S01507 Summary:
BILL NO | S01507C |
  | |
SAME AS | SAME AS UNI. A02007-C |
  | |
SPONSOR | BUDGET |
  | |
COSPNSR | |
  | |
MLTSPNSR | |
  | |
Amd Various Laws, generally | |
  | |
Enacts into law major components of legislation necessary to implement the state health and mental hygiene budget for the 2019-2020 state fiscal year; extends and enhances the Medicaid drug cap and reduces unnecessary pharmacy benefit manager costs to the Medicaid program (Part B); relates to extension of the National Diabetes Prevention Program (Part C); amends chapter 59 of the laws of 2011 in relation to extending the Medicaid global cap (Part D); extends certain provisions of the public health law and the social services law relating to health facilities, certified home health agencies, the general public health work program, state fund medical expenditures, hospital assessments, residential health care facilities, administrative costs, welfare reform, Medicaid, and special needs plans (Part E); extends certain provisions relating to excess coverage (Part F); relates to fiscal intermediary services for the consumer directed personal assistance program; relates to payments to home care aides; establishes a residential health care facilities case mix adjustment workgroup; and repeals certain provisions of the social services law relating thereto (Part G); relates to waivers of certain regulations and to certain rates and payment methodologies; and repeals certain provisions of the public health law relating thereto (Part H); relates to guaranteed availability of health insurance and coverage for pre-existing conditions (Subpart A); relates to actuarial value requirements and essential health benefits (Subpart B); relates to prescription drug coverage (Subpart C); prohibits discrimination based on sex and gender identity (Subpart D)(Part J); relates to the effectiveness of certain provisions relating to payments from the medical indemnity fund (Part K); includes iatrogenic infertility under in-vitro fertilization insurance coverage (Part L); requires medical, major medical, or similar comprehensive type coverage health insurance policies to include certain reproductive health coverage; and clarifies the definition of voluntary sterilization procedures and over-the-counter contraceptive products (Part M); relates to the general public health work program (Part O); relates to lead levels (Part P); relates to the healthcare facility transformation program state III authorizing additional awards for statewide II applications (Part Q); codifies the creation of NY state of health, the official health plan marketplace (Part T); relates to private pay protocols for programs and services administered by the office for the aging (Part U); implements certain compliance requirements on managed care organizations and providers participating in the Medicaid program (Part V); relates to the recovery of exempt income by the office of mental health for community residence treatment programs (Part W); relates to a cost of living adjustment for designated human services programs (Part Y); relates to integrated services (Part Z); relates to mental health and substance use disorder health insurance parity (Subpart A); relates to hospital policies for substance use disorder treatment (Subpart B); relates to court ordered substance use disorder treatment (Subpart D)(Part BB); extends an exemption from requiring direct observation and evaluation of certain temporary employees (Part EE); extends provisions related to the New York state health insurance continuation assistance demonstration project (Part FF); provides funding to programs providing opioid treatment and other services operated by the New York state office of alcoholism and substance abuse services or certain agencies (Part GG); relates to grants awarded for classic NORC programs (Part HH); extends the operation and administration of legislative commissions (Part II); authorizes the dormitory authority to transfer certain funds repaid by borrowers relating to restructuring pool loans (Part JJ); and directs the department of health to conduct a study in relation to staffing enhancement and patient safety (Part KK). |
S01507 Actions:
BILL NO | S01507C | |||||||||||||||||||||||||||||||||||||||||||||||||
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01/18/2019 | REFERRED TO FINANCE | |||||||||||||||||||||||||||||||||||||||||||||||||
02/19/2019 | AMEND (T) AND RECOMMIT TO FINANCE | |||||||||||||||||||||||||||||||||||||||||||||||||
02/19/2019 | PRINT NUMBER 1507A | |||||||||||||||||||||||||||||||||||||||||||||||||
03/12/2019 | AMEND (T) AND RECOMMIT TO FINANCE | |||||||||||||||||||||||||||||||||||||||||||||||||
03/12/2019 | PRINT NUMBER 1507B | |||||||||||||||||||||||||||||||||||||||||||||||||
03/29/2019 | AMEND (T) AND RECOMMIT TO FINANCE | |||||||||||||||||||||||||||||||||||||||||||||||||
03/29/2019 | PRINT NUMBER 1507C | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | ORDERED TO THIRD READING CAL.359 | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | PASSED SENATE | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | DELIVERED TO ASSEMBLY | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | referred to ways and means | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | substituted for a2007c | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | ordered to third reading rules cal.53 | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | motion to amend lost | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | motion to amend lost | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | motion to amend lost | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | message of necessity | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | passed assembly | |||||||||||||||||||||||||||||||||||||||||||||||||
03/31/2019 | returned to senate | |||||||||||||||||||||||||||||||||||||||||||||||||
04/01/2019 | DELIVERED TO GOVERNOR | |||||||||||||||||||||||||||||||||||||||||||||||||
04/12/2019 | SIGNED CHAP.57 |
S01507 Committee Votes:
Go to topS01507 Floor Votes:
No
Abbate
No
Crespo
ER
Gantt
Yes
LiPetri
No
Perry
No
Simon
No
Abinanti
No
Crouch
Yes
Garbarino
No
Lupardo
No
Pheffer Amato
No
Simotas
No
Arroyo
No
Cruz
Yes
Giglio
No
Magnarelli
No
Pichardo
Yes
Smith
Yes
Ashby
Yes
Cusick
No
Glick
Yes
Malliotakis
No
Pretlow
Yes
Smullen
No
Aubry
No
Cymbrowitz
Yes
Goodell
Yes
Manktelow
No
Quart
No
Solages
Yes
Barclay
No
Davila
No
Gottfried
No
McDonald
Yes
Ra
Yes
Stec
ER
Barnwell
No
De La Rosa
No
Griffin
ER
McDonough
Yes
Raia
No
Steck
No
Barrett
No
DenDekker
No
Gunther
No
McMahon
No
Ramos
No
Stern
No
Barron
Yes
DeStefano
Yes
Hawley
Yes
Mikulin
No
Raynor
No
Stirpe
No
Benedetto
No
Dickens
No
Hevesi
Yes
Miller B
Yes
Reilly
Yes
Tague
No
Bichotte
No
Dilan
No
Hunter
Yes
Miller MG
No
Reyes
No
Taylor
No
Blake
No
Dinowitz
No
Hyndman
Yes
Miller ML
No
Richardson
No
Thiele
Yes
Blankenbush
Yes
DiPietro
No
Jacobson
Yes
Montesano
No
Rivera
No
Titus
Yes
Brabenec
No
D'Urso
No
Jaffee
Yes
Morinello
No
Rodriguez
No
Vanel
No
Braunstein
Yes
Eichenstein
No
Jean-Pierre
No
Mosley
No
Romeo
Yes
Walczyk
No
Bronson
No
Englebright
Yes
Johns
No
Niou
No
Rosenthal D
No
Walker
No
Buchwald
No
Epstein
No
Jones
No
Nolan
No
Rosenthal L
No
Wallace
No
Burke
No
Fahy
No
Joyner
Yes
Norris
No
Rozic
Yes
Walsh
Yes
Buttenschon
No
Fall
No
Kim
No
O'Donnell
No
Ryan
No
Weinstein
Yes
Byrne
No
Fernandez
Yes
Kolb
No
Ortiz
Yes
Salka
No
Weprin
Yes
Byrnes
Yes
Finch
Yes
Lalor
No
Otis
No
Santabarbara
No
Williams
No
Cahill
Yes
Fitzpatrick
No
Lavine
Yes
Palmesano
No
Sayegh
No
Woerner
No
Carroll
Yes
Friend
ER
Lawrence
Yes
Palumbo
Yes
Schimminger
No
Wright
No
Colton
No
Frontus
No
Lentol
No
Paulin
Yes
Schmitt
No
Zebrowski
No
Cook
No
Galef
No
Lifton
No
Peoples-Stokes
No
Seawright
No
Mr. Speaker
‡ Indicates voting via videoconference
No
Abbate
No
Crespo
ER
Gantt
Yes
LiPetri
No
Perry
Yes
Simon
No
Abinanti
Yes
Crouch
Yes
Garbarino
No
Lupardo
No
Pheffer Amato
No
Simotas
No
Arroyo
No
Cruz
Yes
Giglio
No
Magnarelli
No
Pichardo
Yes
Smith
Yes
Ashby
No
Cusick
No
Glick
Yes
Malliotakis
No
Pretlow
Yes
Smullen
No
Aubry
No
Cymbrowitz
Yes
Goodell
Yes
Manktelow
No
Quart
No
Solages
Yes
Barclay
No
Davila
No
Gottfried
No
McDonald
Yes
Ra
Yes
Stec
No
Barnwell
No
De La Rosa
No
Griffin
ER
McDonough
Yes
Raia
Yes
Steck
Yes
Barrett
No
DenDekker
Yes
Gunther
No
McMahon
No
Ramos
No
Stern
No
Barron
Yes
DeStefano
Yes
Hawley
Yes
Mikulin
No
Raynor
Yes
Stirpe
No
Benedetto
No
Dickens
No
Hevesi
Yes
Miller B
Yes
Reilly
Yes
Tague
No
Bichotte
No
Dilan
No
Hunter
Yes
Miller MG
No
Reyes
No
Taylor
No
Blake
No
Dinowitz
No
Hyndman
Yes
Miller ML
No
Richardson
Yes
Thiele
Yes
Blankenbush
Yes
DiPietro
No
Jacobson
Yes
Montesano
No
Rivera
No
Titus
Yes
Brabenec
No
D'Urso
No
Jaffee
Yes
Morinello
No
Rodriguez
No
Vanel
No
Braunstein
Yes
Eichenstein
No
Jean-Pierre
No
Mosley
No
Romeo
Yes
Walczyk
No
Bronson
No
Englebright
Yes
Johns
No
Niou
No
Rosenthal D
No
Walker
No
Buchwald
No
Epstein
No
Jones
No
Nolan
No
Rosenthal L
No
Wallace
No
Burke
No
Fahy
No
Joyner
Yes
Norris
No
Rozic
Yes
Walsh
No
Buttenschon
No
Fall
No
Kim
Yes
O'Donnell
No
Ryan
No
Weinstein
Yes
Byrne
No
Fernandez
Yes
Kolb
No
Ortiz
Yes
Salka
No
Weprin
Yes
Byrnes
Yes
Finch
Yes
Lalor
No
Otis
Yes
Santabarbara
No
Williams
No
Cahill
Yes
Fitzpatrick
No
Lavine
Yes
Palmesano
Yes
Sayegh
No
Woerner
No
Carroll
Yes
Friend
ER
Lawrence
Yes
Palumbo
No
Schimminger
No
Wright
No
Colton
No
Frontus
No
Lentol
No
Paulin
Yes
Schmitt
No
Zebrowski
No
Cook
No
Galef
No
Lifton
No
Peoples-Stokes
No
Seawright
No
Mr. Speaker
‡ Indicates voting via videoconference
No
Abbate
No
Crespo
ER
Gantt
Yes
LiPetri
No
Perry
Yes
Simon
No
Abinanti
Yes
Crouch
Yes
Garbarino
No
Lupardo
No
Pheffer Amato
No
Simotas
No
Arroyo
No
Cruz
Yes
Giglio
No
Magnarelli
No
Pichardo
Yes
Smith
Yes
Ashby
No
Cusick
No
Glick
Yes
Malliotakis
No
Pretlow
Yes
Smullen
No
Aubry
No
Cymbrowitz
Yes
Goodell
Yes
Manktelow
No
Quart
No
Solages
Yes
Barclay
No
Davila
No
Gottfried
No
McDonald
Yes
Ra
Yes
Stec
No
Barnwell
No
De La Rosa
No
Griffin
ER
McDonough
Yes
Raia
No
Steck
Yes
Barrett
No
DenDekker
Yes
Gunther
No
McMahon
No
Ramos
No
Stern
No
Barron
Yes
DeStefano
Yes
Hawley
Yes
Mikulin
No
Raynor
No
Stirpe
No
Benedetto
No
Dickens
No
Hevesi
Yes
Miller B
Yes
Reilly
Yes
Tague
No
Bichotte
No
Dilan
No
Hunter
Yes
Miller MG
No
Reyes
No
Taylor
No
Blake
No
Dinowitz
No
Hyndman
Yes
Miller ML
No
Richardson
Yes
Thiele
Yes
Blankenbush
Yes
DiPietro
No
Jacobson
Yes
Montesano
No
Rivera
No
Titus
Yes
Brabenec
No
D'Urso
No
Jaffee
Yes
Morinello
No
Rodriguez
No
Vanel
No
Braunstein
No
Eichenstein
No
Jean-Pierre
No
Mosley
No
Romeo
Yes
Walczyk
No
Bronson
No
Englebright
Yes
Johns
No
Niou
No
Rosenthal D
No
Walker
No
Buchwald
No
Epstein
No
Jones
No
Nolan
No
Rosenthal L
No
Wallace
Yes
Burke
No
Fahy
No
Joyner
Yes
Norris
No
Rozic
Yes
Walsh
No
Buttenschon
No
Fall
No
Kim
No
O'Donnell
No
Ryan
No
Weinstein
Yes
Byrne
No
Fernandez
Yes
Kolb
No
Ortiz
Yes
Salka
No
Weprin
Yes
Byrnes
Yes
Finch
Yes
Lalor
No
Otis
Yes
Santabarbara
No
Williams
No
Cahill
Yes
Fitzpatrick
No
Lavine
Yes
Palmesano
Yes
Sayegh
Yes
Woerner
No
Carroll
Yes
Friend
ER
Lawrence
Yes
Palumbo
No
Schimminger
No
Wright
No
Colton
No
Frontus
No
Lentol
No
Paulin
Yes
Schmitt
No
Zebrowski
No
Cook
No
Galef
No
Lifton
No
Peoples-Stokes
No
Seawright
No
Mr. Speaker
‡ Indicates voting via videoconference
Yes
Abbate
Yes
Crespo
ER
Gantt
No
LiPetri
Yes
Perry
Yes
Simon
Yes
Abinanti
Yes
Crouch
No
Garbarino
Yes
Lupardo
Yes
Pheffer Amato
Yes
Simotas
Yes
Arroyo
Yes
Cruz
Yes
Giglio
Yes
Magnarelli
Yes
Pichardo
No
Smith
No
Ashby
Yes
Cusick
Yes
Glick
Yes
Malliotakis
Yes
Pretlow
No
Smullen
Yes
Aubry
Yes
Cymbrowitz
Yes
Goodell
No
Manktelow
Yes
Quart
Yes
Solages
No
Barclay
Yes
Davila
Yes
Gottfried
Yes
McDonald
No
Ra
No
Stec
Yes
Barnwell
Yes
De La Rosa
Yes
Griffin
ER
McDonough
No
Raia
Yes
Steck
Yes
Barrett
Yes
DenDekker
Yes
Gunther
Yes
McMahon
Yes
Ramos
Yes
Stern
No
Barron
No
DeStefano
No
Hawley
No
Mikulin
Yes
Raynor
Yes
Stirpe
Yes
Benedetto
Yes
Dickens
Yes
Hevesi
No
Miller B
No
Reilly
No
Tague
Yes
Bichotte
Yes
Dilan
Yes
Hunter
Yes
Miller MG
Yes
Reyes
Yes
Taylor
Yes
Blake
Yes
Dinowitz
Yes
Hyndman
Yes
Miller ML
Yes
Richardson
Yes
Thiele
No
Blankenbush
No
DiPietro
Yes
Jacobson
No
Montesano
Yes
Rivera
Yes
Titus
No
Brabenec
Yes
D'Urso
Yes
Jaffee
No
Morinello
Yes
Rodriguez
Yes
Vanel
Yes
Braunstein
Yes
Eichenstein
Yes
Jean-Pierre
No
Mosley
Yes
Romeo
No
Walczyk
Yes
Bronson
Yes
Englebright
Yes
Johns
Yes
Niou
Yes
Rosenthal D
Yes
Walker
Yes
Buchwald
Yes
Epstein
Yes
Jones
Yes
Nolan
Yes
Rosenthal L
Yes
Wallace
Yes
Burke
Yes
Fahy
Yes
Joyner
No
Norris
Yes
Rozic
Yes
Walsh
Yes
Buttenschon
Yes
Fall
Yes
Kim
Yes
O'Donnell
Yes
Ryan
Yes
Weinstein
No
Byrne
Yes
Fernandez
No
Kolb
Yes
Ortiz
No
Salka
Yes
Weprin
No
Byrnes
No
Finch
No
Lalor
Yes
Otis
Yes
Santabarbara
Yes
Williams
Yes
Cahill
No
Fitzpatrick
Yes
Lavine
No
Palmesano
Yes
Sayegh
Yes
Woerner
Yes
Carroll
No
Friend
ER
Lawrence
No
Palumbo
Yes
Schimminger
Yes
Wright
Yes
Colton
Yes
Frontus
Yes
Lentol
Yes
Paulin
No
Schmitt
Yes
Zebrowski
Yes
Cook
Yes
Galef
Yes
Lifton
Yes
Peoples-Stokes
Yes
Seawright
Yes
Mr. Speaker
‡ Indicates voting via videoconference
S01507 Memo:
Memo not availableGo to top
S01507 Text:
Go to top STATE OF NEW YORK ________________________________________________________________________ S. 1507--C A. 2007--C SENATE - ASSEMBLY January 18, 2019 ___________ IN SENATE -- A BUDGET BILL, submitted by the Governor pursuant to arti- cle seven of the Constitution -- read twice and ordered printed, and when printed to be committed to the Committee on Finance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee IN ASSEMBLY -- A BUDGET BILL, submitted by the Governor pursuant to article seven of the Constitution -- read once and referred to the Committee on Ways and Means -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- again reported from said committee with amendments, ordered reprinted as amended and recommitted to said committee -- again reported from said committee with amendments, ordered reprinted as amended and recommitted to said committee AN ACT intentionally omitted (Part A); to amend the public health law, in relation to extending and enhancing the Medicaid drug cap and to reduce unnecessary pharmacy benefit manager costs to the Medicaid program (Part B); to amend the social services law, in relation to extension of the National Diabetes Prevention Program (Part C); to amend chapter 59 of the laws of 2011 amending the public health law and other laws relating to known and projected department of health state fund medicaid expenditures, in relation to extending the medi- caid global cap (Part D); to amend chapter 505 of the laws of 1995, amending the public health law relating to the operation of department of health facilities, in relation to extending the provisions thereof; to amend chapter 56 of the laws of 2013, amending the social services law relating to eligibility conditions, in relation to extending the provisions thereof; to amend chapter 884 of the laws of 1990, amending the public health law relating to authorizing bad debt and charity care allowances for certified home health agencies, in relation to extending the provisions thereof; to amend chapter 303 of the laws of 1999, amending the New York state medical care facilities finance agency act relating to financing health facilities, in relation to the effectiveness thereof; to amend chapter 109 of the laws of 2010, EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD12571-05-9S. 1507--C 2 A. 2007--C amending the social services law relating to transportation costs, in relation to the effectiveness thereof; to amend chapter 58 of the laws of 2009, amending the public health law relating to payment by govern- mental agencies for general hospital inpatient services, in relation to the effectiveness thereof; to amend chapter 56 of the laws of 2013, amending the public health law relating to the general public health work program, in relation to the effectiveness thereof; to amend chap- ter 59 of the laws of 2011, amending the public health law and other laws relating to known and projected department of health state fund medical expenditures, in relation to extending the provisions thereof; to amend the public health law, in relation to hospital assessments; to amend chapter 474 of the laws of 1996, amending the education law and other laws relating to rates for residential health care facili- ties, in relation to the effectiveness thereof; to amend chapter 58 of the laws of 2007, amending the social services law and other laws relating to enacting the major components of legislation necessary to implement the health and mental hygiene budget for the 2007-2008 state fiscal year, in relation to delay of certain administrative costs; to amend chapter 81 of the laws of 1995, amending the public health law and other laws relating to medical reimbursement and welfare reform, in relation to the effectiveness thereof; to amend chapter 56 of the laws of 2013, amending chapter 59 of the laws of 2011 amending the public health law and other laws relating to general hospital reimbursement for annual rates, in relation to rates of payments; to amend the public health law, in relation to reimbursement rate promul- gation for residential health care facilities; to amend the public health law, in relation to residential health care facility, and certified home health agency services payments; to amend chapter 81 of the laws of 1995, amending the public health law and other laws relat- ing to medical reimbursement and welfare reform, in relation to the effectiveness thereof; to amend chapter 56 of the laws of 2013 amend- ing chapter 59 of the laws of 2011 amending the public health law and other laws relating to general hospital reimbursement for annual rates, in relation to extending government rates for behavioral services and adding an alternative payment methodology requirement; to amend chapter 111 of the laws of 2010 relating to increasing Medicaid payments to providers through managed care organizations and providing equivalent fees through an ambulatory patient group methodology, in relation to extending government rates for behavioral services and adding an alternative payment methodology requirement; to amend section 2 of part H of chapter 111 of the laws of 2010, relating to increasing Medicaid payments to providers through managed care organ- izations and providing equivalent fees through an ambulatory patient group methodology, in relation to transfer of funds and the effective- ness thereof; and to amend chapter 649 of the laws of 1996, amending the public health law, the mental hygiene law and the social services law relating to authorizing the establishment of special needs plans, in relation to the effectiveness thereof (Part E); to amend chapter 266 of the laws of 1986, amending the civil practice law and rules and other laws relating to malpractice and professional medical conduct, in relation to apportioning premium for certain policies; to amend part J of chapter 63 of the laws of 2001 amending chapter 266 of the laws of 1986, amending the civil practice law and rules and other laws relating to malpractice and professional medical conduct, relating to the effectiveness of certain provisions of such chapter, in relation to extending certain provisions concerning the hospital excess liabil-S. 1507--C 3 A. 2007--C ity pool; and to amend part H of chapter 57 of the laws of 2017, amending the New York Health Care Reform Act of 1996 and other laws relating to extending certain provisions relating thereto, in relation to extending provisions relating to excess coverage (Part F); to amend the social services law, in relation to fiscal intermediary services for the consumer directed personal assistance program; to amend the public health law, in relation to payments to home care aides; to establish a residential health care facilities case mix adjustment workgroup; and to repeal certain provisions of the social services law relating thereto (Part G); to amend the public health law, in relation to waiver of certain regulations; to amend the public health law, in relation to certain rates and payment methodologies; and to repeal certain provisions of such law relating thereto (Part H); inten- tionally omitted (Part I); to amend the insurance law and the public health law, in relation to guaranteed availability and pre-existing conditions; and to repeal certain provisions of the insurance law relating thereto (Subpart A); to amend the insurance law, in relation to actuarial value requirements and essential health benefits (Subpart B); to amend the insurance law, in relation to prescription drug coverage (Subpart C); and to amend the insurance law, in relation to discrimination based on sex and gender identity (Subpart D) (Part J); to amend the public health law, in relation to the medical indemnity fund; to amend chapter 517 of the laws of 2016 amending the public health law relating to payments from the New York state medical indem- nity fund, in relation to the effectiveness thereof; and to amend the state finance law, in relation to the New York state medical indemnity fund account (Part K); to amend the insurance law, in relation to in-vitro fertilization (Part L); to amend the insurance law, in relation to requiring medical, major medical, or similar comprehensive type coverage health insurance policies to include certain reproduc- tive health coverage; and clarifying the definition of voluntary ster- ilization procedures and over-the-counter contraceptive products (Part M); intentionally omitted (Part N); to amend the public health law, in relation to the general public health work program (Part O); to amend the public health law, in relation to lead levels in residential rental properties (Part P); to amend the public health law, in relation to the healthcare facility transformation program state III authorizing additional awards for statewide II applications (Part Q); intentionally omitted (Part R); intentionally omitted (Part S); to amend the public health law, in relation to codifying the creation of NY State of Health, the official Health Plan Marketplace within the department of health (Part T); to amend the elder law, in relation to the private pay program (Part U); to amend the social services law, in relation to compliance of managed care organizations and providers participating in the Medicaid program (Part V); to amend part D of chapter 111 of the laws of 2010 relating to the recovery of exempt income by the office of mental health for community residences and family-based treatment programs, in relation to the effectiveness thereof (Part W); intentionally omitted (Part X); to amend part C of chapter 57 of the laws of 2006, relating to establishing a cost of living adjustment for designated human services programs, in relation to the inclusion and development of certain cost of living adjustments (Part Y); to amend the public health law and the mental hygiene law, in relation to integrated services (Part Z); intentionally omitted (Part AA); to amend the insurance law, in relation to mental health and substance use disorder health insurance parity; to amend theS. 1507--C 4 A. 2007--C public health law, in relation to health maintenance organizations; and to repeal certain provisions of the insurance law relating thereto (Subpart A); to amend the public health law, in relation to general hospital policies for substance use disorder treatment (Subpart B); intentionally omitted (Subpart C); to amend the social services law, in relation to court ordered substance use disorder treatment (Subpart D); and intentionally omitted (Subpart E)(Part BB); intentionally omitted (Part CC); intentionally omitted (Part DD); to amend the public health law, in relation to direct observation and evaluation of certain temporary employees (Part EE); to amend chapter 495 of the laws of 2004, amending the insurance law and the public health law relating to the New York state health insurance continuation assist- ance demonstration project, in relation to the effectiveness thereof (Part FF); to provide funding to programs providing opioid treatment, recovery and prevention and education services operated by the New York state office of alcoholism and substance abuse services or certain agencies (Part GG); to amend the elder law, in relation to grants awarded for classic NORC programs (Part HH); to amend chapter 141 of the laws of 1994, amending the legislative law and the state finance law relating to the operation and administration of the legis- lature, in relation to extending such provisions (Part II); to amend the public health law, in relation to authorizing the dormitory authority to transfer certain funds repaid by borrowers relating to restructuring pool loans (Part JJ); and directing the department of health to conduct a study in relation to staffing enhancement and patient safety (Part KK) The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. This act enacts into law major components of legislation 2 which are necessary to implement the state fiscal plan for the 2019-2020 3 state fiscal year. Each component is wholly contained within a Part 4 identified as Parts A through KK. The effective date for each particular 5 provision contained within such Part is set forth in the last section of 6 such Part. Any provision in any section contained within a Part, 7 including the effective date of the Part, which makes reference to a 8 section "of this act", when used in connection with that particular 9 component, shall be deemed to mean and refer to the corresponding 10 section of the Part in which it is found. Section three of this act sets 11 forth the general effective date of this act. 12 PART A 13 Intentionally Omitted 14 PART B 15 Section 1. Intentionally omitted. 16 § 2. Intentionally omitted. 17 § 3. Intentionally omitted. 18 § 4. Intentionally omitted. 19 § 5. Paragraphs (b) and (c) of subdivision 2 of section 280 of the 20 public health law, paragraph (b) as amended and paragraph (c) as addedS. 1507--C 5 A. 2007--C 1 by section 8 of part D of chapter 57 of the laws of 2018, are amended 2 and a new paragraph (d) is added to read as follows: 3 (b) for state fiscal year two thousand eighteen--two thousand nine- 4 teen, be limited to the ten-year rolling average of the medical compo- 5 nent of the consumer price index plus four percent and minus a pharmacy 6 savings target of eighty-five million dollars; [and] 7 (c) for state fiscal year two thousand nineteen--two thousand twenty, 8 be limited to the ten-year rolling average of the medical component of 9 the consumer price index plus four percent and minus a pharmacy savings 10 target of eighty-five million dollars[.]; and 11 (d) for state fiscal year two thousand twenty--two thousand twenty- 12 one, be limited to the ten-year rolling average of the medical component 13 of the consumer price index plus four percent and minus a pharmacy 14 savings target of eighty-five million dollars. 15 § 6. Subdivision 3 of section 280 of the public health law, as amended 16 by section 8 of part D of chapter 57 of the laws of 2018, is amended to 17 read as follows: 18 3. The department and the division of the budget shall assess on a 19 quarterly basis the projected total amount to be expended in the year on 20 a cash basis by the Medicaid program for each drug, and the projected 21 annual amount of state funds Medicaid drug expenditures on a cash basis 22 for all drugs, which shall be a component of the projected department of 23 health state funds Medicaid expenditures calculated for purposes of 24 sections ninety-one and ninety-two of part H of chapter fifty-nine of 25 the laws of two thousand eleven. For purposes of this section, state 26 funds Medicaid drug expenditures include amounts expended for drugs in 27 both the Medicaid fee-for-service program and Medicaid managed care 28 programs, minus the amount of any drug rebates or supplemental drug 29 rebates received by the department, including rebates pursuant to subdi- 30 vision five of this section with respect to rebate targets. The depart- 31 ment and the division of the budget shall report [quarterly] in December 32 of each year, for the prior April through October, to the drug utiliza- 33 tion review board the projected state funds Medicaid drug expenditures 34 including the amounts, in aggregate thereof, attributable to the net 35 cost of: changes in the utilization of drugs by Medicaid recipients; 36 changes in the number of Medicaid recipients; changes to the cost of 37 brand name drugs and changes to the cost of generic drugs. The informa- 38 tion contained in the report shall not be publicly released in a manner 39 that allows for the identification of an individual drug or manufacturer 40 or that is likely to compromise the financial competitive, or proprie- 41 tary nature of the information. 42 (a) In the event the director of the budget determines, based on Medi- 43 caid drug expenditures for the previous quarter or other relevant infor- 44 mation, that the total department of health state funds Medicaid drug 45 expenditure is projected to exceed the annual growth limitation imposed 46 by subdivision two of this section, the commissioner may identify and 47 refer drugs to the drug utilization review board established by section 48 three hundred sixty-nine-bb of the social services law for a recommenda- 49 tion as to whether a target supplemental Medicaid rebate should be paid 50 by the manufacturer of the drug to the department and the target amount 51 of the rebate. 52 (b) If the department intends to refer a drug to the drug utilization 53 review board pursuant to paragraph (a) of this subdivision, the depart- 54 ment shall notify the manufacturer of such drug and shall attempt to 55 reach agreement with the manufacturer on a rebate for the drug prior to 56 referring the drug to the drug utilization review board for review.S. 1507--C 6 A. 2007--C 1 Such rebate may be based on evidence-based research, including, but not 2 limited to, such research operated or conducted by or for other state 3 governments, the federal government, the governments of other nations, 4 and third party payers or multi-state coalitions, provided however that 5 the department shall account for the effectiveness of the drug in treat- 6 ing the conditions for which it is prescribed or in improving a 7 patient's health, quality of life, or overall health outcomes, and the 8 likelihood that use of the drug will reduce the need for other medical 9 care, including hospitalization. 10 (c) In the event that the commissioner and the manufacturer have 11 previously agreed to a supplemental rebate for a drug pursuant to para- 12 graph (b) of this subdivision or paragraph (e) of subdivision seven of 13 section three hundred sixty-seven-a of the social services law, the drug 14 shall not be referred to the drug utilization review board for any 15 further supplemental rebate for the duration of the previous rebate 16 agreement, provided however, the commissioner may refer a drug to the 17 drug utilization review board if the commissioner determines there are 18 significant and substantiated utilization or market changes, new 19 evidence-based research, or statutory or federal regulatory changes that 20 warrant additional rebates. In such cases, the department shall notify 21 the manufacturer and provide evidence of the changes or research that 22 would warrant additional rebates, and shall attempt to reach agreement 23 with the manufacturer on a rebate for the drug prior to referring the 24 drug to the drug utilization review board for review. 25 (d) The department shall consider a drug's actual cost to the state, 26 including current rebate amounts, prior to seeking an additional rebate 27 pursuant to paragraph (b) or (c) of this subdivision [and shall take28into consideration whether the manufacturer of the drug is providing29significant discounts relative to other drugs covered by the Medicaid30program]. 31 (e) The commissioner shall be authorized to take the actions described 32 in this section only so long as total Medicaid drug expenditures are 33 projected to exceed the annual growth limitation imposed by subdivision 34 two of this section. 35 § 6-a. Subparagraph (iii) of paragraph (e) of subdivision 5 of section 36 280 of the public health law, as amended by section 8 of part D of chap- 37 ter 57 of the laws of 2018, is amended to read as follows: 38 (iii) information relating to value-based pricing provided, however, 39 if the department directly invites any third party to provide cost-ef- 40 fectiveness analysis or research related to value-based pricing, and the 41 department receives and considers such analysis or research for use by 42 the board, such third party shall disclose any funding sources. The 43 department shall, if reasonably possible, make publicly available the 44 following documents in its possession that it relies upon to provide 45 cost effectiveness analyses or research related to value-based pricing: 46 (A) descriptions of underlying methodologies; (B) assumptions and limi- 47 tations of research findings; and (C) if available, data that presents 48 results in a way that reflects different outcomes for affected subpopu- 49 lations; 50 § 7. Paragraph (a) of subdivision 5 of section 280 of the public 51 health law, as amended by section 8 of part D of chapter 57 of the laws 52 of 2018, is amended to read as follows: 53 (a) If the drug utilization review board recommends a target rebate 54 amount on a drug referred by the commissioner, the [commissioner shall55require] department shall negotiate with the drug's manufacturer for a 56 supplemental rebate to be paid by the [drug's] manufacturer in an amountS. 1507--C 7 A. 2007--C 1 not to exceed such target rebate amount. [With respect to a] A rebate 2 [required in state fiscal year two thousand seventeen--two thousand3eighteen, the rebate] requirement shall apply beginning with the [month4of April, two thousand seventeen,] first day of the state fiscal year 5 during which the rebate was required without regard to the date the 6 department enters into the rebate agreement with the manufacturer. 7 § 8. Paragraph (a) of subdivision 7 of section 280 of the public 8 health law, as amended by section 8 of part D of chapter 57 of the laws 9 of 2018, is amended to read as follows: 10 (a) If, after taking into account all rebates and supplemental rebates 11 received by the department, including rebates received to date pursuant 12 to this section, total Medicaid drug expenditures are still projected to 13 exceed the annual growth limitation imposed by subdivision two of this 14 section, the commissioner may: subject any drug of a manufacturer 15 referred to the drug utilization review board under this section to 16 prior approval in accordance with existing processes and procedures when 17 such manufacturer has not entered into a supplemental rebate agreement 18 as required by this section; [directing] direct managed care plans to 19 remove from their Medicaid formularies those drugs that the drug utili- 20 zation review board recommends a target rebate amount for and the 21 manufacturer has failed to enter into a rebate agreement required by 22 this section; [promoting] promote the use of cost effective and clin- 23 ically appropriate drugs other than those of a manufacturer who has a 24 drug that the drug utilization review board recommends a target rebate 25 amount and the manufacturer has failed to enter into a rebate agreement 26 required by this section; [allowing] allow manufacturers to accelerate 27 rebate payments under existing rebate contracts; and such other actions 28 as authorized by law. The commissioner shall provide written notice to 29 the legislature thirty days prior to taking action pursuant to this 30 paragraph, unless action is necessary in the fourth quarter of a fiscal 31 year to prevent total Medicaid drug expenditures from exceeding the 32 limitation imposed by subdivision two of this section, in which case 33 such notice to the legislature may be less than thirty days. 34 § 9. Subdivision 8 of section 280 of the public health law, as added 35 by section 8 of part D of chapter 57 of the laws of 2018, is amended to 36 read as follows: 37 8. The commissioner shall report by [February] July first annually to 38 the drug utilization review board on savings achieved through the drug 39 cap in the last fiscal year. Such report shall provide data on what 40 savings were achieved through actions pursuant to subdivisions three, 41 five and seven of this section, respectively, and what savings were 42 achieved through other means and how such savings were calculated and 43 implemented. 44 § 10. Section 4406-c of the public health law is amended by adding a 45 new subdivision 10 to read as follows: 46 10. (a) Any contract or other arrangement entered into by a health 47 care plan for the provision and administration of pharmacy benefit 48 management services on behalf of individuals enrolled in a managed care 49 provider, as defined in section three hundred sixty-four-j of the social 50 services law, shall be based on a pass-through pricing model and include 51 the following requirements: 52 (i) Payment to the pharmacy benefit manager for pharmacy benefit 53 management services shall be limited to the actual ingredient costs, 54 dispensing fees paid to pharmacies, and an administrative fee that 55 covers the cost of providing pharmacy benefit management services pursu-S. 1507--C 8 A. 2007--C 1 ant to a contract described in this paragraph. The department may estab- 2 lish a maximum administrative fee; 3 (ii) The pharmacy benefit manager shall identify all sources and 4 amounts of income, payments, and financial benefits to the pharmacy 5 benefit manager related to the provision and administration of pharmacy 6 benefit management services on behalf of the health care plan, includ- 7 ing, but not limited to, any pricing discounts, rebates of any kind, 8 inflationary payments, credits, clawbacks, fees, grants, chargebacks, 9 reimbursements, or other benefits and shall ensure that any portion of 10 such income, payments, and financial benefits is passed through to the 11 health care plan in full to reduce the reportable ingredient cost; 12 (iii) The pharmacy benefit manager shall fully disclose to the depart- 13 ment and to the health care plan the sources and amounts of all income, 14 payments, and financial benefits referred to in subparagraph (ii) of 15 this paragraph received by the pharmacy benefit manager; 16 (iv) The pharmacy benefit manager shall identify all ingredient costs 17 and dispensing fees or similar payments made by the pharmacy benefit 18 manager to any pharmacy in connection with the contract or other 19 arrangement; 20 (v) The pharmacy benefit manager shall not utilize any form of spread 21 pricing in any contract or other arrangement with health care plans. For 22 purposes of this subdivision "spread pricing" means any amount charged 23 or claimed by the pharmacy benefit manager in excess of the amount paid 24 to pharmacies on behalf of the health care plan less an administrative 25 fee as described in this paragraph. Any such excess amount shall be 26 remitted to the health care plan on a quarterly basis; 27 (vi) Pharmacy benefit managers shall make their payment model for 28 administrative fees available to the health care plan and to the depart- 29 ment. The health care plan shall, if so directed by the department, 30 make changes to the payment model and resubmit an amended contract or 31 contracts to the department for review and approval. 32 (b) Any changes to premiums resulting from such contracts shall be 33 subject to certification by the state's actuary as actuarially appropri- 34 ate. 35 (c) Contracts or other arrangements subject to this subdivision shall 36 be submitted to the department for review and approval as required by 37 and in accordance with state law and the regulations of the department. 38 Contracts or other arrangements subject to this subdivision existing 39 and in force at the time of enactment of this subdivision shall be 40 submitted to the department for review and approval on or before July 41 first, two thousand nineteen. 42 § 10-a. Section 364-j of the social services law is amended by adding 43 a new subdivision 37 to read as follows: 44 37. Managed care providers shall report to the department all sources 45 and amounts of income, payments, and financial benefits related to the 46 provision of pharmacy benefits, including, but not limited to, any pric- 47 ing discounts, rebates of any kind, inflationary payments, credits, 48 clawbacks, fees, grants, chargebacks, reimbursements, or other benefits 49 whether such income, payments, or financial benefits are received 50 directly by the managed care provider or passed through from a pharmacy 51 benefit manager or other entity. Managed care providers shall also 52 report to the department the amounts of any administrative fees paid to 53 cover the cost of providing pharmacy benefit management services. The 54 reporting required in this subdivision shall be supplemental to and 55 included with other existing reporting requirements, including but not 56 limited to any quarterly reporting requirements.S. 1507--C 9 A. 2007--C 1 § 11. This act shall take effect immediately and shall be deemed to 2 have been in full force and effect on and after April 1, 2019; provided, 3 further that the amendments to section 364-j of the social services law 4 made by section 10-a of this act shall not affect the repeal of such 5 section and shall be deemed repealed therewith. 6 PART C 7 Section 1. Subdivision 2 of section 365-a of the social services law 8 is amended by adding a new paragraph (ff) to read as follows: 9 (ff) evidence-based prevention and support services recognized by the 10 federal Centers for Disease Control (CDC), provided by a community-based 11 organization, and designed to prevent individuals at risk of developing 12 diabetes from developing Type 2 diabetes. 13 § 2. Intentionally omitted. 14 § 3. Intentionally omitted. 15 § 4. This act shall take effect July 1, 2019. 16 PART D 17 Section 1. Subdivision 1 of section 92 of part H of chapter 59 of the 18 laws of 2011, amending the public health law and other laws relating to 19 known and projected department of health state fund medicaid expendi- 20 tures, as amended by section 2 of part K of chapter 57 of the laws of 21 2018, is amended to read as follows: 22 1. For state fiscal years 2011-12 through [2019-20] 2020-2021, the 23 director of the budget, in consultation with the commissioner of health 24 referenced as "commissioner" for purposes of this section, shall assess 25 on a monthly basis, as reflected in monthly reports pursuant to subdivi- 26 sion five of this section known and projected department of health state 27 funds medicaid expenditures by category of service and by geographic 28 regions, as defined by the commissioner, and if the director of the 29 budget determines that such expenditures are expected to cause medicaid 30 disbursements for such period to exceed the projected department of 31 health medicaid state funds disbursements in the enacted budget finan- 32 cial plan pursuant to subdivision 3 of section 23 of the state finance 33 law, the commissioner of health, in consultation with the director of 34 the budget, shall develop a medicaid savings allocation plan to limit 35 such spending to the aggregate limit level specified in the enacted 36 budget financial plan, provided, however, such projections may be 37 adjusted by the director of the budget to account for any changes in the 38 New York state federal medical assistance percentage amount established 39 pursuant to the federal social security act, changes in provider reven- 40 ues, reductions to local social services district medical assistance 41 administration, minimum wage increases, and beginning April 1, 2012 the 42 operational costs of the New York state medical indemnity fund and state 43 costs or savings from the basic health plan. Such projections may be 44 adjusted by the director of the budget to account for increased or expe- 45 dited department of health state funds medicaid expenditures as a result 46 of a natural or other type of disaster, including a governmental decla- 47 ration of emergency. 48 § 2. This act shall take effect immediately and shall be deemed to 49 have been in full force and effect on and after April 1, 2019. 50 PART ES. 1507--C 10 A. 2007--C 1 Section 1. Section 4 of chapter 505 of the laws of 1995, amending the 2 public health law relating to the operation of department of health 3 facilities, as amended by section 27 of part D of chapter 57 of the laws 4 of 2015, is amended to read as follows: 5 § 4. This act shall take effect immediately; provided, however, that 6 the provisions of paragraph (b) of subdivision 4 of section 409-c of the 7 public health law, as added by section three of this act, shall take 8 effect January 1, 1996 and shall expire and be deemed repealed [twenty-9four] twenty-eight years from the effective date thereof. 10 § 2. Subdivision p of section 76 of part D of chapter 56 of the laws 11 of 2013, amending the social services law relating to eligibility condi- 12 tions, is amended to read as follows: 13 p. the amendments [made] to subparagraph [(7)] 7 of paragraph (b) of 14 subdivision 1 of section 366 of the social services law made by section 15 one of this act shall expire and be deemed repealed October 1, [2019] 16 2024. 17 § 3. Section 11 of chapter 884 of the laws of 1990, amending the 18 public health law relating to authorizing bad debt and charity care 19 allowances for certified home health agencies, as amended by section 1 20 of part I of chapter 57 of the laws of 2017, is amended to read as 21 follows: 22 § 11. This act shall take effect immediately and: 23 (a) sections one and three shall expire on December 31, 1996, 24 (b) sections four through ten shall expire on June 30, [2019] 2021, 25 and 26 (c) provided that the amendment to section 2807-b of the public health 27 law by section two of this act shall not affect the expiration of such 28 section 2807-b as otherwise provided by law and shall be deemed to 29 expire therewith. 30 § 4. Section 3 of chapter 303 of the laws of 1999, amending the New 31 York state medical care facilities finance agency act relating to 32 financing health facilities, as amended by section 16 of part D of chap- 33 ter 57 of the laws of 2015, is amended to read as follows: 34 § 3. This act shall take effect immediately, provided, however, that 35 subdivision 15-a of section 5 of section 1 of chapter 392 of the laws of 36 1973, as added by section one of this act, shall expire and be deemed 37 repealed June 30, [2019] 2023; and provided further, however, that the 38 expiration and repeal of such subdivision 15-a shall not affect or 39 impair in any manner any health facilities bonds issued, or any lease or 40 purchase of a health facility executed, pursuant to such subdivision 41 15-a prior to its expiration and repeal and that, with respect to any 42 such bonds issued and outstanding as of June 30, [2019] 2023, the 43 provisions of such subdivision 15-a as they existed immediately prior to 44 such expiration and repeal shall continue to apply through the latest 45 maturity date of any such bonds, or their earlier retirement or redemp- 46 tion, for the sole purpose of authorizing the issuance of refunding 47 bonds to refund bonds previously issued pursuant thereto. 48 § 5. Subdivision (a) of section 40 of part B of chapter 109 of the 49 laws of 2010, amending the social services law relating to transporta- 50 tion costs, as amended by section 8 of part I of chapter 57 of the laws 51 of 2017, is amended to read as follows: 52 (a) sections two, three, three-a, three-b, three-c, three-d, three-e 53 and twenty-one of this act shall take effect July 1, 2010; sections 54 fifteen, sixteen, seventeen, eighteen and nineteen of this act shall 55 take effect January 1, 2011; and provided further that section twenty of 56 this act shall be deemed repealed [eight] ten years after the date theS. 1507--C 11 A. 2007--C 1 contract entered into pursuant to section 365-h of the social services 2 law, as amended by section twenty of this act, is executed; provided 3 that the commissioner of health shall notify the legislative bill draft- 4 ing commission upon the execution of the contract entered into pursuant 5 to section 367-h of the social services law in order that the commission 6 may maintain an accurate and timely effective data base of the official 7 text of the laws of the state of New York in furtherance of effectuating 8 the provisions of section 44 of the legislative law and section 70-b of 9 the public officers law; 10 § 6. Subdivision (f) of section 129 of part C of chapter 58 of the 11 laws of 2009, amending the public health law relating to payment by 12 governmental agencies for general hospital inpatient services, as 13 amended by section 4 of part D of chapter 59 of the laws of 2016, is 14 amended to read as follows: 15 (f) section twenty-five of this act shall expire and be deemed 16 repealed April 1, [2019] 2022; 17 § 7. Subdivision (c) of section 122 of part E of chapter 56 of the 18 laws of 2013 amending the public health law relating to the general 19 public health work program, as amended by section 5 of part D of chapter 20 59 of the laws of 2016, is amended to read as follows: 21 (c) section fifty of this act shall take effect immediately and shall 22 expire [six] nine years after it becomes law; 23 § 8. Subdivision (i) of section 111 of part H of chapter 59 of the 24 laws of 2011, amending the public health law and other laws relating to 25 known and projected department of health state fund medical expendi- 26 tures, as amended by section 19 of part D of chapter 57 of the laws of 27 2015, is amended to read as follows: 28 (i) the amendments to paragraph (b) and subparagraph (i) of paragraph 29 (g) of subdivision 7 of section 4403-f of the public health law made by 30 section forty-one-b of this act shall expire and be repealed April 1, 31 [2019] 2023; 32 § 9. Subparagraph (vi) of paragraph (b) of subdivision 2 of section 33 2807-d of the public health law, as amended by section 3 of part I of 34 chapter 57 of the laws of 2017, is amended to read as follows: 35 (vi) Notwithstanding any contrary provision of this paragraph or any 36 other provision of law or regulation to the contrary, for residential 37 health care facilities the assessment shall be six percent of each resi- 38 dential health care facility's gross receipts received from all patient 39 care services and other operating income on a cash basis for the period 40 April first, two thousand two through March thirty-first, two thousand 41 three for hospital or health-related services, including adult day 42 services; provided, however, that residential health care facilities' 43 gross receipts attributable to payments received pursuant to title XVIII 44 of the federal social security act (medicare) shall be excluded from the 45 assessment; provided, however, that for all such gross receipts received 46 on or after April first, two thousand three through March thirty-first, 47 two thousand five, such assessment shall be five percent, and further 48 provided that for all such gross receipts received on or after April 49 first, two thousand five through March thirty-first, two thousand nine, 50 and on or after April first, two thousand nine through March thirty- 51 first, two thousand eleven such assessment shall be six percent, and 52 further provided that for all such gross receipts received on or after 53 April first, two thousand eleven through March thirty-first, two thou- 54 sand thirteen such assessment shall be six percent, and further provided 55 that for all such gross receipts received on or after April first, two 56 thousand thirteen through March thirty-first, two thousand fifteen suchS. 1507--C 12 A. 2007--C 1 assessment shall be six percent, and further provided that for all such 2 gross receipts received on or after April first, two thousand fifteen 3 through March thirty-first, two thousand seventeen such assessment shall 4 be six percent, and further provided that for all such gross receipts 5 received on or after April first, two thousand seventeen through March 6 thirty-first, two thousand nineteen such assessment shall be six 7 percent, and further provided that for all such gross receipts received 8 on or after April first, two thousand nineteen through March thirty- 9 first, two thousand twenty-one such assessment shall be six percent. 10 § 10. Subdivision 1 of section 194 of chapter 474 of the laws of 1996, 11 amending the education law and other laws relating to rates for residen- 12 tial health care facilities, as amended by section 4 of part I of chap- 13 ter 57 of the laws of 2017, is amended to read as follows: 14 1. Notwithstanding any inconsistent provision of law or regulation, 15 the trend factors used to project reimbursable operating costs to the 16 rate period for purposes of determining rates of payment pursuant to 17 article 28 of the public health law for residential health care facili- 18 ties for reimbursement of inpatient services provided to patients eligi- 19 ble for payments made by state governmental agencies on and after April 20 1, 1996 through March 31, 1999 and for payments made on and after July 21 1, 1999 through March 31, 2000 and on and after April 1, 2000 through 22 March 31, 2003 and on and after April 1, 2003 through March 31, 2007 and 23 on and after April 1, 2007 through March 31, 2009 and on and after April 24 1, 2009 through March 31, 2011 and on and after April 1, 2011 through 25 March 31, 2013 and on and after April 1, 2013 through March 31, 2015, 26 and on and after April 1, 2015 through March 31, 2017, and on and after 27 April 1, 2017 through March 31, 2019, and on and after April 1, 2019 28 through March 31, 2021 shall reflect no trend factor projections or 29 adjustments for the period April 1, 1996, through March 31, 1997. 30 § 11. Subdivision 1 of section 89-a of part C of chapter 58 of the 31 laws of 2007, amending the social services law and other laws relating 32 to enacting the major components of legislation necessary to implement 33 the health and mental hygiene budget for the 2007-2008 state fiscal 34 year, as amended by section 5 of part I of chapter 57 of the laws of 35 2017, is amended to read as follows: 36 1. Notwithstanding paragraph (c) of subdivision 10 of section 2807-c 37 of the public health law and section 21 of chapter 1 of the laws of 38 1999, as amended, and any other inconsistent provision of law or regu- 39 lation to the contrary, in determining rates of payments by state 40 governmental agencies effective for services provided beginning April 1, 41 2006, through March 31, 2009, and on and after April 1, 2009 through 42 March 31, 2011, and on and after April 1, 2011 through March 31, 2013, 43 and on and after April 1, 2013 through March 31, 2015, and on and after 44 April 1, 2015 through March 31, 2017, and on and after April 1, 2017 45 through March 31, 2019, and on and after April 1, 2019 through March 31, 46 2021 for inpatient and outpatient services provided by general hospitals 47 and for inpatient services and outpatient adult day health care services 48 provided by residential health care facilities pursuant to article 28 of 49 the public health law, the commissioner of health shall apply a trend 50 factor projection of two and twenty-five hundredths percent attributable 51 to the period January 1, 2006 through December 31, 2006, and on and 52 after January 1, 2007, provided, however, that on reconciliation of such 53 trend factor for the period January 1, 2006 through December 31, 2006 54 pursuant to paragraph (c) of subdivision 10 of section 2807-c of the 55 public health law, such trend factor shall be the final US Consumer 56 Price Index (CPI) for all urban consumers, as published by the USS. 1507--C 13 A. 2007--C 1 Department of Labor, Bureau of Labor Statistics less twenty-five 2 hundredths of a percentage point. 3 § 12. Subdivision 5-a of section 246 of chapter 81 of the laws of 4 1995, amending the public health law and other laws relating to medical 5 reimbursement and welfare reform, as amended by section 6 of part I of 6 chapter 57 of the laws of 2017, is amended to read as follows: 7 5-a. Section sixty-four-a of this act shall be deemed to have been in 8 full force and effect on and after April 1, 1995 through March 31, 1999 9 and on and after July 1, 1999 through March 31, 2000 and on and after 10 April 1, 2000 through March 31, 2003 and on and after April 1, 2003 11 through March 31, 2007, and on and after April 1, 2007 through March 31, 12 2009, and on and after April 1, 2009 through March 31, 2011, and on and 13 after April 1, 2011 through March 31, 2013, and on and after April 1, 14 2013 through March 31, 2015, and on and after April 1, 2015 through 15 March 31, 2017 and on and after April 1, 2017 through March 31, 2019, 16 and on and after April 1, 2019 through March 31, 2021; 17 § 13. Section 64-b of chapter 81 of the laws of 1995, amending the 18 public health law and other laws relating to medical reimbursement and 19 welfare reform, as amended by section 7 of part I of chapter 57 of the 20 laws of 2017, is amended to read as follows: 21 § 64-b. Notwithstanding any inconsistent provision of law, the 22 provisions of subdivision 7 of section 3614 of the public health law, as 23 amended, shall remain and be in full force and effect on April 1, 1995 24 through March 31, 1999 and on July 1, 1999 through March 31, 2000 and on 25 and after April 1, 2000 through March 31, 2003 and on and after April 1, 26 2003 through March 31, 2007, and on and after April 1, 2007 through 27 March 31, 2009, and on and after April 1, 2009 through March 31, 2011, 28 and on and after April 1, 2011 through March 31, 2013, and on and after 29 April 1, 2013 through March 31, 2015, and on and after April 1, 2015 30 through March 31, 2017 and on and after April 1, 2017 through March 31, 31 2019, and on and after April 1, 2019 through March 31, 2021. 32 § 14. Section 4-a of part A of chapter 56 of the laws of 2013, amend- 33 ing chapter 59 of the laws of 2011 amending the public health law and 34 other laws relating to general hospital reimbursement for annual rates, 35 as amended by section 5 of part T of chapter 57 of the laws of 2018, is 36 amended to read as follows: 37 § 4-a. Notwithstanding paragraph (c) of subdivision 10 of section 38 2807-c of the public health law, section 21 of chapter 1 of the laws of 39 1999, or any other contrary provision of law, in determining rates of 40 payments by state governmental agencies effective for services provided 41 on and after January 1, 2017 through March 31, [2019] 2021, for inpa- 42 tient and outpatient services provided by general hospitals, for inpa- 43 tient services and adult day health care outpatient services provided by 44 residential health care facilities pursuant to article 28 of the public 45 health law, except for residential health care facilities or units of 46 such facilities providing services primarily to children under twenty- 47 one years of age, for home health care services provided pursuant to 48 article 36 of the public health law by certified home health agencies, 49 long term home health care programs and AIDS home care programs, and for 50 personal care services provided pursuant to section 365-a of the social 51 services law, the commissioner of health shall apply no greater than 52 zero trend factors attributable to the 2017, 2018, [and] 2019, 2020, and 53 2021 calendar years in accordance with paragraph (c) of subdivision 10 54 of section 2807-c of the public health law, provided, however, that such 55 no greater than zero trend factors attributable to such 2017, 2018, 56 [and] 2019, 2020, and 2021 calendar years shall also be applied to ratesS. 1507--C 14 A. 2007--C 1 of payment provided on and after January 1, 2017 through March 31, 2 [2019] 2021 for personal care services provided in those local social 3 services districts, including New York city, whose rates of payment for 4 such services are established by such local social services districts 5 pursuant to a rate-setting exemption issued by the commissioner of 6 health to such local social services districts in accordance with appli- 7 cable regulations; and provided further, however, that for rates of 8 payment for assisted living program services provided on and after Janu- 9 ary 1, 2017 through March 31, [2019] 2021, such trend factors attribut- 10 able to the 2017, 2018, [and] 2019, 2020, and 2021 calendar years shall 11 be established at no greater than zero percent. 