|SAME AS||SAME AS S02078-A|
|COSPNSR||Abinanti, Benedetto, Bronson, Brook-Krasny, Colton, Crespo, Cymbrowitz, Dinowitz, Englebright, Gantt, Hikind, Jacobs, Jaffee, Kavanagh, Kellner, Lavine, Lifton, Lupardo, Peoples-Stokes, Roberts, Rosenthal, Sepulveda, Steck, Sweeney, Titone, Titus, Weinstein, Schimel, Rodriguez, Russell, Kim, Weprin, Mosley, Pichardo|
|MLTSPNSR||Abbate, Arroyo, Aubry, Brennan, Cahill, Camara, Clark, Cook, Davila, Fahy, Farrell, Glick, Gunther, Heastie, Hooper, Lentol, Magee, Magnarelli, Markey, Mayer, McDonald, Millman, O'Donnell, Ortiz, Paulin, Perry, Pretlow, Quart, Ramos, Rivera, Robinson, Rozic, Scarborough, Skartados, Solages, Thiele, Weisenberg, Wright|
|Ren Art 50 SS5000 - 5003 to be Art 80 SS8000 - 8003, add Art 51 SS5100 - 5110, add Art 49 Title 3 SS4920 - 4927, amd S270, Pub Health L; add S89-h, St Fin L|
|Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents: provides for administrative structure of the plan; provides for powers and duties of the board of trustees, the scope of benefits, payment methodologies and care coordination; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; enacts provisions relating to financing of New York Health, including a payroll assessment, similar to the Medicare tax; establishes a temporary commission on implementation of the plan; provides for collective negotiations by health care providers with New York Health.|
Go to top
NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A5389A SPONSOR: Gottfried (MS)
TITLE OF BILL: An act to amend the public health law and the state finance law, in relation to establishing New York Health   PURPOSE OR GENERAL IDEA OF BILL: This bill would create a universal single payer health plan -New York Health - to provide comprehensive health coverage for all New Yorkers.   SUMMARY OF SPECIFIC PROVISIONS: Every New York resident would be eligible to enroll, regardless of age, income, wealth, employment, or other status. There would be no premium, deductibles, or co-pays. Coverage would be publicly funded. The benefits will include comprehensive outpatient and inpatient medical care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc. - all benefits required by current state insurance law or provided by the state public employee package, Family Health Plus, Child Health Plus, Medicare, or Medicaid, and others added by the plan. Everyone would choose a primary care practitioner or other provider to provide care coordination - helping to get the care and follow-up the patient needs, referrals, and navigating the system. But there would be no "gatekeeper" obstacles to care. As with most health coverage, New York Health covers health care services when a member is out of state, either because health care is needed while the member is traveling or because there is a clinical reason for going to a particular out-of-state provider. A broadly representative Board of Trustees will advise the Commissioner of Health. Long-term care coverage is not included at the start, but the bill requires that the Board develop a plan for it within five years of passage. Health care providers, including those providing care coordination, would be paid in full by New York Health, with no co-pays or other charges to patients. The plan would develop alternative payment methods to replace old-style fee-for-service (which rewards volume but not qual- ity), and would negotiate rates with health care provider organizations. (Fee-for-service would continue until new methods are phased in.) The bill would authorize health care providers to form organizations to collectively negotiate with New York Health. Health care would no longer be paid for by insurance companies charging a regressive "tax" - premiums, deductibles and co-pays - imposed regard- less of ability to pay. Instead, New York Health would be paid for by assessments based on ability to pay, through a progressively-graduated payroll tax (paid 80% by employers and 20% by employees, and 100% by self-employed) and a surcharge on other taxable income. A specific revenue plan, following guidelines in the bill, would be submitted to the Legislature by the Governor. Federal funds now received for Medicare, Medicaid, Family Health and Child Health Plus would be combined with the state revenue in a New York Health Trust Fund. New York would seek federal waivers that will allow New York to completely fold those programs into New York Health. The "local share" of Medicaid funding - a major burden on local property taxes - would be ended. Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents. (Existing retiree coverage would be phased out and replaced with New York Health.)   JUSTIFICATION: The state constitution states: "The protection and promotion of the health of the inhabitants of the state are matters of public concern and provision therefor shall be made by the state and by such of its subdi- visions and in such manner, and by such means as the legislature shall from time to time determine." (Article XVII, § 3.) All residents of the state have the right to health care. New Yorkers - as individuals, employers, and taxpayers - have experi- enced a rapid rise in the cost of health care and coverage in recent years. This increase has resulted in a large number of people without health coverage. Businesses have also experienced extraordinary increases in the costs of health care benefits for their employees. An unacceptable number of New Yorkers have no health coverage, and many more are severely underinsured. Health care providers are also affected by inadequate health coverage in New York State. A large portion of voluntary and public hospitals, health centers and other providers now experience substantial losses due to the provision of care that is uncompensated. Individuals often find that they are deprived of affordable care and choice because of deci- sions by health plans guided by the plan's economic needs rather than their health care needs. To address the fiscal crisis facing the health care system and the state and to assure New Yorkers can exercise their right to health care, this legislation would establish a comprehensive universal single-payer health care coverage program, funded by broad-based revenue based on ability to pay, and a health care cost control system for the benefit of all residents of the state of New York. The state will work to obtain waivers relating to Medicaid, Family Health Plus, Child Health Plus, Medicare, the Patient Protection and Affordable Care Act, and any other appropriate federal programs, under which federal funds and other subsidies that would otherwise be paid to New York State will be paid by the federal government to New York State and deposited in the New York Health trust fund. Under such a waiver, health coverage under those programs will be replaced and merged into New York Health, which will operate as a true single-payer program. If such a waiver is not obtained, the state shall use state plan amendments and seek waivers to maximize, and make as seamless as possible, the use of federally-matched health programs and federal health programs in New York Health, The goal of this legislation is that coverage be delivered by New York Health and, as much as possible, the multiple sources of funding will be pooled with other New York Health funds and not be apparent to New York Health members or participating providers. This program will promote movement away from fee-for-service payment, which tends to reward quantity and requires excessive administrative expense, and towards alternate payment methodologies, such as global or capitated payments to providers or health care organizations, that promote quality, efficiency, investment in primary and preventive care, and innovation and integration in the organizing of health care. This act does not create any employment benefit, nor does it require, prohibit, or limit the providing of any employment benefit. In order to promote improved quality of, and access to, health care services and promote improved clinical outcomes, it is the policy of the state to encourage cooperative, collaborative and integrative arrange- ments among health care providers who might otherwise be competitors, under the active supervision of the commissioner. It is the intent of the state to supplant competition with such arrangements and regulation only to the extent necessary to accomplish the purposes of this act, and to provide state action immunity under the state and federal antitrust laws to health care providers, particularly with respect to their relations with the single-payer New York Health plan created by this act.   PRIOR LEGISLATIVE HISTORY:; 1992: A,8912-A passed Assembly 1993: A.5900 reported to Ways and Means 1994: A.5900 referred to Health Committee 1995-96: A.6801 reported to Ways and Means 1997-98: A.6172 reported to Ways and Means 1999-00: A.3571 reported to Ways and Means 2001-02: A.6779 reported to Ways and Means 2003-04: A.6952 reported to Ways and Means 2005: A.6576 reported to Ways and Means 2006: A.6576 referred to Health Committee 2007-08: A.7354 - reported to Ways and Means 2009-10: A.2356- referred to Health Committee 2011-12: A.7860-A - referred to Ways and Means 2013: A5389 referred to Health Committee   FISCAL IMPLICATIONS: Full funding for New York Health would come from the revenue measures to be proposed by the Governor under guidelines in the bill, plus available federal funds. The revenue package would also replace: local share of Medicaid, the state share of Medicaid, state and local payments for public employee health coverage, and various other health care spending. Numerous analyses document that a single-payer system would be most effective for reducing and controlling costs, for taxpayers, employers and individuals.   EFFECTIVE DATE: Immediately. The program will actually begin functioning when the Commissioner of Health declares the beginning of the implementation period.
