Bill Text: NY S04884 | 2009-2010 | General Assembly | Introduced
Bill Title: Establishes New York Health Plus to provide comprehensive health coverage to all New Yorkers; provides for a phase-in period for such program and requires the governor to submit a financing plan to include assessments on employers.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-01-06 - REFERRED TO HEALTH [S04884 Detail]
Download: New_York-2009-S04884-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
S. 4884 A. 7854
2009-2010 Regular Sessions
S E N A T E - A S S E M B L Y
April 27, 2009
___________
IN SENATE -- Introduced by Sen. DUANE -- read twice and ordered printed,
and when printed to be committed to the Committee on Health
IN ASSEMBLY -- Introduced by M. of A. GOTTFRIED -- read once and
referred to the Committee on Health
AN ACT to amend the public health law and the social services law, in
relation to establishing New York health plus
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Article 50 and sections 5000, 5001, 5002 and 5003 of the
2 public health law are renumbered article 80 and sections 8000, 8001,
3 8002 and 8003, respectively, and a new article 51 is added to read as
4 follows:
5 ARTICLE 51
6 NEW YORK HEALTH PLUS
7 SECTION 5100. DEFINITIONS.
8 5101. PROGRAM CREATED.
9 5102. BOARD OF TRUSTEES.
10 5103. ELIGIBILITY AND ENROLLMENT.
11 5104. BENEFITS.
12 5105. HEALTH PLANS.
13 5106. PREMIUMS PAID TO HEALTH PLANS BY THE PROGRAM.
14 5107. PROGRAM STANDARDS.
15 5108. PHASE-IN PERIOD.
16 5109. REGULATIONS.
17 5110. OTHER PROVISIONS.
18 S 5100. DEFINITIONS. AS USED IN THIS ARTICLE, THE FOLLOWING TERMS
19 SHALL HAVE THE FOLLOWING MEANINGS, UNLESS THE CONTEXT CLEARLY REQUIRES
20 OTHERWISE:
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07055-03-9
S. 4884 2 A. 7854
1 1. "BOARD" MEANS THE BOARD OF TRUSTEES OF THE NEW YORK HEALTH PLUS
2 PROGRAM CREATED BY SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS ARTI-
3 CLE, AND "TRUSTEE" MEANS A TRUSTEE OF THE BOARD.
4 2. "PROGRAM" MEANS THE NEW YORK HEALTH PLUS PROGRAM CREATED BY SECTION
5 FIVE THOUSAND ONE HUNDRED ONE OF THIS ARTICLE.
6 3. "MEMBER" MEANS AN INDIVIDUAL WHO IS ENROLLED IN A HEALTH PLAN UNDER
7 THE PROGRAM.
8 4. "PARTICIPATING PROVIDER" MEANS ANY PERSON THAT IS A HEALTH CARE
9 PROVIDER THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS UNDER A HEALTH
10 PLAN.
11 5. "HEALTH CARE SERVICE" MEANS ANY HEALTH CARE SERVICE INCLUDED AS A
12 BENEFIT UNDER THE PROGRAM UNDER SECTION FIVE THOUSAND ONE HUNDRED FOUR
13 OF THIS ARTICLE.
14 6. "RESIDENT" MEANS AN INDIVIDUAL WHOSE PRIMARY PLACE OF ABODE IS IN
15 THE STATE, AS DETERMINED ACCORDING TO REGULATIONS OF THE COMMISSIONER.
16 7. "PERSON" MEANS ANY INDIVIDUAL OR NATURAL PERSON, TRUST, PARTNER-
17 SHIP, ASSOCIATION, UNINCORPORATED ASSOCIATION, CORPORATION, COMPANY,
18 LIMITED LIABILITY COMPANY, PROPRIETORSHIP, JOINT VENTURE, FIRM, JOINT
19 STOCK ASSOCIATION, DEPARTMENT, AGENCY, AUTHORITY, OR OTHER LEGAL ENTITY,
20 WHETHER FOR-PROFIT, NOT-FOR-PROFIT OR GOVERNMENTAL.
21 8. "PHASE-IN PERIOD" MEANS THE PERIOD UNDER SECTION FIVE THOUSAND ONE
22 HUNDRED EIGHT OF THIS ARTICLE DURING WHICH THE PROGRAM WILL BE SUBJECT
23 TO SPECIAL ELIGIBILITY AND FINANCING PROVISIONS UNTIL IT IS FULLY IMPLE-
24 MENTED UNDER THAT SECTION.
25 9. "FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM" MEANS THE MEDICAL ASSIST-
26 ANCE PROGRAM UNDER TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES
27 LAW, THE FAMILY HEALTH PLUS PROGRAM UNDER TITLE ELEVEN-D OF ARTICLE FIVE
28 OF THE SOCIAL SERVICES LAW, THE CHILD HEALTH PLUS PROGRAM UNDER TITLE
29 ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER.
30 10. "HEALTH PLAN" MEANS (I) AN ENTITY THAT IS APPROVED BY THE COMMIS-
31 SIONER UNDER THE PROGRAM TO ENROLL AND PROVIDE HEALTH CARE SERVICES TO
32 MEMBERS UNDER THE PROGRAM AND (II) THE FEE-FOR-SERVICE HEALTH PLAN UNDER
33 SECTION FIVE THOUSAND ONE HUNDRED FIVE OF THIS ARTICLE.
34 11. "MEDICAID" OR "MEDICAL ASSISTANCE" MEANS TITLE ELEVEN OF ARTICLE
35 FIVE OF THE SOCIAL SERVICES LAW AND THE PROGRAM THEREUNDER. "FAMILY
36 HEALTH PLUS" MEANS TITLE ELEVEN-D OF THE SOCIAL SERVICES LAW AND THE
37 PROGRAM THEREUNDER. "CHILD HEALTH PLUS" MEANS TITLE ONE-A OF ARTICLE
38 TWENTY-FIVE OF THIS CHAPTER AND THE PROGRAM THEREUNDER.
39 12. "THRESHOLD INCOME LEVEL" MEANS THE AMOUNT OF INCOME ABOVE WHICH A
40 PREMIUM CONTRIBUTION MAY BE CHARGED DURING THE PHASE-IN PERIOD.
41 13. "INCOME" MEANS NET HOUSEHOLD INCOME, OR THE GROSS EQUIVALENT OF
42 THAT NET INCOME.
43 14. "CARE MANAGEMENT" MEANS SERVICES PROVIDED BY A CARE MANAGER UNDER
44 PARAGRAPH (B) OF SUBDIVISION THREE OF SECTION FIVE THOUSAND ONE HUNDRED
45 FIVE OF THIS ARTICLE.
46 15. "CARE MANAGER" MEANS AN INDIVIDUAL OR ENTITY APPROVED TO PROVIDE
47 CARE MANAGEMENT UNDER PARAGRAPH (B) OF SUBDIVISION THREE OF SECTION FIVE
48 THOUSAND ONE HUNDRED FIVE OF THIS ARTICLE.
49 S 5101. PROGRAM CREATED. 1. THE NEW YORK HEALTH PLUS PROGRAM IS HERE-
50 BY CREATED IN THE DEPARTMENT. THE PROGRAM SHALL PROVIDE COMPREHENSIVE
51 HEALTH COVERAGE TO EVERY RESIDENT WHO ENROLLS AS A MEMBER OF A HEALTH
52 PLAN. HOWEVER, DURING THE PHASE-IN PERIOD, THE PROGRAM SHALL BE SUBJECT
53 TO THE PROVISIONS OF SECTION FIVE THOUSAND ONE HUNDRED EIGHT OF THIS
54 ARTICLE.
55 2. HEALTH COVERAGE UNDER THE PROGRAM SHALL BE PROVIDED THROUGH TITLES
56 ELEVEN AND ELEVEN-D OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW AND TITLE
S. 4884 3 A. 7854
1 ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAPTER. EXCEPT WHERE INCONSISTENT
2 WITH THE PROVISIONS OF THIS ARTICLE, THE PROVISIONS OF TITLES ELEVEN AND
3 ELEVEN-D OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW AND TITLE ONE-A OF
4 ARTICLE TWENTY-FIVE OF THIS CHAPTER SHALL APPLY TO THE PROGRAM.
5 3. THE COMMISSIONER SHALL, TO THE MAXIMUM EXTENT POSSIBLE, ORGANIZE,
6 ADMINISTER AND MARKET THE PROGRAM AND SERVICES UNDER TITLES ELEVEN AND
7 ELEVEN-D OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW AND TITLE ONE-A OF
8 ARTICLE TWENTY-FIVE OF THIS CHAPTER AS A SINGLE PROGRAM UNDER THE NAME
9 "NEW YORK HEALTH PLUS" OR SUCH OTHER NAME AS THE COMMISSIONER SHALL
10 DETERMINE. IN IMPLEMENTING THIS SUBDIVISION, THE COMMISSIONER SHALL
11 AVOID JEOPARDIZING FEDERAL FINANCIAL PARTICIPATION IN THESE PROGRAMS AND
12 SHALL TAKE CARE TO PROMOTE PUBLIC UNDERSTANDING AND AWARENESS OF AVAIL-
13 ABLE BENEFITS AND PROGRAMS.
14 S 5102. BOARD OF TRUSTEES. 1. THE NEW YORK HEALTH PLUS BOARD OF TRUS-
15 TEES IS HEREBY CREATED IN THE DEPARTMENT. THE BOARD OF TRUSTEES SHALL,
16 AT THE REQUEST OF THE COMMISSIONER, CONSIDER ANY MATTER TO EFFECTUATE
17 THE PROVISIONS AND PURPOSES OF THIS ARTICLE, AND MAY ADVISE THE COMMIS-
18 SIONER THEREON; AND IT MAY, FROM TIME TO TIME, SUBMIT TO THE COMMISSION-
19 ER, ANY RECOMMENDATIONS TO EFFECTUATE THE PROVISIONS AND PURPOSES OF
20 THIS ARTICLE. THE COMMISSIONER MAY PROPOSE REGULATIONS AND AMENDMENTS
21 THERETO FOR CONSIDERATION BY THE BOARD. THE BOARD OF TRUSTEES MAY
22 APPOINT ONE OR MORE ADVISORY COMMITTEES. MEMBERS OF ADVISORY COMMITTEES
23 NEED NOT BE MEMBERS OF THE BOARD OF TRUSTEES. THE BOARD OF TRUSTEES
24 SHALL HAVE NO EXECUTIVE, ADMINISTRATIVE OR APPOINTIVE DUTIES EXCEPT AS
25 OTHERWISE PROVIDED BY LAW. THE BOARD OF TRUSTEES SHALL HAVE POWER TO
26 ESTABLISH, AND FROM TIME TO TIME, AMEND REGULATIONS TO EFFECTUATE THE
27 PROVISIONS AND PURPOSES OF THIS ARTICLE, SUBJECT TO APPROVAL BY THE
28 COMMISSIONER.
29 2. THE BOARD SHALL BE COMPOSED OF:
30 (A) THE COMMISSIONER AND THE SUPERINTENDENT OF INSURANCE, AND THE
31 DIRECTOR OF THE BUDGET, OR THEIR DESIGNEES, AS EX OFFICIO MEMBERS;
32 (B) SEVENTEEN TRUSTEES APPOINTED BY THE GOVERNOR:
33 (I) TWO OF WHOM SHALL BE REPRESENTATIVES OF HEALTH CARE CONSUMER ADVO-
34 CACY ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY, WHO
35 HAVE BEEN INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER ADVOCA-
36 CY, INCLUDING ISSUES OF INTEREST TO LOW- AND MODERATE-INCOME INDIVID-
37 UALS;
38 (II) TWO OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
39 TIONS REPRESENTING PHYSICIANS;
40 (III) TWO OF WHOM SHALL BE REPRESENTATIVES OF PROFESSIONAL ORGANIZA-
41 TIONS REPRESENTING LICENSED OR REGISTERED HEALTH CARE PROFESSIONALS
42 OTHER THAN PHYSICIANS;
43 (IV) THREE OF WHOM SHALL BE REPRESENTATIVES OF HOSPITALS, ONE OF WHOM
44 SHALL BE A REPRESENTATIVE OF PUBLIC HOSPITALS;
45 (V) ONE OF WHOM SHALL BE REPRESENTATIVE OF COMMUNITY HEALTH CENTERS OR
46 OTHER HEALTH CARE PROVIDER ENTITIES;
47 (VI) TWO OF WHOM SHALL BE REPRESENTATIVES OF LOCAL GOVERNMENTS;
48 (VII) TWO OF WHOM SHALL BE REPRESENTATIVES BUSINESS;
49 (VIII) TWO OF WHOM SHALL BE REPRESENTATIVES OF ORGANIZED LABOR;
50 (IX) ONE OF WHOM SHALL BE REPRESENTATIVE OF PLANS;
