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2010 New York Code
PBH - Public Health
Article 28 - (2800 - 2822) HOSPITALS
2807-K - General hospital indigent care pool.
§ 2807-k. General hospital indigent care pool. 1. Definitions. For
purposes of this section, the following words or phrases shall have the
following meanings, unless the context otherwise requires:
(a) "Major public general hospital" means all state operated general
hospitals, all general hospitals operated by the New York city health
and hospitals corporation as established by chapter one thousand sixteen
of the laws of nineteen hundred sixty-nine as amended and all other
public general hospitals having annual inpatient operating costs in
excess of twenty-five million dollars.
(b) "Nominal payment amount" shall mean the sum of the dollars
attributable to the application of an incrementally increasing
proportion of reimbursement for percentage increases in targeted need
according to a scale.
(c) "Targeted need" shall mean the relationship of uncompensated care
need to reported costs expressed as a percentage. Reported costs shall
mean costs allocated as prescribed by the commissioner to general
hospital inpatient and ambulatory services, excluding referred
ambulatory services. Targeted need shall be determined based on base
year data and statistics for the calendar year two years prior to the
distribution period. Base year data and statistics for the calendar year
two years prior to the distribution period shall be considered final,
for purposes of this section, one hundred twenty days after hospitals
receive the department's initial statewide rates for the same period as
the distribution period and shall include any appropriate revisions
reported by hospitals during such one hundred twenty days.
(d) "Uncompensated care need" means losses from bad debts reduced to
cost and the costs of charity care of a general hospital for inpatient
and ambulatory services, excluding referred ambulatory services. The
cost of services provided as an employment benefit or as a courtesy
shall not be included.
(e) "Uninsured care" means losses from bad debts reduced to cost and
the costs of charity care of a general hospital for inpatient and
ambulatory services, excluding referred ambulatory services, which are
not eligible for payment in whole or in part by a governmental agency,
insurer or other third-party payor on behalf of a patient, including
payments made directly to the general hospital and indemnity or similar
payments made to the person who is a payor of hospital services. The
cost of services denied reimbursement, other than emergency room
services, for lack of medical necessity or lack of compliance with prior
authorization requirements, or provided as an employment benefit, or as
a courtesy shall not be included.
(f) "Ambulatory services" of a general hospital shall mean all
services delivered on an ambulatory basis, including, for periods on and
after January first, two thousand four, services provided at qualified
hospital-controlled diagnostic and treatment centers except as otherwise
provided in subdivision thirteen of this section.
(g) "Qualified hospital-controlled diagnostic and treatment center"
shall mean a voluntary, non-profit diagnostic and treatment center
providing a comprehensive range of primary health care services that is
controlling, controlled by, or under common control with a general
hospital, and as of June thirtieth, two thousand three:
(i) qualified for an allocation of funds pursuant to section
twenty-eight hundred seven-p of this article or pursuant to section
seven of chapter four hundred thirty-three of the laws of nineteen
hundred ninety-seven, as amended; or
(ii) the outpatient department of such general hospital had been
designated a federally-qualified health center under section 330 of the
Public Health Service Act (42 U.S.C. § 254b) and had directly received a
grant under such section.
2. To the extent of funds appropriated therefor, funds shall be made
available for distribution by or on behalf of the state in accordance
with the following methodology, as payments under the state medical
assistance program provided pursuant to title eleven of article five of
the social services law, from a general hospital indigent care pool
established by the commissioner.
3. Each major public general hospital shall be allocated for
distribution from the pools established pursuant to this section for
each year through December thirty-first, two thousand eleven, an amount
equal to the amount allocated to such major public general hospital from
the regional pool established pursuant to subdivision seventeen of
section twenty-eight hundred seven-c of this article for the period
January first, nineteen hundred ninety-six through December
thirty-first, nineteen hundred ninety-six, provided, however, that
payments on and after January first, two thousand nine shall be subject
to the provisions of subdivision five-a of this section.
4. (a) From funds in the pool for each year, thirty-six million
dollars shall be reserved on an annual basis through December
thirty-first, two thousand eleven, for distribution as high need
adjustments in accordance with subdivision six of this section,
provided, however, that payments on and after January first, two
thousand nine shall be subject to the provisions of subdivision five-a
of this section.
(a-1) From funds in the pool for each year, twenty-seven million
dollars shall be reserved on an annual basis for the periods January
first, two thousand through December thirty-first, two thousand ten, for
distribution in accordance with subdivision sixteen of this section,
provided, however, that payments on and after January first, two
thousand nine through December thirty-first, two thousand nine shall be
subject to the provisions of subdivisions five-a and five-b of this
section, and shall be subject to the provisions of subdivision five-b of
this section for periods on and after January first, two thousand ten.
(b) The balance of funds in a pool not allocated in accordance with
subdivision three of this section or reserved for distributions pursuant
to subdivisions six and sixteen of this section shall be distributed to
eligible general hospitals, excluding major public general hospitals, on
the basis of each general hospital's targeted need share, adjusted for
transition factors in accordance with subdivision seven of this section.
