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A02007 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
            S. 1507--C                                            A. 2007--C
 
                SENATE - ASSEMBLY
 
                                    January 18, 2019
                                       ___________
 
        IN  SENATE -- A BUDGET BILL, submitted by the Governor pursuant to arti-
          cle seven of the Constitution -- read twice and ordered  printed,  and
          when  printed to be committed to the Committee on Finance -- committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee  --  committee  discharged,  bill  amended,  ordered
          reprinted  as  amended  and recommitted to said committee -- committee
          discharged, bill amended, ordered reprinted as amended and recommitted
          to said committee
 
        IN ASSEMBLY -- A BUDGET BILL, submitted  by  the  Governor  pursuant  to
          article  seven  of  the  Constitution -- read once and referred to the
          Committee on Ways and Means --  committee  discharged,  bill  amended,
          ordered  reprinted  as  amended  and  recommitted to said committee --
          again reported from said committee with amendments, ordered  reprinted
          as  amended  and  recommitted to said committee -- again reported from
          said committee with  amendments,  ordered  reprinted  as  amended  and
          recommitted to said committee
 
        AN  ACT  intentionally omitted (Part A); to amend the public health law,
          in relation to extending and enhancing the Medicaid drug  cap  and  to
          reduce  unnecessary  pharmacy  benefit  manager  costs to the Medicaid
          program (Part B); to amend the social services  law,  in  relation  to
          extension  of  the  National  Diabetes Prevention Program (Part C); to
          amend chapter 59 of the laws of 2011 amending the  public  health  law
          and  other  laws  relating to known and projected department of health
          state fund medicaid expenditures, in relation to extending  the  medi-
          caid  global  cap  (Part D); to amend chapter 505 of the laws of 1995,
          amending the public health law relating to the operation of department
          of health facilities, in relation to extending the provisions thereof;
          to amend chapter 56 of the laws of 2013, amending the social  services
          law  relating  to eligibility conditions, in relation to extending the
          provisions thereof; to amend chapter 884 of the laws of 1990, amending
          the public health law relating to authorizing  bad  debt  and  charity
          care  allowances  for  certified  home health agencies, in relation to
          extending the provisions thereof; to amend chapter 303 of the laws  of
          1999,  amending  the  New  York  state medical care facilities finance
          agency act relating to financing health facilities, in relation to the
          effectiveness thereof; to amend chapter  109  of  the  laws  of  2010,
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD12571-05-9

        S. 1507--C                          2                         A. 2007--C
 
          amending  the social services law relating to transportation costs, in
          relation to the effectiveness thereof; to amend chapter 58 of the laws
          of 2009, amending the public health law relating to payment by govern-
          mental  agencies  for general hospital inpatient services, in relation
          to the effectiveness thereof; to amend chapter 56 of the laws of 2013,
          amending the public health law relating to the general  public  health
          work program, in relation to the effectiveness thereof; to amend chap-
          ter  59  of the laws of 2011, amending the public health law and other
          laws relating to known and projected department of health  state  fund
          medical expenditures, in relation to extending the provisions thereof;
          to  amend  the public health law, in relation to hospital assessments;
          to amend chapter 474 of the laws of 1996, amending the  education  law
          and  other  laws relating to rates for residential health care facili-
          ties, in relation to the effectiveness thereof; to amend chapter 58 of
          the laws of 2007, amending the social  services  law  and  other  laws
          relating  to enacting the major components of legislation necessary to
          implement the health and mental hygiene budget for the 2007-2008 state
          fiscal year, in relation to delay of certain administrative costs;  to
          amend  chapter  81 of the laws of 1995, amending the public health law
          and other laws relating to medical reimbursement and  welfare  reform,
          in  relation  to the effectiveness thereof; to amend chapter 56 of the
          laws of 2013, amending chapter 59 of the laws  of  2011  amending  the
          public  health  law  and  other  laws  relating  to  general  hospital
          reimbursement for annual rates, in relation to rates of  payments;  to
          amend the public health law, in relation to reimbursement rate promul-
          gation  for  residential  health  care facilities; to amend the public
          health law, in relation  to  residential  health  care  facility,  and
          certified home health agency services payments; to amend chapter 81 of
          the laws of 1995, amending the public health law and other laws relat-
          ing  to  medical  reimbursement and welfare reform, in relation to the
          effectiveness thereof; to amend chapter 56 of the laws of 2013  amend-
          ing  chapter 59 of the laws of 2011 amending the public health law and
          other laws relating  to  general  hospital  reimbursement  for  annual
          rates,  in  relation  to  extending  government  rates  for behavioral
          services and adding an alternative payment methodology requirement; to
          amend chapter 111 of the laws of 2010 relating to increasing  Medicaid
          payments to providers through managed care organizations and providing
          equivalent  fees  through  an ambulatory patient group methodology, in
          relation to extending government rates  for  behavioral  services  and
          adding  an  alternative  payment  methodology  requirement;  to  amend
          section 2 of part H of chapter 111 of the laws of  2010,  relating  to
          increasing  Medicaid payments to providers through managed care organ-
          izations and providing equivalent fees through an  ambulatory  patient
          group methodology, in relation to transfer of funds and the effective-
          ness  thereof;  and to amend chapter 649 of the laws of 1996, amending
          the public health law, the mental hygiene law and the social  services
          law  relating to authorizing the establishment of special needs plans,
          in relation to the effectiveness thereof (Part E);  to  amend  chapter
          266 of the laws of 1986, amending the civil practice law and rules and
          other  laws  relating to malpractice and professional medical conduct,
          in relation to apportioning premium for  certain  policies;  to  amend
          part  J  of chapter 63 of the laws of 2001 amending chapter 266 of the
          laws of 1986, amending the civil practice law and rules and other laws
          relating to malpractice and professional medical conduct, relating  to
          the  effectiveness  of certain provisions of such chapter, in relation
          to extending certain provisions concerning the hospital excess liabil-

        S. 1507--C                          3                         A. 2007--C
 
          ity pool; and to amend part H of chapter  57  of  the  laws  of  2017,
          amending  the  New  York Health Care Reform Act of 1996 and other laws
          relating to extending certain provisions relating thereto, in relation
          to extending provisions relating to excess coverage (Part F); to amend
          the  social  services law, in relation to fiscal intermediary services
          for the consumer directed personal assistance program;  to  amend  the
          public  health  law,  in  relation  to payments to home care aides; to
          establish a residential health care  facilities  case  mix  adjustment
          workgroup; and to repeal certain provisions of the social services law
          relating thereto (Part G); to amend the public health law, in relation
          to  waiver  of certain regulations; to amend the public health law, in
          relation to certain rates and payment  methodologies;  and  to  repeal
          certain  provisions  of  such  law  relating  thereto (Part H); inten-
          tionally omitted (Part I); to amend the insurance law and  the  public
          health  law,  in  relation to guaranteed availability and pre-existing
          conditions; and to repeal certain  provisions  of  the  insurance  law
          relating  thereto (Subpart A); to amend the insurance law, in relation
          to actuarial value requirements and essential health benefits (Subpart
          B); to amend the insurance  law,  in  relation  to  prescription  drug
          coverage  (Subpart  C); and to amend the insurance law, in relation to
          discrimination based on sex and gender identity (Subpart D) (Part  J);
          to  amend  the public health law, in relation to the medical indemnity
          fund; to amend chapter 517 of the laws of  2016  amending  the  public
          health law relating to payments from the New York state medical indem-
          nity  fund, in relation to the effectiveness thereof; and to amend the
          state finance law, in relation to the New York state medical indemnity
          fund account (Part K); to amend the  insurance  law,  in  relation  to
          in-vitro  fertilization  (Part  L);  to  amend  the  insurance law, in
          relation to requiring medical, major medical, or similar comprehensive
          type coverage health insurance policies to include  certain  reproduc-
          tive health coverage; and clarifying the definition of voluntary ster-
          ilization procedures and over-the-counter contraceptive products (Part
          M); intentionally omitted (Part N); to amend the public health law, in
          relation  to the general public health work program (Part O); to amend
          the public health law, in  relation  to  lead  levels  in  residential
          rental  properties  (Part  P);  to  amend  the  public  health law, in
          relation to the healthcare facility transformation program  state  III
          authorizing  additional awards for statewide II applications (Part Q);
          intentionally omitted (Part R); intentionally  omitted  (Part  S);  to
          amend  the public health law, in relation to codifying the creation of
          NY State of Health, the official Health Plan  Marketplace  within  the
          department  of health (Part T); to amend the elder law, in relation to
          the private pay program (Part U); to amend the social services law, in
          relation to compliance of managed  care  organizations  and  providers
          participating  in  the  Medicaid  program (Part V); to amend part D of
          chapter 111 of the laws of 2010 relating to  the  recovery  of  exempt
          income  by  the  office  of mental health for community residences and
          family-based treatment programs,  in  relation  to  the  effectiveness
          thereof  (Part  W); intentionally omitted (Part X); to amend part C of
          chapter 57 of the laws of 2006, relating to  establishing  a  cost  of
          living  adjustment for designated human services programs, in relation
          to the inclusion and development of certain cost of living adjustments
          (Part Y); to amend the public health law and the mental  hygiene  law,
          in  relation  to  integrated  services (Part Z); intentionally omitted
          (Part AA); to amend the insurance law, in relation  to  mental  health
          and  substance  use  disorder  health  insurance  parity; to amend the

        S. 1507--C                          4                         A. 2007--C
 
          public health law, in relation to  health  maintenance  organizations;
          and to repeal certain provisions of the insurance law relating thereto
          (Subpart  A);  to  amend the public health law, in relation to general
          hospital  policies  for  substance use disorder treatment (Subpart B);
          intentionally omitted (Subpart C); to amend the social  services  law,
          in relation to court ordered substance use disorder treatment (Subpart
          D);  and  intentionally  omitted  (Subpart  E)(Part BB); intentionally
          omitted (Part CC); intentionally  omitted  (Part  DD);  to  amend  the
          public health law, in relation to direct observation and evaluation of
          certain  temporary  employees  (Part  EE); to amend chapter 495 of the
          laws of 2004, amending the insurance law and  the  public  health  law
          relating  to  the New York state health insurance continuation assist-
          ance demonstration project, in relation to the  effectiveness  thereof
          (Part  FF); to provide funding to programs providing opioid treatment,
          recovery and prevention and education services  operated  by  the  New
          York  state  office  of  alcoholism  and  substance  abuse services or
          certain agencies (Part GG); to amend the elder  law,  in  relation  to
          grants  awarded  for classic NORC programs (Part HH); to amend chapter
          141 of the laws of 1994, amending the legislative law  and  the  state
          finance law relating to the operation and administration of the legis-
          lature,  in  relation to extending such provisions (Part II); to amend
          the public health  law,  in  relation  to  authorizing  the  dormitory
          authority  to  transfer  certain funds repaid by borrowers relating to
          restructuring pool loans (Part JJ); and directing  the  department  of
          health  to  conduct  a  study  in relation to staffing enhancement and
          patient safety (Part KK)
 
          The People of the State of New York, represented in Senate and  Assem-
        bly, do enact as follows:
 
     1    Section  1.  This  act enacts into law major components of legislation
     2  which are necessary to implement the state fiscal plan for the 2019-2020
     3  state fiscal year. Each component is  wholly  contained  within  a  Part
     4  identified as Parts A through KK. The effective date for each particular
     5  provision contained within such Part is set forth in the last section of
     6  such  Part.    Any  provision  in  any  section contained within a Part,
     7  including the effective date of the Part, which  makes  reference  to  a
     8  section  "of  this  act",  when  used in connection with that particular
     9  component, shall be deemed  to  mean  and  refer  to  the  corresponding
    10  section of the Part in which it is found. Section three of this act sets
    11  forth the general effective date of this act.
 
    12                                   PART A
 
    13                            Intentionally Omitted
 
    14                                   PART B
 
    15    Section 1. Intentionally omitted.
    16    § 2. Intentionally omitted.
    17    § 3. Intentionally omitted.
    18    § 4. Intentionally omitted.
    19    §  5.  Paragraphs  (b)  and (c) of subdivision 2 of section 280 of the
    20  public health law, paragraph (b) as amended and paragraph (c)  as  added

        S. 1507--C                          5                         A. 2007--C
 
     1  by  section  8  of part D of chapter 57 of the laws of 2018, are amended
     2  and a new paragraph (d) is added to read as follows:
     3    (b)  for  state  fiscal year two thousand eighteen--two thousand nine-
     4  teen, be limited to the ten-year rolling average of the  medical  compo-
     5  nent  of the consumer price index plus four percent and minus a pharmacy
     6  savings target of eighty-five million dollars; [and]
     7    (c) for state fiscal year two thousand nineteen--two thousand  twenty,
     8  be  limited  to the ten-year rolling average of the medical component of
     9  the consumer price index plus four percent and minus a pharmacy  savings
    10  target of eighty-five million dollars[.]; and
    11    (d)  for  state  fiscal year two thousand twenty--two thousand twenty-
    12  one, be limited to the ten-year rolling average of the medical component
    13  of the consumer price index plus  four  percent  and  minus  a  pharmacy
    14  savings target of eighty-five million dollars.
    15    § 6. Subdivision 3 of section 280 of the public health law, as amended
    16  by  section 8 of part D of chapter 57 of the laws of 2018, is amended to
    17  read as follows:
    18    3. The department and the division of the budget  shall  assess  on  a
    19  quarterly basis the projected total amount to be expended in the year on
    20  a  cash  basis  by the Medicaid program for each drug, and the projected
    21  annual amount of state funds Medicaid drug expenditures on a cash  basis
    22  for all drugs, which shall be a component of the projected department of
    23  health  state  funds  Medicaid  expenditures  calculated for purposes of
    24  sections ninety-one and ninety-two of part H of  chapter  fifty-nine  of
    25  the  laws  of  two  thousand eleven. For purposes of this section, state
    26  funds Medicaid drug expenditures include amounts expended for  drugs  in
    27  both  the  Medicaid  fee-for-service  program  and Medicaid managed care
    28  programs, minus the amount of any  drug  rebates  or  supplemental  drug
    29  rebates received by the department, including rebates pursuant to subdi-
    30  vision  five of this section with respect to rebate targets. The depart-
    31  ment and the division of the budget shall report [quarterly] in December
    32  of each year, for the prior April through October, to the drug  utiliza-
    33  tion  review  board the projected state funds Medicaid drug expenditures
    34  including the amounts, in aggregate thereof,  attributable  to  the  net
    35  cost  of:  changes  in  the utilization of drugs by Medicaid recipients;
    36  changes in the number of Medicaid recipients; changes  to  the  cost  of
    37  brand  name drugs and changes to the cost of generic drugs. The informa-
    38  tion contained in the report shall not be publicly released in a  manner
    39  that allows for the identification of an individual drug or manufacturer
    40  or  that  is likely to compromise the financial competitive, or proprie-
    41  tary nature of the information.
    42    (a) In the event the director of the budget determines, based on Medi-
    43  caid drug expenditures for the previous quarter or other relevant infor-
    44  mation, that the total department of health state  funds  Medicaid  drug
    45  expenditure  is projected to exceed the annual growth limitation imposed
    46  by subdivision two of this section, the commissioner  may  identify  and
    47  refer  drugs to the drug utilization review board established by section
    48  three hundred sixty-nine-bb of the social services law for a recommenda-
    49  tion as to whether a target supplemental Medicaid rebate should be  paid
    50  by  the manufacturer of the drug to the department and the target amount
    51  of the rebate.
    52    (b) If the department intends to refer a drug to the drug  utilization
    53  review  board pursuant to paragraph (a) of this subdivision, the depart-
    54  ment shall notify the manufacturer of such drug  and  shall  attempt  to
    55  reach  agreement with the manufacturer on a rebate for the drug prior to
    56  referring the drug to the drug  utilization  review  board  for  review.

        S. 1507--C                          6                         A. 2007--C
 
     1  Such  rebate may be based on evidence-based research, including, but not
     2  limited to, such research operated or conducted by or  for  other  state
     3  governments,  the  federal government, the governments of other nations,
     4  and  third party payers or multi-state coalitions, provided however that
     5  the department shall account for the effectiveness of the drug in treat-
     6  ing the conditions  for  which  it  is  prescribed  or  in  improving  a
     7  patient's  health,  quality of life, or overall health outcomes, and the
     8  likelihood that use of the drug will reduce the need for  other  medical
     9  care, including hospitalization.
    10    (c)  In  the  event  that  the  commissioner and the manufacturer have
    11  previously agreed to a supplemental rebate for a drug pursuant to  para-
    12  graph  (b)  of this subdivision or paragraph (e) of subdivision seven of
    13  section three hundred sixty-seven-a of the social services law, the drug
    14  shall not be referred to the  drug  utilization  review  board  for  any
    15  further  supplemental  rebate  for  the  duration of the previous rebate
    16  agreement, provided however, the commissioner may refer a  drug  to  the
    17  drug  utilization  review board if the commissioner determines there are
    18  significant  and  substantiated  utilization  or  market  changes,   new
    19  evidence-based research, or statutory or federal regulatory changes that
    20  warrant  additional  rebates. In such cases, the department shall notify
    21  the manufacturer and provide evidence of the changes  or  research  that
    22  would  warrant  additional rebates, and shall attempt to reach agreement
    23  with the manufacturer on a rebate for the drug prior  to  referring  the
    24  drug to the drug utilization review board for review.
    25    (d)  The  department shall consider a drug's actual cost to the state,
    26  including current rebate amounts, prior to seeking an additional  rebate
    27  pursuant  to  paragraph  (b)  or (c) of this subdivision [and shall take
    28  into consideration whether the manufacturer of  the  drug  is  providing
    29  significant  discounts  relative  to other drugs covered by the Medicaid
    30  program].
    31    (e) The commissioner shall be authorized to take the actions described
    32  in this section only so long as total  Medicaid  drug  expenditures  are
    33  projected  to exceed the annual growth limitation imposed by subdivision
    34  two of this section.
    35    § 6-a. Subparagraph (iii) of paragraph (e) of subdivision 5 of section
    36  280 of the public health law, as amended by section 8 of part D of chap-
    37  ter 57 of the laws of 2018, is amended to read as follows:
    38    (iii) information relating to value-based pricing  provided,  however,
    39  if  the  department directly invites any third party to provide cost-ef-
    40  fectiveness analysis or research related to value-based pricing, and the
    41  department receives and considers such analysis or research for  use  by
    42  the  board,  such  third  party shall disclose any funding sources.  The
    43  department shall, if reasonably possible, make  publicly  available  the
    44  following  documents  in  its  possession that it relies upon to provide
    45  cost effectiveness analyses or research related to value-based  pricing:
    46  (A)  descriptions of underlying methodologies; (B) assumptions and limi-
    47  tations of research findings; and (C) if available, data  that  presents
    48  results  in a way that reflects different outcomes for affected subpopu-
    49  lations;
    50    § 7. Paragraph (a) of subdivision 5  of  section  280  of  the  public
    51  health  law, as amended by section 8 of part D of chapter 57 of the laws
    52  of 2018, is amended to read as follows:
    53    (a) If the drug utilization review board recommends  a  target  rebate
    54  amount  on  a drug referred by the commissioner, the [commissioner shall
    55  require] department shall negotiate with the drug's manufacturer  for  a
    56  supplemental rebate to be paid by the [drug's] manufacturer in an amount

        S. 1507--C                          7                         A. 2007--C
 
     1  not  to  exceed  such target rebate amount. [With respect to a] A rebate
     2  [required in state fiscal  year  two  thousand  seventeen--two  thousand
     3  eighteen,  the rebate] requirement shall apply beginning with the [month
     4  of  April,  two  thousand seventeen,] first day of the state fiscal year
     5  during which the rebate was required without  regard  to  the  date  the
     6  department enters into the rebate agreement with the manufacturer.
     7    §  8.  Paragraph  (a)  of  subdivision  7 of section 280 of the public
     8  health law, as amended by section 8 of part D of chapter 57 of the  laws
     9  of 2018, is amended to read as follows:
    10    (a) If, after taking into account all rebates and supplemental rebates
    11  received  by the department, including rebates received to date pursuant
    12  to this section, total Medicaid drug expenditures are still projected to
    13  exceed the annual growth limitation imposed by subdivision two  of  this
    14  section,  the  commissioner  may:  subject  any  drug  of a manufacturer
    15  referred to the drug utilization review  board  under  this  section  to
    16  prior approval in accordance with existing processes and procedures when
    17  such  manufacturer  has not entered into a supplemental rebate agreement
    18  as required by this section; [directing] direct managed  care  plans  to
    19  remove  from their Medicaid formularies those drugs that the drug utili-
    20  zation review board recommends  a  target  rebate  amount  for  and  the
    21  manufacturer  has  failed  to  enter into a rebate agreement required by
    22  this section; [promoting] promote the use of cost  effective  and  clin-
    23  ically  appropriate  drugs  other than those of a manufacturer who has a
    24  drug that the drug utilization review board recommends a  target  rebate
    25  amount  and the manufacturer has failed to enter into a rebate agreement
    26  required by this section; [allowing] allow manufacturers  to  accelerate
    27  rebate  payments under existing rebate contracts; and such other actions
    28  as authorized by law.  The commissioner shall provide written notice  to
    29  the  legislature  thirty  days  prior  to taking action pursuant to this
    30  paragraph, unless action is necessary in the fourth quarter of a  fiscal
    31  year  to  prevent  total  Medicaid  drug expenditures from exceeding the
    32  limitation imposed by subdivision two of this  section,  in  which  case
    33  such notice to the legislature may be less than thirty days.
    34    §  9.  Subdivision 8 of section 280 of the public health law, as added
    35  by section 8 of part D of chapter 57 of the laws of 2018, is amended  to
    36  read as follows:
    37    8.  The commissioner shall report by [February] July first annually to
    38  the drug utilization review board on savings achieved through  the  drug
    39  cap  in  the  last  fiscal  year. Such report shall provide data on what
    40  savings were achieved through actions pursuant  to  subdivisions  three,
    41  five  and  seven  of  this  section, respectively, and what savings were
    42  achieved through other means and how such savings  were  calculated  and
    43  implemented.
    44    §  10.  Section 4406-c of the public health law is amended by adding a
    45  new subdivision 10 to read as follows:
    46    10. (a) Any contract or other arrangement entered  into  by  a  health
    47  care  plan  for  the  provision  and  administration of pharmacy benefit
    48  management services on behalf of individuals enrolled in a managed  care
    49  provider, as defined in section three hundred sixty-four-j of the social
    50  services law, shall be based on a pass-through pricing model and include
    51  the following requirements:
    52    (i)  Payment  to  the  pharmacy  benefit  manager for pharmacy benefit
    53  management services shall be limited to  the  actual  ingredient  costs,
    54  dispensing  fees  paid  to  pharmacies,  and  an administrative fee that
    55  covers the cost of providing pharmacy benefit management services pursu-

        S. 1507--C                          8                         A. 2007--C
 
     1  ant to a contract described in this paragraph. The department may estab-
     2  lish a maximum administrative fee;
     3    (ii)  The  pharmacy  benefit  manager  shall  identify all sources and
     4  amounts of income, payments, and  financial  benefits  to  the  pharmacy
     5  benefit  manager related to the provision and administration of pharmacy
     6  benefit management services on behalf of the health care  plan,  includ-
     7  ing,  but  not  limited  to, any pricing discounts, rebates of any kind,
     8  inflationary payments, credits, clawbacks,  fees,  grants,  chargebacks,
     9  reimbursements,  or  other benefits and shall ensure that any portion of
    10  such income, payments, and financial benefits is passed through  to  the
    11  health care plan in full to reduce the reportable ingredient cost;
    12    (iii) The pharmacy benefit manager shall fully disclose to the depart-
    13  ment  and to the health care plan the sources and amounts of all income,
    14  payments, and financial benefits referred to  in  subparagraph  (ii)  of
    15  this paragraph received by the pharmacy benefit manager;
    16    (iv)  The pharmacy benefit manager shall identify all ingredient costs
    17  and dispensing fees or similar payments made  by  the  pharmacy  benefit
    18  manager  to  any  pharmacy  in  connection  with  the  contract or other
    19  arrangement;
    20    (v) The pharmacy benefit manager shall not utilize any form of  spread
    21  pricing in any contract or other arrangement with health care plans. For
    22  purposes  of  this subdivision "spread pricing" means any amount charged
    23  or claimed by the pharmacy benefit manager in excess of the amount  paid
    24  to  pharmacies  on behalf of the health care plan less an administrative
    25  fee as described in this paragraph. Any  such  excess  amount  shall  be
    26  remitted to the health care plan on a quarterly basis;
    27    (vi)  Pharmacy  benefit  managers  shall  make their payment model for
    28  administrative fees available to the health care plan and to the depart-
    29  ment.  The health care plan shall, if so  directed  by  the  department,
    30  make  changes  to  the payment model and resubmit an amended contract or
    31  contracts to the department for review and approval.
    32    (b) Any changes to premiums resulting from  such  contracts  shall  be
    33  subject to certification by the state's actuary as actuarially appropri-
    34  ate.
    35    (c)  Contracts or other arrangements subject to this subdivision shall
    36  be submitted to the department for review and approval  as  required  by
    37  and  in accordance with state law and the regulations of the department.
    38  Contracts or other arrangements subject to   this  subdivision  existing
    39  and  in  force  at  the  time  of enactment of this subdivision shall be
    40  submitted to the department for review and approval on  or  before  July
    41  first, two thousand nineteen.
    42    § 10-a.  Section 364-j of the social services law is amended by adding
    43  a new subdivision 37 to read as follows:
    44    37.  Managed care providers shall report to the department all sources
    45  and  amounts  of income, payments, and financial benefits related to the
    46  provision of pharmacy benefits, including, but not limited to, any pric-
    47  ing discounts, rebates of  any  kind,  inflationary  payments,  credits,
    48  clawbacks,  fees, grants, chargebacks, reimbursements, or other benefits
    49  whether such  income,  payments,  or  financial  benefits  are  received
    50  directly  by the managed care provider or passed through from a pharmacy
    51  benefit manager or other  entity.  Managed  care  providers  shall  also
    52  report  to the department the amounts of any administrative fees paid to
    53  cover the cost of providing pharmacy benefit  management  services.  The
    54  reporting  required  in  this subdivision shall be   supplemental to and
    55  included with other existing reporting requirements, including  but  not
    56  limited to any quarterly reporting requirements.

        S. 1507--C                          9                         A. 2007--C
 
     1    §  11.  This  act shall take effect immediately and shall be deemed to
     2  have been in full force and effect on and after April 1, 2019; provided,
     3  further that the amendments to section 364-j of the social services  law
     4  made  by  section  10-a  of this act shall not affect the repeal of such
     5  section and shall be deemed repealed therewith.
 
     6                                   PART C
 
     7    Section  1.  Subdivision 2 of section 365-a of the social services law
     8  is amended by adding a new paragraph (ff) to read as follows:
     9    (ff) evidence-based prevention and support services recognized by  the
    10  federal Centers for Disease Control (CDC), provided by a community-based
    11  organization,  and designed to prevent individuals at risk of developing
    12  diabetes from developing Type 2 diabetes.
    13    § 2. Intentionally omitted.
    14    § 3. Intentionally omitted.
    15    § 4. This act shall take effect July 1, 2019.
 
    16                                   PART D
 
    17    Section 1. Subdivision 1 of section 92 of part H of chapter 59 of  the
    18  laws  of 2011, amending the public health law and other laws relating to
    19  known and projected department of health state  fund  medicaid  expendi-
    20  tures,  as  amended  by section 2 of part K of chapter 57 of the laws of
    21  2018, is amended to read as follows:
    22    1. For state fiscal years 2011-12  through  [2019-20]  2020-2021,  the
    23  director  of the budget, in consultation with the commissioner of health
    24  referenced as "commissioner" for purposes of this section, shall  assess
    25  on a monthly basis, as reflected in monthly reports pursuant to subdivi-
    26  sion five of this section known and projected department of health state
    27  funds  medicaid  expenditures  by  category of service and by geographic
    28  regions, as defined by the commissioner, and  if  the  director  of  the
    29  budget  determines that such expenditures are expected to cause medicaid
    30  disbursements for such period to  exceed  the  projected  department  of
    31  health  medicaid  state funds disbursements in the enacted budget finan-
    32  cial plan pursuant to subdivision 3 of section 23 of the  state  finance
    33  law,  the  commissioner  of health, in consultation with the director of
    34  the budget, shall develop a medicaid savings allocation  plan  to  limit
    35  such  spending  to  the  aggregate  limit level specified in the enacted
    36  budget financial  plan,  provided,  however,  such  projections  may  be
    37  adjusted by the director of the budget to account for any changes in the
    38  New  York state federal medical assistance percentage amount established
    39  pursuant to the federal social security act, changes in provider  reven-
    40  ues,  reductions  to  local  social services district medical assistance
    41  administration, minimum wage increases, and beginning April 1, 2012  the
    42  operational costs of the New York state medical indemnity fund and state
    43  costs  or  savings  from the basic health plan.  Such projections may be
    44  adjusted by the director of the budget to account for increased or expe-
    45  dited department of health state funds medicaid expenditures as a result
    46  of a natural or other type of disaster, including a governmental  decla-
    47  ration of emergency.
    48    §  2.  This  act  shall take effect immediately and shall be deemed to
    49  have been in full force and effect on and after April 1, 2019.
 
    50                                   PART E

        S. 1507--C                         10                         A. 2007--C
 
     1    Section 1. Section 4 of chapter 505 of the laws of 1995, amending  the
     2  public  health  law  relating  to  the operation of department of health
     3  facilities, as amended by section 27 of part D of chapter 57 of the laws
     4  of 2015, is amended to read as follows:
     5    §  4.  This act shall take effect immediately; provided, however, that
     6  the provisions of paragraph (b) of subdivision 4 of section 409-c of the
     7  public health law, as added by section three of  this  act,  shall  take
     8  effect  January 1, 1996 and shall expire and be deemed repealed [twenty-
     9  four] twenty-eight years from the effective date thereof.
    10    § 2. Subdivision p of section 76 of part D of chapter 56 of  the  laws
    11  of 2013, amending the social services law relating to eligibility condi-
    12  tions, is amended to read as follows:
    13    p.  the  amendments [made] to subparagraph [(7)] 7 of paragraph (b) of
    14  subdivision 1 of section 366 of the social services law made by  section
    15  one  of  this  act shall expire and be deemed repealed October 1, [2019]
    16  2024.
    17    § 3. Section 11 of chapter 884 of  the  laws  of  1990,  amending  the
    18  public  health  law  relating  to  authorizing bad debt and charity care
    19  allowances for certified home health agencies, as amended by  section  1
    20  of  part  I  of  chapter  57  of the laws of 2017, is amended to read as
    21  follows:
    22    § 11. This act shall take effect immediately and:
    23    (a) sections one and three shall expire on December 31, 1996,
    24    (b) sections four through ten shall expire on June  30,  [2019]  2021,
    25  and
    26    (c) provided that the amendment to section 2807-b of the public health
    27  law  by  section two of this act shall not affect the expiration of such
    28  section 2807-b as otherwise provided by  law  and  shall  be  deemed  to
    29  expire therewith.
    30    §  4.  Section  3 of chapter 303 of the laws of 1999, amending the New
    31  York state medical  care  facilities  finance  agency  act  relating  to
    32  financing health facilities, as amended by section 16 of part D of chap-
    33  ter 57 of the laws of 2015, is amended to read as follows:
    34    §  3.  This act shall take effect immediately, provided, however, that
    35  subdivision 15-a of section 5 of section 1 of chapter 392 of the laws of
    36  1973, as added by section one of this act, shall expire  and  be  deemed
    37  repealed  June  30, [2019] 2023; and provided further, however, that the
    38  expiration and repeal of such  subdivision  15-a  shall  not  affect  or
    39  impair in any manner any health facilities bonds issued, or any lease or
    40  purchase  of  a  health  facility executed, pursuant to such subdivision
    41  15-a prior to its expiration and repeal and that, with  respect  to  any
    42  such  bonds  issued  and  outstanding  as  of  June 30, [2019] 2023, the
    43  provisions of such subdivision 15-a as they existed immediately prior to
    44  such expiration and repeal shall continue to apply  through  the  latest
    45  maturity  date of any such bonds, or their earlier retirement or redemp-
    46  tion, for the sole purpose of  authorizing  the  issuance  of  refunding
    47  bonds to refund bonds previously issued pursuant thereto.
    48    §  5.  Subdivision  (a)  of section 40 of part B of chapter 109 of the
    49  laws of 2010, amending the social services law relating  to  transporta-
    50  tion  costs, as amended by section 8 of part I of chapter 57 of the laws
    51  of 2017, is amended to read as follows:
    52    (a) sections two, three, three-a, three-b, three-c,  three-d,  three-e
    53  and  twenty-one  of  this  act  shall take effect July 1, 2010; sections
    54  fifteen, sixteen, seventeen, eighteen and nineteen  of  this  act  shall
    55  take effect January 1, 2011; and provided further that section twenty of
    56  this  act  shall be deemed repealed [eight] ten years after the date the

        S. 1507--C                         11                         A. 2007--C
 
     1  contract entered into pursuant to section 365-h of the  social  services
     2  law,  as  amended  by  section twenty of this act, is executed; provided
     3  that the commissioner of health shall notify the legislative bill draft-
     4  ing  commission upon the execution of the contract entered into pursuant
     5  to section 367-h of the social services law in order that the commission
     6  may maintain an accurate and timely effective data base of the  official
     7  text of the laws of the state of New York in furtherance of effectuating
     8  the  provisions of section 44 of the legislative law and section 70-b of
     9  the public officers law;
    10    § 6. Subdivision (f) of section 129 of part C of  chapter  58  of  the
    11  laws  of  2009,  amending  the  public health law relating to payment by
    12  governmental  agencies  for  general  hospital  inpatient  services,  as
    13  amended  by  section  4  of part D of chapter 59 of the laws of 2016, is
    14  amended to read as follows:
    15    (f) section twenty-five  of  this  act  shall  expire  and  be  deemed
    16  repealed April 1, [2019] 2022;
    17    §  7.  Subdivision  (c)  of section 122 of part E of chapter 56 of the
    18  laws of 2013 amending the public health  law  relating  to  the  general
    19  public health work program, as amended by section 5 of part D of chapter
    20  59 of the laws of 2016, is amended to read as follows:
    21    (c)  section fifty of this act shall take effect immediately and shall
    22  expire [six] nine years after it becomes law;
    23    § 8. Subdivision (i) of section 111 of part H of  chapter  59  of  the
    24  laws  of 2011, amending the public health law and other laws relating to
    25  known and projected department of health  state  fund  medical  expendi-
    26  tures,  as  amended by section 19 of part D of chapter 57 of the laws of
    27  2015, is amended to read as follows:
    28    (i) the amendments to paragraph (b) and subparagraph (i) of  paragraph
    29  (g)  of subdivision 7 of section 4403-f of the public health law made by
    30  section forty-one-b of this act shall expire and be  repealed  April  1,
    31  [2019] 2023;
    32    §  9.  Subparagraph  (vi) of paragraph (b) of subdivision 2 of section
    33  2807-d of the public health law, as amended by section 3 of  part  I  of
    34  chapter 57 of the laws of 2017, is amended to read as follows:
    35    (vi)  Notwithstanding  any contrary provision of this paragraph or any
    36  other provision of law or regulation to the  contrary,  for  residential
    37  health care facilities the assessment shall be six percent of each resi-
    38  dential  health care facility's gross receipts received from all patient
    39  care services and other operating income on a cash basis for the  period
    40  April  first,  two thousand two through March thirty-first, two thousand
    41  three for hospital  or  health-related  services,  including  adult  day
    42  services;  provided,  however,  that residential health care facilities'
    43  gross receipts attributable to payments received pursuant to title XVIII
    44  of the federal social security act (medicare) shall be excluded from the
    45  assessment; provided, however, that for all such gross receipts received
    46  on or after April first, two thousand three through March  thirty-first,
    47  two  thousand  five,  such assessment shall be five percent, and further
    48  provided that for all such gross receipts received  on  or  after  April
    49  first,  two thousand five through March thirty-first, two thousand nine,
    50  and on or after April first, two thousand  nine  through  March  thirty-
    51  first,  two  thousand  eleven  such assessment shall be six percent, and
    52  further provided that for all such gross receipts received on  or  after
    53  April  first,  two thousand eleven through March thirty-first, two thou-
    54  sand thirteen such assessment shall be six percent, and further provided
    55  that for all such gross receipts received on or after April  first,  two
    56  thousand  thirteen through March thirty-first, two thousand fifteen such

        S. 1507--C                         12                         A. 2007--C
 
     1  assessment shall be six percent, and further provided that for all  such
     2  gross  receipts  received  on or after April first, two thousand fifteen
     3  through March thirty-first, two thousand seventeen such assessment shall
     4  be  six  percent,  and further provided that for all such gross receipts
     5  received on or after April first, two thousand seventeen  through  March
     6  thirty-first,  two  thousand  nineteen  such  assessment  shall  be  six
     7  percent, and further provided that for all such gross receipts  received
     8  on  or  after  April  first, two thousand nineteen through March thirty-
     9  first, two thousand twenty-one such assessment shall be six percent.
    10    § 10. Subdivision 1 of section 194 of chapter 474 of the laws of 1996,
    11  amending the education law and other laws relating to rates for residen-
    12  tial health care facilities, as amended by section 4 of part I of  chap-
    13  ter 57 of the laws of 2017, is amended to read as follows:
    14    1.  Notwithstanding  any  inconsistent provision of law or regulation,
    15  the trend factors used to project reimbursable operating  costs  to  the
    16  rate  period  for  purposes  of determining rates of payment pursuant to
    17  article 28 of the public health law for residential health care  facili-
    18  ties for reimbursement of inpatient services provided to patients eligi-
    19  ble  for payments made by state governmental agencies on and after April
    20  1, 1996 through March 31, 1999 and for payments made on and  after  July
    21  1,  1999  through  March 31, 2000 and on and after April 1, 2000 through
    22  March 31, 2003 and on and after April 1, 2003 through March 31, 2007 and
    23  on and after April 1, 2007 through March 31, 2009 and on and after April
    24  1, 2009 through March 31, 2011 and on and after April  1,  2011  through
    25  March  31,  2013  and on and after April 1, 2013 through March 31, 2015,
    26  and on and after April 1, 2015 through March 31, 2017, and on and  after
    27  April  1,  2017  through  March 31, 2019, and on and after April 1, 2019
    28  through March 31, 2021 shall reflect  no  trend  factor  projections  or
    29  adjustments for the period April 1, 1996, through March 31, 1997.
    30    §  11.  Subdivision  1  of section 89-a of part C of chapter 58 of the
    31  laws of 2007, amending the social services law and other  laws  relating
    32  to  enacting  the major components of legislation necessary to implement
    33  the health and mental hygiene budget  for  the  2007-2008  state  fiscal
    34  year,  as  amended  by  section 5 of part I of chapter 57 of the laws of
    35  2017, is amended to read as follows:
    36    1. Notwithstanding paragraph (c) of subdivision 10 of  section  2807-c
    37  of  the  public  health  law  and section 21 of chapter 1 of the laws of
    38  1999, as amended, and any other inconsistent provision of law  or  regu-
    39  lation  to  the  contrary,  in  determining  rates  of payments by state
    40  governmental agencies effective for services provided beginning April 1,
    41  2006, through March 31, 2009, and on and after  April  1,  2009  through
    42  March  31,  2011, and on and after April 1, 2011 through March 31, 2013,
    43  and on and after April 1, 2013 through March 31, 2015, and on and  after
    44  April  1,  2015  through  March 31, 2017, and on and after April 1, 2017
    45  through March 31, 2019, and on and after April 1, 2019 through March 31,
    46  2021 for inpatient and outpatient services provided by general hospitals
    47  and for inpatient services and outpatient adult day health care services
    48  provided by residential health care facilities pursuant to article 28 of
    49  the public health law, the commissioner of health shall  apply  a  trend
    50  factor projection of two and twenty-five hundredths percent attributable
    51  to  the  period  January  1,  2006 through December 31, 2006, and on and
    52  after January 1, 2007, provided, however, that on reconciliation of such
    53  trend factor for the period January 1, 2006 through  December  31,  2006
    54  pursuant  to  paragraph  (c)  of subdivision 10 of section 2807-c of the
    55  public health law, such trend factor shall  be  the  final  US  Consumer
    56  Price  Index  (CPI)  for  all  urban  consumers,  as published by the US

        S. 1507--C                         13                         A. 2007--C

     1  Department  of  Labor,  Bureau  of  Labor  Statistics  less  twenty-five
     2  hundredths of a percentage point.
     3    §  12.  Subdivision  5-a  of  section 246 of chapter 81 of the laws of
     4  1995, amending the public health law and other laws relating to  medical
     5  reimbursement  and  welfare reform, as amended by section 6 of part I of
     6  chapter 57 of the laws of 2017, is amended to read as follows:
     7    5-a. Section sixty-four-a of this act shall be deemed to have been  in
     8  full  force and effect on and after April 1, 1995 through March 31, 1999
     9  and on and after July 1, 1999 through March 31, 2000 and  on  and  after
    10  April  1,  2000  through  March  31, 2003 and on and after April 1, 2003
    11  through March 31, 2007, and on and after April 1, 2007 through March 31,
    12  2009, and on and after April 1, 2009 through March 31, 2011, and on  and
    13  after  April  1,  2011 through March 31, 2013, and on and after April 1,
    14  2013 through March 31, 2015, and on and  after  April  1,  2015  through
    15  March  31,  2017  and on and after April 1, 2017 through March 31, 2019,
    16  and on and after April 1, 2019 through March 31, 2021;
    17    § 13. Section 64-b of chapter 81 of the laws  of  1995,  amending  the
    18  public  health  law and other laws relating to medical reimbursement and
    19  welfare reform, as amended by section 7 of part I of chapter 57  of  the
    20  laws of 2017, is amended to read as follows:
    21    §  64-b.  Notwithstanding  any  inconsistent  provision  of  law,  the
    22  provisions of subdivision 7 of section 3614 of the public health law, as
    23  amended, shall remain and be in full force and effect on April  1,  1995
    24  through March 31, 1999 and on July 1, 1999 through March 31, 2000 and on
    25  and after April 1, 2000 through March 31, 2003 and on and after April 1,
    26  2003  through  March  31,  2007,  and on and after April 1, 2007 through
    27  March 31, 2009, and on and after April 1, 2009 through March  31,  2011,
    28  and  on and after April 1, 2011 through March 31, 2013, and on and after
    29  April 1, 2013 through March 31, 2015, and on and  after  April  1,  2015
    30  through  March 31, 2017 and on and after April 1, 2017 through March 31,
    31  2019, and on and after April 1, 2019 through March 31, 2021.
    32    § 14. Section 4-a of part A of chapter 56 of the laws of 2013,  amend-
    33  ing  chapter  59  of the laws of 2011 amending the public health law and
    34  other laws relating to general hospital reimbursement for annual  rates,
    35  as  amended by section 5 of part T of chapter 57 of the laws of 2018, is
    36  amended to read as follows:
    37    § 4-a. Notwithstanding paragraph (c)  of  subdivision  10  of  section
    38  2807-c  of the public health law, section 21 of chapter 1 of the laws of
    39  1999, or any other contrary provision of law, in  determining  rates  of
    40  payments  by state governmental agencies effective for services provided
    41  on and after January 1, 2017 through March 31, [2019]  2021,  for  inpa-
    42  tient  and  outpatient services provided by general hospitals, for inpa-
    43  tient services and adult day health care outpatient services provided by
    44  residential health care facilities pursuant to article 28 of the  public
    45  health  law,  except  for residential health care facilities or units of
    46  such facilities providing services primarily to children  under  twenty-
    47  one  years  of  age,  for home health care services provided pursuant to
    48  article 36 of the public health law by certified home  health  agencies,
    49  long term home health care programs and AIDS home care programs, and for
    50  personal  care services provided pursuant to section 365-a of the social
    51  services law, the commissioner of health shall  apply  no  greater  than
    52  zero trend factors attributable to the 2017, 2018, [and] 2019, 2020, and
    53  2021  calendar  years in accordance with paragraph (c) of subdivision 10
    54  of section 2807-c of the public health law, provided, however, that such
    55  no greater than zero trend factors  attributable  to  such  2017,  2018,
    56  [and] 2019, 2020, and 2021 calendar years shall also be applied to rates

        S. 1507--C                         14                         A. 2007--C

     1  of  payment  provided  on  and  after  January 1, 2017 through March 31,
     2  [2019] 2021 for personal care services provided in  those  local  social
     3  services  districts, including New York city, whose rates of payment for
     4  such  services  are  established by such local social services districts
     5  pursuant to a rate-setting  exemption  issued  by  the  commissioner  of
     6  health to such local social services districts in accordance with appli-
     7  cable  regulations;  and  provided  further,  however, that for rates of
     8  payment for assisted living program services provided on and after Janu-
     9  ary 1, 2017 through March 31, [2019] 2021, such trend factors  attribut-
    10  able  to the 2017, 2018, [and] 2019, 2020, and 2021 calendar years shall
    11  be established at no greater than zero percent.
    12    § 15. Paragraph (b) of subdivision 17 of section 2808  of  the  public
    13  health law, as amended by section 21 of part D of chapter 57 of the laws
    14  of 2015, is amended to read as follows:
    15    (b) Notwithstanding any inconsistent provision of law or regulation to
    16  the  contrary,  for  the  state  fiscal years beginning April first, two
    17  thousand ten and ending  March  thirty-first,  two  thousand  [nineteen]
    18  twenty-three, the commissioner shall not be required to revise certified
    19  rates  of  payment established pursuant to this article for rate periods
    20  prior to April first, two thousand  [nineteen]  twenty-three,  based  on
    21  consideration  of  rate appeals filed by residential health care facili-
    22  ties or based upon adjustments to capital cost reimbursement as a result
    23  of approval by the commissioner of an application for construction under
    24  section twenty-eight hundred two of this article, in excess of an aggre-
    25  gate annual amount of eighty million dollars for each such state  fiscal
    26  year  provided,  however,  that for the period April first, two thousand
    27  eleven through March thirty-first, two thousand  twelve  such  aggregate
    28  annual  amount  shall  be  fifty million dollars. In revising such rates
    29  within such fiscal limit, the commissioner shall, in  prioritizing  such
    30  rate appeals, include consideration of which facilities the commissioner
    31  determines  are  facing  significant  financial hardship as well as such
    32  other considerations as the commissioner deems appropriate and, further,
    33  the commissioner is authorized to enter into agreements with such facil-
    34  ities or any other facility to resolve  multiple  pending  rate  appeals
    35  based  upon a negotiated aggregate amount and may offset such negotiated
    36  aggregate amounts against any  amounts  owed  by  the  facility  to  the
    37  department,  including,  but  not  limited  to, amounts owed pursuant to
    38  section twenty-eight hundred seven-d of this article; provided, however,
    39  that the commissioner's authority to negotiate such agreements resolving
    40  multiple pending rate appeals as hereinbefore described  shall  continue
    41  on  and  after  April  first, two thousand [nineteen] twenty-three. Rate
    42  adjustments made pursuant to this  paragraph  remain  fully  subject  to
    43  approval by the director of the budget in accordance with the provisions
    44  of  subdivision  two of section twenty-eight hundred seven of this arti-
    45  cle.
    46    § 16. Paragraph (a) of subdivision 13 of section 3614  of  the  public
    47  health law, as amended by section 22 of part D of chapter 57 of the laws
    48  of 2015, is amended to read as follows:
    49    (a)  Notwithstanding  any  inconsistent provision of law or regulation
    50  and subject to the  availability  of  federal  financial  participation,
    51  effective  April  first, two thousand twelve through March thirty-first,
    52  two thousand [nineteen] twenty-three, payments  by  government  agencies
    53  for services provided by certified home health agencies, except for such
    54  services  provided  to  children  under  eighteen years of age and other
    55  discreet groups as may be determined by  the  commissioner  pursuant  to
    56  regulations,  shall  be based on episodic payments. In establishing such

        S. 1507--C                         15                         A. 2007--C
 
     1  payments, a statewide base price shall be established for each sixty day
     2  episode of care and adjusted by a regional  wage  index  factor  and  an
     3  individual patient case mix index. Such episodic payments may be further
     4  adjusted  for  low utilization cases and to reflect a percentage limita-
     5  tion of the cost for high-utilization cases that exceed outlier  thresh-
     6  olds of such payments.
     7    §  17. Subdivision 2 of section 246 of chapter 81 of the laws of 1995,
     8  amending the public health  law  and  other  laws  relating  to  medical
     9  reimbursement  and welfare reform, as amended by section 18 of part I of
    10  chapter 57 of the laws of 2017, is amended to read as follows:
    11    2. Sections five, seven through nine,  twelve  through  fourteen,  and
    12  eighteen  of  this  act  shall  be deemed to have been in full force and
    13  effect on and after April 1, 1995 through March  31,  1999  and  on  and
    14  after July 1, 1999 through March 31, 2000 and on and after April 1, 2000
    15  through  March 31, 2003 and on and after April 1, 2003 through March 31,
    16  2006 and on and after April 1, 2006 through March 31, 2007  and  on  and
    17  after  April  1,  2007  through March 31, 2009 and on and after April 1,
    18  2009 through March 31, 2011 and sections twelve, thirteen  and  fourteen
    19  of  this act shall be deemed to be in full force and effect on and after
    20  April 1, 2011 through March 31, 2015 and on  and  after  April  1,  2015
    21  through  March 31, 2017 and on and after April 1, 2017 through March 31,
    22  2019, and on and after April 1, 2019 through March 31, 2021;
    23    § 18. Section 48-a of part A of chapter 56 of the laws of 2013  amend-
    24  ing  chapter  59  of the laws of 2011 amending the public health law and
    25  other laws relating to general hospital reimbursement for annual  rates,
    26  as  amended by section 1 of part P of chapter 57 of the laws of 2017, is
    27  amended to read as follows:
    28    § 48-a. 1. Notwithstanding any contrary provision of law, the  commis-
    29  sioners of the office of alcoholism and substance abuse services and the
    30  office  of  mental health are authorized, subject to the approval of the
    31  director of the budget, to transfer to the commissioner of health  state
    32  funds  to  be  utilized as the state share for the purpose of increasing
    33  payments under  the  medicaid  program  to  managed  care  organizations
    34  licensed  under  article 44 of the public health law or under article 43
    35  of the insurance law. Such managed care organizations shall utilize such
    36  funds for the purpose of  reimbursing  providers  licensed  pursuant  to
    37  article  28  of  the public health law or article 31 or 32 of the mental
    38  hygiene law for ambulatory behavioral health services, as determined  by
    39  the  commissioner  of  health,  in consultation with the commissioner of
    40  alcoholism and substance abuse services  and  the  commissioner  of  the
    41  office  of  mental health, provided to medicaid enrolled outpatients and
    42  for all other behavioral health services except  inpatient  included  in
    43  New  York  state's  Medicaid redesign waiver approved by the centers for
    44  medicare and Medicaid services (CMS).   Such reimbursement shall  be  in
    45  the  form of fees for such services which are equivalent to the payments
    46  established for such services under the ambulatory patient  group  (APG)
    47  rate-setting  methodology  as  utilized by the department of health, the
    48  office of alcoholism and substance abuse  services,  or  the  office  of
    49  mental  health for rate-setting purposes or any such other fees pursuant
    50  to the Medicaid state plan or otherwise approved by CMS in the  Medicaid
    51  redesign  waiver; provided, however, that the increase to such fees that
    52  shall result from the provisions of  this  section  shall  not,  in  the
    53  aggregate  and as determined by the commissioner of health, in consulta-
    54  tion with the commissioner of alcoholism and  substance  abuse  services
    55  and the commissioner of the office of mental health, be greater than the
    56  increased  funds  made available pursuant to this section.  The increase

        S. 1507--C                         16                         A. 2007--C
 
     1  of such ambulatory behavioral health fees to providers  available  under
     2  this  section  shall  be for all rate periods on and after the effective
     3  date of section [29] 1 of part [B] P of chapter [59] 57 of the  laws  of
     4  [2016]  2017  through  March 31, [2020] 2023 for patients in the city of
     5  New York, for all rate periods  on  and  after  the  effective  date  of
     6  section  [29]  1  of part [B] P of chapter [59] 57 of the laws of [2016]
     7  2017 through [March 31, 2020] March 31, 2023 for  patients  outside  the
     8  city  of  New  York, and for all rate periods on and after the effective
     9  date of such chapter through [March 31, 2020] March  31,  2023  for  all
    10  services  provided  to  persons  under  the age of twenty-one; provided,
    11  however, the commissioner of health, in consultation  with  the  commis-
    12  sioner  of  alcoholism and substance abuse services and the commissioner
    13  of mental health, may require, as a condition of approval of such  ambu-
    14  latory  behavioral health fees, that aggregate managed care expenditures
    15  to eligible providers meet the alternative payment methodology  require-
    16  ments  as  set  forth  in  attachment  I  of the New York state medicaid
    17  section one thousand one hundred fifteen medicaid redesign  team  waiver
    18  as  approved  by  the  centers  for  medicare and medicaid services. The
    19  commissioner of health shall, in consultation with the  commissioner  of
    20  alcoholism  and  substance abuse services and the commissioner of mental
    21  health, waive such conditions if a sufficient number  of  providers,  as
    22  determined  by the commissioner, suffer a financial hardship as a conse-
    23  quence of such alternative payment methodology requirements, or if he or
    24  she shall determine that such alternative payment methodologies  signif-
    25  icantly  threaten  individuals  access  to  ambulatory behavioral health
    26  services.  Such waiver may be applied on a provider specific or industry
    27  wide basis. Further, such conditions may be waived, as the  commissioner
    28  determines  necessary,  to  comply  with  federal  rules  or regulations
    29  governing these payment methodologies.   Nothing in this  section  shall
    30  prohibit  managed  care  organizations  and  providers  from negotiating
    31  different rates and methods of payment  during  such  periods  described
    32  above,  subject to the approval of the department of health. The depart-
    33  ment of health shall consult with the office of alcoholism and substance
    34  abuse services and the office of mental health  in  determining  whether
    35  such  alternative  rates  shall  be approved. The commissioner of health
    36  may, in consultation with the commissioner of alcoholism  and  substance
    37  abuse  services  and  the  commissioner  of the office of mental health,
    38  promulgate  regulations,  including  emergency  regulations  promulgated
    39  prior  to  October  1, 2015 to establish rates for ambulatory behavioral
    40  health services, as are necessary to implement the  provisions  of  this
    41  section.  Rates  promulgated under this section shall be included in the
    42  report required under section 45-c of part A of this chapter.
    43    2. Notwithstanding any contrary provision of law,  the  fees  paid  by
    44  managed  care  organizations  licensed  under  article  44 of the public
    45  health law or under article  43  of  the  insurance  law,  to  providers
    46  licensed  pursuant  to article 28 of the public health law or article 31
    47  or 32 of the  mental  hygiene  law,  for  ambulatory  behavioral  health
    48  services  provided  to  patients  enrolled in the child health insurance
    49  program pursuant to title [one-A] 1-A of article 25 of the public health
    50  law, shall be in the form of fees for such services which are equivalent
    51  to the payments established  for  such  services  under  the  ambulatory
    52  patient  group  (APG)  rate-setting  methodology  or any such other fees
    53  established pursuant to the Medicaid state  plan.  The  commissioner  of
    54  health  shall  consult with the commissioner of alcoholism and substance
    55  abuse services and the commissioner of the office of  mental  health  in
    56  determining  such  services  and establishing such fees. Such ambulatory

