Bill Text: NY S08503 | 2009-2010 | General Assembly | Introduced
Bill Title: Enacts the New York State Health Plan, a comprehensive system of access to health insurance for New York state residents: provides for administrative structure of the plan, including its status as a public benefit corporation; provides for powers and duties of the governing board, the scope of benefits, payment mechanisms and cost controls; establishes the New York Health Trust Fund which would hold monies from a variety of sources to be used solely to finance the plan; establishes a mechanism to collect plan premium payments; establishes a temporary commission on implementation of the plan and makes a $500,000 appropriation therefor; and directs the superintendent of insurance to examine the premium rate structure for insurance underwritten in the state and to identify that portion of premiums which are attributable to health care expenditures due to implementation of the plan.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-10-22 - REFERRED TO FINANCE [S08503 Detail]
Download: New_York-2009-S08503-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
8503
I N S E N A T E
October 22, 2010
___________
Introduced by Sen. DUANE -- read twice and ordered printed, and when
printed to be committed to the Committee on Finance
AN ACT to amend the public health law, the state finance law and the tax
law, in relation to the establishment of the New York health plan and
making an appropriation to the temporary commission on implementation
of the New York health plan and providing for the repeal of certain
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. Article 50 and sections 5000, 5001, 5002 and 5003 of the
2 public health law are renumbered article 80 and sections 8000, 8001,
3 8002 and 8003 and a new article 51 is added to read as follows:
4 ARTICLE 51
5 NEW YORK HEALTH PLAN
6 SECTION 5100. LEGISLATIVE FINDINGS.
7 5101. SHORT TITLE.
8 5102. DEFINITIONS.
9 5103. PLAN CREATED.
10 5104. BOARD OF GOVERNORS.
11 5105. POWERS AND DUTIES OF THE BOARD.
12 5106. POWERS AND DUTIES OF THE EXECUTIVE DIRECTOR.
13 5107. PLAN ELIGIBILITY.
14 5108. PLAN BENEFITS.
15 5109. PAYMENT FOR SERVICES.
16 5110. OUT-OF-STATE PARTICIPATION AND PAYMENTS.