Go to top
STATE OF NEW YORK ________________________________________________________________________ 5389--A 2013-2014 Regular Sessions IN ASSEMBLY February 25, 2013 ___________ Introduced by M. of A. GOTTFRIED, ABINANTI, BENEDETTO, BOYLAND, BRONSON, BROOK-KRASNY, COLTON, CRESPO, CYMBROWITZ, DINOWITZ, ENGLEBRIGHT, ESPI- NAL, GANTT, HIKIND, JACOBS, JAFFEE, KAVANAGH, KELLNER, LAVINE, LIFTON, LUPARDO, MAISEL, PEOPLES-STOKES, ROBERTS, ROSA, ROSENTHAL, SEPULVEDA, STECK, STEVENSON, SWEENEY, TITONE, TITUS, WEINSTEIN, SCHIMEL, RODRI- GUEZ -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, BARRON, BRENNAN, CAHILL, CAMARA, CLARK, COOK, FAHY, FARRELL, GIBSON, GLICK, GUNTHER, HEASTIE, HOOPER, LENTOL, V. LOPEZ, MAGEE, MAGNARELLI, MARKEY, MAYER, McDONALD, MILLMAN, MOSLEY, O'DONNELL, ORTIZ, PAULIN, PERRY, PRETLOW, RAMOS, RIVERA, ROBINSON, ROZIC, SCARBOROUGH, SKARTADOS, THIELE, WEIS- ENBERG, WEPRIN, WRIGHT -- read once and referred to the Committee on Health -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend the public health law and the state finance law, in relation to establishing New York Health The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Legislative findings and intent. 1. The state constitution 2 states: "The protection and promotion of the health of the inhabitants 3 of the state are matters of public concern and provision therefor shall 4 be made by the state and by such of its subdivisions and in such manner, 5 and by such means as the legislature shall from time to time determine." 6 (Article XVII, §3.) The legislature finds and declares that all resi- 7 dents of the state have the right to health care. New Yorkers - as indi- 8 viduals, employers, and taxpayers - have experienced a rapid rise in the 9 cost of health care and coverage in recent years. This increase has 10 resulted in a large number of people without health coverage. Businesses 11 have also experienced extraordinary increases in the costs of health 12 care benefits for their employees. An unacceptable number of New Yorkers 13 have no health coverage, and many more are severely underinsured. Health 14 care providers are also affected by inadequate health coverage in New EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD01606-02-3A. 5389--A 2 1 York state. A large portion of voluntary and public hospitals, health 2 centers and other providers now experience substantial losses due to the 3 provision of care that is uncompensated. Individuals often find that 4 they are deprived of affordable care and choice because of decisions by 5 health plans guided by the plan's economic needs rather than their 6 health care needs. To address the fiscal crisis facing the health care 7 system and the state and to assure New Yorkers can exercise their right 8 to health care, affordable and comprehensive health coverage must be 9 provided. Pursuant to the state constitution's charge to the legislature 10 to provide for the health of New Yorkers, this legislation is an enact- 11 ment of state concern for the purpose of establishing a comprehensive 12 universal single-payer health care coverage program and a health care 13 cost control system for the benefit of all residents of the state of New 14 York. 15 2. It is the intent of the Legislature to create the New York Health 16 program to provide a universal health plan for every New Yorker, funded 17 by broad-based revenue based on ability to pay. The state shall work to 18 obtain waivers relating to Medicaid, Family Health Plus, Child Health 19 Plus, Medicare, the Patient Protection and Affordable Care Act, and any 20 other appropriate federal programs, under which federal funds and other 21 subsidies that would otherwise be paid to New York State and New Yorkers 22 for health coverage that will be equaled or exceeded by New York Health 23 will be paid by the federal government to New York State and deposited 24 in the New York Health trust fund. Under such a waiver, health coverage 25 under those programs will be replaced and merged into New York Health, 26 which will operate as a true single-payer program. 27 If such a waiver is not obtained, the state shall use state plan 28 amendments and seek waivers to maximize, and make as seamless as possi- 29 ble, the use of federally-matched health programs and federal health 30 programs in New York Health. Thus, even where other programs such as 31 Medicaid or Medicare may contribute to paying for care, it is the goal 32 of this legislation that the coverage will be delivered by New York 33 Health and, as much as possible, the multiple sources of funding will be 34 pooled with other New York Health funds and not be apparent to New York 35 Health members or participating providers. This program will promote 36 movement away from fee-for-service payment, which tends to reward quan- 37 tity and requires excessive administrative expense, and towards alter- 38 nate payment methodologies, such as global or capitated payments to 39 providers or health care organizations, that promote quality, efficien- 40 cy, investment in primary and preventive care, and innovation and inte- 41 gration in the organizing of health care. 42 3. This act does not create any employment benefit, nor does it 43 require, prohibit, or limit the providing of any employment benefit. 44 4. In order to promote improved quality of, and access to, health care 45 services and promote improved clinical outcomes, it is the policy of the 46 state to encourage cooperative, collaborative and integrative arrange- 47 ments among health care providers who might otherwise be competitors, 48 under the active supervision of the commissioner of health. It is the 49 intent of the state to supplant competition with such arrangements and 50 regulation only to the extent necessary to accomplish the purposes of 51 this act, and to provide state action immunity under the state and 52 federal antitrust laws to health care providers, particularly with 53 respect to their relations with the single-payer New York Health plan 54 created by this act.A. 5389--A 3 1 § 2. Article 50 and sections 5000, 5001, 5002 and 5003 of the public 2 health law are renumbered article 80 and sections 8000, 8001, 8002 and 3 8003, respectively, and a new article 51 is added to read as follows: 4 ARTICLE 51 5 NEW YORK HEALTH 6 Section 5100. Definitions. 7 5101. Program created. 8 5102. Board of trustees. 9 5103. Eligibility and enrollment. 10 5104. Benefits. 11 5105. Health care providers; care coordination; payment method- 12 ologies. 13 5106. Health care organizations. 14 5107. Program standards. 15 5108. Regulations. 16 5109. Provisions relating to federal health programs. 17 5110. Additional provisions. 18 § 5100. Definitions. As used in this article, the following terms 19 shall have the following meanings, unless the context clearly requires 20 otherwise: 21 1. "Board" means the board of trustees of the New York Health program 22 created by section fifty-one hundred two of this article, and "trustee" 23 means a trustee of the board. 24 2. "Care coordination" means services provided by a care coordinator 25 under paragraph (b) of subdivision two of section fifty-one hundred five 26 of this article. 27 3. "Care coordinator" means an individual or entity approved to 28 provide care coordination under paragraph (b) of subdivision two of 29 section fifty-one hundred five of this article. 30 4. "Federally-matched public health program" means the medical assist- 31 ance program under title eleven of article five of the social services 32 law, the family health plus program under title eleven-D of article five 33 of the social services law, and the child health plus program under 34 title one-A of article twenty-five of this chapter. 35 5. "Health care organization" means an entity that is approved by the 36 commissioner under section fifty-one hundred six of this article to 37 provide health care services to members under the program. 38 6. "Health care service" means any health care service, including care 39 coordination, included as a benefit under the program. 40 7. "Implementation period" means the period under subdivision three of 41 section fifty-one hundred one of this article during which the program 42 will be subject to special eligibility and financing provisions until it 43 is fully implemented under that section. 44 8. "Long term care" means long term care, treatment, maintenance, or 45 services not covered under family health plus or child health plus, as 46 appropriate, with the exception of short term rehabilitation, as defined 47 by the commissioner. 48 9. "Medicaid" or "medical assistance" means title eleven of article 49 five of the social services law and the program thereunder. "Family 50 health plus" means title eleven-D of article five of the social services 51 law and the program thereunder. "Child health plus" means title one-A of 52 article twenty-five of this chapter and the program thereunder. "Medi- 53 care" means title XVIII of the federal social security act and the 54 programs thereunder. 55 10. "Member" means an individual who is enrolled in the program.A. 5389--A 4 1 11. "New York Health trust fund" means the New York Health trust fund 2 established under section eighty-nine-h of the state finance law. 3 12. "Out-of-state health care service" means a health care service 4 provided to a member while the member is out of the state and (a) it is 5 medically necessary that the health care service be provided while the 6 member is out of the state, or (b) it is clinically appropriate that the 7 health care service be provided by a particular health care provider 8 located out of the state rather than in the state. 9 13. "Participating provider" means any individual or entity that is a 10 health care provider that provides health care services to members under 11 the program, or a health care organization. 