STATE OF NEW YORK ________________________________________________________________________ 1366--A Cal. No. 620 2023-2024 Regular Sessions IN SENATE January 11, 2023 ___________ Introduced by Sens. RIVERA, CLEARE, GALLIVAN, GONZALEZ, GOUNARDES, HARCKHAM, HOYLMAN-SIGAL, JACKSON, KRUEGER, LIU, MAY, MYRIE, PERSAUD, SALAZAR, SEPULVEDA, WEBB -- read twice and ordered printed, and when printed to be committed to the Committee on Health -- reported favora- bly from said committee, ordered to first and second report, ordered to a third reading, amended and ordered reprinted, retaining its place in the order of third reading AN ACT to amend the public health law, in relation to the general hospi- tal indigent care pool; and to repeal certain provisions of such law relating thereto The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subdivision 9 of section 2807-k of the public health law, 2 as amended by section 17 of part B of chapter 60 of the laws of 2014, is 3 amended to read as follows: 4 9. In order for a general hospital to participate in the distribution 5 of funds from the pool, the general hospital must [implement minimum 6 collection policies and procedures approved] utilize only a uniform 7 financial assistance policy and form developed and provided by the 8 [commissioner] department. All general hospitals that do not participate 9 in the indigent care pool shall also utilize only the uniform financial 10 assistance policy and form and otherwise comply with subdivision nine-a 11 of this section governing the provision of financial assistance and 12 hospital collection procedures. 13 § 1-a. Subdivision 9 of section 2807-k of the public health law, as 14 amended by section 1 of subpart C of part Y of chapter 57 of the laws of 15 2023, is amended to read as follows: 16 9. In order for a general hospital to participate in the distribution 17 of funds from the pool, the general hospital must [implement minimum 18 collection policies and procedures approved by the commissioner, utiliz- 19 ing] utilize only a uniform financial assistance policy and form devel- EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD02400-03-3
S. 1366--A 2 1 oped and provided by the department. All general hospitals that do not 2 participate in the indigent care pool shall also utilize only the 3 uniform financial assistance policy and form and otherwise comply with 4 subdivision nine-a of this section governing the provision of financial 5 assistance and hospital collection procedures. 6 § 2. Subdivision 9-a of section 2807-k of the public health law, as 7 added by section 39-a of part A of chapter 57 of the laws of 2006, para- 8 graph (k) as added by section 43 of part B of chapter 58 of the laws of 9 2008, is amended to read as follows: 10 9-a. (a) (i) As a condition for participation in pool distributions 11 authorized pursuant to this section and section twenty-eight hundred 12 seven-w of this article for periods on and after January first, two 13 thousand nine, general hospitals shall, effective for periods on and 14 after January first, two thousand seven, establish financial [aid] 15 assistance policies and procedures, in accordance with the provisions of 16 this subdivision, for reducing hospital charges otherwise applicable to 17 low-income individuals [without health insurance, or who have exhausted 18 their health insurance benefits, and] who can demonstrate an inability 19 to pay full charges, and also, at the hospital's discretion, for reduc- 20 ing or discounting the collection of co-pays and deductible payments 21 from those individuals who can demonstrate an inability to pay such 22 amounts. Immigration status shall not be an eligibility criterion for 23 the purpose of determining financial assistance under this section. 24 (ii) A general hospital may use the New York state of health market- 25 place eligibility determination page to establish the patient's house- 26 hold income and residency in lieu of the financial application form, 27 provided it has secured the consent of the patient. A general hospital 28 shall not require a patient to apply for coverage through the New York 29 state of health marketplace in order to receive care or financial 30 assistance. 31 (iii) Upon submission of a completed application form, the patient is 32 not liable for any bills and no interest may accrue until the general 33 hospital has rendered a decision on the application in accordance with 34 this subdivision. 35 (b) [Such] The reductions from charges for [uninsured] patients 36 described in paragraph (a) of this subdivision with incomes below [at 37 least three] six hundred percent of the federal poverty level shall 38 result in a charge to such individuals that does not exceed [the greater 39 of] the amount that would have been paid for the same services [by the 40 "highest volume payor" for such general hospital as defined in subpara- 41 graph (v) of this paragraph, or for services provided pursuant to title 42 XVIII of the federal social security act (medicare), or for services] 43 provided pursuant to title [XIX] XVIII of the federal social security 44 act (medicaid), and provided further that such [amounts] amount shall be 45 adjusted according to income level as follows: 46 (i) For patients with incomes at or below [at least one] two hundred 47 percent of the federal poverty level, the hospital shall [collect no 48 more than a nominal payment amount, consistent with guidelines estab- 49 lished by the commissioner] waive all charges. No nominal payment shall 50 be collected; 51 (ii) For patients with incomes [between at least one] above two 52 hundred [one] percent and [one] up to four hundred [fifty] percent of 53 the federal poverty level, the hospital shall collect no more than the 54 amount identified after application of a proportional sliding fee sched- 55 ule under which patients with lower incomes shall pay the lowest amount. 56 [Such] The schedule shall provide that the amount the hospital may
