Bill Text: NY A04612 | 2019-2020 | General Assembly | Introduced
Bill Title: Enacts provisions relating to collective negotiations by health care providers with certain health care plans in certain counties; applies to health benefit plans that provide benefits for medical or surgical expenses incurred as a result of a health condition, accident or sickness, including an individual, group, blanket or franchise insurance policy or insurance agreement offered by certain enumerated entities.
Spectrum: Moderate Partisan Bill (Democrat 25-4)
Status: (Introduced - Dead) 2020-01-08 - referred to health [A04612 Detail]
Download: New_York-2019-A04612-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 4612 2019-2020 Regular Sessions IN ASSEMBLY February 4, 2019 ___________ Introduced by M. of A. PRETLOW, GOTTFRIED, CAHILL, COLTON, WEPRIN, MAGNARELLI, PERRY, BRONSON, L. ROSENTHAL, LAVINE, THIELE, BENEDETTO, PEOPLES-STOKES, ABINANTI, ENGLEBRIGHT -- Multi-Sponsored by -- M. of A. ABBATE, AUBRY, COOK, CYMBROWITZ, DINOWITZ, GLICK, LENTOL, LUPARDO, MALLIOTAKIS, MONTESANO, ORTIZ, RA, RAIA, WRIGHT -- read once and referred to the Committee on Health AN ACT to amend the public health law, in relation to requirements for collective negotiations by health care providers with certain health benefit plans in certain counties, and providing for the repeal of such provisions upon expiration thereof The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Statement of legislative intent. The legislature finds that 2 collective negotiation by competing health care providers for the terms 3 and conditions of contracts with health plans can result in beneficial 4 results for health care consumers. The legislature further finds 5 instances where health plans dominate the market to such a degree that 6 fair and adequate negotiations between health care providers and the 7 plans are adversely affected, so that it is necessary and appropriate to 8 provide for a demonstration to examine the risks and benefits associated 9 with a system of collective action on behalf of health care providers. 10 Consequently, the legislature finds it appropriate and necessary in the 11 demonstration service area to displace competition with regulation of 12 health plan-provider agreements and authorize collective negotiations on 13 the terms and conditions of the relationship between health care plans 14 and health care providers so the imbalances between the two will not 15 result in adverse conditions of health care. This act is not intended to 16 apply to or affect in any respect collective bargaining relationships 17 involving health care providers as defined in section 4920 of the public 18 health law or rights relating to collective bargaining arising under 19 applicable federal or state collective bargaining statutes. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD04948-01-9A. 4612 2 1 § 2. This act shall be known and may be cited as the "health care 2 consumer and provider protection act". 3 § 3. Article 49 of the public health law is amended by adding a new 4 title III to read as follows: 5 TITLE III 6 COLLECTIVE NEGOTIATIONS BY HEALTH CARE 7 PROVIDERS WITH HEALTH CARE PLANS 8 Section 4920. Definitions. 9 4921. Non-fee related collective negotiation authorized. 10 4922. Fee related collective negotiation. 11 4923. Collective negotiation requirements. 12 4924. Requirements for health care providers' representative. 13 4925. Certain collective action prohibited. 14 4926. Fees. 15 4927. Monitoring of agreements. 16 4928. Confidentiality. 17 4929. Severability and construction. 18 § 4920. Definitions. For purposes of this title: 19 1. "Health care plan" means an entity (other than a health care 20 provider) that approves, provides, arranges for, or pays for health care 21 services in the demonstration service area, including but not limited 22 to: 23 (a) a health maintenance organization licensed pursuant to article 24 forty-three of the insurance law or certified pursuant to article 25 forty-four of this chapter; 26 (b) any other organization certified pursuant to article forty-four of 27 this chapter; or 28 (c) an insurer or corporation subject to the insurance law. 29 2. "Person" means an individual, association, corporation, or any 30 other legal entity. 31 3. "Health care providers' representative" means a third party who is 32 authorized by health care providers to negotiate on their behalf with 33 health care plans over contractual terms and conditions affecting those 34 health care providers. 35 4. "Strike" means a work stoppage in part or in whole, direct or indi- 36 rect, by a body of workers to gain compliance with demands made on an 37 employer. 38 5. "Substantial market share in a business line" exists if a health 39 care plan's market share of a business line within the demonstration 40 service area as approved by the commissioner, in consultation with the 41 superintendent of financial services, alone or in combination with the 42 market shares of affiliates, exceeds either ten percent of the total 43 number of covered lives in that service area for such business line or 44 twenty-five thousand lives, or if the commissioner, in consultation with 45 the superintendent of financial services, determines the market share of 46 the insurer in the relevant insurance product and geographic markets for 47 the services of the providers seeking to collectively negotiate signif- 48 icantly exceeds the countervailing market share of the providers acting 49 individually. 