Relates to regulation of the billing by general hospitals and the distribution of funds from the general hospital indigent care pool; requires use of a uniform application form and policy.
STATE OF NEW YORK
________________________________________________________________________
6027--A
2023-2024 Regular Sessions
IN ASSEMBLY
March 30, 2023
___________
Introduced by M. of A. PAULIN, SEAWRIGHT, REYES, RAMOS, SIMON, EPSTEIN,
BICHOTTE HERMELYN, STECK, MITAYNES, McDONOUGH, L. ROSENTHAL, BENEDET-
TO, FORREST, BURGOS, GONZALEZ-ROJAS, RIVERA, GIBBS, KELLES, THIELE,
ZINERMAN, DE LOS SANTOS, JACKSON, JEAN-PIERRE, HYNDMAN, RAGA, ARDILA,
LEVENBERG, SEPTIMO, AUBRY, HEVESI, MAMDANI, McDONALD, SIMONE, SHRES-
THA, GLICK, ZACCARO, COLTON, STIRPE, DINOWITZ, CUNNINGHAM -- read once
and referred to the Committee on Health -- committee discharged, bill
amended, ordered reprinted as amended and recommitted to said commit-
tee
AN ACT to amend the public health law, in relation to the general hospi-
tal indigent care pool; and to repeal certain provisions of such law
relating thereto
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. Subdivision 9 of section 2807-k of the public health law,
2 as amended by section 17 of part B of chapter 60 of the laws of 2014, is
3 amended to read as follows:
4 9. In order for a general hospital to participate in the distribution
5 of funds from the pool, the general hospital must [implement minimum
6 collection policies and procedures approved] utilize only a uniform
7 financial assistance policy and form developed and provided by the
8 [commissioner] department. All general hospitals that do not participate
9 in the indigent care pool shall also utilize only the uniform financial
10 assistance policy and form and otherwise comply with subdivision nine-a
11 of this section governing the provision of financial assistance and
12 hospital collection procedures.
13 § 1-a. Subdivision 9 of section 2807-k of the public health law, as
14 amended by section 1 of subpart C of part Y of chapter 57 of the laws of
15 2023, is amended to read as follows:
16 9. In order for a general hospital to participate in the distribution
17 of funds from the pool, the general hospital must [implement minimum
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD02400-02-3
A. 6027--A 2
1 collection policies and procedures approved by the commissioner, utiliz-
2 ing] utilize only a uniform financial assistance policy and form devel-
3 oped and provided by the department. All general hospitals that do not
4 participate in the indigent care pool shall also utilize only the
5 uniform financial assistance policy and form and otherwise comply with
6 subdivision nine-a of this section governing the provision of financial
7 assistance and hospital collection procedures.
8 § 2. Subdivision 9-a of section 2807-k of the public health law, as
9 added by section 39-a of part A of chapter 57 of the laws of 2006, para-
10 graph (k) as added by section 43 of part B of chapter 58 of the laws of
11 2008, is amended to read as follows:
12 9-a. (a) (i) As a condition for participation in pool distributions
13 authorized pursuant to this section and section twenty-eight hundred
14 seven-w of this article for periods on and after January first, two
15 thousand nine, general hospitals shall, effective for periods on and
16 after January first, two thousand seven, establish financial [aid]
17 assistance policies and procedures, in accordance with the provisions of
18 this subdivision, for reducing hospital charges otherwise applicable to
19 low-income individuals [without health insurance, or who have exhausted
20 their health insurance benefits, and] who can demonstrate an inability
21 to pay full charges, and also, at the hospital's discretion, for reduc-
22 ing or discounting the collection of co-pays and deductible payments
23 from those individuals who can demonstrate an inability to pay such
24 amounts. Immigration status shall not be an eligibility criterion for
25 the purpose of determining financial assistance under this section.
26 (ii) A general hospital may use the New York state of health market-
27 place eligibility determination page to establish the patient's house-
28 hold income and residency in lieu of the financial application form,
29 provided it has secured the consent of the patient. A general hospital
30 shall not require a patient to apply for coverage through the New York
31 state of health marketplace in order to receive care or financial
32 assistance.
33 (iii) Upon submission of a completed application form, the patient is
34 not liable for any bills and no interest may accrue until the general
35 hospital has rendered a decision on the application in accordance with
36 this subdivision.
37 (b) [Such] The reductions from charges for [uninsured] patients
38 described in paragraph (a) of this subdivision with incomes below [at
39 least three] six hundred percent of the federal poverty level shall
40 result in a charge to such individuals that does not exceed [the greater
41 of] the amount that would have been paid for the same services [by the
42 "highest volume payor" for such general hospital as defined in subpara-
43 graph (v) of this paragraph, or for services provided pursuant to title
44 XVIII of the federal social security act (medicare), or for services]
45 provided pursuant to title [XIX] XVIII of the federal social security
46 act (medicaid), and provided further that such [amounts] amount shall be
47 adjusted according to income level as follows:
48 (i) For patients with incomes at or below [at least one] two hundred
49 percent of the federal poverty level, the hospital shall [collect no
50 more than a nominal payment amount, consistent with guidelines estab-
51 lished by the commissioner] waive all charges. No nominal payment shall
52 be collected;
53 (ii) For patients with incomes [between at least one] above two
54 hundred [one] percent and [one] up to four hundred [fifty] percent of
55 the federal poverty level, the hospital shall collect no more than the
56 amount identified after application of a proportional sliding fee sched-
A. 6027--A 3
1 ule under which patients with lower incomes shall pay the lowest amount.
