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A06058 Summary:

BILL NOA06058
 
SAME ASSAME AS S05474
 
SPONSORGottfried
 
COSPNSRAbinanti, Anderson, Barrett, Barron, Benedetto, Bichotte Hermelyn, Bronson, Burdick, Cahill, Carroll, Clark, Colton, Cook, Cruz, Cymbrowitz, De La Rosa, Dickens, Dilan, Dinowitz, Englebright, Epstein, Fall, Fernandez, Frontus, Gallagher, Gonzalez-Rojas, Hunter, Hyndman, Jackson, Jean-Pierre, Joyner, Kelles, Kim, Lavine, Lunsford, Lupardo, Mamdani, Meeks, Mitaynes, Niou, Paulin, Peoples-Stokes, Perry, Pheffer Amato, Pichardo, Rajkumar, Ramos, Reyes, Richardson, Rivera J, Rodriguez, Rosenthal L, Sayegh, Seawright, Sillitti, Simon, Solages, Forrest, Steck, Stirpe, Taylor, Thiele, Vanel, Walker, Wallace, Weprin, Williams, Burke, Septimo, Zinerman, Burgos, Darling, Rivera JD
 
MLTSPNSRAubry, Davila, Fahy, Galef, Glick, Gunther, Magnarelli, O'Donnell, Pretlow, Quart, Rosenthal D, Rozic
 
Ren Art 50 §§5000 - 5003 to be Art 80 §§8000 - 8003, add Art 51 §§5100 - 5111, add Art 49 Title 3 §§4920 - 4928, amd §270, Pub Health L; add §89-j, St Fin L
 
Establishes the New York Health program, a comprehensive system of access to health insurance for New York state residents; provides for administrative structure of the plan; provides for powers and duties of the board of trustees, the scope of benefits, payment methodologies and care coordination; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; enacts provisions relating to financing of New York Health, including a payroll assessment, similar to the Medicare tax; establishes a temporary commission on implementation of the plan; provides for collective negotiations by health care providers with New York Health.
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A06058 Actions:

BILL NOA06058
 
03/08/2021referred to health
04/19/2021reported referred to codes
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A06058 Memo:

NEW YORK STATE ASSEMBLY
MEMORANDUM IN SUPPORT OF LEGISLATION
submitted in accordance with Assembly Rule III, Sec 1(f)
 
BILL NUMBER: A6058
 
SPONSOR: Gottfried
  TITLE OF BILL: An act to amend the public health law and the state finance law, in relation to enacting the "New York health act" and establishing New York Health   PURPOSE OR GENERAL IDEA OF BILL: This bill would create a universal single payer health plan - New York Health - to provide comprehensive health coverage for all New Yorkers.   SUMMARY OF SPECIFIC PROVISIONS: Every New York resident would be eligible to enroll, regardless of age, income, wealth, employment, or other status. There would be no network restrictions, deductibles, or co-pays. Coverage would be publicly fund- ed. The benefits will include comprehensive outpatient and inpatient medical care, long-term care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative, dental, vision, hearing, etc. - all benefits required by current state insurance law or provided by the state public employee package, Family Health Plus, Child Health Plus, Medicare, or Medicaid, and others added by the plan. Everyone would choose a primary care practitioner or other provider to provide care coordination - helping to get the care and follow-up the patient needs, referrals, and navigating the system. But there would be no "gatekeeper" obstacles to care. As with most health coverage, New York Health covers health care services when a member is out of state, either because health care is needed while the member is traveling or because there is a clinical reason for going to a particular out-of-state provider. A broadly representative Board of Trustees will advise the Commissioner of Health. The Board shall develop proposals relating to retiree health benefits and coverage of health care services covered under the workers' compensation law. In addition to the Board, there will be six regional advisory councils to represent the diverse needs and concerns of the region. The councils shall include but not be limited to representatives of health care consumers, providers, municipal and county government, and organized labor. The councils shall advise the Board, Commissioner, Governor, and Legislature on matters relating to the NY Health program and shall adopt community health improvement plans to promote health care access and quality in their regions. Health care providers, including those providing care coordination, would be paid in full by New York Health, with no co-pays or other charges to patients. The plan would develop alternative payment methods to replace old-style fee-for-service (which rewards volume but not qual- ity), and would. negotiate rates with health care provider organiza- tions. (Fee-for-service would continue until new methods are phased in.) The bill would authorize health care providers to form organizations to collectively negotiate with New York Health. Health care would no longer be paid for by insurance companies charging a regressive "tax" insurance premiums, deductibles and co-pays imposed regardless of ability to pay. Instead, New York Health would be paid for based on ability to pay, through a progressively-graduated payroll-based tax (paid at least 80% by employers and not more than 20% by employees, and 100% by self-em- ployed) and a progressively-graduated tax based on other taxable income, such as capital gains, interest and dividends. A specific revenue plan, following guidelines in the bill, would be submitted to the Legislature by the Governor. Federal funds now received for Medicare, Medicaid, Family Health and Child Health Plus would be combined with the state revenue in a New York Health Trust Fund. New York would seek federal waivers that will allow New York to completely fold those programs into New York Health. The "local share" of Medicaid funding - a major burden on local property taxes - would be ended. Private insurance that duplicates benefits offered under New York Health could not be offered to New York residents. (Existing retiree coverage could be phased out and replaced with New York Health.)   JUSTIFICATION: The state constitution states: "The protection and promotion of the health of the inhabitants of the state are matters of public concern and provision therefor shall be made by the state and by such of its subdi- visions and in such manner, and by such means as the legislature shall from time to time determine." (Article XVII, § 3.) All residents of the state have the right to health care. New Yorkers - as individuals, employers, and taxpayers - have experi- enced a rapid rise in the cost of health care and coverage in recent years. This increase has resulted in a large number of people without health coverage. Businesses have also experienced extraordinary increases in the costs of health care benefits for their employees. An unacceptable number of New Yorkers have no health coverage, and many more are severely underinsured. Health care providers are also affected by inadequate health coverage in New York State. A large portion of voluntary and public hospitals, health centers and other providers now experience substantial losses due to the provision of care that is uncompensated. Individuals often find that they are deprived of affordable care and choice because of deci- sions by health plans guided by the plan's economic needs rather than their health care needs. To address the fiscal crisis facing the health care system and the state and to assure New Yorkers can exercise their right to health care, this legislation would establish a comprehensive universal single-payer health care coverage program, funded by broad-based revenue based on ability to pay, for the benefit of all residents of the state of New York. The state will work to obtain waivers relating to Medicaid, Family Health Plus, Child Health Plus, Medicare, the Patient Protection and Affordable Care Act, and any other appropriate federal programs, under which federal funds and other subsidies that would otherwise be paid to New York State will be paid by the federal government to New York State and deposited in the New York Health trust fund. Under such a waiver, health coverage under those programs will be replaced and merged into New York Health, which will operate as a true single-payer program. If such a waiver is not obtained, the state shall use state plan amendments and seek waivers to maximize, and make as seamless as possible, the use of federally-matched health programs and federal health programs in New York Health, The goal of this legislation is that coverage be delivered by New York Health and, as much as possible, the multiple sources of funding will be pooled with other New York Health funds and not be apparent to New York Health members or participating providers. This program will promote movement away from fee-for-service payment, which tends to reward quantity and requires excessive administrative expense, and towards alternate payment methodologies, such a s global or capitat- ed payments to providers or health care organizations, that promote quality, efficiency, investment in primary and preventive care, and innovation and integration in the organizing of health care. This act does not create any employment benefit, nor does it require, prohibit, or limit the providing of any employment benefit. In order to promote improved quality of, and access to, health care services and promote improved clinical outcomes, it is the policy of the state to encourage cooperative, collaborative and integrative arrangements among health care providers who might otherwise be competitors, under the active supervision of the commissioner. It is the intent of the state to supplant competition with such arrangements and regulation only to the extent necessary to accomplish the purposes of this act, and to provide state action immunity under the state and federal antitrust laws to health care providers, particularly with respect to their relations with the single-payer New York Health plan created by this act.   PRIOR LEGISLATIVE HISTORY: 1992: A.8912-A passed Assembly 1993: A.5900 reported to Ways and Means 1994: A.5900 referred to Health Committee 1995-96: A.6801 reported to Ways and Means 1997-98: A.6172 reported to Ways and Means 1999-00: A.3571 reported to Ways and Means 2001-02: A.6779 reported to Ways and Means 2003-04: A.6952 reported to Ways and Means 2005: A.6576 reported to Ways and Means 2006: A.6576 referred to Health Committee 2007-08: A.7354 - reported to Ways and Means 2009-10: A.2356 - referred to Health Committee 2011-12: A.7860-A - referred to Ways and Means 2013: A5389 referred to Health Committee 2014: A5389 - reported to Ways and Means 2015: A5062 - Passed Assembly / Senate Health 2016: A5062 - passed Assembly / Senate Health 2017: A4738 - passed Assembly / Senate Health 2018: A4738 - passed Assembly / Senate Health 2019: A5248 - Reported to Codes / Senate Health 2020: A5248 - Referred to Health / Senate Health   FISCAL IMPLICATIONS: Full funding for New York Health would come from the revenue measures to be proposed by the Governor under guidelines in the bill, plus available federal funds. The revenue package would also replace: local share of Medicaid, the state share of Medicaid, state and local payments for public employee health coverage, and various other health care spending. Numerous analyses document that a single-payer system would be most effective for reducing and controlling costs, for taxpayers, employers and individuals.   EFFECTIVE DATE: Immediately. The program will actually begin functioning when the Commissioner of Health declares the beginning of the implementation
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A06058 Text:



 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                          6058
 
                               2021-2022 Regular Sessions
 
                   IN ASSEMBLY
 
                                      March 8, 2021
                                       ___________
 
        Introduced  by  M. of A. GOTTFRIED, ABINANTI, ANDERSON, BARRETT, BARRON,
          BENEDETTO,  BICHOTTE HERMELYN,  BRONSON,  BURDICK,  CAHILL,   CARROLL,
          CLARK,  COLTON,  COOK,  CRUZ,  CYMBROWITZ, DE LA ROSA, DICKENS, DILAN,
          DINOWITZ, ENGLEBRIGHT, EPSTEIN, FALL, FERNANDEZ,  FRONTUS,  GALLAGHER,
          GONZALEZ-ROJAS, HUNTER, HYNDMAN, JACKSON, JEAN-PIERRE, JOYNER, KELLES,
          KIM,  LAVINE,  LUNSFORD,  LUPARDO,  MAMDANI,  MEEKS,  MITAYNES,  NIOU,
          PAULIN,  PEOPLES-STOKES,  PERRY,  PHEFFER AMATO,  PICHARDO,  RAJKUMAR,
          RAMOS,  REYES, RICHARDSON, J. RIVERA, RODRIGUEZ, L. ROSENTHAL, SAYEGH,
          SEAWRIGHT, SILLITTI, SIMON, SOLAGES, FORREST, STECK,  STIRPE,  TAYLOR,
          THIELE, VANEL, WALKER, WALLACE, WEPRIN, WILLIAMS -- Multi-Sponsored by
          --  M.  of A.  AUBRY, DAVILA, FAHY, GALEF, GLICK, GUNTHER, MAGNARELLI,
          O'DONNELL, PRETLOW,  QUART,  D. ROSENTHAL,  ROZIC  --  read  once  and
          referred to the Committee on Health
 
        AN  ACT  to  amend  the  public health law and the state finance law, in
          relation to enacting the "New York health act"  and  establishing  New
          York Health
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:

     1    Section 1. Short title. This act shall be known and may  be  cited  as
     2  the "New York health act".
     3    §  2.  Legislative  findings  and  intent.  1.  The state constitution
     4  states: "The protection and promotion of the health of  the  inhabitants
     5  of  the state are matters of public concern and provision therefor shall
     6  be made by the state and by such of its subdivisions and in such manner,
     7  and by such means as the legislature shall from time to time determine."
     8  (Article XVII, §3.) The legislature finds and declares  that  all  resi-
     9  dents  of  the  state  have the right to health care.  While the federal
    10  Affordable Care Act brought many improvements in health care and  health
    11  coverage,  it  still  leaves  many  New Yorkers without coverage or with
    12  inadequate coverage.  Millions of New Yorkers do not get the health care
    13  they need or face financial obstacles and hardships to get it.  That  is
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD00273-03-1