S. 1366--A 3 1 collect for [such patients] the patient increases from the nominal 2 amount described in subparagraph (i) of this paragraph in equal incre- 3 ments as the income of the patient increases, up to a maximum of twenty 4 percent of the [greater of the] amount that would have been paid for the 5 same services [by the "highest volume payor" for such general hospital, 6 as defined in subparagraph (v) of this paragraph, or for services 7 provided pursuant to title XVIII of the federal social security act 8 (medicare) or for services] provided pursuant to title [XIX] XVIII of 9 the federal social security act (medicaid); 10 (iii) [For patients with incomes between at least one hundred fifty- 11 one percent and two hundred fifty percent of the federal poverty level, 12 the hospital shall collect no more than the amount identified after 13 application of a proportional sliding fee schedule under which patients 14 with lower income shall pay the lowest amounts. Such schedule shall 15 provide that the amount the hospital may collect for such patients 16 increases from the twenty percent figure described in subparagraph (ii) 17 of this paragraph in equal increments as the income of the patient 18 increases, up to a maximum of the greater of the amount that would have 19 been paid for the same services by the "highest volume payor" for such 20 general hospital, as defined in subparagraph (v) of this paragraph, or 21 for services provided pursuant to title XVIII of the federal social 22 security act (medicare) or for services provided pursuant to title XIX 23 of the federal social security act (medicaid); and 24 (iv)] For patients with incomes [between at least two hundred fifty- 25 one percent and three hundred] above four hundred percent and up to six 26 hundred percent of the federal poverty level, the hospital shall collect 27 no more than the [greater of the] amount that would have been paid for 28 the same services [by the "highest volume payor" for such general hospi- 29 tal as defined in subparagraph (v) of this paragraph, or for services 30 provided pursuant to title XVIII of the federal social security act 31 (medicare), or for services] provided pursuant to title [XIX] XVIII of 32 the federal social security act (medicaid). 33 [(v) For the purposes of this paragraph, "highest volume payor" shall 34 mean the insurer, corporation or organization licensed, organized or 35 certified pursuant to article thirty-two, forty-two or forty-three of 36 the insurance law or article forty-four of this chapter, or other third- 37 party payor, which has a contract or agreement to pay claims for 38 services provided by the general hospital and incurred the highest 39 volume of claims in the previous calendar year. 40 (vi) A hospital may implement policies and procedures to permit, but 41 not require, consideration on a case-by-case basis of exceptions to the 42 requirements described in subparagraphs (i) and (ii) of this paragraph 43 based upon the existence of significant assets owned by the patient that 44 should be taken into account in determining the appropriate payment 45 amount for that patient's care, provided, however, that such proposed 46 policies and procedures shall be subject to the prior review and 47 approval of the commissioner and, if approved, shall be included in the 48 hospital's financial assistance policy established pursuant to this 49 section, and provided further that, if such approval is granted, the 50 maximum amount that may be collected shall not exceed the greater of the 51 amount that would have been paid for the same services by the "highest 52 volume payor" for such general hospital as defined in subparagraph (v) 53 of this paragraph, or for services provided pursuant to title XVIII of 54 the federal social security act (medicare), or for services provided 55 pursuant to title XIX of the federal social security act (medicaid). In 56 the event that a general hospital reviews a patient's assets in deter-
S. 1366--A 4 1 mining payment adjustments such policies and procedures shall not 2 consider as assets a patient's primary residence, assets held in a tax- 3 deferred or comparable retirement savings account, college savings 4 accounts, or cars used regularly by a patient or immediate family 5 members. 6 (vii)] (c) Nothing in this [paragraph] subdivision shall be construed 7 to limit a hospital's ability to establish patient eligibility for 8 payment discounts at income levels higher than those specified herein 9 and/or to provide greater payment discounts for eligible patients than 10 those required by this [paragraph] subdivision. 11 [(c)] (d) Such policies and procedures shall be clear, understandable, 12 in writing and publicly available in summary form [and each]. Each 13 general hospital participating in the pool shall ensure that every 14 patient is made aware of the existence of [such] the policies and proce- 15 dures and is provided, in a timely manner, with a summary and a copy of 16 [such policies and procedures upon request] the policy and form at 17 intake, admission and discharge. Any summary provided to patients 18 shall, at a minimum, include, in plain language, specific information as 19 to income levels used to determine eligibility for assistance, [a 20 description of the primary service area of the hospital] financial 21 assistance available and the means of applying for assistance. [For 22 general hospitals with twenty-four hour emergency departments, such 23 policies and procedures] A plain language summary of the collections 24 process must also be made available. A general hospital shall [require 25 the notification of patients] notify patients by providing written mate- 26 rials to patients or their authorized representatives during the intake 27 and registration process, by making materials available in conspicuous 28 locations in the hospital including emergency departments, waiting areas 29 and other places patients congregate, through the conspicuous posting of 30 language-appropriate information in the general hospital, and by includ- 31 ing information on bills and statements sent to patients, that financial 32 [aid] assistance may be available to qualified patients and how to 33 obtain further information. [For specialty hospitals without twenty-four 34 hour emergency departments, such notification shall take place through 35 written materials provided to patients during the intake and registra- 36 tion process prior to the provision of any health care services or 37 procedures, and through information on bills and statements sent to 38 patients, that financial aid may be available to qualified patients and 39 how to obtain further information. Application materials shall include a 40 notice to patients that upon submission of a completed application, 41 including any information or documentation needed to determine the 42 patient's eligibility pursuant to the hospital's financial assistance 43 policy, the patient may disregard any bills until the hospital has 44 rendered a decision on the application in accordance with this para- 45 graph] General hospitals shall post the financial assistance application 46 policy, procedures and form, and a summary of the policy and procedures 47 and collection process, in a conspicuous location and downloadable form 48 on the general hospital's website. 49 [(d) Such] (e) The hospital's application materials shall include a 50 notice to patients that upon submission of a completed application form, 51 the patient shall not be liable for any bills until the general hospital 52 has rendered a decision on the application in accordance with this 53 subdivision. The application materials shall include specific informa- 54 tion as the income levels used to determine eligibility for financial 55 assistance, a description of the primary service area of the hospital 56 and the means to apply for assistance. Nothing in this subdivision shall