2 [Such] The schedule shall provide that the amount the hospital may
3 collect for [such patients] the patient increases from the nominal
4 amount described in subparagraph (i) of this paragraph in equal incre-
5 ments as the income of the patient increases, up to a maximum of twenty
6 percent of the [greater of the] amount that would have been paid for the
7 same services [by the "highest volume payor" for such general hospital,
8 as defined in subparagraph (v) of this paragraph, or for services
9 provided pursuant to title XVIII of the federal social security act
10 (medicare) or for services] provided pursuant to title [XIX] XVIII of
11 the federal social security act (medicaid);
12 (iii) [For patients with incomes between at least one hundred fifty-
13 one percent and two hundred fifty percent of the federal poverty level,
14 the hospital shall collect no more than the amount identified after
15 application of a proportional sliding fee schedule under which patients
16 with lower income shall pay the lowest amounts. Such schedule shall
17 provide that the amount the hospital may collect for such patients
18 increases from the twenty percent figure described in subparagraph (ii)
19 of this paragraph in equal increments as the income of the patient
20 increases, up to a maximum of the greater of the amount that would have
21 been paid for the same services by the "highest volume payor" for such
22 general hospital, as defined in subparagraph (v) of this paragraph, or
23 for services provided pursuant to title XVIII of the federal social
24 security act (medicare) or for services provided pursuant to title XIX
25 of the federal social security act (medicaid); and
26 (iv)] For patients with incomes [between at least two hundred fifty-
27 one percent and three hundred] above four hundred percent and up to six
28 hundred percent of the federal poverty level, the hospital shall collect
29 no more than the [greater of the] amount that would have been paid for
30 the same services [by the "highest volume payor" for such general hospi-
31 tal as defined in subparagraph (v) of this paragraph, or for services
32 provided pursuant to title XVIII of the federal social security act
33 (medicare), or for services] provided pursuant to title [XIX] XVIII of
34 the federal social security act (medicaid).
35 [(v) For the purposes of this paragraph, "highest volume payor" shall
36 mean the insurer, corporation or organization licensed, organized or
37 certified pursuant to article thirty-two, forty-two or forty-three of
38 the insurance law or article forty-four of this chapter, or other third-
39 party payor, which has a contract or agreement to pay claims for
40 services provided by the general hospital and incurred the highest
41 volume of claims in the previous calendar year.
42 (vi) A hospital may implement policies and procedures to permit, but
43 not require, consideration on a case-by-case basis of exceptions to the
44 requirements described in subparagraphs (i) and (ii) of this paragraph
45 based upon the existence of significant assets owned by the patient that
46 should be taken into account in determining the appropriate payment
47 amount for that patient's care, provided, however, that such proposed
48 policies and procedures shall be subject to the prior review and
49 approval of the commissioner and, if approved, shall be included in the
50 hospital's financial assistance policy established pursuant to this
51 section, and provided further that, if such approval is granted, the
52 maximum amount that may be collected shall not exceed the greater of the
53 amount that would have been paid for the same services by the "highest
54 volume payor" for such general hospital as defined in subparagraph (v)
55 of this paragraph, or for services provided pursuant to title XVIII of
56 the federal social security act (medicare), or for services provided
A. 6027--A 4
1 pursuant to title XIX of the federal social security act (medicaid). In
2 the event that a general hospital reviews a patient's assets in deter-
3 mining payment adjustments such policies and procedures shall not
4 consider as assets a patient's primary residence, assets held in a tax-
5 deferred or comparable retirement savings account, college savings
6 accounts, or cars used regularly by a patient or immediate family
7 members.
8 (vii)] (c) Nothing in this [paragraph] subdivision shall be construed
9 to limit a hospital's ability to establish patient eligibility for
10 payment discounts at income levels higher than those specified herein
11 and/or to provide greater payment discounts for eligible patients than
12 those required by this [paragraph] subdivision.
13 [(c)] (d) Such policies and procedures shall be clear, understandable,
14 in writing and publicly available in summary form [and each]. Each
15 general hospital participating in the pool shall ensure that every
16 patient is made aware of the existence of [such] the policies and proce-
17 dures and is provided, in a timely manner, with a summary and a copy of
18 [such policies and procedures upon request] the policy and form at
19 intake, admission and discharge. Any summary provided to patients
20 shall, at a minimum, include, in plain language, specific information as
21 to income levels used to determine eligibility for assistance, [a
22 description of the primary service area of the hospital] financial
23 assistance available and the means of applying for assistance. [For
24 general hospitals with twenty-four hour emergency departments, such
25 policies and procedures] A plain language summary of the collections
26 process must also be made available. A general hospital shall [require
27 the notification of patients] notify patients by providing written mate-
28 rials to patients or their authorized representatives during the intake
29 and registration process, by making materials available in conspicuous
30 locations in the hospital including emergency departments, waiting areas
31 and other places patients congregate, through the conspicuous posting of
32 language-appropriate information in the general hospital, and by includ-
33 ing information on bills and statements sent to patients, that financial
34 [aid] assistance may be available to qualified patients and how to
35 obtain further information. [For specialty hospitals without twenty-four
36 hour emergency departments, such notification shall take place through
37 written materials provided to patients during the intake and registra-
38 tion process prior to the provision of any health care services or
39 procedures, and through information on bills and statements sent to
40 patients, that financial aid may be available to qualified patients and
41 how to obtain further information. Application materials shall include a
42 notice to patients that upon submission of a completed application,
43 including any information or documentation needed to determine the
44 patient's eligibility pursuant to the hospital's financial assistance
45 policy, the patient may disregard any bills until the hospital has
46 rendered a decision on the application in accordance with this para-
47 graph] General hospitals shall post the financial assistance application
48 policy, procedures and form, and a summary of the policy and procedures
49 and collection process, in a conspicuous location and downloadable form
50 on the general hospital's website.