51 (C) THREE TRUSTEES APPOINTED BY THE SPEAKER OF THE ASSEMBLY; THREE
52 TRUSTEES APPOINTED BY THE TEMPORARY PRESIDENT OF THE SENATE; ONE TRUSTEE
53 APPOINTED BY THE MINORITY LEADER OF THE ASSEMBLY; AND ONE TRUSTEE
54 APPOINTED BY THE MINORITY LEADER OF THE SENATE.
55 BEGINNING ONE YEAR AFTER THE END OF THE PHASE-IN PERIOD, NO PERSON
56 SHALL BE A TRUSTEE UNLESS HE OR SHE IS A MEMBER OF A HEALTH PLAN, EXCEPT
S. 4884 4 A. 7854
1 THE EX OFFICIO TRUSTEES. EACH TRUSTEE SHALL SERVE AT THE PLEASURE OF THE
2 APPOINTING OFFICER, EXCEPT THE EX OFFICIO TRUSTEES.
3 3. THE CHAIR OF THE BOARD SHALL BE APPOINTED AND MAY BE REMOVED AS
4 CHAIR BY THE GOVERNOR FROM AMONG THE TRUSTEES. THE BOARD SHALL MEET AT
5 LEAST FOUR TIMES EACH CALENDAR YEAR. MEETINGS SHALL BE HELD UPON THE
6 CALL OF THE CHAIR AND AS PROVIDED BY THE BOARD. A MAJORITY OF THE
7 APPOINTED TRUSTEES SHALL BE A QUORUM OF THE BOARD, AND THE AFFIRMATIVE
8 VOTE OF A MAJORITY OF THE TRUSTEES VOTING, BUT NOT LESS THAN TEN, SHALL
9 BE NECESSARY FOR ANY ACTION TO BE TAKEN BY THE BOARD. THE BOARD MAY
10 ESTABLISH AN EXECUTIVE COMMITTEE TO EXERCISE ANY POWERS OR DUTIES OF THE
11 BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO ASSIST THE BOARD OR THE
12 EXECUTIVE COMMITTEE. THE CHAIR OF THE BOARD SHALL CHAIR THE EXECUTIVE
13 COMMITTEE AND SHALL APPOINT THE CHAIR AND MEMBERS OF ALL OTHER COMMIT-
14 TEES. THE BOARD MAY ALSO ESTABLISH ADVISORY COMMITTEES CONSISTING OF
15 INDIVIDUALS OTHER THAN TRUSTEES.
16 4. TRUSTEES SHALL SERVE WITHOUT COMPENSATION BUT SHALL BE REIMBURSED
17 FOR THEIR NECESSARY AND ACTUAL EXPENSES INCURRED WHILE ENGAGED IN THE
18 BUSINESS OF THE BOARD.
19 5. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, NO OFFICER OR
20 EMPLOYEE OF THE STATE OR ANY LOCAL GOVERNMENT SHALL FORFEIT OR BE DEEMED
21 TO HAVE FORFEITED HIS OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A
22 TRUSTEE.
23 6. THE BOARD AND ITS COMMITTEES AND ADVISORY COMMITTEES MAY REQUEST
24 AND RECEIVE THE ASSISTANCE OF THE DEPARTMENT AND ANY OTHER STATE OR
25 LOCAL GOVERNMENTAL ENTITY IN EXERCISING ITS POWERS AND DUTIES.
26 S 5103. ELIGIBILITY AND ENROLLMENT. 1. EVERY RESIDENT SHALL BE ELIGI-
27 BLE AND ENTITLED TO ENROLL AS A MEMBER OF A HEALTH PLAN UNDER THE
28 PROGRAM; PROVIDED THAT NO PERSON SHALL AT ANY TIME BE A MEMBER OF MORE
29 THAN ONE HEALTH PLAN.
30 2. NO MEMBER SHALL BE REQUIRED TO PAY ANY PREMIUM OR OTHER CHARGE FOR
31 ENROLLING IN OR BEING A MEMBER OF A HEALTH PLAN, EXCEPT DURING THE
32 PHASE-IN PERIOD AS PROVIDED IN SECTION FIVE THOUSAND ONE HUNDRED EIGHT
33 OF THIS ARTICLE.
34 3. (A) THE COMMISSIONER MAY APPLY FOR COVERAGE UNDER ANY
35 FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM ON BEHALF OF ANY MEMBER AND
36 ENROLL THE MEMBER IN THE FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM IF THE
37 MEMBER IS ELIGIBLE FOR IT. THE COMMISSIONER SHALL PROVIDE MEMBERS WITH
38 NOTIFICATION OF ANY ENHANCED BENEFITS IF THEY HAVE BEEN ENROLLED IN A
39 FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM; HOWEVER, ENROLLMENT IN A FEDER-
40 ALLY-MATCHED PUBLIC HEALTH PROGRAM SHALL NOT CAUSE ANY MEMBER TO LOSE
41 ANY HEALTH CARE SERVICE PROVIDED BY THE PROGRAM.
42 (B) THE COMMISSIONER MAY BY REGULATION INCREASE THE INCOME ELIGIBILITY
43 LEVEL, INCREASE OR ELIMINATE THE RESOURCE TEST FOR ELIGIBILITY, AND
44 SIMPLIFY ANY PROCEDURAL OR DOCUMENTATION REQUIREMENT FOR ENROLLMENT FOR
45 ANY FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM, NOTWITHSTANDING ANY LAW OR
46 REGULATION TO THE CONTRARY. THE COMMISSIONER MAY ACT UNDER THIS PARA-
47 GRAPH UPON A FINDING, APPROVED BY THE DIRECTOR OF THE BUDGET, THAT THE
48 ACTION (I) WILL HELP TO INCREASE THE NUMBER OF MEMBERS WHO ARE ELIGIBLE
49 FOR AND ENROLL IN FEDERALLY-MATCHED PUBLIC HEALTH PROGRAMS; (II) WILL
50 NOT DIMINISH ANY INDIVIDUAL'S ACCESS TO ANY HEALTH CARE SERVICE AND
51 (III) DOES NOT REQUIRE OR HAS RECEIVED ANY NECESSARY FEDERAL WAIVERS OR
52 APPROVALS TO ENSURE FEDERAL FINANCIAL PARTICIPATION. ACTIONS UNDER THIS
53 PARAGRAPH SHALL NOT APPLY TO INDIVIDUALS SEEKING PAYMENT FOR LONG TERM
54 CARE, TREATMENT, MAINTENANCE, OR SERVICES NOT COVERED UNDER FAMILY
55 HEALTH PLUS OR CHILD HEALTH PLUS, AS APPROPRIATE, WITH THE EXCEPTION OF
56 SHORT TERM REHABILITATION, AS DEFINED BY THE COMMISSIONER.
S. 4884 5 A. 7854
1 4. AS A CONDITION OF CONTINUED ELIGIBILITY FOR HEALTH CARE SERVICES
2 UNDER THE PROGRAM, A MEMBER WHO IS ELIGIBLE FOR BENEFITS UNDER TITLE
3 XVIII OF THE FEDERAL SOCIAL SECURITY ACT (MEDICARE) SHALL ENROLL IN
4 MEDICARE, INCLUDING PARTS A, B AND D.
5 (A) IF A MEMBER WHO IS ENROLLED IN MEDICARE DOES NOT ENROLL IN A MEDI-
6 CARE MANAGED CARE PLAN OR ENROLLS IN A MANAGED CARE PROGRAM THAT IS NOT
7 A MANAGED CARE PROVIDER IN THE PROGRAM, THAT MEMBER SHALL USE THE
8 FEE-FOR-SERVICE HEALTH PLAN CREATED IN SUBDIVISION TWO OF SECTION FIVE
9 THOUSAND ONE HUNDRED FIVE OF THIS ARTICLE.
10 (B) IF A MEMBER ENROLLS IN A MEDICARE MANAGED CARE PLAN OFFERED BY AN
11 ENTITY THAT IS ALSO A MANAGED CARE PROVIDER; THAT MEMBER SHALL HAVE THE
12 OPTION OF RECEIVING HEALTH CARE SERVICES IN THE PROGRAM THROUGH THE SAME
13 ENTITY'S MANAGED CARE PLAN OR THROUGH THE FEE FOR SERVICE OPTION OF THE
14 PROGRAM AS CREATED IN SUBDIVISION TWO OF SECTION FIVE THOUSAND ONE
15 HUNDRED FIVE OF THIS ARTICLE, PROVIDED THAT:
16 (I) IF THE MEMBER CHANGES HIS OR HER MEDICARE MANAGED CARE PLAN AS
17 AUTHORIZED BY MEDICARE AND ENROLLS IN ANOTHER MEDICARE MANAGED CARE PLAN
18 THAT IS ALSO A MANAGED CARE PROVIDER, THE MEMBER SHALL BE ENROLLED IN
19 THAT MANAGED CARE PROVIDER OR RECEIVE HEALTH CARE SERVICES THROUGH THE
20 FEE-FOR-SERVICE HEALTH PLAN CREATED IN SUBDIVISION TWO OF SECTION FIVE
21 THOUSAND ONE HUNDRED FIVE OF THIS ARTICLE;
22 (II) IF THE MEMBER CHANGES HIS OR HER MEDICARE MANAGED CARE PLAN AS
23 AUTHORIZED BY MEDICARE, BUT ENROLLS IN ANOTHER MEDICARE MANAGED CARE
24 PLAN THAT IS NOT ALSO A MANAGED CARE PROVIDER, THE INDIVIDUAL SHALL
25 RECEIVE HEALTH CARE BENEFITS PURSUANT TO PARAGRAPH (A) OF THIS SUBDIVI-
26 SION;
27 (III) IF THE MEMBER DISENROLLS FROM HIS OR HER MEDICARE MANAGED CARE
28 PLAN AS AUTHORIZED BY TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT,
29 AND DOES NOT ENROLL IN ANOTHER MEDICARE MANAGED CARE PLAN, THE MEMBER
30 SHALL RECEIVE HEALTH CARE BENEFITS PURSUANT TO PARAGRAPH (A) OF THIS
31 SUBDIVISION; AND
32 (IV) NOTHING HEREIN SHALL REQUIRE AN INDIVIDUAL ENROLLED IN A MANAGED
33 LONG TERM CARE PLAN, PURSUANT TO SECTION FOUR THOUSAND FOUR HUNDRED
34 THREE-F OF THIS CHAPTER, TO DISENROLL FROM SUCH PROGRAM.
35 (C) THE PROGRAM SHALL PROVIDE PREMIUM ASSISTANCE FOR ALL MEMBERS
36 ENROLLING IN A MEDICARE PART D DRUG COVERAGE UNDER SECTION 1860D OF
37 TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT LIMITED TO THE LOW-INCOME
38 BENCHMARK PREMIUM AMOUNT ESTABLISHED BY THE FEDERAL CENTERS FOR MEDICARE
39 AND MEDICAID SERVICES AND ANY OTHER AMOUNT WHICH SUCH AGENCY ESTABLISHES
40 UNDER ITS DE MINIMUS PREMIUM POLICY, EXCEPT THAT SUCH PAYMENTS MADE ON
41 BEHALF OF MEMBERS ENROLLED IN A MEDICARE ADVANTAGE PLAN MAY EXCEED THE
42 LOW-INCOME BENCHMARK PREMIUM AMOUNT IF DETERMINED TO BE COST EFFECTIVE
43 TO THE PROGRAM.
44 (D) IF THE COMMISSIONER HAS REASONABLE GROUNDS TO BELIEVE THAT A