S. 1366--A 5 1 be construed as precluding the use of presumptive eligibility determi- 2 nations by hospitals on behalf of patients. The policies and procedures 3 shall include clear, objective criteria for determining a patient's 4 ability to pay and for providing such adjustments to payment require- 5 ments as are necessary. In addition to adjustment mechanisms such as 6 sliding fee schedules and discounts to fixed standards, such policies 7 and procedures shall also provide for the use of installment plans for 8 the payment of outstanding balances by patients pursuant to the 9 provisions of the hospital's financial assistance policy. The monthly 10 payment under such a plan shall not exceed [ten] five percent of the 11 gross monthly income of the patient[, provided, however, that if patient 12 assets are considered under such a policy, then patient assets which are 13 not excluded assets pursuant to subparagraph (vi) of paragraph (b) of 14 this subdivision may be considered in addition to the limit on monthly 15 payments]. Installment plan payments may not be required to begin before 16 one hundred eighty days after the date of the service or discharge, 17 whichever is later. The policy shall allow the patient and the hospital 18 to mutually agree to modify the terms of an installment plan. The rate 19 of interest charged to the patient on the unpaid balance, if any, shall 20 not exceed [the rate for a ninety-day security issued by the United 21 States Department of Treasury, plus .5 percent] two percentum per annum 22 and no plan shall include an accelerator or similar clause under which a 23 higher rate of interest is triggered upon a missed payment. [If such] 24 The policies and procedures shall not include a requirement of a deposit 25 prior to [non-emergent,] medically-necessary care[, such deposit must be 26 included as part of any financial aid consideration]. The hospital 27 shall refund any payments made by the patient before the determination 28 of eligibility for financial assistance that exceeds the patient's 29 liability after discounts are applied. Such policies and procedures 30 shall be applied consistently to all eligible patients. 31 [(e) Such policies and procedures shall permit patients to] (f) In any 32 legal action by or on behalf of a hospital to collect a medical debt, 33 the complaint shall be accompanied by an affidavit by the hospital's 34 chief financial officer stating that the hospital has taken reasonable 35 steps to determine whether the patient qualifies for financial assist- 36 ance and upon information and belief the patient does not meet the 37 income or residency criteria for financial assistance. Patients may 38 apply for financial assistance [within at least ninety days of the date 39 of discharge or date of service and provide at least twenty days for 40 patients to submit a completed application] at any time during the 41 collection process, including after the commencement of a medical debt 42 court action or upon the plaintiff obtaining a default judgment. A 43 determination that a patient is eligible for financial assistance shall 44 be valid for a minimum of twelve months and will apply to all outstand- 45 ing medical bills. A hospital may use credit scoring software for the 46 purposes of establishing income eligibility and approving financial 47 assistance, but only if the hospital makes clear to the patient that 48 providing a social security number is not mandatory and the scoring does 49 not negatively impact the patient's credit score. However, credit scor- 50 ing software shall not be solely relied upon by the hospital in denying 51 a patient's application for financial assistance. Further, propensity to 52 pay scores may not disqualify patients who otherwise qualify for eligi- 53 bility from receiving financial assistance. [Such] The policies and 54 procedures [may require that] shall allow patients seeking [payment 55 adjustments] financial assistance to provide [appropriate] the following 56 financial information and documentation in support of their applica-
S. 1366--A 6 1 tion[, provided, however, that such application process shall not be 2 unduly burdensome or complex]: pay checks or pay stubs; unemployment 3 documentation; social security income; rent receipts; a letter from the 4 patient's employer attesting to the patient's gross income; documenta- 5 tion of eligibility for other means-tested government benefits; or, if 6 none of the aforementioned information and documentation are available, 7 a written self-attestation of the patient's income may be used. General 8 hospitals [shall, upon request,] must take reasonable steps to assist 9 patients in understanding the hospital's application and form, policies 10 and procedures and in applying for payment adjustments. Application 11 forms shall be printed and posted to its website in the "primary 12 languages" of patients served by the general hospital. For the purposes 13 of this paragraph, "primary languages" shall include any language that 14 is either (i) used to communicate, during at least five percent of 15 patient visits in a year, by patients who cannot speak, read, write or 16 understand the English language at the level of proficiency necessary 17 for effective communication with health care providers, or (ii) spoken 18 by [non-English] limited-English speaking individuals comprising more 19 than one percent of the primary hospital service area population, as 20 calculated using demographic information available from the United 21 States Bureau of the Census, supplemented by data from school systems. 