51 [(d) Such] (e) The hospital's application materials shall include a
52 notice to patients that upon submission of a completed application form,
53 the patient shall not be liable for any bills until the general hospital
54 has rendered a decision on the application in accordance with this
55 subdivision. The application materials shall include specific informa-
56 tion as the income levels used to determine eligibility for financial
A. 6027--A 5
1 assistance, a description of the primary service area of the hospital
2 and the means to apply for assistance. Nothing in this subdivision shall
3 be construed as precluding the use of presumptive eligibility determi-
4 nations by hospitals on behalf of patients. The policies and procedures
5 shall include clear, objective criteria for determining a patient's
6 ability to pay and for providing such adjustments to payment require-
7 ments as are necessary. In addition to adjustment mechanisms such as
8 sliding fee schedules and discounts to fixed standards, such policies
9 and procedures shall also provide for the use of installment plans for
10 the payment of outstanding balances by patients pursuant to the
11 provisions of the hospital's financial assistance policy. The monthly
12 payment under such a plan shall not exceed [ten] five percent of the
13 gross monthly income of the patient[, provided, however, that if patient
14 assets are considered under such a policy, then patient assets which are
15 not excluded assets pursuant to subparagraph (vi) of paragraph (b) of
16 this subdivision may be considered in addition to the limit on monthly
17 payments]. Installment plan payments may not be required to begin before
18 one hundred eighty days after the date of the service or discharge,
19 whichever is later. The policy shall allow the patient and the hospital
20 to mutually agree to modify the terms of an installment plan. The rate
21 of interest charged to the patient on the unpaid balance, if any, shall
22 not exceed [the rate for a ninety-day security issued by the United
23 States Department of Treasury, plus .5 percent] two percentum per annum
24 and no plan shall include an accelerator or similar clause under which a
25 higher rate of interest is triggered upon a missed payment. [If such]
26 The policies and procedures shall not include a requirement of a deposit
27 prior to [non-emergent,] medically-necessary care[, such deposit must be
28 included as part of any financial aid consideration]. The hospital
29 shall refund any payments made by the patient before the determination
30 of eligibility for financial assistance that exceeds the patient's
31 liability after discounts are applied. Such policies and procedures
32 shall be applied consistently to all eligible patients.