17 S 5100. LEGISLATIVE FINDINGS. THE LEGISLATURE FINDS AND DECLARES THAT
18 ALL RESIDENTS OF THE STATE OF NEW YORK HAVE THE RIGHT TO HEALTH
19 SERVICES, BUT AN INCREASING NUMBER OF NEW YORKERS ARE UNABLE TO EXERCISE
20 THIS RIGHT BECAUSE OF A LACK OF HEALTH COVERAGE. NEW YORKERS HAVE EXPE-
21 RIENCED A RAPID RISE IN THE COST OF HEALTH CARE IN RECENT YEARS. THIS
22 INCREASE HAS RESULTED IN A LARGE NUMBER OF PEOPLE WHO HAVE HAD TO
23 DISCONTINUE THEIR HEALTH COVERAGE. BUSINESSES HAVE ALSO EXPERIENCED
24 EXTRAORDINARY INCREASES IN THE COSTS OF HEALTH CARE BENEFITS FOR THEIR
25 EMPLOYEES. OVER THREE MILLION NEW YORKERS HAVE NO HEALTH COVERAGE, AND
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD18221-01-0
S. 8503 2
1 ANOTHER ESTIMATED THREE MILLION ARE SEVERELY UNDERINSURED. HOSPITALS AND
2 OTHER HEALTH CARE PROVIDERS ARE ALSO AFFECTED BY INADEQUATE HEALTH
3 INSURANCE COVERAGE IN NEW YORK STATE. A LARGE PORTION OF VOLUNTARY AND
4 PUBLIC HOSPITALS, HEALTH CENTERS AND OTHER PROVIDERS NOW EXPERIENCE
5 SUBSTANTIAL LOSSES DUE TO THE PROVISION OF CARE THAT IS UNCOMPENSATED.
6 TO ADDRESS THE FISCAL CRISIS FACING THE HEALTH CARE SYSTEM AND TO ASSURE
7 NEW YORKERS CAN EXERCISE THEIR RIGHT TO HEALTH CARE, AFFORDABLE AND
8 COMPREHENSIVE HEALTH COVERAGE MUST BE PROVIDED. PURSUANT TO THE STATE
9 CONSTITUTION'S CHARGE TO THE LEGISLATURE TO PROVIDE FOR THE HEALTH OF
10 NEW YORKERS, THIS ARTICLE IS AN ENACTMENT OF STATE CONCERN FOR THE
11 PURPOSE OF ESTABLISHING A COMPREHENSIVE UNIVERSAL HEALTH CARE COVERAGE
12 PROGRAM AND A HEALTH CARE COST CONTROL SYSTEM FOR THE BENEFIT OF ALL
13 RESIDENTS OF THE STATE OF NEW YORK.
14 S 5101. SHORT TITLE. THIS ARTICLE SHALL BE KNOWN AND MAY BE CITED AS
15 THE "NEW YORK HEALTH PLAN".
16 S 5102. DEFINITIONS. FOR THE PURPOSES OF THIS ARTICLE, UNLESS THE
17 CONTEXT CLEARLY REQUIRES OTHERWISE:
18 1. "BOARD" MEANS THE BOARD OF GOVERNORS OF THE NEW YORK HEALTH PLAN AS
19 CREATED BY SECTION FIFTY-ONE HUNDRED FOUR OF THIS ARTICLE.
20 2. "PLAN" MEANS THE NEW YORK HEALTH PLAN AS CREATED BY SECTION FIFTY-
21 ONE HUNDRED THREE OF THIS ARTICLE.
22 3. "PLAN MEMBER" MEANS ANY PERSON WHO QUALIFIES FOR BENEFITS UNDER THE
23 PLAN UNDER SECTION FIFTY-ONE HUNDRED SEVEN OF THIS ARTICLE.
24 4. "PARTICIPATING PROVIDER" MEANS ANY PERSON, PARTNERSHIP, CORPORATION
25 OR OTHER ENTITY, AUTHORIZED TO FURNISH COVERED SERVICES PURSUANT TO THIS
26 ARTICLE.
27 5. "PLAN RATE" MEANS THE RATE OF PAYMENT FOR A COVERED SERVICE, UNDER
28 THE PLAN, ESTABLISHED IN ACCORDANCE WITH THIS ARTICLE.
29 6. "GLOBAL BUDGET" MEANS AN INSTITUTION-WIDE BUDGET FOR THE FIXED AND
30 OPERATING COSTS FOR THE PROVISION OF HEALTH CARE SERVICES, EXCLUSIVE OF
31 CAPITAL EXPENDITURES COVERED UNDER SUBPARAGRAPH (III) OF PARAGRAPH (E)
32 OF SUBDIVISION TWO OF SECTION FIFTY-ONE HUNDRED FIVE OF THIS ARTICLE.
33 7. "RESIDENT" MEANS A PERSON WHO HAS ESTABLISHED THEIR PRIMARY PLACE
34 OF ABODE IN THIS STATE, AS DETERMINED ACCORDING TO REGULATIONS OF THE
35 BOARD.
36 S 5103. PLAN CREATED. THERE IS HEREBY ESTABLISHED THE NEW YORK HEALTH
37 PLAN, TO PROVIDE, AS SET OUT IN THIS ARTICLE, AND RELATED LEGISLATION,
38 UNIVERSAL HEALTH COVERAGE FOR ALL RESIDENTS OF THIS STATE, ACCESS TO AND
39 CHOICE OF HEALTH CARE PROVIDERS, CONTROLS ON HEALTH CARE COSTS, DEVELOP-
40 MENT OF HEALTH CARE SERVICES, AND PUBLIC FINANCING FOR THE PROGRAM.
41 SUCH PLAN SHALL BE A CORPORATE GOVERNMENTAL AGENCY CONSTITUTING A PUBLIC
42 BENEFIT CORPORATION.
43 S 5104. BOARD OF GOVERNORS. 1. A BOARD OF GOVERNORS TO ADMINISTER THE
44 PLAN IS HEREBY CREATED. THE BOARD SHALL BE COMPOSED OF EIGHTEEN MEMBERS,
45 TO CONSIST OF THE CHAIR AND SEVENTEEN ADDITIONAL MEMBERS, APPOINTED BY
46 THE GOVERNOR WITH THE ADVICE AND CONSENT OF THE SENATE. THE COMMISSION-
47 ER, THE SUPERINTENDENT OF INSURANCE, AND THE COMMISSIONER OF TAXATION
48 AND FINANCE SHALL SERVE AS NONVOTING EX OFFICIO MEMBERS OF THE BOARD.
49 OF THE SEVENTEEN ADDITIONAL MEMBERS APPOINTED BY THE GOVERNOR:
50 (A) FIVE SHALL BE REPRESENTATIVE OF HEALTH CARE CONSUMER ADVOCACY
51 ORGANIZATIONS WHICH HAVE A STATEWIDE OR REGIONAL CONSTITUENCY, WHO HAVE
52 BEEN INVOLVED IN ACTIVITIES RELATED TO HEALTH CARE CONSUMER ADVOCACY,
53 INCLUDING ISSUES OF INTEREST TO LOW AND MODERATE-INCOME INDIVIDUALS;
54 (B) THREE SHALL BE REPRESENTATIVE OF LABOR ORGANIZATIONS;
55 (C) THREE SHALL BE REPRESENTATIVE OF BUSINESS AND INDUSTRY;
56 (D) TWO SHALL BE REPRESENTATIVE OF HOSPITALS;
S. 8503 3
1 (E) TWO SHALL BE REPRESENTATIVE OF PHYSICIANS; AND
2 (F) TWO SHALL BE REPRESENTATIVE OF LICENSED NON-PHYSICIAN HEALTH CARE
3 PROFESSIONALS.
4 2. MEMBERS SHALL SERVE FOR A TERM OF FIVE YEARS; EACH TERM SHALL END
5 ON DECEMBER THIRTY-FIRST. EACH MEMBER OF THE BOARD SHALL HOLD OFFICE
6 FROM THE DATE OF QUALIFICATION FOR OFFICE UNTIL THE END OF THE TERM FOR
7 WHICH THE MEMBER WAS APPOINTED. ANY MEMBER APPOINTED TO FILL A VACANCY
8 OCCURRING PRIOR TO THE EXPIRATION OF A TERM, SHALL HOLD OFFICE FOR THE
9 REMAINDER OF THAT TERM.
10 3. EACH MEMBER SHALL CONTINUE IN OFFICE SUBSEQUENT TO THE EXPIRATION
11 DATE OF THE TERM UNTIL A SUCCESSOR TAKES OFFICE.
12 4. THE GOVERNOR MAY REMOVE THE CHAIR OF THE BOARD FOR GOOD CAUSE PRIOR
13 TO THE EXPIRATION OF HIS OR HER TERM. IN THE EVENT OF A VACANCY IN THE
14 CHAIR, THE GOVERNOR MAY APPOINT A PERSON TO BE ACTING CHAIR UNTIL A
15 CHAIR SHALL BE CONFIRMED BY THE SENATE.
16 5. THE BOARD SHALL MEET AT LEAST FOUR TIMES IN A CALENDAR YEAR.
17 6. MEETINGS SHALL BE HELD UPON THE CALL OF THE CHAIR AND AS PROVIDED
18 BY THE BOARD.
19 7. TEN MEMBERS OF THE BOARD SHALL CONSTITUTE A QUORUM, AND THE AFFIR-
20 MATIVE VOTE OF TEN MEMBERS SHALL BE NECESSARY FOR ANY ACTION TO BE TAKEN
21 BY THE BOARD.
22 8. THE BOARD MAY ESTABLISH AN EXECUTIVE COMMITTEE TO CARRY OUT ANY
23 POWERS OR DUTIES OF THE BOARD AS IT MAY PROVIDE, AND OTHER COMMITTEES TO
24 ASSIST THE BOARD OR THE EXECUTIVE COMMITTEE. THE CHAIR OF THE BOARD
25 SHALL BE THE CHAIR OF THE EXECUTIVE COMMITTEE AND SHALL APPOINT THE
26 CHAIRS OF OTHER COMMITTEES. THE BOARD MAY ALSO ESTABLISH ADVISORY
27 COMMITTEES, CONSISTING OF PERSONS OTHER THAN MEMBERS OF THE BOARD.
28 9. MEMBERS OF THE BOARD, WITH THE EXCEPTION OF THE CHAIR, SHALL SERVE
29 WITHOUT COMPENSATION, BUT SHALL BE REIMBURSED FOR THEIR NECESSARY AND
30 ACTUAL EXPENSES INCURRED WHILE ENGAGED IN THE BUSINESS OF THE BOARD.
31 10. NOTWITHSTANDING ANY INCONSISTENT PROVISIONS OF LAW, GENERAL,
32 SPECIAL OR LOCAL, NO OFFICER OR EMPLOYEE OF THE STATE OR OF ANY CIVIL
33 DIVISION THEREOF SHALL BE DEEMED TO HAVE FORFEITED OR SHALL FORFEIT HIS
34 OR HER OFFICE OR EMPLOYMENT BY REASON OF BEING A MEMBER OF THE BOARD.
35 S 5105. POWERS AND DUTIES OF THE BOARD. 1. EXCEPT AS OTHERWISE LIMIT-
36 ED BY THIS ARTICLE, THE BOARD SHALL HAVE THE FOLLOWING CORPORATE POWERS:
37 (A) TO SUE AND BE SUED;
38 (B) TO HAVE A SEAL AND ALTER THE SAME AT PLEASURE;
39 (C) TO MAKE AND EXECUTE CONTRACTS AND ALL OTHER INSTRUMENTS NECESSARY
40 OR CONVENIENT FOR THE EXERCISE OF ITS POWERS AND FUNCTIONS UNDER THIS
41 ARTICLE;
42 (D) TO MAKE AND ALTER BY-LAWS FOR ITS ORGANIZATION AND INTERNAL
43 MANAGEMENT;
44 (E) TO ACQUIRE, HOLD AND DISPOSE OF PERSONAL PROPERTY FOR ITS CORPO-
45 RATE PURPOSES;
46 (F) TO APPOINT OFFICERS, AGENTS AND EMPLOYEES, PRESCRIBE THEIR DUTIES
47 AND QUALIFICATIONS AND FIX THEIR COMPENSATION;
48 (G) TO BORROW MONEY AND ISSUE NEGOTIABLE NOTES, BONDS OR OTHER OBLI-
49 GATIONS FOR ITS CORPORATE PURPOSES AND TO PROVIDE FOR THE RIGHTS OF THE
50 HOLDERS THEREOF;
51 (H) TO INVEST ANY FUNDS HELD IN RESERVE OR SINKING FUNDS, OR ANY
52 MONIES NOT REQUIRED FOR THE IMMEDIATE USE OR DISBURSEMENT, AT THE
53 DISCRETION OF THE PLAN, IN OBLIGATIONS OF THE STATE OR THE UNITED STATES
54 GOVERNMENT, OR IN ANY OTHER OBLIGATIONS IN WHICH THE COMPTROLLER OF THE
55 STATE OF NEW YORK IS AUTHORIZED TO INVEST PURSUANT TO SECTION
56 NINETY-EIGHT OF THE STATE FINANCE LAW;
S. 8503 4
1 (I) TO ACCEPT ANY GIFTS OR GRANTS OR LOANS OF FUNDS OR PROPERTY OR
2 FINANCIAL OR OTHER AID IN ANY FORM FROM THE FEDERAL GOVERNMENT OR ANY
3 AGENCY OR INSTRUMENTALITY THEREOF OR FROM THE STATE OR FROM ANY OTHER
4 SOURCE AND TO COMPLY, SUBJECT TO THE PROVISIONS OF THIS ARTICLE, WITH
5 THE TERMS AND CONDITIONS THEREOF; AND
6 (J) TO DO ANY AND ALL THINGS NECESSARY OR CONVENIENT TO CARRY OUT ITS
7 PURPOSES AND EXERCISE THE POWERS EXPRESSLY GIVEN AND GRANTED IN THIS
8 ARTICLE.
9 2. THE BOARD SHALL HAVE THE ADDITIONAL POWER TO DO THE FOLLOWING:
10 (A) (I) ESTABLISH A BUDGET TO INCLUDE ALL HEALTH CARE EXPENDITURES
11 MADE BY THE PLAN, INCLUDING THE ESTABLISHMENT OF AGGREGATE EXPENDITURE
12 TARGETS APPLICABLE TO CATEGORIES OF HEALTH SERVICES. (II) IN ESTABLISH-
13 ING THE BUDGET, THE BOARD SHALL LIMIT THE ANNUAL AGGREGATE LEVEL OF
14 EXPENDITURES FOR ANY YEAR TO A SUM EQUIVALENT TO THE LEVEL OF EXPENDI-
15 TURES IN THE PRECEDING YEAR INCREASED BY ONE HUNDRED TWENTY PERCENT OF
16 THE ANNUAL INCREASE IN THE CONSUMER PRICE INDEX - URBAN AS DEVELOPED BY
17 THE UNITED STATES DEPARTMENT OF COMMERCE. (III) IN ESTABLISHING THE
18 BUDGET, GLOBAL BUDGETS, ALLOCATIONS FOR CAPITAL EXPENDITURES, AND OTHER
19 BUDGET AND EXPENDITURE ACTIONS, THE BOARD SHALL CONSIDER REGIONAL NEEDS
20 AND RESOURCES, FOR REGIONS THAT ARE GEOGRAPHICAL AREAS REASONABLY
21 RELATED TO THE NEED FOR, AND DELIVERY AND USE OF, PARTICULAR HEALTH CARE
22 FACILITIES AND SERVICES, AND SHALL ENCOURAGE THE SHARING AND COOPERATIVE
23 USE OF FACILITIES AND SERVICES BY HEALTH CARE PROVIDERS.
24 (B) ESTABLISH PLAN RATES, IN ACCORDANCE WITH SECTION FIFTY-ONE HUNDRED
25 NINE OF THIS ARTICLE;
26 (C) ESTABLISH GLOBAL BUDGETS, AND DEVELOP RULES AND REGULATIONS
27 CONCERNING ALLOWABLE EXPENDITURES TO BE INCLUDED IN GLOBAL BUDGETS, FOR
28 INSTITUTIONAL PROVIDERS OF SERVICES, IN ACCORDANCE WITH SECTION
29 FIFTY-ONE HUNDRED NINE OF THIS ARTICLE;
30 (D) ADMINISTER, IMPLEMENT AND MONITOR THE OPERATION OF THE PLAN;
31 (E) ADMINISTER THE NEW YORK HEALTH TRUST FUND CREATED PURSUANT TO
32 SECTION EIGHTY-NINE-H OF THE STATE FINANCE LAW, AND INCLUDE WITHIN THE
33 FUND ALLOCATIONS FOR THE FOLLOWING PURPOSES:
34 (I) HEALTH PROMOTION AND PRIMARY PREVENTION PROGRAMS, INCLUDING
35 PROGRAMS WHICH UTILIZE COMMUNITY SETTINGS, SCHOOLS AND PLACES OF WORK,
36 TO PROMOTE HEALTHY LIFESTYLES, ENABLE CONSUMERS TO MAKE INFORMED HEALTH
37 DECISIONS AND PROVIDE SCREENING TESTS NOT PERFORMED AS PART OF ROUTINE
38 CARE. MONEY ALLOCATED FOR THIS PURPOSE SHALL EQUAL AT LEAST ONE-HALF OF
39 ONE PERCENT OF THE MONIES IN THE TRUST FUND;
40 (II) PAYING PARTICIPATING PROVIDERS IN ACCORDANCE WITH SECTION FIFTY-
41 ONE HUNDRED NINE OF THIS ARTICLE;
42 (III) CAPITAL EXPENDITURES FOR THE FOLLOWING PURPOSES:
43 (A) CONSTRUCTION, RENOVATION, AND EQUIPPING OF HEALTH CARE INSTI-
44 TUTIONS, INCLUDING INSTITUTIONAL PROVIDERS OF INPATIENT CARE AND AMBULA-
45 TORY FACILITIES FOR DIAGNOSIS, TREATMENT AND SURGERY, DIAGNOSTIC AND
46 TREATMENT CENTERS PROVIDING A COMPREHENSIVE RANGE OF PRIMARY HEALTH CARE
47 SERVICES, AND MAJOR MEDICAL EQUIPMENT ACQUIRED FOR USE IN PRIVATE PRAC-
48 TITIONER OFFICES;
49 (B) A LOAN PROGRAM FOR FACILITIES AND EQUIPMENT FOR USE BY HEALTH CARE
50 PROFESSIONALS WHO DESIRE TO ESTABLISH PRACTICES IN AREAS OF THIS STATE
51 IN WHICH, ACCORDING TO CRITERIA ESTABLISHED BY THE BOARD, THE LEVEL OF
52 DELIVERY OF HEALTH CARE SERVICES IS INADEQUATE;
53 (IV) TRANSPORTATION OF PLAN MEMBERS FROM ONE GLOBALLY-BUDGETED INSTI-
54 TUTION TO ANOTHER FOR THE PROVISION OF COVERED SERVICES, AND OTHERWISE
55 TO EFFECT COOPERATION AND COMMUNICATION BETWEEN INSTITUTIONS FOR THE
56 DELIVERY OF HEALTH CARE SERVICES; AND
S. 8503 5
1 (V) EDUCATION AND TRAINING OF WORKERS IN THE HEALTH CARE FIELD,
2 INCLUDING, BUT NOT LIMITED TO, RETRAINING OF WORKERS WHO EXPERIENCE JOB
3 LOSS OR DISLOCATION ASSOCIATED WITH THE IMPLEMENTATION OF THE NEW YORK
4 HEALTH PLAN; AND A PROGRAM OF LOAN REPAYMENTS OR OTHER INCENTIVES TO
5 ENCOURAGE HEALTH CARE PRACTITIONERS TO SERVE IN UNDERSERVED AREAS,
6 SPECIALTIES OR FACILITIES. MONIES ALLOCATED SHALL EQUAL AT LEAST
7 ONE-QUARTER OF ONE PERCENT OF THE MONIES IN THE TRUST FUND.
8 (F) IN CARRYING OUT ITS POWERS AND DUTIES, ESTABLISH REASONABLE AND
9 EFFECTIVE MEANS OF:
10 (I) COST CONTAINMENT, INCLUDING BUT NOT LIMITED TO: REDUCING INEFFI-
11 CIENCIES IN HEALTH CARE DELIVERY; PROMOTING EFFECTIVE AND APPROPRIATE
12 USE OF ADVANCEMENTS IN CLINICAL PRACTICE AND TECHNOLOGY; ENCOURAGING THE
13 USE OF LESS COSTLY ALTERNATIVE PROVIDERS WHERE APPROPRIATE; AND ESTAB-
14 LISHING TREATMENT NORMS FOR PROVIDERS TO REDUCE THE INAPPROPRIATE
15 PROVISION OR USE OF SERVICES;
16 (II) QUALITY ASSURANCE, INCLUDING BUT NOT LIMITED TO: DEVELOPING CLIN-
17 ICAL PRACTICE GUIDELINES; AND PROMOTING SYSTEMS FOR REVIEW OF PATIENT
18 OUTCOMES, AND QUALITY AND APPROPRIATENESS OF SERVICES;
19 (III) PROMOTING ACCESS TO SERVICES, INCLUDING BUT NOT LIMITED TO:
20 AVAILABILITY OF PRIMARY, PREVENTIVE AND OTHER SERVICES FOR CONTINUITY OF
21 CARE; ASSURING CONSUMERS FREEDOM TO SELECT AMONG QUALIFIED PROVIDERS FOR
22 APPROPRIATE SERVICES WITHIN THEIR RECOGNIZED SCOPE OF PRACTICE; RESPECT-
23 ING THE PROFESSIONAL JUDGMENT OF PROVIDERS AND THE RIGHTS OF PATIENTS,
24 AND THEIR FAMILIES AND REPRESENTATIVES WHERE APPROPRIATE, TO PARTICIPATE
25 IN DECISIONS AFFECTING THEIR CARE; AND ELIMINATING AND PREVENTING INEQ-
26 UITIES IN, OR BARRIERS TO, ACCESS TO SERVICES BASED ON GEOGRAPHY, SOCIAL
27 OR ECONOMIC STATUS, RACE, RELIGION, GENDER, AGE, ETHNICITY, LANGUAGE,
28 SEXUAL ORIENTATION, FAMILY STATUS OR DEFINITION, AND HEALTH CONDITION;
29 (G) ESTABLISH, AS THE BOARD CONSIDERS IT NECESSARY, A SYSTEM TO
30 PROMOTE CONTINUITY OF CARE;
31 (H) ESTABLISH AN INDEMNITY PLAN TO CARRY OUT THE PURPOSES SET FORTH IN
32 SECTION FIFTY-ONE HUNDRED TEN OF THIS ARTICLE;
33 (I) ESTABLISH A PRESCRIPTION DRUG FORMULARY, IN ACCORDANCE WITH
34 SECTION FIFTY-ONE HUNDRED EIGHT OF THIS ARTICLE;
35 (J) AWARD CONTRACTS TO ADMINISTER THE PAYMENT OF COVERED SERVICES TO
36 PARTICIPATING PROVIDERS, AND OTHER ELEMENTS OF THE PLAN AS THE BOARD
37 DEEMS APPROPRIATE;
38 (K) (I) STUDY AND EVALUATE THE OPERATION OF THE PLAN, INCLUDING BUT
39 NOT LIMITED TO THE ADEQUACY AND QUALITY OF SERVICES COVERED UNDER THE
40 PLAN, THE COST OF EACH TYPE OF SERVICE AND THE EFFECTIVENESS OF COST
41 CONTAINMENT MEASURES UNDER THE PLAN; AND
42 (II) STUDY UTILIZATION OF HEALTH CARE SERVICES UNDER THE PLAN, ENROLL-
43 MENT OF NEW PLAN MEMBERS, EFFECT OF THE PLAN ON PROVIDERS AND PRACTI-
44 TIONERS, INCLUDING RECRUITMENT AND RETENTION OF PRACTITIONERS, AND OTHER
45 MATTERS RELATING TO PLAN EXPERIENCE, OPERATION AND IMPACT. THE BOARD
46 SHALL ESPECIALLY EXAMINE THE PHENOMENON OF INDIVIDUALS BECOMING MEMBERS
