NY State Senate Bill 2023-S1197

Current Bill Status - In Senate Committee Finance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Actions

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	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 22, 2024	reported and committed to finance
Jan 03, 2024	referred to health
Dec 27, 2023	print number 1197b
Dec 27, 2023	amend and recommit to rules
Dec 20, 2023	print number 1197a
Dec 20, 2023	amend (t) and recommit to rules
Jun 10, 2023	committed to rules
Mar 20, 2023	advanced to third reading
Mar 16, 2023	2nd report cal.
Mar 15, 2023	1st report cal.519
Jan 10, 2023	referred to health

Votes

- Jan 22, 2024 - Health Committee Vote
  S1197
  
  10
  
  Aye
  
  0
  
  Nay
  
  5
  
  Aye with Reservations
  
  0
  
  Absent
  
  0
  
  Excused
  
  0
  
  Abstained
  - - Health Committee Vote: Jan 22, 2024
      
      aye (10)
      
      Brouk
      
      Felder
      
      Hoylman-Sigal
      
      Mannion
      
      May
      
      Myrie
      
      Rivera
      
      Salazar
      
      Thomas
      
      Webb
      
      aye wr (5)
      
      Ashby
      
      Gallivan
      
      Martins
      
      Rhoads
      
      Stec
  Mar 14, 2023 - Health Committee Vote
  S1197
  
  11
  
  Aye
  
  1
  
  Nay
  
  3
  
  Aye with Reservations
  
  0
  
  Absent
  
  0
  
  Excused
  
  0
  
  Abstained
  - - Health Committee Vote: Mar 14, 2023
      
      aye (11)
      
      Ashby
      
      Brouk
      
      Felder
      
      Hoylman-Sigal
      
      Mannion
      
      May
      
      Myrie
      
      Rivera
      
      Salazar
      
      Thomas
      
      Webb
      
      nay (1)
      
      Stec
      
      aye wr (3)
      
      Gallivan
      
      Martins
      
      Rhoads

Bill Amendments

Original

B (Active)

co-Sponsors

View additional co-sponsors

2023-S1197 - Details

Current Committee:: Senate Finance
Law Section:: Public Health Law
Laws Affected:: Amd Art 29-AA Art Head, add §2959-b, Pub Health L
Versions Introduced in 2021-2022 Legislative Session:: S6534

2023-S1197 - Summary

Requires health care plans and payors to have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.

2023-S1197 - Sponsor Memo

                                 
BILL NUMBER: S1197

SPONSOR: RIVERA
 
TITLE OF BILL:

An act to amend the public health law, in relation to establishing the
primary care reform commission

 
PURPOSE OR GENERAL ID OF BILL:

Stakeholders would develop recommendations as to how much and by what
means the proportion of health care spending that goes to primary care
services should increase.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1 adds "and Primary Care" to Article 29-AA of Public Health Law.

Section 2 adds a new section 2959-b to Article 29-AA of Public Health
Law, creating the primary care reform commission under Patient Centered
Medical Homes and Primary Care. Participants would include experts on
health care financing, reimbursement, and regulation from primary care

providers, federally qualified health centers, and professional practice
groups, as well as representatives with relevant expertise from busi-
nesses operating within New York, public and commercial health plans
including managed care plans, and primary care professional and advocacy
organizations. Third-party payors would be compelled to provide data
requested by the commission, with protections for proprietary property.
The first report of recommendations would be published by March 31st
following the year of enactment and include a comparative analysis of
current primary care spending and recommendations to the Governor and
the Legislature regarding the barriers to primary care and how to over-
come them.

Section 3 provides an effective date.

 
JUSTIFICATION:

Primary care should be a person's first contact with the health care
system when seeking care. Primary care is understanding and maintaining
wellness as well as identifying, preventing, and treating illness before
it becomes a chronic condition. Research shows that an increase of just
one primary care provider per 10,000 people can generate 5.5% fewer
hospital visits, 11% fewer emergency department visits, and 7% fewer
surgeries. We know that health systems oriented towards primary care
simply function better. Yet, it is estimated that as little as 5% of
U.S. healthcare spending goes toward primary care. New York currently
spends more per capita on health care than the national average, but
consistently ranks below many other states in key health indicators.
This is indicative of a lack of access to and underinvestment in primary
care.

Currently, at least ten states have acted to rebalance their healthcare
spending through legislative, regulatory, or executive means. This
commission will definemesure, and report on current primary care spend-
ing in New York. Further, the commission will identify the means to
increase the proportion of the healthcare dollar that goes to primary
care services across all payers, for the benefit of all patients. An
ounce of prevention is worth a pound of cure.
 
PRIOR LEGISLATIVE HISTORY:

2021-2022: S6534C Rivera / A7230B Gottfried - Vetoed

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
Immediately.

2023-S1197 - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1197
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             January 10, 2023
                                ___________
 
 Introduced  by Sens. RIVERA, BROUK, COONEY, MAY, MYRIE, RAMOS, SEPULVEDA
   -- read twice and ordered printed, and when printed to be committed to
   the Committee on Health
 
 AN ACT to amend the public health law, in relation to  establishing  the
   primary care reform commission

   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. The article heading of article 29-AA of the  public  health
 law, as added by section 35 of part H of chapter 59 of the laws of 2011,
 is amended to read as follows:
              PATIENT CENTERED MEDICAL HOMES AND PRIMARY CARE
   §  2.  The public health law is amended by adding a new section 2959-b
 to read as follows:
   § 2959-B. PRIMARY CARE REFORM COMMISSION.  1.  (A)  COMMISSION  ESTAB-
 LISHED.  THE PRIMARY CARE REFORM COMMISSION, REFERRED TO IN THIS SECTION
 AS THE "COMMISSION",  IS  HEREBY  ESTABLISHED  IN  THE  DEPARTMENT.  THE
 COMMISSION  SHALL  REVIEW,  EXAMINE,  AND  MAKE FINDINGS ON THE LEVEL OF
 PRIMARY CARE SPENDING BY ALL PAYERS IN THE CONTEXT OF  ALL  HEALTH  CARE
 SPENDING  IN  THE STATE, AND SHALL PUBLISH AN ANNUAL REPORT ON THE FIND-
 INGS. THE COMMISSION SHALL ALSO MAKE RECOMMENDATIONS TO INCREASE  SPEND-
 ING  ON  PRIMARY  CARE AND STRENGTHEN PRIMARY CARE INFRASTRUCTURE IN THE
 STATE, TAKING CARE TO AVOID INCREASING COSTS TO PATIENTS  OR  THE  TOTAL
 COST OF HEALTH CARE.
   (B) COMPOSITION AND POWERS. (I) THE COMMISSION SHALL CONSIST OF:
   (1)  THE  COMMISSIONER  AND  THE  SUPERINTENDENT  OF THE DEPARTMENT OF
 FINANCIAL SERVICES, WHO MAY BE REPRESENTED BY  THEIR  RESPECTIVE  DESIG-
 NEES;
   (2) SEVEN MEMBERS APPOINTED BY THE GOVERNOR; AND
   (3)  EIGHT  MEMBERS APPOINTED BY THE GOVERNOR AS FOLLOWS: THREE ON THE
 RECOMMENDATION OF THE SPEAKER OF THE ASSEMBLY, THREE ON THE  RECOMMENDA-
 TION OF THE TEMPORARY PRESIDENT OF THE SENATE, ONE ON THE RECOMMENDATION
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03591-01-3

