N.Y. PBH Law § 2807-K — New York Code / Act PBH / Article 28 / Section 2807-K
General hospital indigent care pool
Status: in_force

§ 2807-k. General hospital indigent care pool. 1. Definitions. For\npurposes of this section, the following words or phrases shall have the\nfollowing meanings, unless the context otherwise requires:\n  (a) "Major public general hospital" means all state operated general\nhospitals, all general hospitals operated by the New York city health\nand hospitals corporation as established by chapter one thousand sixteen\nof the laws of nineteen hundred sixty-nine as amended and all other\npublic general hospitals having annual inpatient operating costs in\nexcess of twenty-five million dollars.\n  (b) "Nominal payment amount" shall mean the sum of the dollars\nattributable to the application of an incrementally increasing\nproportion of reimbursement for percentage increases in targeted need\naccording to a scale.\n  (c) "Targeted need" shall mean the relationship of uncompensated care\nneed to reported costs expressed as a percentage. Reported costs shall\nmean costs allocated as prescribed by the commissioner to general\nhospital inpatient and ambulatory services, excluding referred\nambulatory services. Targeted need shall be determined based on base\nyear data and statistics for the calendar year two years prior to the\ndistribution period. Base year data and statistics for the calendar year\ntwo years prior to the distribution period shall be considered final,\nfor purposes of this section, one hundred twenty days after hospitals\nreceive the department's initial statewide rates for the same period as\nthe distribution period and shall include any appropriate revisions\nreported by hospitals during such one hundred twenty days.\n  (d) "Uncompensated care need" means losses from bad debts reduced to\ncost and the costs of charity care of a general hospital for inpatient\nand ambulatory services, excluding referred ambulatory services. The\ncost of services provided as an employment benefit or as a courtesy\nshall not be included.\n  (e) "Uninsured care" means losses from bad debts reduced to cost and\nthe costs of charity care of a general hospital for inpatient and\nambulatory services, excluding referred ambulatory services, which are\nnot eligible for payment in whole or in part by a governmental agency,\ninsurer or other third-party payor on behalf of a patient, including\npayments made directly to the general hospital and indemnity or similar\npayments made to the person who is a payor of hospital services. The\ncost of services denied reimbursement, other than emergency room\nservices, for lack of medical necessity or lack of compliance with prior\nauthorization requirements, or provided as an employment benefit, or as\na courtesy shall not be included.\n  (f) "Ambulatory services" of a general hospital shall mean all\nservices delivered on an ambulatory basis, including, for periods on and\nafter January first, two thousand four, services provided at qualified\nhospital-controlled diagnostic and treatment centers except as otherwise\nprovided in subdivision thirteen of this section.\n  (g) "Qualified hospital-controlled diagnostic and treatment center"\nshall mean a voluntary, non-profit diagnostic and treatment center\nproviding a comprehensive range of primary health care services that is\ncontrolling, controlled by, or under common control with a general\nhospital, and as of June thirtieth, two thousand three:\n  (i) qualified for an allocation of funds pursuant to section\ntwenty-eight hundred seven-p of this article or pursuant to section\nseven of chapter four hundred thirty-three of the laws of nineteen\nhundred ninety-seven, as amended; or\n  (ii) the outpatient department of such general hospital had been\ndesignated a federally-qualified health center under section 330 of the\nPublic Health Service Act (42 U.S.C. § 254b) and had directly received a\ngrant under such section.\n  (h) "Underinsured" shall mean an individual with out of pocket medical\ncosts accumulated in the past twelve months that amount to more than ten\npercent of such individual's gross annual income.\n  2. To the extent of funds appropriated therefor, funds shall be made\navailable for distribution by or on behalf of the state in accordance\nwith the following methodology, as payments under the state medical\nassistance program provided pursuant to title eleven of article five of\nthe social services law, from a general hospital indigent care pool\nestablished by the commissioner.\n  3. Each major public general hospital shall be allocated for\ndistribution from the pools established pursuant to this section for\neach year through December thirty-first, two thousand fourteen, an\namount equal to the amount allocated to such major public general\nhospital from the regional pool established pursuant to subdivision\nseventeen of section twenty-eight hundred seven-c of this article for\nthe period January first, nineteen hundred ninety-six through December\nthirty-first, nineteen hundred ninety-six, provided, however, that\npayments on and after January first, two thousand nine shall be subject\nto the provisions of subdivision five-a of this section.