Ren Art 50 §§5000 - 5003 to be Art 80 §§8000 - 8003, add Art 51 §§5100 - 5111, add Art 49 Title 3 §§4920 -
4928, amd §270, Pub Health L; add §89-j, 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: A6058
TITLE OF BILL:
An act to amend the public health law and the state finance law, in
relation to enacting the "New York health act" and establishing New York
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 network
restrictions, deductibles, or co-pays. Coverage would be publicly fund-
ed. The benefits will include comprehensive outpatient and inpatient
medical care, long-term 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. The Board shall develop proposals relating to retiree health
benefits and coverage of health care services covered under the workers'
In addition to the Board, there will be six regional advisory councils
to represent the diverse needs and concerns of the region. The councils
shall include but not be limited to representatives of health care
consumers, providers, municipal and county government, and organized
labor. The councils shall advise the Board, Commissioner, Governor, and
Legislature on matters relating to the NY Health program and shall adopt
community health improvement plans to promote health care access and
quality in their regions.
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 organiza-
tions. (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" insurance
premiums, deductibles and co-pays imposed regardless of ability to pay.
Instead, New York Health would be paid for based on ability to pay,
through a progressively-graduated payroll-based tax (paid at least 80%
by employers and not more than 20% by employees, and 100% by self-em-
ployed) and a progressively-graduated tax based on other taxable income,
such as capital gains, interest and dividends. 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
could 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, for the benefit of all residents of the state of New
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 a s global or capitat-
ed 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 arrangements 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
2014: A5389 - reported to Ways and Means
2015: A5062 - Passed Assembly / Senate Health
2016: A5062 - passed Assembly / Senate Health
2017: A4738 - passed Assembly / Senate Health
2018: A4738 - passed Assembly / Senate Health
2019: A5248 - Reported to Codes / Senate Health
2020: A5248 - Referred to Health / Senate Health
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
2021-2022 Regular Sessions
March 8, 2021
Introduced by M. of A. GOTTFRIED, ABINANTI, ANDERSON, BARRETT, BARRON,
BENEDETTO, BICHOTTE HERMELYN, BRONSON, BURDICK, CAHILL, CARROLL,
CLARK, COLTON, COOK, CRUZ, CYMBROWITZ, DE LA ROSA, DICKENS, DILAN,
DINOWITZ, ENGLEBRIGHT, EPSTEIN, FALL, FERNANDEZ, FRONTUS, GALLAGHER,
GONZALEZ-ROJAS, HUNTER, HYNDMAN, JACKSON, JEAN-PIERRE, JOYNER, KELLES,
KIM, LAVINE, LUNSFORD, LUPARDO, MAMDANI, MEEKS, MITAYNES, NIOU,
PAULIN, PEOPLES-STOKES, PERRY, PHEFFER AMATO, PICHARDO, RAJKUMAR,
RAMOS, REYES, RICHARDSON, J. RIVERA, RODRIGUEZ, L. ROSENTHAL, SAYEGH,
SEAWRIGHT, SILLITTI, SIMON, SOLAGES, FORREST, STECK, STIRPE, TAYLOR,
THIELE, VANEL, WALKER, WALLACE, WEPRIN, WILLIAMS -- Multi-Sponsored by
-- M. of A. AUBRY, DAVILA, FAHY, GALEF, GLICK, GUNTHER, MAGNARELLI,
O'DONNELL, PRETLOW, QUART, D. ROSENTHAL, ROZIC -- read once and
referred to the Committee on Health
AN ACT to amend the public health law and the state finance law, in
relation to enacting the "New York health act" and establishing New
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Short title. This act shall be known and may be cited as
2 the "New York health act".
3 § 2. Legislative findings and intent. 1. The state constitution
4 states: "The protection and promotion of the health of the inhabitants
5 of the state are matters of public concern and provision therefor shall
6 be made by the state and by such of its subdivisions and in such manner,
7 and by such means as the legislature shall from time to time determine."
8 (Article XVII, §3.) The legislature finds and declares that all resi-
9 dents of the state have the right to health care. While the federal
10 Affordable Care Act brought many improvements in health care and health
11 coverage, it still leaves many New Yorkers without coverage or with
12 inadequate coverage. Millions of New Yorkers do not get the health care
13 they need or face financial obstacles and hardships to get it. That is
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
 is old law to be omitted.
A. 6058 2
1 not acceptable. There is no plan other than the New York health act
2 that will enable New York state to meet that need. New Yorkers - as
3 individuals, employers, and taxpayers - have experienced a rise in the
4 cost of health care and coverage in recent years, including rising
5 premiums, deductibles and co-pays, restricted provider networks and high
6 out-of-network charges. Many New Yorkers go without health care because
7 they cannot afford it or suffer financial hardship to get it. Busi-
8 nesses have also experienced increases in the costs of health care bene-
9 fits for their employees, and many employers are shifting a larger share
10 of the cost of coverage to their employees or dropping coverage entire-
11 ly. Including long-term services and supports (LTSS) in New York Health
12 is a major step forward for older adults, people with disabilities, and
13 their families. Older adults and people with disabilities often cannot
14 receive the services necessary to stay in the community or other LTSS.
15 Even when older adults and people with disabilities receive LTSS, espe-
16 cially services in the community, it is often at the cost of unreason-
17 able demands on unpaid family caregivers, depleting their own or family
18 resources, or impoverishing themselves to qualify for public coverage.
19 Health care providers are also affected by inadequate health coverage in
20 New York state. A large portion of hospitals, health centers and other
21 providers now experience substantial losses due to the provision of care
22 that is uncompensated. Medicaid and Medicare often do not pay rates
23 that are reasonably related to the cost of efficiently providing health
24 care services and sufficient to assure an adequate and accessible supply
25 of health care services, as guaranteed under the New York Health Act.
26 Individuals often find that they are deprived of affordable care and
27 choice because of decisions by health plans guided by the plan's econom-
28 ic interests rather than the individual's health care needs. To address
29 the fiscal crisis facing the health care system and the state and to
30 assure New Yorkers can exercise their right to health care, affordable
31 and comprehensive health coverage must be provided. Pursuant to the
32 state constitution's charge to the legislature to provide for the health
33 of New Yorkers, this legislation is an enactment of state concern for
34 the purpose of establishing a comprehensive universal guaranteed health
35 care coverage program and a health care cost control system for the
36 benefit of all residents of the state of New York.
37 2. (a) It is the intent of the Legislature to create the New York
38 Health program to provide a universal single payer health plan for every
39 New Yorker, funded by broad-based revenue based on ability to pay. The
40 legislature intends that federal waivers and approvals be sought where
41 they will improve the administration of the New York Health program, but
42 the legislature intends that the program be implemented even in the
43 absence of such waivers or approvals. The state shall work to obtain
44 waivers and other approvals relating to Medicaid, Child Health Plus,
45 Medicare, the Affordable Care Act, and any other appropriate federal
46 programs, under which federal funds and other subsidies that would
47 otherwise be paid to New York State, New Yorkers, and health care
48 providers for health coverage that will be equaled or exceeded by New
49 York Health will be paid by the federal government to New York State and
50 deposited in the New York Health trust fund, or paid to health care
51 providers and individuals in combination with New York Health trust fund
52 payments, and for other program modifications (including elimination of
53 cost sharing and insurance premiums). Under such waivers and approvals,
54 health coverage under those programs will, to the maximum extent possi-
55 ble, be replaced and merged into New York Health, which will operate as
56 a true single-payer program.
A. 6058 3
1 (b) If any necessary waiver or approval is not obtained, the state
2 shall use state plan amendments and seek waivers and approvals to maxi-
3 mize, and make as seamless as possible, the use of federally-matched
4 health programs and federal health programs in New York Health. Thus,
5 even where other programs such as Medicaid or Medicare may contribute to
6 paying for care, it is the goal of this legislation that the coverage
7 will be delivered by New York Health and, as much as possible, the
8 multiple sources of funding will be pooled with other New York Health
9 funds and not be apparent to New York Health members or participating
11 (c) This program will promote movement away from fee-for-service
12 payment, which tends to reward quantity and requires excessive adminis-
13 trative expense, and towards alternate payment methodologies, such as
14 global or capitated payments to providers or health care organizations,
15 that promote quality, efficiency, investment in primary and preventive
16 care, and innovation and integration in the organizing of health care.
17 (d) The program shall promote the use of clinical data to improve the
18 quality of health care and public health, consistent with protection of
19 patient confidentiality. The program shall maximize patient autonomy in
20 choice of health care providers and health care decision making. Care
21 coordination within the program shall ensure management and coordination
22 among a patient's health care services, consistent with patient autonomy
23 and person-centered service planning, rather than acting as a gatekeeper
24 to needed services.
25 (e) The program shall operate with care, skill, prudence, diligence,
26 and professionalism, and for the best interests primarily of the members
27 and health care providers.
28 3. This act does not create or relate to any employment benefit or
29 employment benefit plan, nor does it require, prohibit, or limit the
30 providing of any employment benefit or employment benefit plan.
31 4. In order to promote improved quality of, and access to, health care
32 services and promote improved clinical outcomes, it is the policy of the
33 state to encourage cooperative, collaborative and integrative arrange-
34 ments among health care providers who might otherwise be competitors,
35 under the active supervision of the commissioner of health. It is the
36 intent of the state to supplant competition with such arrangements and
37 regulation only to the extent necessary to accomplish the purposes of
38 this act, and to provide state action immunity under the state and
39 federal antitrust laws to health care providers, particularly with
40 respect to their relations with the single-payer New York Health plan
41 created by this act.
