This bill has been amended

Bill S2606C-2013

Amends various provisions of law relating to implementing the health and mental hygiene budget for the 2013-2014 state fiscal year

Relates to the cap on local Medicaid expenditures; relates to the determination of rates of payments by certain state governmental agencies; relates to the medical assistance information and payment system; relates to managed care programs and managed long term care plans; relates to participation in the state health insurance exchange; relates to liability for certain acts under the false claims act; relates to civil actions pursuant to the false claims act; relates to the delay of certain administrative costs; relates to the preferred drug program; relates to antipsychotic therapeutic drugs; authorizes the commissioner of health to implement an incontinence supply utilization management program; relates to the funding of health home infrastructure development; relates to general hospital inpatient reimbursement; relates to managed care programs; relates to rates of payment for residential health care facilities and rates of reimbursement for inpatient detoxification and withdrawal services; relates to hospital inpatient base years; relates to the Medicaid managed care inpatient psychiatric care default rate; relates to the Medicaid managed care default rate; moves rate setting for child health plus to the department of health; requires the use of an enrollment broker for counties that are mandated Medicaid managed care and managed long term care; repeals the twentieth day of the month enrollment cut-off for managed long term care enrollees; relates to the nursing home financially disadvantaged program; eliminates the recruitment and retention attestation requirement for certain certified home health agencies; extends the office of the Medicaid inspector general's power to audit rebasing rates; relates to rebasing transition payments; relates to payment of claims; establishes the home and community-based care work group; relates to critical access hospitals; eliminates the bed hold requirement; relates to eligibility for Medicaid; relates to treatment of income and resources of institutionalized persons; relates to the people; repeals certain provisions of law relating to the pharmacy and therapeutics committee; relates to payments to hospital assessments; relates to the effectiveness of eligibility for medical assistance and the family health plus program; extends various plans and programs; relates to rates of payment by state governmental agencies; relates to reports on chronic illness demonstration projects and reports by the commissioner of health on health homes; relates to rates of payment for long term home health care programs; extends a demonstration program for physicians suffering from alcoholism, drug abuse or mental illness; relates to indigent care; relates to permitting online and telephone Medicaid applications; allows administrative renewals and self-attestation of residency; ends applications for family health plus; establishes a methodology for modified adjusted gross income; centralizes child health plus eligibility determinations; requires audit standards for eligibility; relates to residency and income attestation and verification for child health plus; eliminates temporary enrollment in child health plus; expands the child health plus social security number requirement to lawfully residing children; requires a status report on the health benefit exchange; relates to health benefit exchange navigators and clarifies the identity of persons to whom insurance licensing requirements apply; relates to coverage limitations requirements and student accident and health insurance; relates to standardization of individual enrollee direct payment contracts; ensures that group and individual insurance policy provisions conform to applicable requirements of federal law; relates to the general public health work program; consolidates the excess medical malpractice liability coverage pool; relates to the addition to the methadone registry of dosage and such other information as is necessary to facilitate disaster management; relates to state aid funding authorization of services funded by the office of alcoholism and substance abuse services; vests all authority to appoint and remove officers and employees of the office of mental health; creates mental health incident review panels; relates to psychiatric emergency programs; relates to foregoing a cost-of-living adjustment during the 2013-2014 state fiscal year; authorizes the actions necessary to manage the loss of federal revenue and create the mental hygiene stabilization fund; provides medical assistance to certain retirees of the New York city off-track betting corporation; and relates to funding to SUNY Downstate Medical Center and directing the restructuring of the hospital.

Details

Actions

  • Mar 10, 2013: PRINT NUMBER 2606C
  • Mar 10, 2013: AMEND (T) AND RECOMMIT TO FINANCE
  • Feb 22, 2013: PRINT NUMBER 2606B
  • Feb 22, 2013: AMEND (T) AND RECOMMIT TO FINANCE
  • Feb 13, 2013: PRINT NUMBER 2606A
  • Feb 13, 2013: AMEND AND RECOMMIT TO FINANCE
  • Jan 22, 2013: REFERRED TO FINANCE

Text

STATE OF NEW YORK ________________________________________________________________________ 2606--C IN SENATE January 22, 2013 ___________ A BUDGET BILL, submitted by the Governor pursuant to article seven of the Constitution -- read twice and ordered printed, and when printed to be committed to the Committee on Finance -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee -- committee discharged, bill amended, ordered reprinted as amended and recommitted to said committee AN ACT to amend chapter 59 of the laws of 2011, amending the public health law and other laws relating to general hospital reimbursement for annual rates, in relation to the cap on local Medicaid expendi- tures; to amend the social services law, in relation to the medical assistance information and payment system; to amend the state finance law, in relation to liability for certain acts under the false claims act; to amend the state finance law, in relation to civil actions pursuant to the false claims act; to amend the public health law, in relation to the preferred drug program; to amend the public health law, in relation to antipsychotic therapeutic drugs; to amend the social services law, in relation to reducing pharmacy reimbursement for name brand drugs; to amend the social services law, in relation to managed care coverage of certain drugs; to amend the public health law, in relation to eliminating the summary posting requirement for the pharmacy and therapeutic committee; to amend the social services law, in relation to early refill of prescriptions; to amend the social services law, in relation to authorizing the commissioner of health to implement an incontinence supply utilization management program; to amend part C of chapter 58 of the laws of 2005, relating to authoriz- ing reimbursements for expenditures made by or on behalf of social services districts for medical assistance for needy persons and the administration thereof, in relation to the effectiveness thereof; to amend the public health law, in relation to general hospital inpatient reimbursement; to amend the social services law, in relation to managed care programs; to amend section 2 of part H of chapter 111 of the laws of 2010, relating to increasing Medicaid payments to provid- ers through managed care organizations and providing equivalent fees through an ambulatory patient group methodology, in relation to the effectiveness thereof; to amend the public health law, in relation to EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD12571-10-3 S. 2606--C 2 rates of payment for residential health care facilities; to amend the public health law, in relation to hospital inpatient base years; to amend the public health law, in relation to the Medicaid managed care inpatient psychiatric care default rate; to amend the public health law, in relation to the Medicaid managed care default rate; to amend the public health law, in relation to moving rate setting for child health plus to the department of health; to amend the social services law and the public health law, in relation to requiring the use of an enrollment broker for counties that are mandated Medicaid managed care and managed long term care; to amend the state finance law, in relation to the federal-state health reform partnership program account; to amend the public health law, in relation to repealing the twentieth day of the month enrollment cut-off for managed long term care enrollees; to amend the public health law, in relation to the nursing home financially disadvantaged program; to amend the public health law, in relation to eliminating the recruitment and retention attestation requirement for certain certified home health agencies; to amend the public health law, in relation to extending the office of the Medicaid inspector general's power to audit rebasing rates; to amend the public health law, in relation to rebasing transition payments; to amend the public health law, in relation to capital cost reimbursement for nursing homes; to amend the public health law, in relation to eliminating the bed hold requirement; to amend the public health law, in relation to authorizing upper payment limits for certain nursing homes; to amend the public health law, in relation to rates for specialty nursing homes; to amend the social services law, in relation to eliminating spousal refusal of medical care; to amend the social services law, in relation to treatment of income and resources of institutionalized persons; to amend the public health law, in relation to certain payments for certain home care agencies and services; to amend the social services law, in relation to Medi- caid eligibility; to amend part H of chapter 59 of the laws of 2011, amending the public health law and other laws relating to general hospital inpatient reimbursement, in relation to the effectiveness thereof; to amend part H of chapter 59 of the laws of 2011, amending the public health law and other laws relating to known and projected department of health state funds Medicaid expenditures, in relation to the effectiveness thereof; in relation to eliminating the 2013-2014 trend factor and thereafter; to repeal certain provisions of the social services law and the public health law relating to managed care programs; and to repeal certain provisions of the public health law and the social services law relating to the pharmacy and therapeutics committee; providing for the repeal of certain provisions upon expira- tion thereof (Part A); to amend the public health law, in relation to payments to hospital assessments; to amend part C of chapter 58 of the laws of 2009 amending the public health law relating to payment by governmental agencies for general hospital inpatient services, in relation to the effectiveness of eligibility for medical assistance and the family health plus program; to amend chapter 474 of the laws of 1996, amending the education law and other laws relating to rates for residential healthcare facilities, in relation to reimbursements; to amend chapter 884 of the laws of 1990, amending the public health law relating to authorizing bad debt and charity care allowances for certified home health agencies, in relation to the effectiveness ther- eof; to amend the long term care integration and finance act of 1997, in relation to extending the expiration of operating demonstrations S. 2606--C 3 operating a managed long term care plan; to amend chapter 81 of the laws of 1995, amending the public health law and other laws relating to medical reimbursement and welfare reform, in relation to reimburse- ments and the effectiveness thereof; to amend the public health law, in relation to capital related inpatient expenses; to amend part C of chapter 58 of the laws of 2007, amending the social services law and other laws relating to enacting the major components of legislation necessary to implement the health and mental hygiene budget for the 2007-2008 state fiscal year, in relation to rates of payment by state governmental agencies and the effectiveness of certain provisions of such chapter; to amend the social services law, in relation to reports on chronic illness demonstration projects and reports by the commis- sioner of health on health homes; to amend chapter 451 of the laws of 2007, amending the public health law, the social services law and the insurance law, relating to providing enhanced consumer and provider protections, in relation to extending the effectiveness of certain provisions thereof; to amend the public health law, in relation to rates of payment for long term home health care programs; to amend chapter 426 of the laws of 1983, amending the public health law relat- ing to professional misconduct proceedings and chapter 582 of the laws of 1984, amending the public health law relating to regulating activ- ities of physicians, in relation to the effectiveness of certain provisions thereof; to amend the public health law, in relation to extending a demonstration program for physicians suffering from alco- holism, drug abuse or mental illness; to amend part X2 of chapter 62 of the laws of 2003 amending the public health law relating to allow- ing the use of funds of the office of professional medical conduct for activities of the patient health information and quality improvement act of 2000, in relation to the effectiveness of certain provisions thereof (Part B); to amend the public health law, in relation to indi- gent care (Part C); to amend the social services law, in relation to eligibility conditions, permitting online and telephone Medicaid applications, allowing administrative renewals and self-attestation of residency, ending applications for family health plus and modified adjusted gross income and Medicaid eligibility groups; to amend the public health law, in relation to establishing methodology for modi- fied adjusted gross income, centralizing child health plus eligibility determinations, requiring audit standards for eligibility, residency and income attestation and verification for child health plus, elimi- nating temporary enrollment in child health plus, expanding the child health plus social security number requirement to lawfully residing children, modified adjusted gross income under child health plus and personal interviews under child health plus; to amend the insurance law and the public health law, in relation to clarifying the identity of persons to whom insurance licensing requirements apply, insurance brokers and agents, coverage limitations requirements and student accident and health insurance and standardization of individual enrol- lee direct payment contracts; to repeal sections 369-ee and 369-ff of the social services law, relating to the family health plus program; to repeal certain other provisions of the social services law relating thereto; to repeal certain provisions of the insurance law relating thereto; and providing for the repeal of certain provisions upon expi- ration thereof (Part D); to amend the public health law, in relation to the general public health work program; to amend chapter 577 of the laws of 2008 amending the public health law, relating to expedited partner therapy for persons infected with chlamydia trachomatis, in S. 2606--C 4 relation to the effectiveness of such chapter; to amend the public health law and the mental hygiene law, in relation to consolidating the excess medical malpractice liability coverage pool; to amend the education law, in relation to medical malpractice reform; to amend part S of chapter 56 of the laws of 2012 relating to the excess medical malpractice liability coverage pool, in relation to the appli- cation of coverage for physicians and dentists; and to repeal certain provisions of the public health law relating to state aid for certain public health programs and provisions relating to sexually transmitted diseases; to amend the public health law, in relation to medical assistance recoupment and reductions; to amend the public health law, in relation to enacting the "home care stabilization act"; to amend the insurance law, the public health law and the financial services law, in relation to establishing protections to prevent surprise medical bills including network adequacy requirements, claim submission requirements, adequacy of and access to out-of-network care and prohibition of excessive emergency charges; to amend the social services law, in relation to coverage of mail order prescriptions by managed care providers; to provide for the rates of payment to general hospitals for total hip or knee joint replacement cases; to amend the public health law, in relation to directing the commissioner of health to report to the legislature on the progress and preparedness of the health benefit exchange; to amend the public health law, in relation to directing the commissioner of health to report to the legislature on the department of health's annual activities, mission and goals; to amend chapter 56 of the laws of 2012, amending the public health law relating to evaluations or services under the early intervention program for infants and toddlers with disabilities and their families, in relation to the effectiveness of certain provisions thereof; to amend the public health law, in relation to establishing the broads- cale systems integration demonstration program; to amend the public health law, in relation to requiring adrenoleukodystrophy screening of newborns; to amend the public health law, in relation to payments to rural hospitals designated as critical access hospitals; to amend the state finance law, in relation to the monies of the spinal cord injury research trust fund; and to amend the social services law, in relation to a health technology assessment committee; to amend the social services law, in relation to creating incentives for counties to investigate and prosecute medicaid fraud; to amend the public health law, in relation to establishing the Medicaid identification and anti- fraud biometric technology program; and to amend the social services law, in relation to conforming medical assistance identification with the Medicaid identification and anti-fraud biometric technology program; to amend the state finance law, in relation to establishing the health care efficiency and affordability law of New Yorkers (HEAL NY) account; to repeal section 365-d of the social services law relat- ing to early and periodic screening diagnosis and treatment outreach demonstration projects; to repeal section 2818 of the public health law, relating to the health care efficiency and affordability law of New Yorkers (HEAL NY) capital grant program; and providing for the repeal of certain provisions upon expiration thereof (Part E); to amend the mental hygiene law, in relation to the addition to the methadone registry of dosage and such other information as is neces- sary to facilitate disaster management (Part F); to amend the mental hygiene law, in relation to state aid funding authorization of services funded by the office of alcoholism and substance abuse S. 2606--C 5 services; to repeal article 26 of such law relating thereto (Part G); to amend the mental hygiene law, in relation to inpatient facilities; to amend chapter 62 of the laws of 2003, amending the mental hygiene law and the state finance law relating to the community mental health support and workforce reinvestment program, the membership of subcom- mittees for mental health of community services boards and the duties of such subcommittees and creating the community mental health and workforce reinvestment account, in relation to extending such provisions relating thereto (Part H); to amend the mental hygiene law, in relation to the recovery of exempt income by the office of mental health for community residential programs and providing for the repeal of such provisions upon expiration thereof (Part I); intentionally omitted (Part J); to amend the mental hygiene law, in relation to an annual examination and notice of rights provided to respondent sex offenders who are confined in a secure treatment facility (Part K); to amend the mental hygiene law and the education law, in relation to creating mental health incident review panels (Part L); to amend the mental hygiene law, in relation to statewide comprehensive plans of service for persons with mental disabilities; and to repeal certain provisions of the mental hygiene law and certain provisions of chapter 723 of the laws of 1989, amending the mental hygiene law and other laws relating to the establishment of comprehensive psychiatric emer- gency programs, relating to eliminating the annual reports on the comprehensive psychiatric emergency program; family care; and the confinement, care and treatment of persons with developmental disabil- ities (Part M); to amend chapter 57 of the laws of 2006, relating to establishing a cost of living adjustment for designated human services programs, in relation to foregoing such adjustment during the 2013-2014 state fiscal year (Part N); to authorize the actions neces- sary to manage the loss of federal revenue and create the Mental Hygiene Stabilization fund (Part O); and in relation to adult homes (Part P) THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: 1 Section 1. This act enacts into law major components of legislation 2 which are necessary to implement the state fiscal plan for the 2013-2014 3 state fiscal year. Each component is wholly contained within a Part 4 identified as Parts A through P. The effective date for each particular 5 provision contained within such Part is set forth in the last section of 6 such Part. Any provision in any section contained within a Part, includ- 7 ing the effective date of the Part, which makes a reference to a section 8 "of this act", when used in connection with that particular component, 9 shall be deemed to mean and refer to the corresponding section of the 10 Part in which it is found. Section three of this act sets forth the 11 general effective date of this act. 12 PART A 13 Section 1. Subdivision (a) of section 90 of part H of chapter 59 of 14 the laws of 2011, amending the public health law and other laws, relat- 15 ing to general hospital inpatient reimbursement for annual rates, is 16 amended to read as follows: S. 2606--C 6 1 (a) Notwithstanding any other provision of law to the contrary, for 2 the state fiscal years beginning April 1, 2011 and ending on [March 31, 3 2013] FEBRUARY 15, 2014 AND FOR THE RATE PERIOD APRIL 1, 2013 THROUGH 4 DECEMBER 31, 2013, all Medicaid payments made for services provided on 5 and after April 1, 2011, shall, except as hereinafter provided, be 6 subject to a uniform two percent reduction and such reduction shall be 7 applied, to the extent practicable, in equal amounts during the fiscal 8 year, provided, however, that an alternative method may be considered at 9 the discretion of the commissioner of health and the director of the 10 budget based upon consultation with the health care industry including 11 but not limited to, a uniform reduction in Medicaid rates of payments or 12 other reductions provided that any method selected achieves up to 13 $345,000,000 in Medicaid state share savings in state fiscal year 2011- 14 12 [and], up to $357,000,000 in state fiscal year 2012-13, AND UP TO 15 $311,000,000 FOR THE PERIOD APRIL 1, 2013 THROUGH DECEMBER 31, 2013 16 except as hereinafter provided, for services provided on and after April 17 1, 2011 through [March] DECEMBER 31, 2013. Any alternative methods to 18 achieve the reduction must be provided in writing and shall be filed 19 with the senate finance committee and the assembly ways and means 20 committee not less than thirty days before the date on which implementa- 21 tion is expected to begin. Nothing in this section shall be deemed to 22 prevent all or part of such alternative reduction plan from taking 23 effect retroactively, to the extent permitted by the federal centers for 24 medicare and medicaid services. 25 S 2. Subdivision 1 of section 91 of part H of chapter 59 of the laws 26 of 2011, amending the public health law and other laws relating to 27 general hospital reimbursement for annual rates, as amended by section 5 28 of part F of chapter 56 of the laws of 2012, is amended to read as 29 follows: 30 1. Notwithstanding any inconsistent provision of state law, rule or 31 regulation to the contrary, subject to federal approval, the year to 32 year rate of growth of department of health state funds Medicaid spend- 33 ing shall not exceed the ten year rolling average of the medical compo- 34 nent of the consumer price index as published by the United States 35 department of labor, bureau of labor statistics, for the preceding ten 36 years[.]; PROVIDED, HOWEVER, THAT FOR STATE FISCAL YEAR 2013-14 AND FOR 37 EACH FISCAL YEAR THEREAFTER, THE MAXIMUM ALLOWABLE ANNUAL INCREASE IN 38 THE AMOUNT OF DEPARTMENT OF HEALTH STATE FUNDS MEDICAID SPENDING SHALL 39 BE CALCULATED BY MULTIPLYING THE DEPARTMENT OF HEALTH STATE FUNDS MEDI- 40 CAID SPENDING FOR THE PREVIOUS YEAR, MINUS THE AMOUNT OF ANY DEPARTMENT 41 OF HEALTH STATE OPERATIONS SPENDING INCLUDED THEREIN, BY SUCH TEN YEAR 42 ROLLING AVERAGE. 43 S 3. Section 92 of part H of chapter 59 of the laws of 2011, amending 44 the public health law and other laws relating to known and projected 45 department of health state funds Medicaid expenditures, subdivision 1 as 46 amended by section 57 of part D of chapter 56 of the laws of 2012, is 47 amended to read as follows: 48 S 92. 1. For state fiscal years 2011-12 through [2013-14] 2014-2015, 49 the director of the budget, in consultation with the commissioner of 50 health referenced as "commissioner" for purposes of this section, shall 51 assess on a monthly basis, as reflected in monthly reports pursuant to 52 subdivision five of this section known and projected department of 53 health state funds medicaid expenditures by category of service and by 54 geographic regions, as defined by the commissioner, and if the director 55 of the budget determines that such expenditures are expected to cause 56 medicaid disbursements for such period to exceed the projected depart- S. 2606--C 7 1 ment of health medicaid state funds disbursements in the enacted budget 2 financial plan pursuant to subdivision 3 of section 23 of the state 3 finance law, the commissioner of health, in consultation with the direc- 4 tor of the budget, shall develop a medicaid savings allocation plan to 5 limit such spending to the aggregate limit level specified in the 6 enacted budget financial plan, provided, however, such projections may 7 be adjusted by the director of the budget to account for any changes in 8 the New York state federal medical assistance percentage amount estab- 9 lished pursuant to the federal social security act, changes in provider 10 revenues, reductions to local social services district medical assist- 11 ance administration, and beginning April 1, 2012 the operational costs 12 of the New York state medical indemnity fund; AND PROVIDED FURTHER, 13 HOWEVER, THAT SUCH PROJECTIONS SHALL BE ADJUSTED BY THE DIRECTOR OF THE 14 BUDGET TO ACCOUNT FOR INCREASED OR EXPEDITED DEPARTMENT OF HEALTH STATE 15 FUNDS MEDICAID EXPENDITURES AS A RESULT OF A NATURAL OR OTHER TYPE OF 16 DISASTER, INCLUDING A GOVERNMENTAL DECLARATION OF EMERGENCY; AND 17 PROVIDED FURTHER, HOWEVER, THAT BEGINNING APRIL 1, 2013 SUCH PROJECTIONS 18 SHALL BE ADJUSTED BY THE DIRECTOR OF THE BUDGET TO ACCOUNT FOR NEW 19 DEPARTMENT OF HEALTH STATE FUNDS MEDICAID EXPENDITURES RELATED TO ANY 20 MEDICAID WAIVER APPROVED BY THE FEDERAL CENTERS FOR MEDICARE AND MEDI- 21 CAID SERVICES. 22 2. Such medicaid savings allocation plan shall be designed, to reduce 23 the disbursements authorized by the appropriations herein in compliance 24 with the following guidelines: (1) reductions shall be made in compli- 25 ance with applicable federal law, including the provisions of the 26 Patient Protection and Affordable Care Act, Public Law No. 111-148, and 27 the Health Care and Education Reconciliation Act of 2010, Public Law No. 28 111-152 (collectively "Affordable Care Act") and any subsequent amend- 29 ments thereto or regulations promulgated thereunder; (2) reductions 30 shall be made in a manner that complies with the state Medicaid plan 31 approved by the federal centers for medicare and medicaid services, 32 provided, however, that the commissioner of health is authorized to 33 submit any state plan amendment or seek other federal approval, includ- 34 ing waiver authority, to implement the provisions of the medicaid 35 savings allocation plan that meets the other criteria set forth herein; 36 (3) reductions shall be made in a manner that maximizes federal finan- 37 cial participation, to the extent practicable, including any federal 38 financial participation that is available or is reasonably expected to 39 become available, in the discretion of the commissioner of health, under 40 the Affordable Care Act; (4) reductions shall be made uniformly among 41 categories of services and geographic regions of the state, to the 42 extent practicable, and shall be made uniformly within a category of 43 service, to the extent practicable, except where the commissioner of 44 health determines that there are sufficient grounds for non-uniformity, 45 including but not limited to: the extent to which specific categories of 46 services contributed to department of health medicaid state funds spend- 47 ing in excess of the limits specified herein; the need to maintain safe- 48 ty net services in underserved communities; or the potential benefits of 49 pursuing innovative payment models contemplated by the Affordable Care 50 Act, in which case such grounds shall be set forth in the medicaid 51 savings allocation plan; and (5) reductions shall be made in a manner 52 that does not unnecessarily create administrative burdens to Medicaid 53 applicants and recipients or providers. 54 3. (a) The commissioner of health shall seek the input of the legisla- 55 ture, as well as organizations representing health care providers, 56 consumers, businesses, workers, health insurers, and others with rele- S. 2606--C 8 1 vant expertise, in developing such medicaid savings allocation plan[, to 2 the extent that all or part of such plan, in the discretion of the 3 commissioner, is likely to have a material impact on the overall medi- 4 caid program, particular categories of service or particular geographic 5 regions of the states]. 6 (b)[(i)] THE MEDICAID SAVINGS ALLOCATION PLAN SHALL BE SUBMITTED TO 7 THE LEGISLATURE FOR THEIR CONSIDERATION AND APPROVAL PRIOR TO IMPLEMEN- 8 TATION OF THE PLAN. 9 (C) The commissioner of health shall post the APPROVED medicaid 10 savings allocation plan on the department of health's website [and shall 11 provide written copies of such plan to the chairs of the senate finance 12 and the assembly ways and means committees] at least 30 days before the 13 date on which implementation is expected to begin. 14 [(ii) The commissioner of health may revise the medicaid savings allo- 15 cation plan subsequent to the provision of notice and prior to implemen- 16 tation but need provide a new notice pursuant to subparagraph (i) of 17 this paragraph only if the commissioner determines, in his or her 18 discretion, that such revisions materially alter the plan. 19 (c)] (D) Notwithstanding the provisions of paragraphs (a) and [(b)] 20 (C) of this subdivision, the commissioner of health need not seek the 21 input described in paragraph (a) of this subdivision or provide notice 22 pursuant to paragraph [(b)] (C) of this [paragraph] SUBDIVISION if, in 23 the discretion of the commissioner, expedited development and implemen- 24 tation of a medicaid savings allocation plan is necessary due to a 25 public health emergency. IF THE COMMISSIONER DECIDES THAT EXPEDITED 26 DEVELOPMENT AND IMPLEMENTATION OF A MEDICAID SAVINGS ALLOCATION PLAN IS 27 NECESSARY, THE COMMISSIONER SHALL NOTIFY THE GOVERNOR, THE TEMPORARY 28 PRESIDENT OF THE SENATE AND THE SPEAKER OF THE ASSEMBLY SEVENTY-TWO 29 HOURS PRIOR TO TAKING ANY ACTION. 30 For purposes of this section, a public health emergency is defined as: 31 (i) a disaster, natural or otherwise, that significantly increases the 32 immediate need for health care personnel in an area of the state; (ii) 33 an event or condition that creates a widespread risk of exposure to a 34 serious communicable disease, or the potential for such widespread risk 35 of exposure; or (iii) any other event or condition determined by the 36 commissioner to constitute an imminent threat to public health. 37 [(d)] (E) Nothing in this paragraph shall be deemed to prevent all or 38 part of such medical savings allocation plan from taking effect retroac- 39 tively to the extent permitted by the federal centers for medicare and 40 medicaid services. 41 4. In accordance with the medicaid savings allocation plan, the 42 commissioner of the department of health shall reduce department of 43 health state funds medicaid disbursements by the amount of the projected 44 overspending through, actions including, but not limited to modifying or 45 suspending reimbursement methods, including but not limited to all fees, 46 premium levels and rates of payment, notwithstanding any provision of 47 law that sets a specific amount or methodology for any such payments or 48 rates of payment; modifying Medicaid program benefits; seeking all 49 necessary Federal approvals, including, but not limited to waivers, 50 waiver amendments; and suspending time frames for notice, approval or 51 certification of rate requirements, notwithstanding any provision of 52 law, rule or regulation to the contrary, including but not limited to 53 sections 2807 and 3614 of the public health law, section 18 of chapter 2 54 of the laws of 1988, and 18 NYCRR 505.14(h). 55 5. The department of health shall prepare a monthly report that sets 56 forth: (a) known and projected department of health medicaid expendi- S. 2606--C 9 1 tures as described in subdivision one of this section, DETAILING THE 2 SPECIFIC MEDICAID EXPENDITURES INCLUDED IN THE REPORT THAT ARE SUBJECT 3 TO THE AGGREGATE LIMIT LEVEL SPECIFIED IN THE ENACTED BUDGET FINANCIAL 4 PLAN AND ANY MEDICAID EXPENDITURES THAT ARE NOT SUBJECT TO THE AGGREGATE 5 LIMIT LEVEL SPECIFIED IN THE ENACTED BUDGET FINANCIAL PLAN; and (b) the 6 actions taken to implement any medicaid savings allocation plan imple- 7 mented pursuant to subdivision four of this section, including informa- 8 tion concerning the impact of such actions on each category of service 9 and each geographic region of the state. Each such monthly report shall 10 be provided to the chairs of the senate finance and the assembly ways 11 and means committees and shall be posted on the department of health's 12 website in a timely manner. 13 6. ON OR BEFORE DECEMBER 31, 2013, THE DIRECTOR OF THE BUDGET, IN 14 CONSULTATION WITH THE CHAIRS OF THE SENATE FINANCE AND ASSEMBLY WAYS AND 15 MEANS COMMITTEES SHALL PROVIDE A REPORT TO THE GOVERNOR, THE TEMPORARY 16 PRESIDENT OF THE SENATE AND THE SPEAKER OF THE ASSEMBLY CONTAINING 17 RECOMMENDATIONS FOR INCLUSION IN THE 2014-2015 EXECUTIVE BUDGET ON MODI- 18 FYING, CONTINUING OR DISCONTINUING SECTION NINETY-ONE OF THIS PART AND 19 THIS SECTION. IN PREPARING SUCH RECOMMENDATIONS, THE FOLLOWING SHALL BE 20 ANALYZED: (A) THE ADEQUACY OF THE YEAR TO YEAR RATE OF GROWTH IN DEPART- 21 MENT OF HEALTH STATE FUNDS MEDICAID SPENDING PROVIDED FOR IN SECTION 22 NINETY-ONE OF THIS PART, (B) THE TYPES OF EXPENDITURES TO BE INCLUDED, 23 AND THE FACTORS THAT MUST BE ACCOUNTED FOR, IN DETERMINING THE DEPART- 24 MENT OF HEALTH STATE FUNDS MEDICAID AGGREGATE LIMIT LEVEL SPECIFIED IN 25 THE ENACTED BUDGET FINANCIAL PLAN, THE PROCESS FOR ASSESSING MONTHLY 26 EXPENDITURE LEVELS AND ESTABLISHING THE MEDICAID SAVINGS ALLOCATION 27 PLAN, AND THE ADEQUACY OF THE MONTHLY REPORT ON KNOWN AND PROJECTED 28 DEPARTMENT OF HEALTH STATE FUNDS MEDICAID EXPENDITURES, AND (C) OTHER 29 RELEVANT ISSUES AS AGREED TO BY THE DIRECTOR OF THE BUDGET AND THE 30 CHAIRS OF THE SENATE FINANCE AND ASSEMBLY WAYS AND MEANS COMMITTEES. IN 31 PREPARING SUCH REPORT, THE DIRECTOR OF THE BUDGET AND THE CHAIRS OF THE 32 SENATE FINANCE AND ASSEMBLY WAYS AND MEANS COMMITTEES SHALL SEEK THE 33 INPUT OF ORGANIZATIONS REPRESENTING HEALTH CARE PROVIDERS, CONSUMERS, 34 BUSINESSES, WORKERS, HEALTH INSURERS, AND OTHERS WITH RELEVANT EXPERI- 35 ENCE. 36 S 4. Section 2 of part H of chapter 59 of the laws of 2011; amending 37 the public health law and other laws relating to general hospital 38 reimbursement for annual rates, is amended to read as follows: 39 S 2. Notwithstanding paragraph (c) of subdivision 10 of section 2807-c 40 of the public health law, section 21 of chapter 1 of the laws of 1999, 41 or any other contrary provision of law, in determining rates of payments 42 by state governmental agencies effective for services provided on and 43 after January 1, 2013 through March 31, [2013] 2014, for inpatient and 44 outpatient services provided by general hospitals, for inpatient 45 services and adult day health care outpatient services provided by resi- 46 dential health care facilities pursuant to article 28 of the public 47 health law, except for residential health care facilities or units of 48 such facilities that provide services primarily to children under twen- 49 ty-one years of age, for home health care services provided pursuant to 50 article 36 of the public health law, by certified home health agencies, 51 long term home health care programs and AIDS home care programs, and for 52 personal care services provided pursuant to section 365-a of the social 53 services law, the commissioner of health shall apply no greater than 54 zero trend factors attributable to the [2013] 2014 calendar year in 55 accordance with paragraph (c) of subdivision 10 of section 2807-c of the 56 public health law, provided, however, that such no greater than zero S. 2606--C 10 1 trend factors for such [2013] 2014 calendar year shall also be applied 2 to rates of payment for personal care services provided in those local 3 social service districts, including New York city, whose rates of 4 payment for such services are established by such local social service 5 districts pursuant to a rate-setting exemption issued by the commission- 6 er of health to such local social service districts in accordance with 7 applicable regulations, and provided further, however, that for rates of 8 payment for assisted living program services provided on and after Janu- 9 ary 1, 2013 through March 31, [2013] 2014, trend factors attributable to 10 the [2013] 2014 calendar year shall be established at no greater than 11 zero percent. 12 S 5. Paragraph (a) of subdivision 8 of section 367-b of the social 13 services law, as amended by chapter 109 of the laws of 2007, is amended 14 to read as follows: 15 (a) For the purpose of orderly and timely implementation of the 16 medical assistance information and payment system, the department is 17 hereby authorized to enter into agreements with fiscal intermediaries or 18 fiscal agents for the design, development, implementation, operation, 19 processing, auditing and making of payments, subject to audits being 20 conducted by the state in accordance with the terms of such agreements, 21 for medical assistance claims under the system described by this section 22 in any social services district. Such agreements shall specifically 23 provide that the state shall have complete oversight responsibility for 24 the fiscal intermediaries' or fiscal agents' performance and shall be 25 solely responsible for establishing eligibility requirements for recipi- 26 ents, provider qualifications, rates of payment, investigation of 27 suspected fraud and abuse, issuance of identification cards, establish- 28 ing and maintaining recipient eligibility files, provider profiles, and 29 conducting state audits of the fiscal intermediaries' or agents' at 30 least once annually. The system described in this subdivision shall be 31 operated by [a] ONE OR MORE fiscal [intermediary] INTERMEDIARIES or 32 fiscal [agent] AGENTS in accordance with this subdivision unless the 33 department is otherwise authorized by a law enacted subsequent to the 34 effective date of this subdivision to operate the system in another 35 manner. In no event shall such intermediary or agent be a political 36 subdivision of the state or any other governmental agency or entity. 37 NOTWITHSTANDING THE FOREGOING, THE DEPARTMENT MAY MAKE PAYMENTS TO A 38 PROVIDER UPON THE COMMISSIONER'S DETERMINATION THAT THE PROVIDER IS 39 TEMPORARILY UNABLE TO COMPLY WITH BILLING REQUIREMENTS. The department 40 shall consult with the office of Medicaid inspector general regarding 41 any activities undertaken by the fiscal intermediaries or fiscal agents 42 regarding investigation of suspected fraud and abuse. 43 S 6. Intentionally omitted. 44 S 7. Intentionally omitted. 45 S 8. Paragraph (g) of subdivision 1 of section 189 of the state 46 finance law, as amended by chapter 379 of the laws of 2010, is amended 47 to read as follows: 48 (g) knowingly makes, uses, or causes to be made or used, a false 49 record or statement material to an obligation to pay or transmit money 50 or property to the state or a local government, OR KNOWINGLY CONCEALS OR 51 KNOWINGLY AND IMPROPERLY AVOIDS OR DECREASES AN OBLIGATION TO PAY OR 52 TRANSMIT MONEY OR PROPERTY TO THE STATE OR A LOCAL GOVERNMENT, shall be 53 liable to the state or a local government, as applicable, for a civil 54 penalty of not less than six thousand dollars and not more than twelve 55 thousand dollars, plus three times the amount of all damages, including S. 2606--C 11 1 consequential damages, which the state or local government sustains 2 because of the act of that person. 3 S 9. Subparagraphs (d) and (e) of subdivision 2 of section 190 of the 4 state finance law, paragraph (d) as amended by chapter 379 of the laws 5 of 2010, paragraph (e) as added by section 39 of part C of chapter 58 of 6 the laws of 2007, are amended to read as follows: 7 (d) If the state notifies the court that it intends to file a 8 complaint against the defendant and thereby be substituted as the plain- 9 tiff in the action, or to permit a local government to do so, such 10 complaint, WHETHER FILED SEPARATELY OR AS AN AMENDMENT TO THE QUI TAM 11 PLAINTIFF'S COMPLAINT, must be filed within thirty days after the 12 notification to the court. For statute of limitations purposes, any such 13 complaint filed by the state or a local government shall relate back to 14 the filing date of the complaint of the qui tam plaintiff, to the extent 15 that the cause of action of the state or local government arises out of 16 the conduct, transactions, or occurrences set forth, or attempted to be 17 set forth, in the [prior] complaint of the qui tam plaintiff. 18 (e) If the state notifies the court that it intends to intervene in 19 the action, or to permit a local government to do so, then such motion 20 [for intervention] TO INTERVENE, WHETHER FILED SEPARATELY OR AS AN 21 AMENDMENT TO THE QUI TAM PLAINTIFF'S COMPLAINT, shall be filed within 22 thirty days after the notification to the court. FOR STATUTE OF LIMITA- 23 TIONS PURPOSES, ANY COMPLAINT FILED BY THE STATE OR A LOCAL GOVERNMENT, 24 WHETHER FILED SEPARATELY OR AS AN AMENDMENT TO THE QUI TAM PLAINTIFF'S 25 COMPLAINT, SHALL RELATE BACK TO THE FILING DATE OF THE COMPLAINT OF THE 26 QUI TAM PLAINTIFF, TO THE EXTENT THAT THE CAUSE OF ACTION OF THE STATE 27 OR LOCAL GOVERNMENT ARISES OUT OF THE CONDUCT, TRANSACTIONS, OR OCCUR- 28 RENCES SET FORTH, OR ATTEMPTED TO BE SET FORTH, IN THE COMPLAINT OF THE 29 QUI TAM PLAINTIFF. 30 S 9-a. Subdivision 4 of section 190 of the state finance law, as added 31 by section 39 of part C of chapter 58 of the laws of 2007, is amended to 32 read as follows: 33 4. Related actions. When a person brings a qui tam action under this 34 section, no person other than the attorney general, or a local govern- 35 ment attorney acting pursuant to subdivision one of this section or 36 paragraph (b) of subdivision two of this section, may intervene or bring 37 a related civil action based upon the facts underlying the pending 38 action[, unless such other person has first obtained the permission of 39 the attorney general to intervene or to bring such related action]; 40 provided, however, that nothing in this subdivision shall be deemed to 41 deny persons the right, upon leave of court, to file briefs amicus curi- 42 ae. 43 S 9-b. Subdivisions 6 and 7 of section 190 of the state finance law, 44 as added by section 39 of part C of chapter 58 of the laws of 2007, are 45 amended and a new subdivision 11 is added to read as follows: 46 6. Awards to qui tam plaintiff. (a) If the attorney general elects to 47 convert the qui tam civil action into an attorney general enforcement 48 action, or to permit a local government to convert the action into a 49 civil enforcement action by such local government, or if the attorney 50 general or a local government elects to intervene in the qui tam civil 51 action, then the person or persons who initiated the qui tam civil 52 action collectively shall be entitled to receive between fifteen and 53 twenty-five percent of the proceeds recovered in the action or in 54 settlement of the action. The court shall determine the percentage of 55 the proceeds to which a person commencing a qui tam civil action is 56 entitled, by considering the extent to which the plaintiff substantially S. 2606--C 12 1 contributed to the prosecution of the action. Where the court finds that 2 the action was based primarily on disclosures of specific information 3 (other than information provided by the person bringing the action) 4 relating to allegations or transactions in a criminal, civil or adminis- 5 trative hearing, in a legislative or administrative report, hearing, 6 audit or investigation, or from the news media, the court may award such 7 sums as it considers appropriate, but in no case more than ten percent 8 of the proceeds, taking into account the significance of the information 9 and the role of the person or persons bringing the action in advancing 10 the case to litigation. ANY SUCH PERSON SHALL ALSO RECEIVE AN AMOUNT 11 FOR REASONABLE EXPENSES THAT THE COURT FINDS TO HAVE BEEN NECESSARILY 12 INCURRED, REASONABLE ATTORNEYS' FEES, AND COSTS PURSUANT TO ARTICLE 13 EIGHTY-ONE OF THE CIVIL PRACTICE LAW AND RULES. ALL SUCH EXPENSES, FEES, 14 AND COSTS SHALL BE AWARDED AGAINST THE DEFENDANT. 15 (b) If the attorney general or a local government does not elect to 16 intervene or convert the action, and the action is successful, then the 17 person or persons who initiated the qui tam action which obtains 18 proceeds shall be entitled to receive between twenty-five and thirty 19 percent of the proceeds recovered in the action or settlement of the 20 action. The court shall determine the percentage of the proceeds to 21 which a person commencing a qui tam civil action is entitled, by consid- 22 ering the extent to which the plaintiff substantially contributed to the 23 prosecution of the action. SUCH PERSON SHALL ALSO RECEIVE AN AMOUNT FOR 24 REASONABLE EXPENSES WHICH THE COURT FINDS TO HAVE BEEN NECESSARILY 25 INCURRED, REASONABLE ATTORNEYS' FEES, AND COSTS PURSUANT TO ARTICLE 26 EIGHTY-ONE OF THE CIVIL PRACTICE LAW AND RULES. ALL SUCH EXPENSES, FEES, 27 AND COSTS SHALL BE AWARDED AGAINST THE DEFENDANT. 28 (c) With the exception of a court award of costs, expenses or attor- 29 neys' fees, any payment to a person pursuant to this paragraph shall be 30 made from the proceeds. 31 (D) IF THE ATTORNEY GENERAL OR A LOCAL GOVERNMENT DOES NOT PROCEED 32 WITH THE ACTION AND THE PERSON BRINGING THE ACTION CONDUCTS THE ACTION, 33 THE COURT MAY AWARD TO THE DEFENDANT ITS REASONABLE ATTORNEYS' FEES AND 34 EXPENSES IF THE DEFENDANT PREVAILS IN THE ACTION AND THE COURT FINDS 35 THAT THE CLAIM OF THE PERSON BRINGING THE ACTION WAS CLEARLY FRIVOLOUS, 36 CLEARLY VEXATIOUS, OR BROUGHT PRIMARILY FOR PURPOSES OF HARASSMENT. 37 7. Costs, expenses, disbursements and attorneys' fees. In any action 38 brought pursuant to this article, the court may award [the attorney 39 general, on behalf of the people of the state of New York, and] any 40 local government that participates as a party in the action[, and any 41 person who is a qui tam plaintiff,] an amount for reasonable expenses 42 which the court finds to have been necessarily incurred, plus reasonable 43 attorneys' fees, plus costs pursuant to article eighty-one of the civil 44 practice law and rules. All such expenses, fees and costs shall be 45 awarded directly against the defendant and shall not be charged from the 46 proceeds, but shall only be awarded if [the state or] a local government 47 [or the qui tam civil action plaintiff] prevails in the action. 48 11. FEES AND EXPENSES TO PREVAILING DEFENDANT. IF, IN A CIVIL ACTION 49 BROUGHT BY THE ATTORNEY GENERAL, THE DEMAND BY THE ATTORNEY GENERAL IS 50 SUBSTANTIALLY IN EXCESS OF THE JUDGMENT FINALLY OBTAINED BY THE ATTORNEY 51 GENERAL AND IS UNREASONABLE WHEN COMPARED WITH SUCH JUDGMENT, UNDER THE 52 FACTS AND CIRCUMSTANCES OF THE CASE, THE COURT SHALL AWARD TO THE PARTY 53 THE FEES AND OTHER EXPENSES RELATED TO DEFENDING AGAINST THE EXCESSIVE 54 DEMAND, UNLESS THE PARTY HAS COMMITTED A WILLFUL VIOLATION OF LAW OR 55 OTHERWISE ACTED IN BAD FAITH, OR SPECIAL CIRCUMSTANCES MAKE AN AWARD 56 UNJUST. S. 2606--C 13 1 S 10. Intentionally omitted. 2 S 11. Intentionally omitted. 3 S 11-a. Section 364-j of the social services law is amended by adding 4 a new subdivision 27 to read as follows: 5 27. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, MANAGED CARE 6 PROVIDERS, INCLUDING A SPECIAL NEEDS MANAGED CARE PLAN OR COMPREHENSIVE 7 HIV SPECIAL NEEDS PLAN, SHALL COVER MEDICALLY NECESSARY PRESCRIPTION 8 DRUGS, INCLUDING NON-FORMULARY DRUGS, UPON DEMONSTRATION BY THE PRESCRI- 9 BER, AFTER CONSULTING WITH THE MANAGED CARE PROVIDER, THAT SUCH DRUGS, 10 IN THE PRESCRIBER'S REASONABLE PROFESSIONAL JUDGMENT, ARE MEDICALLY 11 NECESSARY AND WARRANTED. 12 S 12. Paragraph (g-1) of subdivision 2 of section 365-a of the social 13 services law, as amended by section 23 of part H of chapter 59 of the 14 laws of 2011, is amended to read as follows: 15 (g-1) drugs provided on an in-patient basis, those drugs contained on 16 the list established by regulation of the commissioner of health pursu- 17 ant to subdivision four of this section, and those drugs which may not 18 be dispensed without a prescription as required by section sixty-eight 19 hundred ten of the education law and which the commissioner of health 20 shall determine to be reimbursable based upon such factors as the avail- 21 ability of such drugs or alternatives at low cost if purchased by a 22 medicaid recipient, or the essential nature of such drugs as described 23 by such commissioner in regulations, provided, however, that such drugs, 24 exclusive of long-term maintenance drugs, shall be dispensed in quanti- 25 ties no greater than a thirty day supply or one hundred doses, whichever 26 is greater; provided further that the commissioner of health is author- 27 ized to require prior authorization for any refill of a prescription 28 when [less than seventy-five percent of the previously dispensed amount 29 per fill should have been used] MORE THAN A SIX DAY SUPPLY OF THE PREVI- 30 OUSLY DISPENSED AMOUNT SHOULD REMAIN were the product used as normally 31 indicated; provided further that the commissioner of health is author- 32 ized to require prior authorization of prescriptions of opioid analges- 33 ics in excess of four prescriptions in a thirty-day period in accordance 34 with section two hundred seventy-three of the public health law, medical 35 assistance shall not include any drug provided on other than an in-pa- 36 tient basis for which a recipient is charged or a claim is made in the 37 case of a prescription drug, in excess of the maximum reimbursable 38 amounts to be established by department regulations in accordance with 39 standards established by the secretary of the United States department 40 of health and human services, or, in the case of a drug not requiring a 41 prescription, in excess of the maximum reimbursable amount established 42 by the commissioner of health pursuant to paragraph (a) of subdivision 43 four of this section; 44 S 13. Intentionally omitted. 45 S 14. Section 271 of the public health law is REPEALED. 46 S 15. Subdivision 3 of section 270 of the public health law is 47 REPEALED, subdivision 2 is renumbered subdivision 3 and a new subdivi- 48 sion 2 is added to read as follows: 49 2. "BOARD" SHALL MEAN THE DRUG UTILIZATION REVIEW BOARD CREATED BY 50 SECTION THREE HUNDRED SIXTY-NINE-BB OF THE SOCIAL SERVICES LAW. 51 S 15-a. Subdivision 12 of section 270 of the public health law, as 52 added by section 10 of part C of chapter 58 of the laws of 2005, is 53 amended to read as follows: 54 12. "Supplemental rebate" means a supplemental rebate under subdivi- 55 sion [ten] ELEVEN of section two hundred seventy-two of this article. S. 2606--C 14 1 S 16. Section 272 of the public health law, as added by section 10 of 2 part C of chapter 58 of the laws of 2005, subdivision 4 as amended by 3 section 30 of part A of chapter 58 of the laws of 2008, subdivision 8 as 4 amended by section 5 of part B of chapter 109 of the laws of 2010, para- 5 graph (d) of subdivision 10 as added by section 17 of part H of chapter 6 59 of the laws of 2011, subdivision 11 as amended by section 36 of part 7 C of chapter 58 of the laws of 2009, paragraph (b) of subdivision 11 as 8 amended by section 9 of part H of chapter 59 of the laws of 2011, is 9 amended to read as follows: 10 S 272. Preferred drug program. 1. There is hereby established a 11 preferred drug program to promote access to the most effective 12 prescription drugs while reducing the cost of prescription drugs for 13 persons in state public health plans. 14 2. When a prescriber prescribes a non-preferred drug, state public 15 health plan reimbursement shall be denied unless prior authorization is 16 obtained, unless no prior authorization is required under this article. 17 3. The commissioner shall establish performance standards for the 18 program that, at a minimum, ensure that the preferred drug program and 19 the clinical drug review program provide sufficient technical support 20 and timely responses to consumers, prescribers and pharmacists. 21 4. Notwithstanding any other provision of law to the contrary, no 22 preferred drug program or prior authorization requirement for 23 prescription drugs, except as created by this article, paragraph (a-1) 24 or (a-2) of subdivision four of section three hundred sixty-five-a of 25 the social services law, paragraph (g) of subdivision two of section 26 three hundred sixty-five-a of the social services law, subdivision one 27 of section two hundred forty-one of the elder law and shall apply to the 28 state public health plans. 29 5. The [pharmacy and therapeutics committee] DRUG UTILIZATION REVIEW 30 BOARD shall consider and make recommendations to the commissioner for 31 the adoption of a preferred drug program. (a) In developing the 32 preferred drug program, the [committee] BOARD shall, without limitation: 33 (i) identify therapeutic classes or drugs to be included in the 34 preferred drug program; (ii) identify preferred drugs in each of the 35 chosen therapeutic classes; (iii) evaluate the clinical effectiveness 36 and safety of drugs considering the latest peer-reviewed research and 37 may consider studies submitted to the federal food and drug adminis- 38 tration in connection with its drug approval system; (iv) consider the 39 potential impact on patient care and the potential fiscal impact that 40 may result from making such a therapeutic class subject to prior author- 41 ization; [and] (v) consider the potential impact of the preferred drug 42 program on public health and safety by the use of drug-specific delivery 43 system to reduce illegal or unauthorized use or diversion of opioids; 44 and (vi) consider the potential impact of the preferred drug program on 45 the health of special populations such as children, the elderly, the 46 chronically ill, persons with HIV/AIDS and persons with mental health 47 conditions. 48 (b) In developing the preferred drug program, the [committee] BOARD 49 may consider preferred drug programs or evidence based research operated 50 or conducted by or for other state governments, the federal government, 51 or multi-state coalitions. Notwithstanding any inconsistent provision of 52 section one hundred twelve or article eleven of the state finance law or 53 section one hundred forty-two of the economic development law or any 54 other law, the department may enter into contractual agreements with the 55 Oregon Health and Science University Drug Effectiveness Review Project 56 to provide technical and clinical support to the [committee] BOARD and S. 2606--C 15 1 the department in researching and recommending drugs to be placed on the 2 preferred drug list. 3 (c) The [committee] BOARD shall from time to time review all therapeu- 4 tic classes included in the preferred drug program, and may recommend 5 that the commissioner add or delete drugs or classes of drugs to or from 6 the preferred drug program, subject to this subdivision. 7 (d) The [committee] BOARD shall establish procedures to promptly 8 review prescription drugs newly approved by the federal food and drug 9 administration. 10 6. The [committee] BOARD shall recommend a procedure and criteria for 11 the approval of non-preferred drugs as part of the prior authorization 12 process. In developing these criteria, the [committee] BOARD shall 13 include consideration of the following: 14 (a) the preferred drug has been tried by the patient and has failed to 15 produce the desired health outcomes; 16 (b) the patient has tried the preferred drug and has experienced unac- 17 ceptable side effects; 18 (c) the patient has been stabilized on a non-preferred drug and tran- 19 sition to the preferred drug would be medically contraindicated; and 20 (d) other clinical indications for the use of the non-preferred drug, 21 which shall include consideration of the medical needs of special popu- 22 lations, including children, the elderly, the chronically ill, persons 23 with mental health conditions, and persons affected by HIV/AIDS. 24 7. The commissioner shall provide thirty days public notice on the 25 department's website prior to any meeting of the [committee] BOARD to 26 develop recommendations concerning the preferred drug program. Such 27 notice regarding meetings of the [committee] BOARD shall include a 28 description of the proposed therapeutic class to be reviewed, a listing 29 of drug products in the therapeutic class, and the proposals to be 30 considered by the [committee] BOARD. The [committee] BOARD shall allow 31 interested parties a reasonable opportunity to make an oral presentation 32 to the [committee] BOARD related to the prior authorization of the ther- 33 apeutic class to be reviewed. The [committee] BOARD shall consider any 34 information provided by any interested party, including, but not limited 35 to, prescribers, dispensers, patients, consumers and manufacturers of 36 the drug in developing their recommendations. 37 8. The commissioner shall provide notice of any recommendations devel- 38 oped by the [committee] BOARD regarding the preferred drug program, at 39 least five days before any final determination by the commissioner, by 40 making such information available on the department's website. Such 41 public notice shall include: a summary of the deliberations of the 42 [committee] BOARD; a summary of the positions of those making public 43 comments at meetings of the [committee] BOARD; the response of the 44 [committee] BOARD to those comments, if any; and the findings and recom- 45 mendations of the [committee] BOARD. THE COMMISSIONER SHALL ALSO 46 PROVIDE SUCH NOTICE OF THE BOARD'S RECOMMENDATIONS BY MAKING A VIDEO OR 47 AUDIO OF THE BOARD'S MEETINGS AVAILABLE ON THE DEPARTMENT'S WEBSITE AT 48 LEAST FIVE DAYS BEFORE ANY FINAL DETERMINATION BY THE COMMISSIONER. 49 9. Within ten days of a final determination regarding the preferred 50 drug program, the commissioner shall provide public notice on the 51 department's website of such determinations, including: the nature of 52 the determination; and analysis of the impact of the commissioner's 53 determination on state public health plan populations and providers; and 54 the projected fiscal impact to the state public health plan programs of 55 the commissioner's determination. S. 2606--C 16 1 10. The commissioner shall adopt a preferred drug program and amend- 2 ments after considering the recommendations from the [committee] BOARD 3 and any comments received from prescribers, dispensers, patients, 4 consumers and manufacturers of the drug. 5 (a) The preferred drug list in any therapeutic class included in the 6 preferred drug program shall be developed based initially on an evalu- 7 ation of the clinical effectiveness, safety and patient outcomes, 8 followed by consideration of the cost-effectiveness of the drugs. 9 (b) In each therapeutic class included in the preferred drug program, 10 the [committee] BOARD shall determine whether there is one drug which is 11 significantly more clinically effective and safe, and that drug shall be 12 included on the preferred drug list without consideration of cost. If, 13 among two or more drugs in a therapeutic class, the difference in clin- 14 ical effectiveness and safety is not clinically significant, then cost 15 effectiveness (including price and supplemental rebates) may also be 16 considered in determining which drug or drugs shall be included on the 17 preferred drug list. 18 (c) In addition to drugs selected under paragraph (b) of this subdivi- 19 sion, any prescription drug in the therapeutic class, whose cost to the 20 state public health plans (including net price and supplemental rebates) 21 is equal to or less than the cost of another drug in the therapeutic 22 class that is on the preferred drug list under paragraph (b) of this 23 subdivision, may be selected to be on the preferred drug list, based on 24 clinical effectiveness, safety and cost-effectiveness. 25 (d) Notwithstanding any provision of this section to the contrary, the 26 commissioner may designate therapeutic classes of drugs, including 27 classes with only one drug, as all preferred prior to any review that 28 may be conducted by the [committee] BOARD pursuant to this section. 29 11. (a) The commissioner shall provide an opportunity for pharmaceu- 30 tical manufacturers to provide supplemental rebates to the state public 31 health plans for drugs within a therapeutic class; such supplemental 32 rebates shall be taken into consideration by the [committee] BOARD and 33 the commissioner in determining the cost-effectiveness of drugs within a 34 therapeutic class under the state public health plans. 35 (b) The commissioner may designate a pharmaceutical manufacturer as 36 one with whom the commissioner is negotiating or has negotiated a 37 manufacturer agreement, and all of the drugs it manufactures or markets 38 shall be included in the preferred drug program. The commissioner may 39 negotiate directly with a pharmaceutical manufacturer for rebates relat- 40 ing to any or all of the drugs it manufactures or markets. A manufactur- 41 er agreement shall designate any or all of the drugs manufactured or 42 marketed by the pharmaceutical manufacturer as being preferred or non 43 preferred drugs. When a pharmaceutical manufacturer has been designated 44 by the commissioner under this paragraph but the commissioner has not 45 reached a manufacturer agreement with the pharmaceutical manufacturer, 46 then the commissioner may designate some or all of the drugs manufac- 47 tured or marketed by the pharmaceutical manufacturer as non preferred 48 drugs. However, notwithstanding this paragraph, any drug that is 49 selected to be on the preferred drug list under paragraph (b) of subdi- 50 vision ten of this section on grounds that it is significantly more 51 clinically effective and safer than other drugs in its therapeutic class 52 shall be a preferred drug. 53 (c) Supplemental rebates under this subdivision shall be in addition 54 to those required by applicable federal law and subdivision seven of 55 section three hundred sixty-seven-a of the social services law. In order 56 to be considered in connection with the preferred drug program, such S. 2606--C 17 1 supplemental rebates shall apply to the drug products dispensed under 2 the Medicaid program and the EPIC program. The commissioner is prohibit- 3 ed from approving alternative rebate demonstrations, value added 4 programs or guaranteed savings from other program benefits as a substi- 5 tution for supplemental rebates. 6 13. The commissioner may implement all or a portion of the preferred 7 drug program through contracts with administrators with expertise in 8 management of pharmacy services, subject to applicable laws. 9 14. For a period of eighteen months, commencing with the date of 10 enactment of this article, and without regard to the preferred drug 11 program or the clinical drug review program requirements of this arti- 12 cle, the commissioner is authorized to implement, or continue, a prior 13 authorization requirement for a drug which may not be dispensed without 14 a prescription as required by section sixty-eight hundred ten of the 15 education law, for which there is a non-prescription version within the 16 same drug class, or for which there is a comparable non-prescription 17 version of the same drug. Any such prior authorization requirement shall 18 be implemented in a manner that is consistent with the process employed 19 by the commissioner for such authorizations as of one day prior to the 20 date of enactment of this article. At the conclusion of the eighteen 21 month period, any such drug or drug class shall be subject to the 22 preferred drug program requirements of this article; provided, however, 23 that the commissioner is authorized to immediately subject any such drug 24 to prior authorization without regard to the provisions of subdivisions 25 five through eleven of this section. 26 S 17. Subdivisions 4, 5 and 6 of section 274 of the public health law, 27 as added by section 10 of part C of chapter 58 of the laws of 2005, are 28 amended to read as follows: 29 4. The commissioner shall obtain an evaluation of the factors set 30 forth in subdivision three of this section and a recommendation as to 31 the establishment of a prior authorization requirement for a drug under 32 the clinical drug review program from the [pharmacy and therapeutics 33 committee] DRUG UTILIZATION REVIEW BOARD. For this purpose, the commis- 34 sioner and the [committee] BOARD, as applicable, shall comply with the 35 following meeting and notice processes established by this article: 36 (a) the open meetings law and freedom of information law provisions of 37 subdivision six of section two hundred seventy-one of this article; and 38 (b) the public notice and interested party provisions of subdivisions 39 seven, eight and nine of section two hundred seventy-two of this arti- 40 cle. 41 5. The [committee] BOARD shall recommend a procedure and criteria for 42 the approval of drugs subject to prior authorization under the clinical 43 drug review program. Such criteria shall include the specific approved 44 clinical indications for use of the drug. 45 6. The commissioner shall identify a drug for which prior authori- 46 zation is required, as well as the procedures and criteria for approval 47 of use of the drug, under the clinical drug review program after consid- 48 ering the recommendations from the [committee] BOARD and any comments 49 received from prescribers, dispensers, consumers and manufacturers of 50 the drug. In no event shall the prior authorization criteria for 51 approval pursuant to this subdivision result in denial of the prior 52 authorization request based on the relative cost of the drug subject to 53 prior authorization. 54 S 18. Section 277 of the public health law, as added by section 10 of 55 part C of chapter 58 of the laws of 2005, is amended to read as follows: S. 2606--C 18 1 S 277. Review and reports. 1. The commissioner, in consultation with 2 the [pharmacy and therapeutics committee] DRUG UTILIZATION REVIEW BOARD, 3 shall undertake periodic reviews, at least annually, of the preferred 4 drug program which shall include consideration of: 5 (a) the volume of prior authorizations being handled, including data 6 on the number and characteristics of prior authorization requests for 7 particular prescription drugs; 8 (b) the quality of the program's responsiveness, including the quality 9 of the administrator's responsiveness; 10 (c) complaints received from patients and providers; 11 (d) the savings attributable to the state, and to each county and the 12 city of New York, due to the provisions of this article; 13 (e) the aggregate amount of supplemental rebates received in the 14 previous fiscal year and in the current fiscal year, to date; and such 15 amounts are to be broken out by fiscal year and by month; 16 (f) the education and outreach program established by section two 17 hundred seventy-six of this article. 18 2. The commissioner and the [panel] BOARD shall, beginning March thir- 19 ty-first, two thousand six and annually thereafter, submit a report to 20 the governor and the legislature concerning each of the items subject to 21 periodic review under subdivision one of this section. 22 3. The commissioner and the [panel] BOARD shall, [beginning with the 23 commencement of the preferred drug program and monthly thereafter,] 24 submit a MONTHLY report to the governor and the legislature concerning 25 the amount of supplemental rebates AND REBATES UNDER FEDERAL LAW 26 received. 27 S 19. Subdivision 5 of section 369-bb of the social services law is 28 REPEALED and a new subdivision 5 is added to read as follows: 29 5. (A) THE FUNCTIONS, POWERS AND DUTIES OF THE FORMER PHARMACY AND 30 THERAPEUTICS COMMITTEE AS ESTABLISHED IN ARTICLE TWO-A OF THE PUBLIC 31 HEALTH LAW SHALL NOW BE CONSIDERED A FUNCTION OF THE DRUG UTILIZATION 32 REVIEW BOARD, INCLUDING BUT NOT LIMITED TO: 33 (I) CONDUCTING AN EXECUTIVE SESSION FOR THE PURPOSE OF RECEIVING AND 34 EVALUATING DRUG PRICING INFORMATION RELATED TO SUPPLEMENTAL REBATES, OR 35 RECEIVING AND EVALUATING TRADE SECRETS, OR OTHER INFORMATION WHICH, IF 36 DISCLOSED, WOULD CAUSE SUBSTANTIAL INJURY TO THE COMPETITIVE POSITION OF 37 THE MANUFACTURER; AND 38 (II) EVALUATING AND PROVIDING RECOMMENDATIONS TO THE COMMISSIONER OF 39 HEALTH ON OTHER ISSUES RELATING TO PHARMACY SERVICES UNDER MEDICAID OR 40 EPIC, INCLUDING, BUT NOT LIMITED TO: THERAPEUTIC COMPARISONS; ENHANCED 41 USE OF GENERIC DRUG PRODUCTS; ENHANCED TARGETING OF PHYSICIAN PRESCRIB- 42 ING PATTERNS; AND 43 (III) COLLABORATING WITH MANAGED CARE ORGANIZATIONS TO ADDRESS DRUG 44 UTILIZATION CONCERNS AND TO IMPLEMENT CONSISTENT MANAGEMENT STRATEGIES 45 ACROSS THE FEE-FOR-SERVICE AND MANAGED CARE PHARMACY BENEFITS. 46 (B) ANY BUSINESS OR OTHER MATTER UNDERTAKEN OR COMMENCED BY THE PHAR- 47 MACY AND THERAPEUTICS COMMITTEE PERTAINING TO OR CONNECTED WITH THE 48 FUNCTIONS, POWERS, OBLIGATIONS AND DUTIES ARE HEREBY TRANSFERRED AND 49 ASSIGNED TO THE DRUG UTILIZATION REVIEW BOARD AND PENDING ON THE EFFEC- 50 TIVE DATE OF THIS SUBDIVISION, MAY BE CONDUCTED AND COMPLETED BY THE 51 DRUG UTILIZATION REVIEW BOARD IN THE SAME MANNER AND UNDER THE SAME 52 TERMS AND CONDITIONS AND WITH THE SAME EFFECT AS IF CONDUCTED AND 53 COMPLETED BY THE PHARMACY AND THERAPEUTICS COMMITTEE. ALL BOOKS, PAPERS, 54 AND PROPERTY OF THE PHARMACY AND THERAPEUTICS COMMITTEE SHALL CONTINUE 55 TO BE MAINTAINED BY THE DRUG UTILIZATION REVIEW BOARD. S. 2606--C 19 1 (C) ALL RULES, REGULATIONS, ACTS, ORDERS, DETERMINATIONS, AND DECI- 2 SIONS OF THE PHARMACY AND THERAPEUTICS COMMITTEE PERTAINING TO THE FUNC- 3 TIONS AND POWERS HEREIN TRANSFERRED AND ASSIGNED, IN FORCE AT THE TIME 4 OF SUCH TRANSFER AND ASSUMPTION, SHALL CONTINUE IN FULL FORCE AND EFFECT 5 AS RULES, REGULATIONS, ACTS, ORDERS, DETERMINATIONS AND DECISIONS OF THE 6 DRUG UTILIZATION REVIEW BOARD UNTIL DULY MODIFIED OR ABROGATED BY THE 7 COMMISSIONER OF HEALTH. 8 S 20. Subdivisions 1 and 2 of section 369-bb of the social services 9 law, as added by chapter 632 of the laws of 1992, paragraph (a) of 10 subdivision 2 as amended by chapter 843 of the laws of 1992, is amended 11 to read as follows: 12 1. [A thirteen-member] AN EIGHTEEN MEMBER drug utilization review 13 board is hereby created in the department. [The] IN ADDITION TO THE 14 RESPONSIBILITIES UNDER SECTION TWO HUNDRED SEVENTY-TWO OF THE PUBLIC 15 HEALTH LAW, THE board is responsible for the establishment and implemen- 16 tation of medical standards and criteria for the retrospective and 17 prospective DUR program. 18 2. The members of the DUR board shall be appointed by the commissioner 19 and shall serve a three-year term. Members may be reappointed upon the 20 completion of other terms. The membership shall be comprised of the 21 following: 22 (a) [Five] SIX persons licensed and actively engaged in the practice 23 of medicine in the state, [at least one of whom shall have expertise in 24 the area of mental health, who shall be selected from a list of nominees 25 provided by the medical society of the state of New York and other 26 medical associations] WITH EXPERTISE IN THE AREAS OF MENTAL HEALTH, 27 HIV/AIDS, GERIATRICS, PEDIATRICS OR INTERNAL MEDICINE AND WHO MAY BE 28 SELECTED BASED ON INPUT FROM PROFESSIONAL ASSOCIATIONS AND/OR ADVOCACY 29 GROUPS IN NEW YORK STATE. 30 (b) [Five] SIX persons licensed and actively practicing in [community] 31 pharmacy in the state who [shall] MAY be selected [from a list of nomi- 32 nees provided by pharmaceutical societies/associations of] BASED ON 33 INPUT FROM PROFESSIONAL ASSOCIATIONS AND/OR ADVOCACY GROUPS IN New York 34 state. 35 (c) Two persons with expertise in drug utilization review who are 36 [either] health care professionals licensed under Title VIII of the 37 education law [or who are pharmacologists] AT LEAST ONE OF WHOM IS A 38 PHARMACOLOGIST. 39 (d) [One person from the department of social services (commissioner 40 or designee).] TWO PERSONS THAT ARE CONSUMERS OR CONSUMER REPRESEN- 41 TATIVES OF ORGANIZATIONS WITH A REGIONAL OR STATEWIDE CONSTITUENCY AND 42 WHO HAVE BEEN INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER 43 ADVOCACY, INCLUDING ISSUES AFFECTING MEDICAID OR EPIC RECIPIENTS. 44 (E) ONE PERSON LICENSED AND ACTIVELY PRACTICING AS A NURSE PRACTITION- 45 ER OR MIDWIFE. 46 (F) THE COMMISSIONER SHALL DESIGNATE A PERSON FROM THE DEPARTMENT TO 47 SERVE AS CHAIRPERSON OF THE BOARD. 48 S 21. Paragraph (g) of subdivision 2 of section 365-a of the social 49 services law, as amended by section 7 of part D of chapter 56 of the 50 laws of 2012, is amended to read as follows: 51 (g) sickroom supplies, eyeglasses, prosthetic appliances and dental 52 prosthetic appliances furnished in accordance with the regulations of 53 the department; provided further that: (i) the commissioner of health is 54 authorized to implement a preferred diabetic supply program wherein the 55 department of health will receive enhanced rebates from preferred 56 manufacturers of glucometers and test strips, and may subject non-pre- S. 2606--C 20 1 ferred manufacturers' glucometers and test strips to prior authorization 2 under section two hundred seventy-three of the public health law; (ii) 3 enteral formula therapy and nutritional supplements are limited to 4 coverage only for nasogastric, jejunostomy, or gastrostomy tube feeding, 5 for treatment of an inborn metabolic disorder, or to address growth and 6 development problems in children, or, subject to standards established 7 by the commissioner, for persons with a diagnosis of HIV infection, AIDS 8 or HIV-related illness or other diseases and conditions; (iii) 9 prescription footwear and inserts are limited to coverage only when used 10 as an integral part of a lower limb orthotic appliance, as part of a 11 diabetic treatment plan, or to address growth and development problems 12 in children; [and] (iv) compression and support stockings are limited to 13 coverage only for pregnancy or treatment of venous stasis ulcers; AND 14 (V) THE COMMISSIONER OF HEALTH IS AUTHORIZED TO IMPLEMENT AN INCONTI- 15 NENCE SUPPLY UTILIZATION MANAGEMENT PROGRAM TO REDUCE COSTS WITHOUT 16 LIMITING ACCESS THROUGH THE EXISTING PROVIDER NETWORK, INCLUDING BUT NOT 17 LIMITED TO SINGLE OR MULTIPLE SOURCE CONTRACTS OR, A PREFERRED INCONTI- 18 NENCE SUPPLY PROGRAM WHEREIN THE DEPARTMENT OF HEALTH WILL RECEIVE 19 ENHANCED REBATES FROM PREFERRED MANUFACTURERS OF INCONTINENCE SUPPLIES, 20 AND MAY SUBJECT NON-PREFERRED MANUFACTURERS' INCONTINENCE SUPPLIES TO 21 PRIOR APPROVAL PURSUANT TO REGULATIONS OF THE DEPARTMENT, PROVIDED ANY 22 NECESSARY APPROVALS UNDER FEDERAL LAW HAVE BEEN OBTAINED TO RECEIVE 23 FEDERAL FINANCIAL PARTICIPATION IN THE COSTS OF INCONTINENCE SUPPLIES 24 PROVIDED PURSUANT TO THIS SUBPARAGRAPH; 25 S 22. Intentionally omitted. 26 S 23. Intentionally omitted. 27 S 24. Intentionally omitted. 28 S 25. Intentionally omitted. 29 S 26. Paragraph (c) of subdivision 35 of section 2807-c of the public 30 health law, as added by section 2 of part C of chapter 58 of the laws of 31 2009, is amended to read as follows: 32 (c) The base period reported costs and statistics used for rate-set- 33 ting for operating cost components, including the weights assigned to 34 diagnostic related groups, shall be updated no less frequently than 35 every four years and the new base period shall be no more than four 36 years prior to the first applicable rate period that utilizes such new 37 base period PROVIDED, HOWEVER, THAT THE FIRST UPDATED BASE PERIOD SHALL 38 BEGIN ON JANUARY FIRST, TWO THOUSAND FOURTEEN. 39 S 27. Intentionally omitted. 40 S 28. Intentionally omitted. 41 S 29. Intentionally omitted. 42 S 30. Intentionally omitted. 43 S 31. Intentionally omitted. 44 S 32. Intentionally omitted. 45 S 33. Intentionally omitted. 46 S 33-a. Subparagraphs (ii) and (x) of paragraph (b) of subdivision 35 47 of section 2807-c of the public health law, as added by section 2 of 48 part C of chapter 58 of the laws of 2009, are amended to read as 49 follows: 50 (ii) Only those two thousand five base year costs which relate to the 51 cost of services provided to Medicaid inpatients, as determined by the 52 applicable ratio of costs to charges methodology, shall be utilized for 53 rate-setting purposes, PROVIDED, HOWEVER, THAT THE COMMISSIONER MAY 54 UTILIZE UPDATED MEDICAID INPATIENT RELATED BASE YEAR COSTS AND STATIS- 55 TICS AS NECESSARY TO ADJUST INPATIENT RATES IN ACCORDANCE WITH CLAUSE 56 (C) OF SUBPARAGRAPH (X) OF THIS PARAGRAPH; S. 2606--C 21 1 (x) Such regulations shall provide for administrative rate appeals, 2 but only with regard to: (A) the correction of computational errors or 3 omissions of data, including with regard to the hospital specific compu- 4 tations pertaining to graduate medical education, wage equalization 5 factor adjustments, [and] (B) capital cost reimbursement, AND, (C) 6 CHANGES TO THE BASE YEAR STATISTICS AND COSTS USED TO DETERMINE THE 7 DIRECT AND INDIRECT GRADUATE MEDICAL EDUCATION COMPONENTS OF THE RATES 8 AS A RESULT OF NEW TEACHING PROGRAMS AT NEW TEACHING HOSPITALS AND/OR AS 9 A RESULT OF RESIDENTS DISPLACED AND TRANSFERRED AS A RESULT OF TEACHING 10 HOSPITAL CLOSURES; 11 S 34. Section 364-i of the social services law is amended by adding a 12 new subdivision 7 to read as follows: 13 7. NOTWITHSTANDING THE PROVISIONS OF SECTION ONE HUNDRED THIRTY-THREE 14 OF THIS CHAPTER OR ANY LAW TO THE CONTRARY, NO MEDICAL ASSISTANCE, AS 15 DEFINED IN SECTION THREE HUNDRED SIXTY-FIVE-A OF THIS TITLE, SHALL BE 16 AUTHORIZED OR REQUIRED TO BE FURNISHED TO AN INDIVIDUAL PRIOR TO THE 17 DATE THE INDIVIDUAL IS DETERMINED ELIGIBLE FOR ASSISTANCE UNDER THIS 18 TITLE, EXCEPT AS PROVIDED FOR IN THIS SECTION OR PURSUANT TO THE REGU- 19 LATIONS OF THE DEPARTMENT. 20 S 35. Intentionally Omitted 21 S 35-a. Subparagraph (i) of paragraph (b) of subdivision 1 of section 22 364-j of the social services law, as amended by chapter 433 of the laws 23 of 1997, is amended to read as follows: 24 (i) is authorized to operate under article forty-four of the public 25 health law or article forty-three of the insurance law and provides or 26 arranges, directly or indirectly (including by referral) for covered 27 comprehensive health services on a full capitation basis, INCLUDING A 28 SPECIAL NEEDS MANAGED CARE PLAN OR COMPREHENSIVE HIV SPECIAL NEEDS PLAN; 29 or 30 S 36. Paragraphs (c), (m) and (p) of subdivision 1 of section 364-j of 31 the social services law, paragraph (c) as amended by section 12 of part 32 C of chapter 58 of the laws of 2004, paragraph (m) as amended by section 33 42-b of part H of chapter 59 of the laws of 2011, and paragraph (p) as 34 amended by chapter 649 of the laws of 1996, are amended and a new para- 35 graph (z) is added to read as follows: 36 (c) "Managed care program". A statewide program in which medical 37 assistance recipients enroll on a voluntary or mandatory basis to 38 receive medical assistance services, including case management, directly 39 and indirectly (including by referral) from a managed care provider, 40 [and] INCLUDING as applicable, a [mental health special needs plan] 41 SPECIAL NEEDS MANAGED CARE PLAN or a comprehensive HIV special needs 42 plan, under this section. 43 (m) "Special needs managed care plan" [and "specialized managed care 44 plan"] shall have the same meaning as in section forty-four hundred one 45 of the public health law. 46 (p) "Grievance". Any complaint presented by a participant or a partic- 47 ipant's representative for resolution through the grievance process of a 48 managed care provider[, comprehensive HIV special needs plan or a mental 49 health special needs plan]. 50 (Z) "CREDENTIALED ALCOHOLISM AND SUBSTANCE ABUSE COUNSELOR (CASAC)". 51 AN INDIVIDUAL CREDENTIALED BY THE OFFICE OF ALCOHOLISM AND SUBSTANCE 52 ABUSE SERVICES IN ACCORDANCE WITH APPLICABLE REGULATIONS OF THE COMMIS- 53 SIONER OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES. 54 S 37. Paragraph (c) of subdivision 2 of section 364-j of the social 55 services law, as added by section 42-c of part H of chapter 59 of the 56 laws of 2011, is amended to read as follows: S. 2606--C 22 1 (c) The commissioner of health, jointly with the commissioner of 2 mental health and the commissioner of alcoholism and substance abuse 3 services shall be authorized to establish special needs managed care 4 [and specialized managed care] plans, under the medical assistance 5 program, in accordance with applicable federal law and regulations. The 6 commissioner of health, in cooperation with such commissioners, is 7 authorized, subject to the approval of the director of the division of 8 the budget, to apply for federal waivers when such action would be 9 necessary to assist in promoting the objectives of this section. WITH 10 REGARD TO SUCH SPECIAL NEEDS MANAGED CARE PLANS, SUCH COMMISSIONERS 11 SHALL JOINTLY ESTABLISH STANDARDS AND REQUIREMENTS TO: 12 (I) ENSURE THAT ANY SPECIAL NEEDS MANAGED CARE PLAN SHALL HAVE AN 13 ADEQUATE NETWORK OF PROVIDERS TO MEET THE BEHAVIORAL HEALTH AND HEALTH 14 NEEDS OF ENROLLEES, AND SHALL REVIEW THE ADEQUACY PRIOR TO APPROVAL OF 15 ANY SPECIAL NEEDS MANAGED CARE PLAN, AND UPON CONTRACT RENEWAL OR EXPAN- 16 SION. TO THE EXTENT THAT THE NETWORK HAS BEEN DETERMINED TO MEET STAND- 17 ARDS SET FORTH IN SUBDIVISION FIVE OF SECTION FOUR THOUSAND FOUR HUNDRED 18 THREE OF THE PUBLIC HEALTH LAW, SUCH NETWORK SHALL BE DEEMED ADEQUATE. 19 (II) ENSURE THAT ANY SPECIAL NEEDS MANAGED CARE PLAN SHALL MAKE LEVEL 20 OF CARE AND COVERAGE DETERMINATIONS UTILIZING EVIDENCE-BASED TOOLS OR 21 GUIDELINES DESIGNED TO ADDRESS THE BEHAVIORAL HEALTH NEEDS OF ENROLLEES. 22 (III) ENSURE SUFFICIENT ACCESS TO BEHAVIORAL HEALTH AND HEALTH 23 SERVICES FOR ELIGIBLE ENROLLEES BY ESTABLISHING AND MONITORING PENE- 24 TRATION RATES OF SPECIAL NEEDS MANAGED CARE PLANS. 25 (IV) ESTABLISH STANDARDS TO ENCOURAGE THE USE OF SERVICES, PRODUCTS 26 AND CARE RECOMMENDED, ORDERED OR PRESCRIBED BY A PROVIDER TO SUFFICIENT- 27 LY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF ENROLLEES; 28 AND MONITOR THE APPLICATION OF SUCH STANDARDS TO ENSURE THAT THEY SUFFI- 29 CIENTLY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF 30 ENROLLEES. 31 S 37-a. Paragraphs (b) and (c) of subdivision 3 of section 364-j of 32 the social services law are REPEALED. 33 S 38. Paragraphs (a), (d) and (e) of subdivision 3 of section 364-j 34 of the social services law, paragraph (a) as amended by section 13 of 35 part C of chapter 58 of the laws of 2004, paragraph (d) as amended by 36 chapter 648 of the laws of 1999 and as relettered by section 77 and 37 paragraph (e) as amended by section 77-a of part H of chapter 59 of the 38 laws of 2011, are amended to read as follows: 39 (a) Every person eligible for or receiving medical assistance under 40 this article, who resides in a social services district providing 41 medical assistance, which has implemented the state's managed care 42 program shall participate in the program authorized by this section. 43 Provided, however, that participation in a comprehensive HIV special 44 needs plan also shall be in accordance with article forty-four of the 45 public health law and participation in a [mental health special needs] 46 SPECIAL NEEDS MANAGED CARE plan shall also be in accordance with article 47 forty-four of the public health law and article thirty-one of the mental 48 hygiene law. 49 (d) [The] UNTIL SUCH TIME AS PROGRAM FEATURES AND REIMBURSEMENT RATES 50 ARE APPROVED BY THE COMMISSIONER OF HEALTH, IN CONSULTATION WITH THE 51 COMMISSIONERS OF THE OFFICE OF MENTAL HEALTH, THE OFFICE FOR PEOPLE WITH 52 DEVELOPMENTAL DISABILITIES, THE OFFICE OF CHILDREN AND FAMILY SERVICES, 53 AND THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, AS APPROPRI- 54 ATE, THE following services shall not be provided to medical assistance 55 recipients through managed care programs established pursuant to this S. 2606--C 23 1 section, and shall continue to be provided outside of managed care 2 programs and in accordance with applicable reimbursement methodologies: 3 (i) day treatment services provided to individuals with developmental 4 disabilities; 5 (ii) comprehensive medicaid case management services provided to indi- 6 viduals with developmental disabilities; 7 (iii) services provided pursuant to title two-A of article twenty-five 8 of the public health law; 9 (iv) services provided pursuant to article eighty-nine of the educa- 10 tion law; 11 (v) mental health services provided by a certified voluntary free- 12 standing day treatment program where such services are provided in 13 conjunction with educational services authorized in an individualized 14 education program in accordance with regulations promulgated pursuant to 15 article eighty-nine of the education law; 16 (vi) long term services as determined by the commissioner of mental 17 retardation and developmental disabilities, provided to individuals with 18 developmental disabilities at facilities licensed pursuant to article 19 sixteen of the mental hygiene law or clinics serving individuals with 20 developmental disabilities at facilities licensed pursuant to article 21 twenty-eight of the public health law; 22 (vii) TB directly observed therapy; 23 (viii) AIDS adult day health care; 24 (ix) HIV COBRA case management; and 25 (x) other services as determined by the commissioner of health. 26 (e) The following categories of individuals may be required to enroll 27 with a managed care program when program features and reimbursement 28 rates are approved by the commissioner of health and, as appropriate, 29 the commissioners of the [department] OFFICE of mental health, the 30 office for [persons] PEOPLE with developmental disabilities, the office 31 of children and family services, and the office of [alcohol] ALCOHOLISM 32 and substance abuse services: 33 (i) an individual dually eligible for medical assistance and benefits 34 under the federal Medicare program [and enrolled in a Medicare managed 35 care plan offered by an entity that is also a managed care provider; 36 provided that (notwithstanding paragraph (g) of subdivision four of this 37 section):]; PROVIDED, HOWEVER, NOTHING HEREIN SHALL REQUIRE AN INDIVID- 38 UAL ENROLLED IN A MANAGED LONG TERM CARE PLAN, PURSUANT TO SECTION 39 FORTY-FOUR HUNDRED THREE-F OF THE PUBLIC HEALTH LAW, TO DISENROLL FROM 40 SUCH PROGRAM; 41 [(a) if the individual changes his or her Medicare managed care plan 42 as authorized by title XVIII of the federal social security act, and 43 enrolls in another Medicare managed care plan that is also a managed 44 care provider, the individual shall be (if required by the commissioner 45 under this paragraph) enrolled in that managed care provider; 46 (b) if the individual changes his or her Medicare managed care plan as 47 authorized by title XVIII of the federal social security act, but 48 enrolls in another Medicare managed care plan that is not also a managed 49 care provider, the individual shall be disenrolled from the managed care 50 provider in which he or she was enrolled and withdraw from the managed 51 care program; 52 (c) if the individual disenrolls from his or her Medicare managed care 53 plan as authorized by title XVIII of the federal social security act, 54 and does not enroll in another Medicare managed care plan, the individ- 55 ual shall be disenrolled from the managed care provider in which he or 56 she was enrolled and withdraw from the managed care program; S. 2606--C 24 1 (d) nothing herein shall require an individual enrolled in a managed 2 long term care plan, pursuant to section forty-four hundred three-f of 3 the public health law, to disenroll from such program.] 