12 § 15. Paragraph (b) of subdivision 17 of section 2808 of the public 13 health law, as amended by section 21 of part D of chapter 57 of the laws 14 of 2015, is amended to read as follows: 15 (b) Notwithstanding any inconsistent provision of law or regulation to 16 the contrary, for the state fiscal years beginning April first, two 17 thousand ten and ending March thirty-first, two thousand [nineteen] 18 twenty-three, the commissioner shall not be required to revise certified 19 rates of payment established pursuant to this article for rate periods 20 prior to April first, two thousand [nineteen] twenty-three, based on 21 consideration of rate appeals filed by residential health care facili- 22 ties or based upon adjustments to capital cost reimbursement as a result 23 of approval by the commissioner of an application for construction under 24 section twenty-eight hundred two of this article, in excess of an aggre- 25 gate annual amount of eighty million dollars for each such state fiscal 26 year provided, however, that for the period April first, two thousand 27 eleven through March thirty-first, two thousand twelve such aggregate 28 annual amount shall be fifty million dollars. In revising such rates 29 within such fiscal limit, the commissioner shall, in prioritizing such 30 rate appeals, include consideration of which facilities the commissioner 31 determines are facing significant financial hardship as well as such 32 other considerations as the commissioner deems appropriate and, further, 33 the commissioner is authorized to enter into agreements with such facil- 34 ities or any other facility to resolve multiple pending rate appeals 35 based upon a negotiated aggregate amount and may offset such negotiated 36 aggregate amounts against any amounts owed by the facility to the 37 department, including, but not limited to, amounts owed pursuant to 38 section twenty-eight hundred seven-d of this article; provided, however, 39 that the commissioner's authority to negotiate such agreements resolving 40 multiple pending rate appeals as hereinbefore described shall continue 41 on and after April first, two thousand [nineteen] twenty-three. Rate 42 adjustments made pursuant to this paragraph remain fully subject to 43 approval by the director of the budget in accordance with the provisions 44 of subdivision two of section twenty-eight hundred seven of this arti- 45 cle. 46 § 16. Paragraph (a) of subdivision 13 of section 3614 of the public 47 health law, as amended by section 22 of part D of chapter 57 of the laws 48 of 2015, is amended to read as follows: 49 (a) Notwithstanding any inconsistent provision of law or regulation 50 and subject to the availability of federal financial participation, 51 effective April first, two thousand twelve through March thirty-first, 52 two thousand [nineteen] twenty-three, payments by government agencies 53 for services provided by certified home health agencies, except for such 54 services provided to children under eighteen years of age and other 55 discreet groups as may be determined by the commissioner pursuant to 56 regulations, shall be based on episodic payments. In establishing suchS. 1507--C 15 A. 2007--C 1 payments, a statewide base price shall be established for each sixty day 2 episode of care and adjusted by a regional wage index factor and an 3 individual patient case mix index. Such episodic payments may be further 4 adjusted for low utilization cases and to reflect a percentage limita- 5 tion of the cost for high-utilization cases that exceed outlier thresh- 6 olds of such payments. 7 § 17. Subdivision 2 of section 246 of chapter 81 of the laws of 1995, 8 amending the public health law and other laws relating to medical 9 reimbursement and welfare reform, as amended by section 18 of part I of 10 chapter 57 of the laws of 2017, is amended to read as follows: 11 2. Sections five, seven through nine, twelve through fourteen, and 12 eighteen of this act shall be deemed to have been in full force and 13 effect on and after April 1, 1995 through March 31, 1999 and on and 14 after July 1, 1999 through March 31, 2000 and on and after April 1, 2000 15 through March 31, 2003 and on and after April 1, 2003 through March 31, 16 2006 and on and after April 1, 2006 through March 31, 2007 and on and 17 after April 1, 2007 through March 31, 2009 and on and after April 1, 18 2009 through March 31, 2011 and sections twelve, thirteen and fourteen 19 of this act shall be deemed to be in full force and effect on and after 20 April 1, 2011 through March 31, 2015 and on and after April 1, 2015 21 through March 31, 2017 and on and after April 1, 2017 through March 31, 22 2019, and on and after April 1, 2019 through March 31, 2021; 23 § 18. Section 48-a of part A of chapter 56 of the laws of 2013 amend- 24 ing chapter 59 of the laws of 2011 amending the public health law and 25 other laws relating to general hospital reimbursement for annual rates, 26 as amended by section 1 of part P of chapter 57 of the laws of 2017, is 27 amended to read as follows: 28 § 48-a. 1. Notwithstanding any contrary provision of law, the commis- 29 sioners of the office of alcoholism and substance abuse services and the 30 office of mental health are authorized, subject to the approval of the 31 director of the budget, to transfer to the commissioner of health state 32 funds to be utilized as the state share for the purpose of increasing 33 payments under the medicaid program to managed care organizations 34 licensed under article 44 of the public health law or under article 43 35 of the insurance law. Such managed care organizations shall utilize such 36 funds for the purpose of reimbursing providers licensed pursuant to 37 article 28 of the public health law or article 31 or 32 of the mental 38 hygiene law for ambulatory behavioral health services, as determined by 39 the commissioner of health, in consultation with the commissioner of 40 alcoholism and substance abuse services and the commissioner of the 41 office of mental health, provided to medicaid enrolled outpatients and 42 for all other behavioral health services except inpatient included in 43 New York state's Medicaid redesign waiver approved by the centers for 44 medicare and Medicaid services (CMS). Such reimbursement shall be in 45 the form of fees for such services which are equivalent to the payments 46 established for such services under the ambulatory patient group (APG) 47 rate-setting methodology as utilized by the department of health, the 48 office of alcoholism and substance abuse services, or the office of 49 mental health for rate-setting purposes or any such other fees pursuant 50 to the Medicaid state plan or otherwise approved by CMS in the Medicaid 51 redesign waiver; provided, however, that the increase to such fees that 52 shall result from the provisions of this section shall not, in the 53 aggregate and as determined by the commissioner of health, in consulta- 54 tion with the commissioner of alcoholism and substance abuse services 55 and the commissioner of the office of mental health, be greater than the 56 increased funds made available pursuant to this section. The increaseS. 1507--C 16 A. 2007--C 1 of such ambulatory behavioral health fees to providers available under 2 this section shall be for all rate periods on and after the effective 3 date of section [29] 1 of part [B] P of chapter [59] 57 of the laws of 4 [2016] 2017 through March 31, [2020] 2023 for patients in the city of 5 New York, for all rate periods on and after the effective date of 6 section [29] 1 of part [B] P of chapter [59] 57 of the laws of [2016] 7 2017 through [March 31, 2020] March 31, 2023 for patients outside the 8 city of New York, and for all rate periods on and after the effective 9 date of such chapter through [March 31, 2020] March 31, 2023 for all 10 services provided to persons under the age of twenty-one; provided, 11 however, the commissioner of health, in consultation with the commis- 12 sioner of alcoholism and substance abuse services and the commissioner 13 of mental health, may require, as a condition of approval of such ambu- 14 latory behavioral health fees, that aggregate managed care expenditures 15 to eligible providers meet the alternative payment methodology require- 16 ments as set forth in attachment I of the New York state medicaid 17 section one thousand one hundred fifteen medicaid redesign team waiver 18 as approved by the centers for medicare and medicaid services. The 19 commissioner of health shall, in consultation with the commissioner of 20 alcoholism and substance abuse services and the commissioner of mental 21 health, waive such conditions if a sufficient number of providers, as 22 determined by the commissioner, suffer a financial hardship as a conse- 23 quence of such alternative payment methodology requirements, or if he or 24 she shall determine that such alternative payment methodologies signif- 25 icantly threaten individuals access to ambulatory behavioral health 26 services. Such waiver may be applied on a provider specific or industry 27 wide basis. Further, such conditions may be waived, as the commissioner 28 determines necessary, to comply with federal rules or regulations 29 governing these payment methodologies. Nothing in this section shall 30 prohibit managed care organizations and providers from negotiating 31 different rates and methods of payment during such periods described 32 above, subject to the approval of the department of health. The depart- 33 ment of health shall consult with the office of alcoholism and substance 34 abuse services and the office of mental health in determining whether 35 such alternative rates shall be approved. The commissioner of health 36 may, in consultation with the commissioner of alcoholism and substance 37 abuse services and the commissioner of the office of mental health, 38 promulgate regulations, including emergency regulations promulgated 39 prior to October 1, 2015 to establish rates for ambulatory behavioral 40 health services, as are necessary to implement the provisions of this 41 section. Rates promulgated under this section shall be included in the 42 report required under section 45-c of part A of this chapter. 43 2. Notwithstanding any contrary provision of law, the fees paid by 44 managed care organizations licensed under article 44 of the public 45 health law or under article 43 of the insurance law, to providers 46 licensed pursuant to article 28 of the public health law or article 31 47 or 32 of the mental hygiene law, for ambulatory behavioral health 48 services provided to patients enrolled in the child health insurance 49 program pursuant to title [one-A] 1-A of article 25 of the public health 50 law, shall be in the form of fees for such services which are equivalent 51 to the payments established for such services under the ambulatory 52 patient group (APG) rate-setting methodology or any such other fees 53 established pursuant to the Medicaid state plan. The commissioner of 54 health shall consult with the commissioner of alcoholism and substance 55 abuse services and the commissioner of the office of mental health in 56 determining such services and establishing such fees. Such ambulatoryS. 1507--C 17 A. 2007--C 1 behavioral health fees to providers available under this section shall 2 be for all rate periods on and after the effective date of this chapter 3 through [March 31, 2020] March 31, 2023, provided, however, that managed 4 care organizations and providers may negotiate different rates and meth- 5 ods of payment during such periods described above, subject to the 6 approval of the department of health. The department of health shall 7 consult with the office of alcoholism and substance abuse services and 8 the office of mental health in determining whether such alternative 9 rates shall be approved. The report required under section 16-a of part 10 C of chapter 60 of the laws of 2014 shall also include the population of 11 patients enrolled in the child health insurance program pursuant to 12 title [one-A] 1-A of article 25 of the public health law in its examina- 13 tion on the transition of behavioral health services into managed care. 14 § 19. Section 1 of part H of chapter 111 of the laws of 2010 relating 15 to increasing Medicaid payments to providers through managed care organ- 16 izations and providing equivalent fees through an ambulatory patient 17 group methodology, as amended by section 2 of part P of chapter 57 of 18 the laws of 2017, is amended to read as follows: 19 Section 1. a. Notwithstanding any contrary provision of law, the 20 commissioners of mental health and alcoholism and substance abuse 21 services are authorized, subject to the approval of the director of the 22 budget, to transfer to the commissioner of health state funds to be 23 utilized as the state share for the purpose of increasing payments under 24 the medicaid program to managed care organizations licensed under arti- 25 cle 44 of the public health law or under article 43 of the insurance 26 law. Such managed care organizations shall utilize such funds for the 27 purpose of reimbursing providers licensed pursuant to article 28 of the 28 public health law, or pursuant to article 31 or article 32 of the mental 29 hygiene law for ambulatory behavioral health services, as determined by 30 the commissioner of health in consultation with the commissioner of 31 mental health and commissioner of alcoholism and substance abuse 32 services, provided to medicaid enrolled outpatients and for all other 33 behavioral health services except inpatient included in New York state's 34 Medicaid redesign waiver approved by the centers for medicare and Medi- 35 caid services (CMS). Such reimbursement shall be in the form of fees for 36 such services which are equivalent to the payments established for such 37 services under the ambulatory patient group (APG) rate-setting methodol- 38 ogy as utilized by the department of health or by the office of mental 39 health or office of alcoholism and substance abuse services for rate- 40 setting purposes or any such other fees pursuant to the Medicaid state 41 plan or otherwise approved by CMS in the Medicaid redesign waiver; 42 provided, however, that the increase to such fees that shall result from 43 the provisions of this section shall not, in the aggregate and as deter- 44 mined by the commissioner of health in consultation with the commission- 45 ers of mental health and alcoholism and substance abuse services, be 46 greater than the increased funds made available pursuant to this 47 section. The increase of such behavioral health fees to providers avail- 48 able under this section shall be for all rate periods on and after the 49 effective date of section [30] 2 of part [B] P of chapter [59] 57 of the 50 laws of [2016] 2017 through March 31, [2020] 2023 for patients in the 51 city of New York, for all rate periods on and after the effective date 52 of section [30] 2 of part [B] P of chapter [59] 57 of the laws of [2016] 53 2017 through March 31, [2020] 2023 for patients outside the city of New 54 York, and for all rate periods on and after the effective date of 55 section [30] 2 of part [B] P of chapter [59] 57 of the laws of [2016] 56 2017 through March 31, [2020] 2023 for all services provided to personsS. 1507--C 18 A. 2007--C 1 under the age of twenty-one; provided, however, the commissioner of 2 health, in consultation with the commissioner of alcoholism and 3 substance abuse services and the commissioner of mental health, may 4 require, as a condition of approval of such ambulatory behavioral health 5 fees, that aggregate managed care expenditures to eligible providers 6 meet the alternative payment methodology requirements as set forth in 7 attachment I of the New York state medicaid section one thousand one 8 hundred fifteen medicaid redesign team waiver as approved by the centers 9 for medicare and medicaid services. The commissioner of health shall, in 10 consultation with the commissioner of alcoholism and substance abuse 11 services and the commissioner of mental health, waive such conditions if 12 a sufficient number of providers, as determined by the commissioner, 13 suffer a financial hardship as a consequence of such alternative payment 14 methodology requirements, or if he or she shall determine that such 15 alternative payment methodologies significantly threaten individuals 16 access to ambulatory behavioral health services. Such waiver may be 17 applied on a provider specific or industry wide basis. Further, such 18 conditions may be waived, as the commissioner determines necessary, to 19 comply with federal rules or regulations governing these payment method- 20 ologies. Nothing in this section shall prohibit managed care organiza- 21 tions and providers from negotiating different rates and methods of 22 payment during such periods described, subject to the approval of the 23 department of health. The department of health shall consult with the 24 office of alcoholism and substance abuse services and the office of 25 mental health in determining whether such alternative rates shall be 26 approved. The commissioner of health may, in consultation with the 27 commissioners of mental health and alcoholism and substance abuse 28 services, promulgate regulations, including emergency regulations 29 promulgated prior to October 1, 2013 that establish rates for behavioral 30 health services, as are necessary to implement the provisions of this 31 section. Rates promulgated under this section shall be included in the 32 report required under section 45-c of part A of chapter 56 of the laws 33 of 2013. 34 b. Notwithstanding any contrary provision of law, the fees paid by 35 managed care organizations licensed under article 44 of the public 36 health law or under article 43 of the insurance law, to providers 37 licensed pursuant to article 28 of the public health law or article 31 38 or 32 of the mental hygiene law, for ambulatory behavioral health 39 services provided to patients enrolled in the child health insurance 40 program pursuant to title [one-A] 1-A of article 25 of the public health 41 law, shall be in the form of fees for such services which are equivalent 42 to the payments established for such services under the ambulatory 43 patient group (APG) rate-setting methodology. The commissioner of health 44 shall consult with the commissioner of alcoholism and substance abuse 45 services and the commissioner of the office of mental health in deter- 46 mining such services and establishing such fees. Such ambulatory behav- 47 ioral health fees to providers available under this section shall be for 48 all rate periods on and after the effective date of this chapter through 49 March 31, [2020] 2023, provided, however, that managed care organiza- 50 tions and providers may negotiate different rates and methods of payment 51 during such periods described above, subject to the approval of the 52 department of health. The department of health shall consult with the 53 office of alcoholism and substance abuse services and the office of 54 mental health in determining whether such alternative rates shall be 55 approved. The report required under section 16-a of part C of chapter 56 60 of the laws of 2014 shall also include the population of patientsS. 1507--C 19 A. 2007--C 1 enrolled in the child health insurance program pursuant to title [one-A] 2 1-A of article 25 of the public health law in its examination on the 3 transition of behavioral health services into managed care. 4 § 20. Section 2 of part H of chapter 111 of the laws of 2010, relating 5 to increasing Medicaid payments to providers through managed care organ- 6 izations and providing equivalent fees through an ambulatory patient 7 group methodology, as amended by section 16 of part C of chapter 60 of 8 the laws of 2014, is amended to read as follows: 9 § 2. This act shall take effect immediately and shall be deemed to 10 have been in full force and effect on and after April 1, 2010, and shall 11 expire on [January 1, 2018] March 31, 2023. 12 § 21. Section 10 of chapter 649 of the laws of 1996, amending the 13 public health law, the mental hygiene law and the social services law 14 relating to authorizing the establishment of special needs plans, as 15 amended by section 2 of part D of chapter 59 of the laws of 2016, is 16 amended to read as follows: 17 § 10. This act shall take effect immediately and shall be deemed to 18 have been in full force and effect on and after July 1, 1996; provided, 19 however, that sections one, two and three of this act shall expire and 20 be deemed repealed on March 31, [2020] 2025 provided, however that the 21 amendments to section 364-j of the social services law made by section 22 four of this act shall not affect the expiration of such section and 23 shall be deemed to expire therewith and provided, further, that the 24 provisions of subdivisions 8, 9 and 10 of section 4401 of the public 25 health law, as added by section one of this act; section 4403-d of the 26 public health law as added by section two of this act and the provisions 27 of section seven of this act, except for the provisions relating to the 28 establishment of no more than twelve comprehensive HIV special needs 29 plans, shall expire and be deemed repealed on July 1, 2000. 30 § 22. Paragraph (a) of subdivision 1 of section 212 of chapter 474 of 31 the laws of 1996, amending the education law and other laws relating to 32 rates for residential healthcare facilities, as amended by section 1 of 33 part D of chapter 59 of the laws of 2016, is amended to read as follows: 34 (a) Notwithstanding any inconsistent provision of law or regulation to 35 the contrary, effective beginning August 1, 1996, for the period April 36 1, 1997 through March 31, 1998, April 1, 1998 for the period April 1, 37 1998 through March 31, 1999, August 1, 1999, for the period April 1, 38 1999 through March 31, 2000, April 1, 2000, for the period April 1, 2000 39 through March 31, 2001, April 1, 2001, for the period April 1, 2001 40 through March 31, 2002, April 1, 2002, for the period April 1, 2002 41 through March 31, 2003, and for the state fiscal year beginning April 1, 42 2005 through March 31, 2006, and for the state fiscal year beginning 43 April 1, 2006 through March 31, 2007, and for the state fiscal year 44 beginning April 1, 2007 through March 31, 2008, and for the state fiscal 45 year beginning April 1, 2008 through March 31, 2009, and for the state 46 fiscal year beginning April 1, 2009 through March 31, 2010, and for the 47 state fiscal year beginning April 1, 2010 through March 31, 2016, and 48 for the state fiscal year beginning April 1, 2016 through March 31, 49 2019, and for the state fiscal year beginning April 1, 2019 through 50 March 31, 2022, the department of health is authorized to pay public 51 general hospitals, as defined in subdivision 10 of section 2801 of the 52 public health law, operated by the state of New York or by the state 53 university of New York or by a county, which shall not include a city 54 with a population of over one million, of the state of New York, and 55 those public general hospitals located in the county of Westchester, the 56 county of Erie or the county of Nassau, additional payments for inpa-S. 1507--C 20 A. 2007--C 1 tient hospital services as medical assistance payments pursuant to title 2 11 of article 5 of the social services law for patients eligible for 3 federal financial participation under title XIX of the federal social 4 security act in medical assistance pursuant to the federal laws and 5 regulations governing disproportionate share payments to hospitals up to 6 one hundred percent of each such public general hospital's medical 7 assistance and uninsured patient losses after all other medical assist- 8 ance, including disproportionate share payments to such public general 9 hospital for 1996, 1997, 1998, and 1999, based initially for 1996 on 10 reported 1994 reconciled data as further reconciled to actual reported 11 1996 reconciled data, and for 1997 based initially on reported 1995 12 reconciled data as further reconciled to actual reported 1997 reconciled 13 data, for 1998 based initially on reported 1995 reconciled data as 14 further reconciled to actual reported 1998 reconciled data, for 1999 15 based initially on reported 1995 reconciled data as further reconciled 16 to actual reported 1999 reconciled data, for 2000 based initially on 17 reported 1995 reconciled data as further reconciled to actual reported 18 2000 data, for 2001 based initially on reported 1995 reconciled data as 19 further reconciled to actual reported 2001 data, for 2002 based initial- 20 ly on reported 2000 reconciled data as further reconciled to actual 21 reported 2002 data, and for state fiscal years beginning on April 1, 22 2005, based initially on reported 2000 reconciled data as further recon- 23 ciled to actual reported data for 2005, and for state fiscal years 24 beginning on April 1, 2006, based initially on reported 2000 reconciled 25 data as further reconciled to actual reported data for 2006, for state 26 fiscal years beginning on and after April 1, 2007 through March 31, 27 2009, based initially on reported 2000 reconciled data as further recon- 28 ciled to actual reported data for 2007 and 2008, respectively, for state 29 fiscal years beginning on and after April 1, 2009, based initially on 30 reported 2007 reconciled data, adjusted for authorized Medicaid rate 31 changes applicable to the state fiscal year, and as further reconciled 32 to actual reported data for 2009, for state fiscal years beginning on 33 and after April 1, 2010, based initially on reported reconciled data 34 from the base year two years prior to the payment year, adjusted for 35 authorized Medicaid rate changes applicable to the state fiscal year, 36 and further reconciled to actual reported data from such payment year, 37 and to actual reported data for each respective succeeding year. The 38 payments may be added to rates of payment or made as aggregate payments 39 to an eligible public general hospital. 40 § 23. This act shall take effect immediately and shall be deemed to 41 have been in full force and effect on and after April 1, 2019; provided 42 that the amendments to section 1 of part H of chapter 111 of the laws of 43 2010 made by section nineteen of this act shall not affect the expira- 44 tion of such section and shall expire therewith; and provided further 45 that section twenty of this act shall be deemed to have been in full 46 force and effect on and after January 1, 2018. 47 PART F 48 Section 1. Paragraph (a) of subdivision 1 of section 18 of chapter 266 49 of the laws of 1986, amending the civil practice law and rules and other 50 laws relating to malpractice and professional medical conduct, as 51 amended by section 1 of part M of chapter 57 of the laws of 2018, is 52 amended to read as follows: 53 (a) The superintendent of financial services and the commissioner of 54 health or their designee shall, from funds available in the hospitalS. 1507--C 21 A. 2007--C 1 excess liability pool created pursuant to subdivision 5 of this section, 2 purchase a policy or policies for excess insurance coverage, as author- 3 ized by paragraph 1 of subsection (e) of section 5502 of the insurance 4 law; or from an insurer, other than an insurer described in section 5502 5 of the insurance law, duly authorized to write such coverage and actual- 6 ly writing medical malpractice insurance in this state; or shall 7 purchase equivalent excess coverage in a form previously approved by the 8 superintendent of financial services for purposes of providing equiv- 9 alent excess coverage in accordance with section 19 of chapter 294 of 10 the laws of 1985, for medical or dental malpractice occurrences between 11 July 1, 1986 and June 30, 1987, between July 1, 1987 and June 30, 1988, 12 between July 1, 1988 and June 30, 1989, between July 1, 1989 and June 13 30, 1990, between July 1, 1990 and June 30, 1991, between July 1, 1991 14 and June 30, 1992, between July 1, 1992 and June 30, 1993, between July 15 1, 1993 and June 30, 1994, between July 1, 1994 and June 30, 1995, 16 between July 1, 1995 and June 30, 1996, between July 1, 1996 and June 17 30, 1997, between July 1, 1997 and June 30, 1998, between July 1, 1998 18 and June 30, 1999, between July 1, 1999 and June 30, 2000, between July 19 1, 2000 and June 30, 2001, between July 1, 2001 and June 30, 2002, 20 between July 1, 2002 and June 30, 2003, between July 1, 2003 and June 21 30, 2004, between July 1, 2004 and June 30, 2005, between July 1, 2005 22 and June 30, 2006, between July 1, 2006 and June 30, 2007, between July 23 1, 2007 and June 30, 2008, between July 1, 2008 and June 30, 2009, 24 between July 1, 2009 and June 30, 2010, between July 1, 2010 and June 25 30, 2011, between July 1, 2011 and June 30, 2012, between July 1, 2012 26 and June 30, 2013, between July 1, 2013 and June 30, 2014, between July 27 1, 2014 and June 30, 2015, between July 1, 2015 and June 30, 2016, 28 between July 1, 2016 and June 30, 2017, between July 1, 2017 and June 29 30, 2018, [and] between July 1, 2018 and June 30, 2019, and between July 30 1, 2019 and June 30, 2020 or reimburse the hospital where the hospital 31 purchases equivalent excess coverage as defined in subparagraph (i) of 32 paragraph (a) of subdivision 1-a of this section for medical or dental 33 malpractice occurrences between July 1, 1987 and June 30, 1988, between 34 July 1, 1988 and June 30, 1989, between July 1, 1989 and June 30, 1990, 35 between July 1, 1990 and June 30, 1991, between July 1, 1991 and June 36 30, 1992, between July 1, 1992 and June 30, 1993, between July 1, 1993 37 and June 30, 1994, between July 1, 1994 and June 30, 1995, between July 38 1, 1995 and June 30, 1996, between July 1, 1996 and June 30, 1997, 39 between July 1, 1997 and June 30, 1998, between July 1, 1998 and June 40 30, 1999, between July 1, 1999 and June 30, 2000, between July 1, 2000 41 and June 30, 2001, between July 1, 2001 and June 30, 2002, between July 42 1, 2002 and June 30, 2003, between July 1, 2003 and June 30, 2004, 43 between July 1, 2004 and June 30, 2005, between July 1, 2005 and June 44 30, 2006, between July 1, 2006 and June 30, 2007, between July 1, 2007 45 and June 30, 2008, between July 1, 2008 and June 30, 2009, between July 46 1, 2009 and June 30, 2010, between July 1, 2010 and June 30, 2011, 47 between July 1, 2011 and June 30, 2012, between July 1, 2012 and June 48 30, 2013, between July 1, 2013 and June 30, 2014, between July 1, 2014 49 and June 30, 2015, between July 1, 2015 and June 30, 2016, between July 50 1, 2016 and June 30, 2017, between July 1, 2017 and June 30, 2018, [and] 51 between July 1, 2018 and June 30, 2019, and between July 1, 2019 and 52 June 30, 2020 for physicians or dentists certified as eligible for each 53 such period or periods pursuant to subdivision 2 of this section by a 54 general hospital licensed pursuant to article 28 of the public health 55 law; provided that no single insurer shall write more than fifty percent 56 of the total excess premium for a given policy year; and provided,S. 1507--C 22 A. 2007--C 1 however, that such eligible physicians or dentists must have in force an 2 individual policy, from an insurer licensed in this state of primary 3 malpractice insurance coverage in amounts of no less than one million 4 three hundred thousand dollars for each claimant and three million nine 5 hundred thousand dollars for all claimants under that policy during the 6 period of such excess coverage for such occurrences or be endorsed as 7 additional insureds under a hospital professional liability policy which 8 is offered through a voluntary attending physician ("channeling") 9 program previously permitted by the superintendent of financial services 10 during the period of such excess coverage for such occurrences. During 11 such period, such policy for excess coverage or such equivalent excess 12 coverage shall, when combined with the physician's or dentist's primary 13 malpractice insurance coverage or coverage provided through a voluntary 14 attending physician ("channeling") program, total an aggregate level of 15 two million three hundred thousand dollars for each claimant and six 16 million nine hundred thousand dollars for all claimants from all such 17 policies with respect to occurrences in each of such years provided, 18 however, if the cost of primary malpractice insurance coverage in excess 19 of one million dollars, but below the excess medical malpractice insur- 20 ance coverage provided pursuant to this act, exceeds the rate of nine 21 percent per annum, then the required level of primary malpractice insur- 22 ance coverage in excess of one million dollars for each claimant shall 23 be in an amount of not less than the dollar amount of such coverage 24 available at nine percent per annum; the required level of such coverage 25 for all claimants under that policy shall be in an amount not less than 26 three times the dollar amount of coverage for each claimant; and excess 27 coverage, when combined with such primary malpractice insurance cover- 28 age, shall increase the aggregate level for each claimant by one million 29 dollars and three million dollars for all claimants; and provided 30 further, that, with respect to policies of primary medical malpractice 31 coverage that include occurrences between April 1, 2002 and June 30, 32 2002, such requirement that coverage be in amounts no less than one 33 million three hundred thousand dollars for each claimant and three 34 million nine hundred thousand dollars for all claimants for such occur- 35 rences shall be effective April 1, 2002. 36 § 2. Subdivision 3 of section 18 of chapter 266 of the laws of 1986, 37 amending the civil practice law and rules and other laws relating to 38 malpractice and professional medical conduct, as amended by section 2 of 39 part M of chapter 57 of the laws of 2018, is amended to read as follows: 40 (3)(a) The superintendent of financial services shall determine and 41 certify to each general hospital and to the commissioner of health the 42 cost of excess malpractice insurance for medical or dental malpractice 43 occurrences between July 1, 1986 and June 30, 1987, between July 1, 1988 44 and June 30, 1989, between July 1, 1989 and June 30, 1990, between July 45 1, 1990 and June 30, 1991, between July 1, 1991 and June 30, 1992, 46 between July 1, 1992 and June 30, 1993, between July 1, 1993 and June 47 30, 1994, between July 1, 1994 and June 30, 1995, between July 1, 1995 48 and June 30, 1996, between July 1, 1996 and June 30, 1997, between July 49 1, 1997 and June 30, 1998, between July 1, 1998 and June 30, 1999, 50 between July 1, 1999 and June 30, 2000, between July 1, 2000 and June 51 30, 2001, between July 1, 2001 and June 30, 2002, between July 1, 2002 52 and June 30, 2003, between July 1, 2003 and June 30, 2004, between July 53 1, 2004 and June 30, 2005, between July 1, 2005 and June 30, 2006, 54 between July 1, 2006 and June 30, 2007, between July 1, 2007 and June 55 30, 2008, between July 1, 2008 and June 30, 2009, between July 1, 2009 56 and June 30, 2010, between July 1, 2010 and June 30, 2011, between JulyS. 1507--C 23 A. 2007--C 1 1, 2011 and June 30, 2012, between July 1, 2012 and June 30, 2013, and 2 between July 1, 2013 and June 30, 2014, between July 1, 2014 and June 3 30, 2015, between July 1, 2015 and June 30, 2016, and between July 1, 4 2016 and June 30, 2017, between July 1, 2017 and June 30, 2018, [and] 5 between July 1, 2018 and June 30, 2019, and between July 1, 2019 and 6 June 30, 2020 allocable to each general hospital for physicians or 7 dentists certified as eligible for purchase of a policy for excess 8 insurance coverage by such general hospital in accordance with subdivi- 9 sion 2 of this section, and may amend such determination and certif- 10 ication as necessary. 11 (b) The superintendent of financial services shall determine and 12 certify to each general hospital and to the commissioner of health the 13 cost of excess malpractice insurance or equivalent excess coverage for 14 medical or dental malpractice occurrences between July 1, 1987 and June 15 30, 1988, between July 1, 1988 and June 30, 1989, between July 1, 1989 16 and June 30, 1990, between July 1, 1990 and June 30, 1991, between July 17 1, 1991 and June 30, 1992, between July 1, 1992 and June 30, 1993, 18 between July 1, 1993 and June 30, 1994, between July 1, 1994 and June 19 30, 1995, between July 1, 1995 and June 30, 1996, between July 1, 1996 20 and June 30, 1997, between July 1, 1997 and June 30, 1998, between July 21 1, 1998 and June 30, 1999, between July 1, 1999 and June 30, 2000, 22 between July 1, 2000 and June 30, 2001, between July 1, 2001 and June 23 30, 2002, between July 1, 2002 and June 30, 2003, between July 1, 2003 24 and June 30, 2004, between July 1, 2004 and June 30, 2005, between July 25 1, 2005 and June 30, 2006, between July 1, 2006 and June 30, 2007, 26 between July 1, 2007 and June 30, 2008, between July 1, 2008 and June 27 30, 2009, between July 1, 2009 and June 30, 2010, between July 1, 2010 28 and June 30, 2011, between July 1, 2011 and June 30, 2012, between July 29 1, 2012 and June 30, 2013, between July 1, 2013 and June 30, 2014, 30 between July 1, 2014 and June 30, 2015, between July 1, 2015 and June 31 30, 2016, between July 1, 2016 and June 30, 2017, between July 1, 2017 32 and June 30, 2018, [and] between July 1, 2018 and June 30, 2019, and 33 between July 1, 2019 and June 30, 2020 allocable to each general hospi- 34 tal for physicians or dentists certified as eligible for purchase of a 35 policy for excess insurance coverage or equivalent excess coverage by 36 such general hospital in accordance with subdivision 2 of this section, 37 and may amend such determination and certification as necessary. The 38 superintendent of financial services shall determine and certify to each 39 general hospital and to the commissioner of health the ratable share of 40 such cost allocable to the period July 1, 1987 to December 31, 1987, to 41 the period January 1, 1988 to June 30, 1988, to the period July 1, 1988 42 to December 31, 1988, to the period January 1, 1989 to June 30, 1989, to 43 the period July 1, 1989 to December 31, 1989, to the period January 1, 44 1990 to June 30, 1990, to the period July 1, 1990 to December 31, 1990, 45 to the period January 1, 1991 to June 30, 1991, to the period July 1, 46 1991 to December 31, 1991, to the period January 1, 1992 to June 30, 47 1992, to the period July 1, 1992 to December 31, 1992, to the period 48 January 1, 1993 to June 30, 1993, to the period July 1, 1993 to December 49 31, 1993, to the period January 1, 1994 to June 30, 1994, to the period 50 July 1, 1994 to December 31, 1994, to the period January 1, 1995 to June 51 30, 1995, to the period July 1, 1995 to December 31, 1995, to the period 52 January 1, 1996 to June 30, 1996, to the period July 1, 1996 to December 53 31, 1996, to the period January 1, 1997 to June 30, 1997, to the period 54 July 1, 1997 to December 31, 1997, to the period January 1, 1998 to June 55 30, 1998, to the period July 1, 1998 to December 31, 1998, to the period 56 January 1, 1999 to June 30, 1999, to the period July 1, 1999 to DecemberS. 1507--C 24 A. 2007--C 1 31, 1999, to the period January 1, 2000 to June 30, 2000, to the period 2 July 1, 2000 to December 31, 2000, to the period January 1, 2001 to June 3 30, 2001, to the period July 1, 2001 to June 30, 2002, to the period 4 July 1, 2002 to June 30, 2003, to the period July 1, 2003 to June 30, 5 2004, to the period July 1, 2004 to June 30, 2005, to the period July 1, 6 2005 and June 30, 2006, to the period July 1, 2006 and June 30, 2007, to 7 the period July 1, 2007 and June 30, 2008, to the period July 1, 2008 8 and June 30, 2009, to the period July 1, 2009 and June 30, 2010, to the 9 period July 1, 2010 and June 30, 2011, to the period July 1, 2011 and 10 June 30, 2012, to the period July 1, 2012 and June 30, 2013, to the 11 period July 1, 2013 and June 30, 2014, to the period July 1, 2014 and 12 June 30, 2015, to the period July 1, 2015 and June 30, 2016, [and13between] to the period July 1, 2016 and June 30, 2017, [and] to the 14 period July 1, 2017 to June 30, 2018, [and] to the period July 1, 2018 15 to June 30, 2019, and to the period July 1, 2019 to June 30, 2020. 16 § 3. Paragraphs (a), (b), (c), (d) and (e) of subdivision 8 of section 17 18 of chapter 266 of the laws of 1986, amending the civil practice law 18 and rules and other laws relating to malpractice and professional 19 medical conduct, as amended by section 3 of part M of chapter 57 of the 20 laws of 2018, are amended to read as follows: 21 (a) To the extent funds available to the hospital excess liability 22 pool pursuant to subdivision 5 of this section as amended, and pursuant 23 to section 6 of part J of chapter 63 of the laws of 2001, as may from 24 time to time be amended, which amended this subdivision, are insuffi- 25 cient to meet the costs of excess insurance coverage or equivalent 26 excess coverage for coverage periods during the period July 1, 1992 to 27 June 30, 1993, during the period July 1, 1993 to June 30, 1994, during 28 the period July 1, 1994 to June 30, 1995, during the period July 1, 1995 29 to June 30, 1996, during the period July 1, 1996 to June 30, 1997, 30 during the period July 1, 1997 to June 30, 1998, during the period July 31 1, 1998 to June 30, 1999, during the period July 1, 1999 to June 30, 32 2000, during the period July 1, 2000 to June 30, 2001, during the period 33 July 1, 2001 to October 29, 2001, during the period April 1, 2002 to 34 June 30, 2002, during the period July 1, 2002 to June 30, 2003, during 35 the period July 1, 2003 to June 30, 2004, during the period July 1, 2004 36 to June 30, 2005, during the period July 1, 2005 to June 30, 2006, 37 during the period July 1, 2006 to June 30, 2007, during the period July 38 1, 2007 to June 30, 2008, during the period July 1, 2008 to June 30, 39 2009, during the period July 1, 2009 to June 30, 2010, during the period 40 July 1, 2010 to June 30, 2011, during the period July 1, 2011 to June 41 30, 2012, during the period July 1, 2012 to June 30, 2013, during the 42 period July 1, 2013 to June 30, 2014, during the period July 1, 2014 to 43 June 30, 2015, during the period July 1, 2015 to June 30, 2016, during 44 the period July 1, 2016 to June 30, 2017, during the period July 1, 2017 45 to June 30, 2018, [and] during the period July 1, 2018 to June 30, 2019, 46 and during the period July 1, 2019 to June 30, 2020 allocated or reallo- 47 cated in accordance with paragraph (a) of subdivision 4-a of this 48 section to rates of payment applicable to state governmental agencies, 49 each physician or dentist for whom a policy for excess insurance cover- 50 age or equivalent excess coverage is purchased for such period shall be 51 responsible for payment to the provider of excess insurance coverage or 52 equivalent excess coverage of an allocable share of such insufficiency, 53 based on the ratio of the total cost of such coverage for such physician 54 to the sum of the total cost of such coverage for all physicians applied 55 to such insufficiency.S. 1507--C 25 A. 2007--C 1 (b) Each provider of excess insurance coverage or equivalent excess 2 coverage covering the period July 1, 1992 to June 30, 1993, or covering 3 the period July 1, 1993 to June 30, 1994, or covering the period July 1, 4 1994 to June 30, 1995, or covering the period July 1, 1995 to June 30, 5 1996, or covering the period July 1, 1996 to June 30, 1997, or covering 6 the period July 1, 1997 to June 30, 1998, or covering the period July 1, 7 1998 to June 30, 1999, or covering the period July 1, 1999 to June 30, 8 2000, or covering the period July 1, 2000 to June 30, 2001, or covering 9 the period July 1, 2001 to October 29, 2001, or covering the period 10 April 1, 2002 to June 30, 2002, or covering the period July 1, 2002 to 11 June 30, 2003, or covering the period July 1, 2003 to June 30, 2004, or 12 covering the period July 1, 2004 to June 30, 2005, or covering the peri- 13 od July 1, 2005 to June 30, 2006, or covering the period July 1, 2006 to 14 June 30, 2007, or covering the period July 1, 2007 to June 30, 2008, or 15 covering the period July 1, 2008 to June 30, 2009, or covering the peri- 16 od July 1, 2009 to June 30, 2010, or covering the period July 1, 2010 to 17 June 30, 2011, or covering the period July 1, 2011 to June 30, 2012, or 18 covering the period July 1, 2012 to June 30, 2013, or covering the peri- 19 od July 1, 2013 to June 30, 2014, or covering the period July 1, 2014 to 20 June 30, 2015, or covering the period July 1, 2015 to June 30, 2016, or 21 covering the period July 1, 2016 to June 30, 2017, or covering the peri- 22 od July 1, 2017 to June 30, 2018, or covering the period July 1, 2018 to 23 June 30, 2019, or covering the period July 1, 2019 to June 30, 2020 24 shall notify a covered physician or dentist by mail, mailed to the 25 address shown on the last application for excess insurance coverage or 26 equivalent excess coverage, of the amount due to such provider from such 27 physician or dentist for such coverage period determined in accordance 28 with paragraph (a) of this subdivision. Such amount shall be due from 29 such physician or dentist to such provider of excess insurance coverage 30 or equivalent excess coverage in a time and manner determined by the 31 superintendent of financial services. 32 (c) If a physician or dentist liable for payment of a portion of the 33 costs of excess insurance coverage or equivalent excess coverage cover- 34 ing the period July 1, 1992 to June 30, 1993, or covering the period 35 July 1, 1993 to June 30, 1994, or covering the period July 1, 1994 to 36 June 30, 1995, or covering the period July 1, 1995 to June 30, 1996, or 37 covering the period July 1, 1996 to June 30, 1997, or covering the peri- 38 od July 1, 1997 to June 30, 1998, or covering the period July 1, 1998 to 39 June 30, 1999, or covering the period July 1, 1999 to June 30, 2000, or 40 covering the period July 1, 2000 to June 30, 2001, or covering the peri- 41 od July 1, 2001 to October 29, 2001, or covering the period April 1, 42 2002 to June 30, 2002, or covering the period July 1, 2002 to June 30, 43 2003, or covering the period July 1, 2003 to June 30, 2004, or covering 44 the period July 1, 2004 to June 30, 2005, or covering the period July 1, 45 2005 to June 30, 2006, or covering the period July 1, 2006 to June 30, 46 2007, or covering the period July 1, 2007 to June 30, 2008, or covering 47 the period July 1, 2008 to June 30, 2009, or covering the period July 1, 48 2009 to June 30, 2010, or covering the period July 1, 2010 to June 30, 49 2011, or covering the period July 1, 2011 to June 30, 2012, or covering 50 the period July 1, 2012 to June 30, 2013, or covering the period July 1, 51 2013 to June 30, 2014, or covering the period July 1, 2014 to June 30, 52 2015, or covering the period July 1, 2015 to June 30, 2016, or covering 53 the period July 1, 2016 to June 30, 2017, or covering the period July 1, 54 2017 to June 30, 2018, or covering the period July 1, 2018 to June 30, 55 2019, or covering the period July 1, 2019 to June 30, 2020 determined in 56 accordance with paragraph (a) of this subdivision fails, refuses orS. 1507--C 26 A. 2007--C 1 neglects to make payment to the provider of excess insurance coverage or 2 equivalent excess coverage in such time and manner as determined by the 3 superintendent of financial services pursuant to paragraph (b) of this 4 subdivision, excess insurance coverage or equivalent excess coverage 5 purchased for such physician or dentist in accordance with this section 6 for such coverage period shall be cancelled and shall be null and void 7 as of the first day on or after the commencement of a policy period 8 where the liability for payment pursuant to this subdivision has not 9 been met. 10 (d) Each provider of excess insurance coverage or equivalent excess 11 coverage shall notify the superintendent of financial services and the 12 commissioner of health or their designee of each physician and dentist 13 eligible for purchase of a policy for excess insurance coverage or 14 equivalent excess coverage covering the period July 1, 1992 to June 30, 15 1993, or covering the period July 1, 1993 to June 30, 1994, or covering 16 the period July 1, 1994 to June 30, 1995, or covering the period July 1, 17 1995 to June 30, 1996, or covering the period July 1, 1996 to June 30, 18 1997, or covering the period July 1, 1997 to June 30, 1998, or covering 19 the period July 1, 1998 to June 30, 1999, or covering the period July 1, 20 1999 to June 30, 2000, or covering the period July 1, 2000 to June 30, 21 2001, or covering the period July 1, 2001 to October 29, 2001, or cover- 22 ing the period April 1, 2002 to June 30, 2002, or covering the period 23 July 1, 2002 to June 30, 2003, or covering the period July 1, 2003 to 24 June 30, 2004, or covering the period July 1, 2004 to June 30, 2005, or 25 covering the period July 1, 2005 to June 30, 2006, or covering the peri- 26 od July 1, 2006 to June 30, 2007, or covering the period July 1, 2007 to 27 June 30, 2008, or covering the period July 1, 2008 to June 30, 2009, or 28 covering the period July 1, 2009 to June 30, 2010, or covering the peri- 29 od July 1, 2010 to June 30, 2011, or covering the period July 1, 2011 to 30 June 30, 2012, or covering the period July 1, 2012 to June 30, 2013, or 31 covering the period July 1, 2013 to June 30, 2014, or covering the peri- 32 od July 1, 2014 to June 30, 2015, or covering the period July 1, 2015 to 33 June 30, 2016, or covering the period July 1, 2016 to June 30, 2017, or 34 covering the period July 1, 2017 to June 30, 2018, or covering the peri- 35 od July 1, 2018 to June 30, 2019, or covering the period July 1, 2019 to 36 June 30, 2020 that has made payment to such provider of excess insurance 37 coverage or equivalent excess coverage in accordance with paragraph (b) 38 of this subdivision and of each physician and dentist who has failed, 39 refused or neglected to make such payment. 40 (e) A provider of excess insurance coverage or equivalent excess 41 coverage shall refund to the hospital excess liability pool any amount 42 allocable to the period July 1, 1992 to June 30, 1993, and to the period 43 July 1, 1993 to June 30, 1994, and to the period July 1, 1994 to June 44 30, 1995, and to the period July 1, 1995 to June 30, 1996, and to the 45 period July 1, 1996 to June 30, 1997, and to the period July 1, 1997 to 46 June 30, 1998, and to the period July 1, 1998 to June 30, 1999, and to 47 the period July 1, 1999 to June 30, 2000, and to the period July 1, 2000 48 to June 30, 2001, and to the period July 1, 2001 to October 29, 2001, 49 and to the period April 1, 2002 to June 30, 2002, and to the period July 50 1, 2002 to June 30, 2003, and to the period July 1, 2003 to June 30, 51 2004, and to the period July 1, 2004 to June 30, 2005, and to the period 52 July 1, 2005 to June 30, 2006, and to the period July 1, 2006 to June 53 30, 2007, and to the period July 1, 2007 to June 30, 2008, and to the 54 period July 1, 2008 to June 30, 2009, and to the period July 1, 2009 to 55 June 30, 2010, and to the period July 1, 2010 to June 30, 2011, and to 56 the period July 1, 2011 to June 30, 2012, and to the period July 1, 2012S. 1507--C 27 A. 2007--C 1 to June 30, 2013, and to the period July 1, 2013 to June 30, 2014, and 2 to the period July 1, 2014 to June 30, 2015, and to the period July 1, 3 2015 to June 30, 2016, to the period July 1, 2016 to June 30, 2017, and 4 to the period July 1, 2017 to June 30, 2018, and to the period July 1, 5 2018 to June 30, 2019, and to the period July 1, 2019 to June 30, 2020 6 received from the hospital excess liability pool for purchase of excess 7 insurance coverage or equivalent excess coverage covering the period 8 July 1, 1992 to June 30, 1993, and covering the period July 1, 1993 to 9 June 30, 1994, and covering the period July 1, 1994 to June 30, 1995, 10 and covering the period July 1, 1995 to June 30, 1996, and covering the 11 period July 1, 1996 to June 30, 1997, and covering the period July 1, 12 1997 to June 30, 1998, and covering the period July 1, 1998 to June 30, 13 1999, and covering the period July 1, 1999 to June 30, 2000, and cover- 14 ing the period July 1, 2000 to June 30, 2001, and covering the period 15 July 1, 2001 to October 29, 2001, and covering the period April 1, 2002 16 to June 30, 2002, and covering the period July 1, 2002 to June 30, 2003, 17 and covering the period July 1, 2003 to June 30, 2004, and covering the 18 period July 1, 2004 to June 30, 2005, and covering the period July 1, 19 2005 to June 30, 2006, and covering the period July 1, 2006 to June 30, 20 2007, and covering the period July 1, 2007 to June 30, 2008, and cover- 21 ing the period July 1, 2008 to June 30, 2009, and covering the period 22 July 1, 2009 to June 30, 2010, and covering the period July 1, 2010 to 23 June 30, 2011, and covering the period July 1, 2011 to June 30, 2012, 24 and covering the period July 1, 2012 to June 30, 2013, and covering the 25 period July 1, 2013 to June 30, 2014, and covering the period July 1, 26 2014 to June 30, 2015, and covering the period July 1, 2015 to June 30, 27 2016, and covering the period July 1, 2016 to June 30, 2017, and cover- 28 ing the period July 1, 2017 to June 30, 2018, and covering the period 29 July 1, 2018 to June 30, 2019, and covering the period July 1, 2019 to 30 June 30, 2020 for a physician or dentist where such excess insurance 31 coverage or equivalent excess coverage is cancelled in accordance with 32 paragraph (c) of this subdivision. 33 § 4. Section 40 of chapter 266 of the laws of 1986, amending the civil 34 practice law and rules and other laws relating to malpractice and 35 professional medical conduct, as amended by section 4 of part M of chap- 36 ter 57 of the laws of 2018, is amended to read as follows: 37 § 40. The superintendent of financial services shall establish rates 38 for policies providing coverage for physicians and surgeons medical 39 malpractice for the periods commencing July 1, 1985 and ending June 30, 40 [2019;] 2020; provided, however, that notwithstanding any other 41 provision of law, the superintendent shall not establish or approve any 42 increase in rates for the period commencing July 1, 2009 and ending June 43 30, 2010. The superintendent shall direct insurers to establish segre- 44 gated accounts for premiums, payments, reserves and investment income 45 attributable to such premium periods and shall require periodic reports 46 by the insurers regarding claims and expenses attributable to such peri- 47 ods to monitor whether such accounts will be sufficient to meet incurred 48 claims and expenses. On or after July 1, 1989, the superintendent shall 49 impose a surcharge on premiums to satisfy a projected deficiency that is 50 attributable to the premium levels established pursuant to this section 51 for such periods; provided, however, that such annual surcharge shall 52 not exceed eight percent of the established rate until July 1, [2019,] 53 2020, at which time and thereafter such surcharge shall not exceed twen- 54 ty-five percent of the approved adequate rate, and that such annual 55 surcharges shall continue for such period of time as shall be sufficient 56 to satisfy such deficiency. The superintendent shall not impose suchS. 1507--C 28 A. 2007--C 1 surcharge during the period commencing July 1, 2009 and ending June 30, 2 2010. On and after July 1, 1989, the surcharge prescribed by this 3 section shall be retained by insurers to the extent that they insured 4 physicians and surgeons during the July 1, 1985 through June 30, [2019] 5 2020 policy periods; in the event and to the extent physicians and 6 surgeons were insured by another insurer during such periods, all or a 7 pro rata share of the surcharge, as the case may be, shall be remitted 8 to such other insurer in accordance with rules and regulations to be 9 promulgated by the superintendent. Surcharges collected from physicians 10 and surgeons who were not insured during such policy periods shall be 11 apportioned among all insurers in proportion to the premium written by 12 each insurer during such policy periods; if a physician or surgeon was 13 insured by an insurer subject to rates established by the superintendent 14 during such policy periods, and at any time thereafter a hospital, 15 health maintenance organization, employer or institution is responsible 16 for responding in damages for liability arising out of such physician's 17 or surgeon's practice of medicine, such responsible entity shall also 18 remit to such prior insurer the equivalent amount that would then be 19 collected as a surcharge if the physician or surgeon had continued to 20 remain insured by such prior insurer. In the event any insurer that 21 provided coverage during such policy periods is in liquidation, the 22 property/casualty insurance security fund shall receive the portion of 23 surcharges to which the insurer in liquidation would have been entitled. 24 The surcharges authorized herein shall be deemed to be income earned for 25 the purposes of section 2303 of the insurance law. The superintendent, 26 in establishing adequate rates and in determining any projected defi- 27 ciency pursuant to the requirements of this section and the insurance 28 law, shall give substantial weight, determined in his discretion and 29 judgment, to the prospective anticipated effect of any regulations 30 promulgated and laws enacted and the public benefit of stabilizing 31 malpractice rates and minimizing rate level fluctuation during the peri- 32 od of time necessary for the development of more reliable statistical 33 experience as to the efficacy of such laws and regulations affecting 34 medical, dental or podiatric malpractice enacted or promulgated in 1985, 35 1986, by this act and at any other time. Notwithstanding any provision 36 of the insurance law, rates already established and to be established by 37 the superintendent pursuant to this section are deemed adequate if such 38 rates would be adequate when taken together with the maximum authorized 39 annual surcharges to be imposed for a reasonable period of time whether 40 or not any such annual surcharge has been actually imposed as of the 41 establishment of such rates. 42 § 5. Section 5 and subdivisions (a) and (e) of section 6 of part J of 43 chapter 63 of the laws of 2001, amending chapter 266 of the laws of 44 1986, amending the civil practice law and rules and other laws relating 45 to malpractice and professional medical conduct, relating to the effec- 46 tiveness of certain provisions of such chapter, as amended by section 5 47 of part M of chapter 57 of the laws of 2018, are amended to read as 48 follows: 49 § 5. The superintendent of financial services and the commissioner of 50 health shall determine, no later than June 15, 2002, June 15, 2003, June 51 15, 2004, June 15, 2005, June 15, 2006, June 15, 2007, June 15, 2008, 52 June 15, 2009, June 15, 2010, June 15, 2011, June 15, 2012, June 15, 53 2013, June 15, 2014, June 15, 2015, June 15, 2016, June 15, 2017, June 54 15, 2018, [and] June 15, 2019, and June 15, 2020 the amount of funds 55 available in the hospital excess liability pool, created pursuant to 56 section 18 of chapter 266 of the laws of 1986, and whether such fundsS. 1507--C 29 A. 2007--C 1 are sufficient for purposes of purchasing excess insurance coverage for 2 eligible participating physicians and dentists during the period July 1, 3 2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July 1, 2003 4 to June 30, 2004, or July 1, 2004 to June 30, 2005, or July 1, 2005 to 5 June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007 to June 6 30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to June 30, 7 2010, or July 1, 2010 to June 30, 2011, or July 1, 2011 to June 30, 8 2012, or July 1, 2012 to June 30, 2013, or July 1, 2013 to June 30, 9 2014, or July 1, 2014 to June 30, 2015, or July 1, 2015 to June 30, 10 2016, or July 1, 2016 to June 30, 2017, or July 1, 2017 to June 30, 11 2018, or July 1, 2018 to June 30, 2019, or July 1, 2019 to June 30, 2020 12 as applicable. 