42 5. There have been numerous professional economic analyses of state
43 and national single-payer health proposals, including the New York
44 Health Act, by noted consulting firms and academic economists. They have
45 almost all come to similar conclusions of net savings in the cost of
46 health coverage and health care. These savings are driven by (a) elimi-
47 nating the administrative bureaucracy costs, marketing, and profit of
48 multiple health plans and replacing that with the dramatically lower
49 costs of running a single-payer system; (b) substantially reducing the
50 administrative costs borne by health care providers dealing with those
51 health plans; and (c) using the negotiating power of 20 million consum-
52 ers to achieve lower drug prices. These savings will more than offset
53 costs primarily from (a) relieving patients of deductibles, co-pays, and
54 out-of-network charges; (b) covering the uninsured; (c) increasing
55 provider payment rates above Medicare and Medicaid rates; and (d)
56 replacing uncompensated home health care with paid care. Unlike premiums
A. 6058 4
1 and out-of-pocket spending, the New York Health Act tax will be progres-
2 sively graduated based on ability to pay. The vast majority of New
3 Yorkers today spend dramatically more in premiums, deductibles and other
4 out-of-pocket costs than they will in New York Health Act taxes. They
5 will have broader coverage (including long-term care), no restricted
6 provider networks or out-of-network charges, and no deductibles or
8 § 3. Article 50 and sections 5000, 5001, 5002 and 5003 of the public
9 health law are renumbered article 80 and sections 8000, 8001, 8002 and
10 8003, respectively, and a new article 51 is added to read as follows:
11 ARTICLE 51
12 NEW YORK HEALTH
13 Section 5100. Definitions.
14 5101. Program created.
15 5102. Board of trustees.
16 5103. Eligibility and enrollment.
17 5104. Benefits.
18 5105. Health care providers; care coordination; payment method-
20 5106. Health care organizations.
21 5107. Program standards.
22 5108. Regulations.
23 5109. Provisions relating to federal health programs.
24 5110. Additional provisions.
25 5111. Regional advisory councils.
26 § 5100. Definitions. As used in this article, the following terms
27 shall have the following meanings, unless the context clearly requires
29 1. "Board" means the board of trustees of the New York Health program
30 created by section fifty-one hundred two of this article, and "trustee"
31 means a trustee of the board.
32 2. "Care coordination" means, but is not limited to, managing, refer-
33 ring to, locating, coordinating, and monitoring health care services for
34 the member to assure that all medically necessary health care services
35 are made available to and are effectively used by the member in a timely
36 manner, consistent with patient autonomy. Care coordination does not
37 include a requirement for prior authorization for health care services
38 or for referral for a member to receive a health care service.
39 3. "Care coordinator" means an individual or entity approved to
40 provide care coordination under subdivision two of section fifty-one
41 hundred five of this article.
42 4. "Federally-matched public health program" means the medical assist-
43 ance program under title eleven of article five of the social services
44 law, the basic health program under section three hundred sixty-nine-gg
45 of the social services law, and the child health plus program under
46 title one-A of article twenty-five of this chapter.
47 5. "Health care organization" means an entity that is approved by the
48 commissioner under section fifty-one hundred six of this article to
49 provide health care services to members under the program.
50 6. "Health care provider" means any individual or entity legally
51 authorized to provide a health care service under Medicaid or Medicare
52 or this article. "Health care professional" means a health care provider
53 that is an individual licensed, certified, registered or otherwise
54 authorized to practice under title eight of the education law to provide
55 such health care service, acting within his or her lawful scope of prac-
A. 6058 5
1 7. "Health care service" means any health care service, including care
2 coordination, included as a benefit under the program.
3 8. "Implementation period" means the period under subdivision three of
4 section fifty-one hundred one of this article during which the program
5 will be subject to special eligibility and financing provisions until it
6 is fully implemented under that section.
7 9. "Medicaid" or "medical assistance" means title eleven of article
8 five of the social services law and the program thereunder. "Child
9 health plus" means title one-A of article twenty-five of this chapter
10 and the program thereunder. "Medicare" means title XVIII of the federal
11 social security act and the programs thereunder. "Affordable care act"
12 means the federal patient protection and affordable care act, public law
13 111-148, as amended by the health care and education reconciliation act
14 of 2010, public law 111-152, and as otherwise amended and any regu-
15 lations or guidance issued thereunder. "Basic health program" means
16 section three hundred sixty-nine-gg of the social services law and the
17 program thereunder.
18 10. "Member" means an individual who is enrolled in the program.
19 11. "New York Health", "New York Health program", and "program" mean
20 the New York Health program created by section fifty-one hundred one of
21 this article.
22 12. "New York Health trust fund" means the New York Health trust fund
23 established under section eighty-nine-j of the state finance law.
24 13. "Out-of-state health care service" means a health care service
25 provided to a member while the member is temporarily out of the state
26 and (a) it is medically necessary that the health care service be
27 provided while the member is out of the state, or (b) it is clinically
28 appropriate that the health care service be provided by a particular
29 health care provider located out of the state rather than in the state.
30 However, any health care service provided to a New York Health enrollee
31 by a health care provider qualified under paragraph (a) of subdivision
32 three of section fifty-one hundred five of this article that is located
33 outside the state shall not be considered an out-of-state service and
34 shall be covered as otherwise provided in this article.
35 14. "Participating provider" means any individual or entity that is a
36 health care provider qualified under subdivision three of section
37 fifty-one hundred five of this article that provides health care
38 services to members under the program, or a health care organization.
39 15. "Person" means any individual or natural person, trust, partner-
40 ship, association, unincorporated association, corporation, company,
41 limited liability company, proprietorship, joint venture, firm, joint
42 stock association, department, agency, authority, or other legal entity,
43 whether for-profit, not-for-profit or governmental.
44 16. "Prescription and non-prescription drugs" means prescription drugs
45 as defined in section two hundred seventy of this chapter, and non-pres-
46 cription smoking cessation products or devices.
47 17. "Resident" means an individual whose primary place of abode is in
48 the state or, in the case of an individual whose primary place of abode
49 is not in the state, who is employed or self-employed full-time in the
50 state, without regard to the individual's immigration status, as deter-
51 mined according to regulations of the commissioner. Such regulations
52 shall include a process for appealing denials of residency.
53 § 5101. Program created. 1. The New York Health program is hereby
54 created in the department. The commissioner shall establish and imple-
55 ment the program under this article. The program shall provide compre-
56 hensive health coverage to every resident who enrolls in the program.
A. 6058 6
1 2. The commissioner shall, to the maximum extent possible, organize,
2 administer and market the program and services as a single program under
3 the name "New York Health" or such other name as the commissioner shall
4 determine, regardless of under which law or source the definition of a
5 benefit is found including (on a voluntary basis) retiree health bene-
6 fits. In implementing this article, the commissioner shall avoid jeop-
7 ardizing federal financial participation in these programs and shall
8 take care to promote public understanding and awareness of available
9 benefits and programs.
10 3. The commissioner shall determine when individuals may begin enroll-
11 ing in the program. There shall be an implementation period, which shall
12 begin on the date that individuals may begin enrolling in the program
13 and shall end as determined by the commissioner. Individuals may not
14 enroll in the New York Health program until the legislature has enacted
15 the revenue proposal, as amended, and as the legislature shall further
17 4. An insurer authorized to provide coverage pursuant to the insurance
18 law or a health maintenance organization certified under this chapter
19 may, if otherwise authorized, offer benefits that do not cover any
20 service for which coverage is offered to individuals under the program,
21 but may not offer benefits that cover any service for which coverage is
22 offered to individuals under the program. Provided, however, that this
23 subdivision shall not prohibit (a) the offering of any benefits to or
24 for individuals, including their families, who are employed or self-em-
25 ployed in the state but who are not residents of the state, or (b) the
26 offering of benefits during the implementation period to individuals who
27 enrolled or may enroll as members of the program, or (c) the offering of
28 retiree health benefits.
29 5. A college, university or other institution of higher education in
30 the state may purchase coverage under the program for any student, or
31 student's dependent, who is not a resident of the state.
32 6. To the extent any provision of this chapter, the social services
33 law, the insurance law or the elder law:
34 (a) is inconsistent with any provision of this article or the legisla-
35 tive intent of the New York Health Act, this article shall apply and
36 prevail, except where explicitly provided otherwise by this article; or
37 explicitly required by applicable federal law or regulations and
38 (b) is consistent with the provisions of this article and the legisla-
39 tive intent of the New York Health Act, the provision of that law shall
41 7. (a) (i) The program shall be deemed to be a health care plan for
42 purposes of external appeal under article forty-nine of this chapter
43 (referred to in this subdivision as "article forty-nine"), subject to
44 this subdivision and any other applicable provision of this article.
45 (ii) An external appeal shall not require utilization review or an
46 adverse determination under title one of article forty-nine of this
47 chapter. Any reference in article forty-nine to utilization review or a
48 universal review agent shall mean the program. Where the program makes
49 an adverse determination, an external appeal shall be automatic unless
50 specifically waived or withdrawn by the member or the member's designee.
51 Services, including services provided for a chronic condition, will
52 continue unchanged until the outcome of the external appeal decision is
53 issued. Where an external appeal is initiated or pursued by the
54 patient's health care provider, the provider shall notify the member or
55 the member's designee, and it shall be subject to the member's or
56 member's designee's right to waive or withdraw the external appeal. No
A. 6058 7
1 fee shall be required to be paid by any party to an external appeal,
2 including the member's health care provider.
3 (iii) Where an external appeal is denied, the external appeal agent
4 shall notify the member or the member's designee and, where appropriate,
5 the member's health care provider, within two business days of the
6 determination. The notice shall include a statement that the member,
7 member's designee or health care provider has the right to appeal the
8 determination to a fair hearing under this subdivision and seek judicial
10 (iv) An enrollee may designate a person or entity, including, but not
11 limited to, the enrollee's family member, care coordinator, a health
12 care organization providing the service under review or appeal, or a
13 labor union or an entity affiliated with and designated by a labor union
14 of which the enrollee or enrollee's family member is a member, to serve
15 as the enrollee's designee for purposes of that article, if the person
16 or entity agrees to be the designee.