4 (ii) an individual eligible for supplemental security income; 5 (iii) HIV positive individuals; 6 (iv) persons with serious mental illness and children and adolescents 7 with serious emotional disturbances, as defined in section forty-four 8 hundred one of the public health law; 9 (v) a person receiving services provided by a residential alcohol or 10 substance abuse program or facility for the [mentally retarded] DEVELOP- 11 MENTALLY DISABLED; 12 (vi) a person receiving services provided by an intermediate care 13 facility for the [mentally retarded] DEVELOPMENTALLY DISABLED or who has 14 characteristics and needs similar to such persons; 15 (vii) a person with a developmental or physical disability who 16 receives home and community-based services or care-at-home services 17 through existing waivers under section nineteen hundred fifteen (c) of 18 the federal social security act or who has characteristics and needs 19 similar to such persons; 20 (viii) a person who is eligible for medical assistance pursuant to 21 subparagraph twelve or subparagraph thirteen of paragraph (a) of subdi- 22 vision one of section three hundred sixty-six of this title; 23 (ix) a person receiving services provided by a long term home health 24 care program, or a person receiving inpatient services in a state-oper- 25 ated psychiatric facility or a residential treatment facility for chil- 26 dren and youth; 27 (x) certified blind or disabled children living or expected to be 28 living separate and apart from the parent for thirty days or more; 29 (xi) residents of nursing facilities; 30 (xii) a foster child in the placement of a voluntary agency or in the 31 direct care of the local social services district; 32 (xiii) a person or family that is homeless; [and] 33 (xiv) individuals for whom a managed care provider is not geograph- 34 ically accessible so as to reasonably provide services to the person. A 35 managed care provider is not geographically accessible if the person 36 cannot access the provider's services in a timely fashion due to 37 distance or travel time[.]; 38 (XV) A PERSON ELIGIBLE FOR MEDICARE PARTICIPATING IN A CAPITATED 39 DEMONSTRATION PROGRAM FOR LONG TERM CARE; 40 (XVI) AN INFANT LIVING WITH AN INCARCERATED MOTHER IN A STATE OR LOCAL 41 CORRECTIONAL FACILITY AS DEFINED IN SECTION TWO OF THE CORRECTION LAW; 42 (XVII) A PERSON WHO IS EXPECTED TO BE ELIGIBLE FOR MEDICAL ASSISTANCE 43 FOR LESS THAN SIX MONTHS; 44 (XVIII) A PERSON WHO IS ELIGIBLE FOR MEDICAL ASSISTANCE BENEFITS ONLY 45 WITH RESPECT TO TUBERCULOSIS-RELATED SERVICES; 46 (XIX) INDIVIDUALS RECEIVING HOSPICE SERVICES AT TIME OF ENROLLMENT; 47 (XX) A PERSON WHO HAS PRIMARY MEDICAL OR HEALTH CARE COVERAGE AVAIL- 48 ABLE FROM OR UNDER A THIRD-PARTY PAYOR WHICH MAY BE MAINTAINED BY 49 PAYMENT, OR PART PAYMENT, OF THE PREMIUM OR COST SHARING AMOUNTS, WHEN 50 PAYMENT OF SUCH PREMIUM OR COST SHARING AMOUNTS WOULD BE COST-EFFECTIVE, 51 AS DETERMINED BY THE LOCAL SOCIAL SERVICES DISTRICT; 52 (XXI) A PERSON RECEIVING FAMILY PLANNING SERVICES PURSUANT TO SUBPARA- 53 GRAPH ELEVEN OF PARAGRAPH (A) OF SUBDIVISION ONE OF SECTION THREE 54 HUNDRED SIXTY-SIX OF THIS TITLE; S. 2606--C 25 1 (XXII) A PERSON WHO IS ELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO 2 PARAGRAPH (V) OF SUBDIVISION FOUR OF SECTION THREE HUNDRED SIXTY-SIX OF 3 THIS TITLE; 4 (XXIII) A PERSON WHO IS MEDICARE/MEDICAID DUALLY ELIGIBLE AND WHO IS 5 NOT ENROLLED IN A MEDICARE MANAGED CARE PLAN; 6 (XXIV) INDIVIDUALS WITH A CHRONIC MEDICAL CONDITION WHO ARE BEING 7 TREATED BY A SPECIALIST PHYSICIAN THAT IS NOT ASSOCIATED WITH A MANAGED 8 CARE PROVIDER IN THE INDIVIDUAL'S SOCIAL SERVICES DISTRICT; AND 9 (XXV) NATIVE AMERICANS. 10 S 39. Subparagraphs (ii), (iv) and (vii) of paragraph (e), subpara- 11 graphs (i) and (v) of paragraph (f) and paragraphs (g), (h), (i), (o), 12 (p), (q) and (r) of subdivision 4 of section 364-j of the social 13 services law, subparagraphs (ii), (iv) and (vii) of paragraph (e), 14 subparagraph (v) of paragraph (f) and paragraph (g) as amended by 15 section 14 of part C of chapter 58 of the laws of 2004, subparagraph (i) 16 of paragraph (f) as amended by section 79 of part H of chapter 59 of the 17 laws of 2011, paragraph (h) as amended by chapter 433 of the laws of 18 1997, and paragraphs (i), (o), (p), (q) and (r) as amended by chapter 19 649 of the laws of 1996, are amended and a new paragraph (v) is added to 20 read as follows: 21 (ii) In any social services district which has implemented a mandatory 22 managed care program pursuant to this section, the requirements of this 23 subparagraph shall apply to the extent consistent with federal law and 24 regulations. The department of health, may contract with one or more 25 independent organizations to provide enrollment counseling and enroll- 26 ment services, for participants required to enroll in managed care 27 programs, for each social services district requesting the services of 28 an enrollment broker. To select such organizations, the department of 29 health shall issue a request for proposals (RFP), shall evaluate 30 proposals submitted in response to such RFP and, pursuant to such RFP, 31 shall award a contract to one or more qualified and responsive organiza- 32 tions. Such organizations shall not be owned, operated, or controlled by 33 any governmental agency, managed care provider, [comprehensive HIV 34 special needs plan, mental health special needs plan,] or medical 35 services provider. 36 (iv) Local social services districts or enrollment organizations 37 through their enrollment counselors shall provide participants with the 38 opportunity for face to face counseling including individual counseling 39 upon request of the participant. Local social services districts or 40 enrollment organizations through their enrollment counselors shall also 41 provide participants with information in a culturally and linguistically 42 appropriate and understandable manner, in light of the participant's 43 needs, circumstances and language proficiency, sufficient to enable the 44 participant to make an informed selection of a managed care provider. 45 Such information shall include, but shall not be limited to: how to 46 access care within the program; a description of the medical assistance 47 services that can be obtained other than through a managed care provid- 48 er[, mental health special needs plan or comprehensive HIV special needs 49 plan]; the available managed care providers[, mental health special 50 needs plans and comprehensive HIV special needs plans] and the scope of 51 services covered by each; a listing of the medical services providers 52 associated with each managed care provider; the participants' rights 53 within the managed care program; and how to exercise such rights. 54 Enrollment counselors shall inquire into each participant's existing 55 relationships with medical services providers and explain whether and 56 how such relationships may be maintained within the managed care S. 2606--C 26 1 program. For enrollments made during face to face counseling, if the 2 participant has a preference for particular medical services providers, 3 enrollment counselors shall verify with the medical services providers 4 that such medical services providers whom the participant prefers 5 participate in the managed care provider's network and are available to 6 serve the participant. 7 (vii) Any marketing materials developed by a managed care provider[, 8 comprehensive HIV special needs plan or mental health special needs 9 plan] shall be approved by the department of health or the local social 10 services district, and the commissioner of mental health AND THE COMMIS- 11 SIONER OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, where appropriate, 12 within sixty days prior to distribution to recipients of medical assist- 13 ance. All marketing materials shall be reviewed within sixty days of 14 submission. 15 (i) Participants shall choose a managed care provider at the time of 16 application for medical assistance; if the participant does not choose 17 such a provider the commissioner shall assign such participant to a 18 managed care provider in accordance with subparagraphs (ii), (iii), (iv) 19 and (v) of this paragraph. Participants already in receipt of medical 20 assistance shall have no less than thirty days from the date selected by 21 the district to enroll in the managed care program to select a managed 22 care provider[, and as appropriate, a mental health special needs plan,] 23 and shall be provided with information to make an informed choice. Where 24 a participant has not selected such a provider [or mental health special 25 needs plan,] the commissioner of health shall assign such participant to 26 a managed care provider[, and] WHICH, IF as appropriate, [to] MAY BE a 27 [mental health special needs plan] SPECIAL NEEDS MANAGED CARE PLAN, 28 taking into account capacity and geographic accessibility. The commis- 29 sioner may after the period of time established in subparagraph (ii) of 30 this paragraph assign participants to a managed care provider taking 31 into account quality performance criteria and cost. Provided however, 32 cost criteria shall not be of greater value than quality criteria in 33 assigning participants. 34 (v) The commissioner shall assign all participants not otherwise 35 assigned to a managed care plan pursuant to subparagraphs (ii), (iii) 36 and (iv) of this paragraph equally among each of the managed care 37 providers that meet the criteria established in subparagraph (i) of this 38 paragraph; PROVIDED, HOWEVER, THAT THE COMMISSIONER SHALL ASSIGN INDI- 39 VIDUALS MEETING THE CRITERIA FOR ENROLLMENT IN A SPECIAL NEEDS MANAGED 40 CARE PLAN TO SUCH PLAN OR PLANS WHERE AVAILABLE. 41 (g) If another managed care provider[, mental health special needs 42 plan or comprehensive HIV special needs plan] is available, participants 43 may change such provider or plan without cause within thirty days of 44 notification of enrollment or the effective date of enrollment, whichev- 45 er is later with a managed care provider[, mental health special needs 46 plan or comprehensive HIV special needs plan] by making a request of the 47 local social services district except that such period shall be forty- 48 five days for participants who have been assigned to a provider by the 49 commissioner of health. However, after such thirty or forty-five day 50 period, whichever is applicable, a participant may be prohibited from 51 changing managed care providers more frequently than once every twelve 52 months, as permitted by federal law except for good cause as determined 53 by the commissioner of health through regulations. 54 (h) If another medical services provider is available, a participant 55 may change his or her provider of medical services (including primary 56 care practitioners) without cause within thirty days of the partic- S. 2606--C 27 1 ipant's first appointment with a medical services provider by making a 2 request of the managed care provider[, mental health special needs plan 3 or comprehensive HIV special needs plan]. However, after that thirty day 4 period, no participant shall be permitted to change his or her provider 5 of medical services other than once every six months except for good 6 cause as determined by the commissioner through regulations. 7 (i) A managed care provider[, mental health special needs plan, and 8 comprehensive HIV special needs plan] requesting a disenrollment shall 9 not disenroll a participant without the prior approval of the local 10 social services district in which the participant resides, provided that 11 disenrollment from a [mental health special needs plan] SPECIAL NEEDS 12 MANAGED CARE PLAN must comply with the standards of the commissioner of 13 health, THE COMMISSIONER OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, and 14 the commissioner of mental health. A managed care provider[, mental 15 health special needs plan or comprehensive HIV special needs plan] shall 16 not request disenrollment of a participant based on any diagnosis, 17 condition, or perceived diagnosis or condition, or a participant's 18 efforts to exercise his or her rights under a grievance process, 19 provided however, that a managed care provider may, where medically 20 appropriate, request permission to refer participants to a [mental 21 health special needs plan] MANAGED CARE PROVIDER THAT IS A SPECIAL NEEDS 22 MANAGED CARE PLAN or a comprehensive HIV special needs plan after 23 consulting with such participant and upon obtaining his/her consent to 24 such referral, and[,] provided further that a [mental health special 25 needs plan] SPECIAL NEEDS MANAGED CARE PLAN may, where clinically appro- 26 priate, disenroll individuals who no longer require the level of 27 services provided by a [mental health special needs plan] SPECIAL NEEDS 28 MANAGED CARE PLAN. 29 (o) A managed care provider shall provide or arrange, directly or 30 indirectly, (including by referral) for the full range of covered 31 services to all participants, notwithstanding that such participants may 32 be eligible to be enrolled in a comprehensive HIV special needs plan or 33 [mental health special needs plan] SPECIAL NEEDS MANAGED CARE PLAN. 34 (p) A managed care provider[, comprehensive HIV special needs plan and 35 mental health special needs plan] shall implement procedures to communi- 36 cate appropriately with participants who have difficulty communicating 37 in English and to communicate appropriately with visually-impaired and 38 hearing-impaired participants. 39 (q) A managed care provider[, comprehensive HIV special needs plan and 40 mental health special needs plan] shall comply with applicable state and 41 federal law provisions prohibiting discrimination on the basis of disa- 42 bility. 43 (r) A managed care provider[, comprehensive HIV special needs plan and 44 mental health special needs plan] shall provide services to participants 45 pursuant to an order of a court of competent jurisdiction, provided 46 however, that such services shall be within such provider's or plan's 47 benefit package and are reimbursable under title xix of the federal 48 social security act. 49 (V) A MANAGED CARE PROVIDER MUST ALLOW ENROLLEES TO ACCESS CHEMICAL 50 DEPENDENCE TREATMENT SERVICES FROM FACILITIES CERTIFIED BY THE OFFICE OF 51 ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, EVEN IF SUCH SERVICES ARE 52 RENDERED BY A PRACTITIONER WHO WOULD NOT OTHERWISE BE SEPARATELY REIM- 53 BURSED, INCLUDING BUT NOT LIMITED TO A CREDENTIALED ALCOHOLISM AND 54 SUBSTANCE ABUSE COUNSELOR (CASAC). S. 2606--C 28 1 S 40. Paragraph (a) of subdivision 5 of section 364-j of the social 2 services law, as amended by section 15 of part C of chapter 58 of the 3 laws of 2004, is amended to read as follows: 4 (a) The managed care program shall provide for the selection of quali- 5 fied managed care providers by the commissioner of health [and, as 6 appropriate, mental health special needs plans and comprehensive HIV 7 special needs plans] to participate in the program, INCLUDING COMPREHEN- 8 SIVE HIV SPECIAL NEEDS PLANS AND SPECIAL NEEDS MANAGED CARE PLANS IN 9 ACCORDANCE WITH THE PROVISIONS OF SECTION THREE HUNDRED SIXTY-FIVE-M OF 10 THIS TITLE; provided, however, that the commissioner of health may 11 contract directly with comprehensive HIV special needs plans consistent 12 with standards set forth in this section, and assure that such providers 13 are accessible taking into account the needs of persons with disabili- 14 ties and the differences between rural, suburban, and urban settings, 15 and in sufficient numbers to meet the health care needs of participants, 16 and shall consider the extent to which major public hospitals are 17 included within such providers' networks. 18 S 41. The opening paragraph of subdivision 6 of section 364-j of the 19 social services law, as added by chapter 649 of the laws of 1996, is 20 amended to read as follows: 21 6. A managed care provider[, mental health special needs plan or 22 comprehensive HIV special needs plan provider] shall not engage in the 23 following practices: 24 S 42. Subdivision 17 of section 364-j of the social services law, as 25 amended by section 94 of part B of chapter 436 of the laws of 1997, is 26 amended to read as follows: 27 17. (A) The provisions of this section regarding participation of 28 persons receiving family assistance and supplemental security income in 29 managed care programs shall be effective if, and as long as, federal 30 financial participation is available for expenditures for services 31 provided pursuant to this section. 32 (B) THE PROVISIONS OF THIS SECTION REGARDING THE FURNISHING OF HEALTH 33 AND BEHAVIORAL HEALTH SERVICES THROUGH A SPECIAL NEEDS MANAGED CARE PLAN 34 SHALL BE EFFECTIVE IF, AND AS LONG AS, FEDERAL FINANCIAL PARTICIPATION 35 IS AVAILABLE FOR EXPENDITURES FOR SERVICES PROVIDED BY SUCH PLANS PURSU- 36 ANT TO THIS SECTION. 37 S 43. Subdivision 20 of section 364-j of the social services law, as 38 added by chapter 649 of the laws of 1996, is amended to read as follows: 39 20. Upon a determination that a participant appears to be suitable for 40 admission to a comprehensive HIV special needs plan or a [mental health 41 special needs plan] SPECIAL NEEDS MANAGED CARE PLAN, a managed care 42 provider shall inform the participant of the availability of such plans, 43 where available and appropriate. 44 S 44. Paragraph (a) of subdivision 23 of section 364-j of the social 45 services law, as added by section 65 of part A of chapter 57 of the laws 46 of 2006, is amended to read as follows: 47 (a) As a means of protecting the health, safety and welfare of recipi- 48 ents, in addition to any other sanctions that may be imposed, the 49 commissioner, IN CONSULTATION WITH THE COMMISSIONERS OF THE OFFICE OF 50 MENTAL HEALTH AND THE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES, 51 WHERE APPROPRIATE, shall appoint temporary management of a managed care 52 provider upon determining that the managed care provider has repeatedly 53 failed to meet the substantive requirements of sections 1903(m) and 1932 54 of the federal Social Security Act and regulations. A hearing shall not 55 be required prior to the appointment of temporary management. S. 2606--C 29 1 S 45. The opening paragraph of subdivision 4 of section 365-m of the 2 social services law, as added by section 42-d of part H of chapter 59 of 3 the laws of 2011, is amended to read as follows: 4 The commissioners of the office of mental health, the office of alco- 5 holism and substance abuse services and the department of health, shall 6 have the responsibility for jointly designating on a regional basis, 7 after consultation with the local social services district and local 8 governmental unit, as such term is defined in the mental hygiene law, of 9 a city with a population of over one million persons, and after consul- 10 tation of other affected counties, a limited number of [specialized 11 managed care plans under section three hundred sixty-four-j of this 12 title,] special [need] NEEDS managed care plans under section three 13 hundred sixty-four-j of this title[, and/or integrated physical and 14 behavioral health provider systems certified under article twenty-nine-E 15 of the public health law] capable of managing the behavioral and phys- 16 ical health needs of medical assistance enrollees with significant 17 behavioral health needs. Initial designations of such plans [or provider 18 systems] should be made no later than April first, two thousand [thir- 19 teen] FOURTEEN, provided, however, such designations shall be contingent 20 upon a determination by such state commissioners that the entities to be 21 designated have the capacity and financial ability to provide services 22 in such plans [or provider systems], and that the region has a suffi- 23 cient population and service base to support such plans [and systems]. 24 Once designated, the commissioner of health shall make arrangements to 25 enroll such enrollees in such plans [or integrated provider systems] and 26 to pay such plans [or provider systems] on a capitated or other basis to 27 manage, coordinate, and pay for behavioral and physical health medical 28 assistance services for such enrollees. Notwithstanding any inconsistent 29 provision of section one hundred twelve and one hundred sixty-three of 30 the state finance law, and section one hundred forty-two of the economic 31 development law, or any other law to the contrary, the designations of 32 such plans [and provider systems], and any resulting contracts with such 33 plans[,] OR providers [or provider systems] are authorized to be entered 34 into by such state commissioners without a competitive bid or request 35 for proposal process, provided however that: 36 S 45-a. Paragraph c of subdivision 3 of section 365-m of the social 37 services law, as added by section 42-d of part H of chapter 59 of the 38 laws of 2011, is amended to read as follows: 39 (c) the commissioners of the office of mental health and the office of 40 alcoholism and substance abuse services, in consultation with the 41 commissioner of health and the impacted local governmental units, shall 42 select such contractor or contractors that, in their discretion, have 43 demonstrated the ability to effectively, efficiently, and economically 44 integrate behavioral health and health services; have the requisite 45 expertise and financial resources; have demonstrated that their direc- 46 tors, sponsors, members, managers, partners or operators have the requi- 47 site character, competence and standing in the community, and are best 48 suited to serve the purposes of this section. IN SELECTING SUCH 49 CONTRACTOR OR CONTRACTORS, THE COMMISSIONERS SHALL: 50 (I) ENSURE THAT ANY SUCH CONTRACTOR OR CONTRACTORS HAVE AN ADEQUATE 51 NETWORK OF PROVIDERS TO MEET THE BEHAVIORAL HEALTH AND HEALTH NEEDS OF 52 ENROLLEES, AND SHALL REVIEW THE ADEQUACY PRIOR TO APPROVAL OF ANY SUCH 53 CONTRACT OR CONTRACTS, AND UPON CONTRACT RENEWAL OR EXPANSION. TO THE 54 EXTENT THAT THE NETWORK HAS BEEN DETERMINED TO MEET STANDARDS SET FORTH 55 IN SUBDIVISION FIVE OF SECTION FOUR THOUSAND FOUR HUNDRED THREE OF THE 56 PUBLIC HEALTH LAW, SUCH NETWORK SHALL BE DEEMED ADEQUATE. S. 2606--C 30 1 (II) ENSURE THAT SUCH CONTRACTOR OR CONTRACTORS SHALL MAKE LEVEL OF 2 CARE AND COVERAGE DETERMINATIONS UTILIZING EVIDENCE-BASED TOOLS OR 3 GUIDELINES DESIGNATED TO ADDRESS THE BEHAVIORAL HEALTH NEEDS OF ENROL- 4 LEES. 5 (III) ENSURE SUFFICIENT ACCESS TO BEHAVIORAL HEALTH AND HEALTH 6 SERVICES FOR ELIGIBLE ENROLLEES BY ESTABLISHING AND MONITORING PENE- 7 TRATION RATES OF ANY SUCH CONTRACTOR OR CONTRACTORS. 8 (IV) ESTABLISH STANDARDS TO ENCOURAGE THE USE OF SERVICES, PRODUCTS 9 AND CARE RECOMMENDED, ORDERED OR PRESCRIBED BY A PROVIDER TO SUFFICIENT- 10 LY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF ENROLLEES; 11 AND MONITOR THE APPLICATION OF SUCH STANDARDS TO ENSURE THAT THEY SUFFI- 12 CIENTLY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF 13 ENROLLEES. 14 S 45-b. Paragraph (c) of subdivision 4 of section 365-m of the social 15 services, as added by section 42-d of part H of chapters 59 of the laws 16 of 2011, is amended to read as follows: 17 (c) the commissioners of the office of mental health and the office of 18 alcoholism and substance abuse services, in consultation with the 19 commissioner of health, shall select such plans or systems that, in 20 their discretion, have demonstrated the ability to effectively, effi- 21 ciently, and economically manage the behavioral and physical health 22 needs of medical assistance enrollees with significant behavioral health 23 needs; have the requisite expertise and financial resources; have demon- 24 strated that their directors, sponsors, members, managers, partners or 25 operators have the requisite character, competence and standing in the 26 community, and are best suited to serve the purposes of this section. 27 Oversight of such contracts with such plans, providers or provider 28 systems shall be the joint responsibility of such state commissioners, 29 and for contracts affecting a city with a population of over one million 30 persons, also with the city's local social services district and local 31 governmental unit, as such term is defined in the mental hygiene law. 32 IN SELECTING SUCH PLANS OR SYSTEMS, THE COMMISSIONERS SHALL: 33 (I) ENSURE THAT ANY SUCH PLANS OR SYSTEMS HAVE AN ADEQUATE NETWORK OF 34 PROVIDERS TO MEET THE BEHAVIORAL HEALTH AND HEALTH NEEDS OF ENROLLEES, 35 AND SHALL REVIEW THE ADEQUACY PRIOR TO APPROVAL OF ANY SUCH PLANS OR 36 SYSTEMS, AND UPON CONTRACT RENEWAL OR EXPANSION. TO THE EXTENT THAT THE 37 NETWORK HAS BEEN DETERMINED TO MEET STANDARDS SET FORTH IN SUBDIVISION 38 FIVE OF SECTION FOUR THOUSAND FOUR HUNDRED THREE OF THE PUBLIC HEALTH 39 LAW, SUCH NETWORK SHALL BE DEEMED ADEQUATE. 40 (II) ENSURE THAT SUCH PLANS OR SYSTEMS SHALL MAKE LEVEL OF CARE AND 41 COVERAGE DETERMINATIONS UTILIZING EVIDENCE-BASED TOOLS OR GUIDELINES 42 DESIGNED TO ADDRESS THE BEHAVIORAL HEALTH NEEDS OF ENROLLEES. 43 (III) ENSURE SUFFICIENT ACCESS TO BEHAVIORAL HEALTH AND HEALTH 44 SERVICES FOR ELIGIBLE ENROLLEES BY ESTABLISHING AND MONITORING PENE- 45 TRATION RATES OF ANY SUCH PLANS OR SYSTEMS. 46 (IV) ESTABLISH STANDARDS TO ENCOURAGE THE USE OF SERVICES, PRODUCTS 47 AND CARE RECOMMENDED, ORDERED OR PRESCRIBED BY A PROVIDER TO SUFFICIENT- 48 LY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF ENROLLEES; 49 AND MONITOR THE APPLICATION OF SUCH STANDARDS TO ENSURE THAT THEY SUFFI- 50 CIENTLY ADDRESS THE BEHAVIORAL HEALTH AND HEALTH SERVICES NEEDS OF 51 ENROLLEES. 52 S 45-c. Section 365-m of the social services law is amended by adding 53 a new subdivision 5 to read as follows: 54 5. ON OR BEFORE JUNE THIRTIETH, TWO THOUSAND SIXTEEN, THE COMMISSION- 55 ERS OF THE OFFICE OF MENTAL HEALTH AND THE OFFICE OF ALCOHOLISM AND 56 SUBSTANCE ABUSE SERVICES, IN CONSULTATION WITH THE COMMISSIONER OF S. 2606--C 31 1 HEALTH, SHALL PREPARE A REPORT ON THE EXTENT TO WHICH ENTITIES COVERED 2 UNDER THIS SECTION MEET THE REQUIREMENTS SET FORTH IN SUBPARAGRAPHS (I), 3 (II), (III), AND (IV) OF PARAGRAPH (C) OF SUBDIVISION THREE AND SUBPARA- 4 GRAPHS (I), (II), (III), AND (IV) OF PARAGRAPH (C) OF SUBDIVISION FOUR 5 OF THIS SECTION AND ENTITIES COVERED UNDER PARAGRAPH (C) OF SUBDIVISION 6 2 OF SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE MEET THE REQUIRE- 7 MENTS OF SUBPARAGRAPHS (I), (II), (III), AND (IV) OF SUCH PARAGRAPH. THE 8 REPORT SHALL BE DELIVERED TO THE TEMPORARY PRESIDENT OF THE SENATE, THE 9 SPEAKER OF THE ASSEMBLY, THE MINORITY LEADER OF THE SENATE, AND THE 10 MINORITY LEADER OF THE ASSEMBLY ON OR BEFORE JUNE THIRTIETH, TWO THOU- 11 SAND SIXTEEN. 12 S 46. Subdivision 8 of section 4401 of the public health law, as added 13 by section 42 of part H of chapter 59 of the laws of 2011, is amended to 14 read as follows: 15 8. "Special needs managed care plan" [or "specialized managed care 16 plan"] shall mean a combination of persons natural or corporate, or any 17 groups of such persons, or a county or counties, who enter into an 18 arrangement, agreement or plan, or combination of arrangements, agree- 19 ments or plans, to provide health and behavioral health services to 20 enrollees with significant behavioral health needs. 21 S 47. Section 4403-d of the public health law, as added by section 22 42-a of part H of chapter 59 of the laws of 2011, is amended to read as 23 follows: 24 S 4403-d. Special needs managed care plans [and specialized managed 25 care plans]. No person, group of persons, county or counties may operate 26 a special needs managed care plan [or specialized managed care plan] 27 without first obtaining a certificate of authority from the commission- 28 er, issued jointly with the commissioner of the office of mental health 29 and the commissioner of the office of alcoholism and substance abuse 30 services. 31 S 47-a. Subparagraphs (iii) and (iv) of paragraph (b) of subdivision 32 7 of section 4403-f of the public health law are REPEALED. 33 S 48. Subparagraph (v) of paragraph (b) of subdivision 7 of section 34 4403-f of the public health law, as amended by section 41-b of part H of 35 chapter 59 of the laws of 2011, is amended to read as follows: 36 (v) The following medical assistance recipients shall not be eligible 37 to participate in a managed long term care program or other care coordi- 38 nation model established pursuant to this paragraph until program 39 features and reimbursement rates are approved by the commissioner and, 40 as applicable, the commissioner of developmental disabilities: 41 (1) a person enrolled in a managed care plan pursuant to section three 42 hundred sixty-four-j of the social services law; 43 (2) a participant in the traumatic brain injury waiver program; 44 (3) a participant in the nursing home transition and diversion waiver 45 program; 46 (4) a person enrolled in the assisted living program; 47 (5) a person enrolled in home and community based waiver programs 48 administered by the office for people with developmental 49 disabilities[.]; 50 (6) A PERSON WHO IS EXPECTED TO BE ELIGIBLE FOR MEDICAL ASSISTANCE FOR 51 LESS THAN SIX MONTHS, FOR A REASON OTHER THAN THAT THE PERSON IS ELIGI- 52 BLE FOR MEDICAL ASSISTANCE ONLY THROUGH THE APPLICATION OF EXCESS INCOME 53 TOWARD THE COST OF MEDICAL CARE AND SERVICES; 54 (7) A PERSON WHO IS ELIGIBLE FOR MEDICAL ASSISTANCE BENEFITS ONLY WITH 55 RESPECT TO TUBERCULOSIS-RELATED SERVICES; 56 (8) A PERSON RECEIVING HOSPICE SERVICES AT TIME OF ENROLLMENT; S. 2606--C 32 1 (9) A PERSON WHO HAS PRIMARY MEDICAL OR HEALTH CARE COVERAGE AVAILABLE 2 FROM OR UNDER A THIRD-PARTY PAYOR WHICH MAY BE MAINTAINED BY PAYMENT, OR 3 PART PAYMENT, OF THE PREMIUM OR COST SHARING AMOUNTS, WHEN PAYMENT OF 4 SUCH PREMIUM OR COST SHARING AMOUNTS WOULD BE COST-EFFECTIVE, AS DETER- 5 MINED BY THE SOCIAL SERVICES DISTRICT; 6 (10) A PERSON RECEIVING FAMILY PLANNING SERVICES PURSUANT TO SUBPARA- 7 GRAPH ELEVEN OF PARAGRAPH (A) OF SUBDIVISION ONE OF SECTION THREE 8 HUNDRED SIXTY-SIX OF THE SOCIAL SERVICES LAW; 9 (11) A PERSON WHO IS ELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO PARA- 10 GRAPH (V) OF SUBDIVISION FOUR OF SECTION THREE HUNDRED SIXTY-SIX OF THE 11 SOCIAL SERVICES LAW; AND 12 (12) NATIVE AMERICANS. 13 S 48-a. Notwithstanding any contrary provision of law, the commission- 14 er of alcoholism and substance abuse services is authorized, subject to 15 the approval of the director of the budget, to transfer to the commis- 16 sioner of health state funds to be utilized as the state share for the 17 purpose of increasing payments under the medicaid program to managed 18 care organizations licensed under article 44 of the public health law or 19 under article 43 of the insurance law. Such managed care organizations 20 shall utilize such funds for the purpose of reimbursing hospital-based 21 and free-standing chemical dependence outpatient and opioid treatment 22 clinics licensed pursuant to article 28 of the public health law or 23 article 32 of the mental hygiene law for chemical dependency services, 24 as determined by the commissioner of health, in consultation with the 25 commissioner of alcoholism and substance abuse services, provided to 26 medicaid eligible outpatients. Such reimbursement shall be in the form 27 of fees for such services which are equivalent to the payments estab- 28 lished for such services under the ambulatory patient group (APG) rate- 29 setting methodology as utilized by the department of health or by the 30 office of alcoholism and substance abuse services for rate-setting 31 purposes; provided, however, that the increase to such fees that shall 32 result from the provisions of this section shall not, in the aggregate 33 and as determined by the commissioner of health, in consultation with 34 the commissioner of alcoholism and substance abuse services, be greater 35 than the increased funds made available pursuant to this section. The 36 commissioner of health may, in consultation with the commissioner of 37 alcoholism and substance abuse services, promulgate regulations, includ- 38 ing emergency regulations, as are necessary to implement the provisions 39 of this section. 40 S 49. Section 2 of part H of chapter 111 of the laws of 2010 relating 41 to increasing Medicaid payments to providers through managed care organ- 42 izations and providing equivalent fees through an ambulatory patient 43 group methodology, is amended to read as follows: 44 S 2. This act shall take effect immediately and shall be deemed to 45 have been in full force and effect on and after April 1, 2010, AND SHALL 46 EXPIRE ON MARCH 31, 2017. 47 S 50. Paragraph (e) of subdivision 8 of section 2511 of the public 48 health law, as added by section 21-a of part B of chapter 109 of the 49 laws of 2010, is amended to read as follows: 50 (e) The commissioner shall adjust subsidy payments to approved organ- 51 izations made on and after April first, two thousand ten THROUGH MARCH 52 THIRTY-FIRST, TWO THOUSAND THIRTEEN, so that the amount of each such 53 payment, as otherwise calculated pursuant to this subdivision, is 54 reduced by twenty-eight percent of the amount by which such calculated 55 payment exceeds the statewide average subsidy payment for all approved 56 organizations in effect on April first, two thousand ten. Such statewide S. 2606--C 33 1 average subsidy payment shall be calculated by the commissioner and 2 shall not reflect adjustments made pursuant to this paragraph. 3 S 51. Intentionally Omitted. 4 S 52. Intentionally Omitted. 5 S 53. Intentionally Omitted. 6 S 53-a. Subdivision (c-1) of section 1 of part C of chapter 58 of the 7 laws of 2005, relating to as added by section 1 of part F of chapter 56 8 of the laws of 2012, authorizing reimbursement for expenditures made by 9 or on behalf of social services districts for medical assistance for 10 needy persons and the administration thereof, is amended to read as 11 follows: 12 (c-1) Notwithstanding any provisions of subdivision (c) of this 13 section to the contrary, [effective April 1, 2013,] for the period 14 [January] APRIL 1, 2013 through December 31, 2013 and for each calendar 15 year thereafter, the medical assistance expenditure amount for the 16 social services district for such period shall be equal to the previous 17 calendar year's medical assistance expenditure amount, except that[: 18 (1)] for the period [January] APRIL 1, 2013 through December 31, 2013, 19 the previous calendar year medical assistance expenditure amount will be 20 increased by [2%;] 1%. 21 [(2) for the period January 1, 2014 through December 31, 2014, the 22 previous calendar year medical assistance expenditure amount will be 23 increased by 1%.] 24 S 54. Subparagraph (iii) of paragraph (g) of subdivision 7 of section 25 4403-f of the public health law, as amended by section 41-b of part H of 26 chapter 59 of the laws of 2011, is amended to read as follows: 27 (iii) The enrollment application shall be submitted by the managed 28 long term care plan or demonstration to the entity designated by the 29 department prior to the commencement of services under the managed long 30 term care plan or demonstration. [For purposes of reimbursement of the 31 managed long term care plan or demonstration, if the enrollment applica- 32 tion is submitted on or before the twentieth day of the month, the 33 enrollment shall commence on the first day of the month following the 34 completion and submission and if the enrollment application is submitted 35 after the twentieth day of the month, the enrollment shall commence on 36 the first day of the second month following submission.] Enrollments 37 conducted by a plan or demonstration shall be subject to review and 38 audit by the department or a contractor selected pursuant to paragraph 39 (d) of this subdivision. 40 S 55. Paragraph (a) of subdivision 8 of section 3614 of the public 41 health law, as added by section 54 of part J of chapter 82 of the laws 42 of 2002, is amended to read as follows: 43 (a) Notwithstanding any inconsistent provision of law, rule or regu- 44 lation and subject to the provisions of paragraph (b) of this subdivi- 45 sion and to the availability of federal financial participation, the 46 commissioner shall adjust medical assistance rates of payment for 47 services provided by certified home health agencies FOR SUCH SERVICES 48 PROVIDED TO CHILDREN UNDER EIGHTEEN YEARS OF AGE AND FOR SERVICES 49 PROVIDED TO A SPECIAL NEEDS POPULATION OF MEDICALLY COMPLEX AND FRAGILE 50 CHILDREN, ADOLESCENTS AND YOUNG DISABLED ADULTS BY A CHHA OPERATING 51 UNDER A PILOT PROGRAM APPROVED BY THE DEPARTMENT, long term home health 52 care programs and AIDS home care programs in accordance with this para- 53 graph and paragraph (b) of this subdivision for purposes of improving 54 recruitment and retention of non-supervisory home care services workers 55 or any worker with direct patient care responsibility in the following S. 2606--C 34 1 amounts for services provided on and after December first, two thousand 2 two. 3 (i) rates of payment by governmental agencies for certified home 4 health agency services FOR SUCH SERVICES PROVIDED TO CHILDREN UNDER 5 EIGHTEEN YEARS OF AGE AND FOR SERVICES PROVIDED TO A SPECIAL NEEDS POPU- 6 LATION OF MEDICALLY COMPLEX AND FRAGILE CHILDREN, ADOLESCENTS AND YOUNG 7 DISABLED ADULTS BY A CHHA OPERATING UNDER A PILOT PROGRAM APPROVED BY 8 THE DEPARTMENT (including services provided through contracts with 9 licensed home care services agencies) shall be increased by three 10 percent; 11 (ii) rates of payment by governmental agencies for long term home 12 health care program services (including services provided through 13 contracts with licensed home care services agencies) shall be increased 14 by three percent; and 15 (iii) rates of payment by governmental agencies for AIDS home care 16 programs (including services provided through contracts with licensed 17 home care services agencies) shall be increased by three percent. 18 S 56. The opening paragraph of subdivision 9 of section 3614 of the 19 public health law, as amended by section 5 of part C of chapter 109 of 20 the laws of 2006, is amended to read as follows: 21 Notwithstanding any law to the contrary, the commissioner shall, 22 subject to the availability of federal financial participation, adjust 23 medical assistance rates of payment for certified home health agencies 24 FOR SUCH SERVICES PROVIDED TO CHILDREN UNDER EIGHTEEN YEARS OF AGE AND 25 FOR SERVICES PROVIDED TO A SPECIAL NEEDS POPULATION OF MEDICALLY COMPLEX 26 AND FRAGILE CHILDREN, ADOLESCENTS AND YOUNG DISABLED ADULTS BY A CHHA 27 OPERATING UNDER A PILOT PROGRAM APPROVED BY THE DEPARTMENT, long term 28 home health care programs, AIDS home care programs established pursuant 29 to this article, hospice programs established under article forty of 30 this chapter and for managed long term care plans and approved managed 31 long term care operating demonstrations as defined in section forty-four 32 hundred three-f of this chapter. Such adjustments shall be for purposes 33 of improving recruitment, training and retention of home health aides or 34 other personnel with direct patient care responsibility in the following 35 aggregate amounts for the following periods: 36 S 57. Paragraph (a) of subdivision 10 of section 3614 of the public 37 health law, as amended by section 24 of part C of chapter 59 of the laws 38 of 2011, is amended to read as follows: 39 (a) Such adjustments to rates of payments shall be allocated propor- 40 tionally based on each certified home health [agency's] AGENCY, long 41 term home health care program, AIDS home care and hospice program's home 42 health aide or other direct care services total annual hours of service 43 provided to medicaid patients, as reported in each such agency's most 44 recently available cost report as submitted to the department or for the 45 purpose of the managed long term care program a suitable proxy developed 46 by the department in consultation with the interested parties. Payments 47 made pursuant to this section shall not be subject to subsequent adjust- 48 ment or reconciliation; PROVIDED THAT SUCH ADJUSTMENTS TO RATES OF 49 PAYMENTS TO CERTIFIED HOME HEALTH AGENCIES SHALL ONLY BE FOR THAT 50 PORTION OF SERVICES PROVIDED TO CHILDREN UNDER EIGHTEEN YEARS OF AGE AND 51 FOR SERVICES PROVIDED TO A SPECIAL NEEDS POPULATION OF MEDICALLY COMPLEX 52 AND FRAGILE CHILDREN, ADOLESCENTS AND YOUNG DISABLED ADULTS BY A CHHA 53 OPERATING UNDER A PILOT PROGRAM APPROVED BY THE DEPARTMENT. 54 S 58. Intentionally omitted. S. 2606--C 35 1 S 59. Paragraph (d) of subdivision 2-b of section 2808 of the public 2 health law, as added by section 47 of part C of chapter 109 of the laws 3 of 2006, is amended to read as follows: 4 (d) Cost reports submitted by residential health care facilities for 5 the two thousand two calendar year or any part thereof shall, notwith- 6 standing any contrary provision of law, be subject to audit through 7 December thirty-first, two thousand [fourteen] EIGHTEEN and facilities 8 shall retain for the purpose of such audits all fiscal and statistical 9 records relevant to such cost reports, provided, however, that any such 10 audit commenced on or before December thirty-first, two thousand [four- 11 teen] EIGHTEEN, may be completed and used for the purpose of adjusting 12 any Medicaid rates which utilize such costs. 13 S 60. Subparagraph (ii) of paragraph (a) of subdivision 2-b of section 14 2808 of the public health law, as added by section 47 of part C of chap- 15 ter 109 of the laws of 2006, is amended to read as follows: 16 (ii) Rates for the periods two thousand seven and two thousand eight 17 shall be further adjusted by a per diem add-on amount, as determined by 18 the commissioner, reflecting the proportional amount of each facility's 19 projected Medicaid benefit to the total projected Medicaid benefit for 20 all facilities of the imputed use of the rate-setting methodology set 21 forth in paragraph (b) of this subdivision, provided, however, that for 22 those facilities that do not receive a per diem add-on adjustment pursu- 23 ant to this subparagraph, rates shall be further adjusted to include the 24 proportionate benefit, as determined by the commissioner, of the expira- 25 tion of the opening paragraph and paragraph (a) of subdivision sixteen 26 of this section and of paragraph (a) of subdivision fourteen of this 27 section, provided, further, however, that the aggregate total of the 28 rate adjustments made pursuant to this subparagraph shall not exceed one 29 hundred thirty-seven million five hundred thousand dollars for the two 30 thousand seven rate period and one hundred sixty-seven million five 31 hundred thousand dollars for the two thousand eight rate period AND 32 PROVIDED FURTHER, HOWEVER, THAT SUCH RATE ADJUSTMENTS AS MADE PURSUANT 33 TO THIS SUBPARAGRAPH PRIOR TO TWO THOUSAND TWELVE SHALL NOT BE SUBJECT 34 TO SUBSEQUENT ADJUSTMENT OR RECONCILIATION. 35 S 61. Subparagraph (i) of paragraph (b) of subdivision 2-b of section 36 2808 of the public health law, as amended by section 94 of part H of 37 chapter 59 of the laws of 2011, is amended to read as follows: 38 (i) (A) Subject to the provisions of subparagraphs (ii) through (xiv) 39 of this paragraph, for periods on and after April first, two thousand 40 nine the operating cost component of rates of payment shall reflect 41 allowable operating costs as reported in each facility's cost report for 42 the two thousand two calendar year, as adjusted for inflation on an 43 annual basis in accordance with the methodology set forth in paragraph 44 (c) of subdivision ten of section twenty-eight hundred seven-c of this 45 article, provided, however, that for those facilities which [do not 46 receive a per diem add-on adjustment pursuant to subparagraph (ii) of 47 paragraph (a) of this subdivision] ARE DETERMINED BY THE COMMISSIONER TO 48 BE QUALIFYING FACILITIES IN ACCORDANCE WITH THE PROVISIONS OF CLAUSE (B) 49 OF THIS SUBPARAGRAPH, rates shall be further adjusted to include the 50 proportionate benefit, as determined by the commissioner, of the expira- 51 tion of the opening paragraph and paragraph (a) of subdivision sixteen 52 of this section and of paragraph (a) of subdivision fourteen of this 53 section, and provided further that the operating cost component of rates 54 of payment for those facilities which [did not receive a per diem 55 adjustment in accordance with subparagraph (ii) of paragraph (a) of this 56 subdivision] ARE DETERMINED BY THE COMMISSIONER TO BE QUALIFYING FACILI- S. 2606--C 36 1 TIES IN ACCORDANCE WITH THE PROVISIONS OF CLAUSE (B) OF THIS SUBPARA- 2 GRAPH shall not be less than the operating component such facilities 3 received in the two thousand eight rate period, as adjusted for 4 inflation on an annual basis in accordance with the methodology set 5 forth in paragraph (c) of subdivision ten of section twenty-eight 6 hundred seven-c of this article and further provided, however, that 7 rates for facilities whose operating cost component reflects base year 8 costs subsequent to January first, two thousand two shall have rates 9 computed in accordance with this paragraph, utilizing allowable operat- 10 ing costs as reported in such subsequent base year period, and trended 11 forward to the rate year in accordance with applicable inflation 12 factors. 13 (B) FOR THE PURPOSES OF THIS SUBPARAGRAPH QUALIFYING FACILITIES ARE 14 THOSE FACILITIES FOR WHICH THE COMMISSIONER DETERMINES THAT THEIR 15 REPORTED TWO THOUSAND TWO BASE YEAR OPERATING COST COMPONENT, AS DEFINED 16 IN ACCORDANCE WITH THE REGULATIONS OF THE DEPARTMENT AS SET FORTH IN 10 17 NYCRR 86-2.10(A)(7); IS LESS THAN THE OPERATING COMPONENT SUCH FACILI- 18 TIES RECEIVED IN THE TWO THOUSAND EIGHT RATE PERIOD, AS ADJUSTED BY 19 APPLICABLE TREND FACTORS. 20 S 62. Intentionally omitted. 21 S 63. Paragraph (e-1) of subdivision 12 of section 2808 of the public 22 health law, as amended by section 1 of part D of chapter 59 of the laws 23 of 2011, is amended to read as follows: 24 (e-1) Notwithstanding any inconsistent provision of law or regulation, 25 the commissioner shall provide, in addition to payments established 26 pursuant to this article prior to application of this section, addi- 27 tional payments under the medical assistance program pursuant to title 28 eleven of article five of the social services law for non-state operated 29 public residential health care facilities, including public residential 30 health care facilities located in the county of Nassau, the county of 31 Westchester and the county of Erie, but excluding public residential 32 health care facilities operated by a town or city within a county, in 33 aggregate annual amounts of up to one hundred fifty million dollars in 34 additional payments for the state fiscal year beginning April first, two 35 thousand six and for the state fiscal year beginning April first, two 36 thousand seven and for the state fiscal year beginning April first, two 37 thousand eight and of up to three hundred million dollars in such aggre- 38 gate annual additional payments for the state fiscal year beginning 39 April first, two thousand nine, and for the state fiscal year beginning 40 April first, two thousand ten and for the state fiscal year beginning 41 April first, two thousand eleven, and for the state fiscal years begin- 42 ning April first, two thousand twelve and April first, two thousand 43 thirteen. The amount allocated to each eligible public residential 44 health care facility for this period shall be computed in accordance 45 with the provisions of paragraph (f) of this subdivision, provided, 46 however, that patient days shall be utilized for such computation 47 reflecting actual reported data for two thousand three and each repre- 48 sentative succeeding year as applicable, AND PROVIDED FURTHER, HOWEVER, 49 THAT, IN CONSULTATION WITH IMPACTED PROVIDERS, OF THE FUNDS ALLOCATED 50 FOR DISTRIBUTION IN THE STATE FISCAL YEAR BEGINNING APRIL FIRST, TWO 51 THOUSAND THIRTEEN, UP TO THIRTY-TWO MILLION DOLLARS MAY BE ALLOCATED IN 52 ACCORDANCE WITH PARAGRAPH (F-1) OF THIS SUBDIVISION. 53 S 64. Subdivision 12 of section 2808 of the public health law is 54 amended by adding a new paragraph (f-1) to read as follows: 55 (F-1) FUNDS ALLOCATED BY THE PROVISIONS OF PARAGRAPH (E-1) OF THIS 56 SUBDIVISION FOR DISTRIBUTION PURSUANT TO THIS PARAGRAPH, SHALL BE ALLO- S. 2606--C 37 1 CATED PROPORTIONALLY TO THOSE PUBLIC RESIDENTIAL HEALTH CARE FACILITIES 2 WHICH WERE SUBJECT TO RETROACTIVE REDUCTIONS IN PAYMENTS MADE PURSUANT 3 TO THIS SUBDIVISION FOR STATE FISCAL YEAR PERIODS BEGINNING APRIL FIRST, 4 TWO THOUSAND SIX. 5 S 65. Intentionally omitted. 6 S 66. Paragraph (c) of subdivision 2-c of section 2808 of the public 7 health law, as added by section 95 of part H of chapter 59 of the laws 8 of 2011, is amended to read as follows: 9 (c) The non-capital component of the rates for: (i) AIDS facilities or 10 discrete AIDS units within facilities; (ii) discrete units for residents 11 receiving care in a long-term inpatient rehabilitation program for trau- 12 matic brain injured persons; (iii) discrete units providing specialized 13 programs for residents requiring behavioral interventions; (iv) discrete 14 units for long-term ventilator dependent residents; and (v) facilities 15 or discrete units within facilities that provide extensive nursing, 16 medical, psychological and counseling support services solely to chil- 17 dren shall reflect the rates in effect for such facilities on January 18 first, two thousand nine, as adjusted for inflation and rate appeals in 19 accordance with applicable statutes, provided, however, that such rates 20 for facilities described in subparagraph (i) of this paragraph shall 21 reflect the application of the provisions of section twelve of part D of 22 chapter fifty-eight of the laws of two thousand nine, and provided 23 further, however, that insofar as such rates reflect trend adjustments 24 for trend factors attributable to the two thousand eight and two thou- 25 sand nine calendar years the aggregate amount of such trend factor 26 adjustments shall be subject to the provisions of section two of part D 27 of chapter fifty-eight of the laws of two thousand nine, as amended; AND 28 PROVIDED FURTHER, HOWEVER, THAT NOTWITHSTANDING ANY INCONSISTENT 29 PROVISIONS OF THIS SUBDIVISION AND SUBJECT TO THE AVAILABILITY OF FEDER- 30 AL FINANCIAL PARTICIPATION, FOR ALL RATE PERIODS ON AND AFTER APRIL 31 FIRST, TWO THOUSAND FOURTEEN, RATES CONSISTENT WITH PARAGRAPHS (A) AND 32 (B) OF THIS SUBDIVISION FOR FACILITIES DESCRIBED IN THIS PARAGRAPH, 33 INCLUDING A PATIENT ACUITY ADJUSTMENT FOR FACILITIES DESCRIBED IN 34 SUBPARAGRAPH (V) OF THIS PARAGRAPH, SHALL BE ESTABLISHED BY THE COMMIS- 35 SIONER BY REGULATION AS AUTHORIZED BY PARAGRAPH (D) OF THIS SUBDIVISION 36 AND IN CONSULTATION WITH AFFECTED PROVIDERS. 37 S 67. Intentionally omitted. 38 S 68. Paragraph (a) of subdivision 2 of section 366-c of the social 39 services law, as added by chapter 558 of the laws of 1989, is amended to 40 read as follows: 41 (a) For purposes of this section an "institutionalized spouse" is a 42 person (I) WHO IS in a medical institution or nursing facility [(i) who 43 is] AND expected to remain in such facility or institution for at least 44 thirty consecutive days[,]; or (II) WHO is receiving care, services and 45 supplies pursuant to a waiver pursuant to subsection (c) of section 46 nineteen hundred fifteen of the federal social security act OR IS 47 RECEIVING CARE, SERVICES AND SUPPLIES IN A MANAGED LONG-TERM CARE PLAN 48 PURSUANT TO SECTION ELEVEN HUNDRED FIFTEEN OF THE SOCIAL SECURITY ACT; 49 and [(ii)] (III) who is married to a person who is not in a medical 50 institution or nursing facility or is not receiving WAIVER services 51 [pursuant to a waiver pursuant to subsection (c) of section nineteen 52 hundred fifteen of the federal social security act] DESCRIBED IN SUBPAR- 53 AGRAPH (II) OF THIS PARAGRAPH; PROVIDED, HOWEVER, THAT MEDICAL ASSIST- 54 ANCE SHALL BE FURNISHED PURSUANT TO THIS PARAGRAPH ONLY IF, FOR SO LONG 55 AS, AND TO THE EXTENT THAT FEDERAL FINANCIAL PARTICIPATION IS AVAILABLE 56 THEREFOR. THE COMMISSIONER OF HEALTH SHALL MAKE ANY AMENDMENTS TO THE S. 2606--C 38 1 STATE PLAN FOR MEDICAL ASSISTANCE, OR APPLY FOR ANY WAIVER OR APPROVAL 2 UNDER THE FEDERAL SOCIAL SECURITY ACT THAT ARE NECESSARY TO CARRY OUT 3 THE PROVISIONS OF THIS PARAGRAPH. 4 S 69. Paragraph (b) of subdivision 6 of section 3614 of the public 5 health law, as added by chapter 645 of the laws of 2003, is amended to 6 read as follows: 7 (b) For purposes of this subdivision, real property capital 8 construction costs shall only be included in rates of payment for 9 assisted living programs if: THE FACILITY HOUSES EXCLUSIVELY ASSISTED 10 LIVING PROGRAM BEDS AUTHORIZED PURSUANT TO PARAGRAPH (J) OF SUBDIVISION 11 THREE OF SECTION FOUR HUNDRED SIXTY-ONE-L OF THE SOCIAL SERVICES LAW OR 12 (i) the facility is operated by a not-for-profit corporation; (ii) the 13 facility commenced operation after nineteen hundred ninety-eight and at 14 least ninety-five percent of the certified approved beds are provided to 15 residents who are subject to the assisted living program; and (iii) the 16 assisted living program is in a county with a population of no less than 17 two hundred eighty thousand persons. The methodology used to calculate 18 the rate for such capital construction costs shall be the same methodol- 19 ogy used to calculate the capital construction costs at residential 20 health care facilities for such costs, PROVIDED THAT THE COMMISSIONER 21 MAY ADOPT RULES AND REGULATIONS WHICH ESTABLISH A CAP ON REAL PROPERTY 22 CAPITAL CONSTRUCTION COSTS FOR THOSE FACILITIES THAT HOUSE EXCLUSIVELY 23 ASSISTED LIVING PROGRAM BEDS AUTHORIZED PURSUANT TO PARAGRAPH (J) OF 24 SUBDIVISION THREE OF SECTION FOUR HUNDRED SIXTY-ONE-L OF THE SOCIAL 25 SERVICES LAW. 26 S 70. Subdivision 3 of section 461-l of the social services law is 27 amended by adding a new paragraph (j) to read as follows: 28 (J) THE COMMISSIONER OF HEALTH IS AUTHORIZED TO ADD UP TO FOUR THOU- 29 SAND FIVE HUNDRED ASSISTED LIVING PROGRAM BEDS TO THE GROSS NUMBER OF 30 ASSISTED LIVING PROGRAM BEDS HAVING BEEN DETERMINED TO BE AVAILABLE AS 31 OF APRIL FIRST, TWO THOUSAND TWELVE. APPLICANTS ELIGIBLE TO SUBMIT AN 32 APPLICATION UNDER THIS PARAGRAPH SHALL BE LIMITED TO ADULT HOMES ESTAB- 33 LISHED PURSUANT TO SECTION FOUR HUNDRED SIXTY-ONE-B OF THIS ARTICLE 34 WITH, AS OF SEPTEMBER FIRST, TWO THOUSAND TWELVE, A CERTIFIED CAPACITY 35 OF EIGHTY BEDS OR MORE IN WHICH TWENTY-FIVE PERCENT OR MORE OF THE RESI- 36 DENT POPULATION ARE PERSONS WITH SERIOUS MENTAL ILLNESS AS DEFINED IN 37 REGULATIONS PROMULGATED BY THE COMMISSIONER OF HEALTH. THE COMMISSIONER 38 OF HEALTH SHALL NOT BE REQUIRED TO REVIEW ON A COMPARATIVE BASIS APPLI- 39 CATIONS SUBMITTED FOR ASSISTED LIVING PROGRAM BEDS MADE AVAILABLE UNDER 40 THIS PARAGRAPH. 41 S 71. Subdivision 14 of section 366 of the social services law, as 42 added by section 74 of part H of chapter 59 of the laws of 2011, is 43 amended to read as follows: 44 14. The commissioner of health may make any available amendments to 45 the state plan for medical assistance submitted pursuant to section 46 three hundred sixty-three-a of this title, or, if an amendment is not 47 possible, develop and submit an application for any waiver or approval 48 under the federal social security act that may be necessary to disregard 49 or exempt an amount of income, for the purpose of assisting with housing 50 costs, for individuals receiving coverage of nursing facility services 51 under this title, OTHER THAN SHORT-TERM REHABILITATION SERVICES, AND FOR 52 INDIVIDUALS IN RECEIPT OF MEDICAL ASSISTANCE WHILE IN AN ADULT HOME, AS 53 DEFINED IN SUBDIVISION TWENTY-FIVE OF SECTION TWO OF THIS CHAPTER, who 54 [are]: ARE (i) discharged [from the nursing facility] to the community; 55 AND (ii) IF ELIGIBLE, enrolled in a plan certified pursuant to section 56 forty-four hundred three-f of the public health law; and (iii) [while so S. 2606--C 39 1 enrolled, not] DO NOT MEET THE CRITERIA TO BE considered an "institu- 2 tionalized spouse" for purposes of section three hundred sixty-six-c of 3 this title. 4 S 71-a. Section 97-eeee of the state finance law, as amended by 5 section 10 of part B of chapter 58 of the laws of 2007, is amended to 6 read as follows: 7 S 97-eeee. Federal-state health reform partnership program account. 1. 8 There is hereby established in the joint custody of the state comp- 9 troller and the commissioner of taxation and finance a miscellaneous 10 special revenue account to be known as the "federal-state health reform 11 partnership program account". 12 2. The account shall consist of [those] ALL monies received from the 13 federal government for additional medical assistance revenues [or], 14 savings achieved under the federal-state health reform partnership 15 program [or], monies earned by the state and received from the federal 16 government to support expenditures under the federal-state health reform 17 partnership program and/or successor program pursuant to section 1115 of 18 the federal social security act. 19 3. Notwithstanding any provision of law to the contrary, where and to 20 the extent that federal revenues or savings under subdivision two of 21 this section made available to the state under any such New York State 22 section 1115 waiver or amendment thereto, such revenues or savings shall 23 be deposited in the account. 24 4. [All] NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, ALL 25 monies shall remain in such account unless otherwise disbursed pursuant 26 to appropriation by the legislature. 27 S 72. Section 364-j of the social services law is amended by adding a 28 new subdivision 27 to read as follows: 29 27. (A) THE CENTERS FOR MEDICARE AND MEDICAID SERVICES HAS ESTABLISHED 30 AN INITIATIVE TO ALIGN INCENTIVES BETWEEN MEDICARE AND MEDICAID. THE 31 GOAL OF THE INITIATIVE IS TO INCREASE ACCESS TO SEAMLESS, QUALITY 32 PROGRAMS THAT INTEGRATE SERVICES FOR THE DUALLY ELIGIBLE BENEFICIARY AS 33 WELL AS TO ACHIEVE BOTH STATE AND FEDERAL HEALTH CARE SAVINGS BY IMPROV- 34 ING HEALTH CARE DELIVERY AND ENCOURAGING HIGH-QUALITY, EFFICIENT CARE. 35 IN FURTHERANCE OF THIS GOAL, THE LEGISLATURE AUTHORIZES THE COMMISSIONER 36 OF HEALTH TO ESTABLISH A FULLY INTEGRATED DUALS ADVANTAGE (FIDA) 37 PROGRAM. 38 (B) THE FIDA PROGRAM SHALL PROVIDE TARGETED POPULATIONS OF 39 MEDICARE/MEDICAID DUALLY ELIGIBLE PERSONS WITH COMPREHENSIVE HEALTH 40 SERVICES THAT INCLUDE THE FULL RANGE OF MEDICARE AND MEDICAID COVERED 41 SERVICES, INCLUDING BUT NOT LIMITED TO PRIMARY AND ACUTE CARE, 42 PRESCRIPTION DRUGS, BEHAVIORAL HEALTH SERVICES, CARE COORDINATION 43 SERVICES, AND LONG-TERM SUPPORTS AND SERVICES, AS WELL AS OTHER 44 SERVICES, THROUGH MANAGED CARE PROVIDERS, AS DEFINED IN SUBDIVISION ONE 45 OF THIS SECTION, INCLUDING MANAGED LONG TERM CARE PLANS CERTIFIED PURSU- 46 ANT TO SECTION FORTY-FOUR HUNDRED THREE-F OF THE PUBLIC HEALTH LAW. 47 (C) UNDER THE FIDA PROGRAM ESTABLISHED PURSUANT TO THIS SUBDIVISION, 48 UP TO THREE MANAGED LONG TERM CARE PLANS MAY BE AUTHORIZED TO EXCLUSIVE- 49 LY ENROLL INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES, AS SUCH TERM IS 50 DEFINED IN SECTION 1.03 OF THE MENTAL HYGIENE LAW. THE COMMISSIONER OF 51 HEALTH MAY WAIVE ANY OF THE DEPARTMENT'S REGULATIONS AS THE COMMISSION- 52 ER, IN CONSULTATION WITH THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES, 53 DEEMS NECESSARY TO ALLOW SUCH MANAGED LONG TERM CARE PLANS TO PROVIDE OR 54 ARRANGE FOR SERVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES 55 THAT ARE ADEQUATE AND APPROPRIATE TO MEET THE NEEDS OF SUCH INDIVIDUALS 56 AND THAT WILL ENSURE THEIR HEALTH AND SAFETY. THE COMMISSIONER OF DEVEL- S. 2606--C 40 1 OPMENTAL DISABILITIES MAY WAIVE ANY OF THE OFFICE FOR PEOPLE WITH DEVEL- 2 OPMENTAL DISABILITIES' REGULATIONS AS SUCH COMMISSIONER, IN CONSULTATION 3 WITH THE COMMISSIONER OF HEALTH, DEEMS NECESSARY TO ALLOW SUCH MANAGED 4 LONG TERM CARE PLANS TO PROVIDE OR ARRANGE FOR SERVICES FOR INDIVIDUALS 5 WITH DEVELOPMENTAL DISABILITIES THAT ARE ADEQUATE AND APPROPRIATE TO 6 MEET THE NEEDS OF SUCH INDIVIDUALS AND THAT WILL ENSURE THEIR HEALTH AND 7 SAFETY. 8 (D) THE PROVISIONS OF THIS SUBDIVISION SHALL NOT APPLY UNLESS ALL 9 NECESSARY APPROVALS UNDER FEDERAL LAW AND REGULATION HAVE BEEN OBTAINED 10 TO RECEIVE FEDERAL FINANCIAL PARTICIPATION IN THE COSTS OF HEALTH CARE 11 SERVICES PROVIDED PURSUANT TO THIS SUBDIVISION. 12 (E) THE COMMISSIONER OF HEALTH IS AUTHORIZED TO SUBMIT AMENDMENTS TO 13 THE STATE PLAN FOR MEDICAL ASSISTANCE AND/OR SUBMIT ONE OR MORE APPLICA- 14 TIONS FOR WAIVERS OF THE FEDERAL SOCIAL SECURITY ACT AS MAY BE NECESSARY 15 TO OBTAIN THE FEDERAL APPROVALS NECESSARY TO IMPLEMENT THIS SUBDIVISION. 16 (F) THE COMMISSIONER OF HEALTH, IN CONSULTATION WITH THE COMMISSIONER 17 OF DEVELOPMENTAL DISABILITIES, AS APPROPRIATE, MAY CONTRACT WITH MANAGED 18 CARE PLANS APPROVED TO PARTICIPATE IN THE FIDA PROGRAM WITHOUT THE NEED 19 FOR A COMPETITIVE BID OR REQUEST FOR PROPOSAL PROCESS, AND WITHOUT 20 REGARD TO THE PROVISIONS OF SECTIONS ONE HUNDRED TWELVE AND ONE HUNDRED 21 SIXTY-THREE OF THE STATE FINANCE LAW, SECTION ONE HUNDRED FORTY-TWO OF 22 THE ECONOMIC DEVELOPMENT LAW, OR ANY OTHER PROVISION OF LAW. 23 S 73. The public health law is amended by adding a new section 4403-g 24 to read as follows: 25 S 4403-G. DEVELOPMENTAL DISABILITY INDIVIDUAL SUPPORT AND CARE COORDI- 26 NATION ORGANIZATIONS. 1. DEFINITIONS. AS USED IN THIS SECTION: 27 (A) "DEVELOPMENTAL DISABILITY INDIVIDUAL SUPPORT AND CARE COORDINATION 28 ORGANIZATION" OR "DISCO" MEANS AN ENTITY THAT HAS RECEIVED A CERTIFICATE 29 OF AUTHORITY PURSUANT TO THIS SECTION TO PROVIDE, OR ARRANGE FOR, HEALTH 30 AND LONG TERM CARE SERVICES, AS DETERMINED BY THE COMMISSIONER AND THE 31 COMMISSIONER OF DEVELOPMENTAL DISABILITIES, ON A CAPITATED BASIS IN 32 ACCORDANCE WITH THIS SECTION, FOR A POPULATION OF INDIVIDUALS WITH 33 DEVELOPMENTAL DISABILITIES, AS SUCH TERM IS DEFINED IN SECTION 1.03 OF 34 THE MENTAL HYGIENE LAW, WHICH THE ORGANIZATION IS AUTHORIZED TO ENROLL. 35 (B) "ELIGIBLE APPLICANT" MEANS AN ENTITY CONTROLLED BY ONE OR MORE 36 NON-PROFIT ORGANIZATIONS WHICH HAVE A HISTORY OF PROVIDING OR COORDINAT- 37 ING HEALTH AND LONG TERM CARE SERVICES TO PERSONS WITH DEVELOPMENTAL 38 DISABILITIES. 39 (C) "HABILITATION SERVICES" MEANS SERVICES, INCLUDING BUT NOT LIMITED 40 TO LONG TERM HOME AND COMMUNITY BASED SERVICES, DESIGNED TO ASSIST INDI- 41 VIDUALS IN ACQUIRING, RETAINING, AND IMPROVING THE SELF-HELP, SOCIALIZA- 42 TION, AND ADAPTIVE SKILLS NECESSARY TO RESIDE SUCCESSFULLY IN HOME AND 43 COMMUNITY BASED SETTINGS, INCLUDING PREVOCATIONAL, EDUCATIONAL, AND 44 SUPPORTED EMPLOYMENT SERVICES, BUT NOT INCLUDING SPECIAL EDUCATION AND 45 RELATED SERVICES THAT OTHERWISE ARE AVAILABLE TO THE INDIVIDUAL THROUGH 46 A LOCAL EDUCATIONAL AGENCY, OR VOCATIONAL REHABILITATION SERVICES THAT 47 OTHERWISE ARE AVAILABLE TO THE INDIVIDUAL THROUGH A PROGRAM FUNDED UNDER 48 SECTION ONE HUNDRED TEN OF THE REHABILITATION ACT OF NINETEEN HUNDRED 49 SEVENTY-THREE; 50 (D) "HEALTH AND LONG TERM CARE SERVICES" MEANS SERVICES INCLUDING, BUT 51 NOT LIMITED TO, HABILITATION SERVICES, OTHER HOME AND COMMUNITY-BASED 52 AND INSTITUTION-BASED LONG TERM CARE SERVICES, AND ANCILLARY SERVICES 53 (THAT SHALL INCLUDE MEDICAL SUPPLIES AND NUTRITIONAL SUPPLEMENTS) THAT 54 ARE NECESSARY TO MEET THE NEEDS OF PERSONS WHOM THE PLAN IS AUTHORIZED 55 TO ENROLL, AND MAY INCLUDE PRIMARY CARE AND ACUTE CARE IF THE DISCO IS 56 AUTHORIZED TO PROVIDE OR ARRANGE FOR SUCH SERVICES. EACH PERSON S. 2606--C 41 1 ENROLLED IN A DISCO SHALL RECEIVE THE HABILITATION AND OTHER SERVICES 2 NECESSARY TO ACHIEVE PERSON-CENTERED GOALS, TO LIVE IN THE MOST INTE- 3 GRATED SETTING APPROPRIATE TO THAT PERSON'S NEEDS, AND TO ENABLE THAT 4 PERSON TO INTERACT WITH NONDISABLED PERSONS TO THE FULLEST EXTENT POSSI- 5 BLE, PROVIDED THAT ALL SUCH SERVICES ARE CONSISTENT WITH SUCH PERSON'S 6 WISHES TO THE EXTENT SUCH WISHES ARE KNOWN. 7 2. APPROVAL AUTHORITY. AN APPLICANT SHALL BE ISSUED A CERTIFICATE OF 8 AUTHORITY AS A DISCO UPON A DETERMINATION BY THE COMMISSIONER AND THE 9 COMMISSIONER OF DEVELOPMENTAL DISABILITIES THAT THE APPLICANT COMPLIES 10 WITH THE OPERATING REQUIREMENTS FOR A DISCO UNDER THIS SECTION. 11 3. APPLICATION FOR CERTIFICATE OF AUTHORITY; FORM. THE COMMISSIONER 12 AND THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES SHALL JOINTLY DEVELOP 13 APPLICATION FORMS FOR A CERTIFICATE OF AUTHORITY TO OPERATE A DISCO. AN 14 ELIGIBLE APPLICANT SHALL SUBMIT AN APPLICATION FOR A CERTIFICATE OF 15 AUTHORITY TO OPERATE A DISCO UPON FORMS PRESCRIBED BY SUCH COMMISSION- 16 ERS. SUCH ELIGIBLE APPLICANT SHALL SUBMIT INFORMATION AND DOCUMENTATION 17 TO THE COMMISSIONER WHICH SHALL INCLUDE, BUT NOT BE LIMITED TO: 18 (A) A DESCRIPTION OF THE SERVICE AREA PROPOSED TO BE SERVED BY THE 19 DISCO WITH PROJECTIONS OF ENROLLMENT THAT WILL RESULT IN A FISCALLY 20 SOUND PLAN; 21 (B) A DESCRIPTION OF THE SERVICES TO BE COVERED BY SUCH DISCO; 22 (C) A DESCRIPTION OF THE PROPOSED MARKETING PLAN, AND HOW MARKETING 23 MATERIALS WILL BE PRESENTED TO INDIVIDUALS WITH DEVELOPMENTAL DISABILI- 24 TIES, OR THEIR AUTHORIZED SURROGATES, FOR THE PURPOSES OF ENABLING THEM 25 TO MAKE AN INFORMED CHOICE; 26 (D) THE NAMES OF THE PROVIDERS PROPOSED TO BE IN THE DISCO'S NETWORK; 27 (E) EVIDENCE OF THE CHARACTER AND COMPETENCE OF THE APPLICANT'S 28 PROPOSED OPERATORS; 29 (F) ADEQUATE DOCUMENTATION OF THE APPROPRIATE LICENSES, CERTIFICATIONS 30 OR APPROVALS TO PROVIDE CARE AS PLANNED, INCLUDING AFFILIATE AGREEMENTS 31 OR PROPOSED CONTRACTS WITH SUCH PROVIDERS AS MAY BE NECESSARY TO PROVIDE 32 THE FULL COMPLEMENT OF SERVICES REQUIRED TO BE PROVIDED UNDER THIS 33 SECTION; 34 (G) A DESCRIPTION OF THE PROPOSED QUALITY-ASSURANCE MECHANISMS, GRIEV- 35 ANCE PROCEDURES, MECHANISMS TO PROTECT THE RIGHTS OF ENROLLEES AND CARE 36 COORDINATION SERVICES TO ENSURE CONTINUITY, QUALITY, APPROPRIATENESS AND 37 COORDINATION OF CARE; 38 (H) A DESCRIPTION OF THE PROPOSED QUALITY ASSESSMENT AND PERFORMANCE 39 IMPROVEMENT PROGRAM THAT INCLUDES PERFORMANCE AND OUTCOME BASED QUALITY 40 STANDARDS FOR ENROLLEE HEALTH STATUS AND SATISFACTION, AND DATA 41 COLLECTION AND REPORTING FOR STANDARD PERFORMANCE MEASURES; 42 (I) A DESCRIPTION OF THE MANAGEMENT SYSTEMS AND SYSTEMS TO PROCESS 43 PAYMENT FOR COVERED SERVICES; 44 (J) A DESCRIPTION OF HOW ACHIEVING OF PERSON-CENTERED GOALS, AS 45 DEFINED BY THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES, WILL BE 46 ASSESSED; AS WELL AS A DESCRIPTION OF HOW HABILITATION SERVICES, INCLUD- 47 ING LONG TERM CARE SERVICES, WILL MEET SUCH GOALS; 48 (K) A DESCRIPTION OF THE MECHANISM TO MAXIMIZE REIMBURSEMENT OF AND 49 COORDINATE SERVICES REIMBURSED PURSUANT TO TITLE XVIII OF THE FEDERAL 50 SOCIAL SECURITY ACT AND ALL OTHER APPLICABLE BENEFITS, WITH SUCH BENEFIT 51 COORDINATION INCLUDING, BUT NOT LIMITED TO, MEASURES TO SUPPORT SOUND 52 CLINICAL DECISIONS, REDUCE ADMINISTRATIVE COMPLEXITY, COORDINATE ACCESS 53 TO SERVICES, MAXIMIZE BENEFITS AVAILABLE PURSUANT TO SUCH TITLE AND 54 ENSURE THAT NECESSARY CARE IS PROVIDED; 55 (L) A DESCRIPTION OF THE SYSTEMS FOR SECURING AND INTEGRATING ANY 56 POTENTIAL SOURCES OF FUNDING FOR SERVICES PROVIDED BY OR THROUGH THE S. 2606--C 42 1 ORGANIZATION, INCLUDING, BUT NOT LIMITED TO, FUNDING AVAILABLE UNDER 2 TITLES XVI, XVIII, XIX AND XX OF THE FEDERAL SOCIAL SECURITY ACT AND ALL 3 OTHER AVAILABLE SOURCES OF FUNDING; 4 (M) A DESCRIPTION OF THE PROPOSED CONTRACTUAL ARRANGEMENTS FOR PROVID- 5 ERS OF HEALTH AND LONG TERM CARE SERVICES IN THE BENEFIT PACKAGE; AND 6 (N) INFORMATION RELATED TO THE FINANCIAL CONDITION OF THE APPLICANT. 7 4. CERTIFICATE OF AUTHORITY APPROVAL. THE COMMISSIONER SHALL NOT 8 APPROVE AN APPLICATION FOR A CERTIFICATE OF AUTHORITY UNLESS THE APPLI- 9 CANT DEMONSTRATES TO THE SATISFACTION OF THE COMMISSIONER AND THE 10 COMMISSIONER OF DEVELOPMENTAL DISABILITIES: 11 (A) THAT IT WILL HAVE IN PLACE ACCEPTABLE QUALITY ASSURANCE MECH- 12 ANISMS, GRIEVANCE PROCEDURES AND MECHANISMS TO PROTECT THE RIGHTS OF 13 ENROLLEES AND CARE COORDINATION SERVICES TO ENSURE CONTINUITY, QUALITY, 14 APPROPRIATENESS AND COORDINATION OF CARE; 15 (B) THAT IT WILL HAVE IN PLACE A MECHANISM OR MEANS TO ASSURE THAT 16 INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES CAN MAKE INFORMED CHOICES, 17 EITHER INDEPENDENTLY OR THROUGH AN AUTHORIZED SURROGATE, ON ALL MATTERS 18 PERTINENT TO A PERSON-CENTERED PLAN, AS DEFINED BY THE COMMISSIONER OF 19 DEVELOPMENTAL DISABILITIES, AND WITH RESPECT TO RELATED GOALS, SERVICES, 20 AND OBJECTIVES; 21 (C) THAT IT HAS DEVELOPED A QUALITY ASSESSMENT AND PERFORMANCE 22 IMPROVEMENT PROGRAM THAT INCLUDES PERFORMANCE AND OUTCOME BASED QUALITY 23 STANDARDS FOR ENROLLEE HEALTH STATUS AND SATISFACTION, WHICH SHALL BE 24 REVIEWED BY THE COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISA- 25 BILITIES. THE PROGRAM SHALL INCLUDE DATA COLLECTION AND REPORTING FOR 26 STANDARD PERFORMANCE MEASURES AS REQUIRED BY THE COMMISSIONER AND THE 27 COMMISSIONER OF DEVELOPMENTAL DISABILITIES; 28 (D) THAT AN OTHERWISE ELIGIBLE ENROLLEE SHALL NOT BE INVOLUNTARILY 29 DISENROLLED WITHOUT THE PRIOR APPROVAL OF THE COMMISSIONER OF DEVELOP- 30 MENTAL DISABILITIES; 31 (E) THAT THE APPLICANT SHALL NOT USE DECEPTIVE OR COERCIVE MARKETING 32 METHODS TO ENCOURAGE PARTICIPANTS TO ENROLL AND THAT THE APPLICANT SHALL 33 NOT DISTRIBUTE MARKETING MATERIALS TO POTENTIAL ENROLLEES BEFORE SUCH 34 MATERIALS HAVE BEEN APPROVED BY THE COMMISSIONER AND THE COMMISSIONER OF 35 DEVELOPMENTAL DISABILITIES; 36 (F) SATISFACTORY EVIDENCE OF THE CHARACTER AND COMPETENCE OF THE 37 APPLICANT'S PROPOSED OPERATORS; 38 (G) REASONABLE ASSURANCE THAT THE APPLICANT WILL PROVIDE HIGH QUALITY 39 SERVICES TO AN ENROLLED POPULATION, THAT THE APPLICANT'S NETWORK OF 40 PROVIDERS IS ADEQUATE AND THAT SUCH PROVIDERS HAVE DEMONSTRATED SUFFI- 41 CIENT COMPETENCY TO DELIVER HIGH QUALITY SERVICES TO THE ENROLLED POPU- 42 LATION AND THAT POLICIES AND PROCEDURES WILL BE IN PLACE TO ADDRESS THE 43 CULTURAL AND LINGUISTIC NEEDS OF THE ENROLLED POPULATION; 44 (H) SUFFICIENT MANAGEMENT SYSTEMS CAPACITY TO MEET THE REQUIREMENTS OF 45 THIS SECTION AND THE ABILITY TO EFFICIENTLY PROCESS PAYMENT FOR COVERED 46 SERVICES; 47 (I) READINESS AND CAPABILITY TO MAXIMIZE REIMBURSEMENT OF AND COORDI- 48 NATE SERVICES REIMBURSED PURSUANT TO TITLE XVIII OF THE FEDERAL SOCIAL 49 SECURITY ACT AND ALL OTHER APPLICABLE BENEFITS, WITH SUCH BENEFIT COOR- 50 DINATION INCLUDING, BUT NOT LIMITED TO, MEASURES TO SUPPORT SOUND CLIN- 51 ICAL DECISIONS, REDUCE ADMINISTRATIVE COMPLEXITY, COORDINATE ACCESS TO 52 SERVICES, MAXIMIZE BENEFITS AVAILABLE PURSUANT TO SUCH TITLE AND ENSURE 53 THAT NECESSARY CARE IS PROVIDED; 54 (J) READINESS AND CAPABILITY TO ARRANGE AND MANAGE COVERED SERVICES; 55 (K) WILLINGNESS AND CAPABILITY OF TAKING, OR COOPERATING IN, ALL STEPS 56 NECESSARY TO SECURE AND INTEGRATE ANY POTENTIAL SOURCES OF FUNDING FOR S. 2606--C 43 1 SERVICES PROVIDED BY OR THROUGH THE DISCO, INCLUDING, BUT NOT LIMITED 2 TO, FUNDING AVAILABLE UNDER TITLES XVI, XVIII, XIX AND XX OF THE FEDERAL 3 SOCIAL SECURITY ACT AND ALL OTHER AVAILABLE SOURCES OF FUNDING; 4 (L) THAT THE CONTRACTUAL ARRANGEMENTS FOR PROVIDERS OF HEALTH AND LONG 5 TERM CARE SERVICES IN THE BENEFIT PACKAGE ARE SUFFICIENT TO ENSURE THE 6 AVAILABILITY AND ACCESSIBILITY OF SUCH SERVICES TO THE PROPOSED ENROLLED 7 POPULATION CONSISTENT WITH GUIDELINES ESTABLISHED BY THE COMMISSIONER 8 AND THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES; AND 9 (M) THAT THE APPLICANT IS FINANCIALLY RESPONSIBLE AND SHALL BE 10 EXPECTED TO MEET ITS OBLIGATIONS TO ITS ENROLLED MEMBERS. 11 5. ENROLLMENT. (A) ONLY PERSONS WITH DEVELOPMENTAL DISABILITIES, AS 12 DETERMINED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, 13 SHALL BE ELIGIBLE TO ENROLL IN DISCOS. 14 (B) THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES OR ITS 15 DESIGNEE SHALL ENROLL AN ELIGIBLE PERSON IN THE DISCO CHOSEN BY HIM OR 16 HER, HIS OR HER GUARDIAN OR OTHER LEGAL REPRESENTATIVE, PROVIDED THAT 17 SUCH DISCO IS AUTHORIZED TO ENROLL SUCH PERSON. 18 (C) NO PERSON WITH A DEVELOPMENTAL DISABILITY WHO IS RECEIVING OR 19 APPLYING FOR MEDICAL ASSISTANCE AND WHO IS RECEIVING, OR ELIGIBLE TO 20 RECEIVE, SERVICES FUNDED, CERTIFIED, AUTHORIZED OR APPROVED BY THE 21 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL BE REQUIRED TO 22 ENROLL IN A DISCO IN ORDER TO RECEIVE SUCH SERVICES UNTIL PROGRAM 23 FEATURES AND REIMBURSEMENT RATES ARE APPROVED BY THE COMMISSIONER AND 24 THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES, AND UNTIL SUCH COMMIS- 25 SIONERS DETERMINE THAT THERE ARE A SUFFICIENT NUMBER OF PLANS AUTHORIZED 26 TO COORDINATE CARE FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES 27 PURSUANT TO THIS ARTICLE OPERATING IN THE PERSON'S COUNTY OF RESIDENCE 28 TO MEET THE NEEDS OF PERSONS WITH DEVELOPMENTAL DISABILITIES, AND THAT 29 SUCH DISCOS MEET THE STANDARDS OF THIS SECTION. 30 (D) PERSONS REQUIRED TO ENROLL IN A DISCO SHALL HAVE NO LESS THAN 31 SIXTY DAYS TO SELECT A DISCO, AND SUCH PERSONS AND THEIR GUARDIANS OR 32 OTHER LEGAL REPRESENTATIVES SHALL BE PROVIDED WITH INFORMATION TO MAKE 33 AN INFORMED CHOICE. WHERE A PERSON, GUARDIAN OR OTHER LEGAL REPRESEN- 34 TATIVE HAS NOT SELECTED A DISCO, THE COMMISSIONER OF DEVELOPMENTAL DISA- 35 BILITIES OR ITS DESIGNEE SHALL ENROLL SUCH PERSON IN A DISCO CHOSEN BY 36 SUCH COMMISSIONER, TAKING INTO ACCOUNT QUALITY, CAPACITY AND GEOGRAPHIC 37 ACCESSIBILITY. THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES OR 38 ITS DESIGNEE SHALL AUTOMATICALLY RE-ENROLL A PERSON WITH THE SAME DISCO 39 IF THERE IS A LOSS OF MEDICAID ELIGIBILITY OF TWO MONTHS OR LESS. 40 (E) ENROLLED PERSONS MAY CHANGE THEIR ENROLLMENT AT ANY TIME WITHOUT 41 CAUSE, PROVIDED, HOWEVER, THAT A PERSON REQUIRED TO ENROLL IN A DISCO IN 42 ORDER TO RECEIVE SERVICES FUNDED, LICENSED, AUTHORIZED OR APPROVED BY 43 THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES MAY ONLY DISENROLL 44 FROM A DISCO IF HE OR SHE ENROLLS IN ANOTHER DISCO AUTHORIZED TO ENROLL 45 HIM OR HER. SUCH DISENROLLMENT SHALL BE EFFECTIVE NO LATER THAN THE 46 FIRST DAY OF THE SECOND MONTH FOLLOWING THE REQUEST. 47 (F) A DISCO MAY REQUEST THE INVOLUNTARY DISENROLLMENT OF AN ENROLLED 48 PERSON IN WRITING TO THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILI- 49 TIES. SUCH DISENROLLMENT SHALL NOT BE EFFECTIVE UNTIL THE REQUEST IS 50 REVIEWED AND APPROVED BY SUCH OFFICE. THE DEPARTMENT AND THE OFFICE FOR 51 PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL ADOPT RULES AND REGULATIONS 52 GOVERNING THIS PROCESS. 53 6. ASSESSMENTS. THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILI- 54 TIES, OR ITS DESIGNEE, SHALL COMPLETE A COMPREHENSIVE ASSESSMENT THAT 55 SHALL INCLUDE, BUT NOT BE LIMITED TO, AN EVALUATION OF THE MEDICAL, 56 SOCIAL, HABILITATIVE AND ENVIRONMENTAL NEEDS OF EACH PROSPECTIVE ENROL- S. 2606--C 44 1 LEE IN A DISCO AS SUCH NEEDS RELATE TO EACH INDIVIDUAL'S HEALTH, SAFETY 2 AND ABILITY TO LIVE IN THE MOST INTEGRATED SETTING APPROPRIATE TO THAT 3 PERSON'S NEEDS. THIS ASSESSMENT SHALL ALSO SERVE AS THE BASIS FOR THE 4 DEVELOPMENT AND PROVISION OF AN APPROPRIATE PLAN OF CARE FOR THE ENROL- 5 LEE. SUCH PLAN OF CARE SHALL BE FOCUSED ON THE ACHIEVEMENT OF 6 PERSON-CENTERED GOALS AND SHALL BE CONSISTENT WITH, AND HELP INFORM, ANY 7 OTHER PERSON-CENTERED PLAN REQUIRED FOR THE ENROLLEE BY THE COMMISSIONER 8 OF DEVELOPMENTAL DISABILITIES. THE ASSESSMENT SHALL BE COMPLETED BY THE 9 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES OR ITS DESIGNEE IN 10 CONSULTATION WITH THE PROSPECTIVE ENROLLEE'S HEALTH CARE PRACTITIONER AS 11 NECESSARY. THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES SHALL 12 PRESCRIBE THE FORMS ON WHICH THE ASSESSMENT SHALL BE MADE. THE OFFICE 13 FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES MAY DESIGNATE THE DISCO TO 14 PERFORM SUCH ASSESSMENTS. 15 7. PROGRAM OVERSIGHT AND ADMINISTRATION. (A) THE COMMISSIONER AND THE 16 COMMISSIONER OF DEVELOPMENTAL DISABILITIES SHALL JOINTLY PROMULGATE 17 REGULATIONS TO IMPLEMENT THIS SECTION, TO PROVIDE FOR OVERSIGHT OF 18 DISCOS, INCLUDING ON SITE REVIEWS, AND TO ENSURE THE QUALITY, APPROPRI- 19 ATENESS AND COST-EFFECTIVENESS OF THE SERVICES PROVIDED BY DISCOS. 20 (B) THE COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISABILI- 21 TIES MAY WAIVE RULES AND REGULATIONS OF THEIR RESPECTIVE DEPARTMENT OR 22 OFFICE, INCLUDING BUT NOT LIMITED TO, THOSE PERTAINING TO DUPLICATIVE 23 REQUIREMENTS CONCERNING RECORD KEEPING, BOARDS OF DIRECTORS, STAFFING 24 AND REPORTING, WHEN SUCH WAIVER WILL PROMOTE THE EFFICIENT DELIVERY OF 25 APPROPRIATE, QUALITY, COST-EFFECTIVE SERVICES AND WHEN THE HEALTH, SAFE- 26 TY AND GENERAL WELFARE OF DISCO ENROLLEES WILL NOT BE IMPAIRED AS A 27 RESULT OF SUCH WAIVER. THE COMMISSIONERS WILL REPORT ANNUALLY TO THE 28 LEGISLATURE, AND TO THE JOINT ADVISORY COUNCIL ESTABLISHED PURSUANT TO 29 PARAGRAPH F OF THIS SUBDIVISION, ON ALL RULES AND REGULATIONS WAIVED 30 PURSUANT TO THIS PARAGRAPH, AND ON THE ESTIMATED COST SAVINGS AND QUALI- 31 TY IMPROVEMENTS THAT THE WAIVER OF SUCH RULES AND REGULATIONS ARE 32 EXPECTED TO PRODUCE. IN ORDER TO ACHIEVE DISCO SYSTEM EFFICIENCIES AND 33 COORDINATION AND TO PROMOTE THE OBJECTIVES OF HIGH QUALITY, INTEGRATED 34 AND COST EFFECTIVE CARE, THE COMMISSIONERS SHALL ESTABLISH A SINGLE 35 COORDINATED SURVEILLANCE PROCESS, ALLOW FOR A COMPREHENSIVE QUALITY 36 IMPROVEMENT AND REVIEW PROCESS TO MEET COMPONENT QUALITY REQUIREMENTS, 37 AND REQUIRE A UNIFORM COST REPORT. THE COMMISSIONERS SHALL REQUIRE 38 DISCOS TO UTILIZE QUALITY IMPROVEMENT MEASURES, BASED ON THE ACHIEVEMENT 39 OF PERSONAL OUTCOMES AND QUALITY OF LIFE, HEALTH OUTCOMES DATA, AND 40 ASSESSMENTS OF CONSUMERS AND FAMILY SATISFACTION, FOR INTERNAL QUALITY 41 ASSESSMENT PROCESSES AND MAY UTILIZE SUCH MEASURES AS PART OF THE SINGLE 42 COORDINATED SURVEILLANCE PROCESS. 43 (B-1) THE COMMISSIONER AND THE COMMISSIONER OF THE OFFICE OF DEVELOP- 44 MENTAL DISABILITIES, IN CONSULTATION WITH THE JOINT ADVISORY COUNCIL 45 ESTABLISHED PURSUANT TO PARAGRAPH F OF THIS SUBDIVISION, SHALL IDENTIFY 46 A VALID AND RELIABLE QUALITY ASSURANCE INSTRUMENT THAT INCLUDES ASSESS- 47 MENTS OF CONSUMER AND FAMILY SATISFACTION, PROVISION OF SERVICES, AND 48 PERSONAL OUTCOMES. THE INSTRUMENT SHALL INCLUDE OUTCOME-BASED MEASURES 49 SUCH AS HEALTH, SAFETY, WELL-BEING, RELATIONSHIPS, INTERACTIONS WITH 50 PEOPLE WHO DO NOT HAVE A DISABILITY, EMPLOYMENT, QUALITY OF LIFE, INTE- 51 GRATION, CHOICE, SERVICE AND CONSUMER SATISFACTION. 52 (C) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF THE SOCIAL SERVICES 53 LAW TO THE CONTRARY, THE COMMISSIONER IN CONSULTATION WITH THE COMMIS- 54 SIONER OF DEVELOPMENTAL DISABILITIES SHALL, PURSUANT TO REGULATION, 55 DETERMINE WHETHER AND THE EXTENT TO WHICH THE APPLICABLE PROVISIONS OF 56 THE SOCIAL SERVICES LAW OR REGULATIONS RELATING TO APPROVALS AND AUTHOR- S. 2606--C 45 1 IZATIONS OF, AND UTILIZATION LIMITATIONS ON, HEALTH AND LONG TERM CARE 2 SERVICES REIMBURSED PURSUANT TO TITLE XIX OF THE FEDERAL SOCIAL SECURITY 3 ACT ARE INCONSISTENT WITH THE FLEXIBILITY NECESSARY FOR THE EFFICIENT 4 ADMINISTRATION OF DISCOS, AND SUCH REGULATIONS SHALL PROVIDE THAT SUCH 5 PROVISIONS SHALL NOT BE APPLICABLE TO ENROLLEES OF DISCOS, PROVIDED THAT 6 SUCH DETERMINATIONS ARE CONSISTENT WITH APPLICABLE FEDERAL LAW AND REGU- 7 LATION. 8 (D) THE COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISABILI- 9 TIES SHALL ENSURE, THROUGH PERIODIC REVIEWS OF DISCOS, THAT ORGANIZATION 10 SERVICES ARE PROMPTLY AVAILABLE TO ENROLLEES WHEN APPROPRIATE. SUCH 11 PERIODIC REVIEWS SHALL BE MADE ACCORDING TO STANDARDS AS DETERMINED BY 12 THE COMMISSIONERS IN REGULATIONS. 13 (E) THE COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISABILI- 14 TIES SHALL HAVE THE AUTHORITY TO CONDUCT BOTH ON SITE AND OFF SITE 15 REVIEWS OF DISCOS. SUCH REVIEWS MAY INCLUDE, BUT NOT BE LIMITED TO, THE 16 FOLLOWING COMPONENTS: GOVERNANCE; FISCAL AND FINANCIAL REPORTING; 17 RECORDKEEPING; INTERNAL CONTROLS; MARKETING; NETWORK CONTRACTING AND 18 ADEQUACY; PROGRAM INTEGRITY ASSURANCES; UTILIZATION CONTROL AND REVIEW 19 SYSTEMS; GRIEVANCE AND APPEALS SYSTEMS; QUALITY ASSESSMENT AND ASSURANCE 20 SYSTEMS; CARE MANAGEMENT; ENROLLMENT AND DISENROLLMENT; MANAGEMENT 21 INFORMATION SYSTEMS, AND OTHER OPERATIONAL AND MANAGEMENT COMPONENTS. 22 (F) JOINT ADVISORY COUNCIL. THERE SHALL BE A JOINT ADVISORY COUNCIL 23 CHAIRED BY THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES COMPRISED OF 24 TWELVE MEMBERS, INCLUDING FAMILY MEMBERS OF PEOPLE WITH DEVELOPMENTAL 25 DISABILITIES, DEVELOPMENTAL DISABILITIES PROVIDERS, AND DEVELOPMENTAL 26 DISABILITIES ADVOCATES, INCLUDING SELF ADVOCATES. THE JOINT ADVISORY 27 COUNCIL SHALL MEET MONTHLY TO REVIEW ALL MANAGED CARE OPTIONS PROVIDED 28 TO INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES CONCERNING: THE ADEQUACY 29 OF HABILITATION SERVICES OFFERED; THE RECORD OF COMPLIANCE WITH PERSON- 30 CENTERED CARE PLANS; THE ADEQUACY OF RATES; THE STATUS OF PERSON-CEN- 31 TERED SERVICES AND COMMUNITY INTEGRATION; THE STATUS OF THE TRANSITION 32 OF SERVICES OVERSEEN BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISA- 33 BILITIES TO MANAGED CARE; AND ALL OTHER MATTERS OF IMPORTANCE TO THE 34 QUALITY OF LIFE, HEALTH, SAFETY AND COMMUNITY INTEGRATION OF INDIVIDUALS 35 WITH DEVELOPMENTAL DISABILITIES ENROLLED IN MANAGED CARE. THE JOINT 36 ADVISORY COUNCIL SHALL SUBMIT QUARTERLY REPORTS ON ITS FINDINGS, CONCLU- 37 SIONS, RECOMMENDATIONS, AND ANY PROPOSED AMENDMENTS TO PERTINENT 38 SECTIONS OF THE LAW TO THE GOVERNOR, SENATE MAJORITY LEADER AND SPEAKER 39 OF THE ASSEMBLY. 40 8. SOLVENCY. (A) THE COMMISSIONER, IN CONSULTATION WITH THE COMMIS- 41 SIONER OF DEVELOPMENTAL DISABILITIES, SHALL BE RESPONSIBLE FOR EVALUAT- 42 ING, APPROVING AND REGULATING ALL MATTERS RELATING TO FISCAL SOLVENCY, 43 INCLUDING RESERVES, SURPLUS AND PROVIDER CONTRACTS. THE COMMISSIONER 44 SHALL PROMULGATE REGULATIONS TO IMPLEMENT THIS SECTION. THE COMMISSION- 45 ER, IN THE ADMINISTRATION OF THIS SUBDIVISION: 46 (I) SHALL BE GUIDED BY THE STANDARDS THAT GOVERN THE FISCAL SOLVENCY 47 OF A HEALTH MAINTENANCE ORGANIZATION, PROVIDED, HOWEVER, THAT THE 48 COMMISSIONER SHALL RECOGNIZE THE SPECIFIC DELIVERY COMPONENTS, OPERA- 49 TIONAL CAPACITY AND FINANCIAL CAPABILITY OF THE ELIGIBLE APPLICANT FOR A 50 CERTIFICATE OF AUTHORITY; 51 (II) SHALL NOT APPLY FINANCIAL SOLVENCY STANDARDS THAT EXCEED THOSE 52 REQUIRED FOR A HEALTH MAINTENANCE ORGANIZATION; AND 53 (III) SHALL ESTABLISH REASONABLE CAPITALIZATION AND CONTINGENT RESERVE 54 REQUIREMENTS. 55 (B) STANDARDS ESTABLISHED PURSUANT TO THIS SUBDIVISION SHALL BE 56 ADEQUATE TO PROTECT THE INTERESTS OF ENROLLEES IN THE DISCO. THE COMMIS- S. 2606--C 46 1 SIONER SHALL BE SATISFIED THAT THE ELIGIBLE APPLICANT IS FINANCIALLY 2 SOUND, AND HAS MADE ADEQUATE PROVISIONS TO PAY FOR QUALITY SERVICES THAT 3 ARE COST EFFECTIVE AND APPROPRIATE TO NEEDS AND THE PROTECTION OF THE 4 HEALTH, SAFETY, WELFARE AND SATISFACTION OF THOSE SERVED. 5 9. ROLE OF THE SUPERINTENDENT OF FINANCIAL SERVICES. (A) THE SUPER- 6 INTENDENT OF FINANCIAL SERVICES SHALL DETERMINE AND APPROVE PREMIUMS IN 7 ACCORDANCE WITH THE INSURANCE LAW WHENEVER ANY POPULATION OF ENROLLEES 8 NOT ELIGIBLE UNDER TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT IS TO BE 9 COVERED. THE DETERMINATION AND APPROVAL OF THE SUPERINTENDENT OF FINAN- 10 CIAL SERVICES SHALL RELATE TO PREMIUMS CHARGED TO SUCH ENROLLEES NOT 11 ELIGIBLE UNDER TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT. 12 (B) THE SUPERINTENDENT OF FINANCIAL SERVICES SHALL EVALUATE AND 13 APPROVE ANY ENROLLEE CONTRACTS WHENEVER SUCH ENROLLEE CONTRACTS ARE TO 14 COVER ANY POPULATION OF ENROLLEES NOT ELIGIBLE UNDER TITLE XIX OF THE 15 FEDERAL SOCIAL SECURITY ACT. 16 10. PAYMENT RATES FOR DISCO ENROLLEES ELIGIBLE FOR MEDICAL ASSISTANCE. 17 THE COMMISSIONER SHALL ESTABLISH PAYMENT RATES FOR SERVICES PROVIDED TO 18 ENROLLEES ELIGIBLE UNDER TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT. 19 SUCH PAYMENT RATES SHALL BE SUBJECT TO APPROVAL BY THE DIRECTOR OF THE 20 DIVISION OF THE BUDGET. PAYMENT RATES SHALL BE RISK-ADJUSTED TO TAKE 21 INTO ACCOUNT THE CHARACTERISTICS OF ENROLLEES, OR PROPOSED ENROLLEES, 22 INCLUDING, BUT NOT LIMITED TO: FRAILTY, DISABILITY LEVEL, HEALTH AND 23 FUNCTIONAL STATUS, AGE, GENDER, THE NATURE OF SERVICES PROVIDED TO SUCH 24 ENROLLEES, AND OTHER FACTORS AS DETERMINED BY THE COMMISSIONER AND THE 25 COMMISSIONER OF DEVELOPMENTAL DISABILITIES. THE RISK ADJUSTED PREMIUMS 26 MAY ALSO BE COMBINED WITH DISINCENTIVES OR REQUIREMENTS DESIGNED TO 27 MITIGATE ANY INCENTIVES TO OBTAIN HIGHER PAYMENT CATEGORIES. 28 11. CONTINUATION OF CERTIFICATE OF AUTHORITY. CONTINUATION OF A 29 CERTIFICATE OF AUTHORITY ISSUED UNDER THIS SECTION SHALL BE CONTINGENT 30 UPON COMPLIANCE BY THE DISCO WITH APPLICABLE PROVISIONS OF THIS SECTION 31 AND RULES AND REGULATIONS PROMULGATED THEREUNDER; THE CONTINUING FISCAL 32 SOLVENCY OF THE DISCO; AND FEDERAL FINANCIAL PARTICIPATION IN PAYMENTS 33 ON BEHALF OF ENROLLEES WHO ARE ELIGIBLE TO RECEIVE SERVICES UNDER TITLE 34 XIX OF THE FEDERAL SOCIAL SECURITY ACT. 35 12. PROTECTION OF ENROLLEES. THE COMMISSIONER MAY, IN HIS OR HER 36 DISCRETION AND WITH THE CONCURRENCE OF THE COMMISSIONER OF DEVELOPMENTAL 37 DISABILITIES, FOR THE PURPOSE OF THE PROTECTION OF ENROLLEES, IMPOSE 38 MEASURES INCLUDING, BUT NOT LIMITED TO BANS ON FURTHER ENROLLMENTS UNTIL 39 ANY IDENTIFIED PROBLEMS ARE RESOLVED TO THE SATISFACTION OF THE COMMIS- 40 SIONER, OR FINES UPON A FINDING THAT THE DISCO HAS FAILED TO COMPLY WITH 41 THE PROVISIONS OF ANY APPLICABLE STATUTE, RULE OR REGULATION. 42 13. INFORMATION SHARING. THE COMMISSIONER AND THE COMMISSIONER OF 43 DEVELOPMENTAL DISABILITIES SHALL, AS NECESSARY AND CONSISTENT WITH 44 FEDERAL REGULATIONS PROMULGATED PURSUANT TO THE HEALTH INSURANCE PORTA- 45 BILITY AND ACCOUNTABILITY ACT, SHARE WITH SUCH DISCO THE FOLLOWING DATA 46 IF IT IS AVAILABLE: 47 (A) INFORMATION CONCERNING UTILIZATION OF SERVICES AND PROVIDERS BY 48 EACH OF ITS ENROLLEES PRIOR TO AND DURING ENROLLMENT. 49 (B) AGGREGATE DATA CONCERNING UTILIZATION AND COSTS FOR ENROLLEES AND 50 FOR COMPARABLE COHORTS SERVED THROUGH THE MEDICAID FEE-FOR-SERVICE 51 PROGRAM. 52 14. CONTRACTS. NOTWITHSTANDING ANY INCONSISTENT PROVISIONS OF THIS 53 SECTION AND SECTIONS ONE HUNDRED TWELVE AND ONE HUNDRED SIXTY-THREE OF 54 THE STATE FINANCE LAW, THE COMMISSIONER, IN CONSULTATION WITH THE 55 COMMISSIONER OF DEVELOPMENTAL DISABILITIES, MAY CONTRACT WITH DISCOS 56 APPROVED UNDER THIS SECTION WITHOUT A COMPETITIVE BID OR REQUEST FOR S. 2606--C 47 1 PROPOSAL PROCESS, TO PROVIDE COVERAGE FOR ENROLLEES PURSUANT TO THIS 2 SECTION. NOTWITHSTANDING ANY INCONSISTENT PROVISIONS OF THIS SECTION AND 3 SECTION ONE HUNDRED FORTY-THREE OF THE ECONOMIC DEVELOPMENT LAW, NO 4 NOTICE IN THE PROCUREMENT OPPORTUNITIES NEWSLETTER SHALL BE REQUIRED FOR 5 CONTRACTS AWARDED BY THE COMMISSIONER TO QUALIFIED DISCOS PURSUANT TO 6 THIS SECTION. 7 15. APPLICABILITY OF OTHER LAWS. DISCOS SHALL BE SUBJECT TO THE 8 PROVISIONS OF THE INSURANCE LAW AND REGULATIONS APPLICABLE TO HEALTH 9 MAINTENANCE ORGANIZATIONS, THIS ARTICLE AND REGULATIONS PROMULGATED 10 THEREUNDER. TO THE EXTENT THAT THE PROVISIONS OF THIS SECTION ARE INCON- 11 SISTENT WITH THE PROVISIONS OF THIS CHAPTER OR THE PROVISIONS OF THE 12 INSURANCE LAW, THE PROVISIONS OF THIS SECTION SHALL PREVAIL. 13 16. EFFECTIVENESS. THE PROVISIONS OF THIS SECTION SHALL ONLY BE EFFEC- 14 TIVE IF, FOR SO LONG AS, AND TO THE EXTENT THAT FEDERAL FINANCIAL 15 PARTICIPATION IS AVAILABLE FOR THE COSTS OF SERVICES PROVIDED BY THE 16 DISCOS TO ENROLLEES WHO ARE RECIPIENTS OF MEDICAL ASSISTANCE PURSUANT TO 17 TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW. THE COMMISSION- 18 ER SHALL MAKE ANY NECESSARY AMENDMENTS TO THE STATE PLAN FOR MEDICAL 19 ASSISTANCE SUBMITTED PURSUANT TO SECTION THREE HUNDRED SIXTY-THREE-A OF 20 THE SOCIAL SERVICES LAW, IN ORDER TO ENSURE SUCH FEDERAL FINANCIAL 21 PARTICIPATION. 22 S 74. Section 4403 of the public health law is amended by adding a new 23 subdivision 8 to read as follows: 24 8. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, A HEALTH 25 MAINTENANCE ORGANIZATION MAY EXPAND ITS COMPREHENSIVE HEALTH SERVICES 26 PLAN TO INCLUDE SERVICES OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR 27 APPROVED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, 28 INCLUDING HABILITATION SERVICES AS DEFINED IN PARAGRAPH (C) OF SUBDIVI- 29 SION ONE OF SECTION FORTY-FOUR HUNDRED THREE-G OF THIS CHAPTER, AND MAY 30 OFFER SUCH EXPANDED PLAN TO A POPULATION OF PERSONS WITH DEVELOPMENTAL 31 DISABILITIES, AS SUCH TERM IS DEFINED IN THE MENTAL HYGIENE LAW, SUBJECT 32 TO THE FOLLOWING: 33 (A) SUCH ORGANIZATION SHALL HAVE THE ABILITY TO PROVIDE OR COORDINATE 34 SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES, AS DEMONSTRATED BY 35 CRITERIA TO BE DETERMINED BY THE COMMISSIONER AND THE COMMISSIONER OF 36 DEVELOPMENTAL DISABILITIES; 37 (B) THE PROVISION BY SUCH ORGANIZATION OF SERVICES OPERATED, CERTI- 38 FIED, FUNDED, AUTHORIZED OR APPROVED BY THE OFFICE FOR PEOPLE WITH 39 DEVELOPMENTAL DISABILITIES SHALL BE SUBJECT TO THE JOINT OVERSIGHT AND 40 REVIEW OF BOTH THE DEPARTMENT AND THE OFFICE FOR PEOPLE WITH DEVELOP- 41 MENTAL DISABILITIES; 42 (C) SUCH ORGANIZATION SHALL NOT PROVIDE OR ARRANGE FOR SERVICES OPER- 43 ATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE OFFICE FOR PEOPLE 44 WITH DEVELOPMENTAL DISABILITIES UNTIL THE COMMISSIONER AND COMMISSIONER 45 OF DEVELOPMENTAL DISABILITIES APPROVE PROGRAM FEATURES AND RATES THAT 46 INCLUDE SUCH SERVICES, AND DETERMINE THAT SUCH ORGANIZATION MEETS THE 47 REQUIREMENTS OF THIS PARAGRAPH; 48 (D) AN OTHERWISE ELIGIBLE ENROLLEE RECEIVING SERVICES THROUGH THE PLAN 49 THAT ARE OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE 50 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL NOT BE INVOLUN- 51 TARILY DISENROLLED FROM SUCH PLAN WITHOUT THE PRIOR APPROVAL OF THE 52 COMMISSIONER OF DEVELOPMENTAL DISABILITIES; 53 (E) THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL DETER- 54 MINE THE ELIGIBILITY OF INDIVIDUALS RECEIVING SERVICES OPERATED, CERTI- 55 FIED, FUNDED, AUTHORIZED OR APPROVED BY SUCH OFFICE TO ENROLL IN SUCH A S. 2606--C 48 1 PLAN AND SHALL ENROLL INDIVIDUALS IT DETERMINES ELIGIBLE IN THE PLAN 2 CHOSEN BY SUCH INDIVIDUAL, GUARDIAN OR OTHER LEGAL REPRESENTATIVE; 3 (F) THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, OR IF IT SO 4 DESIGNATES, THE HEALTH MAINTENANCE ORGANIZATION OR OTHER DESIGNEE, SHALL 5 COMPLETE A COMPREHENSIVE ASSESSMENT FOR ENROLLEES THAT RECEIVE SERVICES 6 OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY SUCH OFFICE. 7 THIS ASSESSMENT SHALL INCLUDE, BUT NOT BE LIMITED TO, AN EVALUATION OF 8 THE MEDICAL, SOCIAL, HEALTH, SAFETY, ENVIRONMENTAL AND HABILITATIVE 9 NEEDS OF EACH PROSPECTIVE ENROLLEE. THIS ASSESSMENT SHALL ALSO SERVE AS 10 THE BASIS FOR THE DEVELOPMENT AND PROVISION OF AN APPROPRIATE PLAN OF 11 CARE FOR THE ENROLLEE. THE ASSESSMENT SHALL BE COMPLETED BY SUCH OFFICE 12 OR ITS DESIGNEE, IN CONSULTATION WITH THE PROSPECTIVE ENROLLEE'S HEALTH 13 CARE PRACTITIONER AS NECESSARY. THE COMMISSIONER OF DEVELOPMENTAL DISA- 14 BILITIES SHALL PRESCRIBE THE FORMS ON WHICH THE ASSESSMENT SHALL BE 15 MADE; 16 (G) NO PERSON WITH A DEVELOPMENTAL DISABILITY SHALL BE REQUIRED TO 17 ENROLL IN A COMPREHENSIVE HEALTH SERVICES PLAN AS A CONDITION OF RECEIV- 18 ING MEDICAL ASSISTANCE AND SERVICES OPERATED, CERTIFIED, FUNDED, AUTHOR- 19 IZED OR APPROVED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILI- 20 TIES UNTIL PROGRAM FEATURES AND REIMBURSEMENT RATES ARE APPROVED BY THE 21 COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES AND 22 UNTIL SUCH COMMISSIONERS DETERMINE THAT THERE ARE A SUFFICIENT NUMBER OF 23 PLANS AUTHORIZED TO COORDINATE CARE FOR INDIVIDUALS WITH DEVELOPMENTAL 24 DISABILITIES PURSUANT TO THIS ARTICLE OPERATING IN THE PERSON'S COUNTY 25 OF RESIDENCE TO MEET THE NEEDS OF PERSONS WITH DEVELOPMENTAL DISABILI- 26 TIES, AND THAT SUCH PLANS MEET THE STANDARDS OF THIS SECTION; AND 27 (H) THE PROVISIONS OF THIS SUBDIVISION SHALL ONLY BE EFFECTIVE IF, FOR 28 SO LONG AS, AND TO THE EXTENT THAT FEDERAL FINANCIAL PARTICIPATION IS 29 AVAILABLE FOR THE COSTS OF SERVICES PROVIDED HEREUNDER TO RECIPIENTS OF 30 MEDICAL ASSISTANCE PURSUANT TO TITLE ELEVEN OF ARTICLE FIVE OF THE 31 SOCIAL SERVICES LAW. THE COMMISSIONER SHALL MAKE ANY NECESSARY AMEND- 32 MENTS TO THE STATE PLAN FOR MEDICAL ASSISTANCE SUBMITTED PURSUANT TO 33 SECTION THREE HUNDRED SIXTY-THREE-A OF THE SOCIAL SERVICES LAW, AND/OR 34 SUBMIT ONE OR MORE APPLICATIONS FOR WAIVERS OF THE FEDERAL SOCIAL SECU- 35 RITY ACT, AS MAY BE NECESSARY TO ENSURE SUCH FEDERAL FINANCIAL PARTIC- 36 IPATION. TO THE EXTENT THAT THE PROVISIONS OF THIS SUBDIVISION ARE 37 INCONSISTENT WITH OTHER PROVISIONS OF THIS ARTICLE OR WITH THE 38 PROVISIONS OF SECTION THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES 39 LAW, THE PROVISIONS OF THIS SUBDIVISION SHALL PREVAIL. 