47 OF THE PLAN (OTHER THAN BY BIRTH) FOR THE PURPOSE OF OBTAINING PLAN
48 BENEFITS FOR PRE-EXISTING CONDITIONS FOR WHICH THEY HAD INADEQUATE OR NO
49 HEALTH CARE COVERAGE, AND ITS EXTENT, NATURE AND FINANCIAL AND HEALTH
50 CARE SYSTEM IMPACTS. THE BOARD SHALL CONSIDER THE NEED FOR, AND PROBA-
51 BLE EFFECTIVENESS, ADVANTAGES AND DISADVANTAGES OF, POSSIBLE CHANGES IN
52 THE PLAN INCLUDING LIMITING PLAN BENEFITS FOR SUCH CONDITIONS FOR A
53 PERIOD OF TIME TO EXCLUDE SUCH CONDITIONS OR IMPOSE REQUIREMENTS SUCH AS
54 DEDUCTIBLES, MAXIMUM BENEFITS OR CO-INSURANCE;
55 (L) REPORT ANNUALLY TO THE GOVERNOR AND THE LEGISLATURE ON ITS ACTIV-
56 ITIES AND RECOMMEND ANY CHANGES IN LAWS TO IMPROVE ACCESS TO QUALITY
S. 8503 6
1 HEALTH CARE AND TO MORE EFFECTIVELY CONTROL COSTS OF SERVICES PROVIDED
2 UNDER THE PLAN, CONSISTENT WITH QUALITY HEALTH CARE;
3 (M) DISSEMINATE, TO PROVIDERS OF SERVICES AND TO THE PUBLIC, INFORMA-
4 TION CONCERNING THE PLAN AND THE PERSONS ELIGIBLE TO RECEIVE THE BENE-
5 FITS UNDER THE PLAN;
6 (N) CONDUCT NECESSARY INVESTIGATIONS AND INQUIRIES AND REQUIRE THE
7 SUBMISSION OF INFORMATION, DOCUMENTS AND RECORDS IT CONSIDERS NECESSARY
8 TO CARRY OUT ITS DUTIES UNDER THIS ARTICLE;
9 (O) CREATE A PROGRAM FOR THE RESOLUTION OF COMPLAINTS BROUGHT BY PLAN
10 MEMBERS OR PARTICIPATING PROVIDERS REGARDING ANY MATTER ASSOCIATED WITH
11 COVERAGE UNDER THE PLAN, OR THE OPERATION OF THE PLAN;
12 (P) NO LATER THAN FIVE YEARS AFTER THE EFFECTIVE DATE OF THE PLAN,
13 DEVELOP A PROPOSAL FOR PROVISION BY THE PLAN OF LONG-TERM CARE COVER-
14 AGE, INCLUDING THE DEVELOPMENT OF A PROPOSAL FOR ITS FUNDING. IN DEVEL-
15 OPING THE PROPOSAL, THE BOARD SHALL CONSULT WITH AN ADVISORY COMMITTEE,
16 APPOINTED BY THE CHAIR OF THE BOARD, INCLUDING REPRESENTATIVES OF
17 CONSUMERS AND POTENTIAL CONSUMERS OF LONG-TERM CARE, PROVIDERS OF LONG-
18 TERM CARE, BUSINESS, LABOR, SOCIAL SERVICES DISTRICTS, AND OTHER INTER-
19 ESTED PARTIES;
20 (Q) DEVELOP A PLAN TO COORDINATE ITS ACTIVITIES, INCLUDING PLANNING
21 FOR THE ADEQUACY OF HEALTH CARE SERVICES AND THE APPROVAL OF CAPITAL
22 EXPENDITURES, WITH APPROPRIATE STATE AND LOCAL BODIES, INCLUDING HEALTH
23 SYSTEMS AGENCIES AND THE HOSPITAL REVIEW AND PLANNING COUNCIL;
24 (R) NO LATER THAN ONE YEAR AFTER THE EFFECTIVE DATE OF THE PLAN,
25 RECOMMEND TO THE GOVERNOR AND STATE LEGISLATURE THE REORGANIZATION OF
26 STATE GOVERNMENT AGENCIES TO MOST EFFECTIVELY CARRY OUT ACTIVITIES TO BE
27 CONDUCTED BY THE BOARD; AND
28 (S) CONDUCT OTHER ACTIVITIES NECESSARY AND APPROPRIATE TO CARRY OUT
29 THE PURPOSES OF THIS ARTICLE, INCLUDING THE EMPLOYMENT OF STAFF AND AN
30 EXECUTIVE DIRECTOR.
31 3. THE BOARD, AFTER PROVIDING NOTICE TO THE PUBLIC AND INTERESTED
32 PARTIES, MAY HOLD HEARINGS IN CONNECTION WITH ANY ACTIVITIES IT PROPOSES
33 TO UNDERTAKE.
34 4. THE BOARD SHALL MAINTAIN THE CONFIDENTIALITY OF ALL DATA AND OTHER
35 INFORMATION COLLECTED IN FULFILLING ITS DUTIES WHEN SUCH DATA WOULD BE
36 NORMALLY CONSIDERED CONFIDENTIAL DATA BETWEEN A PATIENT AND HEALTH CARE
37 PROVIDER. AGGREGATE DATA WHICH IS DERIVED FROM CONFIDENTIAL DATA BUT
38 DOES NOT VIOLATE PATIENT CONFIDENTIALITY SHALL BE CONSIDERED PUBLIC
39 INFORMATION.
40 S 5106. POWERS AND DUTIES OF THE EXECUTIVE DIRECTOR. 1. THE EXECUTIVE
41 DIRECTOR OF THE PLAN SHALL BE THE CHIEF EXECUTIVE OFFICER OF THE PLAN.
42 2. THE EXECUTIVE DIRECTOR SHALL PERFORM SUCH DUTIES IN THE ADMINIS-
43 TRATION OF THE PLAN AS THE BOARD MAY ASSIGN, INCLUDING THE EMPLOYMENT
44 AND SUPERVISION OF STAFF.
45 3. THE BOARD MAY DELEGATE TO THE EXECUTIVE DIRECTOR ANY OF ITS FUNC-
46 TIONS OR DUTIES UNDER THIS ARTICLE OTHER THAN THE ISSUANCE OF RULES AND
47 REGULATIONS AND THE ESTABLISHMENT OF THE ANNUAL PLAN BUDGET.
48 S 5107. PLAN ELIGIBILITY. 1. EVERY PERSON WHO IS A RESIDENT OF THIS
49 STATE IS ELIGIBLE TO RECEIVE BENEFITS FOR COVERED SERVICES UNDER THE
50 PLAN AND SHALL BE A PLAN MEMBER.
51 2. EVERY PLAN MEMBER IS ENTITLED TO RECEIVE BENEFITS FOR ANY COVERED
52 SERVICE FURNISHED WITHIN THIS STATE BY A PARTICIPATING PROVIDER, IF THE
53 SERVICE IS NECESSARY OR APPROPRIATE FOR THE MAINTENANCE OF HEALTH OR FOR
54 THE DIAGNOSIS OR TREATMENT OF, OR REHABILITATION FOLLOWING, INJURY,
55 DISABILITY OR DISEASE.
S. 8503 7
1 S 5108. PLAN BENEFITS. 1. COVERED SERVICES UNDER THE PLAN SHALL
2 INCLUDE, BUT ARE NOT LIMITED TO, ALL OF THE FOLLOWING MEDICALLY NECES-
3 SARY INPATIENT AND OUTPATIENT SERVICES:
4 (A) HOSPITAL SERVICES;
5 (B) MEDICAL AND OTHER PROFESSIONAL SERVICES FURNISHED BY AUTHORIZED
6 HEALTH CARE PROFESSIONALS WHO ARE AUTHORIZED TO PROVIDE SUCH SERVICES
7 UNDER THE LAWS OF THIS STATE INCLUDING PRIMARY, PREVENTIVE AND SPECIALTY
8 SERVICES;
9 (C) LABORATORY TESTS AND IMAGING PROCEDURES;
10 (D) SHORT-TERM HOME HEALTH SERVICES FOR PERSONS REQUIRING SERVICES
11 PERFORMED BY OR UNDER THE SUPERVISION OF PROFESSIONAL OR TECHNICAL
12 PERSONNEL;
13 (E) REHABILITATIVE SERVICES WHERE A PATIENT IS RECEIVING ACTIVE CARE
14 WITH A THERAPEUTIC OUTCOME;
15 (F) PRESCRIPTION DRUGS AND DEVICES, PROVIDED, HOWEVER, THAT THE PLAN
16 SHALL PARTIALLY COVER THE COST OF A DRUG DISPENSED IN A PACKAGE, OR FORM
17 OF DOSAGE OR ADMINISTRATION, AS TO WHICH THE BOARD DETERMINES THAT A
18 LESS EXPENSIVE PACKAGE, OR FORM OF DOSAGE OR ADMINISTRATION IS AVAILABLE
19 THAT IS PHARMACEUTICALLY EQUIVALENT AND EQUIVALENT IN ITS THERAPEUTIC
20 EFFECT. IF A PLAN MEMBER CHOOSES TO PURCHASE A MORE EXPENSIVE DRUG THAT
21 HAS A PHARMACEUTICAL AND THERAPEUTIC EQUIVALENT, THE PLAN MEMBER SHALL
22 BE FINANCIALLY RESPONSIBLE FOR PAYING THE AMOUNT EQUAL TO THE DIFFERENCE
23 BETWEEN THE COST OF SUCH DRUG AND ITS EQUIVALENT UNLESS THE PRESCRIBING
24 PRACTITIONER CERTIFIES THAT THE MORE EXPENSIVE DRUG IS MEDICALLY NECES-
25 SARY, IN WHICH CASE THE PLAN SHALL COVER THE FULL COST;
26 (G) MENTAL HEALTH SERVICES SUBJECT TO APPROPRIATENESS GUIDELINES AND
27 REVIEW;
28 (H) SUBSTANCE ABUSE TREATMENT SERVICES;
29 (I) PRIMARY AND ACUTE DENTAL SERVICES;
30 (J) VISION APPLIANCES, INCLUDING LENSES, FRAMES AND CONTACT LENSES,
31 ACCORDING TO A SCHEDULE ESTABLISHED BY THE BOARD;
32 (K) MEDICAL SUPPLIES, DURABLE MEDICAL EQUIPMENT AND SELECTED ASSISTIVE
33 DEVICES; AND
34 (L) HOSPICE CARE.