12 14. "Patient protection and affordable care act" means the federal 13 patient protection and affordable care act, public law 111-148, as 14 amended by the health care and education reconciliation act of 2010, 15 public law 111-152, and any regulations or guidance issued thereunder. 16 15. "Person" means any individual or natural person, trust, partner- 17 ship, association, unincorporated association, corporation, company, 18 limited liability company, proprietorship, joint venture, firm, joint 19 stock association, department, agency, authority, or other legal entity, 20 whether for-profit, not-for-profit or governmental. 21 16. "Program" means the New York Health program created by section 22 fifty-one hundred one of this article. 23 17. "Prescription and non-prescription drugs" shall mean prescription 24 drugs as defined in section two hundred seventy of this chapter, and 25 non-prescription smoking cessation products or devices. 26 18. "Resident" means an individual whose primary place of abode is in 27 the state, as determined according to regulations of the commissioner. 28 § 5101. Program created. 1. The New York Health program is hereby 29 created in the department. The commissioner shall establish and imple- 30 ment the program under this article. The program shall provide compre- 31 hensive health coverage to every resident who enrolls in the program. 32 2. The commissioner shall, to the maximum extent possible, organize, 33 administer and market the program and services as a single program under 34 the name "New York Health" or such other name as the commissioner shall 35 determine, regardless of under which law or source the definition of a 36 benefit is found including (on a voluntary basis) retiree health bene- 37 fits. In implementing this subdivision, the commissioner shall avoid 38 jeopardizing federal financial participation in these programs and shall 39 take care to promote public understanding and awareness of available 40 benefits and programs. 41 3. The commissioner shall determine when individuals may begin enroll- 42 ing in the program. There shall be an implementation period, which shall 43 begin on the date that individuals may begin enrolling in the program 44 and shall end as determined by the commissioner. 45 4. An insurer authorized to provide coverage pursuant to the insurance 46 law or a health maintenance organization certified under this chapter 47 may, if otherwise authorized, offer benefits that do not duplicate 48 coverage offered to an individual under the program, but may not offer 49 benefits that duplicate coverage offered to an individual under the 50 program. Provided, however, that this subdivision shall not prohibit (a) 51 the offering of any benefits to or for individuals, including their 52 families, who are employed or self-employed in the state but who are not 53 residents of the state, or (b) the offering of benefits during the 54 implementation period to individuals who enrolled as members of the 55 program, or (c) the offering of retiree health benefits.A. 5389--A 5 1 5. A college, university or other institution of higher education in 2 the state may purchase coverage under the program for any student, or 3 student's dependent, who is not a resident of the state. 4 § 5102. Board of trustees. 1. The New York Health board of trustees is 5 hereby created in the department. The board of trustees shall, at the 6 request of the commissioner, consider any matter to effectuate the 7 provisions and purposes of this article, and may advise the commissioner 8 thereon; and it may, from time to time, submit to the commissioner any 9 recommendations to effectuate the provisions and purposes of this arti- 10 cle. The commissioner may propose regulations under this article and 11 amendments thereto for consideration by the board. The board of trustees 12 shall have no executive, administrative or appointive duties except as 13 otherwise provided by law. The board of trustees shall have power to 14 establish, and from time to time, amend regulations to effectuate the 15 provisions and purposes of this article, subject to approval by the 16 commissioner. 17 2. The board shall be composed of: 18 (a) the commissioner, the superintendent of financial services, and 19 the director of the budget, or their designees, as ex officio members; 20 (b) seventeen trustees appointed by the governor; 21 (i) five of whom shall be representatives of health care consumer 22 advocacy organizations which have a statewide or regional constituency, 23 who have been involved in activities related to health care consumer 24 advocacy, including issues of interest to low- and moderate-income indi- 25 viduals; 26 (ii) two of whom shall be representatives of professional organiza- 27 tions representing physicians; 28 (iii) two of whom shall be representatives of professional organiza- 29 tions representing licensed or registered health care professionals 30 other than physicians; 31 (iv) three of whom shall be representatives of hospitals, one of whom 32 shall be a representative of public hospitals; 33 (v) one of whom shall be representative of community health centers; 34 (vi) two of whom shall be representatives of health care organiza- 35 tions; and 36 (viii) two of whom shall be representatives of organized labor; 37 (c) three trustees appointed by the speaker of the assembly; three 38 trustees appointed by the temporary president of the senate; one trustee 39 appointed by the minority leader of the assembly; and one trustee 40 appointed by the minority leader of the senate. 41 After the end of the implementation period, no person shall be a trus- 42 tee unless he or she is a member of the program, except the ex officio 43 trustees. Each trustee shall serve at the pleasure of the appointing 44 officer, except the ex officio trustees. 45 3. The chair of the board shall be appointed, and may be removed as 46 chair, by the governor from among the trustees. The board shall meet at 47 least four times each calendar year. Meetings shall be held upon the 48 call of the chair and as provided by the board. A majority of the 49 appointed trustees shall be a quorum of the board, and the affirmative 50 vote of a majority of the trustees voting, but not less than ten, shall 51 be necessary for any action to be taken by the board. The board may 52 establish an executive committee to exercise any powers or duties of the 53 board as it may provide, and other committees to assist the board or the 54 executive committee. The chair of the board shall chair the executive 55 committee and shall appoint the chair and members of all other commit- 56 tees. The board of trustees may appoint one or more advisory committees.A. 5389--A 6 1 Members of advisory committees need not be members of the board of trus- 2 tees. 3 4. Trustees shall serve without compensation but shall be reimbursed 4 for their necessary and actual expenses incurred while engaged in the 5 business of the board. 6 5. Notwithstanding any provision of law to the contrary, no officer or 7 employee of the state or any local government shall forfeit or be deemed 8 to have forfeited his or her office or employment by reason of being a 9 trustee. 10 6. The board and its committees and advisory committees may request 11 and receive the assistance of the department and any other state or 12 local governmental entity in exercising its powers and duties. 13 7. No later than five years after the effective date of this article: 14 (a) The board shall develop a proposal, consistent with the principles 15 of this article, for provision by the program of long-term care cover- 16 age, including the development of a proposal, consistent with the prin- 17 ciples of this article, for its funding. In developing the proposal, 18 the board shall consult with an advisory committee, appointed by the 19 chair of the board, including representatives of consumers and potential 20 consumers of long-term care, providers of long-term care, labor, and 21 other interested parties. The board shall present its proposal to the 22 governor and the legislature. 23 (b) The board shall develop proposals for: (i) incorporating retiree 24 health benefits into New York Health; and (ii) accommodating employer 25 retiree health benefits for people who have been members of New York 26 Health but live as retirees out of the state. 27 § 5103. Eligibility and enrollment. 1. Every resident of the state 28 shall be eligible and entitled to enroll as a member under the program. 29 2. No member shall be required to pay any premium or other charge for 30 enrolling in or being a member under the program. 31 § 5104. Benefits. 1. The program shall provide comprehensive health 32 coverage to every member, which shall include all health care services 33 required to be covered under any of the following, without regard to 34 whether the member would otherwise be eligible for or covered by the 35 program or source referred to: 36 (a) family health plus; 37 (b) for every member under the age of twenty-one, child health plus; 38 (c) Medicaid; 39 (d) Medicare; 40 (e) article forty-four of this chapter or article thirty-two or 41 forty-three of the insurance law; 42 (f) article eleven of the civil service law, as of the date one year 43 before the beginning of the implementation period; 44 (g) any additional health care service authorized to be added to the 45 program's benefits by the program; and 46 (h) provided that none of the above shall include long term care, 47 until a proposal under paragraph (a) of subdivision seven of section 48 fifty-one hundred two of this article is enacted into law. 49 2. No member shall be required to pay any deductible, co-payment or 50 co-insurance under the program. 51 3. The program shall provide for payment under the program for emer- 52 gency and temporary health care services provided to members or individ- 53 uals entitled to become members who have not had a reasonable opportu- 54 nity to become a member or to enroll with a care coordinator. 