Requires health care plans and payors to have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.
NEW YORK STATE ASSEMBLY MEMORANDUM IN SUPPORT OF LEGISLATION submitted in accordance with Assembly Rule III, Sec 1(f)
BILL NUMBER: A8592
SPONSOR: Paulin TITLE OF BILL:
An act to amend the insurance law and the social services law, in
relation to primary care investment
PURPOSE OR GENERAL IDEA OF BILL:
The purpose of this bill is to enhance the role of primary care in New
York's current healthcare delivery to improve the general health of
residents and avoid more costly-health interventions down the road.
SUMMARY OF SPECIFIC PROVISIONS:
Section 1 of the bill would amend the Insurance Law to require plans and
payors to annually report to the Department of Financial Services (DFS)
the percentage of the plan or payor's overall annual healthcare spending
that constituted primary care spending. DFS and the Department of Health
(DOH) would collaborate to provide an annual report to the Legislature
on this primary care spending data and would be required to post the
information on their respective websites. The section would also require
that beginning on April 1, 2026, each plan or payor that reports less
than 12.5% of total expenditures, in the previous year, are on primary
care services would have to provide the Superintendent of DFS a plan to
increase its spending on primary care by 1% of its total overall spend-
ing. This would continue each year on April 1st until the plan or payor
has reported that its spending on primary care has met or exceeded
12.5%. This section would grant the Commissioner of Health (COH) and
Superintendent of DFS authority to make regulations to effectuate the
section. Additionally, under this section no plan or payor would be
required to report or publicly disclose specific rates of reimbursement
for any specific primary care services. No pl an or payor would be
authorized to require any healthcare provider to report additional data
or information.
Section 2 of the bill would amend the Social Services Law to require
Medicaid managed care plans and fee-for services payors to annually
report to the percentage of the plan or payer's overall annual health-
care spending that constituted primary care spending to DOH. The
section would also require that beginning on April 1, 2026, each plan or
payer that reports less than 12.5% of total expenditures, in the previ-
ous year, are on primary care services would have to provide the COH a
plan to increase its spending on primary care by 1% of its total overall
spending. This would continue each year on April 1st until the plan or
payor has reported that its spending on primary care has met or exceeded
12.5%. This section would grant the Commissioner of DOH and Superinten-
dent of DFS authority to make regulations to effectuate the section.
Additionally, under this section no plan or payor would be required to
report or publicly disclose specific rates of reimbursement for any
specific primary care services. No plan or payor would be authorized to
require any healthcare provider to report additional data or informa-
tion.
Section 3 establishes an immediate effective date.
JUSTIFICATION:
Primary care should be a person's first contact with the health care
system when seeking care. Primary care is understanding and maintaining
wellness as well as identifying, preventing, and treating illness before
it becomes a chronic condition. Research shows that an increase of just
one primary care provider per 10,000 people can generate 5.5% fewer
hospital visits, 11% fewer emergency department visits, and 7% fewer
surgeries. We know that health systems oriented towards primary care
simply function better. Yet, it is estimated that as little as 5% of
U.S. healthcare spending goes toward primary care. New York currently
spends more per capita on health care than the national average, but
consistently ranks below many other states in key health indicators.
This is indicative of a lack of access to and underinvestment in primary
care.
Currently, at least ten states have acted to rebalance their healthcare
spending through legislative, regulatory, or executive means. This bill
will define, measure, and report on current primary care spending in New
York. It will also establish tangible metrics for primary care spending
in the state and lays out a process for achieving those goals. By estab-
lishing these metrics this bill will help shift the balance of health-
care spending in the State to place a greater emphasis on proactive and
preventative primary care services. This will serve to improve the
overall health of the residents of New York and potentially avoid more
costly medical interventions that can be avoided.
PRIOR LEGISLATIVE HISTORY:
2021-2022: 56534C Rivera / A7230B Gottfried - Vetoed
FISCAL IMPLICATIONS:
Undetermined.
EFFECTIVE DATE:
Immediately.