        A. 6058                             2
 
     1  not  acceptable.    There  is no plan other than the New York health act
     2  that will enable New York state to meet that need.   New  Yorkers  -  as
     3  individuals,  employers,  and taxpayers - have experienced a rise in the
     4  cost  of  health  care  and  coverage  in recent years, including rising
     5  premiums, deductibles and co-pays, restricted provider networks and high
     6  out-of-network charges.  Many New Yorkers go without health care because
     7  they cannot afford it or suffer financial hardship to  get  it.    Busi-
     8  nesses have also experienced increases in the costs of health care bene-
     9  fits for their employees, and many employers are shifting a larger share
    10  of  the cost of coverage to their employees or dropping coverage entire-
    11  ly.  Including long-term services and supports (LTSS) in New York Health
    12  is a major step forward for older adults, people with disabilities,  and
    13  their  families.  Older adults and people with disabilities often cannot
    14  receive the services necessary to stay in the community or  other  LTSS.
    15  Even  when older adults and people with disabilities receive LTSS, espe-
    16  cially services in the community, it is often at the cost  of  unreason-
    17  able  demands on unpaid family caregivers, depleting their own or family
    18  resources, or impoverishing themselves to qualify for  public  coverage.
    19  Health care providers are also affected by inadequate health coverage in
    20  New  York  state. A large portion of hospitals, health centers and other
    21  providers now experience substantial losses due to the provision of care
    22  that is uncompensated.  Medicaid and Medicare often  do  not  pay  rates
    23  that  are reasonably related to the cost of efficiently providing health
    24  care services and sufficient to assure an adequate and accessible supply
    25  of health care services, as guaranteed under the New  York  Health  Act.
    26  Individuals  often  find  that  they are deprived of affordable care and
    27  choice because of decisions by health plans guided by the plan's econom-
    28  ic interests rather than the individual's health care needs. To  address
    29  the  fiscal  crisis  facing  the health care system and the state and to
    30  assure New Yorkers can exercise their right to health  care,  affordable
    31  and  comprehensive  health  coverage  must  be provided. Pursuant to the
    32  state constitution's charge to the legislature to provide for the health
    33  of New Yorkers, this legislation is an enactment of  state  concern  for
    34  the  purpose of establishing a comprehensive universal guaranteed health
    35  care coverage program and a health care  cost  control  system  for  the
    36  benefit of all residents of the state of New York.
    37    2.  (a)  It  is  the  intent of the Legislature to create the New York
    38  Health program to provide a universal single payer health plan for every
    39  New Yorker, funded by broad-based revenue based on ability to pay.   The
    40  legislature  intends  that federal waivers and approvals be sought where
    41  they will improve the administration of the New York Health program, but
    42  the legislature intends that the program  be  implemented  even  in  the
    43  absence  of  such  waivers or approvals.  The state shall work to obtain
    44  waivers and other approvals relating to  Medicaid,  Child  Health  Plus,
    45  Medicare,  the  Affordable  Care  Act, and any other appropriate federal
    46  programs, under which federal  funds  and  other  subsidies  that  would
    47  otherwise  be  paid  to  New  York  State,  New Yorkers, and health care
    48  providers for health coverage that will be equaled or  exceeded  by  New
    49  York Health will be paid by the federal government to New York State and
    50  deposited  in  the  New  York  Health trust fund, or paid to health care
    51  providers and individuals in combination with New York Health trust fund
    52  payments, and for other program modifications (including elimination  of
    53  cost sharing and insurance premiums).  Under such waivers and approvals,
    54  health  coverage under those programs will, to the maximum extent possi-
    55  ble, be replaced and merged into New York Health, which will operate  as
    56  a true single-payer program.

        A. 6058                             3
 
     1    (b)  If  any  necessary  waiver or approval is not obtained, the state
     2  shall use state plan amendments and seek waivers and approvals to  maxi-
     3  mize,  and  make  as  seamless as possible, the use of federally-matched
     4  health programs and federal health programs in New York Health.    Thus,
     5  even where other programs such as Medicaid or Medicare may contribute to
     6  paying  for  care,  it is the goal of this legislation that the coverage
     7  will be delivered by New York Health  and,  as  much  as  possible,  the
     8  multiple  sources  of  funding will be pooled with other New York Health
     9  funds and not be apparent to New York Health  members  or  participating
    10  providers.
    11    (c)  This  program  will  promote  movement  away from fee-for-service
    12  payment, which tends to reward quantity and requires excessive  adminis-
    13  trative  expense,  and  towards alternate payment methodologies, such as
    14  global or capitated payments to providers or health care  organizations,
    15  that  promote  quality, efficiency, investment in primary and preventive
    16  care, and innovation and integration in the organizing of health care.
    17    (d) The program shall promote the use of clinical data to improve  the
    18  quality  of health care and public health, consistent with protection of
    19  patient confidentiality. The program shall maximize patient autonomy  in
    20  choice  of  health care providers and health care decision making.  Care
    21  coordination within the program shall ensure management and coordination
    22  among a patient's health care services, consistent with patient autonomy
    23  and person-centered service planning, rather than acting as a gatekeeper
    24  to needed services.
    25    (e) The program shall operate with care, skill,  prudence,  diligence,
    26  and professionalism, and for the best interests primarily of the members
    27  and health care providers.
    28    3.  This  act  does  not create or relate to any employment benefit or
    29  employment benefit plan, nor does it require,  prohibit,  or  limit  the
    30  providing of any employment benefit or employment benefit plan.
    31    4. In order to promote improved quality of, and access to, health care
    32  services and promote improved clinical outcomes, it is the policy of the
    33  state  to  encourage cooperative, collaborative and integrative arrange-
    34  ments among health care providers who might  otherwise  be  competitors,
    35  under  the  active  supervision of the commissioner of health. It is the
    36  intent of the state to supplant competition with such  arrangements  and
    37  regulation  only  to  the extent necessary to accomplish the purposes of
    38  this act, and to provide state  action  immunity  under  the  state  and
    39  federal  antitrust  laws  to  health  care  providers, particularly with
    40  respect to their relations with the single-payer New  York  Health  plan
    41  created by this act.
    42    5.  There  have  been numerous professional economic analyses of state
    43  and national single-payer  health  proposals,  including  the  New  York
    44  Health Act, by noted consulting firms and academic economists. They have
    45  almost  all  come  to  similar conclusions of net savings in the cost of
    46  health coverage and health care. These savings are driven by (a)  elimi-
    47  nating  the  administrative  bureaucracy costs, marketing, and profit of
    48  multiple health plans and replacing that  with  the  dramatically  lower
    49  costs  of  running a single-payer system; (b) substantially reducing the
    50  administrative costs borne by health care providers dealing  with  those
    51  health  plans; and (c) using the negotiating power of 20 million consum-
    52  ers to achieve lower drug prices. These savings will  more  than  offset
    53  costs primarily from (a) relieving patients of deductibles, co-pays, and
    54  out-of-network  charges;  (b)  covering  the  uninsured;  (c) increasing
    55  provider payment rates  above  Medicare  and  Medicaid  rates;  and  (d)
    56  replacing uncompensated home health care with paid care. Unlike premiums

        A. 6058                             4
 
     1  and out-of-pocket spending, the New York Health Act tax will be progres-
     2  sively  graduated  based  on  ability to pay.   The vast majority of New
     3  Yorkers today spend dramatically more in premiums, deductibles and other
     4  out-of-pocket  costs  than they will in New York Health Act taxes.  They
     5  will have broader coverage (including  long-term  care),  no  restricted
     6  provider  networks  or  out-of-network  charges,  and  no deductibles or
     7  co-pays.
     8    § 3. Article 50 and sections 5000, 5001, 5002 and 5003 of  the  public
     9  health  law  are renumbered article 80 and sections 8000, 8001, 8002 and
    10  8003, respectively, and a new article 51 is added to read as follows:
    11                                 ARTICLE 51
    12                               NEW YORK HEALTH
    13  Section 5100. Definitions.
    14          5101. Program created.
    15          5102. Board of trustees.
    16          5103. Eligibility and enrollment.
    17          5104. Benefits.
    18          5105. Health care providers; care coordination; payment  method-
    19                  ologies.
    20          5106. Health care organizations.
    21          5107. Program standards.
    22          5108. Regulations.
    23          5109. Provisions relating to federal health programs.
    24          5110. Additional provisions.
    25          5111. Regional advisory councils.
    26    §  5100.  Definitions.  As  used  in this article, the following terms
    27  shall have the following meanings, unless the context  clearly  requires
    28  otherwise:
    29    1.  "Board" means the board of trustees of the New York Health program
    30  created by section fifty-one hundred two of this article, and  "trustee"
    31  means a trustee of the board.
    32    2.  "Care coordination" means, but is not limited to, managing, refer-
    33  ring to, locating, coordinating, and monitoring health care services for
    34  the member to assure that all medically necessary health  care  services
    35  are made available to and are effectively used by the member in a timely
    36  manner,  consistent  with  patient  autonomy. Care coordination does not
    37  include a requirement for prior authorization for health  care  services
    38  or for referral for a member to receive a health care service.
    39    3.  "Care  coordinator"  means  an  individual  or  entity approved to
    40  provide care coordination under subdivision  two  of  section  fifty-one
    41  hundred five of this article.
    42    4. "Federally-matched public health program" means the medical assist-
    43  ance  program  under title eleven of article five of the social services
    44  law, the basic health program under section three hundred  sixty-nine-gg
    45  of  the  social  services  law,  and the child health plus program under
    46  title one-A of article twenty-five of this chapter.
    47    5. "Health care organization" means an entity that is approved by  the
    48  commissioner  under  section  fifty-one  hundred  six of this article to
    49  provide health care services to members under the program.
    50    6. "Health care provider"  means  any  individual  or  entity  legally
    51  authorized  to  provide a health care service under Medicaid or Medicare
    52  or this article. "Health care professional" means a health care provider
    53  that is an  individual  licensed,  certified,  registered  or  otherwise
    54  authorized to practice under title eight of the education law to provide
    55  such health care service, acting within his or her lawful scope of prac-
    56  tice.

        A. 6058                             5
 
     1    7. "Health care service" means any health care service, including care
     2  coordination, included as a benefit under the program.
     3    8. "Implementation period" means the period under subdivision three of
     4  section  fifty-one  hundred one of this article during which the program
     5  will be subject to special eligibility and financing provisions until it
     6  is fully implemented under that section.
     7    9. "Medicaid" or "medical assistance" means title  eleven  of  article
     8  five  of  the  social  services  law and the program thereunder.  "Child
     9  health plus" means title one-A of article twenty-five  of  this  chapter
    10  and  the program thereunder. "Medicare" means title XVIII of the federal
    11  social security act and the programs thereunder.  "Affordable care  act"
    12  means the federal patient protection and affordable care act, public law
    13  111-148,  as amended by the health care and education reconciliation act
    14  of 2010, public law 111-152, and as  otherwise  amended  and  any  regu-
    15  lations  or  guidance  issued thereunder.   "Basic health program" means
    16  section three hundred sixty-nine-gg of the social services law  and  the
    17  program thereunder.
    18    10. "Member" means an individual who is enrolled in the program.
    19    11.  "New  York Health", "New York Health program", and "program" mean
    20  the New York Health program created by section fifty-one hundred one  of
    21  this article.
    22    12.  "New York Health trust fund" means the New York Health trust fund
    23  established under section eighty-nine-j of the state finance law.
    24    13. "Out-of-state health care service" means  a  health  care  service
    25  provided  to  a  member while the member is temporarily out of the state
    26  and (a) it is medically  necessary  that  the  health  care  service  be
    27  provided  while  the member is out of the state, or (b) it is clinically
    28  appropriate that the health care service be  provided  by  a  particular
    29  health  care provider located out of the state rather than in the state.
    30  However, any health care service provided to a New York Health  enrollee
    31  by  a  health care provider qualified under paragraph (a) of subdivision
    32  three of section fifty-one hundred five of this article that is  located
    33  outside  the  state  shall not be considered an out-of-state service and
    34  shall be covered as otherwise provided in this article.
    35    14. "Participating provider" means any individual or entity that is  a
    36  health  care  provider  qualified  under  subdivision  three  of section
    37  fifty-one hundred  five  of  this  article  that  provides  health  care
    38  services to members under the program, or a health care organization.
    39    15.  "Person"  means any individual or natural person, trust, partner-
    40  ship, association,  unincorporated  association,  corporation,  company,
    41  limited  liability  company,  proprietorship, joint venture, firm, joint
    42  stock association, department, agency, authority, or other legal entity,
    43  whether for-profit, not-for-profit or governmental.
    44    16. "Prescription and non-prescription drugs" means prescription drugs
    45  as defined in section two hundred seventy of this chapter, and non-pres-
    46  cription smoking cessation products or devices.
    47    17. "Resident" means an individual whose primary place of abode is  in
    48  the  state or, in the case of an individual whose primary place of abode
    49  is not in the state, who is employed or self-employed full-time  in  the
    50  state,  without regard to the individual's immigration status, as deter-
    51  mined according to regulations of the commissioner.    Such  regulations
    52  shall include a process for appealing denials of residency.
    53    §  5101.  Program  created.  1.  The New York Health program is hereby
    54  created in the department. The commissioner shall establish  and  imple-
    55  ment  the  program under this article. The program shall provide compre-
    56  hensive health coverage to every resident who enrolls in the program.

