41    S 109. Section 5-a of part C of chapter 58 of the laws of 2005, relat-
   42  ing to authorizing reimbursements for expenditures made by or on  behalf
   43  of  social  services  districts for medical assistance for needy persons
   44  and the administration thereof, in  relation  to  the  use  of  Medicaid
   45  recovery  savings,  as  added by section 52-f of part H of chapter 59 of
   46  the laws of 2011, is amended to read as follows:
   47    S 5-a. Notwithstanding any provision  of  law  to  the  contrary,  the
   48  commissioner of health is authorized to approve social services district
   49  demonstration  programs  for  the  purpose of maximizing Medicaid recov-
   50  eries. The commissioner shall evaluate the results of any such programs,
   51  including any savings resulting therefrom.  [Ten] TWENTY percent of  any
   52  such savings, after certification by the director of the division of the
   53  budget,  shall be shared with the applicable social services district in
   54  a manner to be determined jointly by the commissioner of health and  the
   55  director of the division of the budget.
       S. 2606--D                         166                        A. 3006--D

    1    S  110.  Subdivisions  5, 23 and 24 of section 32 of the public health
    2  law, as added by chapter 442 of the laws of 2006, are amended and 2  new
    3  subdivisions 25 and 26 are added to read as follows:
    4    5.  to  keep the governor, attorney general, state comptroller, tempo-
    5  rary president and minority leader of the senate, the  speaker  and  the
    6  minority  leader of the assembly, and the heads of agencies with respon-
    7  sibility for  the  administration  of  the  medical  assistance  program
    8  apprised of efforts to prevent, detect, investigate, and prosecute fraud
    9  and  abuse within the medical assistance program, AND TO PROVIDE A QUAR-
   10  TERLY BRIEFING TO THE LEGISLATURE ON ACTIVITIES OF THE OFFICE;
   11    23. to annually submit a budget request, for the ensuing state  fiscal
   12  year,  to  the division of THE budget, provided that the office's budget
   13  request shall not be subject to review, alteration  or  modification  by
   14  the  commissioner  or any other entity or person prior to its submission
   15  to the division of THE budget; [and]
   16    24.   TO  MEET  QUARTERLY  WITH  REPRESENTATIVES  OF  SOCIAL  SERVICES
   17  DISTRICTS  TO  DISCUSS THE STATUS OF ONGOING COOPERATIVE EFFORTS BETWEEN
   18  THE OFFICE OF MEDICAID INSPECTOR GENERAL AND DISTRICTS, INCLUDING DEMON-
   19  STRATION PROGRAMS AUTHORIZED PURSUANT TO SECTION FIVE-A  OF  PART  C  OF
   20  CHAPTER  FIFTY-EIGHT OF THE LAWS OF TWO THOUSAND FIVE, THE POTENTIAL FOR
   21  ADDITIONAL COLLABORATION AND/OR FOR IMPROVED OR INNOVATIVE TECHNIQUES TO
   22  BE EMPLOYED, AND ANY ISSUES OF CONCERN TO SUCH DISTRICTS WITH RESPECT TO
   23  THE PREVENTION AND DETECTION OF FRAUD AND ABUSE IN THE  MEDICAL  ASSIST-
   24  ANCE PROGRAM;
   25    25.  TO  REQUEST SUBMISSION OF SOCIAL SERVICES DISTRICTS ANNUAL BUDGET
   26  AND AUDIT WORKPLANS FOR PURPOSES OF PLANNING FOR AND EXECUTING THE COUN-
   27  TY DEMONSTRATION PROGRAM AND FOR THE CREATION  OF  THE  OFFICE'S  ANNUAL
   28  WORKPLAN AND TO INCLUDE IN THE OFFICE'S ANNUAL WORKPLAN A DESCRIPTION OF
   29  ACTIVITIES  THAT WILL BE CONDUCTED IN COLLABORATION WITH SOCIAL SERVICES
   30  DISTRICTS;
   31    26. TO DEVELOP TRAINING MATERIALS WITH RESPECT TO THE  OFFICE'S  AUDIT
   32  STANDARDS AND CRITERIA FOR IDENTIFYING FRAUD OR WASTE, FOR USE BY SOCIAL
   33  SERVICES  DISTRICTS  WHO  ARE  ENGAGED  WITH THE OFFICE IN DEMONSTRATION
   34  PROGRAMS OR OTHER COLLABORATIVE EFFORTS; AND
   35    27. to perform any other functions that are necessary  or  appropriate
   36  to  fulfill  the duties and responsibilities of the office in accordance
   37  with federal and state law.
   38    S 111. Paragraphs (e) and (f) of subdivision 1 of section  35  of  the
   39  public  health  law,  as  added  by chapter 442 of the laws of 2006, are
   40  amended and a new paragraph (g) is added to read as follows:
   41    (e) the number, subject and other relevant  characteristics  of  civil
   42  actions  initiated  by  the  office  related  to  improper payments, the
   43  resulting civil settlements entered and overpayments identified and  the
   44  total dollar value both identified and collected; [and]
   45    (f) a narrative that evaluates the office's performance, describes any
   46  specific  problems  and  connection  with  the procedures and agreements
   47  required under this section, discusses any other matters that  may  have
   48  impaired  its  effectiveness  and  summarizes  the  total savings to the
   49  state's medical assistance program[.]; AND
   50    (G) A NARRATIVE, PROVIDED BY  THE  DEPARTMENT  IN  ITS  ANNUAL  REPORT
   51  PURSUANT  TO PARAGRAPH (T) OF SUBDIVISION ONE OF SECTION TWO HUNDRED SIX
   52  OF THIS CHAPTER THAT SUMMARIZES THE DEPARTMENT'S ACTIVITIES TO  MITIGATE
   53  FRAUD, WASTE AND ABUSE DURING THE PRECEDING CALENDAR YEAR.
   54    S  112.    Subdivision  1  of  section 206 of the public health law is
   55  amended by adding a new paragraph (t) to read as follows:
       S. 2606--D                         167                        A. 3006--D

    1    (T) THE DEPARTMENT SHALL SUBMIT AS PART OF ITS ANNUAL REPORT  PREPARED
    2  PURSUANT  TO  SECTION ONE HUNDRED SIXTY-FOUR OF THE EXECUTIVE LAW, WHICH
    3  MAY BE SUBMITTED IN ELECTRONIC FORMAT, COMPREHENSIVE INFORMATION INCLUD-
    4  ING, BUT NOT LIMITED TO, A  DETAILED  DESCRIPTION  OF  THE  DEPARTMENT'S
    5  MISSION, PRIORITIES AND GOALS FOR THE UPCOMING YEAR, ACHIEVEMENTS OF THE
    6  PAST YEAR, AND ANY RELEVANT DATA AND STATISTICS.
    7    S  113. Section 2500-a of the public health law is amended by adding a
    8  new subdivision (c) to read as follows:
    9    (C) BY REGULATION, THE  COMMISSIONER  SHALL  ADD  ADRENOLEUKODYSTROPHY
   10  ("ALD")  TO  THE LIST OF DISEASES AND CONDITIONS FOR WHICH TESTING SHALL
   11  BE PERFORMED PURSUANT TO SUBDIVISION (A) OF THIS SECTION UPON VALIDATION
   12  BY THE WADSWORTH CENTER OF A TEST FOR ALD. THE  WADSWORTH  CENTER  SHALL
   13  UNDERTAKE  THE  PROCESS  FOR  VALIDATION UPON THE DEVELOPMENT OF A TEST.
   14  THIS SUBDIVISION SHALL BE KNOWN AND MAY BE CITED AS "AIDAN'S LAW."
   15    S 114. Intentionally omitted.
   16    S 115. Intentionally omitted.
   17    S 116. Intentionally omitted.
   18    S 117. Intentionally omitted.
   19    S 118. Intentionally omitted.
   20    S 119. Notwithstanding any inconsistent  provision  of  law,  rule  or
   21  regulation,  for  purposes  of implementing the provisions of the public
   22  health law and the social services law, references to titles XIX and XXI
   23  of the federal social security act in the  public  health  law  and  the
   24  social  services  law  shall  be  deemed to include and also to mean any
   25  successor titles thereto under the federal social security act.
   26    S 120. Notwithstanding any inconsistent  provision  of  law,  rule  or
   27  regulation,  the  effectiveness  of  the provisions of sections 2807 and
   28  3614 of the public health law, section 18 of chapter 2 of  the  laws  of
   29  1988,  and 18 NYCRR 505.14(h), as they relate to time frames for notice,
   30  approval or certification of rates of payment, are hereby suspended  and
   31  without  force  or effect for purposes of implementing the provisions of
   32  this act.
   33    S 121. Severability. If any clause, sentence, paragraph,  subdivision,
   34  section  or part of this act shall be adjudged by any court of competent
   35  jurisdiction to be invalid, such judgment shall not  affect,  impair  or
   36  invalidate the remainder thereof, but shall be confined in its operation
   37  to the clause, sentence, paragraph, subdivision, section or part thereof
   38  directly  involved  in  the controversy in which the judgment shall have
   39  been rendered. It is hereby declared to be the intent of the legislature
   40  that this act would have been enacted even if  such  invalid  provisions
   41  had not been included herein.
   42    S  122.  This act shall take effect immediately and shall be deemed to
   43  have been in full force and effect on and after April 1, 2013; provided,
   44  however, that the provisions of this act shall apply only to actions and
   45  proceedings  commenced  on  or  after  such  effective  date;  provided,
   46  further, that:
   47    (a) sections thirty-two, thirty-three, thirty-four, thirty-five, thir-
   48  ty-six,  thirty-seven,  thirty-nine,  forty,  forty-one, and one hundred
   49  eight of this act shall take effect immediately;
   50    (b) sections fourteen, fifteen, sixteen,  seventeen,  eighteen,  nine-
   51  teen,  twenty,  twenty-one, twenty-two, twenty-three, twenty-four, twen-
   52  ty-six, twenty-seven, twenty-eight,  twenty-nine,  thirty,  one  hundred
   53  twelve,  and  one hundred thirteen of this act shall take effect January
   54  1, 2014;
   55    (c) section fifty of this act shall take effect immediately and  shall
   56  expire three years after it becomes law;
       S. 2606--D                         168                        A. 3006--D

    1    (d)  any rules or regulations necessary to implement the provisions of
    2  this act may be promulgated and any procedures, forms,  or  instructions
    3  necessary  for such implementation may be adopted and issued on or after
    4  the date this act shall have become a law;
    5    (e)  this  act shall not be construed to alter, change, affect, impair
    6  or defeat any rights, obligations, duties or interests accrued, incurred
    7  or conferred prior to the effective date of this act;
    8    (f) the commissioner of health and  the  superintendent  of  financial
    9  services  and  any  appropriate  council may take any steps necessary to
   10  implement this act prior to its effective date;
   11    (g) notwithstanding any inconsistent provision of the  state  adminis-
   12  trative procedure act or any other provision of law, rule or regulation,
   13  the  commissioner of health and the superintendent of financial services
   14  and any appropriate council is authorized to adopt or amend  or  promul-
   15  gate  on  an  emergency  basis  any regulation he or she or such council
   16  determines necessary to implement any  provision  of  this  act  on  its
   17  effective date; and
   18    (h)  the provisions of this act shall become effective notwithstanding
   19  the failure of the commissioner  of  health  or  the  superintendent  of
   20  financial  services or any council to adopt or amend or promulgate regu-
   21  lations implementing this act.

