S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   1915
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 14, 2025
                                ___________
 
 Introduced   by   M.  of  A.  PAULIN,  WEPRIN,  HEVESI,  REYES,  SIMONE,
   BICHOTTE HERMELYN, LUNSFORD -- read once and referred to the Committee
   on Insurance
 
 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
 NEEDS INCLUDING (A) DEVELOPING A SUSTAINED  PARTNERSHIP  WITH  PATIENTS;
 (B)  PRACTICING  IN THE CONTEXT OF FAMILY AND COMMUNITY; AND (C) COORDI-
 NATING PATIENTS' CARE, WHICH FOR THE PURPOSES OF THIS SECTION SHALL ONLY
 INCLUDE CARE COORDINATION EFFORTS UNDERTAKEN BY THE CLINICIANS RENDERING
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD04789-01-5
              

 A. 1915                             2
 
 HEALTHCARE SERVICES TO A PATIENT AND SHALL  NOT  INCLUDE  SEPARATE  CARE
 COORDINATION ACTIVITIES UNDERTAKEN BY A PAYOR.
   (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.
 FOR PAYEES THAT  OWN  AND/OR  OPERATE  FACILITIES,  ENTITIES,  OR  OTHER
 PROVIDERS,  SUCH  AS  HEALTH  SYSTEMS  OR HOSPITAL SYSTEMS, THAT PROVIDE
 OTHER MEDICAL SERVICES IN ADDITION TO PRIMARY  CARE,  ONLY  THOSE  FUNDS
 THAT  ARE  SEPARATELY  DOCUMENTED  AS  FUNDS DESIGNATED FOR PRIMARY CARE
 SERVICES SHALL BE CONSIDERED PRIMARY CARE SPENDING.  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.
 A. 1915                             3
 
   (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
 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.
   (E)  LIMITS  ON PREMIUM INCREASES. PLANS OR PAYORS SHALL ADOPT STRATE-
 GIES THAT IMPROVE VALUE AND QUALITY OF CARE AND SHIFT  CURRENT  SPENDING
 WITHOUT INCREASING TOTAL MEDICAL EXPENDITURES. SPENDING SHIFTS RESULTING
 FROM COMPLIANCE WITH THIS SECTION SHALL NOT RESULT IN HIGHER PREMIUMS OR
 COST-SHARING REQUIREMENTS FOR INSURED INDIVIDUALS.
   §  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
 A. 1915                             4
 
 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
 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.
   4. LIMITS ON COST INCREASES. PLANS OR PAYORS  SHALL  ADOPT  STRATEGIES
 THAT  IMPROVE VALUE AND QUALITY OF CARE AND SHIFT CURRENT SPENDING WITH-
 OUT INCREASING TOTAL MEDICAL EXPENDITURES.
   § 3. This act shall take effect immediately.