45 MEMBER COULD BE ELIGIBLE FOR AN INCOME-RELATED SUBSIDY UNDER SECTION
46 1860D-14 OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT, THE MEMBER
47 SHALL PROVIDE, AND AUTHORIZE THE PROGRAM TO OBTAIN, ANY INFORMATION OR
48 DOCUMENTATION REQUIRED TO ESTABLISH THE MEMBER'S ELIGIBILITY FOR SUCH
49 SUBSIDY, PROVIDED THAT THE COMMISSIONER SHALL ATTEMPT TO OBTAIN AS MUCH
50 OF THE INFORMATION AND DOCUMENTATION AS POSSIBLE FROM RECORDS THAT ARE
51 AVAILABLE TO HIM OR HER.
52 (E) THE PROGRAM SHALL MAKE A REASONABLE EFFORT TO NOTIFY MEMBERS OF
53 THEIR OBLIGATIONS UNDER THIS SUBDIVISION. AFTER A REASONABLE EFFORT HAS
54 BEEN MADE TO CONTACT THE MEMBER, THE MEMBER SHALL BE NOTIFIED IN WRITING
55 THAT HE OR SHE HAS SIXTY DAYS TO PROVIDE SUCH REQUIRED INFORMATION. IF
S. 4884 6 A. 7854
1 SUCH INFORMATION IS NOT PROVIDED WITHIN THE SIXTY DAY PERIOD, THE
2 MEMBER'S COVERAGE UNDER THE PROGRAM MAY BE TERMINATED.
3 S 5104. BENEFITS. THE PROGRAM SHALL PROVIDE COMPREHENSIVE HEALTH
4 COVERAGE TO EVERY MEMBER OF A HEALTH PLAN, WHICH SHALL INCLUDE BUT NOT
5 BE LIMITED TO:
6 (A) ALL HEALTH CARE SERVICES UNDER FAMILY HEALTH PLUS; AND
7 (B) FOR EVERY MEMBER UNDER THE AGE OF TWENTY-ONE, ALL COVERED HEALTH
8 CARE SERVICES UNDER CHILD HEALTH PLUS; AND
9 (C) FOR EVERY MEMBER WHO IS ELIGIBLE FOR MEDICAID, ALL MEDICAL CARE
10 AND SERVICES UNDER MEDICAID, PROVIDED THAT THIS SHALL NOT INCLUDE LONG
11 TERM CARE, TREATMENT, MAINTENANCE, OR SERVICES NOT COVERED UNDER FAMILY
12 HEALTH PLUS OR CHILD HEALTH PLUS, AS APPROPRIATE.
13 S 5105. HEALTH PLANS. 1. (A) AN ENTITY SEEKING TO BE A HEALTH PLAN
14 SHALL FILE AN APPLICATION WITH THE COMMISSIONER, IN THE FORM PROVIDED BY
15 THE COMMISSIONER. THE APPLICATION SHALL PROVIDE INFORMATION TO DEMON-
16 STRATE THAT THE ENTITY MEETS ALL REQUIREMENTS TO BE A HEALTH PLAN AND TO
17 PROVIDE HEALTH CARE SERVICES AND COMPLY WITH ALL OTHER REQUIREMENTS OF
18 THIS ARTICLE AND THE PROGRAM, AND ANY ADDITIONAL INFORMATION REQUIRED BY
19 THE COMMISSIONER. UPON APPROVAL BY THE COMMISSIONER, THE ENTITY SHALL
20 BE A HEALTH PLAN UNDER THE PROGRAM. THE COMMISSIONER MAY, AT HIS OR HER
21 DISCRETION, REQUIRE HEALTH PLANS TO RENEW THEIR APPLICATION, PROVIDED
22 THAT THE FREQUENCY OF RENEWAL MAY NOT BE MORE THAN ANNUALLY.
23 (B) THE ENTITY OR HEALTH PLAN SHALL BE UNDER A CONTINUING DUTY TO
24 REPORT TO THE COMMISSIONER ANY CHANGE IN FACTS OR CIRCUMSTANCES
25 REFLECTED IN THE APPLICATION OR ANY NEWLY DISCOVERED OR OCCURRING FACT
26 OR CIRCUMSTANCE WHICH IS REQUIRED TO BE INCLUDED IN THE APPLICATION.
27 (C) THE PUBLIC HEALTH PLAN UNDER SUBDIVISION THREE OF THIS SECTION
28 SHALL BE A HEALTH PLAN WITHOUT COMPLYING WITH THIS SUBDIVISION.
29 2. (A) IN ORDER TO BE A HEALTH PLAN, AN ENTITY SHALL BE A MANAGED CARE
30 PROVIDER UNDER SECTION THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES
31 LAW (MEDICAID MANAGED CARE), AN APPROVED ORGANIZATION UNDER SECTION
32 THREE HUNDRED SIXTY-NINE-EE OF THE SOCIAL SERVICES LAW (FAMILY HEALTH
33 PLUS), AND AN APPROVED ORGANIZATION UNDER TITLE ONE-A OF ARTICLE TWEN-
34 TY-FIVE OF THIS CHAPTER (CHILD HEALTH PLUS). IF A HEALTH PLAN NO LONGER
35 COMPLIES WITH THIS PARAGRAPH IT SHALL CEASE TO BE A HEALTH PLAN.
36 (B) IN ADDITION, THE COMMISSIONER SHALL PROVIDE, BY REGULATION, THAT A
37 HEALTH PLAN ORGANIZED ON OTHER MODELS, INCLUDING BUT NOT LIMITED TO A
38 PREFERRED PROVIDER ORGANIZATION, MAY BE A HEALTH PLAN. A HEALTH PLAN
39 FORMED UNDER THIS PARAGRAPH MAY PROVIDE MEDICAID, FAMILY HEALTH PLUS AND
40 CHILD HEALTH PLUS, AS APPROPRIATE, TO MEMBERS IN THE PROGRAM, NOTWITH-
41 STANDING ANY PROVISION OF MEDICAID, FAMILY HEALTH PLUS OR CHILD HEALTH
42 PLUS TO THE CONTRARY.
43 3. FEE-FOR-SERVICE HEALTH PLAN. (A) GENERAL PROVISIONS. (I) THE
44 COMMISSIONER SHALL ESTABLISH A FEE-FOR-SERVICE HEALTH PLAN UNDER THIS
45 SUBDIVISION. ANY MEMBER WHO IS NOT A MEMBER OF ANOTHER HEALTH PLAN MAY
46 BE A MEMBER OF THE FEE-FOR-SERVICE HEALTH PLAN.
47 (II) ANY HEALTH CARE PROVIDER QUALIFIED TO PARTICIPATE UNDER PARAGRAPH
48 (C) OF THIS SUBDIVISION MAY PROVIDE HEALTH CARE SERVICES UNDER THE FEE-
49 FOR-SERVICE HEALTH PLAN, PROVIDED THAT THE HEALTH CARE PROVIDER IS
50 OTHERWISE LEGALLY AUTHORIZED TO PERFORM THE HEALTH CARE SERVICE FOR THE
51 INDIVIDUAL AND UNDER THE CIRCUMSTANCES INVOLVED.
52 (III) HEALTH CARE SERVICES PROVIDED TO MEMBERS UNDER THE FEE-FOR-SER-
53 VICE HEALTH PLAN SHALL BE PAID FOR UNDER THIS SUBDIVISION ON A FEE-FOR-
54 SERVICE BASIS, EXCEPT THAT CARE MANAGEMENT SHALL BE PAID FOR UNDER PARA-
55 GRAPH (B) OF THIS SUBDIVISION.
S. 4884 7 A. 7854
1 (IV) HEALTH CARE SERVICES PROVIDED TO A MEMBER SHALL NOT BE SUBJECT TO
2 PAYMENT UNDER THIS SUBDIVISION UNLESS THE MEMBER IS ENROLLED WITH A CARE
3 MANAGER UNDER PARAGRAPH (B) OF THIS SUBDIVISION AT THE TIME THE HEALTH
4 CARE SERVICE IS PROVIDED.
5 (B) CARE MANAGEMENT. (I) EVERY MEMBER OF THE FEE-FOR-SERVICE HEALTH
6 PLAN SHALL ENROLL WITH A CARE MANAGER THAT AGREES TO PROVIDE CARE
7 MANAGEMENT TO THE MEMBER, PRIOR TO RECEIVING HEALTH CARE SERVICES TO BE
8 PAID FOR UNDER THIS SUBDIVISION. THE MEMBER SHALL REMAIN ENROLLED WITH
9 THAT CARE MANAGER UNTIL THE MEMBER BECOMES ENROLLED WITH A DIFFERENT
10 CARE MANAGER OR CEASES TO BE A MEMBER OF THE FEE-FOR-SERVICE HEALTH
11 PLAN. THE COMMISSIONER SHALL PROVIDE, BY REGULATION, THAT CARE MANAGE-
12 MENT MEMBERS HAVE THE RIGHT TO CHANGE THEIR CARE MANAGER ON TERMS AT
13 LEAST AS PERMISSIVE AS THE PROVISIONS OF SECTION THREE HUNDRED
14 SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW RELATING TO AN INDIVIDUAL CHANG-
15 ING HIS OR HER PRIMARY CARE PROVIDER OR MANAGED CARE PROVIDER.
16 (II) CARE MANAGEMENT SHALL BE PROVIDED TO THE MEMBER BY THE MEMBER'S
17 CARE MANAGER. CARE MANAGEMENT SHALL INCLUDE BUT NOT BE LIMITED TO
18 MANAGING, REFERRING TO, LOCATING, COORDINATING, AND MONITORING HEALTH
19 CARE SERVICES FOR THE MEMBER TO ASSURE THAT ALL MEDICALLY NECESSARY
20 HEALTH CARE SERVICES ARE MADE AVAILABLE TO AND ARE EFFECTIVELY USED BY
21 THE MEMBER IN A TIMELY MANNER. CARE MANAGEMENT IS NOT A REQUIREMENT FOR
22 PRIOR AUTHORIZATION FOR HEALTH CARE SERVICES AND REFERRAL SHALL NOT BE
23 REQUIRED FOR A MEMBER TO RECEIVE A HEALTH CARE SERVICE.
24 (III) A CARE MANAGER MAY BE AN INDIVIDUAL OR ENTITY THAT IS APPROVED
25 BY THE FEE-FOR-SERVICE HEALTH PLAN THAT IS:
26 (A) A HEALTH CARE PRACTITIONER WHO IS (I) THE MEMBER'S PRIMARY CARE
27 PRACTITIONER; (II) AT THE OPTION OF A FEMALE MEMBER, THE MEMBER'S
28 PROVIDER OF PRIMARY GYNECOLOGICAL CARE; OR (III) AT THE OPTION OF A
29 MEMBER WHO HAS A CHRONIC CONDITION THAT REQUIRES SPECIALTY CARE, A
30 SPECIALIST HEALTH CARE PRACTITIONER WHO REGULARLY AND CONTINUALLY
31 PROVIDES TREATMENT FOR THAT CONDITION TO THE MEMBER.
32 (B) AN ENTITY LICENSED UNDER ARTICLE TWENTY-EIGHT OF THIS CHAPTER OR
33 CERTIFIED UNDER ARTICLE THIRTY-SIX OF THIS CHAPTER, OR, WITH RESPECT TO
34 A MEMBER WHO RECEIVES CHRONIC MENTAL HEALTH CARE SERVICES, AN ENTITY
35 LICENSED UNDER ARTICLE THIRTY-ONE OF THE MENTAL HYGIENE LAW.
36 (C) AN ENTITY AUTHORIZED TO BE A HEALTH PLAN;
37 (D) A TAFT-HARTLEY FUND, WITH RESPECT TO ITS MEMBERS AND THEIR FAMILY
38 MEMBERS;
39 (E) ANY OTHER ENTITY APPROVED BY THE FEE-FOR-SERVICE HEALTH PLAN.