 S. 1197                             2
 
 OF THE MINORITY LEADER OF THE ASSEMBLY, AND ONE ON THE RECOMMENDATION OF
 THE MINORITY LEADER OF THE SENATE.
   (II)  ANY  VACANCY IN THE MEMBERSHIP OF THE COMMISSION SHALL BE FILLED
 IN THE SAME MANNER AS THE MEMBER BEING SUCCEEDED WAS APPOINTED.
   (III) THE COMMISSION SHALL SELECT A CHAIRPERSON FROM AMONG THE MEMBERS
 OF THE COMMISSION.
   (IV) THE COMPOSITION OF THE COMMISSION  SHALL  INCLUDE  AT  LEAST  ONE
 MEMBER WITH EXPERTISE IN HEALTH CARE FINANCING, REIMBURSEMENT, AND REGU-
 LATION, REPRESENTING EACH OF THE FOLLOWING CATEGORIES: PRACTICING PRIMA-
 RY  CARE  PROVIDERS,  FEDERALLY  QUALIFIED  HEALTH CENTERS, PROFESSIONAL
 PRACTICE GROUPS, PRIMARY CARE ADVOCATES,  PRIMARY  CARE  CONSUMER  ADVO-
 CATES,  BUSINESSES,  HEALTH  PLANS,  AND  HOSPITALS  OR  HEALTH SYSTEMS.
 COMMISSION MEMBERS SHALL BE APPOINTED SO AS TO REPRESENT A  GEOGRAPHICAL
 DISTRIBUTION ACROSS THE STATE.
   (V)  MEMBERS OF THE COMMISSION, EXCEPT FOR THOSE REPRESENTING NEW YORK
 STATE DEPARTMENTS, AGENCIES, AUTHORITIES OR COUNCILS, SHALL SERVE FOR  A
 TERM OF FOUR YEARS AND MAY BE REAPPOINTED IN THE SAME MANNER AS PROVIDED
 FOR THEIR INITIAL APPOINTMENT.
   (VI)  A  MAJORITY  OF  THE CURRENT FILLED MEMBERSHIP OF THE COMMISSION
 SHALL CONSTITUTE A QUORUM FOR THE TRANSACTION OF  ANY  BUSINESS  OR  THE
 EXERCISE OF ANY POWER OR FUNCTION OF THE COMMISSION, AND ANY DECISION OR
 ACTION  BY  THE  COMMISSION SHALL BE BY A MAJORITY VOTE OF THOSE PRESENT
 AND VOTING.
   (VII) THE COMMISSION SHALL MEET AT LEAST QUARTERLY AT THE CALL OF  THE
 CHAIRPERSON.  ADDITIONAL  MEETINGS  MAY  BE  CALLED  BY  THE CHAIRPERSON
 SUBJECT TO THE GIVING OF ONE WEEK'S NOTICE, AND SHALL BE CALLED  BY  THE
 CHAIRPERSON  AT  THE REQUEST OF A MAJORITY OF THE MEMBERS OF THE COMMIS-
 SION.
   (VIII) THE MEMBERS OF THE COMMISSION SHALL RECEIVE NO COMPENSATION FOR
 THEIR SERVICES, BUT SHALL BE ALLOWED THEIR ACTUAL AND NECESSARY EXPENSES
 INCURRED IN THE PERFORMANCE OF THEIR DUTIES.
   2. (A) EACH MEDICAID MANAGED CARE PROVIDER UNDER SECTION THREE HUNDRED
 SIXTY-FOUR-J OF THE SOCIAL  SERVICES  LAW  SHALL  PROVIDE  PRIMARY  CARE
 SPENDING  DATA  FOR  THE  FIVE YEARS PRIOR TO THE EFFECTIVE DATE OF THIS
 SECTION AND FOR EACH YEAR THEREAFTER  AS  REQUESTED  BY  THE  COMMISSION
 UNDER  THIS  SECTION.  THE INFORMATION SHALL INCLUDE, BUT NOT BE LIMITED
 TO, PRIMARY CARE SPENDING, TOTAL HEALTH CARE SPENDING, AND  ALL  FURTHER
 INFORMATION THE COMMISSION REQUESTS RELATING TO ITS WORK.  EACH MEDICAID
 MANAGED CARE PROVIDER SHALL ALSO PROVIDE THE TOTAL COST OF CARE PROVIDED
 BY THE PROVIDER ANNUALLY FOR EACH OF THE YEARS.
   (B)  EACH INSURANCE ENTITY PROVIDING MANAGED CARE PRODUCTS, INDIVIDUAL
 COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE OR GROUP OR BLANKET  COMPRE-
 HENSIVE  ACCIDENT AND HEALTH INSURANCE, AS DEFINED IN THE INSURANCE LAW,
 CORPORATION ORGANIZED UNDER ARTICLE FORTY-THREE  OF  THE  INSURANCE  LAW
 PROVIDING  COMPREHENSIVE HEALTH INSURANCE, ENTITY LICENSED UNDER ARTICLE
 FORTY-FOUR OF THIS CHAPTER  PROVIDING  COMPREHENSIVE  HEALTH  INSURANCE,
 EVERY  OTHER  PLAN  OVER  WHICH THE DEPARTMENT OF FINANCIAL SERVICES HAS
 JURISDICTION, AND EVERY  THIRD-PARTY  PAYOR  PROVIDING  HEALTH  COVERAGE
 SHALL PROVIDE PRIMARY CARE SPENDING DATA FOR THE FIVE YEARS PRIOR TO THE
 EFFECTIVE DATE OF THIS SECTION AND FOR EACH YEAR THEREAFTER AS REQUESTED
 BY THE COMMISSION UNDER THIS SECTION. THE INFORMATION SHALL INCLUDE, BUT
 NOT  BE  LIMITED  TO, PRIMARY CARE SPENDING, TOTAL HEALTH CARE SPENDING,
 AND ALL FURTHER INFORMATION THE COMMISSION REQUESTS.  EACH ENTITY  SHALL
 ALSO  PROVIDE THE TOTAL COST OF CARE PROVIDED BY THE ENTITY ANNUALLY FOR
 EACH OF THE YEARS.  AN ENTITY THAT PROVIDES INFORMATION UNDER  PARAGRAPH
 S. 1197                             3
 
