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S T A T E O F N E W Y O R K
________________________________________________________________________
1915
2025-2026 Regular Sessions
I N A S S E M B L Y
January 14, 2025
___________
Introduced by M. of A. PAULIN, WEPRIN, HEVESI, REYES, SIMONE,
BICHOTTE HERMELYN, LUNSFORD -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law and the social services law, in
relation to primary care investment
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. The insurance law is amended by adding a new section 3217-k
2 to read as follows:
3 § 3217-K. PRIMARY CARE SPENDING. (A) DEFINITIONS. AS USED IN THIS
4 SECTION, THE FOLLOWING TERMS SHALL HAVE THE FOLLOWING MEANINGS:
5 (1) "OVERALL HEALTHCARE SPENDING" MEANS THE TOTAL COST OF CARE FOR THE
6 PATIENT POPULATION OF A PAYOR OR PROVIDER ENTITY FOR A GIVEN CALENDAR
7 YEAR, WHERE COST IS CALCULATED FOR SUCH YEAR AS THE SUM OF (A) ALL
8 CLAIMS-BASED SPENDING PAID TO PROVIDERS BY PUBLIC AND PRIVATE PAYORS AND
9 (B) ALL NON-CLAIM PAYMENTS FOR SUCH YEAR, INCLUDING, BUT NOT LIMITED TO,
10 INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
11 (2) "PLAN OR PAYOR" MEANS EVERY INSURANCE ENTITY PROVIDING MANAGED
12 CARE PRODUCTS, INDIVIDUAL COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE OR
13 GROUP OR BLANKET COMPREHENSIVE ACCIDENT AND HEALTH INSURANCE, AS DEFINED
14 IN THIS CHAPTER, CORPORATION ORGANIZED UNDER ARTICLE FORTY-THREE OF THIS
15 CHAPTER PROVIDING COMPREHENSIVE HEALTH INSURANCE, ENTITY LICENSED UNDER
16 ARTICLE FORTY-FOUR OF THIS CHAPTER PROVIDING COMPREHENSIVE HEALTH INSUR-
17 ANCE, EVERY OTHER PLAN OVER WHICH THE DEPARTMENT HAS JURISDICTION, AND
18 EVERY THIRD-PARTY PAYOR PROVIDING HEALTH COVERAGE.
19 (3) "PRIMARY CARE" MEANS INTEGRATED, ACCESSIBLE HEALTHCARE, PROVIDED
20 BY CLINICIANS ACCOUNTABLE FOR ADDRESSING MOST OF A PATIENT'S HEALTHCARE
21 NEEDS INCLUDING (A) DEVELOPING A SUSTAINED PARTNERSHIP WITH PATIENTS;
22 (B) PRACTICING IN THE CONTEXT OF FAMILY AND COMMUNITY; AND (C) COORDI-
23 NATING PATIENTS' CARE, WHICH FOR THE PURPOSES OF THIS SECTION SHALL ONLY
24 INCLUDE CARE COORDINATION EFFORTS UNDERTAKEN BY THE CLINICIANS RENDERING
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD04789-01-5
A. 1915 2
1 HEALTHCARE SERVICES TO A PATIENT AND SHALL NOT INCLUDE SEPARATE CARE
2 COORDINATION ACTIVITIES UNDERTAKEN BY A PAYOR.
3 (4) "PRIMARY CARE SERVICES" MEANS SERVICES PROVIDED IN AN OUTPATIENT,
4 NON-EMERGENCY SETTING BY OR UNDER THE SUPERVISION OF A PHYSICIAN, NURSE
5 PRACTITIONER, PHYSICIAN ASSISTANT, OR MIDWIFE, WHO IS PRACTICING GENERAL
6 PRIMARY CARE IN THE FOLLOWING FIELDS, INCLUDING AS EVIDENCED BY BILLING
7 AND REPORTING CODES: FAMILY PRACTICE; GENERAL PEDIATRICS; PRIMARY CARE