\n  4. (a) From funds in the pool for each year, thirty-six million\ndollars shall be reserved on an annual basis through December\nthirty-first, two thousand fourteen, for distribution as high need\nadjustments in accordance with subdivision six of this section,\nprovided, however, that payments on and after January first, two\nthousand nine shall be subject to the provisions of subdivision five-a\nof this section.\n  (a-1) From funds in the pool for each year, twenty-seven million\ndollars shall be reserved on an annual basis for the periods January\nfirst, two thousand through December thirty-first, two thousand ten, for\ndistribution in accordance with subdivision sixteen of this section,\nprovided, however, that payments on and after January first, two\nthousand nine through December thirty-first, two thousand nine shall be\nsubject to the provisions of subdivisions five-a and five-b of this\nsection, and shall be subject to the provisions of subdivision five-b of\nthis section for periods on and after January first, two thousand ten.\n  (b) The balance of funds in a pool not allocated in accordance with\nsubdivision three of this section or reserved for distributions pursuant\nto subdivisions six and sixteen of this section shall be distributed to\neligible general hospitals, excluding major public general hospitals, on\nthe basis of each general hospital's targeted need share, adjusted for\ntransition factors in accordance with subdivision seven of this section.\n  (c) To be eligible for distributions from the pool, a general\nhospital's targeted need must exceed one-half of one percent.\n  (d) For the periods January first, nineteen hundred ninety-seven\nthrough December thirty-first, nineteen hundred ninety-seven, January\nfirst, nineteen hundred ninety-eight through December thirty-first,\nnineteen hundred ninety-eight, and January first, nineteen hundred\nninety-nine through December thirty-first, nineteen hundred ninety-nine\nand on and after January first, two thousand, each eligible general\nhospital's targeted need share shall mean the relationship of each\ngeneral hospital's nominal payment amount of uncompensated care need\ndetermined in accordance with the scale specified in subdivision five of\nthis section to the nominal payment amounts of uncompensated care need\nfor all eligible general hospitals applied to funds available in the\npool.\n  5. The scale utilized for development of each eligible general\nhospital's nominal payment amount shall be as follows:\n                                        Percentage of Reimbursement\n                                        Attributable to that Portion\n        Targeted Need Percentage            of Targeted Need\n              0     -.5%                          60%\n               .5+  -2%                           65%\n              2+    -3%                           70%\n              3+    -4%                           75%\n              4+    -5%                           80%\n              5+    -6%                           85%\n              6+    -7%                           90%\n              7+    -8%                           95%\n              8+                                 100%\n  5-a. Notwithstanding any inconsistent provision of this section,\nsection twenty-eight hundred seven-w of this article or any other\ncontrary provision of law, subject to the availability of federal\nfinancial participation and within amounts appropriated, for periods on\nand after January first, two thousand nine, ten percent of the aggregate\ndistributions to each general hospital made otherwise pursuant to this\nsection and section twenty-eight hundred seven-w of this article shall\nbe reserved and set aside and distributed in accordance with the\nfollowing:\n  (a) Thirteen million nine hundred thirty thousand dollars of such\nreserved funds shall be distributed to major public hospitals and shall\nbe allocated proportionally, based on each facility's relative\nuncompensated care need as determined in accordance with the provisions\nof paragraph (c) of this subdivision; and\n  (b) Seventy million seven hundred seventy thousand dollars of such\nreserved funds shall be distributed to general hospitals other than\nmajor public general hospitals and shall be allocated proportionally,\nbased on each facility's relative uncompensated care need as determined\nin accordance with the provisions of paragraph (c) of this subdivision;\nand\n  (c) For the purposes of distributions in accordance with paragraphs\n(a) and (b) of this subdivision, each facility's relative uncompensated\ncare need amount shall be determined in accordance with the following:\n  (i) inpatient units of services for all uninsured patients from