17 (b) (i) This paragraph applies where an external appeal is denied in
18 whole or in part; or the program denies coverage for a health care
19 service on any grounds other than under article forty-nine; or the
20 program makes any other determination as to a member or individual seek-
21 ing to become a member, contrary to the interest of the member or indi-
22 vidual (including but not limited to a denial of eligibility for lack of
24 (ii) The program shall notify the member or individual, member's
25 designee or health care provider, as appropriate, that the person has
26 the right to appeal the determination to a fair hearing under this
27 subdivision or seek judicial review.
28 (iii) The commissioner shall establish by regulation a process for
29 fair hearings under this subdivision. The process shall at a minimum
30 conform to the standards for fair hearings under section twenty-two of
31 the social services law.
32 (c) Article seventy-eight of the civil practice law and rules shall
33 apply to any matter under this article.
34 8. (a) No member shall be required to receive any health care service
35 through any entity organized, certified or operating under guidelines
36 under article forty-four of this chapter, or specified under section
37 three hundred sixty-four-j of the social services law, the insurance law
38 or the elder law. No such entity shall receive payment for health care
39 services (other than care coordination) from the program.
40 (b) However, this subdivision shall not preclude the use of a Medicare
41 managed care ("Medicare advantage") entity or other entity created by or
42 under the direction of the program where reasonably necessary to maxi-
43 mize federal financial participation or other federal financial support
44 under any federally-matched public health program, Medicare or the
45 Affordable Care Act. Any entity under this paragraph shall, to the maxi-
46 mum extent feasible, operate in the background, without burden on or
47 interference with the member and health care provider, without depriving
48 the member or health care provider of any right or benefit under the
49 program and otherwise consistent with this article.
50 9. The program shall include provisions for an appropriate reserve
52 10. (a) This subdivision applies to every person who is a retiree of a
53 public employer, as defined in section two hundred one of the civil
54 service law, and any person who is a beneficiary of the retiree's public
55 employee retiree health benefit. Any reference to the retiree shall mean
56 and include any beneficiary of the retiree. This subdivision does not
A. 6058 8
1 create or increase any eligibility for any public employee retiree
2 health benefit that would not otherwise exist and does not diminish any
3 public employee retiree health benefit.
4 (b) This paragraph applies to the retiree while he or she is a resi-
5 dent of New York state. The retiree shall enroll in the program. If, by
6 the implementation date, the retiree has not enrolled in the program,
7 the appropriate public employee retiree health benefit program and the
8 commissioner shall enroll the retiree in the New York Health program. If
9 the retiree's public employee retiree health benefit includes any
10 service for which coverage is not offered under the New York Health
11 program, the retiree shall continue to receive that benefit from the
12 appropriate public employee retiree health benefit program.
13 (c) For every retiree, while he or she is not a resident of New York
14 state, the appropriate public employee retiree health benefit program
15 shall maintain the retiree's public employee retiree health benefit as
16 if this article had not been enacted.
17 § 5102. Board of trustees. 1. The New York Health board of trustees is
18 hereby created in the department. The board of trustees shall, at the
19 request of the commissioner, consider any matter to effectuate the
20 provisions and purposes of this article, and may advise the commissioner
21 thereon; and it may, from time to time, submit to the commissioner any
22 recommendations to effectuate the provisions and purposes of this arti-
23 cle. The commissioner may propose regulations under this article and
24 amendments thereto for consideration by the board. The board of trustees
25 shall have no executive, administrative or appointive duties except as
26 otherwise provided by law. The board of trustees shall have power to
27 establish, and from time to time, amend regulations to effectuate the
28 provisions and purposes of this article, subject to approval by the
30 2. The board shall be composed of:
31 (a) the commissioner, the superintendent of financial services, and
32 the director of the budget, or their designees, as ex officio members:
33 (b) thirty-one trustees appointed by the governor;
34 (i) six of whom shall be representatives of health care consumer advo-
35 cacy organizations which have a statewide or regional constituency, who
36 have been involved in issues of interest to low- and moderate-income
37 individuals, older adults, and people with disabilities; at least three
38 of whom shall represent organizations led by consumers in those groups;
39 (ii) three of whom shall be representatives of professional organiza-
40 tions representing physicians;
41 (iii) five of whom shall be representatives of professional organiza-
42 tions representing licensed or registered health care professionals
43 other than physicians;
44 (iv) three of whom shall be representatives of general hospitals, one
45 of whom shall be a representative of public general hospitals;
46 (v) one of whom shall be a representative of community health centers;
47 (vi) two of whom shall be representatives of rehabilitation or home
48 care providers;
49 (vii) two of whom shall be representatives of behavioral or mental
50 health or disability service providers;
51 (viii) two of whom shall be representatives of health care organiza-
53 (ix) three of whom shall be representatives of organized labor;
54 (x) two of whom shall have demonstrated expertise in health care
55 finance; and
A. 6058 9
1 (xi) two of whom shall be employers or representatives of employers
2 who pay the payroll tax under this article, or, prior to the tax becom-
3 ing effective, will pay the tax; and
4 (c) fourteen trustees appointed by the governor; five of whom to be
5 appointed on the recommendation of the speaker of the assembly; five of
6 whom to be appointed on the recommendation of the temporary president of
7 the senate; two of whom to be appointed on the recommendation of the
8 minority leader of the assembly; and two of whom to be appointed on the
9 recommendation of the minority leader of the senate.
10 3. (a) After the end of the implementation period, no person shall be
11 a trustee unless he or she is a member of the program.
12 (b) Each trustee shall serve at the pleasure of the appointing offi-
13 cer, except the ex officio trustees.
14 4. The chair of the board shall be appointed, and may be removed as
15 chair, by the governor from among the trustees. The board shall meet at
16 least four times each calendar year. Meetings shall be held upon the
17 call of the chair and as provided by the board. A majority of the
18 appointed trustees shall be a quorum of the board, and the affirmative
19 vote of a majority of the trustees voting, but not less than twelve,
20 shall be necessary for any action to be taken by the board. The board
21 may establish an executive committee to exercise any powers or duties of
22 the board as it may provide, and other committees to assist the board or
23 the executive committee. The chair of the board shall chair the execu-
24 tive committee and shall appoint the chair and members of all other
25 committees. The board of trustees may appoint one or more advisory
26 committees. Members of advisory committees need not be members of the
27 board of trustees.
28 5. Trustees shall serve without compensation but shall be reimbursed
29 for their necessary and actual expenses incurred while engaged in the
30 business of the board. However, the board may provide for compensation
31 in cases where a lack of compensation would limit the ability of a trus-
32 tee or represented organization to participate in board business.
33 6. Notwithstanding any provision of law to the contrary, no officer or
34 employee of the state or any local government shall forfeit or be deemed
35 to have forfeited his or her office or employment by reason of being a
37 7. The board and its committees and advisory committees may request
38 and receive the assistance of the department and any other state or
39 local governmental entity in exercising its powers and duties.
40 8. No later than two years after the effective date of this article:
41 (a) The board shall develop proposals for: (i) incorporating retiree
42 health benefits into New York Health; (ii) accommodating employer reti-
43 ree health benefits for people who have been members of New York Health
44 but live as retirees out of the state; and (iii) accommodating employer
45 retiree health benefits for people who earned or accrued such benefits
46 while residing in the state prior to the implementation of New York
47 Health and live as retirees out of the state. The board shall present
48 its proposals to the governor and the legislature.
49 (b) The board shall develop a proposal for New York Health coverage of
50 health care services covered under the workers' compensation law,
51 including whether and how to continue funding for those services under
52 that law and whether and how to incorporate an element of experience
54 (c) The board shall develop a proposal for New York Health coverage,
55 for members, of health care services covered under paragraph one of
56 subsection (a) of section fifty-one hundred two of the insurance law
A. 6058 10
1 relating to motor vehicle insurance reparations, including whether and
2 how to continue funding for those services.
3 (d) The board shall develop a proposal for integration of federal
4 veterans health administration programs with New York Health coverage of
5 health care services; provided however that enrollment in or eligibility
6 for federal veterans health administration programs shall not affect a
7 resident's eligibility for New York Health coverage.
8 § 5103. Eligibility and enrollment. 1. Every resident of the state
9 shall be eligible and entitled to enroll as a member under the program.
10 2. No individual shall be required to pay any premium or other charge
11 for enrolling in or being a member under the program.
12 3. A newborn child shall be enrolled as of the date of the child's
13 birth if enrollment is done prior to the child's birth or within sixty
14 days after the child's birth.
15 § 5104. Benefits. 1. The program shall provide comprehensive health
16 coverage to every member, which shall include all health care services
17 required to be covered under any of the following, without regard to
18 whether the member would otherwise be eligible for or covered by the
19 program or source referred to:
20 (a) child health plus;
21 (b) Medicaid, including but not limited to services provided under
22 Medicaid waiver programs, including but not limited to those granted
23 under section 1915 of the federal social security act to persons with
24 traumatic brain injuries or qualifying for nursing home diversion and
25 transition services;
26 (c) Medicare;
27 (d) article forty-four of this chapter or article thirty-two or
28 forty-three of the insurance law;
29 (e) article eleven of the civil service law, as of the date one year
30 before the beginning of the implementation period;
31 (f) any cost incurred defined in paragraph one of subsection (a) of
32 section fifty-one hundred two of the insurance law, provided that this
33 coverage shall not replace coverage under article fifty-one of the
34 insurance law;
35 (g) any additional health care service authorized to be added to the
36 program's benefits by the program; and
37 (h) provided that where any state law or regulation related to any
38 federally-matched public health program states that a benefit is contin-
39 gent on federal financial participation, or words to that effect, the
40 benefit shall be included under the New York Health program without
41 regard to federal financial participation.
42 2. No member shall be required to pay any premium, deductible, co-pay-
43 ment or co-insurance under the program.