8 INTERNAL MEDICINE; PRIMARY CARE OBSTETRICS; OR PRIMARY CARE GYNECOLOGY.
9 BEHAVIORAL OR MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES ARE
10 INCLUDED IN PRIMARY CARE SERVICES WHEN INTEGRATED INTO A PRIMARY CARE
11 SETTING, INCLUDING WHEN PROVIDED BY A BEHAVIORAL HEALTHCARE PSYCHIA-
12 TRIST, SOCIAL WORKER OR PSYCHOLOGIST. PRIMARY CARE SERVICES SHALL NOT
13 INCLUDE INPATIENT SERVICES, EMERGENCY DEPARTMENT SERVICES, AMBULATORY
14 SURGICAL CENTER SERVICES, OR SERVICES PROVIDED IN AN URGENT CARE SETTING
15 THAT ARE BILLED WITH NON-PRIMARY CARE BILLING AND REPORTING CODES.
16 (5) "PRIMARY CARE SPENDING" MEANS ANY EXPENDITURE OF FUNDS MADE BY
17 THIRD PARTY PAYORS, PUBLIC ENTITIES, OR THE STATE, FOR THE PURPOSE OF
18 PAYING FOR PRIMARY CARE SERVICES DIRECTLY OR PAYING TO IMPROVE THE
19 DELIVERY OF PRIMARY CARE. PRIMARY CARE SPENDING INCLUDES ALL PAYMENT
20 METHODS, SUCH AS FEE-FOR-SERVICE, CAPITATION, INCENTIVES, VALUE-BASED
21 PAYMENTS OR OTHER METHODOLOGIES, AND ALL NON-CLAIM PAYMENTS INCLUDING
22 BUT NOT LIMITED TO INCENTIVE PAYMENTS AND CARE COORDINATION PAYMENTS.
23 FOR PAYEES THAT OWN AND/OR OPERATE FACILITIES, ENTITIES, OR OTHER
24 PROVIDERS, SUCH AS HEALTH SYSTEMS OR HOSPITAL SYSTEMS, THAT PROVIDE
25 OTHER MEDICAL SERVICES IN ADDITION TO PRIMARY CARE, ONLY THOSE FUNDS
26 THAT ARE SEPARATELY DOCUMENTED AS FUNDS DESIGNATED FOR PRIMARY CARE
27 SERVICES SHALL BE CONSIDERED PRIMARY CARE SPENDING. ANY SPENDING SHALL
28 BE ADJUSTED APPROPRIATELY TO EXCLUDE ANY PORTION OF THE EXPENDITURE THAT
29 IS REASONABLY ATTRIBUTED TO INPATIENT SERVICES OR OTHER NON-PRIMARY CARE
30 SERVICES.
31 (B) REPORTING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
32 EACH PLAN OR PAYOR AS DEFINED IN THIS SECTION SHALL ANNUALLY REPORT TO
33 THE DEPARTMENT THE PERCENTAGE OF THE PLAN OR PAYOR'S OVERALL ANNUAL
34 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
35 (2) NOTHING HEREIN SHALL REQUIRE ANY PLAN OR PAYOR TO REPORT OR
36 PUBLICLY DISCLOSE ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY SPECIFIC
37 PRIMARY CARE SERVICES.
38 (3) NO PLAN OR PAYOR SHALL REQUIRE ANY HEALTHCARE PROVIDER TO PROVIDE
39 ADDITIONAL DATA OR INFORMATION IN ORDER TO FULFILL THIS REPORTING
40 REQUIREMENT.
41 (C) REGULATION AND PUBLICATION. (1) THE COMMISSIONER OF HEALTH AND THE
42 SUPERINTENDENT SHALL EACH PROMULGATE CONSISTENT REGULATIONS TO CARRY OUT
43 THE PROVISIONS OF THIS SECTION, INCLUDING BUT NOT LIMITED TO SETTING
44 DEADLINES FOR THE REPORTING REQUIRED IN THIS SECTION, AND ADOPTING
45 FURTHER SPECIFIC DEFINITIONS OF THE PRIMARY CARE SERVICES FOR WHICH
46 COSTS MUST BE REPORTED UNDER THIS SECTION, INCLUDING SPECIFIC BILLING
47 AND REPORTING CODES.
48 (2) THE DEPARTMENT OF HEALTH AND THE DEPARTMENT SHALL TOGETHER PROVIDE
49 AN ANNUAL REPORT TO THE LEGISLATURE WITH A SUMMARY OF THE PRIMARY CARE