the\ncalendar year two years prior to the distribution year, but excluding\nreferred ambulatory units of services, shall be multiplied by the\napplicable Medicaid inpatient rates in effect for such prior year, but\nnot including prospective rate adjustments and rate add-ons, provided,\nhowever, that for distributions on and after January first, two thousand\nten, the uncompensated amount for inpatient services shall utilize the\ninpatient rates in effect as of July first of the prior year;\n  (ii) outpatient units of service for all uninsured patients from the\ncalendar year two years prior to the distribution year, including\nemergency department services and ambulatory surgery services, but\nexcluding referred ambulatory services units of service, shall be\nmultiplied by Medicaid outpatient rates that reflect the exclusive\nutilization of the ambulatory patient groups (APG) rate-setting\nmethodology as set forth in regulations promulgated pursuant to\nsubdivision two-a of section twenty-eight hundred seven of this article,\nas in effect for the distribution year, provided further, however, that\nfor those services for which APG rates are not available the applicable\nMedicaid outpatient rate shall be the rate in effect for the calendar\nyear two years prior to the distribution year;\n  (iii) the uncompensated care need for each facility for periods on and\nafter January first, two thousand ten shall be reduced by the sum of all\npayment amounts collected from such patients; and\n  (iv) the total uncompensated care need for each facility subject to\nthis subdivision shall then be adjusted by application of the nominal\nneed scale set forth in subdivision five of this section.\n  (d)(i) For annual periods commencing on and after January first, two\nthousand nine, no general hospital may receive disproportionate share\npayment distributions made in accordance with this section, section\ntwenty-eight hundred seven-w of this article or made in accordance with\nother provisions of law, that exceed, in aggregate, the costs incurred\nby such general hospital during such period in furnishing inpatient and\noutpatient hospital services to Medicaid eligible patients or to\npatients who have no health insurance or other source of third party\ncoverage, net of all monies received from non-disproportionate share\nrelated Medicaid payments and from payments made by such uninsured\npatients. For purposes of this paragraph, non-Medicaid payments made to\na general hospital by the state or by a unit of local government within\nthe state for services provided to indigent patients shall not be\nconsidered to be a source of third party payment.\n  (ii) Reductions pursuant to this paragraph shall be made in the\nfollowing sequence:\n  (A) payments in accordance with subdivision fourteen-f of section\ntwenty-eight hundred seven-c of this article;\n  (B) payments made to eligible hospitals pursuant to this section and\nsection twenty-eight hundred seven-w of this article.\n  (iii) Notwithstanding any contrary provision of this section or\nsection twenty-eight hundred seven-w of this article, in the event a\npayment made pursuant to this section or section twenty-seven hundred\nseven-w of this article exceeds a hospital's applicable facility\nspecific disproportionate share limit, then fifty percent of the amount\nin excess of such limit shall be paid to such facility as a grant from\nstate funds available for distribution in accordance with this section\nand section twenty-eight hundred seven-w of this article, provided,\nhowever, that if payments made to an eligible rural hospital pursuant to\nthis subdivision or section twenty-eight hundred seven-w of this\narticle, result in payments in excess of such disproportionate share\nlimits, then up to one hundred forty thousand dollars of such payments\nshall be made at one hundred percent of the amount in excess of such\nlimits for each eligible rural hospital.\n  (e) By no later than December first, two thousand ten, the\ncommissioner shall issue a report evaluating the impact of the\ndistributions made pursuant to this subdivision with regard to units of\nservice to uninsured patients provided by each facility, and with regard\nto the extent of services provided by each facility to patients eligible\nfor financial aid in accordance with each facility's financial aid\npolicies and procedures as mandated by subdivision nine-a of this\nsection. Such report shall also include the use of data on services to\nthe uninsured to model the impact of the distribution methodology set\nforth in this subdivision against all funding authorized pursuant to\nthis section and section twenty-eight hundred seven-w of this article.\n  (f) The commissioner shall conduct outreach and educational activities\nto inform hospitals on matters relating to data collection and reporting\nrequirements related to services provided to the uninsured and patients\neligible for financial aid, including definitions to be utilized for\nidentifying uninsured units of service and proper identification of\nout-of-pocket collections from uninsured patients.