        S. 1507--C                         17                         A. 2007--C
 
     1  behavioral health fees to providers available under this  section  shall
     2  be  for all rate periods on and after the effective date of this chapter
     3  through [March 31, 2020] March 31, 2023, provided, however, that managed
     4  care organizations and providers may negotiate different rates and meth-
     5  ods  of  payment  during  such  periods  described above, subject to the
     6  approval of the department of health.   The department of  health  shall
     7  consult  with  the office of alcoholism and substance abuse services and
     8  the office of mental health  in  determining  whether  such  alternative
     9  rates shall be approved.  The report required under section 16-a of part
    10  C of chapter 60 of the laws of 2014 shall also include the population of
    11  patients  enrolled  in  the  child  health insurance program pursuant to
    12  title [one-A] 1-A of article 25 of the public health law in its examina-
    13  tion on the transition of behavioral health services into managed care.
    14    § 19. Section 1 of part H of chapter 111 of the laws of 2010  relating
    15  to increasing Medicaid payments to providers through managed care organ-
    16  izations  and  providing  equivalent  fees through an ambulatory patient
    17  group methodology, as amended by section 2 of part P of  chapter  57  of
    18  the laws of 2017, is amended to read as follows:
    19    Section  1.  a.  Notwithstanding  any  contrary  provision of law, the
    20  commissioners of  mental  health  and  alcoholism  and  substance  abuse
    21  services  are authorized, subject to the approval of the director of the
    22  budget, to transfer to the commissioner of  health  state  funds  to  be
    23  utilized as the state share for the purpose of increasing payments under
    24  the  medicaid program to managed care organizations licensed under arti-
    25  cle 44 of the public health law or under article  43  of  the  insurance
    26  law.  Such  managed  care organizations shall utilize such funds for the
    27  purpose of reimbursing providers licensed pursuant to article 28 of  the
    28  public health law, or pursuant to article 31 or article 32 of the mental
    29  hygiene  law for ambulatory behavioral health services, as determined by
    30  the commissioner of health in  consultation  with  the  commissioner  of
    31  mental  health  and  commissioner  of  alcoholism  and  substance  abuse
    32  services, provided to medicaid enrolled outpatients and  for  all  other
    33  behavioral health services except inpatient included in New York state's
    34  Medicaid  redesign waiver approved by the centers for medicare and Medi-
    35  caid services (CMS). Such reimbursement shall be in the form of fees for
    36  such services which are equivalent to the payments established for  such
    37  services under the ambulatory patient group (APG) rate-setting methodol-
    38  ogy  as  utilized by the department of health or by the office of mental
    39  health or office of alcoholism and substance abuse  services  for  rate-
    40  setting  purposes  or any such other fees pursuant to the Medicaid state
    41  plan or otherwise approved by  CMS  in  the  Medicaid  redesign  waiver;
    42  provided, however, that the increase to such fees that shall result from
    43  the provisions of this section shall not, in the aggregate and as deter-
    44  mined by the commissioner of health in consultation with the commission-
    45  ers  of  mental  health  and alcoholism and substance abuse services, be
    46  greater than  the  increased  funds  made  available  pursuant  to  this
    47  section. The increase of such behavioral health fees to providers avail-
    48  able  under  this section shall be for all rate periods on and after the
    49  effective date of section [30] 2 of part [B] P of chapter [59] 57 of the
    50  laws of [2016] 2017 through March 31, [2020] 2023 for  patients  in  the
    51  city  of  New York, for all rate periods on and after the effective date
    52  of section [30] 2 of part [B] P of chapter [59] 57 of the laws of [2016]
    53  2017 through March 31, [2020] 2023 for patients outside the city of  New
    54  York,  and  for  all  rate  periods  on  and after the effective date of
    55  section [30] 2 of part [B] P of chapter [59] 57 of the  laws  of  [2016]
    56  2017  through March 31, [2020] 2023 for all services provided to persons

        S. 1507--C                         18                         A. 2007--C
 
     1  under the age of twenty-one;  provided,  however,  the  commissioner  of
     2  health,   in  consultation  with  the  commissioner  of  alcoholism  and
     3  substance abuse services and the  commissioner  of  mental  health,  may
     4  require, as a condition of approval of such ambulatory behavioral health
     5  fees,  that  aggregate  managed  care expenditures to eligible providers
     6  meet the alternative payment methodology requirements as  set  forth  in
     7  attachment  I  of  the  New York state medicaid section one thousand one
     8  hundred fifteen medicaid redesign team waiver as approved by the centers
     9  for medicare and medicaid services. The commissioner of health shall, in
    10  consultation with the commissioner of  alcoholism  and  substance  abuse
    11  services and the commissioner of mental health, waive such conditions if
    12  a  sufficient  number  of  providers, as determined by the commissioner,
    13  suffer a financial hardship as a consequence of such alternative payment
    14  methodology requirements, or if he or  she  shall  determine  that  such
    15  alternative  payment  methodologies  significantly  threaten individuals
    16  access to ambulatory behavioral health services.   Such  waiver  may  be
    17  applied  on  a  provider  specific or industry wide basis. Further, such
    18  conditions may be waived, as the commissioner determines  necessary,  to
    19  comply with federal rules or regulations governing these payment method-
    20  ologies.  Nothing  in this section shall prohibit managed care organiza-
    21  tions and providers from negotiating  different  rates  and  methods  of
    22  payment  during  such  periods described, subject to the approval of the
    23  department of health. The department of health shall  consult  with  the
    24  office  of  alcoholism  and  substance  abuse services and the office of
    25  mental health in determining whether such  alternative  rates  shall  be
    26  approved.  The  commissioner  of  health  may,  in consultation with the
    27  commissioners of  mental  health  and  alcoholism  and  substance  abuse
    28  services,   promulgate   regulations,  including  emergency  regulations
    29  promulgated prior to October 1, 2013 that establish rates for behavioral
    30  health services, as are necessary to implement the  provisions  of  this
    31  section.  Rates  promulgated under this section shall be included in the
    32  report required under section 45-c of part A of chapter 56 of  the  laws
    33  of 2013.
    34    b.  Notwithstanding  any  contrary  provision of law, the fees paid by
    35  managed care organizations licensed  under  article  44  of  the  public
    36  health  law  or  under  article  43  of  the insurance law, to providers
    37  licensed pursuant to article 28 of the public health law or  article  31
    38  or  32  of  the  mental  hygiene  law,  for ambulatory behavioral health
    39  services provided to patients enrolled in  the  child  health  insurance
    40  program pursuant to title [one-A] 1-A of article 25 of the public health
    41  law, shall be in the form of fees for such services which are equivalent
    42  to  the  payments  established  for  such  services under the ambulatory
    43  patient group (APG) rate-setting methodology. The commissioner of health
    44  shall consult with the commissioner of alcoholism  and  substance  abuse
    45  services  and  the commissioner of the office of mental health in deter-
    46  mining such services and establishing such fees. Such ambulatory  behav-
    47  ioral health fees to providers available under this section shall be for
    48  all rate periods on and after the effective date of this chapter through
    49  March  31,  [2020]  2023, provided, however, that managed care organiza-
    50  tions and providers may negotiate different rates and methods of payment
    51  during such periods described above, subject  to  the  approval  of  the
    52  department  of  health.  The department of health shall consult with the
    53  office of alcoholism and substance abuse  services  and  the  office  of
    54  mental  health  in  determining  whether such alternative rates shall be
    55  approved.  The report required under section 16-a of part C  of  chapter
    56  60  of  the  laws  of 2014 shall also include the population of patients

        S. 1507--C                         19                         A. 2007--C
 
     1  enrolled in the child health insurance program pursuant to title [one-A]
     2  1-A of article 25 of the public health law in  its  examination  on  the
     3  transition of behavioral health services into managed care.
     4    § 20. Section 2 of part H of chapter 111 of the laws of 2010, relating
     5  to increasing Medicaid payments to providers through managed care organ-
     6  izations  and  providing  equivalent  fees through an ambulatory patient
     7  group methodology, as amended by section 16 of part C of chapter  60  of
     8  the laws of 2014, is amended to read as follows:
     9    §  2.  This  act  shall take effect immediately and shall be deemed to
    10  have been in full force and effect on and after April 1, 2010, and shall
    11  expire on [January 1, 2018] March 31, 2023.
    12    § 21. Section 10 of chapter 649 of the  laws  of  1996,  amending  the
    13  public  health  law,  the mental hygiene law and the social services law
    14  relating to authorizing the establishment of  special  needs  plans,  as
    15  amended  by  section  2  of part D of chapter 59 of the laws of 2016, is
    16  amended to read as follows:
    17    § 10. This act shall take effect immediately and shall  be  deemed  to
    18  have  been in full force and effect on and after July 1, 1996; provided,
    19  however, that sections one, two and three of this act shall  expire  and
    20  be  deemed  repealed on March 31, [2020] 2025 provided, however that the
    21  amendments to section 364-j of the social services law made  by  section
    22  four  of  this  act  shall not affect the expiration of such section and
    23  shall be deemed to expire therewith  and  provided,  further,  that  the
    24  provisions  of  subdivisions  8,  9 and 10 of section 4401 of the public
    25  health law, as added by section one of this act; section 4403-d  of  the
    26  public health law as added by section two of this act and the provisions
    27  of  section seven of this act, except for the provisions relating to the
    28  establishment of no more than twelve  comprehensive  HIV  special  needs
    29  plans, shall expire and be deemed repealed on July 1, 2000.
    30    §  22. Paragraph (a) of subdivision 1 of section 212 of chapter 474 of
    31  the laws of 1996, amending the education law and other laws relating  to
    32  rates  for residential healthcare facilities, as amended by section 1 of
    33  part D of chapter 59 of the laws of 2016, is amended to read as follows:
    34    (a) Notwithstanding any inconsistent provision of law or regulation to
    35  the contrary, effective beginning August 1, 1996, for the  period  April
    36  1,  1997  through  March 31, 1998, April 1, 1998 for the period April 1,
    37  1998 through March 31, 1999, August 1, 1999, for  the  period  April  1,
    38  1999 through March 31, 2000, April 1, 2000, for the period April 1, 2000
    39  through  March  31,  2001,  April  1, 2001, for the period April 1, 2001
    40  through March 31, 2002, April 1, 2002, for  the  period  April  1,  2002
    41  through March 31, 2003, and for the state fiscal year beginning April 1,
    42  2005  through  March  31,  2006, and for the state fiscal year beginning
    43  April 1, 2006 through March 31, 2007, and  for  the  state  fiscal  year
    44  beginning April 1, 2007 through March 31, 2008, and for the state fiscal
    45  year  beginning  April 1, 2008 through March 31, 2009, and for the state
    46  fiscal year beginning April 1, 2009 through March 31, 2010, and for  the
    47  state  fiscal  year  beginning April 1, 2010 through March 31, 2016, and
    48  for the state fiscal year beginning April  1,  2016  through  March  31,
    49  2019,  and  for  the  state  fiscal year beginning April 1, 2019 through
    50  March 31, 2022, the department of health is  authorized  to  pay  public
    51  general  hospitals,  as defined in subdivision 10 of section 2801 of the
    52  public health law, operated by the state of New York  or  by  the  state
    53  university  of  New  York or by a county, which shall not include a city
    54  with a population of over one million, of the state  of  New  York,  and
    55  those public general hospitals located in the county of Westchester, the
    56  county  of  Erie  or the county of Nassau, additional payments for inpa-

        S. 1507--C                         20                         A. 2007--C
 
     1  tient hospital services as medical assistance payments pursuant to title
     2  11 of article 5 of the social services law  for  patients  eligible  for
     3  federal  financial  participation  under title XIX of the federal social
     4  security  act  in  medical  assistance  pursuant to the federal laws and
     5  regulations governing disproportionate share payments to hospitals up to
     6  one hundred percent of  each  such  public  general  hospital's  medical
     7  assistance  and uninsured patient losses after all other medical assist-
     8  ance, including disproportionate share payments to such  public  general
     9  hospital  for  1996,  1997,  1998, and 1999, based initially for 1996 on
    10  reported 1994 reconciled data as further reconciled to  actual  reported
    11  1996  reconciled  data,  and  for  1997 based initially on reported 1995
    12  reconciled data as further reconciled to actual reported 1997 reconciled
    13  data, for 1998 based initially  on  reported  1995  reconciled  data  as
    14  further  reconciled  to  actual  reported 1998 reconciled data, for 1999
    15  based initially on reported 1995 reconciled data as  further  reconciled
    16  to  actual  reported  1999  reconciled data, for 2000 based initially on
    17  reported 1995 reconciled data as further reconciled to  actual  reported
    18  2000  data, for 2001 based initially on reported 1995 reconciled data as
    19  further reconciled to actual reported 2001 data, for 2002 based initial-
    20  ly on reported 2000 reconciled data  as  further  reconciled  to  actual
    21  reported  2002  data,  and  for state fiscal years beginning on April 1,
    22  2005, based initially on reported 2000 reconciled data as further recon-
    23  ciled to actual reported data for  2005,  and  for  state  fiscal  years
    24  beginning  on April 1, 2006, based initially on reported 2000 reconciled
    25  data as further reconciled to actual reported data for 2006,  for  state
    26  fiscal  years  beginning  on  and  after April 1, 2007 through March 31,
    27  2009, based initially on reported 2000 reconciled data as further recon-
    28  ciled to actual reported data for 2007 and 2008, respectively, for state
    29  fiscal years beginning on and after April 1, 2009,  based  initially  on
    30  reported  2007  reconciled  data,  adjusted for authorized Medicaid rate
    31  changes applicable to the state fiscal year, and as  further  reconciled
    32  to  actual  reported  data for 2009, for state fiscal years beginning on
    33  and after April 1, 2010, based initially  on  reported  reconciled  data
    34  from  the  base  year  two years prior to the payment year, adjusted for
    35  authorized Medicaid rate changes applicable to the  state  fiscal  year,
    36  and  further  reconciled to actual reported data from such payment year,
    37  and to actual reported data for each respective succeeding  year.    The
    38  payments  may be added to rates of payment or made as aggregate payments
    39  to an eligible public general hospital.
    40    § 23. This act shall take effect immediately and shall  be  deemed  to
    41  have  been in full force and effect on and after April 1, 2019; provided
    42  that the amendments to section 1 of part H of chapter 111 of the laws of
    43  2010 made by section nineteen of this act shall not affect  the  expira-
    44  tion  of  such  section and shall expire therewith; and provided further
    45  that section twenty of this act shall be deemed to  have  been  in  full
    46  force and effect on and after January 1, 2018.
 
    47                                   PART F
 
    48    Section 1. Paragraph (a) of subdivision 1 of section 18 of chapter 266
    49  of the laws of 1986, amending the civil practice law and rules and other
    50  laws  relating  to  malpractice  and  professional  medical  conduct, as
    51  amended by section 1 of part M of chapter 57 of the  laws  of  2018,  is
    52  amended to read as follows:
    53    (a)  The  superintendent of financial services and the commissioner of
    54  health or their designee shall, from funds  available  in  the  hospital

        S. 1507--C                         21                         A. 2007--C
 
     1  excess liability pool created pursuant to subdivision 5 of this section,
     2  purchase  a policy or policies for excess insurance coverage, as author-
     3  ized by paragraph 1 of subsection (e) of section 5502 of  the  insurance
     4  law; or from an insurer, other than an insurer described in section 5502
     5  of the insurance law, duly authorized to write such coverage and actual-
     6  ly  writing  medical  malpractice  insurance  in  this  state;  or shall
     7  purchase equivalent excess coverage in a form previously approved by the
     8  superintendent of financial services for purposes  of  providing  equiv-
     9  alent  excess  coverage  in accordance with section 19 of chapter 294 of
    10  the laws of 1985, for medical or dental malpractice occurrences  between
    11  July  1, 1986 and June 30, 1987, between July 1, 1987 and June 30, 1988,
    12  between July 1, 1988 and June 30, 1989, between July 1,  1989  and  June
    13  30,  1990,  between July 1, 1990 and June 30, 1991, between July 1, 1991
    14  and June 30, 1992, between July 1, 1992 and June 30, 1993, between  July
    15  1,  1993  and  June  30,  1994,  between July 1, 1994 and June 30, 1995,
    16  between July 1, 1995 and June 30, 1996, between July 1,  1996  and  June
    17  30,  1997,  between July 1, 1997 and June 30, 1998, between July 1, 1998
    18  and June 30, 1999, between July 1, 1999 and June 30, 2000, between  July
    19  1,  2000  and  June  30,  2001,  between July 1, 2001 and June 30, 2002,
    20  between July 1, 2002 and June 30, 2003, between July 1,  2003  and  June
    21  30,  2004,  between July 1, 2004 and June 30, 2005, between July 1, 2005
    22  and June 30, 2006, between July 1, 2006 and June 30, 2007, between  July
    23  1,  2007  and  June  30,  2008,  between July 1, 2008 and June 30, 2009,
    24  between July 1, 2009 and June 30, 2010, between July 1,  2010  and  June
    25  30,  2011,  between July 1, 2011 and June 30, 2012, between July 1, 2012
    26  and June 30, 2013, between July 1, 2013 and June 30, 2014, between  July
    27  1,  2014  and  June  30,  2015,  between July 1, 2015 and June 30, 2016,
    28  between July 1, 2016 and June 30, 2017, between July 1,  2017  and  June
    29  30, 2018, [and] between July 1, 2018 and June 30, 2019, and between July
    30  1,  2019  and June 30, 2020 or reimburse the hospital where the hospital
    31  purchases equivalent excess coverage as defined in subparagraph  (i)  of
    32  paragraph  (a)  of subdivision 1-a of this section for medical or dental
    33  malpractice occurrences between July 1, 1987 and June 30, 1988,  between
    34  July  1, 1988 and June 30, 1989, between July 1, 1989 and June 30, 1990,
    35  between July 1, 1990 and June 30, 1991, between July 1,  1991  and  June
    36  30,  1992,  between July 1, 1992 and June 30, 1993, between July 1, 1993
    37  and June 30, 1994, between July 1, 1994 and June 30, 1995, between  July
    38  1,  1995  and  June  30,  1996,  between July 1, 1996 and June 30, 1997,
    39  between July 1, 1997 and June 30, 1998, between July 1,  1998  and  June
    40  30,  1999,  between July 1, 1999 and June 30, 2000, between July 1, 2000
    41  and June 30, 2001, between July 1, 2001 and June 30, 2002, between  July
    42  1,  2002  and  June  30,  2003,  between July 1, 2003 and June 30, 2004,
    43  between July 1, 2004 and June 30, 2005, between July 1,  2005  and  June
    44  30,  2006,  between July 1, 2006 and June 30, 2007, between July 1, 2007
    45  and June 30, 2008, between July 1, 2008 and June 30, 2009, between  July
    46  1,  2009  and  June  30,  2010,  between July 1, 2010 and June 30, 2011,
    47  between July 1, 2011 and June 30, 2012, between July 1,  2012  and  June
    48  30,  2013,  between July 1, 2013 and June 30, 2014, between July 1, 2014
    49  and June 30, 2015, between July 1, 2015 and June 30, 2016, between  July
    50  1, 2016 and June 30, 2017, between July 1, 2017 and June 30, 2018, [and]
    51  between  July  1,  2018  and June 30, 2019, and between July 1, 2019 and
    52  June 30, 2020 for physicians or dentists certified as eligible for  each
    53  such  period  or  periods pursuant to subdivision 2 of this section by a
    54  general hospital licensed pursuant to article 28 of  the  public  health
    55  law; provided that no single insurer shall write more than fifty percent
    56  of  the  total  excess  premium  for  a given policy year; and provided,

        S. 1507--C                         22                         A. 2007--C
 
     1  however, that such eligible physicians or dentists must have in force an
     2  individual policy, from an insurer licensed in  this  state  of  primary
     3  malpractice  insurance  coverage  in amounts of no less than one million
     4  three  hundred thousand dollars for each claimant and three million nine
     5  hundred thousand dollars for all claimants under that policy during  the
     6  period  of  such  excess coverage for such occurrences or be endorsed as
     7  additional insureds under a hospital professional liability policy which
     8  is  offered  through  a  voluntary  attending  physician  ("channeling")
     9  program previously permitted by the superintendent of financial services
    10  during  the  period of such excess coverage for such occurrences. During
    11  such period, such policy for excess coverage or such  equivalent  excess
    12  coverage  shall, when combined with the physician's or dentist's primary
    13  malpractice insurance coverage or coverage provided through a  voluntary
    14  attending  physician ("channeling") program, total an aggregate level of
    15  two million three hundred thousand dollars for  each  claimant  and  six
    16  million  nine  hundred  thousand dollars for all claimants from all such
    17  policies with respect to occurrences in each  of  such  years  provided,
    18  however, if the cost of primary malpractice insurance coverage in excess
    19  of  one million dollars, but below the excess medical malpractice insur-
    20  ance coverage provided pursuant to this act, exceeds the  rate  of  nine
    21  percent per annum, then the required level of primary malpractice insur-
    22  ance  coverage  in excess of one million dollars for each claimant shall
    23  be in an amount of not less than the  dollar  amount  of  such  coverage
    24  available at nine percent per annum; the required level of such coverage
    25  for  all claimants under that policy shall be in an amount not less than
    26  three times the dollar amount of coverage for each claimant; and  excess
    27  coverage,  when  combined with such primary malpractice insurance cover-
    28  age, shall increase the aggregate level for each claimant by one million
    29  dollars and three  million  dollars  for  all  claimants;  and  provided
    30  further,  that,  with respect to policies of primary medical malpractice
    31  coverage that include occurrences between April 1,  2002  and  June  30,
    32  2002,  such  requirement  that  coverage  be in amounts no less than one
    33  million three hundred thousand  dollars  for  each  claimant  and  three
    34  million  nine hundred thousand dollars for all claimants for such occur-
    35  rences shall be effective April 1, 2002.
    36    § 2. Subdivision 3 of section 18 of chapter 266 of the laws  of  1986,
    37  amending  the  civil  practice  law and rules and other laws relating to
    38  malpractice and professional medical conduct, as amended by section 2 of
    39  part M of chapter 57 of the laws of 2018, is amended to read as follows:
    40    (3)(a) The superintendent of financial services  shall  determine  and
    41  certify  to  each general hospital and to the commissioner of health the
    42  cost of excess malpractice insurance for medical or  dental  malpractice
    43  occurrences between July 1, 1986 and June 30, 1987, between July 1, 1988
    44  and  June 30, 1989, between July 1, 1989 and June 30, 1990, between July
    45  1, 1990 and June 30, 1991, between July  1,  1991  and  June  30,  1992,
    46  between  July  1,  1992 and June 30, 1993, between July 1, 1993 and June
    47  30, 1994, between July 1, 1994 and June 30, 1995, between July  1,  1995
    48  and  June 30, 1996, between July 1, 1996 and June 30, 1997, between July
    49  1, 1997 and June 30, 1998, between July  1,  1998  and  June  30,  1999,
    50  between  July  1,  1999 and June 30, 2000, between July 1, 2000 and June
    51  30, 2001, between July 1, 2001 and June 30, 2002, between July  1,  2002
    52  and  June 30, 2003, between July 1, 2003 and June 30, 2004, between July
    53  1, 2004 and June 30, 2005, between July  1,  2005  and  June  30,  2006,
    54  between  July  1,  2006 and June 30, 2007, between July 1, 2007 and June
    55  30, 2008, between July 1, 2008 and June 30, 2009, between July  1,  2009
    56  and  June 30, 2010, between July 1, 2010 and June 30, 2011, between July

        S. 1507--C                         23                         A. 2007--C
 
     1  1, 2011 and June 30, 2012, between July 1, 2012 and June 30,  2013,  and
     2  between  July  1,  2013 and June 30, 2014, between July 1, 2014 and June
     3  30, 2015, between July 1, 2015 and June 30, 2016, and  between  July  1,
     4  2016  and  June  30, 2017, between July 1, 2017 and June 30, 2018, [and]
     5  between July 1, 2018 and June 30, 2019, and between  July  1,  2019  and
     6  June  30,  2020  allocable  to  each  general hospital for physicians or
     7  dentists certified as eligible for  purchase  of  a  policy  for  excess
     8  insurance  coverage by such general hospital in accordance with subdivi-
     9  sion 2 of this section, and may amend  such  determination  and  certif-
    10  ication as necessary.
    11    (b)  The  superintendent  of  financial  services  shall determine and
    12  certify to each general hospital and to the commissioner of  health  the
    13  cost  of  excess malpractice insurance or equivalent excess coverage for
    14  medical or dental malpractice occurrences between July 1, 1987 and  June
    15  30,  1988,  between July 1, 1988 and June 30, 1989, between July 1, 1989
    16  and June 30, 1990, between July 1, 1990 and June 30, 1991, between  July
    17  1,  1991  and  June  30,  1992,  between July 1, 1992 and June 30, 1993,
    18  between July 1, 1993 and June 30, 1994, between July 1,  1994  and  June
    19  30,  1995,  between July 1, 1995 and June 30, 1996, between July 1, 1996
    20  and June 30, 1997, between July 1, 1997 and June 30, 1998, between  July
    21  1,  1998  and  June  30,  1999,  between July 1, 1999 and June 30, 2000,
    22  between July 1, 2000 and June 30, 2001, between July 1,  2001  and  June
    23  30,  2002,  between July 1, 2002 and June 30, 2003, between July 1, 2003
    24  and June 30, 2004, between July 1, 2004 and June 30, 2005, between  July
    25  1,  2005  and  June  30,  2006,  between July 1, 2006 and June 30, 2007,
    26  between July 1, 2007 and June 30, 2008, between July 1,  2008  and  June
    27  30,  2009,  between July 1, 2009 and June 30, 2010, between July 1, 2010
    28  and June 30, 2011, between July 1, 2011 and June 30, 2012, between  July
    29  1,  2012  and  June  30,  2013,  between July 1, 2013 and June 30, 2014,
    30  between July 1, 2014 and June 30, 2015, between July 1,  2015  and  June
    31  30,  2016,  between July 1, 2016 and June 30, 2017, between July 1, 2017
    32  and June 30, 2018, [and] between July 1, 2018 and  June  30,  2019,  and
    33  between  July 1, 2019 and June 30, 2020 allocable to each general hospi-
    34  tal for physicians or dentists certified as eligible for purchase  of  a
    35  policy  for  excess  insurance coverage or equivalent excess coverage by
    36  such general hospital in accordance with subdivision 2 of this  section,
    37  and  may  amend  such  determination and certification as necessary. The
    38  superintendent of financial services shall determine and certify to each
    39  general hospital and to the commissioner of health the ratable share  of
    40  such  cost allocable to the period July 1, 1987 to December 31, 1987, to
    41  the period January 1, 1988 to June 30, 1988, to the period July 1,  1988
    42  to December 31, 1988, to the period January 1, 1989 to June 30, 1989, to
    43  the  period  July 1, 1989 to December 31, 1989, to the period January 1,
    44  1990 to June 30, 1990, to the period July 1, 1990 to December 31,  1990,
    45  to  the  period  January 1, 1991 to June 30, 1991, to the period July 1,
    46  1991 to December 31, 1991, to the period January 1,  1992  to  June  30,
    47  1992,  to  the  period  July 1, 1992 to December 31, 1992, to the period
    48  January 1, 1993 to June 30, 1993, to the period July 1, 1993 to December
    49  31, 1993, to the period January 1, 1994 to June 30, 1994, to the  period
    50  July 1, 1994 to December 31, 1994, to the period January 1, 1995 to June
    51  30, 1995, to the period July 1, 1995 to December 31, 1995, to the period
    52  January 1, 1996 to June 30, 1996, to the period July 1, 1996 to December
    53  31,  1996, to the period January 1, 1997 to June 30, 1997, to the period
    54  July 1, 1997 to December 31, 1997, to the period January 1, 1998 to June
    55  30, 1998, to the period July 1, 1998 to December 31, 1998, to the period
    56  January 1, 1999 to June 30, 1999, to the period July 1, 1999 to December

        S. 1507--C                         24                         A. 2007--C

     1  31, 1999, to the period January 1, 2000 to June 30, 2000, to the  period
     2  July 1, 2000 to December 31, 2000, to the period January 1, 2001 to June
     3  30,  2001,  to  the  period July 1, 2001 to June 30, 2002, to the period
     4  July  1,  2002  to June 30, 2003, to the period July 1, 2003 to June 30,
     5  2004, to the period July 1, 2004 to June 30, 2005, to the period July 1,
     6  2005 and June 30, 2006, to the period July 1, 2006 and June 30, 2007, to
     7  the period July 1, 2007 and June 30, 2008, to the period  July  1,  2008
     8  and  June 30, 2009, to the period July 1, 2009 and June 30, 2010, to the
     9  period July 1, 2010 and June 30, 2011, to the period July  1,  2011  and
    10  June  30,  2012,  to  the  period July 1, 2012 and June 30, 2013, to the
    11  period July 1, 2013 and June 30, 2014, to the period July  1,  2014  and
    12  June  30,  2015,  to  the  period  July  1, 2015 and June 30, 2016, [and
    13  between] to the period July 1, 2016 and June  30,  2017,  [and]  to  the
    14  period  July  1, 2017 to June 30, 2018, [and] to the period July 1, 2018
    15  to June 30, 2019, and to the period July 1, 2019 to June 30, 2020.
    16    § 3. Paragraphs (a), (b), (c), (d) and (e) of subdivision 8 of section
    17  18 of chapter 266 of the laws of 1986, amending the civil  practice  law
    18  and  rules  and  other  laws  relating  to  malpractice and professional
    19  medical conduct, as amended by section 3 of part M of chapter 57 of  the
    20  laws of 2018, are amended to read as follows:
    21    (a)  To  the  extent  funds available to the hospital excess liability
    22  pool pursuant to subdivision 5 of this section as amended, and  pursuant
    23  to  section  6  of part J of chapter 63 of the laws of 2001, as may from
    24  time to time be amended, which amended this  subdivision,  are  insuffi-
    25  cient  to  meet  the  costs  of  excess insurance coverage or equivalent
    26  excess coverage for coverage periods during the period July 1,  1992  to
    27  June  30,  1993, during the period July 1, 1993 to June 30, 1994, during
    28  the period July 1, 1994 to June 30, 1995, during the period July 1, 1995
    29  to June 30, 1996, during the period July  1,  1996  to  June  30,  1997,
    30  during  the period July 1, 1997 to June 30, 1998, during the period July
    31  1, 1998 to June 30, 1999, during the period July 1,  1999  to  June  30,
    32  2000, during the period July 1, 2000 to June 30, 2001, during the period
    33  July  1,  2001  to  October 29, 2001, during the period April 1, 2002 to
    34  June 30, 2002, during the period July 1, 2002 to June 30,  2003,  during
    35  the period July 1, 2003 to June 30, 2004, during the period July 1, 2004
    36  to  June  30,  2005,  during  the  period July 1, 2005 to June 30, 2006,
    37  during the period July 1, 2006 to June 30, 2007, during the period  July
    38  1,  2007  to  June  30, 2008, during the period July 1, 2008 to June 30,
    39  2009, during the period July 1, 2009 to June 30, 2010, during the period
    40  July 1, 2010 to June 30, 2011, during the period July 1,  2011  to  June
    41  30,  2012,  during  the period July 1, 2012 to June 30, 2013, during the
    42  period July 1, 2013 to June 30, 2014, during the period July 1, 2014  to
    43  June  30,  2015, during the period July 1, 2015 to June 30, 2016, during
    44  the period July 1, 2016 to June 30, 2017, during the period July 1, 2017
    45  to June 30, 2018, [and] during the period July 1, 2018 to June 30, 2019,
    46  and during the period July 1, 2019 to June 30, 2020 allocated or reallo-
    47  cated in accordance with  paragraph  (a)  of  subdivision  4-a  of  this
    48  section  to  rates of payment applicable to state governmental agencies,
    49  each physician or dentist for whom a policy for excess insurance  cover-
    50  age  or equivalent excess coverage is purchased for such period shall be
    51  responsible for payment to the provider of excess insurance coverage  or
    52  equivalent  excess coverage of an allocable share of such insufficiency,
    53  based on the ratio of the total cost of such coverage for such physician
    54  to the sum of the total cost of such coverage for all physicians applied
    55  to such insufficiency.

        S. 1507--C                         25                         A. 2007--C
 
     1    (b) Each provider of excess insurance coverage  or  equivalent  excess
     2  coverage  covering the period July 1, 1992 to June 30, 1993, or covering
     3  the period July 1, 1993 to June 30, 1994, or covering the period July 1,
     4  1994 to June 30, 1995, or covering the period July 1, 1995 to  June  30,
     5  1996,  or covering the period July 1, 1996 to June 30, 1997, or covering
     6  the period July 1, 1997 to June 30, 1998, or covering the period July 1,
     7  1998 to June 30, 1999, or covering the period July 1, 1999 to  June  30,
     8  2000,  or covering the period July 1, 2000 to June 30, 2001, or covering
     9  the period July 1, 2001 to October 29,  2001,  or  covering  the  period
    10  April  1,  2002 to June 30, 2002, or covering the period July 1, 2002 to
    11  June 30, 2003, or covering the period July 1, 2003 to June 30, 2004,  or
    12  covering the period July 1, 2004 to June 30, 2005, or covering the peri-
    13  od July 1, 2005 to June 30, 2006, or covering the period July 1, 2006 to
    14  June  30, 2007, or covering the period July 1, 2007 to June 30, 2008, or
    15  covering the period July 1, 2008 to June 30, 2009, or covering the peri-
    16  od July 1, 2009 to June 30, 2010, or covering the period July 1, 2010 to
    17  June 30, 2011, or covering the period July 1, 2011 to June 30, 2012,  or
    18  covering the period July 1, 2012 to June 30, 2013, or covering the peri-
    19  od July 1, 2013 to June 30, 2014, or covering the period July 1, 2014 to
    20  June  30, 2015, or covering the period July 1, 2015 to June 30, 2016, or
    21  covering the period July 1, 2016 to June 30, 2017, or covering the peri-
    22  od July 1, 2017 to June 30, 2018, or covering the period July 1, 2018 to
    23  June 30, 2019, or covering the period July 1,  2019  to  June  30,  2020
    24  shall  notify  a  covered  physician  or  dentist by mail, mailed to the
    25  address shown on the last application for excess insurance  coverage  or
    26  equivalent excess coverage, of the amount due to such provider from such
    27  physician  or  dentist for such coverage period determined in accordance
    28  with paragraph (a) of this subdivision. Such amount shall  be  due  from
    29  such  physician or dentist to such provider of excess insurance coverage
    30  or equivalent excess coverage in a time and  manner  determined  by  the
    31  superintendent of financial services.
    32    (c)  If  a physician or dentist liable for payment of a portion of the
    33  costs of excess insurance coverage or equivalent excess coverage  cover-
    34  ing  the  period  July  1, 1992 to June 30, 1993, or covering the period
    35  July 1, 1993 to June 30, 1994, or covering the period July  1,  1994  to
    36  June  30, 1995, or covering the period July 1, 1995 to June 30, 1996, or
    37  covering the period July 1, 1996 to June 30, 1997, or covering the peri-
    38  od July 1, 1997 to June 30, 1998, or covering the period July 1, 1998 to
    39  June 30, 1999, or covering the period July 1, 1999 to June 30, 2000,  or
    40  covering the period July 1, 2000 to June 30, 2001, or covering the peri-
    41  od  July  1,  2001  to October 29, 2001, or covering the period April 1,
    42  2002 to June 30, 2002, or covering the period July 1, 2002 to  June  30,
    43  2003,  or covering the period July 1, 2003 to June 30, 2004, or covering
    44  the period July 1, 2004 to June 30, 2005, or covering the period July 1,
    45  2005 to June 30, 2006, or covering the period July 1, 2006 to  June  30,
    46  2007,  or covering the period July 1, 2007 to June 30, 2008, or covering
    47  the period July 1, 2008 to June 30, 2009, or covering the period July 1,
    48  2009 to June 30, 2010, or covering the period July 1, 2010 to  June  30,
    49  2011,  or covering the period July 1, 2011 to June 30, 2012, or covering
    50  the period July 1, 2012 to June 30, 2013, or covering the period July 1,
    51  2013 to June 30, 2014, or covering the period July 1, 2014 to  June  30,
    52  2015,  or covering the period July 1, 2015 to June 30, 2016, or covering
    53  the period July 1, 2016 to June 30, 2017, or covering the period July 1,
    54  2017 to June 30, 2018, or covering the period July 1, 2018 to  June  30,
    55  2019, or covering the period July 1, 2019 to June 30, 2020 determined in
    56  accordance  with  paragraph  (a)  of  this subdivision fails, refuses or

        S. 1507--C                         26                         A. 2007--C
 
     1  neglects to make payment to the provider of excess insurance coverage or
     2  equivalent excess coverage in such time and manner as determined by  the
     3  superintendent  of  financial services pursuant to paragraph (b) of this
     4  subdivision,  excess  insurance  coverage  or equivalent excess coverage
     5  purchased for such physician or dentist in accordance with this  section
     6  for  such  coverage period shall be cancelled and shall be null and void
     7  as of the first day on or after the  commencement  of  a  policy  period
     8  where  the  liability  for  payment pursuant to this subdivision has not
     9  been met.
    10    (d) Each provider of excess insurance coverage  or  equivalent  excess
    11  coverage  shall  notify the superintendent of financial services and the
    12  commissioner of health or their designee of each physician  and  dentist
    13  eligible  for  purchase  of  a  policy  for excess insurance coverage or
    14  equivalent excess coverage covering the period July 1, 1992 to June  30,
    15  1993,  or covering the period July 1, 1993 to June 30, 1994, or covering
    16  the period July 1, 1994 to June 30, 1995, or covering the period July 1,
    17  1995 to June 30, 1996, or covering the period July 1, 1996 to  June  30,
    18  1997,  or covering the period July 1, 1997 to June 30, 1998, or covering
    19  the period July 1, 1998 to June 30, 1999, or covering the period July 1,
    20  1999 to June 30, 2000, or covering the period July 1, 2000 to  June  30,
    21  2001, or covering the period July 1, 2001 to October 29, 2001, or cover-
    22  ing  the  period  April 1, 2002 to June 30, 2002, or covering the period
    23  July 1, 2002 to June 30, 2003, or covering the period July  1,  2003  to
    24  June  30, 2004, or covering the period July 1, 2004 to June 30, 2005, or
    25  covering the period July 1, 2005 to June 30, 2006, or covering the peri-
    26  od July 1, 2006 to June 30, 2007, or covering the period July 1, 2007 to
    27  June 30, 2008, or covering the period July 1, 2008 to June 30, 2009,  or
    28  covering the period July 1, 2009 to June 30, 2010, or covering the peri-
    29  od July 1, 2010 to June 30, 2011, or covering the period July 1, 2011 to
    30  June  30, 2012, or covering the period July 1, 2012 to June 30, 2013, or
    31  covering the period July 1, 2013 to June 30, 2014, or covering the peri-
    32  od July 1, 2014 to June 30, 2015, or covering the period July 1, 2015 to
    33  June 30, 2016, or covering the period July 1, 2016 to June 30, 2017,  or
    34  covering the period July 1, 2017 to June 30, 2018, or covering the peri-
    35  od July 1, 2018 to June 30, 2019, or covering the period July 1, 2019 to
    36  June 30, 2020 that has made payment to such provider of excess insurance
    37  coverage  or equivalent excess coverage in accordance with paragraph (b)
    38  of this subdivision and of each physician and dentist  who  has  failed,
    39  refused or neglected to make such payment.
    40    (e)  A  provider  of  excess  insurance  coverage or equivalent excess
    41  coverage shall refund to the hospital excess liability pool  any  amount
    42  allocable to the period July 1, 1992 to June 30, 1993, and to the period
    43  July  1,  1993  to June 30, 1994, and to the period July 1, 1994 to June
    44  30, 1995, and to the period July 1, 1995 to June 30, 1996,  and  to  the
    45  period  July 1, 1996 to June 30, 1997, and to the period July 1, 1997 to
    46  June 30, 1998, and to the period July 1, 1998 to June 30, 1999,  and  to
    47  the period July 1, 1999 to June 30, 2000, and to the period July 1, 2000
    48  to  June  30,  2001, and to the period July 1, 2001 to October 29, 2001,
    49  and to the period April 1, 2002 to June 30, 2002, and to the period July
    50  1, 2002 to June 30, 2003, and to the period July 1,  2003  to  June  30,
    51  2004, and to the period July 1, 2004 to June 30, 2005, and to the period
    52  July  1,  2005  to June 30, 2006, and to the period July 1, 2006 to June
    53  30, 2007, and to the period July 1, 2007 to June 30, 2008,  and  to  the
    54  period  July 1, 2008 to June 30, 2009, and to the period July 1, 2009 to
    55  June 30, 2010, and to the period July 1, 2010 to June 30, 2011,  and  to
    56  the period July 1, 2011 to June 30, 2012, and to the period July 1, 2012

        S. 1507--C                         27                         A. 2007--C
 
     1  to  June  30, 2013, and to the period July 1, 2013 to June 30, 2014, and
     2  to the period July 1, 2014 to June 30, 2015, and to the period  July  1,
     3  2015  to June 30, 2016, to the period July 1, 2016 to June 30, 2017, and
     4  to  the  period July 1, 2017 to June 30, 2018, and to the period July 1,
     5  2018 to June 30, 2019, and to the period July 1, 2019 to June  30,  2020
     6  received  from the hospital excess liability pool for purchase of excess
     7  insurance coverage or equivalent excess  coverage  covering  the  period
     8  July  1,  1992 to June 30, 1993, and covering the period July 1, 1993 to
     9  June 30, 1994, and covering the period July 1, 1994 to  June  30,  1995,
    10  and  covering the period July 1, 1995 to June 30, 1996, and covering the
    11  period July 1, 1996 to June 30, 1997, and covering the  period  July  1,
    12  1997  to June 30, 1998, and covering the period July 1, 1998 to June 30,
    13  1999, and covering the period July 1, 1999 to June 30, 2000, and  cover-
    14  ing  the  period  July 1, 2000 to June 30, 2001, and covering the period
    15  July 1, 2001 to October 29, 2001, and covering the period April 1,  2002
    16  to June 30, 2002, and covering the period July 1, 2002 to June 30, 2003,
    17  and  covering the period July 1, 2003 to June 30, 2004, and covering the
    18  period July 1, 2004 to June 30, 2005, and covering the  period  July  1,
    19  2005  to June 30, 2006, and covering the period July 1, 2006 to June 30,
    20  2007, and covering the period July 1, 2007 to June 30, 2008, and  cover-
    21  ing  the  period  July 1, 2008 to June 30, 2009, and covering the period
    22  July 1, 2009 to June 30, 2010, and covering the period July 1,  2010  to
    23  June  30,  2011,  and covering the period July 1, 2011 to June 30, 2012,
    24  and covering the period July 1, 2012 to June 30, 2013, and covering  the
    25  period  July  1,  2013 to June 30, 2014, and covering the period July 1,
    26  2014 to June 30, 2015, and covering the period July 1, 2015 to June  30,
    27  2016,  and covering the period July 1, 2016 to June 30, 2017, and cover-
    28  ing the period July 1, 2017 to June 30, 2018, and  covering  the  period
    29  July  1,  2018 to June 30, 2019, and covering the period July 1, 2019 to
    30  June 30, 2020 for a physician or dentist  where  such  excess  insurance
    31  coverage  or  equivalent excess coverage is cancelled in accordance with
    32  paragraph (c) of this subdivision.
    33    § 4. Section 40 of chapter 266 of the laws of 1986, amending the civil
    34  practice law and rules  and  other  laws  relating  to  malpractice  and
    35  professional medical conduct, as amended by section 4 of part M of chap-
    36  ter 57 of the laws of 2018, is amended to read as follows:
    37    §  40.  The superintendent of financial services shall establish rates
    38  for policies providing coverage  for  physicians  and  surgeons  medical
    39  malpractice  for the periods commencing July 1, 1985 and ending June 30,
    40  [2019;]  2020;  provided,  however,  that  notwithstanding   any   other
    41  provision  of law, the superintendent shall not establish or approve any
    42  increase in rates for the period commencing July 1, 2009 and ending June
    43  30, 2010. The superintendent shall direct insurers to  establish  segre-
    44  gated  accounts  for  premiums, payments, reserves and investment income
    45  attributable to such premium periods and shall require periodic  reports
    46  by the insurers regarding claims and expenses attributable to such peri-
    47  ods to monitor whether such accounts will be sufficient to meet incurred
    48  claims  and expenses. On or after July 1, 1989, the superintendent shall
    49  impose a surcharge on premiums to satisfy a projected deficiency that is
    50  attributable to the premium levels established pursuant to this  section
    51  for  such  periods;  provided, however, that such annual surcharge shall
    52  not exceed eight percent of the established rate until July  1,  [2019,]
    53  2020, at which time and thereafter such surcharge shall not exceed twen-
    54  ty-five  percent  of  the  approved  adequate rate, and that such annual
    55  surcharges shall continue for such period of time as shall be sufficient
    56  to satisfy such deficiency. The superintendent  shall  not  impose  such

        S. 1507--C                         28                         A. 2007--C
 
     1  surcharge  during the period commencing July 1, 2009 and ending June 30,
     2  2010. On and after July  1,  1989,  the  surcharge  prescribed  by  this
     3  section  shall  be  retained by insurers to the extent that they insured
     4  physicians  and surgeons during the July 1, 1985 through June 30, [2019]
     5  2020 policy periods; in the event  and  to  the  extent  physicians  and
     6  surgeons  were  insured by another insurer during such periods, all or a
     7  pro rata share of the surcharge, as the case may be, shall  be  remitted
     8  to  such  other  insurer  in accordance with rules and regulations to be
     9  promulgated by the superintendent.  Surcharges collected from physicians
    10  and surgeons who were not insured during such policy  periods  shall  be
    11  apportioned  among  all insurers in proportion to the premium written by
    12  each insurer during such policy periods; if a physician or  surgeon  was
    13  insured by an insurer subject to rates established by the superintendent
    14  during  such  policy  periods,  and  at  any time thereafter a hospital,
    15  health maintenance organization, employer or institution is  responsible
    16  for  responding in damages for liability arising out of such physician's
    17  or surgeon's practice of medicine, such responsible  entity  shall  also
    18  remit  to  such  prior  insurer the equivalent amount that would then be
    19  collected as a surcharge if the physician or surgeon  had  continued  to
    20  remain  insured  by  such  prior  insurer. In the event any insurer that
    21  provided coverage during such policy  periods  is  in  liquidation,  the
    22  property/casualty  insurance  security fund shall receive the portion of
    23  surcharges to which the insurer in liquidation would have been entitled.
    24  The surcharges authorized herein shall be deemed to be income earned for
    25  the purposes of section 2303 of the insurance law.  The  superintendent,
    26  in  establishing  adequate  rates and in determining any projected defi-
    27  ciency pursuant to the requirements of this section  and  the  insurance
    28  law,  shall  give  substantial  weight, determined in his discretion and
    29  judgment, to the  prospective  anticipated  effect  of  any  regulations
    30  promulgated  and  laws  enacted  and the public benefit of   stabilizing
    31  malpractice rates and minimizing rate level fluctuation during the peri-
    32  od of time necessary for the development of  more  reliable  statistical
    33  experience  as  to  the  efficacy of such laws and regulations affecting
    34  medical, dental or podiatric malpractice enacted or promulgated in 1985,
    35  1986, by this act and at any other time.  Notwithstanding any  provision
    36  of the insurance law, rates already established and to be established by
    37  the  superintendent pursuant to this section are deemed adequate if such
    38  rates would be adequate when taken together with the maximum  authorized
    39  annual  surcharges to be imposed for a reasonable period of time whether
    40  or not any such annual surcharge has been actually  imposed  as  of  the
    41  establishment of such rates.
    42    §  5. Section 5 and subdivisions (a) and (e) of section 6 of part J of
    43  chapter 63 of the laws of 2001, amending chapter  266  of  the  laws  of
    44  1986,  amending the civil practice law and rules and other laws relating
    45  to malpractice and professional medical conduct, relating to the  effec-
    46  tiveness  of certain provisions of such chapter, as amended by section 5
    47  of part M of chapter 57 of the laws of 2018,  are  amended  to  read  as
    48  follows:
    49    §  5. The superintendent of financial services and the commissioner of
    50  health shall determine, no later than June 15, 2002, June 15, 2003, June
    51  15, 2004, June 15, 2005, June 15, 2006, June 15, 2007,  June  15,  2008,
    52  June  15,  2009,  June  15, 2010, June 15, 2011, June 15, 2012, June 15,
    53  2013, June 15, 2014, June 15, 2015, June 15, 2016, June 15,  2017,  June
    54  15,  2018,  [and]  June  15, 2019, and June 15, 2020 the amount of funds
    55  available in the hospital excess liability  pool,  created  pursuant  to
    56  section  18  of  chapter 266 of the laws of 1986, and whether such funds

        S. 1507--C                         29                         A. 2007--C

     1  are sufficient for purposes of purchasing excess insurance coverage  for
     2  eligible participating physicians and dentists during the period July 1,
     3  2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July 1, 2003
     4  to  June  30, 2004, or July 1, 2004 to June 30, 2005, or July 1, 2005 to
     5  June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007 to June
     6  30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to June  30,
     7  2010,  or  July  1,  2010  to June 30, 2011, or July 1, 2011 to June 30,
     8  2012, or July 1, 2012 to June 30, 2013, or July  1,  2013  to  June  30,
     9  2014,  or  July  1,  2014  to June 30, 2015, or July 1, 2015 to June 30,
    10  2016, or July 1, 2016 to June 30, 2017, or July  1,  2017  to  June  30,
    11  2018, or July 1, 2018 to June 30, 2019, or July 1, 2019 to June 30, 2020
    12  as applicable.
    13    (a)  This section shall be effective only upon a determination, pursu-
    14  ant to section five of this act,  by  the  superintendent  of  financial
    15  services  and  the  commissioner  of health, and a certification of such
    16  determination to the state director of the  budget,  the  chair  of  the
    17  senate  committee  on finance and the chair of the assembly committee on
    18  ways and means, that the amount of funds in the hospital excess  liabil-
    19  ity  pool,  created pursuant to section 18 of chapter 266 of the laws of
    20  1986, is insufficient for purposes of purchasing excess insurance cover-
    21  age for eligible participating physicians and dentists during the period
    22  July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July
    23  1, 2003 to June 30, 2004, or July 1, 2004 to June 30, 2005, or  July  1,
    24  2005 to June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007
    25  to  June  30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to
    26  June 30, 2010, or July 1, 2010 to June 30, 2011, or July 1, 2011 to June
    27  30, 2012, or July 1, 2012 to June 30, 2013, or July 1, 2013 to June  30,
    28  2014,  or  July  1,  2014  to June 30, 2015, or July 1, 2015 to June 30,
    29  2016, or July 1, 2016 to June 30, 2017, or July  1,  2017  to  June  30,
    30  2018, or July 1, 2018 to June 30, 2019, or July 1, 2019 to June 30, 2020
    31  as applicable.
    32    (e)  The  commissioner  of  health  shall  transfer for deposit to the
    33  hospital excess liability pool created pursuant to section 18 of chapter
    34  266 of the laws of 1986 such amounts as directed by  the  superintendent
    35  of  financial  services  for  the purchase of excess liability insurance
    36  coverage for eligible participating  physicians  and  dentists  for  the
    37  policy  year  July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30,
    38  2003, or July 1, 2003 to June 30, 2004, or July  1,  2004  to  June  30,
    39  2005,  or  July  1,  2005  to June 30, 2006, or July 1, 2006 to June 30,
    40  2007, as applicable, and the cost of administering the  hospital  excess
    41  liability pool for such applicable policy year,  pursuant to the program
    42  established  in  chapter  266  of the laws of 1986, as amended, no later
    43  than June 15, 2002, June 15, 2003, June 15, 2004, June  15,  2005,  June
    44  15,  2006,  June  15, 2007, June 15, 2008, June 15, 2009, June 15, 2010,
    45  June 15, 2011, June 15, 2012, June 15, 2013, June  15,  2014,  June  15,
    46  2015,  June 15, 2016, June 15, 2017, June 15, 2018, [and] June 15, 2019,
    47  and June 15, 2020 as applicable.
    48    § 6. Section 20 of part H of chapter 57 of the laws of 2017,  amending
    49  the  New  York Health Care Reform Act of 1996 and other laws relating to
    50  extending certain provisions thereto, as amended by section 6 of part  M
    51  of chapter 57 of the laws of 2018, is amended to read as follows:
    52    §  20.  Notwithstanding  any  law, rule or regulation to the contrary,
    53  only physicians or dentists who were eligible, and for whom  the  super-
    54  intendent of financial services and the commissioner of health, or their
    55  designee, purchased, with funds available in the hospital excess liabil-
    56  ity  pool,  a  full  or partial policy for excess coverage or equivalent

        S. 1507--C                         30                         A. 2007--C
 
     1  excess coverage for the coverage period ending the  thirtieth  of  June,
     2  two  thousand  [eighteen,] nineteen, shall be eligible to apply for such
     3  coverage for the coverage period beginning the first of July, two  thou-
     4  sand  [eighteen;]  nineteen;  provided,  however, if the total number of
     5  physicians or dentists for  whom  such  excess  coverage  or  equivalent
     6  excess  coverage  was purchased for the policy year ending the thirtieth
     7  of June, two thousand [eighteen] nineteen exceeds the  total  number  of
     8  physicians  or  dentists  certified  as eligible for the coverage period
     9  beginning the first of July, two thousand [eighteen,] nineteen, then the
    10  general hospitals may certify additional eligible physicians or dentists
    11  in a number equal to such general hospital's proportional share  of  the
    12  total  number  of  physicians  or  dentists  for whom excess coverage or
    13  equivalent excess coverage was purchased with  funds  available  in  the
    14  hospital excess liability pool as of the thirtieth of June, two thousand
    15  [eighteen,] nineteen, as applied to the difference between the number of
    16  eligible physicians or dentists for whom a policy for excess coverage or
    17  equivalent  excess coverage was purchased for the coverage period ending
    18  the thirtieth of June, two thousand [eighteen] nineteen and  the  number
    19  of  such  eligible  physicians  or  dentists who have applied for excess
    20  coverage or equivalent excess coverage for the coverage period beginning
    21  the first of July, two thousand [eighteen] nineteen.
    22    § 7. This act shall take effect immediately and  shall  be  deemed  to
    23  have been in full force and effect on and after April 1, 2019.
 