        A. 6058                             6
 
     1    2. The commissioner shall, to the maximum extent  possible,  organize,
     2  administer and market the program and services as a single program under
     3  the  name "New York Health" or such other name as the commissioner shall
     4  determine, regardless of under which law or source the definition  of  a
     5  benefit  is  found including (on a voluntary basis) retiree health bene-
     6  fits. In implementing this article, the commissioner shall  avoid  jeop-
     7  ardizing  federal  financial  participation  in these programs and shall
     8  take care to promote public understanding  and  awareness  of  available
     9  benefits and programs.
    10    3. The commissioner shall determine when individuals may begin enroll-
    11  ing in the program. There shall be an implementation period, which shall
    12  begin  on  the  date that individuals may begin enrolling in the program
    13  and shall end as determined by the commissioner.   Individuals  may  not
    14  enroll  in the New York Health program until the legislature has enacted
    15  the revenue proposal, as amended, and as the legislature  shall  further
    16  provide.
    17    4. An insurer authorized to provide coverage pursuant to the insurance
    18  law  or  a  health maintenance organization certified under this chapter
    19  may, if otherwise authorized, offer  benefits  that  do  not  cover  any
    20  service  for which coverage is offered to individuals under the program,
    21  but may not offer benefits that cover any service for which coverage  is
    22  offered  to  individuals under the program. Provided, however, that this
    23  subdivision shall not prohibit (a) the offering of any  benefits  to  or
    24  for  individuals, including their families, who are employed or self-em-
    25  ployed in the state but who are not residents of the state, or  (b)  the
    26  offering of benefits during the implementation period to individuals who
    27  enrolled or may enroll as members of the program, or (c) the offering of
    28  retiree health benefits.
    29    5.  A  college, university or other institution of higher education in
    30  the state may purchase coverage under the program for  any  student,  or
    31  student's dependent, who is not a resident of the state.
    32    6.  To  the  extent any provision of this chapter, the social services
    33  law, the insurance law or the elder law:
    34    (a) is inconsistent with any provision of this article or the legisla-
    35  tive intent of the New York Health Act, this  article  shall  apply  and
    36  prevail,  except where explicitly provided otherwise by this article; or
    37  explicitly required by applicable federal law or regulations and
    38    (b) is consistent with the provisions of this article and the legisla-
    39  tive intent of the New York Health Act, the provision of that law  shall
    40  apply.
    41    7.    (a) (i) The program shall be deemed to be a health care plan for
    42  purposes of external appeal under article  forty-nine  of  this  chapter
    43  (referred  to  in  this subdivision as "article forty-nine"), subject to
    44  this subdivision and any other applicable provision of this article.
    45    (ii)  An external appeal shall not require utilization  review  or  an
    46  adverse  determination  under  title  one  of article forty-nine of this
    47  chapter.  Any reference in article forty-nine to utilization review or a
    48  universal review agent shall mean the program.  Where the program  makes
    49  an  adverse  determination, an external appeal shall be automatic unless
    50  specifically waived or withdrawn by the member or the member's designee.
    51  Services, including services provided  for  a  chronic  condition,  will
    52  continue  unchanged until the outcome of the external appeal decision is
    53  issued. Where  an  external  appeal  is  initiated  or  pursued  by  the
    54  patient's  health care provider, the provider shall notify the member or
    55  the member's designee, and it  shall  be  subject  to  the  member's  or
    56  member's  designee's right to waive or withdraw the external appeal.  No

        A. 6058                             7
 
     1  fee shall be required to be paid by any party  to  an  external  appeal,
     2  including the member's health care provider.
     3    (iii)    Where an external appeal is denied, the external appeal agent
     4  shall notify the member or the member's designee and, where appropriate,
     5  the member's health care provider,  within  two  business  days  of  the
     6  determination.    The  notice shall include a statement that the member,
     7  member's designee or health care provider has the right  to  appeal  the
     8  determination to a fair hearing under this subdivision and seek judicial
     9  review.
    10    (iv)  An enrollee may designate a person or entity, including, but not
    11  limited  to,  the  enrollee's  family member, care coordinator, a health
    12  care organization providing the service under review  or  appeal,  or  a
    13  labor union or an entity affiliated with and designated by a labor union
    14  of  which the enrollee or enrollee's family member is a member, to serve
    15  as the enrollee's designee for purposes of that article, if  the  person
    16  or entity agrees to be the designee.
    17    (b)  (i)  This paragraph applies where an external appeal is denied in
    18  whole or in part; or the program  denies  coverage  for  a  health  care
    19  service  on  any  grounds  other  than  under article forty-nine; or the
    20  program makes any other determination as to a member or individual seek-
    21  ing to become a member, contrary to the interest of the member or  indi-
    22  vidual (including but not limited to a denial of eligibility for lack of
    23  residence).
    24    (ii)  The  program  shall  notify  the  member or individual, member's
    25  designee or health care provider, as appropriate, that  the  person  has
    26  the  right  to  appeal  the  determination  to a fair hearing under this
    27  subdivision or seek judicial review.
    28    (iii)  The commissioner shall establish by regulation  a  process  for
    29  fair  hearings  under this subdivision.   The process shall at a minimum
    30  conform to the standards for fair hearings under section  twenty-two  of
    31  the social services law.
    32    (c)    Article seventy-eight of the civil practice law and rules shall
    33  apply to any matter under this article.
    34    8. (a) No member shall be required to receive any health care  service
    35  through  any  entity  organized, certified or operating under guidelines
    36  under article forty-four of this chapter,  or  specified  under  section
    37  three hundred sixty-four-j of the social services law, the insurance law
    38  or  the  elder law. No such entity shall receive payment for health care
    39  services (other than care coordination) from the program.
    40    (b) However, this subdivision shall not preclude the use of a Medicare
    41  managed care ("Medicare advantage") entity or other entity created by or
    42  under the direction of the program where reasonably necessary  to  maxi-
    43  mize  federal financial participation or other federal financial support
    44  under any federally-matched  public  health  program,  Medicare  or  the
    45  Affordable Care Act. Any entity under this paragraph shall, to the maxi-
    46  mum  extent  feasible,  operate  in the background, without burden on or
    47  interference with the member and health care provider, without depriving
    48  the member or health care provider of any right  or  benefit  under  the
    49  program and otherwise consistent with this article.
    50    9.  The  program  shall  include provisions for an appropriate reserve
    51  fund.
    52    10. (a) This subdivision applies to every person who is a retiree of a
    53  public employer, as defined in section two  hundred  one  of  the  civil
    54  service law, and any person who is a beneficiary of the retiree's public
    55  employee retiree health benefit. Any reference to the retiree shall mean
    56  and  include  any  beneficiary of the retiree. This subdivision does not

        A. 6058                             8
 
     1  create or increase any  eligibility  for  any  public  employee  retiree
     2  health  benefit that would not otherwise exist and does not diminish any
     3  public employee retiree health benefit.
     4    (b)  This  paragraph applies to the retiree while he or she is a resi-
     5  dent of New York state. The retiree shall enroll in the program.  If, by
     6  the implementation date, the retiree has not enrolled  in  the  program,
     7  the  appropriate  public employee retiree health benefit program and the
     8  commissioner shall enroll the retiree in the New York Health program. If
     9  the retiree's  public  employee  retiree  health  benefit  includes  any
    10  service  for  which  coverage  is  not offered under the New York Health
    11  program, the retiree shall continue to receive  that  benefit  from  the
    12  appropriate public employee retiree health benefit program.
    13    (c)  For  every retiree, while he or she is not a resident of New York
    14  state, the appropriate public employee retiree  health  benefit  program
    15  shall  maintain  the retiree's public employee retiree health benefit as
    16  if this article had not been enacted.
    17    § 5102. Board of trustees. 1. The New York Health board of trustees is
    18  hereby created in the department. The board of trustees  shall,  at  the
    19  request  of  the  commissioner,  consider  any  matter to effectuate the
    20  provisions and purposes of this article, and may advise the commissioner
    21  thereon; and it may, from time to time, submit to the  commissioner  any
    22  recommendations  to effectuate the provisions and purposes of this arti-
    23  cle. The commissioner may propose regulations  under  this  article  and
    24  amendments thereto for consideration by the board. The board of trustees
    25  shall  have  no executive, administrative or appointive duties except as
    26  otherwise provided by law. The board of trustees  shall  have  power  to
    27  establish,  and  from  time to time, amend regulations to effectuate the
    28  provisions and purposes of this article,  subject  to  approval  by  the
    29  commissioner.
    30    2. The board shall be composed of:
    31    (a)  the  commissioner,  the superintendent of financial services, and
    32  the director of the budget, or their designees, as ex officio members:
    33    (b) thirty-one trustees appointed by the governor;
    34    (i) six of whom shall be representatives of health care consumer advo-
    35  cacy organizations which have a statewide or regional constituency,  who
    36  have  been  involved  in  issues of interest to low- and moderate-income
    37  individuals, older adults, and people with disabilities; at least  three
    38  of whom shall represent organizations led by consumers in those groups;
    39    (ii)  three of whom shall be representatives of professional organiza-
    40  tions representing physicians;
    41    (iii) five of whom shall be representatives of professional  organiza-
    42  tions  representing  licensed  or  registered  health care professionals
    43  other than physicians;
    44    (iv) three of whom shall be representatives of general hospitals,  one
    45  of whom shall be a representative of public general hospitals;
    46    (v) one of whom shall be a representative of community health centers;
    47    (vi)  two  of  whom shall be representatives of rehabilitation or home
    48  care providers;
    49    (vii) two of whom shall be representatives  of  behavioral  or  mental
    50  health or disability service providers;
    51    (viii)  two  of whom shall be representatives of health care organiza-
    52  tions;
    53    (ix) three of whom shall be representatives of organized labor;
    54    (x) two of whom shall  have  demonstrated  expertise  in  health  care
    55  finance; and

        A. 6058                             9
 
     1    (xi)  two  of  whom shall be employers or representatives of employers
     2  who pay the payroll tax under this article, or, prior to the tax  becom-
     3  ing effective, will pay the tax; and
     4    (c)  fourteen  trustees  appointed by the governor; five of whom to be
     5  appointed on the recommendation of the speaker of the assembly; five  of
     6  whom to be appointed on the recommendation of the temporary president of
     7  the  senate;  two  of  whom to be appointed on the recommendation of the
     8  minority leader of the assembly; and two of whom to be appointed on  the
     9  recommendation of the minority leader of the senate.
    10    3.  (a) After the end of the implementation period, no person shall be
    11  a trustee unless he or she is a member of the program.
    12    (b) Each trustee shall serve at the pleasure of the  appointing  offi-
    13  cer, except the ex officio trustees.
    14    4.  The  chair  of the board shall be appointed, and may be removed as
    15  chair, by the governor from among the trustees. The board shall meet  at
    16  least  four  times  each  calendar year. Meetings shall be held upon the
    17  call of the chair and as provided  by  the  board.  A  majority  of  the
    18  appointed  trustees  shall be a quorum of the board, and the affirmative
    19  vote of a majority of the trustees voting, but  not  less  than  twelve,
    20  shall  be  necessary  for any action to be taken by the board. The board
    21  may establish an executive committee to exercise any powers or duties of
    22  the board as it may provide, and other committees to assist the board or
    23  the executive committee. The chair of the board shall chair  the  execu-
    24  tive  committee  and  shall  appoint  the chair and members of all other
    25  committees. The board of trustees  may  appoint  one  or  more  advisory
    26  committees.  Members  of  advisory committees need not be members of the
    27  board of trustees.
    28    5. Trustees shall serve without compensation but shall  be  reimbursed
    29  for  their  necessary  and actual expenses incurred while engaged in the
    30  business of the board.  However, the board may provide for  compensation
    31  in cases where a lack of compensation would limit the ability of a trus-
    32  tee or represented organization to participate in board business.
    33    6. Notwithstanding any provision of law to the contrary, no officer or
    34  employee of the state or any local government shall forfeit or be deemed
    35  to  have  forfeited his or her office or employment by reason of being a
    36  trustee.
    37    7. The board and its committees and advisory  committees  may  request
    38  and  receive  the  assistance  of  the department and any other state or
    39  local governmental entity in exercising its powers and duties.
    40    8. No later than two years after the effective date of this article:
    41    (a) The board shall develop proposals for: (i)  incorporating  retiree
    42  health  benefits into New York Health; (ii) accommodating employer reti-
    43  ree health benefits for people who have been members of New York  Health
    44  but  live as retirees out of the state; and (iii) accommodating employer
    45  retiree health benefits for people who earned or accrued  such  benefits
    46  while  residing  in  the  state  prior to the implementation of New York
    47  Health and live as retirees out of the state.  The board  shall  present
    48  its proposals to the governor and the legislature.
    49    (b) The board shall develop a proposal for New York Health coverage of
    50  health  care  services  covered  under  the  workers'  compensation law,
    51  including whether and how to continue funding for those  services  under
    52  that  law  and  whether  and how to incorporate an element of experience
    53  rating.
    54    (c) The board shall develop a proposal for New York  Health  coverage,
    55  for  members,  of  health  care  services covered under paragraph one of
    56  subsection (a) of section fifty-one hundred two  of  the  insurance  law