\n  5-b. Notwithstanding any inconsistent provision of this section,\nsection twenty-eight hundred seven-w of this article or any other\ncontrary provision of law and subject to the availability of federal\nfinancial participation, for periods on and after May first, two\nthousand nine, funds as hereinafter described shall be reserved and set\naside and distributed in accordance with the following:\n  (a) For the period May first, two thousand nine through December\nthirty-first, two thousand nine payments shall be made as follows:\n  (i) Ninety percent of funds available for the two thousand nine\ncalendar year pursuant to paragraph (a-1) of subdivision four of this\nsection shall be reserved and set aside and distributed as Medicaid\ndisproportionate share (DSH) payments to the same hospitals and in the\nsame proportional amounts as received pursuant to such paragraph (a-1)\nin two thousand eight;\n  (ii) Three hundred seven million dollars shall be distributed as\nMedicaid DSH payments to facilities designated by the department as\nteaching hospitals as of December thirty-first, two thousand eight in\naccordance with a schedule of payments to be set forth in regulations\npromulgated by the commissioner to compensate such facilities for\nMedicaid and self-pay losses reported in each facility's two thousand\nseven annual cost report;\n  (iii) Sixteen million dollars shall be proportionally distributed as\nMedicaid DSH payments to non-teaching hospitals based upon their\nproportion of uninsured losses as defined in paragraph (c) of\nsubdivision five-a of this section to such losses of all non-teaching\nhospitals on a statewide basis;\n  (iv) Twenty-five million dollars shall be distributed as Medicaid DSH\npayments to non-major public hospitals having Medicaid discharges of\nforty percent or greater as established by the commissioner from data\nreported in each hospital's two thousand seven annual cost report, in\naccordance with a schedule to be set forth in regulations promulgated by\nthe commissioner, to compensate such facilities for projected Medicaid\nnet losses, as determined by the commissioner, stemming from\nmodifications to Medicaid payments made pursuant to a chapter of the\nlaws of two thousand nine.\n  (b) For annual periods beginning January first, two thousand ten\npayments shall be made as follows:\n  (i) Two hundred sixty-nine million five hundred thousand dollars shall\nbe distributed as Medicaid DSH payments to non-major public teaching\nhospitals, and such distributions shall be made on a regional basis to\ncover, within amounts available for each region, each eligible\nfacility's proportional regional share of unmet need for two thousand\nseven, provided, however, that such regions and regional allocations and\nthe definition of unmet need shall be set forth in regulations\npromulgated by the commissioner;\n  (ii) Twenty-five million dollars shall be distributed as Medicaid DSH\npayments to hospitals eligible for payments made pursuant to\nsubparagraph (iv) of paragraph (a) of this subdivision based upon each\nfacility's proportion of uninsured losses, as defined in paragraph (c)\nof subdivision five-a of this section, to such losses for all hospitals\neligible for such payments;\n  (iii) Sixteen million dollars shall be distributed in accordance with\nthe provisions of subparagraph (iii) of paragraph (a) of this\nsubdivision;\n  (iv) Twenty-five million dollars shall be distributed in accordance\nwith the provisions of subparagraph (iv) of paragraph (a) of this\nsubdivision;\n  5-c. (a) Notwithstanding any contrary provision of law and subject to\nthe availability of federal financial participation, for the period July\nfirst, two thousand ten through December thirty-first, two thousand ten,\ndistributions pursuant to this section and section twenty-eight hundred\nseven-w of this article, shall reflect an aggregate reduction of\nsixty-nine million four hundred thousand dollars, based on the\nproportion of each hospital's indigent care allocations to the total\nallocations of all hospitals' indigent care allocations prior to\napplication of this reduction, provided, however, that such reductions\nshall not be applied to distributions to major public hospitals,\nincluding major public hospitals operated by public benefit\ncorporations, and also shall not be applied to distributions made\npursuant to subparagraph (ii), (iii) or (iv) of paragraph (b) of\nsubdivision five-b of this section.