(c) To be eligible for distributions from the pool, a general
hospital's targeted need must exceed one-half of one percent.
(d) For the periods January first, nineteen hundred ninety-seven
through December thirty-first, nineteen hundred ninety-seven, January
first, nineteen hundred ninety-eight through December thirty-first,
nineteen hundred ninety-eight, and January first, nineteen hundred
ninety-nine through December thirty-first, nineteen hundred ninety-nine
and on and after January first, two thousand, each eligible general
hospital's targeted need share shall mean the relationship of each
general hospital's nominal payment amount of uncompensated care need
determined in accordance with the scale specified in subdivision five of
this section to the nominal payment amounts of uncompensated care need
for all eligible general hospitals applied to funds available in the
pool.
5. The scale utilized for development of each eligible general
hospital's nominal payment amount shall be as follows:
Percentage of Reimbursement
Attributable to that Portion
Targeted Need Percentage of Targeted Need
0 -.5% 60%
.5+ -2% 65%
2+ -3% 70%
3+ -4% 75%
4+ -5% 80%
5+ -6% 85%
6+ -7% 90%
7+ -8% 95%
8+ 100%
5-a. Notwithstanding any inconsistent provision of this section,
section twenty-eight hundred seven-w of this article or any other
contrary provision of law, subject to the availability of federal
financial participation and within amounts appropriated, for periods on
and after January first, two thousand nine, ten percent of the aggregate
distributions to each general hospital made otherwise pursuant to this
section and section twenty-eight hundred seven-w of this article shall
be reserved and set aside and distributed in accordance with the
following:
(a) Thirteen million nine hundred thirty thousand dollars of such
reserved funds shall be distributed to major public hospitals and shall
be allocated proportionally, based on each facility's relative
uncompensated care need as determined in accordance with the provisions
of paragraph (c) of this subdivision; and
(b) Seventy million seven hundred seventy thousand dollars of such
reserved funds shall be distributed to general hospitals other than
major public general hospitals and shall be allocated proportionally,
based on each facility's relative uncompensated care need as determined
in accordance with the provisions of paragraph (c) of this subdivision;
and
(c) For the purposes of distributions in accordance with paragraphs
(a) and (b) of this subdivision, each facility's relative uncompensated
care need amount shall be determined in accordance with the following:
(i) inpatient units of services for all uninsured patients from the
calendar year two years prior to the distribution year, but excluding
referred ambulatory units of services, shall be multiplied by the
applicable Medicaid inpatient rates in effect for such prior year, but
not including prospective rate adjustments and rate add-ons, provided,
however, that for distributions on and after January first, two thousand
ten, the uncompensated amount for inpatient services shall utilize the
inpatient rates in effect as of July first of the prior year;
(ii) outpatient units of service for all uninsured patients from the
calendar year two years prior to the distribution year, including
emergency department services and ambulatory surgery services, but
excluding referred ambulatory services units of service, shall be
multiplied by Medicaid outpatient rates that reflect the exclusive
utilization of the ambulatory patient groups (APG) rate-setting
methodology as set forth in regulations promulgated pursuant to
subdivision two-a of section twenty-eight hundred seven of this article,
as in effect for the distribution year, provided further, however, that
for those services for which APG rates are not available the applicable
Medicaid outpatient rate shall be the rate in effect for the calendar
year two years prior to the distribution year;
(iii) the uncompensated care need for each facility for periods on and
after January first, two thousand ten shall be reduced by the sum of all
payment amounts collected from such patients; and
(iv) the total uncompensated care need for each facility subject to
this subdivision shall then be adjusted by application of the nominal
need scale set forth in subdivision five of this section.
(d)(i) For annual periods commencing on and after January first, two
thousand nine, no general hospital may receive disproportionate share
payment distributions made in accordance with this section, section
twenty-eight hundred seven-w of this article or made in accordance with
other provisions of law, that exceed, in aggregate, the costs incurred
by such general hospital during such period in furnishing inpatient and
outpatient hospital services to Medicaid eligible patients or to
patients who have no health insurance or other source of third party
coverage, net of all monies received from non-disproportionate share
related Medicaid payments and from payments made by such uninsured
patients. For purposes of this paragraph, non-Medicaid payments made to
a general hospital by the state or by a unit of local government within
the state for services provided to indigent patients shall not be
considered to be a source of third party payment.
(ii) Reductions pursuant to this paragraph shall be made in the
following sequence:
(A) payments in accordance with subdivision fourteen-f of section
twenty-eight hundred seven-c of this article;
(B) payments made to eligible hospitals pursuant to this section and
section twenty-eight hundred seven-w of this article.
(iii) Notwithstanding any contrary provision of this section or
section twenty-eight hundred seven-w of this article, in the event a
payment made pursuant to this section or section twenty-seven hundred
seven-w of this article exceeds a hospital's applicable facility
specific disproportionate share limit, then fifty percent of the amount
in excess of such limit shall be paid to such facility as a grant from
state funds available for distribution in accordance with this section
and section twenty-eight hundred seven-w of this article, provided,
however, that if payments made to an eligible rural hospital pursuant to
this subdivision or section twenty-eight hundred seven-w of this
article, result in payments in excess of such disproportionate share
limits, then up to one hundred forty thousand dollars of such payments
shall be made at one hundred percent of the amount in excess of such
limits for each eligible rural hospital.