33 [(e) Such policies and procedures shall permit patients to] (f) In any
34 legal action by or on behalf of a hospital to collect a medical debt,
35 the complaint shall be accompanied by an affidavit by the hospital's
36 chief financial officer stating that the hospital has taken reasonable
37 steps to determine whether the patient qualifies for financial assist-
38 ance and upon information and belief the patient does not meet the
39 income or residency criteria for financial assistance. Patients may
40 apply for financial assistance [within at least ninety days of the date
41 of discharge or date of service and provide at least twenty days for
42 patients to submit a completed application] at any time during the
43 collection process, including after the commencement of a medical debt
44 court action or upon the plaintiff obtaining a default judgment. A
45 determination that a patient is eligible for financial assistance shall
46 be valid for a minimum of twelve months and will apply to all outstand-
47 ing medical bills. A hospital may use credit scoring software for the
48 purposes of establishing income eligibility and approving financial
49 assistance, but only if the hospital makes clear to the patient that
50 providing a social security number is not mandatory and the scoring does
51 not negatively impact the patient's credit score. However, credit scor-
52 ing software shall not be solely relied upon by the hospital in denying
53 a patient's application for financial assistance. Further, propensity to
54 pay scores may not disqualify patients who otherwise qualify for eligi-
55 bility from receiving financial assistance. [Such] The policies and
56 procedures [may require that] shall allow patients seeking [payment
A. 6027--A 6
1 adjustments] financial assistance to provide [appropriate] the following
2 financial information and documentation in support of their applica-
3 tion[, provided, however, that such application process shall not be
4 unduly burdensome or complex]: pay checks or pay stubs; unemployment
5 documentation; social security income; rent receipts; a letter from the
6 patient's employer attesting to the patient's gross income; documenta-
7 tion of eligibility for other means-tested government benefits; or, if
8 none of the aforementioned information and documentation are available,
9 a written self-attestation of the patient's income may be used. General
10 hospitals [shall, upon request,] must take reasonable steps to assist
11 patients in understanding the hospital's application and form, policies
12 and procedures and in applying for payment adjustments. Application
13 forms shall be printed and posted to its website in the "primary
14 languages" of patients served by the general hospital. For the purposes
15 of this paragraph, "primary languages" shall include any language that
16 is either (i) used to communicate, during at least five percent of
17 patient visits in a year, by patients who cannot speak, read, write or
18 understand the English language at the level of proficiency necessary
19 for effective communication with health care providers, or (ii) spoken
20 by [non-English] limited-English speaking individuals comprising more
21 than one percent of the primary hospital service area population, as
22 calculated using demographic information available from the United
23 States Bureau of the Census, supplemented by data from school systems.
24 Decisions regarding such applications shall be made within thirty days
25 of receipt of a completed application. [Such] The policies and proce-
26 dures shall require that the hospital issue any [denial/approval] denial
27 or approval of [such] the application in writing which clearly communi-
28 cates the amount of assistance granted, any amounts still owed with
29 information on how to appeal the [denial] decision and shall require the
30 hospital to establish an appeals process under which it will evaluate
31 the [denial of] decision about an application. [Nothing in this subdivi-
32 sion shall be interpreted as prohibiting a hospital from making the
33 availability of financial assistance contingent upon the patient first
34 applying for coverage under title XIX of the social security act (medi-
35 caid) or another insurance program if, in the judgment of the hospital,
36 the patient may be eligible for medicaid or another insurance program,
37 and upon the patient's cooperation in following the hospital's financial
38 assistance application requirements, including the provision of informa-
39 tion needed to make a determination on the patient's application in
40 accordance with the hospital's financial assistance policy] Nothing in
41 this subdivision shall prevent a hospital from informing and assisting a
42 patient with an application for health insurance coverage with a local
43 services district or the marketplace. A hospital shall not make the
44 availability of financial assistance contingent upon the patient's
45 application for health insurance coverage. The hospital shall inform
46 patients on how to file a complaint against the hospital or a debt
47 collector that is contracted on behalf of the hospital regarding the
48 patient's bill. General hospitals are required to take reasonable meas-
49 ures to determine if a patient is eligible for financial assistance
50 including prior to making a referral to a third-party debt collector or
51 other extraordinary collections measures.
52 [(f) Such] (g) The policies and procedures shall provide that patients
53 with incomes below [three] six hundred percent of the federal poverty
54 level are deemed [presumptively] eligible for payment adjustments and
55 shall conform to the requirements set forth in paragraph (b) of this
56 subdivision, provided, however, that nothing in this subdivision shall
A. 6027--A 7
1 be interpreted as precluding hospitals from extending such payment
2 adjustments to other patients, either generally or on a case-by-case
3 basis. [Such policies and procedures shall provide financial aid for
4 emergency hospital services, including emergency transfers pursuant to
5 the federal emergency medical treatment and active labor act (42 USC
6 1395dd), to patients who reside in New York state and for medically
7 necessary hospital services for patients who reside in the hospital's
8 primary service area as determined according to criteria established by
9 the commissioner. In developing such criteria, the commissioner shall
10 consult with representatives of the hospital industry, health care
11 consumer advocates and local public health officials. Such criteria
12 shall be made available to the public no less than thirty days prior to
13 the date of implementation and shall, at a minimum:
14 (i) prohibit a hospital from developing or altering its primary
15 service area in a manner designed to avoid medically underserved commu-
16 nities or communities with high percentages of uninsured residents;
17 (ii) ensure that every geographic area of the state is included in at
18 least one general hospital's primary service area so that eligible
19 patients may access care and financial assistance; and
20 (iii) require the hospital to notify the commissioner upon making any
21 change to its primary service area, and to include a description of its
22 primary service area in the hospital's annual implementation report
23 filed pursuant to subdivision three of section twenty-eight hundred
24 three-l of this article.
25 (g) Nothing in this subdivision shall be interpreted as precluding
26 hospitals from extending payment adjustments for medically necessary
27 non-emergency hospital services to patients outside of the hospital's
28 primary service area.] For patients determined to be eligible for finan-
29 cial [aid] assistance under the terms of a hospital's financial [aid]
30 assistance policy, [such] the policies and procedures shall prohibit any
31 limitations on financial [aid] assistance for services based on the
32 medical condition of the applicant, other than typical limitations or
33 exclusions based on medical necessity or the clinical or therapeutic
34 benefit of a procedure or treatment.
35 (h) [Such policies and procedures shall not permit the forced] A
36 hospital or its agent shall not issue, authorize or permit an income
37 execution of a patient's wages, secure a lien or force a sale or fore-
38 closure of a patient's primary residence in order to collect an
39 outstanding medical bill and shall [require the hospital to refrain from
40 sending] not send an account to collection if the patient has submitted
41 a completed application for financial [aid, including any required
42 supporting documentation] assistance, while the hospital determines the
43 patient's eligibility for [such aid] financial assistance. [Such] The
44 policies and procedures shall provide for written notification, which
45 shall include notification on a patient bill, to a patient not less than
46 thirty days prior to the referral of debts for collection and shall
47 require that the collection agency obtain the hospital's written consent
48 prior to commencing a legal action. [Such] The policies and procedures
49 shall require all general hospital staff who interact with patients or
50 have responsibility for billing and collections to be trained in [such]
51 the policies and procedures, and require the implementation of a mech-
52 anism for the general hospital to measure its compliance with [such] the
53 policies and procedures. [Such] The policies and procedures shall
54 require that any collection agency, lawyer or firm under contract with a
55 general hospital for the collection of debts follow the hospital's
56 financial assistance policy, including providing information to patients
A. 6027--A 8
1 on how to apply for financial assistance where appropriate. [Such] The
2 policies and procedures shall prohibit collections from a patient who is
3 determined to be eligible for medical assistance [pursuant to title XIX
4 of the federal social security act] under title eleven of article five
5 of the social services law at the time services were rendered and for
6 which services medicaid payment is available.