\n  (b) Notwithstanding any contrary provision of law and subject to the\navailability of federal financial participation, for the period January\nfirst, two thousand eleven through December thirty-first, two thousand\neleven and each calendar year thereafter, distributions pursuant to this\nsection and section twenty-eight hundred seven-w of this article shall\nreflect an aggregate reduction of seventy-three million two hundred\nthousand dollars, based on the proportion of each hospital's indigent\ncare allocation to the total allocations of all hospitals' indigent care\nallocations prior to application of this reduction, provided, however,\nthat such reductions shall not be applied to distributions to major\npublic hospitals, including major public hospitals operated by public\nbenefit corporations, and shall also not be applied to distributions\nmade pursuant to subparagraph (ii), (iii) or (iv) of paragraph (b) of\nsubdivision five-b of this section.\n  5-d. (a) Notwithstanding any inconsistent provision of this section,\nsection twenty-eight hundred seven-w of this article or any other\ncontrary provision of law, and subject to the availability of federal\nfinancial participation, for periods on and after January first, two\nthousand twenty, through December thirty-first, two thousand\ntwenty-nine, all funds available for distribution pursuant to this\nsection, except for funds distributed pursuant to paragraph (b) of\nsubdivision five-b of this section, and all funds available for\ndistribution pursuant to section twenty-eight hundred seven-w of this\narticle, shall be reserved and set aside and distributed in accordance\nwith the provisions of this subdivision.\n  (b) The commissioner shall promulgate regulations, and may promulgate\nemergency regulations, establishing methodologies for the distribution\nof funds as described in paragraph (a) of this subdivision and such\nregulations shall include, but not be limited to, the following:\n  (i) Such regulations shall establish methodologies for determining\neach facility's relative uncompensated care need amount based on\nuninsured inpatient and outpatient units of service from the cost\nreporting year two years prior to the distribution year, multiplied by\nthe applicable medicaid rates in effect January first of the\ndistribution year, as summed and adjusted by a statewide cost adjustment\nfactor and reduced by the sum of all payment amounts collected from such\nuninsured patients, and as further adjusted by application of a nominal\nneed computation that shall take into account each facility's medicaid\ninpatient share.\n  (ii) Annual distributions pursuant to such regulations for the two\nthousand twenty through two thousand twenty-nine calendar years shall be\nin accord with the following:\n  (A) (1) one hundred thirty-nine million four hundred thousand dollars\nshall be distributed as Medicaid Disproportionate Share Hospital ("DSH")\npayments to major public general hospitals;\n  (2) for the calendar years two thousand twenty-five and thereafter,\nthe total distributions to major public general hospitals shall be\nsubject to an aggregate reduction of one hundred thirteen million four\nhundred thousand dollars annually, provided that general hospitals\noperated by the New York city health and hospitals corporation as\nestablished by chapter one thousand sixteen of the laws of nineteen\nhundred sixty-nine, as amended, shall not receive distributions pursuant\nto this subdivision; and\n  (B) nine hundred sixty-nine million nine hundred thousand dollars as\nMedicaid DSH payments to eligible general hospitals, other than major\npublic general hospitals.\n  For the calendar years two thousand twenty through two thousand\ntwenty-two, the total distributions to eligible general hospitals, other\nthan major public general hospitals, shall be subject to an aggregate\nreduction of one hundred fifty million dollars annually, provided that\neligible general hospitals, other than major public general hospitals,\nthat qualify as enhanced safety net hospitals under section two thousand\neight hundred seven-c of this article shall not be subject to such\nreduction.\n  For the calendar years two thousand twenty-three through two thousand\ntwenty-nine, the total distributions to eligible general hospitals,\nother than major public general hospitals, shall be subject to an\naggregate reduction of two hundred thirty-five million four hundred\nthousand dollars annually, provided that eligible general hospitals,\nother than major public general hospitals that qualify as enhanced\nsafety net hospitals under section two thousand eight hundred seven-c of\nthis article as of April first, two thousand twenty, shall not be\nsubject to such reduction.\n  Such reductions shall be determined by a methodology to be established\nby the commissioner. Such methodologies may take into account the payor\nmix of each non-public general hospital, including the percentage of\ninpatient days paid by Medicaid.\n  (iii) For calendar years two thousand twenty through two thousand\ntwenty-nine, sixty-four million six hundred thousand dollars shall be\ndistributed to eligible general hospitals, other than major public\ngeneral hospitals, that experience a reduction in indigent care pool\npayments pursuant to this subdivision, and that qualify as enhanced\nsafety net hospitals under section two thousand eight hundred seven-c of\nthis article as of April first, two thousand twenty. Such distribution\nshall be established pursuant to regulations promulgated by the\ncommissioner and shall be proportional to the reduction experienced by\nthe facility.