   22                                   PART F

   23    Section 1. Section 19.16 of the mental hygiene law, as added by  chap-
   24  ter 223 of the laws of 1992, is amended to read as follows:
   25  S 19.16 Methadone Registry.
   26    The  office  shall  establish and maintain, either directly or through
   27  contract, a central registry for purposes of preventing multiple enroll-
   28  ment,  ENSURING  ACCURATE  DOSAGE  DELIVERY  AND  FACILITATING  DISASTER
   29  MANAGEMENT in methadone programs. The office shall require all methadone
   30  programs  to  utilize  such  registry and shall have the power to assess
   31  methadone programs such fees as are necessary and appropriate.
   32    S 2. The office of  alcoholism  and  substance  abuse  services  shall
   33  ensure  that  accurate dosage delivery and facilitating disaster manage-
   34  ment shall not result in any  new  material  expenditures  by  methadone
   35  programs.
   36    S 3. This act shall take effect April 1, 2013.

   37                                   PART G

   38    Section 1. Article 26 of the mental hygiene law is REPEALED.
   39    S  2.  The article heading of article 25 of the mental hygiene law, as
   40  added by chapter 471 of the laws of 1980, is amended to read as follows:
   41                   [FUNDING FOR SUBSTANCE ABUSE SERVICES]
   42            FUNDING FOR SERVICES OF THE OFFICE OF ALCOHOLISM AND
   43                          SUBSTANCE ABUSE SERVICES
   44    S 3. Paragraphs 1, 2, 3 and 4 of subdivision (a) of section  25.01  of
   45  the  mental hygiene law, paragraph 1 as added by chapter 471 of the laws
   46  of 1980, and paragraphs 2, 3 and 4 as amended by chapter 223 of the laws
   47  of 1992, are amended, and four new paragraphs 5, 6, 7 and 8 are added to
   48  read as follows:
   49    1. ["Local agency" shall mean a county governmental unit for a  county
   50  not wholly within a city, and a city governmental unit for a city having
   51  a  population  of one million or more, designated by such county or city
   52  as responsible for substance abuse services in  such  county  or  city.]
       S. 2606--D                         169                        A. 3006--D

    1  "LOCAL  GOVERNMENTAL UNIT" SHALL HAVE THE SAME MEANING AS THAT CONTAINED
    2  IN ARTICLE FORTY-ONE OF THIS CHAPTER.
    3    2. "Operating  [costs]  EXPENSES"  shall mean expenditures[, excluding
    4  capital costs and debt service, subject to the approval of the  office,]
    5  APPROVED BY THE OFFICE AND incurred for the maintenance and operation of
    6  substance  [abuse]  USE  DISORDER  AND/OR  COMPULSIVE GAMBLING programs,
    7  including but not limited to expenditures for treatment, administration,
    8  personnel, AND contractual services[, rental, depreciation and  interest
    9  expenses incurred, in connection with the design, construction, acquisi-
   10  tion, reconstruction, rehabilitation or improvement of a substance abuse
   11  program facility, and payments made to the facilities development corpo-
   12  ration for substance abuse program facilities; provided that where the].
   13  OPERATING  EXPENSES DO NOT INCLUDE CAPITAL COSTS AND DEBT SERVICE UNLESS
   14  SUCH EXPENSES ARE RELATED TO THE rent, financing or refinancing  of  the
   15  design,  construction,  acquisition,  reconstruction,  rehabilitation or
   16  improvement of a substance [abuse] USE DISORDER AND/OR COMPULSIVE GAMBL-
   17  ING program facility [is through the facilities development corporation,
   18  operating costs shall include the debt service to be  paid  to  amortize
   19  obligations,  including  principal  and interest, issued by the New York
   20  State medical care facilities finance agency to finance or refinance the
   21  capital costs of such facilities] PURSUANT TO THE MENTAL HYGIENE FACILI-
   22  TIES FINANCE PROGRAM THROUGH THE DORMITORY AUTHORITY OF THE STATE OF NEW
   23  YORK (DASNY; SUCCESSOR TO THE FACILITIES  DEVELOPMENT  CORPORATION),  OR
   24  OTHERWISE APPROVED BY THE OFFICE.
   25    3. "Debt  service"  shall mean amounts, subject to the approval of the
   26  office, [as shall be]  required  to  be  paid  to  amortize  obligations
   27  including  principal  and interest [issued by the New York state housing
   28  finance agency, the New York State medical care facilities finance agen-
   29  cy or], ASSUMED by or on behalf of a [substance abuse program] VOLUNTARY
   30  AGENCY or a PROGRAM OPERATED BY A local [agency to finance capital costs
   31  for substance abuse program facilities] GOVERNMENTAL UNIT.
   32    4. "Capital costs" shall mean [expenditures, subject to  the  approval
   33  of the office, as shall be obligated to acquire, construct, reconstruct,
   34  rehabilitate  or  improve a substance abuse program facility.] THE COSTS
   35  OF A PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR A VOLUNTARY AGENCY
   36  WITH RESPECT TO THE ACQUISITION OF REAL PROPERTY ESTATES, INTERESTS, AND
   37  COOPERATIVE INTERESTS IN  REALTY,  THEIR  DESIGN,  CONSTRUCTION,  RECON-
   38  STRUCTION,  REHABILITATION  AND  IMPROVEMENT,  ORIGINAL  FURNISHINGS AND
   39  EQUIPMENT, SITE DEVELOPMENT, AND APPURTENANCES OF A FACILITY.
   40    5. "STATE AID" SHALL MEAN FINANCIAL SUPPORT PROVIDED THROUGH APPROPRI-
   41  ATIONS OF THE OFFICE TO SUPPORT THE PROVISION OF SUBSTANCE USE  DISORDER
   42  TREATMENT, COMPULSIVE GAMBLING, PREVENTION OR OTHER AUTHORIZED SERVICES,
   43  WITH  THE EXCLUSION OF APPROPRIATIONS FOR THE PURPOSE OF MEDICAL ASSIST-
   44  ANCE.
   45    6. "VOLUNTARY AGENCY CONTRIBUTIONS"  SHALL  MEAN  REVENUE  SOURCES  OF
   46  VOLUNTARY AGENCIES EXCLUSIVE OF STATE AID AND LOCAL TAX LEVY.
   47    7.  "APPROVED  NET  OPERATING  COST" SHALL MEAN THE REMAINDER OF TOTAL
   48  OPERATING EXPENSES APPROVED BY THE OFFICE, LESS ALL SOURCES OF  REVENUE,
   49  INCLUDING VOLUNTARY AGENCY CONTRIBUTIONS AND LOCAL TAX LEVY.
   50    8.  "VOLUNTARY  AGENCY" SHALL MEAN A CORPORATION ORGANIZED OR EXISTING
   51  PURSUANT TO THE  NOT-FOR-PROFIT  CORPORATION  LAW  FOR  THE  PURPOSE  OF
   52  PROVIDING   SUBSTANCE  USE  DISORDER,  TREATMENT,  COMPULSIVE  GAMBLING,
   53  PREVENTION OR OTHER AUTHORIZED SERVICES.
   54    S 4. Subdivisions (a) and (b) of section 25.03 of the  mental  hygiene
   55  law,  subdivision  (a) as amended by chapter 558 of the laws of 1999 and
       S. 2606--D                         170                        A. 3006--D

    1  subdivision (b) as amended by chapter 223  of  the  laws  of  1992,  are
    2  amended and a new subdivision (d) is added to read as follows:
    3    (a)  In  accordance  with  the  provisions of this article, AND WITHIN
    4  APPROPRIATIONS  MADE  AVAILABLE,  the  office  may  provide   [financial
    5  support]  STATE AID to a [substance abuse program or a] PROGRAM OPERATED
    6  BY A local [agency] GOVERNMENTAL UNIT OR  VOLUNTARY  AGENCY  up  to  one
    7  hundred per centum of the APPROVED NET operating costs of such [program]
    8  PROGRAM  OPERATED  BY A LOCAL GOVERNMENTAL UNIT or VOLUNTARY agency, and
    9  [either fifty per centum of the capital cost or fifty per centum of  the
   10  debt  service,] STATE AID MAY ALSO BE GRANTED TO A PROGRAM OPERATED BY A
   11  LOCAL GOVERNMENTAL UNIT OR A VOLUNTARY AGENCY FOR CAPITAL COSTS  ASSOCI-
   12  ATED  WITH  THE  PROVISION  OF  SERVICES  AT A RATE OF UP TO ONE HUNDRED
   13  PERCENT OF APPROVED CAPITAL COSTS. SUCH STATE AID SHALL NOT  BE  GRANTED
   14  UNLESS  AND  UNTIL SUCH PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR
   15  VOLUNTARY AGENCY IS IN COMPLIANCE WITH ALL  REGULATIONS  PROMULGATED  BY
   16  THE COMMISSIONER REGARDING THE FINANCING OF CAPITAL PROJECTS. SUCH STATE
   17  AID  for approved [services] NET OPERATING COSTS SHALL BE MADE AVAILABLE
   18  by way of advance or reimbursement,  through  EITHER  contracts  entered
   19  into  between  the  office and such [program or] VOLUNTARY agency[, upon
   20  such terms and conditions as the office shall deem  appropriate,  except
   21  as  provided  in section 25.07 of this article, provided, however, that,
   22  upon issuance of an operating certificate  in  accordance  with  article
   23  thirty-two of this chapter, if required, the office shall provide finan-
   24  cial  support  for  approved  chemical dependence services in accordance
   25  with article twenty-six of this title.] OR BY DISTRIBUTION OF SUCH STATE
   26  AID TO LOCAL GOVERNMENTAL UNITS THROUGH  A  GRANT  PROCESS  PURSUANT  TO
   27  SECTION 25.11 OF THIS ARTICLE.
   28    (b)  Financial  support by the office shall be subject to the approval
   29  of the director of the budget AND WITHIN AVAILABLE APPROPRIATIONS.
   30    (D) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE THE STATE TO
   31  INCREASE SUCH STATE AID SHOULD  A  LOCAL  GOVERNMENTAL  UNIT  CHOOSE  TO
   32  REMOVE  ANY PORTION OF ITS LOCAL TAX LEVY SUPPORT OF VOLUNTARY AGENCIES,
   33  ALTHOUGH THE STATE MAY CHOOSE TO DO SO TO ADDRESS AN URGENT PUBLIC NEED,
   34  OR CONVERSELY, MAY CHOOSE TO  REDUCE  ITS  STATE  AID  UP  TO  THE  SAME
   35  PERCENTAGE AS THE REDUCTION IN LOCAL TAX LEVY.
   36    S  5.  Section  25.05 of the mental hygiene law, as amended by chapter
   37  223 of the laws of 1992, is amended to read as follows:
   38  S 25.05 Reimbursement from other sources.
   39    The office shall not provide a  [substance  abuse  program]  VOLUNTARY
   40  AGENCY  or a PROGRAM OPERATED BY A local [agency] GOVERNMENTAL UNIT with
   41  financial support for obligations incurred  by  or  on  behalf  of  such
   42  program  or  agency for substance [abuse] USE DISORDER AND/OR COMPULSIVE
   43  GAMBLING services for which reimbursement is or may be claimed under any
   44  provision of law other than this article.
   45    S 6. The section heading and subdivisions (a) and (c) of section 25.06
   46  of the mental hygiene law, as amended by chapter  223  of  the  laws  of
   47  1992, are amended to read as follows:
   48  Disclosures  by  closely allied entities of [substance abuse programs] A
   49            VOLUNTARY AGENCY.
   50    (a) A closely allied entity of a [substance abuse  program]  VOLUNTARY
   51  AGENCY  that  is funded or has applied for funding from the office shall
   52  provide the office with the following information:
   53    1. A schedule of the dates, nature and amounts of  all  fiscal  trans-
   54  actions  between  the  closely  allied  entity  and the [substance abuse
   55  program] VOLUNTARY AGENCY that is funded or has applied for funding from
   56  the office.
       S. 2606--D                         171                        A. 3006--D

