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S09952 Summary:

BILL NOS09952
 
SAME ASNo Same As
 
SPONSORKRUEGER
 
COSPNSR
 
MLTSPNSR
 
Ren §2830 to be §2831, add §2832, Pub Health L
 
Relates to fair pricing for low-complexity, routine medical care to more closely align payment rates across ambulatory settings for selected services that are safe and appropriate to provide in all settings.
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S09952 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          9952
 
                    IN SENATE
 
                                    November 20, 2024
                                       ___________
 
        Introduced  by  Sen. KRUEGER -- read twice and ordered printed, and when
          printed to be committed to the Committee on Rules
 
        AN ACT to amend the public health law, in relation to fair  pricing  for
          low-complexity, routine medical care
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1. Section 2830 of the public health law, as added by  chapter
     2  764  of  the  laws  of 2022 is renumbered section 2831 and a new section
     3  2832 is added to read as follows:
     4    § 2832. Fair pricing for certain services. 1. As used in this section:
     5    (a) "Applicable services" means  outpatient  or  ambulatory  items  or
     6  services  that  can  safely be provided across ambulatory care settings;
     7  including:
     8    (i) any outpatient  or  ambulatory  item  or  service  recommended  or
     9  required to be paid on a site-neutral basis by federal or New York stat-
    10  ute,  the  U.S.   Department of Health & Human Services, or the Medicare
    11  Payment Advisory Commission (MedPAC), including without limitation,  the
    12  sixty-six ambulatory payment classifications (APCs) identified by MedPAC
    13  in  its June 2023 Report to Congress and any subsequent APCs or services
    14  so designated;
    15    (ii) the evaluation and management office visit  codes  identified  by
    16  MedPAC  in  its March 2012 report, which are indicated by Current Proce-
    17  dural Terminology codes 99201 through 99215, and any  additional  office
    18  visit  Evaluation and Management Services or preventative wellness visit
    19  codes, such as G0463, or any other codes so designated under the Health-
    20  care Common Procedure Coding System (HCPCS) or Current Procedural Termi-
    21  nology (CPT) coding systems; and
    22    (iii) any other outpatient or ambulatory items or services  as  desig-
    23  nated  by  the commissioner or superintendent as safe and appropriate to
    24  be provided in lower-cost settings in accordance with the provisions  of
    25  this section.
    26    (b) "Health benefit plan" means a plan, policy, contract, certificate,
    27  or  agreement  entered  into,  offered,  or issued by a health insurance
    28  carrier or third-party administrator acting on behalf of a plan  sponsor
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD16312-03-4

