Bill Text: NY S09508 | 2021-2022 | General Assembly | Introduced
Bill Title: Enacts the "health equity, affordability, and reform act"; relates to the basic health program; permits a person or eligible small group to purchase coverage from a basic health plan on behalf of an individual, spouse, and any qualified dependents through the basic health program buy-in as long as the individual, spouse, and any qualified dependents otherwise meet certain eligibility requirements (Part A); relates to cost containment and consumer protection; relates to income execution (Part B); establishes the chronic disease demonstration program to recommend cost-sharing eliminations for targeted high-value services, treatments and prescription drugs used to treat certain chronic conditions (Part C); addresses health equity through safety net hospital support; promotes health equity through commercial rate equity for safety net hospitals that predominantly serve communities that experience health disparities because of race, ethnicity, socioeconomic status or other status (Part D); provides that the commissioner of health may require any health care provider or third-party payer to report additional claim or price information not already reported pursuant to this section to analyze all health care expenditures in the state from public and private sources (Part E).
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2022-07-22 - REFERRED TO RULES [S09508 Detail]
Download: New_York-2021-S09508-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 9508 IN SENATE July 22, 2022 ___________ Introduced by Sen. COONEY -- read twice and ordered printed, and when printed to be committed to the Committee on Rules AN ACT to amend the social services law, in relation to the basic health program (Part A); to amend the financial services law, in relation to cost containment and consumer protection; to amend the civil practice law and rules, in relation to income execution; and to repeal certain provisions of the financial services law relating thereto (Part B); to amend the public health law and the insurance law, in relation to the chronic disease demonstration program (Part C); to amend the public health law, in relation to addressing health equity through safety net hospital support (Part D); and to amend the public health law, in relation to providing that the commissioner of health may require any health care provider or third-party payer to report additional claim or price information not already reported pursuant to section 2816 of such law to analyze all health care expenditures in the state from public and private sources (Part E) The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Short title. This act shall be known and may be cited as 2 the "health equity, affordability, and reform act". 3 § 2. This act enacts into law components of legislation relating to 4 the health equity, affordability, and reform act. Each component is 5 wholly contained within a Part identified as Parts A through E. The 6 effective date for each particular provision contained within such part 7 is set forth in the last section of such Part. Any provision in any 8 section contained within a Part, including the effective date of the 9 Part, which makes reference to a section "of this act", when used in 10 connection with that particular component, shall be deemed to mean and 11 refer to the corresponding section of the Part in which it is found. 12 Section three of this act sets forth the general effective date of this 13 act. 14 PART A EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD15220-03-2S. 9508 2 1 Section 1. Section 369-gg of the social services law, as added by 2 section 51 of part C of chapter 60 of the laws of 2014, paragraph (c) of 3 subdivision 1 as separately amended by sections 4 of part BBB of chapter 4 56 and part P of chapter 57 of the laws of 2022, paragraph (e) of subdi- 5 vision 1, and subdivisions 5 and 7 as amended by section 2 of part H of 6 chapter 57 of the laws of 2021, subdivision 2 as amended and subdivision 7 9 as added by section 28-a, subdivision 6 as added by section 28 and 8 subdivision 8 as amended by section 46 of part B of chapter 57 of the 9 laws of 2015, paragraph (d) of subdivision 3 as amended by section 2 and 10 paragraph (b) of subdivision 5 as amended by section 7-a of part BBB of 11 chapter 56 of the laws of 2022, is amended to read as follows: 12 § 369-gg. Basic health program. 1. Definitions. For purposes of this 13 section: 14 (a) "Eligible organization" means an insurer licensed pursuant to 15 article thirty-two or forty-two of the insurance law, a corporation or 16 an organization under article forty-three of the insurance law, or an 17 organization certified under article forty-four of the public health 18 law, including providers certified under section forty-four hundred 19 three-e of the public health law; 20 (b) "Approved organization" means an eligible organization approved by 21 the commissioner to underwrite a basic health insurance plan pursuant to 22 this title; 23 (c) "Health care services" means (i) the services and supplies as 24 defined by the commissioner in consultation with the superintendent of 25 financial services, and shall be consistent with and subject to the 26 essential health benefits as defined by the commissioner in accordance 27 with the provisions of the patient protection and affordable care act 28 (P.L. 111-148) and consistent with the benefits provided by the refer- 29 ence plan selected by the commissioner for the purposes of defining such 30 benefits, and shall include coverage of and access to the services of 31 any national cancer institute-designated cancer center licensed by the 32 department of health within the service area of the approved organiza- 33 tion that is willing to agree to provide cancer-related inpatient, 34 outpatient and medical services to all enrollees in approved organiza- 35 tions' plans in such cancer center's service area under the prevailing 36 terms and conditions that the approved organization requires of other 37 similar providers to be included in the approved organization's network, 38 provided that such terms shall include reimbursement of such center at 39 no less than the fee-for-service medicaid payment rate and methodology 40 applicable to the center's inpatient and outpatient services; (ii) 41 dental and vision services as defined by the commissioner, and (iii) as 42 defined by the commissioner and subject to federal approval, certain 43 services and supports provided to enrollees eligible pursuant to subpar- 44 agraph one of paragraph (g) of subdivision one of section three hundred 45 sixty-six of this article who have functional limitations and/or chronic 46 illnesses that have the primary purpose of supporting the ability of the 47 enrollee to live or work in the setting of their choice, which may 48 include the individual's home, a worksite, or a provider-owned or 49 controlled residential setting; 50 (d) "Qualified health plan" means a health plan that meets the crite- 51 ria for certification described in § 1311(c) of the Patient Protection 52 and Affordable Care Act (P.L. 111-148), and is offered to individuals 53 through the health insurance exchange marketplace; [and] 54 (e) "Basic health insurance plan" means a standard health plan provid- 55 ing health care services, separate and apart from qualified healthS. 9508 3 1 plans, that is issued by an approved organization and certified in 2 accordance with this section[.]; 3 (f) "Eligible small group" means any employer, or trustee or trustees 4 of a fund established by an employer, members of a trade association, 5 labor union, fund established or participated in by two or more employ- 6 ers or by one or more labor unions, association, or a trustee or trus- 7 tees of a fund established, created or maintained for the benefit of 8 members of one or more associations, church, or any entity that may be 9 eligible to purchase group coverage under the insurance law, provided 10 that any of the foregoing groups identified employ, represent, or cover 11 one hundred or less individuals; 12 (g) "Qualified dependents" mean the spouse, and any dependent children 13 of an individual seeking coverage through the basic health program buy- 14 in; and 15 (h) "Family coverage" means the cost to buy-in to the basic health 16 program for an individual and any eligible partner or qualified depen- 17 dents based on the per member, per month cost applicable. 18 2. Authorization. If it is in the financial interest of the state to 19 do so, the commissioner of health is authorized, with the approval of 20 the director of the budget, to establish a basic health program. The 21 commissioner's authority pursuant to this section is contingent upon 22 obtaining and maintaining all necessary approvals from the secretary of 23 health and human services to offer a basic health program in accordance 24 with 42 U.S.C. 18051. The commissioner may take any and all actions 25 necessary to obtain such approvals. Notwithstanding the foregoing, with- 26 in ninety days of the effective date of [the] part B of chapter fifty- 27 seven of the laws of two thousand fifteen [which amended this subdivi-28sion] the commissioner shall submit a report to the temporary president 29 of the senate and the speaker of the assembly detailing a contingency 30 plan in the event eligibility rules or regulations are modified or 31 repealed; or in the event federal payment is reduced from ninety five 32 percent of the premium tax credits and cost-sharing reductions pursuant 33 to the patient protection and affordable care act (P.L. 111-148). The 34 contingency plan shall be implemented within ninety days of the above 35 stated events or the time period specified in federal law. 36 3. Eligibility. A person is eligible to receive coverage for health 37 care services pursuant to this title if he or she: 38 (a) resides in New York state and is under sixty-five years of age; 39 (b) is not eligible for medical assistance under title eleven of this 40 article or for the child health insurance plan described in title one-A 41 of article twenty-five of the public health law; 42 (c) is not eligible for minimum essential coverage, as defined