        A. 6058                            10
 
     1  relating  to  motor vehicle insurance reparations, including whether and
     2  how to continue funding for those services.
     3    (d)  The  board  shall  develop  a proposal for integration of federal
     4  veterans health administration programs with New York Health coverage of
     5  health care services; provided however that enrollment in or eligibility
     6  for federal veterans health administration programs shall not  affect  a
     7  resident's eligibility for New York Health coverage.
     8    §  5103.  Eligibility  and  enrollment. 1. Every resident of the state
     9  shall be eligible and entitled to enroll as a member under the program.
    10    2. No individual shall be required to pay any premium or other  charge
    11  for enrolling in or being a member under the program.
    12    3.  A  newborn  child  shall be enrolled as of the date of the child's
    13  birth if enrollment is done prior to the child's birth or  within  sixty
    14  days after the child's birth.
    15    §  5104.  Benefits.  1. The program shall provide comprehensive health
    16  coverage to every member, which shall include all health  care  services
    17  required  to  be  covered  under any of the following, without regard to
    18  whether the member would otherwise be eligible for  or  covered  by  the
    19  program or source referred to:
    20    (a) child health plus;
    21    (b)  Medicaid,  including  but  not limited to services provided under
    22  Medicaid waiver programs, including but not  limited  to  those  granted
    23  under  section  1915  of the federal social security act to persons with
    24  traumatic brain injuries or qualifying for nursing  home  diversion  and
    25  transition services;
    26    (c) Medicare;
    27    (d)  article  forty-four  of  this  chapter  or  article thirty-two or
    28  forty-three of the insurance law;
    29    (e) article eleven of the civil service law, as of the date  one  year
    30  before the beginning of the implementation period;
    31    (f)  any  cost  incurred defined in paragraph one of subsection (a) of
    32  section fifty-one hundred two of the insurance law, provided  that  this
    33  coverage  shall  not  replace  coverage  under  article fifty-one of the
    34  insurance law;
    35    (g) any additional health care service authorized to be added  to  the
    36  program's benefits by the program; and
    37    (h)  provided  that  where  any state law or regulation related to any
    38  federally-matched public health program states that a benefit is contin-
    39  gent on federal financial participation, or words to  that  effect,  the
    40  benefit  shall  be  included  under  the New York Health program without
    41  regard to federal financial participation.
    42    2. No member shall be required to pay any premium, deductible, co-pay-
    43  ment or co-insurance under the program.
    44    3. The program shall provide for payment under the program for:
    45    (a) emergency and temporary health care services provided to a  member
    46  or  individual  entitled to become a member who has not had a reasonable
    47  opportunity to become a member or to enroll with a care coordinator; and
    48    (b) health care services provided in an emergency to an individual who
    49  is entitled to become a member or  enrolled  with  a  care  coordinator,
    50  regardless of having had an opportunity to do so.
    51    §  5105.  Health  care providers; care coordination; payment methodol-
    52  ogies.  1. Choice of health care provider. (a) Any health care  provider
    53  qualified  to  participate  under  this  section may provide health care
    54  services under the program, provided that the health  care  provider  is
    55  otherwise  legally authorized to perform the health care service for the
    56  individual and under the circumstances involved.

        A. 6058                            11
 
     1    (b) A member may choose to receive  health  care  services  under  the
     2  program  from  any participating provider, consistent with provisions of
     3  this article relating to care coordination  and  health  care  organiza-
     4  tions,  the  willingness  or  availability  of  the provider (subject to
     5  provisions  of  this article relating to discrimination), and the appro-
     6  priate clinically-relevant circumstances.
     7    2. Care coordination. (a) A care coordinator may be an  individual  or
     8  entity that is approved by the program that is:
     9    (i)  a  health care practitioner who is: (A) the member's primary care
    10  practitioner; (B) at the option of a female member, the member's provid-
    11  er of primary gynecological care; or (C) at the option of a  member  who
    12  has  a  chronic  condition  that  requires  specialty care, a specialist
    13  health care practitioner who regularly and continually  provides  treat-
    14  ment for that condition to the member;
    15    (ii)  an entity licensed under article twenty-eight of this chapter or
    16  certified under article thirty-six of this chapter, or, with respect  to
    17  a  member  who  receives  chronic mental health care services, an entity
    18  licensed under article thirty-one of the mental  hygiene  law  or  other
    19  entity approved by the commissioner in consultation with the commission-
    20  er of mental health;
    21    (iii) a health care organization;
    22    (iv)  a  labor  union or an entity affiliated with and designated by a
    23  labor union of which the enrollee  or  enrollee's  family  member  is  a
    24  member,  with  respect to its members and their family members; provided
    25  that this provision shall not preclude such an entity  from  becoming  a
    26  care  coordinator  under  subparagraph (v) of this paragraph or a health
    27  care organization under section fifty-one hundred six of  this  article;
    28  or
    29    (v) any not-for-profit or governmental entity approved by the program.
    30    (b)(i)  Every  member shall enroll with a care coordinator that agrees
    31  to provide care coordination to the member  prior  to  receiving  health
    32  care  services  to  be paid for under the program.  Health care services
    33  provided to a member shall not be subject to payment under  the  program
    34  unless  the  member  is enrolled with a care coordinator at the time the
    35  health care service is provided.
    36    (ii) This paragraph shall not apply to health care  services  provided
    37  under  subdivision three of section fifty-one hundred four of this arti-
    38  cle (certain emergency or temporary services).
    39    (iii) The member shall remain  enrolled  with  that  care  coordinator
    40  until  the  member becomes enrolled with a different care coordinator or
    41  ceases to be a member. Members have the right to change their care coor-
    42  dinator on terms at least as permissive as  the  provisions  of  section
    43  three  hundred  sixty-four-j  of  the social services law relating to an
    44  individual changing his or her primary care  provider  or  managed  care
    45  provider.
    46    (c)  Care coordination shall be provided to the member by the member's
    47  care coordinator.  A care coordinator may employ or utilize the services
    48  of other individuals or entities to assist  in  providing  care  coordi-
    49  nation for the member, consistent with regulations of the commissioner.
    50    (d)  A  health  care organization may establish rules relating to care
    51  coordination for members in the health care organization, different from
    52  this subdivision but otherwise consistent with this  article  and  other
    53  applicable laws.
    54    (e) The commissioner shall develop and implement procedures and stand-
    55  ards for an individual or entity to be approved to be a care coordinator
    56  in  the  program,  including but not limited to procedures and standards

        A. 6058                            12
 
     1  relating to the revocation,  suspension,  limitation,  or  annulment  of
     2  approval  on a determination that the individual or entity is not quali-
     3  fied or competent to be a care coordinator or has exhibited a course  of
     4  conduct  which  is  either inconsistent with program standards and regu-
     5  lations or which exhibits an unwillingness to meet  such  standards  and
     6  regulations,  or  is  a potential threat to the public health or safety.
     7  Such procedures and standards shall not limit  approval  to  be  a  care
     8  coordinator  in  the  program  for  criteria other than those under this
     9  section and shall be consistent  with  good  professional  practice.  In
    10  developing  the  procedures  and  standards, the commissioner shall: (i)
    11  consider  existing  standards  developed  by  national  accrediting  and
    12  professional  organizations;  and  (ii)  consult with national and local
    13  organizations working on care coordination or similar models,  including
    14  health  care practitioners, hospitals, clinics, birth centers, long-term
    15  supports and service providers, consumers and their representatives, and
    16  labor organizations representing health care  workers.  When  developing
    17  and implementing standards of approval of care coordinators for individ-
    18  uals  receiving  chronic  mental  health care services, the commissioner
    19  shall consult with the commissioner of mental health. An  individual  or
    20  entity  may  not  be  a care coordinator unless the services included in
    21  care coordination are within  the  individual's  professional  scope  of
    22  practice or the entity's legal authority.
    23    (f)  To  maintain approval under the program, a care coordinator must:
    24  (i) renew its status at a frequency determined by the commissioner;  and
    25  (ii)  provide  data to the department as required by the commissioner to
    26  enable the commissioner to evaluate the impact of care  coordinators  on
    27  quality, outcomes, cost, and patient and provider satisfaction.
    28    (g)  Nothing  in  this  subdivision  shall authorize any individual to
    29  engage in any act in violation of title eight of the education law.
    30    3. Health care providers. (a) The  commissioner  shall  establish  and
    31  maintain procedures and standards for health care providers to be quali-
    32  fied  to participate in the program, including but not limited to proce-
    33  dures and standards relating to the revocation, suspension,  limitation,
    34  or annulment of qualification to participate on a determination that the
    35  health  care  provider is not qualified or competent to be a provider of
    36  specific health care services or has exhibited a course of conduct which
    37  is either inconsistent with program standards and regulations  or  which
    38  exhibits  an unwillingness to meet such standards and regulations, or is
    39  a potential threat to the public health or safety. Such  procedures  and
    40  standards  shall  not  limit  health  care provider participation in the
    41  program for criteria other than those under this section  and  shall  be
    42  consistent  with good professional practice.  Such procedures and stand-
    43  ards may be different for different types of health care  providers  and
    44  health  care  professionals.    The commissioner may require that health
    45  care providers and health care professionals  participate  in  Medicaid,
    46  child health plus, or Medicare to qualify to participate in the program.
    47  Any  health  care  provider that is qualified to participate under Medi-
    48  caid, child health plus or Medicare shall be deemed to be  qualified  to
    49  participate  in  the program, and any health care provider's revocation,
    50  suspension, limitation, or annulment of qualification to participate  in
    51  any  of  those programs shall apply to the health care provider's quali-
    52  fication to participate in the program;  provided  that  a  health  care
    53  provider  qualified  under  this sentence shall follow the procedures to
    54  become qualified under the program by  the  end  of  the  implementation
    55  period.

