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.
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
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.)
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
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
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
Immediately. The program will actually begin functioning when the
Commissioner of Health declares the beginning of the implementation
STATE OF NEW YORK
2013-2014 Regular Sessions
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.
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
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-
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
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
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-
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-
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
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
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-
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-
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
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-
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
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
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-
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
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
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
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
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'
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
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.