44 3. The program shall provide for payment under the program for:
45 (a) emergency and temporary health care services provided to a member
46 or individual entitled to become a member who has not had a reasonable
47 opportunity to become a member or to enroll with a care coordinator; and
48 (b) health care services provided in an emergency to an individual who
49 is entitled to become a member or enrolled with a care coordinator,
50 regardless of having had an opportunity to do so.
51 § 5105. Health care providers; care coordination; payment methodol-
52 ogies. 1. Choice of health care provider. (a) Any health care provider
53 qualified to participate under this section may provide health care
54 services under the program, provided that the health care provider is
55 otherwise legally authorized to perform the health care service for the
56 individual and under the circumstances involved.
A. 6058 11
1 (b) A member may choose to receive health care services under the
2 program from any participating provider, consistent with provisions of
3 this article relating to care coordination and health care organiza-
4 tions, the willingness or availability of the provider (subject to
5 provisions of this article relating to discrimination), and the appro-
6 priate clinically-relevant circumstances.
7 2. Care coordination. (a) A care coordinator may be an individual or
8 entity that is approved by the program that is:
9 (i) a health care practitioner who is: (A) the member's primary care
10 practitioner; (B) at the option of a female member, the member's provid-
11 er of primary gynecological care; or (C) at the option of a member who
12 has a chronic condition that requires specialty care, a specialist
13 health care practitioner who regularly and continually provides treat-
14 ment for that condition to the member;
15 (ii) an entity licensed under article twenty-eight of this chapter or
16 certified under article thirty-six of this chapter, or, with respect to
17 a member who receives chronic mental health care services, an entity
18 licensed under article thirty-one of the mental hygiene law or other
19 entity approved by the commissioner in consultation with the commission-
20 er of mental health;
21 (iii) a health care organization;
22 (iv) a labor union or an entity affiliated with and designated by a
23 labor union of which the enrollee or enrollee's family member is a
24 member, with respect to its members and their family members; provided
25 that this provision shall not preclude such an entity from becoming a
26 care coordinator under subparagraph (v) of this paragraph or a health
27 care organization under section fifty-one hundred six of this article;
29 (v) any not-for-profit or governmental entity approved by the program.
30 (b)(i) Every member shall enroll with a care coordinator that agrees
31 to provide care coordination to the member prior to receiving health
32 care services to be paid for under the program. Health care services
33 provided to a member shall not be subject to payment under the program
34 unless the member is enrolled with a care coordinator at the time the
35 health care service is provided.
36 (ii) This paragraph shall not apply to health care services provided
37 under subdivision three of section fifty-one hundred four of this arti-
38 cle (certain emergency or temporary services).
39 (iii) The member shall remain enrolled with that care coordinator
40 until the member becomes enrolled with a different care coordinator or
41 ceases to be a member. Members have the right to change their care coor-
42 dinator on terms at least as permissive as the provisions of section
43 three hundred sixty-four-j of the social services law relating to an
44 individual changing his or her primary care provider or managed care
46 (c) Care coordination shall be provided to the member by the member's
47 care coordinator. A care coordinator may employ or utilize the services
48 of other individuals or entities to assist in providing care coordi-
49 nation for the member, consistent with regulations of the commissioner.
50 (d) A health care organization may establish rules relating to care
51 coordination for members in the health care organization, different from
52 this subdivision but otherwise consistent with this article and other
53 applicable laws.
54 (e) The commissioner shall develop and implement procedures and stand-
55 ards for an individual or entity to be approved to be a care coordinator
56 in the program, including but not limited to procedures and standards
A. 6058 12
1 relating to the revocation, suspension, limitation, or annulment of
2 approval on a determination that the individual or entity is not quali-
3 fied or competent to be a care coordinator or has exhibited a course of
4 conduct which is either inconsistent with program standards and regu-
5 lations or which exhibits an unwillingness to meet such standards and
6 regulations, or is a potential threat to the public health or safety.
7 Such procedures and standards shall not limit approval to be a care
8 coordinator in the program for criteria other than those under this
9 section and shall be consistent with good professional practice. In
10 developing the procedures and standards, the commissioner shall: (i)
11 consider existing standards developed by national accrediting and
12 professional organizations; and (ii) consult with national and local
13 organizations working on care coordination or similar models, including
14 health care practitioners, hospitals, clinics, birth centers, long-term
15 supports and service providers, consumers and their representatives, and
16 labor organizations representing health care workers. When developing
17 and implementing standards of approval of care coordinators for individ-
18 uals receiving chronic mental health care services, the commissioner
19 shall consult with the commissioner of mental health. An individual or
20 entity may not be a care coordinator unless the services included in
21 care coordination are within the individual's professional scope of
22 practice or the entity's legal authority.
23 (f) To maintain approval under the program, a care coordinator must:
24 (i) renew its status at a frequency determined by the commissioner; and
25 (ii) provide data to the department as required by the commissioner to
26 enable the commissioner to evaluate the impact of care coordinators on
27 quality, outcomes, cost, and patient and provider satisfaction.
28 (g) Nothing in this subdivision shall authorize any individual to
29 engage in any act in violation of title eight of the education law.
30 3. Health care providers. (a) The commissioner shall establish and
31 maintain procedures and standards for health care providers to be quali-
32 fied to participate in the program, including but not limited to proce-
33 dures and standards relating to the revocation, suspension, limitation,
34 or annulment of qualification to participate on a determination that the
35 health care provider is not qualified or competent to be a provider of
36 specific health care services or has exhibited a course of conduct which
37 is either inconsistent with program standards and regulations or which
38 exhibits an unwillingness to meet such standards and regulations, or is
39 a potential threat to the public health or safety. Such procedures and
40 standards shall not limit health care provider participation in the
41 program for criteria other than those under this section and shall be
42 consistent with good professional practice. Such procedures and stand-
43 ards may be different for different types of health care providers and
44 health care professionals. The commissioner may require that health
45 care providers and health care professionals participate in Medicaid,
46 child health plus, or Medicare to qualify to participate in the program.
47 Any health care provider that is qualified to participate under Medi-
48 caid, child health plus or Medicare shall be deemed to be qualified to
49 participate in the program, and any health care provider's revocation,
50 suspension, limitation, or annulment of qualification to participate in
51 any of those programs shall apply to the health care provider's quali-
52 fication to participate in the program; provided that a health care
53 provider qualified under this sentence shall follow the procedures to
54 become qualified under the program by the end of the implementation
A. 6058 13
1 (b) The commissioner shall establish and maintain procedures and stan-
2 dards for recognizing health care providers located out of the state for
3 purposes of providing coverage under the program for out-of-state health
4 care services.
5 (c) Procedures and standards under this subdivision shall include
6 provisions for expedited temporary qualification to participate in the
7 program for health care professionals who are (i) temporarily authorized
8 to practice in the state or (ii) are recently arrived in the state or
9 recently authorized to practice in the state.
10 4. Payment for health care services. (a) (i) The commissioner may
11 establish by regulation payment methodologies for health care services
12 and care coordination provided to members under the program by partic-
13 ipating providers, care coordinators, and health care organizations.
14 There may be a variety of different payment methodologies, including
15 those established on a demonstration basis.
16 (ii) All payment methodologies and rates under the program shall be
17 reasonable and reasonably related to the cost of efficiently providing
18 the health care service and assuring an adequate and accessible supply
19 of the health care service.
20 (iii) In determining such payment methodologies and rates, the commis-
21 sioner shall consider factors including usual and customary rates imme-
22 diately prior to the implementation of the program, reported in a bench-
23 marking database maintained by a nonprofit organization specified by the
24 superintendent of financial services, under section six hundred three of
25 the financial services law; the level of training, education, and expe-
26 rience of the health care provider or providers involved; and the scope
27 of services, complexity, and circumstances of care including geographic
28 factors. Until and unless other applicable payment methodologies are
29 established, health care services provided to members under the program
30 shall be paid for on a fee-for-service basis, except for care coordi-
32 (b) The program shall engage in good faith negotiations with health
33 care providers' representatives under title III of article forty-nine of
34 this chapter, including, but not limited to, in relation to rates of
35 payment and payment methodologies.
36 (c) (i) Prescription drugs eligible for reimbursement under this arti-
37 cle and dispensed by a pharmacy shall be provided and paid for under the
38 preferred drug program and the clinical drug review program under title
39 one of article two-A of this chapter, except as otherwise provided in
40 this paragraph. As used in this paragraph, "managed care provider"
41 means an entity under paragraph (b) of subdivision eight of section
42 fifty-one hundred one of this article that qualifies under the federal
43 Public Health Services Act (the "340B program").
44 (ii) Where the member is enrolled in a managed care provider and a
45 prescription for the member is made under section 340B of the federal
46 Public Health Service Act (the "340B program") and under a memorandum of
47 understanding relating to the 340B program between the New York Health
48 program and the relevant 340B program covered entity, the managed care
49 provider shall purchase, pay for and provide for the drugs under the
50 340B program. However, the prescription shall be subject to section two
51 hundred seventy-three (preferred drug program prior authorization) and
52 section two hundred seventy-four (clinical drug review program) of this
54 (iii) The New York Health program shall enter into and maintain a
55 memorandum of understanding relating to the 340B program with each 340B
56 covered entity in the state that agrees to do so.
A. 6058 14
1 (iv) Where prescription drugs are not dispensed through a pharmacy,
2 payment shall be made as otherwise provided in this article, including
3 use of the 340B program as appropriate.
4 (d) Payment for health care services established under this article
5 shall be considered payment in full. A participating provider shall not
6 charge any rate in excess of the payment established under this article
7 for any health care service provided under the program and shall not
8 solicit or accept payment from any member or third party for any such
9 service except as provided under section fifty-one hundred nine of this
10 article. However, this paragraph shall not preclude the program from
11 acting as a primary or secondary payer in conjunction with another
12 third-party payer where permitted under section fifty-one hundred nine
13 of this article.