STATE OF NEW YORK
________________________________________________________________________
8592
IN ASSEMBLY
January 12, 2024
___________
Introduced by M. of A. PAULIN -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law and the social services law, in
relation to primary care investment
The People of the State of New York, represented in Senate and Assem-bly, do enact as follows:
1 Section 1. The insurance law is amended by adding a new section 3217-k
2 to read as follows:
3 § 3217-k. Primary care spending. (a) Definitions. As used in this
4 section, the following terms shall have the following meanings:
5 (1) "Overall healthcare spending" means the total cost of care for the
6 patient population of a payor or provider entity for a given calendar
7 year, where cost is calculated for such year as the sum of (A) all
8 claims-based spending paid to providers by public and private payors and
9 (B) all non-claim payments for such year, including, but not limited to,
10 incentive payments and care coordination payments.
11 (2) "Plan or payor" means every insurance entity providing managed
12 care products, individual comprehensive accident and health insurance or
13 group or blanket comprehensive accident and health insurance, as defined
14 in this chapter, corporation organized under article forty-three of this
15 chapter providing comprehensive health insurance, entity licensed under
16 article forty-four of this chapter providing comprehensive health insur-
17 ance, every other plan over which the department has jurisdiction, and
18 every third-party payor providing health coverage.
19 (3) "Primary care" means integrated, accessible healthcare, provided
20 by clinicians accountable for addressing most of a patient's healthcare
21 needs, developing a sustained partnership with patients, and practicing
22 in the context of family and community.
23 (4) "Primary care services" means services provided in an outpatient,
24 non-emergency setting by or under the supervision of a physician, nurse
25 practitioner, physician assistant, or midwife, who is practicing general
26 primary care in the following fields, including as evidenced by billing
27 and reporting codes: family practice; general pediatrics; primary care
28 internal medicine; primary care obstetrics; or primary care gynecology.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[] is old law to be omitted.
LBD03591-04-3
A. 8592 2
1 Behavioral or mental health and substance use disorder services are
2 included in primary care services when integrated into a primary care
3 setting, including when provided by a behavioral healthcare psychia-
4 trist, social worker or psychologist. Primary care services shall not
5 include inpatient services, emergency department services, ambulatory
6 surgical center services, or services provided in an urgent care setting
7 that are billed with non-primary care billing and reporting codes.
8 (5) "Primary care spending" means any expenditure of funds made by
9 third party payors, public entities, or the state, for the purpose of
10 paying for primary care services directly or paying to improve the
11 delivery of primary care. Primary care spending includes all payment
12 methods, such as fee-for-service, capitation, incentives, value-based
13 payments or other methodologies, and all non-claim payments including
14 but not limited to incentive payments and care coordination payments.
15 Any spending shall be adjusted appropriately to exclude any portion of
16 the expenditure that is reasonably attributed to inpatient services or
17 other non-primary care services.
18 (b) Reporting. (1) Beginning on April first, two thousand twenty-five,
19 each plan or payor as defined in this section shall annually report to
20 the department the percentage of the plan or payor's overall annual
21 healthcare spending that constituted primary care spending.
22 (2) Nothing herein shall require any plan or payor to report or
23 publicly disclose any specific rates of reimbursement for any specific
24 primary care services.
25 (3) No plan or payor shall require any healthcare provider to provide
26 additional data or information in order to fulfill this reporting
27 requirement.
28 (c) Regulation and publication. (1) The commissioner of health and the
29 superintendent shall each promulgate consistent regulations to carry out
30 the provisions of this section, including but not limited to setting
31 deadlines for the reporting required in this section, and adopting
32 further specific definitions of the primary care services for which
33 costs must be reported under this section, including specific billing
34 and reporting codes.
35 (2) The department of health and the department shall together provide
36 an annual report to the legislature with a summary of the primary care
37 spending data required in this section, and shall also make the report
38 publicly available on both agencies' websites, no later than three
39 months after the data has been collected. The first annual report shall
40 provide the spending information without identifying any individual
41 payor or plan's primary care spending. Each year thereafter, the report
42 spending data shall be published including information specific to each
43 plan or payor.