        S. 9952                             2
 
     1  to provide, deliver, arrange for, pay for, or reimburse any of the costs
     2  of  health  care  services and includes nonfederal governmental plans as
     3  defined in 29 U.S.C. § 1002(32). Health benefit plan  does  not  include
     4  any  plans,  programs  of  coverage,  or  benefits administered under 42
     5  U.S.C. § 1395 et seq. (Medicare).
     6    (c) "Plan sponsor" means:
     7    (i) the employer in the case of a benefit plan  established  or  main-
     8  tained by a single employer;
     9    (ii)  the  employee  organization in the case of a benefit plan estab-
    10  lished or maintained by an employee organization, provided that "employ-
    11  ee organization" shall mean any labor union or any organization  of  any
    12  kind,  or  any agency or employee representation committee, association,
    13  group, or plan, in which employees participate and that exists  for  the
    14  purpose,  in  whole  or in part, of dealing with employers concerning an
    15  employee  benefit  plan,  or  other  matters  incidental  to  employment
    16  relationships,  or  any employees' beneficiary association organized for
    17  the purpose in whole or in part, of establishing such a plan; or
    18    (iii) in the case of a benefit plan established or maintained  by  two
    19  or  more  employers  or jointly by one or more employers and one or more
    20  employee organizations, the association, committee, joint board of trus-
    21  tees, or other similar group  of  representatives  of  the  parties  who
    22  establish or maintain the benefit plan.
    23    (d) "Health care contract" means a contract, agreement, or understand-
    24  ing,  either  orally  or in writing, entered into, amended, restated, or
    25  renewed between a health care provider and a health  insurance  carrier,
    26  one  or  more third-party administrators, a plan sponsor or its contrac-
    27  tors or agents for the delivery of health care services to  an  enrollee
    28  of a health benefit plan.
    29    (e)  (i)  "Health  care  provider" means an individual, entity, corpo-
    30  ration, person, or organization, whether for profit or nonprofit,  oper-
    31  ating  under  this  article,  article  thirty-one of this chapter or the
    32  education law, that furnishes, bills or is paid for health care  service
    33  delivery  in  the  normal  course  of  business, and includes hospitals,
    34  hospital extension clinics, diagnostic and treatment centers,  physician
    35  offices,  or  urgent care clinics.  It shall also include any affiliated
    36  provider or entity acting on the health care  provider's  or  affiliated
    37  provider's behalf.
    38    (ii) "Health care provider" shall not include any of the following:
    39    (A)  any  facility that is eligible to be designated or has received a
    40  designation as a federally qualified health center in accordance with 42
    41  USC § 1396a(aa), as amended, or any  successor  law  thereto,  including
    42  those  facilities  that  are  also  licensed under article thirty-one or
    43  article thirty-two of the mental hygiene law;
    44    (B) a public hospital, which for purposes of this  subdivision,  shall
    45  mean  a  general hospital operated by a county, municipality or a public
    46  benefit corporation;
    47    (C) a federally designated critical access hospital;
    48    (D) a federally designated sole community hospital;
    49    (E) a rural emergency hospital; or
    50    (F) a general hospital that  is  a  safety  net  hospital,  which  for
    51  purposes   of   this  subdivision  shall  mean  a  private,  financially
    52  distressed hospital that serves at least forty-five percent Medicaid and
    53  uninsured payor mix. To be considered financially distressed, the hospi-
    54  tal must have an average operating margin that is less than or equal  to
    55  zero  percent  over the past four calendar years of available data based
    56  on audited Hospital Institutional Cost Reports.

        S. 9952                             3
 
     1    (f) "Affiliated provider" means a provider that is billing for medical
     2  goods or services that were delivered at a facility that is:
     3    (i) employed by the health care provider;
     4    (ii)  under  a  professional  services  agreement with the health care
     5  provider; or
     6    (iii) a clinical faculty member of a medical school  or  other  school
     7  that  trains individuals to be providers and that is affiliated with the
     8  health care provider.
     9    (g) "Health insurance carrier" means an entity licensed under articles
    10  thirty-two and forty-three of the insurance law or article forty-four of
    11  this chapter and subject to the insurance laws and regulations  of  this
    12  state  or  subject to the jurisdiction of the commissioner or the super-
    13  intendent of financial services that  offers  health  insurance,  health
    14  benefits,  or  contracts  for  health  care  services, prescription drug
    15  coverage, to large groups, small groups, or individuals  on  or  outside
    16  the  NY State of Health, The official Health Plan Marketplace, including
    17  the Essential Plan.
    18    (h) "Health system" means:
    19    (i) a parent corporation of one  or  more  hospitals  and  any  entity
    20  affiliated  with  such parent corporation through ownership, governance,
    21  membership or other means; or
    22    (ii) a hospital and any entity affiliated with such  hospital  through
    23  ownership, governance, membership or other means.
    24    (i)  "Hospital-based facility" means a facility that is owned or oper-
    25  ated, in whole or in part, by a hospital where hospital or  professional
    26  medical  services  are provided, including without limitation, an outpa-
    27  tient department of the hospital.
    28    (j) "Participating provider" means a provider under  contract  with  a
    29  health  benefit plan, or one of its delegates, who has agreed under such
    30  contract to provide health care services to the  health  benefit  plan's
    31  beneficiaries with an expectation of receiving payment, other than coin-
    32  surance,  copayments, or deductibles from the beneficiary, only from the
    33  health care entity under the terms of the contract.
    34    (k) "Site-neutral payment policy"  means  the  policy  of  reimbursing
    35  health  care providers the same amount for a similar service, regardless
    36  of the site or setting of the service.
    37    (l) "Superintendent" means the superintendent of financial services.
    38    (m) "Third-party administrator" means a health plan administrator  who
    39  acts on behalf of a plan sponsor to administer a health benefit plan.
    40    2.  (a)  All  health  care  providers  that  enter  into a health care
    41  contract to be a participating provider with  any  health  benefit  plan
    42  must  offer  to  accept  as payment in full for all applicable services,
    43  rates that shall not exceed one hundred fifty percent of the amount paid
    44  by Medicare for those same services.
    45    (b) No health care provider shall charge, bill, or accept payment  for
    46  any  applicable  services  that  exceeds  the lesser of: (i) one hundred
    47  fifty percent of the amount paid by Medicare;  or  (ii)  the  negotiated
    48  rate  agreed  upon  by  the  health care provider and the health benefit
    49  plan. This provision applies for all individuals and entities that reim-
    50  burse for applicable services, including self-pay individuals and health
    51  benefit plans that do not have an existing contract with the health care
    52  provider.
    53    (c) No health care provider shall charge, bill, or collect a  facility
    54  fee for any applicable services.
    55    3.  All  health care contracts entered into with health care providers
    56  shall include the following provisions:

        S. 9952                             4

     1    (a) that the health benefit plan shall not  reimburse  a  health  care
     2  provider  for  any applicable services in amounts in excess of the rates
     3  set forth in subdivision two  of  this  section  or  for  facility  fees
     4  prohibited by paragraph (c) of subdivision two of this section; and
     5    (b)  that no beneficiary or self-pay individual shall be liable to any
     6  health care provider for any amounts in excess of the rates set forth in
     7  subdivision two of this section or for facility fees prohibited by para-
     8  graph (c) of subdivision two of this section, including any  copayments,
     9  deductibles and/or coinsurance for any portion of such prohibited rates.
    10    4.  (a)  The  department  shall  collect and compile all available and
    11  relevant hospital, health system,  and  payer-reported  data,  including
    12  Transparency  in  Coverage  data pursuant to 85 FR 72158, Hospital Price
    13  Transparency data pursuant to 84 FR 65602, the all payor database (APD),
    14  the state planning and  research  cooperative  system  (SPARCS),  and/or
    15  other  publicly available data sources on pricing and utilization of the
    16  applicable services.
    17    (b) The department  has  the  authority  to  request  additional  data
    18  reports from health care providers annually as needed to efficiently and
    19  fully  report  on  pricing  and  utilization  trends  of  the applicable
    20  services, and shall request and compile additional data as  needed.  The
    21  reports shall be in such format as the department may specify.
    22    (c)  The department shall publish the information on a publicly-acces-
    23  sible website, in addition to ensuring integration into  the  APD,  with
    24  rates  for  applicable  services charged, billed, and allowed during the
    25  preceding calendar year, broken down by site of service and contract.
    26    5. (a) Each health insurance carrier shall submit a report annually to
    27  the superintendent concerning rates for applicable services  agreed  to,
    28  paid,  or  allowed,  during  the preceding calendar year, broken down by
    29  site of service and contract. The report shall be in such format as  the
    30  superintendent  shall  specify.  The  superintendent  shall  publish the
    31  information reported on a publicly-accessible website designated by  the
    32  superintendent.
    33    (b)  Commencing  one year after the effective date of this section and
    34  every year thereafter, the commissioner  and  the  superintendent  shall
    35  submit  a  joint  report to the governor, the temporary president of the
    36  senate, the speaker of the assembly, the minority leader of  the  senate
    37  and  the minority leader of the assembly that summarizes for the preced-
    38  ing calendar year: (i) multi-year  trends  and  annual  calculations  of
    39  total spending; (ii) average rates charged and allowed relative to Medi-
    40  care rates; (iii) utilization rates; and (iv) service volumes for appli-
    41  cable  services  subject to the site-neutral payment policy set forth in
    42  this section broken down by health care provider, site of  service,  and
    43  payer.    The  report shall also include any instances of non-compliance
    44  and actions taken and an estimate of savings for  payers  and  consumers
    45  compared with rates charged for applicable services in the contract year
    46  immediately  prior  to  the  effective  date of this section inflated to
    47  current dollars.
    48    6. (a) (i) A health care provider that violates any provision of  this
    49  section  or  any  of  the  rules and regulations adopted pursuant hereto
    50  shall be subject to an administrative penalty in an amount which is  the
    51  greater of one thousand dollars per claim improperly billed or a minimum
    52  statutory  penalty  of  one hundred thousand dollars per contract occur-
    53  rence.
    54    (ii) The department or its designee may audit any health care provider
    55  for compliance with the requirements of this section. Until the  expira-
    56  tion  of  four  years  after  the furnishing of any services for which a