    24                                   PART G
 
    25    Section 1. Intentionally omitted.
    26    § 2. Paragraphs (c), (d), (e), (f), (g) and (h) of subdivision 4-a and
    27  subdivision  4-c  of  section  365-f  of  the  social  services  law are
    28  REPEALED, and paragraph (i) of subdivision 4-a is  relettered  paragraph
    29  (c).
    30    § 3. Subparagraphs (i) and (ii) of paragraph (a) of subdivision 4-a of
    31  section  365-f of the social services law, as added by section 1 of part
    32  E of chapter 57 of the laws of 2017, are amended to read as follows:
    33    (i) "Fiscal intermediary" means an entity that provides fiscal  inter-
    34  mediary services and has a contract for providing such services with[:
    35    (A) a local department of social services;
    36    (B)  an  organization  licensed under article forty-four of the public
    37  health law; or
    38    (C) an accountable care organization certified under  article  twenty-
    39  nine-E  of  the  public  health  law  or  an  integrated delivery system
    40  composed primarily of health care providers recognized by the department
    41  as a performing provider system under the delivery system reform  incen-
    42  tive  payment  program] the department of health and is selected through
    43  the procurement process described in paragraph (b) of this  subdivision.
    44  Eligible  applicants for contracts shall be entities that are capable of
    45  appropriately providing fiscal  intermediary  services,  performing  the
    46  responsibilities  of  a  fiscal  intermediary,  and  complying with this
    47  section, including but not limited to entities that:
    48    (A) are a service center for  independent  living  under  section  one
    49  thousand one hundred twenty-one of the education law; or
    50    (B)  have  been  established as fiscal intermediaries prior to January
    51  first, two thousand twelve and have  been  continuously  providing  such
    52  services for eligible individuals under this section.

        S. 1507--C                         31                         A. 2007--C
 
     1    (ii)   Fiscal   intermediary  services  shall  include  the  following
     2  services, performed on behalf of the consumer to facilitate his  or  her
     3  role as the employer:
     4    (A) wage and benefit processing for consumer directed personal assist-
     5  ants;
     6    (B) processing all income tax and other required wage withholdings;
     7    (C)  complying with workers' compensation, disability and unemployment
     8  requirements;
     9    (D) maintaining personnel records for each consumer directed  personal
    10  assistant, including time [sheets] records and other documentation need-
    11  ed for wages and benefit processing and a copy of the medical documenta-
    12  tion required pursuant to regulations established by the commissioner;
    13    (E) ensuring that the health status of each consumer directed personal
    14  assistant  is assessed prior to service delivery pursuant to regulations
    15  issued by the commissioner;
    16    (F) maintaining records of service authorizations or reauthorizations;
    17    (G) monitoring the consumer's or, if applicable, the designated repre-
    18  sentative's continuing ability to fulfill  the  consumer's  responsibil-
    19  ities under the program and promptly notifying the authorizing entity of
    20  any  circumstance  that may affect the consumer's or, if applicable, the
    21  designated representative's ability to fulfill such responsibilities;
    22    (H) complying with regulations established by the commissioner  speci-
    23  fying  the  responsibilities of fiscal intermediaries providing services
    24  under this title; [and]
    25    (I) entering into a department approved  memorandum  of  understanding
    26  with  the  consumer  that  describes the parties' responsibilities under
    27  this program; and
    28    (J) other related responsibilities which may include, as determined by
    29  the commissioner, assisting consumers to perform the consumers'  respon-
    30  sibilities  under  this  section  and department regulations in a manner
    31  that does not infringe upon the consumer's responsibilities and self-di-
    32  rection.
    33    § 4. Paragraph (b) of subdivision 4-a of section 365-f of  the  social
    34  services  law, as added by section 1 of part E of chapter 57 of the laws
    35  of 2017, is amended to read as follows:
    36    (b) [No entity shall provide, directly  or  through  contract,  fiscal
    37  intermediary  services without an authorization as a fiscal intermediary
    38  issued by the commissioner in accordance with this subdivision] Notwith-
    39  standing any inconsistent provision of section one  hundred  sixty-three
    40  of  the  state  finance  law,  or  section  one hundred forty-two of the
    41  economic development law the commissioner  shall  enter  into  contracts
    42  under  this  subdivision  with eligible contractors that submit an offer
    43  for a contract, provided, however, that:
    44    (i) the department shall post on its website:
    45    (A) a description of the proposed services to be provided pursuant  to
    46  contracts in accordance with this subdivision;
    47    (B)  that  the  selection  of  contractors  shall be based on criteria
    48  reasonably related to the contractors' ability to provide fiscal  inter-
    49  mediary  services including but not limited to: ability to appropriately
    50  serve individuals participating in the program, geographic  distribution
    51  that  would  ensure  access in rural and underserved areas, demonstrated
    52  cultural and language competencies specific to the population of consum-
    53  ers and those of the available  workforce,  ability  to  provide  timely
    54  consumer  assistance,  experience serving individuals with disabilities,
    55  the availability of consumer peer support, and  demonstrated  compliance

        S. 1507--C                         32                         A. 2007--C
 
     1  with  all  applicable  federal and state laws and regulations, including
     2  but not limited to those relating to wages and labor;
     3    (C)  the  manner  by  which  prospective  contractors  may  seek  such
     4  selection, which may include submission by electronic means;
     5    (ii) all reasonable and  responsive  offers  that  are  received  from
     6  prospective  contractors  in  timely  fashion  shall  be reviewed by the
     7  commissioner;
     8    (iii) the commissioner shall award such contracts to  the  contractors
     9  that  best  meet the criteria for selection and are best suited to serve
    10  the purposes of this section and the needs of consumers;
    11    (iv) all entities providing fiscal intermediary services on or  before
    12  April first, two thousand nineteen, shall submit an offer for a contract
    13  under  this  section  within sixty days after the commissioner publishes
    14  the initial offer on the department's website. Such  entities  shall  be
    15  deemed  authorized to provide such services unless: (A) the entity fails
    16  to submit an offer for a contract under this section  within  the  sixty
    17  days;  or  (B)  the  entity's offer for a contract under this section is
    18  denied;
    19    (v) all decisions made and approaches taken pursuant to this paragraph
    20  shall be documented in a procurement record as defined  in  section  one
    21  hundred sixty-three of the state finance law; and
    22    (vi)  the  commissioner  is  authorized to reoffer contracts under the
    23  same terms of this subdivision, if determined necessary by  the  commis-
    24  sioner.
    25    §  5.  Subparagraph (i) of paragraph (c) of subdivision 4-a of section
    26  365-f of the social services law, as added by section 1-a of part  K  of
    27  chapter  57 of the laws of 2018 and as relettered by section two of this
    28  act, is amended to read as follows:
    29    (i) The commissioner [may] shall  require  a  fiscal  intermediary  to
    30  report  annually on the direct care and administrative costs of personal
    31  assistance services as accounted for by  the  fiscal  intermediary.  The
    32  department  [may]  shall  specify  the  [frequency  and]  format of such
    33  reports, determine the type and amount of information to  be  submitted,
    34  and require the submission of supporting documentation, provided, howev-
    35  er, that the department shall provide no less than ninety calendar days'
    36  notice before such reports are due.
    37    §  6.  Section 365-f of the social services law is amended by adding a
    38  new subdivision 4-c to read as follows:
    39    4-c. The commissioner shall convene and chair a stakeholder  workgroup
    40  pertaining  to  fiscal intermediary services and the needs of consumers.
    41  The workgroup shall consist of, at a minimum, representatives of service
    42  centers for independent living; statewide associations of fiscal  inter-
    43  mediaries;  representatives  of  managed  care  entities  under  article
    44  forty-four of the public health law and local social service  districts;
    45  consumers; and representatives of advocacy groups representing consumers
    46  of  services  under  this section. The workgroup shall be established no
    47  later than May fifteenth, two thousand  nineteen.  The  workgroup  shall
    48  identify and develop best practices pertaining to the delivery of fiscal
    49  intermediary services; inform the criteria for use by the department for
    50  the  selection  of  entities  under  subdivision four-a of this section;
    51  identify whether services differ for certain consumers  and  under  what
    52  circumstances; inform criteria in relation to the development of quality
    53  reporting  requirements; and work with the department to develop transi-
    54  tion plans for consumers that may need to transition to  another  fiscal
    55  intermediary.

        S. 1507--C                         33                         A. 2007--C
 
     1    §  7.  Section 365-f of the social services law is amended by adding a
     2  new subdivision 4-d to read as follows:
     3    4-d.  Fiscal  intermediaries  ceasing  operation.  (a)  Where a fiscal
     4  intermediary is ceasing operation or will no longer serve the consumer's
     5  area, the fiscal intermediary shall:
     6    (i) deliver written notice forty-five calendar days in advance to  the
     7  affected  consumers,  consumer representatives, personal assistants, the
     8  department, and any local social  services  districts  or  managed  care
     9  plans with which the fiscal intermediary contracts. Within five business
    10  days  of  receipt  of  the notice, the local social services district or
    11  managed care plan shall acknowledge the notice and provide the  affected
    12  consumers  with  a  list of other fiscal intermediaries operating in the
    13  same county or managed care plan network as appropriate;
    14    (ii) not take any action that would prevent a personal assistant  from
    15  moving  to  a  new  fiscal  intermediary  of  the consumer's choice, nor
    16  require the consumer or the personal assistant to switch to  a  personal
    17  care or home health care program not under this section; and
    18    (iii) upon request and consent, promptly transfer all records relating
    19  to  the individual's health and care authorizations, and personnel docu-
    20  ments to the fiscal intermediary or personal care or  home  health  care
    21  provider  chosen  by the consumer and assume all liability for omissions
    22  or errors in such records.
    23    (b) Where a consumer is electing to transfer his or her services to  a
    24  new  fiscal intermediary or a personal care or home health care provider
    25  by the consumer's independent  choice,  the  fiscal  intermediary  being
    26  discontinued shall comply with subparagraphs (ii) and (iii) of paragraph
    27  (a) of this subdivision.
    28    (c)  Where  a  fiscal  intermediary is suspending or ceasing operation
    29  pursuant to an order under subdivision four-b of this  section,  or  has
    30  failed  to submit an offer for a contract, or has been denied a contract
    31  under this section, all the provisions of this subdivision  shall  apply
    32  except  subparagraph (i) of paragraph (a) of this subdivision, notice of
    33  which to all parties shall be provided by the department as appropriate.
    34    (d) The local social services district or managed care plan, as appro-
    35  priate, shall supervise the  transition  of  services  and  transfer  of
    36  records  and maintain provision of services by the personal assistant(s)
    37  chosen by the individual.
    38    (e) Any transfer under this subdivision shall not diminish any  of  an
    39  individual's  rights  relating to continuity of care, utilization review
    40  or fair hearing appeals and aid continuing.
    41    § 8. Subdivision 4-b of section 365-f of the social services  law,  as
    42  added  by  section  1  of  part  E of chapter 57 of the laws of 2017, is
    43  amended to read as follows:
    44    4-b. Actions involving the authorization of a fiscal intermediary.
    45    (a) [A fiscal intermediary's authorization may be revoked,  suspended,
    46  limited  or  annulled  upon  thirty  day's  written notice to the fiscal
    47  intermediary, if the commissioner finds that the fiscal intermediary has
    48  failed to comply with the provisions of this subdivision or  regulations
    49  promulgated  hereunder.]  The department may terminate a fiscal interme-
    50  diary's contract under this section  or  suspend  or  limit  the  fiscal
    51  intermediary's  rights  and  privileges  under  the contract upon thirty
    52  day's written notice to the fiscal  intermediary,  if  the  commissioner
    53  finds  that  the  fiscal  intermediary  has  failed  to  comply with the
    54  provisions of this section or  regulations  promulgated  hereunder.  The
    55  written notice shall include:

        S. 1507--C                         34                         A. 2007--C
 
     1    (i)  A  description of the conduct and the issues related thereto that
     2  have been identified as failure of compliance; and
     3    (ii) the time frame of the conduct that fails compliance.
     4    (b)  Notwithstanding  the  foregoing, upon determining that the public
     5  health or  safety  would  be  imminently  endangered  by  the  continued
     6  [authorization]  operation  or  actions  of the fiscal intermediary, the
     7  commissioner may [revoke, suspend, limit or annul  the  fiscal  interme-
     8  diary's authorization immediately.
     9    (b)]  terminate the fiscal intermediary's contract or suspend or limit
    10  the fiscal intermediary's rights and privileges under the contract imme-
    11  diately upon written notice.
    12    (c) All orders or  determinations  under  this  subdivision  shall  be
    13  subject  to  review  as  provided  in article seventy-eight of the civil
    14  practice law and rules.
    15    § 9. Residential health care facilities case mix adjustment workgroup.
    16  The commissioner of health or his or  her  designee  shall  convene  and
    17  chair  a  workgroup  on  the  implementation  of  the change in case mix
    18  adjustments to Medicaid rates of  payment  of  residential  health  care
    19  facilities that will take effect on July 1, 2019. The workgroup shall be
    20  comprised  of residential health care facilities or representatives from
    21  such facilities, representatives from  the  statewide  associations  and
    22  other such experts on case mix as required by the commissioner or his or
    23  her  designee.  The  workgroup  shall  review  recent  case mix data and
    24  related analyses conducted by the department with respect to the depart-
    25  ment's implementation of the July 1, 2019  change  in  methodology,  the
    26  department's  minimum  data set collection process, and case mix adjust-
    27  ments authorized under subparagraph (ii) of paragraph (b) of subdivision
    28  2-b of section 2808 of the public health law. Such review shall seek  to
    29  promote  a  higher  degree of accuracy in the minimum data set data, and
    30  target abuses. The workgroup may offer recommendations on how to improve
    31  future practice regarding accuracy in the minimum  data  set  collection
    32  process  and how to reduce or eliminate abusive practices. In developing
    33  such recommendations, the workgroup shall  ensure  that  the  collection
    34  process  and  case  mix adjustment recognizes the appropriate acuity for
    35  residential health care residents. The workgroup may provide recommenda-
    36  tions regarding the proposed patient driven payment model and the admin-
    37  istrative complexity in revising the minimum  data  set  collection  and
    38  rate promulgation processes. The commissioner shall not modify the meth-
    39  od  used  to determine the case mix adjustment for periods prior to June
    40  30, 2019. Notwithstanding any  changes  in  federal  law  or  regulation
    41  relating  to  nursing  home  acuity  reimbursement,  the workgroup shall
    42  report its recommendations no later than June 30, 2019.
    43    § 10. Subdivision 2 of section 3614-c of the  public  health  law,  as
    44  amended  by  section  5  of part S of chapter 57 of the laws of 2017, is
    45  amended to read as follows:
    46    2. Notwithstanding any inconsistent provision of law,  rule  or  regu-
    47  lation,  no  payments  by government agencies shall be made to certified
    48  home health agencies, long term home health care programs, managed  care
    49  plans,  [or]  the  consumer  directed  personal assistance program under
    50  section three hundred sixty-five-f of the social services law, the nurs-
    51  ing home transition and diversion waiver  program  under  section  three
    52  hundred  sixty-six  of  the  social services law, or the traumatic brain
    53  injury waiver program under section two thousand seven hundred forty  of
    54  this  chapter for any episode of care furnished, in whole or in part, by
    55  any home care aide who is compensated at amounts less than the  applica-

        S. 1507--C                         35                         A. 2007--C
 
     1  ble minimum rate of home care aide total compensation established pursu-
     2  ant to this section.
     3    §  11.  This  act shall take effect immediately and shall be deemed to
     4  have been in full force and effect on and after April 1, 2019;  provided
     5  however,  that  sections  three, four, five, seven and eight of this act
     6  shall take effect January 1, 2020; and provided further  that  effective
     7  immediately,  the commissioner of health is authorized to request offers
     8  for contracts in accordance with section four of this act, to facilitate
     9  execution of such contracts on and after January 1, 2020.
 
    10                                   PART H
 
    11    Section 1. Subparagraph (v) of paragraph (b)  of  subdivision  5-b  of
    12  section 2807-k of the public health law is REPEALED.
    13    §  2. Section 2807 of the public health law is amended by adding a new
    14  subdivision 20-a to read as follows:
    15    20-a. Notwithstanding any  provision  of  law  to  the  contrary,  the
    16  commissioners  of the department of health, the office of mental health,
    17  the office of people with developmental disabilities, and the office  of
    18  alcoholism  and  substance  abuse services   are authorized to waive any
    19  regulatory requirements as are necessary, consistent  with    applicable
    20  law,  to  allow  providers that are involved in DSRIP projects or repli-
    21  cation and  scaling activities, as approved by the  authorizing  commis-
    22  sioner,  to avoid duplication of requirements and to allow the efficient
    23  scaling and replication of DSRIP promising practices, as  determined  by
    24  the   authorizing   commissioner;  provided  however,  that  regulations
    25  pertaining to patient safety, patient autonomy, patient privacy, patient
    26  rights,  due process, scope of practice, professional  licensure,  envi-
    27  ronmental protections,  provider reimbursement methodologies, or occupa-
    28  tional  standards  and employee rights  may not be waived, nor shall any
    29  regulations be waived if such waiver  would  risk  patient  safety.  Any
    30  regulatory  action  under  this  subdivision  shall  be published on the
    31  applicable  website of the authorizing commissioner and shall include  a
    32  description  of  each  waiver,  including  a citation of each regulation
    33  waived, and a description of the project  of  which    such  relief  was
    34  granted.
    35    §  3.  Subparagraph (i) of paragraph (e-1) of subdivision 4 of section
    36  2807-c of the public health law, as amended by section 29 of part  C  of
    37  chapter 60 of the laws of 2014, is amended to read as follows:
    38    (i)  For rate periods on [and] or after April first, two thousand ten,
    39  the commissioner, in consultation with the commissioner of the office of
    40  mental health, shall promulgate regulations, and may promulgate emergen-
    41  cy regulations, establishing methodologies for determining the operating
    42  cost components of rates of payments  for  services  described  in  this
    43  paragraph.  [Such  regulations shall utilize two thousand five operating
    44  costs as submitted to the department prior to July first,  two  thousand
    45  nine and shall provide for methodologies establishing per diem inpatient
    46  rates  that  utilize  case  mix  adjustment mechanisms. Such regulations
    47  shall contain criteria for adjustments based on length of stay  and  may
    48  also  provide  for a base year update, provided, however, that such base
    49  year update shall take effect no earlier than April first, two  thousand
    50  fifteen,  and  provided further, however, that the] The commissioner may
    51  make such adjustments to [such utilization and to] the  methodology  for
    52  computing such rates as is necessary to achieve no aggregate, net growth
    53  in  overall  Medicaid expenditures related to such rates, as compared to
    54  such aggregate expenditures from the prior year.    In  determining  the

        S. 1507--C                         36                         A. 2007--C

     1  updated  base  year  to  be  utilized pursuant to this subparagraph, the
     2  commissioner shall take into account the base year determined in accord-
     3  ance with paragraph (c) of subdivision thirty-five of this section.
     4    Furthermore,  the commissioner shall establish such rates in consulta-
     5  tion with industry representatives to achieve an appropriate  base  year
     6  update to the operating cost components of rates of payment for services
     7  described  in  this paragraph and that takes into account facility cost,
     8  mix of services, and patient specific conditions.
     9    § 4. Intentionally omitted.
    10    § 5. Intentionally omitted.
    11    § 6. Subdivision 5-d of section 2807-k of the public  health  law,  as
    12  amended  by  section  2  of part A of chapter 57 of the laws of 2018, is
    13  amended to read as follows:
    14    5-d. (a) Notwithstanding any inconsistent provision of  this  section,
    15  section  twenty-eight  hundred  seven-w  of  this  article  or any other
    16  contrary provision of law, and subject to the  availability  of  federal
    17  financial  participation,  for  periods  on and after January first, two
    18  thousand thirteen, through March thirty-first, two thousand twenty,  all
    19  funds  available  for  distribution pursuant to this section, except for
    20  funds distributed pursuant to  subparagraph  (v)  of  paragraph  (b)  of
    21  subdivision five-b of this section, and all funds available for distrib-
    22  ution  pursuant to section twenty-eight hundred seven-w of this article,
    23  shall be reserved and set aside and distributed in accordance  with  the
    24  provisions of this subdivision.
    25    (b)  The commissioner shall promulgate regulations, and may promulgate
    26  emergency regulations, establishing methodologies for  the  distribution
    27  of  funds  as  described  in  paragraph (a) of this subdivision and such
    28  regulations shall include, but not be limited to, the following:
    29    (i) Such regulations shall  establish  methodologies  for  determining
    30  each  facility's  relative uncompensated care need amount based on unin-
    31  sured inpatient and outpatient units of service from the cost  reporting
    32  year  two years prior to the distribution year, multiplied by the appli-
    33  cable medicaid rates in effect January first of the  distribution  year,
    34  as summed and adjusted by a statewide cost adjustment factor and reduced
    35  by  the  sum  of  all  payment  amounts  collected  from  such uninsured
    36  patients, and as further adjusted  by  application  of  a  nominal  need
    37  computation  that shall take into account each facility's medicaid inpa-
    38  tient share.
    39    (ii) Annual distributions pursuant to such  regulations  for  the  two
    40  thousand  thirteen through two thousand [nineteen] twenty calendar years
    41  shall be in accord with the following:
    42    (A) one hundred thirty-nine  million  four  hundred  thousand  dollars
    43  shall be distributed as Medicaid Disproportionate Share Hospital ("DSH")
    44  payments to major public general hospitals; and
    45    (B)  nine hundred ninety-four million nine hundred thousand dollars as
    46  Medicaid DSH payments to eligible general hospitals,  other  than  major
    47  public general hospitals.
    48    (iii)(A)  Such  regulations  shall establish transition adjustments to
    49  the distributions made pursuant to clauses (A) and (B)  of  subparagraph
    50  (ii)  of this paragraph such that no facility experiences a reduction in
    51  indigent care pool payments pursuant to this subdivision that is greater
    52  than the percentages, as specified in clause (C) of this subparagraph as
    53  compared to the average distribution that each  such  facility  received
    54  for  the three calendar years prior to two thousand thirteen pursuant to
    55  this section and section twenty-eight hundred seven-w of this article.

        S. 1507--C                         37                         A. 2007--C
 
     1    (B) Such regulations shall also  establish  adjustments  limiting  the
     2  increases  in  indigent  care  pool  payments  experienced by facilities
     3  pursuant to this subdivision by an amount that will be, as determined by
     4  the commissioner and in conjunction with such other funding  as  may  be
     5  available  for  this  purpose, sufficient to ensure full funding for the
     6  transition adjustment payments authorized by clause (A) of this subpara-
     7  graph.
     8    (C) No facility shall experience a reduction  in  indigent  care  pool
     9  payments pursuant to this subdivision that: for the calendar year begin-
    10  ning  January first, two thousand thirteen, is greater than two and one-
    11  half percent; for the calendar year beginning January first,  two  thou-
    12  sand  fourteen, is greater than five percent; and, for the calendar year
    13  beginning on January first, two thousand fifteen; is greater than  seven
    14  and  one-half  percent,  and  for the calendar year beginning on January
    15  first, two thousand sixteen, is greater than ten percent;  and  for  the
    16  calendar  year  beginning  on  January first, two thousand seventeen, is
    17  greater than twelve and one-half percent;  and  for  the  calendar  year
    18  beginning  on  January  first,  two  thousand  eighteen, is greater than
    19  fifteen percent; and for the calendar year beginning on  January  first,
    20  two  thousand  nineteen, is greater than seventeen and one-half percent;
    21  and for the calendar year beginning on January first, two thousand twen-
    22  ty, is greater than twenty percent.
    23    (iv) Such regulations shall reserve one percent of the funds available
    24  for distribution in the two thousand fourteen and two  thousand  fifteen
    25  calendar  years,  and  for  calendar  years thereafter, pursuant to this
    26  subdivision, subdivision  fourteen-f  of  section  twenty-eight  hundred
    27  seven-c of this article, and sections two hundred eleven and two hundred
    28  twelve  of  chapter  four  hundred  seventy-four of the laws of nineteen
    29  hundred ninety-six, in a  "financial  assistance  compliance  pool"  and
    30  shall establish methodologies for the distribution of such pool funds to
    31  facilities  based  on  their  level  of compliance, as determined by the
    32  commissioner, with the provisions of subdivision nine-a of this section.
    33    (c) The commissioner shall annually report to  the  governor  and  the
    34  legislature  on the distribution of funds under this subdivision includ-
    35  ing, but not limited to:
    36    (i) the impact on safety net providers, including community providers,
    37  rural general hospitals and major public general hospitals;
    38    (ii) the provision of indigent care by units  of  services  and  funds
    39  distributed by general hospitals; and
    40    (iii) the extent to which access to care has been enhanced.
    41    §  7.  This  act  shall take effect immediately and shall be deemed to
    42  have been in full force and effect on and after April 1, 2019, provided,
    43  however, that section two of this act shall expire on April 1, 2020.
 
    44                                   PART I
 
    45                            Intentionally Omitted

    46                                   PART J
 
    47    Section 1. This Part enacts into law major components  of  legislation
    48  which are necessary to protect health care consumers; increase access to
    49  more  affordable  quality  health  insurance  coverage; and preserve and
    50  foster New York's health insurance markets.   Each component  is  wholly
    51  contained  within  a  Subpart  identified  as  Subparts A through D. The
    52  effective date for  each  particular  provision  contained  within  such

        S. 1507--C                         38                         A. 2007--C
 
     1  Subpart  is set forth in the last section of such Subpart. Any provision
     2  in any section contained within a Subpart, including the effective  date
     3  of the Subpart, which makes a reference to a section "of this act," when
     4  used  in  connection  with that particular component, shall be deemed to
     5  mean and refer to the corresponding section of the Subpart in  which  it
     6  is  found.  Section  five  of this Part sets forth the general effective
     7  date of this Part.
 
     8                                  SUBPART A
 
     9    Section 1. Section 3221 of the insurance law is amended  by  adding  a
    10  new subsection (t) to read as follows:
    11    (t) (1) Any insurer that delivers or issues for delivery in this state
    12  hospital,  surgical or medical expense group policies in the small group
    13  or large group market shall offer to any employer in this state all such
    14  policies in the  applicable  market,  and  shall  accept  at  all  times
    15  throughout the year any employer that applies for any of those policies.
    16    (2)  The  requirements of paragraph one of this subsection shall apply
    17  with respect to an employer that applies for  coverage  either  directly
    18  from the insurer or through an association or trust to which the insurer
    19  has issued coverage and in which the employer participates.
    20    §  2.  Paragraph  1 of subsection (g) of section 3231 of the insurance
    21  law, as amended by section 70 of part D of chapter 56  of  the  laws  of
    22  2013, is amended to read as follows:
    23    (1)  This  section  shall  also  apply  to  policies issued to a group
    24  defined in subsection (c) of section four thousand two  hundred  thirty-
    25  five, including but not limited to an association or trust of employers,
    26  if  the  group  includes  one  or  more member employers or other member
    27  groups which have [fifty] one hundred  or  fewer  employees  or  members
    28  exclusive  of  spouses and dependents. For policies issued or renewed on
    29  or after January first, two thousand fourteen, if the group includes one
    30  or more member small group employers eligible for  coverage  subject  to
    31  this  section,  then  such member employers shall be classified as small
    32  groups for rating purposes and the  remaining  members  shall  be  rated
    33  consistent  with  the  rating rules applicable to such remaining members
    34  pursuant to paragraph two of this subsection.
    35    § 3. Subsections (h) and (i) of section 3232 of the insurance law  are
    36  REPEALED.
    37    §  4. Subsections (f) and (g) of section 3232 of the insurance law, as
    38  added by chapter 219 of the  laws  of  2011,  are  amended  to  read  as
    39  follows:
    40    (f)  [With respect to an individual under age nineteen, an insurer may
    41  not impose any pre-existing condition  exclusion  in  an  individual  or
    42  group policy of hospital, medical, surgical or prescription drug expense
    43  insurance  pursuant  to  the  requirements of section 2704 of the Public
    44  Health Service Act, 42 U.S.C. § 300gg-3, as made  effective  by  section
    45  1255(2)  of  the Affordable Care Act, except for an individual under age
    46  nineteen covered under an individual policy of hospital, medical, surgi-
    47  cal or prescription drug  expense  insurance  that  is  a  grandfathered
    48  health plan.
    49    (g)  Beginning  January  first,  two  thousand  fourteen,  pursuant to
    50  section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3,  an]
    51  An  insurer  [may] shall not impose any pre-existing condition exclusion
    52  in an individual or group  policy  of  hospital,  medical,  surgical  or
    53  prescription drug expense insurance [except in an individual policy that
    54  is a grandfathered health plan].

        S. 1507--C                         39                         A. 2007--C
 
     1    § 5. Intentionally omitted.
     2    §  6.  Section  4305  of  the insurance law is amended by adding a new
     3  subsection (n) to read as follows:
     4    (n) (1) Any corporation subject to the provisions of this article that
     5  issues hospital, surgical or medical  expense  contracts  in  the  small
     6  group or large group market in this state shall offer to any employer in
     7  this state all such contracts in the applicable market, and shall accept
     8  at  all  times  throughout the year any employer that applies for any of
     9  those contracts.
    10    (2) The requirements of paragraph one of this subsection  shall  apply
    11  with  respect  to  an employer that applies for coverage either directly
    12  from the corporation or through an association or  trust  to  which  the
    13  corporation has issued coverage and in which the employer participates.
    14    §  7.  Paragraph  1 of subsection (d) of section 4317 of the insurance
    15  law, as amended by section 72 of part D of chapter 56  of  the  laws  of
    16  2013, is amended to read as follows:
    17    (1)  This  section  shall  also  apply to a contract issued to a group
    18  defined in subsection (c) of section four thousand two  hundred  thirty-
    19  five  of  this  chapter,  including but not limited to an association or
    20  trust of employers, if the group includes one or more  member  employers
    21  or other member groups which have [fifty] one hundred or fewer employees
    22  or  members exclusive of spouses and dependents. For contracts issued or
    23  renewed on or after January first, two thousand fourteen, if  the  group
    24  includes  one or more member small group employers eligible for coverage
    25  subject to this section, then such member employers shall be  classified
    26  as  small  groups for rating purposes and the remaining members shall be
    27  rated consistent with the rating  rules  applicable  to  such  remaining
    28  members pursuant to paragraph two of this subsection.
    29    §  8. Subsections (h) and (i) of section 4318 of the insurance law are
    30  REPEALED.
    31    § 9. Subsections (f) and (g) of section 4318 of the insurance law,  as
    32  added  by  chapter  219  of  the  laws  of  2011, are amended to read as
    33  follows:
    34    (f) [With respect to an individual under age nineteen,  a  corporation
    35  may  not impose any pre-existing condition exclusion in an individual or
    36  group contract of  hospital,  medical,  surgical  or  prescription  drug
    37  expense  insurance  pursuant  to the requirements of section 2704 of the
    38  Public Health Service Act, 42 U.S.C. § 300gg-3,  as  made  effective  by
    39  section  1255(2)  of  the  Affordable Care Act, except for an individual
    40  under age nineteen covered under an  individual  contract  of  hospital,
    41  medical,  surgical  or  prescription  drug  expense  insurance that is a
    42  grandfathered health plan.
    43    (g) Beginning  January  first,  two  thousand  fourteen,  pursuant  to
    44  section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A
    45  corporation  [may] shall not impose any pre-existing condition exclusion
    46  in an individual or group contract of  hospital,  medical,  surgical  or
    47  prescription  drug  expense  insurance [except in an individual contract
    48  that is a grandfathered health plan].
    49    § 10. Subdivision 1 of section 4406  of  the  public  health  law,  as
    50  amended  by section 46-a of part D of chapter 56 of the laws of 2013, is
    51  amended to read as follows:
    52    1. The contract between  a  health  maintenance  organization  and  an
    53  enrollee  shall  be subject to regulation by the superintendent as if it
    54  were a health insurance subscriber contract, and shall include, but  not
    55  be  limited to, all mandated benefits required by article forty-three of
    56  the insurance law. Such contract shall fully and clearly state the bene-

        S. 1507--C                         40                         A. 2007--C
 
     1  fits and limitations therein provided or imposed, so  as  to  facilitate
     2  understanding  and  comparisons,  and to exclude provisions which may be
     3  misleading or unreasonably confusing. Such contract shall be  issued  to
     4  any  individual  and  dependents  of  such  individual  and any group of
     5  [fifty] one hundred or fewer employees or members, exclusive of  spouses
     6  and  dependents,  or  to  any employee or member of the group, including
     7  dependents, applying for such contract at any time throughout the year[,
     8  and may include a pre-existing condition provision as  provided  for  in
     9  section  four  thousand  three  hundred  eighteen  of the insurance law,
    10  provided, however, that, the]. An  individual  direct  payment  contract
    11  shall  be  issued  only  in  accordance with section four thousand three
    12  hundred twenty-eight of the insurance law. The superintendent may, after
    13  giving consideration to the public interest, exempt a health maintenance
    14  organization from the requirements of this section provided that another
    15  health insurer or health  maintenance  organization  within  the  health
    16  maintenance  organization's  same  holding company system, as defined in
    17  article fifteen of the insurance law,  including  a  health  maintenance
    18  organization  operated  as a line of business of a health service corpo-
    19  ration licensed under article forty-three of the insurance  law,  offers
    20  coverage that, at a minimum, complies with this section and provides all
    21  of  the consumer protections required to be provided by a health mainte-
    22  nance organization pursuant to this chapter and  regulations,  including
    23  those  consumer  protections  contained  in  sections four thousand four
    24  hundred three and four thousand four hundred eight-a  of  this  chapter.
    25  The  requirements  shall  not apply to a health maintenance organization
    26  exclusively serving individuals enrolled pursuant  to  title  eleven  of
    27  article  five of the social services law, title eleven-D of article five
    28  of the social services law, title one-A of article twenty-five  of  [the
    29  public  health law] this chapter or title eighteen of the federal Social
    30  Security Act, and, further provided, that such health maintenance organ-
    31  ization shall not discontinue a contract  for  an  individual  receiving
    32  comprehensive-type  coverage in effect prior to January first, two thou-
    33  sand four who is ineligible to purchase policies offered after such date
    34  pursuant to this section or section four thousand three  hundred  [twen-
    35  ty-two  of  this  article]  twenty-eight of the insurance law due to the
    36  provision of 42 U.S.C. 1395ss in effect  prior  to  January  first,  two
    37  thousand  four.    [Subject  to  the creditable coverage requirements of
    38  subsection (a) of section four thousand three hundred  eighteen  of  the
    39  insurance  law,  the organization may, as an alternative to the use of a
    40  pre-existing condition provision, elect to  offer  contracts  without  a
    41  pre-existing  condition  provision  to  such groups but may require that
    42  coverage shall not become effective until after a specified  affiliation
    43  period of not more than sixty days after the application for coverage is
    44  submitted.    The  organization  is  not required to provide health care
    45  services or benefits during such period and no premium shall be  charged
    46  for  any  coverage  during  the  period.  After  January first, nineteen
    47  hundred ninety-six, all individual direct  payment  contracts  shall  be
    48  issued  only pursuant to sections four thousand three hundred twenty-one
    49  and four thousand three hundred twenty-two of the  insurance  law.  Such
    50  contracts may not, with respect to an eligible individual (as defined in
    51  section  2741(b)  of  the federal Public Health Service Act, 42 U.S.C. §
    52  300gg-41(b), impose any pre-existing condition exclusion.]
    53    § 11. This act shall take effect immediately, provided that:
    54    (1) sections one, three, four, six, eight and nine of this  act  shall
    55  apply  to  all policies and contracts issued, renewed, modified, altered
    56  or amended on or after January 1, 2020; and

        S. 1507--C                         41                         A. 2007--C
 
     1    (2) sections two and seven of this act shall take effect on  the  same
     2  date  as  the reversion of paragraph 1 of subsection (g) of section 3231
     3  and paragraph 1 of subsection (d) of section 4317 of the insurance  law,
     4  as provided in section 5 of chapter 588 of the laws of 2015, as amended.
 
     5                                  SUBPART B

     6    Section  1.  Subparagraph  (A)  of  paragraph  5  of subsection (c) of
     7  section 3216 of the insurance law, as amended by chapter 388 of the laws
     8  of 2014, is amended to read as follows:
     9    (A) Any family policy providing hospital or surgical expense insurance
    10  (but not including such insurance against accidental injury only)  shall
    11  provide  that, in the event such insurance on any person, other than the
    12  policyholder, is terminated because the person is no longer  within  the
    13  definition  of  the  family  as  set forth in the policy but before such
    14  person has attained the limiting age, if any,  for  coverage  of  adults
    15  specified in the policy, such person shall be entitled to have issued to
    16  that  person  by  the  insurer,  without  evidence of insurability, upon
    17  application therefor and payment of the first premium, within sixty days
    18  after such insurance shall have  terminated,  an  individual  conversion
    19  policy  that contains the essential health benefits package described in
    20  paragraph [one] three of subsection [(b)] (f) of section [four  thousand
    21  three  hundred twenty-eight of this chapter. The insurer shall offer one
    22  policy at each level of coverage as defined in section  1302(d)  of  the
    23  affordable  care  act, 42 U.S.C. § 18022(d).] three thousand two hundred
    24  seventeen-i of this article. The insurer shall offer one policy at  each
    25  level of coverage as defined in subsection (b) of section three thousand
    26  two  hundred  seventeen-i of this article. The individual may choose any
    27  such policy offered by the insurer. Provided, however,  the  superinten-
    28  dent may, after giving due consideration to the public interest, approve
    29  a request made by an insurer for the insurer to satisfy the requirements
    30  of  this  subparagraph through the offering of policies that comply with
    31  this subparagraph by another insurer, corporation or health  maintenance
    32  organization  within the insurer's holding company system, as defined in
    33  article fifteen of this chapter. The conversion privilege afforded here-
    34  in shall also be available upon the divorce or annulment of the marriage
    35  of the policyholder to the former spouse of such policyholder.
    36    § 2. Subparagraph (E) of paragraph 2 of subsection (g) of section 3216
    37  of the insurance law, as added by chapter 388 of the laws  of  2014,  is
    38  amended to read as follows:
    39    (E)  The  superintendent  may,  after  giving due consideration to the
    40  public interest, approve a request made by an insurer for the insurer to
    41  satisfy the requirements of subparagraph (C) of this  paragraph  through
    42  the  offering  of  policies  at  each  level  of  coverage as defined in
    43  subsection (b) of section [1302(d) of the affordable care act, 42 U.S.C.
    44  § 18022(d)] three thousand two hundred seventeen-i of this article  that
    45  contains  the  essential  health benefits package described in paragraph
    46  [one] three of subsection [(b)] (e)  of  section  [four  thousand  three
    47  hundred  twenty-eight of this chapter] three thousand two hundred seven-
    48  teen-i of this article by another insurer, corporation or health mainte-
    49  nance organization within the insurer's same holding company system,  as
    50  defined in article fifteen of this chapter.
    51    § 3. Intentionally omitted.
    52    § 4. Intentionally omitted.
    53    § 5. Intentionally omitted.

        S. 1507--C                         42                         A. 2007--C
 
     1    §  6.  Paragraph 21 of subsection (i) of section 3216 of the insurance
     2  law, as amended by chapter 469 of the laws of 2018, is amended  to  read
     3  as follows:
     4    (21)  Every  policy  [which]  that  provides coverage for prescription
     5  drugs shall include coverage for the cost of enteral formulas  for  home
     6  use, whether administered orally or via tube feeding, for which a physi-
     7  cian  or  other  licensed  health  care  provider  legally authorized to
     8  prescribe under title eight of the education law has  issued  a  written
     9  order. Such written order shall state that the enteral formula is clear-
    10  ly  medically  necessary and has been proven effective as a disease-spe-
    11  cific treatment regimen.  Specific  diseases  and  disorders  for  which
    12  enteral  formulas  have been proven effective shall include, but are not
    13  limited to, inherited diseases of amino acid or organic acid metabolism;
    14  Crohn's Disease; gastroesophageal reflux; disorders of  gastrointestinal
    15  motility  such  as  chronic intestinal pseudo-obstruction; and multiple,
    16  severe food allergies including, but not limited to immunoglobulin E and
    17  nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
    18  food protein induced enterocolitis syndrome; eosinophilic disorders; and
    19  impaired absorption of  nutrients  caused  by  disorders  affecting  the
    20  absorptive surface, function, length, and motility of the gastrointesti-
    21  nal  tract.  Enteral  formulas  [which] that are medically necessary and
    22  taken under written order from a physician for the treatment of specific
    23  diseases shall be distinguished from nutritional supplements taken elec-
    24  tively. Coverage for certain inherited diseases of amino acid and organ-
    25  ic acid metabolism as well as severe protein allergic  conditions  shall
    26  include  modified  solid  food products that are low protein [or which],
    27  contain modified protein, or are  amino  acid  based  [which]  that  are
    28  medically  necessary[,  and  such  coverage for such modified solid food
    29  products for any calendar year or for any continuous  period  of  twelve
    30  months  for  any  insured  individual shall not exceed two thousand five
    31  hundred dollars].
    32    § 7. Paragraph 30 of subsection (i) of section 3216 of  the  insurance
    33  law,  as  amended by chapter 377 of the laws of 2014, is amended to read
    34  as follows:
    35    (30) Every policy [which] that provides medical coverage that includes
    36  coverage for physician services in a physician's office and every policy
    37  [which] that provides major medical or similar comprehensive-type cover-
    38  age shall include coverage for  equipment  and  supplies  used  for  the
    39  treatment  of  ostomies,  if prescribed by a physician or other licensed
    40  health care provider legally authorized to prescribe under  title  eight
    41  of  the  education law. Such coverage shall be subject to annual deduct-
    42  ibles and coinsurance as deemed appropriate by the  superintendent.  The
    43  coverage required by this paragraph shall be identical to, and shall not
    44  enhance  or  increase  the coverage required as part of essential health
    45  benefits as [required pursuant to] defined in subsection (a) of  section
    46  [2707 (a) of the public health services act 42 U.S.C. 300 gg-6(a)] three
    47  thousand two hundred seventeen-i of this article.
    48    §  8. Subsection (l) of section 3216 of the insurance law, as added by
    49  section 42 of part D of chapter 56 of the laws of 2013,  is  amended  to
    50  read as follows:
    51    (l) [On and after October first, two thousand thirteen, an] An insurer
    52  shall  not offer individual hospital, medical or surgical expense insur-
    53  ance policies unless the policies meet the  requirements  of  subsection
    54  (b) of section four thousand three hundred twenty-eight of this chapter.
    55  Such policies that are offered within the health benefit exchange estab-
    56  lished [pursuant to section 1311 of the affordable care act, 42 U.S.C. §

        S. 1507--C                         43                         A. 2007--C

     1  18031,  or  any  regulations promulgated thereunder,] by this state also
     2  shall meet any requirements established by the health benefit exchange.
     3    §  9. Subsection (m) of section 3216 of the insurance law, as added by
     4  section 53 of part D of chapter 56 of the laws of 2013,  is  amended  to
     5  read as follows:
     6    (m)  An  insurer  shall  not be required to offer the policyholder any
     7  benefits that must be made available pursuant to  this  section  if  the
     8  benefits  must  be  covered as essential health benefits. For any policy
     9  issued within the  health  benefit  exchange  established  [pursuant  to
    10  section  1311  of  the  affordable  care act, 42 U.S.C. § 18031] by this
    11  state, an insurer shall not be required to offer  the  policyholder  any
    12  benefits  that  must  be  made  available  pursuant to this section. For
    13  purposes of this subsection, "essential health benefits" shall have  the
    14  meaning  set forth in subsection (a) of section [1302(b) of the afforda-
    15  ble care act, 42 U.S.C. § 18022(b)] three thousand  two  hundred  seven-
    16  teen-i of this article.
    17    §  10.  The insurance law is amended by adding a new section 3217-i to
    18  read as follows:
    19    § 3217-i. Essential health benefits package and limit on cost-sharing.
    20  (a) (1) For purposes of this article, "essential health benefits"  shall
    21  mean the following categories of benefits:
    22    (A) ambulatory patient services;
    23    (B) emergency services;
    24    (C) hospitalization;
    25    (D) maternity and newborn care;
    26    (E)  mental  health  and  substance  use  disorder services, including
    27  behavioral health treatment;
    28    (F) prescription drugs;
    29    (G) rehabilitative and habilitative services and devices;
    30    (H) laboratory services;
    31    (I) preventive and wellness services and chronic  disease  management;
    32  and
    33    (J) pediatric services, including oral and vision care.
    34    (2) An insurer shall not be required to provide coverage for pediatric
    35  oral services as an essential health benefit if:
    36    (A)  for  coverage  offered  through  the exchange established by this
    37  state, the exchange has determined sufficient coverage of the  pediatric
    38  oral  benefit is available through stand-alone dental plans certified by
    39  the exchange; or
    40    (B) for coverage offered outside the  exchange,  the  insurer  obtains
    41  reasonable written assurance that the individual or group has obtained a
    42  stand-alone  dental plan that has been approved by the superintendent as
    43  meeting exchange certification standards.
    44    (b) (1) Every individual and small group accident and health insurance
    45  policy that provides hospital, surgical, or medical expense coverage and
    46  is not a grandfathered health plan shall provide coverage that meets the
    47  actuarial requirements of one of the following levels of coverage:
    48    (A) Bronze Level. A plan in the bronze level shall provide a level  of
    49  coverage  that  is  designed  to  provide  benefits that are actuarially
    50  equivalent to sixty percent of the full actuarial value of the  benefits
    51  provided under the plan;
    52    (B)  Silver Level. A plan in the silver level shall provide a level of
    53  coverage that is designed  to  provide  benefits  that  are  actuarially
    54  equivalent  to  seventy percent of the full actuarial value of the bene-
    55  fits provided under the plan;

        S. 1507--C                         44                         A. 2007--C
 
     1    (C) Gold Level. A plan in the gold level  shall  provide  a  level  of
     2  coverage  that  is  designed  to  provide  benefits that are actuarially
     3  equivalent to eighty percent of the full actuarial value of the benefits
     4  provided under the plan; or
     5    (D) Platinum Level. A plan in the platinum level shall provide a level
     6  of  coverage  that  is designed to provide benefits that are actuarially
     7  equivalent to ninety percent of the full actuarial value of the benefits
     8  provided under the plan.
     9    (2) The superintendent may provide for a variation  in  the  actuarial
    10  values  used  in  determining the level of coverage of a plan to account
    11  for the differences in actuarial estimates.
    12    (3) Every student accident and health insurance policy  shall  provide
    13  coverage  that  meets at least sixty percent of the full actuarial value
    14  of the benefits provided under the  policy.  The  policy's  schedule  of
    15  benefits  shall  include the level as described in paragraph one of this
    16  subsection nearest to, but below the actual actuarial value.
    17    (c) Every individual or group accident  and  health  insurance  policy
    18  that provides hospital, surgical, or medical expense coverage and is not
    19  a  grandfathered  health  plan,  and  every  student accident and health
    20  insurance policy shall limit the insured's cost-sharing  for  in-network
    21  services  in  a  policy  year to not more than the maximum out-of-pocket
    22  amount determined by the superintendent for all policies subject to this
    23  section. Such amount shall not exceed any annual out-of-pocket limit  on
    24  cost-sharing  set  by  the  United  States secretary of health and human
    25  services, if available.
    26    (d) The superintendent may require the use of model language  describ-
    27  ing  the  coverage  requirements  for  any accident and health insurance
    28  policy form that is subject to the superintendent's approval pursuant to
    29  section three thousand two hundred one of this article.
    30    (e) For purposes of this section:
    31    (1) "actuarial value" means  the  percentage  of  the  total  expected
    32  payments  by the insurer for benefits provided to a standard population,
    33  without regard to the population to whom the insurer  actually  provides
    34  benefits;
    35    (2)  "cost-sharing" means annual deductibles, coinsurance, copayments,
    36  or similar charges, for covered services;
    37    (3) "essential health benefits package" means coverage that:
    38    (A) provides for essential health benefits;
    39    (B)  limits  cost-sharing  for  such  coverage  in   accordance   with
    40  subsection (c) of this section; and
    41    (C) provides one of the levels of coverage described in subsection (b)
    42  of this section;
    43    (4)  "grandfathered health plan" means coverage provided by an insurer
    44  in which an individual was enrolled on March twenty-third, two  thousand
    45  ten  for  as  long  as  the  coverage  maintains grandfathered status in
    46  accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.  §
    47  18011(e);
    48    (5)  "small  group" means a group of one hundred or fewer employees or
    49  members exclusive of spouses and dependents; and
    50    (6) "student accident and health insurance" shall have the meaning set
    51  forth in subsection (a) of section three thousand two hundred  forty  of
    52  this article.
    53    §  11. Subsection (g) of section 3221 of the insurance law, as amended
    54  by chapter 388 of the laws of 2014, is amended to read as follows:
    55    (g) For conversion purposes, an insurer shall offer to the employee or
    56  member a policy at each level of coverage as defined in  subsection  (b)

        S. 1507--C                         45                         A. 2007--C
 
     1  of  section  [1302(d)  of the affordable care act, 42 U.S.C. § 18022(d)]
     2  three thousand two hundred seventeen-i of this article that contains the
     3  essential health benefits package described in paragraph [one] three  of
     4  subsection  [(b)]  (e)  of  section [four thousand three hundred twenty-
     5  eight of this chapter] three thousand two hundred  seventeen-i  of  this
     6  article.  Provided,  however,  the  superintendent may, after giving due
     7  consideration to the public interest,  approve  a  request  made  by  an
     8  insurer  for  the insurer to satisfy the requirements of this subsection
     9  and subsections (e) and (f) of this  section  through  the  offering  of
    10  policies  that  comply  with  this subsection by another insurer, corpo-
    11  ration or health maintenance organization within the  insurer's  holding
    12  company system, as defined in article fifteen of this chapter.
    13    § 12. Subsection (h) of section 3221 of the insurance law, as added by
    14  section  54  of  part D of chapter 56 of the laws of 2013, is amended to
    15  read as follows:
    16    (h) Every small group policy or association group policy delivered  or
    17  issued  for  delivery in this state that provides coverage for hospital,
    18  medical or surgical expense insurance and is not a grandfathered  health
    19  plan  shall provide coverage for the essential health [benefit] benefits
    20  package [as required in section 2707(a) of  the  public  health  service
    21  act, 42 U.S.C.  § 300gg-6(a)]. For purposes of this subsection:
    22    (1)  "essential  health  benefits  package" shall have the meaning set
    23  forth in paragraph three of subsection (e) of section  [1302(a)  of  the
    24  affordable  care  act,  42 U.S.C. § 18022(a)] three thousand two hundred
    25  seventeen-i of this article;
    26    (2) "grandfathered health plan" means coverage provided by an  insurer
    27  in  which an individual was enrolled on March twenty-third, two thousand
    28  ten for as long  as  the  coverage  maintains  grandfathered  status  in
    29  accordance  with section 1251(e) of the affordable care act, 42 U.S.C. §
    30  18011(e);
    31    (3) "small group" means a  group  of  [fifty  or  fewer  employees  or
    32  members  exclusive  of  spouses  and dependents; provided, however, that
    33  beginning January first, two thousand sixteen,  "small  group"  means  a
    34  group of] one hundred or fewer employees or members exclusive of spouses
    35  and dependents; and
    36    (4)  "association  group"  means a group defined in subparagraphs (B),
    37  (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of  section
    38  four thousand two hundred thirty-five of this chapter, provided that:
    39    (A) the group includes one or more individual members; or
    40    (B)  the  group  includes one or more member employers or other member
    41  groups that are small groups.
    42    § 13. Subsection (i) of section 3221 of the insurance law, as added by
    43  section 54 of part D of chapter 56 of the laws of 2013,  is  amended  to
    44  read as follows:
    45    (i)  An  insurer  shall  not be required to offer the policyholder any
    46  benefits that must be made available pursuant to  this  section  if  the
    47  benefits must be covered pursuant to subsection (h) of this section. For
    48  any policy issued within the health benefit exchange established [pursu-
    49  ant  to  section  1311 of the affordable care act, 42 U.S.C. § 18031] by
    50  this state, an insurer shall not be required to offer  the  policyholder
    51  any benefits that must be made available pursuant to this section.
    52    §  14. Paragraph 11 of subsection (k) of section 3221 of the insurance
    53  law, as amended by chapter 469 of the laws of 2018, is amended  to  read
    54  as follows:
    55    (11)  Every  policy  [which]  that  provides coverage for prescription
    56  drugs shall include coverage for the cost of enteral formulas  for  home

        S. 1507--C                         46                         A. 2007--C
 
     1  use, whether administered orally or via tube feeding, for which a physi-
     2  cian  or  other  licensed  health  care  provider  legally authorized to
     3  prescribe under title eight of the education law has  issued  a  written
     4  order. Such written order shall state that the enteral formula is clear-
     5  ly  medically  necessary and has been proven effective as a disease-spe-
     6  cific treatment regimen.  Specific  diseases  and  disorders  for  which
     7  enteral  formulas  have been proven effective shall include, but are not
     8  limited to, inherited diseases of amino-acid or organic acid metabolism;
     9  Crohn's Disease; gastroesophageal reflux; disorders of  gastrointestinal
    10  motility  such  as  chronic intestinal pseudo-obstruction; and multiple,
    11  severe food allergies including, but not limited to immunoglobulin E and
    12  nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
    13  food protein induced enterocolitis syndrome; eosinophilic disorders  and
    14  impaired  absorption  of  nutrients  caused  by  disorders affecting the
    15  absorptive surface, function, length, and motility of the gastrointesti-
    16  nal tract. Enteral formulas [which] that  are  medically  necessary  and
    17  taken under written order from a physician for the treatment of specific
    18  diseases shall be distinguished from nutritional supplements taken elec-
    19  tively. Coverage for certain inherited diseases of amino acid and organ-
    20  ic  acid  metabolism as well as severe protein allergic conditions shall
    21  include modified solid food products that are low  protein  [or  which],
    22  contain  modified  protein,  or  are  amino  acid based [which] that are
    23  medically necessary[, and such coverage for  such  modified  solid  food
    24  products  for  any  calendar year or for any continuous period of twelve
    25  months for any insured individual shall not  exceed  two  thousand  five
    26  hundred dollars].
    27    § 15. Intentionally omitted.
    28    §  16. Paragraph 19 of subsection (k) of section 3221 of the insurance
    29  law, as amended by chapter 377 of the laws of 2014, is amended  to  read
    30  as follows:
    31    (19)  Every  group  or  blanket  accident  and health insurance policy
    32  delivered or issued for delivery in this  state  [which]  that  provides
    33  medical  coverage  that  includes  coverage  for physician services in a
    34  physician's office and every policy [which] that provides major  medical
    35  or similar comprehensive-type coverage shall include coverage for equip-
    36  ment and supplies used for the treatment of ostomies, if prescribed by a
    37  physician  or  other licensed health care provider legally authorized to
    38  prescribe under title eight of the education law. Such coverage shall be
    39  subject to annual deductibles and coinsurance as deemed  appropriate  by
    40  the  superintendent.  The  coverage  required by this paragraph shall be
    41  identical to, and shall not enhance or increase the coverage required as
    42  part of essential health benefits as [required pursuant to]  defined  in
    43  subsection (a) of section [2707 (a) of the public health services act 42
    44  U.S.C.    300  gg-6(a)]  three  thousand two hundred seventeen-i of this
    45  article.
    46    § 17. Intentionally omitted.
    47    § 18. Intentionally omitted.
    48    § 19. Intentionally omitted.
    49    § 20. Paragraph 4 of subsection (a) of section 3231 of  the  insurance
    50  law,  as  amended  by  section 69 of part D of chapter 56 of the laws of
    51  2013, is amended to read as follows:
    52    (4) For the purposes of this section, "community rated" means a rating
    53  methodology in which the premium for all persons  covered  by  a  policy
    54  form  is the same based on the experience of the entire pool of risks of
    55  all individuals or small groups covered by the insurer without regard to
    56  age, sex, health status, tobacco usage or  occupation,  excluding  those