22 Decisions regarding such applications shall be made within thirty days 23 of receipt of a completed application. [Such] The policies and proce- 24 dures shall require that the hospital issue any [denial/approval] denial 25 or approval of [such] the application in writing which clearly communi- 26 cates the amount of assistance granted, any amounts still owed with 27 information on how to appeal the [denial] decision and shall require the 28 hospital to establish an appeals process under which it will evaluate 29 the [denial of] decision about an application. [Nothing in this subdivi- 30 sion shall be interpreted as prohibiting a hospital from making the 31 availability of financial assistance contingent upon the patient first 32 applying for coverage under title XIX of the social security act (medi- 33 caid) or another insurance program if, in the judgment of the hospital, 34 the patient may be eligible for medicaid or another insurance program, 35 and upon the patient's cooperation in following the hospital's financial 36 assistance application requirements, including the provision of informa- 37 tion needed to make a determination on the patient's application in 38 accordance with the hospital's financial assistance policy] Nothing in 39 this subdivision shall prevent a hospital from informing and assisting a 40 patient with an application for health insurance coverage with a local 41 services district or the marketplace. A hospital shall not make the 42 availability of financial assistance contingent upon the patient's 43 application for health insurance coverage. The hospital shall inform 44 patients on how to file a complaint against the hospital or a debt 45 collector that is contracted on behalf of the hospital regarding the 46 patient's bill. General hospitals are required to take reasonable meas- 47 ures to determine if a patient is eligible for financial assistance 48 including prior to making a referral to a third-party debt collector or 49 other extraordinary collections measures. 50 [(f) Such] (g) The policies and procedures shall provide that patients 51 with incomes below [three] six hundred percent of the federal poverty 52 level are deemed [presumptively] eligible for payment adjustments and 53 shall conform to the requirements set forth in paragraph (b) of this 54 subdivision, provided, however, that nothing in this subdivision shall 55 be interpreted as precluding hospitals from extending such payment 56 adjustments to other patients, either generally or on a case-by-case
S. 1366--A 7 1 basis. [Such policies and procedures shall provide financial aid for 2 emergency hospital services, including emergency transfers pursuant to 3 the federal emergency medical treatment and active labor act (42 USC 4 1395dd), to patients who reside in New York state and for medically 5 necessary hospital services for patients who reside in the hospital's 6 primary service area as determined according to criteria established by 7 the commissioner. In developing such criteria, the commissioner shall 8 consult with representatives of the hospital industry, health care 9 consumer advocates and local public health officials. Such criteria 10 shall be made available to the public no less than thirty days prior to 11 the date of implementation and shall, at a minimum: 12 (i) prohibit a hospital from developing or altering its primary 13 service area in a manner designed to avoid medically underserved commu- 14 nities or communities with high percentages of uninsured residents; 15 (ii) ensure that every geographic area of the state is included in at 16 least one general hospital's primary service area so that eligible 17 patients may access care and financial assistance; and 18 (iii) require the hospital to notify the commissioner upon making any 19 change to its primary service area, and to include a description of its 20 primary service area in the hospital's annual implementation report 21 filed pursuant to subdivision three of section twenty-eight hundred 22 three-l of this article. 23 (g) Nothing in this subdivision shall be interpreted as precluding 24 hospitals from extending payment adjustments for medically necessary 25 non-emergency hospital services to patients outside of the hospital's 26 primary service area.] For patients determined to be eligible for finan- 27 cial [aid] assistance under the terms of a hospital's financial [aid] 28 assistance policy, [such] the policies and procedures shall prohibit any 29 limitations on financial [aid] assistance for services based on the 30 medical condition of the applicant, other than typical limitations or 31 exclusions based on medical necessity or the clinical or therapeutic 32 benefit of a procedure or treatment. 33 (h) [Such policies and procedures shall not permit the forced] A 34 hospital or its agent shall not issue, authorize or permit an income 35 execution of a patient's wages, secure a lien or force a sale or fore- 36 closure of a patient's primary residence in order to collect an 37 outstanding medical bill and shall [require the hospital to refrain from 38 sending] not send an account to collection if the patient has submitted 39 a completed application for financial [aid, including any required 40 supporting documentation] assistance, while the hospital determines the 41 patient's eligibility for [such aid] financial assistance. [Such] The 42 policies and procedures shall provide for written notification, which 43 shall include notification on a patient bill, to a patient not less than 44 thirty days prior to the referral of debts for collection and shall 45 require that the collection agency obtain the hospital's written consent 46 prior to commencing a legal action. [Such] The policies and procedures 47 shall require all general hospital staff who interact with patients or 48 have responsibility for billing and collections to be trained in [such] 49 the policies and procedures, and require the implementation of a mech- 50 anism for the general hospital to measure its compliance with [such] the 51 policies and procedures. [Such] The policies and procedures shall 52 require that any collection agency, lawyer or firm under contract with a 53 general hospital for the collection of debts follow the hospital's 54 financial assistance policy, including providing information to patients 55 on how to apply for financial assistance where appropriate. [Such] The 56 policies and procedures shall prohibit collections from a patient who is
S. 1366--A 8 1 determined to be eligible for medical assistance [pursuant to title XIX 2 of the federal social security act] under title eleven of article five 3 of the social services law at the time services were rendered and for 4 which services medicaid payment is available. 