\n  (iv) Such regulations shall reserve one percent of the funds available\nfor distribution in the two thousand fourteen and two thousand fifteen\ncalendar years, and for calendar years thereafter, pursuant to this\nsubdivision, subdivision fourteen-f of section twenty-eight hundred\nseven-c of this article, and sections two hundred eleven and two hundred\ntwelve of chapter four hundred seventy-four of the laws of nineteen\nhundred ninety-six, in a "financial assistance compliance pool" and\nshall establish methodologies for the distribution of such pool funds to\nfacilities based on their level of compliance, as determined by the\ncommissioner, with the provisions of subdivision nine-a of this section.\n  (c) The commissioner shall annually report to the governor and the\nlegislature on the distribution of funds under this subdivision\nincluding, but not limited to:\n  (i) the impact on safety net providers, including community providers,\nrural general hospitals and major public general hospitals;\n  (ii) the provision of indigent care by units of services and funds\ndistributed by general hospitals; and\n  (iii) the extent to which access to care has been enhanced.\n  6. Funds reserved for high need adjustments shall be distributed to\ngeneral hospitals, excluding major public general hospitals, with\nnominal need in excess of four percent as follows: each general\nhospital's share of the reserved amount shall be based on such\nhospital's aggregate share of nominal need above four percent compared\nto the total aggregate nominal need above four percent of all eligible\nhospitals.\n  7. (a) Hospital specific transition adjustment. Notwithstanding any\ninconsistent provision of this section, distributions to general\nhospitals determined in accordance with subdivision four of this section\nshall be adjusted as follows:\n  (i) For general hospitals which qualified for distributions pursuant\nto paragraph (c) of subdivision nineteen of section twenty-eight hundred\nseven-c of this article as of December thirty-first, nineteen hundred\nninety-five:\n  (A) for the period January first, nineteen hundred ninety-seven\nthrough December thirty-first, nineteen hundred ninety-seven, each such\ngeneral hospital shall receive as an allocation one hundred percent of\nthe projected distribution, as of June first, nineteen hundred\nninety-seven, to such general hospital pursuant to subdivisions\nfourteen-c and seventeen and paragraph (c) of subdivision nineteen of\nsection twenty-eight hundred seven-c of this article for nineteen\nhundred ninety-six; and\n  (B) for the period January first, nineteen hundred ninety-eight\nthrough December thirty-first, nineteen hundred ninety-eight, each such\ngeneral hospital shall receive as an allocation seventy-five percent of\nthe amount determined in accordance with clause (A) of this subparagraph\nand twenty-five percent of the amount determined in accordance with\nsubdivision four of this section; and\n  (C) for the period January first, nineteen hundred ninety-nine through\nDecember thirty-first, nineteen hundred ninety-nine, each such general\nhospital shall receive as an allocation fifty percent of the amount\ndetermined in accordance with clause (A) of this subparagraph and fifty\npercent of the amount determined in accordance with subdivision four of\nthis section; and\n  (D) for the period January first, two thousand through December\nthirty-first, two thousand, each such general hospital shall receive as\nan allocation twenty-five percent of the amount determined in accordance\nwith clause (A) of this subparagraph and seventy-five percent of the\namount determined in accordance with subdivision four of this section\nprovided, however, that for any general hospital whose distribution is\ngreater when determined solely in accordance with subdivisions four and\nsix of this section than when determined according to this clause, such\ngeneral hospital's distribution shall not be adjusted pursuant to this\nclause; and\n  (E) for periods on and after January first, two thousand one, each\nsuch general hospital shall receive as an allocation one hundred percent\nof the amount determined in accordance with subdivision four of this\nsection.