40 S 75. The opening paragraph of paragraph (h) of subdivision 7 of 41 section 4403-f of the public health law, as amended by section 41-b of 42 part H of chapter 59 of the laws of 2011, is amended to read as follows: 43 The commissioner AND, IN THE CASE OF A PLAN ARRANGING FOR OR PROVIDING 44 SERVICES OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE 45 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, THE COMMISSIONER OF 46 DEVELOPMENTAL DISABILITIES, shall, upon request by a managed long term 47 care plan or operating demonstration, and consistent with federal regu- 48 lations promulgated pursuant to the Health Insurance Portability and 49 Accountability Act, share with such plan or demonstration the following 50 data if it is available: 51 S 76. Section 4403-f of the public health law is amended by adding 52 three new subdivisions 12, 13 and 14 to read as follows: 53 12. NOTWITHSTANDING ANY PROVISION TO THE CONTRARY, A MANAGED LONG TERM 54 CARE PLAN MAY EXPAND THE SERVICES IT PROVIDES OR ARRANGES FOR TO INCLUDE 55 SERVICES OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE 56 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES FOR A POPULATION OF S. 2606--C 49 1 PERSONS WITH DEVELOPMENTAL DISABILITIES, AS SUCH TERM IS DEFINED IN THE 2 MENTAL HYGIENE LAW, INCLUDING HABILITATIVE SERVICES AS DEFINED IN PARA- 3 GRAPH (C) OF SUBDIVISION ONE OF SECTION FORTY-FOUR HUNDRED THREE-G OF 4 THIS CHAPTER, SUBJECT TO THE FOLLOWING: 5 (A) SUCH PLAN SHALL HAVE THE ABILITY TO PROVIDE OR COORDINATE SERVICES 6 FOR PERSONS WITH DEVELOPMENTAL DISABILITIES AS DEMONSTRATED BY CRITERIA 7 TO BE DETERMINED BY THE COMMISSIONER AND THE COMMISSIONER OF DEVELOP- 8 MENTAL DISABILITIES; 9 (B) THE PROVISION BY SUCH PLAN OF SERVICES OPERATED, CERTIFIED, FUND- 10 ED, AUTHORIZED OR APPROVED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL 11 DISABILITIES SHALL BE SUBJECT TO THE JOINT OVERSIGHT AND REVIEW OF BOTH 12 THE DEPARTMENT AND THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILI- 13 TIES; 14 (C) SUCH PLAN SHALL NOT PROVIDE OR ARRANGE FOR SERVICES OPERATED, 15 CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE OFFICE FOR PEOPLE WITH 16 DEVELOPMENTAL DISABILITIES UNTIL THE COMMISSIONER AND COMMISSIONER OF 17 DEVELOPMENTAL DISABILITIES APPROVE PROGRAM FEATURES AND RATES THAT 18 INCLUDE SUCH SERVICES, AND DETERMINE THAT SUCH ORGANIZATION MEETS THE 19 REQUIREMENTS OF THIS SUBDIVISION; 20 (D) AN OTHERWISE ELIGIBLE ENROLLEE RECEIVING SERVICES THROUGH THE PLAN 21 THAT ARE OPERATED, CERTIFIED, FUNDED, AUTHORIZED OR APPROVED BY THE 22 OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL NOT BE INVOLUN- 23 TARILY DISENROLLED FROM SUCH PLAN WITHOUT THE PRIOR APPROVAL OF THE 24 COMMISSIONER OF DEVELOPMENTAL DISABILITIES; 25 (E) THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES SHALL DETER- 26 MINE THE ELIGIBILITY OF INDIVIDUALS RECEIVING SERVICES OPERATED, CERTI- 27 FIED, FUNDED, AUTHORIZED OR APPROVED BY SUCH OFFICE TO ENROLL IN SUCH A 28 PLAN. SUCH OFFICE OR ITS DESIGNEE SHALL ENROLL ELIGIBLE INDIVIDUALS IT 29 DETERMINES ELIGIBLE IN A PLAN CHOSEN BY SUCH INDIVIDUAL, GUARDIAN OR 30 OTHER LEGAL REPRESENTATIVE; 31 (F) THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES, OR IF IT SO 32 DESIGNATES, A PLAN OR OTHER DESIGNEE, SHALL COMPLETE A COMPREHENSIVE 33 ASSESSMENT FOR ENROLLEES WHO RECEIVE SERVICES OPERATED, CERTIFIED, FUND- 34 ED, AUTHORIZED OR APPROVED BY SUCH OFFICE. THIS ASSESSMENT SHALL 35 INCLUDE, BUT NOT BE LIMITED TO, AN EVALUATION OF THE MEDICAL, SOCIAL, 36 HABILITATIVE AND ENVIRONMENTAL NEEDS OF EACH PROSPECTIVE ENROLLEE. THIS 37 ASSESSMENT SHALL ALSO SERVE AS THE BASIS FOR THE DEVELOPMENT AND 38 PROVISION OF AN APPROPRIATE PLAN OF CARE FOR THE ENROLLEE. THE COMMIS- 39 SIONER OF DEVELOPMENTAL DISABILITIES SHALL PRESCRIBE THE FORMS ON WHICH 40 THE ASSESSMENT SHALL BE MADE; AND 41 (G) NO PERSON WITH A DEVELOPMENTAL DISABILITY SHALL BE REQUIRED TO 42 ENROLL IN A MANAGED LONG TERM CARE PLAN AS A CONDITION OF RECEIVING 43 MEDICAL ASSISTANCE AND SERVICES OPERATED, CERTIFIED, FUNDED, AUTHORIZED 44 OR APPROVED BY THE OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES 45 UNTIL PROGRAM FEATURES AND REIMBURSEMENT RATES ARE APPROVED BY THE 46 COMMISSIONER AND THE COMMISSIONER OF DEVELOPMENTAL DISABILITIES AND 47 UNTIL SUCH COMMISSIONERS DETERMINE THAT THERE ARE A SUFFICIENT NUMBER OF 48 PLANS AUTHORIZED TO COORDINATE CARE FOR INDIVIDUALS WITH DEVELOPMENTAL 49 DISABILITIES PURSUANT TO THIS ARTICLE OPERATING IN THE PERSON'S COUNTY 50 OF RESIDENCE TO MEET THE NEEDS OF PERSONS WITH DEVELOPMENTAL DISABILI- 51 TIES, AND THAT SUCH PLANS MEET THE STANDARDS OF THIS SECTION. 52 13. NOTWITHSTANDING ANY INCONSISTENT PROVISION TO THE CONTRARY, THE 53 COMMISSIONER MAY ISSUE A CERTIFICATE OF AUTHORITY TO NO MORE THAN THREE 54 ELIGIBLE APPLICANTS TO OPERATE MANAGED LONG TERM PLANS THAT ARE AUTHOR- 55 IZED TO EXCLUSIVELY ENROLL INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES, 56 AS SUCH TERM IS DEFINED IN SECTION 1.03 OF THE MENTAL HYGIENE LAW. THE S. 2606--C 50 1 COMMISSIONER MAY ONLY ISSUE CERTIFICATES OF AUTHORITY PURSUANT TO THIS 2 SUBDIVISION IF, AND TO THE EXTENT THAT, THE DEPARTMENT HAS RECEIVED 3 FEDERAL APPROVAL TO OPERATE A FULLY INTEGRATED DUALS ADVANTAGE PROGRAM 4 FOR THE INTEGRATION OF SERVICES FOR PERSONS ENROLLED IN MEDICARE AND 5 MEDICAID. THE COMMISSIONER MAY WAIVE ANY OF THE DEPARTMENT'S REGU- 6 LATIONS AS THE COMMISSIONER, IN CONSULTATION WITH THE COMMISSIONER OF 7 DEVELOPMENTAL DISABILITIES, DEEMS NECESSARY TO ALLOW SUCH MANAGED LONG 8 TERM PLANS TO PROVIDE OR ARRANGE FOR SERVICES FOR INDIVIDUALS WITH 9 DEVELOPMENTAL DISABILITIES THAT ARE ADEQUATE AND APPROPRIATE TO MEET THE 10 NEEDS OF SUCH INDIVIDUALS AND THAT WILL ENSURE THEIR HEALTH AND SAFETY. 11 14. THE PROVISIONS OF SUBDIVISIONS TWELVE AND THIRTEEN OF THIS SECTION 12 SHALL ONLY BE EFFECTIVE IF, FOR SO LONG AS, AND TO THE EXTENT THAT 13 FEDERAL FINANCIAL PARTICIPATION IS AVAILABLE FOR THE COSTS OF SERVICES 14 PROVIDED THEREUNDER TO RECIPIENTS OF MEDICAL ASSISTANCE PURSUANT TO 15 TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW. THE COMMISSION- 16 ER SHALL MAKE ANY NECESSARY AMENDMENTS TO THE STATE PLAN FOR MEDICAL 17 ASSISTANCE SUBMITTED PURSUANT TO SECTION THREE HUNDRED SIXTY-THREE-A OF 18 THE SOCIAL SERVICES LAW, AND/OR SUBMIT ONE OR MORE APPLICATIONS FOR 19 WAIVERS OF THE FEDERAL SOCIAL SECURITY ACT, AS MAY BE NECESSARY TO 20 ENSURE SUCH FEDERAL FINANCIAL PARTICIPATION. TO THE EXTENT THAT THE 21 PROVISIONS OF SUBDIVISIONS TWELVE AND THIRTEEN OF THIS SECTION ARE 22 INCONSISTENT WITH OTHER PROVISIONS OF THIS ARTICLE OR WITH THE 23 PROVISIONS OF SECTION THREE HUNDRED SIXTY-FOUR-J OF THE SOCIAL SERVICES 24 LAW, THE PROVISIONS OF THIS SUBDIVISION SHALL PREVAIL. 25 S 77. Subparagraph (ii) of paragraph (b) of subdivision 1 of section 26 364-j of the social services law, as amended by chapter 433 of the laws 27 of 1997, is amended and a new subparagraph (iii) is added to read as 28 follows: 29 (ii) is authorized as a partially capitated program pursuant to 30 section three hundred sixty-four-f of this title or section forty-four 31 hundred three-e of the public health law or section 1915b of the social 32 security act[.]; OR 33 (III) IS AUTHORIZED TO OPERATE UNDER SECTION FORTY-FOUR HUNDRED 34 THREE-G OF THE PUBLIC HEALTH LAW. 35 S 78. Section 364-j of the social services law is amended by adding a 36 new subdivision 28 to read as follows: 37 28. TO THE EXTENT THAT ANY PROVISION OF THIS SECTION IS INCONSISTENT 38 WITH ANY PROVISION OF SECTION FORTY-FOUR HUNDRED THREE-G OF THE PUBLIC 39 HEALTH LAW, SUCH PROVISION OF THIS SECTION SHALL NOT APPLY TO AN ENTITY 40 AUTHORIZED TO OPERATE PURSUANT TO SECTION FORTY-FOUR HUNDRED THREE-G OF 41 THE PUBLIC HEALTH LAW. 42 S 79. Subdivision 2 of section 365-a of the social services law is 43 amended by adding a new paragraph (aa) to read as follows: 44 (AA) CARE AND SERVICES FURNISHED BY A DEVELOPMENTAL DISABILITY INDI- 45 VIDUAL SUPPORT AND CARE COORDINATION ORGANIZATION (DISCO) THAT HAS 46 RECEIVED A CERTIFICATE OF AUTHORITY PURSUANT TO SECTION FORTY-FOUR 47 HUNDRED THREE-G OF THE PUBLIC HEALTH LAW TO ELIGIBLE INDIVIDUALS RESID- 48 ING IN THE GEOGRAPHIC AREA SERVED BY SUCH ENTITY, WHEN SUCH SERVICES ARE 49 FURNISHED IN ACCORDANCE WITH AN AGREEMENT APPROVED BY THE DEPARTMENT OF 50 HEALTH WHICH MEETS THE REQUIREMENTS OF FEDERAL LAW AND REGULATIONS. 51 S 80. The commissioner of health shall, to the extent necessary, 52 submit the appropriate waivers, including, but not limited to, those 53 authorized pursuant to sections eleven hundred fifteen and nineteen 54 hundred fifteen of the federal social security act, or successor 55 provisions, and any other waivers necessary to achieve the purposes of 56 high quality, integrated and cost effective care and integrated finan- S. 2606--C 51 1 cial eligibility policies under the medical assistance program or pursu- 2 ant to title XVIII of the federal social security act and to require 3 medical assistance recipients with developmental disabilities who 4 require home and community-based services, as specified by the commis- 5 sioner, to receive such services through an available organization 6 certified pursuant to article 44 of the public health law. Copies of 7 such original waiver applications and amendments thereto shall be 8 provided to the chairs of the senate finance committee, the assembly 9 ways and means committee and the senate and assembly health committees 10 simultaneously with their submission to the federal government. 11 S 81. Notwithstanding any inconsistent provision of law, rule or regu- 12 lation, for purposes of implementing the provisions of the public health 13 law and the social services law, references to titles XIX and XXI of the 14 federal social security act in the public health law and the social 15 services law shall be deemed to include and also to mean any successor 16 titles thereto under the federal social security act. 17 S 82. Notwithstanding any inconsistent provision of law, rule or regu- 18 lation, the effectiveness of the provisions of sections 2807 and 3614 of 19 the public health law, section 18 of chapter 2 of the laws of 1988, and 20 18 NYCRR 505.14(h), as they relate to time frames for notice, approval 21 or certification of rates of payment, are hereby suspended and without 22 force or effect for purposes of implementing the provisions of this act. 23 S 83. Severability clause. If any clause, sentence, paragraph, subdi- 24 vision, section or part of this act shall be adjudged by any court of 25 competent jurisdiction to be invalid, such judgment shall not affect, 26 impair or invalidate the remainder thereof, but shall be confined in its 27 operation to the clause, sentence, paragraph, subdivision, section or 28 part thereof directly involved in the controversy in which such judgment 29 shall have been rendered. It is hereby declared to be the intent of the 30 legislature that this act would have been enacted even if such invalid 31 provisions had not been included herein. 32 S 84. This act shall take effect immediately and shall be deemed to 33 have been in full force and effect on and after April 1, 2013 provided 34 that: 35 1. the amendments to subdivision 10 of section 2807-c of the public 36 health law, made by section four of this act, shall not affect the expi- 37 ration of such subdivision and shall be deemed repealed therewith; 38 1-a. the amendments to section 364-j of the social services law, made 39 by section eleven-a of this act, shall not affect the expiration and 40 repeal of such section and shall be deemed repealed therewith; 41 1-b. Section twelve of this act shall take effect July 1, 2013; 42 1-c. section thirty-three-a of this act shall take effect January 1, 43 2014; 44 2. any rules or regulations necessary to implement the provisions of 45 this act may be promulgated and any procedures, forms, or instructions 46 necessary for such implementation may be adopted and issued on or after 47 the date this act shall have become a law; 48 3. this act shall not be construed to alter, change, affect, impair or 49 defeat any rights, obligations, duties or interests accrued, incurred or 50 conferred prior to the effective date of this act; 51 4. the commissioner of health and the superintendent of financial 52 services and any appropriate council may take any steps necessary to 53 implement this act prior to its effective date; 54 5. notwithstanding any inconsistent provision of the state administra- 55 tive procedure act or any other provision of law, rule or regulation, 56 the commissioner of health and the superintendent of financial services S. 2606--C 52 1 and any appropriate council is authorized to adopt or amend or promul- 2 gate on an emergency basis any regulation he or she or such council 3 determines necessary to implement any provision of this act on its 4 effective date; 5 6. the provisions of this act shall become effective notwithstanding 6 the failure of the commissioner of health or the superintendent of 7 financial services or any council to adopt or amend or promulgate regu- 8 lations implementing this act; 9 7. the amendments to section 364-j of the social services law made by 10 sections thirty-five-a, thirty-six, thirty-seven, thirty-eight, thirty- 11 nine, forty, forty-one, forty-two, forty-three, forty-four, fifty-two, 12 seventy-two, seventy-seven and seventy-eight of this act shall not 13 affect the repeal of such section and shall be deemed repealed there- 14 with; 15 8. section forty-eight-a of this act shall expire and be deemed 16 repealed March 31, 2017; 17 9. the amendments to paragraph (b) of subdivision 7 of section 4403-f 18 of the public health law made by section forty-eight of this act shall 19 not affect the expiration of such paragraph and repeal of such section 20 and shall be deemed expired and repealed therewith. 21 10. the amendments to section 4403-f of the public health law made by 22 sections fifty-four, seventy-five and seventy-six of this act shall not 23 affect the repeal of such section and shall be deemed repealed there- 24 with; and 25 11. the provisions of this act shall apply to any pending cause of 26 action brought pursuant to article 13 of the state finance law, and 27 shall further apply to claims, records, statements or obligations, as 28 defined by section 188 of the state finance law, that were made, used, 29 or existing prior to, on or after April 1, 2007. 30 12. the amendments to paragraph (c) of subdivision 2-c of section 31 4403-f of the public health law made by section sixty-six of this act 32 shall expire and be deemed repealed April 1, 2016. 33 13. Sections thirty-seven, forty-five-a, forty-five-b and forty-five-c 34 of this act shall take effect on April first, two thousand fourteen. 35 14. the amendments made by subdivision c-1 of section 1 of part C of 36 chapter 58 of the laws of 2005, authorizing reimbursements for expendi- 37 tures made by or on behalf of social services districts for medical 38 assistance for needy persons and the administration thereof, shall take 39 effect on the same date and in the same manner as section 1 of part F of 40 chapter 56 of the laws of 2012 takes effect. 41 PART B 42 Section 1. Subdivision (f) of section 129 of part C of chapter 58 of 43 the laws of 2009, amending the public health law relating to payment by 44 governmental agencies for general hospital inpatient services, is 45 amended to read as follows: 46 (f) section twenty-five of this act shall expire and be deemed 47 repealed April 1, [2013] 2016; 48 S 2. Paragraph (a) of subdivision 1 of section 212 of chapter 474 of 49 the laws of 1996, amending the education law and other laws relating to 50 rates for residential healthcare facilities, as amended by section 2 of 51 part D of chapter 59 of the laws of 2011, is amended to read as follows: 52 (a) Notwithstanding any inconsistent provision of law or regulation to 53 the contrary, effective beginning August 1, 1996, for the period April 54 1, 1997 through March 31, 1998, April 1, 1998 for the period April 1, S. 2606--C 53 1 1998 through March 31, 1999, August 1, 1999, for the period April 1, 2 1999 through March 31, 2000, April 1, 2000, for the period April 1, 2000 3 through March 31, 2001, April 1, 2001, for the period April 1, 2001 4 through March 31, 2002, April 1, 2002, for the period April 1, 2002 5 through March 31, 2003, and for the state fiscal year beginning April 1, 6 2005 through March 31, 2006, and for the state fiscal year beginning 7 April 1, 2006 through March 31, 2007, and for the state fiscal year 8 beginning April 1, 2007 through March 31, 2008, and for the state fiscal 9 year beginning April 1, 2008 through March 31, 2009, and for the state 10 fiscal year beginning April 1, 2009 through March 31, 2010, and for the 11 state fiscal year beginning April 1, 2010 through March 31, [2013] 2016, 12 the department of health is authorized to pay public general hospitals, 13 as defined in subdivision 10 of section 2801 of the public health law, 14 operated by the state of New York or by the state university of New York 15 or by a county, which shall not include a city with a population of over 16 one million, of the state of New York, and those public general hospi- 17 tals located in the county of Westchester, the county of Erie or the 18 county of Nassau, additional payments for inpatient hospital services as 19 medical assistance payments pursuant to title 11 of article 5 of the 20 social services law for patients eligible for federal financial partic- 21 ipation under title XIX of the federal social security act in medical 22 assistance pursuant to the federal laws and regulations governing 23 disproportionate share payments to hospitals up to one hundred percent 24 of each such public general hospital's medical assistance and uninsured 25 patient losses after all other medical assistance, including dispropor- 26 tionate share payments to such public general hospital for 1996, 1997, 27 1998, and 1999, based initially for 1996 on reported 1994 reconciled 28 data as further reconciled to actual reported 1996 reconciled data, and 29 for 1997 based initially on reported 1995 reconciled data as further 30 reconciled to actual reported 1997 reconciled data, for 1998 based 31 initially on reported 1995 reconciled data as further reconciled to 32 actual reported 1998 reconciled data, for 1999 based initially on 33 reported 1995 reconciled data as further reconciled to actual reported 34 1999 reconciled data, for 2000 based initially on reported 1995 recon- 35 ciled data as further reconciled to actual reported 2000 data, for 2001 36 based initially on reported 1995 reconciled data as further reconciled 37 to actual reported 2001 data, for 2002 based initially on reported 2000 38 reconciled data as further reconciled to actual reported 2002 data, and 39 for state fiscal years beginning on April 1, 2005, based initially on 40 reported 2000 reconciled data as further reconciled to actual reported 41 data for 2005, and for state fiscal years beginning on April 1, 2006, 42 based initially on reported 2000 reconciled data as further reconciled 43 to actual reported data for 2006, for state fiscal years beginning on 44 and after April 1, 2007 through March 31, 2009, based initially on 45 reported 2000 reconciled data as further reconciled to actual reported 46 data for 2007 and 2008, respectively, for state fiscal years beginning 47 on and after April 1, 2009, based initially on reported 2007 reconciled 48 data, adjusted for authorized Medicaid rate changes applicable to the 49 state fiscal year, and as further reconciled to actual reported data for 50 2009, for state fiscal years beginning on and after April 1, 2010, based 51 initially on reported reconciled data from the base year two years prior 52 to the payment year, adjusted for authorized Medicaid rate changes 53 applicable to the state fiscal year, and further reconciled to actual 54 reported data from such payment year, and to actual reported data for 55 each respective succeeding year. The payments may be added to rates of S. 2606--C 54 1 payment or made as aggregate payments to an eligible public general 2 hospital. 3 S 3. Section 11 of chapter 884 of the laws of 1990, amending the 4 public health law relating to authorizing bad debt and charity care 5 allowances for certified home health agencies, as amended by section 3 6 of part D of chapter 59 of the laws of 2011, is amended to read as 7 follows: 8 S 11. This act shall take effect immediately and: 9 (a) sections one and three shall expire on December 31, 1996, 10 (b) sections four through ten shall expire on June 30, [2013] 2015, 11 and 12 (c) provided that the amendment to section 2807-b of the public health 13 law by section two of this act shall not affect the expiration of such 14 section 2807-b as otherwise provided by law and shall be deemed to 15 expire therewith. 16 S 4. Subdivision 2 of section 246 of chapter 81 of the laws of 1995, 17 amending the public health law and other laws relating to medical 18 reimbursement and welfare reform, as amended by section 4 of part D of 19 chapter 59 of the laws of 2011, is amended to read as follows: 20 2. Sections five, seven through nine, twelve through fourteen, and 21 eighteen of this act shall be deemed to have been in full force and 22 effect on and after April 1, 1995 through March 31, 1999 and on and 23 after July 1, 1999 through March 31, 2000 and on and after April 1, 2000 24 through March 31, 2003 and on and after April 1, 2003 through March 31, 25 2006 and on and after April 1, 2006 through March 31, 2007 and on and 26 after April 1, 2007 through March 31, 2009 and on and after April 1, 27 2009 through March 31, 2011 and sections twelve, thirteen and fourteen 28 of this act shall be deemed to be in full force and effect on and after 29 April 1, 2011 through March 31, [2013] 2015; 30 S 5. Subparagraph (vi) of paragraph (b) of subdivision 2 of section 31 2807-d of the public health law, as amended by section 102 of part H of 32 chapter 59 of the laws of 2011, is amended to read as follows: 33 (vi) Notwithstanding any contrary provision of this paragraph or any 34 other provision of law or regulation to the contrary, for residential 35 health care facilities the assessment shall be six percent of each resi- 36 dential health care facility's gross receipts received from all patient 37 care services and other operating income on a cash basis for the period 38 April first, two thousand two through March thirty-first, two thousand 39 three for hospital or health-related services, including adult day 40 services; provided, however, that residential health care facilities' 41 gross receipts attributable to payments received pursuant to title XVIII 42 of the federal social security act (medicare) shall be excluded from the 43 assessment; provided, however, that for all such gross receipts received 44 on or after April first, two thousand three through March thirty-first, 45 two thousand five, such assessment shall be five percent, and further 46 provided that for all such gross receipts received on or after April 47 first, two thousand five through March thirty-first, two thousand nine, 48 and on or after April first, two thousand nine through March thirty- 49 first, two thousand eleven such assessment shall be six percent, and 50 further provided that for all such gross receipts received on or after 51 April first, two thousand eleven through March thirty-first, two thou- 52 sand thirteen such assessment shall be six percent, AND FURTHER PROVIDED 53 THAT FOR ALL SUCH GROSS RECEIPTS RECEIVED ON OR AFTER APRIL FIRST, TWO 54 THOUSAND THIRTEEN THROUGH MARCH THIRTY-FIRST, TWO THOUSAND FIFTEEN SUCH 55 ASSESSMENT SHALL BE SIX PERCENT. S. 2606--C 55 1 S 6. Section 88 of chapter 659 of the laws of 1997, constituting the 2 long term care integration and finance act of 1997, as amended by chap- 3 ter 446 of the laws of 2011, is amended to read as follows: 4 S 88. Notwithstanding any provision of law to the contrary, all oper- 5 ating demonstrations, as such term is defined in paragraph (c) of subdi- 6 vision 1 of section 4403-f of the public health law as added by section 7 eighty-two of this act, due to expire prior to January 1, 2001 shall be 8 deemed to expire on December 31, [2013] 2015. 9 S 7. Subparagraph (v) of paragraph (b) of subdivision 35 of section 10 2807-c of the public health law, as amended by section 2 of part G of 11 chapter 56 of the laws of 2012, is amended to read as follows: 12 (v) such regulations shall incorporate quality related measures, 13 including, but not limited to, potentially preventable re-admissions 14 (PPRs) and provide for rate adjustments or payment disallowances related 15 to PPRs and other potentially preventable negative outcomes (PPNOs), 16 which shall be calculated in accordance with methodologies as determined 17 by the commissioner, provided, however, that such methodologies shall be 18 based on a comparison of the actual and risk adjusted expected number of 19 PPRs and other PPNOs in a given hospital and with benchmarks established 20 by the commissioner and provided further that such rate adjustments or 21 payment disallowances shall result in an aggregate reduction in Medicaid 22 payments of no less than thirty-five million dollars for the period July 23 first, two thousand ten through March thirty-first, two thousand eleven 24 and no less than fifty-one million dollars for annual periods beginning 25 April first, two thousand eleven through March thirty-first, two thou- 26 sand [thirteen] FOURTEEN, provided further that such aggregate 27 reductions shall be offset by Medicaid payment reductions occurring as a 28 result of decreased PPRs during the period July first, two thousand ten 29 through March thirty-first, two thousand eleven and the period April 30 first, two thousand eleven through March thirty-first, two thousand 31 [thirteen] FOURTEEN and as a result of decreased PPNOs during the period 32 April first, two thousand eleven through March thirty-first, two thou- 33 sand [thirteen] FOURTEEN; and provided further that for the period July 34 first, two thousand ten through March thirty-first, two thousand [thir- 35 teen] FOURTEEN, such rate adjustments or payment disallowances shall not 36 apply to behavioral health PPRs; or to readmissions that occur on or 37 after fifteen days following an initial admission. By no later than July 38 first, two thousand eleven the commissioner shall enter into consulta- 39 tions with representatives of the health care facilities subject to this 40 section regarding potential prospective revisions to applicable method- 41 ologies and benchmarks set forth in regulations issued pursuant to this 42 subparagraph; 43 S 8. Subdivision 2 of section 93 of part C of chapter 58 of the laws 44 of 2007 amending the social services law and other laws relating to 45 enacting the major components of legislation necessary to implement the 46 health and mental hygiene budget for the 2007-2008 fiscal year, as 47 amended by section 10 of part B of chapter 58 of the laws of 2009, is 48 amended to read as follows: 49 2. section two of this act shall expire and be deemed repealed on 50 March 31, [2013] 2014; 51 S 8-a. Subdivision 8 of section 364-l of the social services law, as 52 added by section 2 of part C of chapter 58 of the laws of 2007, is 53 amended to read as follows: 54 8. The commissioner of health shall provide a report to the governor 55 and the legislature no later than January first, two thousand ten. ON 56 AND AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN SUCH COMMISSIONER SHALL S. 2606--C 56 1 PROVIDE A REPORT ANNUALLY TO THE GOVERNOR AND THE LEGISLATURE. The 2 report shall include findings as to the demonstration projects' effec- 3 tiveness in managing the care needs and improving the health of program 4 participants, an evaluation as to the programs' cost-effectiveness as 5 measured against traditional medicaid care models, and recommendations 6 as to whether the programs should be extended, modified, eliminated, or 7 made permanent. 8 S 9. Section 194 of chapter 474 of the laws of 1996, amending the 9 education law and other laws relating to rates for residential health 10 care facilities, as amended by section 9 of part D of chapter 59 of the 11 laws of 2011, is amended to read as follows: 12 S 194. 1. Notwithstanding any inconsistent provision of law or regu- 13 lation, the trend factors used to project reimbursable operating costs 14 to the rate period for purposes of determining rates of payment pursuant 15 to article 28 of the public health law for residential health care 16 facilities for reimbursement of inpatient services provided to patients 17 eligible for payments made by state governmental agencies on and after 18 April 1, 1996 through March 31, 1999 and for payments made on and after 19 July 1, 1999 through March 31, 2000 and on and after April 1, 2000 20 through March 31, 2003 and on and after April 1, 2003 through March 31, 21 2007 and on and after April 1, 2007 through March 31, 2009 and on and 22 after April 1, 2009 through March 31, 2011 and on and after April 1, 23 2011 through March 31, 2013 AND ON AND AFTER APRIL 1, 2013 THROUGH MARCH 24 31, 2015 shall reflect no trend factor projections or adjustments for 25 the period April 1, 1996, through March 31, 1997. 26 2. The commissioner of health shall adjust such rates of payment to 27 reflect the exclusion pursuant to this section of such specified trend 28 factor projections or adjustments. 29 S 10. Subdivision 1 of section 89-a of part C of chapter 58 of the 30 laws of 2007, amending the social services law and other laws relating 31 to enacting the major components of legislation necessary to implement 32 the health and mental hygiene budget for the 2007-2008 state fiscal 33 year, as amended by section 10 of part D of chapter 59 of the laws of 34 2011, is amended to read as follows: 35 1. Notwithstanding paragraph (c) of subdivision 10 of section 2807-c 36 of the public health law and section 21 of chapter 1 of the laws of 37 1999, as amended, and any other inconsistent provision of law or regu- 38 lation to the contrary, in determining rates of payments by state 39 governmental agencies effective for services provided beginning April 1, 40 2006, through March 31, 2009, and on and after April 1, 2009 through 41 March 31, 2011, and on and after April 1, 2011 through March 31, 2013, 42 AND ON AND AFTER APRIL 1, 2013 THROUGH MARCH 31, 2015 for inpatient and 43 outpatient services provided by general hospitals and for inpatient 44 services and outpatient adult day health care services provided by resi- 45 dential health care facilities pursuant to article 28 of the public 46 health law, the commissioner of health shall apply a trend factor 47 projection of two and twenty-five hundredths percent attributable to the 48 period January 1, 2006 through December 31, 2006, and on and after Janu- 49 ary 1, 2007, provided, however, that on reconciliation of such trend 50 factor for the period January 1, 2006 through December 31, 2006 pursuant 51 to paragraph (c) of subdivision 10 of section 2807-c of the public 52 health law, such trend factor shall be the final US Consumer Price Index 53 (CPI) for all urban consumers, as published by the US Department of 54 Labor, Bureau of Labor Statistics less twenty-five hundredths of a 55 percentage point. S. 2606--C 57 1 S 11. Paragraph (f) of subdivision 1 of section 64 of chapter 81 of 2 the laws of 1995, amending the public health law and other laws relating 3 to medical reimbursement and welfare reform, as amended by section 11 of 4 part D of chapter 59 of the laws of 2011, is amended to read as follows: 5 (f) Prior to February 1, 2001, February 1, 2002, February 1, 2003, 6 February 1, 2004, February 1, 2005, February 1, 2006, February 1, 2007, 7 February 1, 2008, February 1, 2009, February 1, 2010, February 1, 2011, 8 February 1, 2012, [and] February 1, 2013 AND FEBRUARY 1, 2014 AND FEBRU- 9 ARY 1, 2015 the commissioner of health shall calculate the result of the 10 statewide total of residential health care facility days of care 11 provided to beneficiaries of title XVIII of the federal social security 12 act (medicare), divided by the sum of such days of care plus days of 13 care provided to residents eligible for payments pursuant to title 11 of 14 article 5 of the social services law minus the number of days provided 15 to residents receiving hospice care, expressed as a percentage, for the 16 period commencing January 1, through November 30, of the prior year 17 respectively, based on such data for such period. This value shall be 18 called the 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 19 2010, 2011, 2012, [and] 2013, 2014 AND 2015 statewide target percentage 20 respectively. 21 S 12. Subparagraph (ii) of paragraph (b) of subdivision 3 of section 22 64 of chapter 81 of the laws of 1995, amending the public health law and 23 other laws relating to medical reimbursement and welfare reform, as 24 amended by section 12 of part D of chapter 59 of the laws of 2011, is 25 amended to read as follows: 26 (ii) If the 1997, 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 27 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 statewide 28 target percentages are not for each year at least three percentage 29 points higher than the statewide base percentage, the commissioner of 30 health shall determine the percentage by which the statewide target 31 percentage for each year is not at least three percentage points higher 32 than the statewide base percentage. The percentage calculated pursuant 33 to this paragraph shall be called the 1997, 1998, 2000, 2001, 2002, 34 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 35 2014 AND 2015 statewide reduction percentage respectively. If the 1997, 36 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 37 2011, 2012, [and] 2013; 2014 AND 2015 statewide target percentage for 38 the respective year is at least three percentage points higher than the 39 statewide base percentage, the statewide reduction percentage for the 40 respective year shall be zero. 41 S 13. Subparagraph (iii) of paragraph (b) of subdivision 4 of section 42 64 of chapter 81 of the laws of 1995, amending the public health law and 43 other laws relating to medical reimbursement and welfare reform, as 44 amended by section 13 of part D of chapter 59 of the laws of 2011, is 45 amended to read as follows: 46 (iii) The 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 47 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 statewide reduction 48 percentage shall be multiplied by one hundred two million dollars 49 respectively to determine the 1998, 2000, 2001, 2002, 2003, 2004, 2005, 50 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 51 statewide aggregate reduction amount. If the 1998 and the 2000, 2001, 52 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 53 2013, 2014 AND 2015 statewide reduction percentage shall be zero respec- 54 tively, there shall be no 1998, 2000, 2001, 2002, 2003, 2004, 2005, 55 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 56 reduction amount. S. 2606--C 58 1 S 14. Paragraph (b) of subdivision 5 of section 64 of chapter 81 of 2 the laws of 1995, amending the public health law and other laws relating 3 to medical reimbursement and welfare reform, as amended by section 14 of 4 part D of chapter 59 of the laws of 2011, is amended to read as follows: 5 (b) The 1996, 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 6 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 7 statewide aggregate reduction amounts shall for each year be allocated 8 by the commissioner of health among residential health care facilities 9 that are eligible to provide services to beneficiaries of title XVIII of 10 the federal social security act (medicare) and residents eligible for 11 payments pursuant to title 11 of article 5 of the social services law on 12 the basis of the extent of each facility's failure to achieve a two 13 percentage points increase in the 1996 target percentage, a three 14 percentage point increase in the 1997, 1998, 2000, 2001, 2002, 2003, 15 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 16 AND 2015 target percentage and a two and one-quarter percentage point 17 increase in the 1999 target percentage for each year, compared to the 18 base percentage, calculated on a facility specific basis for this 19 purpose, compared to the statewide total of the extent of each facili- 20 ty's failure to achieve a two percentage points increase in the 1996 and 21 a three percentage point increase in the 1997 and a three percentage 22 point increase in the 1998 and a two and one-quarter percentage point 23 increase in the 1999 target percentage and a three percentage point 24 increase in the 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 25 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 target percentage 26 compared to the base percentage. These amounts shall be called the 1996, 27 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 28 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 facility specific 29 reduction amounts respectively. 30 S 14-a. Section 228 of chapter 474 of the laws of 1996, amending the 31 education law and other laws relating to rates for residential health 32 care facilities, as amended by section 14-a of part D of chapter 59 of 33 the laws of 2011, is amended to read as follows: 34 S 228. 1. Definitions. (a) Regions, for purposes of this section, 35 shall mean a downstate region to consist of Kings, New York, Richmond, 36 Queens, Bronx, Nassau and Suffolk counties and an upstate region to 37 consist of all other New York state counties. A certified home health 38 agency or long term home health care program shall be located in the 39 same county utilized by the commissioner of health for the establishment 40 of rates pursuant to article 36 of the public health law. 41 (b) Certified home health agency (CHHA) shall mean such term as 42 defined in section 3602 of the public health law. 43 (c) Long term home health care program (LTHHCP) shall mean such term 44 as defined in subdivision 8 of section 3602 of the public health law. 45 (d) Regional group shall mean all those CHHAs and LTHHCPs, respective- 46 ly, located within a region. 47 (e) Medicaid revenue percentage, for purposes of this section, shall 48 mean CHHA and LTHHCP revenues attributable to services provided to 49 persons eligible for payments pursuant to title 11 of article 5 of the 50 social services law divided by such revenues plus CHHA and LTHHCP reven- 51 ues attributable to services provided to beneficiaries of Title XVIII of 52 the federal social security act (medicare). 53 (f) Base period, for purposes of this section, shall mean calendar 54 year 1995. 55 (g) Target period. For purposes of this section, the 1996 target peri- 56 od shall mean August 1, 1996 through March 31, 1997, the 1997 target S. 2606--C 59 1 period shall mean January 1, 1997 through November 30, 1997, the 1998 2 target period shall mean January 1, 1998 through November 30, 1998, the 3 1999 target period shall mean January 1, 1999 through November 30, 1999, 4 the 2000 target period shall mean January 1, 2000 through November 30, 5 2000, the 2001 target period shall mean January 1, 2001 through November 6 30, 2001, the 2002 target period shall mean January 1, 2002 through 7 November 30, 2002, the 2003 target period shall mean January 1, 2003 8 through November 30, 2003, the 2004 target period shall mean January 1, 9 2004 through November 30, 2004, and the 2005 target period shall mean 10 January 1, 2005 through November 30, 2005, the 2006 target period shall 11 mean January 1, 2006 through November 30, 2006, and the 2007 target 12 period shall mean January 1, 2007 through November 30, 2007 and the 2008 13 target period shall mean January 1, 2008 through November 30, 2008, and 14 the 2009 target period shall mean January 1, 2009 through November 30, 15 2009 and the 2010 target period shall mean January 1, 2010 through 16 November 30, 2010 and the 2011 target period shall mean January 1, 2011 17 through November 30, 2011 and the 2012 target period shall mean January 18 1, 2012 through November 30, 2012 and the 2013 target period shall mean 19 January 1, 2013 through November 30, 2013, AND THE 2014 TARGET PERIOD 20 SHALL MEAN JANUARY 1, 2014 THROUGH NOVEMBER 30, 2014 AND THE 2015 TARGET 21 PERIOD SHALL MEAN JANUARY 1, 2015 THROUGH NOVEMBER 30, 2015. 22 2. (a) Prior to February 1, 1997, for each regional group the commis- 23 sioner of health shall calculate the 1996 medicaid revenue percentages 24 for the period commencing August 1, 1996 to the last date for which such 25 data is available and reasonably accurate. 26 (b) Prior to February 1, 1998, prior to February 1, 1999, prior to 27 February 1, 2000, prior to February 1, 2001, prior to February 1, 2002, 28 prior to February 1, 2003, prior to February 1, 2004, prior to February 29 1, 2005, prior to February 1, 2006, prior to February 1, 2007, prior to 30 February 1, 2008, prior to February 1, 2009, prior to February 1, 2010, 31 prior to February 1, 2011, prior to February 1, 2012 [and], prior to 32 February 1, 2013, PRIOR TO FEBRUARY 1, 2014 AND PRIOR TO FEBRUARY 1, 33 2015 for each regional group the commissioner of health shall calculate 34 the prior year's medicaid revenue percentages for the period commencing 35 January 1 through November 30 of such prior year. 36 3. By September 15, 1996, for each regional group the commissioner of 37 health shall calculate the base period medicaid revenue percentage. 38 4. (a) For each regional group, the 1996 target medicaid revenue 39 percentage shall be calculated by subtracting the 1996 medicaid revenue 40 reduction percentages from the base period medicaid revenue percentages. 41 The 1996 medicaid revenue reduction percentage, taking into account 42 regional and program differences in utilization of medicaid and medicare 43 services, for the following regional groups shall be equal to: 44 (i) one and one-tenth percentage points for CHHAs located within the 45 downstate region; 46 (ii) six-tenths of one percentage point for CHHAs located within the 47 upstate region; 48 (iii) one and eight-tenths percentage points for LTHHCPs located with- 49 in the downstate region; and 50 (iv) one and seven-tenths percentage points for LTHHCPs located within 51 the upstate region. 52 (b) For 1997, 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 53 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 for each 54 regional group, the target medicaid revenue percentage for the respec- 55 tive year shall be calculated by subtracting the respective year's medi- 56 caid revenue reduction percentage from the base period medicaid revenue S. 2606--C 60 1 percentage. The medicaid revenue reduction percentages for 1997, 1998, 2 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, 3 2012, [and] 2013, 2014 AND 2015 taking into account regional and program 4 differences in utilization of medicaid and medicare services, for the 5 following regional groups shall be equal to for each such year: 6 (i) one and one-tenth percentage points for CHHAs located within the 7 downstate region; 8 (ii) six-tenths of one percentage point for CHHAs located within the 9 upstate region; 10 (iii) one and eight-tenths percentage points for LTHHCPs located with- 11 in the downstate region; and 12 (iv) one and seven-tenths percentage points for LTHHCPs located within 13 the upstate region. 14 (c) For each regional group, the 1999 target medicaid revenue percent- 15 age shall be calculated by subtracting the 1999 medicaid revenue 16 reduction percentage from the base period medicaid revenue percentage. 17 The 1999 medicaid revenue reduction percentages, taking into account 18 regional and program differences in utilization of medicaid and medicare 19 services, for the following regional groups shall be equal to: 20 (i) eight hundred twenty-five thousandths (.825) of one percentage 21 point for CHHAs located within the downstate region; 22 (ii) forty-five hundredths (.45) of one percentage point for CHHAs 23 located within the upstate region; 24 (iii) one and thirty-five hundredths percentage points (1.35) for 25 LTHHCPs located within the downstate region; and 26 (iv) one and two hundred seventy-five thousandths percentage points 27 (1.275) for LTHHCPs located within the upstate region. 28 5. (a) For each regional group, if the 1996 medicaid revenue percent- 29 age is not equal to or less than the 1996 target medicaid revenue 30 percentage, the commissioner of health shall compare the 1996 medicaid 31 revenue percentage to the 1996 target medicaid revenue percentage to 32 determine the amount of the shortfall which, when divided by the 1996 33 medicaid revenue reduction percentage, shall be called the 1996 34 reduction factor. These amounts, expressed as a percentage, shall not 35 exceed one hundred percent. If the 1996 medicaid revenue percentage is 36 equal to or less than the 1996 target medicaid revenue percentage, the 37 1996 reduction factor shall be zero. 38 (b) For 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 39 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 for each 40 regional group, if the medicaid revenue percentage for the respective 41 year is not equal to or less than the target medicaid revenue percentage 42 for such respective year, the commissioner of health shall compare such 43 respective year's medicaid revenue percentage to such respective year's 44 target medicaid revenue percentage to determine the amount of the short- 45 fall which, when divided by the respective year's medicaid revenue 46 reduction percentage, shall be called the reduction factor for such 47 respective year. These amounts, expressed as a percentage, shall not 48 exceed one hundred percent. If the medicaid revenue percentage for a 49 particular year is equal to or less than the target medicaid revenue 50 percentage for that year, the reduction factor for that year shall be 51 zero. 52 6. (a) For each regional group, the 1996 reduction factor shall be 53 multiplied by the following amounts to determine each regional group's 54 applicable 1996 state share reduction amount: 55 (i) two million three hundred ninety thousand dollars ($2,390,000) for 56 CHHAs located within the downstate region; S. 2606--C 61 1 (ii) seven hundred fifty thousand dollars ($750,000) for CHHAs located 2 within the upstate region; 3 (iii) one million two hundred seventy thousand dollars ($1,270,000) 4 for LTHHCPs located within the downstate region; and 5 (iv) five hundred ninety thousand dollars ($590,000) for LTHHCPs 6 located within the upstate region. 7 For each regional group reduction, if the 1996 reduction factor shall 8 be zero, there shall be no 1996 state share reduction amount. 9 (b) For 1997, 1998, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 10 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 for each 11 regional group, the reduction factor for the respective year shall be 12 multiplied by the following amounts to determine each regional group's 13 applicable state share reduction amount for such respective year: 14 (i) two million three hundred ninety thousand dollars ($2,390,000) for 15 CHHAs located within the downstate region; 16 (ii) seven hundred fifty thousand dollars ($750,000) for CHHAs located 17 within the upstate region; 18 (iii) one million two hundred seventy thousand dollars ($1,270,000) 19 for LTHHCPs located within the downstate region; and 20 (iv) five hundred ninety thousand dollars ($590,000) for LTHHCPs 21 located within the upstate region. 22 For each regional group reduction, if the reduction factor for a 23 particular year shall be zero, there shall be no state share reduction 24 amount for such year. 25 (c) For each regional group, the 1999 reduction factor shall be multi- 26 plied by the following amounts to determine each regional group's appli- 27 cable 1999 state share reduction amount: 28 (i) one million seven hundred ninety-two thousand five hundred dollars 29 ($1,792,500) for CHHAs located within the downstate region; 30 (ii) five hundred sixty-two thousand five hundred dollars ($562,500) 31 for CHHAs located within the upstate region; 32 (iii) nine hundred fifty-two thousand five hundred dollars ($952,500) 33 for LTHHCPs located within the downstate region; and 34 (iv) four hundred forty-two thousand five hundred dollars ($442,500) 35 for LTHHCPs located within the upstate region. 36 For each regional group reduction, if the 1999 reduction factor shall 37 be zero, there shall be no 1999 state share reduction amount. 38 7. (a) For each regional group, the 1996 state share reduction amount 39 shall be allocated by the commissioner of health among CHHAs and LTHHCPs 40 on the basis of the extent of each CHHA's and LTHHCP's failure to 41 achieve the 1996 target medicaid revenue percentage, calculated on a 42 provider specific basis utilizing revenues for this purpose, expressed 43 as a proportion of the total of each CHHA's and LTHHCP's failure to 44 achieve the 1996 target medicaid revenue percentage within the applica- 45 ble regional group. This proportion shall be multiplied by the applica- 46 ble 1996 state share reduction amount calculation pursuant to paragraph 47 (a) of subdivision 6 of this section. This amount shall be called the 48 1996 provider specific state share reduction amount. 49 (b) For 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 50 2007, 2008, 2009, 2010, 2011, 2012, [and] 2013, 2014 AND 2015 for each 51 regional group, the state share reduction amount for the respective year 52 shall be allocated by the commissioner of health among CHHAs and LTHHCPs 53 on the basis of the extent of each CHHA's and LTHHCP's failure to 54 achieve the target medicaid revenue percentage for the applicable year, 55 calculated on a provider specific basis utilizing revenues for this 56 purpose, expressed as a proportion of the total of each CHHA's and S. 2606--C 62 1 LTHHCP's failure to achieve the target medicaid revenue percentage for 2 the applicable year within the applicable regional group. This propor- 3 tion shall be multiplied by the applicable year's state share reduction 4 amount calculation pursuant to paragraph (b) or (c) of subdivision 6 of 5 this section. This amount shall be called the provider specific state 6 share reduction amount for the applicable year. 7 8. (a) The 1996 provider specific state share reduction amount shall 8 be due to the state from each CHHA and LTHHCP and may be recouped by the 9 state by March 31, 1997 in a lump sum amount or amounts from payments 10 due to the CHHA and LTHHCP pursuant to title 11 of article 5 of the 11 social services law. 12 (b) The provider specific state share reduction amount for 1997, 1998, 13 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2010, 14 2011, 2012, [and] 2013, 2014 AND 2015 respectively, shall be due to the 15 state from each CHHA and LTHHCP and each year the amount due for such 16 year may be recouped by the state by March 31 of the following year in a 17 lump sum amount or amounts from payments due to the CHHA and LTHHCP 18 pursuant to title 11 of article 5 of the social services law. 19 9. CHHAs and LTHHCPs shall submit such data and information at such 20 times as the commissioner of health may require for purposes of this 21 section. The commissioner of health may use data available from third- 22 party payors. 23 10. On or about June 1, 1997, for each regional group the commissioner 24 of health shall calculate for the period August 1, 1996 through March 25 31, 1997 a medicaid revenue percentage, a reduction factor, a state 26 share reduction amount, and a provider specific state share reduction 27 amount in accordance with the methodology provided in paragraph (a) of 28 subdivision 2, paragraph (a) of subdivision 5, paragraph (a) of subdivi- 29 sion 6 and paragraph (a) of subdivision 7 of this section. The provider 30 specific state share reduction amount calculated in accordance with this 31 subdivision shall be compared to the 1996 provider specific state share 32 reduction amount calculated in accordance with paragraph (a) of subdivi- 33 sion 7 of this section. Any amount in excess of the amount determined in 34 accordance with paragraph (a) of subdivision 7 of this section shall be 35 due to the state from each CHHA and LTHHCP and may be recouped in 36 accordance with paragraph (a) of subdivision 8 of this section. If the 37 amount is less than the amount determined in accordance with paragraph 38 (a) of subdivision 7 of this section, the difference shall be refunded 39 to the CHHA and LTHHCP by the state no later than July 15, 1997. CHHAs 40 and LTHHCPs shall submit data for the period August 1, 1996 through 41 March 31, 1997 to the commissioner of health by April 15, 1997. 42 11. If a CHHA or LTHHCP fails to submit data and information as 43 required for purposes of this section: 44 (a) such CHHA or LTHHCP shall be presumed to have no decrease in medi- 45 caid revenue percentage between the applicable base period and the 46 applicable target period for purposes of the calculations pursuant to 47 this section; and 48 (b) the commissioner of health shall reduce the current rate paid to 49 such CHHA and such LTHHCP by state governmental agencies pursuant to 50 article 36 of the public health law by one percent for a period begin- 51 ning on the first day of the calendar month following the applicable due 52 date as established by the commissioner of health and continuing until 53 the last day of the calendar month in which the required data and infor- 54 mation are submitted. 55 12. The commissioner of health shall inform in writing the director of 56 the budget and the chair of the senate finance committee and the chair S. 2606--C 63 1 of the assembly ways and means committee of the results of the calcu- 2 lations pursuant to this section. 3 S 15. Subdivision 5-a of section 246 of chapter 81 of the laws of 4 1995, amending the public health law and other laws relating to medical 5 reimbursement and welfare reform, as amended by section 15 of part D of 6 chapter 59 of the laws of 2011, is amended to read as follows: 7 5-a. Section sixty-four-a of this act shall be deemed to have been in 8 full force and effect on and after April 1, 1995 through March 31, 1999 9 and on and after July 1, 1999 through March 31, 2000 and on and after 10 April 1, 2000 through March 31, 2003 and on and after April 1, 2003 11 through March 31, 2007, and on and after April 1, 2007 through March 31, 12 2009, and on and after April 1, 2009 through March 31, 2011, and on and 13 after April 1, 2011 through March 31, 2013, AND ON AND AFTER APRIL 1, 14 2013 THROUGH MARCH 31, 2015; 15 S 16. Section 64-b of chapter 81 of the laws of 1995, amending the 16 public health law and other laws relating to medical reimbursement and 17 welfare reform, as amended by section 16 of part D of chapter 59 of the 18 laws of 2011, is amended to read as follows: 19 S 64-b. Notwithstanding any inconsistent provision of law, the 20 provisions of subdivision 7 of section 3614 of the public health law, as 21 amended, shall remain and be in full force and effect on April 1, 1995 22 through March 31, 1999 and on July 1, 1999 through March 31, 2000 and on 23 and after April 1, 2000 through March 31, 2003 and on and after April 1, 24 2003 through March 31, 2007, and on and after April 1, 2007 through 25 March 31, 2009, and on and after April 1, 2009 through March 31, 2011, 26 and on and after April 1, 2011 through March 31, 2013, AND ON AND AFTER 27 APRIL 1, 2013 THROUGH MARCH 31, 2015. 28 S 17. Subdivision 1 of section 20 of chapter 451 of the laws of 2007, 29 amending the public health law, the social services law and the insur- 30 ance law, relating to providing enhanced consumer and provider 31 protections, as amended by section 17 of part D of chapter 59 of the 32 laws of 2011, is amended to read as follows: 33 1. sections four, eleven and thirteen of this act shall take effect 34 immediately and shall expire and be deemed repealed June 30, [2013] 35 2015; 36 S 18. The opening paragraph of subdivision 7-a of section 3614 of the 37 public health law, as amended by section 18 of part D of chapter 59 of 38 the laws of 2011, is amended to read as follows: 39 Notwithstanding any inconsistent provision of law or regulation, for 40 the purposes of establishing rates of payment by governmental agencies 41 for long term home health care programs for the period April first, two 42 thousand five, through December thirty-first, two thousand five, and for 43 the period January first, two thousand six through March thirty-first, 44 two thousand seven, and on and after April first, two thousand seven 45 through March thirty-first, two thousand nine, and on and after April 46 first, two thousand nine through March thirty-first, two thousand elev- 47 en, and on and after April first, two thousand eleven through March 48 thirty-first, two thousand thirteen AND ON AND AFTER APRIL FIRST, TWO 49 THOUSAND THIRTEEN THROUGH MARCH THIRTY-FIRST, TWO THOUSAND FIFTEEN, the 50 reimbursable base year administrative and general costs of a provider of 51 services shall not exceed the statewide average of total reimbursable 52 base year administrative and general costs of such providers of 53 services. 54 S 19. Intentionally omitted. 55 S 20. Subdivision 6-a of section 93 of part C of chapter 58 of the 56 laws of 2007 amending the social services law and the public health law S. 2606--C 64 1 relating to adjustments of rates, as amended by section 40 of part D of 2 chapter 58 of the laws of 2009, is amended to read as follows: 3 6-a. section fifty-seven of this act shall expire and be deemed 4 repealed on December 31, [2013] 2018; provided that the amendments made 5 by such section to subdivision 4 of section 366-c of the social services 6 law shall apply with respect to determining initial and continuing 7 eligibility for medical assistance, including the continued eligibility 8 of recipients originally determined eligible prior to the effective date 9 of this act, and provided further that such amendments shall not apply 10 to any person or group of persons if it is subsequently determined by 11 the Centers for Medicare and Medicaid services or by a court of compe- 12 tent jurisdiction that medical assistance with federal financial partic- 13 ipation is available for the costs of services provided to such person 14 or persons under the provisions of subdivision 4 of section 366-c of the 15 social services law in effect immediately prior to the effective date of 16 this act. 17 S 21. Subdivision 12 of section 246 of chapter 81 of the laws of 1995, 18 amending the public health law and other laws relating to medical 19 reimbursement and welfare reform, as amended by section 23 of part D of 20 chapter 59 of the laws of 2011, is amended to read as follows: 21 12. Sections one hundred five-b through one hundred five-f of this act 22 shall expire March 31, [2013] 2015. 23 S 22. Section 5 of chapter 426 of the laws of 1983, amending the 24 public health law relating to professional misconduct proceedings, as 25 amended by chapter 36 of the laws of 2008, is amended to read as 26 follows: 27 S 5. This act shall take effect June 1, 1983 and shall remain in full 28 force and effect until March 31, [2013] 2018. 29 S 23. Section 5 of chapter 582 of the laws of 1984, amending the 30 public health law relating to regulating activities of physicians, as 31 amended by chapter 36 of the laws of 2008, is amended to read as 32 follows: 33 S 5. This act shall take effect immediately, provided however that the 34 provisions of this act shall remain in full force and effect until March 35 31, [2013] 2018 at which time the provisions of this act shall be deemed 36 to be repealed. 37 S 24. Subparagraph (ii) of paragraph (c) of subdivision 11 of section 38 230 of the public health law, as amended by chapter 36 of the laws of 39 2008, is amended to read as follows: 40 (ii) Participation and membership during a three year demonstration 41 period in a physician committee of the Medical Society of the State of 42 New York or the New York State Osteopathic Society whose purpose is to 43 confront and refer to treatment physicians who are thought to be suffer- 44 ing from alcoholism, drug abuse or mental illness. Such demonstration 45 period shall commence on April first, nineteen hundred eighty and termi- 46 nate on May thirty-first, nineteen hundred eighty-three. An additional 47 demonstration period shall commence on June first, nineteen hundred 48 eighty-three and terminate on March thirty-first, nineteen hundred 49 eighty-six. An additional demonstration period shall commence on April 50 first, nineteen hundred eighty-six and terminate on March thirty-first, 51 nineteen hundred eighty-nine. An additional demonstration period shall 52 commence April first, nineteen hundred eighty-nine and terminate March 53 thirty-first, nineteen hundred ninety-two. An additional demonstration 54 period shall commence April first, nineteen hundred ninety-two and 55 terminate March thirty-first, nineteen hundred ninety-five. An addi- 56 tional demonstration period shall commence on April first, nineteen S. 2606--C 65 1 hundred ninety-five and terminate on March thirty-first, nineteen 2 hundred ninety-eight. An additional demonstration period shall commence 3 on April first, nineteen hundred ninety-eight and terminate on March 4 thirty-first, two thousand three. An additional demonstration period 5 shall commence on April first, two thousand three and terminate on March 6 thirty-first, two thousand thirteen[;]. AN ADDITIONAL DEMONSTRATION 7 PERIOD SHALL COMMENCE APRIL FIRST, TWO THOUSAND THIRTEEN AND TERMINATE 8 ON MARCH THIRTY-FIRST, TWO THOUSAND EIGHTEEN provided, however, that the 9 commissioner may prescribe requirements for the continuation of such 10 demonstration program, including periodic reviews of such programs and 11 submission of any reports and data necessary to permit such reviews. 12 During these additional periods, the provisions of this subparagraph 13 shall also apply to a physician committee of a county medical society. 14 S 25. Section 4 of part X2 of chapter 62 of the laws of 2003, amending 15 the public health law relating to allowing for the use of funds of the 16 office of professional medical conduct for activities of the patient 17 health information and quality improvement act of 2000, as amended by 18 section 27 of part A of chapter 59 of the laws of 2011, is amended to 19 read as follows: 20 S 4. This act shall take effect immediately; provided that the 21 provisions of section one of this act shall be deemed to have been in 22 full force and effect on and after April 1, 2003, and shall expire March 23 31, [2013] 2015 when upon such date the provisions of such section shall 24 be deemed repealed. 25 S 26. Notwithstanding any inconsistent provision of law, rule or regu- 26 lation, the effectiveness of the provisions of sections 2807 and 3614 of 27 the public health law, section 18 of chapter 2 of the laws of 1988, and 28 18 NYCRR 505.14(h), as they relate to time frames for notice, approval 29 or certification of rates of payment, are hereby suspended and without 30 force or effect for purposes of implementing the provisions of this act. 31 S 27. Severability clause. If any clause, sentence, paragraph, subdi- 32 vision, section or part of this act shall be adjudged by any court of 33 competent jurisdiction to be invalid, such judgment shall not affect, 34 impair or invalidate the remainder thereof, but shall be confined in its 35 operation to the clause, sentence, paragraph, subdivision, section or 36 part thereof directly involved in the controversy in which such judge- 37 ment shall have been rendered. It is hereby declared to be the intent of 38 the legislature that this act would have been enacted even if such 39 invalid provisions had not been included herein. 40 S 28. This act shall take effect immediately and shall be deemed to 41 have been in full force and effect on and after April 1, 2013; provided 42 that the amendments to subparagraph (ii) of paragraph (c) of subdivision 43 11 of section 230 of the public health law made by section twenty-four 44 of this act shall not affect the expiration of such subparagraph and 45 shall expire therewith. 46 PART C 47 Section 1. Section 2807-k of the public health law is amended by 48 adding a new subdivision 5-d to read as follows: 49 5-D. (A) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF THIS SECTION, 50 SECTION TWENTY-EIGHT HUNDRED SEVEN-W OF THIS ARTICLE OR ANY OTHER 51 CONTRARY PROVISION OF LAW, AND SUBJECT TO THE AVAILABILITY OF FEDERAL 52 FINANCIAL PARTICIPATION, FOR PERIODS ON AND AFTER JANUARY FIRST, TWO 53 THOUSAND THIRTEEN, THROUGH DECEMBER THIRTY-FIRST, TWO THOUSAND FIFTEEN, 54 ALL FUNDS AVAILABLE FOR DISTRIBUTION PURSUANT TO THIS SECTION, EXCEPT S. 2606--C 66 1 FOR FUNDS DISTRIBUTED PURSUANT TO SUBPARAGRAPH (V) OF PARAGRAPH (B) OF 2 SUBDIVISION FIVE-B OF THIS SECTION, AND ALL FUNDS AVAILABLE FOR DISTRIB- 3 UTION PURSUANT TO SECTION TWENTY-EIGHT HUNDRED SEVEN-W OF THIS ARTICLE, 4 SHALL BE RESERVED AND SET ASIDE AND DISTRIBUTED IN ACCORDANCE WITH THE 5 PROVISIONS OF THIS SUBDIVISION. 6 (B) THE COMMISSIONER SHALL PROMULGATE REGULATIONS, AND MAY PROMULGATE 7 EMERGENCY REGULATIONS, ESTABLISHING METHODOLOGIES FOR THE DISTRIBUTION 8 OF FUNDS AS DESCRIBED IN PARAGRAPH (A) OF THIS SUBDIVISION AND SUCH 9 REGULATIONS SHALL INCLUDE, BUT NOT BE LIMITED TO, THE FOLLOWING: 10 (I) SUCH REGULATIONS SHALL ESTABLISH METHODOLOGIES FOR DETERMINING 11 EACH FACILITY'S RELATIVE UNCOMPENSATED CARE NEED AMOUNT BASED ON UNIN- 12 SURED INPATIENT AND OUTPATIENT UNITS OF SERVICE FROM THE COST REPORTING 13 YEAR TWO YEARS PRIOR TO THE DISTRIBUTION YEAR, MULTIPLIED BY THE APPLI- 14 CABLE MEDICAID RATES IN EFFECT JANUARY FIRST OF THE DISTRIBUTION YEAR, 15 AS SUMMED AND ADJUSTED BY A STATEWIDE COST ADJUSTMENT FACTOR AND REDUCED 16 BY THE SUM OF ALL PAYMENT AMOUNTS COLLECTED FROM SUCH UNINSURED 17 PATIENTS, AND AS FURTHER ADJUSTED BY APPLICATION OF A NOMINAL NEED 18 COMPUTATION THAT SHALL TAKE INTO ACCOUNT EACH FACILITY'S MEDICAID INPA- 19 TIENT SHARE. 20 (II) ANNUAL DISTRIBUTIONS PURSUANT TO SUCH REGULATIONS FOR THE TWO 21 THOUSAND THIRTEEN THROUGH TWO THOUSAND FIFTEEN CALENDAR YEARS SHALL BE 22 IN ACCORD WITH THE FOLLOWING: 23 (A) ONE HUNDRED THIRTY-NINE MILLION FOUR HUNDRED THOUSAND DOLLARS 24 SHALL BE DISTRIBUTED AS MEDICAID DISPROPORTIONATE SHARE HOSPITAL ("DSH") 25 PAYMENTS TO MAJOR PUBLIC GENERAL HOSPITALS; AND 26 (B) NINE HUNDRED NINETY-FOUR MILLION NINE HUNDRED THOUSAND DOLLARS AS 27 MEDICAID DSH PAYMENTS TO ELIGIBLE GENERAL HOSPITALS, OTHER THAN MAJOR 28 PUBLIC GENERAL HOSPITALS. 29 (III)(A) SUCH REGULATIONS SHALL ESTABLISH TRANSITION ADJUSTMENTS TO 30 THE DISTRIBUTIONS MADE PURSUANT TO CLAUSES (A) AND (B) OF SUBPARAGRAPH 31 (II) OF THIS PARAGRAPH SUCH THAT NO FACILITY EXPERIENCES A REDUCTION IN 32 INDIGENT CARE POOL PAYMENTS PURSUANT TO THIS SUBDIVISION THAT IS GREATER 33 THAN THE PERCENTAGES, AS SPECIFIED IN CLAUSE (C) OF THIS SUBPARAGRAPH, 34 AS COMPARED TO THE AVERAGE DISTRIBUTION THAT EACH SUCH FACILITY RECEIVED 35 FOR THE THREE CALENDAR YEARS PRIOR TO TWO THOUSAND THIRTEEN PURSUANT TO 36 THIS SECTION AND SECTION TWENTY-EIGHT HUNDRED SEVEN-W OF THIS ARTICLE; 37 PROVIDED, HOWEVER, THAT SUCH REGULATIONS ESTABLISH ADJUSTMENTS FOR 38 VOLUNTARY TEACHING HOSPITALS THAT RECEIVED PAYMENTS FROM THE VOLUNTARY 39 TEACHING HOSPITAL POOL FOR STATE FISCAL YEARS TWO THOUSAND TEN-TWO THOU- 40 SAND TWELVE, BASED ON THE DIFFERENCE BETWEEN WHAT THE HOSPITAL WOULD 41 HAVE RECEIVED FROM SUCH POOL HAD THE REGIONAL ALLOCATION METHODOLOGY NOT 42 INCLUDED DATA FROM PUBLIC TEACHING HOSPITALS AND WHAT THE HOSPITAL ACTU- 43 ALLY RECEIVED, PROVIDED SUCH HOSPITAL APPEALED THIS ISSUE TO THE DEPART- 44 MENT OF HEALTH BEFORE NOVEMBER EIGHTH, TWO THOUSAND TWELVE. 45 (B) SUCH REGULATIONS SHALL ALSO ESTABLISH ADJUSTMENTS LIMITING THE 46 INCREASES IN INDIGENT CARE POOL PAYMENTS EXPERIENCED BY FACILITIES 47 PURSUANT TO THIS SUBDIVISION BY AN AMOUNT THAT WILL BE, AS DETERMINED BY 48 THE COMMISSIONER AND IN CONJUNCTION WITH SUCH OTHER FUNDING AS MAY BE 49 AVAILABLE FOR THIS PURPOSE, SUFFICIENT TO ENSURE FULL FUNDING FOR THE 50 TRANSITION ADJUSTMENT PAYMENTS AUTHORIZED BY CLAUSE (A) OF THIS SUBPARA- 51 GRAPH. 52 (C) NO FACILITY SHALL EXPERIENCE A REDUCTION IN INDIGENT CARE POOL 53 PAYMENTS PURSUANT TO THIS SUBDIVISION THAT: FOR THE CALENDAR YEAR BEGIN- 54 NING JANUARY FIRST, TWO THOUSAND THIRTEEN, IS GREATER THAN TWO AND ONE- 55 HALF PERCENT; FOR THE CALENDAR YEAR BEGINNING JANUARY FIRST, TWO THOU- 56 SAND FOURTEEN, IS GREATER THAN FIVE PERCENT; AND, FOR THE CALENDAR YEAR S. 2606--C 67 1 BEGINNING ON JANUARY FIRST, TWO THOUSAND FIFTEEN, IS GREATER THAN SEVEN 2 AND ONE-HALF PERCENT. 3 (IV) SUCH REGULATIONS SHALL RESERVE ONE PERCENT OF THE FUNDS AVAILABLE 4 FOR DISTRIBUTION IN THE TWO THOUSAND FOURTEEN AND TWO THOUSAND FIFTEEN 5 CALENDAR YEARS PURSUANT TO THIS SUBDIVISION, SUBDIVISION FOURTEEN-F OF 6 SECTION TWENTY-EIGHT HUNDRED SEVEN-C OF THIS ARTICLE, AND SECTIONS TWO 7 HUNDRED ELEVEN AND TWO HUNDRED TWELVE OF CHAPTER FOUR HUNDRED 8 SEVENTY-FOUR OF THE LAWS OF NINETEEN HUNDRED NINETY-SIX, IN A "FINANCIAL 9 ASSISTANCE COMPLIANCE POOL" AND SHALL ESTABLISH METHODOLOGIES FOR THE 10 DISTRIBUTION OF SUCH POOL FUNDS TO FACILITIES BASED ON THEIR LEVEL OF 11 COMPLIANCE, AS DETERMINED BY THE COMMISSIONER, WITH THE PROVISIONS OF 12 SUBDIVISION NINE-A OF THIS SECTION. 13 S 2. Subdivision 14-f of section 2807-c of the public health law, as 14 amended by chapter 1 of the laws of 1999, is amended to read as follows: 15 14-f. Public general hospital indigent care adjustment. Notwithstand- 16 ing any inconsistent provision of this section AND SUBJECT TO THE AVAIL- 17 ABILITY OF FEDERAL FINANCIAL PARTICIPATION, payment for inpatient hospi- 18 tal services for persons eligible for payments made by state 19 governmental agencies for the period January first, nineteen hundred 20 ninety-seven through December thirty-first, nineteen hundred ninety-nine 21 and periods on and after January first, two thousand applicable to 22 patients eligible for federal financial participation under title XIX of 23 the federal social security act in medical assistance provided pursuant 24 to title eleven of article five of the social services law determined in 25 accordance with this section shall include for eligible public general 26 hospitals a public general hospital indigent care adjustment equal to 27 the aggregate amount of the adjustments provided for such public general 28 hospital for the period January first, nineteen hundred ninety-six 29 through December thirty-first, nineteen hundred ninety-six pursuant to 30 subdivisions fourteen-a and fourteen-d of this section on an annualized 31 basis, [provided all federal approvals necessary by federal law and 32 regulation for federal financial participation in payments made for 33 beneficiaries eligible for medical assistance under title XIX of the 34 federal social security act based upon the adjustment provided herein as 35 a component of such payments are granted] PROVIDED, HOWEVER, THAT FOR 36 PERIODS ON AND AFTER JANUARY FIRST, TWO THOUSAND THIRTEEN AN ANNUAL 37 AMOUNT OF FOUR HUNDRED TWELVE MILLION DOLLARS SHALL BE ALLOCATED TO 38 ELIGIBLE MAJOR PUBLIC HOSPITALS BASED ON EACH HOSPITAL'S PROPORTIONATE 39 SHARE OF MEDICAID AND UNINSURED LOSSES TO TOTAL MEDICAID AND UNINSURED 40 LOSSES FOR ALL ELIGIBLE MAJOR PUBLIC HOSPITALS, NET OF ANY DISPROPOR- 41 TIONATE SHARE HOSPITAL PAYMENTS RECEIVED PURSUANT TO SECTIONS 42 TWENTY-EIGHT HUNDRED SEVEN-K AND TWENTY-EIGHT HUNDRED SEVEN-W OF THIS 43 ARTICLE. The adjustment may be made to rates of payment or as aggregate 44 payments to an eligible hospital. 45 S 3. Paragraph (i) of subdivision 2-a of section 2807 of the public 46 health law, as amended by section 16 of part C of chapter 58 of the laws 47 of 2009, is amended to read as follows: 48 (i) Notwithstanding any provision of law to the contrary, rates of 49 payment by governmental agencies for general hospital outpatient 50 services, general hospital emergency services and ambulatory surgical 51 services provided by a general hospital established pursuant to para- 52 graphs (a), (c) and (d) of this subdivision shall result in an aggregate 53 increase in such rates of payment of fifty-six million dollars for the 54 period December first, two thousand eight through March thirty-first, 55 two thousand nine and one hundred seventy-eight million dollars for 56 periods after April first, two thousand nine, THROUGH MARCH S. 2606--C 68 1 THIRTY-FIRST, TWO THOUSAND THIRTEEN, AND ONE HUNDRED FIFTY-THREE MILLION 2 DOLLARS FOR STATE FISCAL YEAR PERIODS ON AND AFTER APRIL FIRST, TWO 3 THOUSAND THIRTEEN, provided, however, that for periods on and after 4 April first, two thousand nine, such amounts may be adjusted to reflect 5 projected decreases in fee-for-service Medicaid utilization and changes 6 in case-mix with regard to such services from the two thousand seven 7 calendar year to the applicable rate year, and provided further, howev- 8 er, that funds made available as a result of any such decreases may be 9 utilized by the commissioner to increase capitation rates paid to Medi- 10 caid managed care plans and family health plus plans to cover increased 11 payments to health care providers for ambulatory care services and to 12 increase such other ambulatory care payment rates as the commissioner 13 determines necessary to facilitate access to quality ambulatory care 14 services. 15 S 4. The opening paragraph of subparagraph (i) of paragraph (i) of 16 subdivision 35 of section 2807-c of the public health law, as added by 17 section 3-a of part B of chapter 109 of the laws of 2010, is amended to 18 read as follows: 19 Notwithstanding any inconsistent provision of this subdivision or any 20 other contrary provision of law and subject to the availability of 21 federal financial participation, for the period July first, two thousand 22 ten through March thirty-first, two thousand eleven, and each state 23 fiscal year period thereafter, the commissioner shall make additional 24 inpatient hospital payments up to the aggregate upper payment limit for 25 inpatient hospital services after all other medical assistance payments, 26 but not to exceed two hundred thirty-five million five hundred thousand 27 dollars for the period July first, two thousand ten through March thir- 28 ty-first, two thousand eleven [and], three hundred fourteen million 29 dollars for each state fiscal year BEGINNING APRIL FIRST, TWO THOUSAND 30 ELEVEN, THROUGH MARCH THIRTY-FIRST, TWO THOUSAND THIRTEEN, AND NO LESS 31 THAN THREE HUNDRED THIRTY-NINE MILLION DOLLARS FOR EACH STATE FISCAL 32 YEAR thereafter, to general hospitals, other than major public general 33 hospitals, providing emergency room services and including safety net 34 hospitals, which shall, for the purpose of this paragraph, be defined as 35 having either: a Medicaid share of total inpatient hospital discharges 36 of at least thirty-five percent, including both fee-for-service and 37 managed care discharges for acute and exempt services; or a Medicaid 38 share of total discharges of at least thirty percent, including both 39 fee-for-service and managed care discharges for acute and exempt 40 services, and also providing obstetrical services. Eligibility to 41 receive such additional payments shall be based on data from the period 42 two years prior to the rate year, as reported on the institutional cost 43 report submitted to the department as of October first of the prior rate 44 year. Such payments shall be made as medical assistance payments for 45 fee-for-service inpatient hospital services pursuant to title eleven of 46 article five of the social services law for patients eligible for feder- 47 al financial participation under title XIX of the federal social securi- 48 ty act and in accordance with the following: 49 S 5. This act shall take effect immediately and shall be deemed to 50 have been in full force and effect on and after April 1, 2013 provided 51 that: 52 a. sections one, two and four of this act shall be deemed to have been 53 in full force and effect on and after January 1, 2013; and 54 b. the amendments to subdivision 14-f of section 2807-c of the public 55 health law made by section two of this act shall not affect the expira- 56 tion of such subdivision and shall be deemed to expire therewith. S. 2606--C 69 1 PART D 2 Section 1. Subdivision 1 of section 366 of the social services law is 3 REPEALED and a new subdivision 1 is added to read as follows: 4 1. (A) DEFINITIONS. FOR PURPOSES OF THIS SECTION: 5 (1) "BENCHMARK COVERAGE" REFERS TO MEDICAL ASSISTANCE COVERAGE DEFINED 6 IN SUBDIVISION ONE OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THIS TITLE; 7 (2) "CARETAKER RELATIVE" MEANS A RELATIVE OF A DEPENDENT CHILD BY 8 BLOOD, ADOPTION, OR MARRIAGE WITH WHOM THE CHILD IS LIVING, WHO ASSUMES 9 PRIMARY RESPONSIBILITY FOR THE CHILD'S CARE AND WHO IS ONE OF THE 10 FOLLOWING: 11 (I) THE CHILD'S FATHER, MOTHER, GRANDFATHER, GRANDMOTHER, BROTHER, 12 SISTER, STEPFATHER, STEPMOTHER, STEPBROTHER, STEPSISTER, UNCLE, AUNT, 13 FIRST COUSIN, NEPHEW, OR NIECE; OR 14 (II) THE SPOUSE OF SUCH PARENT OR RELATIVE, EVEN AFTER THE MARRIAGE IS 15 TERMINATED BY DEATH OR DIVORCE; 16 (3) "FAMILY SIZE" MEANS THE NUMBER OF PERSONS COUNTED AS MEMBERS OF AN 17 INDIVIDUAL'S HOUSEHOLD; 18 (4) "FEDERAL POVERTY LINE" MEANS THE POVERTY LINE DEFINED AND ANNUALLY 19 REVISED BY THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES; 20 (5) "HOUSEHOLD," FOR PURPOSES OF DETERMINING THE FINANCIAL ELIGIBILITY 21 OF APPLICANTS AND RECIPIENTS OF BENEFITS UNDER THIS TITLE, SHALL MEAN 22 THE NUMBER OF INDIVIDUALS IN THE HOME WHO ACT AS A SINGLE ECONOMIC UNIT; 23 (6) "MAGI" MEANS MODIFIED ADJUSTED GROSS INCOME; 24 (7) "MAGI-BASED INCOME" MEANS INCOME CALCULATED USING THE SAME METHOD- 25 OLOGIES USED TO DETERMINE MAGI UNDER SECTION 36B(D)(2)(B) OF THE INTER- 26 NAL REVENUE CODE, WITH THE EXCEPTION OF LUMP SUM PAYMENTS, CERTAIN 27 EDUCATIONAL SCHOLARSHIPS, AND CERTAIN AMERICAN INDIAN AND ALASKA NATIVE 28 INCOME, AS SPECIFIED BY THE COMMISSIONER OF HEALTH CONSISTENT WITH 29 FEDERAL REGULATION AT 42 CFR 435.603 OR ANY SUCCESSOR REGULATION; 30 (8) "MAGI HOUSEHOLD INCOME" MEANS, WITH RESPECT TO AN INDIVIDUAL WHOSE 31 MEDICAL ASSISTANCE ELIGIBILITY IS BASED ON MODIFIED ADJUSTED GROSS 32 INCOME, THE SUM OF THE MAGI-BASED INCOME OF EVERY PERSON INCLUDED IN THE 33 INDIVIDUAL'S MAGI HOUSEHOLD, EXCEPT THAT IT SHALL NOT INCLUDE THE MAGI- 34 BASED INCOME OF THE FOLLOWING PERSONS IF SUCH PERSONS ARE NOT EXPECTED 35 TO BE REQUIRED TO FILE A TAX RETURN IN THE TAXABLE YEAR IN WHICH ELIGI- 36 BILITY FOR MEDICAL ASSISTANCE IS BEING DETERMINED: 37 (I) A BIOLOGICAL, ADOPTED, OR STEP CHILD WHO IS INCLUDED IN THE INDI- 38 VIDUAL'S MAGI HOUSEHOLD; OR 39 (II) A PERSON, OTHER THAN A SPOUSE OR A BIOLOGICAL, ADOPTED, OR STEP 40 CHILD, WHO IS EXPECTED TO BE CLAIMED AS A TAX DEPENDENT BY THE INDIVID- 41 UAL; 42 (9) "STANDARD COVERAGE" REFERS TO MEDICAL ASSISTANCE COVERAGE DEFINED 43 IN SUBDIVISION TWO OF SECTION THREE HUNDRED SIXTY-FIVE-A OF THIS TITLE. 44 (B) MAGI ELIGIBILITY GROUPS. INDIVIDUALS LISTED IN THIS PARAGRAPH ARE 45 ELIGIBLE FOR MEDICAL ASSISTANCE BASED ON MODIFIED ADJUSTED GROSS INCOME. 46 IN DETERMINING THE ELIGIBILITY OF AN INDIVIDUAL FOR THE MAGI ELIGIBILITY 47 GROUP WITH THE HIGHEST INCOME STANDARD UNDER WHICH THE INDIVIDUAL MAY 48 QUALIFY, AN AMOUNT EQUIVALENT TO FIVE PERCENTAGE POINTS OF THE FEDERAL 49 POVERTY LEVEL FOR THE APPLICABLE FAMILY SIZE WILL BE DEDUCTED FROM THE 50 HOUSEHOLD INCOME. 51 (1) AN INDIVIDUAL IS ELIGIBLE FOR BENCHMARK COVERAGE IF HIS OR HER 52 MAGI HOUSEHOLD INCOME DOES NOT EXCEED ONE HUNDRED THIRTY-THREE PERCENT 53 OF THE FEDERAL POVERTY LINE FOR THE APPLICABLE FAMILY SIZE AND HE OR SHE 54 IS: 55 (I) AGE NINETEEN OR OLDER AND UNDER AGE SIXTY-FIVE; AND S. 2606--C 70 1 (II) NOT PREGNANT; AND 2 (III) NOT ENTITLED TO OR ENROLLED FOR BENEFITS UNDER PARTS A OR B OF 3 TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT; AND 4 (IV) NOT OTHERWISE ELIGIBLE FOR AND RECEIVING COVERAGE UNDER SUBPARA- 5 GRAPHS TWO AND THREE OF THIS PARAGRAPH; AND 6 (V) NOT A PARENT OR OTHER CARETAKER RELATIVE OF A DEPENDENT CHILD 7 UNDER TWENTY-ONE YEARS OF AGE AND LIVING WITH SUCH CHILD, UNLESS SUCH 8 CHILD IS RECEIVING BENEFITS UNDER THIS TITLE OR UNDER TITLE 1-A OF ARTI- 9 CLE TWENTY-FIVE OF THE PUBLIC HEALTH LAW, OR OTHERWISE IS ENROLLED IN 10 MINIMUM ESSENTIAL COVERAGE. 11 (2) A PREGNANT WOMAN OR AN INFANT YOUNGER THAN ONE YEAR OF AGE IS 12 ELIGIBLE FOR STANDARD COVERAGE IF HIS OR HER MAGI HOUSEHOLD INCOME DOES 13 NOT EXCEED THE MAGI-EQUIVALENT OF TWO HUNDRED PERCENT OF THE FEDERAL 14 POVERTY LINE FOR THE APPLICABLE FAMILY SIZE, WHICH SHALL BE CALCULATED 15 IN ACCORDANCE WITH GUIDANCE ISSUED BY THE SECRETARY OF THE UNITED STATES 16 DEPARTMENT OF HEALTH AND HUMAN SERVICES, OR AN INFANT YOUNGER THAN ONE 17 YEAR OF AGE WHO MEETS THE PRESUMPTIVE ELIGIBILITY REQUIREMENTS OF SUBDI- 18 VISION FOUR OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE. 19 (3) A CHILD WHO IS AT LEAST ONE YEAR OF AGE BUT YOUNGER THAN NINETEEN 20 YEARS OF AGE IS ELIGIBLE FOR STANDARD COVERAGE IF HIS OR HER MAGI HOUSE- 21 HOLD INCOME DOES NOT EXCEED THE MAGI-EQUIVALENT OF ONE HUNDRED 22 THIRTY-THREE PERCENT OF THE FEDERAL POVERTY LINE FOR THE APPLICABLE 23 FAMILY SIZE, WHICH SHALL BE CALCULATED IN ACCORDANCE WITH GUIDANCE 24 ISSUED BY THE SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND 25 HUMAN SERVICES, OR A CHILD WHO IS AT LEAST ONE YEAR OF AGE BUT YOUNGER 26 THAN NINETEEN YEARS OF AGE WHO MEETS THE PRESUMPTIVE ELIGIBILITY 27 REQUIREMENTS OF SUBDIVISION FOUR OF SECTION THREE HUNDRED SIXTY-FOUR-I 28 OF THIS TITLE. 29 (4) AN INDIVIDUAL WHO IS A PREGNANT WOMAN OR IS A MEMBER OF A FAMILY 30 THAT CONTAINS A DEPENDENT CHILD LIVING WITH A PARENT OR OTHER CARETAKER 31 RELATIVE IS ELIGIBLE FOR STANDARD COVERAGE IF HIS OR HER MAGI HOUSEHOLD 32 INCOME DOES NOT EXCEED THE MAGI-EQUIVALENT OF ONE HUNDRED THIRTY PERCENT 33 OF THE HIGHEST AMOUNT THAT ORDINARILY WOULD HAVE BEEN PAID TO A PERSON 34 WITHOUT ANY INCOME OR RESOURCES UNDER THE FAMILY ASSISTANCE PROGRAM AS 35 IT EXISTED ON THE FIRST DAY OF NOVEMBER, NINETEEN HUNDRED NINETY-SEVEN, 36 WHICH SHALL BE CALCULATED IN ACCORDANCE WITH GUIDANCE ISSUED BY THE 37 SECRETARY OF THE UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES; 38 FOR PURPOSES OF THIS SUBPARAGRAPH, THE TERM DEPENDENT CHILD MEANS A 39 PERSON WHO IS UNDER EIGHTEEN YEARS OF AGE, OR IS EIGHTEEN YEARS OF AGE 40 AND A FULL-TIME STUDENT, WHO IS DEPRIVED OF PARENTAL SUPPORT OR CARE BY 41 REASON OF THE DEATH, CONTINUED ABSENCE, OR PHYSICAL OR MENTAL INCAPACITY 42 OF A PARENT, OR BY REASON OF THE UNEMPLOYMENT OF THE PARENT, AS DEFINED 43 BY THE DEPARTMENT OF HEALTH. 44 (5) A CHILD WHO IS UNDER TWENTY-ONE YEARS OF AGE AND WHO WAS IN FOSTER 45 CARE UNDER THE RESPONSIBILITY OF THE STATE ON HIS OR HER EIGHTEENTH 46 BIRTHDAY IS ELIGIBLE FOR STANDARD COVERAGE; NOTWITHSTANDING ANY 47 PROVISION OF LAW TO THE CONTRARY, THE PROVISIONS OF THIS SUBPARAGRAPH 48 SHALL BE EFFECTIVE ONLY IF AND FOR SO LONG AS FEDERAL FINANCIAL PARTIC- 49 IPATION IS AVAILABLE IN THE COSTS OF MEDICAL ASSISTANCE FURNISHED HERE- 50 UNDER. 51 (6) AN INDIVIDUAL WHO IS NOT OTHERWISE ELIGIBLE FOR MEDICAL ASSISTANCE 52 UNDER THIS SECTION IS ELIGIBLE FOR COVERAGE OF FAMILY PLANNING SERVICES 53 REIMBURSED BY THE FEDERAL GOVERNMENT AT A RATE OF NINETY PERCENT, AND 54 FOR COVERAGE OF THOSE SERVICES IDENTIFIED BY THE COMMISSIONER OF HEALTH 55 AS SERVICES GENERALLY PERFORMED AS PART OF OR AS A FOLLOW-UP TO A 56 SERVICE ELIGIBLE FOR SUCH NINETY PERCENT REIMBURSEMENT, INCLUDING TREAT- S. 2606--C 71 1 MENT FOR SEXUALLY TRANSMITTED DISEASES, IF HIS OR HER INCOME DOES NOT 2 EXCEED THE MAGI-EQUIVALENT OF TWO HUNDRED PERCENT OF THE FEDERAL POVERTY 3 LINE FOR THE APPLICABLE FAMILY SIZE, WHICH SHALL BE CALCULATED IN 4 ACCORDANCE WITH GUIDANCE ISSUED BY THE SECRETARY OF THE UNITED STATES 5 DEPARTMENT OF HEALTH AND HUMAN SERVICES. 6 (7) A CHILD WHO IS NINETEEN OR TWENTY YEARS OF AGE LIVING WITH HIS OR 7 HER PARENT WILL BE ELIGIBLE FOR STANDARD COVERAGE IF THE SUM OF THE 8 MAGI-BASED INCOME OF EVERY PERSON INCLUDED IN THE CHILD'S MAGI HOUSEHOLD 9 EXCEEDS ONE HUNDRED THIRTY-THREE PERCENT, BUT DOES NOT EXCEED ONE 10 HUNDRED FIFTY PERCENT, OF THE FEDERAL POVERTY LINE FOR THE APPLICABLE 11 FAMILY SIZE. 12 (C) NON-MAGI ELIGIBILITY GROUPS. INDIVIDUALS LISTED IN THIS PARAGRAPH 13 ARE ELIGIBLE FOR STANDARD COVERAGE. WHERE A FINANCIAL ELIGIBILITY DETER- 14 MINATION MUST BE MADE BY THE MEDICAL ASSISTANCE PROGRAM FOR INDIVIDUALS 15 IN THESE GROUPS, SUCH FINANCIAL ELIGIBILITY WILL BE DETERMINED IN 16 ACCORDANCE WITH SUBDIVISION TWO OF THIS SECTION. 17 (1) AN INDIVIDUAL RECEIVING OR ELIGIBLE TO RECEIVE FEDERAL SUPPLE- 18 MENTAL SECURITY INCOME PAYMENTS AND/OR ADDITIONAL STATE PAYMENTS PURSU- 19 ANT TO TITLE SIX OF THIS ARTICLE; ANY INCONSISTENT PROVISION OF THIS 20 CHAPTER OR OTHER LAW NOTWITHSTANDING, THE DEPARTMENT MAY DESIGNATE THE 21 OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE AS ITS AGENT TO DISCHARGE 22 ITS RESPONSIBILITY, OR SO MUCH OF ITS RESPONSIBILITY AS IS PERMITTED BY 23 FEDERAL LAW, FOR DETERMINING ELIGIBILITY FOR MEDICAL ASSISTANCE WITH 24 RESPECT TO PERSONS WHO ARE NOT ELIGIBLE TO RECEIVE FEDERAL SUPPLEMENTAL 25 SECURITY INCOME PAYMENTS BUT WHO ARE RECEIVING A STATE ADMINISTERED 26 SUPPLEMENTARY PAYMENT OR MANDATORY MINIMUM SUPPLEMENT IN ACCORDANCE WITH 27 THE PROVISIONS OF SUBDIVISION ONE OF SECTION TWO HUNDRED TWELVE OF THIS 28 ARTICLE. 29 (2) AN INDIVIDUAL WHO, ALTHOUGH NOT RECEIVING PUBLIC ASSISTANCE OR 30 CARE FOR HIS OR HER MAINTENANCE UNDER OTHER PROVISIONS OF THIS CHAPTER, 31 HAS INCOME AND RESOURCES, INCLUDING AVAILABLE SUPPORT FROM RESPONSIBLE 32 RELATIVES, THAT DOES NOT EXCEED THE AMOUNTS SET FORTH IN PARAGRAPH (A) 33 OF SUBDIVISION TWO OF THIS SECTION, AND IS (I) SIXTY-FIVE YEARS OF AGE 34 OR OLDER, OR CERTIFIED BLIND OR CERTIFIED DISABLED OR (II) FOR REASONS 35 OTHER THAN INCOME OR RESOURCES, IS ELIGIBLE FOR FEDERAL SUPPLEMENTAL 36 SECURITY INCOME BENEFITS AND/OR ADDITIONAL STATE PAYMENTS. 37 (3) A CHILD IN FOSTER CARE, OR A CHILD DESCRIBED IN SECTION FOUR 38 HUNDRED FIFTY-FOUR OR FOUR HUNDRED FIFTY-EIGHT-D OF THIS CHAPTER. 39 (4) A DISABLED INDIVIDUAL AT LEAST SIXTEEN YEARS OF AGE, BUT UNDER THE 40 AGE OF SIXTY-FIVE, WHO: WOULD BE ELIGIBLE FOR BENEFITS UNDER THE 41 SUPPLEMENTAL SECURITY INCOME PROGRAM BUT FOR EARNINGS IN EXCESS OF THE 42 ALLOWABLE LIMIT; HAS NET AVAILABLE INCOME THAT DOES NOT EXCEED TWO 43 HUNDRED FIFTY PERCENT OF THE APPLICABLE FEDERAL INCOME OFFICIAL POVERTY 44 LINE, AS DEFINED AND UPDATED BY THE UNITED STATES DEPARTMENT OF HEALTH 45 AND HUMAN SERVICES, FOR A ONE-PERSON OR TWO-PERSON HOUSEHOLD, AS DEFINED 46 BY THE COMMISSIONER IN REGULATION; HAS HOUSEHOLD RESOURCES, AS DEFINED 47 IN PARAGRAPH (E) OF SUBDIVISION TWO OF SECTION THREE HUNDRED SIXTY-SIX-C 48 OF THIS TITLE, OTHER THAN RETIREMENT ACCOUNTS, THAT DO NOT EXCEED TWENTY 49 THOUSAND DOLLARS FOR A ONE-PERSON HOUSEHOLD OR THIRTY THOUSAND DOLLARS 50 FOR A TWO-PERSON HOUSEHOLD, AS DEFINED BY THE COMMISSIONER IN REGU- 51 LATION; AND CONTRIBUTES TO THE COST OF MEDICAL ASSISTANCE PROVIDED 52 PURSUANT TO THIS SUBPARAGRAPH IN ACCORDANCE WITH SUBDIVISION TWELVE OF 53 SECTION THREE HUNDRED SIXTY-SEVEN-A OF THIS TITLE; FOR PURPOSES OF THIS 54 SUBPARAGRAPH, DISABLED MEANS HAVING A MEDICALLY DETERMINABLE IMPAIRMENT 55 OF SUFFICIENT SEVERITY AND DURATION TO QUALIFY FOR BENEFITS UNDER 56 SECTION 1902(A)(10)(A)(II)(XV) OF THE SOCIAL SECURITY ACT. S. 2606--C 72 1 (5) AN INDIVIDUAL AT LEAST SIXTEEN YEARS OF AGE, BUT UNDER THE AGE OF 2 SIXTY-FIVE, WHO: IS EMPLOYED; CEASES TO BE IN RECEIPT OF MEDICAL ASSIST- 3 ANCE UNDER SUBPARAGRAPH FIVE OF THIS PARAGRAPH BECAUSE THE PERSON, BY 4 REASON OF MEDICAL IMPROVEMENT, IS DETERMINED AT THE TIME OF A REGULARLY 5 SCHEDULED CONTINUING DISABILITY REVIEW TO NO LONGER BE ELIGIBLE FOR 6 SUPPLEMENTAL SECURITY INCOME PROGRAM BENEFITS OR DISABILITY INSURANCE 7 BENEFITS UNDER THE SOCIAL SECURITY ACT; CONTINUES TO HAVE A SEVERE 8 MEDICALLY DETERMINABLE IMPAIRMENT, TO BE DETERMINED IN ACCORDANCE WITH 9 APPLICABLE FEDERAL REGULATIONS; AND CONTRIBUTES TO THE COST OF MEDICAL 10 ASSISTANCE PROVIDED PURSUANT TO THIS SUBPARAGRAPH IN ACCORDANCE WITH 11 SUBDIVISION TWELVE OF SECTION THREE HUNDRED SIXTY-SEVEN-A OF THIS TITLE; 12 FOR PURPOSES OF THIS SUBPARAGRAPH, A PERSON IS CONSIDERED TO BE EMPLOYED 13 IF THE PERSON IS EARNING AT LEAST THE APPLICABLE MINIMUM WAGE UNDER 14 SECTION SIX OF THE FEDERAL FAIR LABOR STANDARDS ACT AND WORKING AT LEAST 15 FORTY HOURS PER MONTH; OR 16 (6) AN INDIVIDUAL RECEIVING TREATMENT FOR BREAST OR CERVICAL CANCER 17 WHO MEETS THE ELIGIBILITY REQUIREMENTS OF PARAGRAPH (D) OF SUBDIVISION 18 FOUR OF THIS SECTION OR THE PRESUMPTIVE ELIGIBILITY REQUIREMENTS OF 19 SUBDIVISION FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE. 20 (7) AN INDIVIDUAL RECEIVING TREATMENT FOR COLON OR PROSTATE CANCER WHO 21 MEETS THE ELIGIBILITY REQUIREMENTS OF PARAGRAPH (E) OF SUBDIVISION FOUR 22 OF THIS SECTION OR THE PRESUMPTIVE ELIGIBILITY REQUIREMENTS OF SUBDIVI- 23 SION FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE. 24 (8) AN INDIVIDUAL WHO: 25 (I) IS UNDER TWENTY-SIX YEARS OF AGE; AND 26 (II) WAS IN FOSTER CARE UNDER THE RESPONSIBILITY OF THE STATE ON HIS 27 OR HER EIGHTEENTH BIRTHDAY; AND 28 (III) WAS IN RECEIPT OF MEDICAL ASSISTANCE UNDER THIS TITLE WHILE IN 29 FOSTER CARE; AND 30 (IV) IS NOT OTHERWISE ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS 31 TITLE. 32 (9) A RESIDENT OF A HOME FOR ADULTS OPERATED BY A SOCIAL SERVICES 33 DISTRICT, OR A RESIDENTIAL CARE CENTER FOR ADULTS OR COMMUNITY RESIDENCE 34 OPERATED OR CERTIFIED BY THE OFFICE OF MENTAL HEALTH, AND HAS NOT, 35 ACCORDING TO CRITERIA PROMULGATED BY THE DEPARTMENT CONSISTENT WITH THIS 36 TITLE, SUFFICIENT INCOME, OR IN THE CASE OF A PERSON SIXTY-FIVE YEARS OF 37 AGE OR OLDER, CERTIFIED BLIND, OR CERTIFIED DISABLED, SUFFICIENT INCOME 38 AND RESOURCES, INCLUDING AVAILABLE SUPPORT FROM RESPONSIBLE RELATIVES, 39 TO MEET ALL THE COSTS OF REQUIRED MEDICAL CARE AND SERVICES AVAILABLE 40 UNDER THIS TITLE. 