    1    2. A copy of the closely allied entity's  certified  annual  financial
    2  statements.
    3    3.  With  respect  to  any  lease agreement between the closely allied
    4  entity, as lessor, and the [substance abuse  program]  VOLUNTARY  AGENCY
    5  that is funded or has applied for funding from the office, as lessee, of
    6  real or personal property:
    7    (i) A certified statement by an independent outside entity providing a
    8  fair  market  appraisal of the real property space to be rented, as well
    9  as of any rental of personal property.
   10    (ii) A statement of projected operating costs  of  the  allied  entity
   11  relative  to any such leased property for the budget period. The closely
   12  allied entity must furnish the office with a certified statement of  its
   13  actual operating costs relative to the leased property.
   14    4.  A  statement of the funds received by the closely allied entity in
   15  connection with its fund raising activities conducted on behalf  of  the
   16  substance  [abuse]  USE DISORDER AND/OR COMPULSIVE GAMBLING program that
   17  is funded or has applied for funding from the office which clearly iden-
   18  tifies how such funds were and will be distributed or  applied  to  such
   19  program.
   20    5.  Any  other data or information which the office may deem necessary
   21  for purposes of making a funding decision.
   22    (c) For purposes of this section,  a  "closely  allied  entity"  shall
   23  mean, but not be limited to, a corporation, partnership or unincorporat-
   24  ed  association  or  other  body that has been formed or is organized to
   25  provide financial assistance and aid for the  benefit  of  a  [substance
   26  abuse  program] VOLUNTARY AGENCY that is funded or has applied for fund-
   27  ing from the  office  AND  which  FINANCIAL  ASSISTANCE  AND  AID  shall
   28  include,  but  not  be  limited to, engaging in fund raising activities,
   29  administering funds, holding title to real property, having an  interest
   30  in personal property of any nature whatsoever, and engaging in any other
   31  activities  for  the  benefit  of any such program.  Moreover, an entity
   32  shall be deemed closely allied to a [substance abuse program]  VOLUNTARY
   33  AGENCY  that is funded or has applied for funding from the office to the
   34  extent that such entity and applicable fiscal transactions are  required
   35  to be disclosed within the annual financial statements of the [substance
   36  abuse  program] VOLUNTARY AGENCY that is funded or has applied for fund-
   37  ing from the office, under the category of related  party  transactions,
   38  as defined by and in accordance with generally accepted accounting prin-
   39  ciples  (GAAP)  and  generally  accepted  auditing  standards (GAAS), as
   40  promulgated by the American institute of  certified  public  accountants
   41  (AICPA).
   42    S  7. Section 25.07 of the mental hygiene law, as added by chapter 471
   43  of the laws of 1980, is amended to read as follows:
   44  S 25.07 Non-substitution.
   45    A [substance abuse program] VOLUNTARY AGENCY or a PROGRAM OPERATED  BY
   46  A local [agency] GOVERNMENTAL UNIT shall not substitute state monies for
   47  cash  contributions,  federal aid otherwise committed to or intended for
   48  use in such program or by such agency, revenues derived from the  opera-
   49  tion of such program or agency, or the other resources available for use
   50  in the operation of the program or agency.
   51    S  8.  Section  25.09 of the mental hygiene law, as amended by chapter
   52  223 of the laws of 1992, is amended to read as follows:
   53  S 25.09 Administrative costs.
   54    Subject to the approval of the director  of  the  budget,  the  office
   55  shall  establish a limit on the amount of financial support which may be
   56  advanced or reimbursed to a [substance abuse program]  VOLUNTARY  AGENCY
       S. 2606--D                         172                        A. 3006--D

    1  or  a  PROGRAM  OPERATED  BY  A local [agency] GOVERNMENTAL UNIT for the
    2  administration of a [substance abuse] program.
    3    S  9. Section 25.11 of the mental hygiene law, as added by chapter 471
    4  of the laws of 1980, subdivision (a) as amended by chapter  223  of  the
    5  laws of 1992, is amended to read as follows:
    6  S 25.11 [Comprehensive  plan]  DISTRIBUTION  OF  STATE  AID  TO  A LOCAL
    7            GOVERNMENTAL UNIT.
    8    [(a) A local agency intending  to  seek  financial  support  from  the
    9  office  shall no later than July first of each year submit to the office
   10  a comprehensive substance abuse services plan, which shall describe  the
   11  programs  and  activities planned for its ensuing fiscal year. Such plan
   12  shall indicate to the extent possible, the nature of the services to  be
   13  provided,  whether  such  services  are to be provided directly, through
   14  subcontract, or through the utilization of  existing  public  resources,
   15  the  area  or  areas  to  be served, and an estimate of the cost of such
   16  services, including amounts to be provided other than by  office  finan-
   17  cial  support, specifically identifying the amount of local governmental
   18  funds committed to substance abuse programs during  its  current  fiscal
   19  year,  and  a  commitment  that no less than such an amount will be used
   20  from such funds for the operation  of  such  programs  during  the  next
   21  fiscal  year.  Such  plan shall make provisions for all needed substance
   22  abuse services and for the  evaluation  of  the  effectiveness  of  such
   23  services.
   24    (b)  When  a comprehensive plan includes a local school district based
   25  substance abuse program such  plan  shall  include  the  details  of  an
   26  adequate  distribution of in-school and community-wide preventive educa-
   27  tion services, including, but not limited to, services to be provided by
   28  local drug abuse prevention councils, and shall  emphasize  the  use  of
   29  other  volunteer agency services as may be available. The description of
   30  the program and activities thereunder shall be  separately  stated,  and
   31  the  data  and  information required to be provided shall conform to the
   32  provisions of subdivision (a) of this section except that the period  to
   33  be  covered  may,  notwithstanding  the fiscal year of the local agency,
   34  conform to the school year.] NOTWITHSTANDING SECTION ONE HUNDRED  TWELVE
   35  OF  THE  STATE  FINANCE LAW, THE OFFICE IS AUTHORIZED TO GRANT STATE AID
   36  ANNUALLY TO LOCAL GOVERNMENTAL UNITS IN THE FOLLOWING MANNER:
   37    (A) LOCAL GOVERNMENTAL UNITS SHALL BE GRANTED STATE AID BY A STATE AID
   38  FUNDING AUTHORIZATION LETTER ISSUED BY THE OFFICE FOR APPROVED NET OPER-
   39  ATING COSTS FOR VOLUNTARY AGENCIES TO SUPPORT THE BASE AMOUNT  OF  STATE
   40  AID PROVIDED TO SUCH VOLUNTARY AGENCIES FOR THE PRIOR YEAR PROVIDED THAT
   41  THE  LOCAL  GOVERNMENTAL UNIT HAS APPROVED AND SUBMITTED BUDGETS FOR THE
   42  VOLUNTARY AGENCIES TO THE OFFICE. THE  VOLUNTARY  AGENCY  BUDGETS  SHALL
   43  IDENTIFY  THE  NATURE  OF  THE  SERVICES  TO  BE  PROVIDED WHICH MUST BE
   44  CONSISTENT WITH THE LOCAL SERVICES PLAN SUBMITTED BY THE  LOCAL  GOVERN-
   45  MENTAL  UNIT PURSUANT TO ARTICLE FORTY-ONE OF THIS CHAPTER, THE AREAS TO
   46  BE SERVED AND INCLUDE A DESCRIPTION OF  THE  VOLUNTARY  AGENCY  CONTRIB-
   47  UTIONS  AND  LOCAL GOVERNMENTAL UNIT FUNDING PROVIDED. THE LOCAL GOVERN-
   48  MENTAL UNIT SHALL ENTER  INTO  CONTRACTS  WITH  THE  VOLUNTARY  AGENCIES
   49  RECEIVING  SUCH STATE AID. SUCH CONTRACTS SHALL INCLUDE FUNDING REQUIRE-
   50  MENTS SET BY THE OFFICE INCLUDING BUT NOT LIMITED TO RESPONSIBILITIES OF
   51  VOLUNTARY AGENCIES RELATING TO  WORK  SCOPES,  PROGRAM  PERFORMANCE  AND
   52  OPERATIONS,  APPLICATION  OF  PROGRAM  INCOME,  PROHIBITED USE OF FUNDS,
   53  RECORDKEEPING AND AUDIT OBLIGATIONS. UPON  DESIGNATION  BY  THE  OFFICE,
   54  LOCAL  GOVERNMENTAL  UNITS  SHALL  NOTIFY  VOLUNTARY  AGENCIES AS TO THE
   55  SOURCE OF FUNDING RECEIVED BY SUCH VOLUNTARY AGENCIES.
       S. 2606--D                         173                        A. 3006--D