50 6. "Health care provider" means a person who is licensed, certified, 51 or registered pursuant to title eight of the education law and who prac- 52 tices as a health care provider as an independent contractor and/or who 53 is an owner, officer, shareholder, or proprietor of a health care 54 provider in the demonstration service area. A health care provider 55 under title eight of the education law who practices as an employee of aA. 4612 3 1 health care provider shall not be deemed a health care provider for 2 purposes of this title. 3 7. "Demonstration service area" shall include the counties of Albany, 4 Columbia, Greene, Orange, Rensselaer, Saratoga, Schenectady, Schoharie, 5 Ulster, Warren and Washington. 6 § 4921. Non-fee related collective negotiation authorized. 1. Health 7 care providers practicing within the demonstration service area may meet 8 and communicate for the purpose of collectively negotiating with a 9 health care plan the following terms and conditions of provider 10 contracts with the health care plan: 11 (a) the details of the utilization review plan as defined pursuant to 12 subdivision ten of section forty-nine hundred of this article and 13 subsection (j) of section four thousand nine hundred of the insurance 14 law; 15 (b) coverage provisions; health care benefits; benefit maximums, 16 including benefit limitations; and exclusions of coverage; 17 (c) the definition of medical necessity; 18 (d) the clinical practice guidelines used to make medical necessity 19 and utilization review determinations; 20 (e) preventive care and other medical management practices; 21 (f) drug formularies and standards and procedures for prescribing 22 off-formulary drugs; 23 (g) respective physician liability for the treatment or lack of treat- 24 ment of covered persons; 25 (h) the details of health care plan risk transfer arrangements with 26 providers; 27 (i) plan administrative procedures, including methods and timing of 28 health care provider payment for services; 29 (j) procedures to be utilized to resolve disputes between the health 30 care plan and health care providers; 31 (k) patient referral procedures including, but not limited to, those 32 applicable to out-of-pocket network referrals; 33 (l) the formulation and application of health care provider reimburse- 34 ment procedures; 35 (m) quality assurance programs; 36 (n) the process for rendering utilization review determinations 37 including: establishment of a process for rendering utilization review 38 determinations which shall, at a minimum, include: written procedures to 39 assure that utilization reviews and determinations are conducted within 40 the timeframes established in this article; procedures to notify an 41 enrollee, an enrollee's designee and/or an enrollee's health care 42 provider of adverse determinations; and procedures for appeal of adverse 43 determinations, including the establishment of an expedited appeals 44 process for denials of continued inpatient care or where there is immi- 45 nent or serious threat to the health of the enrollee; and 46 (o) health care provider selection and termination criteria used by 47 the health care plan. 48 2. Nothing in this section shall be construed to allow or authorize an 49 alteration of the terms of the internal and external review procedures 50 set forth in law. 51 3. Nothing in this section shall be construed to allow a strike of a 52 health care plan by health care providers or plans as otherwise set 53 forth in the laws of this state. 54 4. Nothing in this section shall be construed to allow or authorize 55 terms or conditions which would impede the ability of a health care planA. 4612 4 1 to obtain or retain accreditation by the national committee for quality 2 assurance or a similar body. 3 § 4922. Fee related collective negotiation. 1. If the health care plan 4 has substantial market share in a business line in the demonstration 5 service area, health care providers practicing within the demonstration 6 service area may collectively negotiate the following terms and condi- 7 tions relating to that business line with the health care plan: 8 (a) the fees assessed by the health care plan for services, including 9 fees established through the application of reimbursement procedures; 10 (b) the conversion factors used by the health care plan in a 11 resource-based relative value scale reimbursement methodology or other 12 similar methodology; provided the same are not otherwise established by 13 state or federal law or regulation; 14 (c) the amount of any discount granted by the health care plan on the 15 fee of health care services to be rendered by health care providers; 16 (d) the dollar amount of capitation or fixed payment for health 17 services rendered by health care providers to health care plan enrol- 18 lees; 19 (e) the procedure code or other description of a health care service 20 covered by a payment and the appropriate grouping of the procedure 21 codes; or 22 (f) the amount of any other component of the reimbursement methodology 23 for a health care service. 24 2. Nothing herein shall be deemed to affect or limit the right of a 25 health care provider or group of health care providers to collectively 26 petition a government entity for a change in a law, rule, or regulation. 27 § 4923. Collective negotiation requirements. 1. Collective negotiation 28 rights granted by this title must conform to the following requirements: 29 (a) health care providers may communicate with other health care 30 providers regarding the contractual terms and conditions to be negoti- 31 ated with a health care plan; 32 (b) health care providers may communicate with health care providers' 33 representatives; 34 (c) a health care providers' representative is the only party author- 35 ized to negotiate with health care plans on behalf of the health care 36 providers as a group; 37 (d) a health care provider can be bound by the terms and conditions 38 negotiated by the health care providers' representatives; and 39 (e) in communicating or negotiating with the health care providers' 40 representative, a health care plan is entitled to contract with or offer 41 different contract terms and conditions to individual competing health 42 care providers. 