55 § 5105. Health care providers; care coordination; payment methodol- 56 ogies. 1. Choice of health care provider. (a) Any health care providerA. 5389--A 7 1 qualified to participate under this section may provide health care 2 services under the program, provided that the health care provider is 3 otherwise legally authorized to perform the health care service for the 4 individual and under the circumstances involved. 5 (b) A member may choose to receive health care services under the 6 program from any participating provider, consistent with provisions of 7 this article relating to care coordination and health care organiza- 8 tions, the willingness or availability of the provider (subject to 9 provisions of this article relating to discrimination), and the appro- 10 priate clinically-relevant circumstances. 11 2. Care coordination. (a) Health care services provided to a member 12 shall not be subject to payment under the program unless the member is 13 enrolled with a care coordinator at the time the health care service is 14 provided, except where provided under subdivision three of section 15 fifty-one hundred four of this article. Every member shall enroll with a 16 care coordinator that agrees to provide care coordination to the member 17 prior to receiving health care services to be paid for under the 18 program. The member shall remain enrolled with that care coordinator 19 until the member becomes enrolled with a different care coordinator or 20 ceases to be a member. The commissioner shall provide, by regulation, 21 that members have the right to change their care coordinator on terms at 22 least as permissive as the provisions of section three hundred sixty- 23 four-j of the social services law relating to an individual changing his 24 or her primary care provider or managed care provider. 25 (b) Care coordination shall be provided to the member by the member's 26 care coordinator. A care coordinator may employ or utilize the services 27 of other individuals or entities to assist in providing care coordi- 28 nation for the member, consistent with regulations of the commissioner. 29 Care coordination shall include, but not be limited to, managing, refer- 30 ring to, locating, coordinating, and monitoring health care services for 31 the member to assure that all medically necessary health care services 32 are made available to and are effectively used by the member in a timely 33 manner, consistent with patient autonomy. Care coordination is not a 34 requirement for prior authorization for health care services and refer- 35 ral shall not be required for a member to receive a health care service. 36 However: (i) a health care organization may establish rules relating to 37 care coordination for members in the health care organization, different 38 from this subdivision but otherwise consistent with this article and 39 other applicable laws; and (ii) nothing in this subdivision shall 40 authorize any individual to engage in any act in violation of title 41 eight of the education law. 42 (c) Where a member receives chronic mental health care services, at 43 the option of the member, the member may enroll with a care coordinator 44 for his or her mental health care services and another care coordinator 45 approved for his or her other health care services, consistent with 46 standards established by the commissioner in consultation with the 47 commissioner of mental health. In such a case, the two care coordinators 48 shall work in close consultation with each other. 49 (d) A care coordinator may be an individual or entity that is approved 50 by the program that is: 51 (i) a health care practitioner who is: (A) the member's primary care 52 practitioner; (B) at the option of a female member, the member's provid- 53 er of primary gynecological care; or (C) at the option of a member who 54 has a chronic condition that requires specialty care, a specialist 55 health care practitioner who regularly and continually provides treat- 56 ment for that condition to the member;A. 5389--A 8 1 (ii) an entity licensed under article twenty-eight of this chapter or 2 certified under article thirty-six of this chapter, a managed long term 3 care plan under section forty-four hundred three-f of this chapter or 4 other program model under paragraph (b) of subdivision seven of such 5 section, or, with respect to a member who receives chronic mental health 6 care services, an entity licensed under article thirty-one of the mental 7 hygiene law or other entity approved by the commissioner in consultation 8 with the commissioner of mental health; 9 (iii) a health care organization; 10 (iv) a Taft-Hartley fund, with respect to its members and their family 11 members; provided that this provision shall not preclude a Taft-Hartley 12 fund from becoming a care coordinator under subparagraph (v) of this 13 paragraph or a health care organization under section fifty-one hundred 14 six of this article; or 15 (v) any not-for-profit or governmental entity approved by the program. 16 (e) The commissioner shall develop and implement procedures and stand- 17 ards for an individual or entity to be approved to be a care coordinator 18 in the program, including but not limited to procedures and standards 19 relating to the revocation, suspension, limitation, or annulment of 20 approval on a determination that the individual or entity is incompetent 21 to be a care coordinator or has exhibited a course of conduct which is 22 either inconsistent with program standards and regulations or which 23 exhibits an unwillingness to meet such standards and regulations, or is 24 a potential threat to the public health or safety. Such procedures and 25 standards shall not limit approval to be a care coordinator in the 26 program for economic purposes and shall be consistent with good profes- 27 sional practice. In developing the procedures and standards, the commis- 28 sioner shall: (i) consider existing standards developed by national 29 accrediting and professional organizations; and (ii) consult with 30 national and local organizations working on care coordination or similar 31 models, including health care practitioners, hospitals, clinics, and 32 consumers and their representatives. When developing and implementing 33 standards of approval of care coordinators for individuals receiving 34 chronic mental health care services, the commissioner shall consult with 35 the commissioner of mental health. An individual or entity may not be a 36 care coordinator unless the services included in care coordination are 37 within the individual's professional scope of practice or the entity's 38 legal authority. 39 (f) To maintain approval under the program, a care coordinator must: 40 (i) renew its status at a frequency determined by the commissioner; and 41 (ii) provide data to the department as required by the commissioner to 42 enable the commissioner to evaluate the impact of care coordinators on 43 quality, outcomes and cost. 44 3. Health care providers. (a) The commissioner shall establish and 45 maintain procedures and standards for health care providers to be quali- 46 fied to participate in the program, including but not limited to proce- 47 dures and standards relating to the revocation, suspension, limitation, 48 or annulment of qualification to participate on a determination that the 49 health care provider is an incompetent provider of specific health care 50 services or has exhibited a course of conduct which is either inconsist- 51 ent with program standards and regulations or which exhibits an unwill- 52 ingness to meet such standards and regulations, or is a potential threat 53 to the public health or safety. Such procedures and standards shall not 54 limit health care provider participation in the program for economic 55 purposes and shall be consistent with good professional practice. Any 56 health care provider who is qualified to participate under Medicaid,A. 5389--A 9 1 family health plus, child health plus or Medicare shall be deemed to be 2 qualified to participate in the program, and any health care provider's 3 revocation, suspension, limitation, or annulment of qualification to 4 participate in any of those programs shall apply to the health care 5 provider's qualification to participate in the program; provided that a 6 health care provider qualified under this sentence shall follow the 7 procedures to become qualified under the program by the end of the 8 implementation period. 9 (b) The commissioner shall establish and maintain procedures and stan- 10 dards for recognizing health care providers located out of the state for 11 purposes of providing coverage under the program for out-of-state health 12 care services. 13 4. Payment for health care services. (a) Health care services provided 14 to members under the program shall be paid for on a fee-for-service 15 basis, except for care coordination. However, the commissioner may 16 establish by regulation other payment methodologies for health care 17 services and care coordination provided to members under the program by 18 participating providers, care coordinators, and health care organiza- 19 tions. There may be a variety of different payment methodologies, 20 including those established on a demonstration basis. All payment rates 21 under the program shall be reasonable and reasonably related to the cost 22 of efficiently providing the health care service and assuring an 23 adequate and accessible supply of health care service. 24 (b) The program shall engage in good faith negotiations with health 25 care providers' representatives under title III of article forty-nine of 26 this chapter, including, but not limited to, in relation to rates of 27 payment and payment methodologies. 