7 (i) Reports required to be submitted to the department by each general
8 hospital as a condition for participation in the pools[, and which
9 contain, in accordance with applicable regulations,] shall contain: (i)
10 a certification from an independent certified public accountant or inde-
11 pendent licensed public accountant or an attestation from a senior offi-
12 cial of the hospital that the hospital is in compliance with conditions
13 of participation in the pools[, shall also contain, for reporting peri-
14 ods on and after January first, two thousand seven:];
15 [(i)] (ii) a report on hospital costs incurred and uncollected amounts
16 in providing services to [eligible] patients [without insurance] found
17 eligible for financial assistance, including the amount of care provided
18 for [a nominal payment amount] patients under two hundred percent pover-
19 ty, during the period covered by the report;
20 [(ii)] (iii) hospital costs incurred and uncollected amounts for
21 deductibles and coinsurance for eligible patients with insurance or
22 other third-party payor coverage;
23 [(iii)] (iv) the number of patients, organized according to United
24 States postal service zip code, race, ethnicity and gender, who applied
25 for financial assistance [pursuant to] under the hospital's financial
26 assistance policy, and the number, organized according to United States
27 postal service zip code, race, ethnicity and gender, whose applications
28 were approved and whose applications were denied;
29 [(iv)] (v) the reimbursement received for indigent care from the pool
30 established [pursuant to] under this section;
31 [(v)] (vi) the amount of funds that have been expended on [charity
32 care] financial assistance from charitable bequests made or trusts
33 established for the purpose of providing financial assistance to
34 patients who are eligible in accordance with the terms of [such] the
35 bequests or trusts;
36 [(vi)] (vii) for hospitals located in social services districts in
37 which the district allows hospitals to assist patients with such appli-
38 cations, the number of applications for eligibility for medicaid under
39 title [XIX of the social security act (medicaid)] eleven of article five
40 of the social services law that the hospital assisted patients in
41 completing and the number denied and approved;
42 [(vii)] (viii) the hospital's financial losses resulting from services
43 provided under medicaid; and
44 [(viii)] (ix) the number of referrals to collection agents or
45 contracted external collection vendors, court cases and liens placed on
46 [the primary] any residences of patients through the collection process
47 used by a hospital.
48 (j) Within ninety days of the effective date of the chapter of the
49 laws of two thousand twenty-three which amended this subdivision each
50 hospital shall submit to the commissioner a written report on its poli-
51 cies and procedures for financial assistance to patients which are used
52 by the hospital [on the] as of such effective date [of this subdivi-
53 sion]. Such report shall include copies of its policies and procedures,
54 including material which is distributed to patients, and a description
55 of the hospital's financial aid policies and procedures. Such
56 description shall include the income levels of patients on which eligi-
A. 6027--A 9
1 bility is based, the financial aid eligible patients receive and the
2 means of calculating such aid, and the service area, if any, used by the
3 hospital to determine eligibility.
4 (k) The commissioner shall include the data collected under paragraph
5 (i) of this subdivision in regular audits of the annual general hospital
6 institutional cost report.
7 (l) In the event [it is determined by the commissioner that] the state
8 [will be] is unable to secure all necessary federal approvals to
9 include, as part of the state's approved state plan under title nineteen
10 of the federal social security act, a requirement[, as set forth in
11 paragraph one of this subdivision,] that compliance with this subdivi-
12 sion is a condition of participation in pool distributions authorized
13 pursuant to this section and section twenty-eight hundred seven-w of
14 this article, then such condition of participation shall be deemed null
15 and void [and, notwithstanding]. Notwithstanding section twelve of this
16 chapter, failure to comply with [the provisions of] this subdivision by
17 a general hospital [on and after the date of such determination] shall
18 make [such] the hospital liable for a civil penalty not to exceed ten
19 thousand dollars for each [such] violation. The imposition of [such] the
20 civil penalties shall be subject to [the provisions of] section twelve-a
21 of this chapter.
22 (m) A hospital or its collection agents shall not report adverse
23 information about a patient to a consumer or financial reporting entity.
24 A hospital or its collection agent shall not commence a civil action
25 against a patient or delegate a collection activity to a debt collector
26 for nonpayment for one hundred eighty days after the first post-service
27 bill is issued and until a hospital has made reasonable efforts to
28 determine whether a patient qualifies for financial assistance. A hospi-
29 tal shall not commence a civil action against a patient or delegate a
30 collection activity to a debt collector, if: the hospital was notified
31 that an appeal or a review of a health insurance decision is pending
32 within the immediately preceding sixty days; or the patient has a pend-
33 ing application for or qualified for financial assistance.
34 § 3. Subdivision 9-a of section 2807-k of the public health law, as
35 amended by section two of this act, is amended to read as follows:
36 9-a. (a) (i) As a condition for participation in pool distributions
37 authorized pursuant to this section and section twenty-eight hundred
38 seven-w of this article for periods on and after January first, two
39 thousand nine, general hospitals shall, effective for periods on and
40 after January first, two thousand [seven, establish] twenty-five, adopt
41 and implement the uniform financial assistance [policies and procedures,
42 in accordance with the provisions of this subdivision,] form and policy,
43 to be developed and issued by the commissioner. General hospitals shall
44 implement the uniform policy and form for reducing hospital charges
45 otherwise applicable to low-income individuals who can demonstrate an
46 inability to pay full charges, and also, at the hospital's discretion,
47 for reducing or discounting the collection of co-pays and deductible
48 payments from those individuals who can demonstrate an inability to pay
49 such amounts. Immigration status shall not be an eligibility criterion
50 for the purpose of determining financial assistance under this section.
51 As used in this section, "affiliated provider" means a provider that is:
52 (A) employed by the hospital; (B) under a professional services agree-
53 ment with the hospital; or (C) a clinical faculty member of a medical
54 school or other school that trains individuals to be providers and that
55 is affiliated with the hospital or health system.