\n  (ii) For all other general hospitals, excluding major public general\nhospitals, general hospitals qualifying for an adjustment pursuant to\nsubparagraph (i) of this paragraph, general hospitals which qualified\nfor an adjustment pursuant to subdivision fourteen-d of section\ntwenty-eight hundred seven-c of this article and rural general hospitals\nthat met the qualifications as a rural general hospital pursuant to\nparagraph (f) of subdivision four of section twenty-eight hundred\nseven-c of this article in nineteen hundred ninety-six:\n  (A) for the period January first, nineteen hundred ninety-seven\nthrough December thirty-first, nineteen hundred ninety-seven, each such\ngeneral hospital shall receive as an allocation fifty percent of the\nprojected distribution, as of June first, nineteen hundred ninety-seven,\nto such general hospital pursuant to subdivision seventeen of section\ntwenty-eight hundred seven-c of this article for nineteen hundred\nninety-six and fifty percent of the amount determined in accordance with\nsubdivision four of this section; and\n  (B) for the period January first, nineteen hundred ninety-eight\nthrough December thirty-first, nineteen hundred ninety-eight, each such\ngeneral hospital shall receive as an allocation twenty-five percent of\nthe projected distribution, as of June first, nineteen hundred\nninety-seven, to such general hospital pursuant to subdivision seventeen\nof section twenty-eight hundred seven-c of this article for nineteen\nhundred ninety-six and seventy-five percent of the amount determined in\naccordance with subdivision four of this section.\n  (b) Hospital category adjustment. Notwithstanding any inconsistent\nprovision of this section, distributions to each general hospital,\nexcluding major public general hospitals, for nineteen hundred\nninety-seven determined in accordance with subdivision four of this\nsection and paragraph (a) of this subdivision within the categories\nspecified in subparagraph (i) of this paragraph shall be adjusted in\naccordance with subparagraph (ii) of this paragraph.\n  (i)(A) General hospitals that qualified for distributions in\naccordance with subdivision fourteen-d of section twenty-eight hundred\nseven-c of this article for nineteen hundred ninety-six.\n  (B) Rural general hospitals that met the qualifications as a rural\ngeneral hospital pursuant to paragraph (f) of subdivision four of\nsection twenty-eight hundred seven-c of this article for nineteen\nhundred ninety-six.\n  (C) All other general hospitals, excluding general hospitals that\nqualified for distributions pursuant to paragraph (c) of subdivision\nnineteen of section twenty-eight hundred seven-c of this article.\n  (ii) For each category specified in subparagraph (i) of this\nparagraph, fifty percent of the amount by which the allocation pursuant\nto subdivision four of this section and paragraph (a) of this\nsubdivision to a general hospital within such category exceeds the\nprojected distribution, as of June first, nineteen hundred ninety-seven,\npursuant to subdivision seventeen and, if applicable, subdivision\nfourteen-d of section twenty-eight hundred seven-c of this article for\nnineteen hundred ninety-six to such general hospital shall be reserved\nby the commissioner for allocation to general hospitals within such\ncategory that would experience a loss based on such comparison based on\neach such general hospital's proportionate share of the aggregate losses\nfor all general hospitals within such category; provided however, that\nthe amount reserved within a category shall not exceed the aggregate\namount of losses within such category.\n  8. Notwithstanding any inconsistent provision of this section, up to\nfive percent of the amount allocated for each of the periods for\ndistributions pursuant to this section may be transferred by the\ncommissioner, to the extent of funds appropriated therefor, and\nallocated for distributions pursuant to the child health insurance plan\nestablished pursuant to title one-A of article twenty-five of this\nchapter.\n  9. In order for a general hospital to participate in the distribution\nof funds from the pool, the general hospital must implement minimum\ncollection policies and procedures approved by the commissioner,\nutilizing only a uniform financial assistance form developed and\nprovided by the department. All general hospitals that do not\nparticipate in the indigent care pool shall also utilize only the\nuniform financial assistance form and otherwise comply with subdivision\nnine-a of this section governing the provision of financial assistance\nand hospital collection procedures.\n  9-a. (a) For periods on and after January first, two thousand nine,\ngeneral hospitals shall, effective for periods on and after January\nfirst, two thousand seven, establish financial aid policies and\nprocedures, in accordance with the provisions of this subdivision, for\nreducing charges otherwise applicable to low-income individuals without\nhealth insurance or underinsured individuals, or who have exhausted\ntheir health insurance benefits, and who can demonstrate an inability to\npay full charges, and also, at the hospital's discretion, for reducing\nor discounting the collection of co-pays and deductible payments from\nthose individuals who can demonstrate an inability to pay such amounts.\nImmigration status shall not be an eligibility criterion for the purpose\nof determining financial assistance under this section.