 (A)  OF  THIS  SUBDIVISION  SHALL  NOT  BE REQUIRED TO PROVIDE DUPLICATE
 INFORMATION UNDER THIS PARAGRAPH.
   (C)  FAILURE  OF  ANY  ENTITY TO PROVIDE INFORMATION TO THE COMMISSION
 REQUESTED BY THE COMMISSION UNDER THIS SECTION  SHALL  BE  CONSIDERED  A
 VIOLATION UNDER SECTION TWELVE OF THIS CHAPTER.
   (D)  THE  COMMISSIONER,  AND  THE  SUPERINTENDENT OF THE DEPARTMENT OF
 FINANCIAL SERVICES WITH RESPECT TO ENTITIES REGULATED BY THE SUPERINTEN-
 DENT, SHALL ESTABLISH REQUIREMENTS TO ENSURE COMPLIANCE WITH ALL  APPLI-
 CABLE  LAWS AND TO PROTECT THE CONFIDENTIALITY OF ANY PROPRIETARY INFOR-
 MATION THAT IS PROVIDED TO THE COMMISSION UNDER THIS SECTION.
   3. THE DEPARTMENT AND  THE  DEPARTMENT  OF  FINANCIAL  SERVICES  SHALL
 PROVIDE  ASSISTANCE  AND  STAFF  TO  THE COMMISSION, AS REQUESTED BY THE
 COMMISSION.  ASSISTANCE SHALL ALSO BE MADE AVAILABLE,  AS  REQUESTED  BY
 THE COMMISSION, FROM OTHER AGENCIES, DEPARTMENTS, AND PUBLIC AUTHORITIES
 OF  THE  STATE.    THE  COMMISSION MAY ACCEPT FUNDING OR GRANTS FROM THE
 STATE OR FEDERAL GOVERNMENT, OR ANY OTHER  GOVERNMENT  AGENCY  OR  OTHER
 SOURCE DETERMINED BY THE COMMISSION, TO AID IN THE COMMISSION'S WORK.
   4.  THE  FOLLOWING  TERMS,  WHEN  USED IN THIS SECTION, SHALL HAVE THE
 FOLLOWING MEANINGS:
   (A) "PRIMARY CARE" MEANS THE HEALTH CARE FIELDS  OF  FAMILY  PRACTICE,
 GENERAL PEDIATRICS, PRIMARY CARE INTERNAL MEDICINE, PRIMARY CARE OBSTET-
 RICS,  AND  PRIMARY CARE GYNECOLOGY, PROVIDED IN ALL OUTPATIENT SETTINGS
 INCLUDING, BUT NOT LIMITED TO, HEALTH CARE  PROFESSIONAL  PRACTICES  AND
 HOSPITALS  AS  DEFINED BY ARTICLE TWENTY-EIGHT OF THIS CHAPTER.  PRIMARY
 CARE SHALL NOT INCLUDE INPATIENT SERVICES. PRIMARY CARE INCLUDES, BUT IS
 NOT LIMITED TO, PRIMARY CARE SERVICES FOR ACUTE AND  CHRONIC  CONDITIONS
 AND  PREVENTIVE  CARE,  SERVICES  PROVIDED  IN REGULAR CHECK-UPS, OFFICE
 VISITS, TELEMEDICINE, AND OTHER  SERVICES,  PROVIDED  BY  OR  UNDER  THE
 DIRECTION  OF  A  PHYSICIAN, NURSE PRACTITIONER, PHYSICIAN ASSISTANT, OR
 MIDWIFE.  THE COMMISSION SHALL CONSIDER  EXPANDING  THIS  DEFINITION  TO
 INCLUDE  PRIMARY  CARE  SERVICES  PROVIDED  BY OTHER HEALTH CARE PROFES-
 SIONALS.
   (B) "PRIMARY CARE SPENDING" MEANS ANY EXPENDITURE  OF  FUNDS  MADE  BY
 THIRD  PARTY  PAYORS,  PUBLIC  ENTITIES, OR THE STATE FOR THE PURPOSE OF
 PAYING FOR PRIMARY CARE OR SUPPORTING PRIMARY  CARE  PROVIDERS.  PRIMARY
 CARE  SPENDING  IS  INCLUDED  REGARDLESS OF PAYMENT METHODOLOGY, SUCH AS
 FEE-FOR-SERVICE, CAPITATION, INCENTIVES, VALUE-BASED PAYMENTS  OR  OTHER
 METHODOLOGIES,  ADJUSTED  APPROPRIATELY  TO  EXCLUDE  ANY PORTION OF THE
 EXPENDITURE THAT IS REASONABLY APPORTIONED TO EXCLUDE EXPENSES FOR INPA-
 TIENT SERVICES OR OTHER NON-PRIMARY CARE SERVICES.
   5. (A) THE COMMISSION SHALL PUBLISH, POST ON THE DEPARTMENT'S WEBSITE,
 AND DELIVER AN ANNUAL REPORT TO THE GOVERNOR, THE TEMPORARY PRESIDENT OF
 THE SENATE, THE SPEAKER OF THE ASSEMBLY, THE CHAIRPERSON OF  THE  SENATE
 FINANCE  COMMITTEE,  THE  CHAIRPERSON  OF  THE  ASSEMBLY  WAYS AND MEANS
 COMMITTEE AND THE CHAIRS OF THE SENATE AND ASSEMBLY HEALTH AND INSURANCE
 COMMITTEES. THE FIRST REPORT SHALL BE PUBLISHED AND DELIVERED  NO  LATER
 THAN MARCH THIRTY-FIRST OF THE YEAR FOLLOWING THE EFFECTIVE DATE OF THIS
 SECTION.
   (B)  THE  CONTENT  OF THE ANNUAL REPORTS SHALL BE AT THE DISCRETION OF
 THE COMMISSION BUT THE FIRST REPORT SHALL INCLUDE:
   (I) AN  ANALYSIS  OF  CURRENT  PRIMARY  CARE  SPENDING,  INCLUDING  BY
 GEOGRAPHIC  REGION, IN RELATION TO ALL OTHER HEALTH CARE SPENDING IN THE
 AGGREGATE.
   (II) RECOMMENDATIONS TO THE GOVERNOR AND THE LEGISLATURE OF ANY CHANG-
 ES TO THE DEFINITION OF "PRIMARY CARE" FOR THE PURPOSES OF  THE  COMMIS-
 S. 1197                             4
 
 SION'S  FUTURE  WORK. SUCH RECOMMENDATIONS MAY BE MADE PRIOR TO DELIVERY
 OF THE COMMISSION'S REPORT.
   (III) RECOMMENDATIONS FOR LEGISLATIVE AND EXECUTIVE ACTION.
   (IV)  IDENTIFICATION  OF  BARRIERS, INCLUDING PAYMENT METHODOLOGIES BY
 HEALTH CARE PAYORS AND PROVIDERS, TO PROVIDING PRIMARY CARE AND INCREAS-
 ING PRIMARY CARE SPENDING.
   (V) RECOMMENDATIONS TO IMPROVE PROVIDING INCREASED AND  HIGHER-QUALITY
 PRIMARY  CARE  AND  PRIMARY  CARE  SPENDING,  WITH  SPECIAL ATTENTION TO
 INCREASING HEALTH CARE EQUITY, REDUCING  HEALTH  CARE  DISPARITIES,  AND
 AVOIDING INCREASING COSTS TO PATIENTS OR THE TOTAL COST OF HEALTH CARE.
   (VI) RECOMMENDATIONS TO INCREASE PRIMARY CARE SPENDING.
   § 3. This act shall take effect immediately.

co-Sponsors

View additional co-sponsors

2023-S1197A - Details

Current Committee:: Senate Finance
Law Section:: Public Health Law
Laws Affected:: Amd Art 29-AA Art Head, add §2959-b, Pub Health L
Versions Introduced in 2021-2022 Legislative Session:: S6534

2023-S1197A - Summary

Requires health care plans and payors to have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.

2023-S1197A - Sponsor Memo

                                 
BILL NUMBER: S1197A

SPONSOR: RIVERA
 
TITLE OF BILL:

An act to amend the insurance law and the social services law, in
relation to primary care investment

 
PURPOSE OR GENERAL ID OF BILL:

The purpose of this bill is to enhance the role of primary care in New
York's current healthcare delivery to improve the general health of
residents and avoid more costly health interventions down the road.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill would amend the Insurance Law to require plans and
payors to annually report to the Department of Financial Services (DFS)
the percentage of the plan or payor's overall annual healthcare spending
that constituted primary care spending. DFS and the Department of Health
(DOH) would collaborate to provide an annual report to the Legislature
on this primary care spending data and would be required to post the

information on their respective websites. The section would also require
that beginning on April 1, 2026, each plan or payor that reports less
than 12% of total expenditures, in the previous year, are on primary
care services would have to provide the Superintendent of DFS a plan to
increase its spending on primary care by 1% of its total overall spend-
ing.  This would continue each year on April 1st until the plan or payor
has reported that its spending on primary care has met or exceeded 12%.
This section would grant the Commissioner of Health (COH) and Super-
intendent of DFS authority to make regulations to effectuate the
section. Additionally, under this section no plan or payor would be
required to report or publicly disclose specific rates of reimbursement
for any specific primary care services. No plan o r payor would be
authorized to require any healthcare provider to report additional data
or information.

Section 2 of the bill would amend the Social Services Law to require
Medicaid managed care plans and fee-for services payors to annually
report to the percentage of the plan or payor's overall annual health-
care spending that constituted primary care spending to DOH.  The
section would also require that beginning on April 1, 2026, each plan or
payor that reports less than 12% of total expenditures, in the previous
year, are on primary care services would have to provide the COH a plan
to increase its spending on primary care by 1% of its total overall
spending. This would continue each year on April 1st until the plan or
payor has reported that its spending on primary care has met or exceeded
12%. This section would grant the Commissioner of DOH and Superintendent
of DFS authority to make regulations to effectuate the section. Addi-
tionally, under this section no plan or payor would be required to
report or publicly disclose specific rates of reimbursement for any
specific primary care services. No plan or payor would be authorized to
require any healthcare provider to report additional data or informa-
tion.

Section 3 establishes an immediate effective date.