        S. 1507--C                         47                         A. 2007--C
 
     1  individuals  or small groups covered by medicare supplemental insurance.
     2  For medicare supplemental insurance coverage, "community rated" means  a
     3  rating  methodology  in  which the premiums for all persons covered by a
     4  policy  or  contract  form  is  the  same based on the experience of the
     5  entire pool of risks covered by that policy  or  contract  form  without
     6  regard  to  age,  sex,  health  status,  tobacco  usage  or  occupation.
     7  [Catastrophic health  insurance  policies  issued  pursuant  to  section
     8  1302(e) of the affordable care act, 42 U.S.C. § 18022(e), shall be clas-
     9  sified in a distinct community rating pool.]
    10    § 21. Subsection (d) of section 3240 of the insurance law, as added by
    11  section  41  of  part D of chapter 56 of the laws of 2013, is amended to
    12  read as follows:
    13    (d) A student accident and health insurance policy or  contract  shall
    14  provide  coverage for essential health benefits as defined in subsection
    15  (a) of section  [1302(b)  of  the  affordable  care  act,  42  U.S.C.  §
    16  18022(b)]  three  thousand  two hundred seventeen-i or subsection (a) of
    17  section  four  thousand  three  hundred  six-h  of  this   chapter,   as
    18  applicable.
    19    §  22.  Subparagraph  (A)  of paragraph 3 of subsection (d) of section
    20  4235 of the insurance law, as added by section 60 of part D  of  chapter
    21  56 of the laws of 2013, is amended to read as follows:
    22    (A)  "employee"  shall  have the meaning set forth in [section 2791 of
    23  the public health service act, 42 U.S.C. § 300gg-91(d)(5) or  any  regu-
    24  lations  promulgated thereunder] the Employee Retirement Income Security
    25  Act of 1974, 29 U.S.C. § 1002(6); and
    26    § 23. Intentionally omitted.
    27    § 24. Intentionally omitted.
    28    § 25. Intentionally omitted.
    29    § 26. Subsection (u-1) of  section  4303  of  the  insurance  law,  as
    30  amended  by  chapter  377  of  the  laws  of 2014, is amended to read as
    31  follows:
    32    (u-1) A medical expense indemnity  corporation  or  a  health  service
    33  corporation  which  provides medical coverage that includes coverage for
    34  physician services in  a  physician's  office  and  every  policy  which
    35  provides  major  medical  or  similar  comprehensive-type coverage shall
    36  include coverage for equipment and supplies used for  the  treatment  of
    37  ostomies,  if  prescribed  by  a physician or other licensed health care
    38  provider legally authorized to prescribe under title eight of the educa-
    39  tion law. Such coverage shall be subject to annual deductibles and coin-
    40  surance as  deemed  appropriate  by  the  superintendent.  The  coverage
    41  required by this subsection shall be identical to, and shall not enhance
    42  or  increase  the coverage required as part of essential health benefits
    43  as [required pursuant to] defined in subsection (a) of section  [2707(a)
    44  of  the  public health services act 42 U.S.C. 300 gg-6(a)] four thousand
    45  three hundred six-h of this article.
    46    § 27. Subsection (y) of section 4303 of the insurance law, as  amended
    47  by chapter 469 of the laws of 2018, is amended to read as follows:
    48    (y)  Every  contract  [which]  that provides coverage for prescription
    49  drugs shall include coverage for the cost of enteral formulas  for  home
    50  use, whether administered orally or via tube feeding, for which a physi-
    51  cian  or  other  licensed  health  care  provider  legally authorized to
    52  prescribe under title eight of the education law has  issued  a  written
    53  order. Such written order shall state that the enteral formula is clear-
    54  ly  medically  necessary and has been proven effective as a disease-spe-
    55  cific treatment regimen.  Specific  diseases  and  disorders  for  which
    56  enteral  formulas  have been proven effective shall include, but are not

        S. 1507--C                         48                         A. 2007--C
 
     1  limited to, inherited diseases of amino-acid or organic acid metabolism;
     2  Crohn's Disease; gastroesophageal reflux; disorders of  gastrointestinal
     3  motility  such  as  chronic intestinal pseudo-obstruction; and multiple,
     4  severe food allergies including, but not limited to immunoglobulin E and
     5  nonimmunoglobulin E-mediated allergies to multiple food proteins; severe
     6  food protein induced enterocolitis syndrome; eosinophilic disorders; and
     7  impaired  absorption  of  nutrients  caused  by  disorders affecting the
     8  absorptive surface, function, length, and motility of the gastrointesti-
     9  nal tract. Enteral formulas [which] that  are  medically  necessary  and
    10  taken under written order from a physician for the treatment of specific
    11  diseases shall be distinguished from nutritional supplements taken elec-
    12  tively. Coverage for certain inherited diseases of amino acid and organ-
    13  ic  acid  metabolism as well as severe protein allergic conditions shall
    14  include modified solid food products that are low  protein,  [or  which]
    15  contain  modified  protein,  or  are  amino  acid based [which] that are
    16  medically necessary[, and such coverage for  such  modified  solid  food
    17  products  for  any  calendar year or for any continuous period of twelve
    18  months for any insured individual shall not  exceed  two  thousand  five
    19  hundred dollars].
    20    § 28. Intentionally omitted.
    21    §  29.  Subsection (ll) of section 4303 of the insurance law, as added
    22  by section 55 of part D of chapter 56 of the laws of 2013, is amended to
    23  read as follows:
    24    (ll) Every small group contract or association group contract  [deliv-
    25  ered  or  issued  for  delivery  in  this state] issued by a corporation
    26  subject to the provisions of this article  that  provides  coverage  for
    27  hospital,  medical  or  surgical expense insurance and is not a grandfa-
    28  thered health plan shall  provide  coverage  for  the  essential  health
    29  [benefit] benefits package [as required in section 2707(a) of the public
    30  health  service  act,  42  U.S.C.  §  300gg-6(a)].  For purposes of this
    31  subsection:
    32    (1) "essential health benefits package" shall  have  the  meaning  set
    33  forth  in  paragraph three of subsection (e)  of section [1302(a) of the
    34  affordable care act, 42 U.S.C. § 18022(a)] four thousand  three  hundred
    35  six-h of this article;
    36    (2)  "grandfathered  health  plan" means coverage provided by a corpo-
    37  ration in which an individual was enrolled on  March  twenty-third,  two
    38  thousand  ten for as long as the coverage maintains grandfathered status
    39  in accordance with section 1251(e) of the affordable care act, 42 U.S.C.
    40  § 18011(e); and
    41    (3) "small group" means a  group  of  [fifty  or  fewer  employees  or
    42  members  exclusive  of  spouses and dependents. Beginning January first,
    43  two thousand sixteen, "small group" means a group  of]  one  hundred  or
    44  fewer employees or members exclusive of spouses and dependents; and
    45    (4)  "association  group"  means a group defined in subparagraphs (B),
    46  (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of  section
    47  four thousand two hundred thirty-five of this chapter, provided that:
    48    (A) the group includes one or more individual members; or
    49    (B)  the  group  includes one or more member employers or other member
    50  groups that are small groups.
    51    § 30. Subsection (mm) of section 4303 of the insurance law,  as  added
    52  by section 55 of part D of chapter 56 of the laws of 2013, is amended to
    53  read as follows:
    54    (mm)  A corporation shall not be required to offer the contract holder
    55  any benefits that must be made available pursuant  to  this  section  if
    56  such  benefits  must  be  covered  pursuant  to  subsection (kk) of this

        S. 1507--C                         49                         A. 2007--C
 
     1  section. For any contract issued  within  the  health  benefit  exchange
     2  established  [pursuant  to  section  1311 of the affordable care act, 42
     3  U.S.C. § 18031] by this state, a corporation shall not  be  required  to
     4  offer  the  contract  holder  any  benefits  that must be made available
     5  pursuant to this section.
     6    § 31. Item (i) of subparagraph (C) of paragraph 2 of subsection (c) of
     7  section 4304 of the insurance law, as amended by chapter 317 of the laws
     8  of 2017, is amended to read as follows:
     9    (i) Discontinuance of a class of contract upon not  less  than  ninety
    10  days'  prior  written  notice.  In  exercising the option to discontinue
    11  coverage pursuant to this item, the corporation must act uniformly with-
    12  out regard to any health status-related factor of  enrolled  individuals
    13  or  individuals who may become eligible for such coverage and must offer
    14  to subscribers or group remitting agents, as  may  be  appropriate,  the
    15  option  to  purchase  all  other  individual  health  insurance coverage
    16  currently being offered by the corporation to applicants in that market.
    17  Provided, however, the superintendent may, after  giving  due  consider-
    18  ation  to  the  public interest, approve a request made by a corporation
    19  for the corporation to satisfy the requirements of this item through the
    20  offering of contracts at each level of coverage as defined in subsection
    21  (b) of section  [1302(d)  of  the  affordable  care  act,  42  U.S.C.  §
    22  18022(d)]  four  thousand  three  hundred  six-h  of  this  article that
    23  contains the essential health benefits package  described  in  paragraph
    24  [one]  three  of  subsection  [(b)]  (e)  of section four thousand three
    25  hundred [twenty-eight] six-h of this [chapter] article by another corpo-
    26  ration, insurer or health maintenance  organization  within  the  corpo-
    27  ration's  same  holding company system, as defined in article fifteen of
    28  this chapter.
    29    § 32. Paragraph 1 of subsection (e) of section 4304 of  the  insurance
    30  law,  as  amended by chapter 388 of the laws of 2014, is amended to read
    31  as follows:
    32    (1) (A) If any such contract is  terminated  in  accordance  with  the
    33  provisions  of  paragraph  one of subsection (c) of this section, or any
    34  such contract is terminated because of a default by the remitting  agent
    35  in  the  payment  of  premiums not cured within the grace period and the
    36  remitting agent has not replaced the contract with similar  and  contin-
    37  uous coverage for the same group whether insured or self-insured, or any
    38  such contract is terminated in accordance with the provisions of subpar-
    39  agraph  (E) of paragraph two of subsection (c) of this section, or if an
    40  individual other than the contract holder is no longer covered  under  a
    41  "family  contract"  because the individual is no longer within the defi-
    42  nition set forth in the contract, or a spouse is no longer covered under
    43  the contract because of divorce from the contract holder or annulment of
    44  the marriage, or any such contract is terminated because of the death of
    45  the contract holder, then such individual, former spouse, or in the case
    46  of the death of the contract holder the surviving spouse or other depen-
    47  dents of the deceased contract holder covered under the contract, as the
    48  case may be, shall be entitled to convert, without evidence  of  insura-
    49  bility,  upon  application  therefor and the making of the first payment
    50  thereunder within sixty days after  the  date  of  termination  of  such
    51  contract,  to  a  contract  that  contains the essential health benefits
    52  package described in paragraph [one] three of subsection  [(b)]  (e)  of
    53  section  four thousand three hundred [twenty-eight] six-h of this [chap-
    54  ter] article.
    55    (B) The corporation shall offer one contract at each level of coverage
    56  as defined in subsection (b) of section [1302(d) of the affordable  care

        S. 1507--C                         50                         A. 2007--C

     1  act,  42  U.S.C.  §  18022(d)] four thousand three hundred six-h of this
     2  article. The individual may choose any  such  contract  offered  by  the
     3  corporation. Provided, however, the superintendent may, after giving due
     4  consideration to the public interest, approve a request made by a corpo-
     5  ration for the corporation to satisfy the requirements of this paragraph
     6  through  the  offering  of  contracts that comply with this paragraph by
     7  another corporation, insurer or health maintenance  organization  within
     8  the  corporation's  same  holding  company system, as defined in article
     9  fifteen of this chapter.
    10    (C) The effective date of  the  coverage  provided  by  the  converted
    11  direct payment contract shall be the date of the termination of coverage
    12  under the contract from which conversion was made.
    13    § 33. Subsection (l) of section 4304 of the insurance law, as added by
    14  section  43  of  part D of chapter 56 of the laws of 2013, is amended to
    15  read as follows:
    16    (l) [On and after October first, two thousand thirteen,  a]  A  corpo-
    17  ration shall not offer individual hospital, medical, or surgical expense
    18  insurance  contracts  unless  the  contracts  meet  the  requirements of
    19  subsection (b) of section four thousand three  hundred  twenty-eight  of
    20  this  article. Such contracts that are offered within the health benefit
    21  exchange established [pursuant to section 1311 of  the  affordable  care
    22  act,  42  U.S.C. § 18031, or any regulations promulgated thereunder,] by
    23  this state also shall meet any requirements established  by  the  health
    24  benefit  exchange.    To  the  extent that a holder of a special purpose
    25  certificate of authority issued pursuant to section four  thousand  four
    26  hundred  three-a  of  the  public health law offers individual hospital,
    27  medical, or surgical expense insurance contracts,  the  contracts  shall
    28  meet  the  requirements of subsection (b) of section four thousand three
    29  hundred twenty-eight of this article.
    30    § 34. Subparagraph (A) of paragraph 1 of  subsection  (d)  of  section
    31  4305  of  the  insurance  law,  as amended by chapter 388 of the laws of
    32  2014, is amended to read as follows:
    33    (A) A group contract issued pursuant to this section shall  contain  a
    34  provision  to the effect that in case of a termination of coverage under
    35  such contract of any member of the group because of (i) termination  for
    36  any  reason whatsoever of the member's employment or membership, or (ii)
    37  termination for any reason  whatsoever  of  the  group  contract  itself
    38  unless  the  group  contract holder has replaced the group contract with
    39  similar and continuous coverage for the same group  whether  insured  or
    40  self-insured,  the member shall be entitled to have issued to the member
    41  by the corporation, without evidence of insurability,  upon  application
    42  therefor and payment of the first premium made to the corporation within
    43  sixty  days  after  termination  of  the  coverage, an individual direct
    44  payment contract, covering such member and the member's eligible  depen-
    45  dents  who  were  covered by the group contract, which provides coverage
    46  that contains the essential health benefits package described  in  para-
    47  graph [one] three of subsection [(b)] (e) of section four thousand three
    48  hundred  [twenty-eight] six-h of this [chapter] article. The corporation
    49  shall offer one contract  at  each  level  of  coverage  as  defined  in
    50  subsection (b) of section [1302(d) of the affordable care act, 42 U.S.C.
    51  §  18022(d)]  four  thousand  three  hundred  six-h of this article. The
    52  member  may  choose  any  such  contract  offered  by  the  corporation.
    53  Provided,  however,  the  superintendent may, after giving due consider-
    54  ation to the public interest, approve a request made  by  a  corporation
    55  for  the  corporation  to  satisfy the requirements of this subparagraph
    56  through the offering of contracts that comply with this subparagraph  by

        S. 1507--C                         51                         A. 2007--C
 
     1  another  corporation,  insurer or health maintenance organization within
     2  the corporation's same holding company system,  as  defined  in  article
     3  fifteen of this chapter.
     4    §  35.  The insurance law is amended by adding a new section 4306-h to
     5  read as follows:
     6    § 4306-h. Essential health benefits package and limit on cost-sharing.
     7  (a) (1) For purposes of this article, "essential health benefits"  shall
     8  mean the following categories of benefits:
     9    (A) ambulatory patient services;
    10    (B) emergency services;
    11    (C) hospitalization;
    12    (D) maternity and newborn care;
    13    (E)  mental  health  and  substance  use  disorder services, including
    14  behavioral health treatment;
    15    (F) prescription drugs;
    16    (G) rehabilitative and habilitative services and devices;
    17    (H) laboratory services;
    18    (I) preventive and wellness services and chronic  disease  management;
    19  and
    20    (J) pediatric services, including oral and vision care.
    21    (2) A corporation shall not be required to provide coverage for pedia-
    22  tric oral services as an essential health benefit if:
    23    (A)  for  coverage  offered  through  the exchange established by this
    24  state, the exchange has determined sufficient coverage of the  pediatric
    25  oral  benefit is available through stand-alone dental plans certified by
    26  the exchange; or
    27    (B) for coverage offered outside the exchange, the corporation obtains
    28  reasonable written assurance that the individual or group has obtained a
    29  stand-alone dental plan that has been approved by the superintendent  as
    30  meeting exchange certification standards.
    31    (b) (1) Every individual and small group contract that provides hospi-
    32  tal,  surgical,  or  medical expense coverage and is not a grandfathered
    33  health plan shall provide coverage that meets the actuarial requirements
    34  of one of the following levels of coverage:
    35    (A) Bronze Level. A plan in the bronze level shall provide a level  of
    36  coverage  that  is  designed  to  provide  benefits that are actuarially
    37  equivalent to sixty percent of the full actuarial value of the  benefits
    38  provided under the plan;
    39    (B)  Silver Level. A plan in the silver level shall provide a level of
    40  coverage that is designed  to  provide  benefits  that  are  actuarially
    41  equivalent  to  seventy percent of the full actuarial value of the bene-
    42  fits provided under the plan;
    43    (C) Gold Level. A plan in the gold level  shall  provide  a  level  of
    44  coverage  that  is  designed  to  provide  benefits that are actuarially
    45  equivalent to eighty percent of the full actuarial value of the benefits
    46  provided under the plan; or
    47    (D) Platinum Level. A plan in the platinum level shall provide a level
    48  of coverage that is designed to provide benefits  that  are  actuarially
    49  equivalent to ninety percent of the full actuarial value of the benefits
    50  provided under the plan.
    51    (2)  The  superintendent  may provide for a variation in the actuarial
    52  values used in determining the level of coverage of a  plan  to  account
    53  for the differences in actuarial estimates.
    54    (3) Every student accident and health insurance contract shall provide
    55  coverage  that  meets at least sixty percent of the full actuarial value
    56  of the benefits provided under the contract.  The contract's schedule of

        S. 1507--C                         52                         A. 2007--C
 
     1  benefits shall include the level as described in paragraph one  of  this
     2  subsection nearest to, but below the actual actuarial value.
     3    (c)  Every individual or group contract that provides hospital, surgi-
     4  cal, or medical expense coverage and is not a grandfathered health plan,
     5  and every student accident and health insurance contract shall limit the
     6  insured's cost-sharing for in-network services in a contract year to not
     7  more than the maximum out-of-pocket amount determined by the superinten-
     8  dent for all contracts subject to this section. Such  amount  shall  not
     9  exceed  any annual out-of-pocket limit on cost-sharing set by the United
    10  States secretary of health and human services, if available.
    11    (d) The superintendent may require the use of model language  describ-
    12  ing  the  coverage  requirements  for  any  form  that is subject to the
    13  approval of the superintendent pursuant to section four  thousand  three
    14  hundred eight of this article.
    15    (e) For purposes of this section:
    16    (1)  "actuarial  value"  means  the  percentage  of the total expected
    17  payments by the corporation for benefits provided to  a  standard  popu-
    18  lation, without regard to the population to whom the corporation actual-
    19  ly provides benefits;
    20    (2)  "cost-sharing" means annual deductibles, coinsurance, copayments,
    21  or similar charges, for covered services;
    22    (3) "essential health benefits package" means coverage that:
    23    (A) provides for essential health benefits;
    24    (B)  limits  cost-sharing  for  such  coverage  in   accordance   with
    25  subsection (c) of this section; and
    26    (C) provides one of the levels of coverage described in subsection (b)
    27  of this section;
    28    (4)  "grandfathered  health  plan" means coverage provided by a corpo-
    29  ration in which an individual was enrolled on  March  twenty-third,  two
    30  thousand  ten for as long as the coverage maintains grandfathered status
    31  in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C.
    32  § 18011(e);
    33    (5) "small group" means a group of one hundred or fewer  employees  or
    34  members exclusive of spouses and dependents; and
    35    (6) "student accident and health insurance" shall have the meaning set
    36  forth  in  subsection (a) of section three thousand two hundred forty of
    37  this chapter.
    38    § 36. Paragraph 4 of subsection (a) of section 4317 of  the  insurance
    39  law,  as  amended  by  section 72 of part D of chapter 56 of the laws of
    40  2013, is amended to read as follows:
    41    (4) For the purposes of this section, "community rated" means a rating
    42  methodology in which the premium for all persons covered by a policy  or
    43  contract form is the same, based on the experience of the entire pool of
    44  risks  of  all  individuals  or  small groups covered by the corporation
    45  without regard to age, sex, health status, tobacco usage  or  occupation
    46  excluding  those individuals of small groups covered by Medicare supple-
    47  mental insurance. For medicare supplemental insurance coverage,  "commu-
    48  nity  rated"  means  a  rating methodology in which the premiums for all
    49  persons covered by a policy or contract form is the same  based  on  the
    50  experience  of  the  entire  pool  of  risks  covered  by that policy or
    51  contract form without regard to age, sex, health status,  tobacco  usage
    52  or  occupation. [Catastrophic health insurance contracts issued pursuant
    53  to section 1302(e) of the affordable care act,  42  U.S.C.  §  18022(e),
    54  shall be classified in a distinct community rating pool.]

        S. 1507--C                         53                         A. 2007--C
 
     1    §  37.  Subsections  (d), (e) and (j) of section 4326 of the insurance
     2  law, as amended by section 56 of part D of chapter 56  of  the  laws  of
     3  2013, are amended to read as follows:
     4    (d)  A qualifying group health insurance contract shall provide cover-
     5  age for the essential health [benefit] benefits package as [required in]
     6  defined in paragraph three of subsection (e) of section [2707(a) of  the
     7  public  health service act, 42 U.S.C. § 300gg-6(a). For purposes of this
     8  subsection "essential health benefits package" shall  have  the  meaning
     9  set  forth  in  section  1302(a) of the affordable care act, 42 U.S.C. §
    10  18022(a)] four thousand three hundred six-h of this article.
    11    (e) A qualifying group health insurance contract [issued to a qualify-
    12  ing small employer prior to January first, two  thousand  fourteen  that
    13  does  not  include  all  essential  health benefits required pursuant to
    14  section  2707(a)  of  the  public  health  service  act,  42  U.S.C.   §
    15  300gg-6(a), shall be discontinued, including grandfathered health plans.
    16  For  the  purposes of this paragraph, "grandfathered health plans" means
    17  coverage provided by a corporation to individuals who were  enrolled  on
    18  March  twenty-third,  two thousand ten for as long as the coverage main-
    19  tains grandfathered status in accordance with  section  1251(e)  of  the
    20  affordable  care  act, 42 U.S.C. § 18011(e). A qualifying small employer
    21  shall be transitioned to a plan that  provides:  (1)]  shall  provide  a
    22  level of coverage that is designed to provide benefits that are actuari-
    23  ally  equivalent  to  eighty  percent of the full actuarial value of the
    24  benefits provided under the plan[; and (2) coverage  for  the  essential
    25  health  benefit  package  as  required  in section 2707(a) of the public
    26  health service act, 42 U.S.C. § 300gg-6(a)].  The  superintendent  shall
    27  standardize  the benefit package and cost sharing requirements of quali-
    28  fied group health insurance contracts consistent with  coverage  offered
    29  through  the  health  benefit  exchange established [pursuant to section
    30  1311 of the affordable care act, 42 U.S.C. § 18031] by this state.
    31    (j) [Beginning January  first,  two  thousand  fourteen,  pursuant  to
    32  section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A
    33  corporation  shall not impose any pre-existing condition limitation in a
    34  qualifying group health insurance contract.
    35    § 38. Subsection (m-1) of  section  4327  of  the  insurance  law,  as
    36  amended  by  section  58 of part D of chapter 56 of the laws of 2013, is
    37  amended to read as follows:
    38    (m-1) In the event that the superintendent suspends the enrollment  of
    39  new  individuals  for  qualifying  group health insurance contracts, the
    40  superintendent shall ensure that small employers seeking to enroll in  a
    41  qualified  group  health  insurance  contract pursuant to section forty-
    42  three hundred twenty-six of this article are provided information on and
    43  directed to  coverage  options  available  through  the  health  benefit
    44  exchange  established  [pursuant  to section 1311 of the affordable care
    45  act, 42 U.S.C. § 18031] by this state.
    46    § 39. Paragraphs 1, 2 and 3 of subsection (b) of section 4328  of  the
    47  insurance  law,  as  added  by section 46 of part D of chapter 56 of the
    48  laws of 2013, are amended to read as follows:
    49    (1) The individual enrollee direct payment contract  offered  pursuant
    50  to  this  section shall provide coverage for the essential health [bene-
    51  fit] benefits package as [required in] defined  in  paragraph  three  of
    52  subsection  (e) of section [2707(a) of the public health service act, 42
    53  U.S.C. § 300gg-6(a). For purposes of this paragraph,  "essential  health
    54  benefits package" shall have the meaning set forth in section 1302(a) of
    55  the  affordable  care  act,  42  U.S.C.  § 18022(a)] four thousand three
    56  hundred six-h of this article.

        S. 1507--C                         54                         A. 2007--C
 
     1    (2) A health maintenance organization shall offer at least  one  indi-
     2  vidual  enrollee  direct  payment  contract at each level of coverage as
     3  defined in subsection (b) of section [1302(d)  of  the  affordable  care
     4  act,  42  U.S.C.  §  18022(d)] four thousand three hundred six-h of this
     5  article.  A  health maintenance organization also shall offer one child-
     6  only plan, as required by section 1302(f) of the affordable care act, 42
     7  U.S.C. § 18022(f), at each level of coverage  [as  required  in  section
     8  2707(c) of the public health service act, 42 U.S.C. § 300gg-6(c)].
     9    (3)  Within  the  health  benefit  exchange  established  [pursuant to
    10  section 1311 of the affordable care act, 42  U.S.C.  §  18031]  by  this
    11  state,  a health maintenance organization may offer an individual enrol-
    12  lee direct payment contract  that  is  a  catastrophic  health  plan  as
    13  defined  in  section  1302(e)  of  the  affordable care act, 42 U.S.C. §
    14  18022(e), or any regulations promulgated thereunder.
    15    § 40. Subparagraph (A) of paragraph 4 of  subsection  (b)  of  section
    16  4328  of  the insurance law, as added by chapter 11 of the laws of 2016,
    17  is amended to read as follows:
    18    (A) The individual enrollee direct payment contract  offered  pursuant
    19  to  this  section  shall  have  the  same  enrollment periods, including
    20  special enrollment periods, as required for an individual direct payment
    21  contract offered within the health benefit exchange established  [pursu-
    22  ant  to  section  1311 of the affordable care act, 42 U.S.C. § 18031, or
    23  any regulations promulgated thereunder] by this state.
    24    § 41. Subsection (c) of section 4328 of the insurance law, as added by
    25  section 46 of part D of chapter 56 of the laws of 2013,  is  amended  to
    26  read as follows:
    27    (c)  In  addition  to  or  in  lieu  of the individual enrollee direct
    28  payment contracts required under this section,  all  health  maintenance
    29  organizations issued a certificate of authority under article forty-four
    30  of  the public health law or licensed under this article may offer indi-
    31  vidual enrollee direct  payment  contracts  within  the  health  benefit
    32  exchange  established  [pursuant  to section 1311 of the affordable care
    33  act, 42 U.S.C. § 18031, or any regulations  promulgated  thereunder]  by
    34  this  state, subject to any requirements established by the health bene-
    35  fit exchange.   If  a  health  maintenance  organization  satisfies  the
    36  requirements  of  subsection  (a) of this section by offering individual
    37  enrollee direct  payment  contracts,  only  within  the  health  benefit
    38  exchange, the health maintenance organization, not including a holder of
    39  a  special  purpose  certificate of authority issued pursuant to section
    40  four thousand four hundred three-a of the public health law, shall  also
    41  offer  at  least one individual enrollee direct payment contract at each
    42  level of coverage as defined in subsection (b) section [1302 (d) of  the
    43  affordable  care act, 42 U.S.C. § 18022 (d)] four thousand three hundred
    44  six-h of this article, outside the health benefit exchange.
    45    § 42. This act shall take effect on the first of January next succeed-
    46  ing the date on which it shall have become a law and shall apply to  all
    47  policies  and contracts issued, renewed, modified, altered or amended on
    48  or after such date.
 
    49                                  SUBPART C

    50    Section 1. The insurance law is amended by adding a new  section  3242
    51  to read as follows:
    52    §  3242.  Prescription drug coverage.  (a) Every insurer that delivers
    53  or issues for delivery in this state a policy that provides coverage for
    54  prescription drugs shall, with respect to the prescription  drug  cover-

        S. 1507--C                         55                         A. 2007--C
 
     1  age,  publish  an up-to-date, accurate, and complete list of all covered
     2  prescription drugs on its formulary drug  list,  including  any  tiering
     3  structure  that  it  has  adopted  and any restrictions on the manner in
     4  which  a  prescription  drug may be obtained, in a manner that is easily
     5  accessible to insureds and prospective insureds. The formulary drug list
     6  shall clearly identify the preventive prescription drugs that are avail-
     7  able without annual deductibles or coinsurance, including co-payments.
     8    (b) (1) Every policy delivered or issued for delivery  in  this  state
     9  that provides coverage for prescription drugs shall include in the poli-
    10  cy  a  process  that  allows  an insured, the insured's designee, or the
    11  insured's prescribing health care provider to request a formulary excep-
    12  tion.  With respect to the process for such a  formulary  exception,  an
    13  insurer  shall  follow  the  process and procedures specified in article
    14  forty-nine of this chapter and article forty-nine of the  public  health
    15  law,  except  as  otherwise  provided in paragraphs two, three, four and
    16  five of this subsection.
    17    (2) (A) An insurer shall have a process for an insured, the  insured's
    18  designee, or the insured's prescribing health care provider to request a
    19  standard  review  that is not based on exigent circumstances of a formu-
    20  lary exception for a prescription drug that is not covered by the  poli-
    21  cy.
    22    (B)  An  insurer  shall  make  a determination on a standard exception
    23  request that is not  based  on  exigent  circumstances  and  notify  the
    24  insured  or  the insured's designee and the insured's prescribing health
    25  care provider by telephone of its coverage determination no  later  than
    26  seventy-two hours following receipt of the request.
    27    (C)  An  insurer  that grants a standard exception request that is not
    28  based on exigent circumstances shall provide coverage of the  non-formu-
    29  lary  prescription  drug for the duration of the prescription, including
    30  refills.
    31    (D) For the purpose of this subsection, "exigent circumstances"  means
    32  when  an insured is suffering from a health condition that may seriously
    33  jeopardize the insured's life, health,  or  ability  to  regain  maximum
    34  function  or when an insured is undergoing a current course of treatment
    35  using a non-formulary prescription drug.
    36    (3) (A) An insurer shall have a process for an insured, the  insured's
    37  designee,  or  the insured's prescribing health care provider to request
    38  an expedited review based on exigent circumstances of a formulary excep-
    39  tion for a prescription drug that is not covered by the policy.
    40    (B) An insurer shall make  a  determination  on  an  expedited  review
    41  request  based  on  exigent  circumstances and notify the insured or the
    42  insured's designee and the insured's prescribing health care provider by
    43  telephone of its coverage determination no later than twenty-four  hours
    44  following receipt of the request.
    45    (C) An insurer that grants an exception based on exigent circumstances
    46  shall  provide  coverage  of the non-formulary prescription drug for the
    47  duration of the exigent circumstances.
    48    (4) An insurer that denies an exception request under paragraph two or
    49  three of this subsection shall provide written notice  of  its  determi-
    50  nation  to  the  insured  or  the  insured's  designee and the insured's
    51  prescribing health care provider within three business days  of  receipt
    52  of the exception request. The written notice shall be considered a final
    53  adverse  determination  under section four thousand nine hundred four of
    54  this chapter or section four thousand nine hundred four  of  the  public
    55  health law. Written notice shall also include the name or names of clin-

        S. 1507--C                         56                         A. 2007--C
 
     1  ically  appropriate  prescription  drugs covered by the insurer to treat
     2  the insured.
     3    (5)  (A)  If  an insurer denies a request for an exception under para-
     4  graph two or three of this subsection, the insured, the insured's desig-
     5  nee, or the insured's prescribing health care provider  shall  have  the
     6  right  to  request  that  such  denial be reviewed by an external appeal
     7  agent certified by the superintendent pursuant to section four  thousand
     8  nine  hundred  eleven  of this chapter in accordance with article forty-
     9  nine of this chapter or article forty-nine of the public health law.
    10    (B) An external  appeal  agent  shall  make  a  determination  on  the
    11  external  appeal  and  notify  the insurer, the insured or the insured's
    12  designee, and the insured's prescribing health care  provider  by  tele-
    13  phone of its determination no later than seventy-two hours following the
    14  external  appeal agent's receipt of the request, if the original request
    15  was a standard exception request under paragraph two of this subsection.
    16  The external appeal agent shall notify the insurer, the insured  or  the
    17  insured's  designee,  and the insured's prescribing health care provider
    18  in writing of the external appeal determination within two business days
    19  of rendering such determination.
    20    (C) An external  appeal  agent  shall  make  a  determination  on  the
    21  external  appeal  and  notify  the insurer, the insured or the insured's
    22  designee, and the insured's prescribing health care  provider  by  tele-
    23  phone of its determination no later than twenty-four hours following the
    24  external  appeal agent's receipt of the request, if the original request
    25  was an  expedited  exception  request  under  paragraph  three  of  this
    26  subsection  and  the  insured's prescribing health care provider attests
    27  that exigent circumstances exist. The external appeal agent shall notify
    28  the insurer, the insured or the insured's designee,  and  the  insured's
    29  prescribing  health  care  provider  in  writing  of the external appeal
    30  determination within seventy-two hours of the  external  appeal  agent's
    31  receipt of the external appeal.
    32    (D)  An external appeal agent shall make a determination in accordance
    33  with subparagraph (A) of paragraph four of  subsection  (b)  of  section
    34  four  thousand nine hundred fourteen of this chapter or subparagraph (A)
    35  of paragraph (d) of  subdivision  two  of  section  four  thousand  nine
    36  hundred  fourteen of the public health law. When making a determination,
    37  the  external  appeal  agent  shall  consider  whether   the   formulary
    38  prescription  drug  covered  by the insurer will be or has been ineffec-
    39  tive, would not be as effective as the non-formulary prescription  drug,
    40  or would have adverse effects.
    41    (E)  If  an  external appeal agent overturns the insurer's denial of a
    42  standard exception request under paragraph two of this subsection,  then
    43  the  insurer  shall  provide  coverage of the non-formulary prescription
    44  drug for the duration of the  prescription,  including  refills.  If  an
    45  external  appeal  agent  overturns  the insurer's denial of an expedited
    46  exception request under paragraph three of  this  subsection,  then  the
    47  insurer  shall  provide  coverage of the non-formulary prescription drug
    48  for the duration of the exigent circumstances.
    49    § 2. The insurance law is amended by adding a new section 4329 to read
    50  as follows:
    51    § 4329. Prescription drug coverage.  (a) Every corporation subject  to
    52  the  provisions  of  this  article  that issues a contract that provides
    53  coverage for prescription drugs shall, with respect to the  prescription
    54  drug coverage, publish an up-to-date, accurate, and complete list of all
    55  covered  prescription  drugs  on  its formulary drug list, including any
    56  tiering structure that it has adopted and any restrictions on the manner

        S. 1507--C                         57                         A. 2007--C
 
     1  in which a prescription drug may be obtained, in a manner that is easily
     2  accessible to insureds and prospective insureds. The formulary drug list
     3  shall clearly identify the preventive prescription drugs that are avail-
     4  able without annual deductibles or coinsurance, including co-payments.
     5    (b)  (1)  Every  contract  issued  by  a  corporation  subject  to the
     6  provisions of this article that provides coverage for prescription drugs
     7  shall include in the contract a process  that  allows  an  insured,  the
     8  insured's designee, or the insured's prescribing health care provider to
     9  request  a  formulary  exception. With respect to the process for such a
    10  formulary exception, a corporation shall follow the process  and  proce-
    11  dures  specified  in  article  forty-nine  of  this  chapter and article
    12  forty-nine of the public health law, except  as  otherwise  provided  in
    13  paragraphs two, three, four and five of this subsection.
    14    (2)  (A)  A  corporation  shall  have  a  process  for an insured, the
    15  insured's designee, or the insured's prescribing health care provider to
    16  request a standard review that is not based on exigent circumstances  of
    17  a formulary exception for a prescription drug that is not covered by the
    18  contract.
    19    (B)  A  corporation shall make a determination on a standard exception
    20  request that is not  based  on  exigent  circumstances  and  notify  the
    21  insured  or  the insured's designee and the insured's prescribing health
    22  care provider by telephone of its coverage determination no  later  than
    23  seventy-two hours following receipt of the request.
    24    (C) A corporation that grants a standard exception request that is not
    25  based  on exigent circumstances shall provide coverage of the non-formu-
    26  lary prescription drug for the duration of the  prescription,  including
    27  refills.
    28    (D)  For the purpose of this subsection, "exigent circumstances" means
    29  when an insured is suffering from a health condition that may  seriously
    30  jeopardize  the  insured's  life,  health,  or ability to regain maximum
    31  function or when an insured is undergoing a current course of  treatment
    32  using a non-formulary prescription drug.
    33    (3)  (A)  A  corporation  shall  have  a  process  for an insured, the
    34  insured's designee, or the insured's prescribing health care provider to
    35  request an expedited review based on exigent circumstances of  a  formu-
    36  lary exception for a prescription drug is not covered by the contract.
    37    (B)  A  corporation  shall make a determination on an expedited review
    38  request based on exigent circumstances and notify  the  insured  or  the
    39  insured's designee and the insured's prescribing health care provider by
    40  telephone  of its coverage determination no later than twenty-four hours
    41  following receipt of the request.
    42    (C) A corporation that grants an exception based  on  exigent  circum-
    43  stances  shall  provide  coverage of the non-formulary prescription drug
    44  for the duration of the exigent circumstances.
    45    (4) A corporation that denies an exception request under paragraph two
    46  or three of this subsection shall provide written notice of its determi-
    47  nation to the insured  or  the  insured's  designee  and  the  insured's
    48  prescribing  health  care provider within three business days of receipt
    49  of the exception request. The written notice shall be considered a final
    50  adverse determination under section four thousand nine hundred  four  of
    51  this  chapter  or  section four thousand nine hundred four of the public
    52  health law. Written notice shall also include the name or names of clin-
    53  ically appropriate prescription drugs  covered  by  the  corporation  to
    54  treat the insured.
    55    (5) (A) If a corporation denies a request for an exception under para-
    56  graph two or three of this subsection, the insured, the insured's desig-

        S. 1507--C                         58                         A. 2007--C
 
     1  nee,  or  the  insured's prescribing health care provider shall have the
     2  right to request that such denial be  reviewed  by  an  external  appeal
     3  agent  certified by the superintendent pursuant to section four thousand
     4  nine  hundred  eleven  of this chapter in accordance with article forty-
     5  nine of this chapter and article forty-nine of the public health law.
     6    (B) An external  appeal  agent  shall  make  a  determination  on  the
     7  external appeal and notify the corporation, the insured or the insured's
     8  designee,  and  the  insured's prescribing health care provider by tele-
     9  phone of its determination no later than seventy-two hours following the
    10  external appeal agent's receipt of the request, if the original  request
    11  was a standard exception request under paragraph two of this subsection.
    12  The  external  appeal agent shall notify the corporation, the insured or
    13  the insured's designee and the insured's prescribing health care provid-
    14  er in writing of the external appeal determination within  two  business
    15  days of rendering such determination.
    16    (C)  An  external  appeal  agent  shall  make  a  determination on the
    17  external appeal and notify the corporation, the insured or the insured's
    18  designee, and the insured's prescribing health care  provider  by  tele-
    19  phone of its determination no later than twenty-four hours following the
    20  external  appeal agent's receipt of the request, if the original request
    21  was an  expedited  exception  request  under  paragraph  three  of  this
    22  subsection  and  the  insured's prescribing health care provider attests
    23  that exigent circumstances exist. The external appeal agent shall notify
    24  the corporation, the insured or the insured's designee and the insured's
    25  prescribing health care provider  in  writing  of  the  external  appeal
    26  determination  within  seventy-two  hours of the external appeal agent's
    27  receipt of the external appeal.
    28    (D) An external appeal agent shall make a determination in  accordance
    29  with  subparagraph  (A)  of  paragraph four of subsection (b) of section
    30  four thousand nine hundred fourteen of this chapter and subparagraph (A)
    31  of paragraph (d) of  subdivision  two  of  section  four  thousand  nine
    32  hundred  fourteen of the public health law. When making a determination,
    33  the  external  appeal  agent  shall  consider  whether   the   formulary
    34  prescription  drug  covered by the corporation will be or has been inef-
    35  fective, would not be as effective  as  the  non-formulary  prescription
    36  drug, or would have adverse effects.
    37    (E)  If an external appeal agent overturns the corporation's denial of
    38  a standard exception request under paragraph  two  of  this  subsection,
    39  then  the  corporation  shall  provide  coverage  of  the  non-formulary
    40  prescription drug  for  the  duration  of  the  prescription,  including
    41  refills.  If an external appeal agent overturns the corporation's denial
    42  of  an  expedited  exception  request  under  paragraph  three  of  this
    43  subsection,  then the corporation shall provide coverage of the non-for-
    44  mulary prescription drug for the duration of the exigent circumstances.
    45    § 3. This act shall take effect on the first of January next  succeed-
    46  ing  the date on which it shall have become a law and shall apply to all
    47  policies and contracts issued, renewed, modified, altered or amended  on
    48  or after such date.
 
    49                                  SUBPART D
 
    50    Section  1.  Section  2607  of the insurance law is amended to read as
    51  follows:
    52    § 2607. Discrimination because of sex or marital status.  (a) No indi-
    53  vidual or entity shall refuse to  issue  any  policy  of  insurance,  or
    54  cancel or decline to renew [such] the policy because of the sex or mari-

        S. 1507--C                         59                         A. 2007--C

     1  tal  status  of the applicant or policyholder or engage in sexual stere-
     2  otyping.
     3    (b)  For  the  purposes  of  this  section, "sex" shall include sexual
     4  orientation, gender identity or expression, and transgender status.
     5    § 2. The insurance law is amended by adding a new section 3243 to read
     6  as follows:
     7    § 3243. Discrimination because of sex or marital status  in  hospital,
     8  surgical  or  medical expense insurance.  (a) With regard to an accident
     9  and health insurance policy that provides hospital, surgical, or medical
    10  expense coverage or a policy of student accident and  health  insurance,
    11  as defined in subsection (a) of section three thousand two hundred forty
    12  of  this  article,  delivered  or  issued for delivery in this state, no
    13  insurer shall because of sex, marital  status  or  based  on  pregnancy,
    14  false pregnancy, termination of pregnancy, or recovery therefrom, child-
    15  birth or related medical conditions:
    16    (1)  make  any distinction or discrimination between persons as to the
    17  premiums or rates charged for the policy or in any other manner  whatev-
    18  er;
    19    (2)  demand  or  require  a  greater  premium  from any person than it
    20  requires at that time from others in similar cases;
    21    (3) make or require any rebate, discrimination or  discount  upon  the
    22  amount to be paid or the service to be rendered on any policy;
    23    (4)  insert  in  the  policy  any  condition, or make any stipulation,
    24  whereby the insured binds his or herself, or his or  her  heirs,  execu-
    25  tors,  administrators or assigns, to accept any sum or service less than
    26  the full value or amount of such policy  in  case  of  a  claim  thereon
    27  except  such  conditions  and stipulations as are imposed upon others in
    28  similar cases; and any such stipulation or condition so made or inserted
    29  shall be void;
    30    (5) reject any application for a policy issued or sold by it;
    31    (6) cancel or refuse to issue, renew or sell such policy after  appro-
    32  priate application therefor;
    33    (7)  fix  any lower rate or discriminate in the fees or commissions of
    34  insurance agents or insurance brokers for writing  or  renewing  such  a
    35  policy; or
    36    (8) engage in sexual stereotyping.
    37    (b)  For  the  purposes  of  this  section, "sex" shall include sexual
    38  orientation, gender identity or expression, and transgender status.
    39    § 3. The insurance law is amended by adding a new section 4330 to read
    40  as follows:
    41    § 4330. Discrimination because of sex or marital status  in  hospital,
    42  surgical  or  medical expense insurance.   (a) With regard to a contract
    43  issued by a corporation subject to the provisions of this  article  that
    44  provides  hospital,  surgical, or medical expense coverage or a contract
    45  of student accident and health insurance, as defined in  subsection  (a)
    46  of  section  three thousand two hundred forty of this chapter, no corpo-
    47  ration shall because of sex, marital status or based on pregnancy, false
    48  pregnancy, termination of pregnancy, or recovery  therefrom,  childbirth
    49  or related medical conditions:
    50    (1)  make  any distinction or discrimination between persons as to the
    51  premiums or rates charged for the contract or in any other manner  what-
    52  ever;
    53    (2)  demand  or  require  a  greater  premium  from any person than it
    54  requires at that time from others in similar cases;
    55    (3) make or require any rebate, discrimination or  discount  upon  the
    56  amount to be paid or the service to be rendered on any contract;

        S. 1507--C                         60                         A. 2007--C

     1    (4)  insert  in  the  contract any condition, or make any stipulation,
     2  whereby the insured binds his or herself, or his or  her  heirs,  execu-
     3  tors,  administrators or assigns, to accept any sum or service less than
     4  the full value or amount of such contract in case  of  a  claim  thereon
     5  except  such  conditions  and stipulations as are imposed upon others in
     6  similar cases; and any such stipulation or condition so made or inserted
     7  shall be void;
     8    (5) reject any application for a contract issued or sold by it;
     9    (6) cancel or refuse to issue,  renew  or  sell  such  contract  after
    10  appropriate application therefor;
    11    (7)  fix  any lower rate or discriminate in the fees or commissions of
    12  insurance agents or insurance brokers for writing  or  renewing  such  a
    13  contract; or
    14    (8) engage in sexual stereotyping.
    15    (b)  For  purposes  of this section, "sex" shall include sexual orien-
    16  tation, gender identity or expression, and transgender status.
    17    § 4. This act shall take effect on the first of January next  succeed-
    18  ing  the date on which it shall have become a law and shall apply to all
    19  policies and contracts issued, renewed, modified, altered or amended  on
    20  or after such date.
    21    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    22  sion,  section  or subpart of this act shall be adjudged by any court of
    23  competent jurisdiction to be invalid, such judgment  shall  not  affect,
    24  impair,  or  invalidate  the remainder thereof, but shall be confined in
    25  its operation to the clause, sentence, paragraph,  subdivision,  section
    26  or  subpart  thereof  directly involved in the controversy in which such
    27  judgment shall have been rendered. It  is  hereby  declared  to  be  the
    28  intent  of the legislature that this act would have been enacted even if
    29  such invalid provisions had not been included herein.
    30    § 3. Intentionally omitted.
    31    § 4. Legislative intent. It is hereby declared to be the intent of the
    32  legislature in enacting this act, that the laws of  this  state  provide
    33  consumer  and  market  protections at least as robust as those under the
    34  federal Patient Protection and Affordable Care Act, public law  111-148,
    35  as that law existed and was interpreted on January 19, 2017.
    36    §  5.  This  act shall take effect immediately provided, however, that
    37  the applicable effective date of Subparts A through D of this act  shall
    38  be as specifically set forth in the last section of such Subparts.
 
    39                                   PART K
 
    40    Section 1. Subdivisions 4 and 5 of section 2999-h of the public health
    41  law, as added by section 52 of part H of chapter 59 of the laws of 2011,
    42  are amended to read as follows:
    43    4. "Qualified plaintiff" means every plaintiff or claimant who (i) has
    44  been  found  by a jury or court to have sustained a birth-related neuro-
    45  logical injury as  the  result  of  medical  malpractice,  or  (ii)  has
    46  sustained  a  birth-related neurological injury as the result of alleged
    47  medical malpractice, and has settled his or her lawsuit or claim  there-
    48  for; and (iii) has been ordered to be enrolled in the fund by a court in
    49  New York state.
    50    [5.  Any  reference  to the "department of financial services" and the
    51  "superintendent of financial services" in this title shall  mean,  prior
    52  to  October third, two thousand eleven, respectively, the "department of
    53  insurance" and "superintendent of insurance."]