35 2. COVERED SERVICES DO NOT INCLUDE ANY OF THE FOLLOWING:
36 (A) SURGERY FOR COSMETIC PURPOSES OTHER THAN FOR RECONSTRUCTIVE
37 SURGERY;
38 (B) MEDICAL EXAMINATIONS CONDUCTED AND MEDICAL REPORTS PREPARED FOR
39 ANY OF THE FOLLOWING PURPOSES:
40 (I) PURCHASING OR RENEWING LIFE INSURANCE;
41 (II) APPLICATIONS FOR EMPLOYMENT; OR
42 (III) PARTICIPATING AS A PLAINTIFF OR DEFENDANT IN A CIVIL ACTION FOR
43 THE RECOVERY OR SETTLEMENT OF DAMAGES;
44 (C) BASIC OR CUSTODIAL CARE RENDERED IN A NURSING HOME;
45 (D) CUSTODIAL CARE RENDERED IN A FACILITY LICENSED UNDER THE MENTAL
46 HYGIENE LAW; OR
47 (E) COSMETIC DENTAL SERVICES.
48 3. COINSURANCES, DEDUCTIBLES AND COPAYMENTS SHALL NOT BE APPLICABLE TO
49 BENEFITS COVERED UNDER THE PLAN.
50 4. INSURERS AUTHORIZED TO UNDERWRITE COVERAGE PURSUANT TO THE INSUR-
51 ANCE LAW OR A HEALTH MAINTENANCE ORGANIZATION CERTIFIED IN ACCORDANCE
52 WITH ARTICLE FORTY-FOUR OF THIS CHAPTER, MAY OFFER BENEFITS THAT DO NOT
53 DUPLICATE COVERAGE THAT IS OFFERED UNDER THE PLAN BUT MAY NOT OFFER
54 BENEFITS THAT DUPLICATE COVERAGE THAT IS COVERED BY THE PLAN. PROVIDED,
55 HOWEVER, THAT NOTHING IN THIS SUBDIVISION SHALL PROHIBIT THE OFFERING OF
S. 8503 8
1 BENEFITS TO OR FOR PERSONS, INCLUDING THEIR FAMILIES, WHO ARE EMPLOYED
2 OR SELF-EMPLOYED IN THIS STATE BUT ARE NOT RESIDENTS OF THE STATE.
3 5. NO PARTICIPATING PROVIDER SHALL REFUSE TO FURNISH SERVICES TO A
4 PLAN MEMBER ON THE BASIS OF RACE, COLOR, CREED, AGE, NATIONAL ORIGIN,
5 ALIENAGE OR CITIZENSHIP STATUS, GENDER, SEXUAL ORIENTATION, DISABILITY,
6 MARITAL STATUS, OR ARREST RECORD, EXCEPT AS APPROPRIATE TO THE PROVID-
7 ER'S PROFESSIONAL SPECIALIZATION, OR OTHER MEDICALLY APPROPRIATE CIRCUM-
8 STANCES.
9 6. A PLAN MEMBER MAY CHOOSE ANY PARTICIPATING PROVIDER, WHETHER PRAC-
10 TICING ON AN INDEPENDENT BASIS, IN A SMALL GROUP, OR IN A CAPITATED
11 PRACTICE. A PLAN MEMBER WHO ENROLLS IN A CAPITATED PRACTICE SHALL BE
12 SUBJECT TO RULES AND REQUIREMENTS OF THE PLAN AS TO DISENROLLMENT,
13 CHOICE OF PROVIDER, AND AVAILABILITY OF BENEFITS OUTSIDE THE CAPITATED
14 PRACTICE.
15 S 5109. PAYMENT FOR SERVICES. 1. THE PLAN SHALL PAY THE EXPENSES OF
16 INSTITUTIONAL PROVIDERS LICENSED UNDER ARTICLE TWENTY-EIGHT OF THIS
17 CHAPTER FOR COVERED SERVICES ON THE BASIS OF GLOBAL BUDGETS THAT ARE
18 APPROVED BY THE BOARD.
19 2. THE GLOBAL BUDGET OF EACH INSTITUTIONAL PROVIDER SHALL BE SET ANNU-
20 ALLY BY THE PLAN AFTER CONSULTATION AND NEGOTIATION WITH THE INSTITU-
21 TIONAL PROVIDERS, AND SHALL COVER THE COSTS OF ITS ANTICIPATED SERVICES
22 FOR THE NEXT YEAR, BASED ON PAST PERFORMANCE AND PROJECTED CHANGES IN
23 FACTOR PRICES AND SERVICE LEVELS.
24 3. EVERY INDIVIDUAL HEALTH CARE PROVIDER EMPLOYED BY A GLOBALLY BUDG-
25 ETED INSTITUTIONAL PROVIDER SHALL BE PAID THROUGH AND IN A MANNER DETER-
26 MINED BY THE INSTITUTIONAL PROVIDER.
27 4. THE BUDGETING PROCEDURE DESCRIBED IN SUBDIVISIONS ONE, TWO AND
28 THREE OF THIS SECTION ALSO APPLIES TO INSTITUTIONS THAT PROVIDE PLAN
29 SERVICES AND THAT ARE FUNDED BY ANY POLITICAL SUBDIVISION OR ANY AGENCY
30 OR INSTRUMENTALITY OF A POLITICAL SUBDIVISION.
31 5. THE PLAN SHALL REIMBURSE NON-INSTITUTIONAL PARTICIPATING PROVIDERS
32 ON A FEE-FOR-SERVICE BASIS, ESTABLISHED BY THE BOARD. THE FEE SCHEDULE
33 SHALL VARY THE PAYMENT AMOUNT AMONG DIFFERENT SERVICES BASED ON THE
34 RELATIVE VALUE OF THE INPUT FACTORS TO PROVIDE THE SERVICES.
35 6. FEE SCHEDULES MAY TAKE INTO ACCOUNT RECOGNIZED DIFFERENCES AMONG
36 GEOGRAPHIC AREAS REGARDING COST OF PRACTICE.
37 7. TO THE GREATEST EXTENT FEASIBLE, FEE SCHEDULE CATEGORIES SHALL
38 INCLUDE PAYMENT FOR ALL PROCEDURES ROUTINELY PERFORMED FOR A GIVEN DIAG-
39 NOSIS.
40 8. (A) A MULTI-SPECIALTY ORGANIZATION OF PROVIDERS MAY ELECT TO BE
41 REIMBURSED ON A CAPITATION BASIS, IN LIEU OF A FEE-FOR-SERVICE BASIS.
42 (B) IF THE ORGANIZATION MEETS ENROLLMENT AND OTHER REQUIREMENTS ESTAB-
43 LISHED BY THE BOARD, THE ORGANIZATION MAY ELECT TO HAVE INCLUDED IN ITS
44 CAPITATION PAYMENTS, INPATIENT SERVICES PROVIDED BY INSTITUTIONS FUNDED
45 UNDER A BUDGET DESCRIBED IN SUBDIVISION ONE OF THIS SECTION. UPON THAT
46 ELECTION, THE INSTITUTIONAL BUDGETS OF SUCH INSTITUTIONS SHALL BE
47 ADJUSTED ACCORDINGLY.
48 (C) IF THE ORGANIZATION ELECTS, AND MEETS REQUIREMENTS OF THE BOARD,
49 THE BOARD MAY INCLUDE IN THE ORGANIZATION'S CAPITATION PAYMENTS FUNDS TO
50 BE PASSED ON BY THE ORGANIZATION TO PLAN MEMBERS WHO ARE ITS ENROLLED
51 MEMBERS AS A REBATE OR INCENTIVE TO ENCOURAGE MEMBERSHIP IN THE ORGAN-
52 IZATION; PROVIDED THAT THE BOARD FINDS THAT THE REBATE OR INCENTIVE IS
53 IN THE FINANCIAL INTERESTS OF THE PLAN.
54 9. EVERY PARTICIPATING PROVIDER SHALL FURNISH TO THE PLAN SUCH INFOR-
55 MATION, AND PERMIT EXAMINATION OF ITS RECORDS BY THE PLAN, AS MAY BE