5 (i) Reports required to be submitted to the department by each general 6 hospital as a condition for participation in the pools[, and which 7 contain, in accordance with applicable regulations,] shall contain: (i) 8 a certification from an independent certified public accountant or inde- 9 pendent licensed public accountant or an attestation from a senior offi- 10 cial of the hospital that the hospital is in compliance with conditions 11 of participation in the pools[, shall also contain, for reporting peri- 12 ods on and after January first, two thousand seven:]; 13 [(i)] (ii) a report on hospital costs incurred and uncollected amounts 14 in providing services to [eligible] patients [without insurance] found 15 eligible for financial assistance, including the amount of care provided 16 for [a nominal payment amount] patients under two hundred percent pover- 17 ty, during the period covered by the report; 18 [(ii)] (iii) hospital costs incurred and uncollected amounts for 19 deductibles and coinsurance for eligible patients with insurance or 20 other third-party payor coverage; 21 [(iii)] (iv) the number of patients, organized according to United 22 States postal service zip code, race, ethnicity and gender, who applied 23 for financial assistance [pursuant to] under the hospital's financial 24 assistance policy, and the number, organized according to United States 25 postal service zip code, race, ethnicity and gender, whose applications 26 were approved and whose applications were denied; 27 [(iv)] (v) the reimbursement received for indigent care from the pool 28 established [pursuant to] under this section; 29 [(v)] (vi) the amount of funds that have been expended on [charity 30 care] financial assistance from charitable bequests made or trusts 31 established for the purpose of providing financial assistance to 32 patients who are eligible in accordance with the terms of [such] the 33 bequests or trusts; 34 [(vi)] (vii) for hospitals located in social services districts in 35 which the district allows hospitals to assist patients with such appli- 36 cations, the number of applications for eligibility for medicaid under 37 title [XIX of the social security act (medicaid)] eleven of article five 38 of the social services law that the hospital assisted patients in 39 completing and the number denied and approved; 40 [(vii)] (viii) the hospital's financial losses resulting from services 41 provided under medicaid; and 42 [(viii)] (ix) the number of referrals to collection agents or 43 contracted external collection vendors, court cases and liens placed on 44 [the primary] any residences of patients through the collection process 45 used by a hospital. 46 (j) Within ninety days of the effective date of the chapter of the 47 laws of two thousand twenty-three which amended this subdivision each 48 hospital shall submit to the commissioner a written report on its poli- 49 cies and procedures for financial assistance to patients which are used 50 by the hospital [on the] as of such effective date [of this subdivi- 51 sion]. Such report shall include copies of its policies and procedures, 52 including material which is distributed to patients, and a description 53 of the hospital's financial aid policies and procedures. Such 54 description shall include the income levels of patients on which eligi- 55 bility is based, the financial aid eligible patients receive and the
S. 1366--A 9 1 means of calculating such aid, and the service area, if any, used by the 2 hospital to determine eligibility. 3 (k) The commissioner shall include the data collected under paragraph 4 (i) of this subdivision in regular audits of the annual general hospital 5 institutional cost report. 6 (l) In the event [it is determined by the commissioner that] the state 7 [will be] is unable to secure all necessary federal approvals to 8 include, as part of the state's approved state plan under title nineteen 9 of the federal social security act, a requirement[, as set forth in 10 paragraph one of this subdivision,] that compliance with this subdivi- 11 sion is a condition of participation in pool distributions authorized 12 pursuant to this section and section twenty-eight hundred seven-w of 13 this article, then such condition of participation shall be deemed null 14 and void [and, notwithstanding]. Notwithstanding section twelve of this 15 chapter, failure to comply with [the provisions of] this subdivision by 16 a general hospital [on and after the date of such determination] shall 17 make [such] the hospital liable for a civil penalty not to exceed ten 18 thousand dollars for each [such] violation. The imposition of [such] the 19 civil penalties shall be subject to [the provisions of] section twelve-a 20 of this chapter. 21 (m) A hospital or its collection agents shall not report adverse 22 information about a patient to a consumer or financial reporting entity. 23 A hospital or its collection agent shall not commence a civil action 24 against a patient or delegate a collection activity to a debt collector 25 for nonpayment for one hundred eighty days after the first post-service 26 bill is issued and until a hospital has made reasonable efforts to 27 determine whether a patient qualifies for financial assistance. A hospi- 28 tal shall not commence a civil action against a patient or delegate a 29 collection activity to a debt collector, if: the hospital was notified 30 that an appeal or a review of a health insurance decision is pending 31 within the immediately preceding sixty days; or the patient has a pend- 32 ing application for or qualified for financial assistance. 33 § 3. Subdivision 9-a of section 2807-k of the public health law, as 34 amended by section two of this act, is amended to read as follows: 35 9-a. (a) (i) As a condition for participation in pool distributions 36 authorized pursuant to this section and section twenty-eight hundred 37 seven-w of this article for periods on and after January first, two 38 thousand nine, general hospitals shall, effective for periods on and 39 after January first, two thousand [seven, establish] twenty-five, adopt 40 and implement the uniform financial assistance [policies and procedures, 41 in accordance with the provisions of this subdivision,] form and policy, 42 to be developed and issued by the commissioner. General hospitals shall 43 implement the uniform policy and form for reducing hospital charges 44 otherwise applicable to low-income individuals who can demonstrate an 45 inability to pay full charges, and also, at the hospital's discretion, 46 for reducing or discounting the collection of co-pays and deductible 47 payments from those individuals who can demonstrate an inability to pay 48 such amounts. Immigration status shall not be an eligibility criterion 49 for the purpose of determining financial assistance under this section. 50 As used in this section, "affiliated provider" means a provider that is: 51 (A) employed by the hospital; (B) under a professional services agree- 52 ment with the hospital; or (C) a clinical faculty member of a medical 53 school or other school that trains individuals to be providers and that 54 is affiliated with the hospital or health system. 55 (ii) A general hospital may use the New York state of health market- 56 place eligibility determination page to establish the patient's house-