(e) By no later than December first, two thousand ten, the
commissioner shall issue a report evaluating the impact of the
distributions made pursuant to this subdivision with regard to units of
service to uninsured patients provided by each facility, and with regard
to the extent of services provided by each facility to patients eligible
for financial aid in accordance with each facility's financial aid
policies and procedures as mandated by subdivision nine-a of this
section. Such report shall also include the use of data on services to
the uninsured to model the impact of the distribution methodology set
forth in this subdivision against all funding authorized pursuant to
this section and section twenty-eight hundred seven-w of this article.
(f) The commissioner shall conduct outreach and educational activities
to inform hospitals on matters relating to data collection and reporting
requirements related to services provided to the uninsured and patients
eligible for financial aid, including definitions to be utilized for
identifying uninsured units of service and proper identification of
out-of-pocket collections from uninsured patients.
5-b. Notwithstanding any inconsistent provision of this section,
section twenty-eight hundred seven-w of this article or any other
contrary provision of law and subject to the availability of federal
financial participation, for periods on and after May first, two
thousand nine, funds as hereinafter described shall be reserved and set
aside and distributed in accordance with the following:
(a) For the period May first, two thousand nine through December
thirty-first, two thousand nine payments shall be made as follows:
(i) Ninety percent of funds available for the two thousand nine
calendar year pursuant to paragraph (a-1) of subdivision four of this
section shall be reserved and set aside and distributed as Medicaid
disproportionate share (DSH) payments to the same hospitals and in the
same proportional amounts as received pursuant to such paragraph (a-1)
in two thousand eight;
(ii) Three hundred seven million dollars shall be distributed as
Medicaid DSH payments to facilities designated by the department as
teaching hospitals as of December thirty-first, two thousand eight in
accordance with a schedule of payments to be set forth in regulations
promulgated by the commissioner to compensate such facilities for
Medicaid and self-pay losses reported in each facility's two thousand
seven annual cost report;
(iii) Sixteen million dollars shall be proportionally distributed as
Medicaid DSH payments to non-teaching hospitals based upon their
proportion of uninsured losses as defined in paragraph (c) of
subdivision five-a of this section to such losses of all non-teaching
hospitals on a statewide basis;
(iv) Twenty-five million dollars shall be distributed as Medicaid DSH
payments to non-major public hospitals having Medicaid discharges of
forty percent or greater as established by the commissioner from data
reported in each hospital's two thousand seven annual cost report, in
accordance with a schedule to be set forth in regulations promulgated by
the commissioner, to compensate such facilities for projected Medicaid
net losses, as determined by the commissioner, stemming from
modifications to Medicaid payments made pursuant to a chapter of the
laws of two thousand nine.
(b) For annual periods beginning January first, two thousand ten
payments shall be made as follows:
(i) Two hundred sixty-nine million five hundred thousand dollars shall
be distributed as Medicaid DSH payments to non-major public teaching
hospitals, and such distributions shall be made on a regional basis to
cover, within amounts available for each region, each eligible
facility's proportional regional share of unmet need for two thousand
seven, provided, however, that such regions and regional allocations and
the definition of unmet need shall be set forth in regulations
promulgated by the commissioner;
(ii) Twenty-five million dollars shall be distributed as Medicaid DSH
payments to hospitals eligible for payments made pursuant to
subparagraph (iv) of paragraph (a) of this subdivision based upon each
facility's proportion of uninsured losses, as defined in paragraph (c)
of subdivision five-a of this section, to such losses for all hospitals
eligible for such payments;
(iii) Sixteen million dollars shall be distributed in accordance with
the provisions of subparagraph (iii) of paragraph (a) of this
subdivision;
(iv) Twenty-five million dollars shall be distributed in accordance
with the provisions of subparagraph (iv) of paragraph (a) of this
subdivision;
(v) Twenty-four million five hundred thousand dollars shall be
distributed as non-Medicaid grants to non-major public academic medical
centers pursuant to a schedule to be set forth in regulations
promulgated by the commissioner, for funding for the following purposes:
(A) quality of care standards linked to the All Patient Refined (APR)
DRGs;
(B) best practices and evidence-based guidelines with particular focus
on obstetric, psychiatric and other high risk specialties;
(C) inpatient psychiatric case payment system and financial incentives
to divert admissions and improve linkages to outpatient programs;
(D) medical home standards and integrated delivery systems with a
particular focus on chronic care patients served in academic medical
centers and community-based settings; and
(E) reforms to residency training curriculum focusing on cultural
competency, quality of training programs, and physician supply in needed
specialties and geographic areas.