A. 6027--A 10
1 (ii) A general hospital may use the New York state of health market-
2 place eligibility determination page to establish the patient's house-
3 hold income and residency in lieu of the financial application form,
4 provided it has secured the consent of the patient. A general hospital
5 shall not require a patient to apply for coverage through the New York
6 state of health marketplace in order to receive care or financial
7 assistance.
8 (iii) Upon submission of a completed application form, the patient is
9 not liable for any bills and no interest may accrue until the general
10 hospital has rendered a decision on the application in accordance with
11 this subdivision.
12 (b) The reductions from charges for patients described in paragraph
13 (a) of this subdivision with incomes below six hundred percent of the
14 federal poverty level shall result in a charge to such individuals that
15 does not exceed the amount that would have been paid for the same
16 services provided pursuant to title XVIII of the federal social security
17 act (medicaid), and provided further that such amount shall be adjusted
18 according to income level as follows:
19 (i) For patients with incomes at or below two hundred percent of the
20 federal poverty level, the hospital shall waive all charges. No nominal
21 payment shall be collected;
22 (ii) For patients with incomes above two hundred percent and up to
23 four hundred percent of the federal poverty level, the hospital shall
24 collect no more than the amount identified after application of a
25 proportional sliding fee schedule under which patients with lower
26 incomes shall pay the lowest amount. The schedule shall provide that
27 the amount the hospital may collect for the patient increases from the
28 nominal amount described in subparagraph (i) of this paragraph in equal
29 increments as the income of the patient increases, up to a maximum of
30 twenty percent of the amount that would have been paid for the same
31 services provided pursuant to title XVIII of the federal social security
32 act (medicaid);
33 (iii) For patients with incomes above four hundred percent and up to
34 six hundred percent of the federal poverty level, the hospital shall
35 collect no more than the amount that would have been paid for the same
36 services provided pursuant to title XVIII of the federal social security
37 act (medicaid).
38 (c) Nothing in this subdivision shall be construed to limit a hospi-
39 tal's ability to establish patient eligibility for payment discounts at
40 income levels higher than those specified herein and/or to provide
41 greater payment discounts for eligible patients than those required by
42 this subdivision.
43 (d) [Such policies and procedures shall be clear, understandable, in
44 writing and publicly available in summary form.] Each general hospital
45 participating in the pool shall ensure that every patient is made aware
46 of the existence of [the policies and procedures] the uniform financial
47 assistance form and policy and is provided, in a timely manner, with [a
48 summary and] a copy of the policy and form at intake, admission and
49 discharge. [Any summary provided to patients shall, at a minimum,
50 include, in plain language, specific information as to income levels
51 used to determine eligibility for assistance, financial assitance avail-
52 able and the means of applying for assistance.] A plain language summary
53 of the collections process must also be made available. A general hospi-
54 tal shall notify patients by providing written materials to patients or
55 their authorized representatives during the intake and registration
56 process, by making materials available in conspicuous locations in the
A. 6027--A 11
1 hospital including emergency departments, waiting areas and other places
2 patients congregate, through the conspicuous posting of language-appro-
3 priate information in the general hospital, and by including information
4 on bills and statements sent to patients, that financial assistance may
5 be available to qualified patients and how to obtain further informa-
6 tion. General hospitals shall post the uniform financial assistance
7 application policy[, procedures] and form, and a summary of the policy
8 [and procedures] and collection process, in a conspicuous location and
9 downloadable form on the general hospital's website. The commissioner
10 shall post the uniform financial assistance form and policy in download-
11 able form on the department's hospital profile page or any successor
12 website.
13 (e) The [hospital's] commissioner shall provide application materials
14 to general hospitals, including the uniform financial assistance appli-
15 cation form and policy. These application materials shall include a
16 notice to patients that upon submission of a completed application form,
17 the patient shall not be liable for any bills until the general hospital
18 has rendered a decision on the application in accordance with this
19 subdivision. The application materials shall include specific informa-
20 tion as the income levels used to determine eligibility for financial
21 assistance[, a description of the primary service area of the hospital]
22 and the means to apply for assistance. Nothing in this subdivision shall
23 be construed as precluding the use of presumptive eligibility determi-
24 nations by hospitals on behalf of patients. The [policies and proce-
25 dures] uniform application form and policy shall include clear, objec-
26 tive criteria for determining a patient's ability to pay and for
27 providing such adjustments to payment requirements as are necessary. In
28 addition to adjustment mechanisms such as sliding fee schedules and
29 discounts to fixed standards, [such policies and procedures] the uniform
30 policy shall also provide for the use of installment plans for the
31 payment of outstanding balances by patients [pursuant to the provisions
32 of the hospital's financial assistance policy]. The monthly payment
33 under such a plan shall not exceed five percent of the gross monthly
34 income of the patient. Installment plan payments may not be required to
35 begin before one hundred eighty days after the date of the service or
36 discharge, whichever is later. The policy shall allow the patient and
37 the hospital to mutually agree to modify the terms of an installment
38 plan. The rate of interest charged to the patient on the unpaid
39 balance, if any, shall not exceed two percentum per annum and no plan
40 shall include an accelerator or similar clause under which a higher rate
41 of interest is triggered upon a missed payment. The [policies and
42 procedures] uniform policy shall not include a requirement of a deposit
43 prior to medically-necessary care. The hospital shall refund any
44 payments made by the patient before the determination of eligibility for
45 financial assistance that exceeds the patient's liability after
46 discounts are applied. Such policies and procedures shall be applied
47 consistently to all eligible patients.