        S. 1507--C                         61                         A. 2007--C
 
     1    § 2. Section 2999-i of the public health law, as added by  section  52
     2  of part H of chapter 59 of the laws of 2011, subdivision 1 as amended by
     3  section  29  of  part D of chapter 56 of the laws of 2012, is amended to
     4  read as follows:
     5    §  2999-i. Custody and administration of the fund.  1. (a) The commis-
     6  sioner of taxation and finance shall be the custodian of  the  fund  and
     7  the special account established pursuant to section ninety-nine-t of the
     8  state  finance  law.  All  payments  from  the fund shall be made by the
     9  commissioner of taxation and finance upon  certificates  signed  by  the
    10  [superintendent  of  financial  services]  commissioner,  or  his or her
    11  designee, as hereinafter provided. The fund shall be separate and  apart
    12  from  any other fund and from all other state monies; provided, however,
    13  that monies of the fund may be invested as set forth in paragraph (b) of
    14  this subdivision. No monies from the fund shall be  transferred  to  any
    15  other  fund,  nor  shall any such monies be applied to the making of any
    16  payment for any purpose other than the purpose set forth in this title.
    17    (b) Any monies of the fund not required for immediate use may, at  the
    18  discretion  of  the commissioner [of financial services] in consultation
    19  with [the commissioner of health and] the director  of  the  budget,  be
    20  invested  by  the commissioner of taxation and finance in obligations of
    21  the United States or the state or obligations the principal and interest
    22  of which are guaranteed by the United States or the state. The  proceeds
    23  of  any  such  investment  shall be retained by the fund as assets to be
    24  used for the purposes of the fund.
    25    2. (a) The fund shall be administered by the [superintendent of finan-
    26  cial services] commissioner or his or her designee  in  accordance  with
    27  the provisions of this article.
    28    (b) The [superintendent of financial services] commissioner shall have
    29  all powers necessary and proper to carry out the purposes of the fund.
    30    (c)  Notwithstanding  any contrary provision of this section, sections
    31  one hundred twelve and one hundred sixty-three of the state finance  law
    32  or  any other contrary provision of law, the superintendent of financial
    33  services is authorized to [enter into a contract or contracts without  a
    34  competitive bid or request for proposal process for purposes of adminis-
    35  tering  the  fund for the first year of its operation and in preparation
    36  therefor] assign and the commissioner is authorized to  receive  assign-
    37  ment  of  any  and  all  contracts entered into by the superintendent of
    38  financial services to administer the fund for periods prior  to  October
    39  first, two thousand nineteen.
    40    (d)  The  department  [of financial services and the department] shall
    41  post on [their websites] its website information about the fund[, eligi-
    42  bility for enrollment in the fund,] and the process  for  enrollment  in
    43  the fund.
    44    3.  The  expense  of  administering  the fund[, including the expenses
    45  incurred by the department,] shall be paid from the fund.
    46    4. Monies for the fund will be provided pursuant to this chapter.
    47    5. For the state fiscal year beginning April first, two thousand elev-
    48  en and ending March thirty-first, two thousand twelve, the state  fiscal
    49  year  beginning  April first, two thousand twelve and ending March thir-
    50  ty-first, two thousand thirteen, and the  state  fiscal  year  beginning
    51  April  first,  two  thousand thirteen and ending March thirty-first, two
    52  thousand fourteen, the superintendent of financial services shall  cause
    53  to  be  deposited  into  the  fund  for each such fiscal year the amount
    54  appropriated for such purpose. Beginning April first, two thousand four-
    55  teen and annually thereafter, the superintendent of  financial  services
    56  or  the commissioner, whoever is administering the fund for the applica-

        S. 1507--C                         62                         A. 2007--C
 
     1  ble period shall cause to be deposited into the fund, subject to  avail-
     2  able  appropriations,  an  amount  equal  to  the difference between the
     3  amount appropriated to  the  fund  in  the  preceding  fiscal  year,  as
     4  increased  by the adjustment factor defined in subdivision seven of this
     5  section, and the assets of the fund at the  conclusion  of  that  fiscal
     6  year.
     7    6.  (a)  Following  the deposit referenced in subdivision five of this
     8  section, the [superintendent of financial services]  commissioner  shall
     9  conduct  an  actuarial  calculation  of the estimated liabilities of the
    10  fund for  the  coming  year  resulting  from  the  qualified  plaintiffs
    11  enrolled  in  the fund. The administrator shall from time to time adjust
    12  such calculation in accordance with subdivision seven of  this  section.
    13  If  the  total of all estimates of current liabilities equals or exceeds
    14  eighty percent of the fund's assets, then the fund shall not accept  any
    15  new  enrollments  until a new deposit has been made pursuant to subdivi-
    16  sion five of this section. When, as a result of such  new  deposit,  the
    17  fund's liabilities no longer exceed eighty percent of the fund's assets,
    18  the  fund  administrator  shall  enroll  new qualified plaintiffs in the
    19  order that an application for enrollment has been submitted  in  accord-
    20  ance with subdivision seven of section twenty-nine hundred ninety-nine-j
    21  of this title.
    22    (b) Whenever enrollment is suspended pursuant to paragraph (a) of this
    23  subdivision  and  until such time as enrollment resumes pursuant to such
    24  paragraph: (i) notice of such suspension shall be promptly posted on the
    25  department's website [and on the website of the department of  financial
    26  services];  (ii)  the fund administrator shall deny each application for
    27  enrollment that had been received but not accepted prior to the date  of
    28  suspension  and  each application for enrollment received after the date
    29  of such suspension; and (iii) notification of each such denial shall  be
    30  made to the plaintiff or claimant or persons authorized to act on behalf
    31  of  such  plaintiff  or  claimant  and  all defendants in regard to such
    32  plaintiff or claimant, to the extent they are known to the fund adminis-
    33  trator. Judgments and settlements for plaintiffs or claimants  for  whom
    34  applications are denied under this paragraph or who are not eligible for
    35  enrollment  due to suspension pursuant to paragraph (a) of this subdivi-
    36  sion shall be satisfied as if this title had not been enacted.
    37    (c) Following a suspension, whenever enrollment  resumes  pursuant  to
    38  paragraph  (a)  of  this subdivision, notice that enrollment has resumed
    39  shall be promptly posted on the department's website [and on the website
    40  of the department of financial services].
    41    (d) The suspension of enrollment pursuant to  paragraph  (a)  of  this
    42  subdivision  shall  not  impact payment under the fund for any qualified
    43  plaintiffs already enrolled in the fund.
    44    7. For purposes of this section, the adjustment factor  referenced  in
    45  this  section shall be the ten year rolling average medical component of
    46  the consumer price index as published by the United States department of
    47  labor, bureau of labor statistics, for the preceding ten years.
    48    § 3. Subdivisions 2, 5, 6, 7, 9, 11, 12, 15 and 16 of  section  2999-j
    49  of the public health law, subdivision 2 as amended by chapter 517 of the
    50  laws  of 2016, paragraph (c) of subdivision 2 as amended by chapter 4 of
    51  the laws of 2017, and subdivisions 5, 6, 7, 9, 11,  12,  15  and  16  as
    52  added  by  section  52  of part H of chapter 59 of the laws of 2011, are
    53  amended to read as follows:
    54    2. The provision of qualifying health care costs to  qualified  plain-
    55  tiffs  shall  not be subject to prior authorization, except as described
    56  by the commissioner in regulation; provided, however:

        S. 1507--C                         63                         A. 2007--C
 
     1    (a) such  regulation  shall  not  prevent  qualified  plaintiffs  from
     2  receiving  care  or  assistance  that would, at a minimum, be authorized
     3  under the medicaid program;
     4    (b)  if  any  prior  authorization is required by such regulation, the
     5  regulation shall require that requests for prior authorization be  proc-
     6  essed  within  a  reasonably  prompt period of time and[, subject to the
     7  provisions of subdivision two-a of this section,] shall identify a proc-
     8  ess for prompt administrative review of any  denial  of  a  request  for
     9  prior authorization; and
    10    (c)  such  regulations shall not prohibit qualifying health care costs
    11  on the grounds that the qualifying health  care  cost  may  incidentally
    12  benefit other members of the household, provided that whether the quali-
    13  fying health care cost primarily benefits the patient may be considered.
    14    5. Claims for the payment or reimbursement from the fund of qualifying
    15  health  care  costs shall be made upon forms prescribed and furnished by
    16  the fund administrator [in consultation with the  commissioner  and]  in
    17  conjunction  with regulations establishing a mechanism for submission of
    18  claims by health care providers directly to the fund, where practicable.
    19    6. (a)  Every  settlement  agreement  for  claims  arising  out  of  a
    20  plaintiff's  or  claimant's birth related neurological injury subject to
    21  this title, and that provides for the payment of future medical expenses
    22  for the plaintiff or claimant, shall provide  that  [in  the  event  the
    23  administrator of the fund determines that the plaintiff or claimant is a
    24  qualified  plaintiff,] all payments for future medical expenses shall be
    25  paid in accordance with this title[,] in lieu of  that  portion  of  the
    26  settlement  agreement  that  provides  for payment of such expenses. The
    27  plaintiff's or claimant's future  medical  expenses  shall  be  paid  in
    28  accordance with this title. When such a settlement agreement does not so
    29  provide,  the  court  shall  direct the modification of the agreement to
    30  include such term as a condition of court approval.
    31    (b) In any case where the jury or court has made an award  for  future
    32  medical expenses arising out of a birth related neurological injury, any
    33  party to such action or person authorized to act on behalf of such party
    34  may  make  application  to  the court that the judgment reflect that, in
    35  lieu of that portion of the award that  provides  for  payment  of  such
    36  expenses,  [and  upon a determination by the fund administrator that the
    37  plaintiff is a qualified plaintiff,] the future medical expenses of  the
    38  plaintiff  shall  be paid out of the fund in accordance with this title.
    39  Upon a finding by the court that the applicant has made  a  prima  facie
    40  showing  that  the  plaintiff  is a qualified plaintiff, the court shall
    41  ensure that the judgment so provides.
    42    7. A qualified plaintiff shall be enrolled when (a) such plaintiff  or
    43  person  authorized  to  act on behalf of such person, upon notice to all
    44  defendants, or any of the defendants in regard to the plaintiff's claim,
    45  upon notice to such plaintiff, makes an application  for  enrollment  by
    46  providing  the  fund administrator with a certified copy of the judgment
    47  or of the court approved settlement agreement; and (b) the fund adminis-
    48  trator determines [upon the basis of such judgment or settlement  agree-
    49  ment  and  any  additional  information  the  fund  administrator  shall
    50  request] that the relevant provisions of subdivision six of this section
    51  have been met  [and  that  the  plaintiff  is  a  qualified  plaintiff];
    52  provided  that  no  enrollment  shall  occur  when the fund is closed to
    53  enrollment pursuant to subdivision six of  section  twenty-nine  hundred
    54  ninety-nine-i of this title.
    55    9.  Payments  from the fund shall be made by the commissioner of taxa-
    56  tion and finance on the  said  certificate  of  the  [superintendent  of

        S. 1507--C                         64                         A. 2007--C

     1  financial  services]  commissioner.    No  payment  shall be made by the
     2  commissioner of taxation and finance in excess of the amount  certified.
     3  Promptly  upon receipt of the said certificate of the [superintendent of
     4  financial  services]  commissioner,  the  commissioner  of  taxation and
     5  finance shall pay the qualified  plaintiff's  health  care  provider  or
     6  reimburse the qualified plaintiff the amount so certified for payment.
     7    11.  All health care providers shall accept from qualified plaintiff's
     8  or persons authorized to act on behalf of such  plaintiff's  assignments
     9  of  the  right  to  receive payments from the fund for qualifying health
    10  care costs. Such payments shall  constitute  payment  in  full  for  any
    11  services provided to a qualified plaintiff in accordance with this arti-
    12  cle.
    13    12.  Health  insurers  (other than medicare and Medicaid) shall be the
    14  primary payers of qualifying health care costs of qualified  plaintiffs.
    15  Such  costs  shall  be paid from the fund only to the extent that health
    16  insurers or other collateral sources or other persons are not  otherwise
    17  obligated  to make payments therefor. Health insurers that make payments
    18  for qualifying health care costs to or on behalf of qualified plaintiffs
    19  shall have no right of recovery against and shall have no lien upon  the
    20  fund or any person or entity nor shall the fund constitute an additional
    21  payment  source  to offset the payments otherwise contractually required
    22  to be made by such health  insurers.  The  superintendent  of  financial
    23  services  shall  have  the  authority  to enforce the provisions of this
    24  subdivision upon the referral of the commissioner.
    25    15. The commissioner[, in  consultation  with  the  superintendent  of
    26  financial  services,]  shall promulgate, amend and enforce all rules and
    27  regulations necessary for the  proper  administration  of  the  fund  in
    28  accordance  with  the  provisions  of  this  section, including, but not
    29  limited to, those concerning the payment of claims  and  concerning  the
    30  actuarial  calculations  necessary  to  determine,  annually,  the total
    31  amount to be paid into the fund as provided  herein,  and  as  otherwise
    32  needed to implement this title.
    33    [16.  The commissioner shall convene a consumer advisory committee for
    34  the purpose of providing information, as requested by the  commissioner,
    35  in  the development of the regulations authorized by subdivision fifteen
    36  of this section.]
    37    § 4. Section 5 of chapter 517 of the laws of 2016, amending the public
    38  health law relating to payments from the New York state  medical  indem-
    39  nity  fund,  as  amended by chapter 4 of the laws of 2017, is amended to
    40  read as follows:
    41    § 5. This act shall take effect on the forty-fifth day after it  shall
    42  have  become  a  law,  provided  that the amendments to subdivision 4 of
    43  section 2999-j of the public health law made by section two of this  act
    44  shall  take  effect  on  June  30,  2017  and shall expire and be deemed
    45  repealed December 31, [2019] 2020.
    46    § 5. Section 99-t of the state finance law, as added by  section  52-e
    47  of  part  H  of  chapter  59  of the laws of 2011, is amended to read as
    48  follows:
    49    § 99-t. New York state medical indemnity fund  account.  1.  There  is
    50  hereby  established  in  the custody of the commissioner of taxation and
    51  finance a special account to be known as the  "New  York  state  medical
    52  indemnity fund account".
    53    2.  All  moneys  received by the New York state medical indemnity fund
    54  pursuant to title four of article twenty-nine-D of the public health law
    55  from whatever source derived shall be deposited to the exclusive  credit
    56  of  such  fund account. Said moneys shall be kept separate and shall not

        S. 1507--C                         65                         A. 2007--C
 
     1  be commingled with any other moneys in the custody of  the  commissioner
     2  of taxation and finance.
     3    3.  The moneys in said account shall be retained by the fund and shall
     4  be released by the  commissioner  of  taxation  and  finance  only  upon
     5  certificates  signed by the [superintendent of financial services or the
     6  head of any successor agency to the department of insurance] commission-
     7  er of health or his or her designee and only for the purposes set  forth
     8  in title four of article twenty-nine-D of the public health law.
     9    §  6. This act shall take effect October 1, 2019; provided however, on
    10  and after April 1, 2019, the commissioner of health may take  any  steps
    11  necessary to implement this act on its effective date; and notwithstand-
    12  ing any inconsistent provision of the state administrative procedure act
    13  or  any  other provision of law, rule or regulation, the commissioner of
    14  health is authorized to adopt or amend or  promulgate  on  an  emergency
    15  basis  any  regulation  he  or she determines necessary to implement any
    16  provision of this act on its effective date.

    17                                   PART L
 
    18    Section 1. Subparagraph (C)  of  paragraph  6  of  subsection  (k)  of
    19  section  3221 of the insurance law, as amended by section 1 of part K of
    20  chapter 82 of the laws of 2002, is amended to read as follows:
    21    (C)  Coverage  of  diagnostic  and  treatment  procedures,   including
    22  prescription  drugs,  used in the diagnosis and treatment of infertility
    23  as required by subparagraphs (A) and (B)  of  this  paragraph  shall  be
    24  provided in accordance with the provisions of this subparagraph.
    25    (i)  [Coverage  shall  be  provided  for persons whose ages range from
    26  twenty-one through forty-four years, provided that nothing herein  shall
    27  preclude  the  provision  of  coverage  to persons whose age is below or
    28  above such range.
    29    (ii)] Diagnosis and treatment of infertility shall  be  prescribed  as
    30  part  of  a  physician's  overall  plan  of care and consistent with the
    31  guidelines for coverage as referenced in this subparagraph.
    32    [(iii)] (ii) Coverage may be subject to co-payments,  coinsurance  and
    33  deductibles  as  may  be deemed appropriate by the superintendent and as
    34  are consistent with those established for other benefits within a  given
    35  policy.
    36    [(iv)  Coverage  shall  be  limited to those individuals who have been
    37  previously covered under the policy for a period of not less than twelve
    38  months, provided that for the purposes of this subparagraph  "period  of
    39  not  less  than  twelve  months" shall be determined by calculating such
    40  time from either the date the insured was first covered under the exist-
    41  ing policy or from the date the insured was first covered by a previous-
    42  ly in-force converted policy, whichever is earlier.
    43    (v) Coverage] (iii) Except as provided in items (vi) and (vii) of this
    44  subparagraph, coverage shall not be required to  include  the  diagnosis
    45  and treatment of infertility in connection with: (I) in vitro fertiliza-
    46  tion, gamete intrafallopian tube transfers or zygote intrafallopian tube
    47  transfers;  (II)  the  reversal  of  elective  sterilizations; (III) sex
    48  change procedures; (IV) cloning; or (V) medical or surgical services  or
    49  procedures  that  are deemed to be experimental in accordance with clin-
    50  ical guidelines referenced in [clause (vi)] item (iv) of  this  subpara-
    51  graph.
    52    [(vi)]  (iv) The superintendent, in consultation with the commissioner
    53  of health, shall promulgate regulations which shall stipulate the guide-

        S. 1507--C                         66                         A. 2007--C
 
     1  lines and standards which shall be used in carrying out  the  provisions
     2  of this subparagraph, which shall include:
     3    (I)  [The determination of "infertility" in accordance with the stand-
     4  ards and guidelines established and adopted by the American  College  of
     5  Obstetricians  and  Gynecologists and the American Society for Reproduc-
     6  tive Medicine;
     7    (II)] The identification of experimental procedures and treatments not
     8  covered for the diagnosis and treatment  of  infertility  determined  in
     9  accordance  with the standards and guidelines established and adopted by
    10  the American College of Obstetricians and Gynecologists and the American
    11  Society for Reproductive Medicine;
    12    [(III)] (II) The identification of the required  training,  experience
    13  and  other  standards  for  health  care  providers for the provision of
    14  procedures and treatments for the diagnosis and treatment of infertility
    15  determined in accordance with the standards and  guidelines  established
    16  and  adopted  by the American College of Obstetricians and Gynecologists
    17  and the American Society for Reproductive Medicine; and
    18    [(IV)] (III) The determination of appropriate  medical  candidates  by
    19  the  treating  physician in accordance with the standards and guidelines
    20  established and adopted by the American  College  of  Obstetricians  and
    21  Gynecologists and/or the American Society for Reproductive Medicine.
    22    (v)(I)  For  the  purposes  of  this  paragraph, "infertility" means a
    23  disease or condition  characterized  by  the  incapacity  to  impregnate
    24  another  person  or  to  conceive, defined by the failure to establish a
    25  clinical pregnancy after twelve months of  regular,  unprotected  sexual
    26  intercourse  or  therapeutic  donor insemination, or after six months of
    27  regular, unprotected sexual intercourse or therapeutic  donor  insemina-
    28  tion  for a female thirty-five years of age or older. Earlier evaluation
    29  and treatment may be warranted based on an individual's medical  history
    30  or physical findings.
    31    (II) For purposes of this paragraph, "iatrogenic infertility" means an
    32  impairment  of  fertility  by  surgery, radiation, chemotherapy or other
    33  medical treatment affecting reproductive organs or processes.
    34    (vi) Coverage  shall  also  include  standard  fertility  preservation
    35  services  when  a  medical  treatment  may  directly or indirectly cause
    36  iatrogenic infertility to an insured. Coverage may be subject to  annual
    37  deductibles  and  coinsurance,  including  copayments,  as may be deemed
    38  appropriate by the superintendent  and  as  are  consistent  with  those
    39  established for other benefits within a given policy.
    40    (vii)  Every  large  group  policy delivered or issued for delivery in
    41  this state that provides medical, major medical  or  similar  comprehen-
    42  sive-type  coverage  shall provide coverage for three cycles of in-vitro
    43  fertilization used in the treatment of infertility.    Coverage  may  be
    44  subject  to annual deductibles and coinsurance, including copayments, as
    45  may be deemed appropriate by the superintendent and  as  are  consistent
    46  with  those  established  for  other benefits within a given policy. For
    47  purposes of this item, a "cycle" is defined as either all treatment that
    48  starts when:  preparatory medications are administered for ovarian stim-
    49  ulation for oocyte retrieval with  the  intent  of  undergoing  in-vitro
    50  fertilization using a fresh embryo transfer; or medications are adminis-
    51  tered for endometrial preparation with the intent of undergoing in-vitro
    52  fertilization using a frozen embryo transfer.
    53    (viii)  No  insurer  providing  coverage  under  this  paragraph shall
    54  discriminate based on an insured's expected length of life,  present  of
    55  predicted disability, degree of medical dependency, perceived quality of
    56  life, or other health conditions, nor based on personal characteristics,

        S. 1507--C                         67                         A. 2007--C
 
     1  including age, sex, sexual orientation, marital status or gender identi-
     2  ty.
     3    §  2.  Paragraph  3 of subsection (s) of section 4303 of the insurance
     4  law, as amended by section 2 of part K of chapter  82  of  the  laws  of
     5  2002, is amended to read as follows:
     6    (3)   Coverage  of  diagnostic  and  treatment  procedures,  including
     7  prescription drugs used in the diagnosis and treatment of infertility as
     8  required by paragraphs one and two of this subsection shall be  provided
     9  in accordance with this paragraph.
    10    (A)  [Coverage  shall  be  provided  for persons whose ages range from
    11  twenty-one through forty-four years, provided that nothing herein  shall
    12  preclude  the  provision  of  coverage  to persons whose age is below or
    13  above such range.
    14    (B)] Diagnosis and treatment of infertility  shall  be  prescribed  as
    15  part  of  a  physician's  overall  plan  of care and consistent with the
    16  guidelines for coverage as referenced in this paragraph.
    17    [(C)] (B) Coverage may be  subject  to  co-payments,  coinsurance  and
    18  deductibles  as  may  be deemed appropriate by the superintendent and as
    19  are consistent with those established for other benefits within a  given
    20  policy.
    21    [(D)  Coverage  shall  be  limited  to those individuals who have been
    22  previously covered under the policy for a period of not less than twelve
    23  months, provided that for the purposes of this paragraph "period of  not
    24  less  than  twelve  months" shall be determined by calculating such time
    25  from either the date the insured was first covered  under  the  existing
    26  policy  or  from  the date the insured was first covered by a previously
    27  in-force converted policy, whichever is earlier.
    28    (E) Coverage] (C) Except as provided in subparagraphs (F) and  (G)  of
    29  this  paragraph, coverage shall not be required to include the diagnosis
    30  and treatment of infertility in connection with: (i) in vitro fertiliza-
    31  tion, gamete intrafallopian tube transfers or zygote intrafallopian tube
    32  transfers; (ii) the  reversal  of  elective  sterilizations;  (iii)  sex
    33  change  procedures; (iv) cloning; or (v) medical or surgical services or
    34  procedures that are deemed to be experimental in accordance  with  clin-
    35  ical guidelines referenced in subparagraph [(F)] (D) of this paragraph.
    36    [(F)] (D) The superintendent, in consultation with the commissioner of
    37  health,  shall  promulgate  regulations which shall stipulate the guide-
    38  lines and standards which shall be used in carrying out  the  provisions
    39  of this paragraph, which shall include:
    40    (i)  [The determination of "infertility" in accordance with the stand-
    41  ards and guidelines established and adopted by the American  College  of
    42  Obstetricians  and  Gynecologists and the American Society for Reproduc-
    43  tive Medicine;
    44    (ii)] The identification of experimental procedures and treatments not
    45  covered for the diagnosis and treatment  of  infertility  determined  in
    46  accordance  with the standards and guidelines established and adopted by
    47  the American College of Obstetricians and Gynecologists and the American
    48  Society for Reproductive Medicine;
    49    [(iii)] (ii) The identification of the required  training,  experience
    50  and  other  standards  for  health  care  providers for the provision of
    51  procedures and treatments for the diagnosis and treatment of infertility
    52  determined in accordance with the standards and  guidelines  established
    53  and  adopted  by the American College of Obstetricians and Gynecologists
    54  and the American Society for Reproductive Medicine; and
    55    [(iv)] (iii) The determination of appropriate  medical  candidates  by
    56  the  treating  physician in accordance with the standards and guidelines

        S. 1507--C                         68                         A. 2007--C
 
     1  established and adopted by the American  College  of  Obstetricians  and
     2  Gynecologists and/or the American Society for Reproductive Medicine.
     3    (E)(i)  For  the  purposes  of  this subsection, "infertility" means a
     4  disease or condition  characterized  by  the  incapacity  to  impregnate
     5  another  person  or  to  conceive, defined by the failure to establish a
     6  clinical pregnancy after twelve months of  regular,  unprotected  sexual
     7  intercourse  or  therapeutic  donor insemination, or after six months of
     8  regular, unprotected sexual intercourse or therapeutic  donor  insemina-
     9  tion  for a female thirty-five years of age or older. Earlier evaluation
    10  and treatment may be warranted based on an individual's medical  history
    11  or physical findings.
    12    (ii)  For  purposes of this subsection, "iatrogenic infertility" means
    13  an impairment of fertility by surgery, radiation, chemotherapy or  other
    14  medical treatment affecting reproductive organs or processes.
    15    (F)  Coverage  shall  also  include  standard  fertility  preservation
    16  services when a medical  treatment  may  directly  or  indirectly  cause
    17  iatrogenic  infertility to an insured. Coverage may be subject to annual
    18  deductibles and coinsurance, including  copayments,  as  may  be  deemed
    19  appropriate  by  the  superintendent  and  as  are consistent with those
    20  established for other benefits within a given contract.
    21    (G) Every large group contract that provides medical, major medical or
    22  similar comprehensive-type coverage shall  provide  coverage  for  three
    23  cycles  of  in-vitro fertilization used in the treatment of infertility.
    24  Coverage may be subject to annual deductibles and coinsurance, including
    25  copayments, as may be deemed appropriate by the  superintendent  and  as
    26  are  consistent with those established for other benefits within a given
    27  contract. For purposes of this subparagraph, a  "cycle"  is  defined  as
    28  either  all  treatment  that  starts when:   preparatory medications are
    29  administered for ovarian  stimulation  for  oocyte  retrieval  with  the
    30  intent  of undergoing in-vitro fertilization using a fresh embryo trans-
    31  fer; or medications are administered for  endometrial  preparation  with
    32  the  intent  of  undergoing in-vitro fertilization using a frozen embryo
    33  transfer.
    34    (H) No corporation providing  coverage  under  this  subsection  shall
    35  discriminate  based  on an insured's expected length of life, present or
    36  predicted disability, degree of medical dependency, perceived quality of
    37  life, or other health conditions, nor based on personal characteristics,
    38  including age, sex, sexual orientation, marital status or gender identi-
    39  ty.
    40    § 3. Paragraph 13 of subsection (i) of section 3216 of  the  insurance
    41  law is amended by adding a new subparagraph (C) to read as follows:
    42    (C)  Every  policy  that  provides  medical,  major medical or similar
    43  comprehensive-type coverage shall provide coverage for standard fertili-
    44  ty preservation services when a medical treatment may directly or  indi-
    45  rectly  cause  iatrogenic  infertility  to  an  insured. Coverage may be
    46  subject to annual deductibles and coinsurance, including copayments,  as
    47  may  be  deemed  appropriate by the superintendent and as are consistent
    48  with those established for other benefits within a given policy.
    49    (i) For purposes of this subparagraph, "iatrogenic infertility"  means
    50  an  impairment of fertility by surgery, radiation, chemotherapy or other
    51  medical treatment affecting reproductive organs or processes.
    52    (ii) No insurer providing coverage under this paragraph shall discrim-
    53  inate based  on  an  insured's  expected  length  of  life,  present  or
    54  predicted disability, degree of medical dependency, perceived quality of
    55  life, or other health conditions, nor based on personal characteristics,

        S. 1507--C                         69                         A. 2007--C
 
     1  including age, sex, sexual orientation, marital status or gender identi-
     2  ty.
     3    §  4.  This  act  shall take effect January 1, 2020 and shall apply to
     4  policies and contracts issued, renewed, modified, altered or amended  on
     5  or after such date.

     6                                   PART M
 
     7    Section  1.  Subparagraph  (A)  of  paragraph  16 of subsection (l) of
     8  section 3221 of the insurance law, as amended by a chapter of  the  laws
     9  of 2019, amending the insurance law and the social services law relating
    10  to  requiring  health  insurance  policies  to  include  coverage of all
    11  FDA-approved contraceptive drugs, devices,  and  products,  as  well  as
    12  voluntary  sterilization  procedures,  contraceptive education and coun-
    13  seling, and related follow up services and prohibiting a  health  insur-
    14  ance  policy  from  imposing  any  cost-sharing  requirements  or  other
    15  restrictions or delays with respect to this  coverage,  as  proposed  in
    16  legislative  bills  numbers  S. 659-a and A. 585-a, is amended and a new
    17  subparagraph (H) is added to read as follows:
    18    (A) Every  group  or  blanket  policy  that  provides  medical,  major
    19  medical, or similar comprehensive type coverage that is issued, amended,
    20  renewed,  effective or delivered on or after January first, two thousand
    21  twenty, shall provide coverage for all of  the  following  services  and
    22  contraceptive methods:
    23    (1) All FDA-approved contraceptive drugs, devices, and other products.
    24  This  includes  all  FDA-approved  over-the-counter contraceptive drugs,
    25  devices, and products as prescribed or  as  otherwise  authorized  under
    26  state or federal law. The following applies to this coverage:
    27    (a)  where the FDA has approved one or more therapeutic and pharmaceu-
    28  tical equivalent, as defined by the FDA,  versions  of  a  contraceptive
    29  drug,  device,  or product, a group or blanket policy is not required to
    30  include all such therapeutic and pharmaceutical equivalent  versions  in
    31  its  formulary,  so long as at least one is included and covered without
    32  cost-sharing and in accordance with this paragraph;
    33    (b) if the covered therapeutic and pharmaceutical equivalent  versions
    34  of  a drug, device, or product are not available or are deemed medically
    35  inadvisable a group or blanket policy  shall  provide  coverage  for  an
    36  alternate  therapeutic  and  pharmaceutical  equivalent  version  of the
    37  contraceptive drug, device, or product without  cost-sharing.    If  the
    38  attending  health  care  provider, in his or her reasonable professional
    39  judgment, determines that the use of a non-covered therapeutic or  phar-
    40  maceutical  equivalent  of  a drug, device, or product is warranted, the
    41  health care provider's determination shall be final.  The superintendent
    42  shall promulgate regulations establishing  a  process,  including  time-
    43  frames,  for  an  insured,  an insured's designee or an insured's health
    44  care provider to request coverage of a non-covered  contraceptive  drug,
    45  device,  or  product.  Such regulations shall include a requirement that
    46  insurers use an exception form that shall meet criteria  established  by
    47  the superintendent;
    48    (c)  this coverage shall include emergency contraception without cost-
    49  sharing when provided pursuant to a prescription or order under  section
    50  sixty-eight  hundred  thirty-one  of  the education law or when lawfully
    51  provided over the counter; and
    52    (d) this coverage must allow for the dispensing of up to twelve months
    53  worth of a contraceptive at one time;

        S. 1507--C                         70                         A. 2007--C

     1    (2) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and
     2  identified in the  comprehensive  guidelines  supported  by  the  health
     3  resources  and  services  administration and thereby incorporated in the
     4  essential health benefits benchmark plan;
     5    (3) Patient education and counseling on contraception; and
     6    (4)  Follow-up  services  related to the drugs, devices, products, and
     7  procedures covered under this paragraph, including, but not limited  to,
     8  management  of  side  effects,  counseling  for continued adherence, and
     9  device insertion and removal.
    10    (H) For the purposes of this paragraph,  "over-the-counter  contracep-
    11  tive  products"  shall mean those products provided for in comprehensive
    12  guidelines supported by the health resources and services administration
    13  as of January twenty-first, two thousand nineteen.
    14    § 2. Paragraph 1 of subsection (cc) of section 4303 of  the  insurance
    15  law, as amended by a chapter of the laws of 2019, amending the insurance
    16  law  and  the social services law relating to requiring health insurance
    17  policies to include coverage of all  FDA-approved  contraceptive  drugs,
    18  devices,  and  products,  as well as voluntary sterilization procedures,
    19  contraceptive education and counseling, and related follow  up  services
    20  and prohibiting a health insurance policy from imposing any cost-sharing
    21  requirements or other restrictions or delays with respect to this cover-
    22  age,  as proposed in legislative bills numbers S. 659-a and A. 585-a, is
    23  amended and a new paragraph 8 is added to read as follows:
    24    (1) Every contract that provides medical, major  medical,  or  similar
    25  comprehensive  type coverage that is issued, amended, renewed, effective
    26  or delivered on or after  January  first,  two  thousand  twenty,  shall
    27  provide  coverage  for  all  of the following services and contraceptive
    28  methods:
    29    (A) All FDA-approved contraceptive drugs, devices, and other products.
    30  This includes all  FDA-approved  over-the-counter  contraceptive  drugs,
    31  devices,  and  products  as  prescribed or as otherwise authorized under
    32  state or federal law.  The following applies to this coverage:
    33    (i) where the FDA has approved one or more therapeutic and  pharmaceu-
    34  tical  equivalent,  as  defined  by the FDA, versions of a contraceptive
    35  drug, device, or product, a contract is not required to include all such
    36  therapeutic and pharmaceutical equivalent versions in its formulary,  so
    37  long as at least one is included and covered without cost-sharing and in
    38  accordance with this subsection;
    39    (ii) if the covered therapeutic and pharmaceutical equivalent versions
    40  of  a drug, device, or product are not available or are deemed medically
    41  inadvisable a contract shall provide coverage for an alternate therapeu-
    42  tic and pharmaceutical equivalent version  of  the  contraceptive  drug,
    43  device,  or  product without cost-sharing.  If the attending health care
    44  provider, in his or her  reasonable  professional  judgment,  determines
    45  that  the  use of a non-covered therapeutic or pharmaceutical equivalent
    46  of a drug, device, or product is warranted, the health  care  provider's
    47  determination shall be final.  The superintendent shall promulgate regu-
    48  lations establishing a process, including timeframes, for an insured, an
    49  insured's  designee  or  an  insured's  health  care provider to request
    50  coverage of a non-covered contraceptive drug, device, or  product.  Such
    51  regulations  shall  include a requirement that insurers use an exception
    52  form that shall meet criteria established by the superintendent;
    53    (iii) this coverage  shall  include  emergency  contraception  without
    54  cost-sharing  when  provided  pursuant  to a prescription or order under
    55  section sixty-eight hundred thirty-one of  the  education  law  or  when
    56  lawfully provided over the counter; and

        S. 1507--C                         71                         A. 2007--C
 
     1    (iv)  this  coverage  must  allow  for  the dispensing of up to twelve
     2  months worth of a contraceptive at one time;
     3    (B) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and
     4  identified  in  the  comprehensive  guidelines  supported  by the health
     5  resources and services administration and thereby  incorporated  in  the
     6  essential health benefits benchmark plan;
     7    (C) Patient education and counseling on contraception; and
     8    (D)  Follow-up  services  related to the drugs, devices, products, and
     9  procedures covered under this subsection, including, but not limited to,
    10  management of side effects,  counseling  for  continued  adherence,  and
    11  device insertion and removal.
    12    (8)  For  the purposes of this paragraph, "over-the-counter contracep-
    13  tive products" shall mean those products provided for  in  comprehensive
    14  guidelines supported by the health resources and services administration
    15  as of January twenty-first, two thousand nineteen.
    16    §  3. Clause (v) of subparagraph (E) of paragraph 17 of subsection (i)
    17  of section 3216 of the insurance law, as added by a chapter of the  laws
    18  of 2019, amending the insurance law and the social services law relating
    19  to  requiring  health  insurance  policies  to  include  coverage of all
    20  FDA-approved contraceptive drugs, devices,  and  products,  as  well  as
    21  voluntary  sterilization  procedures,  contraceptive education and coun-
    22  seling, and related follow up services and prohibiting a  health  insur-
    23  ance  policy  from  imposing  any  cost-sharing  requirements  or  other
    24  restrictions or delays with respect to this  coverage,  as  proposed  in
    25  legislative  bills  numbers S. 659-a and A. 585-a, is amended to read as
    26  follows:
    27    (v) all FDA-approved contraceptive drugs, devices, and other products,
    28  including  all  over-the-counter  contraceptive  drugs,   devices,   and
    29  products as prescribed or as otherwise authorized under state or federal
    30  law; voluntary sterilization procedures pursuant to 42 U.S.C.  18022 and
    31  identified  in  the  comprehensive  guidelines  supported  by the health
    32  resources and services administration and thereby  incorporated  in  the
    33  essential  health  benefits  benchmark plan; patient education and coun-
    34  seling on contraception; and follow-up services related  to  the  drugs,
    35  devices,  products, and procedures covered under this clause, including,
    36  but not limited to, management of side effects, counseling for continued
    37  adherence, and device insertion and removal. Except as otherwise author-
    38  ized under this clause, a contract shall not impose any restrictions  or
    39  delays  on  the  coverage required under this clause. However, where the
    40  FDA has approved one or more therapeutic and pharmaceutical  equivalent,
    41  as  defined  by  the  FDA,  versions of a contraceptive drug, device, or
    42  product, a contract is not required to include all such therapeutic  and
    43  pharmaceutical equivalent versions in its formulary, so long as at least
    44  one  is included and covered without cost-sharing and in accordance with
    45  this clause. If the covered therapeutic  and  pharmaceutical  equivalent
    46  versions  of  a drug, device, or product are not available or are deemed
    47  medically inadvisable a contract shall provide coverage for an alternate
    48  therapeutic and pharmaceutical equivalent version of  the  contraceptive
    49  drug,  device, or product without cost-sharing.  (a) This coverage shall
    50  include emergency  contraception  without  cost  sharing  when  provided
    51  pursuant  to  a prescription, or order under section sixty-eight hundred
    52  thirty-one of the education law or when lawfully provided over-the-coun-
    53  ter.  (b) If the attending health care provider, in his or  her  reason-
    54  able  professional  judgment,  determines  that the use of a non-covered
    55  therapeutic or pharmaceutical equivalent of a drug, device,  or  product
    56  is  warranted,  the health care provider's determination shall be final.

        S. 1507--C                         72                         A. 2007--C
 
     1  The superintendent shall promulgate regulations establishing a  process,
     2  including  timeframes,  for  an  insured,  an  insured's  designee or an
     3  insured's health care provider to  request  coverage  of  a  non-covered
     4  contraceptive drug, device, or product. Such regulations shall include a
     5  requirement that insurers use an exception form that shall meet criteria
     6  established by the superintendent.  (c) This coverage must allow for the
     7  dispensing  of up to twelve months worth of a contraceptive at one time.
     8  (d) For the purposes of  this  clause,  "over-the-counter  contraceptive
     9  products" shall mean those products provided for in comprehensive guide-
    10  lines  supported  by the health resources and services administration as
    11  of January twenty-first, two thousand nineteen.
    12    § 4. This act shall take effect on the  same  date  and  in  the  same
    13  manner  as a chapter of the laws of 2019, amending the insurance law and
    14  the social services law relating to requiring health insurance  policies
    15  to  include  coverage  of all FDA-approved contraceptive drugs, devices,
    16  and products, as well as voluntary sterilization procedures,  contracep-
    17  tive  education  and  counseling,  and  related  follow  up services and
    18  prohibiting a health insurance policy  from  imposing  any  cost-sharing
    19  requirements or other restrictions or delays with respect to this cover-
    20  age,  as  proposed  in  legislative bills numbers S. 659-a and A. 585-a,
    21  takes effect.
 
    22                                   PART N
 
    23                            Intentionally Omitted
 
    24                                   PART O
 
    25    Section 1. Subdivision 2 of section 605 of the public health  law,  as
    26  amended  by  section  20 of part E of chapter 56 of the laws of 2013, is
    27  amended to read as follows:
    28    2. State aid reimbursement for public health services  provided  by  a
    29  municipality  under  this  title,  shall  be made if the municipality is
    30  providing some or all of the core public health services  identified  in
    31  section  six hundred two of this title, pursuant to an approved applica-
    32  tion for state aid, at a rate of no less  than  thirty-six  per  centum,
    33  except  for the city of New York which shall receive no less than twenty
    34  per centum, of the difference between the amount of moneys  expended  by
    35  the  municipality  for  public  health  services required by section six
    36  hundred two of this title during the fiscal  year  and  the  base  grant
    37  provided pursuant to subdivision one of this section. No such reimburse-
    38  ment  shall be provided for services that are not eligible for state aid
    39  pursuant to this article.
    40    § 2. Subdivision 1 of section 616 of the public health law, as amended
    41  by section 27 of part E of chapter 56 of the laws of 2013, is amended to
    42  read as follows:
    43    1. The total amount of state aid provided  pursuant  to  this  article
    44  shall  be  limited to the amount of the annual appropriation made by the
    45  legislature. In no event, however, shall such state aid be less than  an
    46  amount  to  provide  the  full  base grant and, as otherwise provided by
    47  [paragraph (a) of] subdivision two of section six hundred five  of  this
    48  article,  [at  least] no less than thirty-six per centum, except for the
    49  city of New York which shall receive no less than twenty per centum,  of
    50  the difference between the amount of moneys expended by the municipality
    51  for  eligible public health services pursuant to an approved application

        S. 1507--C                         73                         A. 2007--C
 
     1  for state aid during the fiscal year and the base grant provided  pursu-
     2  ant to subdivision one of section six hundred five of this article.
     3    § 3. This act shall take effect July 1, 2019.

     4                                   PART P
 
     5    Section  1. Subdivision 6 of section 1370 of the public health law, as
     6  amended by chapter 485 of the laws  of  1992,  is  amended  to  read  as
     7  follows:
     8    6.  "Elevated  lead  levels"  means a blood lead level greater than or
     9  equal to [ten] five micrograms of lead per deciliter of whole  blood  or
    10  such  lower  blood  lead  level  as may be established by the department
    11  pursuant to rule or regulation.
    12    § 1-a. (a) Within 180 days after the date  on  which  this  act  takes
    13  effect,  the  department of health shall adopt all necessary regulations
    14  to define "elevated lead levels" to mean a blood lead level greater than
    15  or equal to 5 micrograms per deciliter of whole  blood,  or  such  lower
    16  blood  lead level as the department may establish, to be utilized in its
    17  lead poisoning prevention program.
    18    (b) Within 6 months after the date on which the federal department  of
    19  health  and  human  services has published guidance recommending a lower
    20  concentration of lead in blood than the concentration established pursu-
    21  ant to subdivision 6 of section 1370 of the public  health  law  as  the
    22  reference  level  for  conducting  an  environmental  intervention,  the
    23  department of health shall, in consultation  with  the  New  York  state
    24  advisory  council  on lead poisoning prevention, make recommendations to
    25  the governor and the legislature recommending actions the  state  should
    26  take in response to such guidance.
    27    §  2. Section 1151 of the public health law is amended by adding a new
    28  subdivision 9 to read as follows:
    29    9. General information regarding lead pipes  reasonably  known  to  be
    30  located  within the water system, as that term is defined in subdivision
    31  twenty-six of section two of the public service law.
    32    § 3. This act shall take effect immediately.
 
    33                                   PART Q
 
    34    Section 1. Section 2825-f of the  public  health  law  is  amended  by
    35  adding two new subdivisions 4-a and 4-b to read as follows:
    36    4-a. Notwithstanding subdivision two of this section or any inconsist-
    37  ent  provision of law to the contrary, and upon approval of the director
    38  of the budget, the commissioner may,  subject  to  the  availability  of
    39  lawful  appropriation,  award up to three hundred million dollars of the
    40  funds made available pursuant  to  this  section  for  unfunded  project
    41  applications  submitted  in  response  to  the  request for applications
    42  number 17648 issued by the department on January  eighth,  two  thousand
    43  eighteen  pursuant to section twenty-eight hundred twenty-five-e of this
    44  article, provided however that the provisions of subdivisions three  and
    45  four of this section shall apply.
    46    4-b. Authorized amounts to be awarded pursuant to applications submit-
    47  ted  in  response  to  the request for application number 17648 shall be
    48  awarded no later than May first, two thousand nineteen.
    49    § 2. This act shall take effect immediately.
 
    50                                   PART R

        S. 1507--C                         74                         A. 2007--C
 
     1                            Intentionally Omitted
 
     2                                   PART S

     3                            Intentionally Omitted
 
     4                                   PART T
 
     5    Section  1.  This act shall be known and may be cited as the "NY State
     6  of Health, The Official Health Plan Marketplace Act".
     7    § 2. Article 2 of the public health law is amended  by  adding  a  new
     8  title VII to read as follows:
     9                                  TITLE VII
    10                              NY STATE OF HEALTH
    11  Section 268. Statement of policy and purposes.
    12          268-a. Definitions.
    13          268-b. Establishment  of NY State of Health, The Official Health
    14                 Plan Marketplace.
    15          268-c. Functions of the Marketplace.
    16          268-d. Special functions of the Marketplace  related  to  health
    17                 plan certification and qualified health plan oversight.
    18          268-e. Appeals and appeal hearings; judicial review.
    19          268-f. Marketplace advisory committee.
    20          268-g. Funding of the Marketplace.
    21          268-h. Construction.
    22    §  268. Statement of policy and purposes. The purpose of this title is
    23  to codify the establishment of the health benefit exchange in New  York,
    24  known  as  NY  State  of  Health,  The  Official Health Plan Marketplace
    25  (Marketplace), in conformance with Executive  Order  42  (Cuomo)  issued
    26  April  12,  2012.  The Marketplace shall continue to perform eligibility
    27  determinations for federal and state  insurance  affordability  programs
    28  including  medical  assistance  in accordance with section three hundred
    29  sixty-six of the social services law, child health  plus  in  accordance
    30  with  section  twenty-five  hundred  eleven  of  this chapter, the basic
    31  health program in accordance with section three hundred sixty-nine-gg of
    32  the social services  law,  and  premium  tax  credits  and  cost-sharing
    33  reductions,  together  with  performing  eligibility  determinations for
    34  qualified health plans and  such  other  health  insurance  programs  as
    35  determined  by  the  commissioner. The Marketplace shall also facilitate
    36  enrollment in insurance affordability programs, qualified  health  plans
    37  and  other  health insurance programs as determined by the commissioner,
    38  the purchase and sale of qualified health plans and/or  other  or  addi-
    39  tional health plans certified by the Marketplace pursuant to this title,
    40  and  shall  continue  to  have the authority to operate a small business
    41  health options program ("SHOP") to assist eligible  small  employers  in
    42  selecting qualified health plans and/or other or additional health plans
    43  certified by the Marketplace and to determine small employer eligibility
    44  for  purposes  of  small  employer  tax credits. It is the intent of the
    45  legislature, by codifying the Marketplace in state statute, to  continue
    46  to  promote  quality and affordable health coverage and care, reduce the
    47  number of uninsured persons, provide a transparent marketplace,  educate
    48  consumers  and  assist  individuals  with  access  to  coverage, premium
    49  assistance tax credits and cost-sharing  reductions.  In  addition,  the
    50  legislature  declares  the  intent  that  the Marketplace continue to be
    51  properly integrated with  insurance  affordability  programs,  including

        S. 1507--C                         75                         A. 2007--C
 
     1  Medicaid, child health plus and the basic health program, and such other
     2  health insurance programs as determined by the commissioner.
     3    §  268-a. Definitions. For purposes of this title, the following defi-
     4  nitions shall apply:
     5    1. "Commissioner" means the commissioner of health of the state of New
     6  York.
     7    2. "Marketplace" means the "NY State of Health,  The  official  health
     8  plan  Marketplace"  or  "Marketplace"  established  as  a health benefit
     9  exchange or "marketplace" within the department of  health  pursuant  to
    10  Executive Order 42 (Cuomo) issued April 12, 2012 and this title.
    11    3. "Federal act" means the patient protection and affordable care act,
    12  public  law  111-148, as amended by the health care and education recon-
    13  ciliation act of 2010, public law 111-152, and any regulations or  guid-
    14  ance issued thereunder.
    15    4.  "Health  plan" means a policy, contract or certificate, offered or
    16  issued by an insurer to provide, deliver, arrange for, pay for or  reim-
    17  burse  any  of  the costs of health care services. Health plan shall not
    18  include the following:
    19    (a) accident insurance or disability income insurance, or any combina-
    20  tion thereof;
    21    (b) coverage issued as a supplement to liability insurance;
    22    (c) liability insurance, including  general  liability  insurance  and
    23  automobile liability insurance;
    24    (d) workers' compensation or similar insurance;
    25    (e) automobile no-fault insurance;
    26    (f) credit insurance;
    27    (g)  other  similar  insurance coverage, as specified in federal regu-
    28  lations, under which benefits for medical care are  secondary  or  inci-
    29  dental to other insurance benefits;
    30    (h)  limited  scope  dental or vision benefits, benefits for long-term
    31  care insurance, nursing home insurance,  home  care  insurance,  or  any
    32  combination  thereof,  or  such  other  similar, limited benefits health
    33  insurance as specified in  federal  regulations,  if  the  benefits  are
    34  provided  under  a separate policy, certificate or contract of insurance
    35  or are otherwise not an integral part of the plan;
    36    (i) coverage only for a specified disease or illness, hospital  indem-
    37  nity, or other fixed indemnity coverage;
    38    (j)  Medicare  supplemental insurance as defined in section 1882(g)(1)
    39  of the federal social security act, coverage supplemental to the  cover-
    40  age  provided under chapter 55 of title 10 of the United States Code, or
    41  similar supplemental coverage provided under a group health plan  if  it
    42  is  offered  as a separate policy, certificate or contract of insurance;
    43  or
    44    (k) the New York state medical indemnity fund established pursuant  to
    45  title four of article twenty-nine-D of the public health law.
    46    5.  "Insurer"  means an insurance company subject to article forty-two
    47  or a corporation subject to article forty-three of the insurance law, or
    48  a health maintenance organization certified pursuant to  article  forty-
    49  four  of  the  public health law that contracts or offers to contract to
    50  provide, deliver, arrange, pay or reimburse any of the costs  of  health
    51  care services.
    52    6.  "Stand-Alone  dental  plan"  means a dental services plan that has
    53  been issued pursuant to applicable law and certified by the  Marketplace
    54  in accordance with section two hundred sixty-eight-d of this title.
    55    7. "Qualified health plan" means a health plan that is issued pursuant
    56  to  applicable  law  and certified by the Marketplace in accordance with

        S. 1507--C                         76                         A. 2007--C
 
     1  section two hundred sixty-eight-d of this title, including a stand-alone
     2  dental plan.
     3    8.  "Insurance  affordability  program"  means  Medicaid, child health
     4  plus, the basic health program and any other  health  insurance  subsidy
     5  program designated as such by the commissioner.
     6    9.  "Eligible  individual" means an individual, including a minor, who
     7  is eligible to enroll in an insurance  affordability  program  or  other
     8  health insurance program as determined by the commissioner.
     9    10.  "Qualified  individual"  means,  with respect to qualified health
    10  plans, an individual, including a minor, who:
    11    (a) is eligible to enroll in a qualified health plan offered to  indi-
    12  viduals through the Marketplace;
    13    (b) resides in this state;
    14    (c)  at the time of enrollment, is not incarcerated, other than incar-
    15  ceration pending the disposition of charges; and
    16    (d) is, and is reasonably expected to be, for the  entire  period  for
    17  which  enrollment  is sought, a citizen or national of the United States
    18  or an alien lawfully present in the United States.
    19    11. "Secretary" means the secretary of the United States department of
    20  health and human services.
    21    12. "SHOP" means the small business health options program operated by
    22  the Marketplace to assist eligible small  employers  in  this  state  in
    23  selecting qualified health plans and/or other or additional health plans
    24  certified by the Marketplace and to determine small employer eligibility
    25  for purposes of small employer tax credits in accordance with applicable
    26  federal and state laws and regulations.
    27    13. "Small employer" means an employer which offers coverage where the
    28  coverage  such  employer offers would be considered small group coverage
    29  under the insurance law and regulations promulgated thereunder, provided
    30  that it is not otherwise prohibited under the federal act.
    31    14. "Small group market" means the health insurance market under which
    32  individuals receive health insurance coverage on  behalf  of  themselves
    33  and  their  dependents through a group health plan maintained by a small
    34  employer.
    35    15. "Superintendent" means the superintendent of financial services.
    36    16. "Essential health benefits" shall mean the categories of  benefits
    37  defined  in  subsection (a) of section three thousand two hundred seven-
    38  teen-i and subsection (a) of section four thousand three  hundred  six-h
    39  of the insurance law.
    40    § 268-b. Establishment of NY State of Health, The Official Health Plan
    41  Marketplace. 1. There is hereby established an office within the depart-
    42  ment  of  health  to  be  known as the "NY State of Health, The official
    43  health plan Marketplace".
    44    2. The purpose of the  Marketplace  is  to  facilitate  enrollment  in
    45  health  coverage and the purchase and sale of qualified health plans and
    46  other health plans certified by the Marketplace; enroll  individuals  in
    47  coverage  for  which  they  are  eligible in accordance with federal and
    48  state law; enable eligible individuals to receive premium  tax  credits,
    49  cost-sharing  reductions, and to access insurance affordability programs
    50  and other health insurance programs as determined by  the  commissioner;
    51  assist  eligible  small  employers  in  selecting qualified health plans
    52  and/or other, or additional health plans certified  by  the  Marketplace
    53  and  to qualify for small employer tax credits in accordance with appli-
    54  cable law; and to carry out other functions set forth in this title.
    55    § 268-c. Functions of the Marketplace. The Marketplace shall:

        S. 1507--C                         77                         A. 2007--C
 
     1    1. (a) Perform eligibility determinations for federal and state insur-
     2  ance affordability programs including medical assistance  in  accordance
     3  with  section  three hundred sixty-six of the social services law, child
     4  health plus in accordance with section  twenty-five  hundred  eleven  of
     5  this  chapter, the basic health program in accordance with section three
     6  hundred sixty-nine-gg of the social services law,  premium  tax  credits
     7  and  cost-sharing  reductions  and  qualified health plans in accordance
     8  with applicable law and other health insurance programs as determined by
     9  the commissioner;
    10    (b) certify and make available  to  qualified  individuals,  qualified
    11  health  plans,  including  dental  plans,  certified  by the Marketplace
    12  pursuant to applicable law, provided  that  coverage  under  such  plans
    13  shall  not  become  effective prior to certification by the Marketplace;
    14  and
    15    (c) certify and/or make  available  to  eligible  individuals,  health
    16  plans  certified  by  the Marketplace pursuant to applicable law, and/or
    17  participating in an insurance affordability program pursuant to applica-
    18  ble law, provided that coverage under such plans shall not become effec-
    19  tive prior to certification by the Marketplace, and/or approval  by  the
    20  commissioner.
    21    2.  Assign  an  actuarial  value  to  each  Marketplace certified plan
    22  offered through the Marketplace in accordance with the  criteria  devel-
    23  oped  by  the  secretary  pursuant  to federal law or the superintendent
    24  pursuant to the insurance  law  and/or  requirements  developed  by  the
    25  Marketplace,  and  determine  each  health  plan's  level of coverage in
    26  accordance with regulations issued by the secretary pursuant to  federal
    27  law or the superintendent pursuant to the insurance law.
    28    3. Utilize a standardized format for presenting health benefit options
    29  in the Marketplace, including the use of the uniform outline of coverage
    30  established  under section 2715 of the federal public health service act
    31  or the insurance law.
    32    4. Standardize the benefits available through the Marketplace at  each
    33  level of coverage defined by the superintendent in the insurance law.
    34    5. Maintain enrollment periods in the best interest of qualified indi-
    35  viduals consistent with federal and state law.
    36    6.  Implement  procedures  for  the certification, recertification and
    37  decertification of health plans as  qualified  health  plans  or  health
    38  plans  approved  for  sale  by  the  department of financial services or
    39  department of health and certified by the Marketplace,  consistent  with
    40  guidelines developed by the secretary pursuant to section 1311(c) of the
    41  federal act and requirements developed by the Marketplace.
    42    7.  Contract for health care coverage offered to qualified individuals
    43  through the Marketplace, and in doing so shall seek  to  provide  health
    44  care  coverage  choices  that  offer  the optimal combination of choice,
    45  value, quality, and service.
    46    8. Contract for health care coverage offered to certain eligible indi-
    47  viduals through the Marketplace, pursuant to health  insurance  programs
    48  as determined by the commissioner, and in doing so shall seek to provide
    49  health  care  coverage  choices  that  offer  the optimal combination of
    50  choice, value, quality, and service;
    51    9. Provide the minimum requirements an insurer shall meet  to  partic-
    52  ipate  in the Marketplace, in the best interest of qualified individuals
    53  or eligible individuals;
    54    10. Require qualified health plans and/or other health plans certified
    55  by the Marketplace to offer those benefits determined  to  be  essential
    56  health benefits pursuant to state law or as required by the Marketplace.

        S. 1507--C                         78                         A. 2007--C
 
     1    11. Ensure that insurers offering health plans through the Marketplace
     2  do not charge an individual enrollee a fee or penalty for termination of
     3  coverage.
     4    12.  Provide  for  the  operation  of a toll-free telephone hotline to
     5  respond to requests for assistance.
     6    13. Maintain an internet website through which enrollees and  prospec-
     7  tive  enrollees  of qualified health plans and health plans certified by
     8  the Marketplace may obtain standardized comparative information on  such
     9  plans and insurance affordability programs.
    10    14.  Make  available by electronic means a calculator to determine the
    11  actual cost of coverage after the application of any premium tax  credit
    12  under  section  36B  of  the Internal Revenue Code of 1986 or applicable
    13  state law and any cost-sharing reduction  under  federal  or  applicable
    14  state law.
    15    15.  Operate  a  program  under which the Marketplace awards grants to
    16  entities to serve as navigators in accordance  with  applicable  federal
    17  law and regulations adopted thereunder, and/or a program under which the
    18  Marketplace awards grants to entities to provide community based enroll-
    19  ment assistance in accordance with requirements developed by the Market-
    20  place;  and/or  a program under which the Marketplace certifies New York
    21  state licensed producers to provide assistance to  eligible  individuals
    22  and/or small employers pursuant to federal or state law.
    23    16.  In accordance with applicable federal and state law, inform indi-
    24  viduals of eligibility requirements for the Medicaid program under title
    25  XIX of the social security act and the social services  law,  the  chil-
    26  dren's  health  insurance  program  (CHIP) under title XXI of the social
    27  security act and this chapter, the basic health  program  under  section
    28  three  hundred sixty-nine-gg of the social services law, or any applica-
    29  ble state or local public  health  insurance  program  and  if,  through
    30  screening  of the application by the Marketplace, the Marketplace deter-
    31  mines that such individuals are eligible for any  such  program,  enroll
    32  such individuals in such program.
    33    17.  Grant  a  certification  that  an  individual  is exempt from the
    34  requirement to maintain minimum essential coverage pursuant  to  federal
    35  or  state  law  and  from  any  penalties  imposed  by such requirements
    36  because:
    37    (a) there is no affordable health plan available covering the individ-
    38  ual, as defined by applicable law; or
    39    (b) the individual meets the requirements for any other such exemption
    40  from the requirement to maintain minimum essential coverage  or  to  pay
    41  the penalty pursuant to applicable federal or state law.
    42    18.  Operate a small business health options program ("SHOP") pursuant
    43  to section 1311 of the federal act and  applicable  state  law,  through
    44  which  eligible  small employers may select marketplace-certified quali-
    45  fied health plans offered in the small group market, and  through  which
    46  eligible  small employers may receive assistance in qualifying for small
    47  business tax credits available pursuant to federal and state law.
    48    19. Enter into agreements as necessary with federal and state agencies
    49  and other state Marketplaces to carry  out  its  responsibilities  under
    50  this  title,  provided such agreements include adequate protections with
    51  respect to the confidentiality of  any  information  to  be  shared  and
    52  comply with all state and federal laws and regulations.
    53    20.  Perform  duties  required  by the secretary, the secretary of the
    54  United States department of the treasury or the commissioner related  to
    55  determining  eligibility for premium tax credits or reduced cost-sharing
    56  under applicable federal or state law.