in 43 section 5000A(f) of the Internal Revenue Service Code of 1986, or is 44 eligible for an employer-sponsored plan that is not affordable, in 45 accordance with section 5000A of such code; provided, however, that the 46 commissioner of health may seek authority from the secretary of health 47 and human services to permit individuals who are eligible for an employ- 48 er-sponsored plan to purchase coverage through the basic health program 49 buy-in; and 50 (d) (i) except as provided by subparagraph (ii) of this paragraph, has 51 household income at or below two hundred fifty percent of the federal 52 poverty line defined and annually revised by the United States depart- 53 ment of health and human services for a household of the same size, 54 unless the individual or eligible small group purchases coverage 55 through a basic health plan under the basic health program buy-in 56 set forth under subdivision eleven or twelve of this section; and hasS. 9508 4 1 household income that exceeds one hundred thirty-three percent of the 2 federal poverty line defined and annually revised by the United States 3 department of health and human services for a household of the same 4 size; however, MAGI eligible aliens lawfully present in the United 5 States with household incomes at or below one hundred thirty-three 6 percent of the federal poverty line shall be eligible to receive cover- 7 age for health care services pursuant to the provisions of this title if 8 such alien would be ineligible for medical assistance under title eleven 9 of this article due to their immigration status; provided however, that 10 subject to approval from the secretary of health and human 11 services, a person shall also be eligible to receive coverage for health 12 care services under this title, without regard to federal financial 13 participation, if he or she is a resident of New York state, has house- 14 hold income below two hundred fifty percent of the federal poverty line 15 as defined and annually revised by the United States department of 16 health and human services for a household of the same size, and is inel- 17 igible for federal financial participation in the basic health program 18 under 42 U.S.C. section 18051 on the basis of immigration status, but 19 otherwise meets the eligibility requirements in paragraphs (a), (b), and 20 (c) of this subdivision; 21 (ii) subject to federal approval and the use of state funds, unless 22 the commissioner may use funds under subdivision seven of this section, 23 has household income at or below two hundred fifty percent of the feder- 24 al poverty line defined and annually revised by the United States 25 department of health and human services for a household of the same 26 size; and has household income that exceeds one hundred thirty-three 27 percent of the federal poverty line defined and annually revised by the 28 United States department of health and human services for a household of 29 the same size; however, MAGI eligible aliens lawfully present in the 30 United States with household incomes at or below one hundred thirty- 31 three percent of the federal poverty line shall be eligible to receive 32 coverage for health care services pursuant to the provisions of this 33 title if such alien would be ineligible for medical assistance under 34 title eleven of this article due to their immigration status; 35 (iii) subject to federal approval if required and the use of state 36 funds, unless the commissioner may use funds under subdivision seven of 37 this section, a pregnant individual who is eligible for and receiving 38 coverage for health care services pursuant to this title is eligible to 39 continue to receive health care services pursuant to this title during 40 the pregnancy and for a period of one year following the end of the 41 pregnancy without regard to any change in the income of the household 42 that includes the pregnant individual, even if such change would render 43 the pregnant individual ineligible to receive health care services 44 pursuant to this title; 45 (iv) subject to federal approval, a child born to an individual eligi- 46 ble for and receiving coverage for health care services pursuant to this 47 title who would be eligible for coverage pursuant to subparagraphs [(2)] 48 two or [(4)] four of paragraph (b) of subdivision [1] one of section 49 three hundred [and] sixty-six of [the social services law] this article 50 shall be deemed to have applied for medical assistance and to have been 51 found eligible for such assistance on the date of such birth and to 52 remain eligible for such assistance for a period of one year. 53 An applicant who fails to make an applicable premium payment, if any, 54 shall lose eligibility to receive coverage for health care services in 55 accordance with time frames and procedures determined by the commission- 56 er.S. 9508 5 1 3-a. Basic health program buy-in eligibility. A person or eligible 2 small group shall be permitted to purchase coverage from a basic health 3 plan on behalf of an individual, spouse, and any qualified dependents 4 through the basic health program buy-in described under paragraph eleven 5 or twelve of this section, as long as the individual, spouse, and any 6 qualified dependents otherwise meet the eligibility requirements in 7 paragraphs (a), (b), and (c) of subdivision three of this section. An 8 applicant who fails to make an applicable premium payment shall lose 9 eligibility to receive coverage for health care services in accordance 10 with time frames and procedures determined by the commissioner. 11 4. Enrollment. (a) Subject to federal approval, the commissioner is 12 authorized to establish an application and enrollment procedure for 13 prospective enrollees. Such procedure shall include a verification 14 system for applicants, which shall be consistent with 42 USC § 1320b-7. 15 (b) Such procedure shall allow for continuous enrollment for enrollees 16 to the basic health program where an individual may apply and enroll for 17 coverage at any point. 18 (c) Upon an applicant's enrollment in a basic health insurance plan, 19 coverage for health care services pursuant to the provisions of this 20 title shall be prospective. Coverage shall begin in a manner consistent 21 with the requirements for qualified health plans offered through the 22 health insurance exchange marketplace, as delineated in federal regu- 23 lation at 42 CFR 155.420(b)(1) or any successor regulation thereof. 24 (d) A person who has enrolled for coverage pursuant to this title, and 25 who loses eligibility to enroll in the basic health program for a reason 26 other than citizenship status, lack of state residence, failure to 27 provide a valid social security number, providing inaccurate information 28 that would affect eligibility when requesting or renewing health cover- 29 age pursuant to this title, or failure to make an applicable premium 30 payment, before the end of a twelve month period beginning on the effec- 31 tive date of the person's initial eligibility for coverage, or before 32 the end of a twelve month period beginning on the date of any subsequent 33 determination of eligibility, shall have his or her eligibility for 34 coverage continued until the end of such twelve month period, provided 35 that the state receives federal approval for using funds from the basic 36 health program trust fund, established under section 97-oooo of the 37 state finance law, for the costs associated with such assistance. 38 5. Premiums and cost sharing. (a) Subject to federal approval, the 39 commissioner shall establish premium payments enrollees shall pay to 40 approved organizations for coverage of health care services pursuant to 41 this title. No payment is required for individuals with a household 42 income at or below two hundred percent of the federal poverty line 43 defined and annually revised by the United States department of health 44 and human services for a household of the same size. 45 (a-1) For an individual with a household income above two hundred 46 fifty percent of the federal poverty line defined and annually revised 47 by the United States department of health and human services for a 48 household of the same size, an individual who purchases individual, 49 couple, or family coverage through the basic health program buy-in under 50 subdivision eleven of this section, or an eligible small group who 51 purchases or contributes to the cost of such coverage under subdivision 52 twelve of this section for such individual and any qualified dependents, 53 shall make an applicable premium payment equaling the per member-per 54 month payment received by a basic health plan for providing basic health 55 program services in the region where the individual resides, provided 56 that the commissioner shall pursue any federal waivers and be permittedS. 9508 6 1 to take any other actions necessary to offset the premium payment to the 2 maximum extent possible for individuals with household incomes less than 3 five hundred percent of the federal poverty line, as defined and annual- 4 ly revised by the United States department of health and human services 5 for a household of the same size, including seeking authority to use 6 federal premium tax credits and cost sharing reductions, in an effort to 7 keep the applicable premium payment as low as possible for individuals 8 at these household income levels. The commissioner shall be authorized 9 to assign variable premium amounts based on income such that individuals 10 with lower household incomes are required to pay less premium. 11 (a-2) Eligible small groups that purchase coverage for an individual 12 under subdivision eleven of this section for which the individual or the 13 state receives federal premium tax credits and cost sharing reductions 14 for individuals to subsidize that coverage, shall be required to pay to 15 the basic health plan, or pay directly to the state, the amount of 16 premium tax credits and cost sharing reductions received by the basic 17 health program trust fund for the individual, in addition to any premium 18 supplement that may apply based on the household income of the individ- 19 ual, as set forth under paragraph (ii) of subdivision (a-3) of this 20 section. Basic health plans shall remit these amounts to the basic 21 health program trust fund or a separate state fund, as may be determined 22 by the commissioner. Such fund shall be used to help ensure deficit 23 neutrality and program viability, and for other purposes that may be 24 allowed by the secretary of health and human services, including but not 25 limited to, rate adequacy for approved organizations and network provid- 26 ers, as may be determined by the commissioner. 