56 REASONABLY REQUIRED FOR PURPOSES OF UTILIZATION REVIEW, QUALITY ASSUR-
S. 8503 9
1 ANCE AND COST CONTAINMENT, FOR THE MAKING OF PAYMENTS AND FOR STATIS-
2 TICAL OR OTHER STUDIES OF THE OPERATION OF THE PLAN.
3 10. RATES OF PAYMENT ESTABLISHED UNDER THIS SECTION SHALL BE CONSID-
4 ERED PAYMENT IN FULL. A PROVIDER OF SERVICES SHALL NOT CHARGE RATES THAT
5 ARE IN EXCESS OF SUCH REIMBURSEMENT LEVELS, NOR CHARGE SEPARATELY FOR
6 COVERED SERVICES PROVIDED UNDER SECTION FIFTY-ONE HUNDRED EIGHT OF THIS
7 ARTICLE. PROVIDED, HOWEVER, THE PROVISIONS OF THIS SUBDIVISION SHALL NOT
8 APPLY TO SERVICES RENDERED OUTSIDE OF THIS STATE, OR TO SERVICES
9 RENDERED TO PERSONS WHO ARE NOT PLAN MEMBERS.
10 S 5110. OUT-OF-STATE PARTICIPATION AND PAYMENTS. 1. (A) THE PLAN, IN
11 ACCORDANCE WITH SUBDIVISION FOUR OF THIS SECTION AND EXCEPT AS PROVIDED
12 IN PARAGRAPH (B) OF THIS SUBDIVISION, SHALL PAY FOR SERVICES RENDERED TO
13 PLAN MEMBERS WHILE THEY ARE OUT OF THE STATE (I) WHILE THEY ARE TEMPO-
14 RARILY OUT OF THE STATE FOR REASONS OTHER THAN TO OBTAIN THE SERVICES OR
15 (II) WHERE THE PLAN MEMBER OBTAINS THE SERVICES OUT OF THE STATE FOR
16 COMPELLING REASONS RELATING TO THE SUITABILITY OF SERVICES, THE NATURE
17 OF THE CONDITION AND PERSONAL CIRCUMSTANCES.
18 (B) WHERE THE PLAN MEMBER IS ELIGIBLE FOR HEALTH BENEFITS UNDER TITLE
19 XVIII OR TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT, THEN OUT-OF-STATE
20 SERVICES FOR THE PLAN MEMBER SHALL, TO THE EXTENT ALLOWED BY LAW, BE
21 PAID FOR UNDER THOSE TITLES.
22 2. WHERE AN EMPLOYEE OR SELF-EMPLOYED INDIVIDUAL IS NOT A RESIDENT OF
23 NEW YORK STATE (AND THEREFORE NOT ELIGIBLE TO BE A PLAN MEMBER) BUT IS
24 EMPLOYED OR SELF-EMPLOYED IN THE STATE, THE EMPLOYER OR THE EMPLOYEE, OR
25 THE SELF-EMPLOYED INDIVIDUAL, MAY PURCHASE HEALTH COVERAGE FOR THE
26 PERSON, INCLUDING THE PERSON'S FAMILY, FROM ANY ENTITY AUTHORIZED TO
27 OFFER THAT COVERAGE OR FROM THE PLAN PURSUANT TO SUBDIVISION FIVE OF
28 THIS SECTION.
29 3. ANY PRIVATE OR STATE COLLEGE, UNIVERSITY OR OTHER INSTITUTION OF
30 HIGHER EDUCATION SITUATED IN THIS STATE MAY PURCHASE COVERAGE UNDER THE
31 PLAN FOR ANY STUDENT, OR THEIR DEPENDENTS, WHO IS NOT A RESIDENT OF
32 THIS STATE.
33 4. THE BOARD SHALL ESTABLISH AND OPERATE AN INDEMNITY PLAN TO PROVIDE
34 PAYMENTS FOR SERVICES UNDER SUBDIVISION ONE OF THIS SECTION. THE
35 PAYMENTS SHALL BE MADE AT THE RATES ESTABLISHED BY THE BOARD FOR BENE-
36 FITS FOR COMPARABLE SERVICES PROVIDED BY THE PLAN IN THIS STATE. CHARGES
37 IN EXCESS OF THE PAYMENT RATES ESTABLISHED IN ACCORDANCE WITH THIS
38 SECTION SHALL BE THE RESPONSIBILITY OF THE PLAN MEMBER.
39 5. THE BOARD SHALL ESTABLISH AND OPERATE AN INDEMNITY PLAN TO PROVIDE
40 HEALTH COVERAGE FOR EMPLOYEES AND SELF-EMPLOYED INDIVIDUALS WHO ARE NOT
41 RESIDENTS OF THIS STATE BUT ARE EMPLOYED OR SELF-EMPLOYED IN THE STATE,
42 INCLUDING THEIR FAMILIES, TO BE OFFERED FOR PURCHASE BY THE EMPLOYER OR
43 EMPLOYEE, OR SELF-EMPLOYED INDIVIDUALS, UNDER SUBDIVISION TWO OF THIS
44 SECTION. THE INDEMNITY PLAN SHALL BE OFFERED ON A NOT-FOR-PROFIT BASIS.
45 ITS SCOPE OF BENEFITS AND RATES OF PAYMENT SHALL BE ESTABLISHED BY THE
46 BOARD AND SHALL, TO THE EXTENT PRACTICABLE, BE COMPARABLE TO THOSE UNDER
47 THE NEW YORK HEALTH PLAN.
48 6. NOTHING IN THIS ARTICLE SHALL IMPACT THE EXISTING OR FUTURE OBLI-
49 GATIONS OF EMPLOYERS TO PROVIDE SUPPLEMENTARY HEALTH BENEFITS TO RETI-
50 REES WHO NO LONGER RESIDE IN THIS STATE.
51 S 2. The state finance law is amended by adding a new section 89-h to
52 read as follows:
53 S 89-H. NEW YORK HEALTH TRUST FUND. 1. THERE IS HEREBY ESTABLISHED IN
54 THE JOINT CUSTODY OF THE STATE COMPTROLLER AND THE COMMISSIONER OF TAXA-
55 TION AND FINANCE A SPECIAL REVENUE FUND TO BE KNOWN AS THE "NEW YORK
56 HEALTH TRUST FUND", HEREINAFTER KNOWN AS "THE FUND".
S. 8503 10
1 2. THE FUND SHALL CONSIST OF:
2 (A) ALL MONIES OBTAINED FROM PREMIUM PAYMENT REVENUES PURSUANT TO
3 ARTICLE THIRTY-FIVE OF THE TAX LAW;
4 (B) FEDERAL PAYMENTS RECEIVED AS A RESULT OF ANY WAIVER OF REQUIRE-
5 MENTS GRANTED BY THE UNITED STATES SECRETARY OF HEALTH AND HUMAN
6 SERVICES FOR HEALTH CARE PROGRAMS ESTABLISHED UNDER TITLES XVIII (MEDI-
7 CARE) AND XIX (MEDICAL ASSISTANCE FOR NEEDY PERSONS) OF THE FEDERAL
8 SOCIAL SECURITY ACT;
9 (C) THE AMOUNTS PAID BY THE DEPARTMENT OF HEALTH AND BY LOCAL SOCIAL
10 SERVICES DISTRICTS THAT ARE EQUIVALENT TO THOSE AMOUNTS THAT ARE PAID ON
11 BEHALF OF RESIDENTS OF THIS STATE UNDER TITLES XVIII (MEDICARE) AND XIX
12 (MEDICAL ASSISTANCE FOR NEEDY PERSONS) OF THE FEDERAL SOCIAL SECURITY
13 ACT, AND ARTICLE FIVE, TITLE ELEVEN OF THE SOCIAL SERVICES LAW FOR
14 HEALTH BENEFITS WHICH ARE EQUIVALENT TO HEALTH BENEFITS COVERED UNDER
15 ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW;