41 (D) CONDITIONS OF ELIGIBILITY. A PERSON SHALL NOT BE ELIGIBLE FOR 42 MEDICAL ASSISTANCE UNDER THIS TITLE UNLESS HE OR SHE: 43 (1) IS A RESIDENT OF THE STATE, OR, WHILE TEMPORARILY IN THE STATE, 44 REQUIRES IMMEDIATE MEDICAL CARE WHICH IS NOT OTHERWISE AVAILABLE, 45 PROVIDED THAT SUCH PERSON DID NOT ENTER THE STATE FOR THE PURPOSE OF 46 OBTAINING SUCH MEDICAL CARE; AND 47 (2) ASSIGNS TO THE APPROPRIATE SOCIAL SERVICES OFFICIAL OR TO THE 48 DEPARTMENT, IN ACCORDANCE WITH DEPARTMENT REGULATIONS: (I) ANY BENEFITS 49 WHICH ARE AVAILABLE TO HIM OR HER INDIVIDUALLY FROM ANY THIRD PARTY FOR 50 CARE OR OTHER MEDICAL BENEFITS AVAILABLE UNDER THIS TITLE AND WHICH ARE 51 OTHERWISE ASSIGNABLE PURSUANT TO A CONTRACT OR ANY AGREEMENT WITH SUCH 52 THIRD PARTY; OR (II) ANY RIGHTS, OF THE INDIVIDUAL OR OF ANY OTHER 53 PERSON WHO IS ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS TITLE AND ON 54 WHOSE BEHALF THE INDIVIDUAL HAS THE LEGAL AUTHORITY TO EXECUTE AN 55 ASSIGNMENT OF SUCH RIGHTS, TO SUPPORT SPECIFIED AS SUPPORT FOR THE 56 PURPOSE OF MEDICAL CARE BY A COURT OR ADMINISTRATIVE ORDER; AND S. 2606--C 73 1 (3) COOPERATES WITH THE APPROPRIATE SOCIAL SERVICES OFFICIAL OR THE 2 DEPARTMENT IN ESTABLISHING PATERNITY OR IN ESTABLISHING, MODIFYING, OR 3 ENFORCING A SUPPORT ORDER WITH RESPECT TO HIS OR HER CHILD; PROVIDED, 4 HOWEVER, THAT NOTHING HEREIN CONTAINED SHALL BE CONSTRUED TO REQUIRE A 5 PAYMENT UNDER THIS TITLE FOR CARE OR SERVICES, THE COST OF WHICH MAY BE 6 MET IN WHOLE OR IN PART BY A THIRD PARTY; NOTWITHSTANDING THE FOREGOING, 7 A SOCIAL SERVICES OFFICIAL SHALL NOT REQUIRE SUCH COOPERATION IF THE 8 SOCIAL SERVICES OFFICIAL OR THE DEPARTMENT DETERMINES THAT SUCH ACTIONS 9 WOULD BE DETRIMENTAL TO THE BEST INTEREST OF THE CHILD, APPLICANT, OR 10 RECIPIENT, OR WITH RESPECT TO PREGNANT WOMEN DURING PREGNANCY AND DURING 11 THE SIXTY-DAY PERIOD BEGINNING ON THE LAST DAY OF PREGNANCY, IN ACCORD- 12 ANCE WITH PROCEDURES AND CRITERIA ESTABLISHED BY REGULATIONS OF THE 13 DEPARTMENT CONSISTENT WITH FEDERAL LAW; AND 14 (4) APPLIES FOR AND UTILIZES GROUP HEALTH INSURANCE BENEFITS AVAILABLE 15 THROUGH A CURRENT OR FORMER EMPLOYER, INCLUDING BENEFITS FOR A SPOUSE 16 AND DEPENDENT CHILDREN, IN ACCORDANCE WITH THE REGULATIONS OF THE 17 DEPARTMENT. 18 (E) CONDITIONS OF COVERAGE. AN OTHERWISE ELIGIBLE PERSON SHALL NOT BE 19 ENTITLED TO MEDICAL ASSISTANCE COVERAGE OF CARE, SERVICES, AND SUPPLIES 20 UNDER THIS TITLE WHILE HE OR SHE: 21 (1) IS AN INMATE OR PATIENT IN AN INSTITUTION OR FACILITY WHEREIN 22 MEDICAL ASSISTANCE MAY NOT BE PROVIDED IN ACCORDANCE WITH APPLICABLE 23 FEDERAL OR STATE REQUIREMENTS, EXCEPT FOR PERSONS DESCRIBED IN SUBPARA- 24 GRAPH NINE OF PARAGRAPH (C) OF THIS SUBDIVISION OR SUBDIVISION ONE-A OR 25 SUBDIVISION ONE-B OF THIS SECTION; OR 26 (2) IS A PATIENT IN A PUBLIC INSTITUTION OPERATED PRIMARILY FOR THE 27 TREATMENT OF TUBERCULOSIS OR CARE OF THE MENTALLY DISABLED, WITH THE 28 EXCEPTION OF: (I) A PERSON SIXTY-FIVE YEARS OF AGE OR OLDER AND A 29 PATIENT IN ANY SUCH INSTITUTION; (II) A PERSON UNDER TWENTY-ONE YEARS OF 30 AGE AND RECEIVING IN-PATIENT PSYCHIATRIC SERVICES IN A PUBLIC INSTITU- 31 TION OPERATED PRIMARILY FOR THE CARE OF THE MENTALLY DISABLED; (III) A 32 PATIENT IN A PUBLIC INSTITUTION OPERATED PRIMARILY FOR THE CARE OF THE 33 MENTALLY RETARDED WHO IS RECEIVING MEDICAL CARE OR TREATMENT IN THAT 34 PART OF SUCH INSTITUTION THAT HAS BEEN APPROVED PURSUANT TO LAW AS A 35 HOSPITAL OR NURSING HOME; (IV) A PATIENT IN AN INSTITUTION OPERATED BY 36 THE STATE DEPARTMENT OF MENTAL HYGIENE, WHILE UNDER CARE IN A HOSPITAL 37 ON RELEASE FROM SUCH INSTITUTION FOR THE PURPOSE OF RECEIVING CARE IN 38 SUCH HOSPITAL; OR (V) IS A PERSON RESIDING IN A COMMUNITY RESIDENCE OR A 39 RESIDENTIAL CARE CENTER FOR ADULTS. 40 S 2. Subdivision 4 of section 366 of the social services law is 41 REPEALED and a new subdivision 4 is added to read as follows: 42 4. SPECIAL ELIGIBILITY PROVISIONS. 43 (A) TRANSITIONAL MEDICAL ASSISTANCE. 44 (1) NOTWITHSTANDING ANY OTHER PROVISION OF LAW, EACH FAMILY WHICH WAS 45 ELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH FOUR OF PARA- 46 GRAPH (B) OF SUBDIVISION ONE OF THIS SECTION IN AT LEAST ONE OF THE SIX 47 MONTHS IMMEDIATELY PRECEDING THE MONTH IN WHICH SUCH FAMILY BECAME INEL- 48 IGIBLE FOR SUCH ASSISTANCE BECAUSE OF INCOME FROM THE EMPLOYMENT OF THE 49 CARETAKER RELATIVE SHALL, WHILE SUCH FAMILY INCLUDES A DEPENDENT CHILD, 50 REMAIN ELIGIBLE FOR MEDICAL ASSISTANCE FOR TWELVE CALENDAR MONTHS IMME- 51 DIATELY FOLLOWING THE MONTH IN WHICH SUCH FAMILY WOULD OTHERWISE BE 52 DETERMINED TO BE INELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO THE 53 PROVISIONS OF THIS TITLE AND THE REGULATIONS OF THE DEPARTMENT GOVERNING 54 INCOME AND RESOURCE LIMITATIONS RELATING TO ELIGIBILITY DETERMINATIONS 55 FOR FAMILIES DESCRIBED IN SUBPARAGRAPH FOUR OF PARAGRAPH (B) OF SUBDIVI- 56 SION ONE OF THIS SECTION. S. 2606--C 74 1 (2) (I) UPON GIVING NOTICE OF TERMINATION OF MEDICAL ASSISTANCE 2 PROVIDED PURSUANT TO SUBPARAGRAPH FOUR OF PARAGRAPH (B) OF SUBDIVISION 3 ONE OF THIS SECTION, THE DEPARTMENT SHALL NOTIFY EACH SUCH FAMILY OF ITS 4 RIGHTS TO EXTENDED BENEFITS UNDER SUBPARAGRAPH ONE OF THIS PARAGRAPH AND 5 DESCRIBE THE CONDITIONS UNDER WHICH SUCH EXTENSION MAY BE TERMINATED. 6 (II) THE DEPARTMENT SHALL PROMULGATE REGULATIONS IMPLEMENTING THE 7 REQUIREMENTS OF THIS SUBPARAGRAPH AND SUBPARAGRAPH ONE OF THIS PARAGRAPH 8 RELATING TO THE CONDITIONS UNDER WHICH EXTENDED COVERAGE HEREUNDER MAY 9 BE TERMINATED, THE SCOPE OF COVERAGE, AND THE CONDITIONS UNDER WHICH 10 COVERAGE MAY BE EXTENDED PENDING A REDETERMINATION OF ELIGIBILITY. SUCH 11 REGULATIONS SHALL, AT A MINIMUM, PROVIDE FOR: TERMINATION OF SUCH COVER- 12 AGE AT THE CLOSE OF THE FIRST MONTH IN WHICH THE FAMILY CEASES TO 13 INCLUDE A DEPENDENT CHILD; NOTICE OF TERMINATION PRIOR TO THE EFFECTIVE 14 DATE OF ANY TERMINATIONS; COVERAGE UNDER EMPLOYEE HEALTH PLANS AND 15 HEALTH MAINTENANCE ORGANIZATIONS; AND DISQUALIFICATION OF PERSONS FOR 16 EXTENDED COVERAGE BENEFITS UNDER THIS PARAGRAPH FOR FRAUD. 17 (3) NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, EACH FAMILY 18 WHICH WAS ELIGIBLE FOR MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH FOUR 19 OF PARAGRAPH (B) OF SUBDIVISION ONE OF THIS SECTION IN AT LEAST THREE OF 20 THE SIX MONTHS IMMEDIATELY PRECEDING THE MONTH IN WHICH SUCH FAMILY 21 BECAME INELIGIBLE FOR SUCH ASSISTANCE AS A RESULT, WHOLLY OR PARTLY, OF 22 THE COLLECTION OR INCREASED COLLECTION OF SPOUSAL SUPPORT PURSUANT TO 23 PART D OF TITLE IV OF THE FEDERAL SOCIAL SECURITY ACT, SHALL, FOR 24 PURPOSES OF MEDICAL ASSISTANCE ELIGIBILITY, BE CONSIDERED TO BE ELIGIBLE 25 FOR MEDICAL ASSISTANCE PURSUANT TO SUBPARAGRAPH FOUR OF PARAGRAPH (B) OF 26 SUBDIVISION ONE OF THIS SECTION FOR AN ADDITIONAL FOUR CALENDAR MONTHS 27 BEGINNING WITH THE MONTH INELIGIBILITY FOR SUCH ASSISTANCE BEGINS. 28 (B) PREGNANT WOMEN AND CHILDREN. 29 (1) A PREGNANT WOMAN ELIGIBLE FOR MEDICAL ASSISTANCE UNDER SUBPARA- 30 GRAPH TWO OR FOUR OF PARAGRAPH (B) OF SUBDIVISION ONE OF THIS SECTION ON 31 ANY DAY OF HER PREGNANCY WILL CONTINUE TO BE ELIGIBLE FOR SUCH CARE AND 32 SERVICES THROUGH THE END OF THE MONTH IN WHICH THE SIXTIETH DAY FOLLOW- 33 ING THE END OF THE PREGNANCY OCCURS, WITHOUT REGARD TO ANY CHANGE IN THE 34 INCOME OF THE FAMILY THAT INCLUDES THE PREGNANT WOMAN, EVEN IF SUCH 35 CHANGE OTHERWISE WOULD HAVE RENDERED HER INELIGIBLE FOR MEDICAL ASSIST- 36 ANCE. 37 (2) A CHILD BORN TO A WOMAN ELIGIBLE FOR AND RECEIVING MEDICAL ASSIST- 38 ANCE ON THE DATE OF THE CHILD'S BIRTH SHALL BE DEEMED TO HAVE APPLIED 39 FOR MEDICAL ASSISTANCE AND TO HAVE BEEN FOUND ELIGIBLE FOR SUCH ASSIST- 40 ANCE ON THE DATE OF SUCH BIRTH AND TO REMAIN ELIGIBLE FOR SUCH ASSIST- 41 ANCE FOR A PERIOD OF ONE YEAR, SO LONG AS THE CHILD IS A MEMBER OF THE 42 WOMAN'S HOUSEHOLD AND THE WOMAN REMAINS ELIGIBLE FOR SUCH ASSISTANCE OR 43 WOULD REMAIN ELIGIBLE FOR SUCH ASSISTANCE IF SHE WERE PREGNANT. 44 (3) A CHILD UNDER THE AGE OF NINETEEN WHO IS DETERMINED ELIGIBLE FOR 45 MEDICAL ASSISTANCE UNDER THE PROVISIONS OF THIS SECTION, SHALL, CONSIST- 46 ENT WITH APPLICABLE FEDERAL REQUIREMENTS, REMAIN ELIGIBLE FOR SUCH 47 ASSISTANCE UNTIL THE EARLIER OF: 48 (I) THE LAST DAY OF THE MONTH WHICH IS TWELVE MONTHS FOLLOWING THE 49 DETERMINATION OR REDETERMINATION OF ELIGIBILITY FOR SUCH ASSISTANCE; OR 50 (II) THE LAST DAY OF THE MONTH IN WHICH THE CHILD REACHES THE AGE OF 51 NINETEEN. 52 (4) AN INFANT ELIGIBLE UNDER SUBPARAGRAPH TWO OR FOUR OF PARAGRAPH (B) 53 OF SUBDIVISION ONE OF THIS SECTION WHO IS RECEIVING MEDICALLY NECESSARY 54 IN-PATIENT SERVICES FOR WHICH MEDICAL ASSISTANCE IS PROVIDED ON THE DATE 55 THE CHILD ATTAINS ONE YEAR OF AGE, AND WHO, BUT FOR ATTAINING SUCH AGE, 56 WOULD REMAIN ELIGIBLE FOR MEDICAL ASSISTANCE UNDER SUCH SUBPARAGRAPH, S. 2606--C 75 1 SHALL CONTINUE TO REMAIN ELIGIBLE UNTIL THE END OF THE STAY FOR WHICH 2 IN-PATIENT SERVICES ARE BEING FURNISHED. 3 (5) A CHILD ELIGIBLE UNDER SUBPARAGRAPH THREE OF PARAGRAPH (B) OF 4 SUBDIVISION ONE OF THIS SECTION WHO IS RECEIVING MEDICALLY NECESSARY 5 IN-PATIENT SERVICES FOR WHICH MEDICAL ASSISTANCE IS PROVIDED ON THE DATE 6 THE CHILD ATTAINS NINETEEN YEARS OF AGE, AND WHO, BUT FOR ATTAINING SUCH 7 AGE, WOULD REMAIN ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS PARAGRAPH, 8 SHALL CONTINUE TO REMAIN ELIGIBLE UNTIL THE END OF THE STAY FOR WHICH 9 IN-PATIENT SERVICES ARE BEING FURNISHED. 10 (6) A WOMAN WHO WAS PREGNANT WHILE IN RECEIPT OF MEDICAL ASSISTANCE 11 WHO SUBSEQUENTLY LOSES HER ELIGIBILITY FOR MEDICAL ASSISTANCE SHALL HAVE 12 HER ELIGIBILITY FOR MEDICAL ASSISTANCE CONTINUED FOR A PERIOD OF TWEN- 13 TY-FOUR MONTHS FROM THE END OF THE MONTH IN WHICH THE SIXTIETH DAY 14 FOLLOWING THE END OF HER PREGNANCY OCCURS, BUT ONLY FOR FEDERAL TITLE X 15 SERVICES WHICH ARE ELIGIBLE FOR REIMBURSEMENT BY THE FEDERAL GOVERNMENT 16 AT A RATE OF NINETY PERCENT; PROVIDED, HOWEVER, THAT SUCH NINETY PERCENT 17 LIMITATION SHALL NOT APPLY TO THOSE SERVICES IDENTIFIED BY THE COMMIS- 18 SIONER AS SERVICES, INCLUDING TREATMENT FOR SEXUALLY TRANSMITTED 19 DISEASES, GENERALLY PERFORMED AS PART OF OR AS A FOLLOW-UP TO A SERVICE 20 ELIGIBLE FOR SUCH NINETY PERCENT REIMBURSEMENT; AND PROVIDED FURTHER, 21 HOWEVER, THAT NOTHING IN THIS PARAGRAPH SHALL BE DEEMED TO AFFECT 22 PAYMENT FOR SUCH TITLE X SERVICES IF FEDERAL FINANCIAL PARTICIPATION IS 23 NOT AVAILABLE FOR SUCH CARE, SERVICES AND SUPPLIES. 24 (C) BREAST AND CERVICAL CANCER TREATMENT. 25 (1) PERSONS WHO ARE NOT ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THE 26 TERMS OF SECTION 1902(A)(10)(A)(I) OF THE FEDERAL SOCIAL SECURITY ACT 27 ARE ELIGIBLE FOR MEDICAL ASSISTANCE COVERAGE DURING THE TREATMENT OF 28 BREAST OR CERVICAL CANCER, SUBJECT TO THE PROVISIONS OF THIS PARAGRAPH. 29 (2) (I) MEDICAL ASSISTANCE IS AVAILABLE UNDER THIS PARAGRAPH TO 30 PERSONS WHO ARE UNDER SIXTY-FIVE YEARS OF AGE, HAVE BEEN SCREENED FOR 31 BREAST AND/OR CERVICAL CANCER UNDER THE CENTERS FOR DISEASE CONTROL AND 32 PREVENTION BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM AND NEED 33 TREATMENT FOR BREAST OR CERVICAL CANCER, AND ARE NOT OTHERWISE COVERED 34 UNDER CREDITABLE COVERAGE AS DEFINED IN THE FEDERAL PUBLIC HEALTH 35 SERVICE ACT; PROVIDED HOWEVER THAT MEDICAL ASSISTANCE SHALL BE FURNISHED 36 PURSUANT TO THIS CLAUSE ONLY TO THE EXTENT PERMITTED UNDER FEDERAL LAW, 37 IF, FOR SO LONG AS, AND TO THE EXTENT THAT FEDERAL FINANCIAL PARTIC- 38 IPATION IS AVAILABLE THEREFOR. 39 (II) MEDICAL ASSISTANCE IS AVAILABLE UNDER THIS PARAGRAPH TO PERSONS 40 WHO MEET THE REQUIREMENTS OF CLAUSE (I) OF THIS SUBPARAGRAPH BUT FOR 41 THEIR AGE AND/OR GENDER, WHO HAVE BEEN SCREENED FOR BREAST AND/OR CERVI- 42 CAL CANCER UNDER THE PROGRAM DESCRIBED IN TITLE ONE-A OF ARTICLE TWEN- 43 TY-FOUR OF THE PUBLIC HEALTH LAW AND NEED TREATMENT FOR BREAST OR CERVI- 44 CAL CANCER, AND ARE NOT OTHERWISE COVERED UNDER CREDITABLE COVERAGE AS 45 DEFINED IN THE FEDERAL PUBLIC HEALTH SERVICE ACT; PROVIDED HOWEVER THAT 46 MEDICAL ASSISTANCE SHALL BE FURNISHED PURSUANT TO THIS CLAUSE ONLY IF 47 AND FOR SO LONG AS THE PROVISIONS OF CLAUSE (I) OF THIS SUBPARAGRAPH ARE 48 IN EFFECT. 49 (3) MEDICAL ASSISTANCE PROVIDED TO A PERSON UNDER THIS PARAGRAPH SHALL 50 BE LIMITED TO THE PERIOD IN WHICH SUCH PERSON REQUIRES TREATMENT FOR 51 BREAST OR CERVICAL CANCER. 52 (4) (I) THE COMMISSIONER OF HEALTH SHALL PROMULGATE SUCH REGULATIONS 53 AS MAY BE NECESSARY TO CARRY OUT THE PROVISIONS OF THIS PARAGRAPH. SUCH 54 REGULATIONS SHALL INCLUDE, BUT NOT BE LIMITED TO: ELIGIBILITY REQUIRE- 55 MENTS; A DESCRIPTION OF THE MEDICAL SERVICES WHICH ARE COVERED; AND A 56 PROCESS FOR PROVIDING PRESUMPTIVE ELIGIBILITY WHEN A QUALIFIED ENTITY, S. 2606--C 76 1 AS DEFINED BY THE COMMISSIONER, DETERMINES ON THE BASIS OF PRELIMINARY 2 INFORMATION THAT A PERSON MEETS THE REQUIREMENTS FOR ELIGIBILITY UNDER 3 THIS PARAGRAPH. 4 (II) FOR PURPOSES OF DETERMINING ELIGIBILITY FOR MEDICAL ASSISTANCE 5 UNDER THIS PARAGRAPH, RESOURCES AVAILABLE TO SUCH INDIVIDUAL SHALL NOT 6 BE CONSIDERED NOR REQUIRED TO BE APPLIED TOWARD THE PAYMENT OR PART 7 PAYMENT OF THE COST OF MEDICAL CARE, SERVICES AND SUPPLIES AVAILABLE 8 UNDER THIS PARAGRAPH. 9 (III) AN INDIVIDUAL SHALL BE ELIGIBLE FOR PRESUMPTIVE ELIGIBILITY FOR 10 MEDICAL ASSISTANCE UNDER THIS PARAGRAPH IN ACCORDANCE WITH SUBDIVISION 11 FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE. 12 (5) THE COMMISSIONER OF HEALTH SHALL, CONSISTENT WITH THIS TITLE, MAKE 13 ANY NECESSARY AMENDMENTS TO THE STATE PLAN FOR MEDICAL ASSISTANCE 14 SUBMITTED PURSUANT TO SECTION THREE HUNDRED SIXTY-THREE-A OF THIS TITLE, 15 IN ORDER TO ENSURE FEDERAL FINANCIAL PARTICIPATION IN EXPENDITURES UNDER 16 THIS PARAGRAPH. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, 17 THE PROVISIONS OF CLAUSE (I) OF SUBPARAGRAPH TWO OF THIS PARAGRAPH SHALL 18 BE EFFECTIVE ONLY IF AND FOR SO LONG AS FEDERAL FINANCIAL PARTICIPATION 19 IS AVAILABLE IN THE COSTS OF MEDICAL ASSISTANCE FURNISHED THEREUNDER. 20 (D) COLON AND PROSTATE CANCER TREATMENT. 21 (1) NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE CONTRARY, A 22 PERSON WHO HAS BEEN SCREENED OR REFERRED FOR SCREENING FOR COLON OR 23 PROSTATE CANCER BY THE CANCER SERVICES SCREENING PROGRAM, AS ADMINIS- 24 TERED BY THE DEPARTMENT OF HEALTH, AND HAS BEEN DIAGNOSED WITH COLON OR 25 PROSTATE CANCER IS ELIGIBLE FOR MEDICAL ASSISTANCE FOR THE DURATION OF 26 HIS OR HER TREATMENT FOR SUCH CANCER. 27 (2) PERSONS ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS PARAGRAPH SHALL 28 HAVE AN INCOME OF TWO HUNDRED FIFTY PERCENT OR LESS OF THE COMPARABLE 29 FEDERAL INCOME OFFICIAL POVERTY LINE AS DEFINED AND ANNUALLY REVISED BY 30 THE FEDERAL OFFICE OF MANAGEMENT AND BUDGET. 31 (3) AN INDIVIDUAL SHALL BE ELIGIBLE FOR PRESUMPTIVE ELIGIBILITY FOR 32 MEDICAL ASSISTANCE UNDER THIS PARAGRAPH IN ACCORDANCE WITH SUBDIVISION 33 FIVE OF SECTION THREE HUNDRED SIXTY-FOUR-I OF THIS TITLE. 34 (4) MEDICAL ASSISTANCE IS AVAILABLE UNDER THIS PARAGRAPH TO PERSONS 35 WHO ARE UNDER SIXTY-FIVE YEARS OF AGE, AND ARE NOT OTHERWISE COVERED 36 UNDER CREDITABLE COVERAGE AS DEFINED IN THE FEDERAL PUBLIC HEALTH 37 SERVICE ACT. 38 S 3. Paragraph (a) of subdivision 4 of section 364-i of the social 39 services law, as added by section 29-a of part A of chapter 58 of the 40 laws of 2007, is amended to read as follows: 41 (a) Notwithstanding any inconsistent provision of law to the contrary, 42 a child shall be presumed to be eligible for medical assistance under 43 this title beginning on the date that a qualified entity, as defined in 44 paragraph (c) of this subdivision, determine, on the basis of prelimi- 45 nary information, that the [net] MAGI household income of the child does 46 not exceed the applicable level for eligibility as provided for pursuant 47 to SUBPARAGRAPH TWO OR THREE OF paragraph [(u)] (B) of subdivision 48 [four] ONE of section three hundred sixty-six of this title. 49 S 4. Paragraph (a) of subdivision 5 of section 364-i of the social 50 services law, as added by chapter 176 of the laws of 2006, is amended to 51 read as follows: 52 (a) An individual shall be presumed to be eligible for medical assist- 53 ance under this title beginning on the date that a qualified entity, as 54 defined in paragraph (c) of this subdivision, determines, on the basis 55 of preliminary information, that the individual meets the requirements S. 2606--C 77 1 of paragraph [(v) or (v-1)] (C) OR (D) of subdivision four of section 2 three hundred sixty-six of this title. 3 S 5. Subdivision 6 of section 364-i of the social services law, as 4 added by chapter 484 of the laws of 2009 and paragraph (a-2) as added by 5 section 76 of part H of chapter 59 of the laws of 2011, is amended to 6 read as follows: 7 6. (a) A pregnant woman shall be presumed to be eligible for [coverage 8 of services described in paragraph (c) of this subdivision] MEDICAL 9 ASSISTANCE UNDER THIS TITLE, EXCLUDING INPATIENT SERVICES AND INSTITU- 10 TIONAL LONG TERM CARE, beginning on the date that a prenatal care 11 provider, licensed under article twenty-eight of the public health law 12 or other prenatal care provider approved by the department of health 13 determines, on the basis of preliminary information, that the pregnant 14 woman's [family has: (i) subject to the approval of the federal Centers 15 for Medicare and Medicaid Services, gross income that does not exceed 16 two hundred thirty percent of the federal poverty line (as defined and 17 annually revised by the United States department of health and human 18 services) for a family of the same size, or (ii) in the absence of such 19 approval, net income that does not exceed two hundred percent of the 20 federal poverty line (as defined and annually revised by the United 21 States department of health and human services) for a family of the same 22 size.] MAGI HOUSEHOLD INCOME DOES NOT EXCEED THE MAGI-EQUIVALENT OF TWO 23 HUNDRED PERCENT OF THE FEDERAL POVERTY LINE FOR THE APPLICABLE FAMILY 24 SIZE, AS DEFINED BY THIS CHAPTER. 25 (a-2) At the time of application for presumptive eligibility pursuant 26 to this subdivision, a pregnant woman who resides in a social services 27 district that has implemented the state's managed care program pursuant 28 to section three hundred sixty-four-j of this title must choose a 29 managed care provider. If a managed care provider is not chosen at the 30 time of application, the pregnant woman will be assigned to a managed 31 care provider in accordance with subparagraphs (ii), (iii), (iv) and (v) 32 of paragraph (f) of subdivision four of section three hundred sixty- 33 four-j of this title. 34 (b) Such presumptive eligibility shall continue through the earlier 35 of: the day on which eligibility is determined pursuant to this title; 36 or the last day of the month following the month in which the provider 37 makes preliminary determination, in the case of a pregnant woman who 38 does not file an application for medical assistance on or before such 39 day. 40 (c) [A presumptively eligible pregnant woman is eligible for coverage 41 of: 42 (i) all medical care, services, and supplies available under the 43 medical assistance program, excluding inpatient services and institu- 44 tional long term care, if the woman's family has: (A) subject to the 45 approval of the federal Centers for Medicare and Medicaid Services, 46 gross income that does not exceed one hundred twenty percent of the 47 federal poverty line (as defined and annually revised by the United 48 States department of health and human services) for a family of the same 49 size, or (B) in the absence of such approval, net income that does not 50 exceed one hundred percent of the federal poverty line (as defined and 51 annually revised by the United States department of health and human 52 services) for a family of the same size; or 53 (ii) prenatal care services as described in subparagraph four of para- 54 graph (o) of subdivision four of section three hundred sixty-six of this 55 title, if the woman's family has: (A) subject to the approval of the 56 federal Centers for Medicare and Medicaid Services, gross income that S. 2606--C 78 1 exceeds one hundred twenty percent of the federal poverty line (as 2 defined and annually revised by the United States department of health 3 and human services) for families of the same size, but does not exceed 4 two hundred thirty percent of such federal poverty line, or (B) in the 5 absence of such approval, net income that exceeds one hundred percent 6 but does not exceed two hundred percent of the federal poverty line (as 7 defined and annually revised by the United States department of health 8 and human services) for a family of the same size. 9 (d)] The department of health shall provide prenatal care providers 10 licensed under article twenty-eight of the public health law and other 11 approved prenatal care providers with such forms as are necessary for a 12 pregnant woman to apply and information on how to assist such women in 13 completing and filing such forms. A qualified provider which determines 14 that a pregnant woman is presumptively eligible shall notify the social 15 services district in which the pregnant woman resides of the determi- 16 nation within five working days after the date on which such determi- 17 nation is made and shall inform the woman at the time the determination 18 is made that she is required to make application by the last day of the 19 month following the month in which the determination is made. 20 [(e)] (D) Notwithstanding any other provision of law, care that is 21 furnished to a pregnant woman pursuant to this subdivision during a 22 presumptive eligibility period shall be deemed as medical assistance for 23 purposes of payment and state reimbursement. 24 [(f)] (E) Facilities licensed under article twenty-eight of the public 25 health law providing prenatal care services shall perform presumptive 26 eligibility determinations and assist women in submitting appropriate 27 documentation to the social services district as required by the commis- 28 sioner; provided, however, that a facility may apply to the commissioner 29 for exemption from this requirement on the basis of undue hardship. 30 [(g)] (F) All prenatal care providers enrolled in the medicaid program 31 must provide prenatal care services to eligible service recipients 32 determined presumptively eligible for medical assistance but not yet 33 enrolled in the medical assistance program, and assist women in submit- 34 ting appropriate documentation to the social services district as 35 required by the commissioner. 36 S 6. Subdivision 1 and the opening paragraph of subdivision 2 of 37 section 365-a of the social services law, subdivision 1 as amended by 38 chapter 110 of the laws of 1971 and the opening paragraph of subdivision 39 2 as amended by chapter 41 of the laws of 1992, are amended to read as 40 follows: 41 [1.] The amount, nature and manner of providing medical assistance for 42 needy persons shall be determined by the public welfare official with 43 the advice of a physician and in accordance with the local medical plan, 44 this title, and the regulations of the department. 45 1. "BENCHMARK COVERAGE" SHALL MEAN PAYMENT OF PART OR ALL OF THE COST 46 OF MEDICALLY NECESSARY MEDICAL, DENTAL, AND REMEDIAL CARE, SERVICES, AND 47 SUPPLIES DESCRIBED IN SECTION FOUR THOUSAND THREE HUNDRED TWENTY-SIX OF 48 THE INSURANCE LAW - HEALTHY NY, AND TO THE EXTENT NOT INCLUDED THEREIN, 49 ANY ESSENTIAL BENEFITS AS DEFINED IN 42 U.S.C. 18022(B), SUCH CARE, 50 SERVICES AND SUPPLIES SHALL BE PROVIDED THROUGH A MANAGED CARE PROGRAM. 51 ["Medical assistance"] "STANDARD COVERAGE" shall mean payment of part 52 or all of the cost of medically necessary medical, dental and remedial 53 care, services and supplies, as authorized in this title or the regu- 54 lations of the department, which are necessary to prevent, diagnose, 55 correct or cure conditions in the person that cause acute suffering, 56 endanger life, result in illness or infirmity, interfere with such S. 2606--C 79 1 person's capacity for normal activity, or threaten some significant 2 handicap and which are furnished an eligible person in accordance with 3 this title and the regulations of the department. Such care, services 4 and supplies shall include the following medical care, services and 5 supplies, together with such medical care, services and supplies 6 provided for in subdivisions three, four and five of this section, and 7 such medical care, services and supplies as are authorized in the regu- 8 lations of the department: 9 S 7. Subdivision 1 of section 366-a of the social services law, as 10 amended by section 60 of part C of chapter 58 of the laws of 2009, is 11 amended to read as follows: 12 1. Any person requesting medical assistance may make application 13 therefor [in person, through another in his behalf or by mail] BY A 14 WRITTEN APPLICATION to the social services official of the county[, city 15 or town, or to the service officer of the city or town] in which the 16 applicant resides or is found OR TO THE DEPARTMENT OF HEALTH OR ITS 17 AGENT; A PHONE APPLICATION; OR AN ON-LINE APPLICATION. [In addition, in 18 the case of a person who is sixty-five years of age or older and is a 19 patient in a state hospital for tuberculosis or for the mentally disa- 20 bled, applications may be made to the department or to a social services 21 official designated as the agent of the department.] Notwithstanding any 22 provision of law to the contrary, [a personal] AN IN-PERSON interview 23 with the applicant or with the person who made application on his or her 24 behalf shall not be required as part of a determination of initial or 25 continuing eligibility pursuant to this title. 26 S 8. Paragraph (a) of subdivision 2 of section 366-a of the social 27 services law, as amended by section 60 of part C of chapter 58 of the 28 laws of 2009, is amended to read as follows: 29 (a) Upon receipt of such application, the appropriate social services 30 official, or the department of health or its agent [when the applicant 31 is a patient in a state hospital for the mentally disabled,] shall veri- 32 fy the eligibility of such applicant. In accordance with the regulations 33 of the department of health, it shall be the responsibility of the 34 applicant to provide information and documentation necessary for the 35 determination of initial and ongoing eligibility for medical assistance. 36 If an applicant or recipient is unable to provide necessary documenta- 37 tion, the [public welfare] SOCIAL SERVICES official OR THE DEPARTMENT OF 38 HEALTH OR ITS AGENT shall promptly cause an investigation to be made. 39 Where an investigation is necessary, sources of information other than 40 public records will be consulted only with permission of the applicant 41 or recipient. In the event that such permission is not granted by the 42 applicant or recipient, or necessary documentation cannot be obtained, 43 the social services official or the department of health or its agent 44 may suspend or deny medical assistance until such time as it may be 45 satisfied as to the applicant's or recipient's eligibility therefor. 46 S 9. The opening paragraph of subdivision 3 of section 366-a of the 47 social services law, as added by chapter 256 of the laws of 1966, is 48 amended to read as follows: 49 Upon the receipt of such application, and after the completion of any 50 investigation that shall be deemed necessary, the appropriate [public 51 welfare] SOCIAL SERVICES official[,] or the department OF HEALTH or its 52 agent [when the applicant is a patient in a state hospital for tubercu- 53 losis or for the mentally disabled,] shall 54 S 10. Paragraphs (b) and (c) of subdivision 5 of section 366-a of the 55 social services law, as added by section 52 of part A of chapter 1 of 56 the laws of 2002, are amended to read as follows: S. 2606--C 80 1 (b) The commissioner shall develop a simplified statewide recertif- 2 ication form for use in redetermining eligibility under this title. The 3 form [shall] MAY include requests only for such information that is: 4 (i) reasonably necessary to determine continued eligibility for 5 medical assistance under this title; and 6 (ii) subject to change since the date of the recipient's initial 7 application. 8 (c) [A personal] THE REGULATIONS REQUIRED BY PARAGRAPH (A) OF THIS 9 SUBDIVISION SHALL PROVIDE THAT: 10 (I) THE REDETERMINATION OF ELIGIBILITY WILL BE MADE BASED ON RELIABLE 11 INFORMATION POSSESSED OR AVAILABLE TO THE DEPARTMENT OF HEALTH OR ITS 12 AGENT, INCLUDING INFORMATION ACCESSED FROM DATABASES PURSUANT TO SUBDI- 13 VISION EIGHT OF THIS SECTION; 14 (II) IF THE DEPARTMENT OF HEALTH OR ITS AGENT IS UNABLE TO RENEW 15 ELIGIBILITY BASED ON AVAILABLE INFORMATION, THE RECIPIENT WILL BE 16 REQUESTED TO SUPPLY ANY SUCH INFORMATION AS IS NECESSARY TO DETERMINE 17 CONTINUED ELIGIBILITY FOR MEDICAL ASSISTANCE UNDER THIS TITLE; AND 18 (III) FOR PERSONS WHOSE MEDICAL ASSISTANCE ELIGIBILITY IS BASED ON 19 MODIFIED ADJUSTED GROSS INCOME, ELIGIBILITY MUST BE RENEWED AT LEAST 20 ONCE EVERY TWELVE MONTHS, UNLESS THE DEPARTMENT OF HEALTH OR ITS AGENT 21 RECEIVES INFORMATION ABOUT A CHANGE IN A RECIPIENT'S CIRCUMSTANCES THAT 22 MAY AFFECT ELIGIBILITY. 23 (D) AN IN-PERSON interview with the recipient shall not AUTOMATICALLY 24 be required as part of a redetermination of eligibility pursuant to this 25 subdivision UNLESS THE DEPARTMENT OF HEALTH DETERMINES OTHERWISE. 26 S 11. Paragraph (d) of subdivision 5 of section 366-a of the social 27 services law is REPEALED. 28 S 12. Paragraph (e) of subdivision 5 of section 366-a of the social 29 services law, as added by section 1 of part C of chapter 58 of the laws 30 of 2007, is amended to read as follows: 31 (e) The commissioner of health shall verify the accuracy of the infor- 32 mation provided by [the] AN APPLICANT OR recipient [pursuant to para- 33 graph (d) of this subdivision] by matching it against information to 34 which the commissioner of health has access, including under subdivision 35 eight of this section. In the event there is an inconsistency between 36 the information reported by the recipient and any information obtained 37 by the commissioner of health from other sources and such inconsistency 38 is material to medical assistance eligibility, the commissioner of 39 health shall request that the recipient provide adequate documentation 40 to verify his or her place of residence or income, as applicable. In 41 addition to the documentation of residence and income authorized by this 42 paragraph, the commissioner of health is authorized to periodically 43 require a reasonable sample of recipients to provide documentation of 44 residence and income at recertification. The commissioner of health 45 shall consult with the medicaid inspector general regarding income and 46 residence verification practices and procedures necessary to maintain 47 program integrity and deter fraud and abuse. 48 S 13. Subdivision 11 of section 364-j of the social services law is 49 REPEALED. 50 S 14. Clause (D) of subparagraph (v) of paragraph (a) of subdivision 2 51 of section 369-ee of the social services law, as amended by section 67 52 of part C of chapter 58 of the laws of 2009, is amended, and a new 53 subparagraph (vi) is added to read as follows: 54 (D) is not described in clause (A), (B) or (C) of this subparagraph 55 and has gross family income equal to or less than two hundred percent of 56 the federal income official poverty line (as defined and updated by the S. 2606--C 81 1 United States Department of Health and Human Services) for a family of 2 the same size; provided, however, that eligibility under this clause is 3 subject to sources of federal and non-federal funding for such purpose 4 described in section sixty-seven-a of [the] PART C OF chapter 5 FIFTY-EIGHT of the laws of two thousand nine [that added this clause] or 6 as may be available under the waiver agreement entered into with the 7 federal government under section eleven hundred fifteen of the federal 8 social security act, as jointly determined by the commissioner and the 9 director of the division of the budget. In no case shall state funds be 10 utilized to support the non-federal share of expenditures pursuant to 11 this subparagraph, provided however that the commissioner may demon- 12 strate to the United States department of health and human services the 13 existence of non-federally participating state expenditures as necessary 14 to secure federal funding under an eleven hundred fifteen waiver for the 15 purposes herein. Eligibility under this clause may be provided to resi- 16 dents of all counties or, at the joint discretion of the commissioner 17 and the director of the division of the budget, a subset of counties of 18 the state[.]; AND 19 (VI) CONTINGENT UPON THE REQUIREMENTS OF THE PATIENT PROTECTION AND 20 AFFORDABLE CARE ACT OF 2010 BEING FULLY IMPLEMENTED BY THE STATE AND AS 21 APPROVED BY THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN 22 SERVICES, AND CONTINGENT UPON FULL IMPLEMENTATION OF THE STATE ENROLL- 23 MENT CENTER, MAKES APPLICATION FOR BENEFITS PURSUANT TO THIS TITLE ON OR 24 BEFORE DECEMBER THIRTY-FIRST, TWO THOUSAND THIRTEEN. 25 S 14-a. Subdivision 5 of section 369-ee of the social services law is 26 amended by adding a new paragraph (d) to read as follows: 27 (D) NOTWITHSTANDING THE PROVISIONS OF PARAGRAPH (A) OF THIS SUBDIVI- 28 SION OR ANY OTHER PROVISION OF LAW, IN THE CASE OF A PERSON RECEIVING 29 HEALTH CARE SERVICES PURSUANT TO THIS TITLE ON JANUARY FIRST, TWO THOU- 30 SAND FOURTEEN, SUCH PERSON'S ELIGIBILITY SHALL BE RECERTIFIED AS SOON AS 31 PRACTICABLE THEREAFTER, AND SUCH PERSON'S COVERAGE UNDER THIS TITLE 32 SHALL END ON THE EARLIEST OF: (I) THE DATE THE PERSON IS ENROLLED IN A 33 QUALIFIED HEALTH PLAN OFFERED THROUGH A HEALTH INSURANCE EXCHANGE ESTAB- 34 LISHED IN ACCORDANCE WITH THE REQUIREMENTS OF THE FEDERAL PATIENT 35 PROTECTION AND AFFORDABLE CARE ACT (P.L. 111-148), AS AMENDED BY THE 36 FEDERAL HEALTH CARE AND EDUCATION ACT OF 2010 (P.L. 111-152); (II) 37 DECEMBER THIRTY-FIRST, TWO THOUSAND FOURTEEN; OR (III) THE DATE ON WHICH 38 THE DEPARTMENT OF HEALTH CEASES TO HAVE ALL NECESSARY APPROVALS UNDER 39 FEDERAL LAW AND REGULATION TO RECEIVE FEDERAL FINANCIAL PARTICIPATION, 40 UNDER THE PROGRAM DESCRIBED IN TITLE ELEVEN OF THIS ARTICLE, IN THE 41 COSTS OF HEALTH SERVICES PROVIDED PURSUANT TO THIS SECTION, AND CONTIN- 42 GENT UPON THE REQUIREMENTS OF THE PATIENT PROTECTION AND AFFORDABLE CARE 43 ACT OF 2010 BEING FULLY IMPLEMENTED BY THE STATE AND AS APPROVED BY THE 44 SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, AND CONTINGENT 45 UPON FULL IMPLEMENTATION OF THE STATE ENROLLMENT CENTER. 46 S 15. Section 369-ee of the social services law is REPEALED. 47 S 15-a. Section 369-ff of the social services law is REPEALED. 48 S 16. Subdivision 3 of section 367-a of the social services law is 49 amended by adding a new paragraph (e) to read as follows: 50 (E) (1) PAYMENT OF PREMIUMS FOR ENROLLING INDIVIDUALS IN QUALIFIED 51 HEALTH PLANS OFFERED THROUGH A HEALTH INSURANCE EXCHANGE ESTABLISHED 52 PURSUANT TO THE FEDERAL PATIENT PROTECTION AND AFFORDABLE CARE ACT (P.L. 53 111-148), AS AMENDED BY THE FEDERAL HEALTH CARE AND EDUCATION RECONCIL- 54 IATION ACT OF 2010 (P.L. 111-152), TOGETHER WITH THE COSTS OF APPLICABLE 55 CO-INSURANCE, DEDUCTIBLE AMOUNTS, AND OTHER COST-SHARING OBLIGATIONS, 56 SHALL BE AVAILABLE TO INDIVIDUALS WHO: S. 2606--C 82 1 (I) IMMEDIATELY PRIOR TO BEING ENROLLED IN THE QUALIFIED HEALTH PLAN, 2 OR TO THE EXPIRATION OR REPEAL OF THE FAMILY HEALTH PLUS PROGRAM, WERE 3 ELIGIBLE UNDER SUCH PROGRAM AND ENROLLED IN A FAMILY HEALTH INSURANCE 4 PLAN AS A PARENT OR STEPPARENT OF A CHILD UNDER THE AGE OF TWENTY-ONE, 5 AND WHOSE MAGI HOUSEHOLD INCOME, AS DEFINED IN SUBPARAGRAPH EIGHT OF 6 PARAGRAPH (A) OF SUBDIVISION ONE OF SECTION THREE HUNDRED SIXTY-SIX OF 7 THIS TITLE, EXCEEDS ONE HUNDRED THIRTY-THREE PERCENT OF THE FEDERAL 8 POVERTY LINE FOR THE APPLICABLE FAMILY SIZE; 9 (II) ARE NOT OTHERWISE ELIGIBLE FOR MEDICAL ASSISTANCE UNDER THIS 10 TITLE; AND 11 (III) ARE ENROLLED IN A STANDARD HEALTH PLAN IN THE SILVER LEVEL, AS 12 DEFINED IN 42 U.S.C. 18022. 13 (2) CONTINGENT UPON FULL FEDERAL FINANCIAL PARTICIPATION, PAYMENT 14 PURSUANT TO THIS PARAGRAPH SHALL BE FOR PREMIUMS, CO-INSURANCE, DEDUCT- 15 IBLES, AND OTHER COST-SHARING OBLIGATIONS OF THE INDIVIDUAL UNDER THE 16 QUALIFIED HEALTH PLAN TO THE EXTENT THAT THEY EXCEED THE AMOUNT THAT 17 WOULD HAVE BEEN THE INDIVIDUAL'S CO-PAYMENT OBLIGATION AMOUNT UNDER THE 18 FAMILY HEALTH PLUS PROGRAM, AND SHALL CONTINUE ONLY IF AND FOR SO LONG 19 AS THE INDIVIDUAL'S MAGI HOUSEHOLD INCOME EXCEEDS ONE HUNDRED 20 THIRTY-THREE PERCENT, BUT DOES NOT EXCEED ONE HUNDRED FIFTY PERCENT, OF 21 THE FEDERAL POVERTY LINE FOR THE APPLICABLE FAMILY SIZE. 22 (3) THE COMMISSIONER OF HEALTH IS AUTHORIZED TO SUBMIT AMENDMENTS TO 23 THE STATE PLAN FOR MEDICAL ASSISTANCE AND/OR SUBMIT ONE OR MORE APPLICA- 24 TIONS FOR WAIVERS OF THE FEDERAL SOCIAL SECURITY ACT AS MAY BE NECESSARY 25 TO RECEIVE FEDERAL FINANCIAL PARTICIPATION IN THE COSTS OF PAYMENTS MADE 26 PURSUANT TO THIS PARAGRAPH. 27 (4) THIS PARAGRAPH SHALL BE CONTINGENT UPON THE REQUIREMENTS OF THE 28 PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 BEING FULLY IMPLE- 29 MENTED BY THE STATE AND AS APPROVED BY THE SECRETARY OF THE DEPARTMENT 30 OF HEALTH AND HUMAN SERVICES, AND CONTINGENT UPON FULL IMPLEMENTATION OF 31 THE STATE ENROLLMENT CENTER. 32 S 17. Section 2510 of the public health law amended by adding a new 33 subdivision 13 to read as follows: 34 13. "HOUSEHOLD INCOME" MEANS THE SUM OF THE MODIFIED ADJUSTED GROSS 35 INCOME OF EVERY INDIVIDUAL INCLUDED IN A CHILD'S HOUSEHOLD CALCULATED IN 36 ACCORDANCE WITH APPLICABLE FEDERAL LAW AND REGULATIONS, AS MAY BE 37 AMENDED. THIS DEFINITION SHALL BE EFFECTIVE ON JANUARY FIRST, TWO THOU- 38 SAND FOURTEEN OR A LATER DATE CONCOMITANT WITH THE FULL IMPLEMENTATION 39 OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 BY THE STATE 40 AND AS APPROVED BY THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN 41 SERVICES. 42 S 18. Section 2510 of the public health law is amended by adding two 43 new subdivisions 14 and 15 to read as follows: 44 14. "STATE ENROLLMENT CENTER" MEANS THE CENTRALIZED SYSTEM AND OPERA- 45 TION OF ELIGIBILITY DETERMINATIONS BY THE STATE OR ITS CONTRACTOR FOR 46 ALL INSURANCE AFFORDABILITY PROGRAMS, INCLUDING THE CHILD HEALTH INSUR- 47 ANCE PROGRAM ESTABLISHED PURSUANT TO THIS TITLE. THE STATE ENROLLMENT 48 CENTER SHALL BE SUBJECT TO THE PROVISIONS OF SECTION EIGHT OF THE STATE 49 FINANCE LAW. 50 15. "INSURANCE AFFORDABILITY PROGRAMS" MEANS THOSE PROGRAMS SET FORTH 51 IN SECTION 435.4 OF TITLE 42 OF THE CODE OF FEDERAL REGULATIONS. 52 S 19. Subparagraphs (iv) and (vi) of paragraph (f) of subdivision 2 of 53 section 2511 of the public health law, subparagraph (iv) as added by 54 section 44 of part A of chapter 1 of the laws of 2002 and subparagraph 55 (vi) as added by section 45-b of part C of chapter 58 of the laws of 56 2008, are amended to read as follows: S. 2606--C 83 1 (iv) In the event a household does not provide income documentation 2 required by subparagraph (iii) of this paragraph within two months of 3 the approved organization's OR STATE ENROLLMENT CENTER'S request, WHICH- 4 EVER IS APPLICABLE, the approved organization OR STATE ENROLLMENT CENTER 5 shall disenroll the child at the end of such two month period. Except as 6 provided in paragraph (c) of subdivision five-a of this section, 7 approved organizations shall not be obligated to repay subsidy payments 8 made by the state on behalf of children enrolled during this two month 9 period. 10 (vi) Any income verification response by the department of taxation 11 and finance pursuant to subparagraphs (i) and (ii) of this paragraph 12 shall not be a public record and shall not be released by the commis- 13 sioner, the department of taxation and finance [or], an approved organ- 14 ization, OR THE STATE ENROLLMENT CENTER, except pursuant to this para- 15 graph. Information disclosed pursuant to this paragraph shall be limited 16 to information necessary for verification. Information so disclosed 17 shall be kept confidential by the party receiving such information. Such 18 information shall be expunged within a reasonable time to be determined 19 by the commissioner and the department of taxation and finance. 20 S 20. Paragraph (j) of subdivision 2 of section 2511 of the public 21 health law, as added by section 45 of part A of chapter 1 of the laws of 22 2002, is amended to read as follows: 23 (j) Where an application for recertification of coverage under this 24 title contains insufficient information for a final determination of 25 eligibility for continued coverage, a child shall be presumed eligible 26 for a period not to exceed the earlier of two months beyond the preced- 27 ing period of eligibility or the date upon which a final determination 28 of eligibility is made based on the submission of additional data. In 29 the event such additional information is not submitted within two months 30 of the approved organization's OR STATE ENROLLMENT CENTER'S request, 31 WHICHEVER IS APPLICABLE, the approved organization OR STATE ENROLLMENT 32 CENTER shall disenroll the child following the expiration of such two 33 month period. Except as provided in paragraph (c) of subdivision five-a 34 of this section, approved organizations shall not be obligated to repay 35 subsidy payments received on behalf of children enrolled during this two 36 month period. 37 S 21. Subdivision 4 of section 2511 of the public health law, as 38 amended by section 70 of part B of chapter 58 of the laws of 2005, is 39 amended to read as follows: 40 4. Households shall report to the approved organization OR STATE 41 ENROLLMENT CENTER, WHICHEVER IS APPLICABLE, within thirty days, any 42 changes in New York state residency or health care coverage under insur- 43 ance that may make a child ineligible for subsidy payments pursuant to 44 this section. Any individual who, with the intent to obtain benefits, 45 willfully misstates income or residence to establish eligibility pursu- 46 ant to subdivision two of this section or willfully fails to notify an 47 approved organization OR STATE ENROLLMENT CENTER of a change in resi- 48 dence or health care coverage pursuant to this subdivision shall repay 49 such subsidy to the commissioner. Individuals seeking to enroll children 50 for coverage shall be informed that such willful misstatement or failure 51 to notify shall result in such liability. 52 S 22. The subdivision heading and paragraphs (a) and (b) of subdivi- 53 sion 5-a of section 2511 of the public health law, the subdivision head- 54 ing and paragraph (a) as added by chapter 170 of the laws of 1994 and 55 paragraph (b) as amended by section 71 of part B of chapter 58 of the 56 laws of 2005, are amended to read as follows: S. 2606--C 84 1 Obligations of approved organizations OR THE STATE ENROLLMENT CENTER. 2 (a) An approved organization OR STATE ENROLLMENT CENTER, WHICHEVER IS 3 APPLICABLE, shall have the obligation to review all information provided 4 pursuant to subdivision two of this section and shall not certify or 5 recertify a child as eligible for a subsidy payment unless the child 6 meets the eligibility criteria. 7 (b) An approved organization OR STATE ENROLLMENT CENTER, WHICHEVER IS 8 APPLICABLE, shall promptly review all information relating to a poten- 9 tial change in eligibility based on information provided pursuant to 10 subdivision four of this section. Within at least thirty days after 11 receipt of such information, the approved organization OR STATE ENROLL- 12 MENT CENTER shall make a determination whether the child is still eligi- 13 ble for a subsidy payment and shall notify the household and the commis- 14 sioner if it determines the child is not eligible for a subsidy payment. 15 S 23. Paragraph (a) of subdivision 11 of section 2511 of the public 16 health law, as amended by section 37 of part A of chapter 58 of the laws 17 of 2007, is amended to read as follows: 18 (a) An approved organization shall submit required reports and infor- 19 mation to the commissioner in such form and at times, at least annually, 20 as may be required by the commissioner and specified in contracts and 21 official department of health administrative guidance, in order to eval- 22 uate the operations and results of the program and quality of care being 23 provided by such organizations. Such reports and information shall 24 include, but not be limited to, enrollee demographics (APPLICABLE ONLY 25 UNTIL THE STATE ENROLLMENT CENTER IS IMPLEMENTED), program utilization 26 and expense, patient care outcomes and patient specific medical informa- 27 tion, including encounter data maintained by an approved organization 28 for purposes of quality assurance and oversight. Any information or 29 data collected pursuant to this paragraph shall be kept confidential in 30 accordance with Title XXI of the federal social security act or any 31 other applicable state or federal law. 32 S 24. Subdivision 12 of section 2511 of the public health law, as 33 amended by chapter 2 of the laws of 1998, is amended to read as follows: 34 12. The commissioner shall, in consultation with the superintendent, 35 establish procedures to coordinate the child health insurance plan with 36 the medical assistance program, including but not limited to, procedures 37 to maximize enrollment of eligible children under those programs by 38 identification and transfer of children who are eligible or who become 39 eligible to receive medical assistance and procedures to facilitate 40 changes in enrollment status for children who are ineligible for subsi- 41 dies under this section and for children who are no longer eligible for 42 medical assistance in order to facilitate and ensure continuity of 43 coverage. The commissioner shall review, on an annual basis, the eligi- 44 bility verification and recertification procedures of approved organiza- 45 tions under this title to insure the appropriate enrollment of children. 46 Such review shall include, but not be limited to, an audit of a statis- 47 tically representative sample of cases from among all approved organiza- 48 tions AND SHALL BE APPLICABLE TO ANY PERIOD DURING WHICH AN APPROVED 49 ORGANIZATION'S RESPONSIBILITIES INCLUDE DETERMINING ELIGIBILITY. In the 50 event such review and audit reveals cases which do not meet the eligi- 51 bility criteria for coverage set forth in this section, that information 52 shall be forwarded to the approved organization and the commissioner for 53 appropriate action. 54 S 25. Paragraph (e) of subdivision 12-a of section 2511 of the public 55 health law, as added by chapter 2 of the laws of 1998, is amended and a 56 new paragraph (f) is added to read as follows: S. 2606--C 85 1 (e) standards and procedures for the imposition of penalties for 2 substantial noncompliance, which may include, but not be limited to, 3 financial penalties in addition to penalties set forth in section twelve 4 of this chapter and consistent with applicable federal standards, as 5 specified in contracts, and contract termination[.]; PROVIDED HOWEVER 6 (F) AUDIT STANDARDS AND PROCEDURES ESTABLISHED PURSUANT TO THIS 7 SECTION, INCLUDING PENALTIES, SHALL BE APPLICABLE TO ELIGIBILITY DETER- 8 MINATIONS MADE BY APPROVED ORGANIZATIONS ONLY FOR PERIODS DURING WHICH 9 AN APPROVED ORGANIZATION'S RESPONSIBILITIES INCLUDE MAKING SUCH ELIGI- 10 BILITY DETERMINATIONS. 11 S 26. Paragraph (e) and subparagraphs (i), (ii), (iii) and (v) of 12 paragraph (f) of subdivision 2 of section 2511 of the public health law, 13 paragraph (e) as added by chapter 170 of the laws of 1994 and relettered 14 by chapter 2 of the laws of 1998, and subparagraphs (i) and (ii) of 15 paragraph (f) as amended by section 6 of part B of chapter 58 of the 16 laws of 2010, subparagraph (iii) of paragraph (f) as amended by chapter 17 535 of the laws of 2010, and subparagraph (v) of paragraph (f) as 18 amended by section 7 of part J of chapter 82 of the laws of 2002, are 19 amended to read as follows: 20 (e) is a resident of New York state. Such residency shall be [demon- 21 strated by] ATTESTED TO BY THE APPLICANT FOR INSURANCE, PROVIDED HOWEV- 22 ER, THE COMMISSIONER SHALL REQUIRE adequate proof[, as determined by the 23 commissioner,] of a New York state street address IN ANY CIRCUMSTANCES 24 WHEN THERE IS AN INCONSISTENCY WITH RESIDENCY INFORMATION FROM OTHER 25 DATA SOURCES. [If the child has no street address, such proof may 26 include, but not be limited to, school records or other documentation 27 determined by the commissioner.] 28 (i) In order to establish income eligibility under this subdivision at 29 initial application, a household shall provide [such documentation spec- 30 ified in subparagraph (iii) of this paragraph, as necessary and suffi- 31 cient to determine a child's financial eligibility for a subsidy payment 32 under this title] THE SOCIAL SECURITY NUMBERS FOR EACH PARENT AND LEGAL- 33 LY RESPONSIBLE ADULT WHO IS A MEMBER OF THE HOUSEHOLD, SUBJECT TO 34 SUBPARAGRAPH (V) OF THIS PARAGRAPH. The commissioner [may verify the 35 accuracy of such income information provided by the household by match- 36 ing it against] SHALL DETERMINE ELIGIBILITY BASED ON income information 37 contained in databases to which the commissioner has access, including 38 the state's wage reporting system pursuant to subdivision five of 39 section one hundred seventy-one-a of the tax law and by means of an 40 income verification performed pursuant to a cooperative agreement with 41 the department of taxation and finance pursuant to subdivision four of 42 section one hundred seventy-one-b of the tax law. THE COMMISSIONER 43 SHALL REQUIRE AN ATTESTATION BY THE HOUSEHOLD THAT THE INCOME INFORMA- 44 TION OBTAINED FROM ELECTRONIC DATA SOURCES IS ACCURATE. SUCH ATTESTATION 45 SHALL INCLUDE ANY OTHER HOUSEHOLD INCOME INFORMATION NOT OBTAINED FROM 46 AN ELECTRONIC DATA SOURCE THAT IS NECESSARY TO DETERMINE A CHILD'S 47 FINANCIAL ELIGIBILITY FOR A SUBSIDY PAYMENT UNDER THIS TITLE. IF THE 48 ATTESTATION IS INCONSISTENT WITH INFORMATION OBTAINED FROM AVAILABLE 49 DATA SOURCES, DOCUMENTATION SHALL BE REQUIRED AS SPECIFIED IN SUBPARA- 50 GRAPH (III) OF THIS PARAGRAPH. 51 (ii) In order to establish income eligibility under this subdivision 52 at recertification, a household shall attest to all information regard- 53 ing the household's income that is necessary and sufficient to determine 54 a child's financial eligibility for a subsidy payment under this title 55 and shall provide the social security numbers for each parent and legal- 56 ly responsible adult who is a member of the household and whose income S. 2606--C 86 1 is available to the child, subject to subparagraph (v) of this para- 2 graph. The commissioner may verify the accuracy of such income informa- 3 tion provided by the household by matching it against income information 4 contained in databases to which the commissioner has access, including 5 the state's wage reporting system and by means of an income verification 6 performed pursuant to a cooperative agreement with the department of 7 taxation and finance pursuant to subdivision four of section one hundred 8 seventy-one-b of the tax law, AND MAY MAKE A REDETERMINATION OF ELIGI- 9 BILITY BASED ON RELIABLE INFORMATION CONTAINED IN DATABASES TO WHICH THE 10 COMMISSIONER HAS ACCESS. THE COMMISSIONER SHALL REQUIRE AN ATTESTATION 11 BY THE HOUSEHOLD THAT THE INCOME INFORMATION CONTAINED IN THE ENROLLMENT 12 FILE OR OBTAINED FROM ELECTRONIC DATA SOURCES IS ACCURATE. SUCH ATTESTA- 13 TION SHALL INCLUDE ANY OTHER HOUSEHOLD INCOME INFORMATION NOT OBTAINED 14 FROM AN ELECTRONIC DATA SOURCE. In the event that there is an inconsist- 15 ency between the income information attested to by the household and any 16 information obtained by the commissioner from other sources pursuant to 17 this subparagraph, and such inconsistency is material to the household's 18 eligibility for a subsidy payment under this title, the commissioner 19 shall require the [approved organization to obtain] HOUSEHOLD TO PROVIDE 20 income documentation [from the household] as specified in subparagraph 21 (iii) of this paragraph. 22 (iii) IF THE ATTESTATION OF HOUSEHOLD INCOME REQUIRED BY SUBPARAGRAPHS 23 (I) AND (II) OF THIS PARAGRAPH IS IN ANY WAY INCONSISTENT WITH INFORMA- 24 TION OBTAINED FROM DATA SOURCES, FURTHER DOCUMENTATION SHALL BE 25 REQUIRED. Income documentation shall include, but not be limited to, one 26 or more of the following for each parent and legally responsible adult 27 who is a member of the household and whose income is available to the 28 child; 29 (A) current annual income tax returns; 30 (B) paycheck stubs; 31 (C) written documentation of income from all employers; or 32 (D) written documentation of income eligibility of a child for free or 33 reduced breakfast or lunch through the school meal program certified by 34 the child's school, provided that: 35 (I) the commissioner may verify the accuracy of the information 36 provided in the same manner and way as provided for in subparagraph (ii) 37 of this paragraph; and 38 (II) such documentation may not be suitable proof of income in the 39 event of a material inconsistency in income after the commissioner has 40 performed verification pursuant to subparagraph (ii) of this paragraph; 41 or 42 (E) other documentation of income (earned or unearned) as determined 43 by the commissioner, provided, however, such documentation shall set 44 forth the source of such income. 45 (v) In the event a household chooses not to provide the social securi- 46 ty numbers required by [subparagraph] SUBPARAGRAPHS (I) AND (ii) of this 47 paragraph, such household shall provide income documentation specified 48 in subparagraph (iii) of this paragraph as a condition of the child's 49 enrollment. Nothing in this paragraph shall be construed as obligating a 50 household to provide social security numbers of parents or legally 51 responsible adults as a condition of a child's enrollment or eligibility 52 for a subsidy payment under this title. 53 S 27. Subparagraph (ii) of paragraph (g) of subdivision 2 of section 54 2511 of the public health law, as amended by section 29 of part A of 55 chapter 58 of the laws of 2007, is amended to read as follows: S. 2606--C 87 1 (ii) Effective September first two thousand seven, THROUGH MARCH THIR- 2 TY-FIRST, TWO THOUSAND FOURTEEN OR A LATER DATE CONCOMITANT WITH THE 3 FULL IMPLEMENTATION OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 4 2010 BY THE DATE AND AS APPROVED BY THE SECRETARY OF THE DEPARTMENT OF 5 HEALTH AND HUMAN SERVICES, temporary enrollment pursuant to subparagraph 6 (i) of this paragraph shall be provided only to children who apply for 7 recertification of coverage under this title who appear to be eligible 8 for medical assistance under title eleven of article five of the social 9 services law. 10 S 28. Paragraph (a) of subdivision 2-b of section 2511 of the public 11 health law, as added by section 5 of part B of chapter 58 of the laws of 12 2010, is amended to read as follows: 13 (a) Effective October first, two thousand ten, for purposes of claim- 14 ing federal financial participation under paragraph nine of subsection 15 (c) of section twenty-one hundred five of the federal social security 16 act[,] for individuals declaring to be citizens at initial application, 17 AND, EFFECTIVE JANUARY FIRST, TWO THOUSAND FOURTEEN OR A LATER DATE TO 18 BE DETERMINED BY THE COMMISSIONER CONTINGENT UPON THE REQUIREMENTS OF 19 THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 BEING FULLY 20 IMPLEMENTED BY THE STATE AND AS APPROVED BY THE SECRETARY OF THE DEPART- 21 MENT OF HEALTH AND HUMAN SERVICES, a household shall provide: 22 (i) the social security number for the applicant to be verified by the 23 commissioner in accordance with a process established by the social 24 security administration pursuant to federal law, or 25 (ii) documentation of citizenship and identity of the applicant 26 consistent with requirements under the medical assistance program, as 27 specified by the commissioner on the initial application. 28 S 29. Paragraph (d) of subdivision 9 of section 2510 of the public 29 health law, as added by section 72-a of part C of chapter 58 of the laws 30 of 2009, is amended to read as follows: 31 (d) for periods on or after July first, two thousand nine, amounts as 32 follows: 33 (i) no payments are required for eligible children whose family 34 [gross] household income is less than one hundred sixty percent of the 35 non-farm federal poverty level and for eligible children who are Ameri- 36 can Indians or Alaskan Natives, as defined by the U.S. Department of 37 Health and Human Services, whose family [gross] household income is less 38 than two hundred fifty-one percent of the non-farm federal poverty 39 level; and 40 (ii) nine dollars per month for each eligible child whose family 41 [gross] household income is between one hundred sixty percent and two 42 hundred twenty-two percent of the non-farm federal poverty level, but no 43 more than twenty-seven dollars per month per family; and 44 (iii) fifteen dollars per month for each eligible child whose family 45 [gross] household income is between two hundred twenty-three percent and 46 two hundred fifty percent of the non-farm federal poverty level, but no 47 more than forty-five dollars per month per family; and 48 (iv) thirty dollars per month for each eligible child whose family 49 [gross] household income is between two hundred fifty-one percent and 50 three hundred percent of the non-farm federal poverty level, but no more 51 than ninety dollars per month per family; 52 (v) forty-five dollars per month for each eligible child whose family 53 [gross] household income is between three hundred one percent and three 54 hundred fifty percent of the non-farm federal poverty level, but no more 55 than one hundred thirty-five dollars per month per family; and S. 2606--C 88 1 (vi) sixty dollars per month for each eligible child whose family 2 [gross] household income is between three hundred fifty-one percent and 3 four hundred percent of the non-farm federal poverty level, but no more 4 than one hundred eighty dollars per month per family. 5 S 30. Subparagraph (iii) of paragraph (a) of subdivision 2 of section 6 2511 of the public health law, as amended by section 32 of part B of 7 chapter 58 of the laws of 2008, is amended to read as follows: 8 (iii) effective September first, two thousand eight, resides in a 9 household having a [gross] household income at or below four hundred 10 percent of the non-farm federal poverty level (as defined and updated by 11 the United States department of health and human services); 12 S 31. Subparagraph (ii) of paragraph (d) of subdivision 2 of section 13 2511 of the public health law, as amended by section 33 of part A of 14 chapter 58 of the laws of 2007, clause (B) as amended by section 3 of 15 part OO of chapter 57 of the laws of 2008, is amended to read as 16 follows: 17 (ii) (A) The implementation of this paragraph for a child residing in 18 a household having a [gross] household income at or below two hundred 19 fifty percent of the non-farm federal poverty level (as defined and 20 updated by the United States department of health and human services) 21 shall take effect only upon the commissioner's finding that insurance 22 provided under this title is substituting for coverage under group 23 health plans in excess of a percentage specified by the secretary of the 24 federal department of health and human services. The commissioner shall 25 notify the legislature prior to implementation of this paragraph. 26 (B) The implementation of clauses (A), (B), (C), (D), (E), (F), (G) 27 and (I) of subparagraph (i) of this paragraph for a child residing in a 28 household having a [gross] household income between two hundred fifty- 29 one and four hundred percent of the non-farm federal poverty level (as 30 defined and updated by the United States department of health and human 31 services) shall take effect September first, two thousand eight; 32 provided however, the entirety of subparagraph (i) of this paragraph 33 shall take effect and be applied to such children on the date federal 34 financial participation becomes available for such population in accord- 35 ance with the state's Title XXI child health plan. The commissioner 36 shall monitor the number of children who are subject to the waiting 37 period established pursuant to this clause. 38 S 32. Clauses (A) and (B) of subparagraph (i) of paragraph (b) of 39 subdivision 18 of section 2511 of the public health law, as added by 40 section 31 of part A of chapter 58 of the laws of 2007, are amended to 41 read as follows: 42 (A) participation in the program for a child who resides in a house- 43 hold having a [gross] household income at or below two hundred fifty 44 percent of the non-farm federal poverty level (as defined and updated by 45 the United States department of health and human services) shall be 46 voluntary and an eligible child may disenroll from the premium assist- 47 ance program at any time and enroll in individual coverage under this 48 title; and 49 (B) participation in the program for a child who resides in a house- 50 hold having a [gross] household income between two hundred fifty-one and 51 four hundred percent of the non-farm federal poverty level (as defined 52 and updated by the United States department of health and human 53 services) and meets certain eligibility criteria shall be mandatory. A 54 child in this income group who meets the criteria for enrollment in the 55 premium assistance program shall not be eligible for individual coverage 56 under this title; S. 2606--C 89 1 S 33. Subparagraph (iv) of paragraph (b) and paragraph (d) of subdivi- 2 sion 9 of section 2511 of the public health law, as amended by section 3 18-a of chapter 2 of the laws of 1998, are amended to read as follows: 4 (iv) outstationing of persons who are authorized to provide assistance 5 to families in completing the enrollment application process under this 6 title and title eleven of article five of the social services law, 7 [including the conduct of personal interviews pursuant to section three 8 hundred sixty-six-a of the social services law and personal interviews 9 required upon recertification under such section of the social services 10 law,] in locations, such as community settings, which are geographically 11 accessible to large numbers of children who may be eligible for benefits 12 under such titles, and at times, including evenings and weekends, when 13 large numbers of children who may be eligible for benefits under such 14 titles are likely to be encountered. Persons outstationed in accordance 15 with this subparagraph shall be authorized to make determinations of 16 presumptive eligibility in accordance with paragraph (g) of subdivision 17 two of section two thousand five hundred and eleven of this title; and 18 (d) Subject to the availability of funds therefor, training shall be 19 provided for outstationed persons and employees of approved organiza- 20 tions to enable them to disseminate information, AND facilitate the 21 completion of the application process under this subdivision[, and 22 conduct personal interviews required by section three hundred 23 sixty-six-a of the social services law and personal interviews required 24 upon recertification under such section of the social services law]. 25 S 33-a. Subdivision 1 of section 206 of the public health law is 26 amended by adding a new paragraph (s) to read as follows: 27 (S) ISSUE A READINESS REPORT TO THE LEGISLATURE, DETAILING THE STATUS 28 OF THE STATEWIDE HEALTH BENEFIT EXCHANGE, STATE ENROLLMENT CENTER, AND 29 STATE MEDICAID ENROLLMENT CENTER ESTABLISHED UNDER EXECUTIVE ORDER 30 NUMBER FORTY-TWO OF TWO THOUSAND TWELVE, BY AUGUST THIRTIETH, TWO THOU- 31 SAND THIRTEEN. THE READINESS REPORT MAY BE PROVIDED IN ELECTRONIC FORMAT 32 AND SHALL BE DISTRIBUTED TO THE TEMPORARY PRESIDENT OF THE SENATE, THE 33 SPEAKER OF THE ASSEMBLY, THE CHAIR OF THE SENATE STANDING COMMITTEE ON 34 HEALTH, AND THE CHAIR OF THE ASSEMBLY HEALTH COMMITTEE. THE READINESS 35 REPORT SHALL OUTLINE THE PROGRESS AND PREPAREDNESS OF THE HEALTH BENEFIT 36 EXCHANGE, STATE ENROLLMENT CENTER, AND STATE MEDICAID ENROLLMENT CENTER 37 AND DETAIL HOW THE EXCHANGE, STATE ENROLLMENT CENTER, AND STATE MEDICAID 38 ENROLLMENT CENTER WILL CARRY OUT THEIR RESPECTIVE FUNCTIONS INCLUDING 39 BUT NOT LIMITED TO: 40 (I) THE PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE, STATE ENROLLMENT 41 CENTER, AND STATE MEDICAID ENROLLMENT CENTER WILL BEGIN ACCEPTING APPLI- 42 CATIONS ON OCTOBER FIRST, TWO THOUSAND THIRTEEN; 43 (II) THE PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE, STATE ENROLL- 44 MENT CENTER, AND STATE MEDICAID ENROLLMENT CENTER WILL CERTIFY QUALIFIED 45 HEALTH PLANS; 46 (III) THE ANTICIPATED COST OF INDIVIDUAL AND SMALL GROUP PLANS BEING 47 OFFERED IN THE HEALTH BENEFIT EXCHANGE; 48 (IV) THE NUMBER OF NAVIGATORS APPROVED; 49 (V) THE PLAN FOR FULL OPERATION BY JANUARY FIRST, TWO THOUSAND FOUR- 50 TEEN; AND 51 (VI) THE PLAN TO BECOME FISCALLY SELF-SUSTAINING BY JANUARY FIRST, TWO 52 THOUSAND FIFTEEN. 53 S 34. Paragraphs 9 and 10 of subsection (a) of section 2101 of the 54 insurance law, as added by chapter 687 of the laws of 2003, are amended 55 and a new paragraph 11 is added to read as follows: S. 2606--C 90 1 (9) a person who is not a resident of this state who sells, solicits 2 or negotiates a contract of insurance for commercial property/casualty 3 risks to an insured with risks located in more than one state insured 4 under that contract, provided that such person is otherwise licensed as 5 an insurance producer to sell, solicit or negotiate that insurance in 6 the state where the insured maintains its principal place of business 7 and the contract of insurance insures risks located in that state; [or] 8 (10) any salaried full-time employee who counsels or advises his or 9 her employer relative to the insurance interests of the employer or of 10 the subsidiaries or business affiliates of the employer provided that 11 the employee does not sell or solicit insurance or receive a commis- 12 sion[.]; OR 13 (11) ANY PERSON WHO HAS RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED 14 BY THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF 15 THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, TO ACT AS A NAVIGATOR, 16 INCLUDING ANY PERSON EMPLOYED BY A CERTIFIED NAVIGATOR, PROVIDED THAT 17 THE PERSON HAS COMPLETED THE TRAINING REQUIRED BY THE HEALTH BENEFIT 18 EXCHANGE, AND PROVIDED THE PERSON DOES NOT SELL, SOLICIT, OR NEGOTIATE 19 INSURANCE. 20 S 35. Paragraphs 8 and 9 of subsection (c) of section 2101 of the 21 insurance law, paragraph 8 as amended and paragraph 9 as added by 22 section 5 of part I of chapter 61 of the laws of 2011, are amended and a 23 new paragraph 10 is added to read as follows: 24 (8) a person who is not a resident of this state who sells, solicits 25 or negotiates a contract for commercial property/casualty risks to an 26 insured with risks located in more than one state insured under that 27 contract, provided that such person is otherwise licensed as an insur- 28 ance producer to sell, solicit or negotiate that insurance in the state 29 where the insured maintains its principal place of business and the 30 contract of insurance insures risks located in that state; [or] 31 (9) a person who is not a resident of this state who sells, solicits 32 or negotiates a contract of property/casualty insurance, as defined in 33 paragraph six of subsection (x) of this section, of an insurer not 34 authorized to do business in this state, provided that: (A) the 35 insured's home state is a state other than this state; and (B) such 36 person is otherwise licensed to sell, solicit or negotiate excess line 37 insurance in the insured's home state[.]; OR 38 (10) ANY PERSON WHO HAS RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED 39 BY THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF 40 THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, TO ACT AS A NAVIGATOR, 41 INCLUDING ANY PERSON EMPLOYED BY A CERTIFIED NAVIGATOR, PROVIDED THAT 42 THE PERSON HAS COMPLETED THE TRAINING REQUIRED BY THE HEALTH BENEFIT 43 EXCHANGE, AND PROVIDED THE PERSON DOES NOT SELL, SOLICIT, OR NEGOTIATE 44 INSURANCE. 45 S 36. Paragraphs 10 and 11 of subsection (k) of section 2101 of the 46 insurance law, paragraph 10 as amended and paragraph 11 as added by 47 section 6 of part I of chapter 61 of the laws of 2011, are amended and a 48 new paragraph 12 is added to read as follows: 49 (10) any salaried full-time employee who counsels or advises his or 50 her employer relative to the insurance interests of the employer or of 51 the subsidiaries or business affiliates of the employer, provided that 52 the employee does not sell or solicit insurance or receive a commission; 53 [or] 54 (11) a person who is not a resident of this state who sells, solicits 55 or negotiates a contract of property/casualty insurance, as defined in 56 paragraph six of subsection (x) of this section, of an insurer not S. 2606--C 91 1 authorized to do business in this state, provided that: (A) the 2 insured's home state is a state other than this state; and (B) such 3 person is otherwise licensed to sell, solicit or negotiate excess line 4 insurance in the insured's home state[.]; OR 5 (12) ANY PERSON WHO HAS RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED 6 BY THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF 7 THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031 TO ACT AS A NAVIGATOR, 8 INCLUDING ANY PERSON EMPLOYED BY A CERTIFIED NAVIGATOR, PROVIDED THAT 9 THE PERSON HAS COMPLETED THE TRAINING REQUIRED BY THE HEALTH BENEFIT 10 EXCHANGE, AND PROVIDED THE PERSON DOES NOT SELL, SOLICIT, OR NEGOTIATE 11 INSURANCE. 12 S 37. Intentionally omitted. 13 S 37-a. The section heading and subsections (a) and (c) of section 14 2120 of the insurance law is amended to read as follows: 15 Fiduciary capacity of insurance agents, insurance brokers, NAVIGATORS 16 and reinsurance intermediaries. (a) Every insurance agent and every 17 insurance broker acting as such in this state AND ANY PERSON WHO HAS 18 RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED BY THE HEALTH BENEFIT 19 EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE 20 ACT, 42 U.S.C. S 18031, TO ACT AS A NAVIGATOR shall be responsible in a 21 fiduciary capacity for all funds received or collected as insurance 22 agent [or], insurance broker, OR NAVIGATOR and shall not, without the 23 express consent of his or its principal, mingle any such funds with his 24 or its own funds or with funds held by him or it in any other capacity. 25 (c) This section shall not require any such agent, broker, NAVIGATOR 26 or reinsurance intermediary to maintain a separate bank deposit for the 27 funds of each such principal, if and as long as the funds so held for 28 each such principal are reasonably ascertainable from the books of 29 account and records of such agent, broker or reinsurance intermediary, 30 as the case may be. 31 S 37-b. Subsections (a) and (d) of section 2123 of the insurance law, 32 as amended by chapter 540 of the laws of 1996, paragraph 3 of subsection 33 (a) as added by chapter 616 of the laws of 1997, the opening paragraph 34 of paragraph 3 of subsection (a) as amended by chapter 13 of the laws of 35 2002, are amended to read as follows: 36 (a) (1) No agent or representative of any insurer or health mainte- 37 nance organization authorized to transact life, accident or health 38 insurance or health maintenance organization business in this state and 39 no insurance broker, and no other person, firm, association or corpo- 40 ration, INCLUDING, BUT NOT LIMITED TO, ANY PERSON WHO HAS RECEIVED A 41 GRANT FROM AND HAS BEEN CERTIFIED BY THE HEALTH BENEFIT EXCHANGE ESTAB- 42 LISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 43 18031, TO ACT AS A NAVIGATOR, shall issue or circulate or cause or 44 permit to be issued or circulated, any illustration, circular, statement 45 or memorandum misrepresenting the terms, benefits or advantages of any 46 policy or contract of life, accident or health insurance, any annuity 47 contract or any health maintenance organization contract, delivered or 48 issued for delivery or to be delivered or issued for delivery, in this 49 state, or shall make any misleading estimate as to the dividends or 50 share of surplus or additional amounts to be received in the future on 51 such policy or contract, or shall make any false or misleading statement 52 as to the dividends or share of surplus or additional amounts previously 53 paid by any such insurer or health maintenance organization on similar 54 policies or contracts, or shall make any misleading representation, or 55 any misrepresentation, as to the financial condition of any such insurer S. 2606--C 92 1 or health maintenance organization, or as to the legal reserve system 2 upon which such insurer or health maintenance organization operates. 3 (2) No such person, firm, association or corporation shall make to any 4 person or persons any incomplete comparison of any such policies or 5 contracts of any insurer, insurers, or health maintenance organization, 6 for the purpose of inducing, or tending to induce, such person or 7 persons to lapse, forfeit or surrender any insurance policy or health 8 maintenance organization contract. 9 (3) Any replacement of individual life insurance policies or individ- 10 ual annuity contracts of an insurer by an agent, representative of the 11 same or different insurer or broker shall conform to standards promul- 12 gated by regulation by the superintendent. Such regulation shall: 13 (A) specify what constitutes the replacement of a life insurance poli- 14 cy or annuity contract and the proper disclosure and notification proce- 15 dures to replace a policy or contract; 16 (B) require notification of the proposed replacement to the insurer 17 whose policies or contracts are intended to be replaced; 18 (C) require the timely exchange of illustrative and cost information 19 required by section three thousand two hundred nine of this chapter and 20 necessary for completion of a comparison of the proposed and replaced 21 coverage; and 22 (D) provide for a sixty-day period following issuance of the replace- 23 ment policies or contracts during which the policy or contract owner may 24 return the policies or contracts and reinstate the replaced policies or 25 contracts. 26 (d) Any agent or representative of an insurer or health maintenance 27 organization, any insurance broker and any other person, firm, associ- 28 ation or corporation INCLUDING, BUT NOT LIMITED TO, ANY PERSON WHO HAS 29 RECEIVED A GRANT FROM AND HAS BEEN CERTIFIED BY THE HEALTH BENEFIT 30 EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE 31 ACT, 42 U.S.C. S 18031, TO ACT AS A NAVIGATOR, who, or which, shall 32 violate any of the provisions of this section and shall knowingly 33 receive any compensation or commission for the sale OR PLACEMENT of any 34 insurance policy, health maintenance organization or annuity contract 35 induced by a violation of this section shall also be liable for a civil 36 penalty in the amount received by such violator as compensation or 37 commission, which penalty may be sued for and recovered for his own use 38 and benefit by any person induced to purchase an insurance policy, 39 health maintenance organization or annuity contract by such violation. 40 In addition, such agent, representative, broker, person, firm, associ- 41 ation or corporation violating this section shall be liable for a civil 42 penalty in the amount of any compensation or commission lost by any 43 agent, representative or broker as a result of a violation of this 44 section or the making of such false or misleading statement, which 45 penalty may be sued for and recovered for his own use and benefit by 46 such agent, representative or broker. 47 S 38. Subparagraph (B) of paragraph 25 of subsection (i) of section 48 3216 of the insurance law, as amended by chapter 596 of the laws of 49 2011, is amended to read as follows: 50 (B) Every policy [which] THAT provides physician services, medical, 51 major medical or similar comprehensive-type coverage shall provide 52 coverage for the screening, diagnosis and treatment of autism spectrum 53 disorder in accordance with this paragraph and shall not exclude cover- 54 age for the screening, diagnosis or treatment of medical conditions 55 otherwise covered by the policy because the individual is diagnosed with 56 autism spectrum disorder. Such coverage may be subject to annual deduct- S. 2606--C 93 1 ibles, copayments and coinsurance as may be deemed appropriate by the 2 superintendent and shall be consistent with those imposed on other bene- 3 fits under the policy. Coverage for applied behavior analysis shall be 4 subject to a maximum benefit of [forty-five thousand dollars] SIX 5 HUNDRED EIGHTY HOURS OF TREATMENT per POLICY OR CALENDAR year per 6 covered individual [and such maximum annual benefit will increase by the 7 amount calculated from the average ten year rolling average increase of 8 the medical component of the consumer price index]. This paragraph shall 9 not be construed as limiting the benefits that are otherwise available 10 to an individual under the policy, provided however that such policy 11 shall not contain any limitations on visits that are solely applied to 12 the treatment of autism spectrum disorder. No insurer shall terminate 13 coverage or refuse to deliver, execute, issue, amend, adjust, or renew 14 coverage to an individual solely because the individual is diagnosed 15 with autism spectrum disorder or has received treatment for autism spec- 16 trum disorder. Coverage shall be subject to utilization review and 17 external appeals of health care services pursuant to article forty-nine 18 of this chapter as well as, case management, and other managed care 19 provisions. 20 S 39. Subparagraph (B) of paragraph 17 of subsection (1) of section 21 3221 of the insurance law, as amended by chapter 596 of the laws of 22 2011, is amended to read as follows: 23 (B) Every group or blanket policy [which] THAT provides physician 24 services, medical, major medical or similar comprehensive-type coverage 25 shall provide coverage for the screening, diagnosis and treatment of 26 autism spectrum disorder in accordance with this paragraph and shall not 27 exclude coverage for the screening, diagnosis or treatment of medical 28 conditions otherwise covered by the policy because the individual is 29 diagnosed with autism spectrum disorder. Such coverage may be subject to 30 annual deductibles, copayments and coinsurance as may be deemed appro- 31 priate by the superintendent and shall be consistent with those imposed 32 on other benefits under the group or blanket policy. Coverage for 33 applied behavior analysis shall be subject to a maximum benefit of 34 [forty-five thousand dollars] SIX HUNDRED EIGHTY HOURS OF TREATMENT per 35 POLICY OR CALENDAR year per covered individual [and such maximum annual 36 benefit will increase by the amount calculated from the average ten year 37 rolling average increase of the medical component of the consumer price 38 index]. This paragraph shall not be construed as limiting the benefits 39 that are otherwise available to an individual under the group or blanket 40 policy, provided however that such policy shall not contain any limita- 41 tions on visits that are solely applied to the treatment of autism spec- 42 trum disorder. No insurer shall terminate coverage or refuse to deliver, 43 execute, issue, amend, adjust, or renew coverage to an individual solely 44 because the individual is diagnosed with autism spectrum disorder or has 45 received treatment for autism spectrum disorder. Coverage shall be 46 subject to utilization review and external appeals of health care 47 services pursuant to article forty-nine of this chapter as well as, case 48 management, and other managed care provisions. 49 S 40. Paragraph 2 of subsection (ee) of section 4303 of the insurance 50 law, as amended by chapter 596 of the laws of 2011, is amended to read 51 as follows: 52 (2) Every contract [which] THAT provides physician services, medical, 53 major medical or similar comprehensive-type coverage shall provide 54 coverage for the screening, diagnosis and treatment of autism spectrum 55 disorder in accordance with this [subsection] PARAGRAPH and shall not 56 exclude coverage for the screening, diagnosis or treatment of medical S. 2606--C 94 1 conditions otherwise covered by the contract because the individual is 2 diagnosed with autism spectrum disorder. Such coverage may be subject to 3 annual deductibles, copayments and coinsurance as may be deemed appro- 4 priate by the superintendent and shall be consistent with those imposed 5 on other benefits under the contract. Coverage for applied behavior 6 analysis shall be subject to a maximum benefit of [forty-five thousand 7 dollars] SIX HUNDRED EIGHTY HOURS OF TREATMENT per CONTRACT OR CALENDAR 8 year per covered individual [and such maximum annual benefit will 9 increase by the amount calculated from the average ten year rolling 10 average increase of the medical component of the consumer price index]. 11 This paragraph shall not be construed as limiting the benefits that are 12 otherwise available to an individual under the contract, provided howev- 13 er that such contract shall not contain any limitations on visits that 14 are solely applied to the treatment of autism spectrum disorder. No 15 insurer shall terminate coverage or refuse to deliver, execute, issue, 16 amend, adjust, or renew coverage to an individual solely because the 17 individual is diagnosed with autism spectrum disorder or has received 18 treatment for autism spectrum disorder. Coverage shall be subject to 19 utilization review and external appeals of health care services pursuant 20 to article forty-nine of this chapter as well as, case management, and 21 other managed care provisions. 22 S 40-a. Paragraph 1 of subsection (d) of section 3221 of the insurance 23 law is amended to read as follows: 24 (1) The superintendent may approve any form of certificate to be 25 issued under a blanket accident and health insurance policy as defined 26 in section four thousand two hundred thirty-seven of this chapter, which 27 omits or modifies any of the provisions hereinbefore required, if [he] 28 THE SUPERINTENDENT deems such omission or modification suitable for the 29 character of such insurance and not unjust to the persons insured there- 30 under. CERTIFICATES ISSUED UNDER A POLICY OR CONTRACT OF STUDENT ACCI- 31 DENT AND HEALTH INSURANCE AS DEFINED IN SECTION THREE THOUSAND TWO 32 HUNDRED FORTY OF THIS ARTICLE SHALL COMPLY WITH SUCH SECTION. 33 S 41. The insurance law is amended by adding a new section 3240 to 34 read as follows: 35 S 3240. STUDENT ACCIDENT AND HEALTH INSURANCE. (A) IN THIS SECTION: 36 (1) "STUDENT ACCIDENT AND HEALTH INSURANCE" MEANS A POLICY OR CONTRACT 37 OF HOSPITAL, MEDICAL, OR SURGICAL EXPENSE INSURANCE DELIVERED OR ISSUED 38 FOR DELIVERY IN THIS STATE ON OR AFTER JANUARY FIRST, TWO THOUSAND 39 FOURTEEN, BY AN INSURER OR A CORPORATION, TO AN INSTITUTION OF HIGHER 40 EDUCATION COVERING STUDENTS ENROLLED IN THE INSTITUTION AND THE 41 STUDENTS' DEPENDENTS. 42 (2) "INSTITUTION OF HIGHER EDUCATION" OR "INSTITUTION" SHALL HAVE THE 43 MEANING SET FORTH IN THE HIGHER EDUCATION ACT OF 1965, 20 U.S.C. S 1001. 44 (3) "INSURER" MEANS AN INSURER LICENSED TO WRITE ACCIDENT AND HEALTH 45 INSURANCE PURSUANT TO THIS CHAPTER. 46 (4) "CORPORATION" MEANS A CORPORATION ORGANIZED IN ACCORDANCE WITH 47 ARTICLE FORTY-THREE OF THIS CHAPTER. 48 (B) AN INSURER OR CORPORATION SHALL NOT IMPOSE ANY PRE-EXISTING CONDI- 49 TION EXCLUSION IN A STUDENT ACCIDENT AND HEALTH INSURANCE POLICY OR 50 CONTRACT. AN INSURER OR CORPORATION SHALL NOT CONDITION ELIGIBILITY, 51 INCLUDING CONTINUED ELIGIBILITY, FOR A STUDENT ACCIDENT AND HEALTH 52 INSURANCE POLICY OR CONTRACT ON HEALTH STATUS, MEDICAL CONDITION, 53 INCLUDING BOTH PHYSICAL AND MENTAL ILLNESSES, CLAIMS EXPERIENCE, RECEIPT 54 OF HEALTH CARE, MEDICAL HISTORY, GENETIC INFORMATION, EVIDENCE OF INSUR- 55 ABILITY, INCLUDING CONDITIONS ARISING OUT OF ACTS OF DOMESTIC VIOLENCE, 56 OR DISABILITY. S. 2606--C 95 1 (C) AN INSURER OR CORPORATION SHALL CONDITION ELIGIBILITY INCLUDING 2 CONTINUING ELIGIBILITY, ON THE COVERED INDIVIDUAL BEING ENROLLED AS A 3 STUDENT IN AN INSTITUTION OF HIGHER EDUCATION TO WHICH THE STUDENT ACCI- 4 DENT AND HEALTH INSURANCE POLICY OR CONTRACT IS ISSUED. 5 (D) A STUDENT ACCIDENT AND HEALTH INSURANCE POLICY OR CONTRACT SHALL 6 PROVIDE COVERAGE FOR ESSENTIAL HEALTH BENEFITS AS DEFINED IN SECTION 7 1302(B) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(B). 8 (E) AN INSURER OR CORPORATION SHALL NOT REFUSE TO RENEW OR OTHERWISE 9 TERMINATE A STUDENT ACCIDENT AND HEALTH INSURANCE POLICY OR CONTRACT 10 EXCEPT FOR ONE OR MORE OF THE REASONS SET FORTH IN: 11 (1) SUBPARAGRAPHS (A), (B), (D) OR (G) OF PARAGRAPH TWO OF SUBSECTION 12 (P) OF SECTION THREE THOUSAND TWO HUNDRED TWENTY-ONE OF THIS ARTICLE; OR 13 (2) SUBPARAGRAPHS (A), (B), (D) OR (G) OF PARAGRAPH TWO OF SUBSECTION 14 (J) OF SECTION FOUR THOUSAND THREE HUNDRED FIVE OF THIS CHAPTER. 15 (F) THIS SECTION SHALL NOT APPLY TO COVERAGE UNDER A STUDENT HEALTH 16 PLAN ISSUED PURSUANT TO SECTION ONE THOUSAND ONE HUNDRED TWENTY-FOUR OF 17 THIS CHAPTER. 18 (G) THE RATIO OF BENEFITS TO PREMIUMS SHALL BE NOT LESS THAN 19 EIGHTY-TWO PERCENT AS CALCULATED IN A MANNER TO BE DETERMINED BY THE 20 SUPERINTENDENT. 21 S 42. Intentionally omitted. 22 S 43. Intentionally omitted. 23 S 43-a. Item (i) of subparagraph (C) of paragraph 2 of subsection (c) 24 of section 4304 of the insurance law, as amended by section 9 of part A 25 of chapter 1 of the laws of 2002, is amended to read as follows: 26 (i) Discontinuance of a class of contract upon not less than five 27 months' prior written notice[, except for subscribers to direct pay 28 major medical or similar comprehensive-type coverage issued by a corpo- 29 ration organized pursuant to this article, or any successor corporation 30 organized through a conversion pursuant to subsection (j) of section 31 four thousand three hundred one of this article, and in effect prior to 32 January first, nineteen hundred ninety-six who are ineligible to 33 purchase policies offered after such date pursuant to section four thou- 34 sand three hundred twenty-one or four thousand three hundred twenty-two 35 of this article due to the provisions of 42 U.S.C. 1395ss in effect on 36 the effective date of this item. In the event any such subscriber 37 becomes eligible to purchase policies offered pursuant to section four 38 thousand three hundred twenty-one or four thousand three hundred twen- 39 ty-two of this article, then such subscriber may be discontinued upon 40 not less than five months' prior written notice]. In exercising the 41 option to discontinue coverage pursuant to this item, the corporation 42 must act uniformly without regard to any health status-related factor of 43 enrolled individuals or individuals who may become eligible for such 44 coverage and must offer to subscribers or group remitting agents, as may 45 be appropriate, the option to purchase all other individual health 46 insurance coverage currently being offered by the corporation to appli- 47 cants in that market. 48 S 44. The section heading and subsection (a) of section 4321 of the 49 insurance law, the section heading as added by chapter 504 of the laws 50 of 1995 and subsection (a) as amended by chapter 342 of the laws of 51 2004, are amended to read as follows: 52 Standardization of individual enrollee direct payment contracts 53 offered by health maintenance organizations PRIOR TO OCTOBER FIRST, TWO 54 THOUSAND THIRTEEN. (a) On and after January first, nineteen hundred 55 ninety-six, AND UNTIL SEPTEMBER THIRTIETH, TWO THOUSAND THIRTEEN all 56 health maintenance organizations issued a certificate of authority under S. 2606--C 96 1 article forty-four of the public health law or licensed under this arti- 2 cle shall offer a standardized individual enrollee contract on an open 3 enrollment basis as prescribed by section forty-three hundred seventeen 4 of this article and section forty-four hundred six of the public health 5 law, and regulations promulgated thereunder, provided, however, that 6 such requirements shall not apply to a health maintenance organization 7 exclusively serving individuals enrolled pursuant to title eleven of 8 article five of the social services law, title eleven-D of article five 9 of the social services law, title one-A of article twenty-five of the 10 public health law or title eighteen of the federal Social Security Act[, 11 and, further provided, that such health maintenance organization shall 12 not discontinue a contract for an individual receiving comprehensive- 13 type coverage in effect prior to January first, two thousand four who is 14 ineligible to purchase policies offered after such date pursuant to this 15 section or section four thousand three hundred twenty-two of this arti- 16 cle due to the provision of 42 U.S.C. 1395ss in effect prior to January 17 first, two thousand four]. On and after January first, nineteen hundred 18 ninety-six, AND UNTIL SEPTEMBER THIRTIETH, TWO THOUSAND THIRTEEN, the 19 enrollee contracts issued pursuant to this section and section four 20 thousand three hundred twenty-two of this article shall be the only 21 contracts offered by health maintenance organizations to individuals. 