13 (a) This section shall be effective only upon a determination, pursu- 14 ant to section five of this act, by the superintendent of financial 15 services and the commissioner of health, and a certification of such 16 determination to the state director of the budget, the chair of the 17 senate committee on finance and the chair of the assembly committee on 18 ways and means, that the amount of funds in the hospital excess liabil- 19 ity pool, created pursuant to section 18 of chapter 266 of the laws of 20 1986, is insufficient for purposes of purchasing excess insurance cover- 21 age for eligible participating physicians and dentists during the period 22 July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30, 2003, or July 23 1, 2003 to June 30, 2004, or July 1, 2004 to June 30, 2005, or July 1, 24 2005 to June 30, 2006, or July 1, 2006 to June 30, 2007, or July 1, 2007 25 to June 30, 2008, or July 1, 2008 to June 30, 2009, or July 1, 2009 to 26 June 30, 2010, or July 1, 2010 to June 30, 2011, or July 1, 2011 to June 27 30, 2012, or July 1, 2012 to June 30, 2013, or July 1, 2013 to June 30, 28 2014, or July 1, 2014 to June 30, 2015, or July 1, 2015 to June 30, 29 2016, or July 1, 2016 to June 30, 2017, or July 1, 2017 to June 30, 30 2018, or July 1, 2018 to June 30, 2019, or July 1, 2019 to June 30, 2020 31 as applicable. 32 (e) The commissioner of health shall transfer for deposit to the 33 hospital excess liability pool created pursuant to section 18 of chapter 34 266 of the laws of 1986 such amounts as directed by the superintendent 35 of financial services for the purchase of excess liability insurance 36 coverage for eligible participating physicians and dentists for the 37 policy year July 1, 2001 to June 30, 2002, or July 1, 2002 to June 30, 38 2003, or July 1, 2003 to June 30, 2004, or July 1, 2004 to June 30, 39 2005, or July 1, 2005 to June 30, 2006, or July 1, 2006 to June 30, 40 2007, as applicable, and the cost of administering the hospital excess 41 liability pool for such applicable policy year, pursuant to the program 42 established in chapter 266 of the laws of 1986, as amended, no later 43 than June 15, 2002, June 15, 2003, June 15, 2004, June 15, 2005, June 44 15, 2006, June 15, 2007, June 15, 2008, June 15, 2009, June 15, 2010, 45 June 15, 2011, June 15, 2012, June 15, 2013, June 15, 2014, June 15, 46 2015, June 15, 2016, June 15, 2017, June 15, 2018, [and] June 15, 2019, 47 and June 15, 2020 as applicable. 48 § 6. Section 20 of part H of chapter 57 of the laws of 2017, amending 49 the New York Health Care Reform Act of 1996 and other laws relating to 50 extending certain provisions thereto, as amended by section 6 of part M 51 of chapter 57 of the laws of 2018, is amended to read as follows: 52 § 20. Notwithstanding any law, rule or regulation to the contrary, 53 only physicians or dentists who were eligible, and for whom the super- 54 intendent of financial services and the commissioner of health, or their 55 designee, purchased, with funds available in the hospital excess liabil- 56 ity pool, a full or partial policy for excess coverage or equivalentS. 1507--C 30 A. 2007--C 1 excess coverage for the coverage period ending the thirtieth of June, 2 two thousand [eighteen,] nineteen, shall be eligible to apply for such 3 coverage for the coverage period beginning the first of July, two thou- 4 sand [eighteen;] nineteen; provided, however, if the total number of 5 physicians or dentists for whom such excess coverage or equivalent 6 excess coverage was purchased for the policy year ending the thirtieth 7 of June, two thousand [eighteen] nineteen exceeds the total number of 8 physicians or dentists certified as eligible for the coverage period 9 beginning the first of July, two thousand [eighteen,] nineteen, then the 10 general hospitals may certify additional eligible physicians or dentists 11 in a number equal to such general hospital's proportional share of the 12 total number of physicians or dentists for whom excess coverage or 13 equivalent excess coverage was purchased with funds available in the 14 hospital excess liability pool as of the thirtieth of June, two thousand 15 [eighteen,] nineteen, as applied to the difference between the number of 16 eligible physicians or dentists for whom a policy for excess coverage or 17 equivalent excess coverage was purchased for the coverage period ending 18 the thirtieth of June, two thousand [eighteen] nineteen and the number 19 of such eligible physicians or dentists who have applied for excess 20 coverage or equivalent excess coverage for the coverage period beginning 21 the first of July, two thousand [eighteen] nineteen. 22 § 7. This act shall take effect immediately and shall be deemed to 23 have been in full force and effect on and after April 1, 2019. 24 PART G 25 Section 1. Intentionally omitted. 26 § 2. Paragraphs (c), (d), (e), (f), (g) and (h) of subdivision 4-a and 27 subdivision 4-c of section 365-f of the social services law are 28 REPEALED, and paragraph (i) of subdivision 4-a is relettered paragraph 29 (c). 30 § 3. Subparagraphs (i) and (ii) of paragraph (a) of subdivision 4-a of 31 section 365-f of the social services law, as added by section 1 of part 32 E of chapter 57 of the laws of 2017, are amended to read as follows: 33 (i) "Fiscal intermediary" means an entity that provides fiscal inter- 34 mediary services and has a contract for providing such services with[:35(A) a local department of social services;36(B) an organization licensed under article forty-four of the public37health law; or38(C) an accountable care organization certified under article twenty-39nine-E of the public health law or an integrated delivery system40composed primarily of health care providers recognized by the department41as a performing provider system under the delivery system reform incen-42tive payment program] the department of health and is selected through 43 the procurement process described in paragraph (b) of this subdivision. 44 Eligible applicants for contracts shall be entities that are capable of 45 appropriately providing fiscal intermediary services, performing the 46 responsibilities of a fiscal intermediary, and complying with this 47 section, including but not limited to entities that: 48 (A) are a service center for independent living under section one 49 thousand one hundred twenty-one of the education law; or 50 (B) have been established as fiscal intermediaries prior to January 51 first, two thousand twelve and have been continuously providing such 52 services for eligible individuals under this section.S. 1507--C 31 A. 2007--C 1 (ii) Fiscal intermediary services shall include the following 2 services, performed on behalf of the consumer to facilitate his or her 3 role as the employer: 4 (A) wage and benefit processing for consumer directed personal assist- 5 ants; 6 (B) processing all income tax and other required wage withholdings; 7 (C) complying with workers' compensation, disability and unemployment 8 requirements; 9 (D) maintaining personnel records for each consumer directed personal 10 assistant, including time [sheets] records and other documentation need- 11 ed for wages and benefit processing and a copy of the medical documenta- 12 tion required pursuant to regulations established by the commissioner; 13 (E) ensuring that the health status of each consumer directed personal 14 assistant is assessed prior to service delivery pursuant to regulations 15 issued by the commissioner; 16 (F) maintaining records of service authorizations or reauthorizations; 17 (G) monitoring the consumer's or, if applicable, the designated repre- 18 sentative's continuing ability to fulfill the consumer's responsibil- 19 ities under the program and promptly notifying the authorizing entity of 20 any circumstance that may affect the consumer's or, if applicable, the 21 designated representative's ability to fulfill such responsibilities; 22 (H) complying with regulations established by the commissioner speci- 23 fying the responsibilities of fiscal intermediaries providing services 24 under this title; [and] 25 (I) entering into a department approved memorandum of understanding 26 with the consumer that describes the parties' responsibilities under 27 this program; and 28 (J) other related responsibilities which may include, as determined by 29 the commissioner, assisting consumers to perform the consumers' respon- 30 sibilities under this section and department regulations in a manner 31 that does not infringe upon the consumer's responsibilities and self-di- 32 rection. 33 § 4. Paragraph (b) of subdivision 4-a of section 365-f of the social 34 services law, as added by section 1 of part E of chapter 57 of the laws 35 of 2017, is amended to read as follows: 36 (b) [No entity shall provide, directly or through contract, fiscal37intermediary services without an authorization as a fiscal intermediary38issued by the commissioner in accordance with this subdivision] Notwith- 39 standing any inconsistent provision of section one hundred sixty-three 40 of the state finance law, or section one hundred forty-two of the 41 economic development law the commissioner shall enter into contracts 42 under this subdivision with eligible contractors that submit an offer 43 for a contract, provided, however, that: 44 (i) the department shall post on its website: 45 (A) a description of the proposed services to be provided pursuant to 46 contracts in accordance with this subdivision; 47 (B) that the selection of contractors shall be based on criteria 48 reasonably related to the contractors' ability to provide fiscal inter- 49 mediary services including but not limited to: ability to appropriately 50 serve individuals participating in the program, geographic distribution 51 that would ensure access in rural and underserved areas, demonstrated 52 cultural and language competencies specific to the population of consum- 53 ers and those of the available workforce, ability to provide timely 54 consumer assistance, experience serving individuals with disabilities, 55 the availability of consumer peer support, and demonstrated complianceS. 1507--C 32 A. 2007--C 1 with all applicable federal and state laws and regulations, including 2 but not limited to those relating to wages and labor; 3 (C) the manner by which prospective contractors may seek such 4 selection, which may include submission by electronic means; 5 (ii) all reasonable and responsive offers that are received from 6 prospective contractors in timely fashion shall be reviewed by the 7 commissioner; 8 (iii) the commissioner shall award such contracts to the contractors 9 that best meet the criteria for selection and are best suited to serve 10 the purposes of this section and the needs of consumers; 11 (iv) all entities providing fiscal intermediary services on or before 12 April first, two thousand nineteen, shall submit an offer for a contract 13 under this section within sixty days after the commissioner publishes 14 the initial offer on the department's website. Such entities shall be 15 deemed authorized to provide such services unless: (A) the entity fails 16 to submit an offer for a contract under this section within the sixty 17 days; or (B) the entity's offer for a contract under this section is 18 denied; 19 (v) all decisions made and approaches taken pursuant to this paragraph 20 shall be documented in a procurement record as defined in section one 21 hundred sixty-three of the state finance law; and 22 (vi) the commissioner is authorized to reoffer contracts under the 23 same terms of this subdivision, if determined necessary by the commis- 24 sioner. 25 § 5. Subparagraph (i) of paragraph (c) of subdivision 4-a of section 26 365-f of the social services law, as added by section 1-a of part K of 27 chapter 57 of the laws of 2018 and as relettered by section two of this 28 act, is amended to read as follows: 29 (i) The commissioner [may] shall require a fiscal intermediary to 30 report annually on the direct care and administrative costs of personal 31 assistance services as accounted for by the fiscal intermediary. The 32 department [may] shall specify the [frequency and] format of such 33 reports, determine the type and amount of information to be submitted, 34 and require the submission of supporting documentation, provided, howev- 35 er, that the department shall provide no less than ninety calendar days' 36 notice before such reports are due. 37 § 6. Section 365-f of the social services law is amended by adding a 38 new subdivision 4-c to read as follows: 39 4-c. The commissioner shall convene and chair a stakeholder workgroup 40 pertaining to fiscal intermediary services and the needs of consumers. 41 The workgroup shall consist of, at a minimum, representatives of service 42 centers for independent living; statewide associations of fiscal inter- 43 mediaries; representatives of managed care entities under article 44 forty-four of the public health law and local social service districts; 45 consumers; and representatives of advocacy groups representing consumers 46 of services under this section. The workgroup shall be established no 47 later than May fifteenth, two thousand nineteen. The workgroup shall 48 identify and develop best practices pertaining to the delivery of fiscal 49 intermediary services; inform the criteria for use by the department for 50 the selection of entities under subdivision four-a of this section; 51 identify whether services differ for certain consumers and under what 52 circumstances; inform criteria in relation to the development of quality 53 reporting requirements; and work with the department to develop transi- 54 tion plans for consumers that may need to transition to another fiscal 55 intermediary.S. 1507--C 33 A. 2007--C 1 § 7. Section 365-f of the social services law is amended by adding a 2 new subdivision 4-d to read as follows: 3 4-d. Fiscal intermediaries ceasing operation. (a) Where a fiscal 4 intermediary is ceasing operation or will no longer serve the consumer's 5 area, the fiscal intermediary shall: 6 (i) deliver written notice forty-five calendar days in advance to the 7 affected consumers, consumer representatives, personal assistants, the 8 department, and any local social services districts or managed care 9 plans with which the fiscal intermediary contracts. Within five business 10 days of receipt of the notice, the local social services district or 11 managed care plan shall acknowledge the notice and provide the affected 12 consumers with a list of other fiscal intermediaries operating in the 13 same county or managed care plan network as appropriate; 14 (ii) not take any action that would prevent a personal assistant from 15 moving to a new fiscal intermediary of the consumer's choice, nor 16 require the consumer or the personal assistant to switch to a personal 17 care or home health care program not under this section; and 18 (iii) upon request and consent, promptly transfer all records relating 19 to the individual's health and care authorizations, and personnel docu- 20 ments to the fiscal intermediary or personal care or home health care 21 provider chosen by the consumer and assume all liability for omissions 22 or errors in such records. 23 (b) Where a consumer is electing to transfer his or her services to a 24 new fiscal intermediary or a personal care or home health care provider 25 by the consumer's independent choice, the fiscal intermediary being 26 discontinued shall comply with subparagraphs (ii) and (iii) of paragraph 27 (a) of this subdivision. 28 (c) Where a fiscal intermediary is suspending or ceasing operation 29 pursuant to an order under subdivision four-b of this section, or has 30 failed to submit an offer for a contract, or has been denied a contract 31 under this section, all the provisions of this subdivision shall apply 32 except subparagraph (i) of paragraph (a) of this subdivision, notice of 33 which to all parties shall be provided by the department as appropriate. 34 (d) The local social services district or managed care plan, as appro- 35 priate, shall supervise the transition of services and transfer of 36 records and maintain provision of services by the personal assistant(s) 37 chosen by the individual. 38 (e) Any transfer under this subdivision shall not diminish any of an 39 individual's rights relating to continuity of care, utilization review 40 or fair hearing appeals and aid continuing. 41 § 8. Subdivision 4-b of section 365-f of the social services law, as 42 added by section 1 of part E of chapter 57 of the laws of 2017, is 43 amended to read as follows: 44 4-b. Actions involving the authorization of a fiscal intermediary. 45 (a) [A fiscal intermediary's authorization may be revoked, suspended,46limited or annulled upon thirty day's written notice to the fiscal47intermediary, if the commissioner finds that the fiscal intermediary has48failed to comply with the provisions of this subdivision or regulations49promulgated hereunder.] The department may terminate a fiscal interme- 50 diary's contract under this section or suspend or limit the fiscal 51 intermediary's rights and privileges under the contract upon thirty 52 day's written notice to the fiscal intermediary, if the commissioner 53 finds that the fiscal intermediary has failed to comply with the 54 provisions of this section or regulations promulgated hereunder. The 55 written notice shall include:S. 1507--C 34 A. 2007--C 1 (i) A description of the conduct and the issues related thereto that 2 have been identified as failure of compliance; and 3 (ii) the time frame of the conduct that fails compliance. 4 (b) Notwithstanding the foregoing, upon determining that the public 5 health or safety would be imminently endangered by the continued 6 [authorization] operation or actions of the fiscal intermediary, the 7 commissioner may [revoke, suspend, limit or annul the fiscal interme-8diary's authorization immediately.9(b)] terminate the fiscal intermediary's contract or suspend or limit 10 the fiscal intermediary's rights and privileges under the contract imme- 11 diately upon written notice. 12 (c) All orders or determinations under this subdivision shall be 13 subject to review as provided in article seventy-eight of the civil 14 practice law and rules. 15 § 9. Residential health care facilities case mix adjustment workgroup. 16 The commissioner of health or his or her designee shall convene and 17 chair a workgroup on the implementation of the change in case mix 18 adjustments to Medicaid rates of payment of residential health care 19 facilities that will take effect on July 1, 2019. The workgroup shall be 20 comprised of residential health care facilities or representatives from 21 such facilities, representatives from the statewide associations and 22 other such experts on case mix as required by the commissioner or his or 23 her designee. The workgroup shall review recent case mix data and 24 related analyses conducted by the department with respect to the depart- 25 ment's implementation of the July 1, 2019 change in methodology, the 26 department's minimum data set collection process, and case mix adjust- 27 ments authorized under subparagraph (ii) of paragraph (b) of subdivision 28 2-b of section 2808 of the public health law. Such review shall seek to 29 promote a higher degree of accuracy in the minimum data set data, and 30 target abuses. The workgroup may offer recommendations on how to improve 31 future practice regarding accuracy in the minimum data set collection 32 process and how to reduce or eliminate abusive practices. In developing 33 such recommendations, the workgroup shall ensure that the collection 34 process and case mix adjustment recognizes the appropriate acuity for 35 residential health care residents. The workgroup may provide recommenda- 36 tions regarding the proposed patient driven payment model and the admin- 37 istrative complexity in revising the minimum data set collection and 38 rate promulgation processes. The commissioner shall not modify the meth- 39 od used to determine the case mix adjustment for periods prior to June 40 30, 2019. Notwithstanding any changes in federal law or regulation 41 relating to nursing home acuity reimbursement, the workgroup shall 42 report its recommendations no later than June 30, 2019. 43 § 10. Subdivision 2 of section 3614-c of the public health law, as 44 amended by section 5 of part S of chapter 57 of the laws of 2017, is 45 amended to read as follows: 46 2. Notwithstanding any inconsistent provision of law, rule or regu- 47 lation, no payments by government agencies shall be made to certified 48 home health agencies, long term home health care programs, managed care 49 plans, [or] the consumer directed personal assistance program under 50 section three hundred sixty-five-f of the social services law, the nurs- 51 ing home transition and diversion waiver program under section three 52 hundred sixty-six of the social services law, or the traumatic brain 53 injury waiver program under section two thousand seven hundred forty of 54 this chapter for any episode of care furnished, in whole or in part, by 55 any home care aide who is compensated at amounts less than the applica-S. 1507--C 35 A. 2007--C 1 ble minimum rate of home care aide total compensation established pursu- 2 ant to this section. 3 § 11. This act shall take effect immediately and shall be deemed to 4 have been in full force and effect on and after April 1, 2019; provided 5 however, that sections three, four, five, seven and eight of this act 6 shall take effect January 1, 2020; and provided further that effective 7 immediately, the commissioner of health is authorized to request offers 8 for contracts in accordance with section four of this act, to facilitate 9 execution of such contracts on and after January 1, 2020. 10 PART H 11 Section 1. Subparagraph (v) of paragraph (b) of subdivision 5-b of 12 section 2807-k of the public health law is REPEALED. 13 § 2. Section 2807 of the public health law is amended by adding a new 14 subdivision 20-a to read as follows: 15 20-a. Notwithstanding any provision of law to the contrary, the 16 commissioners of the department of health, the office of mental health, 17 the office of people with developmental disabilities, and the office of 18 alcoholism and substance abuse services are authorized to waive any 19 regulatory requirements as are necessary, consistent with applicable 20 law, to allow providers that are involved in DSRIP projects or repli- 21 cation and scaling activities, as approved by the authorizing commis- 22 sioner, to avoid duplication of requirements and to allow the efficient 23 scaling and replication of DSRIP promising practices, as determined by 24 the authorizing commissioner; provided however, that regulations 25 pertaining to patient safety, patient autonomy, patient privacy, patient 26 rights, due process, scope of practice, professional licensure, envi- 27 ronmental protections, provider reimbursement methodologies, or occupa- 28 tional standards and employee rights may not be waived, nor shall any 29 regulations be waived if such waiver would risk patient safety. Any 30 regulatory action under this subdivision shall be published on the 31 applicable website of the authorizing commissioner and shall include a 32 description of each waiver, including a citation of each regulation 33 waived, and a description of the project of which such relief was 34 granted. 35 § 3. Subparagraph (i) of paragraph (e-1) of subdivision 4 of section 36 2807-c of the public health law, as amended by section 29 of part C of 37 chapter 60 of the laws of 2014, is amended to read as follows: 38 (i) For rate periods on [and] or after April first, two thousand ten, 39 the commissioner, in consultation with the commissioner of the office of 40 mental health, shall promulgate regulations, and may promulgate emergen- 41 cy regulations, establishing methodologies for determining the operating 42 cost components of rates of payments for services described in this 43 paragraph. [Such regulations shall utilize two thousand five operating44costs as submitted to the department prior to July first, two thousand45nine and shall provide for methodologies establishing per diem inpatient46rates that utilize case mix adjustment mechanisms. Such regulations47shall contain criteria for adjustments based on length of stay and may48also provide for a base year update, provided, however, that such base49year update shall take effect no earlier than April first, two thousand50fifteen, and provided further, however, that the] The commissioner may 51 make such adjustments to [such utilization and to] the methodology for 52 computing such rates as is necessary to achieve no aggregate, net growth 53 in overall Medicaid expenditures related to such rates, as compared to 54 such aggregate expenditures from the prior year. In determining theS. 1507--C 36 A. 2007--C 1 updated base year to be utilized pursuant to this subparagraph, the 2 commissioner shall take into account the base year determined in accord- 3 ance with paragraph (c) of subdivision thirty-five of this section. 4 Furthermore, the commissioner shall establish such rates in consulta- 5 tion with industry representatives to achieve an appropriate base year 6 update to the operating cost components of rates of payment for services 7 described in this paragraph and that takes into account facility cost, 8 mix of services, and patient specific conditions. 9 § 4. Intentionally omitted. 10 § 5. Intentionally omitted. 11 § 6. Subdivision 5-d of section 2807-k of the public health law, as 12 amended by section 2 of part A of chapter 57 of the laws of 2018, is 13 amended to read as follows: 14 5-d. (a) Notwithstanding any inconsistent provision of this section, 15 section twenty-eight hundred seven-w of this article or any other 16 contrary provision of law, and subject to the availability of federal 17 financial participation, for periods on and after January first, two 18 thousand thirteen, through March thirty-first, two thousand twenty, all 19 funds available for distribution pursuant to this section, except for 20 funds distributed pursuant to subparagraph (v) of paragraph (b) of 21 subdivision five-b of this section, and all funds available for distrib- 22 ution pursuant to section twenty-eight hundred seven-w of this article, 23 shall be reserved and set aside and distributed in accordance with the 24 provisions of this subdivision. 25 (b) The commissioner shall promulgate regulations, and may promulgate 26 emergency regulations, establishing methodologies for the distribution 27 of funds as described in paragraph (a) of this subdivision and such 28 regulations shall include, but not be limited to, the following: 29 (i) Such regulations shall establish methodologies for determining 30 each facility's relative uncompensated care need amount based on unin- 31 sured inpatient and outpatient units of service from the cost reporting 32 year two years prior to the distribution year, multiplied by the appli- 33 cable medicaid rates in effect January first of the distribution year, 34 as summed and adjusted by a statewide cost adjustment factor and reduced 35 by the sum of all payment amounts collected from such uninsured 36 patients, and as further adjusted by application of a nominal need 37 computation that shall take into account each facility's medicaid inpa- 38 tient share. 39 (ii) Annual distributions pursuant to such regulations for the two 40 thousand thirteen through two thousand [nineteen] twenty calendar years 41 shall be in accord with the following: 42 (A) one hundred thirty-nine million four hundred thousand dollars 43 shall be distributed as Medicaid Disproportionate Share Hospital ("DSH") 44 payments to major public general hospitals; and 45 (B) nine hundred ninety-four million nine hundred thousand dollars as 46 Medicaid DSH payments to eligible general hospitals, other than major 47 public general hospitals. 48 (iii)(A) Such regulations shall establish transition adjustments to 49 the distributions made pursuant to clauses (A) and (B) of subparagraph 50 (ii) of this paragraph such that no facility experiences a reduction in 51 indigent care pool payments pursuant to this subdivision that is greater 52 than the percentages, as specified in clause (C) of this subparagraph as 53 compared to the average distribution that each such facility received 54 for the three calendar years prior to two thousand thirteen pursuant to 55 this section and section twenty-eight hundred seven-w of this article.S. 1507--C 37 A. 2007--C 1 (B) Such regulations shall also establish adjustments limiting the 2 increases in indigent care pool payments experienced by facilities 3 pursuant to this subdivision by an amount that will be, as determined by 4 the commissioner and in conjunction with such other funding as may be 5 available for this purpose, sufficient to ensure full funding for the 6 transition adjustment payments authorized by clause (A) of this subpara- 7 graph. 8 (C) No facility shall experience a reduction in indigent care pool 9 payments pursuant to this subdivision that: for the calendar year begin- 10 ning January first, two thousand thirteen, is greater than two and one- 11 half percent; for the calendar year beginning January first, two thou- 12 sand fourteen, is greater than five percent; and, for the calendar year 13 beginning on January first, two thousand fifteen; is greater than seven 14 and one-half percent, and for the calendar year beginning on January 15 first, two thousand sixteen, is greater than ten percent; and for the 16 calendar year beginning on January first, two thousand seventeen, is 17 greater than twelve and one-half percent; and for the calendar year 18 beginning on January first, two thousand eighteen, is greater than 19 fifteen percent; and for the calendar year beginning on January first, 20 two thousand nineteen, is greater than seventeen and one-half percent; 21 and for the calendar year beginning on January first, two thousand twen- 22 ty, is greater than twenty percent. 23 (iv) Such regulations shall reserve one percent of the funds available 24 for distribution in the two thousand fourteen and two thousand fifteen 25 calendar years, and for calendar years thereafter, pursuant to this 26 subdivision, subdivision fourteen-f of section twenty-eight hundred 27 seven-c of this article, and sections two hundred eleven and two hundred 28 twelve of chapter four hundred seventy-four of the laws of nineteen 29 hundred ninety-six, in a "financial assistance compliance pool" and 30 shall establish methodologies for the distribution of such pool funds to 31 facilities based on their level of compliance, as determined by the 32 commissioner, with the provisions of subdivision nine-a of this section. 33 (c) The commissioner shall annually report to the governor and the 34 legislature on the distribution of funds under this subdivision includ- 35 ing, but not limited to: 36 (i) the impact on safety net providers, including community providers, 37 rural general hospitals and major public general hospitals; 38 (ii) the provision of indigent care by units of services and funds 39 distributed by general hospitals; and 40 (iii) the extent to which access to care has been enhanced. 41 § 7. This act shall take effect immediately and shall be deemed to 42 have been in full force and effect on and after April 1, 2019, provided, 43 however, that section two of this act shall expire on April 1, 2020. 44 PART I 45 Intentionally Omitted 46 PART J 47 Section 1. This Part enacts into law major components of legislation 48 which are necessary to protect health care consumers; increase access to 49 more affordable quality health insurance coverage; and preserve and 50 foster New York's health insurance markets. Each component is wholly 51 contained within a Subpart identified as Subparts A through D. The 52 effective date for each particular provision contained within suchS. 1507--C 38 A. 2007--C 1 Subpart is set forth in the last section of such Subpart. Any provision 2 in any section contained within a Subpart, including the effective date 3 of the Subpart, which makes a reference to a section "of this act," when 4 used in connection with that particular component, shall be deemed to 5 mean and refer to the corresponding section of the Subpart in which it 6 is found. Section five of this Part sets forth the general effective 7 date of this Part. 8 SUBPART A 9 Section 1. Section 3221 of the insurance law is amended by adding a 10 new subsection (t) to read as follows: 11 (t) (1) Any insurer that delivers or issues for delivery in this state 12 hospital, surgical or medical expense group policies in the small group 13 or large group market shall offer to any employer in this state all such 14 policies in the applicable market, and shall accept at all times 15 throughout the year any employer that applies for any of those policies. 16 (2) The requirements of paragraph one of this subsection shall apply 17 with respect to an employer that applies for coverage either directly 18 from the insurer or through an association or trust to which the insurer 19 has issued coverage and in which the employer participates. 20 § 2. Paragraph 1 of subsection (g) of section 3231 of the insurance 21 law, as amended by section 70 of part D of chapter 56 of the laws of 22 2013, is amended to read as follows: 23 (1) This section shall also apply to policies issued to a group 24 defined in subsection (c) of section four thousand two hundred thirty- 25 five, including but not limited to an association or trust of employers, 26 if the group includes one or more member employers or other member 27 groups which have [fifty] one hundred or fewer employees or members 28 exclusive of spouses and dependents. For policies issued or renewed on 29 or after January first, two thousand fourteen, if the group includes one 30 or more member small group employers eligible for coverage subject to 31 this section, then such member employers shall be classified as small 32 groups for rating purposes and the remaining members shall be rated 33 consistent with the rating rules applicable to such remaining members 34 pursuant to paragraph two of this subsection. 35 § 3. Subsections (h) and (i) of section 3232 of the insurance law are 36 REPEALED. 37 § 4. Subsections (f) and (g) of section 3232 of the insurance law, as 38 added by chapter 219 of the laws of 2011, are amended to read as 39 follows: 40 (f) [With respect to an individual under age nineteen, an insurer may41not impose any pre-existing condition exclusion in an individual or42group policy of hospital, medical, surgical or prescription drug expense43insurance pursuant to the requirements of section 2704 of the Public44Health Service Act, 42 U.S.C. § 300gg-3, as made effective by section451255(2) of the Affordable Care Act, except for an individual under age46nineteen covered under an individual policy of hospital, medical, surgi-47cal or prescription drug expense insurance that is a grandfathered48health plan.49(g) Beginning January first, two thousand fourteen, pursuant to50section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, an] 51 An insurer [may] shall not impose any pre-existing condition exclusion 52 in an individual or group policy of hospital, medical, surgical or 53 prescription drug expense insurance [except in an individual policy that54is a grandfathered health plan].S. 1507--C 39 A. 2007--C 1 § 5. Intentionally omitted. 2 § 6. Section 4305 of the insurance law is amended by adding a new 3 subsection (n) to read as follows: 4 (n) (1) Any corporation subject to the provisions of this article that 5 issues hospital, surgical or medical expense contracts in the small 6 group or large group market in this state shall offer to any employer in 7 this state all such contracts in the applicable market, and shall accept 8 at all times throughout the year any employer that applies for any of 9 those contracts. 10 (2) The requirements of paragraph one of this subsection shall apply 11 with respect to an employer that applies for coverage either directly 12 from the corporation or through an association or trust to which the 13 corporation has issued coverage and in which the employer participates. 14 § 7. Paragraph 1 of subsection (d) of section 4317 of the insurance 15 law, as amended by section 72 of part D of chapter 56 of the laws of 16 2013, is amended to read as follows: 17 (1) This section shall also apply to a contract issued to a group 18 defined in subsection (c) of section four thousand two hundred thirty- 19 five of this chapter, including but not limited to an association or 20 trust of employers, if the group includes one or more member employers 21 or other member groups which have [fifty] one hundred or fewer employees 22 or members exclusive of spouses and dependents. For contracts issued or 23 renewed on or after January first, two thousand fourteen, if the group 24 includes one or more member small group employers eligible for coverage 25 subject to this section, then such member employers shall be classified 26 as small groups for rating purposes and the remaining members shall be 27 rated consistent with the rating rules applicable to such remaining 28 members pursuant to paragraph two of this subsection. 29 § 8. Subsections (h) and (i) of section 4318 of the insurance law are 30 REPEALED. 31 § 9. Subsections (f) and (g) of section 4318 of the insurance law, as 32 added by chapter 219 of the laws of 2011, are amended to read as 33 follows: 34 (f) [With respect to an individual under age nineteen, a corporation35may not impose any pre-existing condition exclusion in an individual or36group contract of hospital, medical, surgical or prescription drug37expense insurance pursuant to the requirements of section 2704 of the38Public Health Service Act, 42 U.S.C. § 300gg-3, as made effective by39section 1255(2) of the Affordable Care Act, except for an individual40under age nineteen covered under an individual contract of hospital,41medical, surgical or prescription drug expense insurance that is a42grandfathered health plan.43(g) Beginning January first, two thousand fourteen, pursuant to44section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A 45 corporation [may] shall not impose any pre-existing condition exclusion 46 in an individual or group contract of hospital, medical, surgical or 47 prescription drug expense insurance [except in an individual contract48that is a grandfathered health plan]. 49 § 10. Subdivision 1 of section 4406 of the public health law, as 50 amended by section 46-a of part D of chapter 56 of the laws of 2013, is 51 amended to read as follows: 52 1. The contract between a health maintenance organization and an 53 enrollee shall be subject to regulation by the superintendent as if it 54 were a health insurance subscriber contract, and shall include, but not 55 be limited to, all mandated benefits required by article forty-three of 56 the insurance law. Such contract shall fully and clearly state the bene-S. 1507--C 40 A. 2007--C 1 fits and limitations therein provided or imposed, so as to facilitate 2 understanding and comparisons, and to exclude provisions which may be 3 misleading or unreasonably confusing. Such contract shall be issued to 4 any individual and dependents of such individual and any group of 5 [fifty] one hundred or fewer employees or members, exclusive of spouses 6 and dependents, or to any employee or member of the group, including 7 dependents, applying for such contract at any time throughout the year[,8and may include a pre-existing condition provision as provided for in9section four thousand three hundred eighteen of the insurance law,10provided, however, that, the]. An individual direct payment contract 11 shall be issued only in accordance with section four thousand three 12 hundred twenty-eight of the insurance law. The superintendent may, after 13 giving consideration to the public interest, exempt a health maintenance 14 organization from the requirements of this section provided that another 15 health insurer or health maintenance organization within the health 16 maintenance organization's same holding company system, as defined in 17 article fifteen of the insurance law, including a health maintenance 18 organization operated as a line of business of a health service corpo- 19 ration licensed under article forty-three of the insurance law, offers 20 coverage that, at a minimum, complies with this section and provides all 21 of the consumer protections required to be provided by a health mainte- 22 nance organization pursuant to this chapter and regulations, including 23 those consumer protections contained in sections four thousand four 24 hundred three and four thousand four hundred eight-a of this chapter. 25 The requirements shall not apply to a health maintenance organization 26 exclusively serving individuals enrolled pursuant to title eleven of 27 article five of the social services law, title eleven-D of article five 28 of the social services law, title one-A of article twenty-five of [the29public health law] this chapter or title eighteen of the federal Social 30 Security Act, and, further provided, that such health maintenance organ- 31 ization shall not discontinue a contract for an individual receiving 32 comprehensive-type coverage in effect prior to January first, two thou- 33 sand four who is ineligible to purchase policies offered after such date 34 pursuant to this section or section four thousand three hundred [twen-35ty-two of this article] twenty-eight of the insurance law due to the 36 provision of 42 U.S.C. 1395ss in effect prior to January first, two 37 thousand four. [Subject to the creditable coverage requirements of38subsection (a) of section four thousand three hundred eighteen of the39insurance law, the organization may, as an alternative to the use of a40pre-existing condition provision, elect to offer contracts without a41pre-existing condition provision to such groups but may require that42coverage shall not become effective until after a specified affiliation43period of not more than sixty days after the application for coverage is44submitted. The organization is not required to provide health care45services or benefits during such period and no premium shall be charged46for any coverage during the period. After January first, nineteen47hundred ninety-six, all individual direct payment contracts shall be48issued only pursuant to sections four thousand three hundred twenty-one49and four thousand three hundred twenty-two of the insurance law. Such50contracts may not, with respect to an eligible individual (as defined in51section 2741(b) of the federal Public Health Service Act, 42 U.S.C. §52300gg-41(b), impose any pre-existing condition exclusion.] 53 § 11. This act shall take effect immediately, provided that: 54 (1) sections one, three, four, six, eight and nine of this act shall 55 apply to all policies and contracts issued, renewed, modified, altered 56 or amended on or after January 1, 2020; andS. 1507--C 41 A. 2007--C 1 (2) sections two and seven of this act shall take effect on the same 2 date as the reversion of paragraph 1 of subsection (g) of section 3231 3 and paragraph 1 of subsection (d) of section 4317 of the insurance law, 4 as provided in section 5 of chapter 588 of the laws of 2015, as amended. 5 SUBPART B 6 Section 1. Subparagraph (A) of paragraph 5 of subsection (c) of 7 section 3216 of the insurance law, as amended by chapter 388 of the laws 8 of 2014, is amended to read as follows: 9 (A) Any family policy providing hospital or surgical expense insurance 10 (but not including such insurance against accidental injury only) shall 11 provide that, in the event such insurance on any person, other than the 12 policyholder, is terminated because the person is no longer within the 13 definition of the family as set forth in the policy but before such 14 person has attained the limiting age, if any, for coverage of adults 15 specified in the policy, such person shall be entitled to have issued to 16 that person by the insurer, without evidence of insurability, upon 17 application therefor and payment of the first premium, within sixty days 18 after such insurance shall have terminated, an individual conversion 19 policy that contains the essential health benefits package described in 20 paragraph [one] three of subsection [(b)] (f) of section [four thousand21three hundred twenty-eight of this chapter. The insurer shall offer one22policy at each level of coverage as defined in section 1302(d) of the23affordable care act, 42 U.S.C. § 18022(d).] three thousand two hundred 24 seventeen-i of this article. The insurer shall offer one policy at each 25 level of coverage as defined in subsection (b) of section three thousand 26 two hundred seventeen-i of this article. The individual may choose any 27 such policy offered by the insurer. Provided, however, the superinten- 28 dent may, after giving due consideration to the public interest, approve 29 a request made by an insurer for the insurer to satisfy the requirements 30 of this subparagraph through the offering of policies that comply with 31 this subparagraph by another insurer, corporation or health maintenance 32 organization within the insurer's holding company system, as defined in 33 article fifteen of this chapter. The conversion privilege afforded here- 34 in shall also be available upon the divorce or annulment of the marriage 35 of the policyholder to the former spouse of such policyholder. 36 § 2. Subparagraph (E) of paragraph 2 of subsection (g) of section 3216 37 of the insurance law, as added by chapter 388 of the laws of 2014, is 38 amended to read as follows: 39 (E) The superintendent may, after giving due consideration to the 40 public interest, approve a request made by an insurer for the insurer to 41 satisfy the requirements of subparagraph (C) of this paragraph through 42 the offering of policies at each level of coverage as defined in 43 subsection (b) of section [1302(d) of the affordable care act, 42 U.S.C.44§ 18022(d)] three thousand two hundred seventeen-i of this article that 45 contains the essential health benefits package described in paragraph 46 [one] three of subsection [(b)] (e) of section [four thousand three47hundred twenty-eight of this chapter] three thousand two hundred seven- 48 teen-i of this article by another insurer, corporation or health mainte- 49 nance organization within the insurer's same holding company system, as 50 defined in article fifteen of this chapter. 51 § 3. Intentionally omitted. 52 § 4. Intentionally omitted. 53 § 5. Intentionally omitted.S. 1507--C 42 A. 2007--C 1 § 6. Paragraph 21 of subsection (i) of section 3216 of the insurance 2 law, as amended by chapter 469 of the laws of 2018, is amended to read 3 as follows: 4 (21) Every policy [which] that provides coverage for prescription 5 drugs shall include coverage for the cost of enteral formulas for home 6 use, whether administered orally or via tube feeding, for which a physi- 7 cian or other licensed health care provider legally authorized to 8 prescribe under title eight of the education law has issued a written 9 order. Such written order shall state that the enteral formula is clear- 10 ly medically necessary and has been proven effective as a disease-spe- 11 cific treatment regimen. Specific diseases and disorders for which 12 enteral formulas have been proven effective shall include, but are not 13 limited to, inherited diseases of amino acid or organic acid metabolism; 14 Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal 15 motility such as chronic intestinal pseudo-obstruction; and multiple, 16 severe food allergies including, but not limited to immunoglobulin E and 17 nonimmunoglobulin E-mediated allergies to multiple food proteins; severe 18 food protein induced enterocolitis syndrome; eosinophilic disorders; and 19 impaired absorption of nutrients caused by disorders affecting the 20 absorptive surface, function, length, and motility of the gastrointesti- 21 nal tract. Enteral formulas [which] that are medically necessary and 22 taken under written order from a physician for the treatment of specific 23 diseases shall be distinguished from nutritional supplements taken elec- 24 tively. Coverage for certain inherited diseases of amino acid and organ- 25 ic acid metabolism as well as severe protein allergic conditions shall 26 include modified solid food products that are low protein [or which], 27 contain modified protein, or are amino acid based [which] that are 28 medically necessary[, and such coverage for such modified solid food29products for any calendar year or for any continuous period of twelve30months for any insured individual shall not exceed two thousand five31hundred dollars]. 32 § 7. Paragraph 30 of subsection (i) of section 3216 of the insurance 33 law, as amended by chapter 377 of the laws of 2014, is amended to read 34 as follows: 35 (30) Every policy [which] that provides medical coverage that includes 36 coverage for physician services in a physician's office and every policy 37 [which] that provides major medical or similar comprehensive-type cover- 38 age shall include coverage for equipment and supplies used for the 39 treatment of ostomies, if prescribed by a physician or other licensed 40 health care provider legally authorized to prescribe under title eight 41 of the education law. Such coverage shall be subject to annual deduct- 42 ibles and coinsurance as deemed appropriate by the superintendent. The 43 coverage required by this paragraph shall be identical to, and shall not 44 enhance or increase the coverage required as part of essential health 45 benefits as [required pursuant to] defined in subsection (a) of section 46 [2707 (a) of the public health services act 42 U.S.C. 300 gg-6(a)] three 47 thousand two hundred seventeen-i of this article. 48 § 8. Subsection (l) of section 3216 of the insurance law, as added by 49 section 42 of part D of chapter 56 of the laws of 2013, is amended to 50 read as follows: 51 (l) [On and after October first, two thousand thirteen, an] An insurer 52 shall not offer individual hospital, medical or surgical expense insur- 53 ance policies unless the policies meet the requirements of subsection 54 (b) of section four thousand three hundred twenty-eight of this chapter. 55 Such policies that are offered within the health benefit exchange estab- 56 lished [pursuant to section 1311 of the affordable care act, 42 U.S.C. §S. 1507--C 43 A. 2007--C 118031, or any regulations promulgated thereunder,] by this state also 2 shall meet any requirements established by the health benefit exchange. 3 § 9. Subsection (m) of section 3216 of the insurance law, as added by 4 section 53 of part D of chapter 56 of the laws of 2013, is amended to 5 read as follows: 6 (m) An insurer shall not be required to offer the policyholder any 7 benefits that must be made available pursuant to this section if the 8 benefits must be covered as essential health benefits. For any policy 9 issued within the health benefit exchange established [pursuant to10section 1311 of the affordable care act, 42 U.S.C. § 18031] by this 11 state, an insurer shall not be required to offer the policyholder any 12 benefits that must be made available pursuant to this section. For 13 purposes of this subsection, "essential health benefits" shall have the 14 meaning set forth in subsection (a) of section [1302(b) of the afforda-15ble care act, 42 U.S.C. § 18022(b)] three thousand two hundred seven- 16 teen-i of this article. 17 § 10. The insurance law is amended by adding a new section 3217-i to 18 read as follows: 19 § 3217-i. Essential health benefits package and limit on cost-sharing. 20 (a) (1) For purposes of this article, "essential health benefits" shall 21 mean the following categories of benefits: 22 (A) ambulatory patient services; 23 (B) emergency services; 24 (C) hospitalization; 25 (D) maternity and newborn care; 26 (E) mental health and substance use disorder services, including 27 behavioral health treatment; 28 (F) prescription drugs; 29 (G) rehabilitative and habilitative services and devices; 30 (H) laboratory services; 31 (I) preventive and wellness services and chronic disease management; 32 and 33 (J) pediatric services, including oral and vision care. 34 (2) An insurer shall not be required to provide coverage for pediatric 35 oral services as an essential health benefit if: 36 (A) for coverage offered through the exchange established by this 37 state, the exchange has determined sufficient coverage of the pediatric 38 oral benefit is available through stand-alone dental plans certified by 39 the exchange; or 40 (B) for coverage offered outside the exchange, the insurer obtains 41 reasonable written assurance that the individual or group has obtained a 42 stand-alone dental plan that has been approved by the superintendent as 43 meeting exchange certification standards. 44 (b) (1) Every individual and small group accident and health insurance 45 policy that provides hospital, surgical, or medical expense coverage and 46 is not a grandfathered health plan shall provide coverage that meets the 47 actuarial requirements of one of the following levels of coverage: 48 (A) Bronze Level. A plan in the bronze level shall provide a level of 49 coverage that is designed to provide benefits that are actuarially 50 equivalent to sixty percent of the full actuarial value of the benefits 51 provided under the plan; 52 (B) Silver Level. A plan in the silver level shall provide a level of 53 coverage that is designed to provide benefits that are actuarially 54 equivalent to seventy percent of the full actuarial value of the bene- 55 fits provided under the plan;S. 1507--C 44 A. 2007--C 1 (C) Gold Level. A plan in the gold level shall provide a level of 2 coverage that is designed to provide benefits that are actuarially 3 equivalent to eighty percent of the full actuarial value of the benefits 4 provided under the plan; or 5 (D) Platinum Level. A plan in the platinum level shall provide a level 6 of coverage that is designed to provide benefits that are actuarially 7 equivalent to ninety percent of the full actuarial value of the benefits 8 provided under the plan. 9 (2) The superintendent may provide for a variation in the actuarial 10 values used in determining the level of coverage of a plan to account 11 for the differences in actuarial estimates. 12 (3) Every student accident and health insurance policy shall provide 13 coverage that meets at least sixty percent of the full actuarial value 14 of the benefits provided under the policy. The policy's schedule of 15 benefits shall include the level as described in paragraph one of this 16 subsection nearest to, but below the actual actuarial value. 17 (c) Every individual or group accident and health insurance policy 18 that provides hospital, surgical, or medical expense coverage and is not 19 a grandfathered health plan, and every student accident and health 20 insurance policy shall limit the insured's cost-sharing for in-network 21 services in a policy year to not more than the maximum out-of-pocket 22 amount determined by the superintendent for all policies subject to this 23 section. Such amount shall not exceed any annual out-of-pocket limit on 24 cost-sharing set by the United States secretary of health and human 25 services, if available. 26 (d) The superintendent may require the use of model language describ- 27 ing the coverage requirements for any accident and health insurance 28 policy form that is subject to the superintendent's approval pursuant to 29 section three thousand two hundred one of this article. 30 (e) For purposes of this section: 31 (1) "actuarial value" means the percentage of the total expected 32 payments by the insurer for benefits provided to a standard population, 33 without regard to the population to whom the insurer actually provides 34 benefits; 35 (2) "cost-sharing" means annual deductibles, coinsurance, copayments, 36 or similar charges, for covered services; 37 (3) "essential health benefits package" means coverage that: 38 (A) provides for essential health benefits; 39 (B) limits cost-sharing for such coverage in accordance with 40 subsection (c) of this section; and 41 (C) provides one of the levels of coverage described in subsection (b) 42 of this section; 43 (4) "grandfathered health plan" means coverage provided by an insurer 44 in which an individual was enrolled on March twenty-third, two thousand 45 ten for as long as the coverage maintains grandfathered status in 46 accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. § 47 18011(e); 48 (5) "small group" means a group of one hundred or fewer employees or 49 members exclusive of spouses and dependents; and 50 (6) "student accident and health insurance" shall have the meaning set 51 forth in subsection (a) of section three thousand two hundred forty of 52 this article. 53 § 11. Subsection (g) of section 3221 of the insurance law, as amended 54 by chapter 388 of the laws of 2014, is amended to read as follows: 55 (g) For conversion purposes, an insurer shall offer to the employee or 56 member a policy at each level of coverage as defined in subsection (b)S. 1507--C 45 A. 2007--C 1 of section [1302(d) of the affordable care act, 42 U.S.C. § 18022(d)] 2 three thousand two hundred seventeen-i of this article that contains the 3 essential health benefits package described in paragraph [one] three of 4 subsection [(b)] (e) of section [four thousand three hundred twenty-5eight of this chapter] three thousand two hundred seventeen-i of this 6 article. Provided, however, the superintendent may, after giving due 7 consideration to the public interest, approve a request made by an 8 insurer for the insurer to satisfy the requirements of this subsection 9 and subsections (e) and (f) of this section through the offering of 10 policies that comply with this subsection by another insurer, corpo- 11 ration or health maintenance organization within the insurer's holding 12 company system, as defined in article fifteen of this chapter. 13 § 12. Subsection (h) of section 3221 of the insurance law, as added by 14 section 54 of part D of chapter 56 of the laws of 2013, is amended to 15 read as follows: 16 (h) Every small group policy or association group policy delivered or 17 issued for delivery in this state that provides coverage for hospital, 18 medical or surgical expense insurance and is not a grandfathered health 19 plan shall provide coverage for the essential health [benefit] benefits 20 package [as required in section 2707(a) of the public health service21act, 42 U.S.C. § 300gg-6(a)]. For purposes of this subsection: 22 (1) "essential health benefits package" shall have the meaning set 23 forth in paragraph three of subsection (e) of section [1302(a) of the24affordable care act, 42 U.S.C. § 18022(a)] three thousand two hundred 25 seventeen-i of this article; 26 (2) "grandfathered health plan" means coverage provided by an insurer 27 in which an individual was enrolled on March twenty-third, two thousand 28 ten for as long as the coverage maintains grandfathered status in 29 accordance with section 1251(e) of the affordable care act, 42 U.S.C. § 30 18011(e); 31 (3) "small group" means a group of [fifty or fewer employees or32members exclusive of spouses and dependents; provided, however, that33beginning January first, two thousand sixteen, "small group" means a34group of] one hundred or fewer employees or members exclusive of spouses 35 and dependents; and 36 (4) "association group" means a group defined in subparagraphs (B), 37 (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section 38 four thousand two hundred thirty-five of this chapter, provided that: 39 (A) the group includes one or more individual members; or 40 (B) the group includes one or more member employers or other member 41 groups that are small groups. 