 
JUSTIFICATION:

Primary care should be a person's first contact with the health care
system when seeking care. Primary care is understanding and maintaining
wellness as well as identifying, preventing, and treating illness before
it becomes a chronic condition. Research shows that an increase of just
one primary care provider per 10,000 people can generate 5.5% fewer
hospital visits, 11 fewer emergency department visits, and 7% fewer
surgeries. We know that health systems oriented towards primary care
simply function better. Yet, it is estimated that as little as 5% of
U.S. healthcare spending goes toward primary care. New York currently
spends more per capita on health care than the national average, but
consistently ranks below many other states in key health indicators.
This is indicative of a lack of access to and underinvestment in primary
care.

Currently, at least ten states have acted to rebalance their healthcare
spending through legislative, regulatory, or executive means. This bill
will define, measure, and report on current primary care spending in New
York. It will also establish tangible metrics for primary care spending
in the state and lays out a process for achieving those goals. By estab-
lishing these metrics this bill will help shift the balance of health-
care spending in the State to place a greater emphasis on proactive and
preventative primary care services.  This will serve to improve the
overall health of the residents of New York and potentially avoid more
costly medical interventions that can be avoided.

 
PRIOR LEGISLATIVE HISTORY:

2021-2022: S6534C Rivera / A7230B Gottfried - Vetoed

 
FISCAL IMPLICATIONS:

Undetermined.

 
EFFECTIVE DATE:
Immediately.

2023-S1197A - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  1197--A
     Cal. No. 519
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             January 10, 2023
                                ___________
 
 Introduced  by Sens. RIVERA, BROUK, COONEY, MAY, MYRIE, RAMOS, SEPULVEDA
   -- read twice and ordered printed, and when printed to be committed to
   the Committee on Health -- reported  favorably  from  said  committee,
   ordered  to  first  and  second report, ordered to a third reading, --
   committed to the Committee on  Rules  --  committee  discharged,  bill
   amended,  ordered reprinted as amended and recommitted to said commit-
   tee
 
 AN ACT to amend the insurance  law  and  the  social  services  law,  in
   relation to primary care investment
 
   THE  PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. The insurance law is amended by adding a new section 3217-k
 to read as follows:
   § 3217-K. PRIMARY CARE SPENDING. (A)  DEFINITIONS.  AS  USED  IN  THIS
 SECTION, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS:
   (1) "OVERALL HEALTHCARE SPENDING" MEANS THE TOTAL COST OF CARE FOR THE
 PATIENT  POPULATION  OF  A PAYOR OR PROVIDER ENTITY FOR A GIVEN CALENDAR
 YEAR, WHERE COST IS CALCULATED FOR SUCH YEAR  AS  THE  SUM  OF  (A)  ALL
 CLAIMS-BASED SPENDING PAID TO PROVIDERS BY PUBLIC AND PRIVATE PAYORS AND
 (B) ALL NON-CLAIM PAYMENTS FOR SUCH YEAR, INCLUDING, BUT NOT LIMITED TO,
 INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
   (2)  "PLAN  OR  PAYOR"  MEANS EVERY INSURANCE ENTITY PROVIDING MANAGED
 CARE PRODUCTS, INDIVIDUAL COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE OR
 GROUP OR BLANKET COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE, AS DEFINED
 IN THIS CHAPTER, CORPORATION ORGANIZED UNDER ARTICLE FORTY-THREE OF THIS
 CHAPTER PROVIDING COMPREHENSIVE HEALTH INSURANCE, ENTITY LICENSED  UNDER
 ARTICLE FORTY-FOUR OF THIS CHAPTER PROVIDING COMPREHENSIVE HEALTH INSUR-
 ANCE,  EVERY  OTHER PLAN OVER WHICH THE DEPARTMENT HAS JURISDICTION, AND
 EVERY THIRD-PARTY PAYOR PROVIDING HEALTH COVERAGE.
   (3) "PRIMARY CARE" MEANS INTEGRATED, ACCESSIBLE  HEALTHCARE,  PROVIDED
 BY  CLINICIANS ACCOUNTABLE FOR ADDRESSING MOST OF A PATIENT'S HEALTHCARE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.

                                                            LBD03591-02-3
 S. 1197--A                          2
 
 NEEDS, DEVELOPING A SUSTAINED PARTNERSHIP WITH PATIENTS, AND  PRACTICING
 IN THE CONTEXT OF FAMILY AND COMMUNITY.
   (4)  "PRIMARY CARE SERVICES" MEANS SERVICES PROVIDED IN AN OUTPATIENT,
 NON-EMERGENCY SETTING BY OR UNDER THE SUPERVISION OF A PHYSICIAN,  NURSE
 PRACTITIONER, PHYSICIAN ASSISTANT, OR MIDWIFE, WHO IS PRACTICING GENERAL
 PRIMARY  CARE IN THE FOLLOWING FIELDS, INCLUDING AS EVIDENCED BY BILLING
 AND REPORTING CODES: FAMILY PRACTICE; GENERAL PEDIATRICS;  PRIMARY  CARE
 INTERNAL  MEDICINE; PRIMARY CARE OBSTETRICS; OR PRIMARY CARE GYNECOLOGY.
 BEHAVIORAL OR MENTAL HEALTH AND  SUBSTANCE  USE  DISORDER  SERVICES  ARE
 INCLUDED  IN  PRIMARY  CARE SERVICES WHEN INTEGRATED INTO A PRIMARY CARE
 SETTING, INCLUDING WHEN PROVIDED BY  A  BEHAVIORAL  HEALTHCARE  PSYCHIA-
 TRIST,  SOCIAL  WORKER  OR PSYCHOLOGIST. PRIMARY CARE SERVICES SHALL NOT
 INCLUDE INPATIENT SERVICES, EMERGENCY  DEPARTMENT  SERVICES,  AMBULATORY
 SURGICAL CENTER SERVICES, OR SERVICES PROVIDED IN AN URGENT CARE SETTING
 THAT ARE BILLED WITH NON-PRIMARY CARE BILLING AND REPORTING CODES.
   (5)  "PRIMARY  CARE  SPENDING"  MEANS ANY EXPENDITURE OF FUNDS MADE BY
 THIRD PARTY PAYORS, PUBLIC ENTITIES, OR THE STATE, FOR  THE  PURPOSE  OF
 PAYING  FOR  PRIMARY  CARE  SERVICES  DIRECTLY  OR PAYING TO IMPROVE THE
 DELIVERY OF PRIMARY CARE. PRIMARY CARE  SPENDING  INCLUDES  ALL  PAYMENT
 METHODS,  SUCH  AS  FEE-FOR-SERVICE, CAPITATION, INCENTIVES, VALUE-BASED
 PAYMENTS OR OTHER METHODOLOGIES, AND ALL  NON-CLAIM  PAYMENTS  INCLUDING
 BUT  NOT  LIMITED  TO INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
 ANY SPENDING SHALL BE ADJUSTED APPROPRIATELY TO EXCLUDE ANY  PORTION  OF
 THE  EXPENDITURE  THAT IS REASONABLY ATTRIBUTED TO INPATIENT SERVICES OR
 OTHER NON-PRIMARY CARE SERVICES.
   (B) REPORTING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
 EACH PLAN OR PAYOR AS DEFINED IN THIS SECTION SHALL ANNUALLY  REPORT  TO
 THE  DEPARTMENT  THE  PERCENTAGE  OF  THE PLAN OR PAYOR'S OVERALL ANNUAL
 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
   (2) NOTHING HEREIN SHALL REQUIRE  ANY  PLAN  OR  PAYOR  TO  REPORT  OR
 PUBLICLY  DISCLOSE  ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY SPECIFIC
 PRIMARY CARE SERVICES.
   (3) NO PLAN OR PAYOR SHALL REQUIRE ANY HEALTHCARE PROVIDER TO  PROVIDE
 ADDITIONAL  DATA  OR  INFORMATION  IN  ORDER  TO  FULFILL THIS REPORTING
 REQUIREMENT.
   (C) REGULATION AND PUBLICATION. (1) THE COMMISSIONER OF HEALTH AND THE
 SUPERINTENDENT SHALL EACH PROMULGATE CONSISTENT REGULATIONS TO CARRY OUT
 THE PROVISIONS OF THIS SECTION, INCLUDING BUT  NOT  LIMITED  TO  SETTING
 DEADLINES  FOR  THE  REPORTING  REQUIRED  IN  THIS SECTION, AND ADOPTING
 FURTHER SPECIFIC DEFINITIONS OF THE  PRIMARY  CARE  SERVICES  FOR  WHICH
 COSTS  MUST  BE  REPORTED UNDER THIS SECTION, INCLUDING SPECIFIC BILLING
 AND REPORTING CODES.
   (2) THE DEPARTMENT OF HEALTH AND THE DEPARTMENT SHALL TOGETHER PROVIDE
 AN ANNUAL REPORT TO THE LEGISLATURE WITH A SUMMARY OF THE  PRIMARY  CARE
 SPENDING  DATA  REQUIRED IN THIS SECTION, AND SHALL ALSO MAKE THE REPORT
 PUBLICLY AVAILABLE ON BOTH  AGENCIES'  WEBSITES,  NO  LATER  THAN  THREE
 MONTHS  AFTER THE DATA HAS BEEN COLLECTED. THE FIRST ANNUAL REPORT SHALL
 PROVIDE THE SPENDING  INFORMATION  WITHOUT  IDENTIFYING  ANY  INDIVIDUAL
 PAYOR  OR PLAN'S PRIMARY CARE SPENDING. EACH YEAR THEREAFTER, THE REPORT
 SPENDING DATA SHALL BE PUBLISHED INCLUDING INFORMATION SPECIFIC TO  EACH
 PLAN OR PAYOR.
   (D)  PRIMARY CARE SPENDING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND
 TWENTY-SIX, EACH PLAN OR PAYOR THAT REPORTS LESS THAN TWELVE PERCENT  OF
 ITS  TOTAL  EXPENDITURES  ON  PHYSICAL AND MENTAL HEALTH IS PRIMARY CARE
 SPENDING, AS DEFINED BY THIS SECTION, SHALL ADDITIONALLY SUBMIT  TO  THE
 SUPERINTENDENT  A PLAN TO INCREASE PRIMARY CARE SPENDING AS A PERCENTAGE
 S. 1197--A                          3