44 (d) Primary care spending. (1) Beginning on April first, two thousand
45 twenty-six, each plan or payor that reports less than twelve and one-
46 half percent of its total expenditures on physical and mental health is
47 primary care spending, as defined by this section, shall additionally
48 submit to the superintendent a plan to increase primary care spending as
49 a percentage of its total overall healthcare spending by at least one
50 percent each year. Beginning on April first, two thousand twenty-seven
51 and on April first of every subsequent year after such plan has been
52 submitted, and until such time as the plan or payor's reported primary
53 care spending is equal to or more than twelve and one-half percent of
54 that plan or payor's overall healthcare spending, the plan or payor's
55 annual reporting shall include information regarding steps that have
56 been taken to increase its proportion of primary care spending.
A. 8592 3
1 (2) The commissioner of health and the superintendent may jointly
2 issue guidelines or promulgate regulations regarding the areas on which
3 primary care spending could be increased, including but not limited to:
4 (A) reimbursement;
5 (B) capacity-building, technical assistance and training;
6 (C) upgrading technology, including electronic health record systems
7 and telehealth capabilities;
8 (D) incentive payments, including but not limited to per-member-per-
9 month, value-based-payment arrangements, shared savings, quality-based
10 payments, risk-based payments; and
11 (E) transitioning to value-based-payment arrangements.
12 § 2. The social services law is amended by adding a new section 368-g
13 to read as follows:
14 § 368-g. Primary care spending. 1. Definitions. As used in this
15 section the terms "overall healthcare spending", "plan or payor",
16 "primary care", "primary care services" and "primary care spending"
17 shall have the same meanings as such terms are defined in section thir-
18 ty-two hundred seventeen-k of the insurance law.
19 2. Reporting. (a) Beginning on April first, two thousand twenty-five,
20 each Medicaid managed care provider under section three hundred sixty-
21 four-j of this title and any payor that provides coverage through Medi-
22 caid fee-for-service, as such term is defined in paragraph (e) of subdi-
23 vision thirty-eight of section two of this chapter, shall annually
24 report to the department the percentage of the provider's overall annual
25 healthcare spending that constituted primary care spending.
26 (b) Nothing herein shall require any Medicaid managed care provider to
27 report or publicly disclose any specific rates of reimbursement for any
28 specific primary care services.
29 (c) No Medicaid managed care provider shall require any healthcare
30 provider to provide additional data or information in order to fulfill
31 this reporting requirement.
32 3. Primary care spending. (a) Beginning on April first, two thousand
33 twenty-six, and in each subsequent year, each Medicaid managed care
34 provider under section three hundred sixty-four-j of this title and any
35 payor that provides coverage through Medicaid fee-for-service, as such
36 term is defined in paragraph (e) of subdivision thirty-eight of section
37 two of this chapter, that reports less than twelve and one-half percent
38 of its total expenditures on physical and mental health are on primary
39 care spending shall additionally submit to the commissioner a plan to
40 increase primary care spending as a percentage of its total overall
41 healthcare spending by at least one percent each year. Beginning on
42 April first, two thousand twenty-seven, and in each subsequent year
43 thereafter, until twelve and one-half percent of that provider or
44 payor's expenditures are on primary care spending, the payor or provid-
45 er's annual reporting under this section shall include information on
46 steps that have been taken to increase their proportion of primary care
47 spending.
48 (b) The commissioner and the superintendent of financial services may
49 jointly issue guidelines or promulgate regulations regarding the areas
50 on which spending could be increased, including but not limited to:
51 (i) reimbursement;
52 (ii) capacity-building, technical assistance and training;
53 (iii) upgrading technology, including electronic health record systems
54 and telehealth capabilities;
A. 8592 4
1 (iv) incentive payments, including but not limited to per-member-per-
2 month, value-based-payment arrangements, shared savings, quality-based
3 payments, risk-based payments; and
4 (v) transitioning to value-based-payment arrangements.
5 (c) The provisions of this section are subject to compliance with all
6 applicable federal and state laws and regulations, including the Centers
7 for Medicare and Medicaid Services approved Medicaid state plan. To the
8 extent required by federal law, the commissioner shall seek any federal
9 approvals necessary to implement this section, including, but not limit-
10 ed to, any state-directed payments, permissions, state plan amendments
11 or federal waivers by the federal Centers for Medicare and Medicaid
12 Services. The commissioner may also apply for appropriate waivers or
13 state directed payments under federal law and regulation or take other
14 actions to secure federal financial participation to assist in promoting
15 the objectives of this section.
16 § 3. This act shall take effect immediately.