42 § 13. Subsection (i) of section 3221 of the insurance law, as added by 43 section 54 of part D of chapter 56 of the laws of 2013, is amended to 44 read as follows: 45 (i) An insurer shall not be required to offer the policyholder any 46 benefits that must be made available pursuant to this section if the 47 benefits must be covered pursuant to subsection (h) of this section. For 48 any policy issued within the health benefit exchange established [pursu-49ant to section 1311 of the affordable care act, 42 U.S.C. § 18031] by 50 this state, an insurer shall not be required to offer the policyholder 51 any benefits that must be made available pursuant to this section. 52 § 14. Paragraph 11 of subsection (k) of section 3221 of the insurance 53 law, as amended by chapter 469 of the laws of 2018, is amended to read 54 as follows: 55 (11) Every policy [which] that provides coverage for prescription 56 drugs shall include coverage for the cost of enteral formulas for homeS. 1507--C 46 A. 2007--C 1 use, whether administered orally or via tube feeding, for which a physi- 2 cian or other licensed health care provider legally authorized to 3 prescribe under title eight of the education law has issued a written 4 order. Such written order shall state that the enteral formula is clear- 5 ly medically necessary and has been proven effective as a disease-spe- 6 cific treatment regimen. Specific diseases and disorders for which 7 enteral formulas have been proven effective shall include, but are not 8 limited to, inherited diseases of amino-acid or organic acid metabolism; 9 Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal 10 motility such as chronic intestinal pseudo-obstruction; and multiple, 11 severe food allergies including, but not limited to immunoglobulin E and 12 nonimmunoglobulin E-mediated allergies to multiple food proteins; severe 13 food protein induced enterocolitis syndrome; eosinophilic disorders and 14 impaired absorption of nutrients caused by disorders affecting the 15 absorptive surface, function, length, and motility of the gastrointesti- 16 nal tract. Enteral formulas [which] that are medically necessary and 17 taken under written order from a physician for the treatment of specific 18 diseases shall be distinguished from nutritional supplements taken elec- 19 tively. Coverage for certain inherited diseases of amino acid and organ- 20 ic acid metabolism as well as severe protein allergic conditions shall 21 include modified solid food products that are low protein [or which], 22 contain modified protein, or are amino acid based [which] that are 23 medically necessary[, and such coverage for such modified solid food24products for any calendar year or for any continuous period of twelve25months for any insured individual shall not exceed two thousand five26hundred dollars]. 27 § 15. Intentionally omitted. 28 § 16. Paragraph 19 of subsection (k) of section 3221 of the insurance 29 law, as amended by chapter 377 of the laws of 2014, is amended to read 30 as follows: 31 (19) Every group or blanket accident and health insurance policy 32 delivered or issued for delivery in this state [which] that provides 33 medical coverage that includes coverage for physician services in a 34 physician's office and every policy [which] that provides major medical 35 or similar comprehensive-type coverage shall include coverage for equip- 36 ment and supplies used for the treatment of ostomies, if prescribed by a 37 physician or other licensed health care provider legally authorized to 38 prescribe under title eight of the education law. Such coverage shall be 39 subject to annual deductibles and coinsurance as deemed appropriate by 40 the superintendent. The coverage required by this paragraph shall be 41 identical to, and shall not enhance or increase the coverage required as 42 part of essential health benefits as [required pursuant to] defined in 43 subsection (a) of section [2707 (a) of the public health services act 4244U.S.C. 300 gg-6(a)] three thousand two hundred seventeen-i of this 45 article. 46 § 17. Intentionally omitted. 47 § 18. Intentionally omitted. 48 § 19. Intentionally omitted. 49 § 20. Paragraph 4 of subsection (a) of section 3231 of the insurance 50 law, as amended by section 69 of part D of chapter 56 of the laws of 51 2013, is amended to read as follows: 52 (4) For the purposes of this section, "community rated" means a rating 53 methodology in which the premium for all persons covered by a policy 54 form is the same based on the experience of the entire pool of risks of 55 all individuals or small groups covered by the insurer without regard to 56 age, sex, health status, tobacco usage or occupation, excluding thoseS. 1507--C 47 A. 2007--C 1 individuals or small groups covered by medicare supplemental insurance. 2 For medicare supplemental insurance coverage, "community rated" means a 3 rating methodology in which the premiums for all persons covered by a 4 policy or contract form is the same based on the experience of the 5 entire pool of risks covered by that policy or contract form without 6 regard to age, sex, health status, tobacco usage or occupation. 7 [Catastrophic health insurance policies issued pursuant to section81302(e) of the affordable care act, 42 U.S.C. § 18022(e), shall be clas-9sified in a distinct community rating pool.] 10 § 21. Subsection (d) of section 3240 of the insurance law, as added by 11 section 41 of part D of chapter 56 of the laws of 2013, is amended to 12 read as follows: 13 (d) A student accident and health insurance policy or contract shall 14 provide coverage for essential health benefits as defined in subsection 15 (a) of section [1302(b) of the affordable care act, 42 U.S.C. §1618022(b)] three thousand two hundred seventeen-i or subsection (a) of 17 section four thousand three hundred six-h of this chapter, as 18 applicable. 19 § 22. Subparagraph (A) of paragraph 3 of subsection (d) of section 20 4235 of the insurance law, as added by section 60 of part D of chapter 21 56 of the laws of 2013, is amended to read as follows: 22 (A) "employee" shall have the meaning set forth in [section 2791 of23the public health service act, 42 U.S.C. § 300gg-91(d)(5) or any regu-24lations promulgated thereunder] the Employee Retirement Income Security 25 Act of 1974, 29 U.S.C. § 1002(6); and 26 § 23. Intentionally omitted. 27 § 24. Intentionally omitted. 28 § 25. Intentionally omitted. 29 § 26. Subsection (u-1) of section 4303 of the insurance law, as 30 amended by chapter 377 of the laws of 2014, is amended to read as 31 follows: 32 (u-1) A medical expense indemnity corporation or a health service 33 corporation which provides medical coverage that includes coverage for 34 physician services in a physician's office and every policy which 35 provides major medical or similar comprehensive-type coverage shall 36 include coverage for equipment and supplies used for the treatment of 37 ostomies, if prescribed by a physician or other licensed health care 38 provider legally authorized to prescribe under title eight of the educa- 39 tion law. Such coverage shall be subject to annual deductibles and coin- 40 surance as deemed appropriate by the superintendent. The coverage 41 required by this subsection shall be identical to, and shall not enhance 42 or increase the coverage required as part of essential health benefits 43 as [required pursuant to] defined in subsection (a) of section [2707(a)44of the public health services act 42 U.S.C. 300 gg-6(a)] four thousand 45 three hundred six-h of this article. 46 § 27. Subsection (y) of section 4303 of the insurance law, as amended 47 by chapter 469 of the laws of 2018, is amended to read as follows: 48 (y) Every contract [which] that provides coverage for prescription 49 drugs shall include coverage for the cost of enteral formulas for home 50 use, whether administered orally or via tube feeding, for which a physi- 51 cian or other licensed health care provider legally authorized to 52 prescribe under title eight of the education law has issued a written 53 order. Such written order shall state that the enteral formula is clear- 54 ly medically necessary and has been proven effective as a disease-spe- 55 cific treatment regimen. Specific diseases and disorders for which 56 enteral formulas have been proven effective shall include, but are notS. 1507--C 48 A. 2007--C 1 limited to, inherited diseases of amino-acid or organic acid metabolism; 2 Crohn's Disease; gastroesophageal reflux; disorders of gastrointestinal 3 motility such as chronic intestinal pseudo-obstruction; and multiple, 4 severe food allergies including, but not limited to immunoglobulin E and 5 nonimmunoglobulin E-mediated allergies to multiple food proteins; severe 6 food protein induced enterocolitis syndrome; eosinophilic disorders; and 7 impaired absorption of nutrients caused by disorders affecting the 8 absorptive surface, function, length, and motility of the gastrointesti- 9 nal tract. Enteral formulas [which] that are medically necessary and 10 taken under written order from a physician for the treatment of specific 11 diseases shall be distinguished from nutritional supplements taken elec- 12 tively. Coverage for certain inherited diseases of amino acid and organ- 13 ic acid metabolism as well as severe protein allergic conditions shall 14 include modified solid food products that are low protein, [or which] 15 contain modified protein, or are amino acid based [which] that are 16 medically necessary[, and such coverage for such modified solid food17products for any calendar year or for any continuous period of twelve18months for any insured individual shall not exceed two thousand five19hundred dollars]. 20 § 28. Intentionally omitted. 21 § 29. Subsection (ll) of section 4303 of the insurance law, as added 22 by section 55 of part D of chapter 56 of the laws of 2013, is amended to 23 read as follows: 24 (ll) Every small group contract or association group contract [deliv-25ered or issued for delivery in this state] issued by a corporation 26 subject to the provisions of this article that provides coverage for 27 hospital, medical or surgical expense insurance and is not a grandfa- 28 thered health plan shall provide coverage for the essential health 29 [benefit] benefits package [as required in section 2707(a) of the public30health service act, 42 U.S.C. § 300gg-6(a)]. For purposes of this 31 subsection: 32 (1) "essential health benefits package" shall have the meaning set 33 forth in paragraph three of subsection (e) of section [1302(a) of the34affordable care act, 42 U.S.C. § 18022(a)] four thousand three hundred 35 six-h of this article; 36 (2) "grandfathered health plan" means coverage provided by a corpo- 37 ration in which an individual was enrolled on March twenty-third, two 38 thousand ten for as long as the coverage maintains grandfathered status 39 in accordance with section 1251(e) of the affordable care act, 42 U.S.C. 40 § 18011(e); and 41 (3) "small group" means a group of [fifty or fewer employees or42members exclusive of spouses and dependents. Beginning January first,43two thousand sixteen, "small group" means a group of] one hundred or 44 fewer employees or members exclusive of spouses and dependents; and 45 (4) "association group" means a group defined in subparagraphs (B), 46 (D), (H), (K), (L) or (M) of paragraph one of subsection (c) of section 47 four thousand two hundred thirty-five of this chapter, provided that: 48 (A) the group includes one or more individual members; or 49 (B) the group includes one or more member employers or other member 50 groups that are small groups. 51 § 30. Subsection (mm) of section 4303 of the insurance law, as added 52 by section 55 of part D of chapter 56 of the laws of 2013, is amended to 53 read as follows: 54 (mm) A corporation shall not be required to offer the contract holder 55 any benefits that must be made available pursuant to this section if 56 such benefits must be covered pursuant to subsection (kk) of thisS. 1507--C 49 A. 2007--C 1 section. For any contract issued within the health benefit exchange 2 established [pursuant to section 1311 of the affordable care act, 423U.S.C. § 18031] by this state, a corporation shall not be required to 4 offer the contract holder any benefits that must be made available 5 pursuant to this section. 6 § 31. Item (i) of subparagraph (C) of paragraph 2 of subsection (c) of 7 section 4304 of the insurance law, as amended by chapter 317 of the laws 8 of 2017, is amended to read as follows: 9 (i) Discontinuance of a class of contract upon not less than ninety 10 days' prior written notice. In exercising the option to discontinue 11 coverage pursuant to this item, the corporation must act uniformly with- 12 out regard to any health status-related factor of enrolled individuals 13 or individuals who may become eligible for such coverage and must offer 14 to subscribers or group remitting agents, as may be appropriate, the 15 option to purchase all other individual health insurance coverage 16 currently being offered by the corporation to applicants in that market. 17 Provided, however, the superintendent may, after giving due consider- 18 ation to the public interest, approve a request made by a corporation 19 for the corporation to satisfy the requirements of this item through the 20 offering of contracts at each level of coverage as defined in subsection 21 (b) of section [1302(d) of the affordable care act, 42 U.S.C. §2218022(d)] four thousand three hundred six-h of this article that 23 contains the essential health benefits package described in paragraph 24 [one] three of subsection [(b)] (e) of section four thousand three 25 hundred [twenty-eight] six-h of this [chapter] article by another corpo- 26 ration, insurer or health maintenance organization within the corpo- 27 ration's same holding company system, as defined in article fifteen of 28 this chapter. 29 § 32. Paragraph 1 of subsection (e) of section 4304 of the insurance 30 law, as amended by chapter 388 of the laws of 2014, is amended to read 31 as follows: 32 (1) (A) If any such contract is terminated in accordance with the 33 provisions of paragraph one of subsection (c) of this section, or any 34 such contract is terminated because of a default by the remitting agent 35 in the payment of premiums not cured within the grace period and the 36 remitting agent has not replaced the contract with similar and contin- 37 uous coverage for the same group whether insured or self-insured, or any 38 such contract is terminated in accordance with the provisions of subpar- 39 agraph (E) of paragraph two of subsection (c) of this section, or if an 40 individual other than the contract holder is no longer covered under a 41 "family contract" because the individual is no longer within the defi- 42 nition set forth in the contract, or a spouse is no longer covered under 43 the contract because of divorce from the contract holder or annulment of 44 the marriage, or any such contract is terminated because of the death of 45 the contract holder, then such individual, former spouse, or in the case 46 of the death of the contract holder the surviving spouse or other depen- 47 dents of the deceased contract holder covered under the contract, as the 48 case may be, shall be entitled to convert, without evidence of insura- 49 bility, upon application therefor and the making of the first payment 50 thereunder within sixty days after the date of termination of such 51 contract, to a contract that contains the essential health benefits 52 package described in paragraph [one] three of subsection [(b)] (e) of 53 section four thousand three hundred [twenty-eight] six-h of this [chap-54ter] article. 55 (B) The corporation shall offer one contract at each level of coverage 56 as defined in subsection (b) of section [1302(d) of the affordable careS. 1507--C 50 A. 2007--C 1act, 42 U.S.C. § 18022(d)] four thousand three hundred six-h of this 2 article. The individual may choose any such contract offered by the 3 corporation. Provided, however, the superintendent may, after giving due 4 consideration to the public interest, approve a request made by a corpo- 5 ration for the corporation to satisfy the requirements of this paragraph 6 through the offering of contracts that comply with this paragraph by 7 another corporation, insurer or health maintenance organization within 8 the corporation's same holding company system, as defined in article 9 fifteen of this chapter. 10 (C) The effective date of the coverage provided by the converted 11 direct payment contract shall be the date of the termination of coverage 12 under the contract from which conversion was made. 13 § 33. Subsection (l) of section 4304 of the insurance law, as added by 14 section 43 of part D of chapter 56 of the laws of 2013, is amended to 15 read as follows: 16 (l) [On and after October first, two thousand thirteen, a] A corpo- 17 ration shall not offer individual hospital, medical, or surgical expense 18 insurance contracts unless the contracts meet the requirements of 19 subsection (b) of section four thousand three hundred twenty-eight of 20 this article. Such contracts that are offered within the health benefit 21 exchange established [pursuant to section 1311 of the affordable care22act, 42 U.S.C. § 18031, or any regulations promulgated thereunder,] by 23 this state also shall meet any requirements established by the health 24 benefit exchange. To the extent that a holder of a special purpose 25 certificate of authority issued pursuant to section four thousand four 26 hundred three-a of the public health law offers individual hospital, 27 medical, or surgical expense insurance contracts, the contracts shall 28 meet the requirements of subsection (b) of section four thousand three 29 hundred twenty-eight of this article. 30 § 34. Subparagraph (A) of paragraph 1 of subsection (d) of section 31 4305 of the insurance law, as amended by chapter 388 of the laws of 32 2014, is amended to read as follows: 33 (A) A group contract issued pursuant to this section shall contain a 34 provision to the effect that in case of a termination of coverage under 35 such contract of any member of the group because of (i) termination for 36 any reason whatsoever of the member's employment or membership, or (ii) 37 termination for any reason whatsoever of the group contract itself 38 unless the group contract holder has replaced the group contract with 39 similar and continuous coverage for the same group whether insured or 40 self-insured, the member shall be entitled to have issued to the member 41 by the corporation, without evidence of insurability, upon application 42 therefor and payment of the first premium made to the corporation within 43 sixty days after termination of the coverage, an individual direct 44 payment contract, covering such member and the member's eligible depen- 45 dents who were covered by the group contract, which provides coverage 46 that contains the essential health benefits package described in para- 47 graph [one] three of subsection [(b)] (e) of section four thousand three 48 hundred [twenty-eight] six-h of this [chapter] article. The corporation 49 shall offer one contract at each level of coverage as defined in 50 subsection (b) of section [1302(d) of the affordable care act, 42 U.S.C.51§ 18022(d)] four thousand three hundred six-h of this article. The 52 member may choose any such contract offered by the corporation. 53 Provided, however, the superintendent may, after giving due consider- 54 ation to the public interest, approve a request made by a corporation 55 for the corporation to satisfy the requirements of this subparagraph 56 through the offering of contracts that comply with this subparagraph byS. 1507--C 51 A. 2007--C 1 another corporation, insurer or health maintenance organization within 2 the corporation's same holding company system, as defined in article 3 fifteen of this chapter. 4 § 35. The insurance law is amended by adding a new section 4306-h to 5 read as follows: 6 § 4306-h. Essential health benefits package and limit on cost-sharing. 7 (a) (1) For purposes of this article, "essential health benefits" shall 8 mean the following categories of benefits: 9 (A) ambulatory patient services; 10 (B) emergency services; 11 (C) hospitalization; 12 (D) maternity and newborn care; 13 (E) mental health and substance use disorder services, including 14 behavioral health treatment; 15 (F) prescription drugs; 16 (G) rehabilitative and habilitative services and devices; 17 (H) laboratory services; 18 (I) preventive and wellness services and chronic disease management; 19 and 20 (J) pediatric services, including oral and vision care. 21 (2) A corporation shall not be required to provide coverage for pedia- 22 tric oral services as an essential health benefit if: 23 (A) for coverage offered through the exchange established by this 24 state, the exchange has determined sufficient coverage of the pediatric 25 oral benefit is available through stand-alone dental plans certified by 26 the exchange; or 27 (B) for coverage offered outside the exchange, the corporation obtains 28 reasonable written assurance that the individual or group has obtained a 29 stand-alone dental plan that has been approved by the superintendent as 30 meeting exchange certification standards. 31 (b) (1) Every individual and small group contract that provides hospi- 32 tal, surgical, or medical expense coverage and is not a grandfathered 33 health plan shall provide coverage that meets the actuarial requirements 34 of one of the following levels of coverage: 35 (A) Bronze Level. A plan in the bronze level shall provide a level of 36 coverage that is designed to provide benefits that are actuarially 37 equivalent to sixty percent of the full actuarial value of the benefits 38 provided under the plan; 39 (B) Silver Level. A plan in the silver level shall provide a level of 40 coverage that is designed to provide benefits that are actuarially 41 equivalent to seventy percent of the full actuarial value of the bene- 42 fits provided under the plan; 43 (C) Gold Level. A plan in the gold level shall provide a level of 44 coverage that is designed to provide benefits that are actuarially 45 equivalent to eighty percent of the full actuarial value of the benefits 46 provided under the plan; or 47 (D) Platinum Level. A plan in the platinum level shall provide a level 48 of coverage that is designed to provide benefits that are actuarially 49 equivalent to ninety percent of the full actuarial value of the benefits 50 provided under the plan. 51 (2) The superintendent may provide for a variation in the actuarial 52 values used in determining the level of coverage of a plan to account 53 for the differences in actuarial estimates. 54 (3) Every student accident and health insurance contract shall provide 55 coverage that meets at least sixty percent of the full actuarial value 56 of the benefits provided under the contract. The contract's schedule ofS. 1507--C 52 A. 2007--C 1 benefits shall include the level as described in paragraph one of this 2 subsection nearest to, but below the actual actuarial value. 3 (c) Every individual or group contract that provides hospital, surgi- 4 cal, or medical expense coverage and is not a grandfathered health plan, 5 and every student accident and health insurance contract shall limit the 6 insured's cost-sharing for in-network services in a contract year to not 7 more than the maximum out-of-pocket amount determined by the superinten- 8 dent for all contracts subject to this section. Such amount shall not 9 exceed any annual out-of-pocket limit on cost-sharing set by the United 10 States secretary of health and human services, if available. 11 (d) The superintendent may require the use of model language describ- 12 ing the coverage requirements for any form that is subject to the 13 approval of the superintendent pursuant to section four thousand three 14 hundred eight of this article. 15 (e) For purposes of this section: 16 (1) "actuarial value" means the percentage of the total expected 17 payments by the corporation for benefits provided to a standard popu- 18 lation, without regard to the population to whom the corporation actual- 19 ly provides benefits; 20 (2) "cost-sharing" means annual deductibles, coinsurance, copayments, 21 or similar charges, for covered services; 22 (3) "essential health benefits package" means coverage that: 23 (A) provides for essential health benefits; 24 (B) limits cost-sharing for such coverage in accordance with 25 subsection (c) of this section; and 26 (C) provides one of the levels of coverage described in subsection (b) 27 of this section; 28 (4) "grandfathered health plan" means coverage provided by a corpo- 29 ration in which an individual was enrolled on March twenty-third, two 30 thousand ten for as long as the coverage maintains grandfathered status 31 in accordance with section 1251(e) of the Affordable Care Act, 42 U.S.C. 32 § 18011(e); 33 (5) "small group" means a group of one hundred or fewer employees or 34 members exclusive of spouses and dependents; and 35 (6) "student accident and health insurance" shall have the meaning set 36 forth in subsection (a) of section three thousand two hundred forty of 37 this chapter. 38 § 36. Paragraph 4 of subsection (a) of section 4317 of the insurance 39 law, as amended by section 72 of part D of chapter 56 of the laws of 40 2013, is amended to read as follows: 41 (4) For the purposes of this section, "community rated" means a rating 42 methodology in which the premium for all persons covered by a policy or 43 contract form is the same, based on the experience of the entire pool of 44 risks of all individuals or small groups covered by the corporation 45 without regard to age, sex, health status, tobacco usage or occupation 46 excluding those individuals of small groups covered by Medicare supple- 47 mental insurance. For medicare supplemental insurance coverage, "commu- 48 nity rated" means a rating methodology in which the premiums for all 49 persons covered by a policy or contract form is the same based on the 50 experience of the entire pool of risks covered by that policy or 51 contract form without regard to age, sex, health status, tobacco usage 52 or occupation. [Catastrophic health insurance contracts issued pursuant53to section 1302(e) of the affordable care act, 42 U.S.C. § 18022(e),54shall be classified in a distinct community rating pool.]S. 1507--C 53 A. 2007--C 1 § 37. Subsections (d), (e) and (j) of section 4326 of the insurance 2 law, as amended by section 56 of part D of chapter 56 of the laws of 3 2013, are amended to read as follows: 4 (d) A qualifying group health insurance contract shall provide cover- 5 age for the essential health [benefit] benefits package as [required in] 6 defined in paragraph three of subsection (e) of section [2707(a) of the7public health service act, 42 U.S.C. § 300gg-6(a). For purposes of this8subsection "essential health benefits package" shall have the meaning9set forth in section 1302(a) of the affordable care act, 42 U.S.C. §1018022(a)] four thousand three hundred six-h of this article. 11 (e) A qualifying group health insurance contract [issued to a qualify-12ing small employer prior to January first, two thousand fourteen that13does not include all essential health benefits required pursuant to14section 2707(a) of the public health service act, 42 U.S.C. §15300gg-6(a), shall be discontinued, including grandfathered health plans.16For the purposes of this paragraph, "grandfathered health plans" means17coverage provided by a corporation to individuals who were enrolled on18March twenty-third, two thousand ten for as long as the coverage main-19tains grandfathered status in accordance with section 1251(e) of the20affordable care act, 42 U.S.C. § 18011(e). A qualifying small employer21shall be transitioned to a plan that provides: (1)] shall provide a 22 level of coverage that is designed to provide benefits that are actuari- 23 ally equivalent to eighty percent of the full actuarial value of the 24 benefits provided under the plan[; and (2) coverage for the essential25health benefit package as required in section 2707(a) of the public26health service act, 42 U.S.C. § 300gg-6(a)]. The superintendent shall 27 standardize the benefit package and cost sharing requirements of quali- 28 fied group health insurance contracts consistent with coverage offered 29 through the health benefit exchange established [pursuant to section301311 of the affordable care act, 42 U.S.C. § 18031] by this state. 31 (j) [Beginning January first, two thousand fourteen, pursuant to32section 2704 of the Public Health Service Act, 42 U.S.C. § 300gg-3, a] A 33 corporation shall not impose any pre-existing condition limitation in a 34 qualifying group health insurance contract. 35 § 38. Subsection (m-1) of section 4327 of the insurance law, as 36 amended by section 58 of part D of chapter 56 of the laws of 2013, is 37 amended to read as follows: 38 (m-1) In the event that the superintendent suspends the enrollment of 39 new individuals for qualifying group health insurance contracts, the 40 superintendent shall ensure that small employers seeking to enroll in a 41 qualified group health insurance contract pursuant to section forty- 42 three hundred twenty-six of this article are provided information on and 43 directed to coverage options available through the health benefit 44 exchange established [pursuant to section 1311 of the affordable care45act, 42 U.S.C. § 18031] by this state. 46 § 39. Paragraphs 1, 2 and 3 of subsection (b) of section 4328 of the 47 insurance law, as added by section 46 of part D of chapter 56 of the 48 laws of 2013, are amended to read as follows: 49 (1) The individual enrollee direct payment contract offered pursuant 50 to this section shall provide coverage for the essential health [bene-51fit] benefits package as [required in] defined in paragraph three of 52 subsection (e) of section [2707(a) of the public health service act, 4253U.S.C. § 300gg-6(a). For purposes of this paragraph, "essential health54benefits package" shall have the meaning set forth in section 1302(a) of55the affordable care act, 42 U.S.C. § 18022(a)] four thousand three 56 hundred six-h of this article.S. 1507--C 54 A. 2007--C 1 (2) A health maintenance organization shall offer at least one indi- 2 vidual enrollee direct payment contract at each level of coverage as 3 defined in subsection (b) of section [1302(d) of the affordable care4act, 42 U.S.C. § 18022(d)] four thousand three hundred six-h of this 5 article. A health maintenance organization also shall offer one child- 6 only plan, as required by section 1302(f) of the affordable care act, 42 7 U.S.C. § 18022(f), at each level of coverage [as required in section82707(c) of the public health service act, 42 U.S.C. § 300gg-6(c)]. 9 (3) Within the health benefit exchange established [pursuant to10section 1311 of the affordable care act, 42 U.S.C. § 18031] by this 11 state, a health maintenance organization may offer an individual enrol- 12 lee direct payment contract that is a catastrophic health plan as 13 defined in section 1302(e) of the affordable care act, 42 U.S.C. § 14 18022(e), or any regulations promulgated thereunder. 15 § 40. Subparagraph (A) of paragraph 4 of subsection (b) of section 16 4328 of the insurance law, as added by chapter 11 of the laws of 2016, 17 is amended to read as follows: 18 (A) The individual enrollee direct payment contract offered pursuant 19 to this section shall have the same enrollment periods, including 20 special enrollment periods, as required for an individual direct payment 21 contract offered within the health benefit exchange established [pursu-22ant to section 1311 of the affordable care act, 42 U.S.C. § 18031, or23any regulations promulgated thereunder] by this state. 24 § 41. Subsection (c) of section 4328 of the insurance law, as added by 25 section 46 of part D of chapter 56 of the laws of 2013, is amended to 26 read as follows: 27 (c) In addition to or in lieu of the individual enrollee direct 28 payment contracts required under this section, all health maintenance 29 organizations issued a certificate of authority under article forty-four 30 of the public health law or licensed under this article may offer indi- 31 vidual enrollee direct payment contracts within the health benefit 32 exchange established [pursuant to section 1311 of the affordable care33act, 42 U.S.C. § 18031, or any regulations promulgated thereunder] by 34 this state, subject to any requirements established by the health bene- 35 fit exchange. If a health maintenance organization satisfies the 36 requirements of subsection (a) of this section by offering individual 37 enrollee direct payment contracts, only within the health benefit 38 exchange, the health maintenance organization, not including a holder of 39 a special purpose certificate of authority issued pursuant to section 40 four thousand four hundred three-a of the public health law, shall also 41 offer at least one individual enrollee direct payment contract at each 42 level of coverage as defined in subsection (b) section [1302 (d) of the43affordable care act, 42 U.S.C. § 18022 (d)] four thousand three hundred 44 six-h of this article, outside the health benefit exchange. 45 § 42. This act shall take effect on the first of January next succeed- 46 ing the date on which it shall have become a law and shall apply to all 47 policies and contracts issued, renewed, modified, altered or amended on 48 or after such date. 49 SUBPART C 50 Section 1. The insurance law is amended by adding a new section 3242 51 to read as follows: 52 § 3242. Prescription drug coverage. (a) Every insurer that delivers 53 or issues for delivery in this state a policy that provides coverage for 54 prescription drugs shall, with respect to the prescription drug cover-S. 1507--C 55 A. 2007--C 1 age, publish an up-to-date, accurate, and complete list of all covered 2 prescription drugs on its formulary drug list, including any tiering 3 structure that it has adopted and any restrictions on the manner in 4 which a prescription drug may be obtained, in a manner that is easily 5 accessible to insureds and prospective insureds. The formulary drug list 6 shall clearly identify the preventive prescription drugs that are avail- 7 able without annual deductibles or coinsurance, including co-payments. 8 (b) (1) Every policy delivered or issued for delivery in this state 9 that provides coverage for prescription drugs shall include in the poli- 10 cy a process that allows an insured, the insured's designee, or the 11 insured's prescribing health care provider to request a formulary excep- 12 tion. With respect to the process for such a formulary exception, an 13 insurer shall follow the process and procedures specified in article 14 forty-nine of this chapter and article forty-nine of the public health 15 law, except as otherwise provided in paragraphs two, three, four and 16 five of this subsection. 17 (2) (A) An insurer shall have a process for an insured, the insured's 18 designee, or the insured's prescribing health care provider to request a 19 standard review that is not based on exigent circumstances of a formu- 20 lary exception for a prescription drug that is not covered by the poli- 21 cy. 22 (B) An insurer shall make a determination on a standard exception 23 request that is not based on exigent circumstances and notify the 24 insured or the insured's designee and the insured's prescribing health 25 care provider by telephone of its coverage determination no later than 26 seventy-two hours following receipt of the request. 27 (C) An insurer that grants a standard exception request that is not 28 based on exigent circumstances shall provide coverage of the non-formu- 29 lary prescription drug for the duration of the prescription, including 30 refills. 31 (D) For the purpose of this subsection, "exigent circumstances" means 32 when an insured is suffering from a health condition that may seriously 33 jeopardize the insured's life, health, or ability to regain maximum 34 function or when an insured is undergoing a current course of treatment 35 using a non-formulary prescription drug. 36 (3) (A) An insurer shall have a process for an insured, the insured's 37 designee, or the insured's prescribing health care provider to request 38 an expedited review based on exigent circumstances of a formulary excep- 39 tion for a prescription drug that is not covered by the policy. 40 (B) An insurer shall make a determination on an expedited review 41 request based on exigent circumstances and notify the insured or the 42 insured's designee and the insured's prescribing health care provider by 43 telephone of its coverage determination no later than twenty-four hours 44 following receipt of the request. 45 (C) An insurer that grants an exception based on exigent circumstances 46 shall provide coverage of the non-formulary prescription drug for the 47 duration of the exigent circumstances. 48 (4) An insurer that denies an exception request under paragraph two or 49 three of this subsection shall provide written notice of its determi- 50 nation to the insured or the insured's designee and the insured's 51 prescribing health care provider within three business days of receipt 52 of the exception request. The written notice shall be considered a final 53 adverse determination under section four thousand nine hundred four of 54 this chapter or section four thousand nine hundred four of the public 55 health law. Written notice shall also include the name or names of clin-S. 1507--C 56 A. 2007--C 1 ically appropriate prescription drugs covered by the insurer to treat 2 the insured. 3 (5) (A) If an insurer denies a request for an exception under para- 4 graph two or three of this subsection, the insured, the insured's desig- 5 nee, or the insured's prescribing health care provider shall have the 6 right to request that such denial be reviewed by an external appeal 7 agent certified by the superintendent pursuant to section four thousand 8 nine hundred eleven of this chapter in accordance with article forty- 9 nine of this chapter or article forty-nine of the public health law. 10 (B) An external appeal agent shall make a determination on the 11 external appeal and notify the insurer, the insured or the insured's 12 designee, and the insured's prescribing health care provider by tele- 13 phone of its determination no later than seventy-two hours following the 14 external appeal agent's receipt of the request, if the original request 15 was a standard exception request under paragraph two of this subsection. 16 The external appeal agent shall notify the insurer, the insured or the 17 insured's designee, and the insured's prescribing health care provider 18 in writing of the external appeal determination within two business days 19 of rendering such determination. 20 (C) An external appeal agent shall make a determination on the 21 external appeal and notify the insurer, the insured or the insured's 22 designee, and the insured's prescribing health care provider by tele- 23 phone of its determination no later than twenty-four hours following the 24 external appeal agent's receipt of the request, if the original request 25 was an expedited exception request under paragraph three of this 26 subsection and the insured's prescribing health care provider attests 27 that exigent circumstances exist. The external appeal agent shall notify 28 the insurer, the insured or the insured's designee, and the insured's 29 prescribing health care provider in writing of the external appeal 30 determination within seventy-two hours of the external appeal agent's 31 receipt of the external appeal. 32 (D) An external appeal agent shall make a determination in accordance 33 with subparagraph (A) of paragraph four of subsection (b) of section 34 four thousand nine hundred fourteen of this chapter or subparagraph (A) 35 of paragraph (d) of subdivision two of section four thousand nine 36 hundred fourteen of the public health law. When making a determination, 37 the external appeal agent shall consider whether the formulary 38 prescription drug covered by the insurer will be or has been ineffec- 39 tive, would not be as effective as the non-formulary prescription drug, 40 or would have adverse effects. 41 (E) If an external appeal agent overturns the insurer's denial of a 42 standard exception request under paragraph two of this subsection, then 43 the insurer shall provide coverage of the non-formulary prescription 44 drug for the duration of the prescription, including refills. If an 45 external appeal agent overturns the insurer's denial of an expedited 46 exception request under paragraph three of this subsection, then the 47 insurer shall provide coverage of the non-formulary prescription drug 48 for the duration of the exigent circumstances. 49 § 2. The insurance law is amended by adding a new section 4329 to read 50 as follows: 51 § 4329. Prescription drug coverage. (a) Every corporation subject to 52 the provisions of this article that issues a contract that provides 53 coverage for prescription drugs shall, with respect to the prescription 54 drug coverage, publish an up-to-date, accurate, and complete list of all 55 covered prescription drugs on its formulary drug list, including any 56 tiering structure that it has adopted and any restrictions on the mannerS. 1507--C 57 A. 2007--C 1 in which a prescription drug may be obtained, in a manner that is easily 2 accessible to insureds and prospective insureds. The formulary drug list 3 shall clearly identify the preventive prescription drugs that are avail- 4 able without annual deductibles or coinsurance, including co-payments. 5 (b) (1) Every contract issued by a corporation subject to the 6 provisions of this article that provides coverage for prescription drugs 7 shall include in the contract a process that allows an insured, the 8 insured's designee, or the insured's prescribing health care provider to 9 request a formulary exception. With respect to the process for such a 10 formulary exception, a corporation shall follow the process and proce- 11 dures specified in article forty-nine of this chapter and article 12 forty-nine of the public health law, except as otherwise provided in 13 paragraphs two, three, four and five of this subsection. 14 (2) (A) A corporation shall have a process for an insured, the 15 insured's designee, or the insured's prescribing health care provider to 16 request a standard review that is not based on exigent circumstances of 17 a formulary exception for a prescription drug that is not covered by the 18 contract. 19 (B) A corporation shall make a determination on a standard exception 20 request that is not based on exigent circumstances and notify the 21 insured or the insured's designee and the insured's prescribing health 22 care provider by telephone of its coverage determination no later than 23 seventy-two hours following receipt of the request. 24 (C) A corporation that grants a standard exception request that is not 25 based on exigent circumstances shall provide coverage of the non-formu- 26 lary prescription drug for the duration of the prescription, including 27 refills. 28 (D) For the purpose of this subsection, "exigent circumstances" means 29 when an insured is suffering from a health condition that may seriously 30 jeopardize the insured's life, health, or ability to regain maximum 31 function or when an insured is undergoing a current course of treatment 32 using a non-formulary prescription drug. 33 (3) (A) A corporation shall have a process for an insured, the 34 insured's designee, or the insured's prescribing health care provider to 35 request an expedited review based on exigent circumstances of a formu- 36 lary exception for a prescription drug is not covered by the contract. 37 (B) A corporation shall make a determination on an expedited review 38 request based on exigent circumstances and notify the insured or the 39 insured's designee and the insured's prescribing health care provider by 40 telephone of its coverage determination no later than twenty-four hours 41 following receipt of the request. 42 (C) A corporation that grants an exception based on exigent circum- 43 stances shall provide coverage of the non-formulary prescription drug 44 for the duration of the exigent circumstances. 45 (4) A corporation that denies an exception request under paragraph two 46 or three of this subsection shall provide written notice of its determi- 47 nation to the insured or the insured's designee and the insured's 48 prescribing health care provider within three business days of receipt 49 of the exception request. The written notice shall be considered a final 50 adverse determination under section four thousand nine hundred four of 51 this chapter or section four thousand nine hundred four of the public 52 health law. Written notice shall also include the name or names of clin- 53 ically appropriate prescription drugs covered by the corporation to 54 treat the insured. 55 (5) (A) If a corporation denies a request for an exception under para- 56 graph two or three of this subsection, the insured, the insured's desig-S. 1507--C 58 A. 2007--C 1 nee, or the insured's prescribing health care provider shall have the 2 right to request that such denial be reviewed by an external appeal 3 agent certified by the superintendent pursuant to section four thousand 4 nine hundred eleven of this chapter in accordance with article forty- 5 nine of this chapter and article forty-nine of the public health law. 6 (B) An external appeal agent shall make a determination on the 7 external appeal and notify the corporation, the insured or the insured's 8 designee, and the insured's prescribing health care provider by tele- 9 phone of its determination no later than seventy-two hours following the 10 external appeal agent's receipt of the request, if the original request 11 was a standard exception request under paragraph two of this subsection. 12 The external appeal agent shall notify the corporation, the insured or 13 the insured's designee and the insured's prescribing health care provid- 14 er in writing of the external appeal determination within two business 15 days of rendering such determination. 16 (C) An external appeal agent shall make a determination on the 17 external appeal and notify the corporation, the insured or the insured's 18 designee, and the insured's prescribing health care provider by tele- 19 phone of its determination no later than twenty-four hours following the 20 external appeal agent's receipt of the request, if the original request 21 was an expedited exception request under paragraph three of this 22 subsection and the insured's prescribing health care provider attests 23 that exigent circumstances exist. The external appeal agent shall notify 24 the corporation, the insured or the insured's designee and the insured's 25 prescribing health care provider in writing of the external appeal 26 determination within seventy-two hours of the external appeal agent's 27 receipt of the external appeal. 28 (D) An external appeal agent shall make a determination in accordance 29 with subparagraph (A) of paragraph four of subsection (b) of section 30 four thousand nine hundred fourteen of this chapter and subparagraph (A) 31 of paragraph (d) of subdivision two of section four thousand nine 32 hundred fourteen of the public health law. When making a determination, 33 the external appeal agent shall consider whether the formulary 34 prescription drug covered by the corporation will be or has been inef- 35 fective, would not be as effective as the non-formulary prescription 36 drug, or would have adverse effects. 37 (E) If an external appeal agent overturns the corporation's denial of 38 a standard exception request under paragraph two of this subsection, 39 then the corporation shall provide coverage of the non-formulary 40 prescription drug for the duration of the prescription, including 41 refills. If an external appeal agent overturns the corporation's denial 42 of an expedited exception request under paragraph three of this 43 subsection, then the corporation shall provide coverage of the non-for- 44 mulary prescription drug for the duration of the exigent circumstances. 45 § 3. This act shall take effect on the first of January next succeed- 46 ing the date on which it shall have become a law and shall apply to all 47 policies and contracts issued, renewed, modified, altered or amended on 48 or after such date. 49 SUBPART D 50 Section 1. Section 2607 of the insurance law is amended to read as 51 follows: 52 § 2607. Discrimination because of sex or marital status. (a) No indi- 53 vidual or entity shall refuse to issue any policy of insurance, or 54 cancel or decline to renew [such] the policy because of the sex or mari-S. 1507--C 59 A. 2007--C 1 tal status of the applicant or policyholder or engage in sexual stere- 2 otyping. 3 (b) For the purposes of this section, "sex" shall include sexual 4 orientation, gender identity or expression, and transgender status. 5 § 2. The insurance law is amended by adding a new section 3243 to read 6 as follows: 7 § 3243. Discrimination because of sex or marital status in hospital, 8 surgical or medical expense insurance. (a) With regard to an accident 9 and health insurance policy that provides hospital, surgical, or medical 10 expense coverage or a policy of student accident and health insurance, 11 as defined in subsection (a) of section three thousand two hundred forty 12 of this article, delivered or issued for delivery in this state, no 13 insurer shall because of sex, marital status or based on pregnancy, 14 false pregnancy, termination of pregnancy, or recovery therefrom, child- 15 birth or related medical conditions: 16 (1) make any distinction or discrimination between persons as to the 17 premiums or rates charged for the policy or in any other manner whatev- 18 er; 19 (2) demand or require a greater premium from any person than it 20 requires at that time from others in similar cases; 21 (3) make or require any rebate, discrimination or discount upon the 22 amount to be paid or the service to be rendered on any policy; 23 (4) insert in the policy any condition, or make any stipulation, 24 whereby the insured binds his or herself, or his or her heirs, execu- 25 tors, administrators or assigns, to accept any sum or service less than 26 the full value or amount of such policy in case of a claim thereon 27 except such conditions and stipulations as are imposed upon others in 28 similar cases; and any such stipulation or condition so made or inserted 29 shall be void; 30 (5) reject any application for a policy issued or sold by it; 31 (6) cancel or refuse to issue, renew or sell such policy after appro- 32 priate application therefor; 33 (7) fix any lower rate or discriminate in the fees or commissions of 34 insurance agents or insurance brokers for writing or renewing such a 35 policy; or 36 (8) engage in sexual stereotyping. 37 (b) For the purposes of this section, "sex" shall include sexual 38 orientation, gender identity or expression, and transgender status. 39 § 3. The insurance law is amended by adding a new section 4330 to read 40 as follows: 41 § 4330. Discrimination because of sex or marital status in hospital, 42 surgical or medical expense insurance. (a) With regard to a contract 43 issued by a corporation subject to the provisions of this article that 44 provides hospital, surgical, or medical expense coverage or a contract 45 of student accident and health insurance, as defined in subsection (a) 46 of section three thousand two hundred forty of this chapter, no corpo- 47 ration shall because of sex, marital status or based on pregnancy, false 48 pregnancy, termination of pregnancy, or recovery therefrom, childbirth 49 or related medical conditions: 50 (1) make any distinction or discrimination between persons as to the 51 premiums or rates charged for the contract or in any other manner what- 52 ever; 53 (2) demand or require a greater premium from any person than it 54 requires at that time from others in similar cases; 55 (3) make or require any rebate, discrimination or discount upon the 56 amount to be paid or the service to be rendered on any contract;S. 1507--C 60 A. 2007--C 1 (4) insert in the contract any condition, or make any stipulation, 2 whereby the insured binds his or herself, or his or her heirs, execu- 3 tors, administrators or assigns, to accept any sum or service less than 4 the full value or amount of such contract in case of a claim thereon 5 except such conditions and stipulations as are imposed upon others in 6 similar cases; and any such stipulation or condition so made or inserted 7 shall be void; 8 (5) reject any application for a contract issued or sold by it; 9 (6) cancel or refuse to issue, renew or sell such contract after 10 appropriate application therefor; 11 (7) fix any lower rate or discriminate in the fees or commissions of 12 insurance agents or insurance brokers for writing or renewing such a 13 contract; or 14 (8) engage in sexual stereotyping. 15 (b) For purposes of this section, "sex" shall include sexual orien- 16 tation, gender identity or expression, and transgender status. 17 § 4. This act shall take effect on the first of January next succeed- 18 ing the date on which it shall have become a law and shall apply to all 19 policies and contracts issued, renewed, modified, altered or amended on 20 or after such date. 21 § 2. Severability clause. If any clause, sentence, paragraph, subdivi- 22 sion, section or subpart of this act shall be adjudged by any court of 23 competent jurisdiction to be invalid, such judgment shall not affect, 24 impair, or invalidate the remainder thereof, but shall be confined in 25 its operation to the clause, sentence, paragraph, subdivision, section 26 or subpart thereof directly involved in the controversy in which such 27 judgment shall have been rendered. It is hereby declared to be the 28 intent of the legislature that this act would have been enacted even if 29 such invalid provisions had not been included herein. 30 § 3. Intentionally omitted. 31 § 4. Legislative intent. It is hereby declared to be the intent of the 32 legislature in enacting this act, that the laws of this state provide 33 consumer and market protections at least as robust as those under the 34 federal Patient Protection and Affordable Care Act, public law 111-148, 35 as that law existed and was interpreted on January 19, 2017. 36 § 5. This act shall take effect immediately provided, however, that 37 the applicable effective date of Subparts A through D of this act shall 38 be as specifically set forth in the last section of such Subparts. 39 PART K 40 Section 1. Subdivisions 4 and 5 of section 2999-h of the public health 41 law, as added by section 52 of part H of chapter 59 of the laws of 2011, 42 are amended to read as follows: 43 4. "Qualified plaintiff" means every plaintiff or claimant who (i) has 44 been found by a jury or court to have sustained a birth-related neuro- 45 logical injury as the result of medical malpractice, or (ii) has 46 sustained a birth-related neurological injury as the result of alleged 47 medical malpractice, and has settled his or her lawsuit or claim there- 48 for; and (iii) has been ordered to be enrolled in the fund by a court in 49 New York state. 50 [5. Any reference to the "department of financial services" and the51"superintendent of financial services" in this title shall mean, prior52to October third, two thousand eleven, respectively, the "department of53insurance" and "superintendent of insurance."]S. 1507--C 61 A. 2007--C 1 § 2. Section 2999-i of the public health law, as added by section 52 2 of part H of chapter 59 of the laws of 2011, subdivision 1 as amended by 3 section 29 of part D of chapter 56 of the laws of 2012, is amended to 4 read as follows: 5 § 2999-i. Custody and administration of the fund. 1. (a) The commis- 6 sioner of taxation and finance shall be the custodian of the fund and 7 the special account established pursuant to section ninety-nine-t of the 8 state finance law. All payments from the fund shall be made by the 9 commissioner of taxation and finance upon certificates signed by the 10 [superintendent of financial services] commissioner, or his or her 11 designee, as hereinafter provided. The fund shall be separate and apart 12 from any other fund and from all other state monies; provided, however, 13 that monies of the fund may be invested as set forth in paragraph (b) of 14 this subdivision. No monies from the fund shall be transferred to any 15 other fund, nor shall any such monies be applied to the making of any 16 payment for any purpose other than the purpose set forth in this title. 17 (b) Any monies of the fund not required for immediate use may, at the 18 discretion of the commissioner [of financial services] in consultation 19 with [the commissioner of health and] the director of the budget, be 20 invested by the commissioner of taxation and finance in obligations of 21 the United States or the state or obligations the principal and interest 22 of which are guaranteed by the United States or the state. The proceeds 23 of any such investment shall be retained by the fund as assets to be 24 used for the purposes of the fund. 25 2. (a) The fund shall be administered by the [superintendent of finan-26cial services] commissioner or his or her designee in accordance with 27 the provisions of this article. 28 (b) The [superintendent of financial services] commissioner shall have 29 all powers necessary and proper to carry out the purposes of the fund. 30 (c) Notwithstanding any contrary provision of this section, sections 31 one hundred twelve and one hundred sixty-three of the state finance law 32 or any other contrary provision of law, the superintendent of financial 33 services is authorized to [enter into a contract or contracts without a34competitive bid or request for proposal process for purposes of adminis-35tering the fund for the first year of its operation and in preparation36therefor] assign and the commissioner is authorized to receive assign- 37 ment of any and all contracts entered into by the superintendent of 38 financial services to administer the fund for periods prior to October 39 first, two thousand nineteen. 40 (d) The department [of financial services and the department] shall 41 post on [their websites] its website information about the fund[, eligi-42bility for enrollment in the fund,] and the process for enrollment in 43 the fund. 44 3. The expense of administering the fund[, including the expenses45incurred by the department,] shall be paid from the fund. 46 4. Monies for the fund will be provided pursuant to this chapter. 47 5. For the state fiscal year beginning April first, two thousand elev- 48 en and ending March thirty-first, two thousand twelve, the state fiscal 49 year beginning April first, two thousand twelve and ending March thir- 50 ty-first, two thousand thirteen, and the state fiscal year beginning 51 April first, two thousand thirteen and ending March thirty-first, two 52 thousand fourteen, the superintendent of financial services shall cause 53 to be deposited into the fund for each such fiscal year the amount 54 appropriated for such purpose. Beginning April first, two thousand four- 55 teen and annually thereafter, the superintendent of financial services 56 or the commissioner, whoever is administering the fund for the applica-S. 1507--C 62 A. 2007--C 1 ble period shall cause to be deposited into the fund, subject to avail- 2 able appropriations, an amount equal to the difference between the 3 amount appropriated to the fund in the preceding fiscal year, as 4 increased by the adjustment factor defined in subdivision seven of this 5 section, and the assets of the fund at the conclusion of that fiscal 6 year. 7 6. (a) Following the deposit referenced in subdivision five of this 8 section, the [superintendent of financial services] commissioner shall 9 conduct an actuarial calculation of the estimated liabilities of the 10 fund for the coming year resulting from the qualified plaintiffs 11 enrolled in the fund. The administrator shall from time to time adjust 12 such calculation in accordance with subdivision seven of this section. 