43 2. A health care providers' representative may not represent more than 44 thirty percent of the market of health care providers or of a particular 45 health care provider type or specialty practicing in the demonstration 46 service area or proposed service area of a health care plan that covers 47 less than five percent of the actual number of covered lives of the 48 health care plan in the demonstration service area, as determined by the 49 department. 50 3. Nothing in this section shall be construed to prohibit collective 51 action on the part of any health care provider who is a member of a 52 collective bargaining unit recognized pursuant to the national labor 53 relations act. 54 § 4924. Requirements for health care providers' representative. 1. 55 Before engaging in collective negotiations with a health care plan on 56 behalf of health care providers, a health care providers' representativeA. 4612 5 1 shall file with the commissioner, in the manner prescribed by the 2 commissioner, information identifying the representative, the represen- 3 tative's plan of operation, and the representative's procedures to 4 ensure compliance with this title. 5 2. Before engaging in the collective negotiations, the health care 6 providers' representative shall also submit to the commissioner for the 7 commissioner's approval a report identifying the proposed subject matter 8 of the negotiations or discussions with the health care plan and the 9 efficiencies or benefits expected to be achieved through the negoti- 10 ations for both the providers and consumers of health services. The 11 commissioner shall not approve the report if the commissioner, in 12 consultation with the superintendent of financial services, determines 13 that the proposed negotiations would exceed the authority granted under 14 this title. 15 3. The representative shall supplement the information in the report 16 on a regular basis or as new information becomes available, indicating 17 that the subject matter of the negotiations with the health care plan 18 has changed or will change. In no event shall the report be less than 19 every thirty days. 20 4. With the advice of the superintendent of financial services, the 21 commissioner shall approve or disapprove the report not later than the 22 twentieth day after the date on which the report is filed. If disap- 23 proved, the commissioner shall furnish a written explanation of any 24 deficiencies, along with a statement of specific proposals for remedial 25 measures to cure the deficiencies. If the commissioner does not so act 26 within the twenty days, the report shall be deemed approved. 27 5. A person who acts as a health care providers' representative with- 28 out the approval of the commissioner under this section shall be deemed 29 to be acting outside the authority granted under this title. 30 6. Before reporting the results of negotiations with a health care 31 plan or providing to the affected health care providers an evaluation of 32 any offer made by a health care plan, the health care providers' repre- 33 sentative shall furnish for approval by the commissioner, before dissem- 34 ination to the health care providers, a copy of all communications to be 35 made to the health care providers related to negotiations, discussions, 36 and offers made by the health care plan. 37 7. A health care providers' representative shall report the end of 38 negotiations to the commissioner not later than the fourteenth day after 39 the date of a health care plan decision declining negotiation, canceling 40 negotiations, or failing to respond to a request for negotiation. In 41 such instances, a health care providers' representative may request 42 intervention from the commissioner to require the health care plan to 43 participate in the negotiation pursuant to subdivision eight of this 44 section. 45 8. (a) In the event the commissioner determines that an impasse exists 46 in the negotiations, or in the event a health care plan declines to 47 negotiate, cancels negotiations or fails to respond to a request for 48 negotiation, the commissioner shall render assistance as follows: 49 (1) to assist the parties to effect a voluntary resolution of the 50 negotiations, the commissioner shall appoint a mediator from a list of 51 qualified persons maintained by the commissioner. If the mediator is 52 successful in resolving the impasse, then the health care providers' 53 representative shall proceed as set forth in this article; 54 (2) if an impasse continues, the commissioner shall appoint a fact- 55 finding board of not more than three members from a list of qualified 56 persons maintained by the commissioner, which fact-finding board shallA. 4612 6 1 have, in addition to the powers delegated to it by the board, the power 2 to make recommendations for the resolution of the dispute; 3 (b) The fact-finding board, acting by a majority of its members, shall 4 transmit its findings of fact and recommendations for resolution of the 5 dispute to the commissioner, and may thereafter assist the parties to 6 effect a voluntary resolution of the dispute. The fact-finding board 7 shall also share its findings of fact and recommendations with the 8 health care providers' representative and the health care plan. If with- 9 in twenty days after the submission of the findings of fact and recom- 10 mendations, the impasse continues, the commissioner shall order a resol- 11 ution to the negotiations based upon the findings of fact and 12 recommendations submitted by the fact-finding board. 