40 (IV) WHERE A MEMBER OF THE FEE-FOR-SERVICE HEALTH PLAN RECEIVES CHRON-
41 IC MENTAL HEALTH CARE SERVICES, CONSISTENT WITH STANDARDS ESTABLISHED BY
42 THE FEE-FOR-SERVICE HEALTH PLAN, AT THE OPTION OF THE MEMBER, THE MEMBER
43 MAY ENROLL WITH A CARE MANAGER FOR HIS OR HER MENTAL HEALTH CARE
44 SERVICES AND ANOTHER CARE MANAGER APPROVED FOR HIS OR HER OTHER HEALTH
45 CARE SERVICES. IN SUCH A CASE, THE TWO CARE MANAGERS SHALL WORK IN CLOSE
46 CONSULTATION WITH EACH OTHER.
47 (V) THE COMMISSIONER SHALL DEVELOP AND IMPLEMENT PROCEDURES AND STAND-
48 ARDS FOR AN INDIVIDUAL OR ENTITY TO BE APPROVED TO BE A CARE MANAGER IN
49 THE FEE-FOR-SERVICE HEALTH PLAN, INCLUDING BUT NOT LIMITED TO PROCEDURES
50 AND STANDARDS RELATING TO THE REVOCATION, SUSPENSION, LIMITATION, OR
51 ANNULMENT OF APPROVAL ON A DETERMINATION THAT THE INDIVIDUAL OR ENTITY
52 IS INCOMPETENT TO BE A CARE MANAGER OR HAS EXHIBITED A COURSE OF CONDUCT
53 WHICH IS EITHER INCONSISTENT WITH PROGRAM STANDARDS AND REGULATIONS OR
54 WHICH EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS,
55 OR IS A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES
56 AND STANDARDS SHALL NOT LIMIT APPROVAL TO BE A CARE MANAGER IN THE FEE-
S. 4884 8 A. 7854
1 FOR-SERVICE HEALTH PLAN FOR ECONOMIC PURPOSES AND SHALL BE CONSISTENT
2 WITH GOOD PROFESSIONAL PRACTICE. IN DEVELOPING THE PROCEDURES AND STAND-
3 ARDS, THE COMMISSIONER SHALL: (A) CONSIDER EXISTING STANDARDS DEVELOPED
4 BY NATIONAL ACCREDITING AND PROFESSIONAL ORGANIZATIONS; AND (B) CONSULT
5 WITH NATIONAL AND LOCAL ORGANIZATIONS WORKING ON CARE MANAGEMENT OR
6 SIMILAR MODELS, INCLUDING HEALTH CARE PRACTITIONERS, HOSPITALS, CLINICS,
7 AND CONSUMERS AND THEIR REPRESENTATIVES. WHEN DEVELOPING AND IMPLEMENT-
8 ING STANDARDS OF APPROVAL OF CARE MANAGERS FOR INDIVIDUALS RECEIVING
9 CHRONIC MENTAL HEALTH CARE SERVICES, THE COMMISSIONER SHALL CONSULT WITH
10 THE COMMISSIONER OF MENTAL HEALTH. AN INDIVIDUAL OR ENTITY MAY NOT BE A
11 CARE MANAGER UNLESS THE SERVICES INCLUDED IN CARE MANAGEMENT ARE WITHIN
12 THE INDIVIDUAL'S PROFESSIONAL SCOPE OF PRACTICE OR THE ENTITY'S LEGAL
13 AUTHORITY.
14 (VI) TO MAINTAIN APPROVAL UNDER THE FEE-FOR-SERVICE HEALTH PLAN, A
15 CARE MANAGER MUST: (A) RENEW ITS STATUS AT A FREQUENCY DETERMINED BY THE
16 COMMISSIONER; AND (B) PROVIDE DATA TO THE DEPARTMENT AS REQUIRED BY THE
17 COMMISSIONER TO ENABLE THE COMMISSIONER TO EVALUATE THE IMPACT OF CARE
18 MANAGERS ON QUALITY, OUTCOMES AND COST.
19 (VII) THE FEE-FOR-SERVICE HEALTH PLAN SHALL ESTABLISH METHODOLOGIES
20 FOR PAYING CARE MANAGERS FOR CARE MANAGEMENT SERVICES. THE METHODOLOGIES
21 MAY PROVIDE FOR CAPITATED OR OTHER FORMS OF PAYMENT.
22 (C) HEALTH CARE PROVIDERS. THE COMMISSIONER SHALL ESTABLISH AND MAIN-
23 TAIN PROCEDURES AND STANDARDS FOR HEALTH CARE PROVIDERS TO BE QUALIFIED
24 TO PARTICIPATE IN THE FEE-FOR-SERVICE HEALTH PLAN, INCLUDING BUT NOT
25 LIMITED TO PROCEDURES AND STANDARDS RELATING TO THE REVOCATION, SUSPEN-
26 SION, LIMITATION, OR ANNULMENT OF QUALIFICATION TO PARTICIPATE ON A
27 DETERMINATION THAT THE HEALTH CARE PROVIDER IS AN INCOMPETENT PROVIDER
28 OF SPECIFIC HEALTH CARE SERVICES OR HAS EXHIBITED A COURSE OF CONDUCT
29 WHICH IS EITHER INCONSISTENT WITH PROGRAM STANDARDS AND REGULATIONS OR
30 WHICH EXHIBITS AN UNWILLINGNESS TO MEET SUCH STANDARDS AND REGULATIONS,
31 OR IS A POTENTIAL THREAT TO THE PUBLIC HEALTH OR SAFETY. SUCH PROCEDURES
32 AND STANDARDS SHALL NOT LIMIT HEALTH CARE PROVIDER PARTICIPATION IN THE
33 FEE-FOR-SERVICE HEALTH PLAN FOR ECONOMIC PURPOSES AND SHALL BE CONSIST-
34 ENT WITH GOOD PROFESSIONAL PRACTICE. ANY HEALTH CARE PROVIDER WHO IS
35 QUALIFIED TO PARTICIPATE UNDER MEDICAID, FAMILY HEALTH PLUS OR CHILD
36 HEALTH PLUS SHALL BE DEEMED TO BE QUALIFIED TO PARTICIPATE IN THE
37 FEE-FOR-SERVICE HEALTH PLAN, AND ANY HEALTH CARE PROVIDER'S REVOCATION,
38 SUSPENSION, LIMITATION, OR ANNULMENT OF QUALIFICATION TO PARTICIPATE IN
39 ANY OF THOSE PROGRAMS SHALL APPLY TO THE HEALTH CARE PROVIDER'S QUALI-
40 FICATION TO PARTICIPATE IN THE FEE-FOR-SERVICE HEALTH PLAN.
41 S 5106. PREMIUMS PAID TO HEALTH PLANS BY THE PROGRAM. 1. THE PROGRAM
42 SHALL PAY TO EVERY HEALTH PLAN A PREMIUM ON BEHALF OF EACH MEMBER OF THE
43 HEALTH PLAN, FOR EACH MONTH THE MEMBER IS A MEMBER OF THE HEALTH PLAN.
44 2. THE PROGRAM SHALL, WHERE NOT INCONSISTENT WITH THE RATE SETTING
45 AUTHORITY OF OTHER STATE AGENCIES AND SUBJECT TO APPROVAL OF THE DIREC-
46 TOR OF THE DIVISION OF THE BUDGET, DEVELOP METHODOLOGIES FOR DETERMINING
47 THE AMOUNT OF PREMIUMS TO BE PAID TO HEALTH PLANS UNDER THE PROGRAM.
48 3. THE PROGRAM, IN CONSULTATION WITH ORGANIZATIONS REPRESENTING HEALTH
49 PLANS, SHALL SELECT AN INDEPENDENT ACTUARY TO REVIEW THE METHODOLOGIES
50 AND PREMIUMS. THE INDEPENDENT ACTUARY SHALL REVIEW AND MAKE RECOMMENDA-
51 TIONS CONCERNING APPROPRIATE ACTUARIAL ASSUMPTIONS RELEVANT TO THE
52 ESTABLISHMENT OF METHODOLOGIES AND PREMIUMS, INCLUDING BUT NOT LIMITED,
53 TO THE ADEQUACY OF THE METHODOLOGIES AND PREMIUMS IN RELATION TO THE
54 POPULATION TO BE SERVED ADJUSTED FOR CASE MIX, THE SCOPE OF SERVICES THE
55 PLANS MUST PROVIDE, THE UTILIZATION OF SERVICES AND THE NETWORK OF
56 PROVIDERS NECESSARY TO MEET PROGRAM STANDARDS. THE INDEPENDENT ACTUARY
S. 4884 9 A. 7854
1 SHALL ISSUE AN ANNUAL REPORT, WHICH SHALL BE PROVIDED TO THE PROGRAM,
2 THE GOVERNOR, THE TEMPORARY PRESIDENT AND THE MINORITY LEADER OF THE
3 SENATE AND THE SPEAKER AND THE MINORITY LEADER OF THE ASSEMBLY. THE
4 PROGRAM SHALL ASSESS HEALTH PLANS ON A PER ENROLLEE BASIS TO COVER THE
5 COST OF THE REPORT.
6 S 5107. PROGRAM STANDARDS. 1. THE COMMISSIONER SHALL ESTABLISH
7 REQUIREMENTS AND STANDARDS FOR THE PROGRAM AND FOR HEALTH PLANS, INCLUD-
8 ING REQUIREMENTS AND STANDARDS FOR, AS APPLICABLE:
9 (A) THE SCOPE, QUALITY AND ACCESSIBILITY OF HEALTH CARE SERVICES;
10 (B) RELATIONS BETWEEN HEALTH PLANS AND MEMBERS, INCLUDING APPROVAL OF
11 HEALTH CARE SERVICES; AND
12 (C) RELATIONS BETWEEN HEALTH PLANS AND HEALTH CARE PROVIDERS, INCLUD-
13 ING (I) CREDENTIALING AND PARTICIPATION IN HEALTH PLAN NETWORKS; AND
14 (II) TERMS, METHODS AND RATES OF PAYMENT.
15 2. REQUIREMENTS AND STANDARDS UNDER THE PROGRAM SHALL INCLUDE, BUT NOT
16 BE LIMITED TO, PROVISIONS TO PROMOTE THE FOLLOWING:
17 (A) SIMPLIFICATION, TRANSPARENCY, UNIFORMITY, AND FAIRNESS IN HEALTH
18 CARE PROVIDER CREDENTIALING AND PARTICIPATION IN HEALTH PLAN NETWORKS,
19 REFERRALS, PAYMENT PROCEDURES AND RATES, CLAIMS PROCESSING, AND APPROVAL
20 OF HEALTH CARE SERVICES, AS APPLICABLE.
21 (B) PAYMENT RATES FOR HEALTH CARE SERVICES AND CARE MANAGEMENT THAT
22 ARE REASONABLE AND REASONABLY RELATED TO THE COST OF EFFICIENTLY PROVID-
23 ING THE HEALTH CARE SERVICE.
24 (C) PRIMARY AND PREVENTIVE CARE, CARE MANAGEMENT, EFFICIENT AND EFFEC-
25 TIVE HEALTH CARE SERVICES, QUALITY ASSURANCE, AND COORDINATION AND INTE-
26 GRATION OF HEALTH CARE SERVICES, INCLUDING USE OF APPROPRIATE TECHNOLO-
27 GY.
28 (D) ELIMINATION OF HEALTH CARE DISPARITIES.