5-c. (a) Notwithstanding any contrary provision of law and subject to
the availability of federal financial participation, for the period July
first, two thousand ten through December thirty-first, two thousand ten,
distributions pursuant to this section and section twenty-eight hundred
seven-w of this article, shall reflect an aggregate reduction of
sixty-nine million four hundred thousand dollars, based on the
proportion of each hospital's indigent care allocations to the total
allocations of all hospitals' indigent care allocations prior to
application of this reduction, provided, however, that such reductions
shall not be applied to distributions to major public hospitals,
including major public hospitals operated by public benefit
corporations, and also shall not be applied to distributions made
pursuant to subparagraph (ii), (iii) or (iv) of paragraph (b) of
subdivision five-b of this section.
(b) Notwithstanding any contrary provision of law and subject to the
availability of federal financial participation, for the period January
first, two thousand eleven through December thirty-first, two thousand
eleven and each calendar year thereafter, distributions pursuant to this
section and section twenty-eight hundred seven-w of this article shall
reflect an aggregate reduction of seventy-three million two hundred
thousand dollars, based on the proportion of each hospital's indigent
care allocation to the total allocations of all hospitals' indigent care
allocations prior to application of this reduction, provided, however,
that such reductions shall not be applied to distributions to major
public hospitals, including major public hospitals operated by public
benefit corporations, and shall also not be applied to distributions
made pursuant to subparagraph (ii), (iii) or (iv) of paragraph (b) of
subdivision five-b of this section.
6. Funds reserved for high need adjustments shall be distributed to
general hospitals, excluding major public general hospitals, with
nominal need in excess of four percent as follows: each general
hospital's share of the reserved amount shall be based on such
hospital's aggregate share of nominal need above four percent compared
to the total aggregate nominal need above four percent of all eligible
hospitals.
7. (a) Hospital specific transition adjustment. Notwithstanding any
inconsistent provision of this section, distributions to general
hospitals determined in accordance with subdivision four of this section
shall be adjusted as follows:
(i) For general hospitals which qualified for distributions pursuant
to paragraph (c) of subdivision nineteen of section twenty-eight hundred
seven-c of this article as of December thirty-first, nineteen hundred
ninety-five:
(A) for the period January first, nineteen hundred ninety-seven
through December thirty-first, nineteen hundred ninety-seven, each such
general hospital shall receive as an allocation one hundred percent of
the projected distribution, as of June first, nineteen hundred
ninety-seven, to such general hospital pursuant to subdivisions
fourteen-c and seventeen and paragraph (c) of subdivision nineteen of
section twenty-eight hundred seven-c of this article for nineteen
hundred ninety-six; and
(B) for the period January first, nineteen hundred ninety-eight
through December thirty-first, nineteen hundred ninety-eight, each such
general hospital shall receive as an allocation seventy-five percent of
the amount determined in accordance with clause (A) of this subparagraph
and twenty-five percent of the amount determined in accordance with
subdivision four of this section; and
(C) for the period January first, nineteen hundred ninety-nine through
December thirty-first, nineteen hundred ninety-nine, each such general
hospital shall receive as an allocation fifty percent of the amount
determined in accordance with clause (A) of this subparagraph and fifty
percent of the amount determined in accordance with subdivision four of
this section; and
(D) for the period January first, two thousand through December
thirty-first, two thousand, each such general hospital shall receive as
an allocation twenty-five percent of the amount determined in accordance
with clause (A) of this subparagraph and seventy-five percent of the
amount determined in accordance with subdivision four of this section
provided, however, that for any general hospital whose distribution is
greater when determined solely in accordance with subdivisions four and
six of this section than when determined according to this clause, such
general hospital's distribution shall not be adjusted pursuant to this
clause; and
(E) for periods on and after January first, two thousand one, each
such general hospital shall receive as an allocation one hundred percent
of the amount determined in accordance with subdivision four of this
section.
(ii) For all other general hospitals, excluding major public general
hospitals, general hospitals qualifying for an adjustment pursuant to
subparagraph (i) of this paragraph, general hospitals which qualified
for an adjustment pursuant to subdivision fourteen-d of section
twenty-eight hundred seven-c of this article and rural general hospitals
that met the qualifications as a rural general hospital pursuant to
paragraph (f) of subdivision four of section twenty-eight hundred
seven-c of this article in nineteen hundred ninety-six:
(A) for the period January first, nineteen hundred ninety-seven
through December thirty-first, nineteen hundred ninety-seven, each such
general hospital shall receive as an allocation fifty percent of the
projected distribution, as of June first, nineteen hundred ninety-seven,
to such general hospital pursuant to subdivision seventeen of section
twenty-eight hundred seven-c of this article for nineteen hundred
ninety-six and fifty percent of the amount determined in accordance with
subdivision four of this section; and
(B) for the period January first, nineteen hundred ninety-eight
through December thirty-first, nineteen hundred ninety-eight, each such
general hospital shall receive as an allocation twenty-five percent of
the projected distribution, as of June first, nineteen hundred
ninety-seven, to such general hospital pursuant to subdivision seventeen
of section twenty-eight hundred seven-c of this article for nineteen
hundred ninety-six and seventy-five percent of the amount determined in
accordance with subdivision four of this section.