27 (a-3) (i) The commissioner shall contract with an independent actuary 28 to study and make recommendations around premiums and cost sharing for 29 approved organizations operating a basic health plan, and for all indi- 30 viduals participating in the basic health program buy-in. The analysis 31 for developing premiums for approved organizations shall include an 32 analysis of rates of payment in relation to the expected population to 33 be served adjusted for case mix, the scope of health care services 34 approved organizations must provide, the projected utilization of such 35 services, the network of providers required to meet state standards, and 36 subject to approval from the secretary of health and human services and 37 the division of the budget, existing rates of payment in effect under 38 the basic health program, and subject to approval by the secretary of 39 health and human services and the division of the budget, and once 40 enrollment in the basic health program buy-in has reached more than one 41 hundred thousand enrollees, rates of payment in effect under Medicare 42 Part A, B, and C. 43 (ii) Premium supplement payments. The analysis conducted by the inde- 44 pendent actuary shall include recommended premium supplement amounts 45 that shall be required for certain individuals and may be required for 46 eligible small groups to increase available funds for the basic health 47 program. Premium supplement payments shall be paid by individuals that 48 enroll in the basic health program buy-in, who have household income 49 above eight hundred percent of the federal poverty line, as defined and 50 annually revised by the United States department of health and human 51 services for a household of the same size, and in the discretion of the 52 commissioner, may be required to be paid by eligible small groups that 53 contribute to coverage for any individuals qualified under subdivision 54 twelve of this section. 55 (a-4) For coverage purchased through subdivision eleven of this 56 section, for individuals and qualified dependents with household incomesS. 9508 7 1 above eight hundred percent of the federal poverty line, as defined and 2 annually revised by the United States department of health and human 3 services for a household of the same size, a premium supplement payment 4 shall be paid to increase state share funds for the program. The premium 5 supplement shall be determined by the commissioner in accordance with 6 principles of equity and fairness, increasing commensurate with house- 7 hold income, and may consider assumed savings for the individual 8 compared to traditional insurance coverage, provided the premium supple- 9 ment amount shall be structured in a way to maximize affordability at 10 lower applicable household income levels, and shall not result in cover- 11 age being more expensive under the basic health program buy-in than 12 under a silver level metallic plan offered by a qualified health plan 13 under the New York health benefits exchanges for comparable coverage 14 until household income of an individual meets or exceeds fifteen hundred 15 percent of the federal poverty line, defined and annually revised by the 16 United States department of health and human services for a household of 17 the same size. 18 (a-5) Once enrollment in the basic health program buy-in has reached 19 one hundred thousand individuals, the commissioner shall have discretion 20 to determine whether eligible small groups shall be required to pay 21 premium supplement payments for any individual and qualified dependents 22 who they contribute coverage costs for under subdivision twelve of this 23 section, if it becomes necessary to increase state share funds for the 24 program a premium subsidy amount can be applied without undermining 25 viability and affordability of the program. The premium supplement that 26 would be owed by an eligible small group shall be determined by the 27 commissioner, but shall comprise a per person amount that is developed 28 to ensure maximum fairness for eligible small groups, and take into 29 consideration the size, age, and revenue of the eligible small group, 30 the household income of the covered individual, and the cost savings for 31 the eligible small group under the basic health program buy-in compared 32 to traditional small group insurance coverage, as applicable. 33 (b) The commissioner shall establish cost sharing obligations for 34 enrollees, subject to federal approval. There shall be no cost-sharing 35 obligations for enrollees for dental and vision services as defined in 36 subparagraph (ii) of paragraph (c) of subdivision one of this section; 37 services and supports as defined in subparagraph (iii) of paragraph (c) 38 of subdivision one of this section; and health care services authorized 39 under subparagraphs (iii) and (iv) of paragraph (d) of subdivision three 40 of this section. Such cost sharing shall: (i) not include deductibles 41 for individuals at any household income level; (ii) subject to avail- 42 able funds, not require any cost sharing for household incomes not 43 exceeding five hundred percent of the federal poverty line defined and 44 annually revised by the United States department of health and human 45 services for a household of the same size, but if this is not possible, 46 then such cost sharing shall be set as low as possible for the lowest 47 household incomes; and (iii) not be established as a percentage 48 of the cost of the service and comprise a fixed cost intended to be as 49 affordable as possible and not act as a barrier to care, that 50 in no event shall be more than two hundred dollars for any covered 51 health care service. Cost sharing owed for services above five 52 hundred percent of the federal poverty line shall vary based on income 53 to promote equity and fairness. 54 6. Rates of payment. (a) The commissioner shall select the contract 55 with an independent actuary to study and recommend appropriate 56 reimbursement methodologies for the cost of health care service coverageS. 9508 8 1 pursuant to this title. Such independent actuary shall review and make 2 recommendations concerning appropriate actuarial assumptions relevant to 3 the establishment of reimbursement methodologies, including but not 4 limited to; the adequacy of rates of payment in relation to the popu- 5 lation to be served adjusted for case mix, the scope of health care 6 services approved organizations must provide, the utilization of such 7 services and the network of providers required to meet state standards, 8 existing rates of payment in effect under the basic health program, and 9 subject to approval by the secretary of health and human services and 10 the division of the budget, and once enrollment in the basic health 11 program buy-in has reached more than one hundred thousand enrollees, 12 rates of payment in effect under Medicare Part A, B, and C. 13 (b) Upon consultation with the independent actuary and entities 14 representing approved organizations, the commissioner shall develop 15 reimbursement methodologies and fee schedules for determining rates of 16 payment, which rate shall be approved by the director of the division of 17 the budget, to be made by the department to approved organizations for 18 the cost of health care services coverage pursuant to this title. Such 19 reimbursement methodologies and fee schedules may include provisions for 20 capitation arrangements. Providers and approved organizations shall be 21 permitted to negotiate rates of payment, provided, however, that the 22 commissioner shall be authorized to establish mandatory rates of payment 23 to ensure affordability and viability of the program. 24 (c) The commissioner shall have the authority to promulgate regu- 25 lations, including emergency regulations, necessary to effectuate the 26 provisions of this subdivision. 27 (d) The department shall require the independent actuary selected 28 pursuant to paragraph (a) of this subdivision to provide a complete 29 actuarial report, along with all actuarial assumptions made and all 30 other data, materials and methodologies used in the development of rates 31 for the basic health plan authorized under this section. Such report 32 shall be provided annually to the temporary president of the senate and 33 the speaker of the assembly. 34 7. Any funds transferred by the secretary of health and human services 35 to the state pursuant to 42 U.S.C. 18051(d) shall be deposited in trust. 36 Funds from the trust shall be used for providing health benefits through 37 [an approved organization] a basic health plan, which, at a minimum, 38 shall include essential health benefits as defined in 42 U.S.C. 39 18022(b); to reduce the premiums, if any, and cost sharing of partic- 40 ipants in the basic health program; or for such other purposes as may be 41 allowed by the secretary of health and human services. Health benefits 42 available through the basic health program shall be provided by one or 43 more approved organizations pursuant to an agreement with the department 44 of health and shall meet the requirements of applicable federal and 45 state laws and regulations. 46 8. An individual who is lawfully admitted for permanent residence, 47 permanently residing in the United States under color of law, or who is 48 a non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 49 1101(a)(15), and who would be ineligible for medical assistance under 50 title eleven of this article due to his or her immigration status if the 51 provisions of section one hundred twenty-two of this chapter were 52 applied, shall be considered to be ineligible for medical assistance for 53 purposes of paragraphs (b) and (c) of subdivision three of this section. 