16 (D) ALL SURCHARGES THAT ARE IMPOSED ON RESIDENTS OF THIS STATE TO
17 REPLACE PAYMENTS MADE BY THE RESIDENTS UNDER THE COST-SHARING PROVISIONS
18 OF TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT;
19 (E) FEDERAL, STATE AND LOCAL FUNDS FOR PURPOSES OF THE PROVISION OF
20 SERVICES AUTHORIZED UNDER TITLE XX OF THE FEDERAL SOCIAL SECURITY ACT
21 THAT WOULD OTHERWISE BE COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC
22 HEALTH LAW; AND
23 (F) STATE AND LOCAL GOVERNMENT MONIES THAT WOULD OTHERWISE BE APPRO-
24 PRIATED TO ANY GOVERNMENTAL AGENCY, OFFICE, PROGRAM, INSTRUMENTALITY OR
25 INSTITUTION WHICH PROVIDES HEALTH SERVICES, FOR SERVICES AND BENEFITS
26 COVERED UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW. PAYMENTS TO
27 THE FUND PURSUANT TO THIS PARAGRAPH SHALL BE IN AN AMOUNT EQUAL TO THE
28 MONEY APPROPRIATED FOR SUCH PURPOSES IN THE FISCAL YEAR IMMEDIATELY
29 PRECEDING THE EFFECTIVE DATE OF ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH
30 LAW.
31 3. MONIES IN THE FUND SHALL ONLY BE USED FOR PURPOSES ESTABLISHED
32 UNDER ARTICLE FIFTY-ONE OF THE PUBLIC HEALTH LAW.
33 4. REVENUES HELD IN THE FUND SHALL NOT BE SUBJECT TO APPROPRIATION OR
34 ALLOTMENT BY THE STATE OR ANY POLITICAL SUBDIVISION THEREOF.
35 5. THE BOARD OF GOVERNORS OF THE NEW YORK HEALTH PLAN UNDER ARTICLE
36 FIFTY-ONE OF THE PUBLIC HEALTH LAW SHALL:
37 (A) ADMINISTER THE FUND AND SHALL CONDUCT A QUARTERLY REVIEW OF THE
38 EXPENDITURES FROM AND REVENUES RECEIVED BY THE FUND; AND
39 (B) INVEST THE FUND IN INVESTMENTS THAT ARE AUTHORIZED BY THE LAWS OF
40 THIS STATE FOR THE INVESTMENT OF THE CAPITAL, SURPLUS AND ACCUMULATIONS
41 OF DOMESTIC LIFE INSURANCE COMPANIES. THE LIMITATIONS SET FORTH IN THESE
42 LAWS APPLY TO THE INVESTMENTS OF THE FUND.
43 S 3. The tax law is amended by adding a new article 35 to read as
44 follows:
45 ARTICLE 35
46 NEW YORK HEALTH PLAN PREMIUM PAYMENTS
47 SECTION 1650. DEFINITIONS.
48 1651. PREMIUM PAYMENTS.
49 1652. PROCEDURAL PROVISIONS.
50 S 1650. DEFINITIONS. FOR THE PURPOSES OF THIS ARTICLE, UNLESS THE
51 CONTEXT CLEARLY REQUIRES OTHERWISE:
52 1. "EMPLOY" MEANS TO SUFFER OR PERMIT TO WORK.
53 2. "EMPLOYER" MEANS AN INDIVIDUAL, PARTNERSHIP, ASSOCIATION, CORPO-
54 RATION, BUSINESS TRUST, THE STATE OF NEW YORK, ITS INSTRUMENTALITIES AND
55 ITS POLITICAL SUBDIVISIONS AND THEIR INSTRUMENTALITIES, OR ANY PERSON OR
S. 8503 11
1 GROUP OF PERSONS, ACTING IN THE INTEREST OF AN EMPLOYER IN RELATION TO
2 AN EMPLOYEE.
3 3. "EMPLOYEE" MEANS ANY INDIVIDUAL WHO WORKS FOR AN EMPLOYER.
4 S 1651. PREMIUM PAYMENTS. FOR THE PURPOSE OF PROVIDING REVENUE FOR THE
5 NEW YORK HEALTH PLAN ESTABLISHED PURSUANT TO ARTICLE FIFTY-ONE OF THE
6 PUBLIC HEALTH LAW, AND TO PAY THE EXPENSE OF PLAN ADMINISTRATION, THE
7 FOLLOWING PREMIUM PAYMENTS ARE HEREBY LEVIED:
8 1. ON EACH EMPLOYER, A PREMIUM PAYMENT EQUAL TO TEN PERCENT OF THE
9 EMPLOYER'S PAYROLL. THE EMPLOYER MAY CHOOSE, SUBJECT TO COLLECTIVE
10 BARGAINING AGREEMENTS, TO DEDUCT TWO PERCENT OF EACH EMPLOYEE'S WAGES OR
11 GROSS SALARY AS PARTIAL PAYMENT OF THIS PREMIUM PAYMENT.
12 2. ON EACH SELF-EMPLOYED INDIVIDUAL, A PREMIUM PAYMENT EQUAL TO TEN
13 PERCENT OF THE INDIVIDUAL'S SELF-EMPLOYMENT INCOME, SUBJECT TO THE LIMIT
14 ON TAXABLE SELF-EMPLOYMENT INCOME FOR MEDICARE HOSPITAL INSURANCE UNDER
15 THE "FEDERAL INSURANCE CONTRIBUTIONS ACT", 68A STAT. 415 (1954), 26
16 U.S.C.A. 3101, AS AMENDED.
17 3. A PERSON SUBJECT TO TAXATION UNDER THIS CHAPTER, OTHER THAN A
18 PERSON WHO IS ENTITLED TO COVERAGE UNDER TITLE XVIII OF THE FEDERAL
19 SOCIAL SECURITY ACT, WHO HAS NOT HAD THE PREMIUM PAID ON FIFTY PERCENT
20 OR MORE OF HIS OR HER ADJUSTED GROSS INCOME UNDER SUBDIVISION ONE OR TWO
21 OF THIS SECTION, SHALL MAKE A PREMIUM PAYMENT EQUAL TO TEN PERCENT OF
22 THE DIFFERENCE BETWEEN FIFTY PERCENT OF THE INDIVIDUAL'S ADJUSTED GROSS
23 INCOME AND THE TOTAL AMOUNT OF INCOME ON WHICH THE INDIVIDUAL HAS HAD
24 PREMIUMS PAID UNDER SUBDIVISIONS ONE AND TWO OF THIS SECTION; PROVIDED,
25 HOWEVER, THAT THE TOTAL AMOUNT OF ADJUSTED GROSS INCOME SUBJECT TO
26 PREMIUM PAYMENTS UNDER THIS SUBDIVISION SHALL NOT EXCEED THE LIMIT ON
27 TAXABLE SELF-EMPLOYMENT INCOME FOR MEDICAL HOSPITAL INSURANCE UNDER THE
28 "FEDERAL INSURANCE CONTRIBUTIONS ACT," 68A STAT. 415 (1954), 26 U.S.C.A.
29 3101, AS AMENDED.