28 (c) Notwithstanding any provision of law to the contrary, payment for 29 drugs provided by pharmacies under the program shall be made pursuant to 30 article two-A of this chapter and subdivision four of section three 31 hundred sixty-five-a of the social services law. However, the program 32 shall provide for payment for prescription drugs under section 340B of 33 the federal public service act where applicable. Payment for 34 prescription drugs provided by health care providers other than pharma- 35 cies shall be pursuant to other provisions of this article. 36 (d) Payment for health care services established under this article 37 shall be considered payment in full. A participating provider shall not 38 charge any rate in excess of the payment established under this article 39 for any health care service under the program provided to a member and 40 shall not solicit or accept payment from any member or third party for 41 any such service except as provided under this article. However, this 42 paragraph shall not preclude the program from acting as a primary or 43 secondary payer in conjunction with another third-party payer where 44 permitted under this article. 45 (e) The program may provide in payment methodologies for payment for 46 capital related expenses for specifically identified capital expendi- 47 tures incurred by not-for-profit or governmental entities certified 48 under article twenty-eight of this chapter. Any capital related expense 49 generated by a capital expenditure that requires or required approval 50 under article twenty-eight of this chapter must have received that 51 approval for the capital related expense to be paid for under the 52 program. 53 (f) The commissioner shall provide by regulation for payment method- 54 ologies and procedures for paying for out-of-state health care services. 55 5. (a) For purposes of this subdivision, "income-eligible member" 56 means a member who is enrolled in a federally-matched public healthA. 5389--A 10 1 program and (i) there is federal financial participation in the individ- 2 ual's health coverage, or (ii) the member is eligible to enroll in the 3 federally-matched public health program by reason of income, age, and 4 resources (where applicable) under state law in effect on the effective 5 date of this section, but there is no federal financial participation in 6 the individual's health coverage. A person who is eligible to enroll in 7 a federally-matched public health program solely by reason of section 8 three hundred sixty-nine-ff of the social services law (employer part- 9 nerships for family health plus) is not an income-eligible member. 10 (b) The program, with respect to income-eligible members, shall be 11 considered a federally-matched public health program or government payor 12 under article twenty-eight of this chapter with respect to the following 13 provisions, and with respect to those members who are not income-eligi- 14 ble members, shall not be considered a federally-matched public health 15 program or governmental payor under article twenty-eight of this chapter 16 with respect to the following provisions: 17 (i) patient services payments in accordance with section twenty-eight 18 hundred seven-j of this chapter; 19 (ii) professional education pool funding under section twenty-eight 20 hundred seven-s of this chapter; or 21 (iii) assessments on covered lives under section twenty-eight hundred 22 seven-t of this chapter. 23 § 5106. Health care organizations. 1. A member may choose to enroll 24 with and receive health care services under the program from a health 25 care organization. 26 2. A health care organization shall be a not-for-profit or govern- 27 mental entity that is approved by the commissioner that is: 28 (a) an accountable care organization under article twenty-nine-E of 29 this chapter; or 30 (b) a Taft-Hartley fund (i) with respect to its members and their 31 family members, and (ii) if allowed by applicable law and approved by 32 the commissioner, for other members of the program; provided that the 33 commissioner shall provide by regulation that where a Taft-Hartley fund 34 is acting under this subparagraph there are protections for health care 35 providers and patients comparable to those applicable to accountable 36 care organizations. 37 3. A health care organization may be responsible for all or part of 38 the health care services to which its members are entitled under the 39 program, consistent with the terms of its approval by the commissioner. 40 4. (a) The commissioner shall develop and implement procedures and 41 standards for an entity to be approved to be a health care organization 42 in the program, including but not limited to procedures and standards 43 relating to the revocation, suspension, limitation, or annulment of 44 approval on a determination that the entity is incompetent to be a 45 health care organization or has exhibited a course of conduct which is 46 either inconsistent with program standards and regulations or which 47 exhibits an unwillingness to meet such standards and regulations, or is 48 a potential threat to the public health or safety. Such procedures and 49 standards shall not limit approval to be a health care organization in 50 the program for economic purposes and shall be consistent with good 51 professional practice. In developing the procedures and standards, the 52 commissioner shall: (i) consider existing standards developed by 53 national accrediting and professional organizations; and (ii) consult 54 with national and local organizations working in the field of health 55 care organizations, including health care practitioners, hospitals, 56 clinics, and consumers and their representatives. When developing andA. 5389--A 11 1 implementing standards of approval of health care organizations, the 2 commissioner shall consult with the commissioner of mental health and 3 the commissioner of developmental disabilities. 4 (b) To maintain approval under the program, a health care organization 5 must: (i) renew its status at a frequency determined by the commission- 6 er; and (ii) provide data to the department as required by the commis- 7 sioner to enable the commissioner to evaluate the health care organiza- 8 tion in relation to quality of health care services, health care 9 outcomes, and cost. 10 5. The commissioner shall make regulations relating to health care 11 organizations consistent with and to ensure compliance with this arti- 12 cle. 13 6. The provision of health care services directly or indirectly by a 14 health care organization through health care providers shall not be 15 considered the practice of a profession under title eight of the educa- 16 tion law by the health care organization. 17 § 5107. Program standards. 1. The commissioner shall establish 18 requirements and standards for the program and for health care organiza- 19 tions, care coordinators, and health care providers, including require- 20 ments and standards for, as applicable: 21 (a) the scope, quality and accessibility of health care services; 22 (b) relations between health care organizations or health care provid- 23 ers and members, including approval of health care services; and 24 (c) relations between health care organizations and health care 25 providers, including (i) credentialing and participation in health care 26 organization networks; and (ii) terms, methods and rates of payment. 27 2. Requirements and standards under the program shall include, but not 28 be limited to, provisions to promote the following: 29 (a) simplification, transparency, uniformity, and fairness in health 30 care provider credentialing and participation in health care organiza- 31 tion networks, referrals, payment procedures and rates, claims process- 32 ing, and approval of health care services, as applicable; 33 (b) primary and preventive care, care coordination, efficient and 34 effective health care services, quality assurance, and coordination and 35 integration of health care services, including use of appropriate tech- 36 nology; 37 (c) elimination of health care disparities; 38 (d) non-discrimination with respect to members and health care provid- 39 ers on the basis of race, ethnicity, national origin, religion, disabil- 40 ity, age, sex, sexual orientation, gender identity or expression, or 41 economic circumstances; provided that health care services provided 42 under the program shall be appropriate to the patient's clinically-rele- 43 vant circumstances; and 44 (e) accessibility of care coordination, health care organization 45 services and health care services, including accessibility for people 46 with disabilities and people with limited ability to speak or understand 47 English, and the providing of health care organization services and 48 health care services in a culturally competent manner. 49 3. Any participating provider or care coordinator that is organized as 50 a for-profit entity shall be required to meet the same requirements and 51 standards as entities organized as not-for-profit entities, and payments 52 under the program paid to such entities shall not be calculated to 53 accommodate the generation of profit or revenue for dividends or other 54 return on investment or the payment of taxes that would not be paid by a 55 not-for-profit entity.A. 5389--A 12 1 4. Every participating provider shall furnish to the program such 2 information to, and permit examination of its records by, the program, 3 as may be reasonably required for purposes of utilization review, quali- 4 ty assurance, and cost containment, for the making of payments, and for 5 statistical or other studies of the operation of the program. 6 5. In developing requirements and standards and making other policy 7 determinations under this article, the commissioner shall consult with 8 representatives of members, health care providers, health care organiza- 9 tions and other interested parties. 