54 9. Reporting. The commissioner shall submit a report to the temporary 55 president of the senate and the speaker of the assembly annually by 56 December thirty-first. The report shall include, at a minimum, an analy-S. 9508 9 1 sis of the basic health program and its impact on the financial interest 2 of the state; its impact on the health benefit exchange including 3 enrollment and premiums; its impact on the number of uninsured individ- 4 uals in the state; its impact on the Medicaid global cap; its impact on 5 health care affordability for middle class New Yorkers; its impact on 6 small business and economic activity; its impact on population trends in 7 the state; the impact of basic health program payment rates on hospital 8 finances and financial sustainability, and recommendations to address 9 any potential concerns based on migration from the commercial insurance 10 market to the basic health program; and the demographics of basic health 11 program enrollees including age and immigration status. 12 10. Network participation. Any provider licensed or certified under 13 article thirty-one or thirty-two of the mental hygiene law, and any 14 hospital licensed under article twenty-eight of the public health law, 15 including any clinic, physician or specialist group, outpatient facility 16 or practice, ambulatory care setting or other office-based setting, or 17 other health care setting owned in whole or in part by a hospital 18 licensed under article twenty-eight of the public health law, as well as 19 any single or multi-specialty free-standing ambulatory surgery centers 20 licensed under article twenty-eight of the public health law, shall make 21 health care services available to any individual in the basic health 22 program. Approved organizations operating basic health plans and provid- 23 ers shall use good faith efforts to negotiate network participation 24 arrangements for individuals enrolled in the basic health program. 25 11. Basic health program buy-in for individuals. Any individual who 26 meets the eligibility requirements of paragraphs (a) and (b) of subdivi- 27 sion three of this section shall be permitted to purchase basic health 28 program coverage for themselves and any qualified dependents who other- 29 wise meet the eligibility requirements of paragraphs (a) and (b) of 30 subdivision three of this section, through the basic health program 31 buy-in. Subject to approval from the United States secretary of health 32 and human services, the basic health program buy-in shall allow eligible 33 individuals to pay the regional per member, per month premium that is 34 paid to a basic health plan for eligible individuals in the region, or 35 any subsidized premium based on the availability of federal or state 36 subsidies as basic health program funds permit, for themselves and any 37 qualified dependents, and gain coverage through the basic health 38 program. 39 12. Basic health program buy-in for eligible small groups. Any eligi- 40 ble small group may pay to a basic health plan the full or partial 41 amount of the premium costs for an individual and their qualified depen- 42 dents to buy-in to the basic health program as a benefit to members of 43 the eligible small group. The commissioner shall establish procedures 44 through which eligible small groups can pay voluntary premium contrib- 45 utions, and if contributions are made, any applicable required subsidy 46 equivalency payments and premium supplements for covered individuals and 47 their qualified dependents, directly to a basic health plan on an aggre- 48 gate, monthly basis. 49 13. The commissioner shall seek any federal waivers, approvals, and 50 take any and all actions necessary to implement this section, including 51 but not limited to federal waivers and approvals, and pursue any state 52 statutory or regulatory changes necessary to implement this act, includ- 53 ing establishing penalties, fines, and oversight authority, in conjunc- 54 tion with the department of taxation and finance, to capture accurate 55 information from individuals and eligible small groups, and ensureS. 9508 10 1 eligible small groups are complying with the requirements of this 2 section. 3 § 2. This act shall take effect on the one hundred eightieth day after 4 it shall have become a law. Effective immediately, the addition, amend- 5 ment and/or repeal of any rule or regulation necessary for the implemen- 6 tation of this act on its effective date are authorized to be made and 7 completed on or before such effective date; provided, further, that the 8 amendments to paragraphs (c) and (e) of subdivision 1, paragraph (d) of 9 subdivision 3, and subdivisions 5 and 7 of section 369-gg of the social 10 services law made by section one of this act shall not affect the expi- 11 ration of such paragraphs and subdivisions and shall be deemed to expire 12 therewith. 13 PART B 14 Section 1. Legislative intent. The legislature finds and declares all 15 of the following: 16 Medical care should never result in financial hardship or bankruptcy; 17 that out-of-network service reimbursement should be fair to providers 18 but put consumers first; and that hospitals should not be able to place 19 liens on their patients' homes to secure payment of out-of-pocket costs. 20 For too many New Yorkers, an unexpected medical emergency or diagnosis 21 carries both life-altering health and financial consequences. An indi- 22 vidual should not need to substantially modify theirs and their family's 23 future by liquidating college or retirement savings or need to start an 24 online fundraiser to afford the bills from a medical emergency. For 25 those who have experienced a medical travesty and cannot work, ongoing 26 costs they cannot afford compound the trauma. 27 As a result of the Affordable Care Act, health insurance plans today 28 are required to establish out-of-pocket payment maximums that attempt to 29 limit one's out-of-pocket cost liability for health care. While these 30 are certainly preferred over no coverage, they offer little protection 31 against debt and bankruptcy because they exclude out-of-network care as 32 well as premium contributions paid by an individual. This means that the 33 sum of premium payments a person makes for their health care does not 34 count towards the out-of-pocket cap, meaning the cap is not account for 35 what could be a substantial amount of available resources that have 36 already been devoted to pay for one's health care. In addition, the 37 out-of-pocket maximum does not account for an individual's household 38 income, exacerbating equity issues by failing to consider one's ability 39 to actually afford their out-of-pocket maximum, or if it is an amount 40 that would inevitably lead to debt and bankruptcy. 41 While there are many contributing factors to health care cost 42 increases, one of the drivers continues to be out-of-network charges. 43 While New York has led the way in protecting consumers from surprise 44 bills, studies have shown New York's Independent Dispute Resolution 45 process and its reliance on health care charges to resolve disputes 46 incentivizes out-of-network providers to continually increase their 47 "charges", as charges are part of the criteria used to determine payment 48 of a disputed out-of-network charge. Higher charges result in higher 49 awards and more costs being built into premiums in subsequent years. As 50 long as the state maintains a health care system that permits and incen- 51 tivizes this behavior, the system will continue to incentivize such cost 52 increases while encouraging those who do not participate in networks to 53 continue to do so, with consumers caught in between. It is essential to 54 address out-of-network charges in a way that is fair to providers butS. 9508 11 1 takes patients completely out of the middle of health plan and provider 2 disputes. 3 § 2. Article 6 of the financial services law is REPEALED and a new 4 article 6 is added to read as follows: 5 ARTICLE 6 6 COST CONTAINMENT AND CONSUMER PROTECTIONS 7 Section 601. Applicability. 8 602. Definitions. 9 603. Rates of payment for non-participating services. 10 604. Annual limit on consumer health care expenditures. 11 605. Service level caps on high health care costs. 12 606. Cost growth caps. 13 § 601. Applicability. This article shall not apply to health care 14 services, including emergency services, where physician fees are subject 15 to schedules or other monetary limitations under any other law, includ- 16 ing the workers' compensation law and article fifty-one of the insurance 17 law, and shall not preempt any such law. 18 § 602. Definitions. For purposes of this article: 19 (a) "Emergency health care services" means health care services 20 rendered to an insured experiencing an "emergency condition". 21 (b) "Emergency condition" means medical or behavioral condition that 22 manifests itself by acute symptoms of sufficient severity, including 23 severe pain, such that a prudent layperson, possessing an average know- 24 ledge of medicine and health, could reasonably expect the absence of 25 immediate medical attention to result in: (1) placing the health of the 26 person afflicted with such condition in serious jeopardy, or in the case 27 of a behavioral condition placing the health of such person or others in 28 serious jeopardy; (2) serious impairment to such person's bodily func- 29 tions; (3) serious dysfunction of any bodily organ or part of such 30 person; (4) serious disfigurement of such person; or (5) a condition 31 described in clause (i), (ii) or (iii) of section 1867(e)(1)(A) of the 32 social security act 42 U.S.C. 1395dd. 33 (c) "Health care plan" means an insurer licensed to write accident and 34 health insurance pursuant to article thirty-two of the insurance law; a 35 corporation organized pursuant to article forty-three of the insurance 36 law; a municipal cooperative health benefit plan certified pursuant to 37 article forty-seven of the insurance law; a health maintenance organiza- 38 tion certified pursuant to article forty-four of the public health law; 39 or a student health plan established or maintained pursuant to section 40 one thousand one hundred twenty-four of the insurance law. 41 (d) "Insured" means a patient covered under a health care plan's poli- 42 cy or contract. 