50 SPENDING DATA REQUIRED IN THIS SECTION, AND SHALL ALSO MAKE THE REPORT
51 PUBLICLY AVAILABLE ON BOTH AGENCIES' WEBSITES, NO LATER THAN THREE
52 MONTHS AFTER THE DATA HAS BEEN COLLECTED. THE FIRST ANNUAL REPORT SHALL
53 PROVIDE THE SPENDING INFORMATION WITHOUT IDENTIFYING ANY INDIVIDUAL
54 PAYOR OR PLAN'S PRIMARY CARE SPENDING. EACH YEAR THEREAFTER, THE REPORT
55 SPENDING DATA SHALL BE PUBLISHED INCLUDING INFORMATION SPECIFIC TO EACH
56 PLAN OR PAYOR.
A. 1915 3
1 (D) PRIMARY CARE SPENDING. (1) BEGINNING ON APRIL FIRST, TWO THOUSAND
2 TWENTY-SIX, EACH PLAN OR PAYOR THAT REPORTS LESS THAN TWELVE AND ONE-
3 HALF PERCENT OF ITS TOTAL EXPENDITURES ON PHYSICAL AND MENTAL HEALTH IS
4 PRIMARY CARE SPENDING, AS DEFINED BY THIS SECTION, SHALL ADDITIONALLY
5 SUBMIT TO THE SUPERINTENDENT A PLAN TO INCREASE PRIMARY CARE SPENDING AS
6 A PERCENTAGE OF ITS TOTAL OVERALL HEALTHCARE SPENDING BY AT LEAST ONE
7 PERCENT EACH YEAR. BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-SEVEN
8 AND ON APRIL FIRST OF EVERY SUBSEQUENT YEAR AFTER SUCH PLAN HAS BEEN
9 SUBMITTED, AND UNTIL SUCH TIME AS THE PLAN OR PAYOR'S REPORTED PRIMARY
10 CARE SPENDING IS EQUAL TO OR MORE THAN TWELVE AND ONE-HALF PERCENT OF
11 THAT PLAN OR PAYOR'S OVERALL HEALTHCARE SPENDING, THE PLAN OR PAYOR'S
12 ANNUAL REPORTING SHALL INCLUDE INFORMATION REGARDING STEPS THAT HAVE
13 BEEN TAKEN TO INCREASE ITS PROPORTION OF PRIMARY CARE SPENDING.
14 (2) THE COMMISSIONER OF HEALTH AND THE SUPERINTENDENT MAY JOINTLY
15 ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING THE AREAS ON WHICH
16 PRIMARY CARE SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
17 (A) REIMBURSEMENT;
18 (B) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
19 (C) UPGRADING TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
20 AND TELEHEALTH CAPABILITIES;
21 (D) INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED TO PER-MEMBER-PER-
22 MONTH, VALUE-BASED-PAYMENT ARRANGEMENTS, SHARED SAVINGS, QUALITY-BASED
23 PAYMENTS, RISK-BASED PAYMENTS; AND
24 (E) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
25 (E) LIMITS ON PREMIUM INCREASES. PLANS OR PAYORS SHALL ADOPT STRATE-
26 GIES THAT IMPROVE VALUE AND QUALITY OF CARE AND SHIFT CURRENT SPENDING
27 WITHOUT INCREASING TOTAL MEDICAL EXPENDITURES. SPENDING SHIFTS RESULTING
28 FROM COMPLIANCE WITH THIS SECTION SHALL NOT RESULT IN HIGHER PREMIUMS OR
29 COST-SHARING REQUIREMENTS FOR INSURED INDIVIDUALS.
30 § 2. The social services law is amended by adding a new section 368-g
31 to read as follows:
32 § 368-G. PRIMARY CARE SPENDING. 1. DEFINITIONS. AS USED IN THIS
33 SECTION THE TERMS "OVERALL HEALTHCARE SPENDING", "PLAN OR PAYOR",
34 "PRIMARY CARE", "PRIMARY CARE SERVICES" AND "PRIMARY CARE SPENDING"