10 6. The program shall maintain the confidentiality of all data and 11 other information collected under the program when such data would be 12 normally considered confidential data between a patient and health care 13 provider. Aggregate data of the program which is derived from confiden- 14 tial data but does not violate patient confidentiality shall be public 15 information. 16 § 5108. Regulations. The commissioner may approve regulations and 17 amendments thereto, under subdivision one of section fifty-one hundred 18 two of this article. The commissioner may make regulations or amendments 19 thereto to effectuate the provisions and purposes of this article on an 20 emergency basis under section two hundred two of the state administra- 21 tive procedure act, provided that such regulations or amendments shall 22 not become permanent unless adopted under subdivision one of section 23 fifty-one hundred two of this article. 24 § 5109. Provisions relating to federal health programs. 1. The commis- 25 sioner shall seek all federal waivers and other federal approvals and 26 arrangements and submit state plan amendments necessary to operate the 27 program consistent with this article. 28 2. (a) The commissioner shall apply to the secretary of health and 29 human services or other appropriate federal official for all waivers of 30 requirements, and make other arrangements, under Medicare, any federal- 31 ly-matched public health program, the patient protection and affordable 32 care act, and any other federal programs that provide federal funds for 33 payment for health care services, that are necessary to enable all New 34 York Health members to receive all benefits under the program through 35 the program to enable the state to implement this article and to receive 36 and deposit all federal payments under those programs (including funds 37 that may be provided in lieu of premium tax credits, cost-sharing subsi- 38 dies, and small business tax credits) in the state treasury to the cred- 39 it of the New York Health trust fund created under section eighty-nine-h 40 of the state finance law and to use those funds for the New York Health 41 program and other provisions under this article. To the extent possible, 42 the commissioner shall negotiate arrangements with the federal govern- 43 ment in which bulk or lump-sum federal payments are paid to New York 44 Health in place of federal spending or tax benefits for federally- 45 matched health programs or federal health programs. 46 (b) The commissioner may require members or applicants to be members 47 to provide information necessary for the program to comply with any 48 waiver or arrangement under this subdivision. 49 3. (a) If actions taken under subdivision two of this section do not 50 accomplish all results intended under that subdivision, then this subdi- 51 vision shall apply and shall authorize additional actions to effectively 52 implement New York Health to the maximum extent possible as a single- 53 payer program consistent with this article. 54 (b) The commissioner may take actions consistent with this article to 55 enable New York Health to administer Medicare in New York state and toA. 5389--A 13 1 be a provider of drug coverage under Medicare part D for eligible 2 members of New York Health. 3 (c) The commissioner may waive or modify the applicability of 4 provisions of this section relating to any federally-matched public 5 health program or Medicare as necessary to implement any waiver or 6 arrangement under this section or to maximize the benefit to the New 7 York Health program under this section, provided that the commissioner, 8 in consultation with the director of the budget, shall determine that 9 such waiver or modification is in the best interests of the members 10 affected by the action and the state. 11 (d) The commissioner may apply for coverage under any federally- 12 matched public health program on behalf of any member and enroll the 13 member in the federally-matched public health program if the member is 14 eligible for it. Enrollment in a federally-matched public health 15 program shall not cause any member to lose any health care service 16 provided by the program. 17 (e) The commissioner shall by regulation increase the income eligibil- 18 ity level, increase or eliminate the resource test for eligibility, 19 simplify any procedural or documentation requirement for enrollment, and 20 increase the benefits for any federally-matched public health program, 21 notwithstanding any law or regulation to the contrary. The commissioner 22 may act under this paragraph upon a finding, approved by the director of 23 the budget, that the action (i) will help to increase the number of 24 members who are eligible for and enrolled in federally-matched public 25 health programs; (ii) will not diminish any individual's access to any 26 health care service; and (iii) does not require or has received any 27 necessary federal waivers or approvals to ensure federal financial 28 participation. Actions under this paragraph shall not apply to eligibil- 29 ity for payment for long term care. 30 (f) To enable the commissioner to apply for coverage under any feder- 31 ally-matched public health program on behalf of any member and enroll 32 the member in the federally-matched public health program if the member 33 is eligible for it, the commissioner may require that every member or 34 applicant to be a member shall provide information to enable the commis- 35 sioner to determine whether the applicant is eligible for a federally- 36 matched public health program and for Medicare (and any program or bene- 37 fit under Medicare). The program shall make a reasonable effort to 38 notify members of their obligations under this paragraph. After a 39 reasonable effort has been made to contact the member, the member shall 40 be notified in writing that he or she has sixty days to provide such 41 required information. If such information is not provided within the 42 sixty day period, the member's coverage under the program may be termi- 43 nated. 44 (g) As a condition of continued eligibility for health care services 45 under the program, a member who is eligible for benefits under Medicare 46 shall enroll in Medicare, including parts A, B and D. 47 (h) The program shall provide premium assistance for all members 48 enrolling in a Medicare part D drug coverage under section 1860D of 49 Title XVIII of the federal social security act limited to the low-income 50 benchmark premium amount established by the federal centers for Medicare 51 and Medicaid services and any other amount which such agency establishes 52 under its de minimis premium policy, except that such payments made on 53 behalf of members enrolled in a Medicare advantage plan may exceed the 54 low-income benchmark premium amount if determined to be cost effective 55 to the program.A. 5389--A 14 1 (i) If the commissioner has reasonable grounds to believe that a 2 member could be eligible for an income-related subsidy under section 3 1860D-14 of Title XVIII of the federal social security act, the member 4 shall provide, and authorize the program to obtain, any information or 5 documentation required to establish the member's eligibility for such 6 subsidy, provided that the commissioner shall attempt to obtain as much 7 of the information and documentation as possible from records that are 8 available to him or her. 9 (j) The program shall make a reasonable effort to notify members of 10 their obligations under this subdivision. After a reasonable effort has 11 been made to contact the member, the member shall be notified in writing 12 that he or she has sixty days to provide such required information. If 13 such information is not provided within the sixty day period, the 14 member's coverage under the program may be terminated. 15 § 5110. Additional provisions. 1. The commissioner shall contract 16 with not-for-profit organizations to provide: 17 (a) consumer assistance to individuals with respect to selection of a 18 care coordinator or health care organization, enrolling, obtaining 19 health care services, disenrolling, and other matters relating to the 20 program; 21 (b) health care provider assistance to health care providers providing 22 and seeking or considering whether to provide, health care services 23 under the program, with respect to participating in a health care organ- 24 ization and dealing with a health care organization; and 25 (c) care coordinator assistance to individuals and entities providing 26 and seeking or considering whether to provide, care coordination to 27 members. 28 2. The commissioner shall provide grants from funds in the New York 29 Health trust fund or otherwise appropriated for this purpose, to health 30 systems agencies under section twenty-nine hundred four-b of this chap- 31 ter to support the operation of such health systems agencies. 32 § 3. Financing of New York Health. 1. The governor shall submit to the 33 legislature a plan and legislative bills to implement the plan (referred 34 to collectively in this section as the "revenue proposal") to provide 35 the revenue necessary to finance the New York Health program, as created 36 by article 51 of the public health law (referred to in this section as 37 the "program"), taking into consideration anticipated federal revenue 38 available for the program. The revenue proposal shall be submitted to 39 the legislature as part of the executive budget under article VII of the 40 state constitution, for the fiscal year commencing on the first day of 41 April in the calendar year after this act shall become a law. In devel- 42 oping the revenue proposal, the governor shall consult with appropriate 43 officials of the executive branch; the temporary president of the 44 senate; the speaker of the assembly; the chairs of the fiscal and health 45 committees of the senate and assembly; and representatives of business, 46 labor, consumers and local government. 47 2. (a) Basic structure. The basic structure of the revenue proposal 48 shall be as follows: Revenue for the program shall come from two assess- 49 ments (referred to collectively in this section as the "assessments"). 