43 (e) "Nonemergency health care services" means health care services 44 rendered to an insured experiencing a medical condition other than an 45 emergency condition. 46 (f) "In-network contracted rate" means the rate contracted between an 47 insured's health care plan and a participating health care provider for 48 the reimbursement of health care services delivered by that health care 49 provider to the insured. 50 (g) "Median, in-network contracted rate" means the median allowed 51 amount paid to in-network providers for a specific service by a specific 52 health plan. 53 (h) "Non-participating commercial rate for emergency services" means 54 the amount set pursuant to this section, and used to determine the rate 55 of payment to a health care provider for the provision of emergencyS. 9508 12 1 health care services to an insured when the health care provider is not 2 in the insurer's network. 3 (i) "Noncontracted commercial rate for nonemergency services" means 4 the amount set pursuant to this section, and used to determine the rate 5 of payment to a health care provider for the provision of nonemergency 6 health care services to an insured when the health care provider is not 7 in the insurer's network. 8 (j) "Relative price" means the negotiated allowed amount paid for a 9 medical service by a health care plan, including amounts paid from both 10 the health care plan and the insured, compared against the Medicare 11 reimbursement rate for the same procedure and facility. 12 (k) "Core CPI" means the Consumer Price Index for All Urban Consumers, 13 All Items Less Food & Energy, developed by the United States Bureau of 14 Labor Statistics. 15 § 603. Rates of payment for non-participating services. All health 16 care plans shall pay non-participating providers of emergency and non- 17 emergency health care services provided to an insured at the insurers 18 median, in-network rate for the service provided. Providers shall be 19 prohibited from balance billing an insured for any amount above the 20 median, in-network rate paid for the health care service. The super- 21 intendent may promulgate regulations necessary to implement this 22 section. 23 § 604. Annual limit on consumer health care expenditures. (a) Notwith- 24 standing any out-of-pocket maximums that may exist today, the super- 25 intendent shall establish annual limits on the overall financial amount 26 an insured shall be responsible for in the state regulated commercial 27 health insurance market, for payment of health care costs under a 28 contract with a New York state regulated health plan, which shall be 29 inclusive of all premium contributions made directly by the individual 30 for individual or family coverage, as well as any amounts paid towards 31 copays, coinsurance, and deductibles, for all medically necessary health 32 care services, irrespective of whether the service is provided by an 33 in-network or out-of-network provider, such that when the total amount 34 of health care costs paid by an individual reaches the applicable limit, 35 the consumer is no longer financially responsible to the insurer for 36 payment of out-of-pocket costs. For purposes of this section, any finan- 37 cial contributions toward the premium made by an employer for health 38 insurance coverage shall not count towards the annual out-of-pocket 39 maximum. 40 (b) In implementing subsection (a) of this section, the superintendent 41 may use the IRS Employer Health Plan Affordability Threshold as a base- 42 line, but shall establish cap amounts at various household income 43 levels, such that individuals with less household income shall be 44 subject to a lower annual payment cap, and individuals with higher 45 household income shall be subject to a higher annual cap, but in no 46 event shall the annual out-of-pocket maximum cap more than double the 47 IRS Employer Health Plan Affordability Threshold for individuals at any 48 income level. The superintendent shall be permitted to apply for any 49 federal waivers and pursue any reinsurance options for insurers or the 50 state and take other actions consistent with this section to implement 51 its intent. 52 (c) Insurers shall be prohibited from increasing health insurance 53 premiums to account for the out-of-pocket limits, and the actuarial 54 value of the insurance product shall be regarded as if the underlying 55 insurance product did not include any revised out-of-pocket limit.S. 9508 13 1 (d) The commissioner of health shall work with the commissioner of 2 taxation and finance to establish appropriate penalties and safeguards 3 to ensure proper implementation of this article. 4 § 605. Service level caps on high health care costs. (a) No health 5 care plan shall be permitted to reimburse any inpatient or outpatient 6 hospital licensed under article twenty-eight of the public health law, 7 and any single or multi-specialty free-standing ambulatory surgery 8 centers licensed under article twenty-eight of the public health law, 9 more than two hundred forty percent of the Medicare benchmark rate for 10 the service. 11 (b) Any provider subject to this paragraph shall be prohibited from 12 balance billing an insured for costs above the benchmark rate or cost up 13 to the benchmark rate if the provider has negotiated a lower charge for 14 the service from the health care plan. 15 (c) Any rate filings that may be required shall be subject to presump- 16 tive disapproval if it includes any payment to providers that is more 17 than two hundred forty percent of the Medicare benchmark rate. 18 (d) The superintendent shall assess the impact of this provision on 19 health care costs in consultation with the commissioner of health, and 20 may recommend modifications to the service level caps, including, but 21 not limited to, revising the methodology to establish new caps, estab- 22 lishing regional caps, or lowering or raising caps as may be necessary 23 based on health care utilization, price, and trend analysis conducted by 24 the commissioner of health. 25 § 606. Cost growth caps. Any rate filings submitted to the superinten- 26 dent may not include aggregate unit price growth for nonprofessional 27 services that exceed the following: 28 (a) One year after the analysis on health care cost growth and trends 29 is completed by the commissioner of health under section twenty hundred 30 sixteen of the public health law, the commissioner of health shall 31 establish three tiers of hospitals based on health care prices paid by 32 health care plans to inpatient and outpatient hospitals and hospital 33 systems, and all ambulatory surgery centers licensed or certified under 34 article twenty-eight of the public health law, such that: 35 (1) The first tier shall consist of those facilities in the state that 36 fall below the median of all facilities in terms of relative reimburse- 37 ment received by health care plans for services; hospitals in this tier 38 shall be permitted to negotiate increases to their reimbursement and 39 health care plans are permitted to pay increases without limitation; 40 (2) The second tier shall consist of those facilities between the 41 median and ninety-fifth percentile of all facilities in terms of rela- 42 tive reimbursement received by health care plans for services; beginning 43 for policies that take effect January first, two thousand twenty-four, 44 the superintendent shall permit health care plans to submit rate filings 45 that allow unit price growth for these facilities that does not exceed 46 the greater of 2.5 percent or Core CPI plus 1 percent; and, 47 (3) The third tier shall consist of those facilities above the nine- 48 ty-fifth percentile of all facilities in terms of relative reimbursement 49 received by health care plans for services; beginning for policies that 50 take effect January first, two thousand twenty-four, the superintendent 51 shall not permit any rate filings that allow unit price growth for these 52 facilities. 53 (b) Any rate filings submitted by a health care plan that violates 54 these requirements shall be subject to presumptive disapproval by the 55 superintendent.S. 9508 14 1 (c) The superintendent is permitted to take other actions to enforce 2 the requirements of this section, and shall implement regulations neces- 3 sary to carry out its intent. 4 § 3. Subdivision (b) of section 5201 of the civil practice law and 5 rules is amended to read as follows: 6 (b) Property against which a money judgment may be enforced. A money 7 judgment may be enforced against any property which could be assigned or 8 transferred, whether it consists of a present or future right or inter- 9 est and whether or not it is vested, unless it is exempt from applica- 10 tion to the satisfaction of the judgment. A money judgment entered upon 11 a joint liability of two or more persons may be enforced against indi- 12 vidual property of those persons summoned and joint property of such 13 persons with any other persons against whom the judgment is entered. No 14 property lien shall be entered against a debtor's primary residence in 15 actions brought by a hospital licensed under article twenty-eight of the 16 public health law or a health care professional authorized under title 17 eight of the education law. 18 § 4. Subdivision (b) of section 5231 of the civil practice law and 19 rules, as amended by chapter 575 of the laws of 2008, is amended to read 20 as follows: 21 (b) Issuance. Where a judgment debtor is receiving or will receive 22 money from any source, an income execution for installments therefrom of 23 not more than ten percent thereof may be issued and delivered to the 24 sheriff of the county in which the judgment debtor resides or, where the 25 judgment debtor is a non-resident, the county in which he is employed; 26 provided, however, that (i) no amount shall be withheld from the judg- 27 ment debtor's earnings pursuant to an income execution for any week 28 unless the disposable earnings of the judgment debtor for that week 29 exceed the greater of thirty times the federal minimum hourly wage 30 prescribed in the Fair Labor Standards Act of 1938 or thirty times the 31 state minimum