22 The enrollee contracts issued by a health maintenance organization under 23 this section and section four thousand three hundred twenty-two of this 24 article shall also be the only contracts issued by health maintenance 25 organizations for purposes of conversion pursuant to sections four thou- 26 sand three hundred four and four thousand three hundred five of this 27 article. However, nothing in this section shall be deemed to require 28 health maintenance organizations to terminate individual direct payment 29 contracts issued prior to January first, nineteen hundred ninety-six or 30 prevent health maintenance organizations from terminating individual 31 direct payment contracts issued prior to January first, nineteen hundred 32 ninety-six. 33 S 45. The section heading and subsection (a) of section 4322 of the 34 insurance law, the section heading as added by chapter 504 of the laws 35 of 1995 and subsection (a) as amended by chapter 342 of the laws of 36 2004, are amended to read as follows: 37 Standardization of individual enrollee direct payment contracts 38 offered by health maintenance organizations which provide out-of-plan 39 benefits PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN. (a) On and after 40 January first, nineteen hundred ninety-six, AND UNTIL SEPTEMBER THIRTI- 41 ETH, TWO THOUSAND THIRTEEN, all health maintenance organizations issued 42 a certificate of authority under article forty-four of the public health 43 law or licensed under this article shall offer to individuals, in addi- 44 tion to the standardized contract required by section four thousand 45 three hundred twenty-one of this article, a standardized individual 46 enrollee direct payment contract on an open enrollment basis as 47 prescribed by section four thousand three hundred seventeen of this 48 article and section four thousand four hundred six of the public health 49 law, and regulations promulgated thereunder, with an out-of-plan benefit 50 system, provided, however, that such requirements shall not apply to a 51 health maintenance organization exclusively serving individuals enrolled 52 pursuant to title eleven of article five of the social services law, 53 title eleven-D of article five of the social services law, title one-A 54 of article twenty-five of the public health law or title eighteen of the 55 federal Social Security Act[, and, further provided, that such health 56 maintenance organization shall not discontinue a contract for an indi- S. 2606--C 97 1 vidual receiving comprehensive-type coverage in effect prior to January 2 first, two thousand four who is ineligible to purchase policies offered 3 after such date pursuant to this section or section four thousand three 4 hundred twenty-two of this article due to the provision of 42 U.S.C. 5 1395ss in effect prior to January first, two thousand four]. The out-of- 6 plan benefit system shall either be provided by the health maintenance 7 organization pursuant to subdivision two of section four thousand four 8 hundred six of the public health law or through an accompanying insur- 9 ance contract providing out-of-plan benefits offered by a company appro- 10 priately licensed pursuant to this chapter. On and after January first, 11 nineteen hundred ninety-six, AND UNTIL SEPTEMBER THIRTIETH, TWO THOUSAND 12 THIRTEEN, the contracts issued pursuant to this section and section four 13 thousand three hundred twenty-one of this article shall be the only 14 contracts offered by health maintenance organizations to individuals. 15 The enrollee contracts issued by a health maintenance organization under 16 this section and section four thousand three hundred twenty-one of this 17 article shall also be the only contracts issued by the health mainte- 18 nance organization for purposes of conversion pursuant to sections four 19 thousand three hundred four and four thousand three hundred five of this 20 article. However, nothing in this section shall be deemed to require 21 health maintenance organizations to terminate individual direct payment 22 contracts issued prior to January first, nineteen hundred ninety-six or 23 prohibit health maintenance organizations from terminating individual 24 direct payment contracts issued prior to January first, nineteen hundred 25 ninety-six. 26 S 46. The insurance law is amended by adding a new section 4328 to 27 read as follows: 28 S 4328. INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACTS OFFERED BY HEALTH 29 MAINTENANCE ORGANIZATION ON AND AFTER OCTOBER FIRST, TWO THOUSAND THIR- 30 TEEN. (A) ON AND AFTER OCTOBER FIRST, TWO THOUSAND THIRTEEN, EVERY 31 HEALTH MAINTENANCE ORGANIZATION ISSUED A CERTIFICATE OF AUTHORITY UNDER 32 ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW OR LICENSED UNDER THIS ARTI- 33 CLE, OR AN AFFILIATED INSURER OR HEALTH MAINTENANCE ORGANIZATION SHALL 34 OFFER AN INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT IN ACCORDANCE WITH 35 THE REQUIREMENTS OF THIS SECTION; PROVIDED, HOWEVER, THAT THIS REQUIRE- 36 MENT SHALL NOT APPLY TO A HOLDER OF A SPECIAL PURPOSE CERTIFICATE OF 37 AUTHORITY ISSUED PURSUANT TO SECTION FOUR THOUSAND FOUR HUNDRED THREE-A 38 OF THE PUBLIC HEALTH LAW, EXCEPT AS OTHERWISE REQUIRED UNDER SUBSECTION 39 (L) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR OF THIS ARTICLE, OR A 40 HEALTH MAINTENANCE ORGANIZATION EXCLUSIVELY SERVING INDIVIDUALS ENROLLED 41 PURSUANT TO TITLE ELEVEN OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW, 42 TITLE ELEVEN-D OF ARTICLE FIVE OF THE SOCIAL SERVICES LAW, TITLE ONE-A 43 OF ARTICLE TWENTY-FIVE OF THE PUBLIC HEALTH LAW OR TITLE EIGHTEEN OF THE 44 FEDERAL SOCIAL SECURITY ACT. THE ENROLLEE CONTRACTS ISSUED BY A HEALTH 45 MAINTENANCE ORGANIZATION UNDER THIS SECTION ALSO SHALL BE THE ONLY 46 CONTRACTS ISSUED BY THE HEALTH MAINTENANCE ORGANIZATION FOR PURPOSES OF 47 CONVERSION PURSUANT TO SECTIONS FOUR THOUSAND THREE HUNDRED FOUR AND 48 FOUR THOUSAND THREE HUNDRED FIVE OF THIS ARTICLE. 49 (B) (1) WITHIN THE HEALTH BENEFIT EXCHANGE ESTABLISHED PURSUANT TO 50 SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, A HEALTH 51 MAINTENANCE ORGANIZATION MAY OFFER AN INDIVIDUAL ENROLLEE DIRECT PAYMENT 52 CONTRACT THAT IS A CATASTROPHIC HEALTH PLAN AS DEFINED IN SECTION 53 1302(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(E), OR ANY REGU- 54 LATIONS PROMULGATED THEREUNDER. 55 (2) THE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSUANT 56 TO THIS SECTION SHALL HAVE THE SAME ENROLLMENT PERIODS, INCLUDING S. 2606--C 98 1 SPECIAL ENROLLMENT PERIODS, AS REQUIRED FOR AN INDIVIDUAL DIRECT 2 PAYMENT CONTRACT OFFERED WITHIN THE HEALTH BENEFIT EXCHANGE ESTABLISHED 3 PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031, 4 OR ANY REGULATIONS PROMULGATED THEREUNDER. 5 (3) THE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSUANT 6 TO THIS SECTION SHALL BE ISSUED WITHOUT REGARD TO EVIDENCE OF INSURABIL- 7 ITY AND WITHOUT AN EXCLUSION FOR PRE-EXISTING CONDITIONS. 8 (4) A HEALTH MAINTENANCE ORGANIZATION OFFERING AN INDIVIDUAL ENROLLEE 9 DIRECT PAYMENT CONTRACT PURSUANT TO THIS SECTION SHALL NOT ESTABLISH 10 RULES FOR ELIGIBILITY, INCLUDING CONTINUED ELIGIBILITY, OF ANY INDIVID- 11 UAL OR DEPENDENT OF THE INDIVIDUAL TO ENROLL UNDER THE CONTRACT BASED ON 12 ANY OF THE FOLLOWING HEALTH STATUS-RELATED FACTORS: 13 (A) HEALTH STATUS; 14 (B) MEDICAL CONDITION, INCLUDING BOTH PHYSICAL AND MENTAL ILLNESSES; 15 (C) CLAIMS EXPERIENCE; 16 (D) RECEIPT OF HEALTH CARE; 17 (E) MEDICAL HISTORY; 18 (F) GENETIC INFORMATION; 19 (G) EVIDENCE OF INSURABILITY, INCLUDING CONDITIONS ARISING OUT OF ACTS 20 OF DOMESTIC VIOLENCE; OR 21 (H) DISABILITY. 22 (5) THE INDIVIDUAL ENROLLEE DIRECT PAYMENT CONTRACT OFFERED PURSUANT 23 TO THIS SECTION SHALL BE COMMUNITY RATED. FOR PURPOSES OF THIS PARA- 24 GRAPH, "COMMUNITY RATED" MEANS A RATING METHODOLOGY IN WHICH THE PREMIUM 25 FOR ALL PERSONS COVERED BY A CONTRACT FORM IS THE SAME, BASED ON THE 26 EXPERIENCE OF THE ENTIRE POOL OF RISKS, WITHOUT REGARD TO AGE, SEX, 27 HEALTH STATUS, TOBACCO USAGE, OR OCCUPATION. 28 (C) IN ADDITION TO OR IN LIEU OF THE INDIVIDUAL ENROLLEE DIRECT 29 PAYMENT CONTRACTS REQUIRED UNDER THIS SECTION, ALL HEALTH MAINTENANCE 30 ORGANIZATIONS ISSUED A CERTIFICATE OF AUTHORITY UNDER ARTICLE FORTY-FOUR 31 OF THE PUBLIC HEALTH LAW OR LICENSED UNDER THIS ARTICLE MAY OFFER INDI- 32 VIDUAL ENROLLEE DIRECT PAYMENT CONTRACTS WITHIN THE HEALTH BENEFIT 33 EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE 34 ACT, 42 U.S.C. S 18031, OR ANY REGULATIONS PROMULGATED THEREUNDER. 35 (D)(1) NOTHING IN THIS SECTION SHALL BE DEEMED TO REQUIRE HEALTH MAIN- 36 TENANCE ORGANIZATIONS TO DISCONTINUE INDIVIDUAL DIRECT PAYMENT CONTRACTS 37 ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN OR PREVENT HEALTH 38 MAINTENANCE ORGANIZATIONS FROM DISCONTINUING INDIVIDUAL DIRECT PAYMENT 39 CONTRACTS ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN. IF A 40 HEALTH MAINTENANCE ORGANIZATION DISCONTINUES INDIVIDUAL DIRECT PAYMENT 41 CONTRACTS ISSUED PRIOR TO OCTOBER FIRST, TWO THOUSAND THIRTEEN, REGARD- 42 LESS OF WHETHER IT IS A GRANDFATHERED HEALTH PLAN, THEN THE HEALTH MAIN- 43 TENANCE ORGANIZATION SHALL COMPLY WITH THE REQUIREMENTS OF SUBSECTION 44 (C) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR OF THIS ARTICLE. 45 (2) FOR PURPOSES OF THIS SUBSECTION, "GRANDFATHERED HEALTH PLAN" MEANS 46 COVERAGE PROVIDED BY A CORPORATION IN WHICH AN INDIVIDUAL WAS ENROLLED 47 ON MARCH TWENTY-THIRD, TWO THOUSAND TEN FOR AS LONG AS THE COVERAGE 48 MAINTAINS GRANDFATHERED STATUS IN ACCORDANCE WITH SECTION 1251(E) OF THE 49 AFFORDABLE CARE ACT, 42 U.S.C. S 18011(E). 50 S 46-a. Paragraph 5 of subsection (c) of section 3216 of the insurance 51 law is amended to read as follows: 52 (5) (A) Any family policy providing hospital or surgical expense 53 insurance (but not including such insurance against accidental injury 54 only) shall provide that, in the event such insurance on any person, 55 other than the policyholder, is terminated because the person is no 56 longer within the definition of the family as set forth in the policy S. 2606--C 99 1 but before such person has attained the limiting age, if any, for cover- 2 age of adults specified in the policy, such person shall be entitled to 3 have issued to [him] THAT PERSON by the insurer, without evidence of 4 insurability, upon application therefor and payment of the first premi- 5 um, within thirty-one days after such insurance shall have terminated, 6 an individual conversion policy. The conversion privilege afforded here- 7 in shall also be available upon the divorce or annulment of the marriage 8 of the policyholder to the former spouse of such policyholder. 9 (B) Written notice of entitlement to a conversion policy shall be 10 given by the insurer to the policyholder at least fifteen and not more 11 than sixty days prior to the termination of coverage due to the initial 12 limiting age of the covered dependent. Such notice shall include an 13 explanation of the rights of the dependent with respect to [his] THE 14 DEPENDENT being enrolled in an accredited institution of learning or his 15 incapacity for self-sustaining employment by reason of mental illness, 16 developmental disability or mental retardation as defined in the mental 17 hygiene law or physical handicap. 18 (C) Such individual conversion policy shall be subject to the follow- 19 ing terms and conditions: 20 (i) The premium shall be that applicable to the [class of risk to 21 which such person belongs, to the age of such person and to the] form 22 and amount of insurance therefor. 23 (ii) [Such policy shall provide, on a basis specified in the family 24 policy, the same or substantially the same benefits as those provided in 25 the family policy or such benefits as are provided in a policy specif- 26 ically approved as an individual conversion policy by the superinten- 27 dent. 28 (iii)] The benefits provided under such policy shall become effective 29 upon the date that such person was no longer eligible under the family 30 policy. 31 [(iv) The policy may exclude any condition excluded by the family 32 policy for such person at the time of the termination of his insurance 33 thereunder. The policy shall not exclude any other pre-existing condi- 34 tions, but the benefits paid under such policy may be reduced by the 35 amount of any such benefits payable under the family policy after the 36 termination of such person's insurance thereunder and, during the first 37 policy year of the conversion policy, the benefits payable under the 38 policy may be reduced so that they are not in excess of those that would 39 have been payable had such person's insurance under the family policy 40 remained in force and effect. 41 (v)] (III) No insurer shall be required to issue a conversion policy 42 if it appears that the person applying for such policy shall have at 43 that time in force another insurance policy or hospital service or 44 medical expense indemnity contract providing similar benefits or is 45 covered by or is eligible for coverage by a group insurance policy or 46 contract providing similar benefits or shall be covered by similar bene- 47 fits required by any statute or provided by any welfare plan or program, 48 which together with the conversion policy would result in over insurance 49 or duplication of benefits according to standards on file with the 50 superintendent relating to individual policies. 51 [(vi)] (IV) The policy may include a provision whereby the insurer may 52 request information at any premium due date of the policy of the person 53 covered thereunder as to whether he is then covered by another policy or 54 hospital service or medical expense indemnity corporation subscriber 55 contract providing similar benefits or is then covered by a group 56 contract or policy providing similar benefits or is then provided with S. 2606--C 100 1 similar benefits required by any statute or provided by any welfare plan 2 or program. If any such person is so covered or so provided and fails to 3 furnish the details of such coverage when requested, the benefits paya- 4 ble under the conversion policy may be based on the hospital surgical or 5 medical expenses actually incurred after excluding expenses to the 6 extent they are payable under such other coverage or provided under such 7 statute, plan, or program. 8 S 46-b. Subdivision 1 of section 4406 of the public health law, as 9 amended by chapter 342 of the laws of 2004, is amended to read as 10 follows: 11 1. The contract between a health maintenance organization and an 12 enrollee shall be subject to regulation by the superintendent as if it 13 were a health insurance subscriber contract, and shall include, but not 14 be limited to, all mandated benefits required by article forty-three of 15 the insurance law. Such contract shall fully and clearly state the bene- 16 fits and limitations therein provided or imposed, so as to facilitate 17 understanding and comparisons, and to exclude provisions which may be 18 misleading or unreasonably confusing. Such contract shall be issued to 19 any individual and dependents of such individual [and any group of fifty 20 or fewer employees or members, exclusive of spouses and dependents, or 21 any employee or member of the group, including dependents,] applying for 22 such contract at any time throughout the year, and may include a pre-ex- 23 isting condition provision as provided for in section four thousand 24 three hundred eighteen of the insurance law, provided, however, [that] 25 THE OBLIGATION OF THE HEALTH MAINTENANCE ORGANIZATION SHALL BE DEEMED 26 SATISFIED IF such COVERAGE IS OFFERED BY AN AFFILIATE OR SUBSIDIARY. THE 27 requirements shall not apply to a health maintenance organization exclu- 28 sively serving individuals enrolled pursuant to title eleven of article 29 five of the social services law, title eleven-D of article five of the 30 social services law, title one-A of article twenty-five of the public 31 health law or title eighteen of the federal Social Security Act, and, 32 further provided, that such health maintenance organization shall not 33 discontinue a contract for an individual receiving comprehensive-type 34 coverage in effect prior to January first, two thousand four who is 35 ineligible to purchase policies offered after such date pursuant to this 36 section or section four thousand three hundred twenty-two of [this arti- 37 cle] THE INSURANCE LAW due to the provision of 42 U.S.C. 1395ss in 38 effect prior to January first, two thousand four. Subject to the credit- 39 able coverage requirements of subsection (a) of section four thousand 40 three hundred eighteen of the insurance law, the organization may, as an 41 alternative to the use of a pre-existing condition provision, elect to 42 offer contracts without a pre-existing condition provision to [such 43 groups] INDIVIDUALS but may require that coverage shall not become 44 effective until after a specified affiliation period of not more than 45 sixty days after the application for coverage is submitted. The organ- 46 ization is not required to provide health care services or benefits 47 during such period and no premium shall be charged for any coverage 48 during the period. After January first, nineteen hundred ninety-six, 49 all individual direct payment contracts shall be issued only pursuant to 50 sections four thousand three hundred twenty-one and four thousand three 51 hundred twenty-two of the insurance law. Such contracts may not, with 52 respect to an eligible individual (as defined in section 2741(b) of the 53 federal Public Health Service Act, 42 U.S.C. S 300gg-41(b), impose any 54 pre-existing condition exclusion. 55 S 47. Paragraphs 4, 6, 9 and 10 of subsection (e) of section 3221 of 56 the insurance law are REPEALED, paragraphs 5, 7, 8, 11 and 12 are renum- S. 2606--C 101 1 bered paragraphs 4, 5, 6, 7 and 8 and paragraph 1, as amended by chapter 2 306 of the laws of 1987, is amended to read as follows: 3 (1) A group policy providing hospital, MEDICAL or surgical expense 4 insurance for other than specific diseases or accident only, shall 5 provide that if the insurance on an employee or member insured under the 6 group policy ceases because of termination of [(I)] (A) employment or of 7 membership in the class or classes eligible for coverage under the poli- 8 cy or [(II)] (B) the policy, for any reason whatsoever, unless the poli- 9 cyholder has replaced the group policy with similar and continuous 10 coverage for the same group whether insured or self-insured, such 11 employee or member who has been insured under the group policy [for at 12 least three months] shall be entitled to have issued to [him] THE 13 INSURED by the insurer without evidence of insurability upon application 14 made to the insurer within forty-five days after such termination, and 15 payment of the quarterly, or, at the option of the employee or member, a 16 less frequent premium applicable to the [class of risk to which the 17 person belongs, the age of such person, and the] form and amount of 18 insurance, an individual policy of insurance. The insurer may, at its 19 option elect to provide the insurance coverage under a group insurance 20 policy, delivered in this state, in lieu of the issuance of a converted 21 individual policy of insurance. Such individual policy, or group policy, 22 as the case may be is hereafter referred to as the converted policy. The 23 benefits provided under the converted policy shall be those required by 24 subsection (f)[, (g), (h) or (i) hereof] OF THIS SECTION, [whichever is 25 applicable and,] in the event of termination of the converted group 26 policy of insurance, each insured thereunder shall have a right of 27 conversion to a converted individual policy of insurance. 28 S 48. Paragraph 3 of subsection (e) of section 3221 of the insurance 29 law, as separately amended by chapters 370 and 869 of the laws of 1984, 30 is amended to read as follows: 31 (3) The converted policy shall, at the option of the employee or 32 member, provide identical coverage for the dependents of such employee 33 or member who were covered under the group policy. Provided, however, 34 that if the employee or member chooses the option of dependent coverage 35 then dependents acquired after the permitted time to convert stated in 36 paragraph one of this subsection shall be added to the converted family 37 policy in accordance with the provisions of subsection (c) of section 38 thirty-two hundred sixteen of this article and any regulations promul- 39 gated or guidelines issued by the superintendent. The converted policy 40 need not provide benefits in excess of those provided for such persons 41 under the group policy from which conversion is made [and may contain 42 any exclusion or benefit limitation contained in the group policy or 43 customarily used in individual policies]. The effective date of the 44 individual's coverage under the converted policy shall be the date of 45 the termination of the individual's insurance under the group policy as 46 to those persons covered under the group policy. 47 S 49. Subsections (f) and (g) of section 3221 of the insurance law are 48 REPEALED and a new subsection (f) is added to read as follows: 49 (F) IF THE GROUP INSURANCE POLICY INSURES THE EMPLOYEE OR MEMBER FOR 50 HOSPITAL, MEDICAL OR SURGICAL EXPENSE INSURANCE, OR IF THE GROUP INSUR- 51 ANCE POLICY INSURES THE EMPLOYEE OR MEMBER FOR MAJOR MEDICAL OR SIMILAR 52 COMPREHENSIVE-TYPE COVERAGE, THEN THE CONVERSION PRIVILEGE SHALL ENTITLE 53 THE EMPLOYEE OR MEMBER TO OBTAIN COVERAGE UNDER A CONVERTED POLICY 54 PROVIDING, AT THE INSURED'S OPTION, COVERAGE ON AN EXPENSE INCURRED 55 BASIS. S. 2606--C 102 1 S 50. Subparagraph (D) of paragraph 4 of subsection (l) of section 2 3221 of the insurance law, as amended by chapter 230 of the laws of 3 2004, is amended to read as follows: 4 (D) In addition to the requirements of subparagraph (A) of this para- 5 graph, every insurer issuing a group policy for delivery in this state 6 [which] WHERE THE policy provides reimbursement to insureds for psychi- 7 atric or psychological services or for the diagnosis and treatment of 8 mental, nervous or emotional disorders and ailments, however defined in 9 such policy, by physicians, psychiatrists or psychologists, [must] SHALL 10 provide the same coverage to insureds for such services when performed 11 by a licensed clinical social worker, within the lawful scope of his or 12 her practice, who is licensed pursuant to subdivision two of section 13 seven thousand seven hundred four of the education law and in addition 14 shall have either: (i) three or more additional years experience in 15 psychotherapy, which for the purposes of this subparagraph shall mean 16 the use of verbal methods in interpersonal relationships with the intent 17 of assisting a person or persons to modify attitudes and behavior 18 [which] THAT are intellectually, socially or emotionally maladaptive, 19 under supervision, satisfactory to the state board for social work, in a 20 facility, licensed or incorporated by an appropriate governmental 21 department, providing services for diagnosis or treatment of mental, 22 nervous or emotional disorders or ailments[, or]; (ii) three or more 23 additional years experience in psychotherapy under the supervision, 24 satisfactory to the state board for social work, of a psychiatrist, a 25 licensed and registered psychologist or a licensed clinical social work- 26 er qualified for reimbursement pursuant to subsection [(h)] (E) of this 27 section, or (iii) a combination of the experience specified in items (i) 28 and (ii) OF THIS SUBPARAGRAPH totaling three years, satisfactory to the 29 state board for social work. 30 (E) The state board for social work shall maintain a list of all 31 licensed clinical social workers qualified for reimbursement under 32 [this] subparagraph (D) OF THIS PARAGRAPH. 33 S 51. Paragraph 3 of subsection (e) of section 4304 of the insurance 34 law is REPEALED and paragraphs 4 and 5 are renumbered paragraphs 3 and 35 4, and paragraphs 1 and 2 of such subsection (e), paragraph 1 as amended 36 by chapter 661 of the laws of 1997, and as further amended by section 37 104 of part A of chapter 62 of the laws of 2011, are amended to read as 38 follows: 39 (1) If any such contract is terminated in accordance with the 40 provisions of paragraph one of subsection (c) [hereof] OF THIS SECTION, 41 or any such contract is terminated because of a default by the remitting 42 agent in the payment of premiums not cured within the grace period and 43 the remitting agent has not replaced the contract with similar and 44 continuous coverage for the same group whether insured or self-insured, 45 or any such contract is terminated in accordance with the provisions of 46 subparagraph (E) of paragraph two of subsection (c) [hereof] OF THIS 47 SECTION, or if an individual other than the contract holder is no longer 48 covered under a "family contract" because [he] THE INDIVIDUAL is no 49 longer within the definition set forth in the contract, or a spouse is 50 no longer covered under the contract because of divorce from the 51 contract holder or annulment of the marriage, or any such contract is 52 terminated because of the death of the contract holder, then such indi- 53 vidual, former spouse, or in the case of the death of the contract hold- 54 er the surviving spouse or other dependents of the deceased contract 55 holder covered under the contract, as the case may be, shall be entitled 56 to convert, without evidence of insurability, upon application therefor S. 2606--C 103 1 and the making of the first payment thereunder within thirty-one days 2 after the date of termination of such contract, to a contract [of a type 3 which provides coverage most nearly comparable to the type of coverage 4 under the contract from which the individual converted, which coverage 5 shall be no less than the minimum standards for basic hospital, basic 6 medical, or major medical as provided for in department of financial 7 services regulation; provided, however, that if the corporation does not 8 issue such a major medical contract, then to a comprehensive or compara- 9 ble type of coverage which is most commonly being sold to group remit- 10 ting agents. Notwithstanding the previous sentence, a corporation may 11 elect to issue a standardized individual enrollee contract pursuant to 12 section four thousand three hundred twenty-two of this article in lieu 13 of a major medical contract, comprehensive or comparable type of cover- 14 age required to be offered upon conversion from an indemnity contract] 15 THAT CONTAINS THE BENEFITS DESCRIBED IN PARAGRAPH ONE OF SUBSECTION (B) 16 OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF THIS ARTICLE. 17 The effective date of the coverage provided by the converted direct 18 payment contract shall be the date of the termination of coverage under 19 the contract from which conversion was made. 20 (2) The corporation shall not be required to issue any such converted 21 individual direct payment contract if its issuance would result in over- 22 insurance or duplication of benefits according to standards on file with 23 the superintendent and approved by [him] THE SUPERINTENDENT with regard 24 to such contracts. The individual direct payment contract may include a 25 provision whereby the corporation may request information when any 26 payment is due under the contract of the person covered thereunder as to 27 whether he is then covered by another individual contract providing 28 similar benefits or is then covered by a group contract policy providing 29 similar benefits or is then provided with similar benefits required by 30 any statute or provided by any welfare plan or program which together 31 with the converted individual direct payment contract would result in 32 overinsurance or duplication of benefits according to the standards on 33 file with the superintendent relating to individual contracts. If any 34 such person is so covered or so provided and fails to furnish the 35 details of such coverage when requested, the benefits provided under the 36 converted individual direct payment contract may be based on the hospi- 37 tal, surgical or medical expenses actually incurred after excluding 38 expenses to the extent they are payable under such other coverage or 39 provided under such statute, plan or program. 40 S 52. Paragraphs 1 and 2 of subsection (d) of section 4305 of the 41 insurance law, paragraph 1 as amended by chapter 504 of the laws of 1995 42 and paragraphs 1 and 2 as further amended by section 104 of part A of 43 chapter 62 of the laws of 2011, are amended to read as follows: 44 (1) (A) A group contract issued pursuant to this section shall contain 45 a provision to the effect that in case of a termination of coverage 46 under such contract of any member of the group because of [(I)] (I) 47 termination for any reason whatsoever of [his] THE MEMBER'S employment 48 or membership, [if he has been covered under the group contract for at 49 least three months,] or [(II)] (II) termination for any reason whatsoev- 50 er of the group contract itself unless the group contract holder has 51 replaced the group contract with similar and continuous coverage for the 52 same group whether insured or self-insured, [he] THE MEMBER shall be 53 entitled to have issued to [him] THE MEMBER by the corporation, without 54 evidence of insurability, upon application therefor and payment of the 55 first premium made to the corporation within forty-five days after 56 termination of the coverage, an individual direct payment contract, S. 2606--C 104 1 covering such member and [his] THE MEMBER'S eligible dependents who were 2 covered by the group contract, which provides coverage [most nearly 3 comparable to the type of coverage under the group contract, which 4 coverage shall be no less than the minimum standards for basic hospital, 5 basic medical, or major medical as provided for in department of finan- 6 cial services regulation; provided, however, that if the corporation 7 does not issue such a major medical contract, then to a comprehensive or 8 comparable type of coverage which is most commonly being sold to group 9 remitting agents. Notwithstanding the previous sentence, a corporation 10 may elect to issue a standardized individual enrollee contract pursuant 11 to section four thousand three hundred twenty two of this article in 12 lieu of a major medical contract, comprehensive or comparable type of 13 coverage required to be offered upon conversion from an indemnity 14 contract] THAT CONTAINS THE BENEFITS DESCRIBED IN PARAGRAPH ONE OF 15 SUBSECTION (B) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF 16 THIS ARTICLE. 17 (B) The conversion privilege afforded [herein] IN THIS PARAGRAPH shall 18 also be available: [(A)] (I) upon the divorce or annulment of the 19 marriage of a member, to the divorced spouse or former spouse of such 20 member[, (B)]; (II) upon the death of the member, to the surviving 21 spouse and other dependents covered under the contract[,]; and [(C)] 22 (III) to a dependent if no longer within the definition in the contract. 23 (2) The effective date of the coverage provided by the individual 24 direct payment contract shall be the date of the termination of the 25 individual's coverage under the group contract. [The individual direct 26 payment converted contract may exclude any condition excluded by the 27 group contract. The individual direct payment contract shall not exclude 28 any other pre-existing conditions but the benefits provided under the 29 individual direct payment converted contract may be reduced by the 30 amount of any such benefits provided under the group contract after the 31 termination of the individual's coverage thereunder and during the first 32 contract year of such individual direct payment converted contract the 33 benefits provided under the contract may be reduced so that they are not 34 in excess of those that would have been provided had the individual's 35 contract under the group contract remained in force and effect.] The 36 corporation shall not be required to issue such individual direct 37 payment converted contract covering any person if it appears that such 38 person shall then be covered by another individual contract providing 39 similar coverage or if it shall appear that such person is covered by or 40 eligible to be covered by a group contract or policy providing similar 41 benefits or is provided with similar benefits required by any statute or 42 provided by any welfare plan or program, which together with the indi- 43 vidual direct payment converted contract would result in over-insurance 44 or duplication of benefits according to standards on file with the 45 superintendent of financial services relating to individual contracts. 46 The individual direct payment converted contract may include a provision 47 whereby the corporation may request information when any payment is due 48 under the contract of any person covered thereunder as to whether he is 49 then covered by another contract or by a policy providing similar bene- 50 fits or is then covered by a group contract or policy providing similar 51 benefits or is then provided with similar benefits required by any stat- 52 ute or provided by any welfare plan or program. If any such person is so 53 covered or so provided and fails to furnish the details of such coverage 54 when requested, the benefits payable under the individual direct payment 55 converted contract may be based on the hospital, surgical or medical 56 expenses actually incurred after excluding expenses to the extent they S. 2606--C 105 1 are payable under such other coverage or provided under such statute, 2 plan or program. 3 In the event the benefits provided or payable are reduced in accord- 4 ance with the provisions of this subsection the corporation shall return 5 such portion of the premium paid as shall exceed the pro rata portion of 6 the benefits thus determined. 7 S 53. Intentionally omitted. 8 S 54. Intentionally omitted. 9 S 55. Intentionally omitted. 10 S 56. Section 4326 of the insurance law, as added by chapter 1 of the 11 laws of 1999, subsection (b) as amended by chapter 342 of the laws of 12 2004, subparagraph (A) of paragraph 1 and subparagraph (C) of paragraph 13 3 of subsection (c) as amended by chapter 419 of the laws of 2000, para- 14 graphs 13 and 14 of subsection (d), paragraphs 6 and 7 of subsection (e) 15 and subsection (k) as amended and paragraph 15 of subsection (d) as 16 added by chapter 219 of the laws of 2011 and subsections (d-1), (d-2) 17 and (d-3) as added by chapter 645 of the laws of 2005, is amended to 18 read as follows: 19 S 4326. Standardized health insurance contracts for qualifying small 20 employers and individuals. (a) A program is hereby established for the 21 purpose of making standardized health insurance contracts available to 22 qualifying small employers [and qualifying individuals] as defined in 23 this section. Such program is designed to encourage small employers to 24 offer health insurance coverage to their employees [and to also make 25 coverage available to uninsured employees whose employers do not provide 26 group health insurance]. 27 (b) Participation in the program established by this section and 28 section four thousand three hundred twenty-seven of this article is 29 limited to corporations or insurers organized or licensed under this 30 article or article forty-two of this chapter and health maintenance 31 organizations issued a certificate of authority under article forty-four 32 of the public health law or licensed under this article. Participation 33 by all health maintenance organizations is mandatory, provided, however, 34 that such requirements shall not apply to a HOLDER OF A SPECIAL PURPOSE 35 CERTIFICATE OF AUTHORITY ISSUED PURSUANT TO SECTION FOUR THOUSAND FOUR 36 HUNDRED THREE-A OF THE PUBLIC HEALTH LAW OR A health maintenance organ- 37 ization exclusively serving individuals enrolled pursuant to title elev- 38 en of article five of the social services law, title eleven-D of article 39 five of the social services law, title one-A of article twenty-five of 40 the public health law or title eighteen of the federal Social Security 41 Act[, and, further provided, that such health maintenance organization 42 shall not discontinue a contract for an individual receiving comprehen- 43 sive-type coverage in effect prior to January first, two thousand four 44 who is ineligible to purchase policies offered after such date pursuant 45 to this section or section four thousand three hundred twenty-two of 46 this article due to the provision of 42 U.S.C. 1395ss in effect prior to 47 January first, two thousand four]. On and after January first, two thou- 48 sand one, all health maintenance organizations shall offer qualifying 49 group health insurance contracts [and qualifying individual health 50 insurance contracts] as defined in this section. For the purposes of 51 this section and section four thousand three hundred twenty-seven of 52 this article, article forty-three corporations or article forty-two 53 insurers which voluntarily participate in compliance with the require- 54 ments of this program shall be eligible for reimbursement from the stop 55 loss funds created pursuant to section four thousand three hundred twen- S. 2606--C 106 1 ty-seven of this article under the same terms and conditions as health 2 maintenance organizations. 3 (c) The following definitions shall be applicable to the insurance 4 contracts offered under the program established by this section: 5 (1) (A) A qualifying small employer is [an employer that is either: 6 (A) An individual proprietor who is the only employee of the business: 7 (i) without health insurance which provides benefits on an expense 8 reimbursed or prepaid basis in effect during the twelve month period 9 prior to application for a qualifying group health insurance contract 10 under the program established by this section; and 11 (ii) resides in a household having a net household income at or below 12 two hundred eight percent of the non-farm federal poverty level (as 13 defined and updated by the federal department of health and human 14 services) or the gross equivalent of such net income; 15 (iii) except that the requirements set forth in item (i) of this 16 subparagraph shall not be applicable where an individual proprietor had 17 health insurance coverage during the previous twelve months and such 18 coverage terminated due to one of the reasons set forth in items (i) 19 through (viii) of subparagraph (C) of paragraph three of subsection (c) 20 of this section; or 21 (B) An] AN employer with: 22 (i) not more than fifty eligible employees; 23 (ii) no group health insurance [which] THAT provides benefits on an 24 expense reimbursed or prepaid basis covering employees in effect during 25 the twelve month period prior to application for a qualifying group 26 health insurance contract under the program established by this section; 27 and 28 (iii) at least thirty percent of its eligible employees receiving 29 annual wages from the employer at a level equal to or less than thirty 30 thousand dollars. The thirty thousand dollar figure shall be adjusted 31 periodically pursuant to subparagraph [(F)] (D) of this paragraph. 32 [(C) The requirements set forth in item (i) of subparagraph (A) of 33 this paragraph and in item (ii) of subparagraph (B) of this paragraph 34 shall not be applicable where an individual proprietor or employer is 35 transferring from a health insurance contract issued pursuant to the New 36 York state small business health insurance partnership program estab- 37 lished by section nine hundred twenty-two of the public health law or 38 from health care coverage issued pursuant to a regional pilot project 39 for the uninsured established by section one thousand one hundred eigh- 40 teen of this chapter. 41 (D)] (B) The twelve month period set forth [in item (i) of subpara- 42 graph (A) of this paragraph and] in item (ii) of subparagraph [(B)] (A) 43 of this paragraph may be adjusted by the superintendent from twelve 44 months to eighteen months if he determines that the twelve month period 45 is insufficient to prevent inappropriate substitution of [other health 46 insurance contracts for] qualifying group health insurance contracts FOR 47 OTHER HEALTH INSURANCE CONTRACTS. 48 [(E)] (C) An [individual proprietor or] employer shall cease to be a 49 qualifying small employer if any health insurance [which] THAT provides 50 benefits on an expense reimbursed or prepaid basis covering [the indi- 51 vidual proprietor or] an employer's employees, other than qualifying 52 group health insurance purchased pursuant to this section, is purchased 53 or otherwise takes effect subsequent to purchase of qualifying group 54 health insurance under the program established by this section. 55 [(F)] (D) The wage levels utilized in subparagraph [(B)] (A) of this 56 paragraph shall be adjusted annually, beginning in two thousand two. The S. 2606--C 107 1 adjustment shall take effect on July first of each year. For July first, 2 two thousand two, the adjustment shall be a percentage of the annual 3 wage figure specified in subparagraph [(B)] (A) of this paragraph. For 4 subsequent years, the adjustment shall be a percentage of the annual 5 wage figure [which] THAT took effect on July first of the prior year. 6 The percentage adjustment shall be the same percentage by which the 7 current year's non-farm federal poverty level, as defined and updated by 8 the federal department of health and human services, for a family unit 9 of four persons for the forty-eight contiguous states and Washington, 10 D.C., changed from the same level established for the prior year. 11 (2) A qualifying group health insurance contract is a group contract 12 purchased from a health maintenance organization, corporation or insurer 13 by a qualifying small employer [which] THAT provides the benefits set 14 forth in subsection (d) of this section. The contract must insure not 15 less than fifty percent of the employees [eligible for coverage]. 16 [(3)(A) A qualifying individual is an employed person: 17 (i) who does not have and has not had health insurance with benefits 18 on an expense reimbursed or prepaid basis during the twelve month period 19 prior to the individual's application for health insurance under the 20 program established by this section; 21 (ii) whose employer does not provide group health insurance and has 22 not provided group health insurance with benefits on an expense reim- 23 bursed or prepaid basis covering employees in effect during the twelve 24 month period prior to the individual's application for health insurance 25 under the program established by this section; 26 (iii) resides in a household having a net household income at or below 27 two hundred eight percent of the non-farm federal poverty level (as 28 defined and updated by the federal department of health and human 29 services) or the gross equivalent of such net income; and 30 (iv) is ineligible for Medicare. 31 (B) The requirements set forth in items (i) and (ii) of subparagraph 32 (A) of this paragraph shall not be applicable where an individual is 33 transferring from a health insurance contract issued pursuant to the 34 voucher insurance program established by section one thousand one 35 hundred twenty-one of this chapter, a health insurance contract issued 36 pursuant to the New York state small business health insurance partner- 37 ship program established by section nine hundred twenty-two of the 38 public health law or health care coverage issued pursuant to a regional 39 pilot project for the uninsured established by section one thousand one 40 hundred eighteen of this chapter. 41 (C) The requirements set forth in items (i) and (ii) of subparagraph 42 (A) of this paragraph shall not be applicable where an individual had 43 health insurance coverage during the previous twelve months and such 44 coverage terminated due to: 45 (i) loss of employment due to factors other than voluntary separation; 46 (ii) death of a family member which results in termination of coverage 47 under a health insurance contract under which the individual is covered; 48 (iii) change to a new employer that does not provide group health 49 insurance with benefits on an expense reimbursed or prepaid basis; 50 (iv) change of residence so that no employer-based health insurance 51 with benefits on an expense reimbursed or prepaid basis is available; 52 (v) discontinuation of a group health insurance contract with benefits 53 on an expense reimbursed or prepaid basis covering the qualifying indi- 54 vidual as an employee or dependent; 55 (vi) expiration of the coverage periods established by the continua- 56 tion provisions of the Employee Retirement Income Security Act, 29 S. 2606--C 108 1 U.S.C. section 1161 et seq. and the Public Health Service Act, 42 2 U.S.C. section 300bb-1 et seq. established by the Consolidated Omnibus 3 Budget Reconciliation Act of 1985, as amended, or the continuation 4 provisions of subsection (m) of section three thousand two hundred twen- 5 ty-one, subsection (k) of section four thousand three hundred four and 6 subsection (e) of section four thousand three hundred five of this chap- 7 ter; 8 (vii) legal separation, divorce or annulment which results in termi- 9 nation of coverage under a health insurance contract under which the 10 individual is covered; or 11 (viii) loss of eligibility under a group health plan. 12 (D) The twelve month period set forth in items (i) and (ii) of subpar- 13 agraph (A) of this paragraph may be adjusted by the superintendent from 14 twelve months to eighteen months if he determines that the twelve month 15 period is insufficient to prevent inappropriate substitution of other 16 health insurance contracts for qualifying individual health insurance 17 contracts. 18 (4) A qualifying individual health insurance contract is an individual 19 contract issued directly to a qualifying individual and which provides 20 the benefits set forth in subsection (d) of this section. At the option 21 of the qualifying individual, such contract may include coverage for 22 dependents of the qualifying individual.] 23 (d) [The contracts issued pursuant to this section by health mainte- 24 nance organizations, corporations or insurers and approved by the super- 25 intendent shall only provide in-plan benefits, except for emergency care 26 or where services are not available through a plan provider. Covered 27 services shall include only the following: 28 (1) inpatient hospital services consisting of daily room and board, 29 general nursing care, special diets and miscellaneous hospital services 30 and supplies; 31 (2) outpatient hospital services consisting of diagnostic and treat- 32 ment services; 33 (3) physician services consisting of diagnostic and treatment 34 services, consultant and referral services, surgical services (including 35 breast reconstruction surgery after a mastectomy), anesthesia services, 36 second surgical opinion, and a second opinion for cancer treatment; 37 (4) outpatient surgical facility charges related to a covered surgical 38 procedure; 39 (5) preadmission testing; 40 (6) maternity care; 41 (7) adult preventive health services consisting of mammography screen- 42 ing; cervical cytology screening; periodic physical examinations no more 43 than once every three years; and adult immunizations; 44 (8) preventive and primary health care services for dependent children 45 including routine well-child visits and necessary immunizations; 46 (9) equipment, supplies and self-management education for the treat- 47 ment of diabetes; 48 (10) diagnostic x-ray and laboratory services; 49 (11) emergency services; 50 (12) therapeutic services consisting of radiologic services, chemoth- 51 erapy and hemodialysis; 52 (13) blood and blood products furnished in connection with surgery or 53 inpatient hospital services; 54 (14) prescription drugs obtained at a participating pharmacy. In addi- 55 tion to providing coverage at a participating pharmacy, health mainte- 56 nance organizations may utilize a mail order prescription drug program. S. 2606--C 109 1 Health maintenance organizations may provide prescription drugs pursuant 2 to a drug formulary; however, health maintenance organizations must 3 implement an appeals process so that the use of non-formulary 4 prescription drugs may be requested by a physician; and 5 (15) for a contract that is not a grandfathered health plan, the 6 following additional preventive health services: 7 (A) evidence-based items or services that have in effect a rating of 8 'A' or 'B' in the current recommendations of the United States preven- 9 tive services task force; 10 (B) immunizations that have in effect a recommendation from the advi- 11 sory committee on immunization practices of the centers for disease 12 control and prevention with respect to the individual involved; 13 (C) with respect to children, including infants and adolescents, 14 evidence-informed preventive care and screenings provided for in the 15 comprehensive guidelines supported by the health resources and services 16 administration; and 17 (D) with respect to women, such additional preventive care and screen- 18 ings not described in subparagraph (A) of this paragraph as provided for 19 in comprehensive guidelines supported by the health resources and 20 services administration. 21 (E) For purposes of this paragraph, "grandfathered health plan" means 22 coverage provided by a corporation in which an individual was enrolled 23 on March twenty-third, two thousand ten for as long as the coverage 24 maintains grandfathered status in accordance with section 1251(e) of the 25 Affordable Care Act, 42 U.S.C. S 18011(e)] A QUALIFYING GROUP HEALTH 26 INSURANCE CONTRACT SHALL PROVIDE COVERAGE FOR THE ESSENTIAL HEALTH BENE- 27 FIT PACKAGE AS REQUIRED IN SECTION 2707(A) OF THE PUBLIC HEALTH SERVICE 28 ACT, 42 U.S.C. S 300GG-6(A). FOR PURPOSES OF THIS SUBSECTION "ESSENTIAL 29 HEALTH BENEFITS PACKAGE" SHALL HAVE THE MEANING SET FORTH IN SECTION 30 1302(A) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(A). 31 (d-1) Covered services shall not include drugs, procedures and 32 supplies for the treatment of erectile dysfunction when provided to, or 33 prescribed for use by, a person who is required to register as a sex 34 offender pursuant to article six-C of the correction law, provided that: 35 (1) any denial of coverage pursuant to this subsection shall provide the 36 enrollee with the means of obtaining additional information concerning 37 both the denial and the means of challenging such denial; (2) all drugs, 38 procedures and supplies for the treatment of erectile dysfunction may be 39 subject to prior authorization by corporations, insurers or health main- 40 tenance organizations for the purposes of implementing this subsection; 41 and (3) the superintendent shall promulgate regulations to implement the 42 denial of coverage pursuant to this subsection giving health maintenance 43 organizations, corporations and insurers at least sixty days following 44 promulgation of the regulations to implement their denial procedures 45 pursuant to this subsection. 46 (d-2) No person or entity authorized to provide coverage under this 47 section shall be subject to any civil or criminal liability for damages 48 for any decision or action pursuant to subsection (d-1) of this section, 49 made in the ordinary course of business if that authorized person or 50 entity acted reasonably and in good faith with respect to such informa- 51 tion. 52 (d-3) Notwithstanding any other provision of law, if the commissioner 53 of health makes a finding pursuant to subdivision twenty-three of 54 section two hundred six of the public health law, the superintendent is 55 authorized to remove a drug, procedure or supply from the services 56 covered by the standardized health insurance contract established by S. 2606--C 110 1 this section for those persons required to register as sex offenders 2 pursuant to article six-C of the correction law. 3 (e) [The benefits provided in the contracts described in subsection 4 (d) of this section shall be subject to the following deductibles and 5 copayments: 6 (1) in-patient hospital services shall have a five hundred dollar 7 copayment for each continuous hospital confinement; 8 (2) surgical services shall be subject to a copayment of the lesser of 9 twenty percent of the cost of such services or two hundred dollars per 10 occurrence; 11 (3) outpatient surgical facility charges shall be subject to a facili- 12 ty copayment charge of seventy-five dollars per occurrence; 13 (4) emergency services shall have a fifty dollar copayment which must 14 be waived if hospital admission results from the emergency room visit; 15 (5) prescription drugs shall have a one hundred dollar calendar year 16 deductible per individual. After the deductible is satisfied, each thir- 17 ty-four day supply of a prescription drug will be subject to a copay- 18 ment. The copayment will be ten dollars if the drug is generic. The 19 copayment for a brand name drug will be twenty dollars plus the differ- 20 ence in cost between the brand name drug and the equivalent generic 21 drug. If a mail order drug program is utilized, a twenty dollar copay- 22 ment shall be imposed on a ninety day supply of generic prescription 23 drugs. A forty dollar copayment plus the difference in cost between the 24 brand name drug and the equivalent generic drug shall be imposed on a 25 ninety day supply of brand name prescription drugs. In no event shall 26 the copayment exceed the cost of the prescribed drug; 27 (6) (A) the maximum coverage for prescription drugs in an individual 28 contract that is a grandfathered health plan shall be three thousand 29 dollars per individual in a calendar year; and 30 (B) the maximum dollar amount on coverage for prescription drugs in an 31 individual contract that is not a grandfathered health plan or in any 32 group contract shall be consistent with section 2711 of the Public 33 Health Service Act, 42 U.S.C. S 300gg-11 or any regulations thereunder. 34 (C) For purposes of this paragraph, "grandfathered health plan" means 35 coverage provided by a corporation in which an individual was enrolled 36 on March twenty-third, two thousand ten for as long as the coverage 37 maintains grandfathered status in accordance with section 1251(e) of the 38 Affordable Care Act, 42 U.S.C. S 18011(e); and 39 (7) all other services shall have a twenty dollar copayment with the 40 exception of prenatal care which shall have a ten dollar copayment or 41 preventive health services provided pursuant to paragraph fifteen of 42 subsection (d) of this section, for which no copayment shall apply] A 43 QUALIFYING GROUP HEALTH INSURANCE CONTRACT ISSUED TO A QUALIFYING SMALL 44 EMPLOYER PRIOR TO JANUARY FIRST, TWO THOUSAND FOURTEEN THAT DOES NOT 45 INCLUDE ALL ESSENTIAL HEALTH BENEFITS REQUIRED PURSUANT TO SECTION 46 2707(A) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(A), SHALL 47 BE DISCONTINUED. A QUALIFYING SMALL EMPLOYER SHALL BE TRANSITIONED TO A 48 PLAN THAT PROVIDES: (1) A LEVEL OF COVERAGE THAT IS DESIGNED TO PROVIDE 49 BENEFITS THAT ARE ACTUARIALLY EQUIVALENT TO EIGHTY PERCENT OF THE FULL 50 ACTUARIAL VALUE OF THE BENEFITS PROVIDED UNDER THE PLAN; AND (2) COVER- 51 AGE FOR THE ESSENTIAL HEALTH BENEFIT PACKAGE AS REQUIRED IN SECTION 52 2707(A) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(A). THE 53 SUPERINTENDENT SHALL STANDARDIZE THE BENEFIT PACKAGE AND COST SHARING 54 REQUIREMENTS OF QUALIFIED GROUP HEALTH INSURANCE CONTRACTS CONSISTENT 55 WITH COVERAGE OFFERED THROUGH THE HEALTH BENEFIT EXCHANGE ESTABLISHED 56 PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18031. S. 2606--C 111 1 (f) [Except as included in the list of covered services in subsection 2 (d) of this section, the] THE mandated and make-available benefits set 3 forth in sections [three thousand two hundred sixteen,] three thousand 4 two hundred twenty-one of this chapter and four thousand three hundred 5 three of this article shall not be applicable to the contracts issued 6 pursuant to this section. [Mandated benefits included in such contracts 7 shall be subject to the deductibles and copayments set forth in 8 subsection (e) of this section.] 9 (g) [The superintendent shall be authorized to modify, by regulation, 10 the copayment and deductible amounts described in this section if the 11 superintendent determines such amendments are necessary to facilitate 12 implementation of this section. On or after January first, two thousand 13 two, the superintendent shall be authorized to establish, by regulation, 14 one or more additional standardized health insurance benefit packages if 15 the superintendent determines additional benefit packages with different 16 levels of benefits are necessary to meet the needs of the public. 17 (h)] A health maintenance organization, corporation or insurer must 18 offer the benefit package without change or additional benefits. [Quali- 19 fying] A QUALIFYING small [employers] EMPLOYER shall be issued the bene- 20 fit package in a qualifying group health insurance contract. [Qualifying 21 individuals shall be issued the benefit package in a qualifying individ- 22 ual health insurance contract. 23 (i)] (H) A health maintenance organization, corporation or insurer 24 shall obtain from the employer [or individual] written certification at 25 the time of initial application and annually thereafter ninety days 26 prior to the contract renewal date that such employer [or individual] 27 meets the requirements of a qualifying small employer [or a qualifying 28 individual] pursuant to this section. A health maintenance organization, 29 corporation or insurer may require the submission of appropriate 30 documentation in support of the certification. 31 [(j)] (I) Applications for qualifying group health insurance contracts 32 [and qualifying individual health insurance contracts] must be accepted 33 from [any qualifying individual and] any qualifying small employer at 34 all times throughout the year. The superintendent, by regulation, may 35 require health maintenance organizations, corporations or insurers to 36 give preference to qualifying small employers whose eligible employees 37 have the lowest average salaries. 38 [(k) (1) All coverage under a qualifying group health insurance 39 contract or a qualifying individual health insurance contract must be 40 subject to a pre-existing condition limitation provision as set forth in 41 sections three thousand two hundred thirty-two of this chapter and four 42 thousand three hundred eighteen of this article, including the crediting 43 requirements thereunder. The underwriting of such contracts may not 44 involve more than the imposition of a pre-existing condition limitation. 45 However, as provided in sections three thousand two hundred thirty-two 46 of this chapter and four thousand three hundred eighteen of this arti- 47 cle, a corporation shall not impose a pre-existing condition limitation 48 provision on any person under age nineteen, except may impose such a 49 limitation on those persons covered by a qualifying individual health 50 insurance contract that is a grandfathered health plan. 51 (2)] (J) Beginning January first, two thousand fourteen, pursuant to 52 section 2704 of the Public Health Service Act, 42 U.S.C. S 300gg-3, a 53 corporation shall not impose any pre-existing condition limitation in a 54 qualifying group health insurance contract [or a qualifying individual 55 health insurance contract except may impose such a limitation in a qual- S. 2606--C 112 1 ifying individual health insurance contract that is a grandfathered 2 health plan]. 3 [(3) For purposes of paragraphs one and two of this subsection, 4 "grandfathered health plan" means coverage provided by a corporation in 5 which an individual was enrolled on March twenty-third, two thousand ten 6 for as long as the coverage maintains grandfathered status in accordance 7 with section 1251(e) of the Affordable Care Act, 42 U.S.C. S 18011(e). 8 (l)] (K) A qualifying small employer shall elect whether to make 9 coverage under the qualifying group health insurance contract available 10 to dependents of employees. Any employee or dependent who is enrolled in 11 Medicare is ineligible for coverage, unless required by federal law. 12 Dependents of an employee who is enrolled in Medicare will be eligible 13 for dependent coverage provided the dependent is not also enrolled in 14 Medicare. 15 [(m)] (L) A qualifying small employer must pay at least fifty percent 16 of the premium for employees covered under a qualifying group health 17 insurance contract and must offer coverage to all employees receiving 18 annual wages at a level of thirty thousand dollars or less, and at least 19 one such employee shall accept such coverage. The thirty thousand dollar 20 wage level shall be adjusted periodically in accordance with subpara- 21 graph [(F)] (D) of paragraph one of subsection (c) of this section. The 22 employer premium contribution must be the same percentage for all 23 covered employees. 24 [(n)] (M) Premium rate calculations for qualifying group health insur- 25 ance contracts [and qualifying individual health insurance contracts] 26 shall be subject to the following: 27 (1) coverage must be community rated [and include rate tiers for indi- 28 viduals, two adult families and at least one other family tier. The rate 29 differences must be based upon the cost differences for the different 30 family units and the rate tiers must be uniformly applied. The rate tier 31 structure used by a health maintenance organization, corporation or 32 insurer for the contracts issued to qualifying small employers and to 33 qualifying individuals must be the same] AND ALL RATING TIERS AND STAND- 34 ARD RATING RELATIVITIES BETWEEN TIERS SHALL BE FILED WITH THE SUPER- 35 INTENDENT; 36 (2) [if geographic rating areas are utilized, such geographic areas 37 must be reasonable and in a given case may include a single county. The 38 geographic areas utilized must be the same for the contracts issued to 39 qualifying small employers and to qualifying individuals. The super- 40 intendent shall not require the inclusion of any specific geographic 41 region within the proposed community rated region selected by the health 42 maintenance organization, corporation or insurer so long as the health 43 maintenance organization, corporation or insurer's proposed regions do 44 not contain configurations designed to avoid or segregate particular 45 areas within a county covered by the health maintenance organization, 46 corporation or insurer's community rates.] BEGINNING JANUARY FIRST, TWO 47 THOUSAND FOURTEEN, EVERY POLICY SUBJECT TO THIS SECTION SHALL USE STAND- 48 ARDIZED REGIONS ESTABLISHED BY THE SUPERINTENDENT PROVIDED, HOWEVER, 49 THAT THE COUNTIES OF NASSAU AND SUFFOLK SHALL TOGETHER CONSIST OF THEIR 50 OWN STANDARDIZED REGION; AND 51 (3) claims experience under contracts issued to qualifying small 52 employers [and to qualifying individuals] must be pooled WITH THE HEALTH 53 MAINTENANCE ORGANIZATION, CORPORATION OR INSURER'S SMALL GROUP BUSINESS 54 for rate setting purposes. [The premium rates for qualifying group 55 health insurance contracts and qualifying individual health insurance 56 contracts must be the same. S. 2606--C 113 1 (o)] (N) A health maintenance organization, corporation or insurer 2 shall submit reports to the superintendent in such form and at times as 3 may be reasonably required in order to evaluate the operations and 4 results of the standardized health insurance program established by this 5 section. 6 [(p) Notwithstanding any other provision of law, all individuals and 7 small businesses that are participating in or covered by insurance 8 contracts or policies issued pursuant to the New York state small busi- 9 ness health insurance partnership program established by section nine 10 hundred twenty-two of the public health law, the voucher insurance 11 program established by section one thousand one hundred twenty-one of 12 this chapter, or uninsured pilot programs established pursuant to chap- 13 ter seven hundred three of the laws of nineteen hundred eighty-eight 14 shall be eligible for participation in the standardized health insurance 15 contracts established by this section, regardless of any of the eligi- 16 bility requirements established pursuant to subsection (c) of this 17 section.] 18 S 57. The insurance law is amended by adding a new section 4326-a to 19 read as follows: 20 S 4326-A. TRANSITION OF HEALTHY NEW YORK ENROLLEES. (A) ON DECEMBER 21 THIRTY-FIRST, TWO THOUSAND THIRTEEN, COVERAGE ISSUED TO QUALIFYING INDI- 22 VIDUALS AND QUALIFYING SMALL EMPLOYERS WHO ARE SOLE PROPRIETORS AS 23 DEFINED IN SECTION FOUR THOUSAND THREE HUNDRED TWENTY-SIX SHALL END, 24 CONTINGENT UPON THE REQUIREMENTS OF THE PATIENT PROTECTION AND AFFORDA- 25 BLE CARE ACT OF 2010 BEING FULLY IMPLEMENTED BY THE STATE AND AS 26 APPROVED BY THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN 27 SERVICES, AND CONTINGENT UPON FULL IMPLEMENTATION OF THE STATE ENROLL- 28 MENT CENTER. 29 (B) A HEALTH MAINTENANCE ORGANIZATION, CORPORATION, OR INSURER SHALL 30 PROVIDE WRITTEN NOTICE OF THE PROGRAM DISCONTINUANCE TO EACH ENROLLED 31 INDIVIDUAL AND INDIVIDUAL PROPRIETOR AT LEAST ONE HUNDRED EIGHTY DAYS 32 PRIOR TO THE DATE OF PROGRAM DISCONTINUANCE. THE WRITTEN NOTICE SHALL 33 INCLUDE AN EXPLANATION, IN PLAIN LANGUAGE, OF AVAILABLE HEALTH INSURANCE 34 OPTIONS. 35 (C) QUALIFYING GROUP HEALTH INSURANCE CONTRACTS ISSUED TO SMALL 36 EMPLOYERS PRIOR TO JANUARY FIRST, TWO THOUSAND FOURTEEN THAT DO NOT 37 INCLUDE ALL ESSENTIAL HEALTH BENEFITS REQUIRED PURSUANT TO SECTION 38 2707(A) OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6(A); SHALL 39 BE DISCONTINUED. SMALL EMPLOYERS THAT ARE IMPACTED BY THE DISCONTIN- 40 UANCE SHALL BE TRANSITIONED TO A PLAN THAT MEETS THE REQUIREMENTS OF 41 SUBSECTION (E) OF SECTION FOUR THOUSAND THREE HUNDRED TWENTY-SIX OF THIS 42 CHAPTER. A HEALTH MAINTENANCE ORGANIZATION, CORPORATION, OR INSURER 43 SHALL PROVIDE WRITTEN NOTICE OF THE PROGRAM DISCONTINUANCE TO EACH 44 ENROLLED SMALL EMPLOYER AT LEAST ONE HUNDRED EIGHTY DAYS PRIOR TO THE 45 DATE OF PROGRAM DISCONTINUANCE. THE WRITTEN NOTICE SHALL INCLUDE AN 46 EXPLANATION, IN PLAIN LANGUAGE, OF THE ABILITY TO TRANSITION TO A NEW 47 SMALL GROUP HEALTH INSURANCE CONTRACT OFFERED PURSUANT TO SECTION FOUR 48 THOUSAND THREE HUNDRED TWENTY-SIX OF THIS ARTICLE. 49 S 58. Section 4327 of the insurance law, as added by chapter 1 of the 50 laws of 1999, subsection (h) as amended by chapter 419 of the laws of 51 2000, subsection (m-1) as added by section 12 of part B of chapter 58 of 52 the laws of 2010, subsection (s) as amended and subsection (t) as added 53 by chapter 441 of the laws of 2006, is amended to read as follows: 54 S 4327. Stop loss funds for standardized health insurance contracts 55 issued to qualifying small employers and qualifying individuals. (a) The 56 superintendent shall establish a fund from which health maintenance S. 2606--C 114 1 organizations, corporations or insurers may receive reimbursement, to 2 the extent of funds available therefor, for claims paid by such health 3 maintenance organizations, corporations or insurers for members covered 4 under qualifying group health insurance contracts issued pursuant to 5 section four thousand three hundred twenty-six of this article. This 6 fund shall be known as the "small employer stop loss fund". [The super- 7 intendent shall establish a separate and distinct fund from which health 8 maintenance organizations, corporations or insurers may receive 9 reimbursement, to the extent of funds available therefor, for claims 10 paid by such health maintenance organizations, corporations or insurers 11 for members covered under qualifying individual health insurance 12 contracts issued pursuant to section four thousand three hundred twen- 13 ty-six of this article. This fund shall be known as the "qualifying 14 individual stop loss fund".] 15 (b) [Commencing on January first, two thousand one, health] HEALTH 16 maintenance organizations, corporations or insurers shall be eligible to 17 receive reimbursement for ninety percent of claims paid between [thirty] 18 FIVE thousand and [one hundred] SEVENTY-FIVE thousand dollars in a 19 calendar year for any member covered under a standardized contract 20 issued pursuant to section four thousand three hundred twenty-six of 21 this article. Claims paid for members covered under qualifying group 22 health insurance contracts shall be reimbursable from the small employer 23 stop loss fund. [Claims paid for members covered under qualifying indi- 24 vidual health insurance contracts shall be reimbursable from the quali- 25 fying individual stop loss fund.] For the purposes of this section, 26 claims shall include health care claims paid by a health maintenance 27 organization on behalf of a covered member pursuant to such standardized 28 contracts. 29 (c) The superintendent shall promulgate regulations that set forth 30 procedures for the operation of the small employer stop loss fund [and 31 the qualifying individual stop loss fund] and distribution of monies 32 therefrom. 33 (d) [The small employer stop loss fund shall operate separately from 34 the qualifying individual stop loss fund. Except as specified in 35 subsection (b) of this section with respect to calendar year two thou- 36 sand one, the level of stop loss coverage for the qualifying group 37 health insurance contracts and the qualifying individual health insur- 38 ance contracts need not be the same. The two stop loss funds need not be 39 structured or operated in the same manner, except as specified in this 40 section. The monies available for distribution from the stop loss funds 41 may be reallocated between the small employer stop loss fund and the 42 qualifying individual stop loss fund if the superintendent determines 43 that such reallocation is warranted due to enrollment trends] THE SUPER- 44 INTENDENT MAY ADJUST THE LEVEL OF STOP LOSS COVERAGE SPECIFIED IN 45 SUBSECTION (B) OF THIS SECTION. 46 (e) Claims shall be reported and funds shall be distributed from the 47 small employer stop loss fund [and from the qualifying individual stop 48 loss fund] on a calendar year basis. Claims shall be eligible for 49 reimbursement only for the calendar year in which the claims are paid. 50 Once claims paid on behalf of a covered member reach or exceed one 51 hundred thousand dollars in a given calendar year, no further claims 52 paid on behalf of such member in that calendar year shall be eligible 53 for reimbursement. 54 (f) Each health maintenance organization, corporation or insurer shall 55 submit a request for reimbursement from [each of] the stop loss [funds] 56 FUND on forms prescribed by the superintendent. [Each of the] THE S. 2606--C 115 1 requests for reimbursement shall be submitted no later than April first 2 following the end of the calendar year for which the reimbursement 3 requests are being made. The superintendent may require health mainte- 4 nance organizations, corporations or insurers to submit such claims data 5 in connection with the reimbursement requests as he deems necessary to 6 enable him to distribute monies and oversee the operation of the small 7 employer [and qualifying individual] stop loss [funds] FUND. The super- 8 intendent may require that such data be submitted on a per member, 9 aggregate and/or categorical basis. [Data shall be reported separately 10 for qualifying group health insurance contracts and qualifying individ- 11 ual health insurance contracts issued pursuant to section four thousand 12 three hundred twenty-six of this article.] 13 (g) For [each] THE stop loss fund, the superintendent shall calculate 14 the total claims reimbursement amount for all health maintenance organ- 15 izations, corporations or insurers for the calendar year for which 16 claims are being reported. 17 (1) In the event that the total amount requested for reimbursement for 18 a calendar year exceeds funds available for distribution for claims paid 19 during that same calendar year, the superintendent shall provide for the 20 pro-rata distribution of the available funds. Each health maintenance 21 organization, corporation or insurer shall be eligible to receive only 22 such proportionate amount of the available funds as the individual 23 health maintenance organization's, corporation's or insurer's total 24 eligible claims paid bears to the total eligible claims paid by all 25 health maintenance organizations, corporations or insurers. 26 (2) In the event that funds available for distribution for claims paid 27 by all health maintenance organizations, corporations or insurers during 28 a calendar year exceeds the total amount requested for reimbursement by 29 all health maintenance organizations, corporations or insurers during 30 that same calendar year, any excess funds shall be carried forward and 31 made available for distribution in the next calendar year. Such excess 32 funds shall be in addition to the monies appropriated for the stop loss 33 fund in the next calendar year. 34 (h) Upon the request of the superintendent, each health maintenance 35 organization shall be required to furnish such data as the superinten- 36 dent deems necessary to oversee the operation of the small employer [and 37 qualifying individual] stop loss [funds] FUND. Such data shall be 38 furnished in a form prescribed by the superintendent. Each health main- 39 tenance organization, corporation or insurer shall provide the super- 40 intendent with monthly reports of the total enrollment under the quali- 41 fying group health insurance contracts [and the qualifying individual 42 health insurance contracts] issued pursuant to section four thousand 43 three hundred twenty-six of this article. The reports shall be in a form 44 prescribed by the superintendent. 45 (i) The superintendent shall separately estimate the per member annual 46 cost of total claims reimbursement from each stop loss fund for [quali- 47 fying individual health insurance contracts and for] qualifying group 48 health insurance contracts based upon available data and appropriate 49 actuarial assumptions. Upon request, each health maintenance organiza- 50 tion, corporation or insurer shall furnish to the superintendent claims 51 experience data for use in such estimations. 52 (j) The superintendent shall determine total eligible enrollment under 53 qualifying group health insurance contracts [and qualifying individual 54 health insurance contracts]. [For qualifying group health insurance 55 contracts, the] THE total eligible enrollment shall be determined by 56 dividing the total funds available for distribution from the small S. 2606--C 116 1 employer stop loss fund by the estimated per member annual cost of total 2 claims reimbursement from the small employer stop loss fund. [For quali- 3 fying individual health insurance contracts, the total eligible enroll- 4 ment shall be determined by dividing the total funds available for 5 distribution from the qualifying individual stop loss fund by the esti- 6 mated per member annual cost of total claims reimbursement from the 7 qualifying individual stop loss fund.] 8 (k) The superintendent shall suspend the enrollment of new employers 9 under qualifying group health insurance contracts if [he] THE SUPER- 10 INTENDENT determines that the total enrollment reported by all health 11 maintenance organizations, corporations or insurers under such contracts 12 exceeds the total eligible enrollment, thereby resulting in anticipated 13 annual expenditures from the small employer stop loss fund in excess of 14 the total funds available for distribution from such stop loss fund. 15 [The superintendent shall suspend the enrollment of new individuals 16 under qualifying individual health insurance contracts if he determines 17 that the total enrollment reported by all health maintenance organiza- 18 tions, corporations or insurers under such contracts exceeds the total 19 eligible enrollment, thereby resulting in anticipated annual expendi- 20 tures from the qualifying individual stop loss fund in excess of the 21 total funds available for distribution from such stop loss fund.] 22 (l) The superintendent shall provide the health maintenance organiza- 23 tions, corporations or insurers with notification of any enrollment 24 suspensions as soon as practicable after receipt of all enrollment data. 25 [The superintendent's determination and notification shall be made sepa- 26 rately for the qualifying group health insurance contracts and for the 27 qualifying individual health insurance contracts.] 28 (m) If at any point during a suspension of enrollment of new qualify- 29 ing small employers [and/or qualifying individuals], the superintendent 30 determines that funds are sufficient to provide for the addition of new 31 enrollments, the superintendent shall be authorized to reactivate new 32 enrollments and to notify all health maintenance organizations, corpo- 33 rations or insurers that enrollment of new employers [and/or individ- 34 uals] may again commence. [The superintendent's determination and 35 notification shall be made separately for the qualifying group health 36 insurance contracts and for the qualifying individual health insurance 37 contracts.] 38 (m-1) In the event that the superintendent suspends the enrollment of 39 new individuals for qualifying group health insurance contracts [or 40 qualifying individual health insurance contracts], the superintendent 41 shall ensure that small employers [or sole proprietors] seeking to 42 enroll in a qualified group [or individual] health insurance contract 43 pursuant to section forty-three hundred twenty-six of this article are 44 provided information on and directed to [the family health plus employer 45 partnership program under section three hundred sixty-nine-ff of the 46 social services law] COVERAGE OPTIONS AVAILABLE THROUGH THE HEALTH BENE- 47 FIT EXCHANGE ESTABLISHED PURSUANT TO SECTION 1311 OF THE AFFORDABLE CARE 48 ACT, 42 U.S.C. S 18031. 49 (n) The suspension of issuance of qualifying group health insurance 50 contracts to new qualifying small employers shall not preclude the addi- 51 tion of new employees of an employer already covered under such a 52 contract or new dependents of employees already covered under such 53 contracts. 54 (o) [The suspension of issuance of qualifying individual health insur- 55 ance contracts to new qualifying individuals shall not preclude the S. 2606--C 117 1 addition of new dependents to an existing qualifying individual health 2 insurance contract. 3 (p)] The premiums for qualifying group health insurance contracts must 4 factor in the availability of reimbursement from the small employer stop 5 loss fund. [The premiums for qualifying individual health insurance 6 contracts must factor in the availability of reimbursement from the 7 qualifying individual stop loss funds. 8 (q)] (P) The superintendent may obtain the services of an organization 9 to administer the stop loss funds established by this section. [If the 10 superintendent deems it appropriate, he or she may utilize a separate 11 organization for administration of the small employer stop loss fund and 12 the qualifying individual stop loss fund.] The superintendent shall 13 establish guidelines for the submission of proposals by organizations 14 for the purposes of administering the funds. The superintendent shall 15 make a determination whether to approve, disapprove or recommend modifi- 16 cation to the proposal of an applicant to administer the funds. An 17 organization approved to administer the funds shall submit reports to 18 the superintendent in such form and at times as may be required by the 19 superintendent in order to facilitate evaluation and ensure orderly 20 operation of the funds, including[, but not limited to,] an annual 21 report of the affairs and operations of the fund, such report to be 22 delivered to the superintendent and to the chairs of the senate finance 23 committee and the assembly ways and means committee. An organization 24 approved to administer the funds shall maintain records in a form 25 prescribed by the superintendent and which shall be available for 26 inspection by or at the request of the superintendent. The superinten- 27 dent shall determine the amount of compensation to be allocated to an 28 approved organization as payment for fund administration. Compensation 29 shall be payable from the stop loss coverage funds. An organization 30 approved to administer the funds may be removed by the superintendent 31 and must cooperate in the orderly transition of services to another 32 approved organization or to the superintendent. 33 [(r)] (Q) If the superintendent deems it appropriate for the proper 34 administration of the small employer stop loss fund [and/or the qualify- 35 ing individual stop loss fund], the administrator of the fund, on behalf 36 of and with the prior approval of the superintendent, shall be author- 37 ized to purchase stop loss insurance and/or reinsurance from an insur- 38 ance company licensed to write such type of insurance in this state. 39 Such stop loss insurance and/or reinsurance may be purchased to the 40 extent of funds available therefor within such funds which are available 41 for purposes of the stop loss funds established by this section. 42 [(s)] (R) The superintendent may access funding from the small employ- 43 er stop loss fund [and/or the qualifying individual stop loss fund] for 44 the purposes of developing and implementing public education, outreach 45 and facilitated enrollment strategies targeted to small employers [and 46 working adults] without health insurance. The superintendent may 47 contract with marketing organizations to perform or provide assistance 48 with such education, outreach, and enrollment strategies. The super- 49 intendent shall determine the amount of funding available for the 50 purposes of this subsection which in no event shall exceed eight percent 51 of the annual funding amounts for the small employer stop loss fund [and 52 the qualifying individual stop loss fund]. 53 [(t)] (S) Brooklyn healthworks pilot program and upstate healthworks 54 pilot program. Commencing on July first, two thousand six, the super- 55 intendent shall access funding from the small employer stop loss fund 56 [and the qualifying individual stop loss fund] for the purpose of S. 2606--C 118 1 support and expansion of the existing pilot program Brooklyn healthworks 2 approved by the superintendent and for the establishment and operation 3 of a pilot program to be located in upstate New York. For the purpose of 4 this subsection, in no event shall the amount of funding available 5 exceed two percent of the annual funding [amounts] AMOUNT for the small 6 employer stop loss fund [and the qualifying individual stop loss fund]. 7 S 59. Paragraph 1 of subsection (d) of section 4235 of the insurance 8 law is amended to read as follows: 9 (1) In this section, for the purpose of insurance OTHER THAN FOR GROUP 10 HOSPITAL, MEDICAL, MAJOR MEDICAL OR SIMILAR COMPREHENSIVE-TYPES OF 11 EXPENSE REIMBURSED INSURANCE hereunder: "employees" includes the offi- 12 cers, managers, employees and retired employees of the employer and of 13 subsidiary or affiliated corporations of a corporate employer, and the 14 individual proprietors, partners, employees and retired employees of 15 affiliated individuals and firms controlled by the insured employer 16 through stock ownership, contract or otherwise; "employees" may be 17 deemed to include the individual proprietor or partners if the employer 18 is an individual proprietor or a partnership; and "employees" as used in 19 subparagraph (A) of paragraph one of subsection (c) hereof may also 20 include the directors of the employer and of subsidiary or affiliated 21 corporations of a corporate employer. 22 S 60. Subsection (d) of section 4235 of the insurance law is amended 23 by adding a new paragraph 3 to read as follows: 24 (3) IN THIS SECTION, FOR THE PURPOSE OF GROUP HOSPITAL, MEDICAL, MAJOR 25 MEDICAL OR SIMILAR COMPREHENSIVE-TYPES OF EXPENSE REIMBURSED INSURANCE 26 HEREUNDER, "EMPLOYEE" SHALL HAVE THE MEANING SET FORTH IN SECTION 2791 27 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-91(D)(5) OR ANY 28 REGULATIONS PROMULGATED THEREUNDER. 29 S 61. Subparagraph (B) of paragraph 1 of subsection (e) of section 30 3231 of the insurance law, as amended by chapter 107 of the laws of 31 2010, is amended to read as follows: 32 (B) The expected minimum loss ratio for a policy form subject to this 33 section, for which a rate filing or application is made pursuant to this 34 paragraph, other than a medicare supplemental insurance policy, or, with 35 the approval of the superintendent, an aggregation of policy forms that 36 are combined into one community rating experience pool and rated 37 consistent with community rating requirements, shall not be less than 38 eighty-two percent. In reviewing a rate filing or application, the 39 superintendent may modify the eighty-two percent expected minimum loss 40 ratio requirement if the superintendent determines the modification to 41 be in the interests of the people of this state or if the superintendent 42 determines that a modification is necessary to maintain insurer solven- 43 cy. No later than [June thirtieth] JULY THIRTY-FIRST of each year, every 44 insurer subject to this subparagraph shall annually report the actual 45 loss ratio for the previous calendar year in a format acceptable to the 46 superintendent. If an expected loss ratio is not met, the superintendent 47 may direct the insurer to take corrective action, which may include the 48 submission of a rate filing to reduce future premiums, or to issue divi- 49 dends, premium refunds or credits, or any combination of these. 50 S 62. Subparagraph (A) of paragraph 3 of subsection (c) of section 51 4308 of the insurance law, as added by chapter 107 of the laws of 2010, 52 is amended to read as follows: 53 (A) The expected minimum loss ratio for a contract form subject to 54 this subsection for which a rate filing or application is made pursuant 55 to this paragraph, other than a medicare supplemental insurance 56 contract, or, with the approval of the superintendent, an aggregation of S. 2606--C 119 1 contract forms that are combined into one community rating experience 2 pool and rated consistent with community rating requirements, shall not 3 be less than eighty-two percent. In reviewing a rate filing or applica- 4 tion, the superintendent may modify the eighty-two percent expected 5 minimum loss ratio requirement if the superintendent determines the 6 modification to be in the interests of the people of this state or if 7 the superintendent determines that a modification is necessary to main- 8 tain insurer solvency. No later than [June thirtieth] JULY THIRTY-FIRST 9 of each year, every corporation subject to this subparagraph shall annu- 10 ally report the actual loss ratio for the previous calendar year in a 11 format acceptable to the superintendent. If an expected loss ratio is 12 not met, the superintendent may direct the corporation to take correc- 13 tive action, which may include the submission of a rate filing to reduce 14 future premiums, or to issue dividends, premium refunds or credits, or 15 any combination of these. 16 S 63. Intentionally omitted. 17 S 64. Subparagraph (D) of paragraph 2 of subsection (p) of section 18 3221 of the insurance law, as added by chapter 661 of the laws of 1997, 19 is amended to read as follows: 20 (D) The insurer is ceasing to offer group or blanket policies in a 21 market in accordance with paragraph three OR SEVEN of this subsection. 22 S 65. Subsection (p) of section 3221 of the insurance law is amended 23 by adding a new paragraph 7 to read as follows: 24 (7) NOTWITHSTANDING PARAGRAPH THREE OF THIS SUBSECTION, AN INSURER MAY 25 DISCONTINUE OFFERING A PARTICULAR CLASS OF GROUP OR BLANKET POLICY OF 26 HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE OFFERED IN THE SMALL OR 27 LARGE GROUP MARKET, AND INSTEAD OFFER A GROUP OR BLANKET POLICY OF 28 HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE THAT COMPLIES WITH THE 29 REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, S 42 30 U.S.C. 300GG-6 THAT BECOME APPLICABLE TO SUCH POLICY AS OF JANUARY 31 FIRST, TWO THOUSAND FOURTEEN, PROVIDED THAT THE INSURER: 32 (A) DISCONTINUES THE EXISTING CLASS OF POLICY IN SUCH MARKET AS OF 33 EITHER DECEMBER THIRTY-FIRST, TWO THOUSAND THIRTEEN OR THE POLICY 34 RENEWAL DATE OCCURRING IN TWO THOUSAND FOURTEEN IN ACCORDANCE WITH THIS 35 CHAPTER; 36 (B) PROVIDES WRITTEN NOTICE TO EACH POLICYHOLDER PROVIDED COVERAGE OF 37 THE CLASS IN THE MARKET (AND TO ALL EMPLOYEES AND MEMBER INSUREDS 38 COVERED UNDER SUCH COVERAGE) OF THE DISCONTINUANCE AT LEAST NINETY DAYS 39 PRIOR TO THE DATE OF DISCONTINUANCE OF SUCH COVERAGE; 40 (C) OFFERS TO EACH POLICYHOLDER PROVIDED COVERAGE OF THE CLASS IN THE 41 MARKET, THE OPTION TO PURCHASE ALL (OR, IN THE CASE OF THE LARGE GROUP 42 MARKET, ANY) OTHER HOSPITAL, SURGICAL AND MEDICAL EXPENSE COVERAGE THAT 43 COMPLIES WITH THE REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH 44 SERVICE ACT, 42 U.S.C. S 300GG-6 THAT BECOME APPLICABLE TO SUCH COVERAGE 45 AS OF JANUARY FIRST, TWO THOUSAND FOURTEEN, CURRENTLY BEING OFFERED BY 46 THE INSURER TO A GROUP IN THAT MARKET; 47 (D) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF THE CLASS AND 48 IN OFFERING THE OPTION OF COVERAGE UNDER SUBPARAGRAPH (C) OF THIS PARA- 49 GRAPH, ACTS UNIFORMLY WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE 50 POLICYHOLDERS OR ANY HEALTH STATUS-RELATED FACTOR RELATING TO ANY 51 PARTICULAR COVERED EMPLOYEE, MEMBER INSURED OR DEPENDENT, OR PARTICULAR 52 NEW EMPLOYEE, MEMBER INSURED, OR DEPENDENT WHO MAY BECOME ELIGIBLE FOR 53 SUCH COVERAGE, AND DOES NOT DISCONTINUE THE COVERAGE OF THE CLASS WITH 54 THE INTENT OR AS A PRETEXT TO DISCONTINUING THE COVERAGE OF ANY SUCH 55 EMPLOYEE, MEMBER INSURED, OR DEPENDENT; AND S. 2606--C 120 1 (E) AT LEAST ONE HUNDRED TWENTY DAYS PRIOR TO THE DATE OF THE DISCON- 2 TINUANCE OF SUCH COVERAGE, PROVIDES WRITTEN NOTICE TO THE SUPERINTENDENT 3 OF THE DISCONTINUANCE, INCLUDING CERTIFICATION BY AN OFFICER OR DIRECTOR 4 OF THE INSURER THAT THE REASON FOR THE DISCONTINUANCE IS TO REPLACE THE 5 COVERAGE WITH NEW COVERAGE THAT COMPLIES WITH THE REQUIREMENTS OF 6 SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, S 42 U.S.C. 300GG-6 THAT 7 BECOME EFFECTIVE JANUARY FIRST, TWO THOUSAND FOURTEEN. 8 S 66. Item (iii) of subparagraph (C) of paragraph 2 of subsection (c) 9 of section 4304 of the insurance law, as amended by chapter 661 of the 10 laws of 1997, is amended to read as follows: 11 (iii) Discontinuance of all individual hospital, surgical or medical 12 expense insurance contracts for which the premiums are paid by a remit- 13 ting agent of a group, in the small group market, or the large group 14 market, or both markets, in this state, in conjunction with a withdrawal 15 from the small group market, or the large group market, or both markets, 16 in this state. Withdrawal from the small group market, or the large 17 group market, or both markets, shall be governed by the requirements of 18 subparagraphs [(B)] (E) and [(C)] (F) of paragraph three of subsection 19 (j) of section four thousand three hundred five of this article. For 20 purposes of this item, "withdrawal" from a market means that no coverage 21 is offered or maintained in such market under contracts issued pursuant 22 to this section or contracts issued pursuant to section four thousand 23 three hundred five of this article. 24 S 67. Subparagraph (D) of paragraph 2 of subsection (j) of section 25 4305 of the insurance law, as added by chapter 661 of the laws of 1997, 26 is amended to read as follows: 27 (D) The corporation is ceasing to offer group or blanket contracts in 28 a market in accordance with paragraph three OR PARAGRAPH SIX of this 29 subsection. 30 S 68. Subsection (j) of section 4305 of the insurance law is amended 31 by adding a new paragraph 6 to read as follows: 32 (6) NOTWITHSTANDING PARAGRAPH THREE OF THIS SUBSECTION, A CORPORATION 33 MAY DISCONTINUE OFFERING A PARTICULAR CLASS OF GROUP OR BLANKET CONTRACT 34 OF HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE OFFERED IN THE SMALL 35 OR LARGE GROUP MARKET, AND INSTEAD OFFER A GROUP OR BLANKET CONTRACT OF 36 HOSPITAL, SURGICAL OR MEDICAL EXPENSE INSURANCE THAT COMPLIES WITH THE 37 REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. 