 OF ITS TOTAL OVERALL HEALTHCARE SPENDING BY AT LEAST  ONE  PERCENT  EACH
 YEAR.  BEGINNING  ON APRIL FIRST, TWO THOUSAND TWENTY-SEVEN AND ON APRIL
 FIRST OF EVERY SUBSEQUENT YEAR AFTER SUCH PLAN HAS BEEN  SUBMITTED,  AND
 UNTIL SUCH TIME AS THE PLAN OR PAYOR'S REPORTED PRIMARY CARE SPENDING IS
 EQUAL  TO  OR  MORE  THAN TWELVE PERCENT OF THAT PLAN OR PAYOR'S OVERALL
 HEALTHCARE SPENDING, THE PLAN OR PAYOR'S ANNUAL REPORTING SHALL  INCLUDE
 INFORMATION REGARDING STEPS THAT HAVE BEEN TAKEN TO INCREASE ITS PROPOR-
 TION OF PRIMARY CARE SPENDING.
   (2)  THE  COMMISSIONER  OF  HEALTH  AND THE SUPERINTENDENT MAY JOINTLY
 ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING THE AREAS ON  WHICH
 PRIMARY CARE SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
   (A) REIMBURSEMENT;
   (B) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
   (C)  UPGRADING  TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
 AND TELEHEALTH CAPABILITIES;
   (D) INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED  TO  PER-MEMBER-PER-
 MONTH,  VALUE-BASED-PAYMENT  ARRANGEMENTS, SHARED SAVINGS, QUALITY-BASED
 PAYMENTS, RISK-BASED PAYMENTS; AND
   (E) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
   § 2. The social services law is amended by adding a new section  368-g
 to read as follows:
   §  368-G.  PRIMARY  CARE  SPENDING.  1.  DEFINITIONS.  AS USED IN THIS
 SECTION THE  TERMS  "OVERALL  HEALTHCARE  SPENDING",  "PLAN  OR  PAYOR",
 "PRIMARY  CARE",  "PRIMARY  CARE  SERVICES"  AND "PRIMARY CARE SPENDING"
 SHALL HAVE THE SAME MEANINGS AS SUCH TERMS ARE DEFINED IN SECTION  THIR-
 TY-TWO HUNDRED SEVENTEEN-K OF THE INSURANCE LAW.
   2.  REPORTING. (A) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
 EACH MEDICAID MANAGED CARE PROVIDER UNDER SECTION THREE  HUNDRED  SIXTY-
 FOUR-J  OF THIS TITLE AND ANY PAYOR THAT PROVIDES COVERAGE THROUGH MEDI-
 CAID FEE-FOR-SERVICE, AS SUCH TERM IS DEFINED IN PARAGRAPH (E) OF SUBDI-
 VISION THIRTY-EIGHT OF SECTION  TWO  OF  THIS  CHAPTER,  SHALL  ANNUALLY
 REPORT TO THE DEPARTMENT THE PERCENTAGE OF THE PROVIDER'S OVERALL ANNUAL
 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
   (B) NOTHING HEREIN SHALL REQUIRE ANY MEDICAID MANAGED CARE PROVIDER TO
 REPORT  OR PUBLICLY DISCLOSE ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY
 SPECIFIC PRIMARY CARE SERVICES.
   (C) NO MEDICAID MANAGED CARE PROVIDER  SHALL  REQUIRE  ANY  HEALTHCARE
 PROVIDER  TO  PROVIDE ADDITIONAL DATA OR INFORMATION IN ORDER TO FULFILL
 THIS REPORTING REQUIREMENT.
   3. PRIMARY CARE SPENDING. (A) BEGINNING ON APRIL FIRST,  TWO  THOUSAND
 TWENTY-SIX,  AND  IN  EACH  SUBSEQUENT  YEAR, EACH MEDICAID MANAGED CARE
 PROVIDER UNDER SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE AND  ANY
 PAYOR  THAT  PROVIDES COVERAGE THROUGH MEDICAID FEE-FOR-SERVICE, AS SUCH
 TERM IS DEFINED IN PARAGRAPH (E) OF SUBDIVISION THIRTY-EIGHT OF  SECTION
 TWO  OF THIS CHAPTER, THAT REPORTS LESS THAN TWELVE PERCENT OF ITS TOTAL
 EXPENDITURES ON PHYSICAL AND MENTAL HEALTH ARE ON PRIMARY CARE  SPENDING
 SHALL ADDITIONALLY SUBMIT TO THE COMMISSIONER A PLAN TO INCREASE PRIMARY
 CARE  SPENDING  AS A PERCENTAGE OF ITS TOTAL OVERALL HEALTHCARE SPENDING
 BY AT LEAST ONE PERCENT EACH YEAR. BEGINNING ON APRIL FIRST,  TWO  THOU-
 SAND  TWENTY-SEVEN, AND IN EACH SUBSEQUENT YEAR THEREAFTER, UNTIL TWELVE
 PERCENT OF THAT PROVIDER OR PAYOR'S EXPENDITURES  ARE  ON  PRIMARY  CARE
 SPENDING,  THE  PAYOR  OR PROVIDER'S ANNUAL REPORTING UNDER THIS SECTION
 SHALL INCLUDE INFORMATION ON STEPS THAT  HAVE  BEEN  TAKEN  TO  INCREASE
 THEIR PROPORTION OF PRIMARY CARE SPENDING.
 S. 1197--A                          4
 