29 (E) NON-DISCRIMINATION WITH RESPECT TO MEMBERS AND HEALTH CARE PROVID-
30 ERS ON THE BASIS OF RACE, ETHNICITY, NATIONAL ORIGIN, RELIGION, DISABIL-
31 ITY, AGE, SEX, SEXUAL ORIENTATION, GENDER IDENTITY OR EXPRESSION; OR
32 ECONOMIC CIRCUMSTANCES; HEALTH CARE SERVICES PROVIDED UNDER THE PROGRAM
33 SHALL BE APPROPRIATE TO THE PATIENT'S CIRCUMSTANCES.
34 (F) ACCESSIBILITY OF HEALTH PLAN SERVICES AND HEALTH CARE SERVICES,
35 INCLUDING ACCESSIBILITY FOR PEOPLE WITH DISABILITIES AND PEOPLE WITH
36 LIMITED ABILITY TO SPEAK OR UNDERSTAND ENGLISH, AND THE PROVIDING OF
37 HEALTH PLAN SERVICES AND HEALTH CARE SERVICES IN A CULTURALLY COMPETENT
38 MANNER.
39 3. ANY HEALTH PLAN THAT IS ORGANIZED AS A FOR-PROFIT ENTITY SHALL BE
40 REQUIRED TO MEET THE SAME REQUIREMENTS AND STANDARDS AS HEALTH PLANS
41 ORGANIZED AS NOT-FOR-PROFIT ENTITIES, AND THE PREMIUM PAID TO SUCH A
42 PLAN SHALL NOT BE CALCULATED TO ACCOMMODATE THE GENERATION OF PROFIT OR
43 REVENUE FOR DIVIDENDS OR OTHER RETURN ON INVESTMENT OR THE PAYMENT OF
44 TAXES THAT WOULD NOT BE PAID BY A NOT-FOR-PROFIT ENTITY.
45 4. THE COMMISSIONER SHALL REQUIRE HEALTH PLANS TO COMPILE AND PERIOD-
46 ICALLY REPORT TO THE COMMISSIONER DATA AND INFORMATION ON THE HEALTH
47 PLAN'S PERFORMANCE, INCLUDING THE AVAILABILITY AND QUALITY OF HEALTH
48 CARE SERVICES AND RELEVANT CHARACTERISTICS OF THE HEALTH PLAN'S HEALTH
49 CARE PROVIDERS AND MEMBERS. THE COMMISSIONER SHALL ANALYZE THE DATA AND
50 INFORMATION RECEIVED UNDER THIS SUBDIVISION AND MAKE IT PUBLICLY AVAIL-
51 ABLE, INCLUDING ON THE PROGRAM'S WEBSITE, IN APPROPRIATE RISK-ADJUSTED
52 FORM AND IN A MANNER DESIGNED TO FACILITATE EVALUATION AND COMPARISON OF
53 HEALTH PLANS BY THE PUBLIC AND MEMBERS.
54 5. IN DEVELOPING REQUIREMENTS AND STANDARDS AND MAKING OTHER POLICY
55 DETERMINATIONS UNDER THIS ARTICLE, THE COMMISSIONER SHALL CONSULT WITH
S. 4884 10 A. 7854
1 REPRESENTATIVES OF MEMBERS, HEALTH CARE PROVIDERS, HEALTH PLANS AND
2 OTHER INTERESTED PARTIES.
3 6. (A) FOR PURPOSES OF THIS SECTION, "INCOME-ELIGIBLE MEMBER" MEANS A
4 MEMBER WHO IS ENROLLED IN A FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM AND
5 (I) THERE IS FEDERAL FINANCIAL PARTICIPATION IN THE INDIVIDUAL'S HEALTH
6 COVERAGE, OR (II) THE MEMBER IS ELIGIBLE TO ENROLL IN THE
7 FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM BY REASON OF INCOME, AGE, AND
8 RESOURCES (WHERE APPLICABLE) UNDER STATE LAW IN EFFECT ON THE EFFECTIVE
9 DATE OF THIS SECTION, BUT THERE IS NO FEDERAL FINANCIAL PARTICIPATION IN
10 THE INDIVIDUAL'S HEALTH COVERAGE. A PERSON WHO IS ELIGIBLE TO ENROLL IN
11 A FEDERALLY-MATCHED PUBLIC HEALTH PROGRAM SOLELY BY REASON OF SECTION
12 THREE HUNDRED SIXTY-NINE-FF OF THE SOCIAL SERVICES LAW (EMPLOYER PART-
13 NERSHIPS FOR FAMILY HEALTH PLUS) IS NOT AN INCOME-ELIGIBLE MEMBER.
14 (B) A HEALTH PLAN, WITH RESPECT TO THOSE MEMBERS WHO ARE NOT
15 INCOME-ELIGIBLE MEMBERS, SHALL NOT BE CONSIDERED A FEDERALLY-MATCHED
16 PUBLIC HEALTH PROGRAM OR GOVERNMENTAL PAYOR UNDER ARTICLE TWENTY-EIGHT
17 OF THIS CHAPTER WITH RESPECT TO:
18 (I) PATIENT SERVICES PAYMENTS IN ACCORDANCE WITH SECTION TWENTY-EIGHT
19 HUNDRED SEVEN-J OF THIS CHAPTER;
20 (II) PROFESSIONAL EDUCATION POOL FUNDING UNDER SECTION TWENTY-EIGHT
21 HUNDRED SEVEN-S OF THIS CHAPTER; OR
22 (III) ASSESSMENTS ON COVERED LIVES UNDER SECTION TWENTY-EIGHT HUNDRED
23 SEVEN-T OF THIS CHAPTER.
24 S 5108. PHASE-IN PERIOD. 1. THE COMMISSIONER SHALL DETERMINE WHEN
25 INDIVIDUALS MAY BEGIN ENROLLING IN HEALTH PLANS UNDER THE PROGRAM AND
26 WHEN HEALTH PLANS MAY BEGIN PROVIDING HEALTH CARE SERVICES TO MEMBERS
27 UNDER THE PROGRAM. THE PHASE-IN PERIOD SHALL BEGIN ON THE DATE WHEN
28 HEALTH PLANS MAY BEGIN PROVIDING HEALTH CARE SERVICES TO MEMBERS. THE
29 PHASE-IN PERIOD SHALL CONSIST OF ANNUAL PERIODS, PROVIDED THAT THE FIRST
30 ANNUAL PERIOD MAY BE LESS THAN ONE YEAR, AS DETERMINED BY THE COMMIS-
31 SIONER. THE PHASE-IN PERIOD SHALL END AS DETERMINED BY THE COMMISSIONER.
32 2. (A) DURING THE PHASE-IN PERIOD, THE COMMISSIONER MAY REQUIRE
33 MEMBERS WHOSE INCOMES ARE ABOVE THE THRESHOLD INCOME LEVEL TO PAY A
34 PREMIUM CONTRIBUTION TO THE PROGRAM. ANOTHER PERSON MAY PAY ALL OR PART
35 OF A MEMBER'S PREMIUM CONTRIBUTION ON THE MEMBER'S BEHALF. THE PREMIUM
36 CONTRIBUTION SHALL BE ON A SLIDING SCALE FOR INCOME BRACKETS AND HOUSE-
37 HOLD SIZES DETERMINED BY THE COMMISSIONER AT AND ABOVE THE THRESHOLD
38 INCOME LEVEL.
39 (B) THE PREMIUM CONTRIBUTION FOR AN INCOME BRACKET AND HOUSEHOLD SIZE
40 SHALL NOT EXCEED FIVE PERCENT FOR AN INDIVIDUAL, NOT TO EXCEED A TOTAL
41 OF EIGHT PERCENT FOR ALL THE INDIVIDUALS IN A HOUSEHOLD, OF THE INCOME
42 FOR A HOUSEHOLD IN THE INCOME BRACKET. IN THE CASE OF A MEMBER UNDER THE
43 AGE OF NINETEEN, THE PREMIUM CONTRIBUTION ATTRIBUTABLE TO THE MEMBER
44 SHALL NOT EXCEED THE APPLICABLE ALLOWABLE PREMIUM PAYMENT UNDER CHILD
45 HEALTH PLUS. NO INDIVIDUAL WHO IS ELIGIBLE FOR MEDICAID OR FAMILY HEALTH
46 PLUS (OTHER THAN UNDER SECTION THREE HUNDRED SIXTY-NINE-FF OF THE SOCIAL
47 SERVICES LAW) SHALL BE REQUIRED TO PAY ANY PREMIUM CONTRIBUTION. NO
48 MEMBER'S PREMIUM CONTRIBUTION SHALL EXCEED EIGHTY PERCENT OF THE AVERAGE
49 PER-MEMBER PREMIUM PAID BY THE PROGRAM IN THE MEMBER'S REGION, AS DETER-
50 MINED BY THE COMMISSIONER.
51 (C) FOR EACH ANNUAL PERIOD AFTER THE FIRST ANNUAL PERIOD, THE COMMIS-
52 SIONER SHALL RAISE THE THRESHOLD LEVEL AND INCOME BRACKETS AND DETERMINE
53 THE APPROPRIATE PREMIUM CONTRIBUTION LEVELS.
54 (D) (I) IN ORDER TO DETERMINE A MEMBER'S INCOME BRACKET FOR PURPOSES
55 OF THIS SUBDIVISION, A MEMBER OR AN INDIVIDUAL SEEKING TO ENROLL AS A
56 MEMBER SHALL, AT THE TIME OF THE INITIAL APPLICATION, AND MAY AT ANY
S. 4884 11 A. 7854
1 TIME THEREAFTER, ATTEST TO ALL INFORMATION REGARDING INCOME THAT IS
2 NECESSARY AND SUFFICIENT TO DETERMINE THE INDIVIDUAL'S INCOME BRACKET
3 AND PROVIDE HIS OR HER SOCIAL SECURITY ACCOUNT NUMBER, AS WELL AS THE
4 SOCIAL SECURITY ACCOUNT NUMBER FOR EACH LEGALLY RESPONSIBLE RELATIVE WHO
5 IS A MEMBER OF THE HOUSEHOLD AND WHOSE INCOME IS AVAILABLE TO THE APPLI-
6 CANT. EXCEPT AS PROVIDED IN SUBPARAGRAPH (II) OF THIS PARAGRAPH, THE
7 ATTESTATION OF THE INDIVIDUAL TO ALL INFORMATION NECESSARY TO ESTABLISH
8 THE INDIVIDUAL'S INCOME BRACKET SHALL BE SUFFICIENT TO DO SO. UPON THE
9 RECEIPT OF SUCH INFORMATION, THE COMMISSIONER MAY, IN HIS OR HER
10 DISCRETION, VERIFY THE ACCURACY OF THE INCOME INFORMATION PROVIDED BY
11 THE INDIVIDUAL BY MATCHING IT AGAINST INFORMATION TO WHICH THE COMMIS-
12 SIONER HAS ACCESS, INCLUDING THE STATE'S WAGES REPORTING SYSTEM OR BY
13 INQUIRY TO THE INDIVIDUAL'S EMPLOYER.
14 (II) IN THE EVENT THERE IS AN INCONSISTENCY BETWEEN THE INFORMATION
15 REPORTED BY THE INDIVIDUAL UNDER SUBPARAGRAPH (I) OF THIS PARAGRAPH AND
16 ANY INFORMATION OBTAINED BY THE COMMISSIONER FROM OTHER SOURCES PURSUANT
17 TO THIS PARAGRAPH AND SUCH INCONSISTENCY IS MATERIAL TO THE INDIVIDUAL'S
18 INCOME BRACKET, THE COMMISSIONER MAY REQUIRE THAT THE INDIVIDUAL PROVIDE
19 ADEQUATE DOCUMENTATION TO VERIFY HIS OR HER INCOME BRACKET. SUCH
20 DOCUMENTATION MAY INCLUDE, BUT NOT BE LIMITED TO THE FOLLOWING:
21 (A) PAYCHECK STUBS; OR
22 (B) WRITTEN DOCUMENTATION OF INCOME FROM ALL EMPLOYERS; OR
23 (C) OTHER DOCUMENTATION OF INCOME (EARNED OR UNEARNED) AS DETERMINED
24 BY THE COMMISSIONER, PROVIDED HOWEVER, SUCH DOCUMENTATION SHALL SET
25 FORTH THE SOURCE OF SUCH INCOME; AND
26 (D) PROOF OF IDENTITY AND RESIDENCE AS DETERMINED BY THE COMMISSIONER.