        A. 6058                            13
 
     1    (b) The commissioner shall establish and maintain procedures and stan-
     2  dards for recognizing health care providers located out of the state for
     3  purposes of providing coverage under the program for out-of-state health
     4  care services.
     5    (c)  Procedures  and  standards  under  this subdivision shall include
     6  provisions for expedited temporary qualification to participate  in  the
     7  program for health care professionals who are (i) temporarily authorized
     8  to  practice  in  the state or (ii) are recently arrived in the state or
     9  recently authorized to practice in the state.
    10    4. Payment for health care services.  (a)  (i)  The  commissioner  may
    11  establish  by  regulation payment methodologies for health care services
    12  and care coordination provided to members under the program  by  partic-
    13  ipating  providers,  care  coordinators,  and health care organizations.
    14  There may be a variety of  different  payment  methodologies,  including
    15  those established on a demonstration basis.
    16    (ii)  All  payment  methodologies and rates under the program shall be
    17  reasonable and reasonably related to the cost of  efficiently  providing
    18  the  health  care service and assuring an adequate and accessible supply
    19  of the health care service.
    20    (iii) In determining such payment methodologies and rates, the commis-
    21  sioner shall consider factors including usual and customary rates  imme-
    22  diately prior to the implementation of the program, reported in a bench-
    23  marking database maintained by a nonprofit organization specified by the
    24  superintendent of financial services, under section six hundred three of
    25  the  financial services law; the level of training, education, and expe-
    26  rience of the health care provider or providers involved; and the  scope
    27  of  services, complexity, and circumstances of care including geographic
    28  factors. Until and unless other  applicable  payment  methodologies  are
    29  established,  health care services provided to members under the program
    30  shall be paid for on a fee-for-service basis, except  for  care  coordi-
    31  nation.
    32    (b)  The  program  shall engage in good faith negotiations with health
    33  care providers' representatives under title III of article forty-nine of
    34  this chapter, including, but not limited to, in  relation  to  rates  of
    35  payment and payment methodologies.
    36    (c) (i) Prescription drugs eligible for reimbursement under this arti-
    37  cle and dispensed by a pharmacy shall be provided and paid for under the
    38  preferred  drug program and the clinical drug review program under title
    39  one of article two-A of this chapter, except as  otherwise  provided  in
    40  this  paragraph.    As  used  in this paragraph, "managed care provider"
    41  means an entity under paragraph (b)  of  subdivision  eight  of  section
    42  fifty-one  hundred  one of this article that qualifies under the federal
    43  Public Health Services Act (the "340B program").
    44    (ii) Where the member is enrolled in a managed  care  provider  and  a
    45  prescription  for  the  member is made under section 340B of the federal
    46  Public Health Service Act (the "340B program") and under a memorandum of
    47  understanding relating to the 340B program between the New  York  Health
    48  program  and  the relevant 340B program covered entity, the managed care
    49  provider shall purchase, pay for and provide for  the  drugs  under  the
    50  340B  program. However, the prescription shall be subject to section two
    51  hundred seventy-three (preferred drug program prior  authorization)  and
    52  section  two hundred seventy-four (clinical drug review program) of this
    53  chapter.
    54    (iii) The New York Health program shall  enter  into  and  maintain  a
    55  memorandum  of understanding relating to the 340B program with each 340B
    56  covered entity in the state that agrees to do so.

        A. 6058                            14
 
     1    (iv) Where prescription drugs are not dispensed  through  a  pharmacy,
     2  payment  shall  be made as otherwise provided in this article, including
     3  use of the 340B program as appropriate.
     4    (d)  Payment  for  health care services established under this article
     5  shall be considered payment in full. A participating provider shall  not
     6  charge  any rate in excess of the payment established under this article
     7  for any health care service provided under the  program  and  shall  not
     8  solicit  or  accept  payment from any member or third party for any such
     9  service except as provided under section fifty-one hundred nine of  this
    10  article.    However,  this paragraph shall not preclude the program from
    11  acting as a primary or  secondary  payer  in  conjunction  with  another
    12  third-party  payer  where permitted under section fifty-one hundred nine
    13  of this article.
    14    (e) The program may provide in payment methodologies for  payment  for
    15  capital  related  expenses  for specifically identified capital expendi-
    16  tures incurred by  not-for-profit  or  governmental  entities  certified
    17  under  article twenty-eight of this chapter. Any capital related expense
    18  generated by a capital expenditure that requires  or  required  approval
    19  under  article  twenty-eight  of  this  chapter  must have received that
    20  approval for the capital related  expense  to  be  paid  for  under  the
    21  program.
    22    (f) Payment methodologies and rates shall include a distinct component
    23  of  reimbursement  for direct and indirect graduate medical education as
    24  defined, calculated and implemented  pursuant  to  section  twenty-eight
    25  hundred seven-c of this chapter.
    26    (g)  The commissioner shall provide by  regulation for payment method-
    27  ologies and procedures for paying for out-of-state health care services.
    28    5. Prior authorization. The program shall not require  prior  authori-
    29  zation  for  any  health  care service in any manner more restrictive of
    30  access to or payment for the service than  would  be  required  for  the
    31  service  under  Medicare  Part  A  or  Part  B.  Prior authorization for
    32  prescription drugs provided by pharmacies under  the  program  shall  be
    33  under title one of article two-A of this chapter.
    34    §  5106.  Health  care organizations. 1. A member may choose to enroll
    35  with and receive health care services under the program  from  a  health
    36  care organization.
    37    2.  A  health  care  organization shall be a not-for-profit or govern-
    38  mental entity that is approved by the commissioner that is:
    39    (a) an accountable care organization under  article  twenty-nine-E  of
    40  this chapter; or
    41    (b)  a  labor  union  or an entity affiliated with and designated by a
    42  labor union of which the enrollee  or  enrollee's  family  member  is  a
    43  member  (i)  with  respect  to its members and their family members, and
    44  (ii) if allowed by applicable law and approved by the commissioner,  for
    45  other members of the program.
    46    3.  A health care organization may be responsible for providing all or
    47  part of the health care services to which its members are entitled under
    48  the program, consistent with the terms of its approval  by  the  commis-
    49  sioner.
    50    4.  (a)  The  commissioner  shall develop and implement procedures and
    51  standards for an entity to be approved to be a health care  organization
    52  in  the  program,  including but not limited to procedures and standards
    53  relating to the revocation,  suspension,  limitation,  or  annulment  of
    54  approval  on  a  determination  that the entity is not competent to be a
    55  health care organization or has exhibited a course of conduct  which  is
    56  either  inconsistent  with  program  standards  and regulations or which

        A. 6058                            15
 
     1  exhibits an unwillingness to meet such standards and regulations, or  is
     2  a  potential  threat to the public health or safety. Such procedures and
     3  standards shall not limit approval to be a health care  organization  in
     4  the  program  for criteria other than those under this section and shall
     5  be consistent with good professional practice. In developing the  proce-
     6  dures and standards, the commissioner shall: (i) consider existing stan-
     7  dards  developed by national accrediting and professional organizations;
     8  and (ii) consult with national and local organizations  working  in  the
     9  field of health care organizations, including health care practitioners,
    10  hospitals,  clinics,  birth  centers,  long-term  supports  and  service
    11  providers, consumers and their representatives and  labor  organizations
    12  representing health care workers. When developing and implementing stan-
    13  dards  of  approval of health care organizations, the commissioner shall
    14  consult with the commissioner of  mental  health,  the  commissioner  of
    15  developmental  disabilities,  the  director  of the state office for the
    16  aging,  the  commissioner  of  the  office  of  addiction  services  and
    17  supports, and the commissioner of the division of human rights.
    18    (b) To maintain approval under the program, a health care organization
    19  must:  (i) renew its status at a frequency determined by the commission-
    20  er; and (ii) provide data to the department as required by  the  commis-
    21  sioner  to enable the commissioner to evaluate the health care organiza-
    22  tion in relation  to  quality  of  health  care  services,  health  care
    23  outcomes, cost, and patient and provider satisfaction.
    24    5.  The  commissioner  shall  make regulations relating to health care
    25  organizations consistent with and to ensure compliance with  this  arti-
    26  cle.
    27    6.  The  provision of health care services directly or indirectly by a
    28  health care organization through health  care  providers  shall  not  be
    29  considered  the practice of a profession under title eight of the educa-
    30  tion law by the health care organization.
    31    §  5107.  Program  standards.  1.  The  commissioner  shall  establish
    32  requirements and standards for the program and for health care organiza-
    33  tions,  care  coordinators,  and  health care providers, consistent with
    34  this article, including requirements and standards for, as applicable:
    35    (a) the scope, quality and accessibility of health care services;
    36    (b) relations between health care organizations or health care provid-
    37  ers and members; and
    38    (c) relations  between  health  care  organizations  and  health  care
    39  providers,  including  (i) credentialing and participation in the health
    40  care organization; and (ii) terms, methods and rates of payment.
    41    2. Requirements and standards under the program shall include, but not
    42  be limited to, provisions to promote the following:
    43    (a) simplification, transparency, uniformity, and fairness  in  health
    44  care  provider  credentialing and participation in health care organiza-
    45  tion networks, referrals, payment procedures and rates, claims  process-
    46  ing, and approval of health care services, as applicable;
    47    (b)  primary  and  preventive  care,  care coordination, efficient and
    48  effective health care  services,  quality  assurance,  coordination  and
    49  integration  of health care services, including use of appropriate tech-
    50  nology, and promotion of public, environmental and occupational health;
    51    (c) elimination of health care disparities;
    52    (d) non-discrimination with respect to members and health care provid-
    53  ers on the basis of race, ethnicity, national origin, religion, disabil-
    54  ity, age, sex, sexual orientation, gender  identity  or  expression,  or
    55  economic  circumstances;  provided  that  health  care services provided

        A. 6058                            16
 
     1  under the program shall be appropriate to the patient's clinically-rele-
     2  vant circumstances;
     3    (e)  accessibility  of  care  coordination,  health  care organization
     4  services and health care services, including  accessibility  for  people
     5  with disabilities and people with limited ability to speak or understand
     6  English,  and  the providing of care coordination, health care organiza-
     7  tion services and health care services in a culturally competent manner;
     8  and
     9    (f) especially in relation to long-term  supports  and  services,  the
    10  maximization  and  prioritization of the most integrated community-based
    11  supports and services.
    12    3. Any participating provider or care coordinator that is organized as
    13  a for-profit entity (other than a professional practice of one  or  more
    14  health  care  professionals) shall be required to meet the same require-
    15  ments and standards as entities organized  as  not-for-profit  entities,
    16  and payments under the program paid to such entities shall not be calcu-
    17  lated  to  accommodate the generation of profit or revenue for dividends
    18  or other return on investment or the payment of taxes that would not  be
    19  paid by a not-for-profit entity.
    20    4.  Every  participating  provider  shall  furnish to the program such
    21  information to, and permit examination of its records by,  the  program,
    22  as  may  be  reasonably required for purposes of reviewing accessibility
    23  and utilization of health care services,  quality  assurance,  promoting
    24  improved  patient outcomes and cost containment, the making of payments,
    25  and statistical or other studies of the operation of the program or  for
    26  protection  and  promotion  of  public,  environmental  and occupational
    27  health.
    28    5. In developing requirements and standards and  making  other  policy
    29  determinations  under  this article, the commissioner shall consult with
    30  the commissioner of mental health,  the  commissioner  of  developmental
    31  disabilities,  the  director  of  the  state  office  for the aging, the
    32  commissioner of the office  of  addiction  services  and  supports,  the
    33  commissioner  of  the  division  of  human  rights,  representatives  of
    34  members, health care providers, care coordinators, health care organiza-
    35  tions  employers, organized labor including  representatives  of  health
    36  care workers, and other interested parties.
    37    6.  The program shall maintain the security and confidentiality of all
    38  data and other information collected under the program  when  such  data
    39  would  be normally considered confidential patient data.  Aggregate data
    40  of the program which is derived from  confidential  data  but  does  not
    41  violate  patient  confidentiality  shall be public information including
    42  for purposes of article six of the public officers law.
    43    § 5108. Regulations. The commissioner  shall  make  regulations  under
    44  this  article  by  approving  regulations  and amendments thereto, under
    45  subdivision one of section fifty-one hundred two of  this  article.  The
    46  commissioner may make regulations or amendments thereto under this arti-
    47  cle  on  an  emergency  basis under section two hundred two of the state
    48  administrative procedure act, provided that such regulations  or  amend-
    49  ments shall not become permanent unless adopted under subdivision one of
    50  section fifty-one hundred two of this article.
    51    § 5109. Provisions relating to federal health programs. 1. The commis-
    52  sioner  shall  seek  all federal waivers and other federal approvals and
    53  arrangements and submit state plan amendments necessary to  operate  the
    54  program consistent with this article to the maximum extent possible.  No
    55  provision of this article and no action under the program shall diminish