38 S 300GG-6 THAT BECOME APPLICABLE TO SUCH CONTRACT AS OF JANUARY FIRST, 39 TWO THOUSAND FOURTEEN, PROVIDED THAT THE CORPORATION: 40 (A) DISCONTINUES THE EXISTING CLASS OF CONTRACT IN SUCH MARKET AS OF 41 EITHER DECEMBER THIRTY-FIRST, TWO THOUSAND THIRTEEN OR THE CONTRACT 42 RENEWAL DATE OCCURRING IN TWO THOUSAND FOURTEEN IN ACCORDANCE WITH THIS 43 CHAPTER; 44 (B) PROVIDES WRITTEN NOTICE TO EACH CONTRACT HOLDER PROVIDED COVERAGE 45 OF THE CLASS IN THE MARKET (AND TO ALL EMPLOYEES AND MEMBER INSUREDS 46 COVERED UNDER SUCH COVERAGE) OF THE DISCONTINUANCE AT LEAST NINETY DAYS 47 PRIOR TO THE DATE OF DISCONTINUANCE OF SUCH COVERAGE; 48 (C) OFFERS TO EACH CONTRACT HOLDER PROVIDED COVERAGE OF THE CLASS IN 49 THE MARKET, THE OPTION TO PURCHASE ALL (OR, IN THE CASE OF THE LARGE 50 GROUP MARKET, ANY) OTHER HOSPITAL, SURGICAL AND MEDICAL EXPENSE COVERAGE 51 THAT COMPLIES WITH THE REQUIREMENTS OF SECTION 2707 OF THE PUBLIC HEALTH 52 SERVICE ACT, 42 U.S.C. S 300GG-6 THAT BECOME APPLICABLE TO SUCH COVERAGE 53 AS OF JANUARY FIRST, TWO THOUSAND FOURTEEN, CURRENTLY BEING OFFERED BY 54 THE CORPORATION TO A GROUP IN THAT MARKET; 55 (D) IN EXERCISING THE OPTION TO DISCONTINUE COVERAGE OF THE CLASS AND 56 IN OFFERING THE OPTION OF COVERAGE UNDER SUBPARAGRAPH (C) OF THIS PARA- S. 2606--C 121 1 GRAPH, ACTS UNIFORMLY WITHOUT REGARD TO THE CLAIMS EXPERIENCE OF THOSE 2 CONTRACT HOLDERS OR ANY HEALTH STATUS-RELATED FACTOR RELATING TO ANY 3 PARTICULAR COVERED EMPLOYEE, MEMBER INSURED OR DEPENDENT, OR PARTICULAR 4 NEW EMPLOYEE, MEMBER INSURED, OR DEPENDENT WHO MAY BECOME ELIGIBLE FOR 5 SUCH COVERAGE, AND DOES NOT DISCONTINUE THE COVERAGE OF THE CLASS WITH 6 THE INTENT OR AS A PRETEXT TO DISCONTINUING THE COVERAGE OF ANY SUCH 7 EMPLOYEE, MEMBER INSURED, OR DEPENDENT; AND 8 (E) AT LEAST ONE HUNDRED TWENTY DAYS PRIOR TO THE DATE OF THE DISCON- 9 TINUANCE OF SUCH COVERAGE, PROVIDES WRITTEN NOTICE TO THE SUPERINTENDENT 10 OF THE DISCONTINUANCE, INCLUDING CERTIFICATION BY AN OFFICER OR DIRECTOR 11 OF THE CORPORATION THAT THE REASON FOR THE DISCONTINUANCE IS TO REPLACE 12 THE COVERAGE WITH NEW COVERAGE THAT COMPLIES WITH THE REQUIREMENTS OF 13 SECTION 2707 OF THE PUBLIC HEALTH SERVICE ACT, 42 U.S.C. S 300GG-6 THAT 14 BECOME EFFECTIVE JANUARY FIRST, TWO THOUSAND FOURTEEN. 15 S 69. Subsections (a), (b) and (c) of section 3231 of the insurance 16 law, subsection (a) as amended by chapter 661 of the laws of 1997, 17 subsection (b) as amended by chapter 557 of the laws of 2002, subsection 18 (c) as added by chapter 501 of the laws of 1992, are amended to read as 19 follows: 20 (a) (1) No individual health insurance policy and no group health 21 insurance policy covering between [two] ONE and fifty employees or 22 members of the group OR BETWEEN ONE AND ONE HUNDRED EMPLOYEES OR MEMBERS 23 OF THE GROUP FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANUARY FIRST, 24 TWO THOUSAND SIXTEEN exclusive of spouses and dependents, hereinafter 25 referred to as a small group, providing hospital and/or medical bene- 26 fits, including medicare supplemental insurance, shall be issued in this 27 state unless such policy is community rated and, notwithstanding any 28 other provisions of law, the underwriting of such policy involves no 29 more than the imposition of a pre-existing condition limitation [as] IF 30 OTHERWISE permitted by this article. (2) Any individual, and dependents 31 of such individual, and any small group, including all employees or 32 group members and dependents of employees or members, applying for indi- 33 vidual health insurance coverage, including medicare supplemental cover- 34 age, [or small group health insurance coverage, including medicare 35 supplemental insurance,] OR SMALL GROUP HEALTH INSURANCE COVERAGE, 36 INCLUDING MEDICARE SUPPLEMENTAL INSURANCE, BUT NOT INCLUDING COVERAGE 37 ISSUED ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN, SPECIFIED IN 38 SUBSECTION (L) OF SECTION THREE THOUSAND TWO HUNDRED SIXTEEN OF THIS 39 ARTICLE must be accepted at all times throughout the year for any hospi- 40 tal and/or medical coverage offered by the insurer to individuals or 41 small groups in this state. (3) Once accepted for coverage, an individ- 42 ual or small group cannot be terminated by the insurer due to claims 43 experience. Termination of an individual or small group shall be based 44 only on one or more of the reasons set forth in subsection (g) of 45 section three thousand two hundred sixteen or subsection (p) of section 46 three thousand two hundred twenty-one of this article. Group hospital 47 and/or medical coverage, including medicare supplemental insurance, 48 obtained through an out-of-state trust covering a group of fifty or 49 fewer employees, OR BETWEEN ONE AND ONE HUNDRED EMPLOYEES FOR POLICIES 50 ISSUED OR RENEWED ON OR AFTER JANUARY FIRST, TWO THOUSAND SIXTEEN, or 51 participating persons who are residents of this state must be community 52 rated regardless of the situs of delivery of the policy. Notwithstanding 53 any other provisions of law, the underwriting of such policy may involve 54 no more than the imposition of a pre-existing condition limitation [as] 55 IF permitted by this article, and once accepted for coverage, an indi- 56 vidual or small group cannot be terminated due to claims experience. S. 2606--C 122 1 Termination of an individual or small group shall be based only on one 2 or more of the reasons set forth in subsection (p) of section three 3 thousand two hundred twenty-one of this article. (4) For the purposes 4 of this section, "community rated" means a rating methodology in which 5 the premium for all persons covered by a policy [or contract] form is 6 the same based on the experience of the entire pool of risks [covered by 7 that policy or contract form] OF ALL INDIVIDUALS OR SMALL GROUPS COVERED 8 BY THE INSURER without regard to age, sex, health status, TOBACCO USAGE 9 or occupation, EXCLUDING THOSE INDIVIDUALS OR SMALL GROUPS COVERED BY 10 MEDICARE SUPPLEMENTAL INSURANCE. FOR MEDICARE SUPPLEMENTAL INSURANCE 11 COVERAGE, "COMMUNITY RATED" MEANS A RATING METHODOLOGY IN WHICH THE 12 PREMIUMS FOR ALL PERSONS COVERED BY A POLICY OR CONTRACT FORM IS THE 13 SAME BASED ON THE EXPERIENCE OF THE ENTIRE POOL OF RISKS COVERED BY THAT 14 POLICY OR CONTRACT FORM WITHOUT REGARD TO AGE, SEX, HEALTH STATUS, 15 TOBACCO USAGE OR OCCUPATION. CATASTROPHIC HEALTH INSURANCE POLICIES 16 ISSUED PURSUANT TO SECTION 1302(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. 17 S 18022(E), SHALL BE CLASSIFIED IN A DISTINCT COMMUNITY RATING POOL. 18 (b) [Nothing herein shall prohibit the use of premium rate structures 19 to establish different premium rates for individuals as opposed to fami- 20 ly units or] (1) THE SUPERINTENDENT MAY SET STANDARD PREMIUM TIERS AND 21 STANDARD RATING RELATIVITIES BETWEEN TIERS APPLICABLE TO ALL POLICIES 22 SUBJECT TO THIS SECTION. THE SUPERINTENDENT MAY SET A STANDARD RELATIVI- 23 TY APPLICABLE TO CHILD-ONLY POLICIES ISSUED PURSUANT TO SECTION 1302(F) 24 OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(F). THE RELATIVITY FOR 25 CHILD-ONLY POLICIES SHALL BE ACTUARIALLY JUSTIFIABLE USING THE AGGREGATE 26 EXPERIENCE OF INSURERS. (2) AN INSURER SHALL ESTABLISH separate commu- 27 nity rates for individuals as opposed to small groups. (3) If an insurer 28 is required to issue a [contract] POLICY to individual proprietors 29 pursuant to subsection (i) of this section, such policy shall be subject 30 to subsection (a) of this section. 31 (c) (1) The superintendent shall permit the use of separate community 32 rates for reasonable geographic regions, which may, in a given case, 33 include a single county. The regions shall be approved by the super- 34 intendent as part of the rate filing. The superintendent shall not 35 require the inclusion of any specific geographic regions within the 36 proposed community rated regions selected by the insurer in its rate 37 filing so long as the insurer's proposed regions do not contain config- 38 urations designed to avoid or segregate particular areas within a county 39 covered by the insurer's community rates. (2) BEGINNING ON JANUARY 40 FIRST, TWO THOUSAND FOURTEEN, FOR EVERY POLICY SUBJECT TO THIS SECTION 41 THAT PROVIDES PHYSICIAN SERVICES, MEDICAL, MAJOR MEDICAL OR SIMILAR 42 COMPREHENSIVE-TYPE COVERAGE, EXCEPT FOR MEDICARE SUPPLEMENT PLANS, 43 INSURERS SHALL USE STANDARDIZED REGIONS ESTABLISHED BY THE SUPERINTEN- 44 DENT PROVIDED, HOWEVER, THAT THE COUNTIES OF NASSAU AND SUFFOLK SHALL 45 TOGETHER CONSIST OF THEIR OWN STANDARDIZED REGION. 46 S 70. Subsection (g) of section 3231 of the insurance law, as added by 47 chapter 501 of the laws of 1992, is amended to read as follows: 48 (g) (1) This section shall also apply to policies issued to a group 49 defined in subsection (c) of section four thousand two hundred thirty- 50 five, including but not limited to an association or trust of employers, 51 if the group includes one or more member employers or other member 52 groups which have fifty or fewer employees or members exclusive of 53 spouses and dependents. FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANU- 54 ARY FIRST, TWO THOUSAND FOURTEEN, IF THE GROUP INCLUDES ONE OR MORE 55 MEMBER SMALL GROUP EMPLOYERS ELIGIBLE FOR COVERAGE SUBJECT TO THIS 56 SECTION, THEN SUCH MEMBER EMPLOYERS SHALL BE CLASSIFIED AS SMALL GROUPS S. 2606--C 123 1 FOR RATING PURPOSES AND THE REMAINING MEMBERS SHALL BE RATED CONSISTENT 2 WITH THE RATING RULES APPLICABLE TO SUCH REMAINING MEMBERS PURSUANT TO 3 PARAGRAPH TWO OF THIS SUBSECTION. 4 (2) IF A POLICY IS ISSUED TO A GROUP DEFINED IN SUBSECTION (C) OF 5 SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER, INCLUDING 6 AN ASSOCIATION GROUP, THAT INCLUDES ONE OR MORE INDIVIDUAL OR INDIVIDUAL 7 PROPRIETOR MEMBERS, FOR RATING PURPOSES THE INSURER SHALL INCLUDE SUCH 8 MEMBERS IN ITS INDIVIDUAL POOL OF RISKS IN ESTABLISHING PREMIUM RATES 9 FOR SUCH MEMBERS. 10 S 71. Paragraph 2 of subsection (i) of section 3231 of the insurance 11 law, as amended by chapter 183 of the laws of 2011, is amended to read 12 as follows: 13 (2) For coverage purchased pursuant to this subsection, THROUGH DECEM- 14 BER THIRTY-FIRST, TWO THOUSAND THIRTEEN, individual proprietors shall be 15 classified in their own community rating category, provided however, up 16 to and including December thirty-first, two thousand [fourteen] 17 THIRTEEN, the premium rate established for individual proprietors 18 purchased pursuant to paragraph one of this subsection shall not be 19 greater than one hundred fifteen percent of the rate established for the 20 same coverage issued to groups. COVERAGE PURCHASED OR RENEWED PURSUANT 21 TO THIS SUBSECTION ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN 22 SHALL BE CLASSIFIED IN THE INDIVIDUAL RATING CATEGORY. 23 S 72. Section 4317 of the insurance law, as added by chapter 501 of 24 the laws of 1992, subsection (a) as amended by chapter 661 of the laws 25 of 1997, subsection (b) as amended and subsection (f) as added by chap- 26 ter 557 of the laws of 2002, subsection (d) as amended by section 2 of 27 part A of chapter 494 of the laws of 2009, paragraph 2 of subsection (f) 28 as amended by chapter 183 of the laws of 2011, is amended to read as 29 follows: 30 S 4317. Rating of individual and small group health insurance 31 contracts. (a) (1) No individual health insurance contract and no group 32 health insurance contract covering between [two] ONE and fifty employees 33 or members of the group, OR BETWEEN ONE AND ONE HUNDRED EMPLOYEES OR 34 MEMBERS OF THE GROUP FOR POLICIES ISSUED OR RENEWED ON OR AFTER JANUARY 35 FIRST, TWO THOUSAND SIXTEEN exclusive of spouses and dependents, includ- 36 ing contracts for which the premiums are paid by a remitting agent for a 37 group, hereinafter referred to as a small group, providing hospital 38 and/or medical benefits, including Medicare supplemental insurance, 39 shall be issued in this state unless such contract is community rated 40 and, notwithstanding any other provisions of law, the underwriting of 41 such contract involves no more than the imposition of a pre-existing 42 condition limitation [as] IF OTHERWISE permitted by this article. (2) 43 Any individual, and dependents of such individual, and any small group, 44 including all employees or group members and dependents of employees or 45 members, applying for individual or small group health insurance cover- 46 age INCLUDING MEDICARE SUPPLEMENTAL INSURANCE, BUT NOT INCLUDING COVER- 47 AGE ISSUED ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN SPECIFIED IN 48 SUBSECTION (L) OF SECTION FOUR THOUSAND THREE HUNDRED FOUR, AND SECTION 49 FOUR THOUSAND THREE HUNDRED TWENTY-EIGHT OF THIS CHAPTER, must be 50 accepted at all times throughout the year for any hospital and/or 51 medical coverage[, including Medicare supplemental insurance,] offered 52 by the corporation to individuals or small groups in this state. (3) 53 Once accepted for coverage, an individual or small group cannot be 54 terminated by the insurer due to claims experience. Termination of 55 coverage for individuals or small groups may be based only on one or 56 more of the reasons set forth in subsection (c) of section four thousand S. 2606--C 124 1 three hundred four or subsection (j) of section four thousand three 2 hundred five of this article. (4) For the purposes of this section, 3 "community rated" means a rating methodology in which the premium for 4 all persons covered by a policy or contract form is the same, based on 5 the experience of the entire pool of risks [covered by that policy or 6 contract form] OF ALL INDIVIDUALS OR SMALL GROUPS COVERED BY THE CORPO- 7 RATION without regard to age, sex, health status, TOBACCO USAGE or occu- 8 pation EXCLUDING THOSE INDIVIDUALS OF SMALL GROUPS COVERED BY MEDICARE 9 SUPPLEMENTAL INSURANCE. FOR MEDICARE SUPPLEMENTAL INSURANCE COVERAGE, 10 "COMMUNITY RATED" MEANS A RATING METHODOLOGY IN WHICH THE PREMIUMS FOR 11 ALL PERSONS COVERED BY A POLICY OR CONTRACT FORM IS THE SAME BASED ON 12 THE EXPERIENCE OF THE ENTIRE POOL OF RISKS COVERED BY THAT POLICY OR 13 CONTRACT FORM WITHOUT REGARD TO AGE, SEX, HEALTH STATUS, TOBACCO USAGE 14 OR OCCUPATION. CATASTROPHIC HEALTH INSURANCE CONTRACTS ISSUED PURSUANT 15 TO SECTION 1302(E) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(E), 16 SHALL BE CLASSIFIED IN A DISTINCT COMMUNITY RATING POOL. 17 (b) [Nothing herein shall prohibit the use of premium rate structures 18 to establish different premium rates for individuals as opposed to fami- 19 ly units or] (1) THE SUPERINTENDENT MAY SET STANDARD PREMIUM TIERS AND 20 STANDARD RATING RELATIVITIES BETWEEN TIERS APPLICABLE TO ALL CONTRACTS 21 SUBJECT TO THIS SECTION. THE SUPERINTENDENT MAY ALSO SET A STANDARD 22 RELATIVITY APPLICABLE TO CHILD-ONLY CONTRACTS ISSUED PURSUANT TO SECTION 23 1302(F) OF THE AFFORDABLE CARE ACT, 42 U.S.C. S 18022(F). THE RELATIVI- 24 TY FOR CHILD-ONLY CONTRACTS MUST BE ACTUARIALLY JUSTIFIABLE USING THE 25 AGGREGATE EXPERIENCE OF CORPORATIONS TO PREVENT THE CHARGING OF UNJUSTI- 26 FIED PREMIUMS. THE SUPERINTENDENT MAY ADJUST SUCH PREMIUM TIERS AND 27 RELATIVITIES PERIODICALLY BASED UPON THE AGGREGATE EXPERIENCE OF CORPO- 28 RATIONS ISSUING CONTRACT FORMS SUBJECT TO THIS SECTION. (2) A CORPO- 29 RATION SHALL ESTABLISH separate community rates for individuals as 30 opposed to small groups. (3) If a corporation is required to issue a 31 contract to individual proprietors pursuant to subsection (f) of this 32 section, such contract shall be subject to the requirements of 33 subsection (a) of this section. 34 (c) (1) The superintendent shall permit the use of separate community 35 rates for reasonable geographic regions, which may, in a given case, 36 include a single county. The regions shall be approved by the super- 37 intendent as part of the rate filing. The superintendent shall not 38 require the inclusion of any specific geographic regions within the 39 proposed community rated regions selected by the corporation in its rate 40 filing so long as the corporation's proposed regions do not contain 41 configurations designed to avoid or segregate particular areas within a 42 county covered by the corporation's community rates. (2) BEGINNING ON 43 JANUARY FIRST, TWO THOUSAND FOURTEEN, FOR EVERY CONTRACT SUBJECT TO THIS 44 SECTION THAT PROVIDES PHYSICIAN SERVICES, MEDICAL, MAJOR MEDICAL OR 45 SIMILAR COMPREHENSIVE-TYPE COVERAGE, EXCEPT FOR MEDICARE SUPPLEMENTAL 46 INSURANCE, CORPORATIONS SHALL USE STANDARDIZED REGIONS. 47 (d) (1) This section shall also apply to [contracts] A CONTRACT issued 48 to a group defined in subsection (c) of section four thousand two 49 hundred thirty-five of this chapter, including but not limited to an 50 association or trust of employers, if the group includes one or more 51 member employers or other member groups which have fifty or fewer 52 employees or members exclusive of spouses and dependents. FOR CONTRACTS 53 ISSUED OR RENEWED ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN, IF 54 THE GROUP INCLUDES ONE OR MORE MEMBER SMALL GROUP EMPLOYERS ELIGIBLE FOR 55 COVERAGE SUBJECT TO THIS SECTION, THEN SUCH MEMBER EMPLOYERS SHALL BE 56 CLASSIFIED AS SMALL GROUPS FOR RATING PURPOSES AND THE REMAINING MEMBERS S. 2606--C 125 1 SHALL BE RATED CONSISTENT WITH THE RATING RULES APPLICABLE TO SUCH 2 REMAINING MEMBERS PURSUANT TO PARAGRAPH TWO OF THIS SUBSECTION. 3 (2) IF A CONTRACT IS ISSUED TO A GROUP DEFINED IN SUBSECTION (C) OF 4 SECTION FOUR THOUSAND TWO HUNDRED THIRTY-FIVE OF THIS CHAPTER INCLUDING 5 ASSOCIATION GROUPS, THAT INCLUDES ONE OR MORE INDIVIDUAL MEMBERS, THEN 6 FOR RATING PURPOSES THE CORPORATION SHALL INCLUDE SUCH MEMBERS IN ITS 7 INDIVIDUAL POOL OF RISKS IN ESTABLISHING PREMIUM RATES FOR SUCH MEMBERS. 8 (3) A corporation shall provide specific claims experience to a munic- 9 ipal corporation, as defined in subsection (f) of section four thousand 10 seven hundred two of this chapter, covered by the corporation under a 11 community rated contract when the municipal corporation requests its 12 claims experience for purposes of forming or joining a municipal cooper- 13 ative health benefit plan certified pursuant to article forty-seven of 14 this chapter. Notwithstanding the foregoing provisions, no corporation 15 shall be required to provide more than three years' claims experience to 16 a municipal corporation making this request. 17 (e) (1) Notwithstanding any other provision of this chapter, no insur- 18 er, subsidiary of an insurer, or controlled person of a holding company 19 system may act as an administrator or claims paying agent, as opposed to 20 an insurer, on behalf of small groups which, if they purchased insur- 21 ance, would be subject to this section. No insurer, subsidiary of an 22 insurer, or controlled person of a holding company may provide stop 23 loss, catastrophic or reinsurance coverage to small groups which, if 24 they purchased insurance, would be subject to this section. 25 (2) This subsection shall not apply to coverage insuring a plan 26 [which] THAT was in effect on or before December thirty-first, nineteen 27 hundred ninety-one and was issued to a group [which] THAT includes 28 member small employers or other member small groups, including but not 29 limited to association groups, provided that (A) acceptance of addi- 30 tional small member employers (or other member groups comprised of fifty 31 or fewer employees or members, exclusive of spouses and dependents) into 32 the group on or after June first, nineteen hundred ninety-two and before 33 April first, nineteen hundred ninety-four does not exceed an amount 34 equal to ten percent per year of the total number of persons covered 35 under the group as of June first, nineteen hundred ninety-two, but noth- 36 ing in this subparagraph shall limit the addition of larger member 37 employers; (B) (i) after April first, nineteen hundred ninety-four, the 38 group thereafter accepts member small employers and member small groups 39 without underwriting by any more than the imposition of a pre-existing 40 condition limitation as permitted by this article and the cost for 41 participation in the group for all persons covered shall be the same 42 based on the experience of the entire pool of risks covered under the 43 entire group, without regard to age, sex, health status or occupation; 44 and; (ii) once accepted for coverage, an individual or small group 45 cannot be terminated due to claims experience; (C) the [insurer] CORPO- 46 RATION has registered the names of such groups, including the total 47 number of persons covered as of June first, nineteen hundred ninety-two, 48 with the superintendent, in a form prescribed by the superintendent, on 49 or before April first, nineteen hundred ninety-three and shall report 50 annually thereafter until such groups comply with the provisions of 51 subparagraph (B) of this paragraph; and (D) the types or categories of 52 employers or groups eligible to join the association are not altered or 53 expanded after June first, nineteen hundred ninety-two. 54 (3) A corporation may apply to the superintendent for an extension or 55 extensions of time beyond April first, nineteen hundred ninety-four in 56 which to implement the provisions of this subsection as they relate to S. 2606--C 126 1 groups registered with the superintendent pursuant to subparagraph (C) 2 of paragraph two of this subsection; any such extension or extensions 3 may not exceed two years in aggregate duration, and the ten percent per 4 year limitation of subparagraph (A) of paragraph two of this subsection 5 shall be reduced to five percent per year during the period of any such 6 extension or extensions. Any application for an extension shall demon- 7 strate that a significant financial hardship to such group would result 8 from such implementation. 9 (f)(1) If the [insurer] CORPORATION issues coverage to an association 10 group (including chambers of commerce), as defined in subparagraph (K) 11 of paragraph one of subsection (c) of section four thousand two hundred 12 thirty-five of this chapter, THEN the [insurer must] CORPORATION SHALL 13 issue the same coverage to individual proprietors [which] WHO purchase 14 coverage through the association group as the [insurer] CORPORATION 15 issues to groups [which] THAT purchase coverage through the association 16 group; provided, however, that [an insurer which] A CORPORATION THAT, on 17 the effective date of this subsection, is issuing coverage to individual 18 proprietors not connected with an association group, may continue to 19 issue such coverage provided that the coverage is otherwise in accord- 20 ance with this subsection and all other applicable provisions of law. 21 (2) For coverage purchased pursuant to this subsection THROUGH DECEM- 22 BER THIRTY-FIRST, TWO THOUSAND THIRTEEN, individual proprietors shall be 23 classified in their own community rating category, provided however, up 24 to and including December thirty-first, two thousand [fourteen] 25 THIRTEEN, the premium rate established for individual proprietors 26 purchased pursuant to paragraph one of this subsection shall not be 27 greater than one hundred fifteen percent of the rate established for the 28 same coverage issued to groups. COVERAGE PURCHASED OR RENEWED PURSUANT 29 TO THIS SUBSECTION ON OR AFTER JANUARY FIRST, TWO THOUSAND FOURTEEN 30 SHALL BE CLASSIFIED IN THE INDIVIDUAL RATING CATEGORY. 31 (3) The [insurer] CORPORATION may require members of the association 32 purchasing health insurance to verify that all employees electing health 33 insurance are legitimate employees of the employers, as documented on 34 New York state tax form NYS-45-ATT-MN or comparable documentation. In 35 order to be eligible to purchase health insurance pursuant to this 36 subsection and obtain the same group insurance products as are offered 37 to groups, a sole employee of a corporation or a sole proprietor of an 38 unincorporated business or entity must (A) work at least twenty hours 39 per week, (B) if purchasing the coverage through an association group, 40 be a member of the association for at least sixty days prior to the 41 effective date of the insurance [policy] CONTRACT, and (C) present a 42 copy of the following documentation to the [insurer] CORPORATION or 43 health plan administrator on an annual basis: 44 (i) NYS tax form 45-ATT, or comparable documentation of active employ- 45 ee status; 46 (ii) for an unincorporated business, the prior year's federal income 47 tax Schedule C for an incorporated business subject to Subchapter S with 48 a sole employee, federal income tax Schedule E for other incorporated 49 businesses with a sole employee, a W-2 annual wage statement, or federal 50 tax form 1099 with federal income tax Schedule F; or 51 (iii) for a business in business for less than one year, a cancelled 52 business check, a certificate of doing business, or appropriate tax 53 documentation; and 54 (iv) such other documentation as may be reasonably required by the 55 insurer as approved by the superintendent to verify eligibility of an 56 individual to purchase health insurance pursuant to this subsection. S. 2606--C 127 1 (4) Notwithstanding the provisions of item (I) of clause (i) of 2 subparagraph (K) of paragraph one of subsection (c) of section four 3 thousand two hundred thirty-five of this chapter, for purposes of this 4 section, an association group shall include chambers of commerce with 5 less than two hundred members and which are 501C3 or 501C6 organiza- 6 tions. 7 S 73. Notwithstanding any inconsistent provision of law, rule or regu- 8 lation, for purposes of implementing the provisions of the public health 9 law and the social services law, references to titles XIX and XXI of the 10 federal social security act in the public health law and the social 11 services law shall be deemed to include and also to mean any successor 12 titles thereto under the federal social security act. 13 S 74. Notwithstanding any inconsistent provision of law, rule or regu- 14 lation, the effectiveness of the provisions of sections 2807 and 3614 of 15 the public health law, section 18 of chapter 2 of the laws of 1988, and 16 18 NYCRR 505.14(h), as they relate to time frames for notice, approval 17 or certification of rates of payment, are hereby suspended and without 18 force or effect for purposes of implementing the provisions of this act. 19 S 75. Severability clause. If any clause, sentence, paragraph, subdi- 20 vision, section or part of this act shall be adjudged by any court of 21 competent jurisdiction to be invalid, such judgment shall not affect, 22 impair or invalidate the remainder thereof, but shall be confined in its 23 operation to the clause, sentence, paragraph, subdivision, section or 24 part thereof directly involved in the controversy in which such judgment 25 shall have been rendered. 26 S 76. This act shall take effect immediately and shall be deemed to 27 have been in full force and effect on and after January 1, 2013; 28 provided that: 29 a. sections thirty-eight, thirty-nine, forty, forty-a, forty-one, 30 forty-six-a, forty-seven, forty-eight, forty-nine, fifty, fifty-one and 31 fifty-two of this act shall take effect January 1, 2014, and shall apply 32 to all policies and contracts issued, renewed, modified, altered or 33 amended on or after such date. 34 b. sections forty-three-a, forty-four, forty-five and forty-six of 35 this act shall apply to all policies and contracts issued, renewed, 36 modified, altered or amended on or after October 1, 2013; 37 c. section fifty-six of this act shall take effect January 1, 2014, 38 contingent upon the requirements of the Patient Protection and Afforda- 39 ble Care Act of 2010 being fully implemented by the state and as 40 approved by the secretary of health and human services, and contingent 41 upon full implementation of the state enrollment center; 42 d. section fifty-seven of this act shall be deemed repealed January 1, 43 2014; 44 e. sections fifteen, fifty-eight, sixty-one and sixty-two of this act 45 shall take effect January 1, 2015, contingent upon the requirements of 46 the Patient Protection and Affordable Care Act of 2010 being fully 47 implemented by the state and as approved by the secretary of health and 48 human services, and contingent upon full implementation of the state 49 enrollment center provided that the amendments made to subsection (d) of 50 section 4327 of the insurance law by section fifty-eight of this act 51 shall expire one year after the effective date of such section; 52 e-1. section fifteen-a of this act shall take effect January 1, 2014, 53 contingent upon the requirements of the Patient Protection and Afforda- 54 ble Care Act of 2010 being fully implemented by the state and as 55 approved by the secretary of health and human services, and contingent 56 upon full implementation of the state enrollment center; S. 2606--C 128 1 f. sections fifty-nine and sixty of this act shall take effect January 2 1, 2016 and shall apply to all policies and contracts issued, renewed, 3 modified, altered, or amended on or after such date; 4 g. sections fourteen and fourteen-a of this act shall take effect 5 immediately and shall be deemed to have been in full force and effect on 6 and after April 1, 2013; 7 h. the amendments to paragraphs (e) and (f) of subdivision 2 of 8 section 2511 of the public health law made by sections nineteen and 9 twenty-six of this act shall take effect January 1, 2014 or a later date 10 to be determined by the commissioner of health contingent upon the 11 requirements of the Patient Protection and Affordable Care Act of 2010 12 being fully implemented by the state and as approved by the secretary of 13 the department of health and human services; provided that the commis- 14 sioner of health shall notify the legislative bill drafting commission 15 upon the occurrence of the enactment of the legislation provided for in 16 sections nineteen and twenty-six of this act in order that the commis- 17 sion may maintain an accurate and timely effective data base of the 18 official text of the laws of the state of New York in furtherance of 19 effectuating the provisions of section 44 of the legislative law and 20 section 70-b of the public officers law; 21 h-1. provided however, the amendments to subparagraph (ii) of para- 22 graph (f) of subdivision 2 of section 2511 of the public health law made 23 by section twenty-six of this act shall take effect April 1, 2014; 24 i. the amendments to subdivision 4 of section 2511 of the public 25 health law made by section twenty-one of this act shall not affect the 26 expiration and reversion of such subdivision and shall be deemed to 27 expire therewith; 28 j. the amendments to subparagraph (ii) of paragraph (g) of subdivision 29 2 of section 2511 of the public health law made by section twenty-seven 30 of this act shall not affect the expiration of such paragraph and shall 31 be deemed to expire therewith; 32 j-1. the amendments to subparagraph (iii) of paragraph (a) of subdivi- 33 sion 2 of section 2511 of the public health law made by section thirty 34 of this act shall not affect the expiration of such paragraph and shall 35 be deemed to expire therewith; 36 j-2. the amendments to subparagraph (iv) of paragraph (b) and para- 37 graph (d) of subdivision 9 of section 2511 of the public health law made 38 by section thirty-three of this act shall not affect the expiration of 39 such subdivision and shall be deemed to expire therewith; 40 k. any rules or regulations necessary to implement the provisions of 41 this act may be promulgated and any procedures, forms, or instructions 42 necessary for implementation may be adopted and issued on or after the 43 date this act shall have become a law; 44 l. this act shall not be construed to alter, change, affect, impair or 45 defeat any rights, obligations, duties or interests accrued, incurred or 46 conferred prior to the effective date of this act; 47 m. the commissioner of health and the superintendent of financial 48 services and any appropriate council may take any steps necessary to 49 implement this act prior to its effective date; 50 n. notwithstanding any inconsistent provision of the state administra- 51 tive procedure act or any other provision of law, rule or regulation, 52 the commissioner of health and the superintendent of financial services 53 and any appropriate council is authorized to adopt or amend or promul- 54 gate on an emergency basis any regulation he or she or such council 55 determines necessary to implement any provision of this act on its 56 effective date; S. 2606--C 129 1 o. the provisions of this act shall become effective notwithstanding 2 the failure of the commissioner of health or the superintendent of 3 financial services or any council to adopt or amend or promulgate regu- 4 lations implementing this act; and 5 p. the amendments made to subparagraph (7) of paragraph (b) of subdi- 6 vision 1 of section 366 of the social services law made by section one 7 of this act shall expire and be deemed repealed October 1, 2019. 8 PART E 9 Section 1. Intentionally omitted. 10 S 2. Intentionally omitted. 11 S 3. Intentionally omitted. 12 S 4. Intentionally omitted. 13 S 5. Intentionally omitted. 14 S 6. Intentionally omitted. 15 S 7. Intentionally omitted. 16 S 8. Intentionally omitted. 17 S 9. Intentionally omitted. 18 S 10. Intentionally omitted. 19 S 11. Intentionally omitted. 20 S 12. Intentionally omitted. 21 S 13. Intentionally omitted. 22 S 14. Section 600 of the public health law, as added by chapter 901 of 23 the laws of 1986, is amended to read as follows: 24 S 600. State aid; general requirements. In order to be eligible for 25 state aid under this title, a municipality shall be required to do the 26 following in accordance with the provisions of this article: 27 1. submit an application to the department for state aid WHICH IS 28 APPROVED BY THE COMMISSIONER IN ACCORDANCE WITH SECTION SIX HUNDRED ONE 29 OF THIS TITLE; 30 [2. submit a municipal public health services plan to the department 31 for approval; 32 3. implement and adhere to the municipal public health services plan, 33 as approved; 34 4. submit a detailed report to the department of all expenditures on 35 services funded by this title for the immediately preceding fiscal year 36 of such municipality; 37 5. employ a person to supervise the provision of public health 38 services in accordance with the provisions of section six hundred four 39 of this chapter; and 40 6.] 2. SUBSTANTIALLY PROVIDE CORE PUBLIC HEALTH SERVICES, AS DEFINED 41 IN SECTION SIX HUNDRED TWO OF THIS TITLE; 42 3. SUBMIT A COMMUNITY HEALTH ASSESSMENT IN ACCORDANCE WITH SECTION SIX 43 HUNDRED TWO-A OF THIS TITLE; 44 4. ESTABLISH, COLLECT AND REPORT FEES AND REVENUE FOR SERVICES 45 PROVIDED BY THE MUNICIPALITY, IN ACCORDANCE WITH SECTION SIX HUNDRED SIX 46 OF THIS TITLE; AND 47 5. appropriate or otherwise make funds available to finance a 48 prescribed share of the cost of public health services. 49 S 15. Section 601 of the public health law, as added by chapter 901 of 50 the laws of 1986, is amended to read as follows: 51 S 601. Application for state aid. 1. The governing body of each muni- 52 cipality desiring to make application for state aid under this title 53 shall annually, on such dates as may be fixed by the commissioner, 54 submit an application for such aid. S. 2606--C 130 1 2. The application shall be in such form as the commissioner shall 2 prescribe, and shall include, but not be limited to: 3 (a) an organizational chart of the municipal health agency, AND A 4 STATEMENT PROVIDING THE NUMBER OF EMPLOYEES, BY JOB TITLE, PROPOSED TO 5 PROVIDE PUBLIC HEALTH SERVICES FUNDED BY THIS TITLE; 6 (b) a [detailed] budget of proposed expenditures for services funded 7 by this title; 8 [(c) a description of proposed program activities for services funded 9 by this title; 10 (d) a copy of the municipal public health services plan prepared and 11 submitted pursuant to section six hundred two of this title; 12 (e) a certification by the chief executive officer of the munici- 13 pality, or in those municipalities with no chief executive officer the 14 chairman of the county legislature, that the proposed expenditures and 15 program activities are consistent with the public health services plan; 16 and 17 (f)] (C) A DESCRIPTION OF HOW THE MUNICIPALITY WILL PROVIDE PUBLIC 18 HEALTH SERVICES; 19 (D) AN ATTESTATION BY THE CHIEF EXECUTIVE OFFICER OF THE MUNICIPALITY 20 THAT SUFFICIENT FUNDS HAVE BEEN APPROPRIATED TO PROVIDE THE PUBLIC 21 HEALTH SERVICES FOR WHICH THE MUNICIPALITY IS SEEKING STATE AID; 22 (E) AN ATTESTATION BY THE MUNICIPAL OFFICER IN CHARGE OF ADMINISTERING 23 PUBLIC HEALTH THAT THE MUNICIPALITY HAS DILIGENTLY REVIEWED ITS STATE 24 AID APPLICATION AND THAT THE APPLICATION SEEKS STATE AID ONLY FOR ELIGI- 25 BLE PUBLIC HEALTH SERVICES; 26 (F) A LIST OF PUBLIC HEALTH SERVICES PROVIDED BY THE MUNICIPALITY THAT 27 ARE NOT ELIGIBLE FOR STATE AID, AND THE COST OF EACH SERVICE; 28 (G) A PROJECTION OF FEES AND REVENUE TO BE COLLECTED FOR PUBLIC HEALTH 29 SERVICES ELIGIBLE FOR STATE AID, IN ACCORDANCE WITH SECTION SIX HUNDRED 30 SIX OF THIS TITLE; AND 31 (H) such other information as the commissioner may require. 32 3. THE COMMISSIONER SHALL APPROVE THE STATE AID APPLICATION TO THE 33 EXTENT THAT IT IS CONSISTENT WITH THIS SECTION AND ANY OTHER CONDITIONS 34 OR LIMITATIONS ESTABLISHED IN, OR REGULATIONS PROMULGATED PURSUANT TO, 35 THIS ARTICLE. 36 4. A MUNICIPALITY MAY AMEND ITS STATE AID APPLICATION WITH THE 37 APPROVAL OF THE COMMISSIONER, AND SUBJECT TO ANY RULES AND REGULATIONS 38 THAT THE COMMISSIONER MAY ADOPT. 39 S 16. Section 602 of the public health law is REPEALED and a new 40 section 602 is added to read as follows: 41 S 602. CORE PUBLIC HEALTH SERVICES. 1. TO BE ELIGIBLE FOR STATE AID, 42 A MUNICIPALITY MUST SUBSTANTIALLY PROVIDE THE FOLLOWING CORE PUBLIC 43 HEALTH SERVICES: 44 (A) FAMILY HEALTH, WHICH SHALL INCLUDE ACTIVITIES DESIGNED TO REDUCE 45 PERINATAL, INFANT AND MATERNAL MORTALITY AND MORBIDITY AND TO PROMOTE 46 THE HEALTH OF INFANTS, CHILDREN, ADOLESCENTS, AND PEOPLE OF CHILDBEARING 47 AGE. SUCH ACTIVITIES SHALL INCLUDE FAMILY CENTERED PERINATAL SERVICES 48 AND OTHER SERVICES APPROPRIATE TO PROMOTE THE BIRTH OF A HEALTHY BABY TO 49 A HEALTHY MOTHER, AND SERVICES TO ASSURE THAT INFANTS, YOUNG CHILDREN, 50 AND SCHOOL AGE CHILDREN ARE ENROLLED IN APPROPRIATE HEALTH INSURANCE 51 PROGRAMS AND OTHER HEALTH BENEFIT PROGRAMS FOR WHICH THEY ARE ELIGIBLE, 52 AND THAT THE PARENTS OR GUARDIANS OF SUCH CHILDREN ARE PROVIDED WITH 53 INFORMATION CONCERNING HEALTH CARE PROVIDERS IN THEIR AREA THAT ARE 54 WILLING AND ABLE TO PROVIDE HEALTH SERVICES TO SUCH CHILDREN. 55 (B) COMMUNICABLE DISEASE CONTROL, WHICH SHALL INCLUDE ACTIVITIES TO 56 CONTROL AND MITIGATE THE EXTENT OF INFECTIOUS DISEASES. SUCH ACTIVITIES S. 2606--C 131 1 SHALL INCLUDE, BUT NOT BE LIMITED TO, SURVEILLANCE AND EPIDEMIOLOGICAL 2 PROGRAMS, PROGRAMS TO DETECT DISEASES IN THEIR EARLY STAGES, IMMUNIZA- 3 TIONS AGAINST INFECTIOUS DISEASES, INVESTIGATION OF DISEASES AND 4 PREVENTION OF TRANSMISSION, PREVENTION AND TREATMENT OF SEXUALLY TRAN- 5 SMISSIBLE DISEASES, AND ARTHROPOD VECTOR-BORNE DISEASE PREVENTION. 6 (C) CHRONIC DISEASE PREVENTION, WHICH SHALL INCLUDE PROMOTING PUBLIC, 7 HEALTH CARE PROVIDER AND OTHER COMMUNITY SERVICE PROVIDER ACTIVITIES 8 THAT ENCOURAGE CHRONIC DISEASE PREVENTION, EARLY DETECTION AND QUALITY 9 CARE DELIVERY. SUCH ACTIVITIES INCLUDE, BUT ARE NOT LIMITED TO, THOSE 10 THAT PROMOTE HEALTHY COMMUNITIES AND REDUCE RISK FACTORS SUCH AS TOBACCO 11 USE, POOR NUTRITION AND PHYSICAL INACTIVITY. PROVISION OF CLINICAL 12 SERVICES SHALL NOT BE ELIGIBLE FOR STATE AID, SUBJECT TO SUCH EXCEPTIONS 13 AS THE COMMISSIONER MAY DEEM APPROPRIATE. 14 (D) COMMUNITY HEALTH ASSESSMENT, AS DESCRIBED IN SECTION SIX HUNDRED 15 TWO-A OF THIS ARTICLE. 16 (E) ENVIRONMENTAL HEALTH, WHICH SHALL INCLUDE ACTIVITIES THAT PROMOTE 17 HEALTH AND PREVENT ILLNESS AND INJURY BY ASSURING THAT SAFE AND SANITARY 18 CONDITIONS ARE MAINTAINED AT PUBLIC DRINKING WATER SUPPLIES, FOOD 19 SERVICE ESTABLISHMENTS, AND OTHER REGULATED FACILITIES; INVESTIGATING 20 PUBLIC HEALTH NUISANCES TO ASSURE ABATEMENT BY RESPONSIBLE PARTIES; 21 PROTECTING THE PUBLIC FROM UNNECESSARY EXPOSURE TO RADIATION, CHEMICALS, 22 AND OTHER HARMFUL CONTAMINANTS; AND CONDUCTING INVESTIGATIONS OF INCI- 23 DENTS THAT RESULT IN ILLNESS, INJURY OR DEATH IN ORDER TO IDENTIFY AND 24 MITIGATE THE ENVIRONMENTAL CAUSES TO PREVENT ADDITIONAL MORBIDITY AND 25 MORTALITY. 26 (F) PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE, INCLUDING PLAN- 27 NING, TRAINING, AND MAINTAINING READINESS FOR PUBLIC HEALTH EMERGENCIES. 28 2. THE MUNICIPALITY MUST INCORPORATE INTO EACH CORE PUBLIC HEALTH 29 SERVICE THE FOLLOWING GENERAL ACTIVITIES: 30 (A) ONGOING ASSESSMENT OF COMMUNITY HEALTH NEEDS; 31 (B) EDUCATION ON PUBLIC HEALTH ISSUES; 32 (C) DEVELOPMENT OF POLICIES AND PLANS TO ADDRESS HEALTH NEEDS; 33 (D) ACTIONS TO ASSURE THAT SERVICES NECESSARY TO ACHIEVE AGREED UPON 34 GOALS ARE PROVIDED; AND 35 (E) THE EXTENT TO WHICH THE CORE SERVICES, ONCE IMPLEMENTED, WILL 36 SATISFY STANDARDS WHICH THE COMMISSIONER HAS PROMULGATED THROUGH RULES 37 AND REGULATIONS AFTER CONSULTING WITH THE PUBLIC HEALTH AND HEALTH PLAN- 38 NING COUNCIL AND COUNTY HEALTH COMMISSIONERS, BOARDS AND PUBLIC HEALTH 39 DIRECTORS. SUCH STANDARDS SHALL BE FOR SERVICES FUNDED UNDER THIS TITLE 40 AND SHALL INCLUDE BUT NOT BE LIMITED TO THE EFFECTS SUCH SERVICES SHALL 41 HAVE ON MORTALITY AND MORBIDITY AND THE REDUCTION OF POTENTIAL PUBLIC 42 HEALTH HAZARDS. THE COMMISSIONER SHALL NOT HAVE THE POWER TO PRESCRIBE 43 THE NUMBER OF PERSONS TO BE EMPLOYED IN ANY MUNICIPALITY. 44 3. A MUNICIPALITY MAY PROVIDE FEWER SERVICES THAN THOSE SET FORTH IN 45 SUBDIVISION ONE OF THIS SECTION, IF THE COMMISSIONER DETERMINES WITHIN 46 HIS DISCRETION THAT ANOTHER ENTITY IS WILLING AND ABLE TO PROVIDE SUCH 47 SERVICES. 48 S 17. The public health law is amended by adding a new section 602-a 49 to read as follows: 50 S 602-A. COMMUNITY HEALTH ASSESSMENT. 1. EVERY MUNICIPALITY SHALL 51 SUBMIT TO THE DEPARTMENT NO MORE FREQUENTLY THAN EVERY TWO YEARS A 52 COMMUNITY HEALTH ASSESSMENT. 53 2. THE COMMUNITY HEALTH ASSESSMENT SHALL BE IN SUCH FORM AS THE 54 COMMISSIONER SHALL PRESCRIBE, AND SHALL INCLUDE, BUT NOT BE LIMITED TO: 55 (A) AN ESTIMATE AND DESCRIPTION OF THE HEALTH STATUS OF THE POPULATION 56 AND FACTORS THAT CONTRIBUTE TO HEALTH ISSUES; S. 2606--C 132 1 (B) IDENTIFICATION OF PRIORITY AREAS FOR HEALTH IMPROVEMENT, IN 2 CONJUNCTION WITH THE STATE HEALTH IMPROVEMENT PLAN; 3 (C) IDENTIFICATION OF PUBLIC HEALTH SERVICES IN THE MUNICIPALITY AND 4 IN THE COMMUNITY AND OTHER RESOURCES THAT CAN BE MOBILIZED TO IMPROVE 5 POPULATION HEALTH, PARTICULARLY IN THOSE PRIORITY AREAS IDENTIFIED IN 6 PARAGRAPH (B) OF THIS SUBDIVISION; AND 7 (D) A COMMUNITY HEALTH IMPROVEMENT PLAN CONSISTING OF ACTIONS, POLI- 8 CIES, STRATEGIES AND MEASURABLE OBJECTIVES THROUGH WHICH THE MUNICI- 9 PALITY AND ITS COMMUNITY PARTNERS WILL ADDRESS AREAS FOR HEALTH IMPROVE- 10 MENT AND TRACK PROGRESS TOWARD IMPROVEMENT OF PUBLIC HEALTH OUTCOMES. 11 S 18. Section 603 of the public health law, as added by chapter 901 of 12 the laws of 1986, is amended to read as follows: 13 S 603. [Municipal public health services plan] CORE PUBLIC HEALTH 14 SERVICES; implementation. 1. In order to be eligible for state aid under 15 this title, each municipality shall administer its CORE public health 16 [programs] SERVICES in accordance with [its approved municipal public 17 health services plan and] THE standards of performance established by 18 the commissioner through rules and regulations [and] PURSUANT TO SECTION 19 SIX HUNDRED NINETEEN OF THIS ARTICLE. EACH MUNICIPALITY shall, in 20 particular, ensure that public health services are provided in an effi- 21 cient and effective manner to all persons in the municipality. 22 2. The commissioner may withhold state aid reimbursement under this 23 title for the appropriate services if, on ANY audit [and], review OF A 24 STATE AID APPLICATION OR PERIODIC CLAIM FOR STATE AID, OR OTHER INFORMA- 25 TION AVAILABLE TO THE DEPARTMENT, the commissioner finds that such 26 services are not furnished or rendered in conformance with the rules and 27 regulations established by the commissioner, INCLUDING BUT NOT LIMITED 28 TO THE STANDARDS OF PERFORMANCE ESTABLISHED PURSUANT TO SECTION SIX 29 HUNDRED NINETEEN OF THIS ARTICLE, or that the expenditures were not 30 [made according to the approved public health services plan required by] 31 FOR AN ACTIVITY SET FORTH IN section six hundred two of this title. In 32 such cases, the commissioner, in order to ensure that the public health 33 is promoted as defined in [paragraph (b) of subdivision three of] 34 section six hundred two of this title, may use any proportionate share 35 of a municipality's per capita or base grant that is withheld to 36 contract with agencies, associations, or organizations. The health 37 department may use any such withheld share to provide services upon 38 approval of the director of the division of the budget. Copies of such 39 transactions shall be filed with the fiscal committees of the legisla- 40 ture. 41 3. CONSISTENT WITH PARAGRAPH (H) OF SUBDIVISION TWO OF SECTION SIX 42 HUNDRED ONE OF THIS TITLE, WHEN DETERMINING WHETHER TO APPROVE A STATE 43 AID APPLICATION OR PERIODIC CLAIM FOR STATE AID, THE COMMISSIONER SHALL 44 HAVE AUTHORITY TO REQUEST ANY AND ALL FINANCIAL AND OTHER DOCUMENTS 45 NECESSARY OR RELEVANT TO VERIFY THAT THE CLAIMED EXPENDITURES ARE ELIGI- 46 BLE FOR STATE AID UNDER THIS ARTICLE. 47 S 19. Section 604 of the public health law, as added by chapter 901 of 48 the laws of 1986, is amended to read as follows: 49 S 604. Supervision of public health programs. In order to be eligible 50 for state aid, under this title, each municipality shall employ a full- 51 time local commissioner of health or public health director to supervise 52 the provision of public health services [and to implement the approved 53 public health services plan] for that municipality, SUBJECT TO THE 54 FOLLOWING EXCEPTIONS: 55 1. SUCH PERSON MAY SERVE AS THE HEAD OF A MERGED AGENCY OR MULTIPLE 56 AGENCIES, IF THE APPROVAL OF THE COMMISSIONER IS OBTAINED; AND S. 2606--C 133 1 2. SUCH PERSON MAY SERVE AS THE LOCAL COMMISSIONER OF HEALTH OR PUBLIC 2 HEALTH DIRECTOR OF ADDITIONAL COUNTIES, WHEN AUTHORIZED PURSUANT TO 3 SECTION THREE HUNDRED FIFTY-ONE OF THIS CHAPTER. 4 S 20. Section 605 of the public health law, as added by chapter 901 of 5 the laws of 1986, subdivision 1 as amended by section 6 of part B of 6 chapter 57 of the laws of 2006, subdivision 2 as amended by section 13 7 of part A of chapter 59 of the laws of 2011, is amended to read as 8 follows: 9 S 605. State aid; amount of reimbursement. 1. A state aid base grant 10 shall be reimbursed to municipalities for the [base] CORE public health 11 services identified in [paragraph (b) of subdivision three of] section 12 six hundred two of this title, in an amount of the greater of [fifty- 13 five] SIXTY-FIVE cents per capita, for each person in the municipality, 14 or [five] SIX hundred fifty thousand dollars provided that the munici- 15 pality expends at least [five] SIX hundred fifty thousand dollars for 16 such [base] CORE public health services. A municipality must provide all 17 the [basic] CORE public health services identified in [paragraph (b) of 18 subdivision three of] section six hundred two of this title to qualify 19 for such base grant unless the municipality has the approval of the 20 commissioner to expend the base grant on a portion of such [base] CORE 21 public health services. If [any] services in such [paragraph (b)] 22 SECTION are not [approved in the plan or if no plan is submitted for 23 such services] SUBSTANTIALLY PROVIDED, the commissioner may limit the 24 municipality's per capita or base grant to [that proportionate share 25 which will fund those services that are submitted in a plan and subse- 26 quently approved] REFLECT THE SCOPE OF THE REDUCED SERVICES. The commis- 27 sioner may use the [proportionate share] AMOUNT that is not granted to 28 contract with agencies, associations, or organizations to provide such 29 services; or the health department may use such proportionate share to 30 provide the services upon approval of the director of the division of 31 the budget. 32 2. State aid reimbursement for public health services provided by a 33 municipality under this title, shall be made if the municipality is 34 providing some or all of the [basic] CORE public health services identi- 35 fied in [paragraph (b) of subdivision three of] section six hundred two 36 of this title, pursuant to an approved [plan] APPLICATION FOR STATE AID, 37 at a rate of no less than thirty-six per centum of the difference 38 between the amount of moneys expended by the municipality for public 39 health services required by [paragraph (b) of subdivision three of] 40 section six hundred two of this title during the fiscal year and the 41 base grant provided pursuant to subdivision one of this section. No such 42 reimbursement shall be provided for services [if they are not approved 43 in a plan or if no plan is submitted for such services] THAT ARE NOT 44 ELIGIBLE FOR STATE AID PURSUANT TO THIS ARTICLE. 45 3. Municipalities shall make every reasonable effort to collect 46 payments for public health services provided. All such revenues shall be 47 reported to the commissioner PURSUANT TO SECTION SIX HUNDRED SIX OF THIS 48 TITLE and will be deducted from expenditures identified under subdivi- 49 sion two of this section to produce a net cost eligible for state aid. 50 S 21. Section 606 of the public health law, as added by chapter 901 of 51 the laws of 1986, is amended to read as follows: 52 S 606. Assessment of fees; THIRD-PARTY COVERAGE OR INDEMNIFICATION. 53 1. Assessment of fees by municipalities. [Each municipality shall 54 assess fees for services provided by such municipality in accordance 55 with a fee and revenue plan which shall include a schedule of fees that 56 the municipality proposes to charge for each service identified by the S. 2606--C 134 1 commissioner and each additional service identified by the municipality 2 for which a fee is to be charged. In accordance with the provisions of 3 subdivision four of section six hundred two of this chapter, the commis- 4 sioner shall review each fee and revenue plan submitted to him and, on 5 the basis of such review, issue a notice of intent to disapprove the 6 plan or approve the plan, with or without conditions, within ninety days 7 of his receipt of the plan. In determining whether to approve or disap- 8 prove a plan, the commissioner shall consider the extent to which the 9 plan, once implemented, will satisfy standards which the commissioner 10 has promulgated through rules and regulations after consulting with the 11 public health council and county health commissioners, boards and public 12 health directors. Such standards shall include a list of those environ- 13 mental, personal health and other services for which fees shall be 14 charged, the calculation of cost by each municipality and the relation- 15 ship of cost to fees, and provisions for prohibiting the assessment of 16 fees which would impede the delivery of services deemed essential to the 17 protection of the health of the public.] EACH MUNICIPALITY SHALL ESTAB- 18 LISH A SCHEDULE OF FEES FOR PUBLIC HEALTH SERVICES PROVIDED BY THE MUNI- 19 CIPALITY AND SHALL MAKE EVERY REASONABLE EFFORT TO COLLECT SUCH FEES. 20 Fees for personal health services shall be reflective of an individual's 21 ability to pay and shall not be inconsistent with the reimbursement 22 guidelines of articles twenty-eight and thirty-six of this chapter and 23 applicable federal laws and regulations. To the extent possible revenues 24 generated shall be used to enhance or expand public health services. IN 25 ITS STATE AID APPLICATION, EACH MUNICIPALITY SHALL PROVIDE THE DEPART- 26 MENT WITH A PROJECTION OF FEES AND REVENUE TO BE COLLECTED FOR THAT 27 YEAR. EACH MUNICIPALITY SHALL PERIODICALLY REPORT TO THE DEPARTMENT FEES 28 AND REVENUE ACTUALLY COLLECTED. 29 2. Assessment of fees by the commissioner. In each municipality, the 30 commissioner shall establish a fee and revenue plan for services 31 provided by the department in a manner consistent with the standards and 32 regulations established pursuant to subdivision one of this section. 33 3. THIRD PARTY COVERAGE OR INDEMNIFICATION. FOR ANY PUBLIC HEALTH 34 SERVICE FOR WHICH COVERAGE OR INDEMNIFICATION FROM A THIRD PARTY IS 35 AVAILABLE, THE MUNICIPALITY MUST SEEK SUCH COVERAGE OR INDEMNIFICATION 36 AND REPORT ANY ASSOCIATED REVENUE TO THE DEPARTMENT IN ITS STATE AID 37 APPLICATION. 38 S 22. Subdivisions 1 and 2 of section 609 of the public health law, as 39 amended by chapter 474 of the laws of 1996, are amended to read as 40 follows: 41 1. Where a laboratory shall have been or is hereafter established 42 pursuant to article five of this chapter, the state, through the legis- 43 lature and within the limits to be prescribed by the commissioner, shall 44 provide aid at a per centum, determined in accordance with the 45 provisions of [paragraph (b) of] subdivision two of section six hundred 46 five of this article, of the actual cost of [installation,] REPAIR, 47 RELOCATION, equipment and maintenance of the laboratory or laboratories 48 FOR SERVICES ASSOCIATED WITH A CORE PUBLIC HEALTH SERVICE, AS DESCRIBED 49 IN SECTION SIX HUNDRED TWO OF THIS TITLE. Such cost shall be the 50 excess, if any, of such expenditures over available revenues of all 51 types, including adequate and reasonable fees, derived from or attribut- 52 able to the performance of laboratory services. 53 2. Where a county or city provides or shall have provided for labora- 54 tory service by contracting with an established laboratory FOR SERVICES 55 ASSOCIATED WITH A CORE PUBLIC HEALTH SERVICE, AS DESCRIBED IN SUBDIVI- 56 SION THREE OF SECTION SIX HUNDRED TWO OF THIS TITLE, with the approval S. 2606--C 135 1 of the commissioner, it shall be entitled to state aid at a per centum, 2 determined in accordance with the provisions of [paragraph (b) of] 3 subdivision two of section six hundred five of this article, of the cost 4 of the contracts. [State aid shall be available for a district laborato- 5 ry supply station maintained and operated in accordance with article 6 five of this chapter in the same manner and to the same extent as for 7 laboratory services.] 8 S 23. Intentionally omitted. 9 S 24. Paragraphs (a) and (c) of subdivision 1 and subdivision 4 of 10 section 613 of the public health law, paragraphs (a) and (c) of subdivi- 11 sion 1 as amended by chapter 36 of the laws of 2010, subdivision 4 as 12 amended by chapter 207 of the laws of 2004, are amended to read as 13 follows: 14 (a) The commissioner shall develop and supervise the execution of a 15 program of immunization, surveillance and testing, to raise to the high- 16 est reasonable level the immunity of the children of the state against 17 communicable diseases including, but not limited to, influenza, poliom- 18 yelitis, measles, mumps, rubella, haemophilus influenzae type b (Hib), 19 diphtheria, pertussis, tetanus, varicella, hepatitis B, pneumococcal 20 disease, and the immunity of adults of the state against diseases iden- 21 tified by the commissioner, including but not limited to influenza, 22 smallpox, [and] hepatitis AND SUCH OTHER DISEASES AS THE COMMISSIONER 23 MAY DESIGNATE THROUGH REGULATION. The commissioner shall encourage the 24 municipalities in the state to develop and shall assist them in the 25 development and the execution of local programs of [inoculation] IMMUNI- 26 ZATION to raise the immunity of the children and adults of each munici- 27 pality to the highest reasonable level. Such programs shall include 28 ASSURANCE OF provision of vaccine, [surveillance of vaccine effective- 29 ness by means of laboratory tests,] serological testing of individuals 30 and educational efforts to inform health care providers and target popu- 31 lations or their parents, if they are minors, of the facts relative to 32 these diseases and [inoculation] IMMUNIZATIONS to prevent their occur- 33 rence. 34 (c) The commissioner shall invite and encourage the active assistance 35 and cooperation in such education activities of: the medical societies, 36 organizations of other licensed health personnel, hospitals, corpo- 37 rations subject to article forty-three of the insurance law, trade 38 unions, trade associations, parents and teachers and their associations, 39 organizations of child care resource and referral agencies, the media of 40 mass communication, and such other voluntary groups and organizations of 41 citizens as he or she shall deem appropriate. The public health AND 42 HEALTH PLANNING council, the department of education, the department of 43 family assistance, and the department of mental hygiene shall provide 44 the commissioner with such assistance in carrying out the program as he 45 or she shall request. All other state agencies shall also render such 46 assistance as the commissioner may reasonably require for this program. 47 Nothing in this subdivision shall authorize mandatory immunization of 48 adults or children, except as provided in sections twenty-one hundred 49 sixty-four and twenty-one hundred sixty-five of this chapter. 50 4. The commissioner shall expend such funds as the legislature shall 51 make available for the purchase of the vaccines described in subdivision 52 one of this section. All immunization vaccines purchased with such funds 53 shall be purchased by sealed competitive state bids through the office 54 of general services. [Immunization vaccine] VACCINES purchased with 55 funds made available under this section shall be made available without 56 charge to licensed private physicians, hospitals, clinics and such S. 2606--C 136 1 others as the commissioner shall determine [in accordance with regu- 2 lations to be promulgated by the commissioner], and no charge shall be 3 made to any patient for such vaccines. 4 S 25. Intentionally Omitted. 5 S 26. Subdivision 2 of section 614 of the public health law, as added 6 by chapter 901 of the laws of 1986, is amended to read as follows: 7 2. "City", each city of the state having a population of [fifty thou- 8 sand] ONE MILLION or more, according to the last preceding federal 9 census[, but does not include any such city which is included as a part 10 of a county health district pursuant to this chapter]. 11 S 27. Section 616 of the public health law, as added by chapter 901 of 12 the laws of 1986 and subdivision 1 as amended by section 9 of part B of 13 chapter 57 of the laws of 2006, is amended to read as follows: 14 S 616. Limitations on state aid. 1. The total amount of state aid 15 provided pursuant to this article shall be limited to the amount of the 16 annual appropriation made by the legislature. In no event, however, 17 shall such state aid be less than an amount to provide the full base 18 grant and, as otherwise provided by paragraph (a) of subdivision two of 19 section six hundred five of this article, at least thirty-six per centum 20 of the difference between the amount of moneys expended by the munici- 21 pality for ELIGIBLE public health services [required by paragraph (b) of 22 subdivision three of section six hundred two of this article] PURSUANT 23 TO AN APPROVED APPLICATION FOR STATE AID during the fiscal year and the 24 base grant provided pursuant to subdivision one of section six hundred 25 five of this article. [A municipality shall also receive not less than 26 thirty-six per centum of the moneys expended for other public health 27 services pursuant to paragraph (b) of subdivision two of section six 28 hundred five of this article, and, at least the minimum amount so 29 required for the services identified in title two of this article.] 30 2. No payments shall be made from moneys appropriated for the purpose 31 of this article to a municipality for contributions by the municipality 32 for indirect costs and fringe benefits, including but not limited to, 33 employee retirement funds, health insurance and federal old age and 34 survivors insurance. 35 S 28. Section 617 of the public health law, as added by chapter 901 of 36 the laws of 1986, is amended to read as follows: 37 S 617. Maintenance of effort. Such amount of state aid provided will 38 be used to support and to the extent practicable, to increase the level 39 of funds that would otherwise be made available for such purposes and 40 not to supplant the amount to be provided by the municipalities. If a 41 municipality that is provided state aid pursuant to title one of this 42 article reduces its expenditures beneath the amount expended in its base 43 year, which is [the greater of its expenditures in its fiscal year 44 ending in either nineteen hundred eighty-five or] the most recent fiscal 45 year for which the municipality has filed [an annual] ALL expenditure 46 [report] REPORTS to the department, state aid reimbursement provided 47 pursuant to subdivision one of section six hundred five of this article 48 will be reduced by the [difference between the reduction in local 49 expenditures between its base year and its current fiscal year and the 50 reduction in state aid between the base year and the current fiscal year 51 pursuant to paragraphs (a) and (b) of subdivision two of section six 52 hundred five of this article. A municipality may include revenue, 53 excluding third party reimbursement, raised by the municipality in 54 calculating its maintenance of effort] PERCENTAGE REDUCTION IN EXPENDI- 55 TURES BETWEEN ITS BASE YEAR AND ITS CURRENT FISCAL YEAR. FOR PURPOSES OF 56 THIS SECTION, REDUCTIONS IN EXPENDITURES SHALL BE ADJUSTED FOR: AN S. 2606--C 137 1 ABSENCE OF EXTRAORDINARY EXPENDITURES OF A TEMPORARY NATURE, SUCH AS 2 DISASTER RELIEF; UNAVOIDABLE OR JUSTIFIABLE PROGRAM REDUCTIONS, SUCH AS 3 A PROGRAM BEING SUBSUMED BY ANOTHER AGENCY; OR IN CIRCUMSTANCES WHERE 4 THE MUNICIPALITY CAN DEMONSTRATE, TO THE DEPARTMENT'S SATISFACTION, THAT 5 THE NEED FOR THE EXPENDITURE NO LONGER EXISTS. 6 S 29. Intentionally omitted. 7 S 30. Section 619 of the public health law, as added by chapter 901 of 8 the laws of 1986, is amended to read as follows: 9 S 619. Commissioner; regulatory powers. The commissioner shall adopt 10 regulations to effectuate the provisions and purposes of this article, 11 including, but not limited to: 12 1. setting standards of performance [and reasonable costs] for the 13 provision of [basic] CORE public health services which shall include 14 performance criteria to ensure that reimbursable health services are 15 delivered in an efficient and effective manner by a municipality; and 16 2. monitoring, COLLECTING DATA and evaluating the provision of [basic] 17 CORE public health services by the municipalities and the amounts 18 expended by the municipalities for such services. 19 S 31. The public health law is amended by adding a new section 619-a 20 to read as follows: 21 S 619-A. INCENTIVE STANDARDS OF PERFORMANCE. 1. THE COMMISSIONER SHALL 22 ESTABLISH STATEWIDE INCENTIVE PERFORMANCE STANDARDS, SUBJECT TO LEGISLA- 23 TIVE APPROVAL, FOR THE DELIVERY OF CORE PUBLIC HEALTH SERVICES ON OR 24 BEFORE DECEMBER THIRTY-FIRST, TWO THOUSAND THIRTEEN. 25 2. WITHIN AMOUNTS APPROPRIATED, AND SUBJECT TO THE APPROVAL OF THE 26 DIRECTOR OF THE BUDGET, THE COMMISSIONER MAY INCREASE STATE AID TO ANY 27 MUNICIPALITY THAT MEETS OR EXCEEDS STATEWIDE INCENTIVE PERFORMANCE STAN- 28 DARDS ESTABLISHED UNDER THIS SECTION, PROVIDED THAT THE TOTAL OF SUCH 29 PAYMENTS TO ALL MUNICIPALITIES MAY NOT EXCEED ONE MILLION DOLLARS ANNU- 30 ALLY. 31 S 32. The article heading of article 23 of the public health law, as 32 amended by chapter 878 of the laws of 1980, is amended to read as 33 follows: 34 CONTROL OF SEXUALLY [TRANSMISSIBLE] TRANSMITTED DISEASES 35 S 33. Sections 2300, 2301, 2302 and 2303 of the public health law are 36 REPEALED. 37 S 34. The section heading and subdivisions 1 and 2 of section 2304 of 38 the public health law, as amended by chapter 878 of the laws of 1980, 39 are amended and two new subdivisions 4 and 5 are added to read as 40 follows: 41 Sexually [transmissible] TRANSMITTED diseases; treatment facilities; 42 administration. 1. It shall be the responsibility of each board of 43 health of a health district to provide adequate facilities for the 44 [free] diagnosis and treatment of persons living within its jurisdiction 45 who are suspected of being infected or are infected with a sexually 46 [transmissible] TRANSMITTED disease. 47 2. The health officer of said health district shall administer these 48 facilities DIRECTLY OR THROUGH CONTRACT, and shall promptly examine or 49 arrange for the examination of persons suspected of being infected with 50 a sexually [transmissible] TRANSMITTED disease, and shall promptly 51 institute treatment or arrange for the treatment of those found or 52 otherwise known to be infected with a sexually [transmissible] TRANSMIT- 53 TED disease[,]; provided that any person may, at his OR HER option, be 54 treated at his OR HER own expense by a licensed physician of his OR HER 55 choice. S. 2606--C 138 1 4. EACH BOARD OF HEALTH AND LOCAL HEALTH OFFICER SHALL ENSURE THAT 2 DIAGNOSIS AND TREATMENT SERVICES ARE AVAILABLE AND, TO THE GREATEST 3 EXTENT PRACTICABLE, SEEK THIRD PARTY COVERAGE OR INDEMNIFICATION FOR 4 SUCH SERVICES; PROVIDED, HOWEVER, THAT NO BOARD OF HEALTH, LOCAL HEALTH 5 OFFICER, OR OTHER MUNICIPAL OFFICER OR ENTITY SHALL REQUEST OR REQUIRE 6 THAT SUCH COVERAGE OR INDEMNIFICATION BE UTILIZED AS A CONDITION OF 7 PROVIDING DIAGNOSIS OR TREATMENT SERVICES. 8 5. THE TERM "HEALTH OFFICER" AS USED IN THIS ARTICLE SHALL MEAN A 9 COUNTY HEALTH OFFICER, A CITY HEALTH OFFICER, A TOWN HEALTH OFFICER, A 10 VILLAGE HEALTH OFFICER, THE HEALTH OFFICER OF A CONSOLIDATED HEALTH 11 DISTRICT OR A STATE DISTRICT HEALTH OFFICER. 12 S 35. Intentionally omitted. 13 S 36. Section 2306 of the public health law, as amended by chapter 41 14 of the laws of 2010, is amended to read as follows: 15 S 2306. Sexually [transmissible] TRANSMITTED diseases; reports and 16 information, confidential. All reports or information secured by a board 17 of health or health officer under the provisions of this article shall 18 be confidential except in so far as is necessary to carry out the 19 purposes of this article. Such report or information may be disclosed by 20 court order in a criminal proceeding in which it is otherwise admissible 21 or in a proceeding pursuant to article ten of the family court act in 22 which it is otherwise admissible, to the prosecution and to the defense, 23 or in a proceeding pursuant to article ten of the family court act in 24 which it is otherwise admissible, to the petitioner, respondent and 25 attorney for the child, provided that the subject of the report or 26 information has waived the confidentiality provided for by this section 27 EXCEPT INSOFAR AS IS NECESSARY TO CARRY OUT THE PURPOSES OF THIS ARTI- 28 CLE. INFORMATION MAY BE DISCLOSED TO THIRD PARTY REIMBURSERS OR THEIR 29 AGENTS TO THE EXTENT NECESSARY TO REIMBURSE HEALTH CARE PROVIDERS FOR 30 HEALTH SERVICES; PROVIDED THAT, WHEN NECESSARY, AN OTHERWISE APPROPRIATE 31 AUTHORIZATION FOR SUCH DISCLOSURE HAS BEEN SECURED BY THE PROVIDER. A 32 person waives the confidentiality provided for by this section if such 33 person voluntarily discloses or consents to disclosure of such report or 34 information or a portion thereof. If such person lacks the capacity to 35 consent to such a waiver, his or her parent, guardian or attorney may so 36 consent. An order directing disclosure pursuant to this section shall 37 specify that no report or information shall be disclosed pursuant to 38 such order which identifies or relates to any person other than the 39 subject of the report or information. REPORTS AND INFORMATION MAY BE 40 USED IN THE AGGREGATE IN PROGRAMS APPROVED BY THE COMMISSIONER FOR THE 41 IMPROVEMENT OF THE QUALITY OF MEDICAL CARE PROVIDED TO PERSONS WITH 42 SEXUALLY TRANSMITTED DISEASES; OR WITH PATIENT IDENTIFIERS WHEN USED 43 WITHIN THE STATE OR LOCAL HEALTH DEPARTMENT BY PUBLIC HEALTH DISEASE 44 PROGRAMS TO ASSESS CO-MORBIDITY OR COMPLETENESS OF REPORTING AND TO 45 DIRECT PROGRAM NEEDS, IN WHICH CASE PATIENT IDENTIFIERS SHALL NOT BE 46 DISCLOSED OUTSIDE THE STATE OR LOCAL HEALTH DEPARTMENT. 47 S 37. The section heading of section 2308 of the public health law is 48 amended to read as follows: 49 [Venereal] SEXUALLY TRANSMITTED disease; pregnant women; blood test 50 for syphilis. 51 S 38. Section 2308-a of the public health law, as amended by chapter 52 878 of the laws of 1980, is amended to read as follows: 53 S 2308-a. Sexually [transmissible] TRANSMITTED diseases; tests for 54 sexually [transmissible] TRANSMITTED diseases. 1. The administrative 55 officer or other person in charge of a clinic or other facility provid- 56 ing gynecological, obstetrical, genito-urological, contraceptive, steri- S. 2606--C 139 1 lization or termination of pregnancy services or treatment shall require 2 the staff of such clinic or facility to offer to administer to every 3 resident of the state of New York coming to such clinic or facility for 4 such services or treatment, appropriate examinations or tests for the 5 detection of sexually [transmissible] TRANSMITTED diseases. 6 2. Each physician providing gynecological, obstetrical, genito-urolog- 7 ical, contraceptive, sterilization, or termination of pregnancy services 8 or treatment shall offer to administer to every resident of the state of 9 New York coming to such physician for such services or treatment, appro- 10 priate examinations or tests for the detection of sexually [transmissi- 11 ble] TRANSMITTED diseases. 12 S 39. Sections 2309 and 2310 of the public health law are REPEALED. 13 S 40. Section 2311 of the public health law, as added by chapter 878 14 of the laws of 1980, is amended to read as follows: 15 S 2311. Sexually [transmissible] TRANSMITTED disease list. The commis- 16 sioner shall promulgate a list of sexually [transmissible] TRANSMITTED 17 diseases, such as gonorrhea and syphilis, for the purposes of this arti- 18 cle. The commissioner, in determining the diseases to be included in 19 such list, shall consider those conditions principally transmitted by 20 sexual contact, OTHER SECTIONS OF THIS CHAPTER ADDRESSING COMMUNICABLE 21 DISEASES and the impact of particular diseases on individual morbidity 22 and the health of newborns. 23 S 41. Section 2 of chapter 577 of the laws of 2008, amending the 24 public health law relating to expedited partner therapy for persons 25 infected with chlamydia trachomatis, is amended to read as follows: 26 S 2. This act shall take effect on the one hundred twentieth day after 27 it shall have become a law [and shall expire and be deemed repealed 28 January 1, 2014]. 29 S 42. Intentionally omitted. 30 S 43. Subdivisions 1, 2, 2-a, 2-b and 3 of section 2802 of the public 31 health law, subdivisions 1, 2 and 2-b as amended by section 58 of part A 32 of chapter 58 of the laws of 2010, subdivision 2-a as added and para- 33 graph (e) of subdivision 3 as amended by chapter 731 of the laws of 34 1993, subdivision 3 as amended by chapter 609 of the laws of 1982, are 35 amended to read as follows: 36 1. An application for such construction shall be filed with the 37 department, together with such other forms and information as shall be 38 prescribed by, or acceptable to, the department. Thereafter the depart- 39 ment shall forward a copy of the application and accompanying documents 40 to the public health and health planning council, and the health systems 41 agency, if any, having geographical jurisdiction of the area where the 42 hospital is located. 43 2. The commissioner shall not act upon an application for construction 44 of a hospital until the public health and health planning council and 45 the health systems agency have had a reasonable time to submit their 46 recommendations, and unless (a) the applicant has obtained all approvals 47 and consents required by law for its incorporation or establishment 48 (including the approval of the public health and health planning council 49 pursuant to the provisions of this article) provided, however, that the 50 commissioner may act upon an application for construction by an appli- 51 cant possessing a valid operating certificate when the application qual- 52 ifies for review without the recommendation of the council pursuant to 53 regulations adopted by the council and approved by the commissioner; and 54 (b) the commissioner is satisfied as to the public need for the 55 construction, at the time and place and under the circumstances 56 proposed, provided however that[,] in the case of an application by: (I) S. 2606--C 140 1 a hospital established or operated by an organization defined in subdi- 2 vision one of section four hundred eighty-two-b of the social services 3 law, the needs of the members of the religious denomination concerned, 4 for care or treatment in accordance with their religious or ethical 5 convictions, shall be deemed to be public need[.]; (II) A GENERAL HOSPI- 6 TAL OR DIAGNOSTIC AND TREATMENT CENTER, ESTABLISHED UNDER THIS ARTICLE, 7 TO CONSTRUCT A FACILITY TO PROVIDE PRIMARY CARE SERVICES, AS DEFINED IN 8 REGULATION, THE CONSTRUCTION MAY BE APPROVED WITHOUT REGARD FOR PUBLIC 9 NEED; OR (III) A GENERAL HOSPITAL OR A DIAGNOSTIC AND TREATMENT CENTER, 10 ESTABLISHED UNDER THIS ARTICLE, TO UNDERTAKE CONSTRUCTION THAT DOES NOT 11 INVOLVE: (A) A CHANGE IN CAPACITY, THE TYPES OF SERVICES PROVIDED, 12 MAJOR MEDICAL EQUIPMENT; (B) FACILITY REPLACEMENT; OR (C) THE GEOGRAPHIC 13 LOCATION OF SERVICES, THE CONSTRUCTION MAY BE APPROVED WITHOUT REGARD 14 FOR PUBLIC NEED. 15 2-a. The council shall afford the applicant an opportunity to present 16 information in person concerning an application to a committee desig- 17 nated by the council. 18 2-b. Beginning on January first, nineteen hundred ninety-four, and 19 each year thereafter, a complete application received between January 20 first and June thirtieth of each year shall be reviewed by the appropri- 21 ate health systems agency and the department and presented to the public 22 health and health planning council for its consideration prior to June 23 thirtieth of the following year and a complete application received 24 between July first and December thirty-first of each year shall be 25 reviewed by the appropriate health systems agency and the department and 26 presented to the public health and health planning council for consider- 27 ation prior to December thirty-first of the following year. 28 3. Subject to the provisions of paragraph (b) of subdivision two, the 29 commissioner in approving the construction of a hospital shall take into 30 consideration and be empowered to request information and advice as to 31 (a) the availability of facilities or services such as preadmission, 32 ambulatory or home care services which may serve as alternatives or 33 substitutes for the whole or any part of the proposed hospital 34 construction; 35 (b) the need for special equipment in view of existing utilization of 36 comparable equipment at the time and place and under the circumstances 37 proposed; 38 (c) the possible economies and improvements in service to be antic- 39 ipated from the operation of joint central services including, but not 40 limited to laboratory, research, radiology, pharmacy, laundry and 41 purchasing; 42 (d) the adequacy of financial resources and sources of future revenue, 43 PROVIDED THAT THE COMMISSIONER MAY, BUT IS NOT REQUIRED TO, CONSIDER THE 44 ADEQUACY OF FINANCIAL RESOURCES AND SOURCES OF FUTURE REVENUE IN 45 RELATION TO APPLICATIONS UNDER SUBPARAGRAPHS (II) AND (III) OF PARAGRAPH 46 (B) OF SUBDIVISION TWO OF THIS SECTION; and 47 (e) whether the facility is currently in substantial compliance with 48 all applicable codes, rules and regulations, provided, however, that the 49 commissioner shall not disapprove an application solely on the basis 50 that the facility is not currently in substantial compliance, if the 51 application is specifically: 52 (i) to correct life safety code or patient care deficiencies; 53 (ii) to correct deficiencies which are necessary to protect the life, 54 health, safety and welfare of facility patients, residents or staff; S. 2606--C 141 1 (iii) for replacement of equipment that no longer meets the generally 2 accepted operational standards existing for such equipment at the time 3 it was acquired; and 4 (iv) for decertification of beds and services. 5 S 44. Subdivisions 1, 2 and 3 of section 2807-z of the public health 6 law, as amended by chapter 400 of the laws of 2012, are amended to read 7 as follows: 8 1. Notwithstanding any provision of this chapter or regulations or any 9 other state law or regulation, for any eligible capital project as 10 defined in subdivision six of this section, the department shall have 11 thirty days of receipt of the certificate of need OR CONSTRUCTION appli- 12 cation, PURSUANT TO SECTION TWENTY-EIGHT HUNDRED TWO OF THIS ARTICLE, 13 for a limited or administrative review to deem such application 14 complete. If the department determines the application is incomplete or 15 that more information is required, the department shall notify the 16 applicant in writing within thirty days of the date of the application's 17 submission, and the applicant shall have twenty business days to provide 18 additional information or otherwise correct the deficiency in the appli- 19 cation. 20 2. For an eligible capital project requiring a limited or administra- 21 tive review, within ninety days of the department deeming the applica- 22 tion complete, the department shall make a decision to approve or disap- 23 prove the certificate of need OR CONSTRUCTION application for such 24 project. If the department determines to disapprove the project, the 25 basis for such disapproval shall be provided in writing; however, disap- 26 proval shall not be based on the incompleteness of the application. If 27 the department fails to take action to approve or disapprove the appli- 28 cation within ninety days of the certificate of need application being 29 deemed complete, the application will be deemed approved. 30 3. For an eligible capital project requiring full review by the coun- 31 cil, the certificate of need OR CONSTRUCTION application shall be placed 32 on the next council agenda following the department deeming the applica- 33 tion complete. 34 S 45. Intentionally omitted. 35 S 46. Section 2801-a of the public health law is amended by adding a 36 new subdivision 3-b to read as follows: 37 3-B. NOTWITHSTANDING ANY OTHER PROVISIONS OF THIS CHAPTER TO THE 38 CONTRARY, THE PUBLIC HEALTH AND HEALTH PLANNING COUNCIL MAY APPROVE THE 39 ESTABLISHMENT OF DIAGNOSTIC OR TREATMENT CENTERS TO BE ISSUED OPERATING 40 CERTIFICATES FOR THE PURPOSE OF PROVIDING PRIMARY CARE, AS DEFINED BY 41 THE COMMISSIONER IN REGULATIONS, WITHOUT REGARD TO THE REQUIREMENTS OF 42 PUBLIC NEED AND FINANCIAL RESOURCES AS SET FORTH IN SUBDIVISION THREE OF 43 THIS SECTION. 44 S 47. Intentionally omitted. 45 S 48. Intentionally omitted. 46 S 49. Intentionally omitted. 47 S 50. Intentionally omitted. 48 S 51. The mental hygiene law is amended by adding a new section 32.20 49 to read as follows: 50 S 32.20 TEMPORARY OPERATOR. 1. FOR THE PURPOSES OF THIS SECTION: 51 (A) "CHEMICAL DEPENDENCE TREATMENT PROGRAM" SHALL MEAN A PROGRAM 52 CERTIFIED PURSUANT TO SECTION 32.05 OF THIS ARTICLE; 53 (B) "ESTABLISHED OPERATOR" SHALL MEAN THE OPERATOR OF A CHEMICAL 54 DEPENDENCE TREATMENT PROGRAM THAT HAS BEEN ESTABLISHED AND ISSUED AN 55 OPERATING CERTIFICATE PURSUANT TO SECTION 32.05 OF THIS ARTICLE; S. 2606--C 142 1 (C) "TEMPORARY OPERATOR" SHALL MEAN ANY OASAS STAFF MEMBER, PERSON OR 2 ENTITY THAT: 3 (I) AGREES TO OPERATE A PROGRAM ON A TEMPORARY BASIS IN THE BEST 4 INTERESTS OF ITS PATIENTS AND THE COMMUNITY SERVED BY THE PROGRAM; 5 (II) HAS DEMONSTRATED THAT HE OR SHE HAS THE CHARACTER, COMPETENCE AND 6 ABILITY TO OPERATE AN OASAS-CERTIFIED PROGRAM IN COMPLIANCE WITH APPLI- 7 CABLE STANDARDS; AND 8 (III) PRIOR TO HIS OR HER APPOINTMENT AS TEMPORARY OPERATOR, DEVELOPS 9 WITH GUIDANCE FROM THE COMMISSIONER A SATISFACTORY PLAN TO ADDRESS THE 10 PROGRAM'S DEFICIENCIES; 11 (D) "SERIOUS FINANCIAL INSTABILITY" SHALL INCLUDE BUT NOT BE LIMITED 12 TO DEFAULTING OR VIOLATING KEY COVENANTS OF BOND ISSUES, MISSED MORTGAGE 13 PAYMENTS, GENERAL UNTIMELY PAYMENT OF DEBTS, FAILURE TO PAY ITS EMPLOY- 14 EES OR VENDORS, INSUFFICIENT FUNDS TO MEET THE GENERAL OPERATING 15 EXPENSES OF THE PROGRAM AND/OR FACILITY, FAILURE TO MAINTAIN REQUIRED 16 DEBT SERVICE COVERAGE RATIOS AND/OR, AS APPLICABLE, FACTORS THAT HAVE 17 TRIGGERED A WRITTEN EVENT OF DEFAULT NOTICE TO THE OFFICE BY THE DORMI- 18 TORY AUTHORITY OF THE STATE OF NEW YORK; AND 19 (E) "EXTRAORDINARY FINANCIAL ASSISTANCE" SHALL MEAN STATE FUNDS 20 PROVIDED TO, OR REQUESTED BY, A PROGRAM FOR THE EXPRESS PURPOSE OF 21 PREVENTING THE CLOSURE OF THE PROGRAM THAT THE COMMISSIONER FINDS 22 PROVIDES ESSENTIAL AND NECESSARY SERVICES WITHIN THE COMMUNITY. 23 2. (A) IN THE EVENT THAT: (I) THE OFFICE IMPOSED A PENALTY ON A 24 PROGRAM WITHIN THE PRIOR TWELVE MONTHS; (II) THE PROGRAM IS SEEKING 25 EXTRAORDINARY FINANCIAL ASSISTANCE; (III) OFFICE COLLECTED DATA INDI- 26 CATES THAT THE PROGRAM IS EXPERIENCING SERIOUS FINANCIAL INSTABILITY 27 ISSUES; (IV) OFFICE COLLECTED DATA INDICATES THAT THE PROGRAM'S BOARD OF 28 DIRECTORS OR ADMINISTRATION ARE UNABLE OR UNWILLING TO ENSURE THE PROPER 29 OPERATION OF THE PROGRAM; (V) THE PROGRAM HAS VIOLATED THE TERMS OF ITS 30 CONTRACT WITH THE STATE; OR (VI) OFFICE COLLECTED DATA INDICATES THERE 31 ARE CONDITIONS THAT SERIOUSLY ENDANGER OR JEOPARDIZE CONTINUED ACCESS TO 32 NECESSARY CHEMICAL DEPENDENCE TREATMENT SERVICES WITHIN THE COMMUNITY, 33 THE COMMISSIONER SHALL NOTIFY THE ESTABLISHED OPERATOR OF HIS OR HER 34 INTENTION TO APPOINT A TEMPORARY OPERATOR TO ASSUME SOLE RESPONSIBILITY 35 FOR THE PROGRAM'S TREATMENT OPERATIONS OF THAT FACILITY FOR A LIMITED 36 PERIOD OF TIME. THE APPOINTMENT OF A TEMPORARY OPERATOR SHALL BE EFFEC- 37 TUATED PURSUANT TO THIS SECTION, AND SHALL BE IN ADDITION TO ANY OTHER 38 REMEDIES PROVIDED BY LAW. 39 (B) THE ESTABLISHED OPERATOR OF A PROGRAM MAY AT ANY TIME REQUEST THE 40 COMMISSIONER TO APPOINT A TEMPORARY OPERATOR. UPON RECEIVING SUCH A 41 REQUEST, THE COMMISSIONER MAY, IF HE OR SHE DETERMINES THAT SUCH AN 42 ACTION IS NECESSARY, ENTER INTO AN AGREEMENT WITH THE ESTABLISHED OPERA- 43 TOR FOR THE APPOINTMENT OF A TEMPORARY OPERATOR TO RESTORE OR MAINTAIN 44 THE PROVISION OF QUALITY CARE TO THE PATIENTS UNTIL THE ESTABLISHED 45 OPERATOR CAN RESUME OPERATIONS WITHIN THE DESIGNATED TIME PERIOD; THE 46 PATIENTS MAY BE TRANSFERRED TO OTHER OASAS-CERTIFIED PROVIDERS; OR THE 47 PROGRAM OPERATIONS OF THAT FACILITY SHOULD BE COMPLETELY DISCONTINUED. 48 3. (A) A TEMPORARY OPERATOR APPOINTED PURSUANT TO THIS SECTION SHALL 49 USE HIS OR HER BEST EFFORTS TO IMPLEMENT THE PLAN DEVELOPED WITH THE 50 GUIDANCE OF THE COMMISSIONER TO CORRECT OR ELIMINATE ANY DEFICIENCIES IN 51 THE PROGRAM AND TO PROMOTE THE QUALITY AND ACCESSIBILITY OF CHEMICAL 52 DEPENDENCE TREATMENT SERVICES IN THE COMMUNITY SERVED BY THE PROGRAM. 53 (B) IF THE IDENTIFIED PROGRAM DEFICIENCIES CANNOT BE ADDRESSED IN THE 54 TIME PERIOD DESIGNATED IN THE PLAN, THE PATIENTS SHALL BE TRANSFERRED TO 55 OTHER OASAS-CERTIFIED PROVIDERS. S. 2606--C 143 1 (C) DURING THE TERM OF HIS OR HER APPOINTMENT, THE TEMPORARY OPERATOR 2 SHALL HAVE THE AUTHORITY TO DIRECT THE PROGRAM STAFF OF THE FACILITY IN 3 ALL ASPECTS NECESSARY TO APPROPRIATELY TREAT AND/OR TRANSFER THE 4 PATIENTS. THE TEMPORARY OPERATOR SHALL, DURING THIS PERIOD, OPERATE THE 5 PROGRAM IN SUCH A MANNER AS TO PROMOTE SAFETY AND THE QUALITY AND ACCES- 6 SIBILITY OF CHEMICAL DEPENDENCE TREATMENT SERVICES IN THE COMMUNITY 7 SERVED BY THE FACILITY UNTIL EITHER THE ESTABLISHED OPERATOR CAN RESUME 8 PROGRAM OPERATIONS OR UNTIL THE PATIENTS ARE APPROPRIATELY TRANSFERRED 9 TO OTHER OASAS-CERTIFIED PROVIDERS. 10 (D) THE TEMPORARY OPERATOR SHALL NOT BE REQUIRED TO FILE ANY BOND. NO 11 SECURITY INTEREST IN ANY REAL OR PERSONAL PROPERTY COMPRISING THE FACIL- 12 ITY OR CONTAINED WITHIN THE FACILITY OR IN ANY FIXTURE OF THE FACILITY, 13 SHALL BE IMPAIRED OR DIMINISHED IN PRIORITY BY THE TEMPORARY OPERATOR. 14 NEITHER THE TEMPORARY OPERATOR NOR THE OFFICE SHALL ENGAGE IN ANY ACTIV- 15 ITY THAT CONSTITUTES A CONFISCATION OF PROPERTY. 16 4. THE TEMPORARY OPERATOR SHALL BE ENTITLED TO A REASONABLE FEE, AS 17 DETERMINED BY THE COMMISSIONER, AND NECESSARY EXPENSES INCURRED DURING 18 HIS OR HER PERFORMANCE AS TEMPORARY OPERATOR. THE TEMPORARY OPERATOR 19 SHALL BE LIABLE ONLY IN HIS OR HER CAPACITY AS TEMPORARY OPERATOR OF THE 20 PROGRAM FOR INJURY TO PERSON AND PROPERTY BY REASON OF HIS OR HER OPERA- 21 TION OF SUCH PROGRAM; HE OR SHE SHALL NOT HAVE ANY LIABILITY IN HIS OR 22 HER PERSONAL CAPACITY, EXCEPT FOR GROSS NEGLIGENCE AND INTENTIONAL ACTS. 23 5. (A) THE INITIAL TERM OF THE APPOINTMENT OF THE TEMPORARY OPERATOR 24 SHALL NOT EXCEED NINETY DAYS. AFTER NINETY DAYS, IF THE COMMISSIONER 25 DETERMINES THAT TERMINATION OF THE TEMPORARY OPERATOR WOULD CAUSE 26 SIGNIFICANT DETERIORATION OF THE QUALITY OF, OR ACCESS TO, HEALTH CARE 27 IN THE COMMUNITY OR THAT REAPPOINTMENT IS NECESSARY TO CORRECT THE DEFI- 28 CIENCIES THAT REQUIRED THE APPOINTMENT OF THE TEMPORARY OPERATOR, THE 29 COMMISSIONER MAY AUTHORIZE AN ADDITIONAL NINETY-DAY TERM. HOWEVER, SUCH 30 AUTHORIZATION SHALL INCLUDE THE COMMISSIONER'S REQUIREMENTS FOR CONCLU- 31 SION OF THE TEMPORARY OPERATORSHIP TO BE SATISFIED WITHIN THE ADDITIONAL 32 TERM. 33 (B) WITHIN FOURTEEN DAYS PRIOR TO THE TERMINATION OF EACH TERM OF THE 34 APPOINTMENT OF THE TEMPORARY OPERATOR, THE TEMPORARY OPERATOR SHALL 35 SUBMIT TO THE COMMISSIONER AND TO THE ESTABLISHED OPERATOR A REPORT 36 DESCRIBING: 37 (I) THE ACTIONS TAKEN DURING THE APPOINTMENT TO ADDRESS: THE IDENTI- 38 FIED PROGRAM DEFICIENCIES; THE RESUMPTION OF PROGRAM OPERATIONS BY THE 39 ESTABLISHED OPERATOR; OR THE TRANSFER OF THE PATIENTS TO OTHER 40 OASAS-CERTIFIED PROVIDERS; 41 (II) OBJECTIVES FOR THE CONTINUATION OF THE TEMPORARY OPERATORSHIP IF 42 NECESSARY AND A SCHEDULE FOR SATISFACTION OF SUCH OBJECTIVES; AND 43 (III) IF APPLICABLE, THE RECOMMENDED ACTIONS FOR THE ONGOING OPERATION 44 OF THE PROGRAM SUBSEQUENT TO THE TEMPORARY OPERATORSHIP. 45 (C) THE TERM OF THE INITIAL APPOINTMENT AND OF ANY SUBSEQUENT REAP- 46 POINTMENT MAY BE TERMINATED PRIOR TO THE EXPIRATION OF THE DESIGNATED 47 TERM, IF THE ESTABLISHED OPERATOR AND THE COMMISSIONER AGREE ON A PLAN 48 OF CORRECTION AND THE IMPLEMENTATION OF SUCH PLAN. 49 6. (A) THE COMMISSIONER SHALL, UPON MAKING A DETERMINATION OF AN 50 INTENTION TO APPOINT A TEMPORARY OPERATOR PURSUANT TO PARAGRAPH (A) OF 51 SUBDIVISION TWO OF THIS SECTION CAUSE THE ESTABLISHED OPERATOR OF THE 52 FACILITY TO BE NOTIFIED OF THE INTENTION BY REGISTERED OR CERTIFIED MAIL 53 ADDRESSED TO THE PRINCIPAL OFFICE OF THE ESTABLISHED OPERATOR. SUCH 54 NOTIFICATION SHALL INCLUDE A DETAILED DESCRIPTION OF THE FINDINGS UNDER- 55 LYING THE INTENTION TO APPOINT A TEMPORARY OPERATOR, AND THE DATE AND 56 TIME OF A REQUIRED MEETING WITH THE COMMISSIONER AND/OR HIS OR HER S. 2606--C 144 1 DESIGNEE WITHIN TEN BUSINESS DAYS OF THE RECEIPT OF SUCH NOTICE. AT SUCH 2 MEETING, THE ESTABLISHED OPERATOR SHALL HAVE THE OPPORTUNITY TO REVIEW 3 AND DISCUSS ALL RELEVANT FINDINGS. AT SUCH MEETING, THE COMMISSIONER AND 4 THE ESTABLISHED OPERATOR SHALL ATTEMPT TO DEVELOP A MUTUALLY SATISFAC- 5 TORY PLAN OF CORRECTION AND SCHEDULE FOR IMPLEMENTATION. IN SUCH EVENT, 6 THE COMMISSIONER SHALL NOTIFY THE ESTABLISHED OPERATOR THAT THE COMMIS- 7 SIONER WILL ABSTAIN FROM APPOINTING A TEMPORARY OPERATOR CONTINGENT UPON 8 THE ESTABLISHED OPERATOR REMEDIATING THE IDENTIFIED DEFICIENCIES WITHIN 9 THE AGREED UPON TIMEFRAME. 10 (B) SHOULD THE COMMISSIONER AND THE ESTABLISHED OPERATOR BE UNABLE TO 11 ESTABLISH A PLAN OF CORRECTION PURSUANT TO PARAGRAPH (A) OF THIS SUBDI- 12 VISION, OR SHOULD THE ESTABLISHED OPERATOR FAIL TO RESPOND TO THE 13 COMMISSIONER'S INITIAL NOTIFICATION, THERE SHALL BE AN ADMINISTRATIVE 14 HEARING ON THE COMMISSIONER'S DETERMINATION TO APPOINT A TEMPORARY OPER- 15 ATOR TO BEGIN NO LATER THAN THIRTY DAYS FROM THE DATE OF THE NOTICE TO 16 THE ESTABLISHED OPERATOR. ANY SUCH HEARING SHALL BE STRICTLY LIMITED TO 17 THE ISSUE OF WHETHER THE DETERMINATION OF THE COMMISSIONER TO APPOINT A 18 TEMPORARY OPERATOR IS SUPPORTED BY SUBSTANTIAL EVIDENCE. A COPY OF THE 19 DECISION SHALL BE SENT TO THE ESTABLISHED OPERATOR. 20 (C) IF THE DECISION TO APPOINT A TEMPORARY OPERATOR IS UPHELD SUCH 21 TEMPORARY OPERATOR SHALL BE APPOINTED AS SOON AS IS PRACTICABLE AND 22 SHALL OPERATE THE PROGRAM PURSUANT TO THE PROVISIONS OF THIS SECTION. 23 7. NOTWITHSTANDING THE APPOINTMENT OF A TEMPORARY OPERATOR, THE ESTAB- 24 LISHED OPERATOR REMAINS OBLIGATED FOR THE CONTINUED OPERATION OF THE 25 FACILITY SO THAT THE PROGRAM CAN FUNCTION IN A NORMAL MANNER. NO 26 PROVISION CONTAINED IN THIS SECTION SHALL BE DEEMED TO RELIEVE THE 27 ESTABLISHED OPERATOR OR ANY OTHER PERSON OF ANY CIVIL OR CRIMINAL 28 LIABILITY INCURRED, OR ANY DUTY IMPOSED BY LAW, BY REASON OF ACTS OR 29 OMISSIONS OF THE ESTABLISHED OPERATOR OR ANY OTHER PERSON PRIOR TO THE 30 APPOINTMENT OF ANY TEMPORARY OPERATOR OF THE PROGRAM HEREUNDER; NOR 31 SHALL ANYTHING CONTAINED IN THIS SECTION BE CONSTRUED TO SUSPEND DURING 32 THE TERM OF THE APPOINTMENT OF THE TEMPORARY OPERATOR OF THE PROGRAM ANY 33 OBLIGATION OF THE ESTABLISHED OPERATOR OR ANY OTHER PERSON FOR THE MAIN- 34 TENANCE AND REPAIR OF THE FACILITY, PROVISION OF UTILITY SERVICES, 35 PAYMENT OF TAXES OR OTHER OPERATING AND MAINTENANCE EXPENSES OF THE 36 FACILITY, NOR OF THE ESTABLISHED OPERATOR OR ANY OTHER PERSON FOR THE 37 PAYMENT OF MORTGAGES OR LIENS. 38 S 52. Intentionally omitted. 39 S 53. Intentionally omitted. 40 S 54. Intentionally omitted. 41 S 55. Intentionally omitted. 42 S 56. Intentionally omitted. 43 S 57. Intentionally omitted. 44 S 58. Intentionally omitted. 45 S 59. Intentionally omitted. 46 S 60. Intentionally omitted. 47 S 61. Intentionally omitted. 48 S 62. Intentionally omitted. 49 S 63. Intentionally omitted. 50 S 64. Intentionally omitted. 51 S 65. Intentionally omitted. 52 S 66. Intentionally omitted. 53 S 67. Intentionally omitted. 54 S 68. Intentionally omitted. 55 S 69. Intentionally omitted. 56 S 70. Intentionally omitted. S. 2606--C 145 1 S 71. Intentionally omitted. 2 S 72. Intentionally omitted. 3 S 73. Intentionally omitted. 4 S 74. Intentionally omitted. 5 S 75. Intentionally omitted. 6 S 76. Intentionally omitted. 7 S 77. Intentionally omitted. 8 S 78. Intentionally omitted. 9 S 79. Intentionally omitted. 10 S 80. Intentionally omitted. 11 S 81. Intentionally omitted. 12 S 82. Intentionally omitted. 13 S 83. Intentionally omitted. 