    1    (B) STATE AID MADE AVAILABLE TO A LOCAL GOVERNMENTAL UNIT FOR APPROVED
    2  NET OPERATING COSTS FOR A PROGRAM OPERATED BY A VOLUNTARY  AGENCY  OR  A
    3  LOCAL  GOVERNMENTAL UNIT MAY BE REDUCED WHERE A REVIEW OF SUCH VOLUNTARY
    4  AGENCY'S PRIOR YEAR'S BUDGET AND/OR PERFORMANCE INDICATES:
    5    (1)  THAT  THE PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR VOLUN-
    6  TARY AGENCY  HAS  FAILED  TO  MEET  MINIMUM  PERFORMANCE  STANDARDS  AND
    7  REQUIREMENTS  OF  THE  OFFICE INCLUDING, BUT NOT LIMITED TO, MAINTAINING
    8  SERVICE UTILIZATION RATES AND  PRODUCTIVITY  STANDARDS  AS  SET  BY  THE
    9  OFFICE PROVIDED HOWEVER, THAT UPON DETERMINATION THAT THE PROGRAM IS NOT
   10  MEETING  THE MINIMUM STANDARDS AND REQUIREMENTS, THE OFFICE SHALL NOTIFY
   11  SUCH PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR  VOLUNTARY  AGENCY
   12  OF THEIR DEFICIENCIES, AND IF APPROPRIATE, A CORRECTIVE ACTION PLAN THAT
   13  INCLUDES  SPECIFIC  ACTIONS  TO ADDRESS ANY DEFICIENCIES AND A TIMETABLE
   14  FOR IMPLEMENTATION SHALL BE DEVELOPED. STATE AID MAY  BE  REDUCED  IF  A
   15  CORRECTIVE  ACTION  PLAN  IS NOT APPROVED BY THE OFFICE OR IS NOT IMPLE-
   16  MENTED IN A TIMELY AND SATISFACTORY MANNER;
   17    (2) THAT THE VOLUNTARY AGENCY HAS HAD AN INCREASE IN VOLUNTARY  AGENCY
   18  CONTRIBUTIONS  THAT  REDUCES THE APPROVED NET OPERATING COSTS NECESSARY,
   19  EXCEPT WHERE THE OFFICE HAS APPROVED AN ALTERNATIVE USE OF  SUCH  VOLUN-
   20  TARY  AGENCY  CONTRIBUTIONS  OR  SUCH VOLUNTARY AGENCY CONTRIBUTIONS ARE
   21  NECESSARY TO ENSURE FINANCIAL VIABILITY.
   22    S 10. Section 25.13 of the mental hygiene law, as amended  by  chapter
   23  223 of the laws of 1992, is amended to read as follows:
   24  S 25.13 Office is authorized state agency.
   25    (a)  The  office  when designated by the governor is the agency of the
   26  state to administer and/or supervise the state plan or plans  concerning
   27  substance [abuse] USE DISORDER AND/OR COMPULSIVE GAMBLING services spec-
   28  ified  in  the  federal  drug abuse office and treatment act of nineteen
   29  hundred seventy-two and to cooperate with the  duly  designated  federal
   30  authorities charged with the administration thereof.
   31    (b) The office and all entities to which it provides financial support
   32  shall  do all that is required and shall render necessary cooperation to
   33  ensure optimum use of federal aid for  substance  [abuse]  USE  DISORDER
   34  AND/OR COMPULSIVE GAMBLING services.
   35    (c)  The  commissioner is authorized and empowered to take such steps,
   36  not inconsistent with law, as  may  be  necessary  for  the  purpose  of
   37  procuring  for  the people of this state all of the benefits and assist-
   38  ance, financial and otherwise, provided, or to be provided  for,  by  or
   39  pursuant to any act of congress relating to substance [abuse] USE DISOR-
   40  DER AND/OR COMPULSIVE GAMBLING services.
   41    S  11.  Section 25.15 of the mental hygiene law, as amended by chapter
   42  223 of the laws of 1992, is amended to read as follows:
   43  S 25.15 Optimizing federal aid.
   44    (a) A PROGRAM OPERATED  BY  A  local  [agency]  GOVERNMENTAL  UNIT  or
   45  [substance  abuse  program]  VOLUNTARY  AGENCY  shall, unless a specific
   46  written waiver of this requirement is made by the office, cause applica-
   47  tions to be completed on such forms and in such manner  as  directed  by
   48  the  office and submit the same to the office for the purpose of causing
   49  a determination to be made whether the cost  of  the  services  provided
   50  individuals  and  groups  qualify for federal aid which may be available
   51  for services provided pursuant to titles IV, XVI,  XIX  and  XX  of  the
   52  federal  social  security act, or any other federal law. A PROGRAM OPER-
   53  ATED BY A  local  [agency]  GOVERNMENTAL  UNIT  or  a  [substance  abuse
   54  program] VOLUNTARY AGENCY shall furnish to the office such other data as
   55  may be required and shall render such cooperation as may be necessary to
   56  maximize  such  potential  federal  aid.  All information concerning the
       S. 2606--D                         174                        A. 3006--D

    1  identity of individuals obtained and provided pursuant to this  subdivi-
    2  sion shall be kept confidential.
    3    (b)  To the extent that federal aid may be available for any substance
    4  [abuse] USE DISORDER AND/OR COMPULSIVE GAMBLING  services,  the  office,
    5  notwithstanding  any  other  inconsistent provision of law, and with the
    6  approval of the director of the budget, is  hereby  authorized  to  seek
    7  such federal aid on behalf of [substance abuse programs] VOLUNTARY AGEN-
    8  CIES  and  A  PROGRAM  OPERATED  BY A local [agencies] GOVERNMENTAL UNIT
    9  either directly or through the submission of  claims  to  another  state
   10  agency  authorized  to submit the same to an appropriate federal agency.
   11  The office is further authorized to certify for  payment  to  [substance
   12  abuse  programs]  VOLUNTARY  AGENCIES  and A PROGRAM OPERATED BY A local
   13  [agencies] GOVERNMENTAL UNIT any federal aid received by the state which
   14  is attributable to the activities financed by such  programs  and  agen-
   15  cies.
   16    S  12.  Section 25.17 of the mental hygiene law, as amended by chapter
   17  223 of the laws of 1992, is amended to read as follows:
   18  S 25.17 Fees for services.
   19    [Local agencies GOVERNMENTS and substance  abuse  treatment  programs]
   20  VOLUNTARY  AGENCIES  AND  PROGRAMS  OPERATED BY LOCAL GOVERNMENTAL UNITS
   21  funded in whole or in part by the office shall establish, subject to the
   22  approval of the office, fee schedules for substance [abuse] USE DISORDER
   23  AND/OR COMPULSIVE GAMBLING services, not  specifically  covered  by  the
   24  rates  established pursuant to article twenty-eight of the public health
   25  law or title two of article five of the social services law.  Such  fees
   26  shall  be  charged  for substance [abuse] USE DISORDER AND/OR COMPULSIVE
   27  GAMBLING services furnished to persons who are financially able  to  pay
   28  the  same,  provided,  that  such  services  shall not be refused to any
   29  person because of his inability to pay therefor.
   30    S 13. Subdivision (d) of section 41.18 of the mental hygiene  law,  as
   31  amended  by  chapter  558  of  the  laws  of 1999, is amended to read as
   32  follows:
   33    (d) The liability of the state in any state fiscal year for state  aid
   34  pursuant  to  this  section  shall exclude chemical dependence services,
   35  which are subject to article [twenty-six] TWENTY-FIVE of  this  chapter,
   36  and  shall  be limited to the amounts appropriated for such state aid by
   37  the legislature for such state fiscal year.
   38    S 14. This act shall take effect April  1,  2013;  provided,  however,
   39  that  effective  immediately,  any  rule or regulation necessary for the
   40  implementation of this act on  its  effective  date  is  authorized  and
   41  directed to be made and completed on or before such effective date.

   42                                   PART H

   43    Section  1. Subdivision (b) of section 7.17 of the mental hygiene law,
   44  as amended by section 1 of part O of chapter 56 of the laws of 2012,  is
   45  amended to read as follows:
   46    (b)  There  shall  be  in the office the hospitals named below for the
   47  care, treatment and rehabilitation of persons with  mental  illness  and
   48  for  research  and  teaching  in the science and skills required for the
   49  care, treatment and rehabilitation of such persons with mental illness.
   50    Greater Binghamton Health Center
   51    Bronx Psychiatric Center
   52    Buffalo Psychiatric Center
   53    Capital District Psychiatric Center
   54    Central New York Psychiatric Center
       S. 2606--D                         175                        A. 3006--D

    1    Creedmoor Psychiatric Center
    2    Elmira Psychiatric Center
    3    Kingsboro Psychiatric Center
    4    Kirby Forensic Psychiatric Center
    5    Manhattan Psychiatric Center
    6    Mid-Hudson Forensic Psychiatric Center
    7    Mohawk Valley Psychiatric Center
    8    Nathan S. Kline Institute for Psychiatric Research
    9    New York State Psychiatric Institute
   10    Pilgrim Psychiatric Center
   11    Richard H. Hutchings Psychiatric Center
   12    Rochester Psychiatric Center
   13    Rockland Psychiatric Center
   14    St. Lawrence Psychiatric Center
   15    South Beach Psychiatric Center
   16    New York City Children's Center
   17    Rockland Children's Psychiatric Center
   18    Sagamore Children's Psychiatric Center
   19    Western New York Children's Psychiatric Center
   20    The  New  York  State  Psychiatric  Institute  and The Nathan S. Kline
   21  Institute for Psychiatric Research are designated as institutes for  the
   22  conduct  of medical research and other scientific investigation directed
   23  towards furthering knowledge of the etiology, diagnosis,  treatment  and
   24  prevention  of  mental  illness.  [Whenever  the  term  Bronx Children's
   25  Psychiatric Center, Brooklyn Children's Psychiatric  Center  and  Queens
   26  Children's  Psychiatric Center is referred to or designated in any regu-
   27  lation, contract or document pertaining to the functions, powers,  obli-
   28  gations  and  duties  hereby transferred and assigned, such reference or
   29  designation shall be deemed to refer to the  New  York  City  Children's
   30  Center.]
   31    S  2.  Section 4 of part O of chapter 56 of the laws of 2012, amending
   32  the mental hygiene law relating to the closure and the reduction in size
   33  of certain facilities serving persons with mental  illness,  is  amended
   34  and a new section 1-a is added to read as follows:
   35    S 1-A. WHENEVER THE TERM BRONX CHILDREN'S PSYCHIATRIC CENTER, BROOKLYN
   36  CHILDREN'S PSYCHIATRIC CENTER OR QUEENS CHILDREN'S PSYCHIATRIC CENTER IS
   37  REFERRED  TO  OR  DESIGNATED  IN  ANY  REGULATION,  CONTRACT OR DOCUMENT
   38  PERTAINING TO THE  FUNCTIONS,  POWERS,  OBLIGATIONS  AND  DUTIES  HEREBY
   39  TRANSFERRED  AND ASSIGNED PURSUANT TO THIS ACT, SUCH REFERENCE OR DESIG-
   40  NATION SHALL BE DEEMED TO REFER TO THE NEW YORK CITY CHILDREN'S CENTER.
   41    S 4. This act shall take effect immediately and  shall  be  deemed  to
   42  have  been in full force and effect on and after April 1, 2012; provided
   43  that the date for any closure or  consolidation  pursuant  to  this  act
   44  shall  be  on a date certified by the commissioner of mental health; and
   45  provided further, however, that SECTION TWO OF this act shall expire and
   46  be deemed repealed March 31, 2013.
   47    S 3. Section 7 of part R2 of chapter 62 of the laws of 2003,  amending
   48  the  mental hygiene law and the state finance law relating to the commu-
   49  nity mental health  support  and  workforce  reinvestment  program,  the
   50  membership  of  subcommittees  for  mental  health of community services
   51  boards and the duties of such subcommittees and creating  the  community
   52  mental  health and workforce reinvestment account, as amended by section
   53  2 of part C of chapter 111 of the laws of 2010, is amended  to  read  as
   54  follows:
       S. 2606--D                         176                        A. 3006--D

    1    S 7. This act shall take effect immediately and shall expire March 31,
    2  [2013]  2015  when  upon  such  date the provisions of this act shall be
    3  deemed repealed.
    4    S 4. Severability clause. If any clause, sentence, paragraph, subdivi-
    5  sion,  section  or  part  of  this act shall be adjudged by any court of
    6  competent jurisdiction to be invalid, such judgment  shall  not  affect,
    7  impair,  or  invalidate  the remainder thereof, but shall be confined in
    8  its operation to the clause, sentence, paragraph,  subdivision,  section
    9  or part thereof directly involved in the controversy in which such judg-
   10  ment shall have been rendered. It is hereby declared to be the intent of
   11  the  legislature  that  this  act  would  have been enacted even if such
   12  invalid provisions had not been included herein.
   13    S 5. This act shall take effect April 1, 2013; provided, however  that
   14  if  this act shall become a law after April 1, 2013, this act shall take
   15  effect immediately and shall be deemed to have been in  full  force  and
   16  effect on and after April 1, 2013.