   (B)  THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES MAY
 JOINTLY ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING  THE  AREAS
 ON WHICH SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
   (I) REIMBURSEMENT;
   (II) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
   (III) UPGRADING TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
 AND TELEHEALTH CAPABILITIES;
   (IV)  INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED TO PER-MEMBER-PER-
 MONTH, VALUE-BASED-PAYMENT ARRANGEMENTS, SHARED  SAVINGS,  QUALITY-BASED
 PAYMENTS, RISK-BASED PAYMENTS; AND
   (V) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
   (C)  THE PROVISIONS OF THIS SECTION ARE SUBJECT TO COMPLIANCE WITH ALL
 APPLICABLE FEDERAL AND STATE LAWS AND REGULATIONS, INCLUDING THE CENTERS
 FOR MEDICARE AND MEDICAID SERVICES APPROVED MEDICAID STATE PLAN.  TO THE
 EXTENT REQUIRED BY FEDERAL LAW, THE COMMISSIONER SHALL SEEK ANY  FEDERAL
 APPROVALS NECESSARY TO IMPLEMENT THIS SECTION, INCLUDING, BUT NOT LIMIT-
 ED  TO,  ANY STATE-DIRECTED PAYMENTS, PERMISSIONS, STATE PLAN AMENDMENTS
 OR FEDERAL WAIVERS BY THE FEDERAL  CENTERS  FOR  MEDICARE  AND  MEDICAID
 SERVICES.  THE  COMMISSIONER  MAY  ALSO APPLY FOR APPROPRIATE WAIVERS OR
 STATE DIRECTED PAYMENTS UNDER FEDERAL LAW AND REGULATION OR  TAKE  OTHER
 ACTIONS TO SECURE FEDERAL FINANCIAL PARTICIPATION TO ASSIST IN PROMOTING
 THE OBJECTIVES OF THIS SECTION.
   § 3. This act shall take effect immediately.

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2023-S1197B (ACTIVE) - Details

Current Committee:: Senate Finance
Law Section:: Public Health Law
Laws Affected:: Amd Art 29-AA Art Head, add §2959-b, Pub Health L
Versions Introduced in 2021-2022 Legislative Session:: S6534

2023-S1197B (ACTIVE) - Summary

Requires health care plans and payors to have a minimum of twelve and one-half percent of their total expenditures on physical and mental health annually be for primary care services.

2023-S1197B (ACTIVE) - Sponsor Memo

                                 
BILL NUMBER: S1197B

SPONSOR: RIVERA
 
TITLE OF BILL:

An act to amend the insurance law and the social services law, in
relation to primary care investment

 
PURPOSE OR GENERAL ID OF BILL:

The purpose of this bill is to enhance the role of primary care in New
York's current healthcare delivery to improve the general health of
residents and avoid more costly health interventions down the road.

 
SUMMARY OF SPECIFIC PROVISIONS:

Section 1 of the bill would amend the Insurance Law to require plans and
payors to annually report to the Department of Financial Services (DFS)
the percentage of the plan or payor's overall annual healthcare spending
that constituted primary care spending. DFS and the Department of Health
(DOH) would collaborate to provide an annual report to the Legislature
on this primary care spending data and would be required to post the

information on their respective websites. The section would also require
that beginning on April 1, 2026, each plan or payor that reports less
than 12.5% of total expenditures, in the previous year, are on primary
care services would have to provide the Superintendent of DFS a plan to
increase its spending on primary care by 1% of its total overall spend-
ing.  This would continue each year on April 1st until the plan or payor
has reported that its spending on primary care has met or exceeded
12.5%. This section would grant the Commissioner of Health (COH) and
Superintendent of DFS authority to make regulations to effectuate the
section. Additionally, under this section no plan or payor would be
required to report or publicly disclose specific rates of reimbursement
for any specific primary care services. No plan or payor would be
authorized to require any healthcare provider to report additional data
or information.

Section 2 of the bill would amend the Social Services Law to require
Medicaid managed care plans and fee-for services payors to annually
report to the percentage of the plan or payor's overall annual health-
care spending that constituted primary care spending to DOH.  The
section would also require that beginning on April 1, 2026, each plan or
payor that reports less than 12.5% of total expenditures, in the previ-
ous year, are on primary care services would have to provide the COH a
plan to increase its spending on primary care by 1% of its total overall
spending. This would continue each year on April 1st until the plan or
payor has reported that its spending on primary care has met or exceeded
12.5%. This section would grant the Commissioner of DOH and Superinten-
dent of DFS authority to make regulations to effectuate the section.
Additionally, under this section no plan or payor would be required to
report or publicly disclose specific rates of reimbursement for any
specific primary care services. No plan or payor would be authorized to
require any healthcare provider to report additional data or informa-
tion.

Section 3 establishes an immediate effective date.

 
JUSTIFICATION:

Primary care should be a person's first contact with the health care
system when seeking care. Primary care is understanding and maintaining
wellness as well as identifying, preventing, and treating illness before
it becomes a chronic condition. Research shows that an increase of just
one primary care provider per 10,000 people can generate 5.5% fewer
hospital visits, 11% fewer emergency department visits, and 7% fewer
surgeries. We know that health systems oriented towards primary care
simply function better. Yet, it is estimated that as little as 5% of
U.S. healthcare spending goes toward primary care. New York currently
spends more per capita on health care than the national average, but
consistently ranks below many other states in key health indicators.
This is indicative of a lack of access to and underinvestment in primary
care.

Currently, at least ten states have acted to rebalance their healthcare
spending through legislative, regulatory, or executive means. This bill
will define, measure, and report on current primary care spending in New
York. It will also establish tangible metrics for primary care spending
in the state and lays out a process for achieving those goals. By estab-
lishing these metrics this bill will help shift the balance of health-
care spending in the State to place a greater emphasis on proactive and
preventative primary care services.  This will serve to improve the
overall health of the residents of New York and potentially avoid more
costly medical interventions that can be avoided.

 
PRIOR LEGISLATIVE HISTORY:

2021-2022: S6534C Rivera / A7230B Gottfried - Vetoed

 
FISCAL IMPLICATIONS:

Undetermined.

 
EFFECTIVE DATE:
Immediately.

2023-S1197B (ACTIVE) - Bill Text download pdf

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                  1197--B
 
                        2023-2024 Regular Sessions
 
                             I N  S E N A T E
 
                             January 10, 2023
                                ___________
 
 Introduced  by Sens. RIVERA, BROUK, COONEY, MAY, MYRIE, RAMOS, SEPULVEDA
   -- read twice and ordered printed, and when printed to be committed to
   the Committee on Health -- reported  favorably  from  said  committee,
   ordered  to  first  and  second report, ordered to a third reading, --
   committed to the Committee on  Rules  --  committee  discharged,  bill
   amended,  ordered reprinted as amended and recommitted to said commit-
   tee --  committee  discharged,  bill  amended,  ordered  reprinted  as
   amended and recommitted to said committee
 
 AN  ACT  to  amend  the  insurance  law  and the social services law, in
   relation to primary care investment
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section 1. The insurance law is amended by adding a new section 3217-k
 to read as follows:
   §  3217-K.  PRIMARY  CARE  SPENDING.  (A) DEFINITIONS. AS USED IN THIS
 SECTION, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS:
   (1) "OVERALL HEALTHCARE SPENDING" MEANS THE TOTAL COST OF CARE FOR THE
 PATIENT POPULATION OF A PAYOR OR PROVIDER ENTITY FOR  A  GIVEN  CALENDAR
 YEAR,  WHERE  COST  IS  CALCULATED  FOR  SUCH YEAR AS THE SUM OF (A) ALL
 CLAIMS-BASED SPENDING PAID TO PROVIDERS BY PUBLIC AND PRIVATE PAYORS AND
 (B) ALL NON-CLAIM PAYMENTS FOR SUCH YEAR, INCLUDING, BUT NOT LIMITED TO,
 INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
   (2) "PLAN OR PAYOR" MEANS EVERY  INSURANCE  ENTITY  PROVIDING  MANAGED
 CARE PRODUCTS, INDIVIDUAL COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE OR
 GROUP OR BLANKET COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE, AS DEFINED
 IN THIS CHAPTER, CORPORATION ORGANIZED UNDER ARTICLE FORTY-THREE OF THIS
 CHAPTER  PROVIDING COMPREHENSIVE HEALTH INSURANCE, ENTITY LICENSED UNDER
 ARTICLE FORTY-FOUR OF THIS CHAPTER PROVIDING COMPREHENSIVE HEALTH INSUR-
 ANCE, EVERY OTHER PLAN OVER WHICH THE DEPARTMENT HAS  JURISDICTION,  AND
 EVERY THIRD-PARTY PAYOR PROVIDING HEALTH COVERAGE.
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD03591-03-3
 S. 1197--B                          2