13 If the total of all estimates of current liabilities equals or exceeds 14 eighty percent of the fund's assets, then the fund shall not accept any 15 new enrollments until a new deposit has been made pursuant to subdivi- 16 sion five of this section. When, as a result of such new deposit, the 17 fund's liabilities no longer exceed eighty percent of the fund's assets, 18 the fund administrator shall enroll new qualified plaintiffs in the 19 order that an application for enrollment has been submitted in accord- 20 ance with subdivision seven of section twenty-nine hundred ninety-nine-j 21 of this title. 22 (b) Whenever enrollment is suspended pursuant to paragraph (a) of this 23 subdivision and until such time as enrollment resumes pursuant to such 24 paragraph: (i) notice of such suspension shall be promptly posted on the 25 department's website [and on the website of the department of financial26services]; (ii) the fund administrator shall deny each application for 27 enrollment that had been received but not accepted prior to the date of 28 suspension and each application for enrollment received after the date 29 of such suspension; and (iii) notification of each such denial shall be 30 made to the plaintiff or claimant or persons authorized to act on behalf 31 of such plaintiff or claimant and all defendants in regard to such 32 plaintiff or claimant, to the extent they are known to the fund adminis- 33 trator. Judgments and settlements for plaintiffs or claimants for whom 34 applications are denied under this paragraph or who are not eligible for 35 enrollment due to suspension pursuant to paragraph (a) of this subdivi- 36 sion shall be satisfied as if this title had not been enacted. 37 (c) Following a suspension, whenever enrollment resumes pursuant to 38 paragraph (a) of this subdivision, notice that enrollment has resumed 39 shall be promptly posted on the department's website [and on the website40of the department of financial services]. 41 (d) The suspension of enrollment pursuant to paragraph (a) of this 42 subdivision shall not impact payment under the fund for any qualified 43 plaintiffs already enrolled in the fund. 44 7. For purposes of this section, the adjustment factor referenced in 45 this section shall be the ten year rolling average medical component of 46 the consumer price index as published by the United States department of 47 labor, bureau of labor statistics, for the preceding ten years. 48 § 3. Subdivisions 2, 5, 6, 7, 9, 11, 12, 15 and 16 of section 2999-j 49 of the public health law, subdivision 2 as amended by chapter 517 of the 50 laws of 2016, paragraph (c) of subdivision 2 as amended by chapter 4 of 51 the laws of 2017, and subdivisions 5, 6, 7, 9, 11, 12, 15 and 16 as 52 added by section 52 of part H of chapter 59 of the laws of 2011, are 53 amended to read as follows: 54 2. The provision of qualifying health care costs to qualified plain- 55 tiffs shall not be subject to prior authorization, except as described 56 by the commissioner in regulation; provided, however:S. 1507--C 63 A. 2007--C 1 (a) such regulation shall not prevent qualified plaintiffs from 2 receiving care or assistance that would, at a minimum, be authorized 3 under the medicaid program; 4 (b) if any prior authorization is required by such regulation, the 5 regulation shall require that requests for prior authorization be proc- 6 essed within a reasonably prompt period of time and[, subject to the7provisions of subdivision two-a of this section,] shall identify a proc- 8 ess for prompt administrative review of any denial of a request for 9 prior authorization; and 10 (c) such regulations shall not prohibit qualifying health care costs 11 on the grounds that the qualifying health care cost may incidentally 12 benefit other members of the household, provided that whether the quali- 13 fying health care cost primarily benefits the patient may be considered. 14 5. Claims for the payment or reimbursement from the fund of qualifying 15 health care costs shall be made upon forms prescribed and furnished by 16 the fund administrator [in consultation with the commissioner and] in 17 conjunction with regulations establishing a mechanism for submission of 18 claims by health care providers directly to the fund, where practicable. 19 6. (a) Every settlement agreement for claims arising out of a 20 plaintiff's or claimant's birth related neurological injury subject to 21 this title, and that provides for the payment of future medical expenses 22 for the plaintiff or claimant, shall provide that [in the event the23administrator of the fund determines that the plaintiff or claimant is a24qualified plaintiff,] all payments for future medical expenses shall be 25 paid in accordance with this title[,] in lieu of that portion of the 26 settlement agreement that provides for payment of such expenses. The 27 plaintiff's or claimant's future medical expenses shall be paid in 28 accordance with this title. When such a settlement agreement does not so 29 provide, the court shall direct the modification of the agreement to 30 include such term as a condition of court approval. 31 (b) In any case where the jury or court has made an award for future 32 medical expenses arising out of a birth related neurological injury, any 33 party to such action or person authorized to act on behalf of such party 34 may make application to the court that the judgment reflect that, in 35 lieu of that portion of the award that provides for payment of such 36 expenses, [and upon a determination by the fund administrator that the37plaintiff is a qualified plaintiff,] the future medical expenses of the 38 plaintiff shall be paid out of the fund in accordance with this title. 39 Upon a finding by the court that the applicant has made a prima facie 40 showing that the plaintiff is a qualified plaintiff, the court shall 41 ensure that the judgment so provides. 42 7. A qualified plaintiff shall be enrolled when (a) such plaintiff or 43 person authorized to act on behalf of such person, upon notice to all 44 defendants, or any of the defendants in regard to the plaintiff's claim, 45 upon notice to such plaintiff, makes an application for enrollment by 46 providing the fund administrator with a certified copy of the judgment 47 or of the court approved settlement agreement; and (b) the fund adminis- 48 trator determines [upon the basis of such judgment or settlement agree-49ment and any additional information the fund administrator shall50request] that the relevant provisions of subdivision six of this section 51 have been met [and that the plaintiff is a qualified plaintiff]; 52 provided that no enrollment shall occur when the fund is closed to 53 enrollment pursuant to subdivision six of section twenty-nine hundred 54 ninety-nine-i of this title. 55 9. Payments from the fund shall be made by the commissioner of taxa- 56 tion and finance on the said certificate of the [superintendent ofS. 1507--C 64 A. 2007--C 1financial services] commissioner. No payment shall be made by the 2 commissioner of taxation and finance in excess of the amount certified. 3 Promptly upon receipt of the said certificate of the [superintendent of4financial services] commissioner, the commissioner of taxation and 5 finance shall pay the qualified plaintiff's health care provider or 6 reimburse the qualified plaintiff the amount so certified for payment. 7 11. All health care providers shall accept from qualified plaintiff's 8 or persons authorized to act on behalf of such plaintiff's assignments 9 of the right to receive payments from the fund for qualifying health 10 care costs. Such payments shall constitute payment in full for any 11 services provided to a qualified plaintiff in accordance with this arti- 12 cle. 13 12. Health insurers (other than medicare and Medicaid) shall be the 14 primary payers of qualifying health care costs of qualified plaintiffs. 15 Such costs shall be paid from the fund only to the extent that health 16 insurers or other collateral sources or other persons are not otherwise 17 obligated to make payments therefor. Health insurers that make payments 18 for qualifying health care costs to or on behalf of qualified plaintiffs 19 shall have no right of recovery against and shall have no lien upon the 20 fund or any person or entity nor shall the fund constitute an additional 21 payment source to offset the payments otherwise contractually required 22 to be made by such health insurers. The superintendent of financial 23 services shall have the authority to enforce the provisions of this 24 subdivision upon the referral of the commissioner. 25 15. The commissioner[, in consultation with the superintendent of26financial services,] shall promulgate, amend and enforce all rules and 27 regulations necessary for the proper administration of the fund in 28 accordance with the provisions of this section, including, but not 29 limited to, those concerning the payment of claims and concerning the 30 actuarial calculations necessary to determine, annually, the total 31 amount to be paid into the fund as provided herein, and as otherwise 32 needed to implement this title. 33 [16. The commissioner shall convene a consumer advisory committee for34the purpose of providing information, as requested by the commissioner,35in the development of the regulations authorized by subdivision fifteen36of this section.] 37 § 4. Section 5 of chapter 517 of the laws of 2016, amending the public 38 health law relating to payments from the New York state medical indem- 39 nity fund, as amended by chapter 4 of the laws of 2017, is amended to 40 read as follows: 41 § 5. This act shall take effect on the forty-fifth day after it shall 42 have become a law, provided that the amendments to subdivision 4 of 43 section 2999-j of the public health law made by section two of this act 44 shall take effect on June 30, 2017 and shall expire and be deemed 45 repealed December 31, [2019] 2020. 46 § 5. Section 99-t of the state finance law, as added by section 52-e 47 of part H of chapter 59 of the laws of 2011, is amended to read as 48 follows: 49 § 99-t. New York state medical indemnity fund account. 1. There is 50 hereby established in the custody of the commissioner of taxation and 51 finance a special account to be known as the "New York state medical 52 indemnity fund account". 53 2. All moneys received by the New York state medical indemnity fund 54 pursuant to title four of article twenty-nine-D of the public health law 55 from whatever source derived shall be deposited to the exclusive credit 56 of such fund account. Said moneys shall be kept separate and shall notS. 1507--C 65 A. 2007--C 1 be commingled with any other moneys in the custody of the commissioner 2 of taxation and finance. 3 3. The moneys in said account shall be retained by the fund and shall 4 be released by the commissioner of taxation and finance only upon 5 certificates signed by the [superintendent of financial services or the6head of any successor agency to the department of insurance] commission- 7 er of health or his or her designee and only for the purposes set forth 8 in title four of article twenty-nine-D of the public health law. 9 § 6. This act shall take effect October 1, 2019; provided however, on 10 and after April 1, 2019, the commissioner of health may take any steps 11 necessary to implement this act on its effective date; and notwithstand- 12 ing any inconsistent provision of the state administrative procedure act 13 or any other provision of law, rule or regulation, the commissioner of 14 health is authorized to adopt or amend or promulgate on an emergency 15 basis any regulation he or she determines necessary to implement any 16 provision of this act on its effective date. 17 PART L 18 Section 1. Subparagraph (C) of paragraph 6 of subsection (k) of 19 section 3221 of the insurance law, as amended by section 1 of part K of 20 chapter 82 of the laws of 2002, is amended to read as follows: 21 (C) Coverage of diagnostic and treatment procedures, including 22 prescription drugs, used in the diagnosis and treatment of infertility 23 as required by subparagraphs (A) and (B) of this paragraph shall be 24 provided in accordance with the provisions of this subparagraph. 25 (i) [Coverage shall be provided for persons whose ages range from26twenty-one through forty-four years, provided that nothing herein shall27preclude the provision of coverage to persons whose age is below or28above such range.29(ii)] Diagnosis and treatment of infertility shall be prescribed as 30 part of a physician's overall plan of care and consistent with the 31 guidelines for coverage as referenced in this subparagraph. 32 [(iii)] (ii) Coverage may be subject to co-payments, coinsurance and 33 deductibles as may be deemed appropriate by the superintendent and as 34 are consistent with those established for other benefits within a given 35 policy. 36 [(iv) Coverage shall be limited to those individuals who have been37previously covered under the policy for a period of not less than twelve38months, provided that for the purposes of this subparagraph "period of39not less than twelve months" shall be determined by calculating such40time from either the date the insured was first covered under the exist-41ing policy or from the date the insured was first covered by a previous-42ly in-force converted policy, whichever is earlier.43(v) Coverage] (iii) Except as provided in items (vi) and (vii) of this 44 subparagraph, coverage shall not be required to include the diagnosis 45 and treatment of infertility in connection with: (I) in vitro fertiliza- 46 tion, gamete intrafallopian tube transfers or zygote intrafallopian tube 47 transfers; (II) the reversal of elective sterilizations; (III) sex 48 change procedures; (IV) cloning; or (V) medical or surgical services or 49 procedures that are deemed to be experimental in accordance with clin- 50 ical guidelines referenced in [clause (vi)] item (iv) of this subpara- 51 graph. 52 [(vi)] (iv) The superintendent, in consultation with the commissioner 53 of health, shall promulgate regulations which shall stipulate the guide-S. 1507--C 66 A. 2007--C 1 lines and standards which shall be used in carrying out the provisions 2 of this subparagraph, which shall include: 3 (I) [The determination of "infertility" in accordance with the stand-4ards and guidelines established and adopted by the American College of5Obstetricians and Gynecologists and the American Society for Reproduc-6tive Medicine;7(II)] The identification of experimental procedures and treatments not 8 covered for the diagnosis and treatment of infertility determined in 9 accordance with the standards and guidelines established and adopted by 10 the American College of Obstetricians and Gynecologists and the American 11 Society for Reproductive Medicine; 12 [(III)] (II) The identification of the required training, experience 13 and other standards for health care providers for the provision of 14 procedures and treatments for the diagnosis and treatment of infertility 15 determined in accordance with the standards and guidelines established 16 and adopted by the American College of Obstetricians and Gynecologists 17 and the American Society for Reproductive Medicine; and 18 [(IV)] (III) The determination of appropriate medical candidates by 19 the treating physician in accordance with the standards and guidelines 20 established and adopted by the American College of Obstetricians and 21 Gynecologists and/or the American Society for Reproductive Medicine. 22 (v)(I) For the purposes of this paragraph, "infertility" means a 23 disease or condition characterized by the incapacity to impregnate 24 another person or to conceive, defined by the failure to establish a 25 clinical pregnancy after twelve months of regular, unprotected sexual 26 intercourse or therapeutic donor insemination, or after six months of 27 regular, unprotected sexual intercourse or therapeutic donor insemina- 28 tion for a female thirty-five years of age or older. Earlier evaluation 29 and treatment may be warranted based on an individual's medical history 30 or physical findings. 31 (II) For purposes of this paragraph, "iatrogenic infertility" means an 32 impairment of fertility by surgery, radiation, chemotherapy or other 33 medical treatment affecting reproductive organs or processes. 34 (vi) Coverage shall also include standard fertility preservation 35 services when a medical treatment may directly or indirectly cause 36 iatrogenic infertility to an insured. Coverage may be subject to annual 37 deductibles and coinsurance, including copayments, as may be deemed 38 appropriate by the superintendent and as are consistent with those 39 established for other benefits within a given policy. 40 (vii) Every large group policy delivered or issued for delivery in 41 this state that provides medical, major medical or similar comprehen- 42 sive-type coverage shall provide coverage for three cycles of in-vitro 43 fertilization used in the treatment of infertility. Coverage may be 44 subject to annual deductibles and coinsurance, including copayments, as 45 may be deemed appropriate by the superintendent and as are consistent 46 with those established for other benefits within a given policy. For 47 purposes of this item, a "cycle" is defined as either all treatment that 48 starts when: preparatory medications are administered for ovarian stim- 49 ulation for oocyte retrieval with the intent of undergoing in-vitro 50 fertilization using a fresh embryo transfer; or medications are adminis- 51 tered for endometrial preparation with the intent of undergoing in-vitro 52 fertilization using a frozen embryo transfer. 53 (viii) No insurer providing coverage under this paragraph shall 54 discriminate based on an insured's expected length of life, present of 55 predicted disability, degree of medical dependency, perceived quality of 56 life, or other health conditions, nor based on personal characteristics,S. 1507--C 67 A. 2007--C 1 including age, sex, sexual orientation, marital status or gender identi- 2 ty. 3 § 2. Paragraph 3 of subsection (s) of section 4303 of the insurance 4 law, as amended by section 2 of part K of chapter 82 of the laws of 5 2002, is amended to read as follows: 6 (3) Coverage of diagnostic and treatment procedures, including 7 prescription drugs used in the diagnosis and treatment of infertility as 8 required by paragraphs one and two of this subsection shall be provided 9 in accordance with this paragraph. 10 (A) [Coverage shall be provided for persons whose ages range from11twenty-one through forty-four years, provided that nothing herein shall12preclude the provision of coverage to persons whose age is below or13above such range.14(B)] Diagnosis and treatment of infertility shall be prescribed as 15 part of a physician's overall plan of care and consistent with the 16 guidelines for coverage as referenced in this paragraph. 17 [(C)] (B) Coverage may be subject to co-payments, coinsurance and 18 deductibles as may be deemed appropriate by the superintendent and as 19 are consistent with those established for other benefits within a given 20 policy. 21 [(D) Coverage shall be limited to those individuals who have been22previously covered under the policy for a period of not less than twelve23months, provided that for the purposes of this paragraph "period of not24less than twelve months" shall be determined by calculating such time25from either the date the insured was first covered under the existing26policy or from the date the insured was first covered by a previously27in-force converted policy, whichever is earlier.28(E) Coverage] (C) Except as provided in subparagraphs (F) and (G) of 29 this paragraph, coverage shall not be required to include the diagnosis 30 and treatment of infertility in connection with: (i) in vitro fertiliza- 31 tion, gamete intrafallopian tube transfers or zygote intrafallopian tube 32 transfers; (ii) the reversal of elective sterilizations; (iii) sex 33 change procedures; (iv) cloning; or (v) medical or surgical services or 34 procedures that are deemed to be experimental in accordance with clin- 35 ical guidelines referenced in subparagraph [(F)] (D) of this paragraph. 36 [(F)] (D) The superintendent, in consultation with the commissioner of 37 health, shall promulgate regulations which shall stipulate the guide- 38 lines and standards which shall be used in carrying out the provisions 39 of this paragraph, which shall include: 40 (i) [The determination of "infertility" in accordance with the stand-41ards and guidelines established and adopted by the American College of42Obstetricians and Gynecologists and the American Society for Reproduc-43tive Medicine;44(ii)] The identification of experimental procedures and treatments not 45 covered for the diagnosis and treatment of infertility determined in 46 accordance with the standards and guidelines established and adopted by 47 the American College of Obstetricians and Gynecologists and the American 48 Society for Reproductive Medicine; 49 [(iii)] (ii) The identification of the required training, experience 50 and other standards for health care providers for the provision of 51 procedures and treatments for the diagnosis and treatment of infertility 52 determined in accordance with the standards and guidelines established 53 and adopted by the American College of Obstetricians and Gynecologists 54 and the American Society for Reproductive Medicine; and 55 [(iv)] (iii) The determination of appropriate medical candidates by 56 the treating physician in accordance with the standards and guidelinesS. 1507--C 68 A. 2007--C 1 established and adopted by the American College of Obstetricians and 2 Gynecologists and/or the American Society for Reproductive Medicine. 3 (E)(i) For the purposes of this subsection, "infertility" means a 4 disease or condition characterized by the incapacity to impregnate 5 another person or to conceive, defined by the failure to establish a 6 clinical pregnancy after twelve months of regular, unprotected sexual 7 intercourse or therapeutic donor insemination, or after six months of 8 regular, unprotected sexual intercourse or therapeutic donor insemina- 9 tion for a female thirty-five years of age or older. Earlier evaluation 10 and treatment may be warranted based on an individual's medical history 11 or physical findings. 12 (ii) For purposes of this subsection, "iatrogenic infertility" means 13 an impairment of fertility by surgery, radiation, chemotherapy or other 14 medical treatment affecting reproductive organs or processes. 15 (F) Coverage shall also include standard fertility preservation 16 services when a medical treatment may directly or indirectly cause 17 iatrogenic infertility to an insured. Coverage may be subject to annual 18 deductibles and coinsurance, including copayments, as may be deemed 19 appropriate by the superintendent and as are consistent with those 20 established for other benefits within a given contract. 21 (G) Every large group contract that provides medical, major medical or 22 similar comprehensive-type coverage shall provide coverage for three 23 cycles of in-vitro fertilization used in the treatment of infertility. 24 Coverage may be subject to annual deductibles and coinsurance, including 25 copayments, as may be deemed appropriate by the superintendent and as 26 are consistent with those established for other benefits within a given 27 contract. For purposes of this subparagraph, a "cycle" is defined as 28 either all treatment that starts when: preparatory medications are 29 administered for ovarian stimulation for oocyte retrieval with the 30 intent of undergoing in-vitro fertilization using a fresh embryo trans- 31 fer; or medications are administered for endometrial preparation with 32 the intent of undergoing in-vitro fertilization using a frozen embryo 33 transfer. 34 (H) No corporation providing coverage under this subsection shall 35 discriminate based on an insured's expected length of life, present or 36 predicted disability, degree of medical dependency, perceived quality of 37 life, or other health conditions, nor based on personal characteristics, 38 including age, sex, sexual orientation, marital status or gender identi- 39 ty. 40 § 3. Paragraph 13 of subsection (i) of section 3216 of the insurance 41 law is amended by adding a new subparagraph (C) to read as follows: 42 (C) Every policy that provides medical, major medical or similar 43 comprehensive-type coverage shall provide coverage for standard fertili- 44 ty preservation services when a medical treatment may directly or indi- 45 rectly cause iatrogenic infertility to an insured. Coverage may be 46 subject to annual deductibles and coinsurance, including copayments, as 47 may be deemed appropriate by the superintendent and as are consistent 48 with those established for other benefits within a given policy. 49 (i) For purposes of this subparagraph, "iatrogenic infertility" means 50 an impairment of fertility by surgery, radiation, chemotherapy or other 51 medical treatment affecting reproductive organs or processes. 52 (ii) No insurer providing coverage under this paragraph shall discrim- 53 inate based on an insured's expected length of life, present or 54 predicted disability, degree of medical dependency, perceived quality of 55 life, or other health conditions, nor based on personal characteristics,S. 1507--C 69 A. 2007--C 1 including age, sex, sexual orientation, marital status or gender identi- 2 ty. 3 § 4. This act shall take effect January 1, 2020 and shall apply to 4 policies and contracts issued, renewed, modified, altered or amended on 5 or after such date. 6 PART M 7 Section 1. Subparagraph (A) of paragraph 16 of subsection (l) of 8 section 3221 of the insurance law, as amended by a chapter of the laws 9 of 2019, amending the insurance law and the social services law relating 10 to requiring health insurance policies to include coverage of all 11 FDA-approved contraceptive drugs, devices, and products, as well as 12 voluntary sterilization procedures, contraceptive education and coun- 13 seling, and related follow up services and prohibiting a health insur- 14 ance policy from imposing any cost-sharing requirements or other 15 restrictions or delays with respect to this coverage, as proposed in 16 legislative bills numbers S. 659-a and A. 585-a, is amended and a new 17 subparagraph (H) is added to read as follows: 18 (A) Every group or blanket policy that provides medical, major 19 medical, or similar comprehensive type coverage that is issued, amended, 20 renewed, effective or delivered on or after January first, two thousand 21 twenty, shall provide coverage for all of the following services and 22 contraceptive methods: 23 (1) All FDA-approved contraceptive drugs, devices, and other products. 24 This includes all FDA-approved over-the-counter contraceptive drugs, 25 devices, and products as prescribed or as otherwise authorized under 26 state or federal law. The following applies to this coverage: 27 (a) where the FDA has approved one or more therapeutic and pharmaceu- 28 tical equivalent, as defined by the FDA, versions of a contraceptive 29 drug, device, or product, a group or blanket policy is not required to 30 include all such therapeutic and pharmaceutical equivalent versions in 31 its formulary, so long as at least one is included and covered without 32 cost-sharing and in accordance with this paragraph; 33 (b) if the covered therapeutic and pharmaceutical equivalent versions 34 of a drug, device, or product are not available or are deemed medically 35 inadvisable a group or blanket policy shall provide coverage for an 36 alternate therapeutic and pharmaceutical equivalent version of the 37 contraceptive drug, device, or product without cost-sharing. If the 38 attending health care provider, in his or her reasonable professional 39 judgment, determines that the use of a non-covered therapeutic or phar- 40 maceutical equivalent of a drug, device, or product is warranted, the 41 health care provider's determination shall be final. The superintendent 42 shall promulgate regulations establishing a process, including time- 43 frames, for an insured, an insured's designee or an insured's health 44 care provider to request coverage of a non-covered contraceptive drug, 45 device, or product. Such regulations shall include a requirement that 46 insurers use an exception form that shall meet criteria established by 47 the superintendent; 48 (c) this coverage shall include emergency contraception without cost- 49 sharing when provided pursuant to a prescription or order under section 50 sixty-eight hundred thirty-one of the education law or when lawfully 51 provided over the counter; and 52 (d) this coverage must allow for the dispensing of up to twelve months 53 worth of a contraceptive at one time;S. 1507--C 70 A. 2007--C 1 (2) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and 2 identified in the comprehensive guidelines supported by the health 3 resources and services administration and thereby incorporated in the 4 essential health benefits benchmark plan; 5 (3) Patient education and counseling on contraception; and 6 (4) Follow-up services related to the drugs, devices, products, and 7 procedures covered under this paragraph, including, but not limited to, 8 management of side effects, counseling for continued adherence, and 9 device insertion and removal. 10 (H) For the purposes of this paragraph, "over-the-counter contracep- 11 tive products" shall mean those products provided for in comprehensive 12 guidelines supported by the health resources and services administration 13 as of January twenty-first, two thousand nineteen. 14 § 2. Paragraph 1 of subsection (cc) of section 4303 of the insurance 15 law, as amended by a chapter of the laws of 2019, amending the insurance 16 law and the social services law relating to requiring health insurance 17 policies to include coverage of all FDA-approved contraceptive drugs, 18 devices, and products, as well as voluntary sterilization procedures, 19 contraceptive education and counseling, and related follow up services 20 and prohibiting a health insurance policy from imposing any cost-sharing 21 requirements or other restrictions or delays with respect to this cover- 22 age, as proposed in legislative bills numbers S. 659-a and A. 585-a, is 23 amended and a new paragraph 8 is added to read as follows: 24 (1) Every contract that provides medical, major medical, or similar 25 comprehensive type coverage that is issued, amended, renewed, effective 26 or delivered on or after January first, two thousand twenty, shall 27 provide coverage for all of the following services and contraceptive 28 methods: 29 (A) All FDA-approved contraceptive drugs, devices, and other products. 30 This includes all FDA-approved over-the-counter contraceptive drugs, 31 devices, and products as prescribed or as otherwise authorized under 32 state or federal law. The following applies to this coverage: 33 (i) where the FDA has approved one or more therapeutic and pharmaceu- 34 tical equivalent, as defined by the FDA, versions of a contraceptive 35 drug, device, or product, a contract is not required to include all such 36 therapeutic and pharmaceutical equivalent versions in its formulary, so 37 long as at least one is included and covered without cost-sharing and in 38 accordance with this subsection; 39 (ii) if the covered therapeutic and pharmaceutical equivalent versions 40 of a drug, device, or product are not available or are deemed medically 41 inadvisable a contract shall provide coverage for an alternate therapeu- 42 tic and pharmaceutical equivalent version of the contraceptive drug, 43 device, or product without cost-sharing. If the attending health care 44 provider, in his or her reasonable professional judgment, determines 45 that the use of a non-covered therapeutic or pharmaceutical equivalent 46 of a drug, device, or product is warranted, the health care provider's 47 determination shall be final. The superintendent shall promulgate regu- 48 lations establishing a process, including timeframes, for an insured, an 49 insured's designee or an insured's health care provider to request 50 coverage of a non-covered contraceptive drug, device, or product. Such 51 regulations shall include a requirement that insurers use an exception 52 form that shall meet criteria established by the superintendent; 53 (iii) this coverage shall include emergency contraception without 54 cost-sharing when provided pursuant to a prescription or order under 55 section sixty-eight hundred thirty-one of the education law or when 56 lawfully provided over the counter; andS. 1507--C 71 A. 2007--C 1 (iv) this coverage must allow for the dispensing of up to twelve 2 months worth of a contraceptive at one time; 3 (B) Voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and 4 identified in the comprehensive guidelines supported by the health 5 resources and services administration and thereby incorporated in the 6 essential health benefits benchmark plan; 7 (C) Patient education and counseling on contraception; and 8 (D) Follow-up services related to the drugs, devices, products, and 9 procedures covered under this subsection, including, but not limited to, 10 management of side effects, counseling for continued adherence, and 11 device insertion and removal. 12 (8) For the purposes of this paragraph, "over-the-counter contracep- 13 tive products" shall mean those products provided for in comprehensive 14 guidelines supported by the health resources and services administration 15 as of January twenty-first, two thousand nineteen. 16 § 3. Clause (v) of subparagraph (E) of paragraph 17 of subsection (i) 17 of section 3216 of the insurance law, as added by a chapter of the laws 18 of 2019, amending the insurance law and the social services law relating 19 to requiring health insurance policies to include coverage of all 20 FDA-approved contraceptive drugs, devices, and products, as well as 21 voluntary sterilization procedures, contraceptive education and coun- 22 seling, and related follow up services and prohibiting a health insur- 23 ance policy from imposing any cost-sharing requirements or other 24 restrictions or delays with respect to this coverage, as proposed in 25 legislative bills numbers S. 659-a and A. 585-a, is amended to read as 26 follows: 27 (v) all FDA-approved contraceptive drugs, devices, and other products, 28 including all over-the-counter contraceptive drugs, devices, and 29 products as prescribed or as otherwise authorized under state or federal 30 law; voluntary sterilization procedures pursuant to 42 U.S.C. 18022 and 31 identified in the comprehensive guidelines supported by the health 32 resources and services administration and thereby incorporated in the 33 essential health benefits benchmark plan; patient education and coun- 34 seling on contraception; and follow-up services related to the drugs, 35 devices, products, and procedures covered under this clause, including, 36 but not limited to, management of side effects, counseling for continued 37 adherence, and device insertion and removal. Except as otherwise author- 38 ized under this clause, a contract shall not impose any restrictions or 39 delays on the coverage required under this clause. However, where the 40 FDA has approved one or more therapeutic and pharmaceutical equivalent, 41 as defined by the FDA, versions of a contraceptive drug, device, or 42 product, a contract is not required to include all such therapeutic and 43 pharmaceutical equivalent versions in its formulary, so long as at least 44 one is included and covered without cost-sharing and in accordance with 45 this clause. If the covered therapeutic and pharmaceutical equivalent 46 versions of a drug, device, or product are not available or are deemed 47 medically inadvisable a contract shall provide coverage for an alternate 48 therapeutic and pharmaceutical equivalent version of the contraceptive 49 drug, device, or product without cost-sharing. (a) This coverage shall 50 include emergency contraception without cost sharing when provided 51 pursuant to a prescription, or order under section sixty-eight hundred 52 thirty-one of the education law or when lawfully provided over-the-coun- 53 ter. (b) If the attending health care provider, in his or her reason- 54 able professional judgment, determines that the use of a non-covered 55 therapeutic or pharmaceutical equivalent of a drug, device, or product 56 is warranted, the health care provider's determination shall be final.S. 1507--C 72 A. 2007--C 1 The superintendent shall promulgate regulations establishing a process, 2 including timeframes, for an insured, an insured's designee or an 3 insured's health care provider to request coverage of a non-covered 4 contraceptive drug, device, or product. Such regulations shall include a 5 requirement that insurers use an exception form that shall meet criteria 6 established by the superintendent. (c) This coverage must allow for the 7 dispensing of up to twelve months worth of a contraceptive at one time. 8 (d) For the purposes of this clause, "over-the-counter contraceptive 9 products" shall mean those products provided for in comprehensive guide- 10 lines supported by the health resources and services administration as 11 of January twenty-first, two thousand nineteen. 12 § 4. This act shall take effect on the same date and in the same 13 manner as a chapter of the laws of 2019, amending the insurance law and 14 the social services law relating to requiring health insurance policies 15 to include coverage of all FDA-approved contraceptive drugs, devices, 16 and products, as well as voluntary sterilization procedures, contracep- 17 tive education and counseling, and related follow up services and 18 prohibiting a health insurance policy from imposing any cost-sharing 19 requirements or other restrictions or delays with respect to this cover- 20 age, as proposed in legislative bills numbers S. 659-a and A. 585-a, 21 takes effect. 22 PART N 23 Intentionally Omitted 24 PART O 25 Section 1. Subdivision 2 of section 605 of the public health law, as 26 amended by section 20 of part E of chapter 56 of the laws of 2013, is 27 amended to read as follows: 28 2. State aid reimbursement for public health services provided by a 29 municipality under this title, shall be made if the municipality is 30 providing some or all of the core public health services identified in 31 section six hundred two of this title, pursuant to an approved applica- 32 tion for state aid, at a rate of no less than thirty-six per centum, 33 except for the city of New York which shall receive no less than twenty 34 per centum, of the difference between the amount of moneys expended by 35 the municipality for public health services required by section six 36 hundred two of this title during the fiscal year and the base grant 37 provided pursuant to subdivision one of this section. No such reimburse- 38 ment shall be provided for services that are not eligible for state aid 39 pursuant to this article. 40 § 2. Subdivision 1 of section 616 of the public health law, as amended 41 by section 27 of part E of chapter 56 of the laws of 2013, is amended to 42 read as follows: 43 1. The total amount of state aid provided pursuant to this article 44 shall be limited to the amount of the annual appropriation made by the 45 legislature. In no event, however, shall such state aid be less than an 46 amount to provide the full base grant and, as otherwise provided by 47 [paragraph (a) of] subdivision two of section six hundred five of this 48 article, [at least] no less than thirty-six per centum, except for the 49 city of New York which shall receive no less than twenty per centum, of 50 the difference between the amount of moneys expended by the municipality 51 for eligible public health services pursuant to an approved applicationS. 1507--C 73 A. 2007--C 1 for state aid during the fiscal year and the base grant provided pursu- 2 ant to subdivision one of section six hundred five of this article. 3 § 3. This act shall take effect July 1, 2019. 4 PART P 5 Section 1. Subdivision 6 of section 1370 of the public health law, as 6 amended by chapter 485 of the laws of 1992, is amended to read as 7 follows: 8 6. "Elevated lead levels" means a blood lead level greater than or 9 equal to [ten] five micrograms of lead per deciliter of whole blood or 10 such lower blood lead level as may be established by the department 11 pursuant to rule or regulation. 12 § 1-a. (a) Within 180 days after the date on which this act takes 13 effect, the department of health shall adopt all necessary regulations 14 to define "elevated lead levels" to mean a blood lead level greater than 15 or equal to 5 micrograms per deciliter of whole blood, or such lower 16 blood lead level as the department may establish, to be utilized in its 17 lead poisoning prevention program. 18 (b) Within 6 months after the date on which the federal department of 19 health and human services has published guidance recommending a lower 20 concentration of lead in blood than the concentration established pursu- 21 ant to subdivision 6 of section 1370 of the public health law as the 22 reference level for conducting an environmental intervention, the 23 department of health shall, in consultation with the New York state 24 advisory council on lead poisoning prevention, make recommendations to 25 the governor and the legislature recommending actions the state should 26 take in response to such guidance. 27 § 2. Section 1151 of the public health law is amended by adding a new 28 subdivision 9 to read as follows: 29 9. General information regarding lead pipes reasonably known to be 30 located within the water system, as that term is defined in subdivision 31 twenty-six of section two of the public service law. 32 § 3. This act shall take effect immediately. 33 PART Q 34 Section 1. Section 2825-f of the public health law is amended by 35 adding two new subdivisions 4-a and 4-b to read as follows: 36 4-a. Notwithstanding subdivision two of this section or any inconsist- 37 ent provision of law to the contrary, and upon approval of the director 38 of the budget, the commissioner may, subject to the availability of 39 lawful appropriation, award up to three hundred million dollars of the 40 funds made available pursuant to this section for unfunded project 41 applications submitted in response to the request for applications 42 number 17648 issued by the department on January eighth, two thousand 43 eighteen pursuant to section twenty-eight hundred twenty-five-e of this 44 article, provided however that the provisions of subdivisions three and 45 four of this section shall apply. 46 4-b. Authorized amounts to be awarded pursuant to applications submit- 47 ted in response to the request for application number 17648 shall be 48 awarded no later than May first, two thousand nineteen. 49 § 2. This act shall take effect immediately. 50 PART RS. 1507--C 74 A. 2007--C 1 Intentionally Omitted 2 PART S 3 Intentionally Omitted 4 PART T 5 Section 1. This act shall be known and may be cited as the "NY State 6 of Health, The Official Health Plan Marketplace Act". 7 § 2. Article 2 of the public health law is amended by adding a new 8 title VII to read as follows: 9 TITLE VII 10 NY STATE OF HEALTH 11 Section 268. Statement of policy and purposes. 12 268-a. Definitions. 13 268-b. Establishment of NY State of Health, The Official Health 14 Plan Marketplace. 15 268-c. Functions of the Marketplace. 16 268-d. Special functions of the Marketplace related to health 17 plan certification and qualified health plan oversight. 18 268-e. Appeals and appeal hearings; judicial review. 19 268-f. Marketplace advisory committee. 20 268-g. Funding of the Marketplace. 21 268-h. Construction. 22 § 268. Statement of policy and purposes. The purpose of this title is 23 to codify the establishment of the health benefit exchange in New York, 24 known as NY State of Health, The Official Health Plan Marketplace 25 (Marketplace), in conformance with Executive Order 42 (Cuomo) issued 26 April 12, 2012. The Marketplace shall continue to perform eligibility 27 determinations for federal and state insurance affordability programs 28 including medical assistance in accordance with section three hundred 29 sixty-six of the social services law, child health plus in accordance 30 with section twenty-five hundred eleven of this chapter, the basic 31 health program in accordance with section three hundred sixty-nine-gg of 32 the social services law, and premium tax credits and cost-sharing 33 reductions, together with performing eligibility determinations for 34 qualified health plans and such other health insurance programs as 35 determined by the commissioner. The Marketplace shall also facilitate 36 enrollment in insurance affordability programs, qualified health plans 37 and other health insurance programs as determined by the commissioner, 38 the purchase and sale of qualified health plans and/or other or addi- 39 tional health plans certified by the Marketplace pursuant to this title, 40 and shall continue to have the authority to operate a small business 41 health options program ("SHOP") to assist eligible small employers in 42 selecting qualified health plans and/or other or additional health plans 43 certified by the Marketplace and to determine small employer eligibility 44 for purposes of small employer tax credits. It is the intent of the 45 legislature, by codifying the Marketplace in state statute, to continue 46 to promote quality and affordable health coverage and care, reduce the 47 number of uninsured persons, provide a transparent marketplace, educate 48 consumers and assist individuals with access to coverage, premium 49 assistance tax credits and cost-sharing reductions. In addition, the 50 legislature declares the intent that the Marketplace continue to be 51 properly integrated with insurance affordability programs, includingS. 1507--C 75 A. 2007--C 1 Medicaid, child health plus and the basic health program, and such other 2 health insurance programs as determined by the commissioner. 3 § 268-a. Definitions. For purposes of this title, the following defi- 4 nitions shall apply: 5 1. "Commissioner" means the commissioner of health of the state of New 6 York. 7 2. "Marketplace" means the "NY State of Health, The official health 8 plan Marketplace" or "Marketplace" established as a health benefit 9 exchange or "marketplace" within the department of health pursuant to 10 Executive Order 42 (Cuomo) issued April 12, 2012 and this title. 11 3. "Federal act" means the patient protection and affordable care act, 12 public law 111-148, as amended by the health care and education recon- 13 ciliation act of 2010, public law 111-152, and any regulations or guid- 14 ance issued thereunder. 15 4. "Health plan" means a policy, contract or certificate, offered or 16 issued by an insurer to provide, deliver, arrange for, pay for or reim- 17 burse any of the costs of health care services. Health plan shall not 18 include the following: 19 (a) accident insurance or disability income insurance, or any combina- 20 tion thereof; 21 (b) coverage issued as a supplement to liability insurance; 22 (c) liability insurance, including general liability insurance and 23 automobile liability insurance; 24 (d) workers' compensation or similar insurance; 25 (e) automobile no-fault insurance; 26 (f) credit insurance; 27 (g) other similar insurance coverage, as specified in federal regu- 28 lations, under which benefits for medical care are secondary or inci- 29 dental to other insurance benefits; 30 (h) limited scope dental or vision benefits, benefits for long-term 31 care insurance, nursing home insurance, home care insurance, or any 32 combination thereof, or such other similar, limited benefits health 33 insurance as specified in federal regulations, if the benefits are 34 provided under a separate policy, certificate or contract of insurance 35 or are otherwise not an integral part of the plan; 36 (i) coverage only for a specified disease or illness, hospital indem- 37 nity, or other fixed indemnity coverage; 38 (j) Medicare supplemental insurance as defined in section 1882(g)(1) 39 of the federal social security act, coverage supplemental to the cover- 40 age provided under chapter 55 of title 10 of the United States Code, or 41 similar supplemental coverage provided under a group health plan if it 42 is offered as a separate policy, certificate or contract of insurance; 43 or 44 (k) the New York state medical indemnity fund established pursuant to 45 title four of article twenty-nine-D of the public health law. 46 5. "Insurer" means an insurance company subject to article forty-two 47 or a corporation subject to article forty-three of the insurance law, or 48 a health maintenance organization certified pursuant to article forty- 49 four of the public health law that contracts or offers to contract to 50 provide, deliver, arrange, pay or reimburse any of the costs of health 51 care services. 52 6. "Stand-Alone dental plan" means a dental services plan that has 53 been issued pursuant to applicable law and certified by the Marketplace 54 in accordance with section two hundred sixty-eight-d of this title. 55 7. "Qualified health plan" means a health plan that is issued pursuant 56 to applicable law and certified by the Marketplace in accordance withS. 1507--C 76 A. 2007--C 1 section two hundred sixty-eight-d of this title, including a stand-alone 2 dental plan. 3 8. "Insurance affordability program" means Medicaid, child health 4 plus, the basic health program and any other health insurance subsidy 5 program designated as such by the commissioner. 6 9. "Eligible individual" means an individual, including a minor, who 7 is eligible to enroll in an insurance affordability program or other 8 health insurance program as determined by the commissioner. 9 10. "Qualified individual" means, with respect to qualified health 10 plans, an individual, including a minor, who: 11 (a) is eligible to enroll in a qualified health plan offered to indi- 12 viduals through the Marketplace; 13 (b) resides in this state; 14 (c) at the time of enrollment, is not incarcerated, other than incar- 15 ceration pending the disposition of charges; and 16 (d) is, and is reasonably expected to be, for the entire period for 17 which enrollment is sought, a citizen or national of the United States 18 or an alien lawfully present in the United States. 19 11. "Secretary" means the secretary of the United States department of 20 health and human services. 21 12. "SHOP" means the small business health options program operated by 22 the Marketplace to assist eligible small employers in this state in 23 selecting qualified health plans and/or other or additional health plans 24 certified by the Marketplace and to determine small employer eligibility 25 for purposes of small employer tax credits in accordance with applicable 26 federal and state laws and regulations. 27 13. "Small employer" means an employer which offers coverage where the 28 coverage such employer offers would be considered small group coverage 29 under the insurance law and regulations promulgated thereunder, provided 30 that it is not otherwise prohibited under the federal act. 31 14. "Small group market" means the health insurance market under which 32 individuals receive health insurance coverage on behalf of themselves 33 and their dependents through a group health plan maintained by a small 34 employer. 35 15. "Superintendent" means the superintendent of financial services. 36 16. "Essential health benefits" shall mean the categories of benefits 37 defined in subsection (a) of section three thousand two hundred seven- 38 teen-i and subsection (a) of section four thousand three hundred six-h 39 of the insurance law. 40 § 268-b. Establishment of NY State of Health, The Official Health Plan 41 Marketplace. 1. There is hereby established an office within the depart- 42 ment of health to be known as the "NY State of Health, The official 43 health plan Marketplace". 44 2. The purpose of the Marketplace is to facilitate enrollment in 45 health coverage and the purchase and sale of qualified health plans and 46 other health plans certified by the Marketplace; enroll individuals in 47 coverage for which they are eligible in accordance with federal and 48 state law; enable eligible individuals to receive premium tax credits, 49 cost-sharing reductions, and to access insurance affordability programs 50 and other health insurance programs as determined by the commissioner; 51 assist eligible small employers in selecting qualified health plans 52 and/or other, or additional health plans certified by the Marketplace 53 and to qualify for small employer tax credits in accordance with appli- 54 cable law; and to carry out other functions set forth in this title. 55 § 268-c. Functions of the Marketplace. The Marketplace shall:S. 1507--C 77 A. 2007--C 1 1. (a) Perform eligibility determinations for federal and state insur- 2 ance affordability programs including medical assistance in accordance 3 with section three hundred sixty-six of the social services law, child 4 health plus in accordance with section twenty-five hundred eleven of 5 this chapter, the basic health program in accordance with section three 6 hundred sixty-nine-gg of the social services law, premium tax credits 7 and cost-sharing reductions and qualified health plans in accordance 8 with applicable law and other health insurance programs as determined by 9 the commissioner; 10 (b) certify and make available to qualified individuals, qualified 11 health plans, including dental plans, certified by the Marketplace 12 pursuant to applicable law, provided that coverage under such plans 13 shall not become effective prior to certification by the Marketplace; 14 and 15 (c) certify and/or make available to eligible individuals, health 16 plans certified by the Marketplace pursuant to applicable law, and/or 17 participating in an insurance affordability program pursuant to applica- 18 ble law, provided that coverage under such plans shall not become effec- 19 tive prior to certification by the Marketplace, and/or approval by the 20 commissioner. 21 2. Assign an actuarial value to each Marketplace certified plan 22 offered through the Marketplace in accordance with the criteria devel- 23 oped by the secretary pursuant to federal law or the superintendent 24 pursuant to the insurance law and/or requirements developed by the 25 Marketplace, and determine each health plan's level of coverage in 26 accordance with regulations issued by the secretary pursuant to federal 27 law or the superintendent pursuant to the insurance law. 28 3. Utilize a standardized format for presenting health benefit options 29 in the Marketplace, including the use of the uniform outline of coverage 30 established under section 2715 of the federal public health service act 31 or the insurance law. 32 4. Standardize the benefits available through the Marketplace at each 33 level of coverage defined by the superintendent in the insurance law. 34 5. Maintain enrollment periods in the best interest of qualified indi- 35 viduals consistent with federal and state law. 36 6. Implement procedures for the certification, recertification and 37 decertification of health plans as qualified health plans or health 38 plans approved for sale by the department of financial services or 39 department of health and certified by the Marketplace, consistent with 40 guidelines developed by the secretary pursuant to section 1311(c) of the 41 federal act and requirements developed by the Marketplace. 42 7. Contract for health care coverage offered to qualified individuals 43 through the Marketplace, and in doing so shall seek to provide health 44 care coverage choices that offer the optimal combination of choice, 45 value, quality, and service. 46 8. Contract for health care coverage offered to certain eligible indi- 47 viduals through the Marketplace, pursuant to health insurance programs 48 as determined by the commissioner, and in doing so shall seek to provide 49 health care coverage choices that offer the optimal combination of 50 choice, value, quality, and service; 51 9. Provide the minimum requirements an insurer shall meet to partic- 52 ipate in the Marketplace, in the best interest of qualified individuals 53 or eligible individuals; 54 10. Require qualified health plans and/or other health plans certified 55 by the Marketplace to offer those benefits determined to be essential 56 health benefits pursuant to state law or as required by the Marketplace.S. 1507--C 78 A. 2007--C 1 11. Ensure that insurers offering health plans through the Marketplace 2 do not charge an individual enrollee a fee or penalty for termination of 3 coverage. 4 12. Provide for the operation of a toll-free telephone hotline to 5 respond to requests for assistance. 6 13. Maintain an internet website through which enrollees and prospec- 7 tive enrollees of qualified health plans and health plans certified by 8 the Marketplace may obtain standardized comparative information on such 9 plans and insurance affordability programs. 10 14. Make available by electronic means a calculator to determine the 11 actual cost of coverage after the application of any premium tax credit 12 under section 36B of the Internal Revenue Code of 1986 or applicable 13 state law and any cost-sharing reduction under federal or applicable 14 state law. 15 15. Operate a program under which the Marketplace awards grants to 16 entities to serve as navigators in accordance with applicable federal 17 law and regulations adopted thereunder, and/or a program under which the 18 Marketplace awards grants to entities to provide community based enroll- 19 ment assistance in accordance with requirements developed by the Market- 20 place; and/or a program under which the Marketplace certifies New York 21 state licensed producers to provide assistance to eligible individuals 22 and/or small employers pursuant to federal or state law. 23 16. In accordance with applicable federal and state law, inform indi- 24 viduals of eligibility requirements for the Medicaid program under title 25 XIX of the social security act and the social services law, the chil- 26 dren's health insurance program (CHIP) under title XXI of the social 27 security act and this chapter, the basic health program under section 28 three hundred sixty-nine-gg of the social services law, or any applica- 29 ble state or local public health insurance program and if, through 30 screening of the application by the Marketplace, the Marketplace deter- 31 mines that such individuals are eligible for any such program, enroll 32 such individuals in such program. 33 17. Grant a certification that an individual is exempt from the 34 requirement to maintain minimum essential coverage pursuant to federal 35 or state law and from any penalties imposed by such requirements 36 because: 37 (a) there is no affordable health plan available covering the individ- 38 ual, as defined by applicable law; or 39 (b) the individual meets the requirements for any other such exemption 40 from the requirement to maintain minimum essential coverage or to pay 41 the penalty pursuant to applicable federal or state law. 42 18. Operate a small business health options program ("SHOP") pursuant 43 to section 1311 of the federal act and applicable state law, through 44 which eligible small employers may select marketplace-certified quali- 45 fied health plans offered in the small group market, and through which 46 eligible small employers may receive assistance in qualifying for small 47 business tax credits available pursuant to federal and state law. 48 19. Enter into agreements as necessary with federal and state agencies 49 and other state Marketplaces to carry out its responsibilities under 50 this title, provided such agreements include adequate protections with 51 respect to the confidentiality of any information to be shared and 52 comply with all state and federal laws and regulations. 53 20. Perform duties required by the secretary, the secretary of the 54 United States department of the treasury or the commissioner related to 55 determining eligibility for premium tax credits or reduced cost-sharing 56 under applicable federal or state law.S. 1507--C 79 A. 2007--C 1 21. Meet program integrity requirements under applicable law, includ- 2 ing keeping an accurate accounting of receipts and expenditures and 3 providing reports to the secretary regarding Marketplace related activ- 4 ities in accordance with applicable law. 5 22. Submit information provided by Marketplace applicants for verifi- 6 cation as required by section 1411(c) of the federal act and applicable 7 state law. 8 23. Establish rules and regulations that do not conflict with or 9 prevent the application of regulations promulgated by the secretary. 