(b) Hospital category adjustment. Notwithstanding any inconsistent
provision of this section, distributions to each general hospital,
excluding major public general hospitals, for nineteen hundred
ninety-seven determined in accordance with subdivision four of this
section and paragraph (a) of this subdivision within the categories
specified in subparagraph (i) of this paragraph shall be adjusted in
accordance with subparagraph (ii) of this paragraph.
(i)(A) General hospitals that qualified for distributions in
accordance with subdivision fourteen-d of section twenty-eight hundred
seven-c of this article for nineteen hundred ninety-six.
(B) Rural general hospitals that met the qualifications as a rural
general hospital pursuant to paragraph (f) of subdivision four of
section twenty-eight hundred seven-c of this article for nineteen
hundred ninety-six.
(C) All other general hospitals, excluding general hospitals that
qualified for distributions pursuant to paragraph (c) of subdivision
nineteen of section twenty-eight hundred seven-c of this article.
(ii) For each category specified in subparagraph (i) of this
paragraph, fifty percent of the amount by which the allocation pursuant
to subdivision four of this section and paragraph (a) of this
subdivision to a general hospital within such category exceeds the
projected distribution, as of June first, nineteen hundred ninety-seven,
pursuant to subdivision seventeen and, if applicable, subdivision
fourteen-d of section twenty-eight hundred seven-c of this article for
nineteen hundred ninety-six to such general hospital shall be reserved
by the commissioner for allocation to general hospitals within such
category that would experience a loss based on such comparison based on
each such general hospital's proportionate share of the aggregate losses
for all general hospitals within such category; provided however, that
the amount reserved within a category shall not exceed the aggregate
amount of losses within such category.
8. Notwithstanding any inconsistent provision of this section, up to
five percent of the amount allocated for each of the periods for
distributions pursuant to this section may be transferred by the
commissioner, to the extent of funds appropriated therefor, and
allocated for distributions pursuant to the child health insurance plan
established pursuant to title one-A of article twenty-five of this
chapter.
9. In order for a general hospital to participate in the distribution
of funds from the pool, the general hospital must implement minimum
collection policies and procedures approved by the commissioner and must
be in compliance with bad debt and charity care reporting requirements
established pursuant to this article.
9-a. (a) As a condition for participation in pool distributions
authorized pursuant to this section and section twenty-eight hundred
seven-w of this article for periods on and after January first, two
thousand nine, general hospitals shall, effective for periods on and
after January first, two thousand seven, establish financial aid
policies and procedures, in accordance with the provisions of this
subdivision, for reducing charges otherwise applicable to low-income
individuals without health insurance, or who have exhausted their health
insurance benefits, and who can demonstrate an inability to pay full
charges, and also, at the hospital's discretion, for reducing or
discounting the collection of co-pays and deductible payments from those
individuals who can demonstrate an inability to pay such amounts.
(b) Such reductions from charges for uninsured patients with incomes
below at least three hundred percent of the federal poverty level shall
result in a charge to such individuals that does not exceed the greater
of the amount that would have been paid for the same services by the
"highest volume payor" for such general hospital as defined in
subparagraph (v) of this paragraph, or for services provided pursuant to
title XVIII of the federal social security act (medicare), or for
services provided pursuant to title XIX of the federal social security
act (medicaid), and provided further that such amounts shall be adjusted
according to income level as follows:
(i) For patients with incomes at or below at least one hundred percent
of the federal poverty level, the hospital shall collect no more than a
nominal payment amount, consistent with guidelines established by the
commissioner;
(ii) For patients with incomes between at least one hundred one
percent and one hundred fifty percent of the federal poverty level, the
hospital shall collect no more than the amount identified after
application of a proportional sliding fee schedule under which patients
with lower incomes shall pay the lowest amount. Such schedule shall
provide that the amount the hospital may collect for such patients
increases from the nominal amount described in subparagraph (i) of this
paragraph in equal increments as the income of the patient increases, up
to a maximum of twenty percent of the greater of the amount that would
have been paid for the same services by the "highest volume payor" for
such general hospital, as defined in subparagraph (v) of this paragraph,
or for services provided pursuant to title XVIII of the federal social
security act (medicare) or for services provided pursuant to title XIX
of the federal social security act (medicaid);
(iii) For patients with incomes between at least one hundred fifty-one
percent and two hundred fifty percent of the federal poverty level, the
hospital shall collect no more than the amount identified after
application of a proportional sliding fee schedule under which patients
with lower income shall pay the lowest amounts. Such schedule shall
provide that the amount the hospital may collect for such patients
increases from the twenty percent figure described in subparagraph (ii)
of this paragraph in equal increments as the income of the patient
increases, up to a maximum of the greater of the amount that would have
been paid for the same services by the "highest volume payor" for such
general hospital, as defined in subparagraph (v) of this paragraph, or
for services provided pursuant to title XVIII of the federal social
security act (medicare) or for services provided pursuant to title XIX
of the federal social security act (medicaid); and
(iv) For patients with incomes between at least two hundred fifty-one
percent and three hundred percent of the federal poverty level, the
hospital shall collect no more than the greater of the amount that would
have been paid for the same services by the "highest volume payor" for
such general hospital as defined in subparagraph (v) of this paragraph,
or for services provided pursuant to title XVIII of the federal social
security act (medicare), or for services provided pursuant to title XIX
of the federal social security act (medicaid).