14 S 84. Intentionally omitted. 15 S 85. Intentionally omitted. 16 S 86. Intentionally omitted. 17 S 87. Intentionally omitted. 18 S 88. Intentionally omitted. 19 S 89. Intentionally omitted. 20 S 90. Subdivision 1 of section 6605-b of the education law, as added 21 by chapter 437 of the laws of 2001, is amended to read as follows: 22 1. [A] NOTWITHSTANDING ANY PROVISION HEREIN TO THE CONTRARY, A dental 23 hygienist shall not administer or monitor nitrous oxide analgesia or 24 local infiltration anesthesia in the practice of dental hygiene without 25 a dental hygiene restricted local infiltration anesthesia/nitrous oxide 26 analgesia certificate and except under the personal supervision of a 27 dentist and in conjunction with the performance of dental hygiene proce- 28 dures authorized by law and in accordance with regulations promulgated 29 by the commissioner. Personal supervision, for purposes of this section, 30 means that the supervising dentist remains in the dental office where 31 the local infiltration anesthesia or nitrous oxide analgesia services 32 are being performed, personally authorizes and prescribes the use of 33 local infiltration anesthesia or nitrous oxide analgesia for the patient 34 and, before dismissal of the patient, personally examines the condition 35 of the patient after the use of local infiltration anesthesia or nitrous 36 oxide analgesia is completed. It is professional misconduct for a 37 dentist to fail to provide the supervision required by this section, and 38 any dentist found guilty of such misconduct under the procedures 39 prescribed in section sixty-five hundred ten of this title shall be 40 subject to the penalties prescribed in section sixty-five hundred eleven 41 of this title. 42 S 91. Subdivision 1 of section 6606 of the education law, as amended 43 by chapter 437 of the laws of 2001, is amended to read as follows: 44 1. The practice of the profession of dental hygiene is defined as the 45 performance of dental services which shall include removing calcareous 46 deposits, accretions and stains from the exposed surfaces of the teeth 47 which begin at the epithelial attachment and applying topical agents 48 indicated for a complete dental prophylaxis, removing cement, placing or 49 removing rubber dam, removing sutures, placing matrix band, providing 50 patient education, applying topical medication, placing and exposing 51 DIAGNOSTIC DENTAL X-ray films, performing topical fluoride applications 52 and topical anesthetic applications, polishing teeth, taking medical 53 history, charting caries, taking impressions for study casts, placing 54 and removing temporary restorations, administering and monitoring 55 nitrous oxide analgesia and administering and monitoring local infil- 56 tration anesthesia, subject to certification in accordance with section S. 2606--C 146 1 sixty-six hundred five-b of this article, and any other function in the 2 definition of the practice of dentistry as may be delegated by a 3 licensed dentist in accordance with regulations promulgated by the 4 commissioner. The practice of dental hygiene may be conducted in the 5 office of any licensed dentist or in any appropriately equipped school 6 or public institution but must be done EITHER under the supervision of a 7 licensed dentist OR, IN THE CASE OF A REGISTERED DENTAL HYGIENIST WORK- 8 ING FOR A HOSPITAL AS DEFINED IN ARTICLE TWENTY-EIGHT OF THE PUBLIC 9 HEALTH LAW, PURSUANT TO A COLLABORATIVE ARRANGEMENT WITH A LICENSED 10 DENTIST PURSUANT TO REGULATIONS PROMULGATED PURSUANT TO ARTICLE TWENTY- 11 EIGHT OF THE PUBLIC HEALTH LAW. 12 S 92. Section 6608 of the education law, as amended by chapter 300 of 13 the laws of 2006, is amended to read as follows: 14 S 6608. Definition of practice of certified dental assisting. The 15 practice of certified dental assisting is defined as providing support- 16 ive services to a dentist in his/her performance of dental services 17 authorized under this article. Such support shall include providing 18 patient education, taking preliminary medical histories and vital signs 19 to be reviewed by the dentist, placing and removing rubber dams, select- 20 ing and prefitting provisional crowns, selecting and prefitting ortho- 21 dontic bands, removing orthodontic arch wires and ligature ties, placing 22 and removing matrix bands, taking impressions for study casts or diag- 23 nostic casts, removing periodontal dressings, and such other dental 24 supportive services authorized by the dentist consistent with regu- 25 lations promulgated by the commissioner, provided that such functions 26 are performed under the direct personal supervision of a licensed 27 dentist in the course of the performance of dental services. Such 28 services shall not include diagnosing and/or performing surgical proce- 29 dures, irreversible procedures or procedures that would alter the hard 30 or soft tissue of the oral and maxillofacial area or any other proce- 31 dures determined by the department. The practice of certified dental 32 assisting may be conducted in the office of any licensed dentist or in 33 any appropriately equipped school or public institution but must be done 34 under the direct personal supervision of a licensed dentist. Direct 35 personal supervision, for purposes of this section, means supervision of 36 dental procedures based on instructions given by a licensed dentist in 37 the course of a procedure who remains in the dental office where the 38 supportive services are being performed, personally diagnoses the condi- 39 tion to be treated, personally authorizes the procedures, and before 40 dismissal of the patient, who remains the responsibility of the licensed 41 dentist, evaluates the services performed by the dental assistant. Noth- 42 ing herein authorizes a dental assistant to perform any of the services 43 or functions defined as part of the practice of dental hygiene in 44 accordance with the provisions of subdivision one of section sixty-six 45 hundred six of this article, except those functions authorized pursuant 46 to this section. All dental supportive services provided in this section 47 may be performed by currently registered dental hygienists under a 48 dentist's supervision OR BY A REGISTERED DENTAL HYGIENIST WORKING FOR A 49 HOSPITAL AS DEFINED IN ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW WHO 50 PRACTICES IN COLLABORATION WITH A LICENSED DENTIST IN ACCORDANCE WITH 51 SUBDIVISION ONE OF SECTION SIXTY-SIX HUNDRED SIX OF THIS ARTICLE, as 52 defined in regulations of the commissioner. 53 S 93. Subdivision 10 of section 6611 of the education law, as amended 54 by chapter 65 of the laws of 2011, is amended to read as follows: 55 10. [Beginning January first, two thousand nine, each] EACH dentist 56 AND REGISTERED DENTAL HYGIENIST WORKING FOR A HOSPITAL AS DEFINED IN S. 2606--C 147 1 ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW WHO PRACTICES IN COLLAB- 2 ORATION WITH A LICENSED DENTIST shall become certified in cardiopulmo- 3 nary resuscitation (CPR) from an approved provider and thereafter main- 4 tain current certification, which shall be included in the mandatory 5 hours of continuing education acceptable for dentists to the extent 6 provided in the commissioner's regulations. In the event the dentist OR 7 REGISTERED DENTAL HYGIENIST cannot physically perform CPR, the commis- 8 sioner's regulations shall allow the dentist OR REGISTERED DENTAL 9 HYGIENIST to make arrangements for another individual in the office to 10 administer CPR. All dental facilities shall have an automatic external 11 defibrillator or other defibrillator at the facility. 12 S 94. Subdivision 2 of section 903 of the education law, as added by 13 chapter 281 of the laws of 2007, is amended to read as follows: 14 2. a. A dental health certificate shall be requested from each 15 student. Each student is requested to furnish a dental health certif- 16 icate at the same time that health certificates are required. An [exam- 17 ination] ASSESSMENT and dental health history of any child may be 18 requested by the local school authorities at any time in their 19 discretion to promote the educational interests of such child. Each 20 certificate shall be signed by a duly licensed dentist, OR A REGISTERED 21 DENTAL HYGIENIST who is authorized by law to practice in this state, and 22 consistent with any applicable written practice agreement, or by a duly 23 licensed dentist OR REGISTERED DENTAL HYGIENIST who is authorized to 24 practice in the jurisdiction in which the [examination] ASSESSMENT was 25 given, provided that the commissioner has determined that such jurisdic- 26 tion has standards of licensure and practice comparable to those of New 27 York. Each such certificate shall describe the dental health condition 28 of the student when the [examination] ASSESSMENT was made, which shall 29 not be more than twelve months prior to the commencement of the school 30 year in which the [examination] ASSESSMENT is requested, and shall state 31 whether such student is in fit condition of dental health to permit his 32 or her attendance at the public schools. 33 b. A notice of request for dental health certificates shall be 34 distributed at the same time that parents or person in parental 35 relationship to students are notified of health examination requirements 36 and shall state that a list of DENTAL PRACTICES, dentists AND REGISTERED 37 DENTAL HYGIENISTS to which children [who need comprehensive dental exam- 38 inations] may be referred for [treatment] DENTAL SERVICES on a free or 39 reduced cost basis is available upon request at the child's school. The 40 department shall, in collaboration with the department of health, 41 compile and maintain a list of DENTAL PRACTICES, dentists AND REGISTERED 42 DENTAL HYGIENISTS to which children [who need comprehensive dental exam- 43 inations] may be referred for [treatment] DENTAL SERVICES on a free or 44 reduced cost basis. Such list shall be made available to all public 45 schools and be made available to parents or person in parental relation- 46 ship upon request. The department shall promulgate regulations to ensure 47 the gathering and dissemination of the proper information to interested 48 parties. 49 S 95. Intentionally omitted. 50 S 96. Subdivisions 3 and 5 of section 6542 of the education law, as 51 amended by chapter 48 of the laws of 2012, are amended to read as 52 follows: 53 3. No physician shall employ or supervise more than [two] FOUR physi- 54 cian assistants in his or her private practice. 55 5. Notwithstanding any other provision of this article, nothing shall 56 prohibit a physician employed by or rendering services to the department S. 2606--C 148 1 of corrections and community supervision under contract from supervising 2 no more than [four] SIX physician assistants in his or her practice for 3 the department of corrections and community supervision. 4 S 97. The opening paragraph, and paragraphs (k) and (l) of subdivision 5 1 of section 3510 of the public health law, as added by chapter 175 of 6 the laws of 2006, are amended and four new paragraphs (m), (n), (o) and 7 (p) are added to read as follows: 8 The license, registration or intravenous contrast administration 9 certificate of a [radiological] RADIOLOGIC technologist may be suspended 10 for a fixed period, revoked or annulled, or such licensee censured, 11 reprimanded, subject to a civil penalty not to exceed two thousand 12 dollars for every such violation, or otherwise disciplined, in accord- 13 ance with the provisions and procedures defined in this article, upon 14 decision after due hearing that the individual is guilty of the follow- 15 ing misconduct: 16 (k) using the prefix "Dr.", the word "doctor" or any suffix or affix 17 to indicate or imply that the licensee is a duly licensed practitioner 18 as defined in this article when not so licensed; [or] 19 (l) incompetence or negligence[.]; 20 (M) BEING CONVICTED OF COMMITTING AN ACT CONSTITUTING A CRIME UNDER 21 (I) NEW YORK STATE LAW; (II) FEDERAL LAW; OR (III) THE LAW OF ANOTHER 22 JURISDICTION AND WHICH, IF COMMITTED WITHIN THIS STATE, WOULD HAVE 23 CONSTITUTED A CRIME UNDER NEW YORK STATE LAW; 24 (N) HAVING BEEN FOUND GUILTY OF IMPROPER PROFESSIONAL PRACTICE OR 25 PROFESSIONAL MISCONDUCT BY A DULY AUTHORIZED PROFESSIONAL DISCIPLINARY 26 AGENCY OF ANOTHER STATE WHERE THE CONDUCT UPON WHICH THE FINDING WAS 27 BASED, IF COMMITTED IN NEW YORK STATE, WOULD CONSTITUTE PROFESSIONAL 28 MISCONDUCT UNDER THE LAWS OF NEW YORK STATE; 29 (O) HAVING BEEN FOUND GUILTY IN AN ADJUDICATORY PROCEEDING OF VIOLAT- 30 ING A STATE OR FEDERAL STATUTE OR REGULATION, PURSUANT TO A FINAL DECI- 31 SION OR DETERMINATION, AND WHEN NO APPEAL IS PENDING, OR AFTER RESOL- 32 UTION OF THE PROCEEDING BY STIPULATION OR AGREEMENT, AND WHEN THE 33 VIOLATION WOULD CONSTITUTE PROFESSIONAL MISCONDUCT UNDER THE LAWS OF NEW 34 YORK STATE; OR 35 (P) HAVING HIS OR HER LICENSE TO PRACTICE AS A RADIOLOGIC TECHNOLOGIST 36 REVOKED, SUSPENDED OR HAVING OTHER DISCIPLINARY ACTION TAKEN, OR HAVING 37 HIS OR HER APPLICATION FOR A LICENSE REFUSED, REVOKED OR SUSPENDED OR 38 HAVING VOLUNTARILY OR OTHERWISE SURRENDERED HIS OR HER LICENSE AFTER A 39 DISCIPLINARY ACTION WAS INSTITUTED BY A DULY AUTHORIZED PROFESSIONAL 40 DISCIPLINARY AGENCY OF ANOTHER STATE, WHERE THE CONDUCT RESULTING IN THE 41 REVOCATION, SUSPENSION OR OTHER DISCIPLINARY ACTION INVOLVING THE 42 LICENSE OR REFUSAL, REVOCATION OR SUSPENSION OF AN APPLICATION FOR A 43 LICENSE OR THE SURRENDER OF THE LICENSE WOULD, IF COMMITTED IN NEW YORK 44 STATE, CONSTITUTE PROFESSIONAL MISCONDUCT UNDER THE LAWS OF NEW YORK 45 STATE. A RADIOLOGIC TECHNOLOGIST LICENSED IN NEW YORK STATE WHO IS ALSO 46 LICENSED OR SEEKING LICENSURE IN ANOTHER STATE MUST IMMEDIATELY REPORT 47 TO THE DEPARTMENT ANY REVOCATION, SUSPENSION OR OTHER DISCIPLINARY 48 ACTION INVOLVING THE OUT-OF-STATE LICENSE OR REFUSAL, REVOCATION OR 49 SUSPENSION OF AN APPLICATION FOR AN OUT-OF-STATE LICENSE OR THE SURREN- 50 DER OF THE OUT-OF-STATE LICENSE. 51 S 98. Intentionally omitted. 52 S 99. Intentionally omitted. 53 S 100. Intentionally omitted. 54 S 101. Section 2801-a of the public health law is amended by adding a 55 new subdivision 17 to read as follows: S. 2606--C 149 1 17. (A) DIAGNOSTIC OR TREATMENT CENTERS ESTABLISHED TO PROVIDE HEALTH 2 CARE SERVICES WITHIN THE SPACE OF A RETAIL BUSINESS OPERATION, SUCH AS A 3 PHARMACY, A STORE OPEN TO THE GENERAL PUBLIC OR A SHOPPING MALL, MAY BE 4 OPERATED BY LEGAL ENTITIES FORMED UNDER THE LAWS OF NEW YORK WHOSE 5 STOCKHOLDERS OR MEMBERS, AS APPLICABLE, ARE NOT NATURAL PERSONS AND 6 WHOSE PRINCIPAL STOCKHOLDERS AND MEMBERS, AS APPLICABLE, AND CONTROLLING 7 PERSONS COMPLY WITH ALL APPLICABLE REQUIREMENTS OF THIS SECTION AND 8 DEMONSTRATE, TO THE SATISFACTION OF THE PUBLIC HEALTH AND HEALTH PLAN- 9 NING COUNCIL, SUFFICIENT EXPERIENCE AND EXPERTISE IN DELIVERING HIGH 10 QUALITY HEALTH CARE SERVICES. SUCH DIAGNOSTIC AND TREATMENT CENTERS 11 SHALL BE REFERRED TO IN THIS SECTION AS "LIMITED SERVICES CLINICS". FOR 12 PURPOSES OF THIS SUBDIVISION, THE PUBLIC HEALTH AND HEALTH PLANNING 13 COUNCIL SHALL ADOPT AND AMEND RULES AND REGULATIONS, NOTWITHSTANDING ANY 14 INCONSISTENT PROVISION OF THIS SECTION, TO ADDRESS ANY MATTER IT DEEMS 15 PERTINENT TO THE ESTABLISHMENT OF LIMITED SERVICES CLINICS; PROVIDED 16 THAT SUCH RULES AND REGULATIONS SHALL INCLUDE, BUT NOT BE LIMITED TO, 17 PROVISIONS GOVERNING OR RELATING TO: (I) ANY DIRECT OR INDIRECT CHANGES 18 OR TRANSFERS OF OWNERSHIP INTERESTS OR VOTING RIGHTS IN SUCH ENTITIES OR 19 THEIR STOCKHOLDERS OR MEMBERS, AS APPLICABLE, AND PROVIDE FOR PUBLIC 20 HEALTH AND HEALTH PLANNING COUNCIL APPROVAL OF ANY CHANGE IN CONTROLLING 21 INTERESTS, PRINCIPAL STOCKHOLDERS, CONTROLLING PERSONS, PARENT COMPANY 22 OR SPONSORS; (II) OVERSIGHT OF THE OPERATOR AND ITS SHAREHOLDERS OR 23 MEMBERS, AS APPLICABLE, INCLUDING LOCAL GOVERNANCE OF THE LIMITED 24 SERVICES CLINICS; AND (III) RELATING TO THE CHARACTER AND COMPETENCE AND 25 QUALIFICATIONS OF, AND CHANGES RELATING TO, THE DIRECTORS AND OFFICERS, 26 THE OPERATOR AND ITS PRINCIPAL STOCKHOLDERS, CONTROLLING PERSONS, COMPA- 27 NY OR SPONSORS. 28 (B) THE FOLLOWING PROVISIONS OF THIS SECTION SHALL NOT APPLY TO LIMIT- 29 ED SERVICES CLINICS OPERATED PURSUANT TO THIS SUBDIVISION: (I) PARAGRAPH 30 (B) OF SUBDIVISION THREE OF THIS SECTION, RELATING TO STOCKHOLDERS AND 31 MEMBERS; (II) PARAGRAPH (C) OF SUBDIVISION FOUR OF THIS SECTION, RELAT- 32 ING TO THE DISPOSITION OF STOCK OR VOTING RIGHTS; AND (III) PARAGRAPH 33 (E) OF SUBDIVISION FOUR OF THIS SECTION, RELATING TO THE OWNERSHIP OF 34 STOCK OR MEMBERSHIP. 35 (C) A LIMITED SERVICES CLINIC SHALL BE DEEMED TO BE A "HEALTH CARE 36 PROVIDER" FOR THE PURPOSES OF TITLE TWO-D OF ARTICLE TWO OF THIS CHAP- 37 TER. A PRESCRIBER PRACTICING IN A LIMITED SERVICES CLINIC SHALL NOT BE 38 DEEMED TO BE IN THE EMPLOY OF A PHARMACY OR PRACTICING IN A HOSPITAL FOR 39 PURPOSES OF SUBDIVISION TWO OF SECTION SIXTY-EIGHT HUNDRED SEVEN OF THE 40 EDUCATION LAW. 41 (D) THE COMMISSIONER SHALL PROMULGATE REGULATIONS SETTING FORTH OPERA- 42 TIONAL AND PHYSICAL PLANT STANDARDS FOR LIMITED SERVICES CLINICS, WHICH 43 MAY BE DIFFERENT FROM THE REGULATIONS OTHERWISE APPLICABLE TO DIAGNOSTIC 44 OR TREATMENT CENTERS, INCLUDING, BUT NOT LIMITED TO: DESIGNATING OR 45 LIMITING THE DIAGNOSES AND SERVICES THAT MAY BE PROVIDED; PROHIBITING 46 THE PROVISION OF SERVICES TO PATIENTS TWENTY-FOUR MONTHS OF AGE OR YOUN- 47 GER; AND REQUIREMENTS OR GUIDELINES FOR ADVERTISING AND SIGNAGE, DISCLO- 48 SURE OF OWNERSHIP INTERESTS, INFORMED CONSENT, RECORD KEEPING, REFERRAL 49 FOR TREATMENT AND CONTINUITY OF CARE, CASE REPORTING TO THE PATIENT'S 50 PRIMARY CARE OR OTHER HEALTH CARE PROVIDERS, DESIGN, CONSTRUCTION, 51 FIXTURES, AND EQUIPMENT. IN MAKING REGULATIONS UNDER THIS SECTION, THE 52 COMMISSIONER MAY CONSULT WITH A WORKGROUP INCLUDING BUT NOT LIMITED TO 53 REPRESENTATIVES OF PROFESSIONAL SOCIETIES OF APPROPRIATE HEALTH CARE 54 PROFESSIONALS, INCLUDING THOSE IN PRIMARY CARE AND OTHER SPECIALTIES AND 55 SHALL PROMOTE AND STRENGTHEN PRIMARY CARE; THE INTEGRATION OF SERVICES 56 PROVIDED BY LIMITED SERVICES CLINICS WITH THE SERVICES PROVIDED BY THE S. 2606--C 150 1 PATIENT'S OTHER HEALTH CARE PROVIDERS; AND THE REFERRAL OF PATIENTS TO 2 APPROPRIATE HEALTH CARE PROVIDERS, INCLUDING APPROPRIATE TRANSMISSION OF 3 PATIENT HEALTH RECORDS. 4 (E) NOTWITHSTANDING THIS SUBDIVISION AND ANY OTHER LAW OR REGULATION 5 TO THE CONTRARY AND SUBJECT TO THE PROVISIONS OF SECTION TWENTY-EIGHT 6 HUNDRED TWO OF THIS ARTICLE, A GENERAL HOSPITAL MAY OPERATE A LIMITED 7 SERVICES CLINIC WHICH MEETS THE REGULATION PROMULGATED PURSUANT TO PARA- 8 GRAPH (D) OF THIS SUBDIVISION REGARDING OPERATIONAL AND PHYSICAL PLANT 9 STANDARDS FOR LIMITED SERVICES CLINICS. 10 S 102. Intentionally omitted. 11 S 103. Intentionally omitted. 12 S 104. Section 2801-a of the public health law is amended by adding 13 two new subdivisions 18 and 19 to read as follows: 14 18. (A) THE COMMISSIONER IS AUTHORIZED TO ESTABLISH A PILOT PROGRAM TO 15 ASSIST IN ESTABLISHING OR RESTRUCTURING HEALTH CARE DELIVERY SYSTEMS 16 THROUGH INCREASED CAPITAL INVESTMENT IN HEALTH CARE FACILITIES. PURSU- 17 ANT TO THE PILOT PROGRAM, THE PUBLIC HEALTH AND HEALTH PLANNING COUNCIL 18 SHALL APPROVE THE ESTABLISHMENT, IN ACCORDANCE WITH THE PROVISIONS OF 19 SUBDIVISION THREE OF THIS SECTION, OF NO MORE THAN TEN ENTITIES FORMED 20 UNDER EITHER THIS SUBDIVISION OR SUBDIVISION NINETEEN OF THIS SECTION, 21 AT LEAST ONE OF WHICH SHALL BE THE OPERATOR OF A HOSPITAL OR HOSPITALS 22 IN KINGS COUNTY. SUCH ENTITIES SHALL AFFILIATE, THE EXTENT OF THE AFFIL- 23 IATION TO BE DETERMINED BY THE COMMISSIONER, WITH AT LEAST ONE ACADEMIC 24 MEDICAL INSTITUTION OR TEACHING HOSPITAL APPROVED BY THE COMMISSIONER. 25 (B) IN ORDER TO ACHIEVE SUCCESS IN THE PILOT PROGRAM WHILE MAINTAINING 26 THE HEALTH AND COMMUNITY MISSION OF A HOSPITAL OR HOSPITALS, THE PILOT 27 PROGRAM MAY ADOPT EITHER A PILOT PROGRAM USING THE PROVISIONS OF ARTICLE 28 SEVENTEEN OF THE BUSINESS CORPORATION LAW PERTAINING TO BENEFIT CORPO- 29 RATIONS OR, IN THE ALTERNATIVE, THE PROCESS SET FORTH HEREIN IN SUBDIVI- 30 SION NINETEEN OF THIS SECTION. NOTWITHSTANDING ANY OTHER PROVISIONS TO 31 THE CONTRARY, A PILOT PROGRAM MAY BE A HOSPITAL CORPORATION OWNED OR 32 OPERATED THROUGH A BENEFIT CORPORATION BUT NOT A PUBLICLY TRADED CORPO- 33 RATION. 34 (C) NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, ENTITIES 35 ESTABLISHED PURSUANT TO THIS SUBDIVISION OR SUBDIVISION NINETEEN OF THIS 36 SECTION SHALL BE DEEMED ELIGIBLE TO PARTICIPATE IN DEBT FINANCING 37 PROVIDED BY THE DORMITORY AUTHORITY OF THE STATE OF NEW YORK, LOCAL 38 DEVELOPMENT CORPORATIONS AND ECONOMIC DEVELOPMENT CORPORATIONS. 39 (D) THE FOLLOWING PROVISIONS OF THIS CHAPTER SHALL NOT APPLY TO ENTI- 40 TIES ESTABLISHED PURSUANT TO THIS SUBDIVISION OR SUBDIVISION NINETEEN OF 41 THIS SECTION: (I) PARAGRAPH (B) OF SUBDIVISIONS THREE OF THIS SECTION, 42 RELATING TO STOCKHOLDERS; (II) PARAGRAPH (C) OF SUBDIVISION FOUR OF THIS 43 SECTION, RELATING TO THE DISPOSITION OF STOCK OR VOTING RIGHTS; (III) 44 PARAGRAPH (E) OF SUBDIVISION FOUR OF THIS SECTION, RELATING TO THE 45 OWNERSHIP OF STOCK; AND (IV) PARAGRAPH (A) OF SUBDIVISION THREE OF 46 SECTION FOUR THOUSAND FOUR OF THIS CHAPTER, RELATING TO THE OWNERSHIP OF 47 STOCK. NOTWITHSTANDING THE FOREGOING, THE PUBLIC HEALTH AND HEALTH 48 PLANNING COUNCIL MAY REQUIRE THE DISCLOSURE OF THE IDENTITY OF STOCK- 49 HOLDERS OR OTHER INDIVIDUALS SUCH AS LIMITED PARTNERS, PROVIDED THAT THE 50 NUMBER OF STOCKHOLDERS DOES NOT EXCEED THIRTY-FIVE. 51 (E) THE CORPORATION POWERS AND PURPOSES OF A CORPORATION WHO IS AN 52 OPERATOR PURSUANT TO THIS SUBDIVISION SHALL BE LIMITED TO THE OWNERSHIP 53 AND OPERATION, OR OPERATION, OF A HOSPITAL OR HOSPITALS SPECIFICALLY 54 NAMED AND THE LOCATION OR LOCATIONS OF WHICH ARE SPECIFICALLY DESIGNATED 55 BY STREET ADDRESS, CITY, TOWN, VILLAGE OF LOCALITY AND COUNTY; PROVIDED, 56 HOWEVER, THAT THE CORPORATE POWERS AND PURPOSES MAY ALSO INCLUDE THE S. 2606--C 151 1 OWNERSHIP AND OPERATION, OR OPERATION, OF A CERTIFIED HOME HEALTH AGENCY 2 OR LICENSED HOME CARE SERVICES AGENCY OR AGENCIES AS DEFINED IN ARTICLE 3 THIRTY-SIX OF THIS CHAPTER OR A HOSPICE OR HOSPICES AS DEFINED IN ARTI- 4 CLE FORTY OF THIS CHAPTER, IF THE CORPORATION HAS RECEIVED ALL APPROVALS 5 REQUIRED UNDER SUCH LAW TO OWN AND OPERATE, OR OPERATE, SUCH HOME CARE 6 SERVICE AGENCY OR AGENCIES OR HOSPICE OR HOSPICES. SUCH CORPORATE 7 POWERS AND PURPOSES SHALL NOT BE MODIFIED, AMENDED OR DELETED WITHOUT 8 THE PRIOR APPROVAL OF THE COMMISSIONER. 9 (F) (1) ENTITIES FORMED UNDER THIS SUBDIVISION OR SUBDIVISION NINETEEN 10 OF THIS SECTION SHALL PROVIDE, THAT, IN DISCHARGING THE DUTIES OF THEIR 11 RESPECTIVE POSITIONS, THE BOARD OF DIRECTORS, COMMITTEES OF THE BOARD 12 AND INDIVIDUAL DIRECTORS AND OFFICERS OF AN ENTITY OPERATING PURSUANT TO 13 THIS SUBDIVISION SHALL CONSIDER THE EFFECTS OF ANY ACTION UPON: 14 (A) THE ABILITY OF THE ENTITY TO ACCOMPLISH ITS PURPOSE; 15 (B) THE SHAREHOLDERS OF THE BUSINESS CORPORATION OR PARTNERS IN A 16 PARTNERSHIP; 17 (C) THE EMPLOYEES AND WORKFORCE OF THE BUSINESS; 18 (D) THE INTERESTS OF PATIENTS OF THE HOSPITAL OR HOSPITALS; 19 (E) COMMUNITY AND SOCIETAL CONSIDERATIONS, INCLUDING THOSE OF ANY 20 COMMUNITY IN WHICH FACILITIES OF THE CORPORATION ARE LOCATED; 21 (F) THE LOCAL AND GLOBAL ENVIRONMENT; AND 22 (G) THE SHORT-TERM AND LONG-TERM INTERESTS OF THE ENTITY, INCLUDING 23 BENEFITS THAT MAY ACCRUE FROM ITS LONG TERM PLANS. 24 (2) THE CONSIDERATION OF INTERESTS AND FACTORS IN THE MANNER REQUIRED 25 BY PARAGRAPH ONE OF THIS SUBDIVISION: 26 (A) SHALL NOT CONSTITUTE A VIOLATION OF THE PROVISIONS OF SECTION 27 SEVEN HUNDRED FIFTEEN OR SEVEN HUNDRED SEVENTEEN OF THE BUSINESS CORPO- 28 RATION LAW; AND 29 (B) IS IN ADDITION TO THE ABILITY OF DIRECTORS TO CONSIDER INTERESTS 30 AND FACTORS AS PROVIDED IN SECTION SEVEN HUNDRED SEVENTEEN OF THE BUSI- 31 NESS CORPORATION LAW. 32 (G) A SALE, LEASE, CONVEYANCE, EXCHANGE, TRANSFER, OR OTHER DISPOSI- 33 TION OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF THE CORPORATION SHALL 34 NOT BE EFFECTIVE UNLESS THE TRANSACTION IS APPROVED BY THE COMMISSIONER. 35 (H) NO LATER THAN TWO YEARS AFTER THE ESTABLISHMENT OF A BUSINESS 36 CORPORATION UNDER THIS SUBDIVISION, THE COMMISSIONER SHALL PROVIDE THE 37 GOVERNOR, THE MAJORITY LEADER OF THE SENATE AND THE SPEAKER OF THE 38 ASSEMBLY WITH A WRITTEN EVALUATION OF THE PROGRAM. SUCH EVALUATION SHALL 39 ADDRESS THE OVERALL EFFECTIVENESS OF THE PROGRAM IN ALLOWING FOR ACCESS 40 TO CAPITAL INVESTMENT IN HEALTH CARE FACILITIES AND THE IMPACT SUCH 41 ACCESS MAY HAVE ON THE QUALITY OF CARE PROVIDED BY HOSPITALS OPERATED BY 42 BUSINESS CORPORATIONS ESTABLISHED UNDER THIS SUBDIVISION. 43 19. (A) THE COMMISSIONER MAY ESTABLISH A PROGRAM WHEREBY THE DEPART- 44 MENT ACCEPTS APPLICATIONS FOR DEMONSTRATION PROJECTS IN THE STATE TO 45 DEVELOP, EVALUATE AND IMPLEMENT A FLEXIBLE APPROACH TO ALLOWING PRIVATE 46 CAPITAL INVESTMENTS AND PRIVATE EQUITY INTERESTS IN HOSPITALS. IN LIGHT 47 OF THE SEVERE CONSTRAINTS ON THE AVAILABILITY OF INVESTMENT CAPITAL FOR 48 THE HEALTH CARE SYSTEM IN NEW YORK, DEMONSTRATION PROJECTS SHALL BE 49 DESIGNED TO PROMOTE THE DEVELOPMENT OF NEW SOURCES OF CAPITAL FOR THE 50 OPERATION OF HOSPITALS AND TO EVALUATE THE IMPACT PRIVATE EQUITY INVEST- 51 MENT HAS ON THE QUALITY OF CARE, ACCESS TO CARE AND BENEFIT TO THE 52 HOSPITAL, ITS PATIENTS AND THE SURROUNDING COMMUNITY. THE COMMISSIONER 53 MAY, IN APPROVING A DEMONSTRATION PROJECT, WAIVE THE PROVISIONS OF THIS 54 ARTICLE WHICH RELATE TO THE OWNERSHIP STRUCTURE, PROVIDED THE PUBLIC 55 HEALTH AND HEALTH PLANNING COUNCIL SHALL APPROVE SUCH PROJECT. 56 (B) APPLICANTS SHALL AT A MINIMUM DEMONSTRATE THAT: S. 2606--C 152 1 (I) THE FACILITY OR FACILITIES HAVE HISTORIES OF PROVIDING CARE; 2 (II) THE PROJECT IS COMMITTED TO PRESERVING QUALITY, ACCESS TO CARE 3 AND ACCEPTANCE OF A BROAD MIX OF PAYOR TYPES; 4 (III) THE PROJECT WILL PROVIDE A POSITIVE BENEFIT TO THE HOSPITAL, ITS 5 PATIENTS AND THE COMMUNITY AT LARGE; AND 6 (IV) ALL APPLICABLE DUTIES, PROCEDURES, OBLIGATIONS AND REQUIREMENTS 7 APPLICABLE TO PUBLIC HOSPITALS IN NEW YORK INCLUDING, BUT NOT LIMITED TO 8 CHARITABLE CARE AND SUPPORT, COMMUNITY PLANS AND OBLIGATIONS, PROVISION 9 OF CARE TO THOSE IN NEED AND ALL ATTAINMENT OF QUALITY CARE STANDARDS 10 SET FORTH IN THIS CHAPTER WILL BE ADHERED TO. 11 (C) HOSPITALS PARTICIPATING IN THIS DEMONSTRATION PROGRAM SHALL BE 12 SUBJECT TO ALL OPERATING STANDARDS AS SET FORTH IN THIS CHAPTER AND THE 13 REGULATIONS PROMULGATED PURSUANT THERETO, AND SHALL BE SUBJECT TO ANY 14 PROVISIONS OF THIS CHAPTER FOR FAILURE TO COMPLY WITH SUCH STANDARDS. 15 (D) DEMONSTRATION PROJECTS APPROVED BY THE COMMISSIONER SHALL PROVIDE 16 DETAILED REPORTING NO LESS THAN ANNUALLY TO THE DEPARTMENT IN A FORM AND 17 MANNER TO BE DETERMINED BY THE COMMISSIONER TO INSURE THE GOALS ARE 18 BEING MET. THE COMMISSIONER SHALL PROVIDE THE GOVERNOR, THE TEMPORARY 19 PRESIDENT OF THE SENATE AND THE SPEAKER OF THE ASSEMBLY WITH A WRITTEN 20 REPORT ON THE PROGRAM, INCLUDING DETAILS OF ALL APPLICATIONS RECEIVED, 21 THE BASIS FOR APPROVAL OR DENIAL OF THE APPLICATIONS, AND A FULL EVALU- 22 ATION OF DEMONSTRATION PROJECTS WHICH WERE APPROVED BASED ON THE GOALS 23 OF THE PROGRAM NO LATER THAN TWO YEARS AFTER THE FIRST HOSPITAL MAKES 24 APPLICATION UNDER THE DEMONSTRATION PROGRAM. 25 S 105. Intentionally omitted. 26 S 105-a. Intentionally omitted. 27 S 106. Part S of chapter 56 of the laws of 2012, relating to the 28 excess medical malpractice liability coverage pool, is amended by adding 29 a new section 2-a to read as follows: 30 S 2-A. NOTWITHSTANDING ANY LAW, RULE OR REGULATION TO THE CONTRARY, 31 ONLY PHYSICIANS OR DENTISTS WHO WERE ELIGIBLE, AND FOR WHOM THE SUPER- 32 INTENDENT OF FINANCIAL SERVICES AND THE COMMISSIONER OF HEALTH, OR THEIR 33 DESIGNEE, PURCHASED, WITH FUNDS AVAILABLE IN THE HOSPITAL EXCESS LIABIL- 34 ITY POOL, A FULL OR PARTIAL POLICY FOR EXCESS COVERAGE OR EQUIVALENT 35 EXCESS COVERAGE FOR THE COVERAGE PERIODS ENDING THE THIRTIETH OF JUNE, 36 TWO THOUSAND THIRTEEN, SHALL BE ELIGIBLE TO APPLY FOR SUCH COVERAGE FOR 37 THE COVERAGE PERIOD BEGINNING THE FIRST OF JULY, TWO THOUSAND THIRTEEN. 38 A GENERAL HOSPITAL MAY CERTIFY ADDITIONAL ELIGIBLE PHYSICIANS OR 39 DENTISTS UP TO THE TOTAL NUMBER OF ELIGIBLE PHYSICIANS AND DENTISTS 40 CERTIFIED BY THE GENERAL HOSPITAL FOR THE COVERAGE PERIOD ENDING THE 41 THIRTIETH DAY OF JUNE, TWO THOUSAND THIRTEEN. 42 S 107. Intentionally omitted. 43 S 108. Intentionally omitted. 44 S 109. Intentionally omitted. 45 S 110. Intentionally omitted. 46 S 111. Intentionally omitted. 47 S 112. Intentionally omitted. 48 S 113. Intentionally omitted. 49 S 114. Intentionally omitted. 50 S 115. Intentionally omitted. 51 S 116. Intentionally omitted. 52 S 117. Intentionally omitted. 53 S 118. Intentionally omitted. 54 S 119. Notwithstanding any inconsistent provision of law, rule or 55 regulation, for purposes of implementing the provisions of the public 56 health law and the social services law, references to titles XIX and XXI S. 2606--C 153 1 of the federal social security act in the public health law and the 2 social services law shall be deemed to include and also to mean any 3 successor titles thereto under the federal social security act. 4 S 120. Notwithstanding any inconsistent provision of law, rule or 5 regulation, the effectiveness of the provisions of sections 2807 and 6 3614 of the public health law, section 18 of chapter 2 of the laws of 7 1988, and 18 NYCRR 505.14(h), as they relate to time frames for notice, 8 approval or certification of rates of payment, are hereby suspended and 9 without force or effect for purposes of implementing the provisions of 10 this act. 11 S 121. Intentionally omitted. 12 S 122. Section 2807 of the public health law is amended by adding a 13 new subdivision 20 to read as follows: 14 20. MEDICAL ASSISTANCE RECOUPMENTS AND REDUCTIONS. NOTWITHSTANDING ANY 15 OTHER PROVISION OF LAW TO THE CONTRARY, ON AND AFTER APRIL FIRST, TWO 16 THOUSAND NINE, ANY RECOUPMENTS OR REDUCTIONS IN MEDICAL ASSISTANCE 17 PAYMENTS, INCLUDING BUT NOT LIMITED TO ARTICLE TWENTY-EIGHT FACILITIES 18 LICENSED PURSUANT TO THIS ARTICLE OR FISCAL INTERMEDIARIES OPERATING 19 PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES 20 LAW SHALL NOT BE SUBJECT TO INTEREST OR INTEREST PENALTIES. 21 S 123. Section 2808 of the public health law is amended by adding a 22 new subdivision 27 to read as follows: 23 27. MEDICAL ASSISTANCE RECOUPMENTS AND REDUCTIONS. NOTWITHSTANDING 24 ANY OTHER PROVISION OF LAW TO THE CONTRARY, ON AND AFTER APRIL FIRST, 25 TWO THOUSAND NINE, ANY RECOUPMENTS OR REDUCTIONS IN MEDICAL ASSISTANCE 26 PAYMENTS, INCLUDING BUT NOT LIMITED TO ARTICLE TWENTY-EIGHT FACILITIES 27 LICENSED PURSUANT TO THIS ARTICLE OR FISCAL INTERMEDIARIES OPERATING 28 PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES 29 LAW SHALL NOT BE SUBJECT TO INTEREST OR INTEREST PENALTIES. 30 S 124. Short title. Sections one hundred twenty-four through one 31 hundred twenty-six of this act shall be known and may be cited as the 32 "home care stabilization act". 33 S 125. The public health law is amended by adding two new sections 34 3614-d and 3621 to read as follows: 35 S 3614-D. STANDARDS FOR PROMPT, FAIR AND EQUITABLE SETTLEMENT OF 36 CLAIMS FOR PAYMENTS FOR PERSONAL CARE, HOME HEALTH CARE SERVICES OR 37 OTHER LONG TERM CARE SERVICES. 1. IN THE PROCESSING OF CLAIMS SUBMITTED 38 UNDER CONTRACTS OR AGREEMENTS ISSUED OR ENTERED INTO OR BETWEEN CERTI- 39 FIED HOME HEALTH AGENCIES, LONG TERM HOME HEALTH CARE PROGRAMS, LICENSED 40 HOME CARE SERVICES PROGRAMS, FISCAL INTERMEDIARIES OPERATING PURSUANT TO 41 SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES LAW, INSURERS, 42 MANAGED LONG TERM CARE PLANS, MANAGED CARE PLANS OR ORGANIZATIONS 43 LICENSED OR OPERATED PURSUANT TO THE PROVISIONS OF THIS CHAPTER, THE 44 SOCIAL SERVICES LAW OR THE INSURANCE LAW AND FOR ALL BILLS FOR PERSONAL 45 CARE, HOME HEALTH CARE SERVICES, CONSUMER DIRECTED PERSONAL ASSISTANCE 46 SERVICES OPERATING PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE 47 SOCIAL SERVICES LAW OR OTHER LONG TERM CARE SERVICES RENDERED BY 48 LICENSED HOME CARE SERVICES PROGRAMS, CERTIFIED HOME HEALTH AGENCIES, 49 LONG TERM HOME HEALTH CARE PROGRAMS OR A FISCAL INTERMEDIARY OPERATING 50 PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES 51 LAW PURSUANT TO SUCH CONTRACTS OR AGREEMENTS, ANY CERTIFIED HOME HEALTH 52 CARE AGENCY, LONG TERM HOME HEALTH CARE PROGRAM, INSURER, MANAGED LONG 53 TERM CARE PLAN, MANAGED CARE PLAN OR ORGANIZATION LICENSED OR OPERATED 54 PURSUANT TO THE PROVISIONS OF THIS CHAPTER, THE SOCIAL SERVICES LAW, THE 55 EXECUTIVE LAW OR THE INSURANCE LAW, SHALL ADHERE TO THE FOLLOWING STAND- 56 ARDS: S. 2606--C 154 1 (A) SHALL PAY A CLEAN CLAIM SUBMITTED BY A LICENSED HOME CARE SERVICES 2 PROGRAM, CERTIFIED HOME HEALTH AGENCY, LONG TERM HOME HEALTH CARE 3 PROGRAM OR A FISCAL INTERMEDIARY OPERATING PURSUANT TO SECTION THREE 4 HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES LAW WITHIN THIRTY DAYS OF 5 RECEIPT OF THE CLEAN CLAIM FOR SERVICES RENDERED THAT IS TRANSMITTED VIA 6 THE INTERNET OR ELECTRONIC MAIL, OR FORTY-FIVE DAYS OF RECEIPT OF THE 7 CLEAN CLAIM FOR SERVICES RENDERED THAT IS SUBMITTED BY OTHER MEANS, SUCH 8 AS PAPER OR FACSIMILE; 9 (B) SHALL PAY ANY UNDISPUTED PORTION OF A CLAIM AS A CLEAN CLAIM AS 10 SET FORTH IN PARAGRAPH (A) OF THIS SUBDIVISION SUBMITTED BY A LICENSED 11 HOME CARE SERVICES PROGRAM, CERTIFIED HOME HEALTH AGENCY, LONG TERM HOME 12 HEALTH CARE PROGRAM OR FISCAL INTERMEDIARY OPERATING PURSUANT TO SECTION 13 THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES LAW; 14 (C) NOTIFY ANY SUCH AGENCY, PROGRAM OR FISCAL INTERMEDIARY IN WRITING 15 WITHIN FIFTEEN CALENDAR DAYS OF THE RECEIPT OF AN INITIAL CLAIM OF ALL 16 SPECIFIC DEFECTS OR DISPUTES OF SUCH CLAIM AND SPECIFICALLY REQUEST IN 17 WRITING THE ADDITIONAL INFORMATION OR REMEDY NEEDED TO PROCESS ANY 18 DISPUTED PORTIONS OF THE CLAIM; AND 19 (D) ANY DISPUTED CLAIM REMEDIED SHALL BE PAID AS A CLEAN CLAIM AS SET 20 FORTH IN PARAGRAPH (A) OF THIS SUBDIVISION. 21 2. FOR THE PURPOSES OF THIS SECTION, A "CLEAN CLAIM" SHALL: 22 (A) IDENTIFY THE LICENSED HOME CARE SERVICES PROGRAM, CERTIFIED HOME 23 HEALTH AGENCY, LONG TERM HOME HEALTH CARE PROGRAM OR FISCAL INTERMEDIARY 24 OPERATING PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL 25 SERVICES LAW; 26 (B) SUFFICIENTLY IDENTIFY THE ELIGIBLE COVERED PERSON; 27 (C) LIST THE DATE AND PLACE OF SERVICE; 28 (D) SUBSTANTIATE THE APPROPRIATENESS OF THE SERVICE PROVIDED; 29 (E) STATE IF PRIOR AUTHORIZATION IS REQUIRED FOR SUCH ELIGIBLE COVERED 30 PERSON AND SERVICE; AND 31 (F) STATE ANY DOCUMENTATION AS REASONABLY REQUIRED BY ANY ENTITY 32 REFERENCED IN THIS SECTION. 33 3. EACH CLEAN CLAIM OR PAYMENT FOR SERVICES PROCESSED IN VIOLATION OF 34 THIS SECTION SHALL CONSTITUTE A SEPARATE VIOLATION. IN ADDITION TO THE 35 PENALTIES PROVIDED IN THIS CHAPTER, ANY ORGANIZATION OR CORPORATION THAT 36 FAILS TO ADHERE TO THE STANDARDS CONTAINED IN THIS SECTION SHALL BE 37 OBLIGATED TO PAY TO CERTIFIED HOME HEALTH AGENCIES, LONG TERM HOME 38 HEALTH CARE PROGRAMS, LICENSED HOME HEALTH CARE PROGRAMS OR FISCAL 39 INTERMEDIARIES OPERATING PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F 40 OF THE SOCIAL SERVICES LAW IN FULL SETTLEMENT OF THE BILL, CLAIM OR 41 PAYMENT PLUS INTEREST ON THE AMOUNT OF SUCH BILL, CLAIM OR PAYMENT OF 42 THE GREATER OF THE RATE EQUAL TO THE RATE SET BY THE COMMISSIONER OF 43 TAXATION AND FINANCE FOR CORPORATE TAXES PURSUANT TO PARAGRAPH ONE OF 44 SUBSECTION (E) OF SECTION ONE THOUSAND NINETY-SIX OF THE TAX LAW OR 45 TWELVE PERCENT PER ANNUM, TO BE COMPUTED FROM THE DATE THE BILL, CLAIM 46 OR PAYMENT WAS REQUIRED TO BE MADE. 47 S 3621. MEDICAL ASSISTANCE RECOUPMENTS AND REDUCTIONS. NOTWITHSTAND- 48 ING ANY OTHER PROVISION OF LAW TO THE CONTRARY, ON AND AFTER APRIL 49 FIRST, TWO THOUSAND NINE, ANY RECOUPMENTS OR REDUCTIONS IN MEDICAL 50 ASSISTANCE PAYMENTS FOR LICENSED HOME CARE SERVICES AGENCIES, CERTIFIED 51 HOME HEALTH AGENCIES LICENSED PURSUANT TO THIS ARTICLE OR FISCAL INTER- 52 MEDIARIES OPERATING PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF 53 THE SOCIAL SERVICES LAW SHALL NOT BE SUBJECT TO INTEREST OR INTEREST 54 PENALTIES. 55 S 126. Section 4406-c of the public health law is amended by adding a 56 new subdivision 9 to read as follows: S. 2606--C 155 1 9. NOTWITHSTANDING ANY INCONSISTENT PROVISION OF LAW, CONTRACTS WITH 2 CERTIFIED HOME HEALTH AGENCIES, LONG TERM HOME HEALTH CARE PROGRAMS, 3 LICENSED HOME CARE SERVICES PROGRAMS OR FISCAL INTERMEDIARIES OPERATING 4 PURSUANT TO SECTION THREE HUNDRED SIXTY-FIVE-F OF THE SOCIAL SERVICES 5 LAW TO PROVIDE HOME CARE AIDE SERVICES AS DEFINED IN SECTION THIRTY-SIX 6 HUNDRED FOURTEEN-C OF THIS CHAPTER OR CONSUMER DIRECTED PERSONAL ASSIST- 7 ANCE SERVICES AS AUTHORIZED PURSUANT TO SECTION THREE HUNDRED 8 SIXTY-FIVE-F OF THE SOCIAL SERVICES LAW SHALL AT A MINIMUM ENSURE THAT 9 THE RESOURCES MADE AVAILABLE BY SUCH CONTRACTS SHALL SUPPORT COMPEN- 10 SATION FOR PERSONS PROVIDING SUCH HOME CARE AIDE SERVICES AND CONSUMER 11 DIRECTED PERSONAL ASSISTANCE SERVICES TO ENSURE THE RETENTION OF A QUAL- 12 IFIED WORKFORCE CAPABLE OF PROVIDING HIGH QUALITY CARE TO RECIPIENTS OF 13 SUCH SERVICES CONSISTENT WITH THE PROVISIONS OF SUCH SECTION. 14 S 126-a. Paragraphs 11, 12, 13, 14, 16 and 17 of subsection (a) of 15 section 3217-a of the insurance law, as added by chapter 705 of the laws 16 of 1996, are amended and three new paragraphs 16-a, 18 and 19 are added 17 to read as follows: 18 (11) where applicable, notice that an insured enrolled in a managed 19 care product OR A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF 20 PROVIDERS offered by the insurer may obtain a referral to a health care 21 provider outside of the insurer's network or panel when the insurer does 22 not have a health care provider with appropriate training and experience 23 in the network or panel to meet the particular health care needs of the 24 insured and the procedure by which the insured can obtain such referral; 25 (12) where applicable, notice that an insured enrolled in a managed 26 care product OR A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF 27 PROVIDERS offered by the insurer with a condition which requires ongoing 28 care from a specialist may request a standing referral to such a 29 specialist and the procedure for requesting and obtaining such a stand- 30 ing referral; 31 (13) where applicable, notice that an insured enrolled in a managed 32 care product OR A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF 33 PROVIDERS offered by the insurer with (i) a life-threatening condition 34 or disease, or (ii) a degenerative and disabling condition or disease, 35 either of which requires specialized medical care over a prolonged peri- 36 od of time may request a specialist responsible for providing or coordi- 37 nating the insured's medical care and the procedure for requesting and 38 obtaining such a specialist; 39 (14) where applicable, notice that an insured enrolled in a managed 40 care product OR A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF 41 PROVIDERS offered by the insurer with (i) a life-threatening condition 42 or disease, or (ii) a degenerative and disabling condition or disease, 43 either of which requires specialized medical care over a prolonged peri- 44 od of time, may request access to a specialty care center and the proce- 45 dure by which such access may be obtained; 46 (16) notice of all appropriate mailing addresses and telephone numbers 47 to be utilized by insureds seeking information or authorization; [and] 48 (16-A) WHERE APPLICABLE, NOTICE THAT AN INSURED SHALL HAVE DIRECT 49 ACCESS TO PRIMARY AND PREVENTIVE OBSTETRIC AND GYNECOLOGIC SERVICES 50 INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINA- 51 TIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, FROM A QUALIFIED 52 PROVIDER OF SUCH SERVICES OF HER CHOICE FROM WITHIN THE PLAN OR FOR ANY 53 CARE RELATED TO A PREGNANCY; 54 (17) where applicable, a listing by specialty, which may be in a sepa- 55 rate document that is updated annually, of the name, address, and tele- 56 phone number of all participating providers, including facilities, and S. 2606--C 156 1 in addition, in the case of physicians, board certification[.], 2 LANGUAGES SPOKEN AND AFFILIATION WITH PARTICIPATING HOSPITALS. THE LIST- 3 ING SHALL ALSO BE POSTED ON THE INSURER'S WEBSITE AND THE INSURER SHALL 4 UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF THE ADDITION OR TERMINATION OF 5 A PROVIDER FROM THE INSURER'S NETWORK OR A CHANGE IN A PHYSICIAN'S 6 HOSPITAL AFFILIATION; 7 (18) A DESCRIPTION OF THE METHOD BY WHICH AN INSURED MAY SUBMIT A 8 CLAIM FOR HEALTH CARE SERVICES, INCLUDING THROUGH THE INTERNET, ELEC- 9 TRONIC MAIL OR BY FACSIMILE; AND 10 (19) WHERE APPLICABLE, WHEN A POLICY OFFERS OUT-OF-NETWORK COVERAGE 11 PURSUANT TO SUBSECTIONS (B) AND (C) OF SECTION THREE THOUSAND TWO 12 HUNDRED FORTY OF THIS ARTICLE: 13 (A) A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY THE INSURER TO 14 DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK HEALTH CARE SERVICES; 15 (B) A DESCRIPTION OF THE AMOUNT THAT THE INSURER WILL REIMBURSE UNDER 16 THE METHODOLOGY FOR OUT-OF-NETWORK HEALTH CARE SERVICES SET FORTH AS A 17 PERCENTAGE OF THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK HEALTH 18 CARE SERVICES; AND 19 (C) EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY BILLED 20 OUT-OF-NETWORK HEALTH CARE SERVICES. 21 S 127. Paragraphs 11 and 12 of subsection (b) of section 3217-a of the 22 insurance law, as added by chapter 705 of the laws of 1996, are amended 23 and three new paragraphs 13, 14 and 15 are added to read as follows: 24 (11) where applicable, provide the written application procedures and 25 minimum qualification requirements for health care providers to be 26 considered by the insurer for participation in the insurer's network for 27 a managed care product; [and] 28 (12) disclose such other information as required by the superinten- 29 dent, provided that such requirements are promulgated pursuant to the 30 state administrative procedure act[.]; 31 (13) DISCLOSE WHETHER A HEALTH CARE PROVIDER SCHEDULED TO PROVIDE A 32 HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER; 33 (14) WHERE APPLICABLE, WITH RESPECT TO OUT-OF-NETWORK COVERAGE, 34 DISCLOSE THE DOLLAR AMOUNT THAT THE INSURER WILL PAY FOR A SPECIFIC 35 OUT-OF-NETWORK HEALTH CARE SERVICE; AND 36 (15) PROVIDE INFORMATION IN WRITING AND THROUGH AN INTERNET WEBSITE 37 THAT REASONABLY PERMITS AN INSURED OR PROSPECTIVE INSURED TO DETERMINE 38 THE ANTICIPATED OUT-OF-POCKET COST FOR OUT-OF-NETWORK HEALTH CARE 39 SERVICES IN A GEOGRAPHICAL AREA OR ZIP CODE BASED UPON THE DIFFERENCE 40 BETWEEN WHAT THE INSURER WILL REIMBURSE FOR OUT-OF-NETWORK HEALTH CARE 41 SERVICES AND THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK HEALTH CARE 42 SERVICES. 43 S 128. Section 3217-a of the insurance law is amended by adding a new 44 subsection (f) to read as follows: 45 (F) FOR PURPOSES OF THIS SECTION, "USUAL AND CUSTOMARY COST" SHALL 46 MEAN THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH 47 CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME OR SIMILAR SPECIALTY 48 AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING 49 DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER- 50 INTENDENT. THE NONPROFIT ORGANIZATION SHALL NOT BE AFFILIATED WITH AN 51 INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THIS CHAPTER, A 52 MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE 53 FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTI- 54 FIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW. 55 S 129. Section 3217-d of the insurance law is amended by adding a new 56 subsection (d) to read as follows: S. 2606--C 157 1 (D) AN INSURER THAT ISSUES A COMPREHENSIVE POLICY THAT UTILIZES A 2 NETWORK OF PROVIDERS AND IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT 3 AS DEFINED IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT HUNDRED ONE 4 OF THIS CHAPTER, SHALL PROVIDE ACCESS TO OUT-OF-NETWORK SERVICES 5 CONSISTENT WITH THE REQUIREMENTS OF SUBSECTION (A) OF SECTION FOUR THOU- 6 SAND EIGHT HUNDRED FOUR OF THIS CHAPTER, SUBSECTIONS (G-6) AND (G-7) OF 7 SECTION FOUR THOUSAND NINE HUNDRED OF THIS CHAPTER, SUBSECTIONS (A-1) 8 AND (A-2) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER, 9 PARAGRAPHS THREE AND FOUR OF SUBSECTION (B) OF SECTION FOUR THOUSAND 10 NINE HUNDRED TEN OF THIS CHAPTER, AND SUBPARAGRAPHS (C) AND (D) OF PARA- 11 GRAPH FOUR OF SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED FOUR- 12 TEEN OF THIS CHAPTER. 13 S 130. Section 3224-a of the insurance law is amended by adding a new 14 subsection (j) to read as follows: 15 (J) AN INSURER OR AN ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED 16 PURSUANT TO ARTICLE FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER OR ARTI- 17 CLE FORTY-FOUR OF THE PUBLIC HEALTH LAW SHALL ACCEPT CLAIMS SUBMITTED BY 18 A POLICYHOLDER OR COVERED PERSON THROUGH THE INTERNET, ELECTRONIC MAIL 19 OR BY FACSIMILE. 20 S 131. The insurance law is amended by adding a new section 3240 to 21 read as follows: 22 S 3240. NETWORK COVERAGE. (A) AN INSURER, A CORPORATION ORGANIZED 23 PURSUANT TO ARTICLE FORTY-THREE OF THIS CHAPTER, OR A MUNICIPAL COOPER- 24 ATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF 25 THIS CHAPTER THAT ISSUES A HEALTH INSURANCE POLICY OR CONTRACT WITH A 26 NETWORK OF HEALTH CARE PROVIDERS SHALL ENSURE THAT THE NETWORK IS 27 ADEQUATE TO MEET THE HEALTH NEEDS OF INSUREDS AND PROVIDE AN APPROPRIATE 28 CHOICE OF PROVIDERS SUFFICIENT TO RENDER THE SERVICES COVERED UNDER THE 29 POLICY OR CONTRACT. THE SUPERINTENDENT SHALL REVIEW THE NETWORK OF 30 HEALTH CARE PROVIDERS FOR ADEQUACY AT THE TIME OF THE SUPERINTENDENT'S 31 INITIAL APPROVAL OF A HEALTH INSURANCE POLICY OR CONTRACT; AT LEAST 32 EVERY THREE YEARS THEREAFTER; AND UPON APPLICATION FOR EXPANSION OF ANY 33 SERVICE AREA ASSOCIATED WITH THE POLICY OR CONTRACT. TO THE EXTENT THAT 34 THE NETWORK HAS BEEN DETERMINED BY THE COMMISSIONER OF HEALTH TO MEET 35 THE STANDARDS SET FORTH IN SUBDIVISION FIVE OF SECTION FOUR THOUSAND 36 FOUR HUNDRED THREE OF THE PUBLIC HEALTH LAW, SUCH NETWORK SHALL BE 37 DEEMED ADEQUATE BY THE SUPERINTENDENT. 38 (B) AN INSURER, A CORPORATION ORGANIZED PURSUANT TO ARTICLE 39 FORTY-THREE OF THIS CHAPTER, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN 40 CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH 41 MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE 42 PUBLIC HEALTH LAW, THAT PROVIDES COVERAGE FOR OUT-OF-NETWORK SERVICES 43 SHALL PROVIDE SIGNIFICANT COVERAGE OF THE USUAL AND CUSTOMARY COSTS OF 44 OUT-OF-NETWORK HEALTH CARE SERVICES. 45 (C) AN INSURER, A CORPORATION ORGANIZED PURSUANT TO ARTICLE 46 FORTY-THREE OF THIS CHAPTER, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN 47 CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH 48 MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR OF THE 49 PUBLIC HEALTH LAW, THAT PROVIDES COVERAGE FOR OUT-OF-NETWORK SERVICES 50 SHALL OFFER AT LEAST ONE POLICY OR CONTRACT OPTION IN EACH GEOGRAPHICAL 51 REGION COVERED THAT PROVIDES COVERAGE FOR AT LEAST EIGHTY PERCENT OF THE 52 USUAL AND CUSTOMARY COST OF OUT-OF-NETWORK HEALTH CARE SERVICES AFTER 53 IMPOSITION OF A DEDUCTIBLE. 54 (D) FOR THE PURPOSES OF THIS SECTION "USUAL AND CUSTOMARY COST" SHALL 55 MEAN THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH 56 CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME OR SIMILAR SPECIALTY S. 2606--C 158 1 AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING 2 DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER- 3 INTENDENT. THE NONPROFIT ORGANIZATION SHALL NOT BE AFFILIATED WITH AN 4 INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE OF THIS ARTICLE, A 5 MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE 6 FORTY-SEVEN OF THIS CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTI- 7 FIED PURSUANT TO ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW. 8 S 132. Section 4306-c of the insurance law is amended by adding a new 9 subsection (d) to read as follows: 10 (D) A CORPORATION, INCLUDING A MUNICIPAL COOPERATIVE HEALTH BENEFIT 11 PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS CHAPTER, THAT 12 ISSUES A COMPREHENSIVE POLICY THAT UTILIZES A NETWORK OF PROVIDERS AND 13 IS NOT A MANAGED CARE HEALTH INSURANCE CONTRACT AS DEFINED IN SUBSECTION 14 (C) OF SECTION FOUR THOUSAND EIGHT HUNDRED ONE OF THIS CHAPTER, SHALL 15 PROVIDE ACCESS TO OUT-OF-NETWORK SERVICES CONSISTENT WITH THE REQUIRE- 16 MENTS OF SUBSECTION (A) OF SECTION FOUR THOUSAND EIGHT HUNDRED FOUR OF 17 THIS CHAPTER, SUBSECTIONS (G-6) AND (G-7) OF SECTION FOUR THOUSAND NINE 18 HUNDRED OF THIS CHAPTER, SUBSECTIONS (A-1) AND (A-2) OF SECTION FOUR 19 THOUSAND NINE HUNDRED FOUR OF THIS CHAPTER, PARAGRAPHS THREE AND FOUR OF 20 SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF THIS CHAP- 21 TER, AND SUBPARAGRAPHS (C) AND (D) OF PARAGRAPH FOUR OF SUBSECTION (B) 22 OF SECTION FOUR THOUSAND NINE HUNDRED FOURTEEN OF THIS CHAPTER. 23 S 133. Paragraphs 11, 12, 13, 14, 16-a, 17, and 18 of subsection (a) 24 of section 4324 of the insurance law, as added by chapter 705 of the 25 laws of 1996, paragraph 16-a as added by chapter 554 of the laws of 26 2002, are amended and two new paragraphs 19 and 20 are added to read as 27 follows: 28 (11) where applicable, notice that a subscriber enrolled in a managed 29 care product OR A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF 30 PROVIDERS offered by the corporation may obtain a referral to a health 31 care provider outside of the corporation's network or panel when the 32 corporation does not have a health care provider with appropriate train- 33 ing and experience in the network or panel to meet the particular health 34 care needs of the subscriber and the procedure by which the subscriber 35 can obtain such referral; 36 (12) where applicable, notice that a subscriber enrolled in a managed 37 care product OR A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF 38 PROVIDERS offered by the corporation with a condition which requires 39 ongoing care from a specialist may request a standing referral to such a 40 specialist and the procedure for requesting and obtaining such a stand- 41 ing referral; 42 (13) where applicable, notice that a subscriber enrolled in a managed 43 care product OR A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF 44 PROVIDERS offered by the corporation with (i) a life-threatening condi- 45 tion or disease, or (ii) a degenerative and disabling condition or 46 disease, either of which requires specialized medical care over a 47 prolonged period of time may request a specialist responsible for 48 providing or coordinating the subscriber's medical care and the proce- 49 dure for requesting and obtaining such a specialist; 50 (14) where applicable, notice that a subscriber enrolled in a managed 51 care product OR A COMPREHENSIVE CONTRACT THAT UTILIZES A NETWORK OF 52 PROVIDERS offered by the corporation with (i) a life-threatening condi- 53 tion or disease, or (ii) a degenerative and disabling condition or 54 disease, either of which requires specialized medical care over a 55 prolonged period of time may request access to a specialty care center 56 and the procedure by which such access may be obtained; S. 2606--C 159 1 (16-a) where applicable, notice that an enrollee shall have direct 2 access to primary and preventive obstetric and gynecologic services 3 INCLUDING ANNUAL EXAMINATIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINA- 4 TIONS, AND TREATMENT OF ACUTE GYNECOLOGIC CONDITIONS, from a qualified 5 provider of such services of her choice from within the plan [for no 6 fewer than two examinations annually for such services] or [to] FOR any 7 care related to A pregnancy [and that additionally, the enrollee shall 8 have direct access to primary and preventive obstetric and gynecologic 9 services required as a result of such annual examinations or as a result 10 of an acute gynecologic condition]; 11 (17) where applicable, a listing by specialty, which may be in a sepa- 12 rate document that is updated annually, of the name, address, and tele- 13 phone number of all participating providers, including facilities, and 14 in addition, in the case of physicians, board certification[; and], 15 LANGUAGES SPOKEN AND AFFILIATION WITH PARTICIPATING HOSPITALS. THE 16 LISTING SHALL ALSO BE POSTED ON THE CORPORATION'S WEBSITE AND THE CORPO- 17 RATION SHALL UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF THE ADDITION OR 18 TERMINATION OF A PROVIDER FROM THE CORPORATION'S NETWORK OR A CHANGE IN 19 A PHYSICIAN'S HOSPITAL AFFILIATION; 20 (18) a description of the mechanisms by which subscribers may partic- 21 ipate in the development of the policies of the corporation[.]; 22 (19) A DESCRIPTION OF THE METHOD BY WHICH A SUBSCRIBER MAY SUBMIT A 23 CLAIM FOR HEALTH CARE SERVICES, INCLUDING THROUGH THE INTERNET, ELEC- 24 TRONIC MAIL OR BY FACSIMILE; AND 25 (20) WHERE APPLICABLE, WHEN A CONTRACT OFFERS OUT-OF-NETWORK COVERAGE 26 PURSUANT TO SUBSECTIONS (B) AND (C) OF SECTION THREE THOUSAND TWO 27 HUNDRED FORTY OF THIS CHAPTER: 28 (A) A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY THE CORPORATION TO 29 DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK HEALTH CARE SERVICES; 30 (B) A DESCRIPTION OF THE AMOUNT THAT THE CORPORATION WILL REIMBURSE 31 UNDER THE METHODOLOGY FOR OUT-OF-NETWORK HEALTH CARE SERVICES SET FORTH 32 AS A PERCENTAGE OF THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK 33 HEALTH CARE SERVICES; AND 34 (C) EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY BILLED 35 OUT-OF-NETWORK HEALTH CARE SERVICES. 36 S 134. Paragraphs 11 and 12 of subsection (b) of section 4324 of the 37 insurance law, as added by chapter 705 of the laws of 1996, are amended 38 and three new paragraphs 13, 14 and 15 are added to read as follows: 39 (11) where applicable, provide the written application procedures and 40 minimum qualification requirements for health care providers to be 41 considered by the corporation for participation in the corporation's 42 network for a managed care product; [and] 43 (12) disclose such other information as required by the superinten- 44 dent, provided that such requirements are promulgated pursuant to the 45 state administrative procedure act[.]; 46 (13) DISCLOSE WHETHER A HEALTH CARE PROVIDER SCHEDULED TO PROVIDE A 47 HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER; 48 (14) WHERE APPLICABLE, WITH RESPECT TO OUT-OF-NETWORK COVERAGE, 49 DISCLOSE THE DOLLAR AMOUNT THAT THE CORPORATION WILL PAY FOR A SPECIFIC 50 OUT-OF-NETWORK HEALTH CARE SERVICE; AND 51 (15) PROVIDE INFORMATION IN WRITING AND THROUGH AN INTERNET WEBSITE 52 THAT REASONABLY PERMITS A SUBSCRIBER OR PROSPECTIVE SUBSCRIBER TO DETER- 53 MINE THE ANTICIPATED OUT-OF-POCKET COST FOR OUT-OF-NETWORK HEALTH CARE 54 SERVICES IN A GEOGRAPHICAL AREA OR ZIP CODE BASED UPON THE DIFFERENCE 55 BETWEEN WHAT THE CORPORATION WILL REIMBURSE FOR OUT-OF-NETWORK HEALTH S. 2606--C 160 1 CARE SERVICES AND THE USUAL AND CUSTOMARY COST FOR OUT-OF-NETWORK HEALTH 2 CARE SERVICES. 3 S 135. Section 4324 of the insurance law is amended by adding a new 4 subsection (f) to read as follows: 5 (F) FOR PURPOSES OF THIS SECTION, "USUAL AND CUSTOMARY COST" SHALL 6 MEAN THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH 7 CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME OR SIMILAR SPECIALTY 8 AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING 9 DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER- 10 INTENDENT. THE NONPROFIT ORGANIZATION SHALL NOT BE AFFILIATED WITH AN 11 INSURER, A CORPORATION SUBJECT TO THIS ARTICLE, A MUNICIPAL COOPERATIVE 12 HEALTH BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THIS 13 CHAPTER, OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO 14 ARTICLE FORTY-FOUR OF THE PUBLIC HEALTH LAW. 15 S 136. Subsection (g-7) of section 4900 of the insurance law is redes- 16 ignated subsection (g-8) and a new subsection (g-7) is added to read as 17 follows: 18 (G-7) "OUT-OF-NETWORK REFERRAL DENIAL" MEANS A DENIAL UNDER A MANAGED 19 CARE PRODUCT AS DEFINED IN SUBSECTION (C) OF SECTION FOUR THOUSAND EIGHT 20 HUNDRED ONE OF THIS CHAPTER OF A REQUEST FOR AN AUTHORIZATION OR REFER- 21 RAL TO AN OUT-OF-NETWORK PROVIDER ON THE BASIS THAT THE HEALTH CARE PLAN 22 HAS A HEALTH CARE PROVIDER IN THE IN-NETWORK BENEFITS PORTION OF ITS 23 NETWORK WITH APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR 24 HEALTH CARE NEEDS OF AN INSURED, AND WHO IS ABLE TO PROVIDE THE 25 REQUESTED HEALTH SERVICE. THE NOTICE OF A DENIAL OF AN OUT-OF-NETWORK 26 REFERRAL PROVIDED TO AN INSURED SHALL INCLUDE INFORMATION EXPLAINING 27 WHAT INFORMATION THE INSURED MUST SUBMIT IN ORDER TO APPEAL THE DENIAL 28 OF AN OUT-OF-NETWORK REFERRAL PURSUANT TO SUBSECTION (A-2) OF SECTION 29 FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. A DENIAL OF AN OUT-OF- 30 NETWORK REFERRAL UNDER THIS SUBSECTION DOES NOT CONSTITUTE AN ADVERSE 31 DETERMINATION AS DEFINED IN THIS ARTICLE. A DENIAL OF AN OUT-OF-NETWORK 32 REFERRAL SHALL NOT BE CONSTRUED TO INCLUDE AN OUT-OF-NETWORK DENIAL AS 33 DEFINED IN SUBSECTION (G-6) OF THIS SECTION. 34 S 137. Subsection (b) of section 4903 of the insurance law, as added 35 by chapter 705 of the laws of 1996, is amended to read as follows: 36 (b) A utilization review agent shall make a utilization review deter- 37 mination involving health care services which require pre-authorization 38 and provide notice of a determination to the insured or insured's desig- 39 nee and the insured's health care provider by telephone and in writing 40 within three business days of receipt of the necessary information. THE 41 NOTIFICATION SHALL IDENTIFY WHETHER THE SERVICES ARE CONSIDERED IN-NET- 42 WORK OR OUT-OF-NETWORK. 43 S 138. Section 4904 of the insurance law is amended by adding a new 44 subsection (a-2) to read as follows: 45 (A-2) AN INSURED OR THE INSURED'S DESIGNEE MAY APPEAL A DENIAL OF AN 46 OUT-OF-NETWORK REFERRAL BY A HEALTH CARE PLAN BY SUBMITTING A WRITTEN 47 STATEMENT FROM THE INSURED'S ATTENDING PHYSICIAN, WHO MUST BE A 48 LICENSED, BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRAC- 49 TICE IN THE SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE INSURED 50 FOR THE HEALTH SERVICE SOUGHT THAT: (1) THE IN-NETWORK HEALTH CARE 51 PROVIDER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO NOT HAVE 52 THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH 53 CARE NEEDS OF THE INSURED FOR THE HEALTH SERVICE; AND (2) RECOMMENDS AN 54 OUT-OF-NETWORK PROVIDER WITH THE APPROPRIATE TRAINING AND EXPERIENCE TO 55 MEET THE PARTICULAR HEALTH CARE NEEDS OF THE INSURED, AND WHO IS ABLE TO 56 PROVIDE THE REQUESTED HEALTH SERVICE. S. 2606--C 161 1 S 139. Subsection (b) of section 4910 of the insurance law is amended 2 by adding a new paragraph 4 to read as follows: 3 (4) (A) THE INSURED HAS HAD AN OUT-OF-NETWORK REFERRAL DENIED ON THE 4 GROUNDS THAT THE HEALTH CARE PLAN HAS A HEALTH CARE PROVIDER IN THE 5 IN-NETWORK BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND 6 EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN INSURED, AND 7 WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE. 8 (B) THE INSURED'S ATTENDING PHYSICIAN, WHO SHALL BE A LICENSED, BOARD 9 CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRACTICE IN THE 10 SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE INSURED FOR THE 11 HEALTH SERVICE SOUGHT, CERTIFIES THAT THE IN-NETWORK HEALTH CARE PROVID- 12 ER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO NOT HAVE THE 13 APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE 14 NEEDS OF AN INSURED, AND RECOMMENDS AN OUT-OF-NETWORK PROVIDER WITH THE 15 APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE 16 NEEDS OF AN INSURED, AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH 17 SERVICE. 18 S 140. Paragraph 4 of subsection (b) of section 4914 of the insurance 19 law is amended by adding a new subparagraph (D) to read as follows: 20 (D) FOR EXTERNAL APPEALS REQUESTED PURSUANT TO PARAGRAPH FOUR OF 21 SUBSECTION (B) OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF THIS TITLE 22 RELATING TO AN OUT-OF-NETWORK REFERRAL, THE EXTERNAL APPEAL AGENT SHALL 23 REVIEW THE UTILIZATION REVIEW AGENT'S FINAL ADVERSE DETERMINATION AND, 24 IN ACCORDANCE WITH THE PROVISIONS OF THIS TITLE, SHALL MAKE A DETERMI- 25 NATION AS TO WHETHER THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE 26 HEALTH PLAN; PROVIDED THAT SUCH DETERMINATION SHALL: 27 (I) BE CONDUCTED ONLY BY ONE OR A GREATER ODD NUMBER OF CLINICAL PEER 28 REVIEWERS; 29 (II) BE ACCOMPANIED BY A WRITTEN STATEMENT: 30 (I) THAT THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE HEALTH 31 CARE PLAN EITHER WHEN THE REVIEWER OR A MAJORITY OF THE PANEL OF REVIEW- 32 ERS DETERMINES, UPON REVIEW OF THE TRAINING AND EXPERIENCE OF THE 33 IN-NETWORK HEALTH CARE PROVIDER OR PROVIDERS PROPOSED BY THE PLAN, THE 34 TRAINING AND EXPERIENCE OF THE REQUESTED OUT-OF-NETWORK PROVIDER, THE 35 CLINICAL STANDARDS OF THE PLAN, THE INFORMATION PROVIDED CONCERNING THE 36 INSURED, THE ATTENDING PHYSICIAN'S RECOMMENDATION, THE INSURED'S MEDICAL 37 RECORD, AND ANY OTHER PERTINENT INFORMATION, THAT THE HEALTH PLAN DOES 38 NOT HAVE A PROVIDER WITH THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET 39 THE PARTICULAR HEALTH CARE NEEDS OF AN INSURED WHO IS ABLE TO PROVIDE 40 THE REQUESTED HEALTH SERVICE, AND THAT THE OUT-OF-NETWORK PROVIDER HAS 41 THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH 42 CARE NEEDS OF AN INSURED, IS ABLE TO PROVIDE THE REQUESTED HEALTH 43 SERVICE, AND IS LIKELY TO PRODUCE A MORE CLINICALLY BENEFICIAL OUTCOME; 44 OR 45 (II) UPHOLDING THE HEALTH PLAN'S DENIAL OF COVERAGE; 46 (III) BE SUBJECT TO THE TERMS AND CONDITIONS GENERALLY APPLICABLE TO 47 BENEFITS UNDER THE EVIDENCE OF COVERAGE UNDER THE HEALTH CARE PLAN; 48 (IV) BE BINDING ON THE PLAN AND THE INSURED; AND 49 (V) BE ADMISSIBLE IN ANY COURT PROCEEDING. 50 S 141. The public health law is amended by adding a new section 23 to 51 read as follows: 52 S 23. DISCLOSURE. 1. A HEALTH CARE PROFESSIONAL SHALL DISCLOSE TO 53 PATIENTS OR PROSPECTIVE PATIENTS THROUGH AN INTERNET WEBSITE OR, UPON 54 REQUEST, IN WRITING THE HEALTH CARE PLANS IN WHICH THE HEALTH CARE 55 PROFESSIONAL IS A PARTICIPATING PROVIDER AND THE HOSPITALS WITH WHICH 56 THE HEALTH CARE PROFESSIONAL IS AFFILIATED. S. 2606--C 162 1 2. IF A HEALTH CARE PROFESSIONAL DOES NOT PARTICIPATE IN THE NETWORK 2 OF A PATIENT'S OR PROSPECTIVE PATIENT'S HEALTH CARE PLAN, THE HEALTH 3 CARE PROFESSIONAL SHALL, UPON RECEIPT OF A REQUEST FROM A PATIENT OR 4 PROSPECTIVE PATIENT, DISCLOSE TO THE PATIENT OR PROSPECTIVE PATIENT IN 5 WRITING A GOOD FAITH ESTIMATED AMOUNT THE HEALTH CARE PROFESSIONAL WILL 6 BILL THE PATIENT OR PROSPECTIVE PATIENT FOR HEALTH CARE SERVICES 7 PROVIDED OR ANTICIPATED TO BE PROVIDED TO THE PATIENT OR PROSPECTIVE 8 PATIENT. 9 3. A HEALTH CARE PROFESSIONAL WHO IS A PHYSICIAN SHALL PROVIDE A 10 PATIENT OR PROSPECTIVE PATIENT WITH THE NAME, PRACTICE NAME, MAILING 11 ADDRESS, AND TELEPHONE NUMBER OF ANY HEALTH CARE PROVIDER OF ANESTHE- 12 SIOLOGY, LABORATORY, PATHOLOGY, RADIOLOGY OR ASSISTANT SURGEON SERVICES 13 PERFORMED IN THE PHYSICIAN'S OFFICE OR COORDINATED OR REFERRED BY THE 14 PHYSICIAN. 15 4. A HEALTH CARE PROFESSIONAL WHO IS A PHYSICIAN SHALL, FOR A 16 PATIENT'S SCHEDULED HOSPITAL ADMISSION OR SCHEDULED OUTPATIENT HOSPITAL 17 SERVICES, PROVIDE A PATIENT AND THE HOSPITAL WITH THE NAME, PRACTICE 18 NAME, MAILING ADDRESS AND TELEPHONE NUMBER OF ANY OTHER PHYSICIAN WHOSE 19 SERVICES WILL BE ARRANGED BY THE PHYSICIAN AND ARE SCHEDULED AT THE TIME 20 OF THE PRE-ADMISSION TESTING, REGISTRATION OR ADMISSION. 21 5. A HOSPITAL SHALL ESTABLISH, UPDATE, MAKE PUBLIC AND POST ON THE 22 HOSPITAL'S WEBSITE, A LIST OF THE HOSPITAL'S STANDARD CHARGES FOR ITEMS 23 AND SERVICES PROVIDED BY THE HOSPITAL, INCLUDING FOR DIAGNOSIS-RELATED 24 GROUPS ESTABLISHED UNDER SECTION 1886(D)(4) OF THE FEDERAL SOCIAL SECU- 25 RITY ACT. 26 6. A HOSPITAL SHALL POST ON THE HOSPITAL'S WEBSITE: (A) THE HEALTH 27 CARE PLANS IN WHICH THE HOSPITAL IS A PARTICIPATING PROVIDER; AND (B) 28 THE NAME, PRACTICE NAME, MAILING ADDRESS, AND TELEPHONE NUMBER OF ANY 29 HEALTH CARE PROFESSIONAL WHO IS A PHYSICIAN AND WHOSE SERVICES WILL BE 30 PROVIDED AT THE HOSPITAL, BUT WILL NOT BE BILLED AS PART OF THE HOSPITAL 31 CHARGES. 32 7. A HOSPITAL SHALL, AT THE EARLIER OF EITHER PRE-ADMISSION TESTING, 33 OUTPATIENT REGISTRATION, OR A NON-EMERGENCY HOSPITAL ADMISSION: (A) 34 PROVIDE A PATIENT OR PROSPECTIVE PATIENT WITH THE NAME, PRACTICE NAME, 35 MAILING ADDRESS AND TELEPHONE NUMBER OF ANY HEALTH CARE PROFESSIONAL WHO 36 IS A PHYSICIAN AND WHOSE SERVICES ARE REASONABLY ANTICIPATED AT THE TIME 37 OF THE PRE-ADMISSION TESTING, REGISTRATION OR ADMISSION AND WILL BE 38 PROVIDED AT THE HOSPITAL, BUT WILL NOT BE BILLED AS PART OF THE HOSPITAL 39 CHARGES, AS REPORTED BY THE PATIENT'S PHYSICIAN; AND (B) DISCLOSE WHETH- 40 ER THE SERVICES OF HEALTH CARE PROFESSIONALS WHO ARE PHYSICIANS AND 41 TYPICALLY PROVIDE HOSPITAL SERVICES SUCH AS, BUT NOT LIMITED TO, ANESTH- 42 ESIOLOGY, PATHOLOGY OR RADIOLOGY ARE BILLED AS PART OF THE HOSPITAL 43 CHARGES. 44 8. FOR PURPOSES OF THIS SECTION: 45 (A) "HEALTH CARE PLAN" MEANS A HEALTH INSURER INCLUDING AN INSURER 46 LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE SUBJECT TO ARTICLE THIR- 47 TY-TWO OF THE INSURANCE LAW; A CORPORATION ORGANIZED PURSUANT TO ARTICLE 48 FORTY-THREE OF THE INSURANCE LAW; A MUNICIPAL COOPERATIVE HEALTH BENEFIT 49 PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW; A 50 HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR 51 OF THIS CHAPTER; OR A SELF-FUNDED EMPLOYEE WELFARE BENEFIT PLAN. 52 (B) "HEALTH CARE PROFESSIONAL" MEANS AN APPROPRIATELY LICENSED, REGIS- 53 TERED OR CERTIFIED HEALTH CARE PROFESSIONAL PURSUANT TO TITLE EIGHT OF 54 THE EDUCATION LAW. 55 S 142. Paragraphs (p-1), (q) and (r) of subdivision 1 of section 4408 56 of the public health law, paragraph (p-1) as added by chapter 554 of the S. 2606--C 163 1 laws of 2002 and paragraphs (q) and (r) as added by chapter 705 of the 2 laws of 1996, are amended and two new paragraphs (s) and (t) are added 3 to read as follows: 4 (p-1) notice that an enrollee shall have direct access to primary and 5 preventive obstetric and gynecologic services INCLUDING ANNUAL EXAMINA- 6 TIONS, CARE RESULTING FROM SUCH ANNUAL EXAMINATIONS, AND TREATMENT OF 7 ACUTE GYNECOLOGIC CONDITIONS, from a qualified provider of such services 8 of her choice from within the plan [for no fewer than two examinations 9 annually for such services] or [to] FOR any care related to A pregnancy 10 [and that additionally, the enrollee shall have direct access to primary 11 and preventive obstetric and gynecologic services required as a result 12 of such annual examinations or as a result of an acute gynecologic 13 condition]; 14 (q) notice of all appropriate mailing addresses and telephone numbers 15 to be utilized by enrollees seeking information or authorization; [and] 16 (r) a listing by specialty, which may be in a separate document that 17 is updated annually, of the name, address and telephone number of all 18 participating providers, including facilities, and, in addition, in the 19 case of physicians, board certification[.], LANGUAGES SPOKEN AND AFFIL- 20 IATION WITH PARTICIPATING HOSPITALS. THE LISTING SHALL ALSO BE POSTED ON 21 THE HEALTH MAINTENANCE ORGANIZATION'S WEBSITE AND THE HEALTH MAINTENANCE 22 ORGANIZATION SHALL UPDATE THE WEBSITE WITHIN FIFTEEN DAYS OF THE ADDI- 23 TION OR TERMINATION OF A PROVIDER FROM THE HEALTH MAINTENANCE ORGANIZA- 24 TION'S NETWORK OR A CHANGE IN A PHYSICIAN'S HOSPITAL AFFILIATION; 25 (S) WHERE APPLICABLE, A DESCRIPTION OF THE METHOD BY WHICH AN ENROLLEE 26 MAY SUBMIT A CLAIM FOR HEALTH CARE SERVICES, INCLUDING THROUGH THE 27 INTERNET, ELECTRONIC MAIL OR BY FACSIMILE; AND 28 (T) WHERE APPLICABLE, WHEN A CONTRACT OFFERS OUT-OF-NETWORK COVERAGE 29 PURSUANT TO SUBSECTIONS (B) AND (C) OF SECTION THREE THOUSAND TWO 30 HUNDRED FORTY OF THE INSURANCE LAW: 31 (I) A CLEAR DESCRIPTION OF THE METHODOLOGY USED BY THE HEALTH MAINTE- 32 NANCE ORGANIZATION TO DETERMINE REIMBURSEMENT FOR OUT-OF-NETWORK HEALTH 33 CARE SERVICES; 34 (II) A DESCRIPTION OF THE AMOUNT THAT THE HEALTH MAINTENANCE ORGANIZA- 35 TION WILL REIMBURSE UNDER THE METHODOLOGY FOR OUT-OF-NETWORK HEALTH CARE 36 SERVICES SET FORTH AS A PERCENTAGE OF THE USUAL AND CUSTOMARY COST FOR 37 OUT-OF-NETWORK HEALTH CARE SERVICES; AND 38 (III) EXAMPLES OF ANTICIPATED OUT-OF-POCKET COSTS FOR FREQUENTLY 39 BILLED OUT-OF-NETWORK HEALTH CARE SERVICES. 40 S 143. Paragraphs (k) and (l) of subdivision 2 of section 4408 of the 41 public health law, as added by chapter 705 of the laws of 1996, are 42 amended and three new paragraphs (m), (n) and (o) are added to read as 43 follows: 44 (k) provide the written application procedures and minimum qualifica- 45 tion requirements for health care providers to be considered by the 46 health maintenance organization; [and] 47 (1) disclose other information as required by the commissioner, 48 provided that such requirements are promulgated pursuant to the state 49 administrative procedure act[.]; 50 (M) DISCLOSE WHETHER A HEALTH CARE PROVIDER SCHEDULED TO PROVIDE A 51 HEALTH CARE SERVICE IS AN IN-NETWORK PROVIDER; 52 (N) WHERE APPLICABLE, WITH RESPECT TO OUT-OF-NETWORK COVERAGE, 53 DISCLOSE THE DOLLAR AMOUNT THAT THE HEALTH MAINTENANCE ORGANIZATION WILL 54 PAY FOR A SPECIFIC OUT-OF-NETWORK HEALTH CARE SERVICE; AND 55 (O) PROVIDE INFORMATION IN WRITING AND THROUGH AN INTERNET WEBSITE 56 THAT REASONABLY PERMITS AN ENROLLEE OR PROSPECTIVE ENROLLEE TO DETERMINE S. 2606--C 164 1 THE ANTICIPATED OUT-OF-POCKET COST FOR OUT-OF-NETWORK HEALTH CARE 2 SERVICES IN A GEOGRAPHICAL AREA OR ZIP CODE BASED UPON THE DIFFERENCE 3 BETWEEN WHAT THE HEALTH MAINTENANCE ORGANIZATION WILL REIMBURSE FOR 4 OUT-OF-NETWORK HEALTH CARE SERVICES AND THE USUAL AND CUSTOMARY COST FOR 5 OUT-OF-NETWORK HEALTH CARE SERVICES. 6 S 144. Section 4408 of the public health law is amended by adding a 7 new subdivision 7 to read as follows: 8 7. FOR PURPOSES OF THIS SECTION, "USUAL AND CUSTOMARY COST" SHALL 9 MEAN THE EIGHTIETH PERCENTILE OF ALL CHARGES FOR THE PARTICULAR HEALTH 10 CARE SERVICE PERFORMED BY A PROVIDER IN THE SAME OR SIMILAR SPECIALTY 11 AND PROVIDED IN THE SAME GEOGRAPHICAL AREA AS REPORTED IN A BENCHMARKING 12 DATABASE MAINTAINED BY A NONPROFIT ORGANIZATION SPECIFIED BY THE SUPER- 13 INTENDENT OF FINANCIAL SERVICES. THE NONPROFIT ORGANIZATION SHALL NOT BE 14 AFFILIATED WITH AN INSURER, A CORPORATION SUBJECT TO ARTICLE FORTY-THREE 15 OF THE INSURANCE LAW, A MUNICIPAL COOPERATIVE HEALTH BENEFIT PLAN CERTI- 16 FIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW, OR A HEALTH 17 MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO THIS ARTICLE. 18 S 145. Subdivision 7-g of section 4900 of the public health law is 19 renumbered subdivision 7-h and a new subdivision 7-g is added to read as 20 follows: 21 7-G. "OUT-OF-NETWORK REFERRAL DENIAL" MEANS A DENIAL OF A REQUEST FOR 22 AN AUTHORIZATION OR REFERRAL TO AN OUT-OF-NETWORK PROVIDER ON THE BASIS 23 THAT THE HEALTH CARE PLAN HAS A HEALTH CARE PROVIDER IN THE IN-NETWORK 24 BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND EXPERIENCE 25 TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AND WHO IS ABLE 26 TO PROVIDE THE REQUESTED HEALTH SERVICE. THE NOTICE OF A DENIAL OF AN 27 OUT-OF-NETWORK REFERRAL PROVIDED TO AN ENROLLEE SHALL INCLUDE INFORMA- 28 TION EXPLAINING WHAT INFORMATION THE ENROLLEE MUST SUBMIT IN ORDER TO 29 APPEAL THE DENIAL OF AN OUT-OF-NETWORK REFERRAL PURSUANT TO SUBDIVISION 30 ONE-B OF SECTION FOUR THOUSAND NINE HUNDRED FOUR OF THIS ARTICLE. A 31 DENIAL OF AN OUT-OF-NETWORK REFERRAL UNDER THIS SUBDIVISION DOES NOT 32 CONSTITUTE AN ADVERSE DETERMINATION AS DEFINED IN THIS ARTICLE. A DENIAL 33 OF AN OUT-OF-NETWORK REFERRAL SHALL NOT BE CONSTRUED TO INCLUDE AN OUT- 34 OF-NETWORK DENIAL AS DEFINED IN SUBDIVISION SEVEN-F OF THIS SECTION. 35 S 146. Subdivision 2 of section 4903 of the public health law, as 36 added by chapter 705 of the laws of 1996, is amended to read as follows: 37 2. A utilization review agent shall make a utilization review determi- 38 nation involving health care services which require pre-authorization 39 and provide notice of a determination to the enrollee or enrollee's 40 designee and the enrollee's health care provider by telephone and in 41 writing within three business days of receipt of the necessary informa- 42 tion. THE NOTIFICATION SHALL IDENTIFY WHETHER THE SERVICES ARE CONSID- 43 ERED IN-NETWORK OR OUT-OF-NETWORK. 44 S 147. Section 4904 of the public health law is amended by adding a 45 new subdivision 1-b to read as follows: 46 1-B. AN ENROLLEE OR THE ENROLLEE'S DESIGNEE MAY APPEAL A DENIAL OF AN 47 OUT-OF-NETWORK REFERRAL BY A HEALTH CARE PLAN BY SUBMITTING A WRITTEN 48 STATEMENT FROM THE ENROLLEE'S ATTENDING PHYSICIAN, WHO MUST BE A 49 LICENSED, BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRAC- 50 TICE IN THE SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE ENROLLEE 51 FOR THE HEALTH SERVICE SOUGHT THAT: (A) THE IN-NETWORK HEALTH CARE 52 PROVIDER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO NOT HAVE 53 THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH 54 CARE NEEDS OF THE ENROLLEE FOR THE HEALTH SERVICE; AND (B) RECOMMENDS AN 55 OUT-OF-NETWORK PROVIDER WITH THE APPROPRIATE TRAINING AND EXPERIENCE TO S. 2606--C 165 1 MEET THE PARTICULAR HEALTH CARE NEEDS OF THE ENROLLEE, AND WHO IS ABLE 2 TO PROVIDE THE REQUESTED HEALTH SERVICE. 3 S 148. Subdivision 2 of section 4910 of the public health law is 4 amended by adding a new paragraph (d) to read as follows: 5 (D) (I) THE ENROLLEE HAS HAD AN OUT-OF-NETWORK REFERRAL DENIED ON THE 6 GROUNDS THAT THE HEALTH CARE PLAN HAS A HEALTH CARE PROVIDER IN THE 7 IN-NETWORK BENEFITS PORTION OF ITS NETWORK WITH APPROPRIATE TRAINING AND 8 EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE, AND 9 WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH SERVICE. 10 (II) THE ENROLLEE'S ATTENDING PHYSICIAN, WHO SHALL BE A LICENSED, 11 BOARD CERTIFIED OR BOARD ELIGIBLE PHYSICIAN QUALIFIED TO PRACTICE IN THE 12 SPECIALTY AREA OF PRACTICE APPROPRIATE TO TREAT THE ENROLLEE FOR THE 13 HEALTH SERVICE SOUGHT, CERTIFIES THAT THE IN-NETWORK HEALTH CARE PROVID- 14 ER OR PROVIDERS RECOMMENDED BY THE HEALTH CARE PLAN DO NOT HAVE THE 15 APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE 16 NEEDS OF AN ENROLLEE, AND RECOMMENDS AN OUT-OF-NETWORK PROVIDER WITH THE 17 APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTICULAR HEALTH CARE 18 NEEDS OF AN ENROLLEE, AND WHO IS ABLE TO PROVIDE THE REQUESTED HEALTH 19 SERVICE. 20 S 149. Paragraph (d) of subdivision 2 of section 4914 of the public 21 health law is amended by adding a new subparagraph (D) to read as 22 follows: 23 (D) FOR EXTERNAL APPEALS REQUESTED PURSUANT TO PARAGRAPH (D) OF SUBDI- 24 VISION TWO OF SECTION FOUR THOUSAND NINE HUNDRED TEN OF THIS TITLE 25 RELATING TO AN OUT-OF-NETWORK REFERRAL, THE EXTERNAL APPEAL AGENT SHALL 26 REVIEW THE UTILIZATION REVIEW AGENT'S FINAL ADVERSE DETERMINATION AND, 27 IN ACCORDANCE WITH THE PROVISIONS OF THIS TITLE, SHALL MAKE A DETERMI- 28 NATION AS TO WHETHER THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE 29 HEALTH PLAN; PROVIDED THAT SUCH DETERMINATION SHALL: 30 (I) BE CONDUCTED ONLY BY ONE OR A GREATER ODD NUMBER OF CLINICAL PEER 31 REVIEWERS; 32 (II) BE ACCOMPANIED BY A WRITTEN STATEMENT: 33 (1) THAT THE OUT-OF-NETWORK REFERRAL SHALL BE COVERED BY THE HEALTH 34 CARE PLAN EITHER WHEN THE REVIEWER OR A MAJORITY OF THE PANEL OF REVIEW- 35 ERS DETERMINES, UPON REVIEW OF THE TRAINING AND EXPERIENCE OF THE 36 IN-NETWORK HEALTH CARE PROVIDER OR PROVIDERS PROPOSED BY THE PLAN, THE 37 TRAINING AND EXPERIENCE OF THE REQUESTED OUT-OF-NETWORK PROVIDER, THE 38 CLINICAL STANDARDS OF THE PLAN, THE INFORMATION PROVIDED CONCERNING THE 39 ENROLLEE, THE ATTENDING PHYSICIAN'S RECOMMENDATION, THE ENROLLEE'S 40 MEDICAL RECORD, AND ANY OTHER PERTINENT INFORMATION, THAT THE HEALTH 41 PLAN DOES NOT HAVE A PROVIDER WITH THE APPROPRIATE TRAINING AND EXPERI- 42 ENCE TO MEET THE PARTICULAR HEALTH CARE NEEDS OF AN ENROLLEE WHO IS ABLE 43 TO PROVIDE THE REQUESTED HEALTH SERVICE, AND THAT THE OUT-OF-NETWORK 44 PROVIDER HAS THE APPROPRIATE TRAINING AND EXPERIENCE TO MEET THE PARTIC- 45 ULAR HEALTH CARE NEEDS OF AN ENROLLEE, IS ABLE TO PROVIDE THE REQUESTED 46 HEALTH SERVICE, AND IS LIKELY TO PRODUCE A MORE CLINICALLY BENEFICIAL 47 OUTCOME; OR 48 (2) UPHOLDING THE HEALTH PLAN'S DENIAL OF COVERAGE; 49 (III) BE SUBJECT TO THE TERMS AND CONDITIONS GENERALLY APPLICABLE TO 50 BENEFITS UNDER THE EVIDENCE OF COVERAGE UNDER THE HEALTH CARE PLAN; 51 (IV) BE BINDING ON THE PLAN AND THE ENROLLEE; AND 52 (V) BE ADMISSIBLE IN ANY COURT PROCEEDING. 53 S 150. The financial services law is amended by adding a new article 7 54 to read as follows: 55 ARTICLE 7 56 EMERGENCY MEDICAL SERVICES S. 2606--C 166 1 SECTION 701. DEFINITIONS. 2 702. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES. 3 703. DISPUTE RESOLUTION. 4 704. CRITERIA FOR DETERMINING EXCESSIVE CHARGES. 5 S 701. DEFINITIONS. FOR THE PURPOSES OF THIS ARTICLE: 6 (A) "EMERGENCY CONDITION" MEANS A MEDICAL OR BEHAVIORAL CONDITION THAT 7 MANIFESTS ITSELF BY ACUTE SYMPTOMS OF SUFFICIENT SEVERITY, INCLUDING 8 SEVERE PAIN, SUCH THAT A PRUDENT LAYPERSON, POSSESSING AN AVERAGE KNOW- 9 LEDGE OF MEDICINE AND HEALTH, COULD REASONABLY EXPECT THE ABSENCE OF 10 IMMEDIATE MEDICAL ATTENTION TO RESULT IN (1) PLACING THE HEALTH OF THE 11 PERSON AFFLICTED WITH SUCH CONDITION IN SERIOUS JEOPARDY, OR IN THE CASE 12 OF A BEHAVIORAL CONDITION PLACING THE HEALTH OF SUCH PERSON OR OTHERS IN 13 SERIOUS JEOPARDY; (2) SERIOUS IMPAIRMENT TO SUCH PERSON'S BODILY FUNC- 14 TIONS; (3) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART OF SUCH 15 PERSON; (4) SERIOUS DISFIGUREMENT OF SUCH PERSON; OR (5) A CONDITION 16 DESCRIBED IN CLAUSE (I), (II) OR (III) OF SECTION 1867(E)(1)(A) OF THE 17 SOCIAL SECURITY ACT. 18 (B) "EMERGENCY SERVICES" MEANS, WITH RESPECT TO AN EMERGENCY CONDI- 19 TION: (1) A MEDICAL SCREENING EXAMINATION AS REQUIRED UNDER SECTION 1867 20 OF THE SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, WHICH IS WITHIN THE 21 CAPABILITY OF THE EMERGENCY DEPARTMENT OF A HOSPITAL, INCLUDING ANCIL- 22 LARY SERVICES ROUTINELY AVAILABLE TO THE EMERGENCY DEPARTMENT TO EVALU- 23 ATE SUCH EMERGENCY MEDICAL CONDITION; AND (2) WITHIN THE CAPABILITIES OF 24 THE STAFF AND FACILITIES AVAILABLE AT THE HOSPITAL, SUCH FURTHER MEDICAL 25 EXAMINATION AND TREATMENT AS ARE REQUIRED UNDER SECTION 1867 OF THE 26 SOCIAL SECURITY ACT, 42 U.S.C. S 1395DD, TO STABILIZE THE PATIENT. 27 (C) "EXCESSIVE FEE" MEANS A FEE THAT IS IN EXCESS OF AN AMOUNT DETER- 28 MINED IN ACCORDANCE WITH SECTION SEVEN HUNDRED FOUR OF THIS ARTICLE. 29 (D) "HEALTH CARE PLAN" MEANS A HEALTH INSURER INCLUDING AN INSURER 30 LICENSED TO WRITE ACCIDENT AND HEALTH INSURANCE SUBJECT TO ARTICLE THIR- 31 TY-TWO OF THE INSURANCE LAW; A CORPORATION ORGANIZED PURSUANT TO ARTICLE 32 FORTY-THREE OF THE INSURANCE LAW; A MUNICIPAL COOPERATIVE HEALTH BENEFIT 33 PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE LAW; A 34 HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE FORTY-FOUR 35 OF THE PUBLIC HEALTH LAW; OR A SELF-FUNDED EMPLOYEE WELFARE BENEFIT 36 PLAN. 37 (E) "INSURED" MEANS A PATIENT COVERED UNDER A POLICY OR CONTRACT WITH 38 A HEALTH CARE PLAN. 39 (F) "PATIENT" MEANS A PERSON WHO RECEIVES EMERGENCY SERVICES IN THIS 40 STATE. 41 (G) "USUAL AND CUSTOMARY COST" MEANS THE EIGHTIETH PERCENTILE OF ALL 42 CHARGES FOR THE PARTICULAR HEALTH CARE SERVICE PERFORMED BY A PROVIDER 43 IN THE SAME OR SIMILAR SPECIALTY AND PROVIDED IN THE SAME GEOGRAPHICAL 44 AREA AS REPORTED IN A BENCHMARKING DATABASE MAINTAINED BY A NONPROFIT 45 ORGANIZATION SPECIFIED BY THE SUPERINTENDENT. THE NONPROFIT ORGANIZATION 46 SHALL NOT BE AFFILIATED WITH AN INSURER, A CORPORATION SUBJECT TO ARTI- 47 CLE FORTY-THREE OF THE INSURANCE LAW, A MUNICIPAL COOPERATIVE HEALTH 48 BENEFIT PLAN CERTIFIED PURSUANT TO ARTICLE FORTY-SEVEN OF THE INSURANCE 49 LAW, OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED PURSUANT TO ARTICLE 50 FORTY-FOUR OF THE PUBLIC HEALTH LAW. 51 S 702. PROHIBITION OF EXCESSIVE CHARGES FOR EMERGENCY SERVICES. (A) A 52 PHYSICIAN WHO PROVIDES HEALTH CARE SERVICES IN THIS STATE SHALL NOT 53 CHARGE AN EXCESSIVE FEE BASED ON THE CRITERIA FOR PROVIDING EMERGENCY 54 SERVICES IN SECTION SEVEN HUNDRED THREE OF THIS ARTICLE. 55 (B) THIS ARTICLE SHALL NOT APPLY TO EMERGENCY SERVICES WHERE PROVIDER 56 FEES ARE SUBJECT TO SCHEDULES OR OTHER MONETARY LIMITATIONS UNDER ANY S. 2606--C 167 1 OTHER LAW, INCLUDING THE WORKERS' COMPENSATION LAW AND ARTICLE FIFTY-ONE 2 OF THE INSURANCE LAW, AND SHALL NOT PREEMPT ANY SUCH LAW. 3 S 703. DISPUTE RESOLUTION. (A) A HEALTH CARE PLAN OR A PATIENT ALLEG- 4 ING THAT A PHYSICIAN HAS CHARGED AN EXCESSIVE FEE FOR PROVIDING EMERGEN- 5 CY SERVICES MAY SUBMIT THE DISPUTE FOR REVIEW TO AN INDEPENDENT DISPUTE 6 RESOLUTION ENTITY, IN ACCORDANCE WITH REGULATIONS PROMULGATED BY THE 7 SUPERINTENDENT, IF THE PHYSICIAN'S CHARGE EXCEEDS THE USUAL AND CUSTOM- 8 ARY COST OF THE HEALTH CARE SERVICES. 9 (B) A PATIENT SHALL NOT BE REQUIRED TO PAY THE PHYSICIAN'S FEE IN 10 ORDER TO BE ELIGIBLE TO SUBMIT THE DISPUTE FOR REVIEW TO THE INDEPENDENT 11 DISPUTE RESOLUTION ENTITY. 12 (C) A HEALTH CARE PLAN SHALL NOT SUBMIT THE DISPUTE FOR REVIEW TO THE 13 INDEPENDENT DISPUTE RESOLUTION ENTITY UNLESS SUCH PLAN HAS MADE PAYMENT, 14 IN FULL, OF THE PHYSICIAN'S FEE, EXCEPT FOR THE INSURED'S CO-PAYMENT, 15 COINSURANCE OR DEDUCTIBLE, FOR THE SERVICES RENDERED. THE HEALTH CARE 16 PLAN MAY ADVISE THE PHYSICIAN THAT THE PAYMENT IS BEING MADE UNDER 17 PROTEST. 18 S 704. CRITERIA FOR DETERMINING EXCESSIVE CHARGES. (A) (1) THE INDE- 19 PENDENT DISPUTE RESOLUTION ENTITY SHALL DECIDE WHETHER THE FEE CHARGED 20 BY THE PHYSICIAN FOR THE SERVICES RENDERED IS EXCESSIVE. IN MAKING SUCH 21 A DETERMINATION THE INDEPENDENT DISPUTE RESOLUTION ENTITY SHALL CONSIDER 22 ALL RELEVANT FACTORS INCLUDING: 23 (I) WHETHER THERE IS A GROSS DISPARITY BETWEEN THE FEE CHARGED BY THE 24 PHYSICIAN FOR SERVICES RENDERED AS COMPARED TO: (A) FEES PAID BY THE 25 HEALTH CARE PLAN TO REIMBURSE SIMILARLY QUALIFIED PHYSICIANS FOR THE 26 SAME SERVICES IN THE SAME REGION WHO DO NOT PARTICIPATE WITH THE HEALTH 27 CARE PLAN; AND (B) FEES PAID TO THE INVOLVED PHYSICIAN FOR THE SAME 28 SERVICES RENDERED BY THE PHYSICIAN TO PATIENTS IN HEALTH CARE PLANS IN 29 WHICH THE PHYSICIAN DOES NOT PARTICIPATE; 30 (II) THE LEVEL OF TRAINING, EDUCATION AND EXPERIENCE OF THE PHYSICIAN; 31 (III) THE PHYSICIAN'S USUAL CHARGE FOR COMPARABLE SERVICES WITH REGARD 32 TO PATIENTS IN HEALTH CARE PLANS IN WHICH THE PHYSICIAN DOES NOT PARTIC- 33 IPATE; 34 (IV) THE CIRCUMSTANCES AND COMPLEXITY OF THE PARTICULAR CASE, INCLUD- 35 ING TIME AND PLACE OF THE SERVICE; 36 (V) INDIVIDUAL PATIENT CHARACTERISTICS; AND 37 (VI) THE USUAL AND CUSTOMARY COST OF THE SERVICE. 38 (2) IF THE INDEPENDENT DISPUTE RESOLUTION ENTITY DETERMINES THAT THE 39 FEE CHARGED IS EXCESSIVE, THEN THE INDEPENDENT DISPUTE RESOLUTION ENTITY 40 SHALL DETERMINE A REASONABLE FEE FOR THE SERVICES BASED UPON THE SAME 41 CONDITIONS AND FACTORS SET FORTH IN THIS SUBDIVISION, WHICH FEE SHALL 42 NOT BE LESS THAN THE USUAL AND CUSTOMARY COST FOR SUCH SERVICES. THE 43 PHYSICIAN SHALL RETURN TO THE HEALTH CARE PLAN ANY PORTION OF THE FEE 44 PAID BY THE HEALTH CARE PLAN IN EXCESS OF THE AMOUNT DETERMINED TO BE 45 REASONABLE BY THE INDEPENDENT DISPUTE RESOLUTION ENTITY. 46 (B) THE DETERMINATION OF AN INDEPENDENT DISPUTE RESOLUTION ENTITY 47 SHALL BE BINDING ON THE HEALTH CARE PLAN, PHYSICIAN AND PATIENT, AND 48 SHALL BE ADMISSIBLE IN ANY COURT PROCEEDING BETWEEN THE HEALTH CARE 49 PLAN, PHYSICIAN OR PATIENT, OR IN ANY ADMINISTRATIVE PROCEEDING BETWEEN 50 THIS STATE AND THE PHYSICIAN. 51 (C) THE SUPERINTENDENT SHALL PROMULGATE REGULATIONS TO ESTABLISH STAN- 52 DARDS FOR THE DISPUTE RESOLUTION PROCESS INCLUDING STANDARDS FOR ESTAB- 53 LISHING WHICH PARTY SHALL BE RESPONSIBLE FOR PAYMENT OF THE DISPUTE 54 RESOLUTION PROCESS. S. 2606--C 168 1 S 150-a. Paragraph (u) of subdivision 4 of section 364-j of the social 2 services law, as amended by section 40 of part D of chapter 56 of the 3 laws of 2012, is amended to read as follows: 4 (u) A managed care provider that provides coverage for prescription 5 drugs shall permit each participant to fill any mail order covered 6 prescription, at his or her option, at any mail order pharmacy or non- 7 mail-order retail pharmacy in the managed care provider network, if the 8 non-mail-order retail pharmacy offers to accept a price that is compara- 9 ble to that of the mail order pharmacy. FOR THE PURPOSES OF THIS 10 SECTION, "MAIL ORDER PHARMACY" MEANS A PHARMACY WHOSE PRIMARY BUSINESS 11 IS TO RECEIVE PRESCRIPTIONS BY MAIL, TELEFAX OR THROUGH ELECTRONIC 12 SUBMISSIONS, AND TO DISPENSE MEDICATION TO PATIENTS THROUGH THE USE OF 13 THE UNITED STATES MAIL OR OTHER COMMON OR CONTRACT CARRIER SERVICES, AND 14 PROVIDES ANY CONSULTATION WITH PATIENTS ELECTRONICALLY RATHER THAN FACE 15 TO FACE. Every non-mail-order retail pharmacy in the managed care 16 provider's network with respect to any prescription drug shall be deemed 17 to be in the managed care provider's network for every covered 18 prescription drug[; provided, however, that the managed care provider 19 may limit its network of pharmacies for specified drugs, approved by the 20 commissioner, based on clinical, professional or cost criteria. Such 21 limitation shall not be based solely on cost]. 22 S 151. The public health law is amended by adding a new section 4403-g 23 to read as follows: 24 S 4403-G. HOME AND COMMUNITY-BASED CARE WORK GROUP. 1. THE COMMISSION- 25 ER SHALL CONVENE A HOME AND COMMUNITY-BASED CARE WORK GROUP TO EXAMINE 26 ISSUES SURROUNDING CONTINUITY OF CARE, REGULATORY GUIDANCE, QUALITY 27 ASSURANCE, AND CARE DELIVERY AMONG HOME AND COMMUNITY-BASED HEALTH CARE 28 PROVIDERS IN THEIR TRANSITION TO MANAGED CARE. THE COMMISSIONER SHALL 29 CONVENE THE WORKGROUP AS SOON AS PRACTICABLE, HOWEVER NO LATER THAN MAY 30 FIRST, TWO THOUSAND THIRTEEN. IT SHALL INCLUDE, BUT NOT BE LIMITED TO, 31 REPRESENTATIVES OF MANAGED LONG TERM CARE PLANS, CERTIFIED HOME HEALTH 32 AGENCIES, LONG TERM HOME HEALTH CARE PROGRAMS, LICENSED HOME CARE 33 SERVICES AGENCIES, CONSUMER DIRECTED CARE AGENCIES, CONSUMER ORGANIZA- 34 TIONS AND STATE ASSOCIATIONS REPRESENTATIVES THEREOF ALONG WITH OTHERS 35 WITH DEMONSTRATED EXPERTISE IN QUALITY MEASUREMENTS, REPORTING, AND 36 OTHER AREAS OF CONSIDERATION. THE WORKGROUP SHALL ISSUE RECOMMENDATIONS 37 ON TOPICS INCLUDING, BUT NOT LIMITED TO: 38 (A) THE WORKGROUP SHALL IDENTIFY AND MAKE RECOMMENDATIONS REGARDING 39 CONSOLIDATION, SIMPLIFICATION, AND WHERE POSSIBLE, MAKE UNIFORM RULES 40 AND REGULATIONS RELATED TO THE INTEGRATION OF EXISTING HOME AND COMMUNI- 41 TY-BASED CARE WITHIN MANAGED CARE. RECOMMENDATIONS SHALL INCLUDE, BUT 42 NOT BE LIMITED TO, CONSIDERATIONS OF: 43 (I) STREAMLINING OF DUPLICATIVE FUNCTIONS SHARED BETWEEN MANAGED CARE 44 AND HOME AND COMMUNITY-BASED PROVIDERS; 45 (II) BEST PRACTICES FOR EFFICIENT DELIVERY AND MANAGEMENT OF SERVICES; 46 (III) ASSESSMENT AND REASSESSMENT REQUIREMENTS OF THE PATIENT, INCLUD- 47 ING BUT NOT LIMITED TO THE USE OF A SINGLE FORM FOR ASSESSMENTS AND 48 REASSESSMENTS AND FREQUENCY; 49 (IV) THE DETERMINATION OF ELIGIBILITY; 50 (V) THE DEVELOPMENT OF THE WRITTEN PLAN OF CARE AND PROCUREMENT AND 51 DOCUMENTATION OF VERBAL AND WRITTEN PHYSICIAN ORDERS; 52 (VI) CARE COORDINATION INCLUDING COMMUNICATIONS BETWEEN HEALTH CARE 53 PROVIDERS AND PHYSICIANS; 54 (VII) DOCUMENTATION AND MAINTENANCE OF PATIENT RECORDS; AND 55 (VIII) REQUIREMENTS FOR DIRECT CARE STAFF SUPERVISION. S. 2606--C 169 1 (B) THE WORKGROUP SHALL IDENTIFY AND MAKE RECOMMENDATIONS REGARDING 2 QUALITY IMPROVEMENT MEASURES, HEALTH OUTCOMES DATA, INTERNAL QUALITY 3 ASSESSMENT PROCESSES, AND REPORTING MECHANISMS TO ENSURE AND PROMOTE 4 HIGH QUALITY, INTEGRATED AND COST EFFECTIVE CARE AS INDIVIDUALS TRANSI- 5 TION TO MANAGED CARE. 6 (C) THE WORKGROUP SHALL MAKE RECOMMENDATIONS REGARDING THE CONTINUITY 7 AND TRANSITION OF TELEHEALTH INTO MANAGED CARE SYSTEMS. RECOMMENDATIONS 8 SHALL INCLUDE, BUT NOT BE LIMITED TO, CONSIDERATIONS OF: 9 (I) THE DETERMINATION OF ELIGIBILITY; 10 (II) STREAMLINING DUPLICATIVE FUNCTIONS SHARED BETWEEN MANAGED CARE 11 AND HOME AND COMMUNITY-BASED PROVIDERS; 12 (III) CURRENT ADMINISTRATIVE, REGULATORY, AND INDUSTRY GUIDELINES; 13 (IV) BEST PRACTICES FOR EFFICIENT DELIVERY AND MANAGEMENT OF SERVICES; 14 (V) SPECIFIC DELINEATIONS OF RESPECTIVE RESPONSIBILITIES AMONG THE 15 PROVIDERS WHERE APPROPRIATE; 16 (VI) INFRASTRUCTURE READINESS; 17 (VII) CONTINUITY OF CARE; 18 (VIII) CARE COORDINATION; 19 (IX) CONSISTENT RATING AND REIMBURSEMENT METHODOLOGIES; AND 20 (X) PROJECTED IMPACTS TO COUNTY POPULATIONS DISPROPORTIONATELY RELIANT 21 ON TELEHEALTH, SPECIFICALLY POPULATIONS OF TWO HUNDRED THOUSAND OR LESS. 22 2. THE WORKGROUP SHALL REPORT ITS RECOMMENDATIONS AS SOON AS PRACTICA- 23 BLE BUT NO LATER THAN OCTOBER FIRST, TWO THOUSAND THIRTEEN, TO THE 24 COMMISSIONER, TEMPORARY PRESIDENT OF THE SENATE, SPEAKER OF THE ASSEM- 25 BLY, AND CHAIRS OF THE SENATE AND ASSEMBLY HEALTH COMMITTEES. EVERY 26 EFFORT SHALL BE MADE BY THE COMMISSIONER TO INCORPORATE AND IMPLEMENT 27 THE RECOMMENDATIONS OF THE WORKGROUP. 28 S 152. Notwithstanding any contrary provision of law or regulation, 29 retroactive to January first, two thousand ten, rates of payment made by 30 state governmental agencies for general hospital inpatient total hip 31 joint replacement and total knee joint replacement cases shall utilize 32 the diagnosis-related groups and service intensity weights in effect on 33 December thirty-first, two thousand seven pursuant to subdivision three 34 of section 2807-c of the public health law. Such rates may only be 35 adjusted for a general hospital if the majority of inpatient surgery 36 cases for the general hospital are orthopedic cases, the general hospi- 37 tal has developed a center of excellence in orthopedic surgery and 38 sports medicine, the general hospital incurred a significant reduction 39 in reimbursement for such cases beginning in two thousand eight as a 40 result of revisions to the service intensity weights for these cases, 41 and such adjustment would not increase reimbursement from state govern- 42 mental agencies to the general hospital by more than an average of two 43 hundred thousand dollars a year. Such adjustment shall not affect the 44 diagnosis related groups and service intensity weights for any other 45 cases or for any other general hospital. 46 S 153. Subdivision 1 of section 206 of the public health law is 47 amended by adding a new paragraph (s) to read as follows: 48 (S) ISSUE A READINESS REPORT TO THE LEGISLATURE, DETAILING THE STATUS 49 OF THE STATEWIDE HEALTH BENEFIT EXCHANGE ESTABLISHED UNDER EXECUTIVE 50 ORDER 42 OF 2012, ON OR BEFORE AUGUST THIRTIETH, TWO THOUSAND THIRTEEN. 