hourly wage prescribed in section six hundred fifty-two of 32 the labor law as in effect at the time the earnings are payable; (ii) 33 the amount withheld from the judgment debtor's earnings pursuant to an 34 income execution for any week shall not exceed twenty-five percent of 35 the disposable earnings of the judgment debtor for that week, or, the 36 amount by which the disposable earnings of the judgment debtor for that 37 week exceed the greater of thirty times the federal minimum hourly wage 38 prescribed by the Fair Labor Standards Act of 1938 or thirty times the 39 state minimum hourly wage prescribed in section six hundred fifty-two of 40 the labor law as in effect at the time the earnings are payable, which- 41 ever is less; (iii) if the earnings of the judgment debtor are also 42 subject to deductions for alimony, support or maintenance for family 43 members or former spouses pursuant to section five thousand two hundred 44 forty-one or section five thousand two hundred forty-two of this arti- 45 cle, the amount withheld from the judgment debtor's earnings pursuant to 46 this section shall not exceed the amount by which twenty-five percent of 47 the disposable earnings of the judgment debtor for that week exceeds the 48 amount deducted from the judgment debtor's earnings in accordance with 49 section five thousand two hundred forty-one or section five thousand two 50 hundred forty-two of this article; and (iv) no amount shall be imposed 51 in judgments arising from a medical debt action brought by a hospital 52 licensed under article twenty-eight of the public health law or a health 53 care professional authorized under title eight of the education law. 54 Nothing in this section shall be construed to modify, abrogate, impair, 55 or affect any exemption from the satisfaction of a money judgment other- 56 wise granted by law.S. 9508 15 1 § 5. This act shall take effect immediately, provided however, that 2 it shall apply to all health care plan policies beginning on January 1, 3 2024. Effective immediately, the addition, amendment and/or repeal of 4 any rule or regulation necessary for the implementation of this act on 5 its effective date are authorized to be made and completed on or before 6 such effective date. 7 PART C 8 Section 1. Legislative intent. The legislature finds and declares all 9 of the following: 10 The widening gap in health and life expectancy of New Yorkers based on 11 income is a disturbing phenomenon. One of the many reasons why this is 12 occurring is because those with lower incomes tend to be disproportion- 13 ately impacted by multiple disparities, including higher rates of chron- 14 ic illness and disease, and the ongoing costs of treatment create barri- 15 ers to access and proper self-care. Countless studies have shown 16 individuals are more likely to go without needed care when a deductible 17 is involved, while lower income individuals are more likely to avoid 18 care because of out-of-pocket costs. Thus, individuals with lower 19 incomes do not manage chronic conditions as well as those with higher 20 incomes, and tend to live shorter lives as a result. In addition to 21 disproportionately impacting individuals from lower economic back- 22 grounds, chronic diseases have also been found to disproportionately 23 effect people of color, who face higher rates of diabetes, obesity, 24 stroke, heart disease, and cancer, than caucasians. The impacts of poor 25 health effect more than the individual, as studies have shown poor 26 health can impact the well-being and future of the entire family when 27 one member has a chronic condition. Economic advancement is typically 28 more challenging for those with chronic illnesses, as not only does the 29 disease impact work and productivity, but treatments and medications can 30 account for a significant portion of available resources for those with 31 lower incomes, making it difficult to survive on fixed incomes and forc- 32 ing many to forgo needed care. Families with less income do not have the 33 ability to outsource help and end up taking on more responsibility for 34 family members impacted by disease, which impacts their own education 35 and work opportunities. Thus, in many respects, chronic diseases exacer- 36 bate existing health and socioeconomic disparities, making it difficult 37 for individuals and families from low-income backgrounds to overcome the 38 burden. 39 It is imperative that life-saving services, treatments, and medica- 40 tions be made available to all New Yorkers without cost sharing, so cost 41 is not a barrier for accessing preventive services and care. This is 42 essential as a matter of public policy to address disparities in equity 43 and access; however, there is also evidence that improved adherence and 44 chronic disease management will reduce health care costs in the aggre- 45 gate and could lead to improved health outcomes and other benefits for 46 the individual and their family. 47 § 2. The public health law is amended by adding a new section 2703 to 48 read as follows: 49 § 2703. Chronic disease demonstration program. 1. There shall be 50 established a chronic disease demonstration program within the depart- 51 ment. Such program shall recommend cost sharing eliminations for target- 52 ed high-value services, treatments and prescription drugs used to treat 53 certain chronic conditions. In order to implement such program, the 54 commissioner, in consultation with the superintendent of financialS. 9508 16 1 services, shall identify one to three services, treatments, and 2 prescription drugs in total used to treat each of the following chronic 3 conditions: diabetes, asthma, chronic obstructive pulmonary disease, 4 hypertension, coronary artery disease, congestive heart failure, opioid 5 use disorder, bipolar disorder, and schizophrenia. The commissioner 6 may, by regulation, include any other chronic conditions deemed neces- 7 sary. In determining the targeted high-value services, treatments, and 8 prescription drugs, the commissioner shall consider appropriate 9 services, treatments and prescription drugs that are: 10 (a) out-patient or ambulatory services, including medications, lab 11 tests, procedures, and office visits, generally offered in the primary 12 care or medical home setting; 13 (b) of clear benefit, strongly supported by clinical evidence to be 14 cost-effective; 15 (c) likely to reduce hospitalizations or emergency department visits, 16 or reduce future exacerbations of illness progression, or improve quali- 17 ty of life; 18 (d) relatively low cost when compared to the cost of an acute illness 19 or incident prevented or delayed by the use of the service, treatment or 20 drug; and 21 (e) at low risk for overutilization, abuse, addiction, diversion or 22 fraud. 23 The commissioner and the superintendent of financial services may 24 further take into consideration other independent resources or models 25 proven effective in reducing financial barriers to high-value care. 26 2. Every five years, the commissioner and the superintendent of finan- 27 cial services shall evaluate the effect of this section. Such evaluation 28 shall include the impact on treatment adherence, incidence of related 29 acute events, premiums and cost sharing, overall health, long-term 30 health costs, and other issues that the superintendent and commissioner 31 deem necessary. The superintendent of financial services may collaborate 32 with an independent research organization to conduct such evaluation. 33 The superintendent of financial services shall publish a public report 34 on its findings, and shall make such report available on its website. 35 3. Such program shall be implemented no later than January first, two 36 thousand twenty-three. 37 § 3. Subsection (i) of section 3216 of the insurance law is amended by 38 adding a new paragraph 37 to read as follows: 39 (37) Any policy, contract or certificate of insurance issued pursuant 40 to this section shall provide coverage for the identified services, 41 treatments and prescription drugs of the chronic disease demonstration 42 program established under article twenty-seven of the public health law, 43 at no cost sharing to the member, including co-payments, co-insurance, 44 and such coverage shall not be subject to any deductible. The super- 45 intendent and the commissioner of health may adopt any written policies, 46 procedures or regulations necessary to implement such program. 47 § 4. Section 3221 of the insurance law is amended by adding a new 48 subsection (u) to read as follows: 49 (u) Any policy, contract or certificate of insurance issued pursuant 50 to this section shall provide coverage for the identified services, 51 treatments and prescription drugs of the chronic disease demonstration 52 program established under article twenty-seven of the public health law, 53 at no cost sharing to the member, including co-payments, co-insurance, 54 and such coverage shall not be subject to any deductible. The super- 55 intendent and the commissioner of health may adopt any written policies, 56 procedures or regulations necessary to implement such program.S. 9508 17 1 § 5. Section 4303 of the insurance law is amended by adding a new 2 subsection (tt) to read as follows: 3 (tt) Every contract which provides prescription drugs, or physician 4 services, medical, major medical or similar comprehensive-type coverage, 5 shall provide coverage for the identified services, treatments and 6 prescription drugs of the chronic disease demonstration program estab- 7 lished under article twenty-seven of the public health law, at no cost 8 sharing to the member, including co-payments, co-insurance, and such 9 coverage shall not be subject to any deductible. The superintendent and 10 commissioner of health may adopt any written policies, procedures or 11 regulations necessary to implement such program. 