48 (f) In any legal action by or on behalf of a hospital to collect a
49 medical debt, the complaint shall be accompanied by an affidavit by the
50 hospital's chief financial officer stating that the hospital has taken
51 reasonable steps to determine whether the patient qualifies for finan-
52 cial assistance and upon information and belief the patient does not
53 meet the income or residency criteria for financial assistance. Patients
54 may apply for financial assistance at any time during the collection
55 process, including after the commencement of a medical debt court action
56 or upon the plaintiff obtaining a default judgment. A determination
A. 6027--A 12
1 that a patient is eligible for financial assistance shall be valid for a
2 minimum of twelve months and will apply to all outstanding medical
3 bills. A hospital may use credit scoring software for the purposes of
4 establishing income eligibility and approving financial assistance, but
5 only if the hospital makes clear to the patient that providing a social
6 security number is not mandatory and the scoring does not negatively
7 impact the patient's credit score. However, credit scoring software
8 shall not be solely relied upon by the hospital in denying a patient's
9 application for financial assistance. Further, propensity to pay scores
10 may not disqualify patients who otherwise qualify for eligibility from
11 receiving financial assistance. Further, propensity to pay scores shall
12 not disqualify patients who otherwise qualify for eligibility from
13 receiving financial assistance. The [policies and procedures] uniform
14 policy and form policies and procedures shall allow patients seeking
15 financial assistance to provide the following financial information and
16 documentation in support of their application: pay checks or pay stubs;
17 unemployment documentation; social security income; rent receipts; a
18 letter from the patient's employer attesting to the patient's gross
19 income; documentation of eligibility for other means-tested government
20 benefits; or, if none of the aforementioned information and documenta-
21 tion are available, a written self-attestation of the patient's income
22 may be used. General hospitals must take reasonable steps to assist
23 patients in understanding the hospital's application and form, policies
24 and procedures and in applying for payment adjustments. [Application
25 forms shall be printed and posted] The commissioner shall translate the
26 uniform financial assistance application form and policy into the
27 "primary languages" of each general hospital. Each general hospital
28 shall print and post these materials to its website in the "primary
29 languages" of patients served by the general hospital. For the purposes
30 of this paragraph, "primary languages" shall include any language that
31 is either (i) used to communicate, during at least five percent of
32 patient visits in a year, by patients who cannot speak, read, write or
33 understand the English language at the level of proficiency necessary
34 for effective communication with health care providers, or (ii) spoken
35 by limited-English speaking individuals comprising more than one percent
36 of the primary hospital service area population, as calculated using
37 demographic information available from the United States Bureau of the
38 Census, supplemented by data from school systems. Decisions regarding
39 such applications shall be made within thirty days of receipt of a
40 completed application. The [policies and procedures] uniform financial
41 assistance policy shall require that the hospital issue any denial or
42 approval of the application in writing which clearly communicates the
43 amount of assistance granted, any amounts still owed with information on
44 how to appeal the decision and shall require the hospital to establish
45 an appeals process under which it will evaluate the decision about an
46 application. Nothing in this subdivision shall prevent a hospital from
47 informing and assisting a patient with an application for health insur-
48 ance coverage with a local services district or the marketplace. A
49 hospital shall not make the availability of financial assistance contin-
50 gent upon the patient's application for health insurance coverage. The
51 hospital shall inform patients on how to file a complaint against the
52 hospital or a debt collector that is contracted on behalf of the hospi-
53 tal regarding the patient's bill. General hospitals are required to
54 take reasonable measures to determine if a patient is eligible for
55 financial assistance including prior to making a referral to a third-
56 party debt collector or other extraordinary collections measures.
A. 6027--A 13
1 (g) The [policies and procedures] uniform financial assistance policy
2 shall provide that patients with incomes below six hundred percent of
3 the federal poverty level are deemed eligible for payment adjustments
4 and shall conform to the requirements set forth in paragraph (b) of this
5 subdivision, provided, however, that nothing in this subdivision shall
6 be interpreted as precluding hospitals from extending such payment
7 adjustments to other patients, either generally or on a case-by-case
8 basis. For patients determined to be eligible for financial assistance
9 under the terms of [a hospital's] the uniform financial assistance poli-
10 cy, the [policies and procedures] financial assistance policy shall
11 prohibit any limitations on financial assistance for services based on
12 the medical condition of the applicant, other than typical limitations
13 or exclusions based on medical necessity or the clinical or therapeutic
14 benefit of a procedure or treatment.
15 (h) A hospital or its agent shall not issue, authorize or permit an
16 income execution of a patient's wages, secure a lien or force a sale or
17 foreclosure of a patient's primary residence in order to collect an
18 outstanding medical bill and shall not send an account to collection if
19 the patient has submitted a completed application for financial assist-
20 ance, until it has made reasonable efforts to determine whether a
21 patient qualifies for financial assistance or while the hospital deter-
22 mines the patient's eligibility for financial assistance. The [policies
23 and procedures] uniform policy shall provide for written notification,
24 which shall include notification on a patient bill, to a patient not
25 less than thirty days prior to the referral of debts for collection and
26 shall require that the collection agency obtain the hospital's written
27 consent prior to commencing a legal action. The [policies and proce-
28 dures] uniform policy shall require all general hospital staff who
29 interact with patients or have responsibility for billing and
30 collections to be trained in the [policies and procedures] uniform poli-
31 cy, and require the implementation of a mechanism for the general hospi-
32 tal to measure its compliance with the [policies and procedures] uniform
33 policy. The [policies and procedures] uniform policy shall require that
34 any collection agency, lawyer or firm under contract with a general
35 hospital for the collection of debts follow the [hospital's] uniform
36 financial assistance policy, including providing information to patients
37 on how to apply for financial assistance where appropriate. The [poli-
38 cies and procedures] uniform policy shall prohibit collections from a
39 patient who is determined to be eligible for medical assistance under
40 title eleven of article five of the social services law at the time
41 services were rendered and for which services medicaid payment is avail-
42 able.