   17                                   PART I

   18    Section  1.  Section  1  of  part D of chapter 111 of the laws of 2010
   19  relating to the recovery of exempt income by the office of mental health
   20  for community residences and family-based treatment programs as  amended
   21  by  section 1 of part R of chapter 56 of the laws of 2012, is amended to
   22  read as follows:
   23    Section 1. The office of mental health is authorized to recover  fund-
   24  ing  from  community  residences  and  family-based  treatment providers
   25  licensed by the office of mental  health,  consistent  with  contractual
   26  obligations  of such providers, and notwithstanding any other inconsist-
   27  ent provision of law to the contrary, in an amount equal to  50  percent
   28  of  the income received by such providers which exceeds the fixed amount
   29  of annual Medicaid revenue limitations, as established  by  the  commis-
   30  sioner of mental health. Recovery of such excess income shall be for the
   31  following  fiscal  periods:  for programs in counties located outside of
   32  the city of New York, the applicable fiscal periods shall be January  1,
   33  2003  through December 31, 2009 and January 1, 2011 through December 31,
   34  [2013] 2014; and for programs located within the city of New  York,  the
   35  applicable  fiscal  periods  shall be July 1, 2003 through June 30, 2010
   36  and July 1, 2011 through June 30, [2013] 2014.
   37    S 2. This act shall take effect immediately.

   38                                   PART J

   39    Section 1. Subdivision (a) of section 7.19 of the mental hygiene  law,
   40  as  amended  by  chapter  307 of the laws of 1979, is amended to read as
   41  follows:
   42    (a) The commissioner OR HIS OR HER DESIGNEE may,  within  the  amounts
   43  appropriated  therefor,  appoint  and  remove in accordance with law and
   44  applicable rules of the state civil service  commission,  such  officers
   45  and  employees of the office of mental health [and facility officers and
   46  employees who are designated  managerial  or  confidential  pursuant  to
   47  article  fourteen  of  the civil service law] as are necessary for effi-
   48  cient administration AND SHALL ADMINISTER THE OFFICE'S PERSONNEL  SYSTEM
   49  IN  ACCORDANCE  WITH  SUCH  LAW  AND RULES. IN EXERCISING THE APPOINTING
   50  AUTHORITY, THE COMMISSIONER SHALL  TAKE  ALL  REASONABLE  AND  NECESSARY
   51  STEPS,  CONSISTENT WITH ARTICLE TWENTY-THREE-A OF THE CORRECTION LAW, TO
   52  ENSURE THAT ANY SUCH PERSON SO APPOINTED HAS NOT PREVIOUSLY  ENGAGED  IN
       S. 2606--D                         177                        A. 3006--D

    1  ANY  ACT  IN  VIOLATION OF ANY LAW WHICH COULD COMPROMISE THE HEALTH AND
    2  SAFETY OF PATIENTS.
    3    S  2.  Subdivision  (a)  of section 7.21 of the mental hygiene law, as
    4  amended by chapter 434 of the laws  of  1980,  is  amended  to  read  as
    5  follows:
    6    (a) The director of a facility under the jurisdiction of the office of
    7  mental  health  shall be its chief executive officer. Each such director
    8  shall be in the noncompetitive class and designated as  confidential  as
    9  defined  by  subdivision two-a of section forty-two of the civil service
   10  law and shall be appointed by and serve at the pleasure of  the  commis-
   11  sioner.  [Except  for facility officers and employees for which subdivi-
   12  sion (a) of section 7.19 of this  article  makes  the  commissioner  the
   13  appointing and removing authority, the director of a facility shall have
   14  the  power,  within amounts appropriated therefor, to appoint and remove
   15  in accordance with law and applicable rules of the state  civil  service
   16  commission  such  officers  and employees of the facility of which he is
   17  director as are necessary for its efficient administration. He shall  in
   18  exercising this appointing authority take, consistent with article twen-
   19  ty-three-A  of the correction law, all reasonable and necessary steps to
   20  insure that any such person so appointed has not previously  engaged  in
   21  any  act  in  violation of any law which could compromise the health and
   22  safety of patients in the facility of which he is director.] He  OR  SHE
   23  shall  manage the facility [and administer its personnel system] subject
   24  to applicable law and the regulations  of  the  commissioner  of  mental
   25  health  [and  the  rules of the state civil service commission].  Before
   26  the commissioner shall issue any such regulation  or  any  amendment  or
   27  revision  thereof,  he  OR SHE shall consult with the FACILITY directors
   28  [of the office's hospitals]  regarding  its  suitability.  The  director
   29  shall  maintain  effective  supervision of all parts of the facility and
   30  over all persons employed therein or coming thereon and shall  generally
   31  direct  the  care and treatment of patients. Directors presently serving
   32  at office of mental health facilities shall continue to serve under  the
   33  terms of their original appointment.
   34    S  3.  The  amendments to sections 7.19 and 7.21 of the mental hygiene
   35  law pursuant to Part J of a chapter of the laws of two thousand thirteen
   36  shall not authorize the commissioner of mental health to make any  deci-
   37  sions  with  respect  to employees in contradiction of the civil service
   38  law and regulations, and applicable  collective  bargaining  agreements,
   39  nor otherwise alter any geographically discrete layoff unit structures.
   40    S 4. This act shall take effect April 1, 2013.

   41                                   PART K
   42                            Intentionally omitted

   43                                   PART L

   44    Section  1.  The mental hygiene law is amended by adding a new section
   45  31.37 to read as follows:
   46  S 31.37 MENTAL HEALTH INCIDENT REVIEW PANELS.
   47    (A) THE COMMISSIONER IS AUTHORIZED TO ESTABLISH, ON  HIS  OR  HER  OWN
   48  ACCORD  OR  PURSUANT TO A REQUEST BY A LOCAL GOVERNMENTAL UNIT, A MENTAL
   49  HEALTH INCIDENT REVIEW PANEL FOR THE PURPOSES OF REVIEWING  IN  CONJUNC-
   50  TION  WITH LOCAL REPRESENTATION, THE CIRCUMSTANCES AND EVENTS RELATED TO
   51  A SERIOUS INCIDENT INVOLVING A PERSON WITH MENTAL ILLNESS.  FOR PURPOSES
   52  OF THIS SECTION, A "SERIOUS INCIDENT  INVOLVING  A  PERSON  WITH  MENTAL
       S. 2606--D                         178                        A. 3006--D

    1  ILLNESS"  MEANS AN INCIDENT OCCURRING IN THE COMMUNITY IN WHICH A PERSON
    2  WITH A SERIOUS MENTAL ILLNESS SUFFERS  PHYSICAL  INJURY  AS  DEFINED  IN
    3  SUBDIVISION  NINE OF SECTION 10.00 OF THE PENAL LAW OR CAUSES SUCH PHYS-
    4  ICAL  INJURY  TO  ANOTHER  PERSON,  OR SUFFERS A SERIOUS AND PREVENTABLE
    5  MEDICAL COMPLICATION OR BECOMES INVOLVED IN A CRIMINAL INCIDENT  INVOLV-
    6  ING  VIOLENCE.  A  PANEL SHALL BE AUTHORIZED TO CONDUCT A REVIEW OF SUCH
    7  SERIOUS INCIDENT IN AN ATTEMPT TO IDENTIFY PROBLEMS OR  GAPS  IN  MENTAL
    8  HEALTH  DELIVERY  SYSTEMS  AND  TO  MAKE  RECOMMENDATIONS FOR CORRECTIVE
    9  ACTIONS TO IMPROVE THE PROVISION OF MENTAL HEALTH OR  RELATED  SERVICES,
   10  TO  IMPROVE  THE COORDINATION, INTEGRATION AND ACCOUNTABILITY OF CARE IN
   11  THE MENTAL HEALTH SERVICE SYSTEM, AND TO ENHANCE INDIVIDUAL  AND  PUBLIC
   12  SAFETY.
   13    (B)  A  MENTAL  HEALTH  INCIDENT  REVIEW PANEL SHALL INCLUDE REPRESEN-
   14  TATIVES FROM THE OFFICE OF MENTAL HEALTH AND THE CHIEF EXECUTIVE OFFICER
   15  OR DESIGNEE OF THE LOCAL GOVERNMENTAL UNIT WHERE  THE  SERIOUS  INCIDENT
   16  INVOLVING A PERSON WITH A MENTAL ILLNESS OCCURRED. A MENTAL HEALTH INCI-
   17  DENT REVIEW PANEL MAY ALSO INCLUDE, IF DEEMED APPROPRIATE BY THE COMMIS-
   18  SIONER  BASED  ON THE NATURE OF THE SERIOUS INCIDENT BEING REVIEWED, ONE
   19  OR MORE REPRESENTATIVES FROM MENTAL HEALTH PROVIDERS, LOCAL  DEPARTMENTS
   20  OF  SOCIAL  SERVICES, HUMAN SERVICES PROGRAMS, HOSPITALS, LOCAL SCHOOLS,
   21  EMERGENCY MEDICAL OR MENTAL HEALTH SERVICES, THE OFFICE  OF  THE  COUNTY
   22  ATTORNEY,  STATE  OR  LOCAL  POLICE  AGENCIES, THE OFFICE OF THE MEDICAL
   23  EXAMINER OR THE OFFICE OF THE CORONER, THE JUDICIARY, OR OTHER APPROPRI-
   24  ATE STATE OR LOCAL  OFFICIALS;  PROVIDED,  HOWEVER,  THAT  A  LOCAL  LAW
   25  ENFORCEMENT OFFICIAL MAY NOT SERVE AS A MEMBER OF SUCH A REVIEW PANEL IF
   26  HIS OR HER OFFICE OR AGENCY IS DIRECTLY INVOLVED IN ANY ONGOING INVESTI-
   27  GATION  OR  PROSECUTION  OF  A  CRIME  UNDER REVIEW BY THE PANEL, OR ANY
   28  APPEAL OF A CRIMINAL CONVICTION FOR SUCH CRIME.
   29    (C) (I) NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE CONTRARY AND
   30  TO THE EXTENT CONSISTENT WITH FEDERAL  LAW,  A  MENTAL  HEALTH  INCIDENT
   31  REVIEW  PANEL  SHALL  HAVE  ACCESS TO THOSE RELEVANT CLIENT-IDENTIFIABLE
   32  MENTAL HEALTH RECORDS, AS WELL AS ALL RECORDS, DOCUMENTATION AND REPORTS
   33  RELATING TO THE INVESTIGATION OF AN  INCIDENT  BY  THE  JUSTICE  CENTER,
   34  PURSUANT  TO  ARTICLE  TWENTY  OF THE EXECUTIVE LAW AND AN INCIDENT BY A
   35  FACILITY IN ACCORDANCE WITH REGULATIONS OF THE COMMISSIONER,  WHICH  ARE
   36  NECESSARY  FOR  THE  INVESTIGATION  OF  THE SERIOUS INCIDENT INVOLVING A
   37  PERSON WITH MENTAL ILLNESS AND THE PREPARATION OF A REPORT OF SUCH INCI-
   38  DENT, AS PROVIDED  IN SUBDIVISION (E) OF THIS SECTION. A  MENTAL  HEALTH
   39  INCIDENT  REVIEW  PANEL  INVESTIGATING  A  SERIOUS  INCIDENT INVOLVING A
   40  PERSON WITH A MENTAL ILLNESS PURSUANT TO THIS SECTION SHALL BE  PROVIDED
   41  WITH ACCESS TO ALL RELEVANT, NON-PRIVILEGED RECORDS IN THE POSSESSION OF
   42  STATE  OR LOCAL OFFICIALS OR AGENCIES, WITHIN TWENTY-ONE DAYS OF RECEIPT
   43  OF A REQUEST, EXCEPT: (A) THOSE RECORDS PROTECTED BY SECTION  190.25  OF
   44  THE  CRIMINAL PROCEDURE LAW; (B) WHERE PROVIDING LAW ENFORCEMENT RECORDS
   45  WOULD INTERFERE WITH AN ONGOING LAW ENFORCEMENT INVESTIGATION  OR  JUDI-
   46  CIAL PROCEEDING, IDENTIFY A CONFIDENTIAL SOURCE OR DISCLOSE CONFIDENTIAL
   47  INFORMATION RELATING TO AN ONGOING CRIMINAL INVESTIGATION, HIGHLY SENSI-
   48  TIVE  CRIMINAL  INVESTIGATIVE  TECHNIQUES OR PROCEDURES, OR ENDANGER THE
   49  SAFETY OR WELFARE OF AN INDIVIDUAL; (C) WITH RESPECT TO ANY SUCH  RECORD
   50  THAT IS PRIVILEGED, WHERE THE PRIVILEGE IS HELD BY THE OFFICIAL OR AGEN-
   51  CY  AND  NO SEPARATE PRIVILEGE HELD BY AN INDIVIDUAL APPLIES, SUCH OFFI-
   52  CIAL OR AGENCY SHALL BE AUTHORIZED TO WAIVE SUCH OFFICIAL'S OR  AGENCY'S
   53  PRIVILEGE,  AS  APPLICABLE, AND PROVIDE SUCH RECORD; AND (D) WHENEVER AN
   54  AGENCY, DIRECTOR OR UNIT BELIEVES PURSUANT TO SUBPARAGRAPH (B)  OF  THIS
   55  PARAGRAPH  THAT  RELEASE  OF  RECORDS  WOULD  INTERFERE  WITH A JUDICIAL
   56  PROCEEDING, IT SHALL IDENTIFY THAT PROCEEDING,  AND  THE  MENTAL  HEALTH
       S. 2606--D                         179                        A. 3006--D