12 § 6. This act shall take effect immediately, provided however, that it 13 shall apply to all health care plan policies beginning on January 1, 14 2024. Effective immediately, the addition, amendment and/or repeal of 15 any rule or regulation necessary for the implementation of this act on 16 its effective date are authorized to be made and completed on or before 17 such effective date. 18 PART D 19 Section 1. Legislative intent. The legislature finds and declares all 20 of the following: 21 The COVID-19 pandemic magnified many longstanding health inequities 22 and disparities that disproportionately impact many black and latinx 23 communities. Examples of such racial and ethnic barriers include access 24 to safe and secure housing, quality education, economic opportunity, and 25 access to quality health care. Access to high quality health care has a 26 positive effect not only on one's own health outcomes but significantly 27 impacts how they approach decision-making about their own healthcare. 28 We have the finest medical institutions in the country right here in 29 this state, but access to care and the quality of care received is 30 unevenly experienced. Numerous studies have shown that when it comes to 31 health, where you live has a greater impact on your life expectancy than 32 your own genetic code. A baby born in one zip code may be expected to 33 live an entire generation longer than a baby born in a neighboring zip 34 code. In every major city of our state, there are well-known, vibrant 35 institutions that attract patients who would accept medical care at no 36 lesser institution. At the same time, there are hospitals that predomi- 37 nantly serve the poor and uninsured, whose patients have accepted this 38 is where they go when they need care. If given the choice, most commer- 39 cially insured in this state would not choose to receive their care at 40 one of the financially distressed institutions. 41 Acute care hospitals that serve a higher proportion of Medicaid and 42 Medicare patients tend to serve higher percentages of racial and ethnic 43 minorities, people of color, and communities that are disproportionately 44 impacted by the social determinants of health and other disparities. It 45 is also well known that these hospitals receive lower reimbursement for 46 the services they provide. While this is mostly because Medicaid and 47 Medicare pay these hospitals less than commercial insurance would for 48 the same procedure, it is also true that these hospitals receive 49 substantially less in commercial insurance reimbursement, even when 50 their patients do have commercial coverage. This is due to market posi- 51 tion and negotiating leverage with insurers. While hospital price dereg- 52 ulation and consolidation has allowed some hospital systems to grow and 53 establish dominant market positions with payers, safety net hospitals 54 that serve poorer communities have no leverage to negotiate price withS. 9508 18 1 insurers. As a result, the reimbursement they receive tends to be 2 significantly lower than more affluent hospitals, which means an identi- 3 cal medical procedure can be reimbursed drastically different for hospi- 4 tals located on the same city block. Right now in this state, we have 5 world renown hospitals funding massive capital projects by issuing 6 investment grade bonds on the capital markets, and at the same time, 7 there are hospitals that are so financially destitute they rely on 8 millions of dollars in taxpayer funds every year for capital funding and 9 their very survival. In fiscal year 2019, 28 hospitals across the state 10 received more than $700 million in government support funds from the 11 commissioner of health just to maintain operations. The divide between 12 successful and struggling hospitals is wide and growing. Yet despite 13 this, every hospital in the state is a 501 (c)(3) charitable organiza- 14 tion, required by law to operate exclusively for charitable purposes. 15 A hospital's financial wherewithal has a direct effect on its quality 16 of care, and the quality of the patient experience. Prosperous hospitals 17 attract top physicians, invest in their physical capacity, and contin- 18 ually raise funds to grow operations and improve services, which allows 19 them to improve their reputational standing and continue to attract 20 commercially insured and affluent patients, which helps them remain 21 prosperous. Conversely, safety net hospitals cannot do any of these 22 things. They rely on state and federal grants for operational improve- 23 ments, and Medicaid cash assistance to prevent multimillion-dollar oper- 24 ating losses. They struggle to exist and do the best they can with the 25 minimum reimbursement they receive, from patients beset by multiple 26 disparities. With large hospital systems now located not far from many 27 of these safety net hospitals, it is naive to think safety net insti- 28 tutions could ever compete with their more esteemed neighbors, even if 29 improvements are made. 30 In order to meaningfully address health equity, we must do more than 31 ensure our safety hospitals survive. We need to invest in these hospi- 32 tals so they can provide care that is on par with other institutions 33 throughout the state. As a first step, we need to ensure limited hospi- 34 tal support dollars are allocated to safety net hospitals that need the 35 funds most, and are not allocated to those institutions who do not need 36 the funds, and take other steps to make our health care delivery system 37 more equitable, so safety net hospitals have the resources and ongoing 38 support they need to improve care and operations. 39 § 2. Section 2807-c of the public health law is amended by adding a 40 new subdivision 36 to read as follows: 41 36. Addressing health equity through safety net hospital support. (a) 42 (i) "Safety net hospital" means those hospitals that predominantly serve 43 communities that experience significant racial, economic, and health 44 disparities that have a Medicaid payer mix as of the most recent fiscal 45 year at or above twenty-five percent, and twenty-five percent or less of 46 discharged patients are commercially insured. The commissioner shall 47 annually promulgate a list of those hospitals that qualify as safety net 48 hospitals. 49 (ii) "Health equity pool" means a new trust to be administered by the 50 commissioner to support safety net hospitals, promote health care 51 access, and health equity for communities that experience significant 52 health disparities. 53 (iii) "Commercial average relative price" means the average commercial 54 reimbursement rate for each specific service, for each insurer, by 55 region, for all hospital inpatient and outpatient procedures.S. 9508 19 1 (iv) "Commercial health insurer" means entities authorized to provide 2 health insurance pursuant to articles thirty-two and forty-three of the 3 insurance law, a municipal cooperative health benefit plan established 4 pursuant to article forty-seven of the insurance law, an entity certi- 5 fied pursuant to article forty-four of this chapter, an institution of 6 higher education certified pursuant to section one thousand one hundred 7 twenty-four of the insurance law, the state insurance fund, and the New 8 York state health insurance plan established under article eleven of the 9 civil service law. However, the term commercial health insurer shall not 10 include any of these entities acting as a managed care provider pursuant 11 to title eleven of article five of the social services law and title 12 one-A of article twenty-five of this chapter, or entities providing 13 basic health plans pursuant to the basic health program under section 14 three hundred sixty-nine-gg of the social services law. 15 (b) To promote health equity through commercial rate equity for safety 16 net hospitals that predominantly serve communities that experience 17 health disparities because of race, ethnicity, socioeconomic status or 18 other status: 19 (i) all commercial health insurers shall reimburse safety net hospi- 20 tals for every inpatient and outpatient service at no less than the 21 eightieth percentile of the insurers commercial relative price for the 22 service. Any rate filing that may be required to be submitted by a 23 commercial health insurer that does not reimburse safety net hospitals 24 in accordance with this section shall be subject to presumptive disap- 25 proval by the superintendent of financial services. 26 (ii) any hospital licensed under this article with more than three 27 billion dollars in net patient revenue on its year end cost report shall 28 contribute funds minimally equaling two percent of their annual revenue 29 to the health equity pool to be used to support those safety net hospi- 30 tals within the same geographic region. Hospitals subject to this para- 31 graph shall be prohibited from negotiating for increases to rates of 32 payment from commercial insurers and other health plans to offset 33 payments to the health equity pool. 34 (iii) The commissioner shall revise the indigent care pool distrib- 35 ution formula established in regulations pursuant to section twenty- 36 eight hundred seven-k of this article to prioritize annual distributions 37 for safety net hospitals that ensures no less than seventy-five percent 38 of available funds are distributed annually to those safety net hospi- 39 tals with the greatest financial need. The revised methodology shall 40 further ensure a more equitable distribution of disproportionate share 41 hospital funds such that no funds are distributed to those hospitals 42 that regardless of their reported payer mix or reported uncompensated 43 care need, are in the discretion of the commissioner, financially stable 44 hospitals that do not require disproportionate share hospital funds to 45 maintain operations. 46 (c) The commissioner shall require that all private nonprofit hospi- 47 tals licensed under this article provide charity care and make other 48 investments benefitting the community equaling 5.9% of the hospital's 49 overall expenditures. Any hospital payments to the health equity pool 50 shall count towards the 5.9% threshold. Any hospital that does not 51 contribute the required 5.9% shall be required to make payment up to the 52 5.9% amount to the health equity pool. 53 (d) The commissioner shall provide an annual analysis on the impact of 54 this subdivision on safety net hospitals and health equity no later than 55 January first, two thousand twenty-four.S. 9508 20 1 § 3. This act shall take effect on January 1, 2024, and shall apply to 2 all health care plan policies beginning on January 1, 2024. Effective 3 immediately, the addition, amendment and/or repeal of any rule or regu- 4 lation necessary for the implementation of this act on its effective 5 date are authorized to be made and completed on or before such effective 6 date. 7 PART E 8 Section 1. Legislative intent. The legislature finds and declares all 9 of the following: 10 While there is a general awareness that the United States pays more 11 for prescription drugs than any other nation, there is less awareness 12 that we also pay substantially more for hospital and physician services. 