        S. 1507--C                         79                         A. 2007--C

     1    21. Meet program integrity requirements under applicable law,  includ-
     2  ing  keeping  an  accurate  accounting  of receipts and expenditures and
     3  providing reports to the secretary regarding Marketplace related  activ-
     4  ities in accordance with applicable law.
     5    22.  Submit information provided by Marketplace applicants for verifi-
     6  cation as required by section 1411(c) of the federal act and  applicable
     7  state law.
     8    23.  Establish  rules  and  regulations  that  do not conflict with or
     9  prevent the application of regulations promulgated by the secretary.
    10    24. Determine eligibility, provide notices, and provide  opportunities
    11  for  appeal  and  redetermination in accordance with the requirements of
    12  federal and state law.
    13    § 268-d. Special functions of the Marketplace related to  health  plan
    14  certification  and  qualified  health  plan  oversight.  1. Health plans
    15  certified by the Marketplace shall meet the following requirements:
    16    (a) The insurer offering the health plan:
    17    (i) is licensed or certified by the superintendent or commissioner, in
    18  good standing to offer health insurance  coverage  in  this  state,  and
    19  meets the requirements established by the Marketplace;
    20    (ii)  offers  at least one qualified health plan and/or other or addi-
    21  tional health plans authorized for sale by the department  of  financial
    22  services  or  the  department  in  each of the silver and gold levels as
    23  required by state law,  provided,  however,  that  the  Marketplace  may
    24  require  additional benefit levels to be offered by all insurers partic-
    25  ipating in the Marketplace;
    26    (iii) has filed with and received approval from the superintendent  of
    27  its premium rates and policy or contract forms pursuant to the insurance
    28  law and/or this chapter;
    29    (iv)  does  not  charge  any cancellation fees or penalties for termi-
    30  nation of coverage in violation of applicable law; and
    31    (v) complies with the regulations developed  by  the  secretary  under
    32  section  1311(c)  of  the federal act and such other requirements as the
    33  Marketplace may establish.
    34    (b) The health plan: (i) provides the essential health benefits  pack-
    35  age  described  in state law or required by the Marketplace and includes
    36  such additional benefits as are mandated by state law, except  that  the
    37  health  plan  shall  not  be required to provide essential benefits that
    38  duplicate the minimum benefits of qualified dental plans if:
    39    (A) the Marketplace has determined that at least one qualified  dental
    40  plan  or dental plan approved by the department of financial services or
    41  the department is available to supplement the  health  plan's  coverage;
    42  and
    43    (B)  the  insurer makes prominent disclosure at the time it offers the
    44  health plan, in a form approved by the Marketplace, that the  plan  does
    45  not  provide  the  full  range of essential pediatric benefits, and that
    46  qualified dental plans or dental plans approved  by  the  department  of
    47  financial  services or department of health providing those benefits and
    48  other dental benefits not covered by the plan are  offered  through  the
    49  Marketplace;
    50    (ii)  provides at least a bronze level of coverage as defined by state
    51  law, unless the plan is certified as a qualified catastrophic  plan,  as
    52  defined in section 1302(e) of the federal act and the insurance law, and
    53  shall only be offered to individuals eligible for catastrophic coverage;
    54    (iii)  has  cost-sharing requirements, including deductibles, which do
    55  not exceed the limits established under section 1302(c) of  the  federal
    56  act, state law and any requirements of the Marketplace;

        S. 1507--C                         80                         A. 2007--C

     1    (iv)  complies  with regulations promulgated by the secretary pursuant
     2  to section 1311(c) of the federal act and applicable  state  law,  which
     3  include  minimum  standards in the areas of marketing practices, network
     4  adequacy, essential community providers in underserved  areas,  accredi-
     5  tation,  quality  improvement, uniform enrollment forms and descriptions
     6  of coverage and information on quality measures for health benefit  plan
     7  performance;
     8    (v)  meets  standards  specified  and  determined  by the Marketplace,
     9  provided that the standards do not conflict with or prevent the applica-
    10  tion of federal requirements; and
    11    (vi) complies with the insurance law  and  this  chapter  requirements
    12  applicable  to health insurance issued in this state and any regulations
    13  promulgated pursuant thereto that do not conflict with  or  prevent  the
    14  application of federal requirements; and
    15    (c)  The  Marketplace determines that making the health plan available
    16  through the Marketplace is in the interest of qualified  individuals  in
    17  this state.
    18    2. The Marketplace shall not exclude a health plan:
    19    (a) on the basis that the health plan is a fee-for-service plan;
    20    (b)  through  the  imposition of premium price controls by the Market-
    21  place; or
    22    (c) on the basis that the health plan provides treatments necessary to
    23  prevent patients' deaths in circumstances the Marketplace determines are
    24  inappropriate or too costly.
    25    3. The Marketplace shall require each  insurer  certified  or  seeking
    26  certification  of  a  health  plan  as  a  qualified health plan or plan
    27  approved for sale by the department of financial services or the depart-
    28  ment to:
    29    (a) submit a justification for any premium increase pursuant to appli-
    30  cable law prior to implementation of such increase.  The  insurer  shall
    31  prominently  post  the  information  on its internet website.  Such rate
    32  increases shall be subject to the prior approval of  the  superintendent
    33  pursuant to the insurance law;
    34    (b)(i) make available to the public and submit to the Marketplace, the
    35  secretary and the superintendent, accurate and timely disclosure of:
    36    (A) claims payment policies and practices;
    37    (B) periodic financial disclosures;
    38    (C) data on enrollment and disenrollment;
    39    (D) data on the number of claims that are denied;
    40    (E) data on rating practices;
    41    (F)  information on cost-sharing and payments with respect to any out-
    42  of-network coverage;
    43    (G) information on enrollee and participant rights under  title  I  of
    44  the federal act; and
    45    (H)  other  information  as determined appropriate by the secretary or
    46  otherwise required by the Marketplace;
    47    (ii) the information shall be provided in plain language, as that term
    48  is defined in section 1311(e)(3)(B) of the federal act  and  state  law,
    49  and  in  guidance  jointly  issued  thereunder  by the secretary and the
    50  federal secretary of labor; and
    51    (c) provide to individuals, in a timely manner upon the request of the
    52  individual, the amount of cost-sharing,  including  deductibles,  copay-
    53  ments,  and  coinsurance, under the individual's health plan or coverage
    54  that the individual would be responsible for paying with respect to  the
    55  furnishing of a specific item or service by a participating provider. At
    56  a  minimum,  this  information shall be made available to the individual

        S. 1507--C                         81                         A. 2007--C
 
     1  through an internet website and  through  other  means  for  individuals
     2  without access to the internet.
     3    4.  The Marketplace shall not exempt any insurer seeking certification
     4  of a health plan, regardless of the type or size of  the  insurer,  from
     5  licensing or solvency requirements under the insurance law or this chap-
     6  ter,  and  shall  apply  the  criteria  of this section in a manner that
     7  ensures a level playing field for insurers participating in the  Market-
     8  place.
     9    5.  (a)  The provisions of this article that apply to qualified health
    10  plans and plans  approved  for  sale  by  the  department  of  financial
    11  services  and  the department also shall apply to the extent relevant to
    12  qualified dental plans approved for sale by the department of  financial
    13  services  or  the  department, except as modified in accordance with the
    14  provisions of paragraphs (b) and (c) of this  subdivision  or  otherwise
    15  required by the Marketplace.
    16    (b)  The qualified dental plan or dental plan approved for sale by the
    17  department of financial services and/or the department shall be  limited
    18  to  dental  and  oral health benefits, without substantially duplicating
    19  the benefits typically offered by health benefit  plans  without  dental
    20  coverage,  and  shall  include,  at  a  minimum, the essential pediatric
    21  dental  benefits  prescribed  by  the  secretary  pursuant  to   section
    22  1302(b)(1)(J)  of the federal act, and such other dental benefits as the
    23  Marketplace or secretary may specify in regulations.
    24    (c) Insurers may  jointly  offer  a  comprehensive  plan  through  the
    25  Marketplace  in  which an insurer provides the dental benefits through a
    26  qualified dental plan or plan approved by the  department  of  financial
    27  services  or  the  department and an insurer provides the other benefits
    28  through a qualified health plan, provided  that  the  plans  are  priced
    29  separately  and  also  are made available for purchase separately at the
    30  same price.
    31    § 268-e. Appeals and appeal hearings; judicial review. 1.  Any  appli-
    32  cant  or  enrollee, or any individual authorized to act on behalf of any
    33  such applicant or enrollee, may appeal to the department  from  determi-
    34  nations  of department officials or failures to make determinations upon
    35  grounds specified in subdivision four of this  section.  The  department
    36  must  review  the appeal de novo and give such person an opportunity for
    37  an appeal hearing.  The department may also, on its own  motion,  review
    38  any  decision  made or any case in which a decision has not been made by
    39  the Marketplace or a social services official within the time  specified
    40  by  law  or  regulations of the department. The department may make such
    41  additional investigation as it may deem necessary, and the  commissioner
    42  must  make  such  determination  as  is justified and in accordance with
    43  applicable law.
    44    2. Regarding any appeal pursuant to this section, with or  without  an
    45  appeal hearing, the commissioner may designate and authorize one or more
    46  appropriate  members  of  his staff to consider and decide such appeals.
    47  Any staff member so designated and authorized  will  have  authority  to
    48  decide  such  appeals  on behalf of the commissioner with the same force
    49  and effect as if the commissioner had made the decisions.  Appeal  hear-
    50  ings  must be held on behalf of the commissioner by members of his staff
    51  who are employed for such purposes  or  who  have  been  designated  and
    52  authorized by the commissioner.
    53    3.  Persons  entitled  to  appeal  to  the department pursuant to this
    54  section must include:
    55    (a) applicants for or enrollees in  insurance  affordability  programs
    56  and qualified health plans; and

        S. 1507--C                         82                         A. 2007--C

     1    (b)  other persons entitled to an opportunity for an appeal hearing as
     2  directed by the commissioner.
     3    4.  An  applicant  or  enrollee  has  the right to appeal at least the
     4  following issues:
     5    (a) An eligibility determination made in accordance with this  article
     6  and applicable law, including:
     7    (i) An initial determination of eligibility, including:
     8    (A) eligibility to enroll in a qualified health plan;
     9    (B) eligibility for Medicaid;
    10    (C) eligibility for Child Health Plus;
    11    (D) eligibility for the Basic Health Program;
    12    (E) the amount of advance payments of the premium tax credit and level
    13  of cost-sharing reductions;
    14    (F)  the  amount of any other subsidy that may be available under law;
    15  and
    16    (G) eligibility for such other health insurance programs as determined
    17  by the commissioner; and
    18    (ii) a re-determination of eligibility  of  the  programs  under  this
    19  subdivision.
    20    (b)  An  eligibility determination for an exemption for any mandate to
    21  purchase health insurance.
    22    (c) A failure by NY State of Health to provide timely  written  notice
    23  of an eligibility determination made in accordance with applicable law.
    24    5.  The department may, subject to the discretion of the commissioner,
    25  promulgate such regulations, consistent with federal or  state  law,  as
    26  may be necessary to implement the provisions of this section.
    27    6. Regarding every decision of an appeal pursuant to this section, the
    28  department  must  inform  every party, and his or her representative, if
    29  any, of the availability of judicial review and the time  limitation  to
    30  pursue future review.
    31    7. Applicants and enrollees of qualified health plans, with or without
    32  advance  payments of the premium tax credit and cost-sharing reductions,
    33  also have the right to appeal to the United States Department of  Health
    34  and Human Services appeal entity:
    35    (a) appeals decisions issued by NY State of Health upon the exhaustion
    36  of the NY State of Health appeals process; and
    37    (b)  a  denial of a request to vacate a dismissal made by the NY State
    38  of Health appeals entity.
    39    8. The department must include  notice  of  the  right  to  appeal  as
    40  provided  by subdivision four of this section and instructions regarding
    41  how to file an appeal in any eligibility  determination  issued  to  the
    42  applicant  or  enrollee  in  accordance with applicable law. Such notice
    43  shall include:
    44    (a) an explanation of the applicant or enrollee's appeal rights;
    45    (b) a description of the procedures by which the applicant or enrollee
    46  may request an appeal;
    47    (c) information on the applicant  or  enrollee's  right  to  represent
    48  himself  or  herself,  or  to be represented by legal counsel or another
    49  representative;
    50    (d) an explanation of the circumstances under  which  the  appellant's
    51  eligibility  may be maintained or reinstated pending an appeal decision;
    52  and
    53    (e) an explanation that an appeal decision for  one  household  member
    54  may  result  in  a change in eligibility for other household members and
    55  that such a change will be handled as a redetermination  of  eligibility

        S. 1507--C                         83                         A. 2007--C
 
     1  for  all household members in accordance with the standards specified in
     2  applicable law.
     3    §  268-f.  Marketplace  advisory committee. 1. There is hereby created
     4  the marketplace advisory committee, which shall consider and advise  the
     5  department  and  commissioner  on  matters  concerning  the provision of
     6  health care coverage through the NY  State  of  Health  or  Health  Plan
     7  Marketplace.
     8    2. The marketplace advisory committee shall be composed of up to twen-
     9  ty-eight  members  consisting  of  twenty-four  members appointed by the
    10  commissioner, two members appointed by the speaker of the assembly,  and
    11  two  members  appointed  by  the  temporary president of the senate. The
    12  advisory  committee  shall  at  all  times  be  representative  of  each
    13  geographic area of the state and include:
    14    (a)  representatives  from the following categories, but not more than
    15  six from any single category:
    16    (i) health plan consumer advocates;
    17    (ii) small business consumer representatives;
    18    (iii) health care provider representatives;
    19    (iv) representatives of the health insurance industry;
    20    (b) representatives from the following categories, but not  more  than
    21  two from either category:
    22    (i) licensed insurance producers; and
    23    (ii) representatives of labor organizations.
    24    3.  The  commissioner shall select the chair of the advisory committee
    25  from among the members of such committee and shall designate an  officer
    26  or employee of the department to assist the marketplace advisory commit-
    27  tee in the performance of its duties under this section. The Marketplace
    28  shall  adopt  rules  for the governance of the advisory committee, which
    29  shall meet as frequently as its business may require and at  such  other
    30  times  as  determined by the chair to be necessary, in consultation with
    31  the executive director of the Marketplace.
    32    4. Members of the advisory committee shall serve without  compensation
    33  for  their  services as members, but each shall be allowed the necessary
    34  and actual expenses incurred in the performance of  his  or  her  duties
    35  under this section.
    36    § 268-g. Funding of the Marketplace. 1. The Marketplace shall be fund-
    37  ed by state and federal sources as authorized by applicable law, includ-
    38  ing  but not limited to applicable law authorizing the respective insur-
    39  ance affordability programs available through the Marketplace.
    40    2. The accounts of the Marketplace shall be subject to supervision  of
    41  the  comptroller and such accounts shall include receipts, expenditures,
    42  contracts and other matters which pertain to the fiscal soundness of the
    43  Marketplace.
    44    3. Notwithstanding any law to the contrary,  and  in  accordance  with
    45  section  four  of the state finance law, upon request of the director of
    46  the budget, in consultation with the  commissioner,  the  superintendent
    47  and the executive director of the Marketplace, the comptroller is hereby
    48  authorized  and  directed  to  sub-allocate  or transfer special revenue
    49  federal funds appropriated to the department for planning and implement-
    50  ing various healthcare and insurance reform  initiatives  authorized  by
    51  applicable  law.  Marketplace moneys sub-allocated or transferred pursu-
    52  ant to this section shall be paid out of the fund upon audit and warrant
    53  of the state comptroller  on  vouchers  certified  or  approved  by  the
    54  Marketplace.
    55    § 268-h. Construction. Nothing in this article, and no action taken by
    56  the Marketplace pursuant hereto, shall be construed to:

        S. 1507--C                         84                         A. 2007--C
 
     1    1.  preempt  or  supersede  the authority of the superintendent or the
     2  commissioner; or
     3    2. exempt insurers, insurance producers or qualified health plans from
     4  this chapter or the insurance law and any regulations promulgated there-
     5  under.
     6    §  3.  Severability. If any provision of this article, or the applica-
     7  tion thereof to any person or circumstances is held invalid or unconsti-
     8  tutional, that invalidity or unconstitutionality shall not affect  other
     9  provisions  or  applications  of  this  article that can be given effect
    10  without the invalid or unconstitutional provision or application, and to
    11  this end the provisions and application of this article are severable.
    12    § 4. This act shall take effect immediately.
 
    13                                   PART U
 
    14    Section 1. Section 203 of the elder law is amended  by  adding  a  new
    15  subdivision 12 to read as follows:
    16    12.(a)  The  director  is  hereby  authorized to implement private pay
    17  protocols for programs and services administered by  the  office.  These
    18  protocols  may  be implemented by area agencies on aging at their option
    19  and such protocols shall not be applied to services  for  a  participant
    20  when  being  paid  for with federal funds or funds designated as federal
    21  match, or for individuals with an income below four hundred  percent  of
    22  the  federal poverty level. All private payments received directly by an
    23  area agency on aging or indirectly by one of its  contractors  shall  be
    24  used  to  supplement,  not  supplant, funds by state, federal, or county
    25  appropriations. Such private pay payments shall be set at a cost to  the
    26  participant  of  not more than twenty percent above either the unit cost
    27  to the area agency on aging to provide the program or service  directly,
    28  or  the  amount  that the area agency on aging pays to its contractor to
    29  provide the program or service. Private pay payments received under this
    30  subdivision shall be used by the area agency on aging  to  first  reduce
    31  any  unmet  need  for  programs  and  services,  and then to support and
    32  enhance services or programs provided by the area agency on aging.    No
    33  participant,  regardless  of  income,  shall  be required to pay for any
    34  program or service that they are receiving at the time  these  protocols
    35  are  implemented by the area agency on aging. This subdivision shall not
    36  prevent cost sharing for the programs and services established  pursuant
    37  to section two hundred fourteen of this title for individuals below four
    38  hundred  percent  of  the federal poverty level. Consistent with federal
    39  and state statute and regulations, when providing programs and services,
    40  area agencies on aging and their  contractors  shall  continue  to  give
    41  priority  for  programs  and  services  to individuals with the greatest
    42  economic or social needs. In the event  that  the  capacity  to  provide
    43  programs  and  services  is limited, such programs and services shall be
    44  provided to individuals with incomes below four hundred percent  of  the
    45  federal  poverty level before such programs and services are provided to
    46  those participating in the private pay protocol pursuant to this  subdi-
    47  vision.
    48    (b)  Area  agencies on aging participating in the private pay protocol
    49  shall annually report to the office the unmet  need,  if  any,  for  all
    50  programs and services offered, the number of participants that privately
    51  paid  for  each program or service for that year, the rates participants
    52  were charged for each program or service provided, and  how  unmet  need
    53  for  programs  or  services  offered  by  the  area agency on aging were
    54  affected by revenue from the private pay protocol.  Such  annual  report

        S. 1507--C                         85                         A. 2007--C
 
     1  shall  also be shared with the Temporary President of the Senate and the
     2  Speaker of the Assembly no later than July first, two  thousand  twenty-
     3  one and shall be updated and reissued on an annual basis thereafter.
     4    §  2.  This act shall take effect on the three hundred sixty-fifth day
     5  after it shall have become a  law;  provided,  however,  that  effective
     6  immediately, any actions necessary for the implementation of this act on
     7  its  effective  date  are  authorized  to be completed on or before such
     8  date.
 
     9                                   PART V
 
    10    Section 1. Paragraph (d) of subdivision 32 of  section  364-j  of  the
    11  social  services  law, as added by section 15 of part B of chapter 59 of
    12  the laws of 2016, is amended to read as follows:
    13    (d) (i) Penalties under this subdivision may be applied to any and all
    14  circumstances described in paragraph (b) of this subdivision  until  the
    15  managed  care organization complies with the requirements for submission
    16  of encounter data.
    17    (ii) No penalties for late, incomplete or  inaccurate  encounter  data
    18  shall  be  assessed  against  managed  care organizations in addition to
    19  those provided for in this subdivision, provided, however, that  nothing
    20  in  this  paragraph shall prohibit the imposition of penalties, in cases
    21  of fraud or abuse, otherwise authorized by law.
    22    § 2. Section 364-j of the social services law is amended by  adding  a
    23  new subdivision 34 read as follows:
    24    34.  For  purposes of recovery of overpayments pursuant to subdivision
    25  thirty-five of this section, any payment made pursuant  to  the  state's
    26  managed  care program, including payments made by managed long term care
    27  plans, shall be deemed a  payment  by  the  state's  medical  assistance
    28  program,  provided that this subdivision shall not permit the imposition
    29  of a lien or recovery against property of an  individual  or  estate  on
    30  account  of  medical  assistance payments where recovery is made against
    31  the individual's managed care provider or provider of medical assistance
    32  program items or services. Provided however nothing in this  subdivision
    33  shall  be construed to limit recoveries under other relevant sections of
    34  law.
    35    § 3. Section 364-j of the social services law is amended by  adding  a
    36  new subdivision 36 to read as follows:
    37    36.  Medicaid  Program  Integrity  Reviews.  (a)  For purposes of this
    38  subdivision, managed care provider shall also include managed long  term
    39  care plans.
    40    (b)  The  Medicaid inspector general shall conduct periodic reviews of
    41  the contractual performance of each managed care provider as it  relates
    42  to  the  managed care provider's program integrity obligations under its
    43  contract with the department. The Medicaid inspector general, in consul-
    44  tation with the commissioner, shall publish on its website,  a  list  of
    45  those contractual obligations pursuant to which the managed care provid-
    46  er's  program integrity performance shall be evaluated, including bench-
    47  marks, prior to commencing any  review.  A  Medicaid  program  integrity
    48  review  of  a  managed care provider conducted pursuant to this subdivi-
    49  sion, may be completed no more than annually. Reviews performed pursuant
    50  to this subdivision shall include a review of compliance with contractu-
    51  al standards which prevent fraud, waste, or abuse.  Such  standards  may
    52  include  but are not limited to excluded providers, restricted recipient
    53  program, reporting obligations, compliance programs, and  suspension  of
    54  payments.  However,  if the Medicaid inspector general determines that a

        S. 1507--C                         86                         A. 2007--C
 
     1  subsequent review, pursuant to this subdivision, is necessary, a  second
     2  review may occur within one year.
     3    (c)  If,  as  a  result  of  his or her review, the Medicaid inspector
     4  general determines that a managed  care  provider  is  not  meeting  its
     5  program  integrity  obligations,  the  Medicaid  inspector  general  may
     6  recover from the managed care provider up to two percent of the Medicaid
     7  premiums paid to the managed care provider for the period under  review.
     8  Any premium recovery under this subdivision shall be a percentage of the
     9  administrative  component  of  the  Medicaid  premium  calculated by the
    10  department and may be recovered by the department in the same manner  it
    11  recovers overpayments.
    12    (d)  The  managed  care  provider shall be entitled to receive a draft
    13  audit report and final audit report containing the results of the  Medi-
    14  caid  inspector  general's  review.  If  the  Medicaid inspector general
    15  determines to recover a percentage of the premium as described in  para-
    16  graph  (c) of this subdivision, the managed care provider shall be enti-
    17  tled to notice and an opportunity to be heard in accordance with section
    18  twenty-two of this chapter.
    19    § 4. Subdivision 3 of section 363-d of the  social  services  law,  as
    20  amended  by  section  44 of part C of chapter 58 of the laws of 2007, is
    21  amended to read as follows:
    22    3. Upon enrollment in the medical assistance program, a provider shall
    23  certify to the department that the  provider  satisfactorily  meets  the
    24  requirements  of  this section. Additionally, the commissioner of health
    25  and Medicaid inspector general shall have the authority to determine  at
    26  any  time  if  a  provider  has a compliance program that satisfactorily
    27  meets the requirements of this section.
    28    (a) A compliance program that is accepted by the federal department of
    29  health and human services office of inspector  general  and  remains  in
    30  compliance with the standards promulgated by such office shall be deemed
    31  in compliance with the provisions of this section, so long as such plans
    32  adequately  address medical assistance program risk areas and compliance
    33  issues.
    34    (b) A compliance program that meets Federal requirements  for  managed
    35  care  provider  compliance  programs,  as  specified  in the contract or
    36  contracts between the department and the Medicaid managed care  provider
    37  shall  be  deemed  in compliance with the provisions in this section, so
    38  long as such programs adequately address medical assistance program risk
    39  areas and compliance issues. For purposes of  this  section,  a  managed
    40  care  provider  is  as  defined  in  paragraph (c) of subdivision one of
    41  section three hundred sixty-four-j of this chapter, and includes managed
    42  long term care plans.
    43    (c) In the event that the  commissioner  of  health  or  the  Medicaid
    44  inspector  general  finds that the provider does not have a satisfactory
    45  program within ninety days after the effective date of  the  regulations
    46  issued pursuant to subdivision four of this section, the provider may be
    47  subject to any sanctions or penalties permitted by federal or state laws
    48  and  regulations,  including  revocation  of the provider's agreement to
    49  participate in the medical assistance program.
    50    § 5. Intentionally omitted.
    51    § 6. Section 364-j of the social services law is amended by  adding  a
    52  new subdivision 35 to read as follows:
    53    35.  Recovery  of  overpayments  from network providers. (a) Where the
    54  Medicaid inspector general during the course of an audit, investigation,
    55  or review, or the deputy attorney general for the Medicaid fraud control
    56  unit during the course of an investigation or prosecution  for  Medicaid

        S. 1507--C                         87                         A. 2007--C
 
     1  fraud, identifies medical assistance overpayments made by a managed care
     2  provider  or managed long term care plan to its subcontractor or subcon-
     3  tractors or provider or providers, the state shall  have  the  right  to
     4  recover  the  overpayment  from  the  subcontractor  or  subcontractors,
     5  provider or providers, or the managed care provider or managed long term
     6  care plan; provided, however, in no event shall the state duplicate  the
     7  recovery of an overpayment from a provider or subcontractor.
     8    (b)  Where the state is unsuccessful in recovering an overpayment from
     9  the subcontractor or subcontractors or provider or providers, the  Medi-
    10  caid  inspector general may require the managed care provider or managed
    11  long term care plan to recover the medical assistance overpayment  iden-
    12  tified  in paragraph (a) of this subdivision on behalf of the state. The
    13  managed care provider or managed long term care plan shall remit to  the
    14  state  the  full  amount of the identified overpayment no later than six
    15  months after receiving notice of the overpayment from the state.
    16    § 7. This act shall take effect immediately and  shall  be  deemed  to
    17  have been in full force and effect on and after April 1, 2019; provided,
    18  however, that the amendments to section 364-j of the social services law
    19  made  by  sections one, two, three, and six of this act shall not affect
    20  the repeal of such section  and  shall  be  deemed  repealed  therewith;
    21  provided  further,  that  section  three  of  this  act shall apply to a
    22  contract or contracts in effect as of January 1, 2015 or thereafter  and
    23  any  review  period  in section three of this act shall not begin before
    24  January 1, 2018.
 
    25                                   PART W
 
    26    Section 1. Section 1 of part D of chapter 111  of  the  laws  of  2010
    27  relating to the recovery of exempt income by the office of mental health
    28  for community residences and family-based treatment programs, as amended
    29  by  section 1 of part H of chapter 59 of the laws of 2016, is amended to
    30  read as follows:
    31    Section 1. The office of mental health is authorized to recover  fund-
    32  ing  from  community  residences  and  family-based  treatment providers
    33  licensed by the office of mental  health,  consistent  with  contractual
    34  obligations  of such providers, and notwithstanding any other inconsist-
    35  ent provision of law to the contrary, in an amount equal to  50  percent
    36  of  the income received by such providers which exceeds the fixed amount
    37  of annual Medicaid revenue limitations, as established  by  the  commis-
    38  sioner of mental health. Recovery of such excess income shall be for the
    39  following  fiscal  periods:  for programs in counties located outside of
    40  the city of New York, the applicable fiscal periods shall be January  1,
    41  2003  through December 31, 2009 and January 1, 2011 through December 31,
    42  [2019] 2022; and for programs located within the city of New  York,  the
    43  applicable  fiscal  periods  shall be July 1, 2003 through June 30, 2010
    44  and July 1, 2011 through June 30, [2019] 2022.
    45    § 2. This act shall take effect immediately.
 
    46                                   PART X
 
    47                            Intentionally Omitted
 
    48                                   PART Y
 
    49    Section 1. Subdivisions 3-b and 3-c of section 1 of part C of  chapter
    50  57  of  the  laws  of  2006,  relating  to establishing a cost of living

        S. 1507--C                         88                         A. 2007--C
 
     1  adjustment for designated human services programs, as amended by section
     2  1 of part AA of chapter 57 of the laws of 2018, are amended to  read  as
     3  follows:
     4    3-b.  Notwithstanding  any  inconsistent  provision  of law, beginning
     5  April 1, 2009 and ending March 31, 2016 and beginning April 1, 2017  and
     6  ending March 31, [2019] 2020, the commissioners shall not include a COLA
     7  for  the  purpose  of  establishing  rates of payments, contracts or any
     8  other form of reimbursement, provided  that  the  commissioners  of  the
     9  office  for people with developmental disabilities, the office of mental
    10  health, and the office of alcoholism and substance abuse services  shall
    11  not  include  a COLA beginning April 1, 2017 and ending March 31, [2019]
    12  2021.
    13    3-c. Notwithstanding any  inconsistent  provision  of  law,  beginning
    14  April 1, [2019] 2020 and ending March 31, [2022] 2023, the commissioners
    15  shall develop the COLA under this section using the actual U.S. consumer
    16  price  index  for  all  urban  consumers (CPI-U) published by the United
    17  States department of labor, bureau of labor statistics  for  the  twelve
    18  month  period  ending  in  July  of  the budget year prior to such state
    19  fiscal  year,  for  the  purpose  of  establishing  rates  of  payments,
    20  contracts or any other form of reimbursement.
    21    §  2.  Section 1 of part C of chapter 57 of the laws of 2006, relating
    22  to establishing  a  cost  of  living  adjustment  for  designated  human
    23  services programs, is amended by adding a new subdivision 3-f to read as
    24  follows:
    25    3-f.  (i)  Notwithstanding  the  provisions of subdivision 3-b of this
    26  section or any other inconsistent provision of law, and subject  to  the
    27  availability  of  the appropriation therefor, for the programs listed in
    28  paragraphs (i), (ii), and (iii) of subdivision 4 of  this  section,  the
    29  commissioners  shall  provide  funding to support (1) an overall average
    30  two percent (2.00%) increase to total salaries for  direct  care  staff,
    31  direct  support  professionals  for  each  eligible state-funded program
    32  beginning January 1, 2020;  and  (2)  an  overall  average  two  percent
    33  (2.00%)  increase  to  total  salaries  for direct care staff and direct
    34  support professionals, and clinical staff for each eligible state-funded
    35  program beginning April  1,  2020.  For  the  purpose  of  this  funding
    36  increase,  direct  support  professionals  are  individuals  employed in
    37  consolidated fiscal reporting position title codes ranging from  100  to
    38  199;  direct  care staff are individuals employed in consolidated fiscal
    39  reporting position title codes ranging from 200  to  299;  and  clinical
    40  staff are individuals employed in consolidated fiscal reporting position
    41  title codes ranging from 300 to 399.
    42    (ii)  The  funding  made  available  pursuant to paragraph (i) of this
    43  subdivision shall be used: (1) to help  alleviate  the  recruitment  and
    44  retention  challenges of direct care staff, direct support professionals
    45  and clinical staff employed in eligible programs; and  (2)  to  continue
    46  and  to expand efforts to support the professionalism of the direct care
    47  workforce. Each  local  government  unit  or  direct  contract  provider
    48  receiving such funding shall have flexibility in allocating such funding
    49  to support salary increases to particular job titles to best address the
    50  needs  of  its direct care staff, direct support professionals and clin-
    51  ical staff. Each local  government  unit  or  direct  contract  provider
    52  receiving  such  funding  shall  also submit a written certification, in
    53  such form and at such time as each commissioner shall prescribe, attest-
    54  ing to how such funding will be or was used for purposes eligible  under
    55  this  section.  Further,  providers shall submit a resolution from their
    56  governing body to the appropriate commissioner, attesting that the fund-

        S. 1507--C                         89                         A. 2007--C
 
     1  ing received will be used solely to support  salary  and  salary-related
     2  fringe  benefit  increases for direct care staff, direct support profes-
     3  sionals and clinical staff, pursuant to paragraph (i) of  this  subdivi-
     4  sion.  Salary  increases that take effect on and after April 1, 2019 may
     5  be used to demonstrate compliance  with  the  January  1,  2020  funding
     6  increase  authorized by this section, except for salary increases neces-
     7  sary to comply with state minimum wage requirements. Such  commissioners
     8  shall  be  authorized  to recoup any funds as appropriated herein deter-
     9  mined to have been used in a manner inconsistent with such standards  or
    10  inconsistent  with  the provisions of this subdivision, and such commis-
    11  sioners shall be authorized to employ any legal mechanism to recoup such
    12  funds, including an offset of other funds that are owed  to  such  local
    13  governmental unit or provider.
    14    (iii) Where appropriate transfers to the department of health shall be
    15  made as reimbursement for the state share of medical assistance.
    16    §  3.  This  act  shall take effect immediately and shall be deemed to
    17  have been in full force and effect on and after April 1, 2019; provided,
    18  however, that the amendments to section 1 of part C of chapter 57 of the
    19  laws of 2006 made by sections one and two of this act shall  not  affect
    20  the repeal of such section and shall be deemed repealed therewith.
 
    21                                   PART Z
 
    22    Section  1. Subdivision 1 of section 2801 of the public health law, as
    23  amended by section 1 of subpart B of part S of chapter 57 of the laws of
    24  2018, is amended to read as follows:
    25    1. "Hospital" means a facility or institution engaged  principally  in
    26  providing services by or under the supervision of a physician or, in the
    27  case  of  a dental clinic or dental dispensary, of a dentist, or, in the
    28  case of a midwifery birth center, of  a  midwife,  for  the  prevention,
    29  diagnosis  or  treatment  of  human  disease, pain, injury, deformity or
    30  physical condition, including, but not limited to, a  general  hospital,
    31  public  health center, diagnostic center, treatment center, dental clin-
    32  ic, dental dispensary, rehabilitation center other than a facility  used
    33  solely  for vocational rehabilitation, nursing home, tuberculosis hospi-
    34  tal, chronic  disease  hospital,  maternity  hospital,  midwifery  birth
    35  center,  lying-in-asylum,  out-patient  department,  out-patient  lodge,
    36  dispensary and a laboratory or central service facility serving  one  or
    37  more  such  institutions,  but  the  term  hospital shall not include an
    38  institution, sanitarium or other facility engaged principally in provid-
    39  ing services for the prevention, diagnosis or treatment of mental  disa-
    40  bility  and  which  is subject to the powers of visitation, examination,
    41  inspection and investigation of the department of mental hygiene  except
    42  for  those  distinct  parts  of  such  a facility which provide hospital
    43  service. The provisions of this article shall not apply to a facility or
    44  institution engaged principally in providing services by  or  under  the
    45  supervision of the bona fide members and adherents of a recognized reli-
    46  gious  organization  whose teachings include reliance on spiritual means
    47  through prayer alone for healing in the practice of the religion of such
    48  organization and where services are provided in  accordance  with  those
    49  teachings.  No  provision  of this article or any other provision of law
    50  shall be construed to: (a) limit  the  volume  of  mental  health  [or],
    51  substance  use  disorder  services  or developmental disability services
    52  that can be provided by a provider of  primary  care  services  licensed
    53  under  this  article  and  authorized  to provide integrated services in
    54  accordance with regulations issued by the commissioner  in  consultation

        S. 1507--C                         90                         A. 2007--C
 
     1  with  the commissioner of the office of mental health [and], the commis-
     2  sioner of the office of alcoholism and substance abuse services and  the
     3  commissioner  of  the office for people with developmental disabilities,
     4  including  regulations  issued  pursuant to subdivision seven of section
     5  three hundred sixty-five-l of the social services law or part L of chap-
     6  ter fifty-six of the laws of two thousand twelve; (b) require a provider
     7  licensed pursuant to article thirty-one of the  mental  hygiene  law  or
     8  certified  pursuant  to  article  sixteen  or  article thirty-two of the
     9  mental hygiene law to obtain an operating certificate from  the  depart-
    10  ment if such provider has been authorized to provide integrated services
    11  in  accordance  with regulations issued by the commissioner in consulta-
    12  tion with the commissioner of the office of  mental  health  [and],  the
    13  commissioner  of  the  office of alcoholism and substance abuse services
    14  and the commissioner of the office for people with  developmental  disa-
    15  bilities,  including regulations issued pursuant to subdivision seven of
    16  section three hundred sixty-five-l of the social services law or part  L
    17  of chapter fifty-six of the laws of two thousand twelve.
    18    §  2.  Subdivision  (f) of section 31.02 of the mental hygiene law, as
    19  added by section 2 of subpart B of part S of chapter 57 of the  laws  of
    20  2018, is amended to read as follows:
    21    (f)  No  provision of this article or any other provision of law shall
    22  be construed to require a provider licensed pursuant to article  twenty-
    23  eight  of the public health law or certified pursuant to article sixteen
    24  or article thirty-two of this chapter to obtain an operating certificate
    25  from the office of mental health if such provider has been authorized to
    26  provide integrated services in accordance with regulations issued by the
    27  commissioner of the office of mental health  in  consultation  with  the
    28  commissioner  of the department of health [and], the commissioner of the
    29  office of alcoholism and substance abuse services and  the  commissioner
    30  of  the  office  for  people  with developmental disabilities, including
    31  regulations issued  pursuant  to  subdivision  seven  of  section  three
    32  hundred  sixty-five-l  of  the  social services law or part L of chapter
    33  fifty-six of the laws of two thousand twelve.
    34    § 3. Subdivision (b) of section 32.05 of the mental  hygiene  law,  as
    35  amended by section 3 of subpart B of part S of chapter 57 of the laws of
    36  2018, is amended to read as follow:
    37    (b)  (i)  Methadone,  or such other controlled substance designated by
    38  the commissioner of health as appropriate for such use, may be  adminis-
    39  tered  to  an  addict, as defined in section thirty-three hundred two of
    40  the public health law, by individual physicians,  groups  of  physicians
    41  and  public  or private medical facilities certified pursuant to article
    42  twenty-eight or thirty-three of the public health law as part of a chem-
    43  ical dependence program which has been issued an  operating  certificate
    44  by the commissioner pursuant to subdivision (b) of section 32.09 of this
    45  article,  provided,  however,  that  such administration must be done in
    46  accordance with all applicable federal and state laws  and  regulations.
    47  Individual physicians or groups of physicians who have obtained authori-
    48  zation  from  the  federal  government  to  administer  buprenorphine to
    49  addicts may do so without obtaining an operating  certificate  from  the
    50  commissioner.  (ii)  No provision of this article or any other provision
    51  of law shall be construed to require a  provider  licensed  pursuant  to
    52  article  twenty-eight  of the public health law [or], article thirty-one
    53  of this chapter or a provider certified pursuant to article  sixteen  of
    54  this chapter to obtain an operating certificate from the office of alco-
    55  holism and substance abuse services if such provider has been authorized
    56  to  provide integrated services in accordance with regulations issued by

        S. 1507--C                         91                         A. 2007--C
 
     1  the commissioner of alcoholism and substance abuse services in consulta-
     2  tion with the commissioner  of  the  department  of  health  [and],  the
     3  commissioner  of the office of mental health and the commissioner of the
     4  office for people with developmental disabilities, including regulations
     5  issued  pursuant  to  subdivision  seven of section three hundred sixty-
     6  five-l of the social services law or part L of chapter fifty-six of  the
     7  laws of two thousand twelve.
     8    §  4.  Section  16.03 of the mental hygiene law is amended by adding a
     9  new subdivision (g) to read as follows:
    10    (g) No provision of this article or any other provision of  law  shall
    11  be  construed to require a provider licensed pursuant to article twenty-
    12  eight of the public health law or certified pursuant to article  thirty-
    13  one  or  thirty-two  of  this chapter to obtain an operating certificate
    14  from the office for  people  with  developmental  disabilities  if  such
    15  provider  has  been authorized to provide integrated services in accord-
    16  ance with regulations issued by  the  commissioner  of  the  office  for
    17  people with developmental disabilities, in consultation with the commis-
    18  sioner  of  the  department of health, the commissioner of the office of
    19  mental health and the commissioner  of  the  office  of  alcoholism  and
    20  substance  abuse  services,  including  regulations  issued  pursuant to
    21  subdivision seven of section three hundred sixty-five-l  of  the  social
    22  services  law or part L of chapter fifty-six of the laws of two thousand
    23  twelve.
    24    § 5. This act shall take effect October 1,  2019;  provided,  however,
    25  that  the  commissioner of the department of health, the commissioner of
    26  the office of mental health, the commissioner of the office of  alcohol-
    27  ism and substance abuse services, and the commissioner of the office for
    28  people  with developmental disabilities are authorized to issue any rule
    29  or regulation necessary for the implementation of this act on or  before
    30  its effective date.
 
    31                                   PART AA
 
    32                            Intentionally Omitted
 
    33                                   PART BB
 
    34    Section  1.  This part enacts into law major components of legislation
    35  which are necessary to effectuate provisions relating to  mental  health
    36  and  substance  use  disorder  treatment.    Each  component  is  wholly
    37  contained within a Subpart identified  as  Subparts  A  through  E.  The
    38  effective  date  for  each  particular  provision  contained within such
    39  Subpart is set forth in the last section of such Subpart. Any  provision
    40  in  any section contained within a Subpart, including the effective date
    41  of the Subpart, which makes a reference to a section "of this act", when
    42  used in connection with that particular component, shall  be  deemed  to
    43  mean  and  refer to the corresponding section of the Subpart in which it
    44  is found. Section three of this Part sets forth  the  general  effective
    45  date of this Part.
 
    46                                  SUBPART A
 
    47    Section 1. Paragraph 4 of subsection (i) of section 3216 of the insur-
    48  ance law is amended to read as follows:
    49    (4)  If a policy provides for reimbursement for psychiatric or psycho-
    50  logical services or for diagnosis and treatment of  mental[,nervous,  or

        S. 1507--C                         92                         A. 2007--C

     1  emotional  disorders  or ailments,] health conditions however defined in
     2  the policy, the insured shall be  entitled  to  reimbursement  for  such
     3  services,  diagnosis  or  treatment  whether  performed  by a physician,
     4  psychiatrist  [or],  a certified and registered psychologist, or a nurse
     5  practitioner when the services rendered are within the lawful  scope  of
     6  their practice.
     7    §  2.  Subparagraph  (B)  of paragraph 25 of subsection (i) of section
     8  3216 of the insurance law, as amended by section 38 of part D of chapter
     9  56 of the laws of 2013, is amended to read as follows:
    10    (B) Every policy that  provides  physician  services,  medical,  major
    11  medical  or  similar  comprehensive-type coverage shall provide coverage
    12  for the screening, diagnosis and treatment of autism  spectrum  disorder
    13  in accordance with this paragraph and shall not exclude coverage for the
    14  screening,  diagnosis  or  treatment  of  medical  conditions  otherwise
    15  covered by the policy because the individual is  diagnosed  with  autism
    16  spectrum  disorder.  Such coverage may be subject to annual deductibles,
    17  copayments and coinsurance as may be deemed appropriate  by  the  super-
    18  intendent  and  shall be consistent with those imposed on other benefits
    19  under the policy. [Coverage  for  applied  behavior  analysis  shall  be
    20  subject  to  a  maximum benefit of six hundred eighty hours of treatment
    21  per policy or calendar year  per  covered  individual.]  This  paragraph
    22  shall  not  be  construed  as  limiting  the benefits that are otherwise
    23  available to an individual under the policy, provided however that  such
    24  policy  shall  not  contain  any  limitations  on visits that are solely
    25  applied to the treatment of autism spectrum disorder. No  insurer  shall
    26  terminate  coverage or refuse to deliver, execute, issue, amend, adjust,
    27  or renew coverage to an individual  solely  because  the  individual  is
    28  diagnosed  with  autism  spectrum disorder or has received treatment for
    29  autism spectrum disorder.  Coverage  shall  be  subject  to  utilization
    30  review  and external appeals of health care services pursuant to article
    31  forty-nine of this chapter as well as[,] case  management[,]  and  other
    32  managed care provisions.
    33    §  3.  Items  (i)  and  (iii)  of  subparagraph (C) of paragraph 25 of
    34  subsection (i) of section 3216 of the insurance law, as amended by chap-
    35  ter 596 of the laws of 2011, are amended to read as follows:
    36    (i) "autism  spectrum  disorder"  means  any  pervasive  developmental
    37  disorder  as  defined  in  the most recent edition of the diagnostic and
    38  statistical manual of mental disorders[,  including  autistic  disorder,
    39  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
    40  or pervasive developmental disorder not otherwise specified (PDD-NOS)].
    41    (iii)  "behavioral  health  treatment"  means counseling and treatment
    42  programs, when provided by a licensed  provider,  and  applied  behavior
    43  analysis, when provided [or supervised] by a [behavior analyst certified
    44  pursuant  to  the behavior analyst certification board] person licensed,
    45  certified or otherwise authorized to provide applied behavior  analysis,
    46  that  are  necessary  to  develop,  maintain, or restore, to the maximum
    47  extent practicable, the functioning of an individual. [Individuals  that
    48  provide behavioral health treatment under the supervision of a certified
    49  behavior  analyst  pursuant to this paragraph shall be subject to stand-
    50  ards of professionalism, supervision and relevant experience pursuant to
    51  regulations promulgated by the superintendent in consultation  with  the
    52  commissioners of health and education.]
    53    §  4.  Paragraph 25 of subsection (i) of section 3216 of the insurance
    54  law is amended by adding four new subparagraphs (H), (I), (J),  and  (K)
    55  to read as follows:

        S. 1507--C                         93                         A. 2007--C
 
     1    (H)  Coverage  under this paragraph shall not apply financial require-
     2  ments or treatment limitations to autism spectrum disorder benefits that
     3  are more  restrictive than the predominant  financial  requirements  and
     4  treatment  limitations applied to substantially all medical and surgical
     5  benefits covered  by the policy.
     6    (I) The criteria for medical necessity determinations under the policy
     7  with  respect  to autism spectrum disorder benefits shall be made avail-
     8  able by the  insurer to any insured, prospective insured, or  in-network
     9  provider upon request.
    10    (J) For purposes of this paragraph:
    11    (i)  "financial requirement" means deductible, copayments, coinsurance
    12  and out-of-pocket expenses;
    13    (ii) "predominant" means that a  financial  requirement  or  treatment
    14  limitation  is  the  most  common  or  frequent of such type of limit or
    15  requirement; and
    16    (iii) "treatment limitation" means limits on the frequency  of  treat-
    17  ment, number of visits, days of coverage, or other similar limits on the
    18  scope  or  duration  of treatment and includes nonquantitative treatment
    19  limitations such as: medical management standards limiting or  excluding
    20  benefits  based on medical  necessity, or based on whether the treatment
    21  is experimental or investigational; formulary  design  for  prescription
    22  drugs; network tier design; standards for  provider admission to partic-
    23  ipate  in  a network, including reimbursement rates;  methods for deter-
    24  mining usual, customary, and reasonable charges;  fail-first  or    step
    25  therapy  protocols;  exclusions based on failure to complete a course of
    26  treatment; and restrictions based on geographic location, facility type,
    27  provider specialty, and other criteria that limit the scope or  duration
    28  of  benefits for services provided under the policy.
    29    (K) An insurer shall provide coverage under this paragraph, at a mini-
    30  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    31  Health  Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    32    §  5.  Paragraph 30 of subsection (i) of section 3216 of the insurance
    33  law, as amended by section 1 of part B of chapter  71  of  the  laws  of
    34  2016, is amended to read as follows:
    35    (30)(A)  Every policy that provides hospital, major medical or similar
    36  comprehensive coverage [must] shall provide inpatient coverage  for  the
    37  diagnosis and treatment of substance use disorder, including detoxifica-
    38  tion  and rehabilitation services. Such inpatient coverage shall include
    39  unlimited medically  necessary  treatment  for  substance  use  disorder
    40  treatment  services provided in residential settings [as required by the
    41  Mental Health Parity and Addiction Equity  Act  of  2008  (29  U.S.C.  §
    42  1185a)].    Further,  such  inpatient coverage shall not apply financial
    43  requirements or  treatment  limitations,  including  utilization  review
    44  requirements, to inpatient substance use disorder benefits that are more
    45  restrictive  than  the  predominant financial requirements and treatment
    46  limitations applied to substantially all medical and  surgical  benefits
    47  covered  by  the  policy.  [Further,  such  coverage  shall  be provided
    48  consistent with the federal Paul  Wellstone  and  Pete  Domenici  Mental
    49  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
    50    (B)  Coverage  provided under this paragraph may be limited to facili-
    51  ties in New York state [which are certified] that are  licensed,  certi-
    52  fied  or  otherwise authorized by the office of alcoholism and substance
    53  abuse services and, in other states, to those which  are  accredited  by
    54  the joint commission as alcoholism, substance abuse, or chemical depend-
    55  ence  treatment programs and are similarly licensed, certified or other-
    56  wise authorized in the state in which the facility is located.