43 (i) Reports required to be submitted to the department by each general
44 hospital as a condition for participation in the pools shall contain:
45 (i) a certification from an independent certified public accountant or
46 independent licensed public accountant or an attestation from a senior
47 official of the hospital that the hospital is in compliance with condi-
48 tions of participation in the pools;
49 (ii) a report on hospital costs incurred and uncollected amounts in
50 providing services to patients found eligible for financial assistance,
51 including the amount of care provided for patients under two hundred
52 percent poverty, during the period covered by the report;
53 (iii) hospital costs incurred and uncollected amounts for deductibles
54 and coinsurance for eligible patients with insurance or other third-par-
55 ty payor coverage;
A. 6027--A 14
1 (iv) the number of patients, organized according to United States
2 postal service zip code, race, ethnicity and gender, who applied for
3 financial assistance under the [hospital's] uniform financial assistance
4 policy, and the number, organized according to United States postal
5 service zip code, race, ethnicity and gender, whose applications were
6 approved and whose applications were denied;
7 (v) the reimbursement received for indigent care from the pool estab-
8 lished under this section;
9 (vi) the amount of funds that have been expended on financial assist-
10 ance from charitable bequests made or trusts established for the purpose
11 of providing financial assistance to patients who are eligible in
12 accordance with the terms of the bequests or trusts;
13 (vii) for hospitals located in social services districts in which the
14 district allows hospitals to assist patients with such applications, the
15 number of applications for eligibility for medicaid under title eleven
16 of article five of the social services law that the hospital assisted
17 patients in completing and the number denied and approved;
18 (viii) the hospital's financial losses resulting from services
19 provided under medicaid; and
20 (ix) the number of referrals to collection agents or contracted
21 external collection vendors, court cases and liens placed on any resi-
22 dences of patients through the collection process used by a hospital.
23 (j) [Within ninety days of the effective date of the chapter of the
24 laws of two thousand twenty-three which amended this subdivision each
25 hospital shall submit to the commissioner a written report on its poli-
26 cies and procedures for financial assistance to patients which are used
27 by the hospital as of such effective date. Such report shall include
28 copies of its policies and procedures, including material which is
29 distributed to patients, and a description of the hospital's financial
30 aid policies and procedures. Such description shall include the income
31 levels of patients on which eligibility is based, the financial aid
32 eligible patients receive and the means of calculating such aid, and the
33 service area, if any, used by the hospital to determine eligibility.
34 (k)] The commissioner shall include the data collected under paragraph
35 (i) of this subdivision in regular audits of the annual general hospital
36 institutional cost report.
37 [(l)] (k) In the event the state is unable to secure all necessary
38 federal approvals to include, as part of the state's approved state plan
39 under title nineteen of the federal social security act, a requirement
40 that compliance with this subdivision is a condition of participation in
41 pool distributions authorized pursuant to this section and section twen-
42 ty-eight hundred seven-w of this article, then such condition of partic-
43 ipation shall be deemed null and void. Notwithstanding section twelve of
44 this chapter, failure to comply with this subdivision by a general
45 hospital shall make the hospital liable for a civil penalty not to
46 exceed ten thousand dollars for each violation. The imposition of the
47 civil penalties shall be subject to section twelve-a of this chapter.
48 [(m)] (l) A hospital or its collection agents shall not report adverse
49 information about a patient to a consumer or financial reporting entity.
50 A hospital or its collection agent shall not commence civil action
51 against a patient or delegate a collection activity to a debt collector
52 for nonpayment for one hundred eighty days after the first post-service
53 bill is issued and until a hospital has made reasonable efforts to
54 determine whether a patient qualifies for financial assistance. A hospi-
55 tal or its collection agent shall not commence a civil action against a
56 patient or delegate a collection activity to a debt collector, if: the
A. 6027--A 15
1 hospital was notified that an appeal or a review of a health insurance
2 decision is pending within the immediately preceding sixty days; or the
3 patient has a pending application for or qualified for financial assist-
4 ance.
5 § 4. Subdivision 14 of section 2807-k of the public health law is
6 REPEALED and subdivisions 15, 16 and 17 are renumbered subdivisions 14,
7 15 and 16.
8 § 5. This act shall take effect immediately; provided that (a)
9 section two of this act shall take effect on the one hundred twentieth
10 day after it shall have become a law; and (b) sections one, one-a and
11 three of this act shall take effect October 1, 2024 and apply to funding
12 distributions made on or after January 1, 2025; provided, however, that
13 if subpart C of part Y of chapter 57 of the laws of 2023 shall not have
14 taken effect on or before such date then section one-a of this act shall
15 take effect on the same date and in the same manner as such subpart of
16 such part of such chapter of the laws of 2023, takes effect. Effective
17 immediately, the commissioner of health may make regulations and take
18 other actions reasonably necessary to implement sections one, two and
19 three of this act on their respective effective dates.