50 First, there shall be an assessment on all payroll and self-employed 51 income (referred to in this section as the "payroll assessment"), paid 52 by employers, employees and self-employed, similar to the Medicare tax. 53 Higher brackets of income subject to this assessment shall be assessed 54 at a higher marginal rate than lower brackets. Second, there shall be a 55 progressively-graduated assessment on taxable income (such as interest, 56 dividends, and capital gains) not subject to the payroll assessmentA. 5389--A 15 1 (referred to in this section as the "non-payroll assessment"). The 2 assessments will be set at levels anticipated to produce sufficient 3 revenue to finance the program and other provisions of article 51 of the 4 public health law, to be scaled up as enrollment grows, taking into 5 consideration anticipated federal revenue available for the program. 6 Provision shall be made for state residents (who are eligible for the 7 program) who are employed out-of-state, and non-residents (who are not 8 eligible for the program) who are employed in the state. 9 (b) Payroll assessment. The income to be subject to the payroll 10 assessment shall be all income subject to the Medicare tax. The assess- 11 ment shall be set at a particular percentage of that income, which shall 12 be progressively graduated, so the percentage is higher on higher brack- 13 ets of income. For employed individuals, the employer shall pay eighty 14 percent of the assessment and the employee shall pay twenty percent 15 (unless the employer agrees to pay a higher percentage). A self-employed 16 individual shall pay the full assessment. 17 (c) Non-payroll income assessment. There shall be a second assessment, 18 on upper-bracket taxable income that is not subject to the payroll 19 assessment. It shall be progressively graduated and structured as a 20 percentage of the personal income tax on that income. 21 (d) Phased-in rates. Early in the program, when enrollment is growing, 22 the amount of the assessments shall be at an appropriate level, and 23 shall be raised as anticipated enrollment grows, to cover the actual 24 cost of the program and other provisions of article 51 of the public 25 health law. The revenue proposal shall include a mechanism for determin- 26 ing the rates of the assessments. 27 (e) Cross-border employees. (i) State residents employed out-of-state. 28 If an individual is employed out-of-state by an employer that is subject 29 to New York state law, the employer and employee shall be required to 30 pay the payroll assessment as if the employment were in the state. If an 31 individual is employed out-of-state by an employer that is not subject 32 to New York state law, either (A) the employer and employee shall volun- 33 tarily comply with the assessment or (B) the employee shall pay the 34 assessment as if he or she were self-employed. 35 (ii) Out-of-state residents employed in the state. (A) The payroll 36 assessment shall apply to any out-of-state resident who is employed or 37 self-employed in the state. (B) In the case of an out-of-state resident 38 who is employed or self-employed in the state, such individual's employ- 39 er (which term shall include a Taft-Hartley fund) shall be able to take 40 a credit against the payroll assessments they would otherwise pay, for 41 amounts they spend on health benefits that would otherwise be covered by 42 the program. For employers, the credit shall be available regardless of 43 the form of the health benefit (e.g., health insurance, a self-insured 44 plan, direct services, or reimbursement for services), to make sure that 45 the revenue proposal does not relate to employment benefits in violation 46 of the federal ERISA. An employee may take the credit for his or her 47 contribution to an employment-based health benefit. For non-employment- 48 based spending by individuals, the credit shall be available for and 49 limited to spending for health coverage (not out-of-pocket health spend- 50 ing). The credit shall be available without regard to how little is 51 spent or how sparse the benefit. The credit may only be taken against 52 the payroll assessments. Any excess amount may not be applied to other 53 tax liability. For employment-based health benefits, the credit shall be 54 distributed between the employer and employee in the same proportion as 55 the spending by each for the benefit. The employer and employee may each 56 apply their respective portion of the credit to their respective portionA. 5389--A 16 1 of the assessment. If any provision of this clause (B) or any applica- 2 tion of it shall be ruled to violate federal ERISA, the provision or the 3 application of it shall be null and void and the ruling shall not affect 4 any other provision or application of this section or the act that 5 enacted it. 6 3. The revenue proposal shall include a plan and legislative 7 provisions for ending the requirement for local social services 8 districts to pay part of the cost of Medicaid and replacing those 9 payments with revenue from the assessments under the revenue proposal. 10 4. To the extent that the revenue proposal differs from the terms of 11 subdivision 2 of this section, the revenue proposal shall state how it 12 differs from those terms and reasons for and the effects of the differ- 13 ences. 14 5. All revenue from the assessments shall be deposited in the New York 15 Health trust fund account under section 89-h of the state finance law. 16 § 4. Article 49 of the public health law is amended by adding a new 17 title 3 to read as follows: 18 TITLE III 19 COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH 20 NEW YORK HEALTH 21 Section 4920. Definitions. 22 4921. Collective negotiation authorized. 23 4922. Collective negotiation requirements. 24 4923. Requirements for health care providers' representative. 25 4924. Certain collective action prohibited. 26 4925. Fees. 27 4926. Confidentiality. 28 4927. Severability and construction. 29 § 4920. Definitions. For purposes of this title: 30 1. "New York Health" means the program under article fifty-one of this 31 chapter. 32 2. "Person" means an individual, association, corporation, or any 33 other legal entity. 34 3. "Health care providers' representative" means a third party who is 35 authorized by health care providers to negotiate on their behalf with 36 New York Health over terms and conditions affecting those health care 37 providers. 38 4. "Strike" means a work stoppage in part or in whole, direct or indi- 39 rect, by a body of workers to gain compliance with demands made on an 40 employer. 41 5. "Health care provider" means a person who is licensed, certified, 42 or registered pursuant to title eight of the education law and who prac- 43 tices as a health care provider as an independent contractor or who is 44 an owner, officer, shareholder, or proprietor of a health care provider; 45 or an entity that employs or utilizes health care providers to provide 46 health care services, including but not limited to a hospital licensed 47 under article twenty-eight of this chapter or an accountable care organ- 48 ization under article twenty-nine-E of this chapter. A health care 49 provider under title eight of the education law who practices as an 50 employee of a health care provider shall not be deemed a health care 51 provider for purposes of this title. 52 § 4921. Collective negotiation authorized. 1. Health care providers 53 may meet and communicate for the purpose of collectively negotiating the 54 following terms and conditions of provider contracts with New York 55 Health:A. 5389--A 17 1 (a) the details of the utilization review plan as defined pursuant to 2 subdivision ten of section forty-nine hundred of this article; 3 (b) the definition of medical necessity; 4 (c) the clinical practice guidelines used to make medical necessity 5 and utilization review determinations; 6 (d) preventive care and other medical coordination practices; 7 (e) drug formularies and standards and procedures for prescribing 8 off-formulary drugs; 9 (f) the details of risk transfer arrangements with providers; 10 (g) administrative procedures; 11 (h) procedures to be utilized to resolve disputes between New York 12 Health and health care providers; 13 (i) patient referral procedures; 14 (j) the formulation and application of health care provider reimburse- 15 ment procedures; 16 (k) quality assurance programs; 17 (l) the process for rendering utilization review determinations 18 including: establishment of a process for rendering utilization review 19 determinations which shall, at a minimum, include: written procedures to 20 assure that utilization reviews and determinations are conducted within 21 the timeframes established in this article; procedures to notify an 22 enrollee, an enrollee's designee and/or an enrollee's health care 23 provider of adverse determinations; and procedures for appeal of adverse 24 determinations, including the establishment of an expedited appeals 25 process for denials of continued inpatient care or where there is immi- 26 nent or serious threat to the health of the enrollee; 27 (m) health care provider selection and termination criteria used by 28 New York Health; 29 (n) the fees assessed by New York Health for services, including fees 30 established through the application of reimbursement procedures; 31 (o) the conversion factors used by New York Health in a resource-based 32 relative value scale reimbursement methodology or other similar method- 33 ology; provided the same are not otherwise established by state or 34 federal law or regulation; 35 (p) the amount of any discount granted by New York Health on the fee 36 of health care services to be rendered by health care providers; 37 (q) the dollar amount of capitation or fixed payment for health care 38 services rendered by health care providers to New York Health members; 39 (r) the procedure code or other description of a health care service 40 covered by a payment and the appropriate grouping of the procedure 41 codes; and 42 (s) the amount of any other component of the reimbursement methodology 43 for a health care service. 