S. 1366--A 10 1 hold income and residency in lieu of the financial application form, 2 provided it has secured the consent of the patient. A general hospital 3 shall not require a patient to apply for coverage through the New York 4 state of health marketplace in order to receive care or financial 5 assistance. 6 (iii) Upon submission of a completed application form, the patient is 7 not liable for any bills and no interest may accrue until the general 8 hospital has rendered a decision on the application in accordance with 9 this subdivision. 10 (b) The reductions from charges for patients described in paragraph 11 (a) of this subdivision with incomes below six hundred percent of the 12 federal poverty level shall result in a charge to such individuals that 13 does not exceed the amount that would have been paid for the same 14 services provided pursuant to title XVIII of the federal social security 15 act (medicaid), and provided further that such amount shall be adjusted 16 according to income level as follows: 17 (i) For patients with incomes at or below two hundred percent of the 18 federal poverty level, the hospital shall waive all charges. No nominal 19 payment shall be collected; 20 (ii) For patients with incomes above two hundred percent and up to 21 four hundred percent of the federal poverty level, the hospital shall 22 collect no more than the amount identified after application of a 23 proportional sliding fee schedule under which patients with lower 24 incomes shall pay the lowest amount. The schedule shall provide that 25 the amount the hospital may collect for the patient increases from the 26 nominal amount described in subparagraph (i) of this paragraph in equal 27 increments as the income of the patient increases, up to a maximum of 28 twenty percent of the amount that would have been paid for the same 29 services provided pursuant to title XVIII of the federal social security 30 act (medicaid); 31 (iii) For patients with incomes above four hundred percent and up to 32 six hundred percent of the federal poverty level, the hospital shall 33 collect no more than the amount that would have been paid for the same 34 services provided pursuant to title XVIII of the federal social security 35 act (medicaid). 36 (c) Nothing in this subdivision shall be construed to limit a hospi- 37 tal's ability to establish patient eligibility for payment discounts at 38 income levels higher than those specified herein and/or to provide 39 greater payment discounts for eligible patients than those required by 40 this subdivision. 41 (d) [Such policies and procedures shall be clear, understandable, in 42 writing and publicly available in summary form.] Each general hospital 43 participating in the pool shall ensure that every patient is made aware 44 of the existence of [the policies and procedures] the uniform financial 45 assistance form and policy and is provided, in a timely manner, with [a 46 summary and] a copy of the policy and form at intake, admission and 47 discharge. [Any summary provided to patients shall, at a minimum, 48 include, in plain language, specific information as to income levels 49 used to determine eligibility for assistance, financial assitance avail- 50 able and the means of applying for assistance.] A plain language summary 51 of the collections process must also be made available. A general hospi- 52 tal shall notify patients by providing written materials to patients or 53 their authorized representatives during the intake and registration 54 process, by making materials available in conspicuous locations in the 55 hospital including emergency departments, waiting areas and other places 56 patients congregate, through the conspicuous posting of language-appro-
S. 1366--A 11 1 priate information in the general hospital, and by including information 2 on bills and statements sent to patients, that financial assistance may 3 be available to qualified patients and how to obtain further informa- 4 tion. General hospitals shall post the uniform financial assistance 5 application policy[, procedures] and form, and a summary of the policy 6 [and procedures] and collection process, in a conspicuous location and 7 downloadable form on the general hospital's website. The commissioner 8 shall post the uniform financial assistance form and policy in download- 9 able form on the department's hospital profile page or any successor 10 website. 11 (e) The [hospital's] commissioner shall provide application materials 12 to general hospitals, including the uniform financial assistance appli- 13 cation form and policy. These application materials shall include a 14 notice to patients that upon submission of a completed application form, 15 the patient shall not be liable for any bills until the general hospital 16 has rendered a decision on the application in accordance with this 17 subdivision. The application materials shall include specific informa- 18 tion as the income levels used to determine eligibility for financial 19 assistance[, a description of the primary service area of the hospital] 20 and the means to apply for assistance. Nothing in this subdivision shall 21 be construed as precluding the use of presumptive eligibility determi- 22 nations by hospitals on behalf of patients. The [policies and proce- 23 dures] uniform application form and policy shall include clear, objec- 24 tive criteria for determining a patient's ability to pay and for 25 providing such adjustments to payment requirements as are necessary. In 26 addition to adjustment mechanisms such as sliding fee schedules and 27 discounts to fixed standards, [such policies and procedures] the uniform 28 policy shall also provide for the use of installment plans for the 29 payment of outstanding balances by patients [pursuant to the provisions 30 of the hospital's financial assistance policy]. The monthly payment 31 under such a plan shall not exceed five percent of the gross monthly 32 income of the patient. Installment plan payments may not be required to 33 begin before one hundred eighty days after the date of the service or 34 discharge, whichever is later. The policy shall allow the patient and 35 the hospital to mutually agree to modify the terms of an installment 36 plan. The rate of interest charged to the patient on the unpaid 37 balance, if any, shall not exceed two percentum per annum and no plan 38 shall include an accelerator or similar clause under which a higher rate 39 of interest is triggered upon a missed payment. The [policies and 40 procedures] uniform policy shall not include a requirement of a deposit 41 prior to medically-necessary care. The hospital shall refund any 42 payments made by the patient before the determination of eligibility for 43 financial assistance that exceeds the patient's liability after 44 discounts are applied. Such policies and procedures shall be applied 45 consistently to all eligible patients. 46 (f) In any legal action by or on behalf of a hospital to collect a 47 medical debt, the complaint shall be accompanied by an affidavit by the 48 hospital's chief financial officer stating that the hospital has taken 49 reasonable steps to determine whether the patient qualifies for finan- 50 cial assistance and upon information and belief the patient does not 51 meet the income or residency criteria for financial assistance. Patients 52 may apply for financial assistance at any time during the collection 53 process, including after the commencement of a medical debt court action 54 or upon the plaintiff obtaining a default judgment. A determination 55 that a patient is eligible for financial assistance shall be valid for a 56 minimum of twelve months and will apply to all outstanding medical