(v) For the purposes of this paragraph, "highest volume payor" shall
mean the insurer, corporation or organization licensed, organized or
certified pursuant to article thirty-two, forty-two or forty-three of
the insurance law or article forty-four of this chapter, or other
third-party payor, which has a contract or agreement to pay claims for
services provided by the general hospital and incurred the highest
volume of claims in the previous calendar year.
(vi) A hospital may implement policies and procedures to permit, but
not require, consideration on a case-by-case basis of exceptions to the
requirements described in subparagraphs (i) and (ii) of this paragraph
based upon the existence of significant assets owned by the patient that
should be taken into account in determining the appropriate payment
amount for that patient's care, provided, however, that such proposed
policies and procedures shall be subject to the prior review and
approval of the commissioner and, if approved, shall be included in the
hospital's financial assistance policy established pursuant to this
section, and provided further that, if such approval is granted, the
maximum amount that may be collected shall not exceed the greater of the
amount that would have been paid for the same services by the "highest
volume payor" for such general hospital as defined in subparagraph (v)
of this paragraph, or for services provided pursuant to title XVIII of
the federal social security act (medicare), or for services provided
pursuant to title XIX of the federal social security act (medicaid). In
the event that a general hospital reviews a patient's assets in
determining payment adjustments such policies and procedures shall not
consider as assets a patient's primary residence, assets held in a
tax-deferred or comparable retirement savings account, college savings
accounts, or cars used regularly by a patient or immediate family
members.
(vii) Nothing in this paragraph shall be construed to limit a
hospital's ability to establish patient eligibility for payment
discounts at income levels higher than those specified herein and/or to
provide greater payment discounts for eligible patients than those
required by this paragraph.
(c) Such policies and procedures shall be clear, understandable, in
writing and publicly available in summary form and each general hospital
participating in the pool shall ensure that every patient is made aware
of the existence of such policies and procedures and is provided, in a
timely manner, with a summary of such policies and procedures upon
request. Any summary provided to patients shall, at a minimum, include
specific information as to income levels used to determine eligibility
for assistance, a description of the primary service area of the
hospital and the means of applying for assistance. For general hospitals
with twenty-four hour emergency departments, such policies and
procedures shall require the notification of patients during the intake
and registration process, through the conspicuous posting of
language-appropriate information in the general hospital, and
information on bills and statements sent to patients, that financial aid
may be available to qualified patients and how to obtain further
information. For specialty hospitals without twenty-four hour emergency
departments, such notification shall take place through written
materials provided to patients during the intake and registration
process prior to the provision of any health care services or
procedures, and through information on bills and statements sent to
patients, that financial aid may be available to qualified patients and
how to obtain further information. Application materials shall include a
notice to patients that upon submission of a completed application,
including any information or documentation needed to determine the
patient's eligibility pursuant to the hospital's financial assistance
policy, the patient may disregard any bills until the hospital has
rendered a decision on the application in accordance with this
paragraph.
(d) Such policies and procedures shall include clear, objective
criteria for determining a patient's ability to pay and for providing
such adjustments to payment requirements as are necessary. In addition
to adjustment mechanisms such as sliding fee schedules and discounts to
fixed standards, such policies and procedures shall also provide for the
use of installment plans for the payment of outstanding balances by
patients pursuant to the provisions of the hospital's financial
assistance policy. The monthly payment under such a plan shall not
exceed ten percent of the gross monthly income of the patient, provided,
however, that if patient assets are considered under such a policy, then
patient assets which are not excluded assets pursuant to subparagraph
(vi) of paragraph (b) of this subdivision may be considered in addition
to the limit on monthly payments. The rate of interest charged to the
patient on the unpaid balance, if any, shall not exceed the rate for a
ninety-day security issued by the United States Department of Treasury,
plus .5 percent and no plan shall include an accelerator or similar
clause under which a higher rate of interest is triggered upon a missed
payment. If such policies and procedures include a requirement of a
deposit prior to non-emergent, medically-necessary care, such deposit
must be included as part of any financial aid consideration. Such
policies and procedures shall be applied consistently to all eligible
patients.