        S. 9952                             5
 
     1  facility fee was charged, billed, or collected, each health care provid-
     2  er shall make available, upon written request of the department  or  its
     3  designee,  copies  of  any  books,  documents, records, or data that are
     4  necessary for the purposes of completing the audit.
     5    (iii)  The  department  may  refer any health care provider subject to
     6  this section to the attorney general to review the contract for  compli-
     7  ance with this section.
     8    (b) (i) All records and papers of health insurance carriers pertaining
     9  to  health  benefit  plans  or negotiations between the health insurance
    10  carrier and any health care provider shall be subject to  inspection  by
    11  the  superintendent or by any agent the superintendent may designate for
    12  that purpose.
    13    (ii) The superintendent may require any health  insurance  carrier  to
    14  produce  a list or copies of all health care contracts, transactions, or
    15  pricing arrangements entered into within the preceding twelve months.
    16    (iii) The superintendent may impose upon a health insurance carrier an
    17  administrative penalty of up to fifty thousand dollars per day for  each
    18  day that a contract in violation of subdivision three of this section is
    19  in effect.
    20    (iv)  The superintendent may, under section three thousand two hundred
    21  thirty-one of the insurance law,  disapprove  of  health  care  contract
    22  between  a health insurance carrier and any health care provider that is
    23  in violation of subdivision three of this section.
    24    (v) The superintendent may refer any health care contract  subject  to
    25  this  section to the attorney general to review the contract for compli-
    26  ance with this section. The referral of any health care contract by  the
    27  superintendent  to  the attorney general does not constitute a violation
    28  of any confidentiality agreement between the  health  insurance  carrier
    29  and  the superintendent that may exist under paragraph one of subsection
    30  (b) of section three thousand two hundred one of the insurance law.
    31    (c) Any violation of this section shall constitute an unlawful  decep-
    32  tive  act  or  practice  under  section  three hundred forty-nine of the
    33  general business law. Any person who suffers a loss as  a  result  of  a
    34  violation  of  this  section shall be entitled to initiate an action and
    35  seek all remedies, damages, costs, and fees available under  subdivision
    36  (h) of section three hundred forty-nine of the general business law.
    37    7.  The  commissioner  and  the  superintendent shall promulgate joint
    38  regulations necessary to implement this section, specify the format  and
    39  content  of  reports, and the department shall impose penalties for non-
    40  compliance consistent with the department's authority to regulate health
    41  care providers and health insurers.   The commissioner  and  the  super-
    42  intendent  shall have the discretion to add additional services based on
    43  additional ambulatory payment classifications (APCs) or services  desig-
    44  nated, any additional office visit Evaluation and Management Services or
    45  preventative  wellness  visit  codes,  or  any other codes so designated
    46  under the Healthcare Common Procedure Coding System (HCPCS)  or  Current
    47  Procedural  Terminology  (CPT) coding systems identified by the Medicare
    48  Payment Advisory Commission (MedPAC), through processes such as  notice-
    49  and-comment rulemaking, technical advisory panels, or other processes to
    50  gain community and expert input.
    51    §  2.  Severability.  If any clause, sentence, paragraph, subdivision,
    52  section or part of this act shall be adjudged by any court of  competent
    53  jurisdiction  to  be invalid, such judgment shall not affect, impair, or
    54  invalidate the remainder thereof, but shall be confined in its operation
    55  to the clause, sentence, paragraph, subdivision, section or part thereof
    56  directly involved in the controversy in which such judgment  shall  have

        S. 9952                             6
 
     1  been rendered. It is hereby declared to be the intent of the legislature
     2  that  this  act  would have been enacted even if such invalid provisions
     3  had not been included herein.
     4    § 3. This act shall take effect immediately.
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