S. 1366--A 12 1 bills. A hospital may use credit scoring software for the purposes of 2 establishing income eligibility and approving financial assistance, but 3 only if the hospital makes clear to the patient that providing a social 4 security number is not mandatory and the scoring does not negatively 5 impact the patient's credit score. However, credit scoring software 6 shall not be solely relied upon by the hospital in denying a patient's 7 application for financial assistance. Further, propensity to pay scores 8 may not disqualify patients who otherwise qualify for eligibility from 9 receiving financial assistance. Further, propensity to pay scores shall 10 not disqualify patients who otherwise qualify for eligibility from 11 receiving financial assistance. The [policies and procedures] uniform 12 policy and form policies and procedures shall allow patients seeking 13 financial assistance to provide the following financial information and 14 documentation in support of their application: pay checks or pay stubs; 15 unemployment documentation; social security income; rent receipts; a 16 letter from the patient's employer attesting to the patient's gross 17 income; documentation of eligibility for other means-tested government 18 benefits; or, if none of the aforementioned information and documenta- 19 tion are available, a written self-attestation of the patient's income 20 may be used. General hospitals must take reasonable steps to assist 21 patients in understanding the hospital's application and form, policies 22 and procedures and in applying for payment adjustments. [Application 23 forms shall be printed and posted] The commissioner shall translate the 24 uniform financial assistance application form and policy into the 25 "primary languages" of each general hospital. Each general hospital 26 shall print and post these materials to its website in the "primary 27 languages" of patients served by the general hospital. For the purposes 28 of this paragraph, "primary languages" shall include any language that 29 is either (i) used to communicate, during at least five percent of 30 patient visits in a year, by patients who cannot speak, read, write or 31 understand the English language at the level of proficiency necessary 32 for effective communication with health care providers, or (ii) spoken 33 by limited-English speaking individuals comprising more than one percent 34 of the primary hospital service area population, as calculated using 35 demographic information available from the United States Bureau of the 36 Census, supplemented by data from school systems. Decisions regarding 37 such applications shall be made within thirty days of receipt of a 38 completed application. The [policies and procedures] uniform financial 39 assistance policy shall require that the hospital issue any denial or 40 approval of the application in writing which clearly communicates the 41 amount of assistance granted, any amounts still owed with information on 42 how to appeal the decision and shall require the hospital to establish 43 an appeals process under which it will evaluate the decision about an 44 application. Nothing in this subdivision shall prevent a hospital from 45 informing and assisting a patient with an application for health insur- 46 ance coverage with a local services district or the marketplace. A 47 hospital shall not make the availability of financial assistance contin- 48 gent upon the patient's application for health insurance coverage. The 49 hospital shall inform patients on how to file a complaint against the 50 hospital or a debt collector that is contracted on behalf of the hospi- 51 tal regarding the patient's bill. General hospitals are required to 52 take reasonable measures to determine if a patient is eligible for 53 financial assistance including prior to making a referral to a third- 54 party debt collector or other extraordinary collections measures. 55 (g) The [policies and procedures] uniform financial assistance policy 56 shall provide that patients with incomes below six hundred percent of
S. 1366--A 13 1 the federal poverty level are deemed eligible for payment adjustments 2 and shall conform to the requirements set forth in paragraph (b) of this 3 subdivision, provided, however, that nothing in this subdivision shall 4 be interpreted as precluding hospitals from extending such payment 5 adjustments to other patients, either generally or on a case-by-case 6 basis. For patients determined to be eligible for financial assistance 7 under the terms of [a hospital's] the uniform financial assistance poli- 8 cy, the [policies and procedures] financial assistance policy shall 9 prohibit any limitations on financial assistance for services based on 10 the medical condition of the applicant, other than typical limitations 11 or exclusions based on medical necessity or the clinical or therapeutic 12 benefit of a procedure or treatment. 13 (h) A hospital or its agent shall not issue, authorize or permit an 14 income execution of a patient's wages, secure a lien or force a sale or 15 foreclosure of a patient's primary residence in order to collect an 16 outstanding medical bill and shall not send an account to collection if 17 the patient has submitted a completed application for financial assist- 18 ance, until it has made reasonable efforts to determine whether a 19 patient qualifies for financial assistance or while the hospital deter- 20 mines the patient's eligibility for financial assistance. The [policies 21 and procedures] uniform policy shall provide for written notification, 22 which shall include notification on a patient bill, to a patient not 23 less than thirty days prior to the referral of debts for collection and 24 shall require that the collection agency obtain the hospital's written 25 consent prior to commencing a legal action. The [policies and proce- 26 dures] uniform policy shall require all general hospital staff who 27 interact with patients or have responsibility for billing and 28 collections to be trained in the [policies and procedures] uniform poli- 29 cy, and require the implementation of a mechanism