14 (e) The program may provide in payment methodologies for payment for
15 capital related expenses for specifically identified capital expendi-
16 tures incurred by not-for-profit or governmental entities certified
17 under article twenty-eight of this chapter. Any capital related expense
18 generated by a capital expenditure that requires or required approval
19 under article twenty-eight of this chapter must have received that
20 approval for the capital related expense to be paid for under the
22 (f) Payment methodologies and rates shall include a distinct component
23 of reimbursement for direct and indirect graduate medical education as
24 defined, calculated and implemented pursuant to section twenty-eight
25 hundred seven-c of this chapter.
26 (g) The commissioner shall provide by regulation for payment method-
27 ologies and procedures for paying for out-of-state health care services.
28 5. Prior authorization. The program shall not require prior authori-
29 zation for any health care service in any manner more restrictive of
30 access to or payment for the service than would be required for the
31 service under Medicare Part A or Part B. Prior authorization for
32 prescription drugs provided by pharmacies under the program shall be
33 under title one of article two-A of this chapter.
34 § 5106. Health care organizations. 1. A member may choose to enroll
35 with and receive health care services under the program from a health
36 care organization.
37 2. A health care organization shall be a not-for-profit or govern-
38 mental entity that is approved by the commissioner that is:
39 (a) an accountable care organization under article twenty-nine-E of
40 this chapter; or
41 (b) a labor union or an entity affiliated with and designated by a
42 labor union of which the enrollee or enrollee's family member is a
43 member (i) with respect to its members and their family members, and
44 (ii) if allowed by applicable law and approved by the commissioner, for
45 other members of the program.
46 3. A health care organization may be responsible for providing all or
47 part of the health care services to which its members are entitled under
48 the program, consistent with the terms of its approval by the commis-
50 4. (a) The commissioner shall develop and implement procedures and
51 standards for an entity to be approved to be a health care organization
52 in the program, including but not limited to procedures and standards
53 relating to the revocation, suspension, limitation, or annulment of
54 approval on a determination that the entity is not competent to be a
55 health care organization or has exhibited a course of conduct which is
56 either inconsistent with program standards and regulations or which
A. 6058 15
1 exhibits an unwillingness to meet such standards and regulations, or is
2 a potential threat to the public health or safety. Such procedures and
3 standards shall not limit approval to be a health care organization in
4 the program for criteria other than those under this section and shall
5 be consistent with good professional practice. In developing the proce-
6 dures and standards, the commissioner shall: (i) consider existing stan-
7 dards developed by national accrediting and professional organizations;
8 and (ii) consult with national and local organizations working in the
9 field of health care organizations, including health care practitioners,
10 hospitals, clinics, birth centers, long-term supports and service
11 providers, consumers and their representatives and labor organizations
12 representing health care workers. When developing and implementing stan-
13 dards of approval of health care organizations, the commissioner shall
14 consult with the commissioner of mental health, the commissioner of
15 developmental disabilities, the director of the state office for the
16 aging, the commissioner of the office of addiction services and
17 supports, and the commissioner of the division of human rights.
18 (b) To maintain approval under the program, a health care organization
19 must: (i) renew its status at a frequency determined by the commission-
20 er; and (ii) provide data to the department as required by the commis-
21 sioner to enable the commissioner to evaluate the health care organiza-
22 tion in relation to quality of health care services, health care
23 outcomes, cost, and patient and provider satisfaction.
24 5. The commissioner shall make regulations relating to health care
25 organizations consistent with and to ensure compliance with this arti-
27 6. The provision of health care services directly or indirectly by a
28 health care organization through health care providers shall not be
29 considered the practice of a profession under title eight of the educa-
30 tion law by the health care organization.
31 § 5107. Program standards. 1. The commissioner shall establish
32 requirements and standards for the program and for health care organiza-
33 tions, care coordinators, and health care providers, consistent with
34 this article, including requirements and standards for, as applicable:
35 (a) the scope, quality and accessibility of health care services;
36 (b) relations between health care organizations or health care provid-
37 ers and members; and
38 (c) relations between health care organizations and health care
39 providers, including (i) credentialing and participation in the health
40 care organization; and (ii) terms, methods and rates of payment.
41 2. Requirements and standards under the program shall include, but not
42 be limited to, provisions to promote the following:
43 (a) simplification, transparency, uniformity, and fairness in health
44 care provider credentialing and participation in health care organiza-
45 tion networks, referrals, payment procedures and rates, claims process-
46 ing, and approval of health care services, as applicable;
47 (b) primary and preventive care, care coordination, efficient and
48 effective health care services, quality assurance, coordination and
49 integration of health care services, including use of appropriate tech-
50 nology, and promotion of public, environmental and occupational health;
51 (c) elimination of health care disparities;
52 (d) non-discrimination with respect to members and health care provid-
53 ers on the basis of race, ethnicity, national origin, religion, disabil-
54 ity, age, sex, sexual orientation, gender identity or expression, or
55 economic circumstances; provided that health care services provided
A. 6058 16
1 under the program shall be appropriate to the patient's clinically-rele-
2 vant circumstances;
3 (e) accessibility of care coordination, health care organization
4 services and health care services, including accessibility for people
5 with disabilities and people with limited ability to speak or understand
6 English, and the providing of care coordination, health care organiza-
7 tion services and health care services in a culturally competent manner;
9 (f) especially in relation to long-term supports and services, the
10 maximization and prioritization of the most integrated community-based
11 supports and services.
12 3. Any participating provider or care coordinator that is organized as
13 a for-profit entity (other than a professional practice of one or more
14 health care professionals) shall be required to meet the same require-
15 ments and standards as entities organized as not-for-profit entities,
16 and payments under the program paid to such entities shall not be calcu-
17 lated to accommodate the generation of profit or revenue for dividends
18 or other return on investment or the payment of taxes that would not be
19 paid by a not-for-profit entity.
20 4. Every participating provider shall furnish to the program such
21 information to, and permit examination of its records by, the program,
22 as may be reasonably required for purposes of reviewing accessibility
23 and utilization of health care services, quality assurance, promoting
24 improved patient outcomes and cost containment, the making of payments,
25 and statistical or other studies of the operation of the program or for
26 protection and promotion of public, environmental and occupational
28 5. In developing requirements and standards and making other policy
29 determinations under this article, the commissioner shall consult with
30 the commissioner of mental health, the commissioner of developmental
31 disabilities, the director of the state office for the aging, the
32 commissioner of the office of addiction services and supports, the
33 commissioner of the division of human rights, representatives of
34 members, health care providers, care coordinators, health care organiza-
35 tions employers, organized labor including representatives of health
36 care workers, and other interested parties.
37 6. The program shall maintain the security and confidentiality of all
38 data and other information collected under the program when such data
39 would be normally considered confidential patient data. Aggregate data
40 of the program which is derived from confidential data but does not
41 violate patient confidentiality shall be public information including
42 for purposes of article six of the public officers law.
43 § 5108. Regulations. The commissioner shall make regulations under
44 this article by approving regulations and amendments thereto, under
45 subdivision one of section fifty-one hundred two of this article. The
46 commissioner may make regulations or amendments thereto under this arti-
47 cle on an emergency basis under section two hundred two of the state
48 administrative procedure act, provided that such regulations or amend-
49 ments shall not become permanent unless adopted under subdivision one of
50 section fifty-one hundred two of this article.
51 § 5109. Provisions relating to federal health programs. 1. The commis-
52 sioner shall seek all federal waivers and other federal approvals and
53 arrangements and submit state plan amendments necessary to operate the
54 program consistent with this article to the maximum extent possible. No
55 provision of this article and no action under the program shall diminish
A. 6058 17
1 any right or benefit the member would otherwise have under any federal-
2 ly-matched program or Medicare.
3 2. (a) The commissioner shall apply to the secretary of health and
4 human services or other appropriate federal official for all waivers of
5 requirements, and make other arrangements, under Medicare, any federal-
6 ly-matched public health program, the affordable care act, and any other
7 federal programs that provide federal funds for payment for health care
8 services, that are necessary to enable all New York Health members to
9 receive all benefits under the program through the program to enable the
10 state to implement this article and to receive and deposit all federal
11 payments under those programs (including funds that may be provided in
12 lieu of premium tax credits, cost-sharing subsidies, and small business
13 tax credits) in the state treasury to the credit of the New York Health
14 trust fund and to use those funds for the New York Health program and
15 other provisions under this article. To the extent possible, the commis-
16 sioner shall negotiate arrangements with the federal government in which
17 bulk or lump-sum federal payments are paid to New York Health in place
18 of federal spending or tax benefits for federally-matched health
19 programs or federal health programs. The commissioner shall take
20 actions under paragraph (b) of subdivision eight of section fifty-one
21 hundred one of this article as reasonably necessary.
22 (b) The commissioner may require members or applicants to be members
23 to provide information necessary for the program to comply with any
24 waiver or arrangement under this subdivision.
25 3. (a) The commissioner may take actions consistent with this article
26 to enable New York Health to administer Medicare in New York state, to
27 create a Medicare managed care plan ("Medicare Advantage") that would
28 operate consistent with this article, and to be a provider of drug
29 coverage under Medicare part D for eligible members of New York Health.
30 (b) The commissioner may waive or modify the applicability of
31 provisions of this section relating to any federally-matched public
32 health program or Medicare as necessary to implement any waiver or
33 arrangement under this section or to maximize the benefit to the New
34 York Health program under this section, provided that the commissioner,
35 in consultation with the director of the budget, shall determine that
36 such waiver or modification is in the best interests of the members
37 affected by the action and the state, and provided further that no
38 action under this paragraph shall diminish any right or benefit the
39 member would otherwise have under the program or any federally-matched
40 public health program or Medicare.