10 24. Determine eligibility, provide notices, and provide opportunities 11 for appeal and redetermination in accordance with the requirements of 12 federal and state law. 13 § 268-d. Special functions of the Marketplace related to health plan 14 certification and qualified health plan oversight. 1. Health plans 15 certified by the Marketplace shall meet the following requirements: 16 (a) The insurer offering the health plan: 17 (i) is licensed or certified by the superintendent or commissioner, in 18 good standing to offer health insurance coverage in this state, and 19 meets the requirements established by the Marketplace; 20 (ii) offers at least one qualified health plan and/or other or addi- 21 tional health plans authorized for sale by the department of financial 22 services or the department in each of the silver and gold levels as 23 required by state law, provided, however, that the Marketplace may 24 require additional benefit levels to be offered by all insurers partic- 25 ipating in the Marketplace; 26 (iii) has filed with and received approval from the superintendent of 27 its premium rates and policy or contract forms pursuant to the insurance 28 law and/or this chapter; 29 (iv) does not charge any cancellation fees or penalties for termi- 30 nation of coverage in violation of applicable law; and 31 (v) complies with the regulations developed by the secretary under 32 section 1311(c) of the federal act and such other requirements as the 33 Marketplace may establish. 34 (b) The health plan: (i) provides the essential health benefits pack- 35 age described in state law or required by the Marketplace and includes 36 such additional benefits as are mandated by state law, except that the 37 health plan shall not be required to provide essential benefits that 38 duplicate the minimum benefits of qualified dental plans if: 39 (A) the Marketplace has determined that at least one qualified dental 40 plan or dental plan approved by the department of financial services or 41 the department is available to supplement the health plan's coverage; 42 and 43 (B) the insurer makes prominent disclosure at the time it offers the 44 health plan, in a form approved by the Marketplace, that the plan does 45 not provide the full range of essential pediatric benefits, and that 46 qualified dental plans or dental plans approved by the department of 47 financial services or department of health providing those benefits and 48 other dental benefits not covered by the plan are offered through the 49 Marketplace; 50 (ii) provides at least a bronze level of coverage as defined by state 51 law, unless the plan is certified as a qualified catastrophic plan, as 52 defined in section 1302(e) of the federal act and the insurance law, and 53 shall only be offered to individuals eligible for catastrophic coverage; 54 (iii) has cost-sharing requirements, including deductibles, which do 55 not exceed the limits established under section 1302(c) of the federal 56 act, state law and any requirements of the Marketplace;S. 1507--C 80 A. 2007--C 1 (iv) complies with regulations promulgated by the secretary pursuant 2 to section 1311(c) of the federal act and applicable state law, which 3 include minimum standards in the areas of marketing practices, network 4 adequacy, essential community providers in underserved areas, accredi- 5 tation, quality improvement, uniform enrollment forms and descriptions 6 of coverage and information on quality measures for health benefit plan 7 performance; 8 (v) meets standards specified and determined by the Marketplace, 9 provided that the standards do not conflict with or prevent the applica- 10 tion of federal requirements; and 11 (vi) complies with the insurance law and this chapter requirements 12 applicable to health insurance issued in this state and any regulations 13 promulgated pursuant thereto that do not conflict with or prevent the 14 application of federal requirements; and 15 (c) The Marketplace determines that making the health plan available 16 through the Marketplace is in the interest of qualified individuals in 17 this state. 18 2. The Marketplace shall not exclude a health plan: 19 (a) on the basis that the health plan is a fee-for-service plan; 20 (b) through the imposition of premium price controls by the Market- 21 place; or 22 (c) on the basis that the health plan provides treatments necessary to 23 prevent patients' deaths in circumstances the Marketplace determines are 24 inappropriate or too costly. 25 3. The Marketplace shall require each insurer certified or seeking 26 certification of a health plan as a qualified health plan or plan 27 approved for sale by the department of financial services or the depart- 28 ment to: 29 (a) submit a justification for any premium increase pursuant to appli- 30 cable law prior to implementation of such increase. The insurer shall 31 prominently post the information on its internet website. Such rate 32 increases shall be subject to the prior approval of the superintendent 33 pursuant to the insurance law; 34 (b)(i) make available to the public and submit to the Marketplace, the 35 secretary and the superintendent, accurate and timely disclosure of: 36 (A) claims payment policies and practices; 37 (B) periodic financial disclosures; 38 (C) data on enrollment and disenrollment; 39 (D) data on the number of claims that are denied; 40 (E) data on rating practices; 41 (F) information on cost-sharing and payments with respect to any out- 42 of-network coverage; 43 (G) information on enrollee and participant rights under title I of 44 the federal act; and 45 (H) other information as determined appropriate by the secretary or 46 otherwise required by the Marketplace; 47 (ii) the information shall be provided in plain language, as that term 48 is defined in section 1311(e)(3)(B) of the federal act and state law, 49 and in guidance jointly issued thereunder by the secretary and the 50 federal secretary of labor; and 51 (c) provide to individuals, in a timely manner upon the request of the 52 individual, the amount of cost-sharing, including deductibles, copay- 53 ments, and coinsurance, under the individual's health plan or coverage 54 that the individual would be responsible for paying with respect to the 55 furnishing of a specific item or service by a participating provider. At 56 a minimum, this information shall be made available to the individualS. 1507--C 81 A. 2007--C 1 through an internet website and through other means for individuals 2 without access to the internet. 3 4. The Marketplace shall not exempt any insurer seeking certification 4 of a health plan, regardless of the type or size of the insurer, from 5 licensing or solvency requirements under the insurance law or this chap- 6 ter, and shall apply the criteria of this section in a manner that 7 ensures a level playing field for insurers participating in the Market- 8 place. 9 5. (a) The provisions of this article that apply to qualified health 10 plans and plans approved for sale by the department of financial 11 services and the department also shall apply to the extent relevant to 12 qualified dental plans approved for sale by the department of financial 13 services or the department, except as modified in accordance with the 14 provisions of paragraphs (b) and (c) of this subdivision or otherwise 15 required by the Marketplace. 16 (b) The qualified dental plan or dental plan approved for sale by the 17 department of financial services and/or the department shall be limited 18 to dental and oral health benefits, without substantially duplicating 19 the benefits typically offered by health benefit plans without dental 20 coverage, and shall include, at a minimum, the essential pediatric 21 dental benefits prescribed by the secretary pursuant to section 22 1302(b)(1)(J) of the federal act, and such other dental benefits as the 23 Marketplace or secretary may specify in regulations. 24 (c) Insurers may jointly offer a comprehensive plan through the 25 Marketplace in which an insurer provides the dental benefits through a 26 qualified dental plan or plan approved by the department of financial 27 services or the department and an insurer provides the other benefits 28 through a qualified health plan, provided that the plans are priced 29 separately and also are made available for purchase separately at the 30 same price. 31 § 268-e. Appeals and appeal hearings; judicial review. 1. Any appli- 32 cant or enrollee, or any individual authorized to act on behalf of any 33 such applicant or enrollee, may appeal to the department from determi- 34 nations of department officials or failures to make determinations upon 35 grounds specified in subdivision four of this section. The department 36 must review the appeal de novo and give such person an opportunity for 37 an appeal hearing. The department may also, on its own motion, review 38 any decision made or any case in which a decision has not been made by 39 the Marketplace or a social services official within the time specified 40 by law or regulations of the department. The department may make such 41 additional investigation as it may deem necessary, and the commissioner 42 must make such determination as is justified and in accordance with 43 applicable law. 44 2. Regarding any appeal pursuant to this section, with or without an 45 appeal hearing, the commissioner may designate and authorize one or more 46 appropriate members of his staff to consider and decide such appeals. 47 Any staff member so designated and authorized will have authority to 48 decide such appeals on behalf of the commissioner with the same force 49 and effect as if the commissioner had made the decisions. Appeal hear- 50 ings must be held on behalf of the commissioner by members of his staff 51 who are employed for such purposes or who have been designated and 52 authorized by the commissioner. 53 3. Persons entitled to appeal to the department pursuant to this 54 section must include: 55 (a) applicants for or enrollees in insurance affordability programs 56 and qualified health plans; andS. 1507--C 82 A. 2007--C 1 (b) other persons entitled to an opportunity for an appeal hearing as 2 directed by the commissioner. 3 4. An applicant or enrollee has the right to appeal at least the 4 following issues: 5 (a) An eligibility determination made in accordance with this article 6 and applicable law, including: 7 (i) An initial determination of eligibility, including: 8 (A) eligibility to enroll in a qualified health plan; 9 (B) eligibility for Medicaid; 10 (C) eligibility for Child Health Plus; 11 (D) eligibility for the Basic Health Program; 12 (E) the amount of advance payments of the premium tax credit and level 13 of cost-sharing reductions; 14 (F) the amount of any other subsidy that may be available under law; 15 and 16 (G) eligibility for such other health insurance programs as determined 17 by the commissioner; and 18 (ii) a re-determination of eligibility of the programs under this 19 subdivision. 20 (b) An eligibility determination for an exemption for any mandate to 21 purchase health insurance. 22 (c) A failure by NY State of Health to provide timely written notice 23 of an eligibility determination made in accordance with applicable law. 24 5. The department may, subject to the discretion of the commissioner, 25 promulgate such regulations, consistent with federal or state law, as 26 may be necessary to implement the provisions of this section. 27 6. Regarding every decision of an appeal pursuant to this section, the 28 department must inform every party, and his or her representative, if 29 any, of the availability of judicial review and the time limitation to 30 pursue future review. 31 7. Applicants and enrollees of qualified health plans, with or without 32 advance payments of the premium tax credit and cost-sharing reductions, 33 also have the right to appeal to the United States Department of Health 34 and Human Services appeal entity: 35 (a) appeals decisions issued by NY State of Health upon the exhaustion 36 of the NY State of Health appeals process; and 37 (b) a denial of a request to vacate a dismissal made by the NY State 38 of Health appeals entity. 39 8. The department must include notice of the right to appeal as 40 provided by subdivision four of this section and instructions regarding 41 how to file an appeal in any eligibility determination issued to the 42 applicant or enrollee in accordance with applicable law. Such notice 43 shall include: 44 (a) an explanation of the applicant or enrollee's appeal rights; 45 (b) a description of the procedures by which the applicant or enrollee 46 may request an appeal; 47 (c) information on the applicant or enrollee's right to represent 48 himself or herself, or to be represented by legal counsel or another 49 representative; 50 (d) an explanation of the circumstances under which the appellant's 51 eligibility may be maintained or reinstated pending an appeal decision; 52 and 53 (e) an explanation that an appeal decision for one household member 54 may result in a change in eligibility for other household members and 55 that such a change will be handled as a redetermination of eligibilityS. 1507--C 83 A. 2007--C 1 for all household members in accordance with the standards specified in 2 applicable law. 3 § 268-f. Marketplace advisory committee. 1. There is hereby created 4 the marketplace advisory committee, which shall consider and advise the 5 department and commissioner on matters concerning the provision of 6 health care coverage through the NY State of Health or Health Plan 7 Marketplace. 8 2. The marketplace advisory committee shall be composed of up to twen- 9 ty-eight members consisting of twenty-four members appointed by the 10 commissioner, two members appointed by the speaker of the assembly, and 11 two members appointed by the temporary president of the senate. The 12 advisory committee shall at all times be representative of each 13 geographic area of the state and include: 14 (a) representatives from the following categories, but not more than 15 six from any single category: 16 (i) health plan consumer advocates; 17 (ii) small business consumer representatives; 18 (iii) health care provider representatives; 19 (iv) representatives of the health insurance industry; 20 (b) representatives from the following categories, but not more than 21 two from either category: 22 (i) licensed insurance producers; and 23 (ii) representatives of labor organizations. 24 3. The commissioner shall select the chair of the advisory committee 25 from among the members of such committee and shall designate an officer 26 or employee of the department to assist the marketplace advisory commit- 27 tee in the performance of its duties under this section. The Marketplace 28 shall adopt rules for the governance of the advisory committee, which 29 shall meet as frequently as its business may require and at such other 30 times as determined by the chair to be necessary, in consultation with 31 the executive director of the Marketplace. 32 4. Members of the advisory committee shall serve without compensation 33 for their services as members, but each shall be allowed the necessary 34 and actual expenses incurred in the performance of his or her duties 35 under this section. 36 § 268-g. Funding of the Marketplace. 1. The Marketplace shall be fund- 37 ed by state and federal sources as authorized by applicable law, includ- 38 ing but not limited to applicable law authorizing the respective insur- 39 ance affordability programs available through the Marketplace. 40 2. The accounts of the Marketplace shall be subject to supervision of 41 the comptroller and such accounts shall include receipts, expenditures, 42 contracts and other matters which pertain to the fiscal soundness of the 43 Marketplace. 44 3. Notwithstanding any law to the contrary, and in accordance with 45 section four of the state finance law, upon request of the director of 46 the budget, in consultation with the commissioner, the superintendent 47 and the executive director of the Marketplace, the comptroller is hereby 48 authorized and directed to sub-allocate or transfer special revenue 49 federal funds appropriated to the department for planning and implement- 50 ing various healthcare and insurance reform initiatives authorized by 51 applicable law. Marketplace moneys sub-allocated or transferred pursu- 52 ant to this section shall be paid out of the fund upon audit and warrant 53 of the state comptroller on vouchers certified or approved by the 54 Marketplace. 55 § 268-h. Construction. Nothing in this article, and no action taken by 56 the Marketplace pursuant hereto, shall be construed to:S. 1507--C 84 A. 2007--C 1 1. preempt or supersede the authority of the superintendent or the 2 commissioner; or 3 2. exempt insurers, insurance producers or qualified health plans from 4 this chapter or the insurance law and any regulations promulgated there- 5 under. 6 § 3. Severability. If any provision of this article, or the applica- 7 tion thereof to any person or circumstances is held invalid or unconsti- 8 tutional, that invalidity or unconstitutionality shall not affect other 9 provisions or applications of this article that can be given effect 10 without the invalid or unconstitutional provision or application, and to 11 this end the provisions and application of this article are severable. 12 § 4. This act shall take effect immediately. 13 PART U 14 Section 1. Section 203 of the elder law is amended by adding a new 15 subdivision 12 to read as follows: 16 12.(a) The director is hereby authorized to implement private pay 17 protocols for programs and services administered by the office. These 18 protocols may be implemented by area agencies on aging at their option 19 and such protocols shall not be applied to services for a participant 20 when being paid for with federal funds or funds designated as federal 21 match, or for individuals with an income below four hundred percent of 22 the federal poverty level. All private payments received directly by an 23 area agency on aging or indirectly by one of its contractors shall be 24 used to supplement, not supplant, funds by state, federal, or county 25 appropriations. Such private pay payments shall be set at a cost to the 26 participant of not more than twenty percent above either the unit cost 27 to the area agency on aging to provide the program or service directly, 28 or the amount that the area agency on aging pays to its contractor to 29 provide the program or service. Private pay payments received under this 30 subdivision shall be used by the area agency on aging to first reduce 31 any unmet need for programs and services, and then to support and 32 enhance services or programs provided by the area agency on aging. No 33 participant, regardless of income, shall be required to pay for any 34 program or service that they are receiving at the time these protocols 35 are implemented by the area agency on aging. This subdivision shall not 36 prevent cost sharing for the programs and services established pursuant 37 to section two hundred fourteen of this title for individuals below four 38 hundred percent of the federal poverty level. Consistent with federal 39 and state statute and regulations, when providing programs and services, 40 area agencies on aging and their contractors shall continue to give 41 priority for programs and services to individuals with the greatest 42 economic or social needs. In the event that the capacity to provide 43 programs and services is limited, such programs and services shall be 44 provided to individuals with incomes below four hundred percent of the 45 federal poverty level before such programs and services are provided to 46 those participating in the private pay protocol pursuant to this subdi- 47 vision. 48 (b) Area agencies on aging participating in the private pay protocol 49 shall annually report to the office the unmet need, if any, for all 50 programs and services offered, the number of participants that privately 51 paid for each program or service for that year, the rates participants 52 were charged for each program or service provided, and how unmet need 53 for programs or services offered by the area agency on aging were 54 affected by revenue from the private pay protocol. Such annual reportS. 1507--C 85 A. 2007--C 1 shall also be shared with the Temporary President of the Senate and the 2 Speaker of the Assembly no later than July first, two thousand twenty- 3 one and shall be updated and reissued on an annual basis thereafter. 4 § 2. This act shall take effect on the three hundred sixty-fifth day 5 after it shall have become a law; provided, however, that effective 6 immediately, any actions necessary for the implementation of this act on 7 its effective date are authorized to be completed on or before such 8 date. 9 PART V 10 Section 1. Paragraph (d) of subdivision 32 of section 364-j of the 11 social services law, as added by section 15 of part B of chapter 59 of 12 the laws of 2016, is amended to read as follows: 13 (d) (i) Penalties under this subdivision may be applied to any and all 14 circumstances described in paragraph (b) of this subdivision until the 15 managed care organization complies with the requirements for submission 16 of encounter data. 17 (ii) No penalties for late, incomplete or inaccurate encounter data 18 shall be assessed against managed care organizations in addition to 19 those provided for in this subdivision, provided, however, that nothing 20 in this paragraph shall prohibit the imposition of penalties, in cases 21 of fraud or abuse, otherwise authorized by law. 22 § 2. Section 364-j of the social services law is amended by adding a 23 new subdivision 34 read as follows: 24 34. For purposes of recovery of overpayments pursuant to subdivision 25 thirty-five of this section, any payment made pursuant to the state's 26 managed care program, including payments made by managed long term care 27 plans, shall be deemed a payment by the state's medical assistance 28 program, provided that this subdivision shall not permit the imposition 29 of a lien or recovery against property of an individual or estate on 30 account of medical assistance payments where recovery is made against 31 the individual's managed care provider or provider of medical assistance 32 program items or services. Provided however nothing in this subdivision 33 shall be construed to limit recoveries under other relevant sections of 34 law. 35 § 3. Section 364-j of the social services law is amended by adding a 36 new subdivision 36 to read as follows: 37 36. Medicaid Program Integrity Reviews. (a) For purposes of this 38 subdivision, managed care provider shall also include managed long term 39 care plans. 40 (b) The Medicaid inspector general shall conduct periodic reviews of 41 the contractual performance of each managed care provider as it relates 42 to the managed care provider's program integrity obligations under its 43 contract with the department. The Medicaid inspector general, in consul- 44 tation with the commissioner, shall publish on its website, a list of 45 those contractual obligations pursuant to which the managed care provid- 46 er's program integrity performance shall be evaluated, including bench- 47 marks, prior to commencing any review. A Medicaid program integrity 48 review of a managed care provider conducted pursuant to this subdivi- 49 sion, may be completed no more than annually. Reviews performed pursuant 50 to this subdivision shall include a review of compliance with contractu- 51 al standards which prevent fraud, waste, or abuse. Such standards may 52 include but are not limited to excluded providers, restricted recipient 53 program, reporting obligations, compliance programs, and suspension of 54 payments. However, if the Medicaid inspector general determines that aS. 1507--C 86 A. 2007--C 1 subsequent review, pursuant to this subdivision, is necessary, a second 2 review may occur within one year. 3 (c) If, as a result of his or her review, the Medicaid inspector 4 general determines that a managed care provider is not meeting its 5 program integrity obligations, the Medicaid inspector general may 6 recover from the managed care provider up to two percent of the Medicaid 7 premiums paid to the managed care provider for the period under review. 8 Any premium recovery under this subdivision shall be a percentage of the 9 administrative component of the Medicaid premium calculated by the 10 department and may be recovered by the department in the same manner it 11 recovers overpayments. 12 (d) The managed care provider shall be entitled to receive a draft 13 audit report and final audit report containing the results of the Medi- 14 caid inspector general's review. If the Medicaid inspector general 15 determines to recover a percentage of the premium as described in para- 16 graph (c) of this subdivision, the managed care provider shall be enti- 17 tled to notice and an opportunity to be heard in accordance with section 18 twenty-two of this chapter. 19 § 4. Subdivision 3 of section 363-d of the social services law, as 20 amended by section 44 of part C of chapter 58 of the laws of 2007, is 21 amended to read as follows: 22 3. Upon enrollment in the medical assistance program, a provider shall 23 certify to the department that the provider satisfactorily meets the 24 requirements of this section. Additionally, the commissioner of health 25 and Medicaid inspector general shall have the authority to determine at 26 any time if a provider has a compliance program that satisfactorily 27 meets the requirements of this section. 28 (a) A compliance program that is accepted by the federal department of 29 health and human services office of inspector general and remains in 30 compliance with the standards promulgated by such office shall be deemed 31 in compliance with the provisions of this section, so long as such plans 32 adequately address medical assistance program risk areas and compliance 33 issues. 34 (b) A compliance program that meets Federal requirements for managed 35 care provider compliance programs, as specified in the contract or 36 contracts between the department and the Medicaid managed care provider 37 shall be deemed in compliance with the provisions in this section, so 38 long as such programs adequately address medical assistance program risk 39 areas and compliance issues. For purposes of this section, a managed 40 care provider is as defined in paragraph (c) of subdivision one of 41 section three hundred sixty-four-j of this chapter, and includes managed 42 long term care plans. 43 (c) In the event that the commissioner of health or the Medicaid 44 inspector general finds that the provider does not have a satisfactory 45 program within ninety days after the effective date of the regulations 46 issued pursuant to subdivision four of this section, the provider may be 47 subject to any sanctions or penalties permitted by federal or state laws 48 and regulations, including revocation of the provider's agreement to 49 participate in the medical assistance program. 50 § 5. Intentionally omitted. 51 § 6. Section 364-j of the social services law is amended by adding a 52 new subdivision 35 to read as follows: 53 35. Recovery of overpayments from network providers. (a) Where the 54 Medicaid inspector general during the course of an audit, investigation, 55 or review, or the deputy attorney general for the Medicaid fraud control 56 unit during the course of an investigation or prosecution for MedicaidS. 1507--C 87 A. 2007--C 1 fraud, identifies medical assistance overpayments made by a managed care 2 provider or managed long term care plan to its subcontractor or subcon- 3 tractors or provider or providers, the state shall have the right to 4 recover the overpayment from the subcontractor or subcontractors, 5 provider or providers, or the managed care provider or managed long term 6 care plan; provided, however, in no event shall the state duplicate the 7 recovery of an overpayment from a provider or subcontractor. 8 (b) Where the state is unsuccessful in recovering an overpayment from 9 the subcontractor or subcontractors or provider or providers, the Medi- 10 caid inspector general may require the managed care provider or managed 11 long term care plan to recover the medical assistance overpayment iden- 12 tified in paragraph (a) of this subdivision on behalf of the state. The 13 managed care provider or managed long term care plan shall remit to the 14 state the full amount of the identified overpayment no later than six 15 months after receiving notice of the overpayment from the state. 16 § 7. This act shall take effect immediately and shall be deemed to 17 have been in full force and effect on and after April 1, 2019; provided, 18 however, that the amendments to section 364-j of the social services law 19 made by sections one, two, three, and six of this act shall not affect 20 the repeal of such section and shall be deemed repealed therewith; 21 provided further, that section three of this act shall apply to a 22 contract or contracts in effect as of January 1, 2015 or thereafter and 23 any review period in section three of this act shall not begin before 24 January 1, 2018. 25 PART W 26 Section 1. Section 1 of part D of chapter 111 of the laws of 2010 27 relating to the recovery of exempt income by the office of mental health 28 for community residences and family-based treatment programs, as amended 29 by section 1 of part H of chapter 59 of the laws of 2016, is amended to 30 read as follows: 31 Section 1. The office of mental health is authorized to recover fund- 32 ing from community residences and family-based treatment providers 33 licensed by the office of mental health, consistent with contractual 34 obligations of such providers, and notwithstanding any other inconsist- 35 ent provision of law to the contrary, in an amount equal to 50 percent 36 of the income received by such providers which exceeds the fixed amount 37 of annual Medicaid revenue limitations, as established by the commis- 38 sioner of mental health. Recovery of such excess income shall be for the 39 following fiscal periods: for programs in counties located outside of 40 the city of New York, the applicable fiscal periods shall be January 1, 41 2003 through December 31, 2009 and January 1, 2011 through December 31, 42 [2019] 2022; and for programs located within the city of New York, the 43 applicable fiscal periods shall be July 1, 2003 through June 30, 2010 44 and July 1, 2011 through June 30, [2019] 2022. 45 § 2. This act shall take effect immediately. 46 PART X 47 Intentionally Omitted 48 PART Y 49 Section 1. Subdivisions 3-b and 3-c of section 1 of part C of chapter 50 57 of the laws of 2006, relating to establishing a cost of livingS. 1507--C 88 A. 2007--C 1 adjustment for designated human services programs, as amended by section 2 1 of part AA of chapter 57 of the laws of 2018, are amended to read as 3 follows: 4 3-b. Notwithstanding any inconsistent provision of law, beginning 5 April 1, 2009 and ending March 31, 2016 and beginning April 1, 2017 and 6 ending March 31, [2019] 2020, the commissioners shall not include a COLA 7 for the purpose of establishing rates of payments, contracts or any 8 other form of reimbursement, provided that the commissioners of the 9 office for people with developmental disabilities, the office of mental 10 health, and the office of alcoholism and substance abuse services shall 11 not include a COLA beginning April 1, 2017 and ending March 31, [2019] 12 2021. 13 3-c. Notwithstanding any inconsistent provision of law, beginning 14 April 1, [2019] 2020 and ending March 31, [2022] 2023, the commissioners 15 shall develop the COLA under this section using the actual U.S. consumer 16 price index for all urban consumers (CPI-U) published by the United 17 States department of labor, bureau of labor statistics for the twelve 18 month period ending in July of the budget year prior to such state 19 fiscal year, for the purpose of establishing rates of payments, 20 contracts or any other form of reimbursement. 21 § 2. Section 1 of part C of chapter 57 of the laws of 2006, relating 22 to establishing a cost of living adjustment for designated human 23 services programs, is amended by adding a new subdivision 3-f to read as 24 follows: 25 3-f. (i) Notwithstanding the provisions of subdivision 3-b of this 26 section or any other inconsistent provision of law, and subject to the 27 availability of the appropriation therefor, for the programs listed in 28 paragraphs (i), (ii), and (iii) of subdivision 4 of this section, the 29 commissioners shall provide funding to support (1) an overall average 30 two percent (2.00%) increase to total salaries for direct care staff, 31 direct support professionals for each eligible state-funded program 32 beginning January 1, 2020; and (2) an overall average two percent 33 (2.00%) increase to total salaries for direct care staff and direct 34 support professionals, and clinical staff for each eligible state-funded 35 program beginning April 1, 2020. For the purpose of this funding 36 increase, direct support professionals are individuals employed in 37 consolidated fiscal reporting position title codes ranging from 100 to 38 199; direct care staff are individuals employed in consolidated fiscal 39 reporting position title codes ranging from 200 to 299; and clinical 40 staff are individuals employed in consolidated fiscal reporting position 41 title codes ranging from 300 to 399. 42 (ii) The funding made available pursuant to paragraph (i) of this 43 subdivision shall be used: (1) to help alleviate the recruitment and 44 retention challenges of direct care staff, direct support professionals 45 and clinical staff employed in eligible programs; and (2) to continue 46 and to expand efforts to support the professionalism of the direct care 47 workforce. Each local government unit or direct contract provider 48 receiving such funding shall have flexibility in allocating such funding 49 to support salary increases to particular job titles to best address the 50 needs of its direct care staff, direct support professionals and clin- 51 ical staff. Each local government unit or direct contract provider 52 receiving such funding shall also submit a written certification, in 53 such form and at such time as each commissioner shall prescribe, attest- 54 ing to how such funding will be or was used for purposes eligible under 55 this section. Further, providers shall submit a resolution from their 56 governing body to the appropriate commissioner, attesting that the fund-S. 1507--C 89 A. 2007--C 1 ing received will be used solely to support salary and salary-related 2 fringe benefit increases for direct care staff, direct support profes- 3 sionals and clinical staff, pursuant to paragraph (i) of this subdivi- 4 sion. Salary increases that take effect on and after April 1, 2019 may 5 be used to demonstrate compliance with the January 1, 2020 funding 6 increase authorized by this section, except for salary increases neces- 7 sary to comply with state minimum wage requirements. Such commissioners 8 shall be authorized to recoup any funds as appropriated herein deter- 9 mined to have been used in a manner inconsistent with such standards or 10 inconsistent with the provisions of this subdivision, and such commis- 11 sioners shall be authorized to employ any legal mechanism to recoup such 12 funds, including an offset of other funds that are owed to such local 13 governmental unit or provider. 14 (iii) Where appropriate transfers to the department of health shall be 15 made as reimbursement for the state share of medical assistance. 16 § 3. This act shall take effect immediately and shall be deemed to 17 have been in full force and effect on and after April 1, 2019; provided, 18 however, that the amendments to section 1 of part C of chapter 57 of the 19 laws of 2006 made by sections one and two of this act shall not affect 20 the repeal of such section and shall be deemed repealed therewith. 21 PART Z 22 Section 1. Subdivision 1 of section 2801 of the public health law, as 23 amended by section 1 of subpart B of part S of chapter 57 of the laws of 24 2018, is amended to read as follows: 25 1. "Hospital" means a facility or institution engaged principally in 26 providing services by or under the supervision of a physician or, in the 27 case of a dental clinic or dental dispensary, of a dentist, or, in the 28 case of a midwifery birth center, of a midwife, for the prevention, 29 diagnosis or treatment of human disease, pain, injury, deformity or 30 physical condition, including, but not limited to, a general hospital, 31 public health center, diagnostic center, treatment center, dental clin- 32 ic, dental dispensary, rehabilitation center other than a facility used 33 solely for vocational rehabilitation, nursing home, tuberculosis hospi- 34 tal, chronic disease hospital, maternity hospital, midwifery birth 35 center, lying-in-asylum, out-patient department, out-patient lodge, 36 dispensary and a laboratory or central service facility serving one or 37 more such institutions, but the term hospital shall not include an 38 institution, sanitarium or other facility engaged principally in provid- 39 ing services for the prevention, diagnosis or treatment of mental disa- 40 bility and which is subject to the powers of visitation, examination, 41 inspection and investigation of the department of mental hygiene except 42 for those distinct parts of such a facility which provide hospital 43 service. The provisions of this article shall not apply to a facility or 44 institution engaged principally in providing services by or under the 45 supervision of the bona fide members and adherents of a recognized reli- 46 gious organization whose teachings include reliance on spiritual means 47 through prayer alone for healing in the practice of the religion of such 48 organization and where services are provided in accordance with those 49 teachings. No provision of this article or any other provision of law 50 shall be construed to: (a) limit the volume of mental health [or], 51 substance use disorder services or developmental disability services 52 that can be provided by a provider of primary care services licensed 53 under this article and authorized to provide integrated services in 54 accordance with regulations issued by the commissioner in consultationS. 1507--C 90 A. 2007--C 1 with the commissioner of the office of mental health [and], the commis- 2 sioner of the office of alcoholism and substance abuse services and the 3 commissioner of the office for people with developmental disabilities, 4 including regulations issued pursuant to subdivision seven of section 5 three hundred sixty-five-l of the social services law or part L of chap- 6 ter fifty-six of the laws of two thousand twelve; (b) require a provider 7 licensed pursuant to article thirty-one of the mental hygiene law or 8 certified pursuant to article sixteen or article thirty-two of the 9 mental hygiene law to obtain an operating certificate from the depart- 10 ment if such provider has been authorized to provide integrated services 11 in accordance with regulations issued by the commissioner in consulta- 12 tion with the commissioner of the office of mental health [and], the 13 commissioner of the office of alcoholism and substance abuse services 14 and the commissioner of the office for people with developmental disa- 15 bilities, including regulations issued pursuant to subdivision seven of 16 section three hundred sixty-five-l of the social services law or part L 17 of chapter fifty-six of the laws of two thousand twelve. 18 § 2. Subdivision (f) of section 31.02 of the mental hygiene law, as 19 added by section 2 of subpart B of part S of chapter 57 of the laws of 20 2018, is amended to read as follows: 21 (f) No provision of this article or any other provision of law shall 22 be construed to require a provider licensed pursuant to article twenty- 23 eight of the public health law or certified pursuant to article sixteen 24 or article thirty-two of this chapter to obtain an operating certificate 25 from the office of mental health if such provider has been authorized to 26 provide integrated services in accordance with regulations issued by the 27 commissioner of the office of mental health in consultation with the 28 commissioner of the department of health [and], the commissioner of the 29 office of alcoholism and substance abuse services and the commissioner 30 of the office for people with developmental disabilities, including 31 regulations issued pursuant to subdivision seven of section three 32 hundred sixty-five-l of the social services law or part L of chapter 33 fifty-six of the laws of two thousand twelve. 34 § 3. Subdivision (b) of section 32.05 of the mental hygiene law, as 35 amended by section 3 of subpart B of part S of chapter 57 of the laws of 36 2018, is amended to read as follow: 37 (b) (i) Methadone, or such other controlled substance designated by 38 the commissioner of health as appropriate for such use, may be adminis- 39 tered to an addict, as defined in section thirty-three hundred two of 40 the public health law, by individual physicians, groups of physicians 41 and public or private medical facilities certified pursuant to article 42 twenty-eight or thirty-three of the public health law as part of a chem- 43 ical dependence program which has been issued an operating certificate 44 by the commissioner pursuant to subdivision (b) of section 32.09 of this 45 article, provided, however, that such administration must be done in 46 accordance with all applicable federal and state laws and regulations. 47 Individual physicians or groups of physicians who have obtained authori- 48 zation from the federal government to administer buprenorphine to 49 addicts may do so without obtaining an operating certificate from the 50 commissioner. (ii) No provision of this article or any other provision 51 of law shall be construed to require a provider licensed pursuant to 52 article twenty-eight of the public health law [or], article thirty-one 53 of this chapter or a provider certified pursuant to article sixteen of 54 this chapter to obtain an operating certificate from the office of alco- 55 holism and substance abuse services if such provider has been authorized 56 to provide integrated services in accordance with regulations issued byS. 1507--C 91 A. 2007--C 1 the commissioner of alcoholism and substance abuse services in consulta- 2 tion with the commissioner of the department of health [and], the 3 commissioner of the office of mental health and the commissioner of the 4 office for people with developmental disabilities, including regulations 5 issued pursuant to subdivision seven of section three hundred sixty- 6 five-l of the social services law or part L of chapter fifty-six of the 7 laws of two thousand twelve. 8 § 4. Section 16.03 of the mental hygiene law is amended by adding a 9 new subdivision (g) to read as follows: 10 (g) No provision of this article or any other provision of law shall 11 be construed to require a provider licensed pursuant to article twenty- 12 eight of the public health law or certified pursuant to article thirty- 13 one or thirty-two of this chapter to obtain an operating certificate 14 from the office for people with developmental disabilities if such 15 provider has been authorized to provide integrated services in accord- 16 ance with regulations issued by the commissioner of the office for 17 people with developmental disabilities, in consultation with the commis- 18 sioner of the department of health, the commissioner of the office of 19 mental health and the commissioner of the office of alcoholism and 20 substance abuse services, including regulations issued pursuant to 21 subdivision seven of section three hundred sixty-five-l of the social 22 services law or part L of chapter fifty-six of the laws of two thousand 23 twelve. 24 § 5. This act shall take effect October 1, 2019; provided, however, 25 that the commissioner of the department of health, the commissioner of 26 the office of mental health, the commissioner of the office of alcohol- 27 ism and substance abuse services, and the commissioner of the office for 28 people with developmental disabilities are authorized to issue any rule 29 or regulation necessary for the implementation of this act on or before 30 its effective date. 31 PART AA 32 Intentionally Omitted 33 PART BB 34 Section 1. This part enacts into law major components of legislation 35 which are necessary to effectuate provisions relating to mental health 36 and substance use disorder treatment. Each component is wholly 37 contained within a Subpart identified as Subparts A through E. The 38 effective date for each particular provision contained within such 39 Subpart is set forth in the last section of such Subpart. Any provision 40 in any section contained within a Subpart, including the effective date 41 of the Subpart, which makes a reference to a section "of this act", when 42 used in connection with that particular component, shall be deemed to 43 mean and refer to the corresponding section of the Subpart in which it 44 is found. Section three of this Part sets forth the general effective 45 date of this Part. 46 SUBPART A 47 Section 1. Paragraph 4 of subsection (i) of section 3216 of the insur- 48 ance law is amended to read as follows: 49 (4) If a policy provides for reimbursement for psychiatric or psycho- 50 logical services or for diagnosis and treatment of mental[,nervous, orS. 1507--C 92 A. 2007--C 1emotional disorders or ailments,] health conditions however defined in 2 the policy, the insured shall be entitled to reimbursement for such 3 services, diagnosis or treatment whether performed by a physician, 4 psychiatrist [or], a certified and registered psychologist, or a nurse 5 practitioner when the services rendered are within the lawful scope of 6 their practice. 7 § 2. Subparagraph (B) of paragraph 25 of subsection (i) of section 8 3216 of the insurance law, as amended by section 38 of part D of chapter 9 56 of the laws of 2013, is amended to read as follows: 10 (B) Every policy that provides physician services, medical, major 11 medical or similar comprehensive-type coverage shall provide coverage 12 for the screening, diagnosis and treatment of autism spectrum disorder 13 in accordance with this paragraph and shall not exclude coverage for the 14 screening, diagnosis or treatment of medical conditions otherwise 15 covered by the policy because the individual is diagnosed with autism 16 spectrum disorder. Such coverage may be subject to annual deductibles, 17 copayments and coinsurance as may be deemed appropriate by the super- 18 intendent and shall be consistent with those imposed on other benefits 19 under the policy. [Coverage for applied behavior analysis shall be20subject to a maximum benefit of six hundred eighty hours of treatment21per policy or calendar year per covered individual.] This paragraph 22 shall not be construed as limiting the benefits that are otherwise 23 available to an individual under the policy, provided however that such 24 policy shall not contain any limitations on visits that are solely 25 applied to the treatment of autism spectrum disorder. No insurer shall 26 terminate coverage or refuse to deliver, execute, issue, amend, adjust, 27 or renew coverage to an individual solely because the individual is 28 diagnosed with autism spectrum disorder or has received treatment for 29 autism spectrum disorder. Coverage shall be subject to utilization 30 review and external appeals of health care services pursuant to article 31 forty-nine of this chapter as well as[,] case management[,] and other 32 managed care provisions. 33 § 3. Items (i) and (iii) of subparagraph (C) of paragraph 25 of 34 subsection (i) of section 3216 of the insurance law, as amended by chap- 35 ter 596 of the laws of 2011, are amended to read as follows: 36 (i) "autism spectrum disorder" means any pervasive developmental 37 disorder as defined in the most recent edition of the diagnostic and 38 statistical manual of mental disorders[, including autistic disorder,39Asperger's disorder, Rett's disorder, childhood disintegrative disorder,40or pervasive developmental disorder not otherwise specified (PDD-NOS)]. 41 (iii) "behavioral health treatment" means counseling and treatment 42 programs, when provided by a licensed provider, and applied behavior 43 analysis, when provided [or supervised] by a [behavior analyst certified44pursuant to the behavior analyst certification board] person licensed, 45 certified or otherwise authorized to provide applied behavior analysis, 46 that are necessary to develop, maintain, or restore, to the maximum 47 extent practicable, the functioning of an individual. [Individuals that48provide behavioral health treatment under the supervision of a certified49behavior analyst pursuant to this paragraph shall be subject to stand-50ards of professionalism, supervision and relevant experience pursuant to51regulations promulgated by the superintendent in consultation with the52commissioners of health and education.] 53 § 4. Paragraph 25 of subsection (i) of section 3216 of the insurance 54 law is amended by adding four new subparagraphs (H), (I), (J), and (K) 55 to read as follows:S. 1507--C 93 A. 2007--C 1 (H) Coverage under this paragraph shall not apply financial require- 2 ments or treatment limitations to autism spectrum disorder benefits that 3 are more restrictive than the predominant financial requirements and 4 treatment limitations applied to substantially all medical and surgical 5 benefits covered by the policy. 6 (I) The criteria for medical necessity determinations under the policy 7 with respect to autism spectrum disorder benefits shall be made avail- 8 able by the insurer to any insured, prospective insured, or in-network 9 provider upon request. 10 (J) For purposes of this paragraph: 11 (i) "financial requirement" means deductible, copayments, coinsurance 12 and out-of-pocket expenses; 13 (ii) "predominant" means that a financial requirement or treatment 14 limitation is the most common or frequent of such type of limit or 15 requirement; and 16 (iii) "treatment limitation" means limits on the frequency of treat- 17 ment, number of visits, days of coverage, or other similar limits on the 18 scope or duration of treatment and includes nonquantitative treatment 19 limitations such as: medical management standards limiting or excluding 20 benefits based on medical necessity, or based on whether the treatment 21 is experimental or investigational; formulary design for prescription 22 drugs; network tier design; standards for provider admission to partic- 23 ipate in a network, including reimbursement rates; methods for deter- 24 mining usual, customary, and reasonable charges; fail-first or step 25 therapy protocols; exclusions based on failure to complete a course of 26 treatment; and restrictions based on geographic location, facility type, 27 provider specialty, and other criteria that limit the scope or duration 28 of benefits for services provided under the policy. 29 (K) An insurer shall provide coverage under this paragraph, at a mini- 30 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 31 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 32 § 5. Paragraph 30 of subsection (i) of section 3216 of the insurance 33 law, as amended by section 1 of part B of chapter 71 of the laws of 34 2016, is amended to read as follows: 35 (30)(A) Every policy that provides hospital, major medical or similar 36 comprehensive coverage [must] shall provide inpatient coverage for the 37 diagnosis and treatment of substance use disorder, including detoxifica- 38 tion and rehabilitation services. Such inpatient coverage shall include 39 unlimited medically necessary treatment for substance use disorder 40 treatment services provided in residential settings [as required by the41Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §421185a)]. Further, such inpatient coverage shall not apply financial 43 requirements or treatment limitations, including utilization review 44 requirements, to inpatient substance use disorder benefits that are more 45 restrictive than the predominant financial requirements and treatment 46 limitations applied to substantially all medical and surgical benefits 47 covered by the policy. [Further, such coverage shall be provided48consistent with the federal Paul Wellstone and Pete Domenici Mental49Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).] 50 (B) Coverage provided under this paragraph may be limited to facili- 51 ties in New York state [which are certified] that are licensed, certi- 52 fied or otherwise authorized by the office of alcoholism and substance 53 abuse services and, in other states, to those which are accredited by 54 the joint commission as alcoholism, substance abuse, or chemical depend- 55 ence treatment programs and are similarly licensed, certified or other- 56 wise authorized in the state in which the facility is located.S. 1507--C 94 A. 2007--C 1 (C) Coverage provided under this paragraph may be subject to annual 2 deductibles and co-insurance as deemed appropriate by the superintendent 3 and that are consistent with those imposed on other benefits within a 4 given policy. 5 (D) This subparagraph shall apply to facilities in this state that are 6 licensed, certified or otherwise authorized by the office of alcoholism 7 and substance abuse services that are participating in the insurer's 8 provider network. Coverage provided under this paragraph shall not be 9 subject to preauthorization. Coverage provided under this paragraph 10 shall also not be subject to concurrent utilization review during the 11 first [fourteen] twenty-eight days of the inpatient admission provided 12 that the facility notifies the insurer of both the admission and the 13 initial treatment plan within [forty-eight hours] two business days of 14 the admission. The facility shall perform daily clinical review of the 15 patient, including [the] periodic consultation with the insurer at or 16 just prior to the fourteenth day of treatment to ensure that the facili- 17 ty is using the evidence-based and peer reviewed clinical review tool 18 utilized by the insurer which is designated by the office of alcoholism 19 and substance abuse services and appropriate to the age of the patient, 20 to ensure that the inpatient treatment is medically necessary for the 21 patient. Prior to discharge, the facility shall provide the patient and 22 the insurer with a written discharge plan which shall describe arrange- 23 ments for additional services needed following discharge from the inpa- 24 tient facility as determined using the evidence-based and peer-reviewed 25 clinical review tool utilized by the insurer which is designated by the 26 office of alcoholism and substance abuse services. Prior to discharge, 27 the facility shall indicate to the insurer whether services included in 28 the discharge plan are secured or determined to be reasonably available. 29 Any utilization review of treatment provided under this subparagraph may 30 include a review of all services provided during such inpatient treat- 31 ment, including all services provided during the first [fourteen] twen- 32 ty-eight days of such inpatient treatment. Provided, however, the insur- 33 er shall only deny coverage for any portion of the initial [fourteen] 34 twenty-eight day inpatient treatment on the basis that such treatment 35 was not medically necessary if such inpatient treatment was contrary to 36 the evidence-based and peer reviewed clinical review tool utilized by 37 the insurer which is designated by the office of alcoholism and 38 substance abuse services. An insured shall not have any financial obli- 39 gation to the facility for any treatment under this subparagraph other 40 than any copayment, coinsurance, or deductible otherwise required under 41 the policy. 42 (E) An insurer shall make available to any insured, prospective 43 insured, or in-network provider, upon request, the criteria for medical 44 necessity determinations under the policy with respect to inpatient 45 substance use disorder benefits. 46 (F) For purposes of this paragraph: 47 (i) "financial requirement" means deductible, copayments, coinsurance 48 and out-of-pocket expenses; 49 (ii) "predominant" means that a financial requirement or treatment 50 limitation is the most common or frequent of such type of limit or 51 requirement; 52 (iii) "treatment limitation" means limits on the frequency of treat- 53 ment, number of visits, days of coverage, or other similar limits on the 54 scope or duration of treatment and includes nonquantitative treatment 55 limitations such as: medical management standards limiting or excluding 56 benefits based on medical necessity, or based on whether the treatmentS. 1507--C 95 A. 2007--C 1 is experimental or investigational; formulary design for prescription 2 drugs; network tier design; standards for provider admission to partic- 3 ipate in a network, including reimbursement rates; methods for determin- 4 ing usual, customary, and reasonable charges; fail-first or step therapy 5 protocols; exclusions based on failure to complete a course of treat- 6 ment; and restrictions based on geographic location, facility type, 7 provider specialty, and other criteria that limit the scope or duration 8 of benefits for services provided under the policy; and 9 (iv) "substance use disorder" shall have the meaning set forth in the 10 most recent edition of the diagnostic and statistical manual of mental 11 disorders or the most recent edition of another generally recognized 12 independent standard of current medical practice, such as the interna- 13 tional classification of diseases. 14 (G) An insurer shall provide coverage under this paragraph, at a mini- 15 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 16 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 17 § 6. Paragraph 31 of subsection (i) of section 3216 of the insurance 18 law, as added by chapter 41 of the laws of 2014 and subparagraph (E) as 19 added by section 3 of part MM of chapter 57 of the laws of 2018, is 20 amended to read as follows: 21 (31) (A) Every policy that provides medical, major medical or similar 22 comprehensive-type coverage [must] shall provide outpatient coverage for 23 the diagnosis and treatment of substance use disorder, including detoxi- 24 fication and rehabilitation services. Such coverage shall not apply 25 financial requirements or treatment limitations to outpatient substance 26 use disorder benefits that are more restrictive than the predominant 27 financial requirements and treatment limitations applied to substantial- 28 ly all medical and surgical benefits covered by the policy. [Further,29such coverage shall be provided consistent with the federal Paul Well-30stone and Pete Domenici Mental Health Parity and Addiction Equity Act of312008 (29 U.S.C. § 1185a).] 32 (B) Coverage under this paragraph may be limited to facilities in New 33 York state [certified] that are licensed, certified or otherwise author- 34 ized by the office of alcoholism and substance abuse services [or35licensed by such office as outpatient clinics or medically supervised36ambulatory] to provide outpatient substance [abuse programs] use disor- 37 der services and, in other states, to those which are accredited by the 38 joint commission as alcoholism or chemical dependence substance abuse 39 treatment programs and are similarly licensed, certified, or otherwise 40 authorized in the state in which the facility is located. 41 (C) Coverage provided under this paragraph may be subject to annual 42 deductibles and co-insurance as deemed appropriate by the superintendent 43 and that are consistent with those imposed on other benefits within a 44 given policy. 