27 IN THE EVENT AN INDIVIDUAL IS NOT REQUIRED AND ELECTS NOT TO PROVIDE
28 HIS OR HER SOCIAL SECURITY ACCOUNT NUMBER OR THE SOCIAL SECURITY ACCOUNT
29 NUMBERS OF EACH LEGALLY RESPONSIBLE RELATIVE WHO IS A MEMBER OF THE
30 HOUSEHOLD AND WHOSE INCOME IS AVAILABLE TO THE INDIVIDUAL, THE INDIVID-
31 UAL SHALL PROVIDE ADEQUATE DOCUMENTATION TO VERIFY HIS OR HER INCOME
32 BRACKET. IN THE EVENT THAT AN INCONSISTENCY IS FOUND, AND IT IS DUE TO
33 INACCURATE REPORTING ON BEHALF OF AN EMPLOYER, THE INDIVIDUAL SHALL NOT
34 BE HELD LIABLE FOR THE ERROR, UNLESS IT CAN BE DETERMINED THAT THE INDI-
35 VIDUAL WAS A WILLFUL PARTICIPANT IN MISLEADING THE DEPARTMENT.
36 (III) ONCE AN INDIVIDUAL'S INCOME BRACKET IS DETERMINED FOR PURPOSES
37 OF THE PHASE-IN PERIOD, IT SHALL NOT BE NECESSARY FOR IT TO BE RE-DETER-
38 MINED EVEN IF THE INDIVIDUAL WOULD BE IN A HIGHER INCOME BRACKET. AN
39 INDIVIDUAL SEEKING TO CHANGE HIS OR HER INCOME BRACKET MAY APPLY TO HAVE
40 IT RE-DETERMINED IN ACCORDANCE WITH THIS PARAGRAPH. AN INDIVIDUAL MAY
41 CHOOSE NOT TO HAVE HIS OR HER INCOME BRACKET DETERMINED, IN WHICH CASE
42 THE INDIVIDUAL SHALL PAY THE MAXIMUM PREMIUM CONTRIBUTION, SUBJECT TO
43 PARAGRAPH (B) OF THIS SUBDIVISION.
44 S 5109. REGULATIONS. THE COMMISSIONER MAY APPROVE REGULATIONS AND
45 AMENDMENTS THERETO, UNDER SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS
46 ARTICLE. THE COMMISSIONER MAY MAKE REGULATIONS OR AMENDMENTS THERETO TO
47 EFFECTUATE THE PROVISIONS AND PURPOSES OF THIS ARTICLE ON AN EMERGENCY
48 BASIS UNDER SECTION TWO HUNDRED TWO OF THE STATE ADMINISTRATIVE PROCE-
49 DURE ACT, PROVIDED THAT SUCH REGULATIONS OR AMENDMENTS SHALL NOT BECOME
50 PERMANENT UNLESS ADOPTED UNDER SECTION FIVE THOUSAND ONE HUNDRED TWO OF
51 THIS ARTICLE.
52 S 5110. OTHER PROVISIONS. 1. THE COMMISSIONER SHALL SEEK ALL FEDERAL
53 WAIVERS AND OTHER FEDERAL APPROVALS NECESSARY TO OPERATE THE PROGRAM
54 CONSISTENT WITH THIS ARTICLE.
S. 4884 12 A. 7854
1 2. CONSUMER, HEALTH CARE PROVIDER, AND CARE MANAGER ASSISTANCE. THE
2 COMMISSIONER SHALL CONTRACT WITH NOT-FOR-PROFIT ORGANIZATIONS TO
3 PROVIDE:
4 (A) CONSUMER ASSISTANCE TO MEMBERS AND INDIVIDUALS SEEKING OR CONSID-
5 ERING WHETHER TO BECOME MEMBERS, WITH RESPECT TO SELECTION OF A HEALTH
6 PLAN, ENROLLING, OBTAINING HEALTH CARE SERVICES, DISENROLLING, AND OTHER
7 MATTERS RELATING TO THE PROGRAM;
8 (B) HEALTH CARE PROVIDER ASSISTANCE TO HEALTH CARE PROVIDERS PROVIDING
9 AND SEEKING OR CONSIDERING WHETHER TO PROVIDE, HEALTH CARE SERVICES TO
10 MEMBERS UNDER THE PROGRAM, WITH RESPECT TO PARTICIPATING IN A HEALTH
11 PLAN AND DEALING WITH A HEALTH PLAN; AND
12 (C) CARE MANAGER ASSISTANCE TO INDIVIDUALS AND ENTITIES PROVIDING AND
13 SEEKING OR CONSIDERING WHETHER TO PROVIDE, CARE MANAGEMENT TO MEMBERS
14 UNDER THE FEE-FOR-SERVICE HEALTH PLAN.
15 S 2. Subdivision 3 of section 2510 of the public health law, as added
16 by chapter 922 of the laws of 1990, is amended to read as follows:
17 3. "Eligible organization" means:
18 (a) a commercial insurer;
19 (b) a corporation or health maintenance organization licensed under
20 article forty-three of the insurance law;
21 (c) a health maintenance organization certified under article forty-
22 four of this chapter; or
23 (d) a comprehensive health services plan operating pursuant to regu-
24 lations of the department of social services or the department [of
25 health]; OR
26 (E) A HEALTH PLAN UNDER SECTION FIVE THOUSAND ONE HUNDRED FIVE OF THIS
27 CHAPTER, INCLUDING THE FEE-FOR-SERVICE HEALTH PLAN.
28 S 3. Paragraph (b) of subdivision 1 of section 364-j of the social
29 services law, as amended by chapter 649 of the laws of 1996, subpara-
30 graphs (i) and (ii) as amended by chapter 433 of the laws of 1997, is
31 amended to read as follows:
32 (b) "Managed care provider". An entity that provides or arranges for
33 the provision of medical assistance services and supplies to partic-
34 ipants directly or indirectly (including by referral), including case
35 management; and:
36 (i) is authorized to operate under article forty-four of the public
37 health law or article forty-three of the insurance law and provides or
38 arranges, directly or indirectly (including by referral) for covered
39 comprehensive health services on a full capitation basis; or
40 (ii) is authorized as a partially capitated program pursuant to
41 section three hundred sixty-four-f of this title or section forty-four
42 hundred three-e of the public health law or section 1915b of the social
43 security act; OR
44 (III) IS A HEALTH PLAN UNDER SECTION FIVE THOUSAND ONE HUNDRED FIVE OF
45 THE PUBLIC HEALTH LAW, INCLUDING THE FEE-FOR-SERVICE HEALTH PLAN.
46 S 4. Paragraph (b) of subdivision 1 of section 369-ee of the social
47 services law, as added by chapter 1 of the laws of 1999, is amended to
48 read as follows:
49 (b) "Eligible organization" means an insurer licensed pursuant to
50 article thirty-two or forty-two of the insurance law, a corporation or
51 an organization under article forty-three of the insurance law, or an
52 organization certified under article forty-four of the public health
53 law, including providers certified under section forty-four hundred
54 three-e of such article, OR A HEALTH PLAN UNDER SECTION FIVE THOUSAND
55 ONE HUNDRED FIVE OF THE PUBLIC HEALTH LAW, INCLUDING THE FEE-FOR-SERVICE
56 HEALTH PLAN.
S. 4884 13 A. 7854
1 S 5. Financing of New York health plus. 1. The governor shall submit
2 to the legislature a plan and legislative bills to implement the plan
3 (referred to collectively in this section as the "revenue proposal") to
4 provide the revenue necessary to finance the New York Health Plus
5 program, as created by article 51 of the public health law (referred to
6 in this section as the "program") to be enacted by this act. The revenue
7 proposal shall be submitted to the legislature as part of the executive
8 budget under article VII of the state constitution, for the fiscal year
9 commencing on the first day of April in the calendar year after this act
10 shall become a law. In developing the revenue proposal, the governor
11 shall consult with appropriate officials of the executive branch; the
12 majority leader of the senate; the speaker of the assembly; the chairs
13 of the fiscal and health committees of the senate and assembly; and
14 representatives of business, labor, consumers and local government.
15 2. (a) The basic structure of the revenue proposal shall be as
16 follows: Revenue for the program shall come from two assessments
17 (referred to collectively in this section as the "assessments"). First,
18 there shall be an assessment on all payroll and self-employed income
19 (referred to in this section as the "payroll assessment"), paid by
20 employers, employees and self-employed, similar to the Medicare tax.
21 Higher brackets of income subject to this assessment shall be assessed
22 at a higher marginal rate than lower brackets. Second, there shall be a
23 progressively-graduated assessment on taxable income (such as interest,
24 dividends, and capital gains) not subject to the payroll assessment
25 (referred to in this section as the "non-payroll assessment"). The
26 assessments will be set at levels anticipated to produce sufficient
27 revenue to finance the program, to be scaled up as enrollment grows.
28 Individuals and employers who choose to pay for private health coverage
29 instead of participating in the program shall be allowed to take a
30 limited credit against the assessments they pay. Provision shall be made
31 for state residents (who are eligible for the program) who are employed
32 out-of-state, and non-residents (who are not eligible for the program)
33 who are employed in the state.
34 (b) Payroll assessment. The income to be subject to the payroll
35 assessment shall be all income subject to the Medicare tax. The assess-
36 ment shall be set at a particular percentage of that income, which shall
37 be progressively graduated, so the percentage is higher on higher brack-
38 ets of income. For employed individuals, the employer shall pay eighty
39 percent of the assessment and the employee shall pay twenty percent
40 (unless the employer agrees to pay a higher percentage). A self-em-
41 ployed individual shall pay the full assessment.
42 (c) Non-payroll income assessment. There shall be a second assessment,
43 on upper-bracket taxable income that is not subject to the payroll
44 assessment. It shall be progressively graduated and structured as a
45 percentage of personal income tax.
46 (d) Phased-in rates. Early in the program, when enrollment is low, the
47 amount of the assessments shall be low, and shall be raised as enroll-
48 ment grows, to cover the actual cost of the program. The revenue
49 proposal shall include a mechanism for determining the rates of the
50 assessments.
51 (e) Credit against the assessments. (i) Employers and individuals
52 shall be able to take a credit against the assessments they would other-
53 wise pay, for amounts they spend on health benefits that would otherwise
54 be covered by the program. For employers, the credit shall be available
55 regardless of the form of the health benefit (e.g., health insurance, a
56 self-insured plan, direct services, or reimbursement for services), to
S. 4884 14 A. 7854
1 make sure that the revenue proposal does not relate to employment bene-
2 fits in violation of the federal ERISA. An employee may take the credit
3 for his or her contribution to an employment-based health benefit. For
4 non-employment-based spending by individuals, the credit shall be avail-
5 able for and limited to spending for health coverage (not out-of-pocket
6 health spending). The credit shall be available without regard to how
7 little is spent or how sparse the benefit.
8 (ii) The amount of the total credit relating to an individual (whether
9 taken by an employer, employee or individual) shall not exceed eighty
10 percent of the total includable spending relating to that individual
11 (including the individual's family as appropriate).
12 (iii) The credit may only be taken against the assessments. Any excess
13 amount may not be applied to other tax liability.
14 (iv) For employment-based health benefits, the credit shall be
15 distributed between the employer and employee in the same proportion as
16 the spending by each for the benefit. The employer and employee may each
17 apply their respective portion of the credit to their respective portion
18 of the assessment.
19 (f) Cross-border employees. (i) State residents employed out-of-state.
20 If an individual is employed out-of-state by an employer that is subject
21 to New York state law, the employer and employee shall be required to
22 pay the payroll assessment as if the employment were in the state and
23 may take the credit against the payroll assessment. If an individual is
24 employed out-of-state by an employer that is not subject to New York
25 state law, either (A) the employer and employee shall voluntarily comply
26 with the assessment and may take the credit against the assessment or
27 (B) the employee shall pay the assessment as if he or she were self-em-
28 ployed and may take the credit against the assessment.
29 (ii) Out-of-state residents employed in the state. The payroll assess-
30 ment and the credit against the payroll assessment shall apply to any
31 out-of-state resident who is employed or self-employed in the state.
32 3. To the extent that the revenue proposal differs from the terms of
33 subdivision two of this section, the revenue proposal shall state how it
34 differs from those terms and reasons for and the effects of the differ-
35 ences.
36 S 6. Article 49 of the public health law is amended by adding a new
37 title 3 to read as follows:
38 TITLE III
39 COLLECTIVE NEGOTIATIONS BY HEALTH CARE PROVIDERS WITH HEALTH CARE
40 PLANS
41 SECTION 4920. DEFINITIONS.
42 4921. COLLECTIVE NEGOTIATION AUTHORIZED.
43 4922. LIMITATIONS ON COLLECTIVE NEGOTIATION.
44 4923. COLLECTIVE NEGOTIATION REQUIREMENTS.
45 4924. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE.
46 4925. CERTAIN COLLECTIVE ACTION PROHIBITED.
47 4926. FEES.
48 4927. CONFIDENTIALITY.
49 4928. SEVERABILITY AND CONSTRUCTION.
50 S 4920. DEFINITIONS. FOR PURPOSES OF THIS TITLE:
51 1. "HEALTH CARE PLAN" MEANS AN ENTITY (OTHER THAN A HEALTH CARE
52 PROVIDER) THAT APPROVES, PROVIDES, ARRANGES FOR, OR PAYS FOR HEALTH CARE
53 SERVICES, INCLUDING BUT NOT LIMITED TO:
54 (A) A HEALTH MAINTENANCE ORGANIZATION LICENSED PURSUANT TO ARTICLE
55 FORTY-THREE OF THE INSURANCE LAW OR CERTIFIED PURSUANT TO ARTICLE
56 FORTY-FOUR OF THIS CHAPTER;
S. 4884 15 A. 7854
1 (B) ANY OTHER ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF
2 THIS CHAPTER;
3 (C) AN INSURER OR CORPORATION SUBJECT TO THE INSURANCE LAW;
4 (D) A MANAGED CARE PROVIDER LICENSED PURSUANT TO SECTION THREE HUNDRED
5 SIXTY-FOUR-J OF THE SOCIAL SERVICES LAW; OR
6 (E) A HEALTH PLAN OPERATING UNDER ARTICLE FIFTY-ONE OF THIS CHAPTER.