        S. 1507--C                         94                         A. 2007--C
 
     1    (C) Coverage provided under this paragraph may be  subject  to  annual
     2  deductibles and co-insurance as deemed appropriate by the superintendent
     3  and  that  are  consistent with those imposed on other benefits within a
     4  given policy.
     5    (D) This subparagraph shall apply to facilities in this state that are
     6  licensed,  certified or otherwise authorized by the office of alcoholism
     7  and substance abuse services that are  participating  in  the  insurer's
     8  provider  network.  Coverage  provided under this paragraph shall not be
     9  subject to preauthorization.  Coverage  provided  under  this  paragraph
    10  shall  also  not  be subject to concurrent utilization review during the
    11  first [fourteen] twenty-eight days of the inpatient  admission  provided
    12  that  the  facility  notifies  the insurer of both the admission and the
    13  initial treatment plan within [forty-eight hours] two business  days  of
    14  the  admission.  The facility shall perform daily clinical review of the
    15  patient, including [the] periodic consultation with the  insurer  at  or
    16  just prior to the fourteenth day of treatment to ensure that the facili-
    17  ty  is  using  the evidence-based and peer reviewed clinical review tool
    18  utilized by the insurer which is designated by the office of  alcoholism
    19  and  substance abuse services and appropriate to the age of the patient,
    20  to ensure that the inpatient treatment is medically  necessary  for  the
    21  patient.  Prior to discharge, the facility shall provide the patient and
    22  the  insurer with a written discharge plan which shall describe arrange-
    23  ments for additional services needed following discharge from the  inpa-
    24  tient  facility as determined using the evidence-based and peer-reviewed
    25  clinical review tool utilized by the insurer which is designated by  the
    26  office  of alcoholism and substance abuse services.  Prior to discharge,
    27  the facility shall indicate to the insurer whether services included  in
    28  the discharge plan are secured or determined to be reasonably available.
    29  Any utilization review of treatment provided under this subparagraph may
    30  include  a  review of all services provided during such inpatient treat-
    31  ment, including all services provided during the first [fourteen]  twen-
    32  ty-eight days of such inpatient treatment. Provided, however, the insur-
    33  er  shall  only  deny coverage for any portion of the initial [fourteen]
    34  twenty-eight day inpatient treatment on the basis  that  such  treatment
    35  was  not medically necessary if such inpatient treatment was contrary to
    36  the evidence-based and peer reviewed clinical review  tool  utilized  by
    37  the  insurer  which  is  designated  by  the  office  of  alcoholism and
    38  substance abuse services. An insured shall not have any financial  obli-
    39  gation  to  the facility for any treatment under this subparagraph other
    40  than any copayment, coinsurance, or deductible otherwise required  under
    41  the policy.
    42    (E)  An  insurer  shall  make  available  to  any insured, prospective
    43  insured, or in-network provider, upon request, the criteria for  medical
    44  necessity  determinations  under  the  policy  with respect to inpatient
    45  substance use disorder benefits.
    46    (F) For purposes of this paragraph:
    47    (i) "financial requirement" means deductible, copayments,  coinsurance
    48  and out-of-pocket expenses;
    49    (ii)  "predominant"  means  that  a financial requirement or treatment
    50  limitation is the most common or frequent  of  such  type  of  limit  or
    51  requirement;
    52    (iii)  "treatment  limitation" means limits on the frequency of treat-
    53  ment, number of visits, days of coverage, or other similar limits on the
    54  scope or duration of treatment and  includes  nonquantitative  treatment
    55  limitations  such as: medical management standards limiting or excluding
    56  benefits based on medical necessity, or based on whether  the  treatment

        S. 1507--C                         95                         A. 2007--C
 
     1  is  experimental  or  investigational; formulary design for prescription
     2  drugs; network tier design; standards for provider admission to  partic-
     3  ipate in a network, including reimbursement rates; methods for determin-
     4  ing usual, customary, and reasonable charges; fail-first or step therapy
     5  protocols;  exclusions  based  on failure to complete a course of treat-
     6  ment; and restrictions based  on  geographic  location,  facility  type,
     7  provider  specialty, and other criteria that limit the scope or duration
     8  of benefits for services provided under the policy; and
     9    (iv) "substance use disorder" shall have the meaning set forth in  the
    10  most  recent  edition of the diagnostic and statistical manual of mental
    11  disorders or the most recent edition  of  another  generally  recognized
    12  independent  standard  of current medical practice, such as the interna-
    13  tional classification of diseases.
    14    (G) An insurer shall provide coverage under this paragraph, at a mini-
    15  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    16  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    17    § 6. Paragraph 31 of subsection (i) of section 3216 of  the  insurance
    18  law,  as added by chapter 41 of the laws of 2014 and subparagraph (E) as
    19  added by section 3 of part MM of chapter 57 of  the  laws  of  2018,  is
    20  amended to read as follows:
    21    (31)  (A) Every policy that provides medical, major medical or similar
    22  comprehensive-type coverage [must] shall provide outpatient coverage for
    23  the diagnosis and treatment of substance use disorder, including detoxi-
    24  fication and rehabilitation services.  Such  coverage  shall  not  apply
    25  financial  requirements or treatment limitations to outpatient substance
    26  use disorder benefits that are more  restrictive  than  the  predominant
    27  financial requirements and treatment limitations applied to substantial-
    28  ly  all  medical and surgical benefits covered by the policy.  [Further,
    29  such coverage shall be provided consistent with the federal  Paul  Well-
    30  stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
    31  2008 (29 U.S.C. § 1185a).]
    32    (B)  Coverage under this paragraph may be limited to facilities in New
    33  York state [certified] that are licensed, certified or otherwise author-
    34  ized by the office  of  alcoholism  and  substance  abuse  services  [or
    35  licensed  by  such  office as outpatient clinics or medically supervised
    36  ambulatory] to provide outpatient substance [abuse programs] use  disor-
    37  der  services and, in other states, to those which are accredited by the
    38  joint commission as alcoholism or chemical  dependence  substance  abuse
    39  treatment  programs  and are similarly licensed, certified, or otherwise
    40  authorized in the state in which the facility is located.
    41    (C) Coverage provided under this paragraph may be  subject  to  annual
    42  deductibles and co-insurance as deemed appropriate by the superintendent
    43  and  that  are  consistent with those imposed on other benefits within a
    44  given policy.
    45    (D) A policy providing coverage for substance  use  disorder  services
    46  pursuant  to this paragraph shall provide up to twenty outpatient visits
    47  per policy or calendar year to  an  individual  who  identifies  him  or
    48  herself  as  a  family  member  of a person suffering from substance use
    49  disorder and who seeks treatment as a family  member  who  is  otherwise
    50  covered  by the applicable policy pursuant to this paragraph. The cover-
    51  age required by this paragraph  shall  include  treatment  as  a  family
    52  member  pursuant to such family member's own policy provided such family
    53  member:
    54    (i) does not exceed the allowable number of family visits provided  by
    55  the applicable policy pursuant to this paragraph; and

        S. 1507--C                         96                         A. 2007--C
 
     1    (ii)  is otherwise entitled to coverage pursuant to this paragraph and
     2  such family member's applicable policy.
     3    (E) This subparagraph shall apply to facilities in this state that are
     4  licensed,  certified or otherwise authorized by the office of alcoholism
     5  and substance abuse services for the provision of outpatient,  intensive
     6  outpatient,  outpatient  rehabilitation  and  opioid  treatment that are
     7  participating in the insurer's provider network. Coverage provided under
     8  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
     9  provided  under this paragraph shall not be subject to concurrent review
    10  for the first [two] four weeks of continuous treatment,  not  to  exceed
    11  [fourteen]  twenty-eight  visits,  provided  the  facility  notifies the
    12  insurer of both the start of treatment and the  initial  treatment  plan
    13  within [forty-eight hours] two business days. The facility shall perform
    14  clinical  assessment of the patient at each visit, including [the] peri-
    15  odic consultation with the insurer at or just prior  to  the  fourteenth
    16  day of treatment to ensure that the facility is using the evidence-based
    17  and  peer reviewed clinical review tool utilized by the insurer which is
    18  designated by the office of alcoholism and substance abuse services  and
    19  appropriate  to  the  age  of the patient, to ensure that the outpatient
    20  treatment is medically necessary for the patient. Any utilization review
    21  of the treatment provided under this subparagraph may include  a  review
    22  of all services provided during such outpatient treatment, including all
    23  services provided during the first [two] four weeks of continuous treat-
    24  ment,  not  to exceed [fourteen] twenty-eight visits, of such outpatient
    25  treatment. Provided, however, the insurer shall only deny  coverage  for
    26  any portion of the initial [two] four weeks of continuous treatment, not
    27  to  exceed  [fourteen]  twenty-eight visits, for outpatient treatment on
    28  the basis that such treatment was not medically necessary if such outpa-
    29  tient treatment was contrary to the  evidence-based  and  peer  reviewed
    30  clinical  review tool utilized by the insurer which is designated by the
    31  office of alcoholism and substance abuse services. An insured shall  not
    32  have  any  financial  obligation to the facility for any treatment under
    33  this subparagraph other than any copayment, coinsurance,  or  deductible
    34  otherwise required under the policy.
    35    (F) The criteria for medical necessity determinations under the policy
    36  with respect to outpatient substance use disorder benefits shall be made
    37  available by the insurer to any insured, prospective insured, or in-net-
    38  work provider upon request.
    39    (G) For purposes of this paragraph:
    40    (i)  "financial requirement" means deductible, copayments, coinsurance
    41  and out-of-pocket expenses;
    42    (ii) "predominant" means that a  financial  requirement  or  treatment
    43  limitation  is  the  most  common  or  frequent of such type of limit or
    44  requirement;
    45    (iii) "treatment limitation" means limits on the frequency  of  treat-
    46  ment, number of visits, days of coverage, or other similar limits on the
    47  scope  or  duration  of treatment and includes nonquantitative treatment
    48  limitations such as: medical management standards limiting or  excluding
    49  benefits  based  on medical necessity, or based on whether the treatment
    50  is experimental or investigational; formulary  design  for  prescription
    51  drugs;  network tier design; standards for provider admission to partic-
    52  ipate in a network, including reimbursement rates; methods for determin-
    53  ing usual, customary, and reasonable charges; fail-first or step therapy
    54  protocols; exclusions based on failure to complete a  course  of  treat-
    55  ment;  and  restrictions  based  on  geographic location, facility type,

        S. 1507--C                         97                         A. 2007--C
 
     1  provider specialty, and other criteria that limit the scope or  duration
     2  of benefits for services provided under the policy; and
     3    (iv)  "substance use disorder" shall have the meaning set forth in the
     4  most recent edition of the diagnostic and statistical manual  of  mental
     5  disorders  or  the  most  recent edition of another generally recognized
     6  independent standard of current medical practice such  as  the  interna-
     7  tional classification of diseases.
     8    (H) An insurer shall provide coverage under this paragraph, at a mini-
     9  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    10  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    11    § 7. Paragraph 31-a of subsection (i) of section 3216 of the insurance
    12  law,  as added by section 1 of part B of chapter 69 of the laws of 2016,
    13  is amended to read as follows:
    14    (31-a) [(A)] Every policy that  provides  medical,  major  medical  or
    15  similar   comprehensive-type   coverage   and   provides   coverage  for
    16  prescription drugs for medication for the treatment of a  substance  use
    17  disorder shall include immediate access, without prior authorization, to
    18  [a  five day emergency supply] the formulary forms of prescribed medica-
    19  tions covered under the policy for the treatment of substance use disor-
    20  der [where an emergency condition exists], including a  prescribed  drug
    21  or medication associated with the management of opioid withdrawal and/or
    22  stabilization, except where otherwise prohibited by law. Further, cover-
    23  age  [of  an emergency supply] without prior authorization shall include
    24  formulary forms of medication for  opioid  overdose  reversal  otherwise
    25  covered  under  the  policy  prescribed  or  dispensed  to an individual
    26  covered by the policy.
    27    [(B) For purposes of this paragraph, an "emergency condition" means  a
    28  substance use disorder condition that manifests itself by acute symptoms
    29  of  sufficient  severity,  including  severe  pain or the expectation of
    30  severe pain, such that a prudent layperson, possessing an average  know-
    31  ledge  of  medicine  and  health, could reasonably expect the absence of
    32  immediate medical attention to result in:
    33    (i) placing the health of the person afflicted with such condition  in
    34  serious  jeopardy, or in the case of a behavioral condition, placing the
    35  health of such person or others in serious jeopardy;
    36    (ii) serious impairment to such person's bodily functions;
    37    (iii) serious dysfunction of any bodily organ or part of such person;
    38    (iv) serious disfigurement of such person; or
    39    (v) a condition described in clause (i), (ii),  or  (iii)  of  section
    40  1867(e)(1)(A) of the Social Security Act.
    41    (C)  Coverage  provided  under this paragraph may be subject to copay-
    42  ments, coinsurance, and annual  deductibles  that  are  consistent  with
    43  those imposed on other benefits within the policy; provided, however, no
    44  policy shall impose an additional copayment or coinsurance on an insured
    45  who received an emergency supply of medication and then received up to a
    46  thirty  day  supply of the same medication in the same thirty day period
    47  in which the emergency supply of medication was dispensed. This subpara-
    48  graph shall not preclude the imposition of a copayment or coinsurance on
    49  the initial emergency supply of medication in an  amount  that  is  less
    50  than  the  copayment or coinsurance otherwise applicable to a thirty day
    51  supply of such medication, provided that the total sum of the copayments
    52  or coinsurance for an entire thirty day supply of  the  medication  does
    53  not exceed the copayment or coinsurance otherwise applicable to a thirty
    54  day supply of such medication.]
    55    § 8. Subsection (i) of section 3216 of the insurance law is amended by
    56  adding a new paragraph 35 to read as follows:

        S. 1507--C                         98                         A. 2007--C
 
     1    (35)  (A)  Every policy delivered or issued for delivery in this state
     2  that provides coverage for  inpatient  hospital  care  or  coverage  for
     3  physician  services  shall provide coverage for the diagnosis and treat-
     4  ment of mental health conditions as follows:
     5    (i)  where  the  policy provides coverage for inpatient hospital care,
     6  benefits for inpatient care in a hospital as defined by subdivision  ten
     7  of  section  1.03  of the mental hygiene law and benefits for outpatient
     8  care provided in a facility  issued  an  operating  certificate  by  the
     9  commissioner  of  mental  health  pursuant  to the provisions of article
    10  thirty-one of the mental hygiene law, or in a facility operated  by  the
    11  office of mental health, or, for care provided in other states, to simi-
    12  larly licensed or certified hospitals or facilities; and
    13    (ii)  where the policy provides coverage for physician services, bene-
    14  fits for outpatient care provided  by  a  psychiatrist  or  psychologist
    15  licensed  to  practice  in this state, a licensed clinical social worker
    16  who meets the requirements of subparagraph  (D)  of  paragraph  four  of
    17  subsection  (1) of section three thousand two hundred twenty-one of this
    18  article, a nurse practitioner licensed to practice in this state,  or  a
    19  professional  corporation  or  university  faculty  practice corporation
    20  thereof.
    21    (B) Coverage required by this  paragraph  may  be  subject  to  annual
    22  deductibles,  copayments and coinsurance as may be deemed appropriate by
    23  the superintendent and shall be consistent with those imposed  on  other
    24  benefits under the policy.
    25    (C)  Coverage  under this paragraph shall not apply financial require-
    26  ments or treatment limitations to mental health benefits that  are  more
    27  restrictive  than  the  predominant financial requirements and treatment
    28  limitations applied to substantially all medical and  surgical  benefits
    29  covered by the policy.
    30    (D) The criteria for medical necessity determinations under the policy
    31  with  respect  to  mental health benefits shall be made available by the
    32  insurer to any insured, prospective insured, or in-network provider upon
    33  request.
    34    (E) For purposes of this paragraph:
    35    (i) "financial requirement" means deductible, copayments,  coinsurance
    36  and out-of-pocket expenses;
    37    (ii)  "predominant"  means  that  a financial requirement or treatment
    38  limitation is the most common or frequent  of  such  type  of  limit  or
    39  requirement;
    40    (iii)  "treatment  limitation" means limits on the frequency of treat-
    41  ment, number of visits, days of coverage, or other similar limits on the
    42  scope or duration of treatment and  includes  nonquantitative  treatment
    43  limitations such as:  medical management standards limiting or excluding
    44  benefits  based  on medical necessity, or based on whether the treatment
    45  is experimental or investigational; formulary  design  for  prescription
    46  drugs;  network tier design; standards for provider admission to partic-
    47  ipate in a network, including reimbursement rates; methods for determin-
    48  ing usual, customary, and reasonable charges; fail-first or step therapy
    49  protocols; exclusions based on failure to complete a  course  of  treat-
    50  ment;  and  restrictions  based  on  geographic location, facility type,
    51  provider specialty, and other criteria that limit the scope or  duration
    52  of benefits for services provided under the policy; and
    53    (iv)  "mental  health  condition"  means any mental health disorder as
    54  defined in the most recent edition of  the  diagnostic  and  statistical
    55  manual  of mental disorders or the most recent edition of another gener-

        S. 1507--C                         99                         A. 2007--C
 
     1  ally recognized independent standard of current medical practice such as
     2  the international classification of diseases.
     3    (F) An insurer shall provide coverage under this paragraph, at a mini-
     4  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
     5  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
     6    (G)  This subparagraph shall apply to hospitals in this state that are
     7  licensed by the office of mental health that are  participating  in  the
     8  insurer's provider network. Where the policy provides coverage for inpa-
     9  tient  hospital care, benefits for inpatient hospital care in a hospital
    10  as defined by subdivision ten of section 1.03 of the mental hygiene  law
    11  provided  to individuals who have not attained the age of eighteen shall
    12  not be subject to preauthorization. Coverage provided under this subpar-
    13  agraph shall also not be subject to concurrent utilization review during
    14  the first fourteen days of the inpatient admission, provided the facili-
    15  ty notifies the insurer of both the admission and the initial  treatment
    16  plan  within two business days of the admission, performs daily clinical
    17  review of the patient, and participates in  periodic  consultation  with
    18  the  insurer to ensure that the facility is using the evidence-based and
    19  peer reviewed clinical review criteria utilized by the insurer which  is
    20  approved  by  the  office of mental health and appropriate to the age of
    21  the patient, to ensure that the inpatient care  is  medically  necessary
    22  for  the  patient. All treatment provided under this subparagraph may be
    23  reviewed retrospectively.  Where  care  is  denied  retrospectively,  an
    24  insured  shall not have any financial obligation to the facility for any
    25  treatment under this subparagraph other than any copayment, coinsurance,
    26  or deductible otherwise required under the policy.
    27    § 9. Paragraphs 17, 19 and 20 of subsection 2 of section 3217-a of the
    28  insurance law, paragraph 17 as amended and paragraphs 19 and 20 as added
    29  by section 1 of part H of chapter 60 of the laws of  2014,  are  amended
    30  and a new paragraph 21 is added to read as follows:
    31    (17) where applicable, a listing by specialty, which may be in a sepa-
    32  rate  document that is updated annually, of the name, address, and tele-
    33  phone number of all participating providers, including facilities,  and:
    34  (A)  whether  the provider is accepting new patients; (B) in the case of
    35  mental health or substance use disorder services providers,  any  affil-
    36  iations  with  participating  facilities  certified or authorized by the
    37  office of mental health or the office of alcoholism and substance  abuse
    38  services,  and  any restrictions regarding the availability of the indi-
    39  vidual provider's services; and [in addition,] (C) in the case of physi-
    40  cians, board certification, languages spoken and any  affiliations  with
    41  participating  hospitals. The listing shall also be posted on the insur-
    42  er's website and the insurer shall update  the  website  within  fifteen
    43  days  of  the  addition  or termination of a provider from the insurer's
    44  network or a change in a physician's hospital affiliation;
    45    (19) with respect to out-of-network coverage:
    46    (A) a clear description of the methodology  used  by  the  insurer  to
    47  determine reimbursement for out-of-network health care services;
    48    (B)  the  amount that the insurer will reimburse under the methodology
    49  for out-of-network health care services set forth as a percentage of the
    50  usual and customary cost for out-of-network health care services; and
    51    (C) examples of anticipated out-of-pocket costs for frequently  billed
    52  out-of-network health care services; [and]
    53    (20)  information  in  writing  and  through  an internet website that
    54  reasonably permits an insured or prospective  insured  to  estimate  the
    55  anticipated  out-of-pocket  cost for out-of-network health care services
    56  in a geographical area or zip code based  upon  the  difference  between

        S. 1507--C                         100                        A. 2007--C

     1  what  the insurer will reimburse for out-of-network health care services
     2  and  the  usual  and  customary  cost  for  out-of-network  health  care
     3  services[.]; and
     4    (21)  the most recent comparative analysis performed by the insurer to
     5  assess the provision of its covered services in accordance with the Paul
     6  Wellstone and Pete Domenici Mental Health Parity  and  Addiction  Equity
     7  Act  of  2008,  42  U.S.C.  18031(j), and any amendments to, and federal
     8  guidance or regulations issued under those acts.
     9    § 10. Subsection (b) of section 3217-b of the insurance law, as  added
    10  by chapter 705 of the laws of 1996, is amended to read as follows:
    11    (b)  No  insurer  subject  to  this article shall by contract, written
    12  policy [or], written procedure or  practice  prohibit  or  restrict  any
    13  health  care  provider  from  filing  a  complaint,  making  a report or
    14  commenting to an appropriate governmental body regarding the policies or
    15  practices of such insurer which the  provider  believes  may  negatively
    16  impact  upon  the  quality of, or access to, patient care.  Nor shall an
    17  insurer subject to this article take any adverse action,  including  but
    18  not limited to refusing to renew or execute a contract or agreement with
    19  a health care provider as retaliation against a health care provider for
    20  filing  a  complaint,  making  a  report or commenting to an appropriate
    21  governmental body regarding policies or practices of such insurer  which
    22  may  violate this chapter including paragraphs thirty, as added by chap-
    23  ter forty-one of the laws of 2014, thirty-one, thirty-one-a and  thirty-
    24  five  of  subsection (i) of section thirty-two hundred sixteen and para-
    25  graphs five, six, seven,  seven-a  and  seven-b  of  subsection  (l)  of
    26  section thirty-two hundred twenty-one of this article.
    27    §  11.  Subparagraph  (A)  of paragraph 4 of subsection (l) of section
    28  3221 of the insurance law, as amended by chapter  230  of  the  laws  of
    29  2004, is amended to read as follows:
    30    (A)  Every insurer delivering a group policy or issuing a group policy
    31  for delivery, in this state, [which]  that  provides  reimbursement  for
    32  psychiatric or psychological services or for the diagnosis and treatment
    33  of  mental[,  nervous or emotional disorders and ailments] health condi-
    34  tions, however defined in such policy, by physicians,  psychiatrists  or
    35  psychologists, [must] shall make available and if requested by the poli-
    36  cyholder  provide  the  same coverage to insureds for such services when
    37  performed by a licensed clinical social worker, within the lawful  scope
    38  of  his or her practice, who is licensed pursuant to article one hundred
    39  fifty-four of the education law. Written notice of the  availability  of
    40  such  coverage shall be delivered to the policyholder prior to inception
    41  of such group policy and annually thereafter, except  that  this  notice
    42  shall  not be required where a policy covers two hundred or more employ-
    43  ees or where  the  benefit  structure  was  the  subject  of  collective
    44  bargaining affecting persons who are employed in more than one state.
    45    §  12.  Subparagraph  (D)  of paragraph 4 of subsection (l) of section
    46  3221 of the insurance law, as amended by section 50 of part D of chapter
    47  56 of the laws of 2013, is amended to read as follows:
    48    (D) In addition to the requirements of subparagraph (A) of this  para-
    49  graph,  every  insurer issuing a group policy for delivery in this state
    50  where the policy provides reimbursement to insureds for  psychiatric  or
    51  psychological  services  or  for the diagnosis and treatment of mental[,
    52  nervous or emotional disorders and ailments] health conditions,  however
    53  defined  in  such policy, by physicians, psychiatrists or psychologists,
    54  shall provide the same coverage  to  insureds  for  such  services  when
    55  performed  by a licensed clinical social worker, within the lawful scope
    56  of his or her practice, who is licensed pursuant to subdivision  two  of

        S. 1507--C                         101                        A. 2007--C
 
     1  section  seven  thousand  seven hundred four of the education law and in
     2  addition shall have either: (i) three or more additional  years  experi-
     3  ence in psychotherapy, which for the purposes of this subparagraph shall
     4  mean  the  use of verbal methods in interpersonal relationships with the
     5  intent of assisting a person or persons to modify attitudes and behavior
     6  that are intellectually,  socially  or  emotionally  maladaptive,  under
     7  supervision,  satisfactory  to  the  state  board  for social work, in a
     8  facility,  licensed  or  incorporated  by  an  appropriate  governmental
     9  department,  providing  services  for diagnosis or treatment of mental[,
    10  nervous or emotional disorders  or  ailments]  health  conditions;  (ii)
    11  three  or  more  additional  years experience in psychotherapy under the
    12  supervision, satisfactory to the state  board  for  social  work,  of  a
    13  psychiatrist, a licensed and registered psychologist or a licensed clin-
    14  ical  social  worker  qualified for reimbursement pursuant to subsection
    15  (e) of this section, or (iii) a combination of the experience  specified
    16  in  items (i) and (ii) of this subparagraph totaling three years, satis-
    17  factory to the state board for social work.
    18    § 13. Subparagraphs (A) and (B) of paragraph 5 of  subsection  (l)  of
    19  section 3221 of the insurance law, as amended by chapter 502 of the laws
    20  of 2007, are amended to read as follows:
    21    (A) Every insurer delivering a group or school blanket policy or issu-
    22  ing  a group or school blanket policy for delivery, in this state, which
    23  provides coverage for inpatient hospital care or coverage for  physician
    24  services shall provide [as part of such policy broad-based] coverage for
    25  the  diagnosis  and treatment of mental[, nervous or emotional disorders
    26  or ailments, however defined in such  policy,  at  least  equal  to  the
    27  coverage provided for other] health conditions and:
    28    (i)  where  the  policy provides coverage for inpatient hospital care,
    29  benefits for inpatient care in a hospital as defined by subdivision  ten
    30  of section 1.03 of the mental hygiene law[, which benefits may be limit-
    31  ed  to  not  less  than  thirty days of active treatment in any contract
    32  year, plan year or calendar year,]  and  benefits  for  outpatient  care
    33  provided  in  a  facility issued an operating certificate by the commis-
    34  sioner of mental health pursuant to the provisions of article thirty-one
    35  of the mental hygiene law, or in a facility operated by  the  office  of
    36  mental  health[,  which  benefits may be limited to not less than twenty
    37  visits in any contract year, plan year or calendar  year.  Benefits  for
    38  partial  hospitalization program services shall be provided as an offset
    39  to covered inpatient days at a  ratio  of  two  partial  hospitalization
    40  visits  to  one  inpatient  day  of treatment.] or, for care provided in
    41  other states, to similarly licensed or certified  hospitals  or  facili-
    42  ties; and
    43    (ii)  where  the  policy  provides coverage for physician services, it
    44  shall include benefits for outpatient care provided by a psychiatrist or
    45  psychologist licensed to practice in this  state,  a  licensed  clinical
    46  social  worker  who  meets the requirements of subparagraph (D) of para-
    47  graph four of this subsection, a nurse practitioner licensed to practice
    48  in this state, or a professional corporation or university faculty prac-
    49  tice corporation thereof. [Such benefits may be limited to not less than
    50  twenty visits in any contract year, plan year, or calendar year.]
    51    [(iii)] (B) Coverage required by this paragraph may be [provided on  a
    52  contract  year, plan year or calendar year basis and shall be consistent
    53  with the provision of other benefits under the policy. Such coverage may
    54  be] subject to annual deductibles, co-pays and  coinsurance  as  may  be
    55  deemed  appropriate  by  the superintendent and shall be consistent with
    56  those imposed on other benefits under the policy. [In the event  that  a

        S. 1507--C                         102                        A. 2007--C

     1  policy  provides coverage for both inpatient hospital care and physician
     2  services, the aggregate of the benefits  for  outpatient  care  obtained
     3  under  this  paragraph  may be limited to not less than twenty visits in
     4  any contract year, plan year or calendar year.
     5    (iv)  In  this paragraph, "active treatment" means treatment furnished
     6  in  conjunction  with  inpatient  confinement  for  mental,  nervous  or
     7  emotional  disorders or ailments that meet standards prescribed pursuant
     8  to the regulations of the commissioner of mental health.
     9    (B) (i) Every insurer delivering a group or school blanket  policy  or
    10  issuing  a  group  or school blanket policy for delivery, in this state,
    11  which provides coverage for inpatient  hospital  care  or  coverage  for
    12  physician  services,  shall  provide  comparable coverage for adults and
    13  children with biologically based mental  illness.  Such  group  policies
    14  issued  or  delivered  in  this state shall also provide such comparable
    15  coverage for children with serious emotional disturbances. Such coverage
    16  shall be provided under the terms and  conditions  otherwise  applicable
    17  under  the  policy,  including network limitations or variations, exclu-
    18  sions, co-pays, coinsurance, deductibles or other specific cost  sharing
    19  mechanisms.  Provided  further,  where a policy provides both in-network
    20  and  out-of-network  benefits,  the  out-of-network  benefits  may  have
    21  different  coinsurance,  co-pays,  or  deductibles,  than the in-network
    22  benefits, regardless of whether the policy is written under one  license
    23  or two licenses.
    24    (ii)  For  purposes  of  this  paragraph, the term "biologically based
    25  mental illness" means a mental, nervous, or emotional condition that  is
    26  caused by a biological disorder of the brain and results in a clinically
    27  significant, psychological syndrome or pattern that substantially limits
    28  the  functioning of the person with the illness. Such biologically based
    29  mental illnesses are defined as schizophrenia/psychotic disorders, major
    30  depression, bipolar  disorder,  delusional  disorders,  panic  disorder,
    31  obsessive compulsive disorders, bulimia, and anorexia.] Provided that no
    32  copayment  or  coinsurance imposed for outpatient mental health services
    33  provided in a facility licensed, certified or  otherwise  authorized  by
    34  the  office  of mental health shall exceed the copayments or coinsurance
    35  imposed for a primary care office visit under the policy.
    36    § 14. Subparagraphs (C), (D) and (E) of paragraph 5 of subsection  (l)
    37  of  section 3221 of the insurance law are REPEALED and five new subpara-
    38  graphs (C), (D), (E), (F) and (G) are added to read as follows:
    39    (C) Coverage under this paragraph shall not apply  financial  require-
    40  ments  or  treatment limitations to mental health benefits that are more
    41  restrictive than the predominant financial  requirements  and  treatment
    42  limitations  applied  to substantially all medical and surgical benefits
    43  covered by the policy.
    44    (D) The criteria for medical necessity determinations under the policy
    45  with respect to mental health benefits shall be made  available  by  the
    46  insurer to any insured, prospective insured, or in-network provider upon
    47  request.
    48    (E) For purposes of this paragraph:
    49    (i)  "financial requirement" means deductible, copayments, coinsurance
    50  and out-of-pocket expenses;
    51    (ii) "predominant" means that a  financial  requirement  or  treatment
    52  limitation  is  the  most  common  or  frequent of such type of limit or
    53  requirement;
    54    (iii) "treatment limitation" means limits on the frequency  of  treat-
    55  ment, number of visits, days of coverage, or other similar limits on the
    56  scope  or  duration  of treatment and includes nonquantitative treatment

        S. 1507--C                         103                        A. 2007--C
 
     1  limitations such as: medical management standards limiting or  excluding
     2  benefits  based  on medical necessity, or based on whether the treatment
     3  is experimental or investigational; formulary  design  for  prescription
     4  drugs;  network tier design; standards for provider admission to partic-
     5  ipate in a network, including reimbursement rates; methods for determin-
     6  ing usual, customary, and reasonable charges; fail-first or step therapy
     7  protocols; exclusions based on failure to complete a  course  of  treat-
     8  ment;  and  restrictions  based  on  geographic location, facility type,
     9  provider specialty, and other criteria that limit the scope or  duration
    10  of benefits for services provided under the policy; and
    11    (iv)  "mental  health  condition"  means any mental health disorder as
    12  defined in the most recent edition of  the  diagnostic  and  statistical
    13  manual  of mental disorders or the most recent edition of another gener-
    14  ally recognized independent standard of current medical practice such as
    15  the international classification of diseases.
    16    (F) An insurer shall provide coverage under this paragraph, at a mini-
    17  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    18  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    19    (G) This subparagraph shall apply to hospitals in this state that  are
    20  licensed  by  the  office of mental health that are participating in the
    21  insurer's provider network. Where the policy provides coverage for inpa-
    22  tient hospital care, benefits for inpatient hospital care in a  hospital
    23  as  defined by subdivision ten of section 1.03 of the mental hygiene law
    24  provided to individuals who have not attained the age of eighteen  shall
    25  not be subject to preauthorization. Coverage provided under this subpar-
    26  agraph shall also not be subject to concurrent utilization review during
    27  the first fourteen days of the inpatient admission, provided the facili-
    28  ty  notifies the insurer of both the admission and the initial treatment
    29  plan within two business days of the admission, performs daily  clinical
    30  review  of  the  patient, and participates in periodic consultation with
    31  the insurer to ensure that the facility is using the evidence-based  and
    32  peer  reviewed clinical review criteria utilized by the insurer which is
    33  approved by the office of mental health and appropriate to  the  age  of
    34  the  patient,  to  ensure that the inpatient care is medically necessary
    35  for the patient. All treatment provided under this subparagraph  may  be
    36  reviewed  retrospectively.  Where  care  is  denied  retrospectively, an
    37  insured shall not have any financial obligation to the facility for  any
    38  treatment under this subparagraph other than any copayment, coinsurance,
    39  or deductible otherwise required under the policy.
    40    §  15. Subparagraphs (A), (B) and (D) of paragraph 6 of subsection (l)
    41  of section 3221 of the insurance law, as amended by section 2 of part  B
    42  of  chapter  71  of the laws of 2016, are amended and three new subpara-
    43  graphs (E), (F) and (G) are added to read as follows:
    44    (A) Every policy that provides  hospital,  major  medical  or  similar
    45  comprehensive  coverage  [must] shall provide inpatient coverage for the
    46  diagnosis and treatment of substance use disorder, including detoxifica-
    47  tion and rehabilitation services. Such inpatient coverage shall  include
    48  unlimited  medically  necessary  treatment  for  substance  use disorder
    49  treatment services provided in residential settings [as required by  the
    50  Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
    51  1185a)].  Further, such inpatient coverage  shall  not  apply  financial
    52  requirements  or  treatment  limitations,  including  utilization review
    53  requirements, to inpatient substance use disorder benefits that are more
    54  restrictive than the predominant financial  requirements  and  treatment
    55  limitations  applied  to substantially all medical and surgical benefits
    56  covered by  the  policy.  [Further,  such  coverage  shall  be  provided

        S. 1507--C                         104                        A. 2007--C

     1  consistent  with  the  federal  Paul  Wellstone and Pete Domenici Mental
     2  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
     3    (B)  Coverage  provided under this paragraph may be limited to facili-
     4  ties in New York state [which are certified] that are  licensed,  certi-
     5  fied  or  otherwise authorized by the office of alcoholism and substance
     6  abuse services and, in other states, to those which  are  accredited  by
     7  the  joint commission as alcoholism, substance abuse or chemical depend-
     8  ence treatment programs and are similarly licensed, certified, or other-
     9  wise authorized in the state in which the facility is located.
    10    (D) This subparagraph shall apply to facilities in this state that are
    11  licensed, certified or otherwise authorized by the office of  alcoholism
    12  and  substance  abuse  services  that are participating in the insurer's
    13  provider network. Coverage provided under this paragraph  shall  not  be
    14  subject  to  preauthorization.  Coverage  provided  under this paragraph
    15  shall also not be subject to concurrent utilization  review  during  the
    16  first  [fourteen]  twenty-eight days of the inpatient admission provided
    17  that the facility notifies the insurer of both  the  admission  and  the
    18  initial  treatment  plan within [forty-eight hours] two business days of
    19  the admission. The facility shall perform daily clinical review  of  the
    20  patient,  including  [the]  periodic consultation with the insurer at or
    21  just prior to the fourteenth day of treatment to ensure that the facili-
    22  ty is using the evidence-based and peer reviewed  clinical  review  tool
    23  utilized  by the insurer which is designated by the office of alcoholism
    24  and substance abuse services and appropriate to the age of the  patient,
    25  to  ensure  that  the inpatient treatment is medically necessary for the
    26  patient.  Prior to discharge, the facility shall provide the patient and
    27  the insurer with a written discharge plan which shall describe  arrange-
    28  ments  for additional services needed following discharge from the inpa-
    29  tient facility as determined using the evidence-based and  peer-reviewed
    30  clinical  review tool utilized by the insurer which is designated by the
    31  office of alcoholism and substance abuse services.  Prior to  discharge,
    32  the  facility shall indicate to the insurer whether services included in
    33  the discharge plan are secured or determined to be reasonably available.
    34  Any utilization review of treatment provided under this subparagraph may
    35  include a review of all services provided during such  inpatient  treat-
    36  ment,  including all services provided during the first [fourteen] twen-
    37  ty-eight days of such inpatient treatment. Provided, however, the insur-
    38  er shall only deny coverage for any portion of  the  initial  [fourteen]
    39  twenty-eight  day  inpatient  treatment on the basis that such treatment
    40  was not medically necessary if such inpatient treatment was contrary  to
    41  the  evidence-based  and  peer reviewed clinical review tool utilized by
    42  the insurer  which  is  designated  by  the  office  of  alcoholism  and
    43  substance  abuse services. An insured shall not have any financial obli-
    44  gation to the facility for any treatment under this  subparagraph  other
    45  than  any copayment, coinsurance, or deductible otherwise required under
    46  the policy.
    47    (E) The criteria for medical necessity determinations under the policy
    48  with respect to inpatient substance use disorder benefits shall be  made
    49  available by the insurer to any insured, prospective insured, or in-net-
    50  work provider upon request.
    51    (F) For purposes of this paragraph:
    52    (i)  "financial requirement" means deductible, copayments, coinsurance
    53  and out-of-pocket expenses;
    54    (ii) "predominant" means that a  financial  requirement  or  treatment
    55  limitation  is  the  most  common  or  frequent of such type of limit or
    56  requirement;

        S. 1507--C                         105                        A. 2007--C
 
     1    (iii) "treatment limitation" means limits on the frequency  of  treat-
     2  ment, number of visits, days of coverage, or other similar limits on the
     3  scope  or  duration  of treatment and includes nonquantitative treatment
     4  limitations such as: medical management standards limiting or  excluding
     5  benefits  based  on medical necessity, or based on whether the treatment
     6  is experimental or investigational; formulary  design  for  prescription
     7  drugs;  network tier design; standards for provider admission to partic-
     8  ipate in a network, including reimbursement rates; methods for determin-
     9  ing usual, customary, and reasonable charges; fail-first or step therapy
    10  protocols; exclusions based on failure to complete a  course  of  treat-
    11  ment;  and  restrictions  based  on  geographic location, facility type,
    12  provider specialty, and other criteria that limit the scope or  duration
    13  of benefits for services provided under the policy; and
    14    (iv)  "substance use disorder" shall have the meaning set forth in the
    15  most recent edition of the diagnostic and statistical manual  of  mental
    16  disorders  or  the  most  recent edition of another generally recognized
    17  independent standard of current medical practice such  as  the  interna-
    18  tional classification of diseases.
    19    (G) An insurer shall provide coverage under this paragraph, at a mini-
    20  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    21  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    22    §  16.  Subparagraphs  (A) and (B) of paragraph 7 of subsection (l) of
    23  section 3221 of the insurance law, as amended by chapter 41 of the  laws
    24  of  2014,  are  amended and a new subparagraph (C-1) is added to read as
    25  follows:
    26    (A) Every policy that  provides  medical,  major  medical  or  similar
    27  comprehensive-type coverage [must] shall provide outpatient coverage for
    28  the diagnosis and treatment of substance use disorder, including detoxi-
    29  fication  and  rehabilitation  services.  Such  coverage shall not apply
    30  financial requirements or treatment limitations to outpatient  substance
    31  use  disorder  benefits  that  are more restrictive than the predominant
    32  financial requirements and treatment limitations applied to substantial-
    33  ly all medical and surgical benefits covered by the policy.    [Further,
    34  such  coverage  shall be provided consistent with the federal Paul Well-
    35  stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
    36  2008 (29 U.S.C. § 1185a).]
    37    (B) Coverage under this paragraph may be limited to facilities in  New
    38  York  state  that are licensed, certified or otherwise authorized by the
    39  office of alcoholism and substance abuse services [or licensed  by  such
    40  office   as   outpatient  clinics  or  medically  supervised  ambulatory
    41  substance abuse programs] to provide outpatient substance  use  disorder
    42  services  and,  in  other  states,  to those which are accredited by the
    43  joint commission as alcoholism or chemical dependence treatment programs
    44  and similarly licensed, certified or otherwise authorized in  the  state
    45  in which the facility is located.
    46    (C-1) A large group policy that provides coverage under this paragraph
    47  shall  not impose copayments or coinsurance for outpatient substance use
    48  disorder services that exceeds the copayment or coinsurance imposed  for
    49  a  primary  care  office  visit.  Provided that no greater than one such
    50  copayment may be imposed for all services provided in a single day by  a
    51  facility  licensed,  certified  or otherwise authorized by the office of
    52  alcoholism and substance abuse services to provide outpatient  substance
    53  use disorder services.
    54    §  17.  Subparagraph  (E)  of paragraph 7 of subsection (l) of section
    55  3221 of the insurance law, as added by section 4 of part MM  of  chapter

        S. 1507--C                         106                        A. 2007--C
 
     1  57  of the laws of 2018, is amended and three new subparagraphs (F), (G)
     2  and (H) are added to read as follows:
     3    (E) This subparagraph shall apply to facilities in this state that are
     4  licensed,  certified or otherwise authorized by the office of alcoholism
     5  and substance abuse services for the provision of outpatient,  intensive
     6  outpatient,  outpatient  rehabilitation  and  opioid  treatment that are
     7  participating in the insurer's provider network. Coverage provided under
     8  this paragraph  shall  not  be  subject  to  preauthorization.  Coverage
     9  provided  under this paragraph shall not be subject to concurrent review
    10  for the first [two] four weeks of continuous treatment,  not  to  exceed
    11  [fourteen]  twenty-eight  visits,  provided  the  facility  notifies the
    12  insurer of both the start of treatment and the  initial  treatment  plan
    13  within  [forty-eight  hours]  two  business  days.    The facility shall
    14  perform clinical assessment of the  patient  at  each  visit,  including
    15  [the]  periodic  consultation  with  the insurer at or just prior to the
    16  fourteenth day of treatment to ensure that the  facility  is  using  the
    17  evidence-based  and  peer  reviewed clinical review tool utilized by the
    18  insurer which is designated by the office of  alcoholism  and  substance
    19  abuse services and appropriate to the age of the patient, to ensure that
    20  the  outpatient  treatment  is  medically necessary for the patient. Any
    21  utilization review of the treatment provided under this subparagraph may
    22  include a review of all services provided during such outpatient  treat-
    23  ment,  including all services provided during the first [two] four weeks
    24  of continuous treatment, not to exceed [fourteen]  twenty-eight  visits,
    25  of  such outpatient treatment. Provided, however, the insurer shall only
    26  deny coverage for any portion of the initial [two] four weeks of contin-
    27  uous treatment, not to exceed [fourteen] twenty-eight visits, for outpa-
    28  tient treatment on the basis  that  such  treatment  was  not  medically
    29  necessary  if  such  outpatient  treatment was contrary to the evidence-
    30  based and peer reviewed clinical review tool  utilized  by  the  insurer
    31  which  is  designated  by  the  office of alcoholism and substance abuse
    32  services. An insured shall not have  any  financial  obligation  to  the
    33  facility for any treatment under this subparagraph other than any copay-
    34  ment, coinsurance, or deductible otherwise required under the policy.
    35    (F) The criteria for medical necessity determinations under the policy
    36  with respect to outpatient substance use disorder benefits shall be made
    37  available by the insurer to any insured, prospective insured, or in-net-
    38  work provider upon request.
    39    (G) For purposes of this paragraph:
    40    (i)  "financial requirement" means deductible, copayments, coinsurance
    41  and out-of-pocket expenses;
    42    (ii) "predominant" means that a  financial  requirement  or  treatment
    43  limitation  is  the  most  common  or  frequent of such type of limit or
    44  requirement;
    45    (iii) "treatment limitation" means limits on the frequency  of  treat-
    46  ment, number of visits, days of coverage, or other similar limits on the
    47  scope  or  duration  of treatment and includes nonquantitative treatment
    48  limitations such as: medical management standards limiting or  excluding
    49  benefits  based  on medical necessity, or based on whether the treatment
    50  is experimental or investigational; formulary  design  for  prescription
    51  drugs;  network tier design; standards for provider admission to partic-
    52  ipate in a network, including reimbursement rates; methods for determin-
    53  ing usual, customary, and reasonable charges; fail-first or step therapy
    54  protocols; exclusions based on failure to complete a  course  of  treat-
    55  ment;  and  restrictions  based  on  geographic location, facility type,

        S. 1507--C                         107                        A. 2007--C
 
     1  provider specialty, and other criteria that limit the scope or  duration
     2  of benefits for services provided under the policy; and
     3    (iv)  "substance use disorder" shall have the meaning set forth in the
     4  most recent edition of the diagnostic and statistical manual  of  mental
     5  disorders  or  the  most  recent edition of another generally recognized
     6  independent standard of current medical practice such  as  the  interna-
     7  tional classification of diseases.
     8    (H) An insurer shall provide coverage under this paragraph, at a mini-
     9  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    10  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    11    § 18. Paragraph 7-b of subsection (l) of section 3221 of the insurance
    12  law,  as added by section 2 of part B of chapter 69 of the laws of 2016,
    13  is amended to read as follows:
    14    (7-b) [(A)] Every policy that provides medical, major medical or simi-
    15  lar comprehensive-type coverage and provides coverage  for  prescription
    16  drugs for medication for the treatment of a substance use disorder shall
    17  include  immediate  access,  without prior authorization, [to a five day
    18  emergency supply] to  the  formulary  forms  of  prescribed  medications
    19  covered  under  the  policy  for the treatment of substance use disorder
    20  [where an emergency condition exists], including a  prescribed  drug  or
    21  medication  associated  with  the management of opioid withdrawal and/or
    22  stabilization, except where otherwise prohibited by law. Further, cover-
    23  age [of an emergency supply] without prior authorization  shall  include
    24  formulary  forms  medication  for  opioid  overdose  reversal  otherwise
    25  covered under the  policy  prescribed  or  dispensed  to  an  individual
    26  covered by the policy.
    27    [(B)  For purposes of this paragraph, an "emergency condition" means a
    28  substance use disorder condition that manifests itself by acute symptoms
    29  of sufficient severity, including severe  pain  or  the  expectation  of
    30  severe  pain, such that a prudent layperson, possessing an average know-
    31  ledge of medicine and health, could reasonably  expect  the  absence  of
    32  immediate medical attention to result in:
    33    (i)  placing the health of the person afflicted with such condition in
    34  serious jeopardy, or in the case of a behavioral condition, placing  the
    35  health of such person or others in serious jeopardy;
    36    (ii) serious impairment to such person's bodily functions;
    37    (iii) serious dysfunction of any bodily organ or part of such person;
    38    (iv) serious disfigurement of such person; or
    39    (v)  a  condition  described  in clause (i), (ii), or (iii) of section
    40  1867(e)(1)(A) of the Social Security Act.
    41    (C) Coverage provided under this paragraph may be  subject  to  copay-
    42  ments,  coinsurance,  and  annual  deductibles  that are consistent with
    43  those imposed on other benefits within the policy; provided, however, no
    44  policy shall impose an additional copayment or coinsurance on an insured
    45  who received an emergency supply of medication and then received up to a
    46  thirty day supply of the same medication in the same thirty  day  period
    47  in which the emergency supply of medication was dispensed. This subpara-
    48  graph shall not preclude the imposition of a copayment or coinsurance on
    49  the  initial  emergency  supply  of medication in an amount that is less
    50  than the copayment or coinsurance otherwise applicable to a  thirty  day
    51  supply of such medication, provided that the total sum of the copayments
    52  or  coinsurance  for  an entire thirty day supply of the medication does
    53  not exceed the copayment or coinsurance otherwise applicable to a thirty
    54  day supply of such medication.]

        S. 1507--C                         108                        A. 2007--C

     1    § 19. Subparagraph (B) of paragraph 17 of subsection  (l)  of  section
     2  3221 of the insurance law, as amended by section 39 of part D of chapter
     3  56 of the laws of 2013, is amended to read as follows:
     4    (B)  Every  group  or blanket policy that provides physician services,
     5  medical, major medical  or  similar  comprehensive-type  coverage  shall
     6  provide  coverage  for  the screening, diagnosis and treatment of autism
     7  spectrum disorder in  accordance  with  this  paragraph  and  shall  not
     8  exclude  coverage  for  the screening, diagnosis or treatment of medical
     9  conditions otherwise covered by the policy  because  the  individual  is
    10  diagnosed with autism spectrum disorder. Such coverage may be subject to
    11  annual  deductibles,  copayments and coinsurance as may be deemed appro-
    12  priate by the superintendent and shall be consistent with those  imposed
    13  on  other  benefits  under  the  group  or blanket policy. [Coverage for
    14  applied behavior analysis shall be subject to a maximum benefit  of  six
    15  hundred  eighty  hours  of  treatment  per  policy  or calendar year per
    16  covered individual.] This paragraph shall not be construed  as  limiting
    17  the  benefits  that  are  otherwise available to an individual under the
    18  group or blanket policy, provided however that  such  policy  shall  not
    19  contain  any limitations on visits that are solely applied to the treat-
    20  ment of autism spectrum disorder. No insurer shall terminate coverage or
    21  refuse to deliver, execute, issue, amend, adjust, or renew  coverage  to
    22  an  individual  solely  because  the individual is diagnosed with autism
    23  spectrum disorder or has received treatment for autism  spectrum  disor-
    24  der.  Coverage  shall  be  subject  to  utilization  review and external
    25  appeals of health care services pursuant to article forty-nine  of  this
    26  chapter  as  well  as[,]  case  management[,]  and  other  managed  care
    27  provisions.
    28    § 20. Items (i) and (iii) of  subparagraph  (C)  of  paragraph  17  of
    29  subsection (l) of section 3221 of the insurance law, as amended by chap-
    30  ter 596 of the laws of 2011, are amended to read as follows:
    31    (i)  "autism  spectrum  disorder"  means  any  pervasive developmental
    32  disorder as defined in the most recent edition  of  the  diagnostic  and
    33  statistical  manual  of  mental disorders[, including autistic disorder,
    34  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
    35  or pervasive developmental disorder not otherwise specified (PDD-NOS)].
    36    (iii) "behavioral health treatment"  means  counseling  and  treatment
    37  programs,  when  provided  by  a licensed provider, and applied behavior
    38  analysis, when provided [or supervised] by a [behavior  analyst]  person
    39  licensed,  certified  [pursuant  to  the  behavior analyst certification
    40  board,] or otherwise authorized to provide  applied  behavior  analysis,
    41  that  are  necessary  to  develop,  maintain, or restore, to the maximum
    42  extent practicable, the functioning of an individual. [Individuals  that
    43  provide behavioral health treatment under the supervision of a certified
    44  behavior  analyst  pursuant to this paragraph shall be subject to stand-
    45  ards of professionalism, supervision and relevant experience pursuant to
    46  regulations promulgated by the superintendent in consultation  with  the
    47  commissioners of health and education.]
    48    §  21. Paragraph 17 of subsection (l) of section 3221 of the insurance
    49  law is amended by adding four new subparagraphs (H), (I), (J) and (K) to
    50  read as follows:
    51    (H) Coverage under this paragraph shall not apply  financial  require-
    52  ments or treatment limitations to autism spectrum disorder benefits that
    53  are  more    restrictive than the predominant financial requirements and
    54  treatment  limitations applied to substantially all medical and surgical
    55  benefits covered by the policy.

        S. 1507--C                         109                        A. 2007--C
 
     1    (I) The criteria for medical necessity determinations under the policy
     2  with  respect to autism spectrum disorder benefits shall be made  avail-
     3  able  by  the insurer to any insured, prospective insured, or in-network
     4  provider upon  request.
     5    (J) For purposes of this paragraph:
     6    (i)  "financial requirement" means deductible, copayments, coinsurance
     7  and out-of-pocket expenses;
     8    (ii) "predominant" means that a  financial  requirement  or  treatment
     9  limitation  is    the  most  common or frequent of such type of limit or
    10  requirement; and
    11    (iii) "treatment limitation" means limits on the frequency  of  treat-
    12  ment,  number    of visits, days of coverage, or other similar limits on
    13  the scope or duration of  treatment and includes nonquantitative  treat-
    14  ment  limitations  such  as:  medical   management standards limiting or
    15  excluding benefits based on medical necessity,  or based on whether  the
    16  treatment  is  experimental  or  investigational; formulary   design for
    17  prescription drugs; network tier design; standards for provider   admis-
    18  sion to participate in a network, including reimbursement rates; methods
    19  for  determining usual, customary, and reasonable charges; fail-first or
    20  step therapy protocols; exclusions based on failure to complete a course
    21  of treatment; and restrictions based on  geographic  location,  facility
    22  type,  provider  specialty,  and  other criteria that limit the scope or
    23  duration of  benefits for services provided under the policy.
    24    (K) An insurer shall provide coverage under this paragraph, at a mini-
    25  mum, consistent with the federal Paul Wellstone and Pete Domenici Mental
    26  Health  Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).
    27    § 22. Paragraphs 1, 2, and 3 of subsection (g) of section 4303 of  the
    28  insurance  law,  as  amended  by  chapter  502  of the laws of 2007, are
    29  amended to read as follows:
    30    [(1)] A medical expense indemnity corporation, hospital service corpo-
    31  ration or a health service corporation,  [which]  that  provides  group,
    32  group  remittance  or  school  blanket  coverage  for inpatient hospital
    33  care[,] or coverage for physician services shall provide as part of  its
    34  contract  [broad-based]  coverage  for  the  diagnosis  and treatment of
    35  mental[, nervous or emotional disorders or ailments, however defined  in
    36  such contract, at least equal to the coverage provided for other] health
    37  conditions and [shall include]:
    38    [(A)]
    39    (1)  where the contract provides coverage for inpatient hospital care,
    40  benefits for in-patient care in a hospital as defined by subdivision ten
    41  of section 1.03 of the mental hygiene law[, which benefits may be limit-
    42  ed to not less than thirty days of  active  treatment  in  any  contract
    43  year, plan year or calendar year.
    44    (B)]  or  for  inpatient  care  provided in other states, to similarly
    45  licensed hospitals, and benefits for  out-patient  care  provided  in  a
    46  facility  issued  an operating certificate by the commissioner of mental
    47  health pursuant to the provisions of article thirty-one  of  the  mental
    48  hygiene  law  or in a facility operated by the office of mental health[,
    49  which benefits may be limited to not less  than  twenty  visits  in  any
    50  contract  year,  plan year or calendar year. Benefits for partial hospi-
    51  talization program services shall be provided as an  offset  to  covered
    52  inpatient  days  at a ratio of two partial hospitalization visits to one
    53  inpatient day of treatment.
    54    (C) Such coverage may be provided on a contract  year,  plan  year  or
    55  calendar  year basis and shall be consistent with the provision of other

        S. 1507--C                         110                        A. 2007--C

     1  benefits under the contract.] or for out-patient care provided in  other
     2  states, to similarly certified facilities; and
     3    (2)  where the contract provides coverage for physician services bene-
     4  fits for outpatient care provided  by  a  psychiatrist  or  psychologist
     5  licensed  to  practice  in this state, a licensed clinical social worker
     6  who meets the requirements of subsection (n) of this  section,  a  nurse
     7  practitioner  licensed to practice on this state, or professional corpo-
     8  ration or university faculty practice corporation thereof.
     9    (3) Such coverage may be subject to annual  deductibles,  co-pays  and
    10  coinsurance as may be deemed appropriate by the superintendent and shall
    11  be  consistent  with those imposed on other benefits under the contract.
    12  Provided that no copayment or coinsurance imposed for outpatient  mental
    13  health  services provided in a facility licensed, certified or otherwise
    14  authorized by the office of mental health shall exceed the copayments or
    15  coinsurance imposed for a primary care office visit under the contract.
    16    [(D) For the purpose of  this  subsection,  "active  treatment"  means
    17  treatment  furnished  in  conjunction  with  in-patient  confinement for
    18  mental, nervous or emotional disorders or ailments that meet such stand-
    19  ards as shall be prescribed pursuant to the regulations of  the  commis-
    20  sioner of mental health.
    21    (E)  In  the  event  the  group remittance group or contract holder is
    22  provided coverage under this  subsection  and  under  paragraph  one  of
    23  subsection (h) of this section from the same health service corporation,
    24  or  under  a contract that is jointly underwritten by two health service
    25  corporations or by a health service corporation and  a  medical  expense
    26  indemnity corporation, the aggregate of the benefits for outpatient care
    27  obtained  under  subparagraph (B) of this paragraph and paragraph one of
    28  subsection (h) of this section may be limited to not  less  than  twenty
    29  visits in any contract year, plan year or calendar year.
    30    (2)  (A)  A  hospital  service  corporation or a health service corpo-
    31  ration, which provides group, group remittance or school blanket  cover-
    32  age  for  inpatient hospital care, shall provide comparable coverage for
    33  adults and children with biologically based mental illness. Such  hospi-
    34  tal service corporation or health service corporation shall also provide
    35  such  comparable  coverage  for children with serious emotional disturb-
    36  ances. Such coverage shall be provided under the  terms  and  conditions
    37  otherwise  applicable  under the contract, including network limitations
    38  or variations, exclusions, co-pays, coinsurance,  deductibles  or  other
    39  specific  cost  sharing  mechanisms.  Provided further, where a contract
    40  provides both in-network and out-of-network benefits, the out-of-network
    41  benefits may have different coinsurance, co-pays, or  deductibles,  than
    42  the  in-network  benefits, regardless of whether the contract is written
    43  under one license or two licenses.
    44    (B) For purposes of this  subsection,  the  term  "biologically  based
    45  mental  illness" means a mental, nervous, or emotional condition that is
    46  caused by a biological disorder of the brain and results in a clinically
    47  significant, psychological syndrome or pattern that substantially limits
    48  the functioning of the person with the illness. Such biologically  based
    49  mental illnesses are defined as schizophrenia/psychotic disorders, major
    50  depression,  bipolar  disorder,  delusional  disorders,  panic disorder,
    51  obsessive compulsive disorders, anorexia, and bulimia.
    52    (3) For purposes of this subsection, the term "children  with  serious
    53  emotional  disturbances"  means  persons under the age of eighteen years
    54  who have diagnoses of attention deficit disorders,  disruptive  behavior
    55  disorders,  or  pervasive development disorders, and where there are one
    56  or more of the following:

        S. 1507--C                         111                        A. 2007--C

     1    (A) serious suicidal symptoms or other life-threatening  self-destruc-
     2  tive behaviors;
     3    (B)  significant psychotic symptoms (hallucinations, delusion, bizarre
     4  behaviors);
     5    (C) behavior caused by emotional disturbances that placed the child at
     6  risk of causing personal injury or significant property damage; or
     7    (D) behavior caused by emotional disturbances that placed the child at
     8  substantial risk of removal from the household.]
     9    § 23. Paragraphs 4 and 5 of subsection (g)  of  section  4303  of  the
    10  insurance  law are REPEALED and five new paragraphs 4, 5, 6, 7 and 8 are
    11  added to read as follows:
    12    (4) Coverage under this subsection shall not apply financial  require-
    13  ments  or  treatment limitations to mental health benefits that are more
    14  restrictive than  the predominant financial requirements  and  treatment
    15  limitations  applied to  substantially all medical and surgical benefits
    16  covered by the contract.
    17    (5) The  criteria  for  medical  necessity  determinations  under  the
    18  contract with  respect to mental health benefits shall be made available
    19  by  the  corporation to  any insured, prospective insured, or in-network
    20  provider upon request.
    21    (6) For purposes of this subsection:
    22    (A) "financial requirement" means deductible, copayments,  coinsurance
    23  and out-of-pocket expenses;
    24    (B)  "predominant"  means  that  a  financial requirement or treatment
    25  limitation is  the most common or frequent of  such  type  of  limit  or
    26  requirement;
    27    (C) "treatment limitation" means limits on the frequency of treatment,
    28  number  of    visits,  days  of coverage, or other similar limits on the
    29  scope or duration of  treatment and includes  nonquantitative  treatment
    30  limitations such as: medical  management standards limiting or excluding
    31  benefits  based on medical necessity,  or based on whether the treatment
    32  is experimental or investigational; formulary   design for  prescription
    33  drugs; network tier design; standards for provider  admission to partic-
    34  ipate  in  a network, including reimbursement rates; methods  for deter-
    35  mining usual, customary, and  reasonable  charges;  fail-first  or  step
    36  therapy  protocols;  exclusions based on failure to complete a course of
    37  treatment; and restrictions based on geographic location, facility type,
    38  provider specialty, and other criteria that limit the scope or  duration
    39  of  benefits for services provided under the contract; and
    40    (D)  "mental  health  condition"  means  any mental health disorder as
    41  defined in the  most recent edition of the  diagnostic  and  statistical
    42  manual of mental disorders  or the most recent edition of another gener-
    43  ally recognized independent standard of current medical practice such as
    44  the international classification of diseases.
    45    (7)  A  corporation shall provide coverage under this subsection, at a
    46  minimum,  consistent with the federal Paul Wellstone and  Pete  Domenici
    47  Mental  Health    Parity  and  Addiction Equity Act of 2008 (29 U.S.C. §
    48  1185a).
    49    (8) This paragraph shall apply to hospitals in  this  state  that  are
    50  licensed  by  the  office of mental health that are participating in the
    51  corporation's provider network. Where the contract provides coverage for
    52  inpatient hospital care, benefits  for  inpatient  hospital  care  in  a
    53  hospital  as    defined by subdivision ten of section 1.03 of the mental
    54  hygiene law provided to individuals who have not  attained  the  age  of
    55  eighteen  shall  not  be  subject to preauthorization. Coverage provided
    56  under this paragraph shall also not be  subject to  concurrent  utiliza-