 
   (3)  "PRIMARY  CARE" MEANS INTEGRATED, ACCESSIBLE HEALTHCARE, PROVIDED
 BY CLINICIANS ACCOUNTABLE FOR ADDRESSING MOST OF A PATIENT'S  HEALTHCARE
 NEEDS,  DEVELOPING A SUSTAINED PARTNERSHIP WITH PATIENTS, AND PRACTICING
 IN THE CONTEXT OF FAMILY AND COMMUNITY.
   (4)  "PRIMARY CARE SERVICES" MEANS SERVICES PROVIDED IN AN OUTPATIENT,
 NON-EMERGENCY SETTING BY OR UNDER THE SUPERVISION OF A PHYSICIAN,  NURSE
 PRACTITIONER, PHYSICIAN ASSISTANT, OR MIDWIFE, WHO IS PRACTICING GENERAL
 PRIMARY  CARE IN THE FOLLOWING FIELDS, INCLUDING AS EVIDENCED BY BILLING
 AND REPORTING CODES: FAMILY PRACTICE; GENERAL PEDIATRICS;  PRIMARY  CARE
 INTERNAL  MEDICINE; PRIMARY CARE OBSTETRICS; OR PRIMARY CARE GYNECOLOGY.
 BEHAVIORAL OR MENTAL HEALTH AND  SUBSTANCE  USE  DISORDER  SERVICES  ARE
 INCLUDED  IN  PRIMARY  CARE SERVICES WHEN INTEGRATED INTO A PRIMARY CARE
 SETTING, INCLUDING WHEN PROVIDED BY  A  BEHAVIORAL  HEALTHCARE  PSYCHIA-
 TRIST,  SOCIAL  WORKER  OR PSYCHOLOGIST. PRIMARY CARE SERVICES SHALL NOT
 INCLUDE INPATIENT SERVICES, EMERGENCY  DEPARTMENT  SERVICES,  AMBULATORY
 SURGICAL CENTER SERVICES, OR SERVICES PROVIDED IN AN URGENT CARE SETTING
 THAT ARE BILLED WITH NON-PRIMARY CARE BILLING AND REPORTING CODES.
   (5)  "PRIMARY  CARE  SPENDING"  MEANS ANY EXPENDITURE OF FUNDS MADE BY
 THIRD PARTY PAYORS, PUBLIC ENTITIES, OR THE STATE, FOR  THE  PURPOSE  OF
 PAYING  FOR  PRIMARY  CARE  SERVICES  DIRECTLY  OR PAYING TO IMPROVE THE
 DELIVERY OF PRIMARY CARE. PRIMARY CARE  SPENDING  INCLUDES  ALL  PAYMENT
 METHODS,  SUCH  AS  FEE-FOR-SERVICE, CAPITATION, INCENTIVES, VALUE-BASED
 PAYMENTS OR OTHER METHODOLOGIES, AND ALL  NON-CLAIM  PAYMENTS  INCLUDING
 BUT  NOT  LIMITED  TO INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
 ANY SPENDING SHALL BE ADJUSTED APPROPRIATELY TO EXCLUDE ANY  PORTION  OF
 THE  EXPENDITURE  THAT IS REASONABLY ATTRIBUTED TO INPATIENT SERVICES OR
 OTHER NON-PRIMARY CARE SERVICES.
   (B) REPORTING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
 EACH PLAN OR PAYOR AS DEFINED IN THIS SECTION SHALL ANNUALLY  REPORT  TO
 THE  DEPARTMENT  THE  PERCENTAGE  OF  THE PLAN OR PAYOR'S OVERALL ANNUAL
 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
   (2) NOTHING HEREIN SHALL REQUIRE  ANY  PLAN  OR  PAYOR  TO  REPORT  OR
 PUBLICLY  DISCLOSE  ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY SPECIFIC
 PRIMARY CARE SERVICES.
   (3) NO PLAN OR PAYOR SHALL REQUIRE ANY HEALTHCARE PROVIDER TO  PROVIDE
 ADDITIONAL  DATA  OR  INFORMATION  IN  ORDER  TO  FULFILL THIS REPORTING
 REQUIREMENT.
   (C) REGULATION AND PUBLICATION. (1) THE COMMISSIONER OF HEALTH AND THE
 SUPERINTENDENT SHALL EACH PROMULGATE CONSISTENT REGULATIONS TO CARRY OUT
 THE PROVISIONS OF THIS SECTION, INCLUDING BUT  NOT  LIMITED  TO  SETTING
 DEADLINES  FOR  THE  REPORTING  REQUIRED  IN  THIS SECTION, AND ADOPTING
 FURTHER SPECIFIC DEFINITIONS OF THE  PRIMARY  CARE  SERVICES  FOR  WHICH
 COSTS  MUST  BE  REPORTED UNDER THIS SECTION, INCLUDING SPECIFIC BILLING
 AND REPORTING CODES.
   (2) THE DEPARTMENT OF HEALTH AND THE DEPARTMENT SHALL TOGETHER PROVIDE
 AN ANNUAL REPORT TO THE LEGISLATURE WITH A SUMMARY OF THE  PRIMARY  CARE
 SPENDING  DATA  REQUIRED IN THIS SECTION, AND SHALL ALSO MAKE THE REPORT
 PUBLICLY AVAILABLE ON BOTH  AGENCIES'  WEBSITES,  NO  LATER  THAN  THREE
 MONTHS  AFTER THE DATA HAS BEEN COLLECTED. THE FIRST ANNUAL REPORT SHALL
 PROVIDE THE SPENDING  INFORMATION  WITHOUT  IDENTIFYING  ANY  INDIVIDUAL
 PAYOR  OR PLAN'S PRIMARY CARE SPENDING. EACH YEAR THEREAFTER, THE REPORT
 SPENDING DATA SHALL BE PUBLISHED INCLUDING INFORMATION SPECIFIC TO  EACH
 PLAN OR PAYOR.
   (D)  PRIMARY CARE SPENDING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND
 TWENTY-SIX, EACH PLAN OR PAYOR THAT REPORTS LESS THAN  TWELVE  AND  ONE-
 HALF  PERCENT OF ITS TOTAL EXPENDITURES ON PHYSICAL AND MENTAL HEALTH IS
 S. 1197--B                          3
 