44 2. Nothing in this section shall be construed to allow or authorize an 45 alteration of the terms of the internal and external review procedures 46 set forth in law. 47 3. Nothing in this section shall be construed to allow a strike of New 48 York Health by health care providers. 49 4. Nothing in this section shall be construed to allow or authorize 50 terms or conditions which would impede the ability of New York Health to 51 obtain or retain accreditation by the national committee for quality 52 assurance or a similar body or to comply with applicable state or feder- 53 al law. 54 5. Nothing in this section shall be deemed to affect or limit the 55 right of a health care provider or group of health care providers toA. 5389--A 18 1 collectively petition a government entity for a change in a law, rule, 2 or regulation. 3 § 4922. Collective negotiation requirements. 1. Collective negotiation 4 rights granted by this title must conform to the following requirements: 5 (a) health care providers may communicate with other health care 6 providers regarding the terms and conditions to be negotiated with New 7 York Health; 8 (b) health care providers may communicate with health care providers' 9 representatives; 10 (c) a health care providers' representative is the only party author- 11 ized to negotiate with New York Health on behalf of the health care 12 providers as a group; 13 (d) a health care provider can be bound by the terms and conditions 14 negotiated by the health care providers' representatives; and 15 (e) in communicating or negotiating with the health care providers' 16 representative, New York Health is entitled to offer and provide differ- 17 ent terms and conditions to individual competing health care providers. 18 2. Nothing in this title shall be construed to prohibit or limit 19 collective action or collective bargaining on the part of any health 20 care provider with his or her employer or any other lawful collective 21 action or collective bargaining. 22 § 4923. Requirements for health care providers' representative. Before 23 engaging in collective negotiations with New York Health on behalf of 24 health care providers, a health care providers' representative shall 25 file with the commissioner, in the manner prescribed by the commission- 26 er, information identifying the representative, the representative's 27 plan of operation, and the representative's procedures to ensure compli- 28 ance with this title. 29 § 4924. Certain collective action prohibited. 1. This title is not 30 intended to authorize competing health care providers to act in concert 31 in response to a health care providers' representative's discussions or 32 negotiations with New York Health. 33 2. No health care providers' representative shall negotiate any agree- 34 ment that excludes, limits the participation or reimbursement of, or 35 otherwise limits the scope of services to be provided by any health care 36 provider or group of health care providers with respect to the perform- 37 ance of services that are within the health care provider's scope of 38 practice, license, registration, or certificate. 39 § 4925. Fees. Each person who acts as the representative or negotiat- 40 ing parties under this title shall pay to the department a fee to act as 41 a representative. The commissioner, by rule, shall set fees in amounts 42 deemed reasonable and necessary to cover the costs incurred by the 43 department in administering this title. 44 § 4926. Confidentiality. All reports and other information required to 45 be reported to the department under this title shall not be subject to 46 disclosure under article six of the public officers law or article thir- 47 ty-one of the civil practice law and rules. 48 § 4927. Severability and construction. If any provision or application 49 of this title shall be held to be invalid, or to violate or be incon- 50 sistent with any applicable federal law or regulation, that shall not 51 affect other provisions or applications of this title which can be given 52 effect without that provision or application; and to that end, the 53 provisions and applications of this title are severable. The provisions 54 of this title shall be liberally construed to give effect to the 55 purposes thereof.A. 5389--A 19 1 § 5. Subdivision 11 of section 270 of the public health law, as 2 amended by section 2-a of part C of chapter 58 of the laws of 2008, is 3 amended to read as follows: 4 11. "State public health plan" means the medical assistance program 5 established by title eleven of article five of the social services law 6 (referred to in this article as "Medicaid"), the elderly pharmaceutical 7 insurance coverage program established by title three of article two of 8 the elder law (referred to in this article as "EPIC"), [ and] the family 9 health plus program established by section three hundred sixty-nine-ee 10 of the social services law to the extent that section provides that the 11 program shall be subject to this article, and the New York Health 12 program established by article fifty-one of this chapter. 13 § 6. The state finance law is amended by adding a new section 89-h to 14 read as follows: 15 § 89-h. New York Health trust fund. 1. There is hereby established in 16 the joint custody of the state comptroller and the commissioner of taxa- 17 tion and finance a special revenue fund to be known as the "New York 18 Health trust fund", hereinafter known as "the fund". The definitions in 19 section fifty-one hundred of the public health law shall apply to this 20 section. 21 2. The fund shall consist of: 22 (a) all monies obtained from assessments pursuant to legislation 23 enacted as proposed under section three of the chapter of the laws of 24 New York that added this section; 25 (b) federal payments received as a result of any waiver of require- 26 ments granted or other arrangements agreed to by the United States 27 secretary of health and human services or other appropriate federal 28 officials for health care programs established under Medicare, any 29 federally-matched public health program, or the patient protection and 30 affordable care act; 31 (c) the amounts paid by the department of health and by local social 32 services districts that are equivalent to those amounts that are paid on 33 behalf of residents of this state under Medicare, any federally-matched 34 public health program, or the patient protection and affordable care act 35 for health benefits which are equivalent to health benefits covered 36 under New York Health; 37 (d) all surcharges that are imposed on residents of this state to 38 replace payments made by the residents under the cost-sharing provisions 39 of Medicare; 40 (e) federal, state and local funds for purposes of the provision of 41 services authorized under title XX of the federal social security act 42 that would otherwise be covered under article fifty-one of the public 43 health law; and 44 (f) state and local government monies that would otherwise be appro- 45 priated to any governmental agency, office, program, instrumentality or 46 institution which provides health services, for services and benefits 47 covered under New York Health. Payments to the fund pursuant to this 48 paragraph shall be in an amount equal to the money appropriated for such 49 purposes in the fiscal year immediately preceding the effective date of 50 article fifty-one of the public health law. 51 3. Monies in the fund shall only be used for purposes established 52 under article fifty-one of the public health law. 53 § 7. Temporary commission on implementation. 1. There is hereby estab- 54 lished a temporary commission on implementation of the New York Health 55 program, hereinafter to be known as the commission, consisting of 56 fifteen members: five members, including the chair, shall be appointedA. 5389--A 20 1 by the governor; four members shall be appointed by the temporary presi- 2 dent of the senate, one member shall be appointed by the senate minority 3 leader; four members shall be appointed by the speaker of the assembly, 4 and one member shall be appointed by the assembly minority leader. The 5 commissioner of health, the superintendent of financial services, and 6 the commissioner of taxation and finance, or their designees shall serve 7 as non-voting ex-officio members of the commission. 8 2. Members of the commission shall receive such assistance as may be 9 necessary from other state agencies and entities, and shall receive 10 necessary expenses incurred in the performance of their duties. The 11 commission may employ staff as needed, prescribe their duties, and fix 12 their compensation within amounts appropriate for the commission. 13 3. The commission shall examine the laws and regulations of the state 14 and make such recommendations as are necessary to conform the laws and 15 regulations of the state and article 51 of the public health law estab- 16 lishing the New York Health program and other provisions of law relating 17 to the New York Health program, and to improve and implement the 18 program. The commission shall report its recommendations to the governor 19 and the legislature. 20 § 8. Severability. If any provision or application of this act shall 21 be held to be invalid, or to violate or be inconsistent with any appli- 22 cable federal law or regulation, that shall not affect other provisions 23 or applications of this act which can be given effect without that 24 provision or application; and to that end, the provisions and applica- 25 tions of this act are severable. 26 § 9. This act shall take effect immediately.