        S. 1507--C                         112                        A. 2007--C
 
     1  tion  review  during the first fourteen days of the inpatient admission,
     2  provided the facility notifies the corporation of both the admission and
     3  the initial treatment plan within two business days  of  the  admission,
     4  performs daily clinical review of the patient, and participates in peri-
     5  odic  consultation  with  the corporation to ensure that the facility is
     6  using the evidence-based and  peer  reviewed  clinical  review  criteria
     7  utilized  by  the  corporation which is approved by the office of mental
     8  health and appropriate to the age of the patient,  to  ensure  that  the
     9  inpatient  care  is  medically  necessary for the patient. All treatment
    10  provided under this paragraph may  be  reviewed  retrospectively.  Where
    11  care  is denied retrospectively, an insured shall not have any financial
    12  obligation to the facility for any treatment under this paragraph  other
    13  than  any copayment, coinsurance, or deductible otherwise required under
    14  the contract.
    15    § 24. Subsection (h) of section 4303 of the insurance law is REPEALED.
    16    § 25. Subsection (i) of section 4303 of the insurance law, as  amended
    17  by chapter 230 of the laws of 2004, is amended to read as follows:
    18    (i)  A  medical expense indemnity corporation or health service corpo-
    19  ration [which] that provides coverage for physicians,  psychiatrists  or
    20  psychologists for psychiatric or psychological services or for the diag-
    21  nosis  and  treatment  of  [mental,  nervous  or emotional disorders and
    22  ailments] mental health conditions, however defined  in  such  contract,
    23  [must]  shall  make  available  and  if requested by all persons holding
    24  individual contracts in a group whose premiums are paid by  a  remitting
    25  agent  or  by the contract holder in the case of a group contract issued
    26  pursuant to section four thousand three hundred five  of  this  article,
    27  provide the same coverage for such services when performed by a licensed
    28  clinical  social worker, within the lawful scope of his or her practice,
    29  who is licensed pursuant to article one hundred fifty-four of the educa-
    30  tion law. The state board for social work shall maintain a list  of  all
    31  licensed  clinical social workers qualified for reimbursement under this
    32  subsection. Such coverage shall be made available at  the  inception  of
    33  all new contracts and, with respect to all other contracts, at any anni-
    34  versary  date subject to evidence of insurability. Written notice of the
    35  availability of such coverage shall be delivered to the group  remitting
    36  agent  or  group contract holder prior to inception of such contract and
    37  annually thereafter, except that this notice shall not be required where
    38  a [policy] contract covers two hundred or more employees  or  where  the
    39  benefit  structure  was  the  subject of collective bargaining affecting
    40  persons who are employed in more than one state.
    41    § 26. Subsection (k) of section 4303 of the insurance law, as  amended
    42  by  section 3 of part B of chapter 71 of the laws of 2016, is amended to
    43  read as follows:
    44    (k)(1) Every contract that provides hospital, major medical or similar
    45  comprehensive coverage [must] shall provide inpatient coverage  for  the
    46  diagnosis and treatment of substance use disorder, including detoxifica-
    47  tion  and rehabilitation services. Such inpatient coverage shall include
    48  unlimited medically  necessary  treatment  for  substance  use  disorder
    49  treatment  services provided in residential settings [as required by the
    50  Mental Health Parity and Addiction Equity  Act  of  2008  (29  U.S.C.  §
    51  1185a)].    Further,  such  inpatient coverage shall not apply financial
    52  requirements or  treatment  limitations,  including  utilization  review
    53  requirements, to inpatient substance use disorder benefits that are more
    54  restrictive  than  the  predominant financial requirements and treatment
    55  limitations applied to substantially all medical and  surgical  benefits
    56  covered  by  the  contract.  [Further,  such  coverage shall be provided

        S. 1507--C                         113                        A. 2007--C

     1  consistent with the federal Paul  Wellstone  and  Pete  Domenici  Mental
     2  Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).]
     3    (2)  Coverage provided under this subsection may be limited to facili-
     4  ties in New York state [which are certified] that are  licensed,  certi-
     5  fied  or  otherwise authorized by the office of alcoholism and substance
     6  abuse services and, in other states, to those which  are  accredited  by
     7  the joint commission as alcoholism, substance abuse, or chemical depend-
     8  ence  treatment programs and are similarly licensed, certified or other-
     9  wise authorized in the state in which the facility is located.
    10    (3) Coverage provided under this subsection may be subject  to  annual
    11  deductibles and co-insurance as deemed appropriate by the superintendent
    12  and  that  are  consistent with those imposed on other benefits within a
    13  given contract.
    14    (4) This paragraph shall apply to facilities in this state [certified]
    15  that are licensed, certified or otherwise authorized by  the  office  of
    16  alcoholism  and  substance  abuse services that are participating in the
    17  corporation's provider network. Coverage provided under this  subsection
    18  shall  not  be subject to preauthorization. Coverage provided under this
    19  subsection shall also not be subject to  concurrent  utilization  review
    20  during the first [fourteen] twenty-eight days of the inpatient admission
    21  provided  that  the facility notifies the corporation of both the admis-
    22  sion and the initial treatment plan within [forty-eight hours] two busi-
    23  ness days of the admission. The facility shall  perform  daily  clinical
    24  review  of  the  patient, including [the] periodic consultation with the
    25  corporation at or just prior to  the  fourteenth  day  of  treatment  to
    26  ensure  that  the facility is using the evidence-based and peer reviewed
    27  clinical review tool utilized by the corporation which is designated  by
    28  the office of alcoholism and substance abuse services and appropriate to
    29  the  age  of  the  patient,  to  ensure  that the inpatient treatment is
    30  medically necessary for the patient.  Prior to discharge,  the  facility
    31  shall  provide  the patient and the corporation with a written discharge
    32  plan which shall describe arrangements for  additional  services  needed
    33  following  discharge from the inpatient facility as determined using the
    34  evidence-based and peer-reviewed clinical review tool  utilized  by  the
    35  corporation  which  is  designated  by  the  office  of  alcoholism  and
    36  substance abuse services.  Prior to discharge, the facility shall  indi-
    37  cate  to the corporation whether services included in the discharge plan
    38  are secured or determined to be reasonably  available.  Any  utilization
    39  review  of  treatment provided under this paragraph may include a review
    40  of all services provided during such inpatient treatment, including  all
    41  services  provided during the first [fourteen] twenty-eight days of such
    42  inpatient treatment.  Provided, however, the corporation shall only deny
    43  coverage for any portion of  the  initial  [fourteen]  twenty-eight  day
    44  inpatient  treatment  on the basis that such treatment was not medically
    45  necessary if such inpatient treatment was contrary to the evidence-based
    46  and peer reviewed clinical review tool utilized by the corporation which
    47  is designated by the office of alcoholism and substance abuse  services.
    48  An  insured  shall not have any financial obligation to the facility for
    49  any treatment under this paragraph other  than  any  copayment,  coinsu-
    50  rance, or deductible otherwise required under the contract.
    51    (5)  The  criteria  for  medical  necessity  determinations  under the
    52  contract with   respect to inpatient  substance  use  disorder  benefits
    53  shall  be  made available by the corporation to any insured, prospective
    54  insured or in-network provider upon  request.
    55    (6) For purposes of this subsection:

        S. 1507--C                         114                        A. 2007--C
 
     1    (A) "financial requirement" means deductible, copayments,  coinsurance
     2  and out-of-pocket expenses;
     3    (B)  "predominant"  means  that  a  financial requirement or treatment
     4  limitation is  the most common or frequent of  such  type  of  limit  or
     5  requirement;
     6    (C) "treatment limitation" means limits on the frequency of treatment,
     7  number  of    visits,  days  of coverage, or other similar limits on the
     8  scope or duration of  treatment and includes  nonquantitative  treatment
     9  limitations such as: medical  management standards limiting or excluding
    10  benefits  based on medical necessity,  or based on whether the treatment
    11  is experimental or investigational; formulary   design for  prescription
    12  drugs; network tier design; standards for provider  admission to partic-
    13  ipate  in  a network, including reimbursement rates; methods  for deter-
    14  mining usual, customary, and  reasonable  charges;  fail-first  or  step
    15  therapy  protocols;  exclusions based on failure to complete a course of
    16  treatment; and restrictions based on geographic location, facility type,
    17  provider specialty, and other criteria that limit the scope or  duration
    18  of  benefits for services provided under the contract; and
    19    (D)  "substance  use disorder" shall have the meaning set forth in the
    20  most recent  edition of the diagnostic and statistical manual of  mental
    21  disorders  or  the most   recent edition of another generally recognized
    22  independent standard of current  medical practice such as  the  interna-
    23  tional classification of diseases.
    24    (7)  A  corporation shall provide coverage under this subsection, at a
    25  minimum,  consistent with the federal Paul Wellstone and  Pete  Domenici
    26  Mental  Health    Parity  and  Addiction Equity Act of 2008 (29 U.S.C. §
    27  1185a).
    28    § 27. Paragraphs 1 and 2 of subsection (l)  of  section  4303  of  the
    29  insurance law, as amended by chapter 41 of the laws of 2014, are amended
    30  and a new paragraph 3-a is added to read as follows:
    31    (1)  Every  contract  that  provides medical, major medical or similar
    32  comprehensive-type coverage [must] shall provide outpatient coverage for
    33  the diagnosis and treatment of substance use disorder, including detoxi-
    34  fication and rehabilitation services.  Such  coverage  shall  not  apply
    35  financial  requirements or treatment limitations to outpatient substance
    36  use disorder benefits that are more  restrictive  than  the  predominant
    37  financial requirements and treatment limitations applied to substantial-
    38  ly all medical and surgical benefits covered by the contract.  [Further,
    39  such  coverage  shall be provided consistent with the federal Paul Well-
    40  stone and Pete Domenici Mental Health Parity and Addiction Equity Act of
    41  2008 (29 U.S.C. § 1185a).]
    42    (2) Coverage under this subsection may be limited to facilities in New
    43  York state that are licensed, certified or otherwise authorized  by  the
    44  office  of  alcoholism and substance abuse services [or licensed by such
    45  office as outpatient clinics  or  medically  supervised  ambulatory]  to
    46  provide outpatient substance [abuse programs] use disorder services and,
    47  in  other  states, to those which are accredited by the joint commission
    48  as alcoholism or chemical dependence substance abuse treatment  programs
    49  and  are  similarly  licensed,  certified or otherwise authorized in the
    50  state in which the facility is located.
    51    (3-a) A  contract  that  provides  large  group  coverage  under  this
    52  subsection  shall  not  impose  copayments or coinsurance for outpatient
    53  substance use disorder services that exceed the copayment or coinsurance
    54  imposed for a primary care office visit. Provided that no  greater  than
    55  one  such copayment may be imposed for all services provided in a single
    56  day by a facility licensed, certified or  otherwise  authorized  by  the

        S. 1507--C                         115                        A. 2007--C
 
     1  office  of alcoholism and substance abuse services to provide outpatient
     2  substance use disorder services.
     3    §  28.  Paragraph 5 of subsection (l) of section 4303 of the insurance
     4  law, as added by section 5 of part MM of chapter 57 of the laws of 2018,
     5  is amended and three new paragraphs 6, 7 and 8  are  added  to  read  as
     6  follows:
     7    (5) This paragraph shall apply to facilities in this state [certified]
     8  that  are  licensed,  certified or otherwise authorized by the office of
     9  alcoholism and substance abuse services for the provision of outpatient,
    10  intensive outpatient, outpatient  rehabilitation  and  opioid  treatment
    11  that  are  participating in the corporation's provider network. Coverage
    12  provided under this subsection shall not be subject to preauthorization.
    13  Coverage provided under this subsection shall not be subject to  concur-
    14  rent  review for the first [two] four weeks of continuous treatment, not
    15  to exceed [fourteen] twenty-eight visits, provided the facility notifies
    16  the corporation of both the start of treatment and the initial treatment
    17  plan within [forty-eight hours] two business days.  The  facility  shall
    18  perform  clinical  assessment  of  the  patient at each visit, including
    19  [the] periodic consultation with the corporation at or just prior to the
    20  fourteenth day of treatment to ensure that the  facility  is  using  the
    21  evidence-based  and  peer  reviewed clinical review tool utilized by the
    22  corporation  which  is  designated  by  the  office  of  alcoholism  and
    23  substance  abuse  services and appropriate to the age of the patient, to
    24  ensure that the outpatient treatment  is  medically  necessary  for  the
    25  patient.    Any  utilization review of the treatment provided under this
    26  paragraph may include a review of  all  services  provided  during  such
    27  outpatient  treatment,  including all services provided during the first
    28  [two] four weeks of continuous treatment, not to exceed [fourteen] twen-
    29  ty-eight visits, of such outpatient treatment.  Provided,  however,  the
    30  corporation  shall  only  deny  coverage  for any portion of the initial
    31  [two] four weeks of continuous treatment, not to exceed [fourteen] twen-
    32  ty-eight visits, for outpatient treatment on the basis that such  treat-
    33  ment  was  not  medically  necessary  if  such  outpatient treatment was
    34  contrary to the evidence-based and peer reviewed  clinical  review  tool
    35  utilized  by  the corporation which is designated by the office of alco-
    36  holism and substance abuse services. A subscriber  shall  not  have  any
    37  financial  obligation to the facility for any treatment under this para-
    38  graph other than any copayment,  coinsurance,  or  deductible  otherwise
    39  required under the contract.
    40    (6)  The  criteria  for  medical  necessity  determinations  under the
    41  contract with respect to  outpatient  substance  use  disorder  benefits
    42  shall  be  made available by the corporation to any insured, prospective
    43  insured, or in-network provider upon request.
    44    (7) For purposes of this subsection:
    45    (A) "financial requirement" means deductible, copayments,  coinsurance
    46  and out-of-pocket expenses;
    47    (B)  "predominant"  means  that  a  financial requirement or treatment
    48  limitation is the most common or frequent  of  such  type  of  limit  or
    49  requirement.
    50    (C) "treatment limitation" means limits on the frequency of treatment,
    51  number of visits, days of coverage, or other similar limits on the scope
    52  or  duration of treatment and includes nonquantitative treatment limita-
    53  tions such as: medical management standards limiting or excluding  bene-
    54  fits  based  on  medical necessity, or based on whether the treatment is
    55  experimental  or  investigational;  formulary  design  for  prescription
    56  drugs;  network tier design; standards for provider admission to partic-

        S. 1507--C                         116                        A. 2007--C

     1  ipate in a network, including reimbursement rates; methods for determin-
     2  ing usual, customary, and reasonable charges; fail-first or step therapy
     3  protocols; exclusions based on failure to complete a  course  of  treat-
     4  ment;  and  restrictions  based  on  geographic location, facility type,
     5  provider specialty, and other criteria that limit the scope or  duration
     6  of benefits for services provided under the contract; and
     7    (D)  "substance  use disorder" shall have the meaning set forth in the
     8  most recent edition of the diagnostic and statistical manual  of  mental
     9  disorders  or  the  most  recent edition of another generally recognized
    10  independent standard of current medical practice such  as  the  interna-
    11  tional classification of diseases.
    12    (8)  A  corporation shall provide coverage under this subsection, at a
    13  minimum, consistent with the federal Paul Wellstone  and  Pete  Domenici
    14  Mental  Health  Parity  and  Addiction  Equity  Act of 2008 (29 U.S.C. §
    15  1185a).
    16    § 29. Subsection (l-2) of section 4303 of the insurance law, as  added
    17  by  section 3 of part B of chapter 69 of the laws of 2016, is amended to
    18  read as follows:
    19    (l-2) [(1)] Every contract that provides  medical,  major  medical  or
    20  similar   comprehensive-type   coverage   and   provides   coverage  for
    21  prescription drugs for medication for the treatment of a  substance  use
    22  disorder shall include immediate access, without prior authorization, to
    23  [a  five day emergency supply] the formulary forms of prescribed medica-
    24  tions covered under the contract for  the  treatment  of  substance  use
    25  disorder  [where  an emergency condition exists], including a prescribed
    26  drug or medication associated with the management of  opioid  withdrawal
    27  and/or stabilization, except where otherwise prohibited by law. Further,
    28  coverage  [of  an  emergency  supply]  without prior authorization shall
    29  include formulary forms  of  medication  for  opioid  overdose  reversal
    30  otherwise covered under the contract prescribed or dispensed to an indi-
    31  vidual covered by the contract.
    32    [(2)  For purposes of this paragraph, an "emergency condition" means a
    33  substance use disorder condition that manifests itself by acute symptoms
    34  of sufficient severity, including severe  pain  or  the  expectation  of
    35  severe  pain, such that a prudent layperson, possessing an average know-
    36  ledge of medicine and health, could reasonably  expect  the  absence  of
    37  immediate medical attention to result in:
    38    (i)  placing the health of the person afflicted with such condition in
    39  serious jeopardy, or in the case of a behavioral condition, placing  the
    40  health of such person or others in serious jeopardy;
    41    (ii) serious impairment to such person's bodily functions;
    42    (iii) serious dysfunction of any bodily organ or part of such person;
    43    (iv) serious disfigurement of such person; or
    44    (v)  a  condition  described  in  clause (i), (ii) or (iii) of section
    45  1867(e)(1)(A) of the Social Security Act.
    46    (3) Coverage provided under this subsection may be subject  to  copay-
    47  ments,  coinsurance,  and  annual  deductibles  that are consistent with
    48  those imposed on other benefits within the contract; provided,  however,
    49  no  contract  shall  impose an additional copayment or coinsurance on an
    50  insured who received an emergency supply of medication and then received
    51  up to a thirty day supply of the same medication in the same thirty  day
    52  period  in  which the emergency supply of medication was dispensed. This
    53  paragraph shall not preclude the imposition of a  copayment  or  coinsu-
    54  rance  on  the initial limited supply of medication in an amount that is
    55  less than the copayment or coinsurance otherwise applicable to a  thirty
    56  day supply of such medication, provided that the total sum of the copay-

        S. 1507--C                         117                        A. 2007--C

     1  ments  or  coinsurance for an entire thirty day supply of the medication
     2  does not exceed the copayment or coinsurance otherwise applicable  to  a
     3  thirty day supply of such medication.]
     4    §  30. Subsection (n) of section 4303 of the insurance law, as amended
     5  by chapter 230 of the laws of 2004, is amended to read as follows:
     6    (n) In addition to the requirements of subsection (i) of this section,
     7  every health service or medical expense indemnity corporation issuing  a
     8  group  contract  pursuant to this section or a group remittance contract
     9  for delivery in this state  which  contract  provides  reimbursement  to
    10  subscribers  or physicians, psychiatrists or psychologists for psychiat-
    11  ric or psychological services or for  the  diagnosis  and  treatment  of
    12  [mental,  nervous  or  emotional  disorders and ailments,] mental health
    13  conditions, however defined in such  contract,  must  provide  the  same
    14  coverage  to  persons covered under the group contract for such services
    15  when performed by a licensed clinical social worker, within  the  lawful
    16  scope  of  his  or her practice, who is licensed pursuant to subdivision
    17  two of section seven thousand seven hundred four of  the  education  law
    18  and  in  addition  shall  have either (i) three or more additional years
    19  experience in psychotherapy, which for the purposes of  this  subsection
    20  shall mean the use of verbal methods in interpersonal relationships with
    21  the  intent  of  assisting  a  person or persons to modify attitudes and
    22  behavior which are intellectually, socially or emotionally  maladaptive,
    23  under supervision, satisfactory to the state board for social work, in a
    24  facility,  licensed  or  incorporated  by  an  appropriate  governmental
    25  department, providing services for diagnosis or  treatment  of  [mental,
    26  nervous  or  emotional disorders or ailments,] mental health conditions,
    27  or (ii) three or more additional years experience in psychotherapy under
    28  the supervision, satisfactory to the state board for social work,  of  a
    29  psychiatrist, a licensed and registered psychologist or a licensed clin-
    30  ical  social  worker  qualified for reimbursement pursuant to subsection
    31  (i) of this section, or (iii) a combination of the experience  specified
    32  in  paragraphs  (i)  and  (ii) totaling three years, satisfactory to the
    33  state board for social work.   The state board  for  social  work  shall
    34  maintain  a  list  of all licensed clinical social workers qualified for
    35  reimbursement under this subsection.
    36    § 31. Paragraph 2 of subsection (ee) of section 4303 of the  insurance
    37  law,  as  amended  by  section 40 of part D of chapter 56 of the laws of
    38  2013, is amended to read as follows:
    39    (2) Every contract that provides physician  services,  medical,  major
    40  medical  or  similar  comprehensive-type coverage shall provide coverage
    41  for the screening, diagnosis and treatment of autism  spectrum  disorder
    42  in accordance with this paragraph and shall not exclude coverage for the
    43  screening,  diagnosis  or  treatment  of  medical  conditions  otherwise
    44  covered by the contract because the individual is diagnosed with  autism
    45  spectrum  disorder.  Such coverage may be subject to annual deductibles,
    46  copayments and coinsurance as may be deemed appropriate  by  the  super-
    47  intendent  and  shall be consistent with those imposed on other benefits
    48  under the contract. [Coverage for applied  behavior  analysis  shall  be
    49  subject  to  a  maximum benefit of six hundred eighty hours of treatment
    50  per contract or calendar year per covered  individual.]  This  paragraph
    51  shall  not  be  construed  as  limiting  the benefits that are otherwise
    52  available to an individual under the  contract,  provided  however  that
    53  such contract shall not contain any limitations on visits that are sole-
    54  ly  applied  to  the  treatment  of autism spectrum disorder. No insurer
    55  shall terminate coverage or refuse to deliver,  execute,  issue,  amend,
    56  adjust, or renew coverage to an individual solely because the individual

        S. 1507--C                         118                        A. 2007--C
 
     1  is diagnosed with autism spectrum disorder or has received treatment for
     2  autism  spectrum  disorder.  Coverage  shall  be  subject to utilization
     3  review and external appeals of health care services pursuant to  article
     4  forty-nine  of  this  chapter as well as[,] case management[,] and other
     5  managed care provisions.
     6    § 32. Subparagraphs (A) and (C) of paragraph 3 of subsection  (ee)  of
     7  section 4303 of the insurance law, as amended by chapter 596 of the laws
     8  of 2011, are amended to read as follows:
     9    (A)  "autism  spectrum  disorder"  means  any  pervasive developmental
    10  disorder as defined in the most recent edition  of  the  diagnostic  and
    11  statistical  manual  of  mental disorders[, including autistic disorder,
    12  Asperger's disorder, Rett's disorder, childhood disintegrative disorder,
    13  or pervasive developmental disorder not otherwise specified (PDD-NOS)].
    14    (C) "behavioral  health  treatment"  means  counseling  and  treatment
    15  programs,  when  provided  by  a licensed provider, and applied behavior
    16  analysis, when provided [or supervised] by a [behavior analyst certified
    17  pursuant to the behavior analyst certification  board]  person  that  is
    18  licensed,  certified or otherwise authorized to provide applied behavior
    19  analysis, that are necessary to develop, maintain, or  restore,  to  the
    20  maximum  extent practicable, the functioning of an individual. [Individ-
    21  uals that provide behavioral health treatment under the supervision of a
    22  certified behavior analyst pursuant to this subsection shall be  subject
    23  to  standards  of  professionalism,  supervision and relevant experience
    24  pursuant to regulations promulgated by the superintendent  in  consulta-
    25  tion with the commissioners of health and education.]
    26    §  33. Subsection (ee) of section 4303 of the insurance law is amended
    27  by adding four new paragraphs 8, 9, 10, and 11 to read as follows:
    28    (8) Coverage under this subsection shall not apply financial  require-
    29  ments or treatment limitations to autism spectrum disorder benefits that
    30  are  more  restrictive  than  the predominant financial requirements and
    31  treatment limitations applied to substantially all medical and  surgical
    32  benefits covered by the policy.
    33    (9)  The  criteria  for  medical  necessity  determinations  under the
    34  contract with respect to autism spectrum disorder benefits shall be made
    35  available by the corporation to any  insured,  prospective  insured,  or
    36  in-network provider upon request.
    37    (10) For purposes of this subsection:
    38    (A)  "financial requirement" means deductible, copayments, coinsurance
    39  and out-of-pocket expenses;
    40    (B) "predominant" means that  a  financial  requirement  or  treatment
    41  limitation  is  the  most  common  or  frequent of such type of limit or
    42  requirement; and
    43    (C) "treatment limitation" means limits on the frequency of treatment,
    44  number of visits, days of coverage, or other similar limits on the scope
    45  or duration of treatment and includes nonquantitative treatment  limita-
    46  tions  such as: medical management standards limiting or excluding bene-
    47  fits based on medical necessity, or based on whether  the  treatment  is
    48  experimental  or  investigational;  formulary  design  for  prescription
    49  drugs; network tier design; standards for provider admission to  partic-
    50  ipate in a network, including reimbursement rates; methods for determin-
    51  ing usual, customary, and reasonable charges; fail-first or step therapy
    52  protocols;  exclusions  based  on failure to complete a course of treat-
    53  ment; and restrictions based  on  geographic  location,  facility  type,
    54  provider  specialty, and other criteria that limit the scope or duration
    55  of benefits for services provided under the contract.

        S. 1507--C                         119                        A. 2007--C
 
     1    (11) A corporation shall provide coverage under this subsection, at  a
     2  minimum,  consistent  with  the federal Paul Wellstone and Pete Domenici
     3  Mental Health Parity and Addiction Equity  Act  of  2008  (29  U.S.C.  §
     4  1185a).
     5    §  34.  Paragraphs  17, 20 and 21 of subsection (a) of section 4324 of
     6  the insurance law, paragraph 17 as amended and paragraphs 20 and  21  as
     7  added  by  section  8  of  part H of chapter 60 of the laws of 2014, are
     8  amended and a new paragraph 22 is added to read as follows:
     9    (17) where applicable, a listing by specialty, which may be in a sepa-
    10  rate document that is updated annually, of the name, address, and  tele-
    11  phone  number of all participating providers, including facilities, [and
    12  in addition,] and: (A) whether the provider is accepting  new  patients;
    13  (B)  in  the  case  of  mental health or substance use disorder services
    14  providers, any affiliations with participating facilities  certified  or
    15  authorized  by  the  office of mental health or the office of alcoholism
    16  and substance abuse services, and any restrictions regarding the  avail-
    17  ability of the individual provider's services; (C) in the case of physi-
    18  cians,  board  certification, languages spoken and any affiliations with
    19  participating hospitals. The listing shall also be posted on the  corpo-
    20  ration's  website  and  the  corporation shall update the website within
    21  fifteen days of the addition or  termination  of  a  provider  from  the
    22  corporation's network or a change in a physician's hospital affiliation;
    23    (20) with respect to out-of-network coverage:
    24    (A)  a clear description of the methodology used by the corporation to
    25  determine reimbursement for out-of-network health care services;
    26    (B) a description of the amount that the  corporation  will  reimburse
    27  under  the methodology for out-of-network health care services set forth
    28  as a percentage of the  usual  and  customary  cost  for  out-of-network
    29  health care services; and
    30    (C)  examples of anticipated out-of-pocket costs for frequently billed
    31  out-of-network health care services; [and]
    32    (21) information in writing  and  through  an  internet  website  that
    33  reasonably  permits  a  subscriber or prospective subscriber to estimate
    34  the  anticipated  out-of-pocket  cost  for  out-of-network  health  care
    35  services  in  a  geographical area or zip code based upon the difference
    36  between what the corporation will reimburse  for  out-of-network  health
    37  care services and the usual and customary cost for out-of-network health
    38  care services[.]; and
    39    (22) the most recent comparative analysis performed by the corporation
    40  to  assess  the provision of its covered services in accordance with the
    41  Paul Wellstone and Pete Domenici  Mental  Health  Parity  and  Addiction
    42  Equity  Act  of  2008,  42  U.S.C. 18031 (j), and any amendments to, and
    43  federal guidance or regulations issued under, those Acts.
    44    § 35. Subsection (b) of section 4325 of the insurance law, as added by
    45  chapter 705 of the laws of 1996, is amended to read as follows:
    46    (b) No corporation organized under this  article  shall  by  contract,
    47  written  policy [or], written procedure or practice prohibit or restrict
    48  any health care provider from filing a complaint,  making  a  report  or
    49  commenting to an appropriate governmental body regarding the policies or
    50  practices of such corporation which the provider believes may negatively
    51  impact upon the quality of or access to patient care. Nor shall a corpo-
    52  ration  organized  under this article take any adverse action, including
    53  but not limited to refusing to renew or execute a contract or  agreement
    54  with a health care provider as retaliation against a health care provid-
    55  er for filing a complaint, making a report or commenting to an appropri-
    56  ate  governmental  body  regarding  policies or practices of such corpo-

        S. 1507--C                         120                        A. 2007--C
 
     1  ration which may violate this chapter  including  subsection  (g),  (k),
     2  (1),  (1-1)  or (1-2) of section forty-three hundred three of this arti-
     3  cle.
     4    §  36.  Subparagraph  (C)  of paragraph 1 of subsection (b) of section
     5  4900 of the insurance law, as added by chapter 41 of the laws  of  2014,
     6  is amended and a new subparagraph (D) is added to read as follows:
     7    (C)  for  purposes of a determination involving substance use disorder
     8  treatment:
     9    (i) a physician who  possesses  a  current  and  valid  non-restricted
    10  license  to  practice  medicine and who specializes in behavioral health
    11  and has experience in the delivery of substance use disorder courses  of
    12  treatment; or
    13    (ii)  a  health  care professional other than a licensed physician who
    14  specializes in behavioral health and has experience in the  delivery  of
    15  substance  use  disorder  courses  of  treatment  and, where applicable,
    16  possesses a current and valid  non-restricted  license,  certificate  or
    17  registration or, where no provision for a license, certificate or regis-
    18  tration  exists, is credentialed by the national accrediting body appro-
    19  priate to the profession; [and] or
    20    (D) for purposes of a determination involving treatment for  a  mental
    21  health condition:
    22    (i)  a  physician  who  possesses  a  current and valid non-restricted
    23  license to practice medicine and who specializes  in  behavioral  health
    24  and  has  experience  in the delivery of mental health courses of treat-
    25  ment; or
    26    (ii) a health care professional other than a  licensed  physician  who
    27  specializes  in  behavioral health and has experience in the delivery of
    28  mental health courses of treatment and, where  applicable,  possesses  a
    29  current  and  valid non-restricted license, certificate, or registration
    30  or, where no  provision  for  a  license,  certificate  or  registration
    31  exists,  is credentialed by the national accrediting body appropriate to
    32  the profession; and
    33    § 37. Paragraph 9 of subsection (a) of section 4902 of  the  insurance
    34  law,  as  amended  by  section  1 of part A of chapter 69 of the laws of
    35  2016, is amended to read as follows:
    36    (9) When conducting utilization review  for  purposes  of  determining
    37  health care coverage for substance use disorder treatment, a utilization
    38  review  agent shall utilize an evidence-based and peer reviewed clinical
    39  review [tools designated by the office of alcoholism and substance abuse
    40  services that are appropriate to the age of the patient  and  consistent
    41  with  the  treatment  service levels within the office of alcoholism and
    42  substance abuse services system] tool that is appropriate to the age  of
    43  the  patient.  When  conducting  such  utilization  review for treatment
    44  provided in this state, a utilization  review  agent  shall  utilize  an
    45  evidence-based  and peer reviewed clinical tool designated by the office
    46  of alcoholism and substance abuse services that is consistent  with  the
    47  treatment  service  levels within the office of alcoholism and substance
    48  abuse services system. All approved tools shall have inter  rater  reli-
    49  ability   testing  completed  by  December  thirty-first,  two  thousand
    50  sixteen.
    51    § 38. Subsection (a) of section 4902 of the insurance law  is  amended
    52  by adding a new paragraph 12 to read as follows:
    53    (12)  When  conducting  utilization review for purposes of determining
    54  health care coverage for a mental health condition, a utilization review
    55  agent shall utilize evidence-based and  peer  reviewed  clinical  review
    56  criteria that is appropriate to the age of the patient.  The utilization

        S. 1507--C                         121                        A. 2007--C
 
     1  review  agent  shall use clinical review criteria deemed appropriate and
     2  approved for such use by  the  commissioner  of  the  office  of  mental
     3  health,  in  consultation with the commissioner of health and the super-
     4  intendent.  Approved  clinical  review  criteria  shall have inter rater
     5  reliability testing completed by  December  thirty-first,  two  thousand
     6  nineteen.
     7    §  39.  Paragraph  (b)  of  subsection 5 of section 4403 of the public
     8  health law, as added by chapter 705 of the laws of 1996, is  amended  to
     9  read as follows:
    10    (b)  The following criteria shall be considered by the commissioner at
    11  the time of a review: (i) the availability  of  appropriate  and  timely
    12  care  that  is  provided in compliance with the standards of the Federal
    13  Americans with Disability Act to assure access to health  care  for  the
    14  enrollee  population;  (ii)  the network's ability to provide culturally
    15  and linguistically competent care to meet  the  needs  of  the  enrollee
    16  population;  [and] (iii) the availability of appropriate and timely care
    17  that is in compliance with the standards of the Paul Wellstone and  Pete
    18  Domenici  Mental  Health  Parity  and  Addiction  Equity Act of 2008, 42
    19  U.S.C.  18031(j), and any amendments to, and federal guidance and  regu-
    20  lations  issued under those Acts, which shall include an analysis of the
    21  rate  of  out-of-network  utilization  for  covered  mental  health  and
    22  substance  use  disorder services as compared to the rate of out-of-net-
    23  work utilization for the respective category of  medical  services;  and
    24  (iv)  with  the exception of initial licensure, the number of grievances
    25  filed by enrollees relating to waiting times for appointments, appropri-
    26  ateness of referrals and other indicators of plan capacity.
    27    § 40. Subdivision 3 of section 4406-c of the  public  health  law,  as
    28  added by chapter 705 of the laws of 1996, is amended to read as follows:
    29    3. No health care plan shall by contract, written policy [or], written
    30  procedure or practice prohibit or restrict any health care provider from
    31  filing  a  complaint,  making  a  report or commenting to an appropriate
    32  governmental body regarding the policies or  practices  of  such  health
    33  care  plan  which  the  provider believes may negatively impact upon the
    34  quality of, or access to, patient care. Nor shall  a  health  care  plan
    35  take  any adverse action, including but not limited to refusing to renew
    36  or execute a contract or agreement with a health care provider as retal-
    37  iation against a health care provider for filing a complaint,  making  a
    38  report or commenting to an appropriate governmental body regarding poli-
    39  cies  or practices of such health care plan which may violate this chap-
    40  ter or the insurance law including subsection (g), (k),  (l),  (l-1)  or
    41  (1-2) of section forty-three hundred three of the insurance law.
    42    §  41. Paragraphs (r), (t) and (u) of subdivision 1 of section 4408 of
    43  the public health law, paragraph (r) as amended and paragraphs  (t)  and
    44  (u)  as added by section 18 of part H of chapter 60 of the laws of 2014,
    45  are amended and a new paragraph (v) is added to read as follows:
    46    (r) a listing by specialty, which may be in a separate  document  that
    47  is  updated  annually,  of the name, address and telephone number of all
    48  participating providers, including facilities, [and, in addition,]  and:
    49  (i)  whether the provider is accepting new patients; (ii) in the case of
    50  mental health or substance use disorder services providers,  any  affil-
    51  iations  with  participating  facilities  certified or authorized by the
    52  office of mental health or the office of alcoholism and substance  abuse
    53  services,  and  any restrictions regarding the availability of the indi-
    54  vidual provider's services; and (iii) in the case of  physicians,  board
    55  certification,  languages spoken and any affiliations with participating
    56  hospitals. The listing shall also be posted on  the  health  maintenance

        S. 1507--C                         122                        A. 2007--C
 
     1  organization's  website  and  the  health maintenance organization shall
     2  update the website within fifteen days of the addition or termination of
     3  a provider from the  health  maintenance  organization's  network  or  a
     4  change in a physician's hospital affiliation;
     5    (t) with respect to out-of-network coverage:
     6    (i)  a clear description of the methodology used by the health mainte-
     7  nance organization to determine reimbursement for out-of-network  health
     8  care services;
     9    (ii)  the  amount  that the health maintenance organization will reim-
    10  burse under the methodology for out-of-network health care services  set
    11  forth as a percentage of the usual and customary cost for out-of-network
    12  health care services;
    13    (iii)  examples  of  anticipated  out-of-pocket  costs  for frequently
    14  billed out-of-network health care services; [and]
    15    (u) information in  writing  and  through  an  internet  website  that
    16  reasonably  permits  an enrollee or prospective enrollee to estimate the
    17  anticipated out-of-pocket cost for out-of-network health  care  services
    18  in  a  geographical  area  or zip code based upon the difference between
    19  what the health maintenance organization will reimburse for  out-of-net-
    20  work  health  care services and the usual and customary cost for out-of-
    21  network health care services[.]; and
    22    (v) the most recent comparative analysis performed by the health main-
    23  tenance organization to assess the provision of its covered services  in
    24  accordance with the Paul Wellstone and Pete Dominici Mental Health Pari-
    25  ty  and  Addiction Equity Act of 2008, 42 U.S.C. 18031(j) and any amend-
    26  ments to, and federal guidance and regulations issued under, those Acts.
    27    § 42. Subparagraph (iii) of paragraph (a) of subdivision 2 of  section
    28  4900    of  the public health law, as added by chapter 41 of the laws of
    29  2014, is amended and a  new  subparagraph  (iv)  is  added  to  read  as
    30  follows:
    31    (iii) for purposes of a determination involving substance use disorder
    32  treatment:
    33    (A)  a  physician  who  possesses  a  current and valid non-restricted
    34  license to practice medicine and who specializes  in  behavioral  health
    35  and  has experience in the delivery of substance use disorder courses of
    36  treatment; or
    37    (B) a health care professional other than  a  licensed  physician  who
    38  specializes  in  behavioral health and has experience in the delivery of
    39  substance use disorder  courses  of  treatment  and,  where  applicable,
    40  possesses  a  current  and  valid non-restricted license, certificate or
    41  registration or, where no provision for a license, certificate or regis-
    42  tration exists, is credentialed by the national accrediting body  appro-
    43  priate to the profession; [and] or
    44    (iv)  for purposes of a determination involving treatment for a mental
    45  health condition:
    46    (A) a physician who  possesses  a  current  and  valid  non-restricted
    47  license  to  practice  medicine and who specializes in behavioral health
    48  and has experience in the delivery of mental health  courses  of  treat-
    49  ment; or
    50    (B)  a  health  care  professional other than a licensed physician who
    51  specializes in behavioral health and has experience in the delivery of a
    52  mental health courses of treatment and, where  applicable,  possesses  a
    53  current  and  valid non-restricted license, certificate, or registration
    54  or, where no  provision  for  a  license,  certificate  or  registration
    55  exists,  is credentialed by the national accrediting body appropriate to
    56  the profession; and

        S. 1507--C                         123                        A. 2007--C
 
     1    § 43. Paragraph (i) of subdivision 1 of section  4902  of  the  public
     2  health  law, as amended by section 2 of part A of chapter 69 of the laws
     3  of 2016, is amended and a new paragraph (j) is added to read as follows:
     4    (i)  When  conducting  utilization  review for purposes of determining
     5  health care coverage for substance use disorder treatment, a utilization
     6  review agent shall utilize an evidence-based and peer reviewed  clinical
     7  review [tools designated by the office of alcoholism and substance abuse
     8  services  that  are appropriate to the age of the patient and consistent
     9  with the treatment service levels within the office  of  alcoholism  and
    10  substance  abuse services system] tool that is appropriate to the age of
    11  the patient. When  conducting  such  utilization  review  for  treatment
    12  provided  in  this  state,  a  utilization review agent shall utilize an
    13  evidence-based and peer reviewed clinical tool designated by the  office
    14  of  alcoholism  and substance abuse services that is consistent with the
    15  treatment service levels within the office of alcoholism  and  substance
    16  abuse  services  system. All approved tools shall have inter rater reli-
    17  ability  testing  completed  by  December  thirty-first,  two   thousand
    18  sixteen.
    19    (j)  When  conducting  utilization  review for purposes of determining
    20  health care coverage for a mental health condition, a utilization review
    21  agent shall utilize evidence-based and  peer  reviewed  clinical  review
    22  criteria that is appropriate to the age of the patient.  The utilization
    23  review  agent  shall use clinical review criteria deemed appropriate and
    24  approved for such use by  the  commissioner  of  the  office  of  mental
    25  health,  in consultation with the commissioner and the superintendent of
    26  financial services.  Approved clinical review criteria shall have  inter
    27  rater  reliability testing completed by December thirty-first, two thou-
    28  sand nineteen.
    29    § 44. This act shall take effect on the first of January next succeed-
    30  ing the date on which it shall have become a law and shall apply to  all
    31  policies  and contracts issued, renewed, modified, altered or amended on
    32  or after such date; provided, however, notwithstanding any provision  of
    33  law to the contrary, nothing in this act shall limit the rights accruing
    34  to  employees  pursuant  to  a  collective bargaining agreement with any
    35  state or local government employer for the unexpired term of such agree-
    36  ment where such agreement is in effect on the effective date of this act
    37  and so long as such agreement remains in effect thereafter or the eligi-
    38  bility of any member of an employee organization to join a health insur-
    39  ance plan open to him or her pursuant to such a collectively  negotiated
    40  agreement.
 
    41                                  SUBPART B
 
    42    Section  1.  Subdivision 1 of section 2803-u of the public health law,
    43  as added by section 1 of part C of chapter 70 of the laws  of  2016,  is
    44  amended to read as follows:
    45    1. The office of alcoholism and substance abuse services, in consulta-
    46  tion  with the department, shall develop or utilize existing educational
    47  materials to be provided to general hospitals to disseminate to individ-
    48  uals with a documented substance use disorder or who appear to  have  or
    49  be at risk for a substance use disorder during discharge planning pursu-
    50  ant  to  section twenty-eight hundred three-i of this [chapter] article.
    51  Such materials shall include information regarding the various types  of
    52  treatment  and  recovery  services, including but not limited to:  inpa-
    53  tient, outpatient, and medication-assisted treatment; how  to  recognize
    54  the  need  for treatment services; information for individuals to deter-

        S. 1507--C                         124                        A. 2007--C
 
     1  mine what type and level of  treatment  is  most  appropriate  and  what
     2  resources  are  available to them; and any other information the commis-
     3  sioner deems appropriate. General hospitals shall include in their poli-
     4  cies  and procedures treatment protocols, consistent with medical stand-
     5  ards, to be utilized by the emergency departments in  general  hospitals
     6  for  the  appropriate  use  of  medication-assisted treatment, including
     7  buprenorphine, prior to discharge, or referral protocols for  evaluation
     8  of medication-assisted treatment when initiation in an emergency depart-
     9  ment of a general hospital is not feasible.
    10    § 2. This act shall take effect immediately.
 
    11                                  SUBPART C
 
    12                            Intentionally Omitted
 
    13                                  SUBPART D
 
    14    Section  1.  Paragraph  (r)  of  subdivision 4 of section 364-j of the
    15  social services law, as amended by section 39 of part A of chapter 56 of
    16  the laws of 2013, is amended to read as follows:
    17    (r) A managed care provider shall  provide  services  to  participants
    18  pursuant  to  an  order  of  a court of competent jurisdiction, provided
    19  however, that such services shall be within such  provider's  or  plan's
    20  benefit  package  and  are  reimbursable  under title xix of the federal
    21  social security act, provided that services for a substance use disorder
    22  shall be provided by a program licensed, certified or otherwise  author-
    23  ized by the office of alcoholism and substance abuse services.
    24    §  2.  This  act shall take effect immediately; provided, however that
    25  the amendments to paragraph (r) of subdivision 4 of section 364-j of the
    26  social services law made by section one of this act shall not affect the
    27  repeal of such section and shall be deemed to be repealed therewith.
 
    28                                  SUBPART E
 
    29                            Intentionally Omitted

    30    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    31  sion, section or part of this act shall be  adjudged  by  any  court  of
    32  competent  jurisdiction  to  be invalid, such judgment shall not affect,
    33  impair, or invalidate the remainder thereof, but shall  be  confined  in
    34  its  operation  to the clause, sentence, paragraph, subdivision, section
    35  or part thereof directly involved in the controversy in which such judg-
    36  ment shall have been rendered. It has hereby declared to be  the  intent
    37  of  the  legislature  that this act would have been enacted even if such
    38  invalid provisions had not been included herein.
    39    § 3. This act shall take effect immediately  provided,  however,  that
    40  the  applicable effective date of Subparts A through E of this act shall
    41  be as specifically set forth in the last section of such Subparts.

    42                                   PART CC
 
    43                            Intentionally Omitted
 
    44                                   PART DD

        S. 1507--C                         125                        A. 2007--C
 
     1                            Intentionally Omitted
 
     2                                   PART EE
 
     3    Section  1. Subdivision 10 of section 2899-a of the public health law,
     4  as amended by section 5 of part C of chapter 57 of the laws of 2018,  is
     5  amended to read as follows:
     6    10.  Notwithstanding  subdivision  eleven  of  section  eight  hundred
     7  forty-five-b of the executive  law,  a  certified  home  health  agency,
     8  licensed home care services agency or long term home health care program
     9  certified, licensed or approved under article thirty-six of this chapter
    10  or  a  home  care services agency exempt from certification or licensure
    11  under article thirty-six of this chapter, a hospice program under  arti-
    12  cle forty of this chapter, or an adult home, enriched housing program or
    13  residence for adults licensed under article seven of the social services
    14  law,  or  a  health  home, or any subcontractor of such health home, who
    15  contracts with or is approved or otherwise authorized by the  department
    16  to  provide health home services to all enrollees enrolled pursuant to a
    17  diagnosis of a developmental disability as defined in subdivision  twen-
    18  ty-two  of  section 1.03 of the mental hygiene law and enrollees who are
    19  under twenty-one years of age under section three  hundred  sixty-five-l
    20  of  the social services law, or any entity that provides home and commu-
    21  nity based services to enrollees who are under twenty-one years  of  age
    22  under a demonstration program pursuant to section eleven hundred fifteen
    23  of the federal social security act may temporarily approve a prospective
    24  employee while the results of the criminal history information check and
    25  the  determination  are  pending,  upon  the condition that the provider
    26  conducts appropriate direct observation and evaluation of the  temporary
    27  employee,  while he or she is temporarily employed, and the care recipi-
    28  ent; provided, however, that for a health home, or any subcontractor  of
    29  a health home, who contracts with or is approved or otherwise authorized
    30  by  the  department  to  provide  health  home services to all enrollees
    31  enrolled pursuant to a diagnosis of developmental disability as  defined
    32  in  subdivision twenty-two of section 1.03 of the mental hygiene law and
    33  enrollees who are under twenty-one years  of  age  under  section  three
    34  hundred  sixty-five-l  of  the  social  services law, or any entity that
    35  provides home and community based services to enrollees  who  are  under
    36  twenty-one  years  of  age  under  a  demonstration  program pursuant to
    37  section eleven hundred fifteen  of  the  federal  social  security  act,
    38  direct  observation  and  evaluation of temporary employees shall not be
    39  required until [April] July first, two thousand nineteen. The results of
    40  such observations  shall  be  documented  in  the  temporary  employee's
    41  personnel  file  and shall be maintained. For purposes of providing such
    42  appropriate  direct  observation  and  evaluation,  the  provider  shall
    43  utilize  an  individual  employed by such provider with a minimum of one
    44  year's experience working in an agency certified, licensed  or  approved
    45  under  article  thirty-six  of  this  chapter or an adult home, enriched
    46  housing program or residence for adults licensed under article seven  of
    47  the  social  services  law,  a health home, or any subcontractor of such
    48  health home, who contracts with or is approved or  otherwise  authorized
    49  by  the  department  to  provide  health home services to those enrolled
    50  pursuant to a diagnosis of a  developmental  disability  as  defined  in
    51  subdivision  twenty-two  of  section  1.03 of the mental hygiene law and
    52  enrollees who are under twenty-one years  of  age  under  section  three
    53  hundred  sixty-five-l  of  the  social  services law, or any entity that
    54  provides home and community based services to enrollees  who  are  under

        S. 1507--C                         126                        A. 2007--C
 
     1  twenty-one  years  of  age  under  a  demonstration  program pursuant to
     2  section eleven hundred fifteen of the federal social  security  act.  If
     3  the  temporary  employee is working under contract with another provider
     4  certified,  licensed  or approved under article thirty-six of this chap-
     5  ter, such contract provider's appropriate direct observation and  evalu-
     6  ation  of the temporary employee, shall be considered sufficient for the
     7  purposes of complying with this subdivision.
     8    § 2. This act shall take effect immediately, except that if  this  act
     9  shall  have  become  a law on or after April 1, 2019 this act shall take
    10  effect immediately and shall be deemed to have been in  full  force  and
    11  effect on and after April 1, 2019.
 
    12                                   PART FF
 
    13    Section  1. Section 4 of chapter 495 of the laws of 2004, amending the
    14  insurance law and the public health law relating to the New  York  state
    15  health  insurance  continuation  assistance  demonstration  project,  as
    16  amended by section 1 of part QQ of chapter 58 of the laws  of  2018,  is
    17  amended to read as follows:
    18    §  4.  This  act  shall take effect on the sixtieth day after it shall
    19  have become a law; provided, however, that  this  act  shall  remain  in
    20  effect  until  July 1, [2019] 2020 when upon such date the provisions of
    21  this act shall expire and be deemed repealed; provided, further, that  a
    22  displaced  worker shall be eligible for continuation assistance retroac-
    23  tive to July 1, 2004.
    24    § 2. This act shall take effect immediately.
 
    25                                   PART GG
 
    26    Section 1. It is the intent of the legislature that,  subject  to  the
    27  approval  of  the  director  of  the budget and sufficient appropriation
    28  authority, no less than one hundred million dollars of existing  revenue
    29  shall be made available annually to support programs operated by the New
    30  York state office of alcoholism and substance abuse services or agencies
    31  certified,  authorized,  approved  or  otherwise  funded by the New York
    32  state office of alcoholism  and  substance  abuse  services  to  provide
    33  opioid treatment, recovery and prevention and education services.
    34    § 2. This act shall take effect immediately.
 
    35                                   PART HH
 
    36    Section  1.  Subdivision 5 of section 209 of the elder law, as amended
    37  by section 1 of part S of chapter 59 of the laws of 2016, is amended  to
    38  read as follows:
    39    5.  Within  amounts  specifically appropriated therefor and consistent
    40  with the criteria developed and required pursuant to  this  section  the
    41  director  shall approve grants to eligible applicants. Individual grants
    42  awarded for classic NORC programs shall be  in  amounts  not  to  exceed
    43  [two]  three  hundred  thousand  ([$200,000]  $300,000)  dollars and for
    44  neighborhood NORCs not less than sixty thousand ($60,000) dollars in any
    45  twelve month period.
    46    § 2. This act shall take effect immediately.
 
    47                                   PART II

        S. 1507--C                         127                        A. 2007--C
 
     1    Section 1. Section 13 of chapter 141 of the laws of 1994, amending the
     2  legislative law and the state finance law relating to the operation  and
     3  administration  of  the legislature, as amended by section 2 of part GGG
     4  of chapter 59 of the laws of 2018, is amended to read as follows:
     5    §  13.  This  act shall take effect immediately and shall be deemed to
     6  have been in full force and effect as of April 1, 1994,  provided  that,
     7  the  provisions  of  section  5-a  of  the legislative law as amended by
     8  sections two and two-a of this act shall take effect on January 1, 1995,
     9  and provided further that, the provisions of article 5-A of the legisla-
    10  tive law as added by section eight of this act  shall  expire  June  30,
    11  [2019]  2020 when upon such date the provisions of such article shall be
    12  deemed repealed; and provided further that section twelve  of  this  act
    13  shall be deemed to have been in full force and effect on and after April
    14  10, 1994.
    15    §  2.  This  act  shall take effect immediately, provided, however, if
    16  section one of this act shall take effect on  or  after  June  30,  2019
    17  section  one  of this act shall be deemed to have been in full force and
    18  effect on and after June 30, 2019.

    19                                   PART JJ
 
    20    Section 1. Section 2815 of the public health law is amended by  adding
    21  a new subdivision 5-a to read as follows:
    22    5-a.  Notwithstanding  anything  in  this section to the contrary, the
    23  authority is authorized and directed to transfer from the  restructuring
    24  pool  to  the  department,  upon  written request of the director of the
    25  budget and within thirty days thereof,  funds  repaid  by  participating
    26  borrowers,  and  held  by  the  authority relating to restructuring pool
    27  loans funded by amounts transferred to the  restructuring  pool  by  the
    28  department or remaining funds in the restructuring pool that were trans-
    29  ferred  by the department, not to exceed a total of eighty-three million
    30  five hundred thousand dollars, excepting therefrom amounts necessary  to
    31  pay  expenses of the authority as provided in the agreement described in
    32  subdivision three of this section. All participating borrowers shall  be
    33  obligated  in  their loan agreement to repay no later than March thirty-
    34  first, two thousand twenty all  funds  borrowed  from  the  eighty-three
    35  million  five  hundred  thousand  dollars  transferred by the department
    36  pursuant to this  section,  to  fund  these  restructuring  pool  loans.
    37  Further, in respect of these borrowed funds, all participating borrowers
    38  shall be required under the terms of their loan agreement to immediately
    39  upon  receipt  of  quality  improvement incentive payments or additional
    40  supplemental assistance initiate repayment of an  amount  equal  to  the
    41  quality   improvement  incentive  payments  or  additional  supplemental
    42  assistance not to exceed the amount of such  borrowed  funds,  unless  a
    43  waiver  or  extension  of repayment has been approved by the director of
    44  the budget.
    45    § 2. This act shall take effect immediately.
 
    46                                   PART KK
 
    47    Section 1. The Department of Health shall conduct a study  to  examine
    48  how staffing enhancements and other initiatives could be used to improve
    49  patient  safety and the quality of healthcare service delivery in hospi-
    50  tals and nursing homes subject to article 28 of the public  health  law.
    51  The  Department  study  shall  consider  minimum  staffing levels, other
    52  staffing enhancement strategies, and other patient  quality  improvement

        S. 1507--C                         128                        A. 2007--C
 
     1  initiatives for registered nurses, licensed practical nurses, and certi-
     2  fied nurse aides to improve the quality of care and patient safety.
     3    The study will analyze the range of potential fiscal impacts of staff-
     4  ing  levels,  other  staffing  enhancement strategies, and other patient
     5  quality improvement initiatives.
     6    The Department study will commence no later  than  May  1,  2019,  and
     7  shall  engage stakeholders, including the statewide hospital and nursing
     8  home associations, direct care health workers, and patient and community
     9  health advocates, and shall report its findings and  recommendations  to
    10  the Commissioner of the Department of Health and to the Temporary Presi-
    11  dent  of  the  Senate and Speaker of the Assembly no later than December
    12  31, 2019.
    13    § 2. This act shall take effect immediately and  shall  be  deemed  to
    14  have been in full force and effect on and after April 1, 2019.
    15    § 2. Severability clause. If any clause, sentence, paragraph, subdivi-
    16  sion,  section  or  part  of  this act shall be adjudged by any court of
    17  competent jurisdiction to be invalid, such judgment  shall  not  affect,
    18  impair,  or  invalidate  the remainder thereof, but shall be confined in
    19  its operation to the clause, sentence, paragraph,  subdivision,  section
    20  or part thereof directly involved in the controversy in which such judg-
    21  ment shall have been rendered. It is hereby declared to be the intent of
    22  the  legislature  that  this  act  would  have been enacted even if such
    23  invalid provisions had not been included herein.
    24    § 3. This act shall take effect immediately  provided,  however,  that
    25  the applicable effective date of Parts A through KK of this act shall be
    26  as specifically set forth in the last section of such Parts.
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