13 This is particularly true in New York, where we spend more on per-person 14 health care costs than nearly any other state, with spending that 15 exceeds the national average, year after year. Health care costs direct- 16 ly effect health insurance premiums, and the cost of health insurance 17 has grown significantly faster in New York than inflation and wages-- 18 compounding at an annual rate of 6.5% per year between 1996 and 2019, 19 turning a family premium of $5,300 in 1996 into $22,874 in 2019--without 20 any end in sight. 21 Higher health care costs have also led to the growth in adoption of 22 health benefit designs that not in the best interest of the health care 23 consumer, like high deductible plans and plans with high out-of-pocket 24 cost sharing. In 2019, the average New Yorker with employer-sponsored 25 health coverage paid $5,149 in premiums and $2,899 in deductibles before 26 their health insurance contributed at all to the cost of their care. 27 These changes were designed to provide lower premium options and make 28 consumers more responsible for their own costs, but too often they end 29 up dissuading necessary health care utilization because of cost. 30 Yet, despite the overall cost growth this state has seen, numerous 31 studies show that the growth in costs is not uniform across-the-board. 32 Market power remains a key driver of price, resulting in significant 33 variation in prices charged for the very same medical services, even in 34 the same geographic region, as some entities are able to demand regular 35 cost increases due to their name and status as an organization. 36 It is clear that health care costs, and the underlying factors that 37 contribute to cost growth, is an issue that can no longer be ignored, 38 must be better understood, and cannot simply be left to the private 39 market to resolve. This has become much more than a health care issue, 40 as critical services like education, childcare, social services, and 41 economic growth will continue to see resources shifted as long as health 42 care cost growth continues to outpace wages, inflation, or any measure 43 of rational economic output. 44 § 2. Section 2816 of the public health law is amended by adding a new 45 subdivision 9-a to read as follows: 46 9-a. (a) The commissioner may require any health care provider or 47 third-party payer to report additional claim or price information not 48 already reported pursuant to this section to analyze all health care 49 expenditures in the state from public and private sources, including: 50 (i) all categories of medical expenses and all non-claims related 51 payments to providers; (ii) all patient cost sharing amounts, such as, 52 deductibles and copayments; and (iii) the net cost of private health 53 insurance, or as otherwise defined in regulations promulgated by the 54 center.S. 9508 21 1 (b) The commissioner shall publish an annual report based on the 2 information submitted pursuant to this section concerning health care 3 providers, third-party payer costs and cost trends. The commissioner 4 shall compare the costs and cost trends by region, and shall detail: 5 (i) baseline information about health care cost, price, quality, 6 utilization, and market power in the state's health care system; (ii) 7 cost growth trends by provider sector, including but not limited to, 8 hospitals, hospital systems, non-acute providers, pharmaceuticals, 9 medical devices and durable medical equipment; provided, however, that 10 any detailed cost growth trend in the pharmaceutical sector shall 11 consider the effect of drug rebates and other price concessions in the 12 aggregate without disclosure of any product or manufacturer-specific 13 rebate or price concession information, and without limiting or other- 14 wise affecting the confidential or proprietary nature of any rebate or 15 price concession agreement; (iii) factors that contribute to cost growth 16 within the state's health care system, including provider consolidation, 17 hospital acquisitions of physician practices, and to the relationship 18 between provider costs and third-party payer premium rates; (iv) the 19 impact of any assessments including, but not limited to, the HCRA 20 surcharge on health insurance premiums; (v) trends in utilization of 21 high-cost, unnecessary, or duplicative services, with particular empha- 22 sis on imaging and other high-cost services; (vi) the development and 23 status of provider organizations, including, but not limited to, acqui- 24 sitions, mergers, consolidations and any evidence of excess consol- 25 idation or anti-competitive behavior by provider organizations; (vii) 26 the impact of health care payment and delivery reform on the quality of 27 care delivered in the state; and (viii) any other information the 28 commissioner deems necessary. 29 (c) As part of such report, the commissioner shall report on price 30 variation of inpatient and outpatient medical services. The report 31 shall include: (i) baseline information about price variation, identify- 32 ing hospital inpatient and outpatient prices relative to Medicare; (ii) 33 the annual change in price variation of hospital inpatient and outpa- 34 tient prices; (iii) factors that contribute to price variation in the 35 health care system; (iv) the impact of price variations on safety net 36 hospitals and health insurance premiums; and (v) any recommendations to 37 address cost growth to make health care as affordable and accessible as 38 possible in this state. 39 (d) The commissioner may contract with an outside organization with 40 expertise in reviewing data and preparing such reports to conduct the 41 analysis and prepare the report required. The superintendent shall 42 publish the report and provide the report to the legislature at least 43 thirty days before the public hearing required under paragraph (e) of 44 this section. 45 (e) Not later than October first of every year, the commissioner shall 46 hold a public hearing which shall examine health care provider, provider 47 organization and third-party payer costs, prices and cost trends, with 48 particular attention to factors that contribute to cost growth within 49 the state. Public notice of any hearing shall be provided at least sixty 50 days prior to such hearing date. The commissioner shall identify as 51 witnesses for the public hearing a representative sample of health care 52 providers, third-party payers and other relevant persons. Witnesses 53 shall provide testimony under oath and be subject to questioning by a 54 panel that shall consist of the commissioner, the superintendent of 55 financial services or a designee, three appointees by the governor, 56 three appointees by the temporary president of the senate, threeS. 9508 22 1 appointees by the speaker of the assembly, two appointees of the attor- 2 ney general, and two appointees of the state comptroller. Witnesses 3 shall be instructed on which topics they should be prepared to discuss, 4 which may include: (i) in the case of providers and provider organiza- 5 tions, testimony concerning payment systems, care delivery models, payer 6 mix, cost structures, administrative and labor costs, capital and tech- 7 nology cost, adequacy of public payer reimbursement levels, reserve 8 levels, utilization trends, relative price, quality improvement and 9 care-coordination strategies, investments in health information technol- 10 ogy, the relation of private payer reimbursement levels to public payer 11 reimbursements for similar services, efforts to improve the efficiency 12 of the delivery system, efforts to reduce the inappropriate or duplica- 13 tive use of technology and the impact of price transparency on prices; 14 and (ii) in the case of private and public payers, testimony concerning 15 factors underlying premium cost and rate increases, the relation of 16 reserves to premium costs, the payer's efforts to develop benefit 17 design, network design and payment policies that enhance product afford- 18 ability and encourage efficient use of health resources and technology 19 including utilization of alternative payment methodologies, efforts by 20 the payer to increase consumer access to health care information, 21 efforts by the payer to promote the standardization of administrative 22 practices, the impact of price transparency, the extent of price vari- 23 ation between the payer's participating providers and efforts to reduce 24 such price variation, and any other matters as determined by the commis- 25 sioner. 26 § 3. This act shall take effect immediately; provided, however, that 27 the amendments to section 2816 of the public health law made by section 28 two of this act shall not affect the expiration of such section and 29 shall expire therewith. 30 § 3. Severability clause. If any clause, sentence, paragraph, subdivi- 31 sion, section or part of this act shall be adjudged by a court of compe- 32 tent jurisdiction to be invalid, such judgment shall not affect, impair, 33 or invalidate the remainder thereof, but shall be confined in its opera- 34 tion to the clause, sentence, paragraph, subdivision, section or part 35 thereof directly involved in the controversy in which such judgment 36 shall have been rendered. It is hereby declared to be the intent of the 37 legislature that this act would have been enacted even if such invalid 38 provision had not been included herein. 39 § 4. This act shall take effect immediately; provided, however, that 40 the applicable effective date of Parts A through E of this act shall be 41 as specifically set forth in the last section of such Parts.