(e) Such policies and procedures shall permit patients to apply for
assistance within at least ninety days of the date of discharge or date
of service and provide at least twenty days for patients to submit a
completed application. Such policies and procedures may require that
patients seeking payment adjustments provide appropriate financial
information and documentation in support of their application, provided,
however, that such application process shall not be unduly burdensome or
complex. General hospitals shall, upon request, assist patients in
understanding the hospital's policies and procedures and in applying for
payment adjustments. Application forms shall be printed in the "primary
languages" of patients served by the general hospital. For the purposes
of this paragraph, "primary languages" shall include any language that
is either (i) used to communicate, during at least five percent of
patient visits in a year, by patients who cannot speak, read, write or
understand the English language at the level of proficiency necessary
for effective communication with health care providers, or (ii) spoken
by non-English speaking individuals comprising more than one percent of
the primary hospital service area population, as calculated using
demographic information available from the United States Bureau of the
Census, supplemented by data from school systems. Decisions regarding
such applications shall be made within thirty days of receipt of a
completed application. Such policies and procedures shall require that
the hospital issue any denial/approval of such application in writing
with information on how to appeal the denial and shall require the
hospital to establish an appeals process under which it will evaluate
the denial of an application. Nothing in this subdivision shall be
interpreted as prohibiting a hospital from making the availability of
financial assistance contingent upon the patient first applying for
coverage under title XIX of the social security act (medicaid) or
another insurance program if, in the judgment of the hospital, the
patient may be eligible for medicaid or another insurance program, and
upon the patient's cooperation in following the hospital's financial
assistance application requirements, including the provision of
information needed to make a determination on the patient's application
in accordance with the hospital's financial assistance policy.
(f) Such policies and procedures shall provide that patients with
incomes below three hundred percent of the federal poverty level are
deemed presumptively eligible for payment adjustments and shall conform
to the requirements set forth in paragraph (b) of this subdivision,
provided, however, that nothing in this subdivision shall be interpreted
as precluding hospitals from extending such payment adjustments to other
patients, either generally or on a case-by-case basis. Such policies and
procedures shall provide financial aid for emergency hospital services,
including emergency transfers pursuant to the federal emergency medical
treatment and active labor act (42 USC 1395dd), to patients who reside
in New York state and for medically necessary hospital services for
patients who reside in the hospital's primary service area as determined
according to criteria established by the commissioner. In developing
such criteria, the commissioner shall consult with representatives of
the hospital industry, health care consumer advocates and local public
health officials. Such criteria shall be made available to the public no
less than thirty days prior to the date of implementation and shall, at
a minimum:
(i) prohibit a hospital from developing or altering its primary
service area in a manner designed to avoid medically underserved
communities or communities with high percentages of uninsured residents;
(ii) ensure that every geographic area of the state is included in at
least one general hospital's primary service area so that eligible
patients may access care and financial assistance; and
(iii) require the hospital to notify the commissioner upon making any
change to its primary service area, and to include a description of its
primary service area in the hospital's annual implementation report
filed pursuant to subdivision three of section twenty-eight hundred
three-l of this article.
(g) Nothing in this subdivision shall be interpreted as precluding
hospitals from extending payment adjustments for medically necessary
non-emergency hospital services to patients outside of the hospital's
primary service area. For patients determined to be eligible for
financial aid under the terms of a hospital's financial aid policy, such
policies and procedures shall prohibit any limitations on financial aid
for services based on the medical condition of the applicant, other than
typical limitations or exclusions based on medical necessity or the
clinical or therapeutic benefit of a procedure or treatment.
(h) Such policies and procedures shall not permit the forced sale or
foreclosure of a patient's primary residence in order to collect an
outstanding medical bill and shall require the hospital to refrain from
sending an account to collection if the patient has submitted a
completed application for financial aid, including any required
supporting documentation, while the hospital determines the patient's
eligibility for such aid. Such policies and procedures shall provide for
written notification, which shall include notification on a patient
bill, to a patient not less than thirty days prior to the referral of
debts for collection and shall require that the collection agency obtain
the hospital's written consent prior to commencing a legal action. Such
policies and procedures shall require all general hospital staff who
interact with patients or have responsibility for billing and
collections to be trained in such policies and procedures, and require
the implementation of a mechanism for the general hospital to measure
its compliance with such policies and procedures. Such policies and
procedures shall require that any collection agency under contract with
a general hospital for the collection of debts follow the hospital's
financial assistance policy, including providing information to patients
on how to apply for financial assistance where appropriate. Such
policies and procedures shall prohibit collections from a patient who is
determined to be eligible for medical assistance pursuant to title XIX
of the federal social security act at the time services were rendered
and for which services medicaid payment is available.
(i) Reports required to be submitted to the department by each general
hospital as a condition for participation in the pools, and which
contain, in accordance with applicable regulations, a certification from
an independent certified public accountant or independent licensed
public accountant or an attestation from a senior official of the
hospital that the hospital is in compliance with conditions of
participation in the pools, shall also contain, for reporting periods on
and after January first, two thousand seven:
(i) a report on hospital costs incurred and uncollected amounts in
providing services to eligible patients without insurance, including the
amount of care provided for a nominal payment amount, during the period
covered by the report;
(ii) hospital costs incurred and uncollected amounts for deductibles
and coinsurance for eligible patients with insurance or other
third-party payor coverage;
(iii) the number of patients, organized according to United States
postal service zip code, who applied for financial assistance pursuant
to the hospital's financial assistance policy, and the number, organized
according to United States postal service zip code, whose applications
were approved and whose applications were denied;
(iv) the reimbursement received for indigent care from the pool
established pursuant to this section;
(v) the amount of funds that have been expended on charity care from
charitable bequests made or trusts established for the purpose of
providing financial assistance to patients who are eligible in
accordance with the terms of such bequests or trusts;
(vi) for hospitals located in social services districts in which the
district allows hospitals to assist patients with such applications, the
number of applications for eligibility under title XIX of the social
security act (medicaid) that the hospital assisted patients in
completing and the number denied and approved;
(vii) the hospital's financial losses resulting from services provided
under medicaid; and
(viii) the number of liens placed on the primary residences of
patients through the collection process used by a hospital.