51 THE READINESS REPORT MAY BE PROVIDED IN ELECTRONIC FORMAT AND SHALL BE 52 DISTRIBUTED TO THE TEMPORARY PRESIDENT OF THE SENATE, THE SPEAKER OF THE 53 ASSEMBLY, THE CHAIR OF THE SENATE STANDING COMMITTEE ON HEALTH, AND THE 54 CHAIR OF THE ASSEMBLY HEALTH COMMITTEE. THE READINESS REPORT SHALL 55 OUTLINE THE PROGRESS AND PREPAREDNESS OF THE HEALTH BENEFIT EXCHANGE, S. 2606--C 170 1 AND DETAIL HOW THE EXCHANGE WILL CARRY OUT ITS FUNCTIONS INCLUDING, BUT 2 NOT BE LIMITED TO: 3 (1) THE PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE WILL BEGIN 4 ACCEPTING APPLICATIONS ON OCTOBER FIRST, TWO THOUSAND THIRTEEN; 5 (2) THE PROCESS BY WHICH THE HEALTH BENEFIT EXCHANGE WILL CERTIFY 6 QUALIFIED HEALTH PLANS; 7 (3) THE ANTICIPATED COST OF INDIVIDUAL AND SMALL GROUP PLANS BEING 8 OFFERED IN THE HEALTH BENEFIT EXCHANGE; 9 (4) THE NUMBER OF NAVIGATORS APPROVED; 10 (5) THE PLAN FOR FULL OPERATION BY JANUARY FIRST, TWO THOUSAND FOUR- 11 TEEN; AND 12 (6) THE PLAN TO BECOME FISCALLY SELF-SUSTAINING BY JANUARY FIRST, TWO 13 THOUSAND FIFTEEN. 14 S 154. Subdivision 1 of section 206 of the public health law is 15 amended by adding a new paragraph (t) to read as follows: 16 (T) MAKE AN ANNUAL REPORT TO THE LEGISLATURE ON OR BEFORE THE FIRST 17 DAY OF DECEMBER. THIS REPORT MAY BE PROVIDED IN ELECTRONIC FORMAT AND 18 SHALL BE DISTRIBUTED TO THE TEMPORARY PRESIDENT OF THE SENATE, THE 19 SPEAKER OF THE ASSEMBLY, THE CHAIR OF THE SENATE STANDING COMMITTEE ON 20 HEALTH, AND THE CHAIR OF THE ASSEMBLY HEALTH COMMITTEE. THE REPORT SHALL 21 ALSO BE POSTED ON THE DEPARTMENT'S WEBSITE. THIS REPORT SHALL INCLUDE, 22 BUT NOT LIMITED TO: 23 (1) A DETAILED DESCRIPTION OF THE DEPARTMENT'S MISSION, PRIORITIES AND 24 GOALS FOR THE UPCOMING YEAR; 25 (2) ANY AND ALL RELEVANT DATA AND STATISTICS; 26 (3) A SUMMARY OF THE ACHIEVEMENTS AND INITIATIVES OF THE DEPARTMENT IN 27 THE PAST YEAR; 28 (4) INFORMATION CONCERNING EACH DIVISION, BUREAU, OFFICE OR INSTITU- 29 TION WITHIN THE DEPARTMENT, AND THEIR ACTIVITIES, AFFAIRS AND RECOMMEN- 30 DATIONS; 31 (5) ANY MATTERS EXPRESSLY REQUIRED BY LAW TO BE INCLUDED IN THE 32 REPORT; AND 33 (6) ANY OTHER MATTERS DEEMED NECESSARY BY THE COMMISSIONER. 34 S 155. Section 23 of part A of chapter 56 of the laws of 2012, amend- 35 ing the public health law relating to evaluations or services under the 36 early intervention program for infants and toddlers with disabilities 37 and their families, is amended to read as follows: 38 S 23. This act shall take effect January 1, 2013; provided, however, 39 that sections two-a, four, five, seven, eight, nine-a, ten, eighteen and 40 nineteen of this act shall take effect April 1, 2013, AND THE PROVISIONS 41 OF SUBPARAGRAPH (III) OF PARAGRAPH (A) OF SUBDIVISION 3 OF SECTION 2559 42 OF THE PUBLIC HEALTH LAW, AS ADDED BY SECTION ELEVEN OF THIS ACT, SHALL 43 TAKE EFFECT AUGUST 1, 2013; AND PROVIDED, FURTHER, THAT THE DEPARTMENT 44 OF HEALTH SHALL NOT PROMULGATE REGULATIONS OR TAKE ANY ADMINISTRATIVE 45 ACTION PURSUANT TO THIS ACT AFFECTING PROVIDER RELATIONSHIPS OR AGREE- 46 MENTS PRIOR TO APRIL 1, 2014. 47 S 156. Article 29-A of the public health law is amended by adding a 48 new title 3 to read as follows: 49 TITLE 3 50 BROADSCALE SYSTEMS INTEGRATION 51 DEMONSTRATION PROGRAM 52 SECTION 2959-1. BROADSCALE SYSTEMS INTEGRATION DEMONSTRATION PROGRAM. 53 S 2959-1. BROADSCALE SYSTEMS INTEGRATION DEMONSTRATION PROGRAM. 1. 54 FEDERAL HEALTH CARE REFORM AND THE CURRENT PROPOSALS TO TRANSITION NEW 55 YORK STATE MEDICAID PROVIDERS TO A MANAGED CARE MODEL, HAVE INITIATED 56 SIGNIFICANT CHANGES TO HEALTH CARE DELIVERY WITHIN THE STATE. THE S. 2606--C 171 1 LEGISLATURE RECOGNIZES THESE CHANGES, AS WELL AS THE NEED FOR GUIDANCE 2 ON HOW PROVIDERS CAN COMPLY IN AN EFFECTIVE AND COST-EFFICIENT MANNER. 3 GIVEN THE UNIQUE CHARACTERISTICS AND NEEDS OF RURAL COUNTIES WITHIN THE 4 STATE, INCLUDING DISPARITIES IN SUPPLY AND ACCESS TO HEALTH CARE, AS 5 WELL AS PROVIDER SHORTAGES AND HIGHER RATES OF UNDERINSURED AND UNIN- 6 SURED, IT IS IMPERATIVE THAT THE STATE ADDRESS THE UNIQUE NEEDS OF ITS 7 RURAL POPULATION AND PROVIDE INFORMATION ON THE KEY VARIABLES THAT 8 PROVIDERS MUST UTILIZE FOR A RESPONSIBLE TRANSITION TO MANAGED CARE. 9 2.(A) THE COMMISSIONER SHALL, WITHIN MONIES APPROPRIATED THEREFOR, 10 ESTABLISH A BROADSCALE SYSTEMS INTEGRATION DEMONSTRATION PROGRAM IN 11 COUNTIES HAVING A POPULATION OF NOT LESS THAN ONE HUNDRED THIRTY THOU- 12 SAND AND NOT MORE THAN ONE HUNDRED FORTY THOUSAND, ACCORDING TO THE TWO 13 THOUSAND TEN DECENNIAL FEDERAL CENSUS. THE COMMISSIONER AND THE COMMIS- 14 SIONER OF MENTAL HEALTH SHALL, IN COORDINATION WITH A NON-PROFIT ORGAN- 15 IZATION ACTING AS A SAFETY NET PROVIDER SERVING IN SUCH COUNTY TO STUDY 16 COST SAVINGS ACHIEVED THROUGH THE PROVISION OF SERVICES, INCLUDING BUT 17 NOT LIMITED TO, DENTAL, HEALTH, BEHAVIORAL HEALTH, EMPLOYMENT, AND 18 SOCIAL SERVICES INTERVENTION WITHIN A MANAGED CARE MODEL IN A RURAL 19 SETTING. SUCH A STUDY SHALL DETERMINE: 20 (I) THE QUALITY OF CARE PROVIDED THROUGH AN INTEGRATED MODEL VERSUS 21 CURRENT DELIVERY SYSTEMS; 22 (II) COST SAVINGS ACHIEVED BY IMPLEMENTING AN INTEGRATED MANAGED CARE 23 DELIVERY SYSTEM; 24 (III) COROLLARIES BETWEEN AN INTEGRATED SYSTEM AND IMPROVED PATIENT 25 OUTCOMES; 26 (IV) CARE COORDINATION/CASE MANAGEMENT AMONG DELIVERY SYSTEMS; 27 (V) IMPLEMENTATION AND TRANSITION COSTS; 28 (VI) DATA ON ACCESS TO CARE AND THE UNINSURED IN RURAL AREAS; 29 (VII) SOCIOECONOMIC BENCHMARKS AND IMPROVEMENTS INCLUDING BUT NOT 30 LIMITED TO DATA OF UNEMPLOYMENT, POVERTY, AND UNDERINSURED AND UNIN- 31 SURED; 32 (VIII) STAFFING SHORTAGES AND/OR STAFFING MODIFICATIONS IN THE TRANSI- 33 TION TO A MANAGED CARE MODEL; 34 (IX) RECOMMENDATIONS FOR REPLICATION/IMPROVEMENT IN OTHER RURAL AREAS; 35 AND 36 (X) SUCH OTHER ACTIVITIES AS THE COMMISSIONER MAY DEEM NECESSARY AND 37 APPROPRIATE TO THIS SECTION. 38 (B) THE ORGANIZATION, IN CONSULTATION WITH THE DEPARTMENT AND THE 39 OFFICE OF MENTAL HEALTH, SHALL EVALUATE THE FINDINGS OF THE STUDY AND 40 REPORT TO THE GOVERNOR, THE TEMPORARY PRESIDENT OF THE SENATE, THE 41 SPEAKER OF THE ASSEMBLY, THE COMMISSIONER AND THE CHAIR OF THE LEGISLA- 42 TIVE COMMISSION ON RURAL RESOURCES ON ITS FINDINGS, SO AS TO PROVIDE THE 43 COST BENCHMARKS WITH AND WITHOUT THE BROADSCALE SYSTEMS INTEGRATION, AS 44 WELL AS PROVIDING COST BENEFIT MEASUREMENTS IN TERMS OF THE QUALITY 45 BENEFIT OUTCOMES FOR EACH OF THE BENCHMARKS. 46 (C) ADDITIONALLY, TO THE EXTENT OF FUNDS APPROPRIATED THEREFOR, 47 MEDICAL ASSISTANCE FUNDS, INCLUDING ANY FUNDING OR SHARED SAVINGS AS MAY 48 BECOME AVAILABLE THROUGH FEDERAL WAIVERS OR OTHERWISE UNDER TITLES 18 49 AND 19 OF THE FEDERAL SOCIAL SECURITY ACT, MAY BE USED FOR EXPENDITURES 50 IN SUPPORT OF THE DEMONSTRATION PROGRAM. 51 S 157. Sections one hundred fifty-seven and one hundred fifty-eight 52 this act shall be known and may be cited as "Aidan's Law". 53 S 158. Subdivision (a) of section 2500-a of the public health law, as 54 amended by chapter 863 of the laws of 1986, is amended to read as 55 follows: S. 2606--C 172 1 (a) It shall be the duty of the administrative officer or other person 2 in charge of each institution caring for infants twenty-eight days or 3 less of age and the person required in pursuance of the provisions of 4 section forty-one hundred thirty of this chapter to register the birth 5 of a child, to cause to have administered to every such infant or child 6 in its or his care a test for phenylketonuria, homozygous sickle cell 7 disease, hypothyroidism, branched-chain ketonuria, galactosemia, homo- 8 cystinuria, ADRENOLEUKODYSTROPHY and such other diseases and conditions 9 as may from time to time be designated by the commissioner in accordance 10 with rules or regulations prescribed by the commissioner. Testing, the 11 recording of the results of such tests, tracking, follow-up reviews and 12 educational activities shall be performed at such times and in such 13 manner as may be prescribed by the commissioner. The commissioner shall 14 promulgate regulations setting forth the manner in which information 15 describing the purposes of the requirements of this section shall be 16 disseminated to parents or a guardian of the infant tested. 17 S 159. Subdivision 2-a of section 2807 of the public health law is 18 amended by adding a new paragraph (j) to read as follows: 19 (J) NOTWITHSTANDING ANY OTHER PROVISION OF THIS SUBDIVISION OR ANY 20 OTHER PROVISION OF LAW TO THE CONTRARY AND, SUBJECT TO AN APPROPRIATION 21 THEREFOR, ON AND AFTER APRIL FIRST, TWO THOUSAND THIRTEEN, RATES OF 22 PAYMENT FOR DIAGNOSTIC AND TREATMENT CENTER SERVICES, EMERGENCY 23 SERVICES, GENERAL HOSPITAL OUTPATIENT SERVICES, AMBULATORY SURGICAL 24 SERVICES AND REFERRED AMBULATORY SERVICES, PROVIDED BY A RURAL HOSPITAL 25 DESIGNATED AS A CRITICAL ACCESS HOSPITAL IN ACCORDANCE WITH TITLE XVIII 26 OF THE FEDERAL SOCIAL SECURITY ACT SHALL BE EQUAL TO ONE HUNDRED ONE 27 PERCENT OF THE REASONABLE COSTS OF A FACILITY IN PROVIDING SUCH SERVICES 28 TO PATIENTS ELIGIBLE FOR PAYMENTS MADE IN ACCORDANCE WITH THIS SUBDIVI- 29 SION. REASONABLE COSTS SHALL BE DETERMINED IN A MANNER CONSISTENT WITH 30 THAT USED TO DETERMINE PAYMENT FOR OUTPATIENT CRITICAL ACCESS HOSPITAL 31 SERVICES PROVIDED TO BENEFICIARIES OF TITLE XVIII OF THE FEDERAL SOCIAL 32 SECURITY ACT. FOR FACILITIES WITHOUT ADEQUATE COST EXPERIENCE, SUCH 33 RATES SHALL BE BASED ON BUDGETED COSTS SUBSEQUENTLY ADJUSTED TO ONE 34 HUNDRED ONE PERCENT OF REASONABLE ACTUAL COSTS. 35 S 160. Subdivision 2 of section 99-f of the state finance law, as 36 amended by chapter 612 of the laws of 1999, is amended to read as 37 follows: 38 2. The fund shall consist of all monies appropriated for its purpose, 39 all monies required by this section or any other provision of law to be 40 paid into or credited to such fund, and FIVE AND SIX-TENTHS PER CENTUM 41 OF monies COLLECTED BY THE MANDATORY SURCHARGES IMPOSED PURSUANT TO 42 SUBDIVISION ONE OF SECTION EIGHTEEN HUNDRED NINE OF THE VEHICLE AND 43 TRAFFIC LAW in an amount not to exceed eight million five hundred thou- 44 sand dollars [collected by the mandatory surcharges imposed pursuant to 45 subdivision one of section eighteen hundred nine of the vehicle and 46 traffic law]. Nothing contained herein shall prevent the department of 47 health from receiving grants, gifts or bequests for the purposes of the 48 fund as defined in this section and depositing them into the fund 49 according to law. 50 S 161. Section 365-d of the social services law is REPEALED and a new 51 section 365-d is added to read as follows: 52 S 365-D. HEALTH TECHNOLOGY ASSESSMENT COMMITTEE. 1. THE DEPARTMENT 53 SHALL CONVENE A HEALTH TECHNOLOGY ASSESSMENT COMMITTEE. THE COMMITTEE 54 SHALL, AT THE REQUEST OF THE COMMISSIONER, PROVIDE ADVICE AND MAKE 55 RECOMMENDATIONS REGARDING COVERAGE OF HEALTH TECHNOLOGY FOR PURPOSES OF 56 THE MEDICAL ASSISTANCE PROGRAM. THE COMMISSIONER SHALL CONSULT SUCH S. 2606--C 173 1 COMMITTEE PRIOR TO ANY DETERMINATION TO EXCLUDE FROM COVERAGE ANY HEALTH 2 TECHNOLOGY FROM THE MEDICAL ASSISTANCE PROGRAM. FOR PURPOSES OF THIS 3 SECTION, "HEALTH TECHNOLOGY" MEANS MEDICAL DEVICES AND SURGICAL PROCE- 4 DURES USED IN THE PREVENTION, DIAGNOSIS AND TREATMENT OF DISEASE AND 5 OTHER MEDICAL CONDITIONS. 6 2. (A) THE HEALTH TECHNOLOGY ASSESSMENT COMMITTEE SHALL CONSIST OF 7 THIRTEEN MEMBERS, WHO SHALL BE APPOINTED BY THE COMMISSIONER AND WHO 8 SHALL SERVE THREE YEAR TERMS; EXCEPT THAT FOR THE INITIAL APPOINTMENTS 9 TO THE COMMITTEE, FIVE MEMBERS SHALL SERVE ONE YEAR TERMS, FIVE MEMBERS 10 SHALL SERVE TWO YEAR TERMS, AND THREE MEMBERS SHALL SERVE THREE YEAR 11 TERMS. COMMITTEE MEMBERS MAY BE REAPPOINTED UPON THE COMPLETION OF THEIR 12 TERMS. WITH THE EXCEPTION OF THE CHAIRPERSON, NO MEMBER OF THE COMMITTEE 13 SHALL BE AN EMPLOYEE OF THE STATE OR ANY POLITICAL SUBDIVISION OF THE 14 STATE, OTHER THAN FOR HIS OR HER MEMBERSHIP ON THE COMMITTEE, EXCEPT FOR 15 EMPLOYEES OF HEALTH CARE FACILITIES OR UNIVERSITIES OPERATED BY THE 16 STATE, A PUBLIC BENEFIT CORPORATION, THE STATE UNIVERSITY OF NEW YORK OR 17 MUNICIPALITIES. 18 (B) THE MEMBERSHIP OF SUCH COMMITTEE SHALL BE AS FOLLOWS: 19 (I) SIX PERSONS LICENSED AND ACTIVELY ENGAGED IN THE PRACTICE OF MEDI- 20 CINE IN THIS STATE; 21 (II) ONE PERSON LICENSED AND ACTIVELY ENGAGED IN THE PRACTICE OF NURS- 22 ING AS A NURSE PRACTITIONER, OR IN THE PRACTICE OF MIDWIFERY IN THIS 23 STATE; 24 (III) ONE PERSON WHO IS A REPRESENTATIVE OF A HEALTH TECHNOLOGY OR 25 MEDICAL DEVICE ORGANIZATION WITH A REGIONAL, STATEWIDE OR NATIONAL 26 CONSTITUENCY AND WHO IS A HEALTH CARE PROFESSIONAL LICENSED UNDER TITLE 27 EIGHT OF THE EDUCATION LAW; 28 (IV) ONE PERSON WITH EXPERTISE IN HEALTH TECHNOLOGY ASSESSMENT WHO IS 29 A HEALTH CARE PROFESSIONAL LICENSED UNDER TITLE EIGHT OF THE EDUCATION 30 LAW; 31 (V) THREE PERSONS WHO SHALL BE CONSUMERS OR REPRESENTATIVES OF ORGAN- 32 IZATIONS WITH A REGIONAL OR STATEWIDE CONSTITUENCY AND WHO HAVE BEEN 33 INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER ADVOCACY; AND 34 (VI) A MEMBER OF THE DEPARTMENT WHO SHALL ACT AS CHAIRPERSON AS DESIG- 35 NATED BY THE COMMISSIONER. 36 3. THE HEALTH TECHNOLOGY ASSESSMENT COMMITTEE SHALL BE A PUBLIC BODY 37 UNDER ARTICLE SEVEN OF THE PUBLIC OFFICERS LAW AND SUBJECT TO ARTICLE 38 SIX OF THE PUBLIC OFFICERS LAW. THE DEPARTMENT SHALL PROVIDE INTERNET 39 ACCESS TO ALL MEETINGS OF SUCH COMMITTEE THROUGH THE DEPARTMENT'S 40 WEBSITE. 41 4. THE MEMBERS OF THE HEALTH TECHNOLOGY ASSESSMENT COMMITTEE SHALL 42 RECEIVE NO COMPENSATION FOR THEIR SERVICES BUT SHALL BE REIMBURSED FOR 43 EXPENSES ACTUALLY AND NECESSARILY INCURRED IN THE PERFORMANCE OF THEIR 44 DUTIES. COMMITTEE MEMBERS SHALL BE DEEMED TO BE EMPLOYEES OF THE DEPART- 45 MENT FOR PURPOSES OF SECTION SEVENTEEN OF THE PUBLIC OFFICERS LAW, AND 46 SHALL NOT PARTICIPATE IN ANY MATTER FOR WHICH A CONFLICT OF INTEREST 47 EXISTS. 48 5. THE HEALTH TECHNOLOGY ASSESSMENT COMMITTEE SHALL, AT THE REQUEST OF 49 THE COMMISSIONER, CONSIDER ANY MATTER RELATING TO HEALTH TECHNOLOGY 50 ASSESSMENT. THE COMMISSIONER SHALL PROVIDE THIRTY DAYS PUBLIC NOTICE ON 51 THE DEPARTMENT'S WEBSITE PRIOR TO ANY MEETING OF THE COMMITTEE TO DEVEL- 52 OP RECOMMENDATIONS CONCERNING HEALTH TECHNOLOGY COVERAGE DETERMINATIONS. 53 SUCH NOTICE SHALL INCLUDE A DESCRIPTION OF THE PROPOSED HEALTH TECHNOLO- 54 GY TO BE REVIEWED, THE CONDITIONS OR DISEASES IMPACTED BY THE HEALTH 55 TECHNOLOGY, AND THE PROPOSALS TO BE CONSIDERED BY THE COMMITTEE. THE 56 COMMITTEE SHALL ALLOW INTERESTED PARTIES A REASONABLE OPPORTUNITY TO S. 2606--C 174 1 MAKE AN ORAL PRESENTATION TO THE COMMITTEE RELATED TO THE HEALTH TECH- 2 NOLOGY TO BE REVIEWED AND TO SUBMIT WRITTEN INFORMATION. THE COMMITTEE 3 SHALL CONSIDER ANY INFORMATION PROVIDED BY ANY INTERESTED PARTY, INCLUD- 4 ING, BUT NOT LIMITED TO, HEALTH CARE PROVIDERS, HEALTH CARE FACILITIES, 5 PATIENTS, CONSUMERS AND MANUFACTURERS. 6 6. THE COMMISSIONER SHALL PROVIDE NOTICE OF ANY COVERAGE RECOMMENDA- 7 TIONS DEVELOPED BY THE COMMITTEE BY MAKING SUCH INFORMATION AVAILABLE ON 8 THE DEPARTMENT'S WEBSITE. SUCH PUBLIC NOTICE SHALL INCLUDE: A SUMMARY OF 9 THE DELIBERATIONS OF THE COMMITTEE; A SUMMARY OF THE POSITIONS OF THOSE 10 MAKING PUBLIC COMMENTS AT MEETINGS OF THE COMMITTEE; THE RESPONSE OF THE 11 COMMITTEE TO THOSE COMMENTS, IF ANY; THE CLINICAL EVIDENCE UPON WHICH 12 THE COMMITTEE BASES ITS RECOMMENDATION; AND THE FINDINGS AND RECOMMENDA- 13 TIONS OF THE COMMITTEE. 14 7. THE COMMISSIONER SHALL PROVIDE PUBLIC NOTICE ON THE DEPARTMENT'S 15 WEBSITE OF HIS OR HER FINAL DETERMINATION, INCLUDING: THE NATURE OF THE 16 DETERMINATION; AN ANALYSIS OF THE IMPACT OF THE COMMISSIONER'S DETERMI- 17 NATION ON STATE PUBLIC HEALTH PLAN POPULATIONS AND PROVIDERS; AND THE 18 PROJECTED FISCAL IMPACT TO THE STATE PUBLIC HEALTH PLAN PROGRAMS OF THE 19 COMMISSIONER'S DETERMINATION. THE COMMISSIONER'S FINAL DETERMINATION 20 SHALL NOT OCCUR PRIOR TO THE THIRTIETH DAY FROM THE POSTING OF THE 21 COMMITTEE'S RECOMMENDATIONS AND FINDINGS ON THE DEPARTMENT'S WEBSITE. 22 8. THE RECOMMENDATIONS OF THE HEALTH TECHNOLOGY ASSESSMENT COMMITTEE, 23 MADE PURSUANT TO THIS SECTION, SHALL BE BASED ON CLINICAL EFFECTIVENESS 24 AND SAFETY. THE COMMITTEE SHALL TRIENNIALLY REVIEW PREVIOUS RECOMMENDA- 25 TIONS OF THE COMMITTEE AND PERMIT ORAL PRESENTATIONS AND THE SUBMISSION 26 OF NEW EVIDENCE AT SUCH TRIENNIAL REVIEW. SUCH REVIEW SHALL OCCUR PURSU- 27 ANT TO THE PROCEDURE ESTABLISHED IN SUBDIVISIONS FIVE AND SIX OF THIS 28 SECTION. THE COMMISSIONER MAY ALTER OR REVOKE HIS OR HER FINAL DETERMI- 29 NATION AFTER SUCH TRIENNIAL REVIEW PURSUANT TO THE PROCEDURE ESTABLISHED 30 IN SUBDIVISION SEVEN OF THIS SECTION. 31 9. THE DEPARTMENT SHALL PROVIDE ADMINISTRATIVE SUPPORT TO THE COMMIT- 32 TEE. 33 S 162. Section 33 of the public health law, as added by chapter 442 of 34 the laws of 2006, subdivision 1 as amended by section 45 of part C of 35 chapter 58 of the laws of 2007, is amended to read as follows: 36 S 33. Cooperation of agency officials and employees. 1. In addition to 37 the authority otherwise provided by this title, the inspector, in carry- 38 ing out the provisions of this title, is authorized to request such 39 information, assistance and cooperation from any federal, state or local 40 governmental department, board, bureau, commission, or other agency or 41 unit thereof as may be necessary for carrying out the duties and respon- 42 sibilities enjoined upon the inspector by this section. State and local 43 agencies or units thereof are hereby authorized and directed to provide 44 to the inspector, or, at the request of the inspector, to state agencies 45 or their contractors, such information, assistance and cooperation. 46 Notwithstanding any other provision of law to the contrary, requests for 47 information, assistance and cooperation may include, but not be limited 48 to, all state and local government birth, death and vital statistics 49 which may be contained in files, databases or registries, and for all 50 information shall, upon request, include, where possible, making elec- 51 tronic copies or record exchanges available. Executive agencies shall 52 coordinate and facilitate the transfer of appropriate functions and 53 positions to the office as necessary and in accordance with applicable 54 law. 55 2. NOTWITHSTANDING ANY PROVISIONS OF THIS ARTICLE A LOCAL SOCIAL 56 SERVICES DISTRICT IS DEEMED TO HAVE THE AUTHORITY TO CONDUCT MEDICAID S. 2606--C 175 1 PROVIDER INVESTIGATIONS, AND UPON A FINDING OF FRAUD AND ABUSE, TO REFER 2 THE SUSPECTED FRAUD OR CRIMINALITY TO ITS DISTRICT ATTORNEY'S OFFICE. 3 3. Upon request of a local social services district or a prosecutor of 4 competent jurisdiction, the office, department, any other state or local 5 government entity and the Medicaid fraud control unit shall provide such 6 information and assistance [as such entity or unit shall deem neces- 7 sary,] appropriate and available to aid and facilitate the investigation 8 of fraud and abuse within the medical assistance program and the recoup- 9 ment of improperly expended funds. 10 S 163. The public health law is amended by adding a new section 37 to 11 read as follows: 12 S 37. OVERSIGHT AUDIT, REVIEW AND EVALUATION. THE DEPARTMENT SHALL 13 CONTRACT WITH AN INDEPENDENT AGENCY FOR THE PURPOSE OF CONDUCTING AN 14 ANNUAL AUDIT, REVIEW AND EVALUATION OF THE STATE MEDICAID PROGRAM AND 15 THE OFFICE OF THE MEDICAID INSPECTOR GENERAL. THE AUDIT, REVIEW AND 16 EVALUATION SHALL ENSURE MEDICAID FUNDS ARE BEING EFFECTIVELY AND EFFI- 17 CIENTLY SPENT, AND THAT CASES OF FRAUD AND ABUSE ARE BEING APPROPRIATELY 18 INVESTIGATED AND PURSUED. THE REVIEW SHALL INCLUDE RECOMMENDATIONS FOR 19 INCREASING COST EFFECTIVENESS AND FRAUD AND ABUSE RECOVERIES. THE REVIEW 20 SHALL ALSO PROVIDE AN EVALUATION OF PATIENT CARE, HEALTH OUTCOMES AND 21 THE COMPARATIVE COSTS IN EACH SECTOR OF HEALTH CARE FUNDED BY MEDICAID, 22 ALONG WITH RECOMMENDATIONS FOR SYSTEMIC IMPROVEMENTS TO EACH SECTOR. THE 23 AUDIT, REVIEW AND EVALUATION SHALL BE DISTRIBUTED TO THE TEMPORARY PRES- 24 IDENT OF THE SENATE, THE SPEAKER OF THE ASSEMBLY, THE CHAIR OF THE 25 SENATE STANDING COMMITTEE ON HEALTH, AND THE CHAIR OF THE ASSEMBLY 26 HEALTH COMMITTEE BY THE FIRST OF JANUARY EACH YEAR. 27 S 164. The social services law is amended by adding a new article 5-A 28 to read as follows: 29 ARTICLE 5-A 30 MEDICAID FRAUD REIMBURSEMENT 31 SECTION 370-BB. DISPOSITION OF MONEYS RECEIVED AS THE RESULT OF THE 32 PROSECUTION OF MEDICAID FRAUD. 33 S 370-BB. DISPOSITION OF MONEYS RECEIVED AS THE RESULT OF THE PROSE- 34 CUTION OF MEDICAID FRAUD. 1. FOR THE PURPOSES OF THIS SECTION, "MEDICAID 35 FRAUD" SHALL MEAN THE KNOWING COMMISSION OF ANY CRIME WITH INTENT TO 36 ILLEGALLY RECEIVE BENEFITS, OR REIMBURSEMENT FROM THE MEDICAL ASSISTANCE 37 FOR NEEDY PERSONS PROGRAM ESTABLISHED AND ADMINISTERED PURSUANT TO THIS 38 CHAPTER, THE PUBLIC HEALTH LAW AND FEDERAL LAW. 39 2. SHOULD ANY COUNTY OR THE CITY OF NEW YORK SUCCESSFULLY PROSECUTE 40 ANY CASE FOR MEDICAID FRAUD AND A COURT AWARDS RESTITUTION OR CIVIL 41 FORFEITURE, THE FOLLOWING PORTION OF THE NON-FEDERAL SHARE OF THE 42 PROCEEDS OF SUCH RESTITUTION OR CIVIL FORFEITURE SHALL BE ALLOCATED AS 43 FOLLOWS: 44 (I) THE COUNTY OR THE CITY OF NEW YORK SHALL RECEIVE ONE HUNDRED 45 PERCENT OF THE LOCAL SHARE OF SUCH FUNDS, IN EFFECT IMMEDIATELY PRIOR TO 46 SUCH DATE AS CERTIFIED BY THE DIVISION OF BUDGET OR TEN PERCENT OF THE 47 TOTAL RECOVERY WHICHEVER NUMBER IS GREATER; 48 (II) THE REMAINDER THEREOF SHALL BE DEPOSITED INTO THE GENERAL FUND OF 49 THE STATE. 50 3. NOTHING IN THIS ARTICLE SHALL IMPAIR ANY COUNTY OR THE CITY OF NEW 51 YORK'S ABILITY TO SEEK DAMAGES UNDER SECTION ONE HUNDRED FORTY-FIVE-B OF 52 THIS CHAPTER. 53 S 165. Paragraph (a) of subdivision 2 of section 145-b of the social 54 services law, as amended by chapter 109 of the laws of 2007, is amended 55 to read as follows: S. 2606--C 176 1 (a) For civil damages collected by a local social services district, 2 relating to the medical assistance program, pursuant to a judgment OR A 3 SETTLEMENT under this subdivision, such amounts shall be apportioned 4 between the local social services district and the state. [If the 5 violation occurred: (i) prior to January first, two thousand six, the] 6 THE amount apportioned to the local social services district shall be 7 ONE HUNDRED PERCENT OF the local share [percentage] OF SUCH FUNDS, in 8 effect immediately prior to such date as certified by the division of 9 budget[, or (ii) after January first, two thousand six, the amount 10 apportioned to the local social services district shall be based on a 11 reimbursement schedule, created by the office of Medicaid inspector 12 general, in effect at the time the violation occurred; provided that, if 13 there is no schedule in effect at the time the violation occurred, the 14 schedule to be used shall be the first schedule adopted pursuant to this 15 subdivision. Such schedule shall provide for reimbursement to a local 16 social services district in an amount between ten and fifteen percent of 17 the gross amount collected. Such schedule shall be set on a county by 18 county basis and shall be periodically reviewed and updated as neces- 19 sary; provided, however, that any such updated schedule shall not be 20 less than ten percent nor greater than fifteen percent of the gross 21 amount collected] OR TEN PERCENT OF THE TOTAL RECOVERY WHICHEVER NUMBER 22 IS GREATER; and 23 S 166. The public health law is amended by adding a new article 2-B to 24 read as follows: 25 ARTICLE 2-B 26 MEDICAID IDENTIFICATION AND ANTI-FRAUD BIOMETRIC 27 TECHNOLOGY PILOT PROGRAM 28 SECTION 290. MEDICAID IDENTIFICATION AND ANTI-FRAUD BIOMETRIC TECHNOLOGY 29 PILOT PROGRAM. 30 291. DEFINITIONS. 31 292. BIOMETRIC TECHNOLOGY USE. 32 293. RULES AND REGULATIONS. 33 S 290. MEDICAID IDENTIFICATION AND ANTI-FRAUD BIOMETRIC TECHNOLOGY 34 PILOT PROGRAM. THERE IS HEREBY ESTABLISHED IN THE DEPARTMENT THE MEDI- 35 CAID IDENTIFICATION AND ANTI-FRAUD BIOMETRIC TECHNOLOGY PILOT PROGRAM. 36 THE DEPARTMENT, IN CONSULTATION WITH THE OFFICE OF THE MEDICAID INSPEC- 37 TOR GENERAL AND THE OFFICE OF THE ATTORNEY GENERAL, SHALL IMPLEMENT SUCH 38 PILOT PROGRAM AT TWO GENERAL HOSPITALS, AS DEFINED BY SUBDIVISION TEN OF 39 SECTION TWENTY-EIGHT HUNDRED ONE OF THIS CHAPTER, AS AN ANTI-FRAUD 40 APPLICATION IN THE MEDICAID PROGRAM. 41 S 291. DEFINITIONS. AS USED IN THIS ARTICLE: 42 1. "BIOMETRIC TECHNOLOGY" MEANS TECHNOLOGY THAT MEASURES AND ANALYZES 43 BIOLOGICAL DATA, INCLUDING BUT NOT LIMITED TO DNA, FINGER IMAGING, 44 VASCULAR PATTERNS, EYE RETINAS AND IRISES, VOICE PATTERNS, FACIAL 45 PATTERNS AND HAND MEASUREMENTS, FOR AUTHENTICATION PURPOSES. 46 2. "BIOMETRIC VERIFICATION DEVICE" MEANS A DEVICE CAPABLE OF USING 47 BIOMETRIC VERIFICATION TECHNOLOGY TO VERIFY THE IDENTITY OF A MEDICAID 48 RECIPIENT OR PROVIDER. 49 S 292. BIOMETRIC TECHNOLOGY USE. 1. THE DEPARTMENT, IN CONSULTATION 50 WITH THE OFFICE OF THE MEDICAID INSPECTOR GENERAL AND THE OFFICE OF THE 51 ATTORNEY GENERAL, SHALL DEVELOP A REQUEST FOR PROPOSALS TO IMPLEMENT A 52 PROGRAM UTILIZING BIOMETRIC TECHNOLOGY BY HOSPITALS FOR THE PURPOSES OF 53 PATIENT AND PROVIDER IDENTIFICATION AND FOR USE AS AN ANTI-FRAUD APPLI- 54 CATION IN THE MEDICAID PROGRAM. 55 2. SUCH REQUEST FOR PROPOSALS SHALL INCLUDE AT A MINIMUM THAT (A) 56 MEDICAID RECIPIENTS AND PROVIDERS SHALL PROVIDE BIOMETRIC PROOF OF THEIR S. 2606--C 177 1 IDENTITY ALONG WITH OTHER INFORMATION DEEMED NECESSARY BY THE COMMIS- 2 SIONER. 3 (B) SUCH PROGRAM WILL BE CAPABLE OF STORING BIOMETRIC MARKERS AND A 4 LOG OF GENERAL HOSPITAL AND PHARMACY VISITS FOR EACH SERVICE BILLED TO 5 THE MEDICAID PROGRAM. 6 (C) MEDICAID IDENTIFICATION SHALL BE ISSUED TO AND ACCEPTED BY THE 7 ADMITTING STAFF OF HEALTH CARE FACILITIES, MEDICAL STAFF PROVIDING 8 SERVICE TO MEDICAID RECIPIENTS AND PHARMACY STAFF. 9 (D) MEDICAID RECIPIENTS SHALL BE REQUIRED TO PROVIDE BIOMETRIC PROOF 10 OF IDENTIFY AT THE TIME OF EACH VISIT TO A GENERAL HOSPITAL AT THE POINT 11 OF ACTUALLY BEING SEEN BY THE DOCTOR OR CLINICAL STAFF, AND SHALL AGAIN 12 PROVIDE PROOF OF IDENTITY UPON COMPLETION OF CARE OR SERVICES. 13 (E) PROVISIONS MAY BE INCLUDED FOR EMERGENCY SERVICES OR PRESCRIPTIONS 14 AND ALTERNATE IDENTIFICATION METHODS FOR MEDICAID RECIPIENTS PHYSICALLY 15 OR MENTALLY UNABLE TO PROVIDE BIOMETRIC IDENTIFICATION. 16 (F) FRAUD PREVENTION MARKERS INCORPORATED INTO SOFTWARE WHICH MAY BE 17 USED TO OPERATE THE HARDWARE COMPONENT OF THE BIOMETRIC TECHNOLOGY SHALL 18 PREVENT AND/OR REJECT THE PAYMENT BY THE MEDICAID PROGRAM AND ALERT THE 19 SERVICE PROVIDER AT POINT OF SERVICE IF FRAUD OR POTENTIAL FRAUD IS 20 IDENTIFIED BY THE BIOMETRIC TECHNOLOGY SYSTEM. 21 (G) PROVISIONS SHALL BE INCLUDED TO ENSURE THAT MEDICAID RECIPIENTS 22 HAVE ACCESS TO EMERGENCY HEALTH SERVICES IN THE CASE OF A BIOMETRIC 23 TECHNOLOGY SYSTEM MALFUNCTION OR FRAUD DETECTION ALARM. 24 (H) EVALUATION AND SELECTION OF PROPOSALS THAT ADDRESS THE REQUIRE- 25 MENTS OF MEDICAID BENEFICIARIES AND PROVIDERS SHALL BE BASED ON THE 26 FOLLOWING CRITERIA: SECURITY, PRIVACY, USABILITY, PERFORMANCE, HYGIENE, 27 BIOMETRIC CAPTURE AND STORAGE REQUIREMENTS, AND INTEROPERABILITY. 28 3. SUCH REQUEST FOR PROPOSALS SHALL SET FORTH REQUIREMENTS AS TO THE 29 RESULTS AND GOALS TO BE ACHIEVED, RATHER THAN SPECIFIC TECHNICAL METHODS 30 OR SYSTEMS, TO ALLOW CONSIDERATION OF THE WIDEST POSSIBLE CHOICE OF 31 AVAILABLE TECHNOLOGY. 32 4. SUCH REQUEST FOR PROPOSALS SHALL REQUIRE: (A) THAT THE PROGRAM 33 SHALL BE REVENUE NEUTRAL ON AN ANNUAL BASIS, WHEREBY ANY PROGRAM COSTS 34 ARE AT LEAST OFFSET BY STATE MEDICAID SAVINGS, AND SHALL HAVE AS A 35 PRIMARY GOAL REDUCTION OF MEDICAID EXPENDITURES THROUGH ELIMINATION OF 36 FRAUD AND ABUSE; AND (B) THAT THE PROGRAM SHALL BE COST NEUTRAL TO 37 PROVIDERS FROM INCEPTION, WHEREBY ANY PROVIDER COSTS ARE AT LEAST OFFSET 38 BY PROVIDER SAVINGS, AND SHALL HAVE AS A PRIMARY GOAL PROVIDER SAVINGS 39 THROUGH INCREASED EFFICIENCIES. 40 5. THE COMMISSIONER SHALL ACCEPT TWO PROPOSALS FOR PILOT PROGRAM 41 PARTICIPATION, PROVIDED, HOWEVER, THAT AT LEAST ONE PROPOSAL SHALL BE 42 FROM THE UPSTATE REGION. FOR THE PURPOSES OF THIS ARTICLE, "UPSTATE 43 REGION" SHALL INCLUDE THE FOLLOWING COUNTIES: ALBANY, ALLEGANY, BROOME, 44 CATTARAUGUS, CAYUGA, CHAUTAUQUA, CHEMUNG, CHENANGO, CLINTON, COLUMBIA, 45 CORTLAND, DELAWARE, ERIE, ESSEX, FRANKLIN, FULTON, GENESEE, GREENE, 46 HAMILTON, HERKIMER, JEFFERSON, LEWIS, LIVINGSTON, MADISON, MONROE, MONT- 47 GOMERY, NIAGARA, ONEIDA, ONONDAGA, ONTARIO, ORLEANS, OSWEGO, OTSEGO, 48 RENSSELAER, SARATOGA, SCHENECTADY, SCHOHARIE, SCHUYLER, SENECA, ST. 49 LAWRENCE, STEUBEN, SULLIVAN, TIOGA, TOMKINS, WARREN, WASHINGTON, WAYNE, 50 WYOMING AND YATES. 51 6. (A) SUCH REQUEST FOR PROPOSALS FOR THE IMPLEMENTATION OF A PROGRAM 52 FOR BIOMETRIC TECHNOLOGY USE SHALL BE PUBLISHED ON OR BEFORE JANUARY 53 FIFTEENTH, TWO THOUSAND FOURTEEN, AND SHALL PROVIDE THAT PROPOSALS SHALL 54 BE OPENED ON OR BEFORE MARCH FIRST, TWO THOUSAND FOURTEEN. 55 (B) THE COMMISSIONER SHALL REPORT TO THE GOVERNOR, THE TEMPORARY PRES- 56 IDENT OF THE SENATE AND THE SPEAKER OF THE ASSEMBLY ONE YEAR AFTER THE S. 2606--C 178 1 EFFECTIVE DATE OF THIS ARTICLE WITH REGARD TO THE PROGRESS MADE IN THE 2 DEVELOPMENT OF CRITERIA FOR A PILOT PROGRAM OF BIOMETRIC IDENTIFICATION 3 AND OF THE IMPLEMENTATION OF SUCH PILOT PROGRAM. 4 S 293. RULES AND REGULATIONS. THE COMMISSIONER IS AUTHORIZED AND 5 DIRECTED TO PROMULGATE SUCH RULES AND REGULATIONS AS HE OR SHE MAY DEEM 6 NECESSARY OR APPROPRIATE TO EFFECTUATE THE PURPOSES OF THIS ARTICLE. 7 S 167. Subdivision 1 of section 367-b of the social services law, as 8 added by chapter 639 of the laws of 1976, is amended to read as follows: 9 1. The department, IN CONSULTATION WITH THE COMMISSIONER OF HEALTH, 10 shall design and implement a statewide medical assistance information 11 and payments system for the purpose of providing individual and aggre- 12 gate data to social services districts to assist them in making basic 13 management decisions, to the department and other state agencies to 14 assist in the administration of the medical assistance program, and to 15 the governor and the legislature as may be necessary to assist in making 16 major administrative and policy decisions affecting such program. Such 17 system shall be designed so as to be capable of the following: 18 a. receiving and processing information relating to the eligibility of 19 each person applying for medical assistance and of issuing a medical 20 assistance identification card, AND WHEN AVAILABLE UTILIZING THE BIOME- 21 TRIC IDENTIFICATION ISSUED BY THE DEPARTMENT OF HEALTH, CONFORMING TO 22 THE REQUIREMENTS SET FORTH IN THE MEDICAID IDENTIFICATION AND ANTI-FRAUD 23 BIOMETRIC TECHNOLOGY PROGRAM ESTABLISHED PURSUANT TO ARTICLE TWO-B OF 24 THE PUBLIC HEALTH LAW to persons determined by a social services offi- 25 cial to be eligible for such assistance; 26 b. ACTIVATING MEDICAL ASSISTANCE IDENTIFICATION BY REQUIRING AN 27 APPLICANT RECEIVING SUCH IDENTIFICATION FROM THE DEPARTMENT TO HAVE IT 28 VERIFIED AT A SOCIAL SERVICES DISTRICT OFFICE IN THE SOCIAL SERVICES 29 DISTRICT IN WHICH THE APPLICANT RESIDES; 30 C. receiving and processing information relating to each qualified 31 provider of medical assistance furnishing care, services or supplies for 32 which claims for payment are made pursuant to this title; 33 [c.] D. receiving and processing, in a form and manner prescribed by 34 the department, all claims for medical care, services and supplies, and 35 making payments for valid claims to providers of medical care, services 36 and supplies on behalf of social services districts; AND 37 [d.] E. maintaining information necessary to allow the department, 38 consistent with the powers and duties of the department of health, to 39 review the appropriateness, scope and duration of medical care, services 40 and supplies provided to any eligible person pursuant to this chapter[; 41 and 42 e. initiating implementation of such a system for the district 43 comprising the city of New York, in a manner compatible with expansion 44 of such system to districts other than the district comprising the city 45 of New York]. 46 S 168. Section 2818 of the public health law is REPEALED. 47 S 169. The state finance law is amended by adding a new section 99-u 48 to read as follows: 49 S 99-U. HEALTH CARE EFFICIENCY AND AFFORDABILITY LAW OF NEW YORKERS 50 (HEAL NY) ACCOUNT. 1. THERE IS HEREBY ESTABLISHED IN THE JOINT CUSTODY 51 OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXATION AND FINANCE 52 THE "HEALTH CARE EFFICIENCY AND AFFORDABILITY LAW OF NEW YORKERS (HEAL 53 NY) ACCOUNT". 54 2. THE ACCOUNT SHALL CONSIST OF ALL MONIES RECEIVED AND/OR APPROPRI- 55 ATED FOR THE HEALTH CARE EFFICIENCY AND AFFORDABILITY LAW OF NEW YORKERS 56 (HEAL NY) CAPITAL GRANT PROGRAM. S. 2606--C 179 1 3. NOTWITHSTANDING ANY PROVISION OF LAW TO THE CONTRARY, ALL MONIES 2 SHALL REMAIN IN SUCH ACCOUNT UNLESS OTHERWISE DISBURSED PURSUANT TO 3 APPROPRIATION BY THE LEGISLATURE. 4 S 170. Severability. If any clause, sentence, paragraph, subdivision, 5 section or part of this act shall be adjudged by any court of competent 6 jurisdiction to be invalid, such judgment shall not affect, impair or 7 invalidate the remainder thereof, but shall be confined in its operation 8 to the clause, sentence, paragraph, subdivision, section or part thereof 9 directly involved in the controversy in which the judgment shall have 10 been rendered. It is hereby declared to be the intent of the legislature 11 that this act would have been enacted even if such invalid provisions 12 had not been included herein. 13 S 171. This act shall take effect immediately; provided that sections 14 one through one hundred twenty of this act shall be deemed to have been 15 in full force and effect on and after April 1, 2013; provided, however, 16 that the provisions of sections one through one hundred twenty of this 17 act shall apply only to actions and proceedings commenced on or after 18 such effective date; provided, further, that: 19 (a) sections fourteen, fifteen, sixteen, seventeen, eighteen, nine- 20 teen, twenty, twenty-one, twenty-two, twenty-four, twenty-six, twenty- 21 seven, twenty-eight, and thirty of this act shall take effect January 1, 22 2014; 23 (b) sections forty-three, forty-four, forty-six and one hundred one of 24 this act shall take effect on the one hundred eightieth day after it 25 shall have become a law; 26 (c) sections ninety, ninety-one, ninety-three and ninety-four of this 27 act shall take effect April 1, 2014, provided that effective immediate- 28 ly, the addition, amendment and/or repeal of any rule or regulation 29 necessary for the implementation of such sections on the effective date 30 of this act are authorized and directed to be made and completed on or 31 before such effective date; 32 (d) section ninety-six of this act shall take effect on the ninetieth 33 day after it shall have become a law; 34 (e) any rules or regulations necessary to implement the provisions of 35 this act may be promulgated and any procedures, forms, or instructions 36 necessary for such implementation may be adopted and issued on or after 37 the date this act shall have become a law; 38 (f) this act shall not be construed to alter, change, affect, impair 39 or defeat any rights, obligations, duties or interests accrued, incurred 40 or conferred prior to the effective date of this act; 41 (g) the commissioner of health and the superintendent of financial 42 services and any appropriate council may take any steps necessary to 43 implement this act prior to its effective date; 44 (h) notwithstanding any inconsistent provision of the state adminis- 45 trative procedure act or any other provision of law, rule or regulation, 46 the commissioner of health and the superintendent of financial services 47 and any appropriate council is authorized to adopt or amend or promul- 48 gate on an emergency basis any regulation he or she or such council 49 determines necessary to implement any provision of this act on its 50 effective date; 51 (i) the provisions of this act shall become effective notwithstanding 52 the failure of the commissioner of health or the superintendent of 53 financial services or any council to adopt or amend or promulgate regu- 54 lations implementing this act; S. 2606--C 180 1 (j) section 3621 of the public health law, as added by section one 2 hundred twenty-five of this act shall expire and be deemed repealed 3 March 31, 2015; 4 (k) sections one hundred twenty-six-a through one hundred fifty of 5 this act shall take effect September 1, 2013, provided, however, that 6 for policies renewed on and after such date, such sections shall take 7 effect on the renewal date; 8 (l) sections one hundred thirty-seven, one hundred forty-one, one 9 hundred forty-six and one hundred fifty of this act shall apply to 10 health care services provided on and after such date and section one 11 hundred fifty of this act shall expire and be deemed repealed January 1, 12 2016; 13 (m) sections one hundred thirty-six, one hundred thirty-eight, one 14 hundred thirty-nine, one hundred forty, one hundred forty-five, one 15 hundred forty-seven, one hundred forty-eight and one hundred forty-nine 16 of this act shall apply to denials issued on and after such date; 17 (n) the amendments to section 364-j of the social services law, made 18 by section one hundred fifty-a of this act shall not affect the expira- 19 tion and repeal of such section and shall expire and be deemed repealed 20 therewith; 21 (o) sections one hundred fifty-seven and one hundred fifty-eight of 22 this act shall take effect on the one hundred eightieth day after it 23 shall have become a law; provided, however, that effective immediately, 24 the addition, amendment and/or repeal of any rule or regulation neces- 25 sary for the implementation of this act on its effective date are 26 authorized and directed to be made and completed on or before such 27 effective date; 28 (p) the implementation of the provisions of section one hundred 29 fifty-nine of this act shall be subject to the appropriation of moneys 30 specifically for the purposes thereof; 31 (q) the amendments to section 33 of the public health law, made by 32 section one hundred sixty-two of this act shall expire and be deemed 33 repealed one year after the effective date of this act; and 34 (r) sections one hundred sixty-four and one hundred sixty-five of this 35 act shall expire and be deemed repealed three years after the effective 36 date of this act. 37 PART F 38 Section 1. Section 19.16 of the mental hygiene law, as added by chap- 39 ter 223 of the laws of 1992, is amended to read as follows: 40 S 19.16 Methadone Registry. 41 The office shall establish and maintain, either directly or through 42 contract, a central registry for purposes of preventing multiple enroll- 43 ment, ENSURING ACCURATE DOSAGE DELIVERY AND FACILITATING DISASTER 44 MANAGEMENT in methadone programs. The office shall require all methadone 45 programs to utilize such registry and shall have the power to assess 46 methadone programs such fees as are necessary and appropriate; PROVIDED, 47 HOWEVER, THAT PROVISIONS RELATING TO ENSURING ACCURATE DOSAGE DELIVERY 48 AND FACILITATING DISASTER MANAGEMENT SHALL NOT RESULT IN UNREIMBURSED 49 COSTS TO, OR EXPENDITURES BY, METHADONE PROGRAMS. 50 S 2. This act shall take effect April 1, 2013. 51 PART G 52 Section 1. Article 26 of the mental hygiene law is REPEALED. S. 2606--C 181 1 S 2. The article heading of article 25 of the mental hygiene law, as 2 added by chapter 471 of the laws of 1980, is amended to read as follows: 3 [FUNDING FOR SUBSTANCE ABUSE SERVICES] 4 FUNDING FOR SERVICES OF THE OFFICE OF ALCOHOLISM AND 5 SUBSTANCE ABUSE SERVICES 6 S 3. Paragraphs 1, 2, 3 and 4 of subdivision (a) of section 25.01 of 7 the mental hygiene law, paragraph 1 as added by chapter 471 of the laws 8 of 1980, and paragraphs 2, 3 and 4 as amended by chapter 223 of the laws 9 of 1992, are amended, and four new paragraphs 5, 6, 7 and 8 are added to 10 read as follows: 11 1. ["Local agency" shall mean a county governmental unit for a county 12 not wholly within a city, and a city governmental unit for a city having 13 a population of one million or more, designated by such county or city 14 as responsible for substance abuse services in such county or city.] 15 "LOCAL GOVERNMENTAL UNIT" SHALL HAVE THE SAME MEANING AS THAT CONTAINED 16 IN ARTICLE FORTY-ONE OF THIS CHAPTER. 17 2. "Operating [costs] EXPENSES" shall mean expenditures[, excluding 18 capital costs and debt service, subject to the approval of the office,] 19 APPROVED BY THE OFFICE AND incurred for the maintenance and operation of 20 substance [abuse] USE DISORDER programs, including but not limited to 21 expenditures for treatment, administration, personnel, AND contractual 22 services[, rental, depreciation and interest expenses incurred, in 23 connection with the design, construction, acquisition, reconstruction, 24 rehabilitation or improvement of a substance abuse program facility, and 25 payments made to the facilities development corporation for substance 26 abuse program facilities; provided that where the]. OPERATING EXPENSES 27 DO NOT INCLUDE CAPITAL COSTS AND DEBT SERVICE UNLESS SUCH EXPENSES ARE 28 RELATED TO THE rent, financing or refinancing of the design, 29 construction, acquisition, reconstruction, rehabilitation or improvement 30 of a substance [abuse] USE DISORDER program facility [is through the 31 facilities development corporation, operating costs shall include the 32 debt service to be paid to amortize obligations, including principal and 33 interest, issued by the New York State medical care facilities finance 34 agency to finance or refinance the capital costs of such facilities] 35 PURSUANT TO THE MENTAL HYGIENE FACILITIES FINANCE PROGRAM THROUGH THE 36 DORMITORY AUTHORITY OF THE STATE OF NEW YORK (DASNY; SUCCESSOR TO THE 37 FACILITIES DEVELOPMENT CORPORATION), OR OTHERWISE APPROVED BY THE 38 OFFICE. 39 3. "Debt service" shall mean amounts, subject to the approval of the 40 office, [as shall be] required to be paid to amortize obligations 41 including principal and interest [issued by the New York state housing 42 finance agency, the New York State medical care facilities finance agen- 43 cy or], ASSUMED by or on behalf of a [substance abuse program] VOLUNTARY 44 AGENCY or a PROGRAM OPERATED BY A local [agency to finance capital costs 45 for substance abuse program facilities] GOVERNMENTAL UNIT. 46 4. "Capital costs" shall mean [expenditures, subject to the approval 47 of the office, as shall be obligated to acquire, construct, reconstruct, 48 rehabilitate or improve a substance abuse program facility.] THE COSTS 49 OF A PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR A VOLUNTARY AGENCY 50 WITH RESPECT TO THE ACQUISITION OF REAL PROPERTY ESTATES, INTERESTS, AND 51 COOPERATIVE INTERESTS IN REALTY, THEIR DESIGN, CONSTRUCTION, RECON- 52 STRUCTION, REHABILITATION AND IMPROVEMENT, ORIGINAL FURNISHINGS AND 53 EQUIPMENT, SITE DEVELOPMENT, AND APPURTENANCES OF A FACILITY. 54 5. "STATE AID" SHALL MEAN FINANCIAL SUPPORT PROVIDED THROUGH APPROPRI- 55 ATIONS OF THE OFFICE TO SUPPORT THE PROVISION OF SUBSTANCE USE DISORDER 56 TREATMENT, COMPULSIVE GAMBLING, PREVENTION OR OTHER AUTHORIZED SERVICES, S. 2606--C 182 1 WITH THE EXCLUSION OF APPROPRIATIONS FOR THE PURPOSE OF MEDICAL ASSIST- 2 ANCE. 3 6. "VOLUNTARY AGENCY CONTRIBUTIONS" SHALL MEAN REVENUE SOURCES OF 4 VOLUNTARY AGENCIES EXCLUSIVE OF STATE AID AND LOCAL TAX LEVY. 5 7. "APPROVED NET OPERATING COST" SHALL MEAN THE REMAINDER OF TOTAL 6 OPERATING EXPENSES APPROVED BY THE OFFICE, LESS ALL SOURCES OF REVENUE, 7 INCLUDING VOLUNTARY AGENCY CONTRIBUTIONS AND LOCAL TAX LEVY. 8 8. "VOLUNTARY AGENCY" SHALL MEAN A CORPORATION ORGANIZED OR EXISTING 9 PURSUANT TO THE NOT-FOR-PROFIT CORPORATION LAW FOR THE PURPOSE OF 10 PROVIDING SUBSTANCE USE DISORDER, TREATMENT, COMPULSIVE GAMBLING, 11 PREVENTION OR OTHER AUTHORIZED SERVICES. 12 S 4. Subdivisions (a) and (b) of section 25.03 of the mental hygiene 13 law, subdivision (a) as amended by chapter 558 of the laws of 1999 and 14 subdivision (b) as amended by chapter 223 of the laws of 1992, are 15 amended and a new subdivision (d) is added to read as follows: 16 (a) In accordance with the provisions of this article, AND WITHIN 17 APPROPRIATIONS MADE AVAILABLE, the office may provide [financial 18 support] STATE AID to a [substance abuse program or a] PROGRAM OPERATED 19 BY A local [agency] GOVERNMENTAL UNIT OR VOLUNTARY AGENCY up to one 20 hundred per centum of the APPROVED NET operating costs of such [program] 21 PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT or VOLUNTARY agency, and 22 [either fifty per centum of the capital cost or fifty per centum of the 23 debt service,] STATE AID MAY ALSO BE GRANTED TO A PROGRAM OPERATED BY A 24 LOCAL GOVERNMENTAL UNIT OR A VOLUNTARY AGENCY FOR CAPITAL COSTS ASSOCI- 25 ATED WITH THE PROVISION OF SERVICES AT A RATE OF UP TO ONE HUNDRED 26 PERCENT OF APPROVED CAPITAL COSTS. SUCH STATE AID SHALL NOT BE GRANTED 27 UNLESS AND UNTIL SUCH PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR 28 VOLUNTARY AGENCY IS IN COMPLIANCE WITH ALL REGULATIONS PROMULGATED BY 29 THE COMMISSIONER REGARDING THE FINANCING OF CAPITAL PROJECTS. SUCH STATE 30 AID for approved [services] NET OPERATING COSTS SHALL BE MADE AVAILABLE 31 by way of advance or reimbursement, through EITHER contracts entered 32 into between the office and such [program or] VOLUNTARY agency[, upon 33 such terms and conditions as the office shall deem appropriate, except 34 as provided in section 25.07 of this article, provided, however, that, 35 upon issuance of an operating certificate in accordance with article 36 thirty-two of this chapter, if required, the office shall provide finan- 37 cial support for approved chemical dependence services in accordance 38 with article twenty-six of this title.] OR BY DISTRIBUTION OF SUCH STATE 39 AID TO LOCAL GOVERNMENTS THROUGH A GRANT PROCESS PURSUANT TO SECTION 40 25.11 OF THIS ARTICLE. 41 (b) Financial support by the office shall be subject to the approval 42 of the director of the budget AND WITHIN AVAILABLE APPROPRIATIONS. 43 (D) NOTHING IN THIS SECTION SHALL BE CONSTRUED TO REQUIRE THE STATE TO 44 INCREASE SUCH STATE AID SHOULD A LOCAL GOVERNMENTAL UNIT CHOOSE TO 45 REMOVE ANY PORTION OF ITS LOCAL TAX LEVY SUPPORT OF VOLUNTARY AGENCIES, 46 ALTHOUGH THE STATE MAY CHOOSE TO DO SO TO ADDRESS AN URGENT PUBLIC NEED, 47 OR CONVERSELY, MAY CHOOSE TO REDUCE ITS STATE AID. 48 S 5. Section 25.05 of the mental hygiene law, as amended by chapter 49 223 of the laws of 1992, is amended to read as follows: 50 S 25.05 Reimbursement from other sources. 51 The office shall not provide a [substance abuse program] VOLUNTARY 52 AGENCY or a PROGRAM OPERATED BY A local [agency] GOVERNMENTAL UNIT with 53 financial support for obligations incurred by or on behalf of such 54 program or agency for substance [abuse] USE DISORDER services for which 55 reimbursement is or may be claimed under any provision of law other than 56 this article. S. 2606--C 183 1 S 6. The section heading and subdivisions (a) and (c) of section 25.06 2 of the mental hygiene law, as amended by chapter 223 of the laws of 3 1992, are amended to read as follows: 4 Disclosures by closely allied entities of [substance abuse programs] A 5 VOLUNTARY AGENCY. 6 (a) A closely allied entity of a [substance abuse program] VOLUNTARY 7 AGENCY that is funded or has applied for funding from the office shall 8 provide the office with the following information: 9 1. A schedule of the dates, nature and amounts of all fiscal trans- 10 actions between the closely allied entity and the [substance abuse 11 program] VOLUNTARY AGENCY that is funded or has applied for funding from 12 the office. 13 2. A copy of the closely allied entity's certified annual financial 14 statements. 15 3. With respect to any lease agreement between the closely allied 16 entity, as lessor, and the [substance abuse program] VOLUNTARY AGENCY 17 that is funded or has applied for funding from the office, as lessee, of 18 real or personal property: 19 (i) A certified statement by an independent outside entity providing a 20 fair market appraisal of the real property space to be rented, as well 21 as of any rental of personal property. 22 (ii) A statement of projected operating costs of the allied entity 23 relative to any such leased property for the budget period. The closely 24 allied entity must furnish the office with a certified statement of its 25 actual operating costs relative to the leased property. 26 4. A statement of the funds received by the closely allied entity in 27 connection with its fund raising activities conducted on behalf of the 28 substance [abuse] USE DISORDER program that is funded or has applied for 29 funding from the office which clearly identifies how such funds were and 30 will be distributed or applied to such program. 31 5. Any other data or information which the office may deem necessary 32 for purposes of making a funding decision. 33 (c) For purposes of this section, a "closely allied entity" shall 34 mean, but not be limited to, a corporation, partnership or unincorporat- 35 ed association or other body that has been formed or is organized to 36 provide financial assistance and aid for the benefit of a [substance 37 abuse program] VOLUNTARY AGENCY that is funded or has applied for fund- 38 ing from the office AND which FINANCIAL ASSISTANCE AND AID shall 39 include, but not be limited to, engaging in fund raising activities, 40 administering funds, holding title to real property, having an interest 41 in personal property of any nature whatsoever, and engaging in any other 42 activities for the benefit of any such program. Moreover, an entity 43 shall be deemed closely allied to a [substance abuse program] VOLUNTARY 44 AGENCY that is funded or has applied for funding from the office to the 45 extent that such entity and applicable fiscal transactions are required 46 to be disclosed within the annual financial statements of the [substance 47 abuse program] VOLUNTARY AGENCY that is funded or has applied for fund- 48 ing from the office, under the category of related party transactions, 49 as defined by and in accordance with generally accepted accounting prin- 50 ciples (GAAP) and generally accepted auditing standards (GAAS), as 51 promulgated by the American institute of certified public accountants 52 (AICPA). 53 S 7. Section 25.07 of the mental hygiene law, as added by chapter 471 54 of the laws of 1980, is amended to read as follows: 55 S 25.07 Non-substitution. S. 2606--C 184 1 A [substance abuse program] VOLUNTARY AGENCY or a PROGRAM OPERATED BY 2 A local [agency] GOVERNMENTAL UNIT shall not substitute state monies for 3 cash contributions, federal aid otherwise committed to or intended for 4 use in such program or by such agency, revenues derived from the opera- 5 tion of such program or agency, or the other resources available for use 6 in the operation of the program or agency. 7 S 8. Section 25.09 of the mental hygiene law, as amended by chapter 8 223 of the laws of 1992, is amended to read as follows: 9 S 25.09 Administrative costs. 10 Subject to the approval of the director of the budget, the office 11 shall establish a limit on the amount of financial support which may be 12 advanced or reimbursed to a [substance abuse program] VOLUNTARY AGENCY 13 or a PROGRAM OPERATED BY A local [agency] GOVERNMENTAL UNIT for the 14 administration of a [substance abuse] program. 15 S 9. Section 25.11 of the mental hygiene law, as added by chapter 471 16 of the laws of 1980, subdivision (a) as amended by chapter 223 of the 17 laws of 1992, is amended to read as follows: 18 S 25.11 [Comprehensive plan] DISTRIBUTION OF STATE AID TO A LOCAL 19 GOVERNMENTAL UNIT. 20 [(a) A local agency intending to seek financial support from the 21 office shall no later than July first of each year submit to the office 22 a comprehensive substance abuse services plan, which shall describe the 23 programs and activities planned for its ensuing fiscal year. Such plan 24 shall indicate to the extent possible, the nature of the services to be 25 provided, whether such services are to be provided directly, through 26 subcontract, or through the utilization of existing public resources, 27 the area or areas to be served, and an estimate of the cost of such 28 services, including amounts to be provided other than by office finan- 29 cial support, specifically identifying the amount of local governmental 30 funds committed to substance abuse programs during its current fiscal 31 year, and a commitment that no less than such an amount will be used 32 from such funds for the operation of such programs during the next 33 fiscal year. Such plan shall make provisions for all needed substance 34 abuse services and for the evaluation of the effectiveness of such 35 services. 36 (b) When a comprehensive plan includes a local school district based 37 substance abuse program such plan shall include the details of an 38 adequate distribution of in-school and community-wide preventive educa- 39 tion services, including, but not limited to, services to be provided by 40 local drug abuse prevention councils, and shall emphasize the use of 41 other volunteer agency services as may be available. The description of 42 the program and activities thereunder shall be separately stated, and 43 the data and information required to be provided shall conform to the 44 provisions of subdivision (a) of this section except that the period to 45 be covered may, notwithstanding the fiscal year of the local agency, 46 conform to the school year.] NOTWITHSTANDING SECTION ONE HUNDRED TWELVE 47 OF THE STATE FINANCE LAW, THE OFFICE IS AUTHORIZED TO GRANT STATE AID 48 ANNUALLY TO LOCAL GOVERNMENTAL UNITS IN THE FOLLOWING MANNER: 49 (A) LOCAL GOVERNMENTAL UNITS SHALL BE GRANTED STATE AID BY A STATE AID 50 FUNDING AUTHORIZATION LETTER ISSUED BY THE OFFICE FOR APPROVED NET OPER- 51 ATING COSTS FOR VOLUNTARY AGENCIES TO SUPPORT THE BASE AMOUNT OF STATE 52 AID PROVIDED TO SUCH VOLUNTARY AGENCIES FOR THE PRIOR YEAR PROVIDED THAT 53 THE LOCAL GOVERNMENTAL UNIT HAS APPROVED AND SUBMITTED BUDGETS FOR THE 54 VOLUNTARY AGENCIES TO THE OFFICE. THE VOLUNTARY AGENCY BUDGETS SHALL 55 IDENTIFY THE NATURE OF THE SERVICES TO BE PROVIDED WHICH MUST BE 56 CONSISTENT WITH THE LOCAL SERVICES PLAN SUBMITTED BY THE LOCAL GOVERN- S. 2606--C 185 1 MENTAL UNIT PURSUANT TO ARTICLE FORTY-ONE OF THIS CHAPTER, THE AREAS TO 2 BE SERVED AND INCLUDE A DESCRIPTION OF THE VOLUNTARY AGENCY CONTRIB- 3 UTIONS AND LOCAL GOVERNMENTAL UNIT FUNDING PROVIDED. THE LOCAL GOVERN- 4 MENTAL UNIT SHALL ENTER INTO CONTRACTS WITH THE VOLUNTARY AGENCIES 5 RECEIVING SUCH STATE AID. SUCH CONTRACTS SHALL INCLUDE FUNDING REQUIRE- 6 MENTS SET BY THE OFFICE INCLUDING BUT NOT LIMITED TO RESPONSIBILITIES OF 7 VOLUNTARY AGENCIES RELATING TO WORK SCOPES, PROGRAM PERFORMANCE AND 8 OPERATIONS, APPLICATION OF PROGRAM INCOME, PROHIBITED USE OF FUNDS, 9 RECORDKEEPING AND AUDIT OBLIGATIONS. UPON DESIGNATION BY THE OFFICE, 10 LOCAL GOVERNMENTAL UNITS SHALL NOTIFY VOLUNTARY AGENCIES AS TO THE 11 SOURCE OF FUNDING RECEIVED BY SUCH VOLUNTARY AGENCIES. 12 (B) STATE AID MADE AVAILABLE TO A LOCAL GOVERNMENTAL UNIT FOR APPROVED 13 NET OPERATING COSTS FOR A VOLUNTARY AGENCY MAY BE REDUCED WHERE A REVIEW 14 OF SUCH VOLUNTARY AGENCY'S PRIOR YEAR'S BUDGET AND/OR PERFORMANCE INDI- 15 CATES: 16 (1) THAT THE PROGRAM OPERATED BY A LOCAL GOVERNMENTAL UNIT OR VOLUN- 17 TARY AGENCY HAS FAILED TO MEET MINIMUM PERFORMANCE STANDARDS AND 18 REQUIREMENTS OF THE OFFICE INCLUDING, BUT NOT LIMITED TO, MAINTAINING 19 SERVICE UTILIZATION RATES AND PRODUCTIVITY STANDARDS AS SET BY THE 20 OFFICE; 21 (2) THAT THE VOLUNTARY AGENCY HAS HAD AN INCREASE IN VOLUNTARY AGENCY 22 CONTRIBUTIONS THAT REDUCES THE APPROVED NET OPERATING COSTS NECESSARY; 23 (3) THAT THE OFFICE, UPON CONSULTATION WITH THE LOCAL GOVERNMENTAL 24 UNIT, OTHERWISE DETERMINES THERE IS A NEED TO REDUCE THE AMOUNT OF STATE 25 AID AVAILABLE. 26 S 10. Section 25.13 of the mental hygiene law, as amended by chapter 27 223 of the laws of 1992, is amended to read as follows: 28 S 25.13 Office is authorized state agency. 29 (a) The office when designated by the governor is the agency of the 30 state to administer and/or supervise the state plan or plans concerning 31 substance [abuse] USE DISORDER services specified in the federal drug 32 abuse office and treatment act of nineteen hundred seventy-two and to 33 cooperate with the duly designated federal authorities charged with the 34 administration thereof. 35 (b) The office and all entities to which it provides financial support 36 shall do all that is required and shall render necessary cooperation to 37 ensure optimum use of federal aid for substance [abuse] USE DISORDER 38 services. 39 (c) The commissioner is authorized and empowered to take such steps, 40 not inconsistent with law, as may be necessary for the purpose of 41 procuring for the people of this state all of the benefits and assist- 42 ance, financial and otherwise, provided, or to be provided for, by or 43 pursuant to any act of congress relating to substance [abuse] USE DISOR- 44 DER services. 45 S 11. Section 25.15 of the mental hygiene law, as amended by chapter 46 223 of the laws of 1992, is amended to read as follows: 47 S 25.15 Optimizing federal aid. 48 (a) A PROGRAM OPERATED BY A local [agency] GOVERNMENTAL UNIT or 49 [substance abuse program] VOLUNTARY AGENCY shall, unless a specific 50 written waiver of this requirement is made by the office, cause applica- 51 tions to be completed on such forms and in such manner as directed by 52 the office and submit the same to the office for the purpose of causing 53 a determination to be made whether the cost of the services provided 54 individuals and groups qualify for federal aid which may be available 55 for services provided pursuant to titles IV, XVI, XIX and XX of the 56 federal social security act, or any other federal law. A PROGRAM OPER- S. 2606--C 186 1 ATED BY A local [agency] GOVERNMENTAL UNIT or a [substance abuse 2 program] VOLUNTARY AGENCY shall furnish to the office such other data as 3 may be required and shall render such cooperation as may be necessary to 4 maximize such potential federal aid. All information concerning the 5 identity of individuals obtained and provided pursuant to this subdivi- 6 sion shall be kept confidential. 7 (b) To the extent that federal aid may be available for any substance 8 [abuse] USE DISORDER services, the office, notwithstanding any other 9 inconsistent provision of law, and with the approval of the director of 10 the budget, is hereby authorized to seek such federal aid on behalf of 11 [substance abuse programs] VOLUNTARY AGENCIES and A PROGRAM OPERATED BY 12 A local [agencies] GOVERNMENTAL UNIT either directly or through the 13 submission of claims to another state agency authorized to submit the 14 same to an appropriate federal agency. The office is further authorized 15 to certify for payment to [substance abuse programs] VOLUNTARY AGENCIES 16 and A PROGRAM OPERATED BY A local [agencies] GOVERNMENTAL UNIT any 17 federal aid received by the state which is attributable to the activ- 18 ities financed by such programs and agencies. 19 S 12. Section 25.17 of the mental hygiene law, as amended by chapter 20 223 of the laws of 1992, is amended to read as follows: 21 S 25.17 Fees for services. 22 [Local agencies GOVERNMENTS and substance abuse treatment programs] 23 VOLUNTARY AGENCIES AND PROGRAMS OPERATED BY LOCAL GOVERNMENTAL UNITS 24 funded in whole or in part by the office shall establish, subject to the 25 approval of the office, fee schedules for substance [abuse] USE DISORDER 26 services, not specifically covered by the rates established pursuant to 27 article twenty-eight of the public health law or title two of article 28 five of the social services law. Such fees shall be charged for 29 substance [abuse] USE DISORDER services furnished to persons who are 30 financially able to pay the same, provided, that such services shall not 31 be refused to any person because of his inability to pay therefor. 32 S 13. Subdivision (d) of section 41.18 of the mental hygiene law, as 33 amended by chapter 558 of the laws of 1999, is amended to read as 34 follows: 35 (d) The liability of the state in any state fiscal year for state aid 36 pursuant to this section shall exclude chemical dependence services, 37 which are subject to article [twenty-six] TWENTY-FIVE of this chapter, 38 and shall be limited to the amounts appropriated for such state aid by 39 the legislature for such state fiscal year. 40 S 14. This act shall take effect April 1, 2013; provided, however, 41 that effective immediately, any rule or regulation necessary for the 42 implementation of this act on its effective date is authorized and 43 directed to be made and completed on or before such effective date. 44 PART H 45 Section 1. Section 7.17 of the mental hygiene law is amended by adding 46 a new subdivision (a-1) to read as follows: 47 (A-1) NOTWITHSTANDING ANY LAW TO THE CONTRARY, INPATIENT FACILITIES IN 48 THE OFFICE SHALL ONLY BE ESTABLISHED PURSUANT TO EXPLICIT STATUTORY 49 AUTHORITY. 50 S 2. The commissioner of mental health shall provide a report regard- 51 ing the proposed restructuring of state-operated facilities that provide 52 inpatient care to individuals with mental illness to the legislature no 53 later than September 1, 2013, and shall provide an update of such report S. 2606--C 187 1 every six months thereafter. Such report shall address topics including, 2 but not limited to: 3 (a) the size and location of, and type of services to be provided by, 4 facilities; 5 (b) the relative quality of the care and treatment provided by any 6 hospital subject to a proposed closure, as may be informed by internal 7 or external quality or accreditation reviews; 8 (c) the current and anticipated long-term need for the types of 9 services provided by existing and proposed facilities; 10 (d) the availability of staff sufficient to address current and antic- 11 ipated long term service needs; 12 (e) the long term capital investment required to ensure that the 13 facilities meets relevant state and federal regulatory and capital 14 construction requirements, and national accreditation standards; 15 (f) anticipated savings based upon economics of scale or other 16 factors; 17 (g) community mental health services available in the catchment area 18 of proposed facilities and hospitals subject to proposed closure, and 19 the ability of such community mental health services to meet the behav- 20 ioral health needs of the impacted consumers; 21 (h) how restructuring would address the obligations of the state to 22 place persons with mental disabilities in community settings rather than 23 in institutions, when appropriate; 24 (i) the anticipated impact of a proposed closure on access to mental 25 health services; 26 (j) the impact on the state workforce, and strategies for the develop- 27 ment of necessary retraining and redeployment programs; 28 (k) the impact on the local and regional economies; and 29 (l) proposed alternative uses for land and buildings to be vacated by 30 the office of mental health. 31 S 3. Section 7 of part R2 of chapter 62 of the laws of 2003, amending 32 the mental hygiene law and the state finance law relating to the commu- 33 nity mental health support and workforce reinvestment program, the 34 membership of subcommittees for mental health of community services 35 boards and the duties of such subcommittees and creating the community 36 mental health and workforce reinvestment account, as amended by section 37 2 of part C of chapter 111 of the laws of 2010, is amended to read as 38 follows: 39 S 7. This act shall take effect immediately and shall expire March 31, 40 [2013] 2014 when upon such date the provisions of this act shall be 41 deemed repealed. 42 S 4. Severability clause. If any clause, sentence, paragraph, subdivi- 43 sion, section or part of this act shall be adjudged by any court of 44 competent jurisdiction to be invalid, such judgment shall not affect, 45 impair, or invalidate the remainder thereof, but shall be confined in 46 its operation to the clause, sentence, paragraph, subdivision, section 47 or part thereof directly involved in the controversy in which such judg- 48 ment shall have been rendered. It is hereby declared to be the intent of 49 the legislature that this act would have been enacted even if such 50 invalid provisions had not been included herein. 51 S 5. This act shall take effect April 1, 2013; provided, however that 52 if this act shall become a law after April 1, 2013, this act shall take 53 effect immediately and shall be deemed to have been in full force and 54 effect on and after April 1, 2013. 55 PART I S. 2606--C 188 1 Section 1. Subdivisions (d), (e), (f) and (g) of section 41.44 of the 2 mental hygiene law are relettered subdivisions (e), (f), (g), and (h) 3 and a new subdivision (d) is added to read as follows: 4 (D) THE COMMISSIONER IS AUTHORIZED TO RECOVER FUNDING FROM PROVIDERS 5 OF COMMUNITY RESIDENCES LICENSED BY THE OFFICE OF MENTAL HEALTH, 6 CONSISTENT WITH CONTRACTUAL OBLIGATIONS OF SUCH PROVIDERS, AND NOTWITH- 7 STANDING ANY OTHER INCONSISTENT PROVISION OF LAW TO THE CONTRARY, SUCH 8 RECOVERY AMOUNT SHALL EQUAL FIFTY PERCENT OF THE MEDICAID REVENUE 9 RECEIVED BY SUCH PROVIDERS WHICH EXCEEDS THE FIXED AMOUNT OF ANNUAL 10 MEDICAID REVENUE LIMITATIONS, AS ESTABLISHED BY THE COMMISSIONER. 11 S 2. This act shall take effect immediately, shall be deemed to have 12 been in full force and effect on and after April 1, 2013, and shall 13 expire and be deemed repealed March 31, 2014. 14 PART J 15 Intentionally Omitted 16 PART K 17 Section 1. Subdivisions (a), (b) and (c) of section 10.09 of the 18 mental hygiene law, subdivisions (a) and (c) as added by chapter 7 of 19 the laws of 2007 and subdivision (b) as amended by section 3 of part P 20 of chapter 56 of the laws of 2012, are amended to read as follows: 21 (a) The commissioner shall provide the respondent and counsel for 22 respondent with [an annual] A written notice of the right to petition 23 the court for discharge, WHICH SHALL BE PROVIDED NO LATER THAN ELEVEN 24 MONTHS AFTER THE DATE ON WHICH THE SUPREME OR COUNTY COURT JUDGE LAST 25 ORDERED OR CONFIRMED THE NEED FOR CONTINUED CONFINEMENT PURSUANT TO THIS 26 ARTICLE. The notice shall contain a form for the waiver of the right to 27 petition for discharge. 28 (b) The commissioner shall also assure that each respondent committed 29 under this article shall have an examination for evaluation of his or 30 her mental condition made [at least once every] NO LATER THAN ONE year 31 [(calculated from] AFTER the date on which the supreme or county court 32 judge last ordered or confirmed the need for continued confinement 33 pursuant to this article [or the date on which the respondent waived the 34 right to petition for discharge pursuant to this section, whichever is 35 later, as applicable)]. SUCH EXAMINATION SHALL BE conducted by a psychi- 36 atric examiner who shall report to the commissioner his or her written 37 findings as to whether the respondent is currently a dangerous sex 38 offender requiring confinement. At such time, the respondent also shall 39 have the right to be evaluated by an independent psychiatric examiner. 40 If the respondent is financially unable to obtain an examiner, the court 41 shall appoint an examiner of the respondent's choice to be paid within 42 the limits prescribed by law. Following such evaluation, each psychiat- 43 ric examiner shall report his or her findings in writing to the commis- 44 sioner and to counsel for respondent. The commissioner shall review 45 relevant records and reports, along with the findings of the psychiatric 46 examiners, and shall make a determination in writing as to whether the 47 respondent is currently a dangerous sex offender requiring confinement. 48 (c) The commissioner shall [annually] forward the notice and waiver 49 form, along with a report including the commissioner's written determi- 50 nation and the findings of the psychiatric examination, to the supreme 51 or county court where the respondent is located, WHICH SHALL BE PROVIDED 52 NO LATER THAN ONE YEAR AFTER THE DATE ON WHICH THE SUPREME OR COUNTY S. 2606--C 189 1 COURT JUDGE LAST ORDERED OR CONFIRMED THE NEED FOR CONTINUED CONFINEMENT 2 PURSUANT TO THIS ARTICLE. 3 S 2. This act shall take effect immediately and shall be deemed to 4 have been in full force and effect on and after April 1, 2013. 5 PART L 6 Section 1. The mental hygiene law is amended by adding a new section 7 31.37 to read as follows: 8 S 31.37 MENTAL HEALTH INCIDENT REVIEW PANELS. 9 (A) THE COMMISSIONER IS AUTHORIZED TO, ON HIS OR HER OWN ACCORD OR 10 PURSUANT TO A REQUEST BY A LOCAL GOVERNMENT UNIT, ESTABLISH A MENTAL 11 HEALTH INCIDENT REVIEW PANEL FOR THE PURPOSES OF REVIEWING IN CONJUNC- 12 TION WITH LOCAL REPRESENTATION, THE CIRCUMSTANCES AND EVENTS RELATED TO 13 A SERIOUS INCIDENT INVOLVING A PERSON WITH MENTAL ILLNESS. FOR PURPOSES 14 OF THIS SECTION, A "SERIOUS INCIDENT INVOLVING A PERSON WITH MENTAL 15 ILLNESS" MEANS AN INCIDENT OCCURRING IN THE COMMUNITY IN WHICH A PERSON 16 WITH A SERIOUS MENTAL ILLNESS IS PHYSICALLY INJURED OR CAUSES PHYSICAL 17 INJURY TO ANOTHER PERSON, OR SUFFERS A SERIOUS AND PREVENTABLE MEDICAL 18 COMPLICATION OR BECOMES INVOLVED IN A CRIMINAL INCIDENT INVOLVING 19 VIOLENCE. A PANEL SHALL CONDUCT A REVIEW OF SUCH SERIOUS INCIDENT IN AN 20 ATTEMPT TO IDENTIFY PROBLEMS OR GAPS IN MENTAL HEALTH DELIVERY SYSTEMS 21 AND TO MAKE RECOMMENDATIONS FOR CORRECTIVE ACTIONS TO IMPROVE THE 22 PROVISION OF MENTAL HEALTH OR RELATED SERVICES, TO IMPROVE THE COORDI- 23 NATION, INTEGRATION AND ACCOUNTABILITY OF CARE IN THE MENTAL HEALTH 24 SERVICE SYSTEM, AND TO ENHANCE INDIVIDUAL AND PUBLIC SAFETY. 25 (B) A MENTAL HEALTH INCIDENT REVIEW PANEL SHALL INCLUDE, BUT NEED NOT 26 BE LIMITED TO, REPRESENTATIVES FROM THE OFFICE OF MENTAL HEALTH AND THE 27 LOCAL GOVERNMENTAL UNIT WHERE THE SERIOUS INCIDENT INVOLVING A PERSON 28 WITH A MENTAL ILLNESS OCCURRED. A MENTAL HEALTH INCIDENT REVIEW PANEL 29 MAY ALSO INCLUDE, IF DEEMED APPROPRIATE BY THE COMMISSIONER BASED ON THE 30 NATURE OF THE SERIOUS INCIDENT BEING REVIEWED, ONE OR MORE REPRESEN- 31 TATIVES FROM MENTAL HEALTH PROVIDERS, LOCAL DEPARTMENTS OF SOCIAL 32 SERVICES, HUMAN SERVICES PROGRAMS, HOSPITALS, LOCAL SCHOOLS, EMERGENCY 33 MEDICAL OR MENTAL HEALTH SERVICES, THE OFFICE OF THE COUNTY ATTORNEY, A 34 COUNTY PROSECUTOR'S OFFICE, STATE OR LOCAL LAW ENFORCEMENT AGENCIES, THE 35 OFFICE OF THE MEDICAL EXAMINER OR THE OFFICE OF THE CORONER, THE JUDICI- 36 ARY, OR OTHER APPROPRIATE STATE OR LOCAL OFFICIALS. 37 (C) NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE CONTRARY AND TO 38 THE EXTENT CONSISTENT WITH FEDERAL LAW, A MENTAL HEALTH INCIDENT REVIEW 39 PANEL SHALL HAVE ACCESS TO THOSE CLIENT-IDENTIFIABLE MENTAL HEALTH 40 RECORDS, AS WELL AS ALL RECORDS, DOCUMENTATION AND REPORTS RELATING TO 41 THE INVESTIGATION OF AN INCIDENT BY A FACILITY IN ACCORDANCE WITH REGU- 42 LATIONS OF THE COMMISSIONER, WHICH ARE NECESSARY FOR THE INVESTIGATION 43 OF THE INCIDENT AND THE PREPARATION OF A REPORT OF THE INCIDENT, AS 44 PROVIDED IN SUBDIVISION (E) OF THIS SECTION. A MENTAL HEALTH INCIDENT 45 REVIEW PANEL ESTABLISHED PURSUANT TO THIS SECTION SHALL BE PROVIDED WITH 46 ACCESS TO ALL OTHER RECORDS IN THE POSSESSION OF STATE OR LOCAL OFFI- 47 CIALS OR AGENCIES, WITHIN TWENTY-ONE DAYS OF RECEIPT OF A REQUEST, 48 EXCEPT: (1) THOSE RECORDS PROTECTED BY SECTION 190.25 OF THE CRIMINAL 49 PROCEDURE LAW; AND (2) WHERE PROVISION OF LAW ENFORCEMENT RECORDS WOULD 50 INTERFERE WITH AN ONGOING LAW ENFORCEMENT INVESTIGATION OR JUDICIAL 51 PROCEEDING, IDENTIFY A CONFIDENTIAL SOURCE OR DISCLOSE CONFIDENTIAL 52 INFORMATION RELATING TO AN ONGOING CRIMINAL INVESTIGATION, HIGHLY SENSI- 53 TIVE CRIMINAL INVESTIGATIVE TECHNIQUES OR PROCEDURES, OR ENDANGER THE 54 SAFETY OR WELFARE OF AN INDIVIDUAL. S. 2606--C 190 1 (D) MENTAL HEALTH INCIDENT REVIEW PANELS, MEMBERS OF THE REVIEW PANELS 2 AND PERSONS WHO PRESENT INFORMATION TO A REVIEW PANEL SHALL HAVE IMMUNI- 3 TY FROM CIVIL AND CRIMINAL LIABILITY FOR ALL REASONABLE AND GOOD FAITH 4 ACTIONS TAKEN PURSUANT TO THIS SECTION, AND SHALL NOT BE QUESTIONED IN 5 ANY CIVIL OR CRIMINAL PROCEEDING REGARDING ANY OPINIONS FORMED AS A 6 RESULT OF A MEETING OF SUCH REVIEW PANEL. NOTHING IN THIS SECTION SHALL 7 BE CONSTRUED TO PREVENT A PERSON FROM TESTIFYING AS TO INFORMATION 8 OBTAINED INDEPENDENTLY OF A MENTAL HEALTH INCIDENT REVIEW PANEL, OR 9 INFORMATION WHICH IS PUBLIC. 10 (E) NOTWITHSTANDING ANY OTHER PROVISION OF LAW TO THE CONTRARY, ALL 11 MEETINGS CONDUCTED, ALL REPORTS AND RECORDS MADE AND MAINTAINED AND ALL 12 BOOKS AND PAPERS OBTAINED BY A MENTAL HEALTH INCIDENT REVIEW PANEL SHALL 13 BE CONFIDENTIAL, AND SHALL NOT BE OPEN OR MADE AVAILABLE, EXCEPT BY 14 COURT ORDER OR AS SET FORTH IN SUBDIVISION (G) OF THIS SECTION. EACH 15 MENTAL HEALTH INCIDENT REVIEW PANEL SHALL DEVELOP A REPORT OF THE INCI- 16 DENT INVESTIGATED. SUCH REPORT SHALL NOT CONTAIN ANY INDIVIDUALLY IDEN- 17 TIFIABLE INFORMATION AND SHALL BE PROVIDED TO THE OFFICE OF MENTAL 18 HEALTH UPON COMPLETION. SUCH REPORTS MUST BE APPROVED BY THE OFFICE OF 19 MENTAL HEALTH PRIOR TO BECOMING FINAL. 20 (F) IF QUALITY PROBLEMS OF PARTICULAR MENTAL HEALTH PROGRAMS ARE IDEN- 21 TIFIED BASED ON SUCH REVIEWS, THE COMMISSIONER IS AUTHORIZED, PURSUANT 22 TO THE RELEVANT PROVISIONS OF THIS CHAPTER, TO TAKE APPROPRIATE ACTIONS 23 REGARDING THE LICENSURE OF PARTICULAR PROVIDERS, TO REFER THE ISSUE TO 24 OTHER RESPONSIBLE PARTIES FOR INVESTIGATION, OR TO TAKE OTHER APPROPRI- 25 ATE ACTION WITHIN THE SCOPE OF HIS OR HER AUTHORITY. 26 (G) IN HIS OR HER DISCRETION, THE COMMISSIONER SHALL BE AUTHORIZED TO 27 PROVIDE THE FINAL REPORT OF A REVIEW PANEL OR PORTIONS THEREOF TO ANY 28 INDIVIDUAL OR ENTITY FOR WHOM THE REPORT MAKES RECOMMENDATIONS FOR 29 CORRECTIVE OR OTHER APPROPRIATE ACTIONS THAT SHOULD BE TAKEN. ANY FINAL 30 REPORT OR PORTION THEREOF SHALL NOT BE FURTHER DISSEMINATED BY THE INDI- 31 VIDUAL OR ENTITY RECEIVING SUCH REPORT. FURTHER, THE COMMISSIONER SHALL 32 SUBMIT THE FINAL REPORT OF A REVIEW PANEL, WITHIN FIFTEEN DAYS OF THE 33 CONCLUSION OF A PANEL, TO THE TEMPORARY PRESIDENT OF THE SENATE AND THE 34 SPEAKER OF THE ASSEMBLY. 35 (H) THE COMMISSIONER SHALL SUBMIT AN ANNUAL CUMULATIVE REPORT TO THE 36 GOVERNOR AND THE LEGISLATURE INCORPORATING THE DATA IN THE MENTAL HEALTH 37 INCIDENT REVIEW PANEL REPORTS AND INCLUDING A SUMMARY OF THE FINDINGS 38 AND RECOMMENDATIONS MADE BY SUCH REVIEW PANELS, WHICH MEASURES THAT HAVE 39 BEEN IMPLEMENTED, AND A DESCRIPTION OF THE IMPACT OF SUCH IMPLEMENTA- 40 TIONS. THE ANNUAL CUMULATIVE REPORTS MAY THEREAFTER BE MADE AVAILABLE 41 TO THE PUBLIC. 42 S 2. Subdivision (c) of section 33.13 of the mental hygiene law is 43 amended by adding a new paragraph 16 to read as follows: 44 16. TO A MENTAL HEALTH INCIDENT REVIEW PANEL, OR MEMBERS THEREOF, 45 ESTABLISHED BY THE COMMISSIONER PURSUANT TO SECTION 31.37 OF THIS TITLE, 46 IN CONNECTION WITH INCIDENT REVIEWS CONDUCTED BY SUCH PANEL. 47 S 3. Subdivision 3 of section 6527 of the education law, as amended by 48 chapter 257 of the laws of 1987, is amended to read as follows: 49 3. No individual who serves as a member of (a) a committee established 50 to administer a utilization review plan of a hospital, including a 51 hospital as defined in article twenty-eight of the public health law or 52 a hospital as defined in subdivision ten of section 1.03 of the mental 53 hygiene law, or (b) a committee having the responsibility of the inves- 54 tigation of an incident reported pursuant to section 29.29 of the mental 55 hygiene law or the evaluation and improvement of the quality of care 56 rendered in a hospital as defined in article twenty-eight of the public S. 2606--C 191 1 health law or a hospital as defined in subdivision ten of section 1.03 2 of the mental hygiene law, or (c) any medical review committee or 3 subcommittee thereof of a local, county or state medical, dental, podia- 4 try or optometrical society, any such society itself, a professional 5 standards review organization or an individual when such committee, 6 subcommittee, society, organization or individual is performing any 7 medical or quality assurance review function including the investigation 8 of an incident reported pursuant to section 29.29 of the mental hygiene 9 law, either described in clauses (a) and (b) of this subdivision, 10 required by law, or involving any controversy or dispute between (i) a 11 physician, dentist, podiatrist or optometrist or hospital administrator 12 and a patient concerning the diagnosis, treatment or care of such 13 patient or the fees or charges therefor or (ii) a physician, dentist, 14 podiatrist or optometrist or hospital administrator and a provider of 15 medical, dental, podiatric or optometrical services concerning any 16 medical or health charges or fees of such physician, dentist, podiatrist 17 or optometrist, or (d) a committee appointed pursuant to section twen- 18 ty-eight hundred five-j of the public health law to participate in the 19 medical and dental malpractice prevention program, or (e) any individual 20 who participated in the preparation of incident reports required by the 21 department of health pursuant to section twenty-eight hundred five-l of 22 the public health law, or (f) a committee established to administer a 23 utilization review plan, or a committee having the responsibility of 24 evaluation and improvement of the quality of care rendered, in a health 25 maintenance organization organized under article forty-four of the 26 public health law or article forty-three of the insurance law, including 27 a committee of an individual practice association or medical group 28 acting pursuant to a contract with such a health maintenance organiza- 29 tion, OR (G) A MENTAL HEALTH INCIDENT REVIEW PANEL CONVENED PURSUANT TO 30 SECTION 31.37 OF THE MENTAL HYGIENE LAW, shall be liable in damages to 31 any person for any action taken or recommendations made, by him OR HER 32 within the scope of his OR HER function in such capacity provided that 33 (a) such individual has taken action or made recommendations within the 34 scope of his OR HER function and without malice, and (b) in the reason- 35 able belief after reasonable investigation that the act or recommenda- 36 tion was warranted, based upon the facts disclosed. 37 Neither the proceedings nor the records relating to performance of a 38 medical or a quality assurance review function or participation in a 39 medical and dental malpractice prevention program nor any report 40 required by the department of health pursuant to section twenty-eight 41 hundred five-l of the public health law described herein, including the 42 investigation of an incident reported pursuant to section 29.29 of the 43 mental hygiene law OR REVIEWED PURSUANT TO SECTION 31.37 OF THE MENTAL 44 HYGIENE LAW, shall be subject to disclosure under article thirty-one of 45 the civil practice law and rules except as hereinafter provided or as 46 provided by any other provision of law. No person in attendance at a 47 meeting when a medical or a quality assurance review or a medical and 48 dental malpractice prevention program or an incident reporting function 49 described herein was performed, including the investigation of an inci- 50 dent reported pursuant to section 29.29 of the mental hygiene law OR AN 51 INCIDENT REVIEWED PURSUANT TO SECTION 31.37 OF THE MENTAL HYGIENE LAW, 52 shall be required to testify as to what transpired thereat. The prohibi- 53 tion relating to discovery of testimony shall not apply to the state- 54 ments made by any person in attendance at such a meeting who is a party 55 to an action or proceeding the subject matter of which was reviewed at 56 such meeting. S. 2606--C 192 1 S 4. This act shall take effect on the sixtieth day after it shall 2 have become a law. 3 PART M 4 Section 1. Section 20 of chapter 723 of the laws of 1989, amending the 5 mental hygiene law and other laws relating to the establishment of 6 comprehensive psychiatric emergency programs, is REPEALED. 7 S 2. Subdivision (c) of section 7.15 of the mental hygiene law is 8 REPEALED. 9 S 3. Subdivision (c) of section 13.15 of the mental hygiene law is 10 REPEALED. 11 S 4. Paragraph 3 of subdivision (d) of section 16.19 of the mental 12 hygiene law is REPEALED. 13 S 5. Subparagraph e of paragraph 2 of subdivision (b) of section 5.07 14 of the mental hygiene law, as added by chapter 322 of the laws of 1992, 15 is amended as follows: 16 e. a description of the available community-based acute inpatient, 17 out-patient, [emergency, and community support] COMMUNITY SUPPORT AND 18 EMERGENCY services, WHICH SHALL INCLUDE COMPREHENSIVE PSYCHIATRIC EMER- 19 GENCY PROGRAMS LICENSED PURSUANT TO SECTION 31.27 OF THIS CHAPTER. Such 20 description should include the extent to which these services are 21 currently utilized by persons with mental illness and, as available, 22 compare estimates of utilization with estimates of the prevalence of 23 mental illness among persons residing in the service area to determine 24 unmet need; 25 S 6. This act shall take effect April 1, 2013. 26 PART N 27 Section 1. Subdivisions 3-b and 3-c of section 1 and section 4 of 28 part C of chapter 57 of the laws of 2006, relating to establishing a 29 cost of living adjustment for designated human services programs, as 30 amended by section 1 of part H of chapter 56 of the laws of 2012, is 31 amended to read as follows: 32 3-b. Notwithstanding any inconsistent provision of law, beginning 33 April 1, 2009 and ending March 31, [2013] 2014, the commissioners shall 34 not include a COLA for the purpose of establishing rates of payments, 35 contracts or any other form of reimbursement. 36 3-c. Notwithstanding any inconsistent provision of law, beginning 37 April 1, [2013] 2014 and ending March 31, [2016] 2017, the commissioners 38 shall develop the COLA under this section using the actual U.S. consumer 39 price index for all urban consumers (CPI-U) published by the United 40 States department of labor, bureau of labor statistics for the twelve 41 month period ending in July of the budget year prior to such state 42 fiscal year, for the purpose of establishing rates of payments, 43 contracts or any other form of reimbursement. 44 S 4. This act shall take effect immediately and shall be deemed to 45 have been in full force and effect on and after April 1, 2006; provided 46 section one of this act shall expire and be deemed repealed April 1, 47 [2016] 2017; provided, further, that sections two and three of this act 48 shall expire and be deemed repealed December 31, 2009. 49 S 2. This act shall take effect immediately and shall be deemed to 50 have been in full force and effect on and after April 1, 2013; provided, 51 however, that the amendments to section 1 of part C of chapter 57 of the S. 2606--C 193 1 laws of 2006 made by section one of this act shall not affect the repeal 2 of such section and shall be deemed repealed therewith. 3 PART O 4 Section 1. Legislative findings and purpose. Recent actions by the 5 United States Center for Medicare and Medicaid Services impact the 6 stability of New York state's mental hygiene system. While the state 7 must embark on a deliberate path to replace the existing, long-standing 8 financing system for developmental disability services, replacement of 9 the sudden loss of $1.1 billion in federal revenue is too significant to 10 be solved solely by actions within the mental hygiene system. A partner- 11 ship with the entire health care community is needed to manage this loss 12 over time. Accordingly, this part authorizes the actions necessary and 13 creates the Mental Hygiene Stabilization Fund that will be supported by 14 department of health medicaid resources under the Global Cap in annual 15 amounts not to exceed $730,000,000 in state fiscal year 2013-14, 16 $445,000,000 in 2014-15, $267,000,000 in 2015-16, and $267,000,000 in 17 2016-17. 18 S 2. Notwithstanding any contrary provision of law, the commissioner 19 of health shall annul implementation of the reimbursement reductions 20 authorized by section one of part A of this act commencing February 15, 21 2014. 22 S 3. Notwithstanding any contrary provision of law, implementation of 23 the provisions of sections twenty-two, twenty-three, and/or twenty-four 24 of part A of this act shall be delayed to the state fiscal year begin- 25 ning April 1, 2014. 26 S 4. Notwithstanding any inconsistent provision of law, rule or regu- 27 lation, for purposes of implementing the provisions of the public health 28 law and the social services law, references to titles XIX and XXI of the 29 federal social security act in the public health law and the social 30 services law shall be deemed to include and also to mean any successor 31 titles thereto under the federal social security act. 32 S 5. Notwithstanding any inconsistent provision of law, rule or regu- 33 lation, the effectiveness of the provisions of sections 2807 and 3614 of 34 the public health law, section 18 of chapter 2 of the laws of 1988, as 35 amended, and 18 NYCRR 505.14(h), as they relate to time frames for 36 notice, approval or certification of rates of payment, are hereby 37 suspended and without force or effect for purposes of implementing the 38 provisions of this act. 39 S 6. Severability clause. If any clause, sentence, paragraph, subdivi- 40 sion, section or part of this act shall be adjudged by any court of 41 competent jurisdiction to be invalid, such judgment shall not affect, 42 impair or invalidate the remainder thereof, but shall be confined in its 43 operation to the clause, sentence, paragraph, subdivision, section or 44 part thereof directly involved in the controversy in which such judgment 45 shall have been rendered. It is hereby declared to be the intent of the 46 legislature that this act would have been enacted even if such invalid 47 provisions had not been included herein. 48 S 7. This act shall take effect immediately and shall be deemed to 49 have been in full force and effect on and after April 1, 2013. 50 PART P 51 Section 1. Legislative intent. The legislature hereby finds that the 52 goals of the state include providing individuals with mental illnesses S. 2606--C 194 1 the tools necessary to: (a) make informed choices and decisions; and (b) 2 achieve equality of opportunity, full inclusion and integration in soci- 3 ety, employment, independent living, and economic and social self-suffi- 4 ciency. The legislature further finds that such goals are best achieved 5 by providing individuals with mental illnesses a variety of residential 6 options that are both integrated and appropriate to the needs of each 7 person. Therefore, the legislature finds it appropriate and prudent to 8 continue overseeing the regulation of adult homes as the state develops 9 community based settings sufficient to meet the desires and needs of 10 individuals with mental illnesses. 11 S 2. Definitions. For the purposes of this act, the following terms 12 shall have the following meanings: 13 (a) "Administrative action" means any decision or action by an execu- 14 tive agency, including but not limited to, the promulgation, implementa- 15 tion or enforcement of regulations. 16 (b) "Adult home" means an adult care facility established and operated 17 for the purpose of providing long-term residential care, room, board, 18 housekeeping, personal care and supervision to five or more adults who 19 are unrelated to the operator. 20 (c) "Mental health census" means the number or percentage of residents 21 in a facility who are persons with serious mental illness, as defined in 22 subdivision (d) of this section. 23 (d) "Persons with serious mental illness" means persons who are in 24 psychiatric crisis; or persons who have a designated diagnosis of mental 25 illness under the most recent edition of the Diagnostic and Statistical 26 Manual of Mental Disorders, and whose severity and duration of mental 27 illness results in substantial functional disability. 28 S 3. Notwithstanding any law, rule or regulation to the contrary, 29 absent explicit statutory authority, no executive agency shall undertake 30 any administrative action designed to limit or reduce the mental health 31 census of an adult home. 32 (a) Prior to provision of such statutory authority: 33 (1) The commissioner of health and the commissioner of mental health 34 shall, in consultation with stakeholders, including representation from 35 the legislature, mental health advocacy organizations, and the adult 36 home industry, jointly develop a report and recommendations regarding 37 the provision of integrated housing that is appropriate to the needs of 38 individuals with serious mental illnesses. Such report and recommenda- 39 tions shall include a plan and timeline for developing community 40 settings and community services in all regions of the state; guidance as 41 to how adult homes impacted by such plan can support, and continue to 42 serve, residents; details as to which adult homes and residents would be 43 impacted by such plan, as well as any foreseeable effects on local econ- 44 omies; proposals for evaluating persons with serious mental illnesses 45 residing in adult homes, and providing the support necessary to aid them 46 in making informed decisions regarding future treatment; and details 47 with regard to the progress of the department of health and the office 48 of mental health in facilitating such informed decisions. 49 (2) The commissioner of health and the commissioner of mental health 50 shall certify that sufficient alternative housing options exist to 51 accommodate those persons with serious mental illnesses residing in 52 adult homes who chose to transition to an appropriate community setting, 53 within a reasonable distance from individuals' current housing. 54 (b) Such report and recommendations shall be provided to the temporary 55 president of the senate and the speaker of the assembly no later than S. 2606--C 195 1 December 31, 2013, and shall be updated no less frequently than once per 2 year. 3 S 4. This act shall take effect immediately. 4 S 2. Severability clause. If any clause, sentence, paragraph, subdivi- 5 sion, section or part of this act shall be adjudged by any court of 6 competent jurisdiction to be invalid, such judgment shall not affect, 7 impair, or invalidate the remainder thereof, but shall be confined in 8 its operation to the clause, sentence, paragraph, subdivision, section 9 or part thereof directly involved in the controversy in which such judg- 10 ment shall have been rendered. It is hereby declared to be the intent of 11 the legislature that this act would have been enacted even if such 12 invalid provisions had not been included herein. 13 S 3. This act shall take effect immediately provided, however, that 14 the applicable effective date of Parts A through P of this act shall be 15 as specifically set forth in the last section of such Parts.

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