    1  INCIDENT  REVIEW  PANEL SHALL BE AUTHORIZED, UPON NOTICE TO SUCH AGENCY,
    2  DIRECTOR OR UNIT, TO REQUEST IN WRITING TO THE JUDGE  BEFORE  WHOM  SUCH
    3  JUDICIAL PROCEEDING IS PENDING, THAT SUCH JUDGE DETERMINE WHETHER ACCESS
    4  TO  SUCH  RECORDS  SHOULD  BE  DENIED ON THE GROUND THAT RELEASE OF SUCH
    5  RECORDS WOULD INTERFERE WITH THE PENDING  PROCEEDING.  UPON  RECEIPT  OF
    6  SUCH  A  REQUEST, THE JUDGE SHALL OFFER THE AGENCY, DIRECTOR OR UNIT AND
    7  THE PANEL A REASONABLE OPPORTUNITY TO  BE  HEARD,  AND  MAY  REVIEW  THE
    8  DISPUTED  RECORDS IN CAMERA. THE JUDGE SHALL SUBMIT ITS DETERMINATION TO
    9  THE AGENCY, DIRECTOR OR UNIT  AND  THE  MENTAL  HEALTH  INCIDENT  REVIEW
   10  PANEL, AND THE AGENCY, DIRECTOR OR UNIT SHALL THEN PROCEED IN ACCORDANCE
   11  WITH THE JUDGE'S DETERMINATION.
   12    (II) IN ANY CASE IN WHICH ACCESS TO RECORDS IS DENIED PURSUANT TO THIS
   13  SUBDIVISION, THE APPROPRIATE AGENCY SHALL INFORM THE PANEL IN WRITING OF
   14  THE REASONING FOR SUCH DENIAL.
   15    (D)  MENTAL  HEALTH  INCIDENT  REVIEW PANELS AND MEMBERS OF THE REVIEW
   16  PANELS SHALL HAVE IMMUNITY FROM CIVIL AND  CRIMINAL  LIABILITY  FOR  ALL
   17  REASONABLE  AND  GOOD  FAITH ACTIONS TAKEN PURSUANT TO THIS SECTION, AND
   18  SHALL NOT BE QUESTIONED IN ANY CIVIL OR  CRIMINAL  PROCEEDING  REGARDING
   19  ANY  DISCUSSIONS,  DELIBERATIONS  OR  FINDINGS  RELATING TO THE OFFICIAL
   20  DUTIES OF SUCH REVIEW PANEL. NOTHING IN THIS SECTION SHALL BE  CONSTRUED
   21  TO PREVENT A PERSON FROM TESTIFYING AS TO INFORMATION OBTAINED INDEPEND-
   22  ENTLY  OF A MENTAL HEALTH INCIDENT REVIEW PANEL, OR INFORMATION WHICH IS
   23  PUBLIC.
   24    (D-1) PERSONS WHO PRESENT INFORMATION TO THE PANEL SHALL HAVE IMMUNITY
   25  FROM CIVIL AND CRIMINAL LIABILITY FOR  ALL  REASONABLE  AND  GOOD  FAITH
   26  ACTIONS  TAKEN  PURSUANT TO THIS SECTION, AND SHALL NOT BE QUESTIONED IN
   27  ANY CIVIL OR CRIMINAL  PROCEEDING  REGARDING  THEIR  AUTHORIZED  PARTIC-
   28  IPATION  AT  A  MEETING  OF  THE  PANEL. NEITHER INFORMATION NOR RECORDS
   29  RELATING TO THE PERFORMANCE OF A REVIEW PANEL FUNCTION, NOR  A  PERSON'S
   30  PARTICIPATION  IN A REVIEW PANEL SHALL BE SUBJECT TO DISCLOSURE PURSUANT
   31  TO ARTICLE THIRTY-ONE OF THE CIVIL PRACTICE LAW AND  RULES.  NOTHING  IN
   32  THIS  SECTION SHALL BE CONSTRUED TO PREVENT THE DISCLOSURE OF, OR TESTI-
   33  MONY REGARDING, INFORMATION THAT EXISTS OR IS OBTAINED INDEPENDENTLY  OF
   34  THE PANEL OR INFORMATION THAT IS PUBLIC.
   35    (E)  NOTWITHSTANDING  ANY  OTHER PROVISION OF LAW TO THE CONTRARY, ALL
   36  MEETINGS CONDUCTED, ALL REPORTS AND RECORDS MADE AND MAINTAINED AND  ALL
   37  BOOKS AND PAPERS OBTAINED BY A MENTAL HEALTH INCIDENT REVIEW PANEL SHALL
   38  BE  CONFIDENTIAL,  AND  SHALL  NOT  BE OPEN OR MADE AVAILABLE, EXCEPT BY
   39  COURT ORDER FOR GOOD CAUSE SHOWN OR AS SET FORTH IN SUBDIVISION  (G)  OF
   40  THIS  SECTION.  EACH MENTAL HEALTH INCIDENT REVIEW PANEL SHALL DEVELOP A
   41  REPORT OF THE INCIDENT INVESTIGATED. SUCH REPORT SHALL NOT  CONTAIN  ANY
   42  INDIVIDUALLY  IDENTIFIABLE  INFORMATION  AND  SHALL  BE  PROVIDED TO THE
   43  OFFICE OF MENTAL HEALTH UPON COMPLETION. RECORDS,  REPORTS,  INFORMATION
   44  REGARDING  TESTIMONY  AND  OTHER INFORMATION GATHERED BY THE PANEL SHALL
   45  NOT BE FURTHER DISSEMINATED BY A PANEL MEMBER.
   46    (F) IF QUALITY PROBLEMS OF PARTICULAR MENTAL HEALTH PROGRAMS ARE IDEN-
   47  TIFIED BASED ON SUCH REVIEWS, THE COMMISSIONER IS  AUTHORIZED,  PURSUANT
   48  TO  THE RELEVANT PROVISIONS OF THIS CHAPTER, TO TAKE APPROPRIATE ACTIONS
   49  REGARDING THE LICENSURE OF PARTICULAR PROVIDERS, TO REFER THE  ISSUE  TO
   50  OTHER  RESPONSIBLE PARTIES FOR INVESTIGATION, OR TO TAKE OTHER APPROPRI-
   51  ATE ACTION WITHIN THE SCOPE OF HIS OR HER AUTHORITY.
   52    (G) IN HIS OR HER DISCRETION, THE COMMISSIONER SHALL BE AUTHORIZED  TO
   53  PROVIDE  THE  FINAL  REPORT OF A REVIEW PANEL OR PORTIONS THEREOF TO ANY
   54  INDIVIDUAL OR ENTITY FOR  WHOM  THE  REPORT  MAKES  RECOMMENDATIONS  FOR
   55  CORRECTIVE  OR OTHER APPROPRIATE ACTIONS THAT SHOULD BE TAKEN. ANY FINAL
   56  REPORT OR PORTION THEREOF SHALL NOT BE FURTHER DISSEMINATED BY THE INDI-
       S. 2606--D                         180                        A. 3006--D

    1  VIDUAL OR ENTITY RECEIVING SUCH REPORT.  FURTHER, THE COMMISSIONER SHALL
    2  SUBMIT THE FINAL REPORT OF A REVIEW PANEL TO THE GOVERNOR, THE TEMPORARY
    3  PRESIDENT OF THE SENATE AND THE SPEAKER OF THE ASSEMBLY, CONSISTENT WITH
    4  FEDERAL AND STATE CONFIDENTIALITY PROTECTIONS.
    5    (H)  THE  COMMISSIONER SHALL SUBMIT AN ANNUAL CUMULATIVE REPORT TO THE
    6  GOVERNOR AND THE LEGISLATURE INCORPORATING THE DATA IN THE MENTAL HEALTH
    7  INCIDENT REVIEW PANEL REPORTS AND INCLUDING A SUMMARY  OF  THE  FINDINGS
    8  AND  RECOMMENDATIONS MADE BY SUCH REVIEW PANELS AND, TO THE EXTENT PRAC-
    9  TICABLE, ANY  RECOMMENDATIONS  THAT  HAVE  BEEN  IMPLEMENTED,  INCLUDING
   10  RECOMMENDATIONS  FROM  PRIOR YEAR REPORTS, AND THE IMPACT OF SUCH IMPLE-
   11  MENTATIONS.   THE ANNUAL CUMULATIVE REPORTS  SHALL  THEREAFTER  BE  MADE
   12  AVAILABLE TO THE PUBLIC CONSISTENT WITH FEDERAL AND STATE CONFIDENTIALI-
   13  TY PROTECTIONS.
   14    S  2.  Subdivision  (c)  of section 33.13 of the mental hygiene law is
   15  amended by adding a new paragraph 16 to read as follows:
   16    16. TO A MENTAL HEALTH INCIDENT  REVIEW  PANEL,  OR  MEMBERS  THEREOF,
   17  ESTABLISHED BY THE COMMISSIONER PURSUANT TO SECTION 31.37 OF THIS TITLE,
   18  IN CONNECTION WITH INCIDENT REVIEWS CONDUCTED BY SUCH PANEL.
   19    S  3.  This  act  shall take effect on the sixtieth day after it shall
   20  have become a law.

   21                                   PART M

   22    Section 1. Section 20 of chapter 723 of the laws of 1989, amending the
   23  mental hygiene law and other  laws  relating  to  the  establishment  of
   24  comprehensive psychiatric emergency programs, is REPEALED.
   25    S  2.  Subdivision  (c)  of  section 7.15 of the mental hygiene law is
   26  REPEALED.
   27    S 3.  Subdivision (c) of section 13.15 of the mental  hygiene  law  is
   28  REPEALED.
   29    S  4.  Paragraph  3  of subdivision (d) of section 16.19 of the mental
   30  hygiene law is REPEALED.
   31    S 5. Subparagraph e of paragraph 2 of subdivision (b) of section  5.07
   32  of  the mental hygiene law, as added by chapter 322 of the laws of 1992,
   33  is amended to read as follows:
   34    e. a description of the  available  community-based  acute  inpatient,
   35  out-patient,  [emergency,  and  community support] COMMUNITY SUPPORT AND
   36  EMERGENCY services, WHICH SHALL INCLUDE COMPREHENSIVE PSYCHIATRIC  EMER-
   37  GENCY  PROGRAMS LICENSED PURSUANT TO SECTION 31.27 OF THIS CHAPTER. Such
   38  description should include  the  extent  to  which  these  services  are
   39  currently  utilized  by  persons  with mental illness and, as available,
   40  compare estimates of utilization with estimates  of  the  prevalence  of
   41  mental  illness  among persons residing in the service area to determine
   42  unmet need;
   43    S 6. This act shall take effect April 1, 2013.