(j) Within ninety days of the effective date of this subdivision each
hospital shall submit to the commissioner a written report on its
policies and procedures for financial assistance to patients which are
used by the hospital on the effective date of this subdivision. Such
report shall include copies of its policies and procedures, including
material which is distributed to patients, and a description of the
hospital's financial aid policies and procedures. Such description shall
include the income levels of patients on which eligibility is based, the
financial aid eligible patients receive and the means of calculating
such aid, and the service area, if any, used by the hospital to
determine eligibility.
(k) In the event it is determined by the commissioner that the state
will be unable to secure all necessary federal approvals to include, as
part of the state's approved state plan under title nineteen of the
federal social security act, a requirement, as set forth in paragraph
one of this subdivision, that compliance with this subdivision is a
condition of participation in pool distributions authorized pursuant to
this section and section twenty-eight hundred seven-w of this article,
then such condition of participation shall be deemed null and void and,
notwithstanding section twelve of this chapter, failure to comply with
the provisions of this subdivision by a hospital on and after the date
of such determination shall make such hospital liable for a civil
penalty not to exceed ten thousand dollars for each such violation. The
imposition of such civil penalties shall be subject to the provisions of
section twelve-a of this chapter.
10. In order for a general hospital to be eligible for distribution of
funds from the pool, such general hospital if it provides obstetrical
care and services must be in compliance with the provisions of paragraph
(e) of subdivision sixteen of section twenty-eight hundred seven-c of
this article.
11. Minimum hospital procedures to determine the availability of
insurance or other third-party coverage for hospital services shall be
specified by the commissioner.
12. Each general hospital shall submit reports to the department at
such time and in such form as the commissioner shall require of:
(a) hospital costs incurred and uncollected amounts in providing
services to the uninsured during the period covered by the report; and
(b) hospital costs incurred and uncollected amounts for deductibles
and coinsurance for patients with insurance or other third-party payor
coverage.
(c) Such reports shall comply with the reporting requirements
established for receipt of bad debt and charity care pool payments as
provided in accordance with section twenty-eight hundred seven-c of this
article and regulations promulgated thereunder for periods prior to
January first, nineteen hundred ninety-seven.
13. Distributions to general hospitals pursuant to this section and
the adjustments provided in accordance with subdivision fourteen-f of
section twenty-eight hundred seven-c of this article shall be considered
disproportionate share payments for inpatient hospital services to
general hospitals serving a disproportionate number of low income
patients with special needs for purposes of providing assurances to the
secretary of health and human services as necessary to meet federal
requirements for securing federal financial participation pursuant to
title XIX of the federal social security act.
14. Notwithstanding any inconsistent provision of law to the contrary,
the availability or payment of funds to a general hospital pursuant to
this section shall not be admissible as a defense, offset or reduction
in any action or proceeding relating to any bill or claim for amounts
due for hospital services provided.
15. Revenue from distributions pursuant to this section and
adjustments pursuant to subdivision fourteen-f of section twenty-eight
hundred seven-c of this article shall not be included in gross revenue
received for purposes of the assessments pursuant to subdivision
eighteen of section twenty-eight hundred seven-c of this article,
subject to the provisions of paragraph (e) of subdivision eighteen of
section twenty-eight hundred seven-c of this article, and shall not be
included in gross revenue received for purposes of the assessments
pursuant to section twenty-eight hundred seven-d of this article,
subject to the provisions of subdivision twelve of section twenty-eight
hundred seven-d of this article.
16. Supplemental indigent care distributions. From available resources
established pursuant to paragraph (a-1) of subdivision four of this
section, each hospital shall receive a proportionate share, provided
that no hospital shall receive less than the reduction amount calculated
pursuant to paragraph (d) of subdivision three of section twenty-eight
hundred seven-m of this article, subject to hospital specific
disproportionate share payment limits calculated in accordance with
subdivision twenty-one of section twenty-eight hundred seven-c of this
article.
17. Indigent care reductions. For each hospital receiving payments
pursuant to paragraph (i) of subdivision thirty-five of section
twenty-eight hundred seven-c of this article, the commissioner shall
reduce the sum of any amounts paid pursuant to this section and pursuant
to section twenty-eight hundred seven-w of this article, as computed
based on projected facility specific disproportionate share hospital
ceilings, by an amount equal to the lower of such sum or each such
hospital's payments pursuant to paragraph (i) of subdivision thirty-five
of section twenty-eight hundred seven-c of this article, provided,
however, that any additional aggregate reductions enacted in a chapter
of the laws of two thousand ten to the aggregate amounts payable
pursuant to this section and pursuant to section twenty-eight hundred
seven-w of this article shall be applied subsequent to the adjustments
otherwise provided for in this subdivision.
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