        A. 6058                            17
 
     1  any  right or benefit the member would otherwise have under any federal-
     2  ly-matched program or Medicare.
     3    2.  (a)  The  commissioner  shall apply to the secretary of health and
     4  human services or other appropriate federal official for all waivers  of
     5  requirements,  and make other arrangements, under Medicare, any federal-
     6  ly-matched public health program, the affordable care act, and any other
     7  federal programs that provide federal funds for payment for health  care
     8  services,  that  are  necessary to enable all New York Health members to
     9  receive all benefits under the program through the program to enable the
    10  state to implement this article and to receive and deposit  all  federal
    11  payments  under  those programs (including funds that may be provided in
    12  lieu of premium tax credits, cost-sharing subsidies, and small  business
    13  tax  credits) in the state treasury to the credit of the New York Health
    14  trust fund and to use those funds for the New York  Health  program  and
    15  other provisions under this article. To the extent possible, the commis-
    16  sioner shall negotiate arrangements with the federal government in which
    17  bulk  or  lump-sum federal payments are paid to New York Health in place
    18  of  federal  spending  or  tax  benefits  for  federally-matched  health
    19  programs  or  federal  health  programs.    The  commissioner shall take
    20  actions under paragraph (b) of subdivision eight  of  section  fifty-one
    21  hundred one of this article as reasonably necessary.
    22    (b)  The  commissioner may require members or applicants to be members
    23  to provide information necessary for the  program  to  comply  with  any
    24  waiver or arrangement under this subdivision.
    25    3.  (a) The commissioner may take actions consistent with this article
    26  to enable New York Health to administer Medicare in New York  state,  to
    27  create  a  Medicare  managed care plan ("Medicare Advantage") that would
    28  operate consistent with this article, and  to  be  a  provider  of  drug
    29  coverage under Medicare part D for eligible members of New York Health.
    30    (b)  The  commissioner  may  waive  or  modify  the  applicability  of
    31  provisions of this section  relating  to  any  federally-matched  public
    32  health  program  or  Medicare  as  necessary  to implement any waiver or
    33  arrangement under this section or to maximize the  benefit  to  the  New
    34  York  Health program under this section, provided that the commissioner,
    35  in consultation with the director of the budget,  shall  determine  that
    36  such  waiver  or  modification  is  in the best interests of the members
    37  affected by the action and the  state,  and  provided  further  that  no
    38  action  under  this  paragraph  shall  diminish any right or benefit the
    39  member would otherwise have under the program or  any  federally-matched
    40  public health program or Medicare.
    41    (c)  The  commissioner  may  apply  for  coverage under any federally-
    42  matched public health program on behalf of any  member  and  enroll  the
    43  member in the federally-matched public health program or Medicare if the
    44  member  is  eligible  for it.   Enrollment in a federally-matched public
    45  health program or Medicare shall not cause any member to lose any health
    46  care service provided by the program or diminish any  right  or  benefit
    47  the member would otherwise have.
    48    (d) The commissioner shall by regulation increase the income eligibil-
    49  ity  level,  increase  or  eliminate  the resource test for eligibility,
    50  simplify any procedural or documentation requirement for enrollment, and
    51  increase the benefits for any federally-matched public  health  program,
    52  and  for any program to reduce or eliminate an individual's coinsurance,
    53  cost-sharing or premium obligations or increase an  individual's  eligi-
    54  bility  for  any  federal  financial  support related to Medicare or the
    55  affordable care act notwithstanding any law or regulation to the contra-
    56  ry. The commissioner may  act  under  this  paragraph  upon  a  finding,

        A. 6058                            18
 
     1  approved by the director of the budget, that the action (i) will help to
     2  increase  the  number  of  members  who are eligible for and enrolled in
     3  federally-matched public health programs, or for any program  to  reduce
     4  or  eliminate an individual's coinsurance, cost-sharing or premium obli-
     5  gations or increase an individual's eligibility for any  federal  finan-
     6  cial  support  related to Medicare or the affordable care act; (ii) will
     7  not diminish any individual's access to any health care service, benefit
     8  or right the individual would otherwise have; (iii) is in  the  interest
     9  of  the program; and (iv) does not require or has received any necessary
    10  federal waivers or approvals to ensure federal financial participation.
    11    (e) To enable the commissioner to  apply  for  coverage  or  financial
    12  support  under any federally-matched public health program, the Afforda-
    13  ble Care Act, or Medicare on behalf of any member and enroll the  member
    14  in any such program, including an entity under paragraph (b) of subdivi-
    15  sion  eight  of  section  fifty-one  hundred  one of this article if the
    16  member is eligible for it,  the  commissioner  may  require  that  every
    17  member  or  applicant to be a member shall provide information to enable
    18  the commissioner to determine whether the applicant is eligible for such
    19  program.  The program shall make a reasonable effort to  notify  members
    20  of their obligations under this paragraph. After a reasonable effort has
    21  been made to contact the member, the member shall be notified in writing
    22  that  he  or she has sixty days to provide such required information. If
    23  such information is not  provided  within  the  sixty  day  period,  the
    24  member's coverage under the program may be terminated. Upon the member's
    25  satisfactory  provision  of the information, the member's coverage under
    26  the program shall be reinstated retroactive to the date upon  which  the
    27  coverage was terminated.
    28    (f)  To the extent necessary for purposes of this section, as a condi-
    29  tion of  continued  eligibility  for  health  care  services  under  the
    30  program,  a  member  who  is  eligible for benefits under Medicare shall
    31  enroll in Medicare, including parts A, B and D.
    32    (g) The program shall  provide  premium  assistance  for  all  members
    33  enrolling  in  a  Medicare  part  D drug coverage under section 1860D of
    34  Title XVIII of the federal social security act limited to the low-income
    35  benchmark premium amount established by the federal centers for Medicare
    36  and Medicaid services and any other amount which such agency establishes
    37  under its de minimis premium policy, except that such payments  made  on
    38  behalf  of  members enrolled in a Medicare advantage plan may exceed the
    39  low-income benchmark premium amount if determined to be  cost  effective
    40  to the program.
    41    (h)  If  the  commissioner  has  reasonable  grounds to believe that a
    42  member could be eligible for an  income-related  subsidy  under  section
    43  1860D-14  of  Title XVIII of the federal social security act, the member
    44  shall provide, and authorize the program to obtain, any  information  or
    45  documentation  required  to  establish the member's eligibility for such
    46  subsidy, provided that the commissioner shall attempt to obtain as  much
    47  of  the  information and documentation as possible from records that are
    48  available to him or her.
    49    (i) The program shall make a reasonable effort to  notify  members  of
    50  their  obligations under this subdivision. After a reasonable effort has
    51  been made to contact the member, the member shall be notified in writing
    52  that he or she has sixty days to provide such required  information.  If
    53  such  information  is  not  provided  within  the  sixty day period, the
    54  member's coverage under  the  program  may  be  terminated.    Upon  the
    55  member's  satisfactory provision of the information, the member's cover-

        A. 6058                            19
 
     1  age under the program shall be reinstated retroactive to the  date  upon
     2  which the coverage was terminated.
     3    §  5110.  Additional  provisions.   1. The commissioner shall contract
     4  with not-for-profit organizations to provide:
     5    (a) consumer assistance to individuals with respect to  selection  and
     6  changing  selection  of  a care coordinator or health care organization,
     7  enrolling, obtaining health care services, and other matters relating to
     8  the program;
     9    (b) health care provider assistance to health care providers providing
    10  and seeking or considering whether  to  provide,  health  care  services
    11  under the program, with respect to participating in a health care organ-
    12  ization and dealing with a health care organization; and
    13    (c)  care coordinator assistance to individuals and entities providing
    14  and seeking or considering whether  to  provide,  care  coordination  to
    15  members.
    16    2.  The  commissioner  shall provide grants from funds in the New York
    17  Health trust fund or otherwise appropriated for this purpose, to  health
    18  systems  agencies under section twenty-nine hundred four-b of this chap-
    19  ter to support the operation of such health systems agencies.
    20    3. Retraining and re-employment of impacted employees. (a) As used  in
    21  this subdivision:
    22    (i)  "Third  party  payer"  has  its ordinary meaning and includes any
    23  entity that provides or arranges reimbursement in whole or in  part  for
    24  the purchase of health care services.
    25    (ii)  "Health care provider administrative employee" means an employee
    26  of a health care provider primarily engaged  in  relations  or  dealings
    27  with  third  party payers or seeking payment or reimbursement for health
    28  care services from third party payers.
    29    (iii) "Impacted employee" means an individual who, at  any  time  from
    30  the date this section becomes a law until two years after the end of the
    31  implementation period, is employed by a third party payer or is a health
    32  care  provider  administrative employee, and whose employment ends or is
    33  reasonably anticipated to end as a result of the implementation  of  the
    34  New York Health program.
    35    (b)  Within  ninety  days  after  this section shall become a law, the
    36  commissioner of labor shall convene a retraining and re-employment  task
    37  force  including  but  not  limited  to:  representatives  of  potential
    38  impacted employees, human resource departments of third party payers and
    39  health care providers, individuals  with  experience  and  expertise  in
    40  retraining  and  re-employment programs relevant to the circumstances of
    41  impacted employees, and representatives of the  commissioner  of  labor.
    42  The commissioner of labor and the task force shall review and provide:
    43    (i)  analysis  of  potential  impacted  employees  by  job  title  and
    44  geography;
    45    (ii) competency mapping and labor market analysis of impacted employee
    46  occupations with job openings; and
    47    (iii) establishment of regional retraining and re-employment  systems,
    48  including  but  not  limited  to  job boards, outplacement services, job
    49  search services, career advisement services, and retraining  advisement,
    50  to  be coordinated with the regional advisory councils established under
    51  section fifty-one hundred eleven of this article.
    52    (c) (i) Three or more impacted employees, a recognized union of  work-
    53  ers  including  impacted employees, or an employer of impacted employees
    54  may file a petition with the  commissioner  of  labor  to  certify  such
    55  employees as being impacted employees.
    56    (ii) Impacted employees shall be eligible for:

        A. 6058                            20
 
     1    (A) up to two years of retraining at any training provider approved by
     2  the commissioner of labor; and
     3    (B)  up  to  two  years  of  unemployment  benefits, provided that the
     4  impacted employee is enrolled in a department of labor approved training
     5  program, is actively seeking employment, and is not  currently  employed
     6  full  time;  provided, however, that such impacted employee may maintain
     7  unemployment benefits for up to two years even if he  or  she  does  not
     8  meet  the  criteria set forth in this clause but is sixty-three years of
     9  age or older at the time of loss of employment as an impacted employee.
    10    (d) The commissioner shall provide funds  from  the  New  York  Health
    11  trust fund or otherwise appropriated for this purpose to the commission-
    12  er  of  labor  for  retraining  and  re-employment programs for impacted
    13  employees under this subdivision.
    14    (e) The commissioner of labor shall make regulations  and  take  other
    15  actions  reasonably necessary to implement this subdivision. This subdi-
    16  vision shall be implemented consistent with  applicable  law  and  regu-
    17  lations.
    18    4. The commissioner shall, directly and through grants to not-for-pro-
    19  fit entities, conduct programs using data collected through the New York
    20  Health  program,  to  promote  and  protect  the  quality of health care
    21  services, patient outcomes, and public, environmental  and  occupational
    22  health,  including  cooperation  with other data collection and research
    23  programs of the department, consistent with this article, the protection
    24  of the security and confidentiality of individually identifiable patient
    25  information, and otherwise applicable law.
    26    5. Settlements and  judgments.  This  subdivision  applies  where  any
    27  settlement,  judgment  or  order  in  the  course  of litigation, or any
    28  contract or agreement made as an  alternative  to  litigation,  provides
    29  that  one party shall pay for health care coverage for another party who
    30  is entitled to enroll in the program. Any party to the settlement, judg-
    31  ment, order, contract or agreement may apply to an appropriate court for
    32  modification of the judgment, order, contract or agreement. The  modifi-
    33  cation  may  provide that the paying party, instead of paying for health
    34  care coverage, shall pay all or part of the New York Health tax that  is
    35  owed  by  the  other party, and may include other or further provisions.
    36  The modifications shall be appropriate, consistent with the program, and
    37  in the interest of justice. As  used  in  this  subdivision,  "New  York
    38  Health tax" means the tax or taxes enacted by the legislature as part of
    39  the revenue proposal, as amended, to fund the program.
    40    §  5111.  Regional advisory councils.  1. The New York Health regional
    41  advisory councils (each referred to in this article as a "regional advi-
    42  sory council") are hereby created in the department.
    43    2. There shall be a regional advisory council established in  each  of
    44  the following regions:
    45    (a) Long Island, consisting of Nassau and Suffolk counties;
    46    (b) New York City;
    47    (c)  Hudson  Valley, consisting of Delaware, Dutchess, Orange, Putnam,
    48  Rockland, Sullivan, Ulster, Westchester counties;
    49    (d) Northern, consisting of Albany, Clinton, Columbia,  Essex,  Frank-
    50  lin,  Fulton,  Greene, Hamilton, Herkimer, Jefferson, Lewis, Montgomery,
    51  Otsego, Rensselaer,  Saratoga,  Schenectady,  Schoharie,  St.  Lawrence,
    52  Warren, Washington counties;
    53    (e)  Central,  consisting  of Broome, Cayuga, Chemung, Chenango, Cort-
    54  land, Livingston, Madison, Monroe, Oneida,  Onondaga,  Ontario,  Oswego,
    55  Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne, Yates counties; and