   44                                   PART N

   45    Section 1.  Subdivisions 3-b and 3-c of section 1  and  section  4  of
   46  part  C  of  chapter  57 of the laws of 2006, relating to establishing a
   47  cost of living adjustment for designated  human  services  programs,  as
   48  amended  by  section  1  of part H of chapter 56 of the laws of 2012, is
   49  amended to read as follows:
   50    3-b. Notwithstanding any  inconsistent  provision  of  law,  beginning
   51  April  1, 2009 and ending March 31, [2013] 2014, the commissioners shall
       S. 2606--D                         181                        A. 3006--D

    1  not include a COLA for the purpose of establishing  rates  of  payments,
    2  contracts or any other form of reimbursement.
    3    3-c.  Notwithstanding  any  inconsistent  provision  of law, beginning
    4  April 1, [2013] 2014 and ending March 31, [2016] 2017, the commissioners
    5  shall develop the COLA under this section using the actual U.S. consumer
    6  price index for all urban consumers  (CPI-U)  published  by  the  United
    7  States  department  of  labor, bureau of labor statistics for the twelve
    8  month period ending in July of the  budget  year  prior  to  such  state
    9  fiscal  year,  for  the  purpose  of  establishing  rates  of  payments,
   10  contracts or any other form of reimbursement.
   11    S 4. This act shall take effect immediately and  shall  be  deemed  to
   12  have  been in full force and effect on and after April 1, 2006; provided
   13  section one of this act shall expire and be  deemed  repealed  April  1,
   14  [2016]  2017; provided, further, that sections two and three of this act
   15  shall expire and be deemed repealed December 31, 2009.
   16    S 2. This act shall take effect immediately and  shall  be  deemed  to
   17  have been in full force and effect on and after April 1, 2013; provided,
   18  however, that the amendments to section 1 of part C of chapter 57 of the
   19  laws of 2006 made by section one of this act shall not affect the repeal
   20  of such section and shall be deemed repealed therewith.

   21                                   PART O

   22    Section  1.  Legislative  findings  and purpose. Recent actions by the
   23  United States Center for  Medicare  and  Medicaid  Services  impact  the
   24  stability  of  New  York  state's mental hygiene system. While the state
   25  must embark on a deliberate path to replace the existing,  long-standing
   26  financing  system  for developmental disability services, replacement of
   27  the sudden loss of $1.1 billion in federal revenue is too significant to
   28  be solved solely by actions within the mental hygiene system. A partner-
   29  ship with the entire health care community is needed to manage this loss
   30  over time. Accordingly, this part authorizes the actions  necessary  and
   31  creates  the Mental Hygiene Stabilization Fund that will be supported by
   32  department of health medicaid resources under the Global Cap  in  annual
   33  amounts  not  to  exceed  $730,000,000  in  state  fiscal  year 2013-14,
   34  $445,000,000 in 2014-15, $267,000,000 in 2015-16,  and  $267,000,000  in
   35  2016-17.
   36    S  2.  Notwithstanding any contrary provision of law, the commissioner
   37  of health may, in consultation with the director of  the  budget,  annul
   38  implementation of the reimbursement reductions authorized by section one
   39  of  part  A  of this act with regard to any period between April 1, 2013
   40  and March 31, 2015 if it is determined by the commissioner of health, in
   41  consultation with the director of the budget, that such annulment may be
   42  accomplished consistent with the implementation  of  the  provisions  of
   43  section 92 of part H of chapter 59 of the laws of 2011, as amended.
   44    S  3. Notwithstanding any contrary provision of law, implementation of
   45  the provisions of sections twenty-two, twenty-three, and/or  twenty-four
   46  of  part  A of this act shall be delayed to the state fiscal year begin-
   47  ning April 1, 2014, provided, however, that the commissioner  of  health
   48  may,  in  consultation with the director of the budget, implement one or
   49  more of such provisions during the 2013-14 state fiscal year  if  it  is
   50  determined  that such implementation may be accomplished consistent with
   51  the implementation of the provisions of section 92 of part H of  chapter
   52  59 of the laws of 2011, as amended.
   53    S  4. Notwithstanding any inconsistent provision of law, rule or regu-
   54  lation, for purposes of implementing the provisions of the public health
       S. 2606--D                         182                        A. 3006--D

    1  law and the social services law, references to titles XIX and XXI of the
    2  federal social security act in the public  health  law  and  the  social
    3  services  law  shall be deemed to include and also to mean any successor
    4  titles thereto under the federal social security act.
    5    S  5. Notwithstanding any inconsistent provision of law, rule or regu-
    6  lation, the effectiveness of the provisions of sections 2807 and 3614 of
    7  the public health law, section 18 of chapter 2 of the laws of  1988,  as
    8  amended,  and  18  NYCRR  505.14(h),  as  they relate to time frames for
    9  notice, approval or  certification  of  rates  of  payment,  are  hereby
   10  suspended  and  without force or effect for purposes of implementing the
   11  provisions of this act.
   12    S 6. Severability clause. If any clause, sentence, paragraph, subdivi-
   13  sion, section or part of this act shall be  adjudged  by  any  court  of
   14  competent  jurisdiction  to  be invalid, such judgment shall not affect,
   15  impair or invalidate the remainder thereof, but shall be confined in its
   16  operation to the clause, sentence, paragraph,  subdivision,  section  or
   17  part thereof directly involved in the controversy in which such judgment
   18  shall  have been rendered. It is hereby declared to be the intent of the
   19  legislature that this act would have been enacted even if  such  invalid
   20  provisions had not been included herein.
   21    S  7.  This  act  shall take effect immediately and shall be deemed to
   22  have been in full force and effect on and after April 1, 2013.

   23                                   PART P

   24    Section 1. Notwithstanding any  other  provision  of  law,  for  state
   25  fiscal  year  2013-14,  and for each state fiscal year thereafter, up to
   26  five million dollars shall be  available  annually  to  provide  medical
   27  assistance for individuals who reside in New York state and are retirees
   28  of  the  New  York  city  off-track  betting  corporation or were active
   29  employees of such corporation with vested pension time or credit  as  of
   30  December 7, 2010, and for the dependents of such individuals, in accord-
   31  ance with the provisions of this section. Such individuals who are Medi-
   32  care  beneficiaries under title XVIII of the federal social security act
   33  shall be eligible for assistance under title 11  of  article  5  of  the
   34  social services law with the cost of Medicare premiums and/or cost shar-
   35  ing obligations, as determined in accordance with guidelines established
   36  by  the  commissioner  of  health.  For the period from April 1, 2013 to
   37  December 31, 2013, such individuals who are not  Medicare  beneficiaries
   38  under  title  XVIII of the federal social security act shall be eligible
   39  for standard fee-for-service coverage under title 11 of article 5 of the
   40  social services law, as determined in accordance with guidelines  estab-
   41  lished  by  the  commissioner of health.   Prior to October 1, 2013, the
   42  state enrollment center  shall  provide  a  written  notice  of  program
   43  discontinuance  that  will  become effective as of December 31, 2013, to
   44  each individual eligible by a Medicaid fee-for-service plan  established
   45  pursuant  to  this section. The notice shall be in such form and contain
   46  such information as the commissioner of health may require. In  addition
   47  to  any  other  information  required  by such commissioner, the written
   48  notice shall include  a  conspicuous  explanation,  in  plain  language,
   49  informing such individual of available health insurance options, includ-
   50  ing coverage through the health benefit exchange established pursuant to
   51  section  1311  of  the federal affordable care act, (42 USC S 18031) and
   52  information on the process by which application therefore  may  be  made
   53  through the state enrollment center in order to effectuate health cover-
   54  age  under the health benefit exchange for such individuals beginning on
       S. 2606--D                         183                        A. 3006--D

    1  January 1, 2014. Such commissioner shall  direct  the  state  enrollment
    2  center  to facilitate the enrollment of such individuals into the health
    3  benefit exchange established in accordance with the requirements of  the
    4  federal  patient  protection  and affordable care act (P.L. 111-148), as
    5  amended by the federal health care and education act of 2010 (P.L.  111-
    6  152).  Upon  notice  to participating individuals, the size and scope of
    7  program benefits in a given fiscal year may be reduced  by  the  commis-
    8  sioner of health to remain within program funding levels.
    9    S 2. This act shall take effect immediately.

   10                                   PART Q

   11    Section  1.  Legislative  findings.  The  legislature hereby finds and
   12  declares that it is necessary  to  restructure  University  Hospital  of
   13  Brooklyn ("Downstate Hospital") in order to achieve its continued fiscal
   14  viability.
   15    S 2. On or before June 1, 2013, the chancellor of the state university
   16  of New York shall submit to the governor, the chair of the assembly ways
   17  and  means  committee,  the  chair  of the senate finance committee, the
   18  chair of the senate health committee, the chair of the  assembly  health
   19  committee,  the  chair  of the senate higher education committee and the
   20  chair of the assembly higher education committee, a sustainability  plan
   21  achieving the fiscal viability of Downstate Hospital.
   22    S  3. Such sustainability plan shall be subject to the approval of the
   23  commissioner of health and the director of the division  of  the  budget
   24  and  shall set forth recommendations for accomplishing the restructuring
   25  of Downstate Hospital for the  purpose  of  achieving  fiscal  viability
   26  while  preserving its status as a teaching hospital. Such sustainability
   27  plan shall include the elimination and/or reduction of acute, ambulatory
   28  and support services that are not necessary or  financially  sustainable
   29  and  any additional measures necessary to achieve such restructuring and
   30  achieve financial stability.
   31    S 4. In the development of the  sustainability  plan,  the  chancellor
   32  shall consult with labor representatives, community representatives, and
   33  other regional stakeholders. The chancellor shall, to the maximum extent
   34  practicable, allow for public comment and input from consumers of health
   35  care services in the development of the plan.
   36    S  5.  Notwithstanding  any  contrary  provision  of law, the approved
   37  sustainability plan for Downstate Hospital shall be deemed final and the
   38  chancellor shall initiate implementation of such sustainability plan  by
   39  June 15, 2013.
   40    S  6.  Notwithstanding  any inconsistent provision of sections 112 and
   41  163 of the state finance law, section  355  of  the  education  law,  or
   42  section  142  of  the  economic  development  law,  or any other law, in
   43  academic fiscal year 2013-14 the chancellor, for the purpose  of  imple-
   44  menting  a  sustainability plan for Downstate Hospital is hereby author-
   45  ized to enter into a contract or contracts under this section  without a
   46  competitive bid or request for proposal  process  and  provided  further
   47  that such contract or contracts shall not be subject to the requirements
   48  set  forth  in  subdivisions 2 and 3 of section 112 of the state finance
   49  law, provided, however, that:
   50    (a) (i) such contracts are  limited  to  the  purchase  of  goods  and
   51  supplies  where exigencies require an expedited process, and may also be
   52  authorized for restructuring consultant services, revenue collection and
   53  billing services, electronic and medical health records,  and  insurance
   54  eligibility  and  verification  services;  and  (ii)  due  to the unique
       S. 2606--D                         184                        A. 3006--D