41 (c) The commissioner may apply for coverage under any federally-
42 matched public health program on behalf of any member and enroll the
43 member in the federally-matched public health program or Medicare if the
44 member is eligible for it. Enrollment in a federally-matched public
45 health program or Medicare shall not cause any member to lose any health
46 care service provided by the program or diminish any right or benefit
47 the member would otherwise have.
48 (d) The commissioner shall by regulation increase the income eligibil-
49 ity level, increase or eliminate the resource test for eligibility,
50 simplify any procedural or documentation requirement for enrollment, and
51 increase the benefits for any federally-matched public health program,
52 and for any program to reduce or eliminate an individual's coinsurance,
53 cost-sharing or premium obligations or increase an individual's eligi-
54 bility for any federal financial support related to Medicare or the
55 affordable care act notwithstanding any law or regulation to the contra-
56 ry. The commissioner may act under this paragraph upon a finding,
A. 6058 18
1 approved by the director of the budget, that the action (i) will help to
2 increase the number of members who are eligible for and enrolled in
3 federally-matched public health programs, or for any program to reduce
4 or eliminate an individual's coinsurance, cost-sharing or premium obli-
5 gations or increase an individual's eligibility for any federal finan-
6 cial support related to Medicare or the affordable care act; (ii) will
7 not diminish any individual's access to any health care service, benefit
8 or right the individual would otherwise have; (iii) is in the interest
9 of the program; and (iv) does not require or has received any necessary
10 federal waivers or approvals to ensure federal financial participation.
11 (e) To enable the commissioner to apply for coverage or financial
12 support under any federally-matched public health program, the Afforda-
13 ble Care Act, or Medicare on behalf of any member and enroll the member
14 in any such program, including an entity under paragraph (b) of subdivi-
15 sion eight of section fifty-one hundred one of this article if the
16 member is eligible for it, the commissioner may require that every
17 member or applicant to be a member shall provide information to enable
18 the commissioner to determine whether the applicant is eligible for such
19 program. The program shall make a reasonable effort to notify members
20 of their obligations under this paragraph. After a reasonable effort has
21 been made to contact the member, the member shall be notified in writing
22 that he or she has sixty days to provide such required information. If
23 such information is not provided within the sixty day period, the
24 member's coverage under the program may be terminated. Upon the member's
25 satisfactory provision of the information, the member's coverage under
26 the program shall be reinstated retroactive to the date upon which the
27 coverage was terminated.
28 (f) To the extent necessary for purposes of this section, as a condi-
29 tion of continued eligibility for health care services under the
30 program, a member who is eligible for benefits under Medicare shall
31 enroll in Medicare, including parts A, B and D.
32 (g) The program shall provide premium assistance for all members
33 enrolling in a Medicare part D drug coverage under section 1860D of
34 Title XVIII of the federal social security act limited to the low-income
35 benchmark premium amount established by the federal centers for Medicare
36 and Medicaid services and any other amount which such agency establishes
37 under its de minimis premium policy, except that such payments made on
38 behalf of members enrolled in a Medicare advantage plan may exceed the
39 low-income benchmark premium amount if determined to be cost effective
40 to the program.
41 (h) If the commissioner has reasonable grounds to believe that a
42 member could be eligible for an income-related subsidy under section
43 1860D-14 of Title XVIII of the federal social security act, the member
44 shall provide, and authorize the program to obtain, any information or
45 documentation required to establish the member's eligibility for such
46 subsidy, provided that the commissioner shall attempt to obtain as much
47 of the information and documentation as possible from records that are
48 available to him or her.
49 (i) The program shall make a reasonable effort to notify members of
50 their obligations under this subdivision. After a reasonable effort has
51 been made to contact the member, the member shall be notified in writing
52 that he or she has sixty days to provide such required information. If
53 such information is not provided within the sixty day period, the
54 member's coverage under the program may be terminated. Upon the
55 member's satisfactory provision of the information, the member's cover-
A. 6058 19
1 age under the program shall be reinstated retroactive to the date upon
2 which the coverage was terminated.
3 § 5110. Additional provisions. 1. The commissioner shall contract
4 with not-for-profit organizations to provide:
5 (a) consumer assistance to individuals with respect to selection and
6 changing selection of a care coordinator or health care organization,
7 enrolling, obtaining health care services, and other matters relating to
8 the program;
9 (b) health care provider assistance to health care providers providing
10 and seeking or considering whether to provide, health care services
11 under the program, with respect to participating in a health care organ-
12 ization and dealing with a health care organization; and
13 (c) care coordinator assistance to individuals and entities providing
14 and seeking or considering whether to provide, care coordination to
16 2. The commissioner shall provide grants from funds in the New York
17 Health trust fund or otherwise appropriated for this purpose, to health
18 systems agencies under section twenty-nine hundred four-b of this chap-
19 ter to support the operation of such health systems agencies.
20 3. Retraining and re-employment of impacted employees. (a) As used in
21 this subdivision:
22 (i) "Third party payer" has its ordinary meaning and includes any
23 entity that provides or arranges reimbursement in whole or in part for
24 the purchase of health care services.
25 (ii) "Health care provider administrative employee" means an employee
26 of a health care provider primarily engaged in relations or dealings
27 with third party payers or seeking payment or reimbursement for health
28 care services from third party payers.
29 (iii) "Impacted employee" means an individual who, at any time from
30 the date this section becomes a law until two years after the end of the
31 implementation period, is employed by a third party payer or is a health
32 care provider administrative employee, and whose employment ends or is
33 reasonably anticipated to end as a result of the implementation of the
34 New York Health program.
35 (b) Within ninety days after this section shall become a law, the
36 commissioner of labor shall convene a retraining and re-employment task
37 force including but not limited to: representatives of potential
38 impacted employees, human resource departments of third party payers and
39 health care providers, individuals with experience and expertise in
40 retraining and re-employment programs relevant to the circumstances of
41 impacted employees, and representatives of the commissioner of labor.
42 The commissioner of labor and the task force shall review and provide:
43 (i) analysis of potential impacted employees by job title and
45 (ii) competency mapping and labor market analysis of impacted employee
46 occupations with job openings; and
47 (iii) establishment of regional retraining and re-employment systems,
48 including but not limited to job boards, outplacement services, job
49 search services, career advisement services, and retraining advisement,
50 to be coordinated with the regional advisory councils established under
51 section fifty-one hundred eleven of this article.
52 (c) (i) Three or more impacted employees, a recognized union of work-
53 ers including impacted employees, or an employer of impacted employees
54 may file a petition with the commissioner of labor to certify such
55 employees as being impacted employees.
56 (ii) Impacted employees shall be eligible for:
A. 6058 20
1 (A) up to two years of retraining at any training provider approved by
2 the commissioner of labor; and
3 (B) up to two years of unemployment benefits, provided that the
4 impacted employee is enrolled in a department of labor approved training
5 program, is actively seeking employment, and is not currently employed
6 full time; provided, however, that such impacted employee may maintain
7 unemployment benefits for up to two years even if he or she does not
8 meet the criteria set forth in this clause but is sixty-three years of
9 age or older at the time of loss of employment as an impacted employee.
10 (d) The commissioner shall provide funds from the New York Health
11 trust fund or otherwise appropriated for this purpose to the commission-
12 er of labor for retraining and re-employment programs for impacted
13 employees under this subdivision.
14 (e) The commissioner of labor shall make regulations and take other
15 actions reasonably necessary to implement this subdivision. This subdi-
16 vision shall be implemented consistent with applicable law and regu-
18 4. The commissioner shall, directly and through grants to not-for-pro-
19 fit entities, conduct programs using data collected through the New York
20 Health program, to promote and protect the quality of health care
21 services, patient outcomes, and public, environmental and occupational
22 health, including cooperation with other data collection and research
23 programs of the department, consistent with this article, the protection
24 of the security and confidentiality of individually identifiable patient
25 information, and otherwise applicable law.
26 5. Settlements and judgments. This subdivision applies where any
27 settlement, judgment or order in the course of litigation, or any
28 contract or agreement made as an alternative to litigation, provides
29 that one party shall pay for health care coverage for another party who
30 is entitled to enroll in the program. Any party to the settlement, judg-
31 ment, order, contract or agreement may apply to an appropriate court for
32 modification of the judgment, order, contract or agreement. The modifi-
33 cation may provide that the paying party, instead of paying for health
34 care coverage, shall pay all or part of the New York Health tax that is
35 owed by the other party, and may include other or further provisions.
36 The modifications shall be appropriate, consistent with the program, and
37 in the interest of justice. As used in this subdivision, "New York
38 Health tax" means the tax or taxes enacted by the legislature as part of
39 the revenue proposal, as amended, to fund the program.
40 § 5111. Regional advisory councils. 1. The New York Health regional
41 advisory councils (each referred to in this article as a "regional advi-
42 sory council") are hereby created in the department.
43 2. There shall be a regional advisory council established in each of
44 the following regions:
45 (a) Long Island, consisting of Nassau and Suffolk counties;
46 (b) New York City;
47 (c) Hudson Valley, consisting of Delaware, Dutchess, Orange, Putnam,
48 Rockland, Sullivan, Ulster, Westchester counties;
49 (d) Northern, consisting of Albany, Clinton, Columbia, Essex, Frank-
50 lin, Fulton, Greene, Hamilton, Herkimer, Jefferson, Lewis, Montgomery,
51 Otsego, Rensselaer, Saratoga, Schenectady, Schoharie, St. Lawrence,
52 Warren, Washington counties;
53 (e) Central, consisting of Broome, Cayuga, Chemung, Chenango, Cort-
54 land, Livingston, Madison, Monroe, Oneida, Onondaga, Ontario, Oswego,
55 Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne, Yates counties; and
A. 6058 21
1 (f) Western, consisting of Allegany, Cattaraugus, Chautauqua, Erie,
2 Genesee, Niagara, Orleans, Wyoming counties.
3 3. Each regional advisory council shall be composed of not fewer than
4 twenty-seven members, as determined by the commissioner and the board,
5 as necessary to appropriately represent the diverse needs and concerns
6 of the region. Members of a regional advisory council shall be residents
7 of or have their principal place of business in the region served by the
8 regional advisory council.