45 (D) A policy providing coverage for substance use disorder services 46 pursuant to this paragraph shall provide up to twenty outpatient visits 47 per policy or calendar year to an individual who identifies him or 48 herself as a family member of a person suffering from substance use 49 disorder and who seeks treatment as a family member who is otherwise 50 covered by the applicable policy pursuant to this paragraph. The cover- 51 age required by this paragraph shall include treatment as a family 52 member pursuant to such family member's own policy provided such family 53 member: 54 (i) does not exceed the allowable number of family visits provided by 55 the applicable policy pursuant to this paragraph; andS. 1507--C 96 A. 2007--C 1 (ii) is otherwise entitled to coverage pursuant to this paragraph and 2 such family member's applicable policy. 3 (E) This subparagraph shall apply to facilities in this state that are 4 licensed, certified or otherwise authorized by the office of alcoholism 5 and substance abuse services for the provision of outpatient, intensive 6 outpatient, outpatient rehabilitation and opioid treatment that are 7 participating in the insurer's provider network. Coverage provided under 8 this paragraph shall not be subject to preauthorization. Coverage 9 provided under this paragraph shall not be subject to concurrent review 10 for the first [two] four weeks of continuous treatment, not to exceed 11 [fourteen] twenty-eight visits, provided the facility notifies the 12 insurer of both the start of treatment and the initial treatment plan 13 within [forty-eight hours] two business days. The facility shall perform 14 clinical assessment of the patient at each visit, including [the] peri- 15 odic consultation with the insurer at or just prior to the fourteenth 16 day of treatment to ensure that the facility is using the evidence-based 17 and peer reviewed clinical review tool utilized by the insurer which is 18 designated by the office of alcoholism and substance abuse services and 19 appropriate to the age of the patient, to ensure that the outpatient 20 treatment is medically necessary for the patient. Any utilization review 21 of the treatment provided under this subparagraph may include a review 22 of all services provided during such outpatient treatment, including all 23 services provided during the first [two] four weeks of continuous treat- 24 ment, not to exceed [fourteen] twenty-eight visits, of such outpatient 25 treatment. Provided, however, the insurer shall only deny coverage for 26 any portion of the initial [two] four weeks of continuous treatment, not 27 to exceed [fourteen] twenty-eight visits, for outpatient treatment on 28 the basis that such treatment was not medically necessary if such outpa- 29 tient treatment was contrary to the evidence-based and peer reviewed 30 clinical review tool utilized by the insurer which is designated by the 31 office of alcoholism and substance abuse services. An insured shall not 32 have any financial obligation to the facility for any treatment under 33 this subparagraph other than any copayment, coinsurance, or deductible 34 otherwise required under the policy. 35 (F) The criteria for medical necessity determinations under the policy 36 with respect to outpatient substance use disorder benefits shall be made 37 available by the insurer to any insured, prospective insured, or in-net- 38 work provider upon request. 39 (G) For purposes of this paragraph: 40 (i) "financial requirement" means deductible, copayments, coinsurance 41 and out-of-pocket expenses; 42 (ii) "predominant" means that a financial requirement or treatment 43 limitation is the most common or frequent of such type of limit or 44 requirement; 45 (iii) "treatment limitation" means limits on the frequency of treat- 46 ment, number of visits, days of coverage, or other similar limits on the 47 scope or duration of treatment and includes nonquantitative treatment 48 limitations such as: medical management standards limiting or excluding 49 benefits based on medical necessity, or based on whether the treatment 50 is experimental or investigational; formulary design for prescription 51 drugs; network tier design; standards for provider admission to partic- 52 ipate in a network, including reimbursement rates; methods for determin- 53 ing usual, customary, and reasonable charges; fail-first or step therapy 54 protocols; exclusions based on failure to complete a course of treat- 55 ment; and restrictions based on geographic location, facility type,S. 1507--C 97 A. 2007--C 1 provider specialty, and other criteria that limit the scope or duration 2 of benefits for services provided under the policy; and 3 (iv) "substance use disorder" shall have the meaning set forth in the 4 most recent edition of the diagnostic and statistical manual of mental 5 disorders or the most recent edition of another generally recognized 6 independent standard of current medical practice such as the interna- 7 tional classification of diseases. 8 (H) An insurer shall provide coverage under this paragraph, at a mini- 9 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 10 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 11 § 7. Paragraph 31-a of subsection (i) of section 3216 of the insurance 12 law, as added by section 1 of part B of chapter 69 of the laws of 2016, 13 is amended to read as follows: 14 (31-a) [(A)] Every policy that provides medical, major medical or 15 similar comprehensive-type coverage and provides coverage for 16 prescription drugs for medication for the treatment of a substance use 17 disorder shall include immediate access, without prior authorization, to 18 [a five day emergency supply] the formulary forms of prescribed medica- 19 tions covered under the policy for the treatment of substance use disor- 20 der [where an emergency condition exists], including a prescribed drug 21 or medication associated with the management of opioid withdrawal and/or 22 stabilization, except where otherwise prohibited by law. Further, cover- 23 age [of an emergency supply] without prior authorization shall include 24 formulary forms of medication for opioid overdose reversal otherwise 25 covered under the policy prescribed or dispensed to an individual 26 covered by the policy. 27 [(B) For purposes of this paragraph, an "emergency condition" means a28substance use disorder condition that manifests itself by acute symptoms29of sufficient severity, including severe pain or the expectation of30severe pain, such that a prudent layperson, possessing an average know-31ledge of medicine and health, could reasonably expect the absence of32immediate medical attention to result in:33(i) placing the health of the person afflicted with such condition in34serious jeopardy, or in the case of a behavioral condition, placing the35health of such person or others in serious jeopardy;36(ii) serious impairment to such person's bodily functions;37(iii) serious dysfunction of any bodily organ or part of such person;38(iv) serious disfigurement of such person; or39(v) a condition described in clause (i), (ii), or (iii) of section401867(e)(1)(A) of the Social Security Act.41(C) Coverage provided under this paragraph may be subject to copay-42ments, coinsurance, and annual deductibles that are consistent with43those imposed on other benefits within the policy; provided, however, no44policy shall impose an additional copayment or coinsurance on an insured45who received an emergency supply of medication and then received up to a46thirty day supply of the same medication in the same thirty day period47in which the emergency supply of medication was dispensed. This subpara-48graph shall not preclude the imposition of a copayment or coinsurance on49the initial emergency supply of medication in an amount that is less50than the copayment or coinsurance otherwise applicable to a thirty day51supply of such medication, provided that the total sum of the copayments52or coinsurance for an entire thirty day supply of the medication does53not exceed the copayment or coinsurance otherwise applicable to a thirty54day supply of such medication.] 55 § 8. Subsection (i) of section 3216 of the insurance law is amended by 56 adding a new paragraph 35 to read as follows:S. 1507--C 98 A. 2007--C 1 (35) (A) Every policy delivered or issued for delivery in this state 2 that provides coverage for inpatient hospital care or coverage for 3 physician services shall provide coverage for the diagnosis and treat- 4 ment of mental health conditions as follows: 5 (i) where the policy provides coverage for inpatient hospital care, 6 benefits for inpatient care in a hospital as defined by subdivision ten 7 of section 1.03 of the mental hygiene law and benefits for outpatient 8 care provided in a facility issued an operating certificate by the 9 commissioner of mental health pursuant to the provisions of article 10 thirty-one of the mental hygiene law, or in a facility operated by the 11 office of mental health, or, for care provided in other states, to simi- 12 larly licensed or certified hospitals or facilities; and 13 (ii) where the policy provides coverage for physician services, bene- 14 fits for outpatient care provided by a psychiatrist or psychologist 15 licensed to practice in this state, a licensed clinical social worker 16 who meets the requirements of subparagraph (D) of paragraph four of 17 subsection (1) of section three thousand two hundred twenty-one of this 18 article, a nurse practitioner licensed to practice in this state, or a 19 professional corporation or university faculty practice corporation 20 thereof. 21 (B) Coverage required by this paragraph may be subject to annual 22 deductibles, copayments and coinsurance as may be deemed appropriate by 23 the superintendent and shall be consistent with those imposed on other 24 benefits under the policy. 25 (C) Coverage under this paragraph shall not apply financial require- 26 ments or treatment limitations to mental health benefits that are more 27 restrictive than the predominant financial requirements and treatment 28 limitations applied to substantially all medical and surgical benefits 29 covered by the policy. 30 (D) The criteria for medical necessity determinations under the policy 31 with respect to mental health benefits shall be made available by the 32 insurer to any insured, prospective insured, or in-network provider upon 33 request. 34 (E) For purposes of this paragraph: 35 (i) "financial requirement" means deductible, copayments, coinsurance 36 and out-of-pocket expenses; 37 (ii) "predominant" means that a financial requirement or treatment 38 limitation is the most common or frequent of such type of limit or 39 requirement; 40 (iii) "treatment limitation" means limits on the frequency of treat- 41 ment, number of visits, days of coverage, or other similar limits on the 42 scope or duration of treatment and includes nonquantitative treatment 43 limitations such as: medical management standards limiting or excluding 44 benefits based on medical necessity, or based on whether the treatment 45 is experimental or investigational; formulary design for prescription 46 drugs; network tier design; standards for provider admission to partic- 47 ipate in a network, including reimbursement rates; methods for determin- 48 ing usual, customary, and reasonable charges; fail-first or step therapy 49 protocols; exclusions based on failure to complete a course of treat- 50 ment; and restrictions based on geographic location, facility type, 51 provider specialty, and other criteria that limit the scope or duration 52 of benefits for services provided under the policy; and 53 (iv) "mental health condition" means any mental health disorder as 54 defined in the most recent edition of the diagnostic and statistical 55 manual of mental disorders or the most recent edition of another gener-S. 1507--C 99 A. 2007--C 1 ally recognized independent standard of current medical practice such as 2 the international classification of diseases. 3 (F) An insurer shall provide coverage under this paragraph, at a mini- 4 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 5 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 6 (G) This subparagraph shall apply to hospitals in this state that are 7 licensed by the office of mental health that are participating in the 8 insurer's provider network. Where the policy provides coverage for inpa- 9 tient hospital care, benefits for inpatient hospital care in a hospital 10 as defined by subdivision ten of section 1.03 of the mental hygiene law 11 provided to individuals who have not attained the age of eighteen shall 12 not be subject to preauthorization. Coverage provided under this subpar- 13 agraph shall also not be subject to concurrent utilization review during 14 the first fourteen days of the inpatient admission, provided the facili- 15 ty notifies the insurer of both the admission and the initial treatment 16 plan within two business days of the admission, performs daily clinical 17 review of the patient, and participates in periodic consultation with 18 the insurer to ensure that the facility is using the evidence-based and 19 peer reviewed clinical review criteria utilized by the insurer which is 20 approved by the office of mental health and appropriate to the age of 21 the patient, to ensure that the inpatient care is medically necessary 22 for the patient. All treatment provided under this subparagraph may be 23 reviewed retrospectively. Where care is denied retrospectively, an 24 insured shall not have any financial obligation to the facility for any 25 treatment under this subparagraph other than any copayment, coinsurance, 26 or deductible otherwise required under the policy. 27 § 9. Paragraphs 17, 19 and 20 of subsection 2 of section 3217-a of the 28 insurance law, paragraph 17 as amended and paragraphs 19 and 20 as added 29 by section 1 of part H of chapter 60 of the laws of 2014, are amended 30 and a new paragraph 21 is added to read as follows: 31 (17) where applicable, a listing by specialty, which may be in a sepa- 32 rate document that is updated annually, of the name, address, and tele- 33 phone number of all participating providers, including facilities, and: 34 (A) whether the provider is accepting new patients; (B) in the case of 35 mental health or substance use disorder services providers, any affil- 36 iations with participating facilities certified or authorized by the 37 office of mental health or the office of alcoholism and substance abuse 38 services, and any restrictions regarding the availability of the indi- 39 vidual provider's services; and [in addition,] (C) in the case of physi- 40 cians, board certification, languages spoken and any affiliations with 41 participating hospitals. The listing shall also be posted on the insur- 42 er's website and the insurer shall update the website within fifteen 43 days of the addition or termination of a provider from the insurer's 44 network or a change in a physician's hospital affiliation; 45 (19) with respect to out-of-network coverage: 46 (A) a clear description of the methodology used by the insurer to 47 determine reimbursement for out-of-network health care services; 48 (B) the amount that the insurer will reimburse under the methodology 49 for out-of-network health care services set forth as a percentage of the 50 usual and customary cost for out-of-network health care services; and 51 (C) examples of anticipated out-of-pocket costs for frequently billed 52 out-of-network health care services; [and] 53 (20) information in writing and through an internet website that 54 reasonably permits an insured or prospective insured to estimate the 55 anticipated out-of-pocket cost for out-of-network health care services 56 in a geographical area or zip code based upon the difference betweenS. 1507--C 100 A. 2007--C 1 what the insurer will reimburse for out-of-network health care services 2 and the usual and customary cost for out-of-network health care 3 services[.]; and 4 (21) the most recent comparative analysis performed by the insurer to 5 assess the provision of its covered services in accordance with the Paul 6 Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 7 Act of 2008, 42 U.S.C. 18031(j), and any amendments to, and federal 8 guidance or regulations issued under those acts. 9 § 10. Subsection (b) of section 3217-b of the insurance law, as added 10 by chapter 705 of the laws of 1996, is amended to read as follows: 11 (b) No insurer subject to this article shall by contract, written 12 policy [or], written procedure or practice prohibit or restrict any 13 health care provider from filing a complaint, making a report or 14 commenting to an appropriate governmental body regarding the policies or 15 practices of such insurer which the provider believes may negatively 16 impact upon the quality of, or access to, patient care. Nor shall an 17 insurer subject to this article take any adverse action, including but 18 not limited to refusing to renew or execute a contract or agreement with 19 a health care provider as retaliation against a health care provider for 20 filing a complaint, making a report or commenting to an appropriate 21 governmental body regarding policies or practices of such insurer which 22 may violate this chapter including paragraphs thirty, as added by chap- 23 ter forty-one of the laws of 2014, thirty-one, thirty-one-a and thirty- 24 five of subsection (i) of section thirty-two hundred sixteen and para- 25 graphs five, six, seven, seven-a and seven-b of subsection (l) of 26 section thirty-two hundred twenty-one of this article. 27 § 11. Subparagraph (A) of paragraph 4 of subsection (l) of section 28 3221 of the insurance law, as amended by chapter 230 of the laws of 29 2004, is amended to read as follows: 30 (A) Every insurer delivering a group policy or issuing a group policy 31 for delivery, in this state, [which] that provides reimbursement for 32 psychiatric or psychological services or for the diagnosis and treatment 33 of mental[, nervous or emotional disorders and ailments] health condi- 34 tions, however defined in such policy, by physicians, psychiatrists or 35 psychologists, [must] shall make available and if requested by the poli- 36 cyholder provide the same coverage to insureds for such services when 37 performed by a licensed clinical social worker, within the lawful scope 38 of his or her practice, who is licensed pursuant to article one hundred 39 fifty-four of the education law. Written notice of the availability of 40 such coverage shall be delivered to the policyholder prior to inception 41 of such group policy and annually thereafter, except that this notice 42 shall not be required where a policy covers two hundred or more employ- 43 ees or where the benefit structure was the subject of collective 44 bargaining affecting persons who are employed in more than one state. 45 § 12. Subparagraph (D) of paragraph 4 of subsection (l) of section 46 3221 of the insurance law, as amended by section 50 of part D of chapter 47 56 of the laws of 2013, is amended to read as follows: 48 (D) In addition to the requirements of subparagraph (A) of this para- 49 graph, every insurer issuing a group policy for delivery in this state 50 where the policy provides reimbursement to insureds for psychiatric or 51 psychological services or for the diagnosis and treatment of mental[,52nervous or emotional disorders and ailments] health conditions, however 53 defined in such policy, by physicians, psychiatrists or psychologists, 54 shall provide the same coverage to insureds for such services when 55 performed by a licensed clinical social worker, within the lawful scope 56 of his or her practice, who is licensed pursuant to subdivision two ofS. 1507--C 101 A. 2007--C 1 section seven thousand seven hundred four of the education law and in 2 addition shall have either: (i) three or more additional years experi- 3 ence in psychotherapy, which for the purposes of this subparagraph shall 4 mean the use of verbal methods in interpersonal relationships with the 5 intent of assisting a person or persons to modify attitudes and behavior 6 that are intellectually, socially or emotionally maladaptive, under 7 supervision, satisfactory to the state board for social work, in a 8 facility, licensed or incorporated by an appropriate governmental 9 department, providing services for diagnosis or treatment of mental[,10nervous or emotional disorders or ailments] health conditions; (ii) 11 three or more additional years experience in psychotherapy under the 12 supervision, satisfactory to the state board for social work, of a 13 psychiatrist, a licensed and registered psychologist or a licensed clin- 14 ical social worker qualified for reimbursement pursuant to subsection 15 (e) of this section, or (iii) a combination of the experience specified 16 in items (i) and (ii) of this subparagraph totaling three years, satis- 17 factory to the state board for social work. 18 § 13. Subparagraphs (A) and (B) of paragraph 5 of subsection (l) of 19 section 3221 of the insurance law, as amended by chapter 502 of the laws 20 of 2007, are amended to read as follows: 21 (A) Every insurer delivering a group or school blanket policy or issu- 22 ing a group or school blanket policy for delivery, in this state, which 23 provides coverage for inpatient hospital care or coverage for physician 24 services shall provide [as part of such policy broad-based] coverage for 25 the diagnosis and treatment of mental[, nervous or emotional disorders26or ailments, however defined in such policy, at least equal to the27coverage provided for other] health conditions and: 28 (i) where the policy provides coverage for inpatient hospital care, 29 benefits for inpatient care in a hospital as defined by subdivision ten 30 of section 1.03 of the mental hygiene law[, which benefits may be limit-31ed to not less than thirty days of active treatment in any contract32year, plan year or calendar year,] and benefits for outpatient care 33 provided in a facility issued an operating certificate by the commis- 34 sioner of mental health pursuant to the provisions of article thirty-one 35 of the mental hygiene law, or in a facility operated by the office of 36 mental health[, which benefits may be limited to not less than twenty37visits in any contract year, plan year or calendar year. Benefits for38partial hospitalization program services shall be provided as an offset39to covered inpatient days at a ratio of two partial hospitalization40visits to one inpatient day of treatment.] or, for care provided in 41 other states, to similarly licensed or certified hospitals or facili- 42 ties; and 43 (ii) where the policy provides coverage for physician services, it 44 shall include benefits for outpatient care provided by a psychiatrist or 45 psychologist licensed to practice in this state, a licensed clinical 46 social worker who meets the requirements of subparagraph (D) of para- 47 graph four of this subsection, a nurse practitioner licensed to practice 48 in this state, or a professional corporation or university faculty prac- 49 tice corporation thereof. [Such benefits may be limited to not less than50twenty visits in any contract year, plan year, or calendar year.] 51 [(iii)] (B) Coverage required by this paragraph may be [provided on a52contract year, plan year or calendar year basis and shall be consistent53with the provision of other benefits under the policy. Such coverage may54be] subject to annual deductibles, co-pays and coinsurance as may be 55 deemed appropriate by the superintendent and shall be consistent with 56 those imposed on other benefits under the policy. [In the event that aS. 1507--C 102 A. 2007--C 1policy provides coverage for both inpatient hospital care and physician2services, the aggregate of the benefits for outpatient care obtained3under this paragraph may be limited to not less than twenty visits in4any contract year, plan year or calendar year.5(iv) In this paragraph, "active treatment" means treatment furnished6in conjunction with inpatient confinement for mental, nervous or7emotional disorders or ailments that meet standards prescribed pursuant8to the regulations of the commissioner of mental health.9(B) (i) Every insurer delivering a group or school blanket policy or10issuing a group or school blanket policy for delivery, in this state,11which provides coverage for inpatient hospital care or coverage for12physician services, shall provide comparable coverage for adults and13children with biologically based mental illness. Such group policies14issued or delivered in this state shall also provide such comparable15coverage for children with serious emotional disturbances. Such coverage16shall be provided under the terms and conditions otherwise applicable17under the policy, including network limitations or variations, exclu-18sions, co-pays, coinsurance, deductibles or other specific cost sharing19mechanisms. Provided further, where a policy provides both in-network20and out-of-network benefits, the out-of-network benefits may have21different coinsurance, co-pays, or deductibles, than the in-network22benefits, regardless of whether the policy is written under one license23or two licenses.24(ii) For purposes of this paragraph, the term "biologically based25mental illness" means a mental, nervous, or emotional condition that is26caused by a biological disorder of the brain and results in a clinically27significant, psychological syndrome or pattern that substantially limits28the functioning of the person with the illness. Such biologically based29mental illnesses are defined as schizophrenia/psychotic disorders, major30depression, bipolar disorder, delusional disorders, panic disorder,31obsessive compulsive disorders, bulimia, and anorexia.] Provided that no 32 copayment or coinsurance imposed for outpatient mental health services 33 provided in a facility licensed, certified or otherwise authorized by 34 the office of mental health shall exceed the copayments or coinsurance 35 imposed for a primary care office visit under the policy. 36 § 14. Subparagraphs (C), (D) and (E) of paragraph 5 of subsection (l) 37 of section 3221 of the insurance law are REPEALED and five new subpara- 38 graphs (C), (D), (E), (F) and (G) are added to read as follows: 39 (C) Coverage under this paragraph shall not apply financial require- 40 ments or treatment limitations to mental health benefits that are more 41 restrictive than the predominant financial requirements and treatment 42 limitations applied to substantially all medical and surgical benefits 43 covered by the policy. 44 (D) The criteria for medical necessity determinations under the policy 45 with respect to mental health benefits shall be made available by the 46 insurer to any insured, prospective insured, or in-network provider upon 47 request. 48 (E) For purposes of this paragraph: 49 (i) "financial requirement" means deductible, copayments, coinsurance 50 and out-of-pocket expenses; 51 (ii) "predominant" means that a financial requirement or treatment 52 limitation is the most common or frequent of such type of limit or 53 requirement; 54 (iii) "treatment limitation" means limits on the frequency of treat- 55 ment, number of visits, days of coverage, or other similar limits on the 56 scope or duration of treatment and includes nonquantitative treatmentS. 1507--C 103 A. 2007--C 1 limitations such as: medical management standards limiting or excluding 2 benefits based on medical necessity, or based on whether the treatment 3 is experimental or investigational; formulary design for prescription 4 drugs; network tier design; standards for provider admission to partic- 5 ipate in a network, including reimbursement rates; methods for determin- 6 ing usual, customary, and reasonable charges; fail-first or step therapy 7 protocols; exclusions based on failure to complete a course of treat- 8 ment; and restrictions based on geographic location, facility type, 9 provider specialty, and other criteria that limit the scope or duration 10 of benefits for services provided under the policy; and 11 (iv) "mental health condition" means any mental health disorder as 12 defined in the most recent edition of the diagnostic and statistical 13 manual of mental disorders or the most recent edition of another gener- 14 ally recognized independent standard of current medical practice such as 15 the international classification of diseases. 16 (F) An insurer shall provide coverage under this paragraph, at a mini- 17 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 18 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 19 (G) This subparagraph shall apply to hospitals in this state that are 20 licensed by the office of mental health that are participating in the 21 insurer's provider network. Where the policy provides coverage for inpa- 22 tient hospital care, benefits for inpatient hospital care in a hospital 23 as defined by subdivision ten of section 1.03 of the mental hygiene law 24 provided to individuals who have not attained the age of eighteen shall 25 not be subject to preauthorization. Coverage provided under this subpar- 26 agraph shall also not be subject to concurrent utilization review during 27 the first fourteen days of the inpatient admission, provided the facili- 28 ty notifies the insurer of both the admission and the initial treatment 29 plan within two business days of the admission, performs daily clinical 30 review of the patient, and participates in periodic consultation with 31 the insurer to ensure that the facility is using the evidence-based and 32 peer reviewed clinical review criteria utilized by the insurer which is 33 approved by the office of mental health and appropriate to the age of 34 the patient, to ensure that the inpatient care is medically necessary 35 for the patient. All treatment provided under this subparagraph may be 36 reviewed retrospectively. Where care is denied retrospectively, an 37 insured shall not have any financial obligation to the facility for any 38 treatment under this subparagraph other than any copayment, coinsurance, 39 or deductible otherwise required under the policy. 40 § 15. Subparagraphs (A), (B) and (D) of paragraph 6 of subsection (l) 41 of section 3221 of the insurance law, as amended by section 2 of part B 42 of chapter 71 of the laws of 2016, are amended and three new subpara- 43 graphs (E), (F) and (G) are added to read as follows: 44 (A) Every policy that provides hospital, major medical or similar 45 comprehensive coverage [must] shall provide inpatient coverage for the 46 diagnosis and treatment of substance use disorder, including detoxifica- 47 tion and rehabilitation services. Such inpatient coverage shall include 48 unlimited medically necessary treatment for substance use disorder 49 treatment services provided in residential settings [as required by the50Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §511185a)]. Further, such inpatient coverage shall not apply financial 52 requirements or treatment limitations, including utilization review 53 requirements, to inpatient substance use disorder benefits that are more 54 restrictive than the predominant financial requirements and treatment 55 limitations applied to substantially all medical and surgical benefits 56 covered by the policy. [Further, such coverage shall be providedS. 1507--C 104 A. 2007--C 1consistent with the federal Paul Wellstone and Pete Domenici Mental2Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).] 3 (B) Coverage provided under this paragraph may be limited to facili- 4 ties in New York state [which are certified] that are licensed, certi- 5 fied or otherwise authorized by the office of alcoholism and substance 6 abuse services and, in other states, to those which are accredited by 7 the joint commission as alcoholism, substance abuse or chemical depend- 8 ence treatment programs and are similarly licensed, certified, or other- 9 wise authorized in the state in which the facility is located. 10 (D) This subparagraph shall apply to facilities in this state that are 11 licensed, certified or otherwise authorized by the office of alcoholism 12 and substance abuse services that are participating in the insurer's 13 provider network. Coverage provided under this paragraph shall not be 14 subject to preauthorization. Coverage provided under this paragraph 15 shall also not be subject to concurrent utilization review during the 16 first [fourteen] twenty-eight days of the inpatient admission provided 17 that the facility notifies the insurer of both the admission and the 18 initial treatment plan within [forty-eight hours] two business days of 19 the admission. The facility shall perform daily clinical review of the 20 patient, including [the] periodic consultation with the insurer at or 21 just prior to the fourteenth day of treatment to ensure that the facili- 22 ty is using the evidence-based and peer reviewed clinical review tool 23 utilized by the insurer which is designated by the office of alcoholism 24 and substance abuse services and appropriate to the age of the patient, 25 to ensure that the inpatient treatment is medically necessary for the 26 patient. Prior to discharge, the facility shall provide the patient and 27 the insurer with a written discharge plan which shall describe arrange- 28 ments for additional services needed following discharge from the inpa- 29 tient facility as determined using the evidence-based and peer-reviewed 30 clinical review tool utilized by the insurer which is designated by the 31 office of alcoholism and substance abuse services. Prior to discharge, 32 the facility shall indicate to the insurer whether services included in 33 the discharge plan are secured or determined to be reasonably available. 34 Any utilization review of treatment provided under this subparagraph may 35 include a review of all services provided during such inpatient treat- 36 ment, including all services provided during the first [fourteen] twen- 37 ty-eight days of such inpatient treatment. Provided, however, the insur- 38 er shall only deny coverage for any portion of the initial [fourteen] 39 twenty-eight day inpatient treatment on the basis that such treatment 40 was not medically necessary if such inpatient treatment was contrary to 41 the evidence-based and peer reviewed clinical review tool utilized by 42 the insurer which is designated by the office of alcoholism and 43 substance abuse services. An insured shall not have any financial obli- 44 gation to the facility for any treatment under this subparagraph other 45 than any copayment, coinsurance, or deductible otherwise required under 46 the policy. 47 (E) The criteria for medical necessity determinations under the policy 48 with respect to inpatient substance use disorder benefits shall be made 49 available by the insurer to any insured, prospective insured, or in-net- 50 work provider upon request. 51 (F) For purposes of this paragraph: 52 (i) "financial requirement" means deductible, copayments, coinsurance 53 and out-of-pocket expenses; 54 (ii) "predominant" means that a financial requirement or treatment 55 limitation is the most common or frequent of such type of limit or 56 requirement;S. 1507--C 105 A. 2007--C 1 (iii) "treatment limitation" means limits on the frequency of treat- 2 ment, number of visits, days of coverage, or other similar limits on the 3 scope or duration of treatment and includes nonquantitative treatment 4 limitations such as: medical management standards limiting or excluding 5 benefits based on medical necessity, or based on whether the treatment 6 is experimental or investigational; formulary design for prescription 7 drugs; network tier design; standards for provider admission to partic- 8 ipate in a network, including reimbursement rates; methods for determin- 9 ing usual, customary, and reasonable charges; fail-first or step therapy 10 protocols; exclusions based on failure to complete a course of treat- 11 ment; and restrictions based on geographic location, facility type, 12 provider specialty, and other criteria that limit the scope or duration 13 of benefits for services provided under the policy; and 14 (iv) "substance use disorder" shall have the meaning set forth in the 15 most recent edition of the diagnostic and statistical manual of mental 16 disorders or the most recent edition of another generally recognized 17 independent standard of current medical practice such as the interna- 18 tional classification of diseases. 19 (G) An insurer shall provide coverage under this paragraph, at a mini- 20 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 21 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 22 § 16. Subparagraphs (A) and (B) of paragraph 7 of subsection (l) of 23 section 3221 of the insurance law, as amended by chapter 41 of the laws 24 of 2014, are amended and a new subparagraph (C-1) is added to read as 25 follows: 26 (A) Every policy that provides medical, major medical or similar 27 comprehensive-type coverage [must] shall provide outpatient coverage for 28 the diagnosis and treatment of substance use disorder, including detoxi- 29 fication and rehabilitation services. Such coverage shall not apply 30 financial requirements or treatment limitations to outpatient substance 31 use disorder benefits that are more restrictive than the predominant 32 financial requirements and treatment limitations applied to substantial- 33 ly all medical and surgical benefits covered by the policy. [Further,34such coverage shall be provided consistent with the federal Paul Well-35stone and Pete Domenici Mental Health Parity and Addiction Equity Act of362008 (29 U.S.C. § 1185a).] 37 (B) Coverage under this paragraph may be limited to facilities in New 38 York state that are licensed, certified or otherwise authorized by the 39 office of alcoholism and substance abuse services [or licensed by such40office as outpatient clinics or medically supervised ambulatory41substance abuse programs] to provide outpatient substance use disorder 42 services and, in other states, to those which are accredited by the 43 joint commission as alcoholism or chemical dependence treatment programs 44 and similarly licensed, certified or otherwise authorized in the state 45 in which the facility is located. 46 (C-1) A large group policy that provides coverage under this paragraph 47 shall not impose copayments or coinsurance for outpatient substance use 48 disorder services that exceeds the copayment or coinsurance imposed for 49 a primary care office visit. Provided that no greater than one such 50 copayment may be imposed for all services provided in a single day by a 51 facility licensed, certified or otherwise authorized by the office of 52 alcoholism and substance abuse services to provide outpatient substance 53 use disorder services. 54 § 17. Subparagraph (E) of paragraph 7 of subsection (l) of section 55 3221 of the insurance law, as added by section 4 of part MM of chapterS. 1507--C 106 A. 2007--C 1 57 of the laws of 2018, is amended and three new subparagraphs (F), (G) 2 and (H) are added to read as follows: 3 (E) This subparagraph shall apply to facilities in this state that are 4 licensed, certified or otherwise authorized by the office of alcoholism 5 and substance abuse services for the provision of outpatient, intensive 6 outpatient, outpatient rehabilitation and opioid treatment that are 7 participating in the insurer's provider network. Coverage provided under 8 this paragraph shall not be subject to preauthorization. Coverage 9 provided under this paragraph shall not be subject to concurrent review 10 for the first [two] four weeks of continuous treatment, not to exceed 11 [fourteen] twenty-eight visits, provided the facility notifies the 12 insurer of both the start of treatment and the initial treatment plan 13 within [forty-eight hours] two business days. The facility shall 14 perform clinical assessment of the patient at each visit, including 15 [the] periodic consultation with the insurer at or just prior to the 16 fourteenth day of treatment to ensure that the facility is using the 17 evidence-based and peer reviewed clinical review tool utilized by the 18 insurer which is designated by the office of alcoholism and substance 19 abuse services and appropriate to the age of the patient, to ensure that 20 the outpatient treatment is medically necessary for the patient. Any 21 utilization review of the treatment provided under this subparagraph may 22 include a review of all services provided during such outpatient treat- 23 ment, including all services provided during the first [two] four weeks 24 of continuous treatment, not to exceed [fourteen] twenty-eight visits, 25 of such outpatient treatment. Provided, however, the insurer shall only 26 deny coverage for any portion of the initial [two] four weeks of contin- 27 uous treatment, not to exceed [fourteen] twenty-eight visits, for outpa- 28 tient treatment on the basis that such treatment was not medically 29 necessary if such outpatient treatment was contrary to the evidence- 30 based and peer reviewed clinical review tool utilized by the insurer 31 which is designated by the office of alcoholism and substance abuse 32 services. An insured shall not have any financial obligation to the 33 facility for any treatment under this subparagraph other than any copay- 34 ment, coinsurance, or deductible otherwise required under the policy. 35 (F) The criteria for medical necessity determinations under the policy 36 with respect to outpatient substance use disorder benefits shall be made 37 available by the insurer to any insured, prospective insured, or in-net- 38 work provider upon request. 39 (G) For purposes of this paragraph: 40 (i) "financial requirement" means deductible, copayments, coinsurance 41 and out-of-pocket expenses; 42 (ii) "predominant" means that a financial requirement or treatment 43 limitation is the most common or frequent of such type of limit or 44 requirement; 45 (iii) "treatment limitation" means limits on the frequency of treat- 46 ment, number of visits, days of coverage, or other similar limits on the 47 scope or duration of treatment and includes nonquantitative treatment 48 limitations such as: medical management standards limiting or excluding 49 benefits based on medical necessity, or based on whether the treatment 50 is experimental or investigational; formulary design for prescription 51 drugs; network tier design; standards for provider admission to partic- 52 ipate in a network, including reimbursement rates; methods for determin- 53 ing usual, customary, and reasonable charges; fail-first or step therapy 54 protocols; exclusions based on failure to complete a course of treat- 55 ment; and restrictions based on geographic location, facility type,S. 1507--C 107 A. 2007--C 1 provider specialty, and other criteria that limit the scope or duration 2 of benefits for services provided under the policy; and 3 (iv) "substance use disorder" shall have the meaning set forth in the 4 most recent edition of the diagnostic and statistical manual of mental 5 disorders or the most recent edition of another generally recognized 6 independent standard of current medical practice such as the interna- 7 tional classification of diseases. 8 (H) An insurer shall provide coverage under this paragraph, at a mini- 9 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 10 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 11 § 18. Paragraph 7-b of subsection (l) of section 3221 of the insurance 12 law, as added by section 2 of part B of chapter 69 of the laws of 2016, 13 is amended to read as follows: 14 (7-b) [(A)] Every policy that provides medical, major medical or simi- 15 lar comprehensive-type coverage and provides coverage for prescription 16 drugs for medication for the treatment of a substance use disorder shall 17 include immediate access, without prior authorization, [to a five day18emergency supply] to the formulary forms of prescribed medications 19 covered under the policy for the treatment of substance use disorder 20 [where an emergency condition exists], including a prescribed drug or 21 medication associated with the management of opioid withdrawal and/or 22 stabilization, except where otherwise prohibited by law. Further, cover- 23 age [of an emergency supply] without prior authorization shall include 24 formulary forms medication for opioid overdose reversal otherwise 25 covered under the policy prescribed or dispensed to an individual 26 covered by the policy. 27 [(B) For purposes of this paragraph, an "emergency condition" means a28substance use disorder condition that manifests itself by acute symptoms29of sufficient severity, including severe pain or the expectation of30severe pain, such that a prudent layperson, possessing an average know-31ledge of medicine and health, could reasonably expect the absence of32immediate medical attention to result in:33(i) placing the health of the person afflicted with such condition in34serious jeopardy, or in the case of a behavioral condition, placing the35health of such person or others in serious jeopardy;36(ii) serious impairment to such person's bodily functions;37(iii) serious dysfunction of any bodily organ or part of such person;38(iv) serious disfigurement of such person; or39(v) a condition described in clause (i), (ii), or (iii) of section401867(e)(1)(A) of the Social Security Act.41(C) Coverage provided under this paragraph may be subject to copay-42ments, coinsurance, and annual deductibles that are consistent with43those imposed on other benefits within the policy; provided, however, no44policy shall impose an additional copayment or coinsurance on an insured45who received an emergency supply of medication and then received up to a46thirty day supply of the same medication in the same thirty day period47in which the emergency supply of medication was dispensed. This subpara-48graph shall not preclude the imposition of a copayment or coinsurance on49the initial emergency supply of medication in an amount that is less50than the copayment or coinsurance otherwise applicable to a thirty day51supply of such medication, provided that the total sum of the copayments52or coinsurance for an entire thirty day supply of the medication does53not exceed the copayment or coinsurance otherwise applicable to a thirty54day supply of such medication.]S. 1507--C 108 A. 2007--C 1 § 19. Subparagraph (B) of paragraph 17 of subsection (l) of section 2 3221 of the insurance law, as amended by section 39 of part D of chapter 3 56 of the laws of 2013, is amended to read as follows: 4 (B) Every group or blanket policy that provides physician services, 5 medical, major medical or similar comprehensive-type coverage shall 6 provide coverage for the screening, diagnosis and treatment of autism 7 spectrum disorder in accordance with this paragraph and shall not 8 exclude coverage for the screening, diagnosis or treatment of medical 9 conditions otherwise covered by the policy because the individual is 10 diagnosed with autism spectrum disorder. Such coverage may be subject to 11 annual deductibles, copayments and coinsurance as may be deemed appro- 12 priate by the superintendent and shall be consistent with those imposed 13 on other benefits under the group or blanket policy. [Coverage for14applied behavior analysis shall be subject to a maximum benefit of six15hundred eighty hours of treatment per policy or calendar year per16covered individual.] This paragraph shall not be construed as limiting 17 the benefits that are otherwise available to an individual under the 18 group or blanket policy, provided however that such policy shall not 19 contain any limitations on visits that are solely applied to the treat- 20 ment of autism spectrum disorder. No insurer shall terminate coverage or 21 refuse to deliver, execute, issue, amend, adjust, or renew coverage to 22 an individual solely because the individual is diagnosed with autism 23 spectrum disorder or has received treatment for autism spectrum disor- 24 der. Coverage shall be subject to utilization review and external 25 appeals of health care services pursuant to article forty-nine of this 26 chapter as well as[,] case management[,] and other managed care 27 provisions. 28 § 20. Items (i) and (iii) of subparagraph (C) of paragraph 17 of 29 subsection (l) of section 3221 of the insurance law, as amended by chap- 30 ter 596 of the laws of 2011, are amended to read as follows: 31 (i) "autism spectrum disorder" means any pervasive developmental 32 disorder as defined in the most recent edition of the diagnostic and 33 statistical manual of mental disorders[, including autistic disorder,34Asperger's disorder, Rett's disorder, childhood disintegrative disorder,35or pervasive developmental disorder not otherwise specified (PDD-NOS)]. 36 (iii) "behavioral health treatment" means counseling and treatment 37 programs, when provided by a licensed provider, and applied behavior 38 analysis, when provided [or supervised] by a [behavior analyst] person 39 licensed, certified [pursuant to the behavior analyst certification40board,] or otherwise authorized to provide applied behavior analysis, 41 that are necessary to develop, maintain, or restore, to the maximum 42 extent practicable, the functioning of an individual. [Individuals that43provide behavioral health treatment under the supervision of a certified44behavior analyst pursuant to this paragraph shall be subject to stand-45ards of professionalism, supervision and relevant experience pursuant to46regulations promulgated by the superintendent in consultation with the47commissioners of health and education.] 48 § 21. Paragraph 17 of subsection (l) of section 3221 of the insurance 49 law is amended by adding four new subparagraphs (H), (I), (J) and (K) to 50 read as follows: 51 (H) Coverage under this paragraph shall not apply financial require- 52 ments or treatment limitations to autism spectrum disorder benefits that 53 are more restrictive than the predominant financial requirements and 54 treatment limitations applied to substantially all medical and surgical 55 benefits covered by the policy.S. 1507--C 109 A. 2007--C 1 (I) The criteria for medical necessity determinations under the policy 2 with respect to autism spectrum disorder benefits shall be made avail- 3 able by the insurer to any insured, prospective insured, or in-network 4 provider upon request. 5 (J) For purposes of this paragraph: 6 (i) "financial requirement" means deductible, copayments, coinsurance 7 and out-of-pocket expenses; 8 (ii) "predominant" means that a financial requirement or treatment 9 limitation is the most common or frequent of such type of limit or 10 requirement; and 11 (iii) "treatment limitation" means limits on the frequency of treat- 12 ment, number of visits, days of coverage, or other similar limits on 13 the scope or duration of treatment and includes nonquantitative treat- 14 ment limitations such as: medical management standards limiting or 15 excluding benefits based on medical necessity, or based on whether the 16 treatment is experimental or investigational; formulary design for 17 prescription drugs; network tier design; standards for provider admis- 18 sion to participate in a network, including reimbursement rates; methods 19 for determining usual, customary, and reasonable charges; fail-first or 20 step therapy protocols; exclusions based on failure to complete a course 21 of treatment; and restrictions based on geographic location, facility 22 type, provider specialty, and other criteria that limit the scope or 23 duration of benefits for services provided under the policy. 24 (K) An insurer shall provide coverage under this paragraph, at a mini- 25 mum, consistent with the federal Paul Wellstone and Pete Domenici Mental 26 Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a). 27 § 22. Paragraphs 1, 2, and 3 of subsection (g) of section 4303 of the 28 insurance law, as amended by chapter 502 of the laws of 2007, are 29 amended to read as follows: 30 [(1)] A medical expense indemnity corporation, hospital service corpo- 31 ration or a health service corporation, [which] that provides group, 32 group remittance or school blanket coverage for inpatient hospital 33 care[,] or coverage for physician services shall provide as part of its 34 contract [broad-based] coverage for the diagnosis and treatment of 35 mental[, nervous or emotional disorders or ailments, however defined in36such contract, at least equal to the coverage provided for other] health 37 conditions and [shall include]: 38 [(A)] 39 (1) where the contract provides coverage for inpatient hospital care, 40 benefits for in-patient care in a hospital as defined by subdivision ten 41 of section 1.03 of the mental hygiene law[, which benefits may be limit-42ed to not less than thirty days of active treatment in any contract43year, plan year or calendar year.44(B)] or for inpatient care provided in other states, to similarly 45 licensed hospitals, and benefits for out-patient care provided in a 46 facility issued an operating certificate by the commissioner of mental 47 health pursuant to the provisions of article thirty-one of the mental 48 hygiene law or in a facility operated by the office of mental health[,49which benefits may be limited to not less than twenty visits in any50contract year, plan year or calendar year. Benefits for partial hospi-51talization program services shall be provided as an offset to covered52inpatient days at a ratio of two partial hospitalization visits to one53inpatient day of treatment.54(C) Such coverage may be provided on a contract year, plan year or55calendar year basis and shall be consistent with the provision of otherS. 1507--C 110 A. 2007--C 1benefits under the contract.] or for out-patient care provided in other 2 states, to similarly certified facilities; and 3 (2) where the contract provides coverage for physician services bene- 4 fits for outpatient care provided by a psychiatrist or psychologist 5 licensed to practice in this state, a licensed clinical social worker 6 who meets the requirements of subsection (n) of this section, a nurse 7 practitioner licensed to practice on this state, or professional corpo- 8 ration or university faculty practice corporation thereof. 9 (3) Such coverage may be subject to annual deductibles, co-pays and 10 coinsurance as may be deemed appropriate by the superintendent and shall 11 be consistent with those imposed on other benefits under the contract. 12 Provided that no copayment or coinsurance imposed for outpatient mental 13 health services provided in a facility licensed, certified or otherwise 14 authorized by the office of mental health shall exceed the copayments or 15 coinsurance imposed for a primary care office visit under the contract. 16 [(D) For the purpose of this subsection, "active treatment" means17treatment furnished in conjunction with in-patient confinement for18mental, nervous or emotional disorders or ailments that meet such stand-19ards as shall be prescribed pursuant to the regulations of the commis-20sioner of mental health.21(E) In the event the group remittance group or contract holder is22provided coverage under this subsection and under paragraph one of23subsection (h) of this section from the same health service corporation,24or under a contract that is jointly underwritten by two health service25corporations or by a health service corporation and a medical expense26indemnity corporation, the aggregate of the benefits for outpatient care27obtained under subparagraph (B) of this paragraph and paragraph one of28subsection (h) of this section may be limited to not less than twenty29visits in any contract year, plan year or calendar year.30(2) (A) A hospital service corporation or a health service corpo-31ration, which provides group, group remittance or school blanket cover-32age for inpatient hospital care, shall provide comparable coverage for33adults and children with biologically based mental illness. Such hospi-34tal service corporation or health service corporation shall also provide35such comparable coverage for children with serious emotional disturb-36ances. Such coverage shall be provided under the terms and conditions37otherwise applicable under the contract, including network limitations38or variations, exclusions, co-pays, coinsurance, deductibles or other39specific cost sharing mechanisms. Provided further, where a contract40provides both in-network and out-of-network benefits, the out-of-network41benefits may have different coinsurance, co-pays, or deductibles, than42the in-network benefits, regardless of whether the contract is written43under one license or two licenses.44(B) For purposes of this subsection, the term "biologically based45mental illness" means a mental, nervous, or emotional condition that is46caused by a biological disorder of the brain and results in a clinically47significant, psychological syndrome or pattern that substantially limits48the functioning of the person with the illness. Such biologically based49mental illnesses are defined as schizophrenia/psychotic disorders, major50depression, bipolar disorder, delusional disorders, panic disorder,51obsessive compulsive disorders, anorexia, and bulimia.52(3) For purposes of this subsection, the term "children with serious53emotional disturbances" means persons under the age of eighteen years54who have diagnoses of attention deficit disorders, disruptive behavior55disorders, or pervasive development disorders, and where there are one56or more of the following:S. 1507--C 111 A. 2007--C 1(A) serious suicidal symptoms or other life-threatening self-destruc-2tive behaviors;3(B) significant psychotic symptoms (hallucinations, delusion, bizarre4behaviors);5(C) behavior caused by emotional disturbances that placed the child at6risk of causing personal injury or significant property damage; or7(D) behavior caused by emotional disturbances that placed the child at8substantial risk of removal from the household.] 9 § 23. Paragraphs 4 and 5 of subsection (g) of section 4303 of the 10 insurance law are REPEALED and five new paragraphs 4, 5, 6, 7 and 8 are 11 added to read as follows: 12 (4) Coverage under this subsection shall not apply financial require- 13 ments or treatment limitations to mental health benefits that are more 14 restrictive than the predominant financial requirements and treatment 15 limitations applied to substantially all medical and surgical benefits 16 covered by the contract. 17 (5) The criteria for medical necessity determinations under the 18 contract with respect to mental health benefits shall be made available 19 by the corporation to any insured, prospective insured, or in-network 20 provider upon request. 21 (6) For purposes of this subsection: 22 (A) "financial requirement" means deductible, copayments, coinsurance 23 and out-of-pocket expenses; 24 (B) "predominant" means that a financial requirement or treatment 25 limitation is the most common or frequent of such type of limit or 26 requirement; 27 (C) "treatment limitation" means limits on the frequency of treatment, 28 number of visits, days of coverage, or other similar limits on the 29 scope or duration of treatment and includes nonquantitative treatment 30 limitations such as: medical management standards limiting or excluding 31 benefits based on medical necessity, or based on whether the treatment 32 is experimental or investigational; formulary design for prescription 33 drugs; network tier design; standards for provider admission to partic- 34 ipate in a network, including reimbursement rates; methods for deter- 35 mining usual, customary, and reasonable charges; fail-first or step 36 therapy protocols; exclusions based on failure to complete a course of 37 treatment; and restrictions based on geographic location, facility type, 38 provider specialty, and other criteria that limit the scope or duration 39 of benefits for services provided under the contract; and 40 (D) "mental health condition" means any mental health disorder as 41 defined in the most recent edition of the diagnostic and statistical 42 manual of mental disorders or the most recent edition of another gener- 43 ally recognized independent standard of current medical practice such as 44 the international classification of diseases. 45 (7) A corporation shall provide coverage under this subsection, at a 46 minimum, consistent with the federal Paul Wellstone and Pete Domenici 47 Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 48 1185a). 