A05389 Summary:

BILL NOA05389A
 
SAME ASSAME AS S02078-A
 
SPONSORGottfried (MS)
 
COSPNSRAbinanti, 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
 
MLTSPNSRAbbate, 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.
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A05389 Memo:

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.
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A05389 Text:



 
                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.
                                                                   LBD01606-02-3

        A. 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  provider

        A. 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  health

        A. 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 and

        A. 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  to

        A. 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  assessment

        A. 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 portion

        A. 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 to

        A. 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  appointed

        A. 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.
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