7 2. "PERSON" MEANS AN INDIVIDUAL, ASSOCIATION, CORPORATION, OR ANY
8 OTHER LEGAL ENTITY.
9 3. "HEALTH CARE PROVIDERS' REPRESENTATIVE" MEANS A THIRD PARTY WHO IS
10 AUTHORIZED BY HEALTH CARE PROVIDERS TO NEGOTIATE ON THEIR BEHALF WITH
11 HEALTH CARE PLANS OVER CONTRACTUAL TERMS AND CONDITIONS AFFECTING THOSE
12 HEALTH CARE PROVIDERS.
13 4. "STRIKE" MEANS A WORK STOPPAGE IN PART OR IN WHOLE, DIRECT OR INDI-
14 RECT, BY A BODY OF WORKERS TO GAIN COMPLIANCE WITH DEMANDS MADE ON AN
15 EMPLOYER.
16 5. "SUBSTANTIAL MARKET POWER IN A BUSINESS LINE" EXISTS IF A HEALTH
17 CARE PLAN'S MARKET SHARE OF A BUSINESS LINE WITHIN A SERVICE AREA AS
18 APPROVED BY THE COMMISSIONER, ALONE OR IN COMBINATION WITH THE MARKET
19 SHARES OF AFFILIATES, EXCEEDS EITHER TEN PERCENT OF THE TOTAL NUMBER OF
20 COVERED LIVES IN THAT SERVICE AREA FOR SUCH BUSINESS LINE OR TWENTY-FIVE
21 THOUSAND LIVES, OR IF THE COMMISSIONER DETERMINES THE MARKET POWER OF
22 THE INSURER IN THE RELEVANT INSURANCE PRODUCT AND GEOGRAPHIC MARKETS FOR
23 THE SERVICES OF THE PROVIDERS SEEKING TO COLLECTIVELY NEGOTIATE SIGNIF-
24 ICANTLY EXCEEDS THE COUNTERVAILING MARKET POWER OF THE PROVIDERS ACTING
25 INDIVIDUALLY.
26 6. "HEALTH CARE PROVIDER" MEANS A PERSON WHO IS LICENSED, CERTIFIED,
27 OR REGISTERED PURSUANT TO TITLE EIGHT OF THE EDUCATION LAW AND WHO PRAC-
28 TICES AS A HEALTH CARE PROVIDER AS AN INDEPENDENT CONTRACTOR AND/OR WHO
29 IS AN OWNER, OFFICER, SHAREHOLDER, OR PROPRIETOR OF A HEALTH CARE
30 PROVIDER. A HEALTH CARE PROVIDER UNDER TITLE EIGHT OF THE EDUCATION LAW
31 WHO PRACTICES AS AN EMPLOYEE OF A HEALTH CARE PROVIDER SHALL NOT BE
32 DEEMED A HEALTH CARE PROVIDER FOR PURPOSES OF THIS TITLE.
33 S 4921. COLLECTIVE NEGOTIATION AUTHORIZED. 1. HEALTH CARE PROVIDERS
34 PRACTICING WITHIN THE SERVICE AREA OF A HEALTH CARE PLAN MAY MEET AND
35 COMMUNICATE FOR THE PURPOSE OF COLLECTIVELY NEGOTIATING THE FOLLOWING
36 TERMS AND CONDITIONS OF PROVIDER CONTRACTS WITH THE HEALTH CARE PLAN:
37 (A) THE DETAILS OF THE UTILIZATION REVIEW PLAN AS DEFINED PURSUANT TO
38 SUBDIVISION TEN OF SECTION FORTY-NINE HUNDRED OF THIS ARTICLE;
39 (B) COVERAGE PROVISIONS; HEALTH CARE BENEFITS; BENEFIT MAXIMUMS,
40 INCLUDING BENEFIT LIMITATIONS; AND EXCLUSIONS OF COVERAGE;
41 (C) THE DEFINITION OF MEDICAL NECESSITY;
42 (D) THE CLINICAL PRACTICE GUIDELINES USED TO MAKE MEDICAL NECESSITY
43 AND UTILIZATION REVIEW DETERMINATIONS;
44 (E) PREVENTIVE CARE AND OTHER MEDICAL MANAGEMENT PRACTICES;
45 (F) DRUG FORMULARIES AND STANDARDS AND PROCEDURES FOR PRESCRIBING
46 OFF-FORMULARY DRUGS;
47 (G) RESPECTIVE PHYSICIAN LIABILITY FOR THE TREATMENT OR LACK OF TREAT-
48 MENT OF COVERED PERSONS;
49 (H) THE DETAILS OF HEALTH CARE PLAN RISK TRANSFER ARRANGEMENTS WITH
50 PROVIDERS;
51 (I) PLAN ADMINISTRATIVE PROCEDURES, INCLUDING METHODS AND TIMING OF
52 HEALTH CARE PROVIDER PAYMENT FOR SERVICES PURSUANT TO SECTION FORTY-FOUR
53 HUNDRED SIX-C OF THIS CHAPTER;
54 (J) PROCEDURES TO BE UTILIZED TO RESOLVE DISPUTES BETWEEN THE HEALTH
55 CARE PLAN AND HEALTH CARE PROVIDERS;
S. 4884 16 A. 7854
1 (K) PATIENT REFERRAL PROCEDURES INCLUDING, BUT NOT LIMITED TO, THOSE
2 APPLICABLE TO OUT-OF-POCKET NETWORK REFERRALS;
3 (L) THE FORMULATION AND APPLICATION OF HEALTH CARE PROVIDER REIMBURSE-
4 MENT PROCEDURES;
5 (M) QUALITY ASSURANCE PROGRAMS;
6 (N) THE PROCESS FOR RENDERING UTILIZATION REVIEW DETERMINATIONS
7 INCLUDING: ESTABLISHMENT OF A PROCESS FOR RENDERING UTILIZATION REVIEW
8 DETERMINATIONS WHICH SHALL, AT A MINIMUM, INCLUDE: WRITTEN PROCEDURES
9 TO ASSURE THAT UTILIZATION REVIEWS AND DETERMINATIONS ARE CONDUCTED
10 WITHIN THE TIMEFRAMES ESTABLISHED IN THIS ARTICLE; PROCEDURES TO NOTIFY
11 AN ENROLLEE, AN ENROLLEE'S DESIGNEE AND/OR AN ENROLLEE'S HEALTH CARE
12 PROVIDER OF ADVERSE DETERMINATIONS; AND PROCEDURES FOR APPEAL OF ADVERSE
13 DETERMINATIONS, INCLUDING THE ESTABLISHMENT OF AN EXPEDITED APPEALS
14 PROCESS FOR DENIALS OF CONTINUED INPATIENT CARE OR WHERE THERE IS IMMI-
15 NENT OR SERIOUS THREAT TO THE HEALTH OF THE ENROLLEE; AND
16 (O) HEALTH CARE PROVIDER SELECTION AND TERMINATION CRITERIA USED BY
17 THE HEALTH CARE PLAN.
18 2. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE AN
19 ALTERATION OF THE TERMS OF THE INTERNAL AND EXTERNAL REVIEW PROCEDURES
20 SET FORTH IN LAW.
21 3. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW A STRIKE OF A
22 HEALTH CARE PLAN BY HEALTH CARE PROVIDERS OR PLANS AS OTHERWISE SET
23 FORTH IN THE LAWS OF THIS STATE.
24 4. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO ALLOW OR AUTHORIZE
25 TERMS OR CONDITIONS WHICH WOULD IMPEDE THE ABILITY OF A HEALTH CARE PLAN
26 TO OBTAIN OR RETAIN ACCREDITATION BY THE NATIONAL COMMITTEE FOR QUALITY
27 ASSURANCE OR A SIMILAR BODY.
28 S 4922. LIMITATIONS ON COLLECTIVE NEGOTIATION. 1. IF THE HEALTH CARE
29 PLAN HAS SUBSTANTIAL MARKET POWER IN A BUSINESS LINE IN ANY SERVICE
30 AREA, HEALTH CARE PROVIDERS PRACTICING WITHIN THAT SERVICE AREA MAY
31 COLLECTIVELY NEGOTIATE THE FOLLOWING TERMS AND CONDITIONS RELATING TO
32 THAT BUSINESS LINE WITH THE HEALTH CARE PLAN:
33 (A) THE FEES ASSESSED BY THE HEALTH CARE PLAN FOR SERVICES, INCLUDING
34 FEES ESTABLISHED THROUGH THE APPLICATION OF REIMBURSEMENT PROCEDURES;
35 (B) THE CONVERSION FACTORS USED BY THE HEALTH CARE PLAN IN A
36 RESOURCE-BASED RELATIVE VALUE SCALE REIMBURSEMENT METHODOLOGY OR OTHER
37 SIMILAR METHODOLOGY; PROVIDED THE SAME ARE NOT OTHERWISE ESTABLISHED BY
38 STATE OR FEDERAL LAW OR REGULATION;
39 (C) THE AMOUNT OF ANY DISCOUNT GRANTED BY THE HEALTH CARE PLAN ON THE
40 FEE OF HEALTH CARE SERVICES TO BE RENDERED BY HEALTH CARE PROVIDERS;
41 (D) THE DOLLAR AMOUNT OF CAPITATION OR FIXED PAYMENT FOR HEALTH
42 SERVICES RENDERED BY HEALTH CARE PROVIDERS TO HEALTH CARE PLAN ENROL-
43 LEES;
44 (E) THE PROCEDURE CODE OR OTHER DESCRIPTION OF A HEALTH CARE SERVICE
45 COVERED BY A PAYMENT AND THE APPROPRIATE GROUPING OF THE PROCEDURE
46 CODES; OR
47 (F) THE AMOUNT OF ANY OTHER COMPONENT OF THE REIMBURSEMENT METHODOLOGY
48 FOR A HEALTH CARE SERVICE.
49 2. NOTHING IN THIS SECTION SHALL BE DEEMED TO AFFECT OR LIMIT THE
50 RIGHT OF A HEALTH CARE PROVIDER OR GROUP OF HEALTH CARE PROVIDERS TO
51 COLLECTIVELY PETITION A GOVERNMENT ENTITY FOR A CHANGE IN A LAW, RULE,
52 OR REGULATION.
53 S 4923. COLLECTIVE NEGOTIATION REQUIREMENTS. 1. COLLECTIVE NEGOTIATION
54 RIGHTS GRANTED BY THIS TITLE MUST CONFORM TO THE FOLLOWING REQUIREMENTS:
S. 4884 17 A. 7854
1 (A) HEALTH CARE PROVIDERS MAY COMMUNICATE WITH OTHER HEALTH CARE
2 PROVIDERS REGARDING THE CONTRACTUAL TERMS AND CONDITIONS TO BE NEGOTI-
3 ATED WITH A HEALTH CARE PLAN;
4 (B) HEALTH CARE PROVIDERS MAY COMMUNICATE WITH HEALTH CARE PROVIDERS'
5 REPRESENTATIVES;
6 (C) A HEALTH CARE PROVIDERS' REPRESENTATIVE IS THE ONLY PARTY AUTHOR-
7 IZED TO NEGOTIATE WITH HEALTH CARE PLANS ON BEHALF OF THE HEALTH CARE
8 PROVIDERS AS A GROUP;
9 (D) A HEALTH CARE PROVIDER CAN BE BOUND BY THE TERMS AND CONDITIONS
10 NEGOTIATED BY THE HEALTH CARE PROVIDERS' REPRESENTATIVES; AND
11 (E) IN COMMUNICATING OR NEGOTIATING WITH THE HEALTH CARE PROVIDERS'