        A. 6058                            21
 
     1    (f)  Western,  consisting  of Allegany, Cattaraugus, Chautauqua, Erie,
     2  Genesee, Niagara, Orleans, Wyoming counties.
     3    3.  Each regional advisory council shall be composed of not fewer than
     4  twenty-seven members, as determined by the commissioner and  the  board,
     5  as  necessary  to appropriately represent the diverse needs and concerns
     6  of the region. Members of a regional advisory council shall be residents
     7  of or have their principal place of business in the region served by the
     8  regional advisory council.
     9    4. Appointment of members of the regional advisory councils.
    10    (a) The twenty-seven members shall be appointed as follows:
    11    (i) nine members shall be appointed by the governor;
    12    (ii) six members shall be appointed by the governor on the recommenda-
    13  tion of the speaker of the assembly;
    14    (iii) six members shall be appointed by the governor on the  recommen-
    15  dation of the temporary president of the senate;
    16    (iv) three members shall be appointed by the governor on the recommen-
    17  dation of the minority leader of the assembly; and
    18    (v)  three members shall be appointed by the governor on the recommen-
    19  dation of the minority leader of the senate.
    20    Where a regional advisory council has more than twenty-seven  members,
    21  additional members shall be appointed and recommended by these officials
    22  in the same proportion as the twenty-seven members.
    23    (b)  Regional  advisory  council  membership  shall include but not be
    24  limited to:
    25    (i) representatives of organizations with a regional constituency that
    26  advocate for health care consumers, older adults, and people with  disa-
    27  bilities  including  organizations  led  by members of those groups, who
    28  shall constitute at least one third of the membership of  each  regional
    29  council;
    30    (ii) representatives of professional organizations representing physi-
    31  cians;
    32    (iii)   representatives  of  professional  organizations  representing
    33  health care professionals other than physicians;
    34    (iv) representatives of general hospitals, including public hospitals;
    35    (v) representatives of community health centers;
    36    (vi) representatives of mental health,  behavioral  health  (including
    37  substance use), physical disability, developmental disability, rehabili-
    38  tation, home care and other service providers;
    39    (vii) representatives of women's health service providers;
    40    (viii)  representatives  of  health service providers serving lesbian,
    41  gay,  bisexual,  transgender,  gender  non-conforming,   and   nonbinary
    42  patients;
    43    (ix) representatives of health care organizations;
    44    (x)  representatives  of  organized labor including representatives of
    45  health care workers;
    46    (xi) representatives of employers; and
    47    (xii) representatives of municipal and county government.
    48    5. Members of a regional advisory council shall be appointed for terms
    49  of three years provided, however, that of the members  first  appointed,
    50  one-third  shall  be appointed for one year terms and one-third shall be
    51  appointed for two year terms. Vacancies shall  be  filled  in  the  same
    52  manner as original appointments for the remainder of any unexpired term.
    53  No person shall be a member of a regional advisory council for more than
    54  six years in any period of twelve consecutive years.
    55    6.  Members  of  the  regional  advisory  councils shall serve without
    56  compensation but shall be reimbursed  for  their  necessary  and  actual

        A. 6058                            22
 
     1  expenses  incurred  while  engaged in the business of the advisory coun-
     2  cils. The program shall provide financial support for such expenses  and
     3  other expenses of the regional advisory councils. However, the board may
     4  provide  for  compensation  in  cases where a lack of compensation would
     5  limit the ability of a trustee or represented  organization  to  partic-
     6  ipate in council business.
     7    7.  Each regional advisory council shall meet at least quarterly. Each
     8  regional advisory council may form committees to assist it in its  work.
     9  Members  of  a  committee  need  not be members of the regional advisory
    10  council.   The New York City regional  advisory  council  shall  form  a
    11  committee  for  each  borough  of  New York City, to assist the regional
    12  advisory council in its work as it relates particularly to that borough.
    13    8. Each regional advisory council shall advise the  commissioner,  the
    14  board,  the  governor and the legislature on all matters relating to the
    15  development and implementation of the New York Health program.
    16    9. Each regional advisory council shall adopt, and from time  to  time
    17  revise,  a  community  health  improvement  plan  for its region for the
    18  purpose of:
    19    (a) promoting the delivery of health  care  services  in  the  region,
    20  improving  the  quality  and  accessibility  of care, including cultural
    21  competency, clinical  integration  of  care  between  service  providers
    22  including  but  not  limited to physical, mental, and behavioral health,
    23  physical and developmental disability services, and  long-term  supports
    24  and services;
    25    (b) facility and health services planning in the region;
    26    (c) identifying gaps in regional health care services;
    27    (d)  promoting increased public knowledge and responsibility regarding
    28  the availability and appropriate utilization of  health  care  services.
    29  Each community health improvement plan shall be submitted to the commis-
    30  sioner and the board and shall be posted on the department's website;
    31    (e)  identifying  needs in professional and service personnel required
    32  to deliver health care services; and
    33    (f) coordinating regional implementation of retraining and  re-employ-
    34  ment  programs for impacted employees under subdivision three of section
    35  fifty-one hundred ten of this article.
    36    10. Each regional advisory council shall hold  at  least  four  public
    37  hearings annually on matters relating to the New York Health program and
    38  the  development  and implementation of the community health improvement
    39  plan.
    40    11. Each regional advisory council shall publish an annual  report  to
    41  the  commissioner  and the board on the progress of the community health
    42  improvement plan. These reports shall  be  posted  on  the  department's
    43  website.
    44    12.  All  meetings  of  the  regional advisory councils and committees
    45  shall be subject to article six of the public officers law.
    46    § 4. Financing of New York Health. 1.  (a) As used  in  this  section,
    47  unless the context clearly requires otherwise:
    48    (i)  "New  York  Health  program"  and the "program" mean the New York
    49  Health program, as created by article 51 of the public  health  law  and
    50  all provisions of that article.
    51    (ii)  "Revenue proposal" means the revenue plan and legislative bills,
    52  as proposed and enacted under  this  section,  to  provide  the  revenue
    53  necessary to finance the New York Health program.
    54    (iii)  "Tax"  means  the  payroll tax or non-payroll tax to be enacted
    55  under the revenue proposal. "Payroll  tax"  means  the  tax  on  payroll
    56  income  and  self-employed  income  subject  to the Medicare Part A tax,

        A. 6058                            23
 
     1  provided for in subdivision two of this section. "Non-payroll tax" means
     2  the tax on taxable income (such  as  interest,  dividends,  and  capital
     3  gains)  not  subject to the payroll tax, provided for in subdivision two
     4  of this section.
     5    (b)  The  governor shall submit to the legislature a revenue proposal.
     6  The revenue proposal shall be submitted to the legislature  as  part  of
     7  the  executive  budget  under article VII of the state constitution, for
     8  the fiscal year commencing on the first day of  April  in  the  calendar
     9  year  after  this  act  shall  become  a  law. In developing the revenue
    10  proposal, the governor shall consult with appropriate officials  of  the
    11  executive  branch; the temporary president of the senate; the speaker of
    12  the assembly; the chairs of the fiscal  and  health  committees  of  the
    13  senate  and  assembly; and representatives of business, labor, consumers
    14  and local government.
    15    2. (a) Basic structure. The basic structure of  the  revenue  proposal
    16  shall  be as follows: Revenue for the program shall come from two taxes.
    17  First, there shall be a progressively graduated tax on all  payroll  and
    18  self-employed  income,  paid  by  employers, employees and self-employed
    19  individuals.  Second, there shall be a progressively  graduated  tax  on
    20  taxable  income  (such  as  interest,  dividends, and capital gains) not
    21  subject to the payroll tax.   Income in the  bracket  below  twenty-five
    22  thousand  dollars per year shall be exempt from the taxes; provided that
    23  for individuals enrolled in Medicare as defined in the  program,  income
    24  in  the  bracket  below  fifty thousand dollars per year shall be exempt
    25  from the taxes.  Higher brackets of income subject to the taxes shall be
    26  assessed at a higher marginal rate than lower brackets.  The taxes shall
    27  be set at levels anticipated to produce sufficient  revenue  to  finance
    28  the  program, to be scaled up as enrollment grows, taking into consider-
    29  ation anticipated federal revenue available for the  program.  Provision
    30  shall  be  made  for  state residents who are employed out-of-state, and
    31  non-residents who are employed in the state  (including  those  employed
    32  less than full-time).
    33    (b)  Payroll tax. The income to be subject to the payroll tax shall be
    34  all income subject to the Medicare Part A tax. The payroll tax shall  be
    35  set  at a percentage of that income, which shall be progressively gradu-
    36  ated, so the percentage is higher on  higher  brackets  of  income.  For
    37  employed  individuals,  the  employer  shall  pay  eighty percent of the
    38  payroll tax and the employee shall pay twenty percent of the tax, except
    39  that an employer may agree to pay all or part of the  employee's  share.
    40  A self-employed individual shall pay the full tax.
    41    (c)  Non-payroll  income  tax.  There shall be a tax on income that is
    42  subject to the personal income tax under article 22 of the tax  law  and
    43  is  not  subject  to the payroll tax. It shall be set at a percentage of
    44  that income, which shall be progressively graduated, so  the  percentage
    45  is higher on higher brackets of income.
    46    (d) Phased-in rates. Early in the program, when enrollment is growing,
    47  the  amount  of the taxes shall be at an appropriate level, and shall be
    48  changed as anticipated enrollment grows, to cover the actual cost of the
    49  program. The revenue proposal shall include a mechanism for  determining
    50  the rates of the taxes.
    51    (e) Cross-border employees. (i) State residents employed out-of-state.
    52  If an individual is employed out-of-state by an employer that is subject
    53  to  New  York  state law, the employer and employee shall be required to
    54  pay the payroll tax as to that employee as if the employment were in the
    55  state. If an individual is employed out-of-state by an employer that  is
    56  not  subject to New York state law, either (A) the employer and employee

        A. 6058                            24
 
     1  shall voluntarily comply with the tax or (B) the employee shall pay  the
     2  tax as if he or she were self-employed.
     3    (ii)  Out-of-state  residents  employed in the state.  The payroll tax
     4  shall apply to any out-of-state resident who  is  employed  or  self-em-
     5  ployed in the state.  Such individual and individual's employer shall be
     6  able to take a credit against the payroll taxes each would otherwise pay
     7  as  to  that  individual  for  amounts they spend respectively on health
     8  benefits (A) for the individual, if the individual is not eligible to be
     9  a member of the program, and (B) for  any  member  of  the  individual's
    10  immediate  family.    For  the  employer,  the credit shall be available
    11  regardless of the form of the health benefit (e.g., health insurance,  a
    12  self-insured  plan,  direct services, or reimbursement for services), to
    13  make sure that the revenue proposal does not relate to employment  bene-
    14  fits  in violation of any federal law. For non-employment-based spending
    15  by the individual, the credit shall be  available  for  and  limited  to
    16  spending  for  health  coverage (not out-of-pocket health spending). The
    17  credit shall be available without regard to how little is spent  or  how
    18  sparse  the  benefit.  The  credit may only be taken against the payroll
    19  tax. Any excess amount may not be applied to other  tax  liability.  The
    20  credit  shall  be  distributed  between the employer and employee in the
    21  same proportion as the spending by each  for  the  benefit  and  may  be
    22  applied to their respective portion of the tax. If any provision of this
    23  subparagraph  or any application of it shall be ruled to violate federal
    24  law, the provision or the application of it shall be null and  void  and
    25  the  ruling  shall not affect any other provision or application of this
    26  section or the act that enacted it.
    27    3. (a) The revenue proposal  shall  include  a  plan  and  legislative
    28  provisions   for  ending  the  requirement  for  local  social  services
    29  districts to pay part of  the  cost  of  Medicaid  and  replacing  those
    30  payments with revenue from the taxes under the revenue proposal.
    31    (b)  The  taxes  under this section shall not supplant the spending of
    32  other state revenue to pay for the Medicaid program as it exists  as  of
    33  the  enactment  of  the  revenue proposal as amended, unless the revenue
    34  proposal as amended provides otherwise.
    35    4. To the extent that the revenue proposal differs from the  terms  of
    36  subdivision  two  or paragraph (b) of subdivision three of this section,
    37  the revenue proposal shall state how it differs  from  those  terms  and
    38  reasons for and the effects of the differences.
    39    5.  All  revenue  from  the  taxes  shall be deposited in the New York
    40  Health trust fund account under section 89-j of the state finance law.
    41    § 5.  Article 49 of the public health law is amended by adding  a  new
    42  title 3 to read as follows:
    43                                  TITLE III
    44            COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH
    45                               NEW YORK HEALTH
    46  Section 4920. Definitions.
    47          4921. Collective negotiation authorized.
    48          4922. Collective negotiation requirements.
    49          4923. Requirements for health care providers' representative.
    50          4924. Mediation.
    51          4925. Certain collective action prohibited.
    52          4926. Fees.
    53          4927. Confidentiality.
    54          4928. Severability and construction.
    55    § 4920. Definitions. For purposes of this title:

        A. 6058                            25
 
     1    1. "New York Health" means the program under article fifty-one of this
     2  chapter.
     3    2.  "Person"  means  an  individual,  association, corporation, or any
     4  other legal entity.
     5    3. "Health care providers' representative" means a third party that is
     6  authorized by health care providers to negotiate on  their  behalf  with
     7  New  York  Health  over terms and conditions affecting those health care
     8  providers.
     9    4. "Strike" means a work stoppage in part or in whole, direct or indi-
    10  rect, by a body of workers to gain compliance with demands  made  on  an
    11  employer.
    12    5.  "Health  care provider" means a health care provider under article
    13  fifty-one of this chapter. A health  care  professional  as  defined  in
    14  article  fifty-one of this chapter who practices as an employee or inde-
    15  pendent contractor of another health care provider shall not be deemed a
    16  health care provider for purposes of this title.
    17    § 4921. Collective negotiation authorized. 1.  Health  care  providers
    18  may  meet  and  communicate  for the purpose of collectively negotiating
    19  with New York Health on any matter relating to New York Health,  includ-
    20  ing but not limited to rates of payment and payment methodologies.
    21    2. Nothing in this section shall be construed to allow or authorize an
    22  alteration  of  the terms of the internal and external review procedures
    23  set forth in law.
    24    3. Nothing in this section shall be construed to allow a strike of New
    25  York Health by health care providers.
    26    4. Nothing in this section shall be construed to  allow  or  authorize
    27  terms or conditions which would impede the ability of New York Health to
    28  obtain  or  retain  accreditation  by the national committee for quality
    29  assurance or a similar body or to comply with applicable state or feder-
    30  al law.
    31    § 4922. Collective negotiation requirements. 1. Collective negotiation
    32  rights granted by this title must conform to the following requirements:
    33    (a) health care providers  may  communicate  with  other  health  care
    34  providers  regarding  the terms and conditions to be negotiated with New
    35  York Health;
    36    (b) health care providers may communicate with health care  providers'
    37  representatives;
    38    (c)  a health care providers' representative is the only party author-
    39  ized to negotiate with New York Health on  behalf  of  the  health  care
    40  providers as a group;
    41    (d)  a  health  care provider can be bound by the terms and conditions
    42  negotiated by the health care providers' representatives; and
    43    (e) in communicating or negotiating with the  health  care  providers'
    44  representative, New York Health is entitled to offer and provide differ-
    45  ent terms and conditions to individual competing health care providers.
    46    2.  Nothing  in this title shall affect or limit the right of a health
    47  care provider or group of health care providers to collectively petition
    48  a government entity for a change in a law, rule, or regulation.
    49    3. Nothing in this title shall affect or limit  collective  action  or
    50  collective  bargaining  on the part of any health care provider with his
    51  or her employer or any other  lawful  collective  action  or  collective
    52  bargaining.
    53    § 4923. Requirements for health care providers' representative. Before
    54  engaging  in  collective  negotiations with New York Health on behalf of
    55  health care providers, a health  care  providers'  representative  shall
    56  file  with the commissioner, in the manner prescribed by the commission-

        A. 6058                            26
 
     1  er, information identifying  the  representative,  the  representative's
     2  plan of operation, and the representative's procedures to ensure compli-
     3  ance with this title.
     4    § 4924. Mediation. 1. In the event the commissioner determines that an
     5  impasse  exists  in  the  negotiations,  the  commissioner  shall render
     6  assistance as follows:
     7    (a) to assist the parties to effect  a  voluntary  resolution  of  the
     8  negotiations,  the commissioner shall appoint a mediator who is mutually
     9  acceptable to both the health care  providers'  representative  and  the
    10  representative  of  New  York  Health.  If the mediator is successful in
    11  resolving the impasse, then the health  care  providers'  representative
    12  shall proceed as set forth in this article;
    13    (b)  if  an  impasse continues, the commissioner shall appoint a fact-
    14  finding board of not more than three members, who are mutually  accepta-
    15  ble  to both the health care providers' representative and the represen-
    16  tative of New  York  Health.  The  fact-finding  board  shall  have,  in
    17  addition  to  the powers delegated to it by the board, the power to make
    18  recommendations for the resolution of the dispute;
    19    (c) the fact-finding board, acting by a majority of its members, shall
    20  transmit its findings of fact and recommendations for resolution of  the
    21  dispute  to  the  commissioner, and may thereafter assist the parties to
    22  effect a voluntary resolution of the  dispute.  The  fact-finding  board
    23  shall  also  share  its  findings  of  fact and recommendations with the
    24  health care providers' representative and the representative of New York
    25  Health. If within twenty days after the submission of  the  findings  of
    26  fact  and recommendations, the impasse continues, the commissioner shall
    27  order a resolution to the negotiations based upon the findings  of  fact
    28  and recommendations submitted by the fact-finding board.
    29    §  4925.  Certain  collective  action prohibited. 1. This title is not
    30  intended to authorize competing health care providers to act in  concert
    31  in  response to a health care providers' representative's discussions or
    32  negotiations with New York Health except as authorized by other law.
    33    2. No health care providers' representative shall negotiate any agree-
    34  ment that excludes, limits the participation  or  reimbursement  of,  or
    35  otherwise limits the scope of services to be provided by any health care
    36  provider  or group of health care providers with respect to the perform-
    37  ance of services that are within the health care provider's lawful scope
    38  or terms of practice, license, registration, or certificate.
    39    § 4926. Fees. Each person who acts as the representative of  negotiat-
    40  ing parties under this title shall pay to the department a fee to act as
    41  a  representative.  The  commissioner,  by regulation, shall set fees in
    42  amounts deemed reasonable and necessary to cover the costs  incurred  by
    43  the department in administering this title.
    44    § 4927. Confidentiality. All reports and other information required to
    45  be  reported  to the department under this title shall not be subject to
    46  disclosure under article six of the public officers law.
    47    § 4928. Severability and construction. If any provision or application
    48  of this title shall be held to be invalid, or to violate  or  be  incon-
    49  sistent  with  any  applicable federal law or regulation, that shall not
    50  affect other provisions or applications of this title which can be given
    51  effect without that provision or  application;  and  to  that  end,  the
    52  provisions  and applications of this title are severable. The provisions
    53  of this title shall  be  liberally  construed  to  give  effect  to  the
    54  purposes thereof.

        A. 6058                            27
 
     1    §  6.  Subdivision  11  of  section  270  of the public health law, as
     2  amended by section 2-a of part C of chapter 58 of the laws of  2008,  is
     3  amended to read as follows:
     4    11.  "State  public  health plan" means the medical assistance program
     5  established by title eleven of article five of the social  services  law
     6  (referred  to in this article as "Medicaid"), the elderly pharmaceutical
     7  insurance coverage program established by title three of article two  of
     8  the  elder  law (referred to in this article as "EPIC"), and the [family
     9  health plus program established by section three  hundred  sixty-nine-ee
    10  of  the social services law to the extent that section provides that the
    11  program shall be subject to this article] New York Health program estab-
    12  lished by article fifty-one of this chapter.
    13    § 7. The state finance law is amended by adding a new section 89-j  to
    14  read as follows:
    15    §  89-j. New York Health trust fund. 1. There is hereby established in
    16  the joint custody of the state comptroller and the commissioner of taxa-
    17  tion and finance a special revenue fund to be known  as  the  "New  York
    18  Health trust fund", referred to in this section as "the fund". The defi-
    19  nitions  in  section  fifty-one  hundred  of the public health law shall
    20  apply to this section.
    21    2. The fund shall consist of:
    22    (a) all monies obtained from taxes pursuant to legislation enacted  as
    23  proposed under section three of the New York Health act;
    24    (b)  federal  payments  received  as  a  result of any waiver or other
    25  arrangements agreed to by the United  States  secretary  of  health  and
    26  human  services  or  other appropriate federal officials for health care
    27  programs established under Medicare, any federally-matched public health
    28  program, or the affordable care act;
    29    (c) the amounts paid by the department of health that  are  equivalent
    30  to  those  amounts  that  are  paid on behalf of residents of this state
    31  under Medicare, any federally-matched  public  health  program,  or  the
    32  affordable  care  act for health benefits which are equivalent to health
    33  benefits covered under New York Health;
    34    (d) federal and state funds for purposes of the provision of  services
    35  authorized  under title XX of the federal social security act that would
    36  otherwise be covered under article fifty-one of the public  health  law;
    37  and
    38    (e)  state  monies that would otherwise be appropriated to any govern-
    39  mental agency, office, program,  instrumentality  or  institution  which
    40  provides  health  services,  for services and benefits covered under New
    41  York Health. Payments to the fund pursuant to this paragraph shall be in
    42  an amount equal to the money  appropriated  for  such  purposes  in  the
    43  fiscal  year  beginning  immediately preceding the effective date of the
    44  New York Health act.
    45    3. Monies in the fund shall only  be  used  for  purposes  established
    46  under article fifty-one of the public health law.
    47    § 8. Temporary commission on implementation. 1. There is hereby estab-
    48  lished  a  temporary commission on implementation of the New York Health
    49  program, referred to in this section as the  commission,  consisting  of
    50  fifteen  members:  five members, including the chair, shall be appointed
    51  by the governor; four members shall be appointed by the temporary presi-
    52  dent of the senate, one member shall be appointed by the senate minority
    53  leader; four members shall be appointed by the speaker of the  assembly,
    54  and  one  member shall be appointed by the assembly minority leader. The
    55  commissioner of health, the superintendent of  financial  services,  and

        A. 6058                            28
 
     1  the commissioner of taxation and finance, or their designees shall serve
     2  as non-voting ex-officio members of the commission.
     3    2.  Members  of the commission shall receive such assistance as may be
     4  necessary from other state agencies  and  entities,  and  shall  receive
     5  reasonable  and  necessary expenses incurred in the performance of their
     6  duties. The commission may  employ  staff  as  needed,  prescribe  their
     7  duties,  and  fix their compensation within amounts appropriated for the
     8  commission.
     9    3. The commission shall examine the laws and regulations of the  state
    10  and  consult with health care providers, consumers, and other stakehold-
    11  ers and make such recommendations as are necessary to conform  the  laws
    12  and  regulations  of  the  state and article 51 of the public health law
    13  establishing the New York Health program and  other  provisions  of  law
    14  relating  to  the  New York Health program, and to improve and implement
    15  the program. The commission shall  report  its  recommendations  to  the
    16  governor  and  the legislature.   The commission shall immediately begin
    17  development of proposals consistent with the principles of article 51 of
    18  the public health law for provision  of  health  care  services  covered
    19  under the workers' compensation law; and incorporation of retiree health
    20  benefits,  as  described in paragraphs (a), (b) and (c) of subdivision 8
    21  of section 5102 of the public health law.  The commission shall  provide
    22  its  work  product  and  assistance to the board established pursuant to
    23  section 5102 of the public health law upon completion of the appointment
    24  of the board.
    25    § 9.  Severability. If any provision or application of this act  shall
    26  be  held to be invalid, or to violate or be inconsistent with any appli-
    27  cable federal law or regulation, that shall not affect other  provisions
    28  or  applications  of  this  act  which  can be given effect without that
    29  provision or application; and to that end, the provisions  and  applica-
    30  tions of this act are severable.
    31    § 10. This act shall take effect immediately.
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