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.