30 4. (A) WHERE A NEW YORK STATE RESIDENT IS EMPLOYED OUTSIDE THE STATE
31 BY AN EMPLOYER THAT DOES BUSINESS IN THE STATE, OR THAT ELECTS TO BE
32 SUBJECT TO THIS SUBDIVISION, THEN THE EMPLOYER SHALL PAY THE PREMIUM
33 UNDER SUBDIVISION ONE OF THIS SECTION, CALCULATED ON THE PRO RATA
34 PORTION OF THE EMPLOYER'S PAYROLL ATTRIBUTABLE TO ALL NEW YORK STATE
35 RESIDENTS EMPLOYED BY THE EMPLOYER.
36 (B) WHERE A NEW YORK RESIDENT IS EMPLOYED OUTSIDE THE STATE BY AN
37 EMPLOYER THAT DOES NOT DO BUSINESS IN THE STATE AND THAT DOES NOT ELECT
38 TO BE SUBJECT TO THIS SUBDIVISION, THEN THE EMPLOYEE SHALL PAY THE
39 PREMIUM UNDER SUBDIVISION ONE OF THIS SECTION, AS IF THE EMPLOYEE'S
40 INCOME FROM THE EMPLOYER WAS SELF-EMPLOYMENT INCOME.
41 5. WHERE AN EMPLOYEE IS NOT A RESIDENT OF NEW YORK STATE (AND THERE-
42 FORE NOT ELIGIBLE TO BE A NEW YORK HEALTH PLAN MEMBER), AND THE EMPLOYER
43 PURCHASES HEALTH COVERAGE FOR THE EMPLOYEE, INCLUDING THE EMPLOYEE'S
44 FAMILY, UNDER SUBDIVISION TWO OF SECTION FIFTY-ONE HUNDRED TEN OF THE
45 PUBLIC HEALTH LAW, THE EMPLOYER MAY TAKE A CREDIT AGAINST THE PREMIUM
46 PAID UNDER SUBDIVISION ONE OF THIS SECTION, UP TO THE PRO RATA PORTION
47 OF THE EMPLOYER'S PREMIUM ATTRIBUTABLE TO THAT EMPLOYEE, FOR THE AMOUNT
48 PAID BY THE EMPLOYER TO PURCHASE THAT COVERAGE. WHERE SUCH AN EMPLOYEE
49 PURCHASES OR PAYS A PORTION OF THE COST OF SUCH COVERAGE, THE EMPLOYEE
50 MAY TAKE A CREDIT FOR THE AMOUNT PAID BY HIM OR HER FOR THAT COVERAGE
51 AGAINST ANY PREMIUM THE EMPLOYEE IS REQUIRED BY THE EMPLOYER TO PAY
52 UNDER SUBDIVISION ONE OF THIS SECTION.
53 6. WHERE A SELF-EMPLOYED INDIVIDUAL IS NOT A RESIDENT OF NEW YORK
54 STATE (AND THEREFORE NOT ELIGIBLE TO BE A NEW YORK HEALTH PLAN MEMBER),
55 AND THE PERSON PURCHASES HEALTH COVERAGE UNDER SUBDIVISION TWO OF
56 SECTION FIFTY-ONE HUNDRED TEN OF THE PUBLIC HEALTH LAW, THE SELF-EM-
S. 8503 12
1 PLOYED INDIVIDUAL MAY TAKE A CREDIT FOR THE AMOUNT PAID BY HIM OR HER
2 FOR THAT COVERAGE AGAINST THE PREMIUM PAID BY THE SELF-EMPLOYED PERSON
3 UNDER SUBDIVISION ONE OF THIS SECTION.
4 7. THE TOTAL AMOUNT OF CREDITS TAKEN UNDER SUBDIVISIONS FIVE AND SIX
5 OF THIS SECTION, AGAINST PREMIUMS PAID UNDER THIS SECTION, FOR HEALTH
6 COVERAGE FOR A PERSON, INCLUDING THAT PERSON'S FAMILY, SHALL NOT EXCEED
7 THE TOTAL AMOUNT OF PREMIUM PAID BY OR ATTRIBUTABLE TO THAT PERSON,
8 WHETHER PAID BY THAT PERSON OR BY AN EMPLOYER.
9 8. NEW YORK HEALTH PLAN MEMBERS ENTITLED TO COVERAGE UNDER TITLE XVIII
10 OF THE FEDERAL SOCIAL SECURITY ACT, WHO ARE NOT ALSO ENTITLED TO COVER-
11 AGE UNDER TITLE XIX OF THE FEDERAL SOCIAL SECURITY ACT, SHALL MAKE
12 PREMIUM PAYMENTS EQUAL TO THE PREMIUM PAYMENT DEVELOPED BY THE FEDERAL
13 SECRETARY OF HEALTH AND HUMAN SERVICES FOR COVERAGE UNDER PART B OF
14 TITLE XVIII OF THE FEDERAL SOCIAL SECURITY ACT; PROVIDED, HOWEVER, THAT
15 PLAN MEMBERS WHO MAKE PREMIUM PAYMENTS DIRECTLY TO THE SECRETARY OF
16 HEALTH AND HUMAN SERVICES SHALL BE ENTITLED TO A CREDIT AGAINST THE
17 AMOUNT PAID UNDER THIS SUBDIVISION.
18 S 1652. PROCEDURAL PROVISIONS. THE BOARD OF GOVERNORS OF THE NEW YORK
19 HEALTH PLAN SHALL ADOPT RULES REGARDING THE LEVY AND COLLECTION OF THE
20 PREMIUM PAYMENTS UNDER THIS ARTICLE AND MAY ENTER INTO CONTRACTS WITH
21 THE DEPARTMENT FOR THE COLLECTION OF THE PREMIUM PAYMENTS LEVIED BY THIS
22 ARTICLE. FOR PURPOSES OF ENFORCEMENT, PREMIUM PAYMENTS DUE UNDER THIS
23 ARTICLE SHALL BE SUBJECT TO THE PROVISIONS OF THIS CHAPTER APPLICABLE TO
24 INCOME TAXES DUE UNDER ARTICLE TWENTY-TWO OF THIS CHAPTER.
25 S 4. 1. There is hereby established a temporary commission on imple-
26 mentation of the New York health plan, hereinafter to be known as the
27 commission, consisting of fifteen members: five members, including the
28 chair, shall be appointed by the governor; five members shall be
29 appointed by the temporary president of the senate, two of which shall
30 be upon recommendation of the senate minority leader; and, five members
31 shall be appointed by the speaker of the assembly, two of which shall be
32 upon recommendation of the assembly minority leader. The commissioner
33 of health, the superintendent of insurance, and the commissioner of
34 taxation and finance, or their designees shall serve as non-voting
35 ex-officio members of the commission.
36 2. Members of the commission shall receive such assistance as may be
37 necessary from other state agencies and entities, and shall receive
38 necessary expenses incurred in the performance of their duty. The
39 commission may employ staff as needed, prescribe their duties, and fix
40 their compensation within amounts appropriate for the commission.
41 3. The commission shall examine the statutes of this state and make
42 such recommendations as are necessary to conform the laws of this state,
43 and to eliminate any inconsistency between the laws of this state, and
44 the provisions of article 51 of the public health law establishing the
45 New York health plan as added by section one of this act, and other
46 provisions of law relating to the New York health plan, and to improve
47 and implement the plan.
48 4. On or before 270 days subsequent to the enactment of this act, the
49 commission shall report to the governor and the legislature, with recom-
50 mendations, as provided in subdivision three of this section.
51 S 5. The superintendent of insurance, in consultation with a techni-
52 cal advisory committee which shall include representation from insurers,
53 consumers, organized labor, and business, shall examine the premium rate
54 structure for insurance underwritten and offered in this state by insur-
55 ers licensed pursuant to the insurance law, and determine the extent to
56 which such premiums reflect expenditures for health care services
S. 8503 13
1 covered under the provisions of article 51 of the public health law
2 establishing the New York health plan as added by section one of this
3 act. On or before 270 days following the enactment of this act, the
4 superintendent shall report to the governor and the legislature on the
5 extent to which the premium rate structure for insurance, by line of
6 insurance, underwritten and offered in this state reflects expenditures
7 for health care services covered under article 51 of the public health
8 law as added by section one of this act, and make such recommendations
9 as are necessary for an adjustment in such premium rate structures to
10 reflect a reduction in health care expenditures due to implementation of
11 the New York health plan.
12 S 6. The sum of five hundred thousand dollars ($500,000), or so much
13 thereof as may be necessary, is hereby appropriated to the temporary
14 commission on implementation of the New York health plan created pursu-
15 ant to section four of this act out of any moneys in the state treasury
16 in the general fund to the credit of the state purposes account not
17 otherwise appropriated. Such sum shall be payable on the audit and
18 warrant of the state comptroller on vouchers certified or approved by
19 the chair of the temporary commission on implementation of the New York
20 health plan created pursuant to section four of this act.
21 S 7. (a) This act shall take effect on the first of January next
22 succeeding the date on which it shall have become a law provided, howev-
23 er, that sections four and five of this act shall take effect immediate-
24 ly and shall remain in full force and effect until the first of January
25 following the date upon which benefits under article 51 of the public
26 health law as added by section one of this act begin whereupon such
27 sections shall be deemed repealed. The commissioner of health shall
28 notify the Legislative Bill Drafting Commission of such event.
29 (b) Not later than the thirty-first of March following the effective
30 date of this act, the commissioner of health shall do both of the
31 following:
32 1. Apply to the secretary of health and human services for all waivers
33 of requirements under health care programs established under titles
34 XVIII and XIX of the federal social security act that are necessary to
35 enable this state to deposit all federal payments under those programs
36 in the state treasury to the credit of the New York health trust fund
37 created pursuant to section 89-h of the state finance law, as added by
38 section two of this act;
39 2. Identify any other federal programs that provide federal funds for
40 payment of health care services to individuals. The commissioner of
41 health shall comply with any requirements under those programs and apply
42 for any waivers of those requirements that are necessary to enable this
43 state to deposit such federal funds to the credit of the New York health
44 trust fund.
45 (c) No later than the thirty-first of December following the effective
46 date of this act, the board of governors of the New York health plan and
47 the commissioner of health shall explore and cooperate with, enter into
48 any necessary contract or other arrangement with, and otherwise pursue
49 any other reasonable course of action with, the secretary of health and
50 human services to establish procedures, standards and conditions under
51 which the commissioner of health shall pay to the New York health trust
52 fund amounts equivalent to those amounts that, on the effective date of
53 this section, are paid on behalf of residents of this state for health
54 benefits covered under the plan under titles XVIII and XIX of the feder-
55 al social security act.
S. 8503 14
1 (d) Commencing on the first of January following the effective date of
2 this act the following shall occur:
3 1. New York health premium payments that are authorized pursuant to
4 article 35 of the tax law, as added by section three of this act, shall
5 be levied.
6 2. Benefits under the New York health plan established pursuant to
7 article 51 of the public health law, as added by section one of this act
8 shall begin.
9 3. Payments into the New York health trust fund created pursuant to
10 section 89-h of the state finance law shall begin.
11 (e) Not later than the twenty-eighth of February following the effec-
12 tive date of this act, the governor shall make the initial appointments
13 to the board of governors of the New York health plan established pursu-
14 ant to article 51 of the public health law, as added by section one of
15 this act, provided, however, that of the initial appointments made by
16 the governor, four shall be for a term of one year; four shall be for a
17 term of two years; three shall be for a term of three years; three shall
18 be for a term of four years; and four, including the chair, shall be for
19 a term of five years. Thereafter, all appointments shall be for a term
20 of five years, except in those instances where an appointment is to fill
21 a vacancy occurring prior to the expiration of a term.