49 (8) This paragraph shall apply to hospitals in this state that are 50 licensed by the office of mental health that are participating in the 51 corporation's provider network. Where the contract provides coverage for 52 inpatient hospital care, benefits for inpatient hospital care in a 53 hospital as defined by subdivision ten of section 1.03 of the mental 54 hygiene law provided to individuals who have not attained the age of 55 eighteen shall not be subject to preauthorization. Coverage provided 56 under this paragraph shall also not be subject to concurrent utiliza-S. 1507--C 112 A. 2007--C 1 tion review during the first fourteen days of the inpatient admission, 2 provided the facility notifies the corporation of both the admission and 3 the initial treatment plan within two business days of the admission, 4 performs daily clinical review of the patient, and participates in peri- 5 odic consultation with the corporation to ensure that the facility is 6 using the evidence-based and peer reviewed clinical review criteria 7 utilized by the corporation which is approved by the office of mental 8 health and appropriate to the age of the patient, to ensure that the 9 inpatient care is medically necessary for the patient. All treatment 10 provided under this paragraph may be reviewed retrospectively. Where 11 care is denied retrospectively, an insured shall not have any financial 12 obligation to the facility for any treatment under this paragraph other 13 than any copayment, coinsurance, or deductible otherwise required under 14 the contract. 15 § 24. Subsection (h) of section 4303 of the insurance law is REPEALED. 16 § 25. Subsection (i) of section 4303 of the insurance law, as amended 17 by chapter 230 of the laws of 2004, is amended to read as follows: 18 (i) A medical expense indemnity corporation or health service corpo- 19 ration [which] that provides coverage for physicians, psychiatrists or 20 psychologists for psychiatric or psychological services or for the diag- 21 nosis and treatment of [mental, nervous or emotional disorders and22ailments] mental health conditions, however defined in such contract, 23 [must] shall make available and if requested by all persons holding 24 individual contracts in a group whose premiums are paid by a remitting 25 agent or by the contract holder in the case of a group contract issued 26 pursuant to section four thousand three hundred five of this article, 27 provide the same coverage for such services when performed by a licensed 28 clinical social worker, within the lawful scope of his or her practice, 29 who is licensed pursuant to article one hundred fifty-four of the educa- 30 tion law. The state board for social work shall maintain a list of all 31 licensed clinical social workers qualified for reimbursement under this 32 subsection. Such coverage shall be made available at the inception of 33 all new contracts and, with respect to all other contracts, at any anni- 34 versary date subject to evidence of insurability. Written notice of the 35 availability of such coverage shall be delivered to the group remitting 36 agent or group contract holder prior to inception of such contract and 37 annually thereafter, except that this notice shall not be required where 38 a [policy] contract covers two hundred or more employees or where the 39 benefit structure was the subject of collective bargaining affecting 40 persons who are employed in more than one state. 41 § 26. Subsection (k) of section 4303 of the insurance law, as amended 42 by section 3 of part B of chapter 71 of the laws of 2016, is amended to 43 read as follows: 44 (k)(1) Every contract that provides hospital, major medical or similar 45 comprehensive coverage [must] shall provide inpatient coverage for the 46 diagnosis and treatment of substance use disorder, including detoxifica- 47 tion and rehabilitation services. Such inpatient coverage shall include 48 unlimited medically necessary treatment for substance use disorder 49 treatment services provided in residential settings [as required by the50Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. §511185a)]. Further, such inpatient coverage shall not apply financial 52 requirements or treatment limitations, including utilization review 53 requirements, to inpatient substance use disorder benefits that are more 54 restrictive than the predominant financial requirements and treatment 55 limitations applied to substantially all medical and surgical benefits 56 covered by the contract. [Further, such coverage shall be providedS. 1507--C 113 A. 2007--C 1consistent with the federal Paul Wellstone and Pete Domenici Mental2Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 1185a).] 3 (2) Coverage provided under this subsection may be limited to facili- 4 ties in New York state [which are certified] that are licensed, certi- 5 fied or otherwise authorized by the office of alcoholism and substance 6 abuse services and, in other states, to those which are accredited by 7 the joint commission as alcoholism, substance abuse, or chemical depend- 8 ence treatment programs and are similarly licensed, certified or other- 9 wise authorized in the state in which the facility is located. 10 (3) Coverage provided under this subsection may be subject to annual 11 deductibles and co-insurance as deemed appropriate by the superintendent 12 and that are consistent with those imposed on other benefits within a 13 given contract. 14 (4) This paragraph shall apply to facilities in this state [certified] 15 that are licensed, certified or otherwise authorized by the office of 16 alcoholism and substance abuse services that are participating in the 17 corporation's provider network. Coverage provided under this subsection 18 shall not be subject to preauthorization. Coverage provided under this 19 subsection shall also not be subject to concurrent utilization review 20 during the first [fourteen] twenty-eight days of the inpatient admission 21 provided that the facility notifies the corporation of both the admis- 22 sion and the initial treatment plan within [forty-eight hours] two busi- 23 ness days of the admission. The facility shall perform daily clinical 24 review of the patient, including [the] periodic consultation with the 25 corporation at or just prior to the fourteenth day of treatment to 26 ensure that the facility is using the evidence-based and peer reviewed 27 clinical review tool utilized by the corporation which is designated by 28 the office of alcoholism and substance abuse services and appropriate to 29 the age of the patient, to ensure that the inpatient treatment is 30 medically necessary for the patient. Prior to discharge, the facility 31 shall provide the patient and the corporation with a written discharge 32 plan which shall describe arrangements for additional services needed 33 following discharge from the inpatient facility as determined using the 34 evidence-based and peer-reviewed clinical review tool utilized by the 35 corporation which is designated by the office of alcoholism and 36 substance abuse services. Prior to discharge, the facility shall indi- 37 cate to the corporation whether services included in the discharge plan 38 are secured or determined to be reasonably available. Any utilization 39 review of treatment provided under this paragraph may include a review 40 of all services provided during such inpatient treatment, including all 41 services provided during the first [fourteen] twenty-eight days of such 42 inpatient treatment. Provided, however, the corporation shall only deny 43 coverage for any portion of the initial [fourteen] twenty-eight day 44 inpatient treatment on the basis that such treatment was not medically 45 necessary if such inpatient treatment was contrary to the evidence-based 46 and peer reviewed clinical review tool utilized by the corporation which 47 is designated by the office of alcoholism and substance abuse services. 48 An insured shall not have any financial obligation to the facility for 49 any treatment under this paragraph other than any copayment, coinsu- 50 rance, or deductible otherwise required under the contract. 51 (5) The criteria for medical necessity determinations under the 52 contract with respect to inpatient substance use disorder benefits 53 shall be made available by the corporation to any insured, prospective 54 insured or in-network provider upon request. 55 (6) For purposes of this subsection:S. 1507--C 114 A. 2007--C 1 (A) "financial requirement" means deductible, copayments, coinsurance 2 and out-of-pocket expenses; 3 (B) "predominant" means that a financial requirement or treatment 4 limitation is the most common or frequent of such type of limit or 5 requirement; 6 (C) "treatment limitation" means limits on the frequency of treatment, 7 number of visits, days of coverage, or other similar limits on the 8 scope or duration of treatment and includes nonquantitative treatment 9 limitations such as: medical management standards limiting or excluding 10 benefits based on medical necessity, or based on whether the treatment 11 is experimental or investigational; formulary design for prescription 12 drugs; network tier design; standards for provider admission to partic- 13 ipate in a network, including reimbursement rates; methods for deter- 14 mining usual, customary, and reasonable charges; fail-first or step 15 therapy protocols; exclusions based on failure to complete a course of 16 treatment; and restrictions based on geographic location, facility type, 17 provider specialty, and other criteria that limit the scope or duration 18 of benefits for services provided under the contract; and 19 (D) "substance use disorder" shall have the meaning set forth in the 20 most recent edition of the diagnostic and statistical manual of mental 21 disorders or the most recent edition of another generally recognized 22 independent standard of current medical practice such as the interna- 23 tional classification of diseases. 24 (7) A corporation shall provide coverage under this subsection, at a 25 minimum, consistent with the federal Paul Wellstone and Pete Domenici 26 Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 27 1185a). 28 § 27. Paragraphs 1 and 2 of subsection (l) of section 4303 of the 29 insurance law, as amended by chapter 41 of the laws of 2014, are amended 30 and a new paragraph 3-a is added to read as follows: 31 (1) Every contract that provides medical, major medical or similar 32 comprehensive-type coverage [must] shall provide outpatient coverage for 33 the diagnosis and treatment of substance use disorder, including detoxi- 34 fication and rehabilitation services. Such coverage shall not apply 35 financial requirements or treatment limitations to outpatient substance 36 use disorder benefits that are more restrictive than the predominant 37 financial requirements and treatment limitations applied to substantial- 38 ly all medical and surgical benefits covered by the contract. [Further,39such coverage shall be provided consistent with the federal Paul Well-40stone and Pete Domenici Mental Health Parity and Addiction Equity Act of412008 (29 U.S.C. § 1185a).] 42 (2) Coverage under this subsection may be limited to facilities in New 43 York state that are licensed, certified or otherwise authorized by the 44 office of alcoholism and substance abuse services [or licensed by such45office as outpatient clinics or medically supervised ambulatory] to 46 provide outpatient substance [abuse programs] use disorder services and, 47 in other states, to those which are accredited by the joint commission 48 as alcoholism or chemical dependence substance abuse treatment programs 49 and are similarly licensed, certified or otherwise authorized in the 50 state in which the facility is located. 51 (3-a) A contract that provides large group coverage under this 52 subsection shall not impose copayments or coinsurance for outpatient 53 substance use disorder services that exceed the copayment or coinsurance 54 imposed for a primary care office visit. Provided that no greater than 55 one such copayment may be imposed for all services provided in a single 56 day by a facility licensed, certified or otherwise authorized by theS. 1507--C 115 A. 2007--C 1 office of alcoholism and substance abuse services to provide outpatient 2 substance use disorder services. 3 § 28. Paragraph 5 of subsection (l) of section 4303 of the insurance 4 law, as added by section 5 of part MM of chapter 57 of the laws of 2018, 5 is amended and three new paragraphs 6, 7 and 8 are added to read as 6 follows: 7 (5) This paragraph shall apply to facilities in this state [certified] 8 that are licensed, certified or otherwise authorized by the office of 9 alcoholism and substance abuse services for the provision of outpatient, 10 intensive outpatient, outpatient rehabilitation and opioid treatment 11 that are participating in the corporation's provider network. Coverage 12 provided under this subsection shall not be subject to preauthorization. 13 Coverage provided under this subsection shall not be subject to concur- 14 rent review for the first [two] four weeks of continuous treatment, not 15 to exceed [fourteen] twenty-eight visits, provided the facility notifies 16 the corporation of both the start of treatment and the initial treatment 17 plan within [forty-eight hours] two business days. The facility shall 18 perform clinical assessment of the patient at each visit, including 19 [the] periodic consultation with the corporation at or just prior to the 20 fourteenth day of treatment to ensure that the facility is using the 21 evidence-based and peer reviewed clinical review tool utilized by the 22 corporation which is designated by the office of alcoholism and 23 substance abuse services and appropriate to the age of the patient, to 24 ensure that the outpatient treatment is medically necessary for the 25 patient. Any utilization review of the treatment provided under this 26 paragraph may include a review of all services provided during such 27 outpatient treatment, including all services provided during the first 28 [two] four weeks of continuous treatment, not to exceed [fourteen] twen- 29 ty-eight visits, of such outpatient treatment. Provided, however, the 30 corporation shall only deny coverage for any portion of the initial 31 [two] four weeks of continuous treatment, not to exceed [fourteen] twen- 32 ty-eight visits, for outpatient treatment on the basis that such treat- 33 ment was not medically necessary if such outpatient treatment was 34 contrary to the evidence-based and peer reviewed clinical review tool 35 utilized by the corporation which is designated by the office of alco- 36 holism and substance abuse services. A subscriber shall not have any 37 financial obligation to the facility for any treatment under this para- 38 graph other than any copayment, coinsurance, or deductible otherwise 39 required under the contract. 40 (6) The criteria for medical necessity determinations under the 41 contract with respect to outpatient substance use disorder benefits 42 shall be made available by the corporation to any insured, prospective 43 insured, or in-network provider upon request. 44 (7) For purposes of this subsection: 45 (A) "financial requirement" means deductible, copayments, coinsurance 46 and out-of-pocket expenses; 47 (B) "predominant" means that a financial requirement or treatment 48 limitation is the most common or frequent of such type of limit or 49 requirement. 50 (C) "treatment limitation" means limits on the frequency of treatment, 51 number of visits, days of coverage, or other similar limits on the scope 52 or duration of treatment and includes nonquantitative treatment limita- 53 tions such as: medical management standards limiting or excluding bene- 54 fits based on medical necessity, or based on whether the treatment is 55 experimental or investigational; formulary design for prescription 56 drugs; network tier design; standards for provider admission to partic-S. 1507--C 116 A. 2007--C 1 ipate in a network, including reimbursement rates; methods for determin- 2 ing usual, customary, and reasonable charges; fail-first or step therapy 3 protocols; exclusions based on failure to complete a course of treat- 4 ment; and restrictions based on geographic location, facility type, 5 provider specialty, and other criteria that limit the scope or duration 6 of benefits for services provided under the contract; and 7 (D) "substance use disorder" shall have the meaning set forth in the 8 most recent edition of the diagnostic and statistical manual of mental 9 disorders or the most recent edition of another generally recognized 10 independent standard of current medical practice such as the interna- 11 tional classification of diseases. 12 (8) A corporation shall provide coverage under this subsection, at a 13 minimum, consistent with the federal Paul Wellstone and Pete Domenici 14 Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 15 1185a). 16 § 29. Subsection (l-2) of section 4303 of the insurance law, as added 17 by section 3 of part B of chapter 69 of the laws of 2016, is amended to 18 read as follows: 19 (l-2) [(1)] Every contract that provides medical, major medical or 20 similar comprehensive-type coverage and provides coverage for 21 prescription drugs for medication for the treatment of a substance use 22 disorder shall include immediate access, without prior authorization, to 23 [a five day emergency supply] the formulary forms of prescribed medica- 24 tions covered under the contract for the treatment of substance use 25 disorder [where an emergency condition exists], including a prescribed 26 drug or medication associated with the management of opioid withdrawal 27 and/or stabilization, except where otherwise prohibited by law. Further, 28 coverage [of an emergency supply] without prior authorization shall 29 include formulary forms of medication for opioid overdose reversal 30 otherwise covered under the contract prescribed or dispensed to an indi- 31 vidual covered by the contract. 32 [(2) For purposes of this paragraph, an "emergency condition" means a33substance use disorder condition that manifests itself by acute symptoms34of sufficient severity, including severe pain or the expectation of35severe pain, such that a prudent layperson, possessing an average know-36ledge of medicine and health, could reasonably expect the absence of37immediate medical attention to result in:38(i) placing the health of the person afflicted with such condition in39serious jeopardy, or in the case of a behavioral condition, placing the40health of such person or others in serious jeopardy;41(ii) serious impairment to such person's bodily functions;42(iii) serious dysfunction of any bodily organ or part of such person;43(iv) serious disfigurement of such person; or44(v) a condition described in clause (i), (ii) or (iii) of section451867(e)(1)(A) of the Social Security Act.46(3) Coverage provided under this subsection may be subject to copay-47ments, coinsurance, and annual deductibles that are consistent with48those imposed on other benefits within the contract; provided, however,49no contract shall impose an additional copayment or coinsurance on an50insured who received an emergency supply of medication and then received51up to a thirty day supply of the same medication in the same thirty day52period in which the emergency supply of medication was dispensed. This53paragraph shall not preclude the imposition of a copayment or coinsu-54rance on the initial limited supply of medication in an amount that is55less than the copayment or coinsurance otherwise applicable to a thirty56day supply of such medication, provided that the total sum of the copay-S. 1507--C 117 A. 2007--C 1ments or coinsurance for an entire thirty day supply of the medication2does not exceed the copayment or coinsurance otherwise applicable to a3thirty day supply of such medication.] 4 § 30. Subsection (n) of section 4303 of the insurance law, as amended 5 by chapter 230 of the laws of 2004, is amended to read as follows: 6 (n) In addition to the requirements of subsection (i) of this section, 7 every health service or medical expense indemnity corporation issuing a 8 group contract pursuant to this section or a group remittance contract 9 for delivery in this state which contract provides reimbursement to 10 subscribers or physicians, psychiatrists or psychologists for psychiat- 11 ric or psychological services or for the diagnosis and treatment of 12 [mental, nervous or emotional disorders and ailments,] mental health 13 conditions, however defined in such contract, must provide the same 14 coverage to persons covered under the group contract for such services 15 when performed by a licensed clinical social worker, within the lawful 16 scope of his or her practice, who is licensed pursuant to subdivision 17 two of section seven thousand seven hundred four of the education law 18 and in addition shall have either (i) three or more additional years 19 experience in psychotherapy, which for the purposes of this subsection 20 shall mean the use of verbal methods in interpersonal relationships with 21 the intent of assisting a person or persons to modify attitudes and 22 behavior which are intellectually, socially or emotionally maladaptive, 23 under supervision, satisfactory to the state board for social work, in a 24 facility, licensed or incorporated by an appropriate governmental 25 department, providing services for diagnosis or treatment of [mental,26nervous or emotional disorders or ailments,] mental health conditions, 27 or (ii) three or more additional years experience in psychotherapy under 28 the supervision, satisfactory to the state board for social work, of a 29 psychiatrist, a licensed and registered psychologist or a licensed clin- 30 ical social worker qualified for reimbursement pursuant to subsection 31 (i) of this section, or (iii) a combination of the experience specified 32 in paragraphs (i) and (ii) totaling three years, satisfactory to the 33 state board for social work. The state board for social work shall 34 maintain a list of all licensed clinical social workers qualified for 35 reimbursement under this subsection. 36 § 31. Paragraph 2 of subsection (ee) of section 4303 of the insurance 37 law, as amended by section 40 of part D of chapter 56 of the laws of 38 2013, is amended to read as follows: 39 (2) Every contract that provides physician services, medical, major 40 medical or similar comprehensive-type coverage shall provide coverage 41 for the screening, diagnosis and treatment of autism spectrum disorder 42 in accordance with this paragraph and shall not exclude coverage for the 43 screening, diagnosis or treatment of medical conditions otherwise 44 covered by the contract because the individual is diagnosed with autism 45 spectrum disorder. Such coverage may be subject to annual deductibles, 46 copayments and coinsurance as may be deemed appropriate by the super- 47 intendent and shall be consistent with those imposed on other benefits 48 under the contract. [Coverage for applied behavior analysis shall be49subject to a maximum benefit of six hundred eighty hours of treatment50per contract or calendar year per covered individual.] This paragraph 51 shall not be construed as limiting the benefits that are otherwise 52 available to an individual under the contract, provided however that 53 such contract shall not contain any limitations on visits that are sole- 54 ly applied to the treatment of autism spectrum disorder. No insurer 55 shall terminate coverage or refuse to deliver, execute, issue, amend, 56 adjust, or renew coverage to an individual solely because the individualS. 1507--C 118 A. 2007--C 1 is diagnosed with autism spectrum disorder or has received treatment for 2 autism spectrum disorder. Coverage shall be subject to utilization 3 review and external appeals of health care services pursuant to article 4 forty-nine of this chapter as well as[,] case management[,] and other 5 managed care provisions. 6 § 32. Subparagraphs (A) and (C) of paragraph 3 of subsection (ee) of 7 section 4303 of the insurance law, as amended by chapter 596 of the laws 8 of 2011, are amended to read as follows: 9 (A) "autism spectrum disorder" means any pervasive developmental 10 disorder as defined in the most recent edition of the diagnostic and 11 statistical manual of mental disorders[, including autistic disorder,12Asperger's disorder, Rett's disorder, childhood disintegrative disorder,13or pervasive developmental disorder not otherwise specified (PDD-NOS)]. 14 (C) "behavioral health treatment" means counseling and treatment 15 programs, when provided by a licensed provider, and applied behavior 16 analysis, when provided [or supervised] by a [behavior analyst certified17pursuant to the behavior analyst certification board] person that is 18 licensed, certified or otherwise authorized to provide applied behavior 19 analysis, that are necessary to develop, maintain, or restore, to the 20 maximum extent practicable, the functioning of an individual. [Individ-21uals that provide behavioral health treatment under the supervision of a22certified behavior analyst pursuant to this subsection shall be subject23to standards of professionalism, supervision and relevant experience24pursuant to regulations promulgated by the superintendent in consulta-25tion with the commissioners of health and education.] 26 § 33. Subsection (ee) of section 4303 of the insurance law is amended 27 by adding four new paragraphs 8, 9, 10, and 11 to read as follows: 28 (8) Coverage under this subsection shall not apply financial require- 29 ments or treatment limitations to autism spectrum disorder benefits that 30 are more restrictive than the predominant financial requirements and 31 treatment limitations applied to substantially all medical and surgical 32 benefits covered by the policy. 33 (9) The criteria for medical necessity determinations under the 34 contract with respect to autism spectrum disorder benefits shall be made 35 available by the corporation to any insured, prospective insured, or 36 in-network provider upon request. 37 (10) For purposes of this subsection: 38 (A) "financial requirement" means deductible, copayments, coinsurance 39 and out-of-pocket expenses; 40 (B) "predominant" means that a financial requirement or treatment 41 limitation is the most common or frequent of such type of limit or 42 requirement; and 43 (C) "treatment limitation" means limits on the frequency of treatment, 44 number of visits, days of coverage, or other similar limits on the scope 45 or duration of treatment and includes nonquantitative treatment limita- 46 tions such as: medical management standards limiting or excluding bene- 47 fits based on medical necessity, or based on whether the treatment is 48 experimental or investigational; formulary design for prescription 49 drugs; network tier design; standards for provider admission to partic- 50 ipate in a network, including reimbursement rates; methods for determin- 51 ing usual, customary, and reasonable charges; fail-first or step therapy 52 protocols; exclusions based on failure to complete a course of treat- 53 ment; and restrictions based on geographic location, facility type, 54 provider specialty, and other criteria that limit the scope or duration 55 of benefits for services provided under the contract.S. 1507--C 119 A. 2007--C 1 (11) A corporation shall provide coverage under this subsection, at a 2 minimum, consistent with the federal Paul Wellstone and Pete Domenici 3 Mental Health Parity and Addiction Equity Act of 2008 (29 U.S.C. § 4 1185a). 5 § 34. Paragraphs 17, 20 and 21 of subsection (a) of section 4324 of 6 the insurance law, paragraph 17 as amended and paragraphs 20 and 21 as 7 added by section 8 of part H of chapter 60 of the laws of 2014, are 8 amended and a new paragraph 22 is added to read as follows: 9 (17) where applicable, a listing by specialty, which may be in a sepa- 10 rate document that is updated annually, of the name, address, and tele- 11 phone number of all participating providers, including facilities, [and12in addition,] and: (A) whether the provider is accepting new patients; 13 (B) in the case of mental health or substance use disorder services 14 providers, any affiliations with participating facilities certified or 15 authorized by the office of mental health or the office of alcoholism 16 and substance abuse services, and any restrictions regarding the avail- 17 ability of the individual provider's services; (C) in the case of physi- 18 cians, board certification, languages spoken and any affiliations with 19 participating hospitals. The listing shall also be posted on the corpo- 20 ration's website and the corporation shall update the website within 21 fifteen days of the addition or termination of a provider from the 22 corporation's network or a change in a physician's hospital affiliation; 23 (20) with respect to out-of-network coverage: 24 (A) a clear description of the methodology used by the corporation to 25 determine reimbursement for out-of-network health care services; 26 (B) a description of the amount that the corporation will reimburse 27 under the methodology for out-of-network health care services set forth 28 as a percentage of the usual and customary cost for out-of-network 29 health care services; and 30 (C) examples of anticipated out-of-pocket costs for frequently billed 31 out-of-network health care services; [and] 32 (21) information in writing and through an internet website that 33 reasonably permits a subscriber or prospective subscriber to estimate 34 the anticipated out-of-pocket cost for out-of-network health care 35 services in a geographical area or zip code based upon the difference 36 between what the corporation will reimburse for out-of-network health 37 care services and the usual and customary cost for out-of-network health 38 care services[.]; and 39 (22) the most recent comparative analysis performed by the corporation 40 to assess the provision of its covered services in accordance with the 41 Paul Wellstone and Pete Domenici Mental Health Parity and Addiction 42 Equity Act of 2008, 42 U.S.C. 18031 (j), and any amendments to, and 43 federal guidance or regulations issued under, those Acts. 44 § 35. Subsection (b) of section 4325 of the insurance law, as added by 45 chapter 705 of the laws of 1996, is amended to read as follows: 46 (b) No corporation organized under this article shall by contract, 47 written policy [or], written procedure or practice prohibit or restrict 48 any health care provider from filing a complaint, making a report or 49 commenting to an appropriate governmental body regarding the policies or 50 practices of such corporation which the provider believes may negatively 51 impact upon the quality of or access to patient care. Nor shall a corpo- 52 ration organized under this article take any adverse action, including 53 but not limited to refusing to renew or execute a contract or agreement 54 with a health care provider as retaliation against a health care provid- 55 er for filing a complaint, making a report or commenting to an appropri- 56 ate governmental body regarding policies or practices of such corpo-S. 1507--C 120 A. 2007--C 1 ration which may violate this chapter including subsection (g), (k), 2 (1), (1-1) or (1-2) of section forty-three hundred three of this arti- 3 cle. 4 § 36. Subparagraph (C) of paragraph 1 of subsection (b) of section 5 4900 of the insurance law, as added by chapter 41 of the laws of 2014, 6 is amended and a new subparagraph (D) is added to read as follows: 7 (C) for purposes of a determination involving substance use disorder 8 treatment: 9 (i) a physician who possesses a current and valid non-restricted 10 license to practice medicine and who specializes in behavioral health 11 and has experience in the delivery of substance use disorder courses of 12 treatment; or 13 (ii) a health care professional other than a licensed physician who 14 specializes in behavioral health and has experience in the delivery of 15 substance use disorder courses of treatment and, where applicable, 16 possesses a current and valid non-restricted license, certificate or 17 registration or, where no provision for a license, certificate or regis- 18 tration exists, is credentialed by the national accrediting body appro- 19 priate to the profession; [and] or 20 (D) for purposes of a determination involving treatment for a mental 21 health condition: 22 (i) a physician who possesses a current and valid non-restricted 23 license to practice medicine and who specializes in behavioral health 24 and has experience in the delivery of mental health courses of treat- 25 ment; or 26 (ii) a health care professional other than a licensed physician who 27 specializes in behavioral health and has experience in the delivery of 28 mental health courses of treatment and, where applicable, possesses a 29 current and valid non-restricted license, certificate, or registration 30 or, where no provision for a license, certificate or registration 31 exists, is credentialed by the national accrediting body appropriate to 32 the profession; and 33 § 37. Paragraph 9 of subsection (a) of section 4902 of the insurance 34 law, as amended by section 1 of part A of chapter 69 of the laws of 35 2016, is amended to read as follows: 36 (9) When conducting utilization review for purposes of determining 37 health care coverage for substance use disorder treatment, a utilization 38 review agent shall utilize an evidence-based and peer reviewed clinical 39 review [tools designated by the office of alcoholism and substance abuse40services that are appropriate to the age of the patient and consistent41with the treatment service levels within the office of alcoholism and42substance abuse services system] tool that is appropriate to the age of 43 the patient. When conducting such utilization review for treatment 44 provided in this state, a utilization review agent shall utilize an 45 evidence-based and peer reviewed clinical tool designated by the office 46 of alcoholism and substance abuse services that is consistent with the 47 treatment service levels within the office of alcoholism and substance 48 abuse services system. All approved tools shall have inter rater reli- 49 ability testing completed by December thirty-first, two thousand 50 sixteen. 51 § 38. Subsection (a) of section 4902 of the insurance law is amended 52 by adding a new paragraph 12 to read as follows: 53 (12) When conducting utilization review for purposes of determining 54 health care coverage for a mental health condition, a utilization review 55 agent shall utilize evidence-based and peer reviewed clinical review 56 criteria that is appropriate to the age of the patient. The utilizationS. 1507--C 121 A. 2007--C 1 review agent shall use clinical review criteria deemed appropriate and 2 approved for such use by the commissioner of the office of mental 3 health, in consultation with the commissioner of health and the super- 4 intendent. Approved clinical review criteria shall have inter rater 5 reliability testing completed by December thirty-first, two thousand 6 nineteen. 7 § 39. Paragraph (b) of subsection 5 of section 4403 of the public 8 health law, as added by chapter 705 of the laws of 1996, is amended to 9 read as follows: 10 (b) The following criteria shall be considered by the commissioner at 11 the time of a review: (i) the availability of appropriate and timely 12 care that is provided in compliance with the standards of the Federal 13 Americans with Disability Act to assure access to health care for the 14 enrollee population; (ii) the network's ability to provide culturally 15 and linguistically competent care to meet the needs of the enrollee 16 population; [and] (iii) the availability of appropriate and timely care 17 that is in compliance with the standards of the Paul Wellstone and Pete 18 Domenici Mental Health Parity and Addiction Equity Act of 2008, 42 19 U.S.C. 18031(j), and any amendments to, and federal guidance and regu- 20 lations issued under those Acts, which shall include an analysis of the 21 rate of out-of-network utilization for covered mental health and 22 substance use disorder services as compared to the rate of out-of-net- 23 work utilization for the respective category of medical services; and 24 (iv) with the exception of initial licensure, the number of grievances 25 filed by enrollees relating to waiting times for appointments, appropri- 26 ateness of referrals and other indicators of plan capacity. 27 § 40. Subdivision 3 of section 4406-c of the public health law, as 28 added by chapter 705 of the laws of 1996, is amended to read as follows: 29 3. No health care plan shall by contract, written policy [or], written 30 procedure or practice prohibit or restrict any health care provider from 31 filing a complaint, making a report or commenting to an appropriate 32 governmental body regarding the policies or practices of such health 33 care plan which the provider believes may negatively impact upon the 34 quality of, or access to, patient care. Nor shall a health care plan 35 take any adverse action, including but not limited to refusing to renew 36 or execute a contract or agreement with a health care provider as retal- 37 iation against a health care provider for filing a complaint, making a 38 report or commenting to an appropriate governmental body regarding poli- 39 cies or practices of such health care plan which may violate this chap- 40 ter or the insurance law including subsection (g), (k), (l), (l-1) or 41 (1-2) of section forty-three hundred three of the insurance law. 42 § 41. Paragraphs (r), (t) and (u) of subdivision 1 of section 4408 of 43 the public health law, paragraph (r) as amended and paragraphs (t) and 44 (u) as added by section 18 of part H of chapter 60 of the laws of 2014, 45 are amended and a new paragraph (v) is added to read as follows: 46 (r) a listing by specialty, which may be in a separate document that 47 is updated annually, of the name, address and telephone number of all 48 participating providers, including facilities, [and, in addition,] and: 49 (i) whether the provider is accepting new patients; (ii) in the case of 50 mental health or substance use disorder services providers, any affil- 51 iations with participating facilities certified or authorized by the 52 office of mental health or the office of alcoholism and substance abuse 53 services, and any restrictions regarding the availability of the indi- 54 vidual provider's services; and (iii) in the case of physicians, board 55 certification, languages spoken and any affiliations with participating 56 hospitals. The listing shall also be posted on the health maintenanceS. 1507--C 122 A. 2007--C 1 organization's website and the health maintenance organization shall 2 update the website within fifteen days of the addition or termination of 3 a provider from the health maintenance organization's network or a 4 change in a physician's hospital affiliation; 5 (t) with respect to out-of-network coverage: 6 (i) a clear description of the methodology used by the health mainte- 7 nance organization to determine reimbursement for out-of-network health 8 care services; 9 (ii) the amount that the health maintenance organization will reim- 10 burse under the methodology for out-of-network health care services set 11 forth as a percentage of the usual and customary cost for out-of-network 12 health care services; 13 (iii) examples of anticipated out-of-pocket costs for frequently 14 billed out-of-network health care services; [and] 15 (u) information in writing and through an internet website that 16 reasonably permits an enrollee or prospective enrollee to estimate the 17 anticipated out-of-pocket cost for out-of-network health care services 18 in a geographical area or zip code based upon the difference between 19 what the health maintenance organization will reimburse for out-of-net- 20 work health care services and the usual and customary cost for out-of- 21 network health care services[.]; and 22 (v) the most recent comparative analysis performed by the health main- 23 tenance organization to assess the provision of its covered services in 24 accordance with the Paul Wellstone and Pete Dominici Mental Health Pari- 25 ty and Addiction Equity Act of 2008, 42 U.S.C. 18031(j) and any amend- 26 ments to, and federal guidance and regulations issued under, those Acts. 27 § 42. Subparagraph (iii) of paragraph (a) of subdivision 2 of section 28 4900 of the public health law, as added by chapter 41 of the laws of 29 2014, is amended and a new subparagraph (iv) is added to read as 30 follows: 31 (iii) for purposes of a determination involving substance use disorder 32 treatment: 33 (A) a physician who possesses a current and valid non-restricted 34 license to practice medicine and who specializes in behavioral health 35 and has experience in the delivery of substance use disorder courses of 36 treatment; or 37 (B) a health care professional other than a licensed physician who 38 specializes in behavioral health and has experience in the delivery of 39 substance use disorder courses of treatment and, where applicable, 40 possesses a current and valid non-restricted license, certificate or 41 registration or, where no provision for a license, certificate or regis- 42 tration exists, is credentialed by the national accrediting body appro- 43 priate to the profession; [and] or 44 (iv) for purposes of a determination involving treatment for a mental 45 health condition: 46 (A) a physician who possesses a current and valid non-restricted 47 license to practice medicine and who specializes in behavioral health 48 and has experience in the delivery of mental health courses of treat- 49 ment; or 50 (B) a health care professional other than a licensed physician who 51 specializes in behavioral health and has experience in the delivery of a 52 mental health courses of treatment and, where applicable, possesses a 53 current and valid non-restricted license, certificate, or registration 54 or, where no provision for a license, certificate or registration 55 exists, is credentialed by the national accrediting body appropriate to 56 the profession; andS. 1507--C 123 A. 2007--C 1 § 43. Paragraph (i) of subdivision 1 of section 4902 of the public 2 health law, as amended by section 2 of part A of chapter 69 of the laws 3 of 2016, is amended and a new paragraph (j) is added to read as follows: 4 (i) When conducting utilization review for purposes of determining 5 health care coverage for substance use disorder treatment, a utilization 6 review agent shall utilize an evidence-based and peer reviewed clinical 7 review [tools designated by the office of alcoholism and substance abuse8services that are appropriate to the age of the patient and consistent9with the treatment service levels within the office of alcoholism and10substance abuse services system] tool that is appropriate to the age of 11 the patient. When conducting such utilization review for treatment 12 provided in this state, a utilization review agent shall utilize an 13 evidence-based and peer reviewed clinical tool designated by the office 14 of alcoholism and substance abuse services that is consistent with the 15 treatment service levels within the office of alcoholism and substance 16 abuse services system. All approved tools shall have inter rater reli- 17 ability testing completed by December thirty-first, two thousand 18 sixteen. 19 (j) When conducting utilization review for purposes of determining 20 health care coverage for a mental health condition, a utilization review 21 agent shall utilize evidence-based and peer reviewed clinical review 22 criteria that is appropriate to the age of the patient. The utilization 23 review agent shall use clinical review criteria deemed appropriate and 24 approved for such use by the commissioner of the office of mental 25 health, in consultation with the commissioner and the superintendent of 26 financial services. Approved clinical review criteria shall have inter 27 rater reliability testing completed by December thirty-first, two thou- 28 sand nineteen. 29 § 44. This act shall take effect on the first of January next succeed- 30 ing the date on which it shall have become a law and shall apply to all 31 policies and contracts issued, renewed, modified, altered or amended on 32 or after such date; provided, however, notwithstanding any provision of 33 law to the contrary, nothing in this act shall limit the rights accruing 34 to employees pursuant to a collective bargaining agreement with any 35 state or local government employer for the unexpired term of such agree- 36 ment where such agreement is in effect on the effective date of this act 37 and so long as such agreement remains in effect thereafter or the eligi- 38 bility of any member of an employee organization to join a health insur- 39 ance plan open to him or her pursuant to such a collectively negotiated 40 agreement. 41 SUBPART B 42 Section 1. Subdivision 1 of section 2803-u of the public health law, 43 as added by section 1 of part C of chapter 70 of the laws of 2016, is 44 amended to read as follows: 45 1. The office of alcoholism and substance abuse services, in consulta- 46 tion with the department, shall develop or utilize existing educational 47 materials to be provided to general hospitals to disseminate to individ- 48 uals with a documented substance use disorder or who appear to have or 49 be at risk for a substance use disorder during discharge planning pursu- 50 ant to section twenty-eight hundred three-i of this [chapter] article. 51 Such materials shall include information regarding the various types of 52 treatment and recovery services, including but not limited to: inpa- 53 tient, outpatient, and medication-assisted treatment; how to recognize 54 the need for treatment services; information for individuals to deter-S. 1507--C 124 A. 2007--C 1 mine what type and level of treatment is most appropriate and what 2 resources are available to them; and any other information the commis- 3 sioner deems appropriate. General hospitals shall include in their poli- 4 cies and procedures treatment protocols, consistent with medical stand- 5 ards, to be utilized by the emergency departments in general hospitals 6 for the appropriate use of medication-assisted treatment, including 7 buprenorphine, prior to discharge, or referral protocols for evaluation 8 of medication-assisted treatment when initiation in an emergency depart- 9 ment of a general hospital is not feasible. 10 § 2. This act shall take effect immediately. 11 SUBPART C 12 Intentionally Omitted 13 SUBPART D 14 Section 1. Paragraph (r) of subdivision 4 of section 364-j of the 15 social services law, as amended by section 39 of part A of chapter 56 of 16 the laws of 2013, is amended to read as follows: 17 (r) A managed care provider shall provide services to participants 18 pursuant to an order of a court of competent jurisdiction, provided 19 however, that such services shall be within such provider's or plan's 20 benefit package and are reimbursable under title xix of the federal 21 social security act, provided that services for a substance use disorder 22 shall be provided by a program licensed, certified or otherwise author- 23 ized by the office of alcoholism and substance abuse services. 24 § 2. This act shall take effect immediately; provided, however that 25 the amendments to paragraph (r) of subdivision 4 of section 364-j of the 26 social services law made by section one of this act shall not affect the 27 repeal of such section and shall be deemed to be repealed therewith. 28 SUBPART E 29 Intentionally Omitted 30 § 2. Severability clause. If any clause, sentence, paragraph, subdivi- 31 sion, section or part of this act shall be adjudged by any court of 32 competent jurisdiction to be invalid, such judgment shall not affect, 33 impair, or invalidate the remainder thereof, but shall be confined in 34 its operation to the clause, sentence, paragraph, subdivision, section 35 or part thereof directly involved in the controversy in which such judg- 36 ment shall have been rendered. It has hereby declared to be the intent 37 of the legislature that this act would have been enacted even if such 38 invalid provisions had not been included herein. 39 § 3. This act shall take effect immediately provided, however, that 40 the applicable effective date of Subparts A through E of this act shall 41 be as specifically set forth in the last section of such Subparts. 42 PART CC 43 Intentionally Omitted 44 PART DDS. 1507--C 125 A. 2007--C 1 Intentionally Omitted 2 PART EE 3 Section 1. Subdivision 10 of section 2899-a of the public health law, 4 as amended by section 5 of part C of chapter 57 of the laws of 2018, is 5 amended to read as follows: 6 10. Notwithstanding subdivision eleven of section eight hundred 7 forty-five-b of the executive law, a certified home health agency, 8 licensed home care services agency or long term home health care program 9 certified, licensed or approved under article thirty-six of this chapter 10 or a home care services agency exempt from certification or licensure 11 under article thirty-six of this chapter, a hospice program under arti- 12 cle forty of this chapter, or an adult home, enriched housing program or 13 residence for adults licensed under article seven of the social services 14 law, or a health home, or any subcontractor of such health home, who 15 contracts with or is approved or otherwise authorized by the department 16 to provide health home services to all enrollees enrolled pursuant to a 17 diagnosis of a developmental disability as defined in subdivision twen- 18 ty-two of section 1.03 of the mental hygiene law and enrollees who are 19 under twenty-one years of age under section three hundred sixty-five-l 20 of the social services law, or any entity that provides home and commu- 21 nity based services to enrollees who are under twenty-one years of age 22 under a demonstration program pursuant to section eleven hundred fifteen 23 of the federal social security act may temporarily approve a prospective 24 employee while the results of the criminal history information check and 25 the determination are pending, upon the condition that the provider 26 conducts appropriate direct observation and evaluation of the temporary 27 employee, while he or she is temporarily employed, and the care recipi- 28 ent; provided, however, that for a health home, or any subcontractor of 29 a health home, who contracts with or is approved or otherwise authorized 30 by the department to provide health home services to all enrollees 31 enrolled pursuant to a diagnosis of developmental disability as defined 32 in subdivision twenty-two of section 1.03 of the mental hygiene law and 33 enrollees who are under twenty-one years of age under section three 34 hundred sixty-five-l of the social services law, or any entity that 35 provides home and community based services to enrollees who are under 36 twenty-one years of age under a demonstration program pursuant to 37 section eleven hundred fifteen of the federal social security act, 38 direct observation and evaluation of temporary employees shall not be 39 required until [April] July first, two thousand nineteen. The results of 40 such observations shall be documented in the temporary employee's 41 personnel file and shall be maintained. For purposes of providing such 42 appropriate direct observation and evaluation, the provider shall 43 utilize an individual employed by such provider with a minimum of one 44 year's experience working in an agency certified, licensed or approved 45 under article thirty-six of this chapter or an adult home, enriched 46 housing program or residence for adults licensed under article seven of 47 the social services law, a health home, or any subcontractor of such 48 health home, who contracts with or is approved or otherwise authorized 49 by the department to provide health home services to those enrolled 50 pursuant to a diagnosis of a developmental disability as defined in 51 subdivision twenty-two of section 1.03 of the mental hygiene law and 52 enrollees who are under twenty-one years of age under section three 53 hundred sixty-five-l of the social services law, or any entity that 54 provides home and community based services to enrollees who are underS. 1507--C 126 A. 2007--C 1 twenty-one years of age under a demonstration program pursuant to 2 section eleven hundred fifteen of the federal social security act. If 3 the temporary employee is working under contract with another provider 4 certified, licensed or approved under article thirty-six of this chap- 5 ter, such contract provider's appropriate direct observation and evalu- 6 ation of the temporary employee, shall be considered sufficient for the 7 purposes of complying with this subdivision. 8 § 2. This act shall take effect immediately, except that if this act 9 shall have become a law on or after April 1, 2019 this act shall take 10 effect immediately and shall be deemed to have been in full force and 11 effect on and after April 1, 2019. 12 PART FF 13 Section 1. Section 4 of chapter 495 of the laws of 2004, amending the 14 insurance law and the public health law relating to the New York state 15 health insurance continuation assistance demonstration project, as 16 amended by section 1 of part QQ of chapter 58 of the laws of 2018, is 17 amended to read as follows: 18 § 4. This act shall take effect on the sixtieth day after it shall 19 have become a law; provided, however, that this act shall remain in 20 effect until July 1, [2019] 2020 when upon such date the provisions of 21 this act shall expire and be deemed repealed; provided, further, that a 22 displaced worker shall be eligible for continuation assistance retroac- 23 tive to July 1, 2004. 24 § 2. This act shall take effect immediately. 25 PART GG 26 Section 1. It is the intent of the legislature that, subject to the 27 approval of the director of the budget and sufficient appropriation 28 authority, no less than one hundred million dollars of existing revenue 29 shall be made available annually to support programs operated by the New 30 York state office of alcoholism and substance abuse services or agencies 31 certified, authorized, approved or otherwise funded by the New York 32 state office of alcoholism and substance abuse services to provide 33 opioid treatment, recovery and prevention and education services. 34 § 2. This act shall take effect immediately. 35 PART HH 36 Section 1. Subdivision 5 of section 209 of the elder law, as amended 37 by section 1 of part S of chapter 59 of the laws of 2016, is amended to 38 read as follows: 39 5. Within amounts specifically appropriated therefor and consistent 40 with the criteria developed and required pursuant to this section the 41 director shall approve grants to eligible applicants. Individual grants 42 awarded for classic NORC programs shall be in amounts not to exceed 43 [two] three hundred thousand ([$200,000] $300,000) dollars and for 44 neighborhood NORCs not less than sixty thousand ($60,000) dollars in any 45 twelve month period. 46 § 2. This act shall take effect immediately. 47 PART IIS. 1507--C 127 A. 2007--C 1 Section 1. Section 13 of chapter 141 of the laws of 1994, amending the 2 legislative law and the state finance law relating to the operation and 3 administration of the legislature, as amended by section 2 of part GGG 4 of chapter 59 of the laws of 2018, is amended to read as follows: 5 § 13. This act shall take effect immediately and shall be deemed to 6 have been in full force and effect as of April 1, 1994, provided that, 7 the provisions of section 5-a of the legislative law as amended by 8 sections two and two-a of this act shall take effect on January 1, 1995, 9 and provided further that, the provisions of article 5-A of the legisla- 10 tive law as added by section eight of this act shall expire June 30, 11 [2019] 2020 when upon such date the provisions of such article shall be 12 deemed repealed; and provided further that section twelve of this act 13 shall be deemed to have been in full force and effect on and after April 14 10, 1994. 15 § 2. This act shall take effect immediately, provided, however, if 16 section one of this act shall take effect on or after June 30, 2019 17 section one of this act shall be deemed to have been in full force and 18 effect on and after June 30, 2019. 19 PART JJ 20 Section 1. Section 2815 of the public health law is amended by adding 21 a new subdivision 5-a to read as follows: 22 5-a. Notwithstanding anything in this section to the contrary, the 23 authority is authorized and directed to transfer from the restructuring 24 pool to the department, upon written request of the director of the 25 budget and within thirty days thereof, funds repaid by participating 26 borrowers, and held by the authority relating to restructuring pool 27 loans funded by amounts transferred to the restructuring pool by the 28 department or remaining funds in the restructuring pool that were trans- 29 ferred by the department, not to exceed a total of eighty-three million 30 five hundred thousand dollars, excepting therefrom amounts necessary to 31 pay expenses of the authority as provided in the agreement described in 32 subdivision three of this section. All participating borrowers shall be 33 obligated in their loan agreement to repay no later than March thirty- 34 first, two thousand twenty all funds borrowed from the eighty-three 35 million five hundred thousand dollars transferred by the department 36 pursuant to this section, to fund these restructuring pool loans. 37 Further, in respect of these borrowed funds, all participating borrowers 38 shall be required under the terms of their loan agreement to immediately 39 upon receipt of quality improvement incentive payments or additional 40 supplemental assistance initiate repayment of an amount equal to the 41 quality improvement incentive payments or additional supplemental 42 assistance not to exceed the amount of such borrowed funds, unless a 43 waiver or extension of repayment has been approved by the director of 44 the budget. 45 § 2. This act shall take effect immediately. 46 PART KK 47 Section 1. The Department of Health shall conduct a study to examine 48 how staffing enhancements and other initiatives could be used to improve 49 patient safety and the quality of healthcare service delivery in hospi- 50 tals and nursing homes subject to article 28 of the public health law. 51 The Department study shall consider minimum staffing levels, other 52 staffing enhancement strategies, and other patient quality improvementS. 1507--C 128 A. 2007--C 1 initiatives for registered nurses, licensed practical nurses, and certi- 2 fied nurse aides to improve the quality of care and patient safety. 3 The study will analyze the range of potential fiscal impacts of staff- 4 ing levels, other staffing enhancement strategies, and other patient 5 quality improvement initiatives. 6 The Department study will commence no later than May 1, 2019, and 7 shall engage stakeholders, including the statewide hospital and nursing 8 home associations, direct care health workers, and patient and community 9 health advocates, and shall report its findings and recommendations to 10 the Commissioner of the Department of Health and to the Temporary Presi- 11 dent of the Senate and Speaker of the Assembly no later than December 12 31, 2019. 13 § 2. This act shall take effect immediately and shall be deemed to 14 have been in full force and effect on and after April 1, 2019. 15 § 2. Severability clause. If any clause, sentence, paragraph, subdivi- 16 sion, section or part of this act shall be adjudged by any court of 17 competent jurisdiction to be invalid, such judgment shall not affect, 18 impair, or invalidate the remainder thereof, but shall be confined in 19 its operation to the clause, sentence, paragraph, subdivision, section 20 or part thereof directly involved in the controversy in which such judg- 21 ment shall have been rendered. It is hereby declared to be the intent of 22 the legislature that this act would have been enacted even if such 23 invalid provisions had not been included herein. 24 § 3. This act shall take effect immediately provided, however, that 25 the applicable effective date of Parts A through KK of this act shall be 26 as specifically set forth in the last section of such Parts.
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