for the general hospi- 30 tal to measure its compliance with the [policies and procedures] uniform 31 policy. The [policies and procedures] uniform policy shall require that 32 any collection agency, lawyer or firm under contract with a general 33 hospital for the collection of debts follow the [hospital's] uniform 34 financial assistance policy, including providing information to patients 35 on how to apply for financial assistance where appropriate. The [poli- 36 cies and procedures] uniform policy shall prohibit collections from a 37 patient who is determined to be eligible for medical assistance under 38 title eleven of article five of the social services law at the time 39 services were rendered and for which services medicaid payment is avail- 40 able. 41 (i) Reports required to be submitted to the department by each general 42 hospital as a condition for participation in the pools shall contain: 43 (i) a certification from an independent certified public accountant or 44 independent licensed public accountant or an attestation from a senior 45 official of the hospital that the hospital is in compliance with condi- 46 tions of participation in the pools; 47 (ii) a report on hospital costs incurred and uncollected amounts in 48 providing services to patients found eligible for financial assistance, 49 including the amount of care provided for patients under two hundred 50 percent poverty, during the period covered by the report; 51 (iii) hospital costs incurred and uncollected amounts for deductibles 52 and coinsurance for eligible patients with insurance or other third-par- 53 ty payor coverage; 54 (iv) the number of patients, organized according to United States 55 postal service zip code, race, ethnicity and gender, who applied for 56 financial assistance under the [hospital's] uniform financial assistance
S. 1366--A 14 1 policy, and the number, organized according to United States postal 2 service zip code, race, ethnicity and gender, whose applications were 3 approved and whose applications were denied; 4 (v) the reimbursement received for indigent care from the pool estab- 5 lished under this section; 6 (vi) the amount of funds that have been expended on financial assist- 7 ance from charitable bequests made or trusts established for the purpose 8 of providing financial assistance to patients who are eligible in 9 accordance with the terms of the bequests or trusts; 10 (vii) for hospitals located in social services districts in which the 11 district allows hospitals to assist patients with such applications, the 12 number of applications for eligibility for medicaid under title eleven 13 of article five of the social services law that the hospital assisted 14 patients in completing and the number denied and approved; 15 (viii) the hospital's financial losses resulting from services 16 provided under medicaid; and 17 (ix) the number of referrals to collection agents or contracted 18 external collection vendors, court cases and liens placed on any resi- 19 dences of patients through the collection process used by a hospital. 20 (j) [Within ninety days of the effective date of the chapter of the 21 laws of two thousand twenty-three which amended this subdivision each 22 hospital shall submit to the commissioner a written report on its poli- 23 cies and procedures for financial assistance to patients which are used 24 by the hospital as of such effective date. Such report shall include 25 copies of its policies and procedures, including material which is 26 distributed to patients, and a description of the hospital's financial 27 aid policies and procedures. Such description shall include the income 28 levels of patients on which eligibility is based, the financial aid 29 eligible patients receive and the means of calculating such aid, and the 30 service area, if any, used by the hospital to determine eligibility. 31 (k)] The commissioner shall include the data collected under paragraph 32 (i) of this subdivision in regular audits of the annual general hospital 33 institutional cost report. 34 [(l)] (k) In the event the state is unable to secure all necessary 35 federal approvals to include, as part of the state's approved state plan 36 under title nineteen of the federal social security act, a requirement 37 that compliance with this subdivision is a condition of participation in 38 pool distributions authorized pursuant to this section and section twen- 39 ty-eight hundred seven-w of this article, then such condition of partic- 40 ipation shall be deemed null and void. Notwithstanding section twelve of 41 this chapter, failure to comply with this subdivision by a general 42 hospital shall make the hospital liable for a civil penalty not to 43 exceed ten thousand dollars for each violation. The imposition of the 44 civil penalties shall be subject to section twelve-a of this chapter. 45 [(m)] (l) A hospital or its collection agents shall not report adverse 46 information about a patient to a consumer or financial reporting entity. 47 A hospital or its collection agent shall not commence civil action 48 against a patient or delegate a collection activity to a debt collector 49 for nonpayment for one hundred eighty days after the first post-service 50 bill is issued and until a hospital has made reasonable efforts to 51 determine whether a patient qualifies for financial assistance. A hospi- 52 tal or its collection agent shall not commence a civil action against a 53 patient or delegate a collection activity to a debt collector, if: the 54 hospital was notified that an appeal or a review of a health insurance 55 decision is pending within the immediately preceding sixty days; or the
S. 1366--A 15 1 patient has a pending application for or qualified for financial assist- 2 ance. 3 § 4. Subdivision 14 of section 2807-k of the public health law is 4 REPEALED and subdivisions 15, 16 and 17 are renumbered subdivisions 14, 5 15 and 16. 6 § 5. This act shall take effect immediately; provided that (a) 7 section two of this act shall take effect on the one hundred twentieth 8 day after it shall have become a law; and (b) sections one, one-a and 9 three of this act shall take effect October 1, 2024 and apply to funding 10 distributions made on or after January 1, 2025; provided, however, that 11 if subpart C of part Y of chapter 57 of the laws of 2023 shall not have 12 taken effect on or before such date then section one-a of this act shall 13 take effect on the same date and in the same manner as such subpart of 14 such part of such chapter of the laws of 2023, takes effect. Effective 15 immediately, the commissioner of health may make regulations and take 16 other actions reasonably necessary to implement sections one, two and 17 three of this act on their respective effective dates.