    1  circumstances facing Downstate Hospital, such contracts may also include
    2  clinical services pursuant to the sustainability plan, provided,  howev-
    3  er, that such contracts shall not be of such scope or nature as to alter
    4  the  character  of Downstate Hospital as a public hospital, and shall be
    5  limited to fifteen percent of clinical services unless the  commissioner
    6  of  health determines that additional actions are necessary for the full
    7  implementation of the sustainability plan, in which case, up  to  twenty
    8  percent of such clinical services may be authorized; and
    9    (b)  Downstate  Hospital shall post on its website, for a period of no
   10  less than fifteen days:
   11    (i) a description of the proposed goods or  services  to  be  provided
   12  pursuant to the contract or contracts;
   13    (ii) the criteria for contractor selection;
   14    (iii)  the  period  of  time during which a prospective contractor may
   15  seek selection, which shall be no less  than  fifteen  days  after  such
   16  information is first posted on the website; and
   17    (iv)  the  manner  by  which  a  prospective  contractor may seek such
   18  selection, which may include submission by electronic means; and
   19    (c) all reasonable and responsive submissions that are  received  from
   20  prospective  contractors  in  a  timely fashion shall be reviewed by the
   21  chancellor or his or her designee.
   22    S 7.  Paragraph a of subdivision 16 of section 355  of  the  education
   23  law,  as added by chapter 363 of the laws of 1998, is amended to read as
   24  follows:
   25    a. Notwithstanding  section  one  hundred  sixty-three  of  the  state
   26  finance  law,  authorize  contracts  for  a state university health care
   27  facility for participation in managed care networks and other joint  and
   28  cooperative  arrangements  with  public, non-profit or business entities
   29  including entering into a maximum of  twenty  network  arrangements  per
   30  year,  as partners, JOINT VENTURES, SOLE MEMBER OR members of non-profit
   31  OR FOR-PROFIT corporations, SOLE MEMBER  OR  MEMBERS  OF  NON-PROFIT  OR
   32  FOR-PROFIT  LIMITED LIABILITY COMPANIES, AS LESSOR OR LESSEE, AS PARTIC-
   33  IPANTS IN JOINT  OPERATING  AGREEMENTS,  and  shareholders  of  business
   34  corporations,   and  the  provision  of  management  and  administrative
   35  services by or for state university; PROVIDED, HOWEVER,  THAT  ANY  SUCH
   36  CONTRACTS  WITH  FOR-PROFIT  ENTITIES  SHALL  BE  AUTHORIZED  ONLY  UPON
   37  APPROVAL BY THE COMMISSIONER OF HEALTH AND THE DIRECTOR OF THE  DIVISION
   38  OF  THE  BUDGET  OF  A REQUEST BY THE CHANCELLOR DEMONSTRATING FINANCIAL
   39  NEED OF A STATE UNIVERSITY HEALTH CARE FACILITY. Any  contract  for  the
   40  provision  of  management  services shall be subject to any provision of
   41  the public health law and health regulations  applicable  to  the  state
   42  university  as  a  health  care  provider,  including  any review by the
   43  commissioner of health pursuant to 10 NYCRR section 405.3(f).  In  addi-
   44  tion, the commissioner of health shall provide for public comment within
   45  thirty  days  of  a submission of any management contract required to be
   46  reviewed  pursuant  to  regulation.  The  trustees  may  also  authorize
   47  contracts, including capitation contracts, for a state university health
   48  care  facility  for the provision of general comprehensive and specialty
   49  health care services, directly or through contract  with  other  service
   50  providers  or entities, including state university employees or entities
   51  comprised thereof. Contracts authorized hereunder shall be:
   52    (1) consistent with trustee guidelines respecting all terms and condi-
   53  tions necessary and appropriate for  managed  care  and  other  network,
   54  joint  or cooperative arrangements, including guidelines for comparative
   55  review where appropriate;
       S. 2606--D                         185                        A. 3006--D

    1    (2) subject to laws and regulations applicable to the state university
    2  as a health care provider, including with respect to rates  and  certif-
    3  icates of need; and
    4    (3)  subject  to  article  fourteen  of  the civil service law and the
    5  applicable provisions of  agreements  between  the  state  and  employee
    6  organizations pursuant to article fourteen of the civil service law.
    7    S  8. Subdivision 8-a of section 355 of the education law, as added by
    8  chapter 363 of the laws of 1998, is amended to read as follows:
    9    8-a. All monies received by state university  health  care  facilities
   10  from  fees,  charges, and reimbursement and from all other sources shall
   11  be credited to a state university health care account in a  fund  to  be
   12  designated  by  the state comptroller.  NOTWITHSTANDING THE PROVISION OF
   13  ANY LAW, RULE OR REGULATION TO THE CONTRARY, A PORTION  OF  SUCH  MONIES
   14  CREDITED  MAY  BE TRANSFERRED TO A STATE UNIVERSITY ACCOUNT AS REQUESTED
   15  BY THE STATE UNIVERSITY CHANCELLOR OR HIS OR  HER  DESIGNEE.  Monies  to
   16  establish  reserves  for  long-term  expenses of state university health
   17  care facilities and to fulfill obligations required for any contract for
   18  health care services authorized pursuant to subdivision sixteen of  this
   19  section  may  be  designated  by  the  state university as a reserve and
   20  transferred to a separate contractual reserve account.  The  amounts  in
   21  such  accounts shall be available for use in accordance with paragraph b
   22  of subdivision four and subdivision eight of this section. Monies  shall
   23  only  be  expended from the state university health care account and the
   24  contractual reserve account pursuant to  appropriation.  Notwithstanding
   25  any provision of this chapter, the state finance law or any other law to
   26  the  contrary, such appropriations shall remain in full force and effect
   27  for two years from the effective date of the  appropriation  act  making
   28  the  appropriation.  Monies  so transferred may be returned to the state
   29  university health care account; provided, however, that  funds  in  such
   30  contractual  reserve  account must be sufficient to meet the obligations
   31  of all such contracts.
   32    S 9. Section 2807 of the public health law is amended by adding a  new
   33  subdivision 20 to read as follows:
   34    20.  NOTWITHSTANDING  ANY CONTRARY PROVISION OF LAW AND SUBJECT TO THE
   35  RECEIPT OF ALL NECESSARY  FEDERAL  APPROVALS  AND  THE  AVAILABILITY  OF
   36  FEDERAL FINANCIAL PARTICIPATION, THE COMMISSIONER IS AUTHORIZED TO ENTER
   37  INTO AGREEMENTS WITH SUNY DOWNSTATE MEDICAL CENTER, OTHER PUBLIC GENERAL
   38  HOSPITALS,  AND/OR  WITH  THE SPONSORING LOCAL GOVERNMENTS OF SUCH OTHER
   39  PUBLIC GENERAL HOSPITALS, UNDER WHICH SUCH FACILITIES AND/OR SUCH  LOCAL
   40  GOVERNMENT  SHALL,  BY  INTERGOVERNMENTAL TRANSFER, FUND THE NON-FEDERAL
   41  SHARE OF MEDICAID FUNDS MADE AVAILABLE FOR DELIVERY SYSTEM REFORM INCEN-
   42  TIVE PAYMENTS ("DSRIPS") TO  SUCH  FACILITIES.  SUCH  NON-FEDERAL  SHARE
   43  PAYMENTS  SHALL BE DEEMED VOLUNTARY AND, FURTHER, SUCH PAYMENTS SHALL BE
   44  EXCLUDED FROM COMPUTATIONS MADE PURSUANT TO SECTION ONE  OF  PART  C  OF
   45  CHAPTER  FIFTY-EIGHT  OF  THE LAWS OF TWO THOUSAND FIVE, AS AMENDED.  IN
   46  ADDITION, THE FACILITIES, AND/OR THE  SPONSORING  LOCAL  GOVERNMENTS  OF
   47  SUCH  FACILITIES  OR THE STATE MAY, BY WRITTEN NOTIFICATION TO THE OTHER
   48  PARTIES TO THE AGREEMENT, CANCEL SUCH AGREEMENT AT ANY TIME PRIOR TO THE
   49  PAYMENT OF THE DSRIP FUNDS.
   50    S 10. Section 2807 of the public health law is amended by adding a new
   51  subdivision 21 to read as follows:
   52    21. NOTWITHSTANDING ANY CONTRARY PROVISION OF LAW AND SUBJECT  TO  THE
   53  RECEIPT  OF  ALL  NECESSARY  FEDERAL  APPROVALS  AND THE AVAILABILITY OF
   54  FEDERAL FINANCIAL PARTICIPATION, THE COMMISSIONER IS AUTHORIZED TO ENTER
   55  INTO AGREEMENTS WITH SUNY DOWNSTATE MEDICAL CENTER, OTHER PUBLIC GENERAL
   56  HOSPITALS, AND/OR WITH THE SPONSORING LOCAL GOVERNMENTS  OF  SUCH  OTHER
       S. 2606--D                         186                        A. 3006--D

    1  PUBLIC  GENERAL HOSPITALS, UNDER WHICH SUCH FACILITIES AND/OR SUCH LOCAL
    2  GOVERNMENT SHALL, BY INTERGOVERNMENTAL TRANSFER,  FUND  THE  NON-FEDERAL
    3  SHARE  OF  MEDICAID  FUNDS MADE AVAILABLE FOR IMPLEMENTATION OF MEDICAID
    4  REDESIGN  TEAM  INITIATIVES.  SUCH  NON-FEDERAL  SHARE PAYMENTS SHALL BE
    5  DEEMED VOLUNTARY AND, FURTHER, SUCH  PAYMENTS  SHALL  BE  EXCLUDED  FROM
    6  COMPUTATIONS  MADE  PURSUANT  TO  SECTION  ONE  OF  PART  C  OF  CHAPTER
    7  FIFTY-EIGHT OF THE LAWS OF TWO THOUSAND FIVE, AS AMENDED.  IN  ADDITION,
    8  THE  FACILITIES, AND/OR THE SPONSORING LOCAL GOVERNMENTS OF SUCH FACILI-
    9  TIES OR THE STATE MAY, BY WRITTEN NOTIFICATION TO THE OTHER  PARTIES  TO
   10  THE AGREEMENT, CANCEL SUCH AGREEMENT AT ANY TIME PRIOR TO THE PAYMENT OF
   11  THE MEDICAID REDESIGN TEAM INITIATIVES FUNDS.
   12    S 11. This act shall take effect immediately.
   13    S 2. Severability clause. If any clause, sentence, paragraph, subdivi-
   14  sion,  section  or  part  of  this act shall be adjudged by any court of
   15  competent jurisdiction to be invalid, such judgment  shall  not  affect,
   16  impair,  or  invalidate  the remainder thereof, but shall be confined in
   17  its operation to the clause, sentence, paragraph,  subdivision,  section
   18  or part thereof directly involved in the controversy in which such judg-
   19  ment shall have been rendered. It is hereby declared to be the intent of
   20  the  legislature  that  this  act  would  have been enacted even if such
   21  invalid provisions had not been included herein.
   22    S 3. This act shall take effect immediately  provided,  however,  that
   23  the  applicable effective date of Parts A through Q of this act shall be
   24  as specifically set forth in the last section of such Parts.
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