9 4. Appointment of members of the regional advisory councils.
10 (a) The twenty-seven members shall be appointed as follows:
11 (i) nine members shall be appointed by the governor;
12 (ii) six members shall be appointed by the governor on the recommenda-
13 tion of the speaker of the assembly;
14 (iii) six members shall be appointed by the governor on the recommen-
15 dation of the temporary president of the senate;
16 (iv) three members shall be appointed by the governor on the recommen-
17 dation of the minority leader of the assembly; and
18 (v) three members shall be appointed by the governor on the recommen-
19 dation of the minority leader of the senate.
20 Where a regional advisory council has more than twenty-seven members,
21 additional members shall be appointed and recommended by these officials
22 in the same proportion as the twenty-seven members.
23 (b) Regional advisory council membership shall include but not be
24 limited to:
25 (i) representatives of organizations with a regional constituency that
26 advocate for health care consumers, older adults, and people with disa-
27 bilities including organizations led by members of those groups, who
28 shall constitute at least one third of the membership of each regional
30 (ii) representatives of professional organizations representing physi-
32 (iii) representatives of professional organizations representing
33 health care professionals other than physicians;
34 (iv) representatives of general hospitals, including public hospitals;
35 (v) representatives of community health centers;
36 (vi) representatives of mental health, behavioral health (including
37 substance use), physical disability, developmental disability, rehabili-
38 tation, home care and other service providers;
39 (vii) representatives of women's health service providers;
40 (viii) representatives of health service providers serving lesbian,
41 gay, bisexual, transgender, gender non-conforming, and nonbinary
43 (ix) representatives of health care organizations;
44 (x) representatives of organized labor including representatives of
45 health care workers;
46 (xi) representatives of employers; and
47 (xii) representatives of municipal and county government.
48 5. Members of a regional advisory council shall be appointed for terms
49 of three years provided, however, that of the members first appointed,
50 one-third shall be appointed for one year terms and one-third shall be
51 appointed for two year terms. Vacancies shall be filled in the same
52 manner as original appointments for the remainder of any unexpired term.
53 No person shall be a member of a regional advisory council for more than
54 six years in any period of twelve consecutive years.
55 6. Members of the regional advisory councils shall serve without
56 compensation but shall be reimbursed for their necessary and actual
A. 6058 22
1 expenses incurred while engaged in the business of the advisory coun-
2 cils. The program shall provide financial support for such expenses and
3 other expenses of the regional advisory councils. However, the board may
4 provide for compensation in cases where a lack of compensation would
5 limit the ability of a trustee or represented organization to partic-
6 ipate in council business.
7 7. Each regional advisory council shall meet at least quarterly. Each
8 regional advisory council may form committees to assist it in its work.
9 Members of a committee need not be members of the regional advisory
10 council. The New York City regional advisory council shall form a
11 committee for each borough of New York City, to assist the regional
12 advisory council in its work as it relates particularly to that borough.
13 8. Each regional advisory council shall advise the commissioner, the
14 board, the governor and the legislature on all matters relating to the
15 development and implementation of the New York Health program.
16 9. Each regional advisory council shall adopt, and from time to time
17 revise, a community health improvement plan for its region for the
18 purpose of:
19 (a) promoting the delivery of health care services in the region,
20 improving the quality and accessibility of care, including cultural
21 competency, clinical integration of care between service providers
22 including but not limited to physical, mental, and behavioral health,
23 physical and developmental disability services, and long-term supports
24 and services;
25 (b) facility and health services planning in the region;
26 (c) identifying gaps in regional health care services;
27 (d) promoting increased public knowledge and responsibility regarding
28 the availability and appropriate utilization of health care services.
29 Each community health improvement plan shall be submitted to the commis-
30 sioner and the board and shall be posted on the department's website;
31 (e) identifying needs in professional and service personnel required
32 to deliver health care services; and
33 (f) coordinating regional implementation of retraining and re-employ-
34 ment programs for impacted employees under subdivision three of section
35 fifty-one hundred ten of this article.
36 10. Each regional advisory council shall hold at least four public
37 hearings annually on matters relating to the New York Health program and
38 the development and implementation of the community health improvement
40 11. Each regional advisory council shall publish an annual report to
41 the commissioner and the board on the progress of the community health
42 improvement plan. These reports shall be posted on the department's
44 12. All meetings of the regional advisory councils and committees
45 shall be subject to article six of the public officers law.
46 § 4. Financing of New York Health. 1. (a) As used in this section,
47 unless the context clearly requires otherwise:
48 (i) "New York Health program" and the "program" mean the New York
49 Health program, as created by article 51 of the public health law and
50 all provisions of that article.
51 (ii) "Revenue proposal" means the revenue plan and legislative bills,
52 as proposed and enacted under this section, to provide the revenue
53 necessary to finance the New York Health program.
54 (iii) "Tax" means the payroll tax or non-payroll tax to be enacted
55 under the revenue proposal. "Payroll tax" means the tax on payroll
56 income and self-employed income subject to the Medicare Part A tax,
A. 6058 23
1 provided for in subdivision two of this section. "Non-payroll tax" means
2 the tax on taxable income (such as interest, dividends, and capital
3 gains) not subject to the payroll tax, provided for in subdivision two
4 of this section.
5 (b) The governor shall submit to the legislature a revenue proposal.
6 The revenue proposal shall be submitted to the legislature as part of
7 the executive budget under article VII of the state constitution, for
8 the fiscal year commencing on the first day of April in the calendar
9 year after this act shall become a law. In developing the revenue
10 proposal, the governor shall consult with appropriate officials of the
11 executive branch; the temporary president of the senate; the speaker of
12 the assembly; the chairs of the fiscal and health committees of the
13 senate and assembly; and representatives of business, labor, consumers
14 and local government.
15 2. (a) Basic structure. The basic structure of the revenue proposal
16 shall be as follows: Revenue for the program shall come from two taxes.
17 First, there shall be a progressively graduated tax on all payroll and
18 self-employed income, paid by employers, employees and self-employed
19 individuals. Second, there shall be a progressively graduated tax on
20 taxable income (such as interest, dividends, and capital gains) not
21 subject to the payroll tax. Income in the bracket below twenty-five
22 thousand dollars per year shall be exempt from the taxes; provided that
23 for individuals enrolled in Medicare as defined in the program, income
24 in the bracket below fifty thousand dollars per year shall be exempt
25 from the taxes. Higher brackets of income subject to the taxes shall be
26 assessed at a higher marginal rate than lower brackets. The taxes shall
27 be set at levels anticipated to produce sufficient revenue to finance
28 the program, to be scaled up as enrollment grows, taking into consider-
29 ation anticipated federal revenue available for the program. Provision
30 shall be made for state residents who are employed out-of-state, and
31 non-residents who are employed in the state (including those employed
32 less than full-time).
33 (b) Payroll tax. The income to be subject to the payroll tax shall be
34 all income subject to the Medicare Part A tax. The payroll tax shall be
35 set at a percentage of that income, which shall be progressively gradu-
36 ated, so the percentage is higher on higher brackets of income. For
37 employed individuals, the employer shall pay eighty percent of the
38 payroll tax and the employee shall pay twenty percent of the tax, except
39 that an employer may agree to pay all or part of the employee's share.
40 A self-employed individual shall pay the full tax.
41 (c) Non-payroll income tax. There shall be a tax on income that is
42 subject to the personal income tax under article 22 of the tax law and
43 is not subject to the payroll tax. It shall be set at a percentage of
44 that income, which shall be progressively graduated, so the percentage
45 is higher on higher brackets of income.
46 (d) Phased-in rates. Early in the program, when enrollment is growing,
47 the amount of the taxes shall be at an appropriate level, and shall be
48 changed as anticipated enrollment grows, to cover the actual cost of the
49 program. The revenue proposal shall include a mechanism for determining
50 the rates of the taxes.
51 (e) Cross-border employees. (i) State residents employed out-of-state.
52 If an individual is employed out-of-state by an employer that is subject
53 to New York state law, the employer and employee shall be required to
54 pay the payroll tax as to that employee as if the employment were in the
55 state. If an individual is employed out-of-state by an employer that is
56 not subject to New York state law, either (A) the employer and employee
A. 6058 24
1 shall voluntarily comply with the tax or (B) the employee shall pay the
2 tax as if he or she were self-employed.
3 (ii) Out-of-state residents employed in the state. The payroll tax
4 shall apply to any out-of-state resident who is employed or self-em-
5 ployed in the state. Such individual and individual's employer shall be
6 able to take a credit against the payroll taxes each would otherwise pay
7 as to that individual for amounts they spend respectively on health
8 benefits (A) for the individual, if the individual is not eligible to be
9 a member of the program, and (B) for any member of the individual's
10 immediate family. For the employer, the credit shall be available
11 regardless of the form of the health benefit (e.g., health insurance, a
12 self-insured plan, direct services, or reimbursement for services), to
13 make sure that the revenue proposal does not relate to employment bene-
14 fits in violation of any federal law. For non-employment-based spending
15 by the individual, the credit shall be available for and limited to
16 spending for health coverage (not out-of-pocket health spending). The
17 credit shall be available without regard to how little is spent or how
18 sparse the benefit. The credit may only be taken against the payroll
19 tax. Any excess amount may not be applied to other tax liability. The
20 credit shall be distributed between the employer and employee in the
21 same proportion as the spending by each for the benefit and may be
22 applied to their respective portion of the tax. If any provision of this
23 subparagraph or any application of it shall be ruled to violate federal
24 law, the provision or the application of it shall be null and void and
25 the ruling shall not affect any other provision or application of this
26 section or the act that enacted it.