13 9. Any proposed agreement between health care providers and a health 14 care plan negotiated pursuant to this title shall be submitted to the 15 commissioner for final approval. The commissioner shall approve or 16 disapprove the agreement within sixty days of such submission. The 17 commissioner, after consultation with the superintendent of financial 18 services shall disapprove the agreement if he or she finds that the 19 agreement would result in a significant increase in costs to the Medi- 20 caid managed care program pursuant to section three hundred sixty-four-j 21 of the social services law, the family health plus program pursuant to 22 section three hundred sixty-nine-gg of the social services law, or the 23 child health plus program pursuant to section twenty-five hundred eleven 24 of this chapter. 25 10. The commissioner may collect information from the department of 26 financial services and other persons to assist in evaluating the impact 27 of the proposed arrangement on the health care marketplace. The commis- 28 sioner shall collect information from health plan companies and health 29 care providers operating in the same geographic area as the health care 30 cooperative. 31 § 4925. Certain collective action prohibited. 1. This title is not 32 intended to authorize competing health care providers to act in concert 33 in response to a report issued by the health care providers' represen- 34 tative related to the representative's discussions or negotiations with 35 health care plans. 36 2. No health care providers' representative shall negotiate any agree- 37 ment that excludes, limits the participation or reimbursement of, or 38 otherwise limits the scope of services to be provided by any health care 39 provider or group of health care providers with respect to the perform- 40 ance of services that are within the health care provider's scope of 41 practice, license, registration, or certificate. 42 § 4926. Fees. Each person who acts as the representative or negotiat- 43 ing parties under this title shall pay to the department a fee to act as 44 a representative. The commissioner, by rule, shall set fees in amounts 45 deemed reasonable and necessary to cover the costs incurred by the 46 department in administering this title. Any fee collected under this 47 section shall be deposited in the state treasury to the credit of the 48 general fund/state operations for the New York state department of 49 health fund. 50 § 4927. Monitoring of agreements. The commissioner shall actively 51 monitor agreements approved under this title to ensure that the agree- 52 ment remains in compliance with the conditions of approval. Upon 53 request, a health care plan or health care provider shall provide infor- 54 mation regarding compliance. The commissioner may revoke an approval 55 upon a finding that the agreement is not in substantial compliance with 56 the terms of the application or the conditions of approval.A. 4612 7 1 § 4928. Confidentiality. All reports and other information required to 2 be reported to the department under this title including information 3 obtained by the commissioner pursuant to subdivision ten of section 4 forty-nine hundred twenty-four of this title shall not be subject to 5 disclosure under article six of the public officers law or article thir- 6 ty-one of the civil practice law and rules. 7 § 4929. Severability and construction. The provisions of this title 8 shall be severable, and if any court of competent jurisdiction declares 9 any phrase, clause, sentence or provision of this title to be invalid, 10 or its applicability to any government, agency, person or circumstance 11 is declared invalid, the remainder of this title and its relevant appli- 12 cability shall not be affected. The provisions of this title shall be 13 liberally construed to give effect to the purposes thereof. 14 § 4. The department of health, in consultation with the department of 15 financial services, shall prepare or shall arrange for the preparation 16 of a report on the implementation of the demonstration program on 17 collective negotiation. The report shall be submitted to the governor, 18 the speaker of the assembly, the temporary president of the senate and 19 the chairs of the senate and assembly health and insurance committees at 20 least four months prior to the expiration of this act. The report shall 21 review the extent to which collective negotiations were conducted in the 22 demonstration service area and shall examine whether and the extent to 23 which collective negotiation contributed to the improvement of quality 24 of care for patients, enhanced access to medically necessary care, 25 reduced unnecessary health care expenditures, and was otherwise in the 26 public interest. The report may make recommendations regarding the 27 extension, alteration and/or expansion of these provisions and make any 28 other recommendations related to the implementation of collective nego- 29 tiation pursuant to this act. 30 § 5. This act shall take effect on the one hundred twentieth day after 31 it shall have become a law and shall expire and be deemed repealed three 32 years after it shall take effect. Effective immediately, the commission- 33 er of health is authorized to promulgate any and all rules and regu- 34 lations and take any other measures necessary to implement this act on 35 its effective date on or before such date.