35 SHALL HAVE THE SAME MEANINGS AS SUCH TERMS ARE DEFINED IN SECTION THIR-
36 TY-TWO HUNDRED SEVENTEEN-K OF THE INSURANCE LAW.
37 2. REPORTING. (A) BEGINNING ON APRIL FIRST, TWO THOUSAND TWENTY-FIVE,
38 EACH MEDICAID MANAGED CARE PROVIDER UNDER SECTION THREE HUNDRED SIXTY-
39 FOUR-J OF THIS TITLE AND ANY PAYOR THAT PROVIDES COVERAGE THROUGH MEDI-
40 CAID FEE-FOR-SERVICE, AS SUCH TERM IS DEFINED IN PARAGRAPH (E) OF SUBDI-
41 VISION THIRTY-EIGHT OF SECTION TWO OF THIS CHAPTER, SHALL ANNUALLY
42 REPORT TO THE DEPARTMENT THE PERCENTAGE OF THE PROVIDER'S OVERALL ANNUAL
43 HEALTHCARE SPENDING THAT CONSTITUTED PRIMARY CARE SPENDING.
44 (B) NOTHING HEREIN SHALL REQUIRE ANY MEDICAID MANAGED CARE PROVIDER TO
45 REPORT OR PUBLICLY DISCLOSE ANY SPECIFIC RATES OF REIMBURSEMENT FOR ANY
46 SPECIFIC PRIMARY CARE SERVICES.
47 (C) NO MEDICAID MANAGED CARE PROVIDER SHALL REQUIRE ANY HEALTHCARE
48 PROVIDER TO PROVIDE ADDITIONAL DATA OR INFORMATION IN ORDER TO FULFILL
49 THIS REPORTING REQUIREMENT.
50 3. PRIMARY CARE SPENDING. (A) BEGINNING ON APRIL FIRST, TWO THOUSAND
51 TWENTY-SIX, AND IN EACH SUBSEQUENT YEAR, EACH MEDICAID MANAGED CARE
52 PROVIDER UNDER SECTION THREE HUNDRED SIXTY-FOUR-J OF THIS TITLE AND ANY
53 PAYOR THAT PROVIDES COVERAGE THROUGH MEDICAID FEE-FOR-SERVICE, AS SUCH
54 TERM IS DEFINED IN PARAGRAPH (E) OF SUBDIVISION THIRTY-EIGHT OF SECTION
55 TWO OF THIS CHAPTER, THAT REPORTS LESS THAN TWELVE AND ONE-HALF PERCENT
56 OF ITS TOTAL EXPENDITURES ON PHYSICAL AND MENTAL HEALTH ARE ON PRIMARY
A. 1915 4
1 CARE SPENDING SHALL ADDITIONALLY SUBMIT TO THE COMMISSIONER A PLAN TO
2 INCREASE PRIMARY CARE SPENDING AS A PERCENTAGE OF ITS TOTAL OVERALL
3 HEALTHCARE SPENDING BY AT LEAST ONE PERCENT EACH YEAR. BEGINNING ON
4 APRIL FIRST, TWO THOUSAND TWENTY-SEVEN, AND IN EACH SUBSEQUENT YEAR
5 THEREAFTER, UNTIL TWELVE AND ONE-HALF PERCENT OF THAT PROVIDER OR
6 PAYOR'S EXPENDITURES ARE ON PRIMARY CARE SPENDING, THE PAYOR OR PROVID-
7 ER'S ANNUAL REPORTING UNDER THIS SECTION SHALL INCLUDE INFORMATION ON
8 STEPS THAT HAVE BEEN TAKEN TO INCREASE THEIR PROPORTION OF PRIMARY CARE
9 SPENDING.
10 (B) THE COMMISSIONER AND THE SUPERINTENDENT OF FINANCIAL SERVICES MAY
11 JOINTLY ISSUE GUIDELINES OR PROMULGATE REGULATIONS REGARDING THE AREAS
12 ON WHICH SPENDING COULD BE INCREASED, INCLUDING BUT NOT LIMITED TO:
13 (I) REIMBURSEMENT;
14 (II) CAPACITY-BUILDING, TECHNICAL ASSISTANCE AND TRAINING;
15 (III) UPGRADING TECHNOLOGY, INCLUDING ELECTRONIC HEALTH RECORD SYSTEMS
16 AND TELEHEALTH CAPABILITIES;
17 (IV) INCENTIVE PAYMENTS, INCLUDING BUT NOT LIMITED TO PER-MEMBER-PER-
18 MONTH, VALUE-BASED-PAYMENT ARRANGEMENTS, SHARED SAVINGS, QUALITY-BASED
19 PAYMENTS, RISK-BASED PAYMENTS; AND
20 (V) TRANSITIONING TO VALUE-BASED-PAYMENT ARRANGEMENTS.
21 (C) THE PROVISIONS OF THIS SECTION ARE SUBJECT TO COMPLIANCE WITH ALL
22 APPLICABLE FEDERAL AND STATE LAWS AND REGULATIONS, INCLUDING THE CENTERS
23 FOR MEDICARE AND MEDICAID SERVICES APPROVED MEDICAID STATE PLAN. TO THE
24 EXTENT REQUIRED BY FEDERAL LAW, THE COMMISSIONER SHALL SEEK ANY FEDERAL
25 APPROVALS NECESSARY TO IMPLEMENT THIS SECTION, INCLUDING, BUT NOT LIMIT-
26 ED TO, ANY STATE-DIRECTED PAYMENTS, PERMISSIONS, STATE PLAN AMENDMENTS
27 OR FEDERAL WAIVERS BY THE FEDERAL CENTERS FOR MEDICARE AND MEDICAID
28 SERVICES. THE COMMISSIONER MAY ALSO APPLY FOR APPROPRIATE WAIVERS OR
29 STATE DIRECTED PAYMENTS UNDER FEDERAL LAW AND REGULATION OR TAKE OTHER
30 ACTIONS TO SECURE FEDERAL FINANCIAL PARTICIPATION TO ASSIST IN PROMOTING
31 THE OBJECTIVES OF THIS SECTION.
32 4. LIMITS ON COST INCREASES. PLANS OR PAYORS SHALL ADOPT STRATEGIES
33 THAT IMPROVE VALUE AND QUALITY OF CARE AND SHIFT CURRENT SPENDING WITH-
34 OUT INCREASING TOTAL MEDICAL EXPENDITURES.
35 § 3. This act shall take effect immediately.