 PRIMARY CARE SPENDING, AS DEFINED BY THIS  SECTION,  SHALL  ADDITIONALLY
 SUBMIT TO THE SUPERINTENDENT A PLAN TO INCREASE PRIMARY CARE SPENDING AS
 A  PERCENTAGE  OF  ITS TOTAL OVERALL HEALTHCARE SPENDING BY AT LEAST ONE
 PERCENT  EACH  YEAR. BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-SEVEN
 AND ON APRIL FIRST OF EVERY SUBSEQUENT YEAR AFTER  SUCH  PLAN  HAS  BEEN
 SUBMITTED,  AND  UNTIL SUCH TIME AS THE PLAN OR PAYOR'S REPORTED PRIMARY
 CARE SPENDING IS EQUAL TO OR MORE THAN TWELVE AND  ONE-HALF  PERCENT  OF
 THAT  PLAN  OR  PAYOR'S OVERALL HEALTHCARE SPENDING, THE PLAN OR PAYOR'S
 ANNUAL REPORTING SHALL INCLUDE INFORMATION  REGARDING  STEPS  THAT  HAVE
 BEEN TAKEN TO INCREASE ITS PROPORTION OF PRIMARY CARE SPENDING.
   (2)  THE  COMMISSIONER  OF  HEALTH  AND THE SUPERINTENDENT MAY JOINTLY
 ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING THE AREAS ON  WHICH
 PRIMARY CARE SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
   (A) REIMBURSEMENT;
   (B) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
   (C)  UPGRADING  TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
 AND TELEHEALTH CAPABILITIES;
   (D) INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED  TO  PER-MEMBER-PER-
 MONTH,  VALUE-BASED-PAYMENT  ARRANGEMENTS, SHARED SAVINGS, QUALITY-BASED
 PAYMENTS, RISK-BASED PAYMENTS; AND
   (E) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
   § 2. The social services law is amended by adding a new section  368-g
 to read as follows:
   §  368-G.  PRIMARY  CARE  SPENDING.  1.  DEFINITIONS.  AS USED IN THIS
 SECTION THE  TERMS  "OVERALL  HEALTHCARE  SPENDING",  "PLAN  OR  PAYOR",
 "PRIMARY  CARE",  "PRIMARY  CARE  SERVICES"  AND "PRIMARY CARE SPENDING"
 SHALL HAVE THE SAME MEANINGS AS SUCH TERMS ARE DEFINED IN SECTION  THIR-
 TY-TWO HUNDRED SEVENTEEN-K OF THE INSURANCE LAW.
   2.  REPORTING. (A) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
 EACH MEDICAID MANAGED CARE PROVIDER UNDER SECTION THREE  HUNDRED  SIXTY-
 FOUR-J  OF THIS TITLE AND ANY PAYOR THAT PROVIDES COVERAGE THROUGH MEDI-
 CAID FEE-FOR-SERVICE, AS SUCH TERM IS DEFINED IN PARAGRAPH (E) OF SUBDI-
 VISION THIRTY-EIGHT OF SECTION  TWO  OF  THIS  CHAPTER,  SHALL  ANNUALLY
 REPORT TO THE DEPARTMENT THE PERCENTAGE OF THE PROVIDER'S OVERALL ANNUAL
 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
   (B) NOTHING HEREIN SHALL REQUIRE ANY MEDICAID MANAGED CARE PROVIDER TO
 REPORT  OR PUBLICLY DISCLOSE ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY
 SPECIFIC PRIMARY CARE SERVICES.
   (C) NO MEDICAID MANAGED CARE PROVIDER  SHALL  REQUIRE  ANY  HEALTHCARE
 PROVIDER  TO  PROVIDE ADDITIONAL DATA OR INFORMATION IN ORDER TO FULFILL
 THIS REPORTING REQUIREMENT.
   3. PRIMARY CARE SPENDING. (A) BEGINNING ON APRIL FIRST,  TWO  THOUSAND
 TWENTY-SIX,  AND  IN  EACH  SUBSEQUENT  YEAR, EACH MEDICAID MANAGED CARE
 PROVIDER UNDER SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE AND  ANY
 PAYOR  THAT  PROVIDES COVERAGE THROUGH MEDICAID FEE-FOR-SERVICE, AS SUCH
 TERM IS DEFINED IN PARAGRAPH (E) OF SUBDIVISION THIRTY-EIGHT OF  SECTION
 TWO  OF THIS CHAPTER, THAT REPORTS LESS THAN TWELVE AND ONE-HALF PERCENT
 OF ITS TOTAL EXPENDITURES ON PHYSICAL AND MENTAL HEALTH ARE  ON  PRIMARY
 CARE  SPENDING  SHALL  ADDITIONALLY SUBMIT TO THE COMMISSIONER A PLAN TO
 INCREASE PRIMARY CARE SPENDING AS A  PERCENTAGE  OF  ITS  TOTAL  OVERALL
 HEALTHCARE  SPENDING  BY  AT  LEAST  ONE PERCENT EACH YEAR. BEGINNING ON
 APRIL FIRST, TWO THOUSAND TWENTY-SEVEN,  AND  IN  EACH  SUBSEQUENT  YEAR
 THEREAFTER,  UNTIL  TWELVE  AND  ONE-HALF  PERCENT  OF  THAT PROVIDER OR
 PAYOR'S EXPENDITURES ARE ON PRIMARY CARE SPENDING, THE PAYOR OR  PROVID-
 ER'S  ANNUAL  REPORTING  UNDER THIS SECTION SHALL INCLUDE INFORMATION ON
 S. 1197--B                          4

 STEPS THAT HAVE BEEN TAKEN TO INCREASE THEIR PROPORTION OF PRIMARY  CARE
 SPENDING.
   (B)  THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES MAY
 JOINTLY ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING  THE  AREAS
 ON WHICH SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
   (I) REIMBURSEMENT;
   (II) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
   (III) UPGRADING TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
 AND TELEHEALTH CAPABILITIES;
   (IV)  INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED TO PER-MEMBER-PER-
 MONTH, VALUE-BASED-PAYMENT ARRANGEMENTS, SHARED  SAVINGS,  QUALITY-BASED
 PAYMENTS, RISK-BASED PAYMENTS; AND
   (V) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
   (C)  THE PROVISIONS OF THIS SECTION ARE SUBJECT TO COMPLIANCE WITH ALL
 APPLICABLE FEDERAL AND STATE LAWS AND REGULATIONS, INCLUDING THE CENTERS
 FOR MEDICARE AND MEDICAID SERVICES APPROVED MEDICAID STATE PLAN.  TO THE
 EXTENT REQUIRED BY FEDERAL LAW, THE COMMISSIONER SHALL SEEK ANY  FEDERAL
 APPROVALS NECESSARY TO IMPLEMENT THIS SECTION, INCLUDING, BUT NOT LIMIT-
 ED  TO,  ANY STATE-DIRECTED PAYMENTS, PERMISSIONS, STATE PLAN AMENDMENTS
 OR FEDERAL WAIVERS BY THE FEDERAL  CENTERS  FOR  MEDICARE  AND  MEDICAID
 SERVICES.  THE  COMMISSIONER  MAY  ALSO APPLY FOR APPROPRIATE WAIVERS OR
 STATE DIRECTED PAYMENTS UNDER FEDERAL LAW AND REGULATION OR  TAKE  OTHER
 ACTIONS TO SECURE FEDERAL FINANCIAL PARTICIPATION TO ASSIST IN PROMOTING
 THE OBJECTIVES OF THIS SECTION.
   § 3. This act shall take effect immediately.

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Senate Bill S1197

Sponsored By

Current Bill Status - In Senate Committee Finance Committee

Jan 22, 2024 - Health Committee Vote

Health Committee Vote: Jan 22, 2024

Mar 14, 2023 - Health Committee Vote

Health Committee Vote: Mar 14, 2023

Bill Amendments

co-Sponsors

2023-S1197 - Details

2023-S1197 - Summary

2023-S1197 - Sponsor Memo

2023-S1197 - Bill Text download pdf

co-Sponsors

2023-S1197A - Details

2023-S1197A - Summary

2023-S1197A - Sponsor Memo

2023-S1197A - Bill Text download pdf

co-Sponsors

2023-S1197B (ACTIVE) - Details

2023-S1197B (ACTIVE) - Summary

2023-S1197B (ACTIVE) - Sponsor Memo

2023-S1197B (ACTIVE) - Bill Text download pdf

Comments

Senate Bill S1197

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Sponsored By

Current Bill Status - In Senate Committee Finance Committee

Bill Amendments

co-Sponsors

2023-S1197 - Details

2023-S1197 - Summary

2023-S1197 - Sponsor Memo

2023-S1197 - Bill Text download pdf

co-Sponsors

2023-S1197A - Details

2023-S1197A - Summary

2023-S1197A - Sponsor Memo

2023-S1197A - Bill Text download pdf

co-Sponsors

2023-S1197B (ACTIVE) - Details

2023-S1197B (ACTIVE) - Summary

2023-S1197B (ACTIVE) - Sponsor Memo

2023-S1197B (ACTIVE) - Bill Text download pdf

Comments