12 REPRESENTATIVE, A HEALTH CARE PLAN IS ENTITLED TO CONTRACT WITH OR OFFER
13 DIFFERENT CONTRACT TERMS AND CONDITIONS TO INDIVIDUAL COMPETING HEALTH
14 CARE PROVIDERS.
15 2. A HEALTH CARE PROVIDERS' REPRESENTATIVE MAY NOT REPRESENT MORE THAN
16 THIRTY PERCENT OF THE MARKET OF HEALTH CARE PROVIDERS OR OF A PARTICULAR
17 HEALTH CARE PROVIDER TYPE OR SPECIALTY PRACTICING IN THE SERVICE AREA OR
18 PROPOSED SERVICE AREA OF A HEALTH CARE PLAN THAT COVERS LESS THAN FIVE
19 PERCENT OF THE ACTUAL NUMBER OF COVERED LIVES OF THE HEALTH CARE PLAN IN
20 THE AREA, AS DETERMINED BY THE DEPARTMENT.
21 3. NOTHING IN THIS SECTION SHALL BE CONSTRUED TO PROHIBIT COLLECTIVE
22 ACTION ON THE PART OF ANY HEALTH CARE PROVIDER WHO IS A MEMBER OF A
23 COLLECTIVE BARGAINING UNIT RECOGNIZED PURSUANT TO THE NATIONAL LABOR
24 RELATIONS ACT.
25 S 4924. REQUIREMENTS FOR HEALTH CARE PROVIDERS' REPRESENTATIVE. 1.
26 BEFORE ENGAGING IN COLLECTIVE NEGOTIATIONS WITH A HEALTH CARE PLAN ON
27 BEHALF OF HEALTH CARE PROVIDERS, A HEALTH CARE PROVIDERS' REPRESENTATIVE
28 SHALL FILE WITH THE COMMISSIONER, IN THE MANNER PRESCRIBED BY THE
29 COMMISSIONER, INFORMATION IDENTIFYING THE REPRESENTATIVE, THE REPRESEN-
30 TATIVE'S PLAN OF OPERATION, AND THE REPRESENTATIVE'S PROCEDURES TO
31 ENSURE COMPLIANCE WITH THIS TITLE.
32 2. BEFORE ENGAGING IN THE COLLECTIVE NEGOTIATIONS, THE HEALTH CARE
33 PROVIDERS' REPRESENTATIVE SHALL ALSO SUBMIT TO THE COMMISSIONER FOR THE
34 COMMISSIONER'S APPROVAL A REPORT IDENTIFYING THE PROPOSED SUBJECT MATTER
35 OF THE NEGOTIATIONS OR DISCUSSIONS WITH THE HEALTH CARE PLAN AND THE
36 EFFICIENCIES OR BENEFITS EXPECTED TO BE ACHIEVED THROUGH THE NEGOTI-
37 ATIONS. THE COMMISSIONER SHALL NOT APPROVE THE REPORT IF THE COMMISSION-
38 ER DETERMINES THAT THE PROPOSED NEGOTIATIONS WOULD EXCEED THE AUTHORITY
39 GRANTED UNDER THIS TITLE.
40 3. THE REPRESENTATIVE SHALL SUPPLEMENT THE INFORMATION IN THE REPORT
41 ON A REGULAR BASIS OR AS NEW INFORMATION BECOMES AVAILABLE, INDICATING
42 THAT THE SUBJECT MATTER OF THE NEGOTIATIONS WITH THE HEALTH CARE PLAN
43 HAS CHANGED OR WILL CHANGE. IN NO EVENT SHALL THE REPORT BE LESS THAN
44 EVERY THIRTY DAYS.
45 4. WITH THE ADVICE OF THE SUPERINTENDENT OF INSURANCE, THE COMMISSION-
46 ER SHALL APPROVE OR DISAPPROVE THE REPORT NOT LATER THAN THE TWENTIETH
47 DAY AFTER THE DATE ON WHICH THE REPORT IS FILED. IF DISAPPROVED, THE
48 COMMISSIONER SHALL FURNISH A WRITTEN EXPLANATION OF ANY DEFICIENCIES,
49 ALONG WITH A STATEMENT OF SPECIFIC PROPOSALS FOR REMEDIAL MEASURES TO
50 CURE THE DEFICIENCIES. IF THE COMMISSIONER DOES NOT SO ACT WITHIN THE
51 TWENTY DAYS, THE REPORT SHALL BE DEEMED APPROVED.
52 5. A PERSON WHO ACTS AS A HEALTH CARE PROVIDERS' REPRESENTATIVE WITH-
53 OUT THE APPROVAL OF THE COMMISSIONER UNDER THIS SECTION SHALL BE DEEMED
54 TO BE ACTING OUTSIDE THE AUTHORITY GRANTED UNDER THIS TITLE.
55 6. BEFORE REPORTING THE RESULTS OF NEGOTIATIONS WITH A HEALTH CARE
56 PLAN OR PROVIDING TO THE AFFECTED HEALTH CARE PROVIDERS AN EVALUATION OF
S. 4884 18 A. 7854
1 ANY OFFER MADE BY A HEALTH CARE PLAN, THE HEALTH CARE PROVIDERS' REPRE-
2 SENTATIVE SHALL FURNISH FOR APPROVAL BY THE COMMISSIONER, BEFORE DISSEM-
3 INATION TO THE HEALTH CARE PROVIDERS, A COPY OF ALL COMMUNICATIONS TO BE
4 MADE TO THE HEALTH CARE PROVIDERS RELATED TO NEGOTIATIONS, DISCUSSIONS,
5 AND OFFERS MADE BY THE HEALTH CARE PLAN.
6 7. A HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL REPORT THE END OF
7 NEGOTIATIONS TO THE COMMISSIONER NOT LATER THAN THE FOURTEENTH DAY AFTER
8 THE DATE OF A HEALTH CARE PLAN DECISION DECLINING NEGOTIATION, CANCELING
9 NEGOTIATIONS, OR FAILING TO RESPOND TO A REQUEST FOR NEGOTIATION.
10 S 4925. CERTAIN COLLECTIVE ACTION PROHIBITED. 1. THIS TITLE IS NOT
11 INTENDED TO AUTHORIZE COMPETING HEALTH CARE PROVIDERS TO ACT IN CONCERT
12 IN RESPONSE TO A REPORT ISSUED BY THE HEALTH CARE PROVIDERS' REPRESEN-
13 TATIVE RELATED TO THE REPRESENTATIVE'S DISCUSSIONS OR NEGOTIATIONS WITH
14 HEALTH CARE PLANS.
15 2. NO HEALTH CARE PROVIDERS' REPRESENTATIVE SHALL NEGOTIATE ANY AGREE-
16 MENT THAT EXCLUDES, LIMITS THE PARTICIPATION OR REIMBURSEMENT OF, OR
17 OTHERWISE LIMITS THE SCOPE OF SERVICES TO BE PROVIDED BY ANY HEALTH CARE
18 PROVIDER OR GROUP OF HEALTH CARE PROVIDERS WITH RESPECT TO THE PERFORM-
19 ANCE OF SERVICES THAT ARE WITHIN THE HEALTH CARE PROVIDER'S SCOPE OF
20 PRACTICE, LICENSE, REGISTRATION, OR CERTIFICATE.
21 S 4926. FEES. EACH PERSON WHO ACTS AS THE REPRESENTATIVE OR NEGOTIAT-
22 ING PARTIES UNDER THIS TITLE SHALL PAY TO THE DEPARTMENT A FEE TO ACT AS
23 A REPRESENTATIVE. THE COMMISSIONER, BY RULE, SHALL SET FEES IN AMOUNTS
24 DEEMED REASONABLE AND NECESSARY TO COVER THE COSTS INCURRED BY THE
25 DEPARTMENT IN ADMINISTERING THIS TITLE. ANY FEE COLLECTED UNDER THIS
26 SECTION SHALL BE DEPOSITED IN THE STATE TREASURY TO THE CREDIT OF THE
27 GENERAL FUND/STATE OPERATIONS - 003 FOR THE NEW YORK STATE DEPARTMENT OF
28 HEALTH FUND.
29 S 4927. CONFIDENTIALITY. ALL REPORTS AND OTHER INFORMATION REQUIRED TO
30 BE REPORTED TO THE DEPARTMENT UNDER THIS TITLE SHALL NOT BE SUBJECT TO
31 DISCLOSURE UNDER ARTICLE SIX OF THE PUBLIC OFFICERS LAW OR ARTICLE THIR-
32 TY-ONE OF THE CIVIL PRACTICE LAW AND RULES.
33 S 4928. SEVERABILITY AND CONSTRUCTION. THE PROVISIONS OF THIS TITLE
34 SHALL BE SEVERABLE, AND IF ANY COURT OF COMPETENT JURISDICTION DECLARES
35 ANY PHRASE, CLAUSE, SENTENCE OR PROVISION OF THIS TITLE TO BE INVALID,
36 OR ITS APPLICABILITY TO ANY GOVERNMENT, AGENCY, PERSON OR CIRCUMSTANCE
37 IS DECLARED INVALID, THE REMAINDER OF THIS TITLE AND ITS RELEVANT APPLI-
38 CABILITY SHALL NOT BE AFFECTED. THE PROVISIONS OF THIS TITLE SHALL BE
39 LIBERALLY CONSTRUED TO GIVE EFFECT TO THE PURPOSES THEREOF.
40 S 7. Section 2510 of the public health law is amended by adding a new
41 subdivision 13 to read as follows:
42 13. "PRESCRIPTION AND NON-PRESCRIPTION DRUGS" SHALL MEAN PRESCRIPTION
43 DRUGS AS DEFINED IN SECTION TWO HUNDRED SEVENTY OF THE PUBLIC HEALTH
44 LAW, WHICH SHALL BE PROVIDED PURSUANT TO SUBDIVISION FOUR-B OF SECTION
45 TWO THOUSAND FIVE HUNDRED ELEVEN OF THIS ARTICLE, AND NON-PRESCRIPTION
46 SMOKING CESSATION PRODUCTS OR DEVICES.
47 S 8. Section 2511 of the public health law is amended by adding a new
48 subdivision 4-b to read as follows:
49 4-B. PRESCRIPTION AND NON-PRESCRIPTION DRUG PAYMENTS. NOTWITHSTANDING
50 SUBDIVISIONS THREE AND FOUR OF THIS SECTION, PAYMENT FOR DRUGS, EXCEPT
51 FOR SUCH DRUGS PROVIDED BY MEDICAL PRACTITIONERS, AND FOR WHICH PAYMENT
52 IS AUTHORIZED PURSUANT TO SUBDIVISION THIRTEEN OF SECTION TWO THOUSAND
53 FIVE HUNDRED TEN OF THIS TITLE, SHALL BE MADE PURSUANT TO SUBDIVISION
54 NINE OF SECTION THREE HUNDRED SIXTY-SEVEN-A OF THE SOCIAL SERVICES LAW,
55 ARTICLE TWO-A OF THIS CHAPTER AND SUBDIVISION FOUR OF SECTION THREE
56 HUNDRED SIXTY-FIVE-A OF THE SOCIAL SERVICES LAW. PAYMENT FOR SUCH DRUGS
S. 4884 19 A. 7854
1 PROVIDED BY MEDICAL PRACTITIONERS SHALL BE INCLUDED IN THE CAPITATION
2 PAYMENT FOR SERVICES OR SUPPLIES PROVIDED TO PERSONS ELIGIBLE FOR HEALTH
3 CARE SERVICES UNDER THIS TITLE.
4 S 9. Subdivision 11 of section 270 of the public health law, as
5 amended by section 2-a of part C of chapter 58 of the laws of 2008, is
6 amended to read as follows:
7 11. "State public health plan" means the medical assistance program
8 established by title eleven of article five of the social services law
9 (referred to in this article as "Medicaid"), the elderly pharmaceutical
10 insurance coverage program established by title three of article two of
11 the elder law (referred to in this article as "EPIC"), [and] the family
12 health plus program established by section three hundred sixty-nine-ee
13 of the social services law to the extent that section provides that the
14 program shall be subject to this article, THE CHILD HEALTH INSURANCE
15 PROGRAM ESTABLISHED BY TITLE ONE-A OF ARTICLE TWENTY-FIVE OF THIS CHAP-
16 TER, AND THE NEW YORK HEALTH PLUS PROGRAM ESTABLISHED BY ARTICLE FIFTY-
17 ONE OF THIS CHAPTER.
18 S 10. Severability. If any provision of law enacted by this act or
19 any application thereof shall be adjudged by any court of competent
20 jurisdiction to be invalid, or ruled by any appropriate federal agency
21 to violate or be inconsistent with any applicable federal law or regu-
22 lation, the judgment or ruling shall not affect, impair or invalidate
23 the remainder thereof or any other application thereof, but shall be
24 confined in its operation to the provision or application thereof
25 directly involved in the controversy or matter in which the judgment or
26 ruling shall have been rendered.
27 S 11. This act shall take effect immediately; provided that the amend-
28 ments made to section 364-j of the social services law by section three
29 of this act and to section 270 of the public health law by section nine
30 of this act shall not affect the expiration and repeal of such sections
31 and shall expire and be deemed repealed therewith.