27 3. (a) The revenue proposal shall include a plan and legislative
28 provisions for ending the requirement for local social services
29 districts to pay part of the cost of Medicaid and replacing those
30 payments with revenue from the taxes under the revenue proposal.
31 (b) The taxes under this section shall not supplant the spending of
32 other state revenue to pay for the Medicaid program as it exists as of
33 the enactment of the revenue proposal as amended, unless the revenue
34 proposal as amended provides otherwise.
35 4. To the extent that the revenue proposal differs from the terms of
36 subdivision two or paragraph (b) of subdivision three of this section,
37 the revenue proposal shall state how it differs from those terms and
38 reasons for and the effects of the differences.
39 5. All revenue from the taxes shall be deposited in the New York
40 Health trust fund account under section 89-j of the state finance law.
41 § 5. Article 49 of the public health law is amended by adding a new
42 title 3 to read as follows:
43 TITLE III
44 COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
45 NEW YORK HEALTH
46 Section 4920. Definitions.
47 4921. Collective negotiation authorized.
48 4922. Collective negotiation requirements.
49 4923. Requirements for health care providers' representative.
50 4924. Mediation.
51 4925. Certain collective action prohibited.
52 4926. Fees.
53 4927. Confidentiality.
54 4928. Severability and construction.
55 § 4920. Definitions. For purposes of this title:
A. 6058 25
1 1. "New York Health" means the program under article fifty-one of this
3 2. "Person" means an individual, association, corporation, or any
4 other legal entity.
5 3. "Health care providers' representative" means a third party that is
6 authorized by health care providers to negotiate on their behalf with
7 New York Health over terms and conditions affecting those health care
9 4. "Strike" means a work stoppage in part or in whole, direct or indi-
10 rect, by a body of workers to gain compliance with demands made on an
12 5. "Health care provider" means a health care provider under article
13 fifty-one of this chapter. A health care professional as defined in
14 article fifty-one of this chapter who practices as an employee or inde-
15 pendent contractor of another health care provider shall not be deemed a
16 health care provider for purposes of this title.
17 § 4921. Collective negotiation authorized. 1. Health care providers
18 may meet and communicate for the purpose of collectively negotiating
19 with New York Health on any matter relating to New York Health, includ-
20 ing but not limited to rates of payment and payment methodologies.
21 2. Nothing in this section shall be construed to allow or authorize an
22 alteration of the terms of the internal and external review procedures
23 set forth in law.
24 3. Nothing in this section shall be construed to allow a strike of New
25 York Health by health care providers.
26 4. Nothing in this section shall be construed to allow or authorize
27 terms or conditions which would impede the ability of New York Health to
28 obtain or retain accreditation by the national committee for quality
29 assurance or a similar body or to comply with applicable state or feder-
30 al law.
31 § 4922. Collective negotiation requirements. 1. Collective negotiation
32 rights granted by this title must conform to the following requirements:
33 (a) health care providers may communicate with other health care
34 providers regarding the terms and conditions to be negotiated with New
35 York Health;
36 (b) health care providers may communicate with health care providers'
38 (c) a health care providers' representative is the only party author-
39 ized to negotiate with New York Health on behalf of the health care
40 providers as a group;
41 (d) a health care provider can be bound by the terms and conditions
42 negotiated by the health care providers' representatives; and
43 (e) in communicating or negotiating with the health care providers'
44 representative, New York Health is entitled to offer and provide differ-
45 ent terms and conditions to individual competing health care providers.
46 2. Nothing in this title shall affect or limit the right of a health
47 care provider or group of health care providers to collectively petition
48 a government entity for a change in a law, rule, or regulation.
49 3. Nothing in this title shall affect or limit collective action or
50 collective bargaining on the part of any health care provider with his
51 or her employer or any other lawful collective action or collective
53 § 4923. Requirements for health care providers' representative. Before
54 engaging in collective negotiations with New York Health on behalf of
55 health care providers, a health care providers' representative shall
56 file with the commissioner, in the manner prescribed by the commission-
A. 6058 26
1 er, information identifying the representative, the representative's
2 plan of operation, and the representative's procedures to ensure compli-
3 ance with this title.
4 § 4924. Mediation. 1. In the event the commissioner determines that an
5 impasse exists in the negotiations, the commissioner shall render
6 assistance as follows:
7 (a) to assist the parties to effect a voluntary resolution of the
8 negotiations, the commissioner shall appoint a mediator who is mutually
9 acceptable to both the health care providers' representative and the
10 representative of New York Health. If the mediator is successful in
11 resolving the impasse, then the health care providers' representative
12 shall proceed as set forth in this article;
13 (b) if an impasse continues, the commissioner shall appoint a fact-
14 finding board of not more than three members, who are mutually accepta-
15 ble to both the health care providers' representative and the represen-
16 tative of New York Health. The fact-finding board shall have, in
17 addition to the powers delegated to it by the board, the power to make
18 recommendations for the resolution of the dispute;
19 (c) the fact-finding board, acting by a majority of its members, shall
20 transmit its findings of fact and recommendations for resolution of the
21 dispute to the commissioner, and may thereafter assist the parties to
22 effect a voluntary resolution of the dispute. The fact-finding board
23 shall also share its findings of fact and recommendations with the
24 health care providers' representative and the representative of New York
25 Health. If within twenty days after the submission of the findings of
26 fact and recommendations, the impasse continues, the commissioner shall
27 order a resolution to the negotiations based upon the findings of fact
28 and recommendations submitted by the fact-finding board.
29 § 4925. 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 except as authorized by other law.
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 lawful scope
38 or terms of practice, license, registration, or certificate.
39 § 4926. Fees. Each person who acts as the representative of negotiat-
40 ing parties under this title shall pay to the department a fee to act as
41 a representative. The commissioner, by regulation, shall set fees in
42 amounts deemed reasonable and necessary to cover the costs incurred by
43 the department in administering this title.
44 § 4927. 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.
47 § 4928. Severability and construction. If any provision or application
48 of this title shall be held to be invalid, or to violate or be incon-
49 sistent with any applicable federal law or regulation, that shall not
50 affect other provisions or applications of this title which can be given
51 effect without that provision or application; and to that end, the
52 provisions and applications of this title are severable. The provisions
53 of this title shall be liberally construed to give effect to the
54 purposes thereof.
A. 6058 27
1 § 6. 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] New York Health program estab-
12 lished by article fifty-one of this chapter.
13 § 7. The state finance law is amended by adding a new section 89-j to
14 read as follows:
15 § 89-j. 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", referred to in this section as "the fund". The defi-
19 nitions in section fifty-one hundred of the public health law shall
20 apply to this section.
21 2. The fund shall consist of:
22 (a) all monies obtained from taxes pursuant to legislation enacted as
23 proposed under section three of the New York Health act;
24 (b) federal payments received as a result of any waiver or other
25 arrangements agreed to by the United States secretary of health and
26 human services or other appropriate federal officials for health care
27 programs established under Medicare, any federally-matched public health
28 program, or the affordable care act;
29 (c) the amounts paid by the department of health that are equivalent
30 to those amounts that are paid on behalf of residents of this state
31 under Medicare, any federally-matched public health program, or the
32 affordable care act for health benefits which are equivalent to health
33 benefits covered under New York Health;
34 (d) federal and state funds for purposes of the provision of services
35 authorized under title XX of the federal social security act that would
36 otherwise be covered under article fifty-one of the public health law;
38 (e) state monies that would otherwise be appropriated to any govern-
39 mental agency, office, program, instrumentality or institution which
40 provides health services, for services and benefits covered under New
41 York Health. Payments to the fund pursuant to this paragraph shall be in
42 an amount equal to the money appropriated for such purposes in the
43 fiscal year beginning immediately preceding the effective date of the
44 New York Health act.
45 3. Monies in the fund shall only be used for purposes established
46 under article fifty-one of the public health law.
47 § 8. Temporary commission on implementation. 1. There is hereby estab-
48 lished a temporary commission on implementation of the New York Health
49 program, referred to in this section as the commission, consisting of
50 fifteen members: five members, including the chair, shall be appointed
51 by the governor; four members shall be appointed by the temporary presi-
52 dent of the senate, one member shall be appointed by the senate minority
53 leader; four members shall be appointed by the speaker of the assembly,
54 and one member shall be appointed by the assembly minority leader. The
55 commissioner of health, the superintendent of financial services, and
A. 6058 28
1 the commissioner of taxation and finance, or their designees shall serve
2 as non-voting ex-officio members of the commission.
3 2. Members of the commission shall receive such assistance as may be
4 necessary from other state agencies and entities, and shall receive
5 reasonable and necessary expenses incurred in the performance of their
6 duties. The commission may employ staff as needed, prescribe their
7 duties, and fix their compensation within amounts appropriated for the
9 3. The commission shall examine the laws and regulations of the state
10 and consult with health care providers, consumers, and other stakehold-
11 ers and make such recommendations as are necessary to conform the laws
12 and regulations of the state and article 51 of the public health law
13 establishing the New York Health program and other provisions of law
14 relating to the New York Health program, and to improve and implement
15 the program. The commission shall report its recommendations to the
16 governor and the legislature. The commission shall immediately begin
17 development of proposals consistent with the principles of article 51 of
18 the public health law for provision of health care services covered
19 under the workers' compensation law; and incorporation of retiree health
20 benefits, as described in paragraphs (a), (b) and (c) of subdivision 8
21 of section 5102 of the public health law. The commission shall provide
22 its work product and assistance to the board established pursuant to
23 section 5102 of the public health law upon completion of the appointment
24 of the board.
25 § 9. Severability. If any provision or application of this act shall
26 be held to be invalid, or to violate or be inconsistent with any appli-
27 cable federal law or regulation, that shall not affect other provisions
28 or applications of this act which can be given effect without that
29 provision or application; and to that end, the provisions and applica-
30 tions of this act are severable.
31 § 10. This act shall take effect immediately.