\n  (b) Such reductions from charges for patients with incomes below at\nleast four hundred percent of the federal poverty level shall result in\na charge to such individuals that does not exceed the amount that would\nhave been paid for the same services provided pursuant to title XIX of\nthe federal social security act (medicaid), and provided further that\nsuch amounts shall be adjusted according to income level as follows:\n  (i) For patients with incomes below at least two hundred percent of\nthe federal poverty level, the hospital shall waive all charges. No\nnominal payment shall be collected;\n  (ii) For patients with incomes between at least two hundred percent\nand up to three hundred percent of the federal poverty level, the\nhospital shall collect no more than the amount identified after\napplication of a proportional sliding fee schedule under which patients\nwith lower incomes shall pay the lowest amount. Such schedule shall\nprovide that the amount the hospital may collect for such patients\nincreases in equal increments as the income of the patient increases, up\nto a maximum of ten percent of the amount that would have been paid for\nthe same services provided pursuant to title XIX of the federal social\nsecurity act (medicaid), or for underinsured patients, up to a maximum\nof ten percent of the amount that would have been paid pursuant to such\npatient's insurance cost sharing;\n  (iii) For patients with incomes between at least three hundred one\npercent and four hundred percent of the federal poverty level, the\nhospital shall collect no more than the amount identified after\napplication of a proportional sliding fee schedule under which patients\nwith lower income shall pay the lowest amounts. Such schedule shall\nprovide that the amount the hospital may collect for such patients\nincreases from the ten percent figure described in subparagraph (ii) of\nthis paragraph in equal increments as the income of the patient\nincreases, up to a maximum of twenty percent of the amount that would\nhave been paid for the same services provided pursuant to title XIX of\nthe federal social security act (medicaid), or for underinsured\npatients, up to a maximum of twenty percent of the amount that would\nhave been paid pursuant to such patient's insurance cost sharing;\n  (iv) Nothing in this paragraph shall be construed to limit a\nhospital's ability to establish patient eligibility for payment\ndiscounts at income levels higher than those specified herein and/or to\nprovide greater payment discounts for eligible patients than those\nrequired by this paragraph.\n  (c) Such policies and procedures shall be clear, understandable, in\nwriting and publicly available in summary form and each general hospital\nparticipating in the pool shall ensure that every patient is made aware\nof the existence of such policies and procedures and is provided, in a\ntimely manner, with a summary of such policies and procedures. Any\nsummary provided to patients shall, at a minimum, include specific\ninformation as to income levels used to determine eligibility for\nassistance, a description of the primary service area of the hospital\nand the means of applying for assistance. For general hospitals with\ntwenty-four hour emergency departments, such policies and procedures\nshall require the written notification of patients during the intake and\nregistration process, and during discharge of the patient, and through\nthe conspicuous posting of language-appropriate information in the\ngeneral hospital, and information on bills and statements sent to\npatients, that financial aid may be available to qualified patients and\nhow to obtain further information. For specialty hospitals without\ntwenty-four hour emergency departments, such notification shall take\nplace through written materials provided to patients during the intake\nand registration process prior to the provision of any health care\nservices or procedures, and during discharge of the patient, and through\ninformation on bills and statements sent to patients, that financial aid\nmay be available to qualified patients and how to obtain further\ninformation. Application materials shall include a notice to patients\nthat upon submission of a completed application, including any\ninformation or documentation needed to determine the patient's\neligibility pursuant to the hospital's financial assistance policy, the\npatient may disregard any bills until the hospital has rendered a\ndecision on the application in accordance with this paragraph.\n  (d) Such policies and procedures shall include clear, objective\ncriteria for determining a patient's ability to pay and for providing\nsuch adjustments to payment requirements as are necessary. In addition\nto adjustment mechanisms such as sliding fee schedules and discounts to\nfixed standards, such policies and procedures shall also provide for the\nuse of installment plans for the payment of outstanding balances by\npatients pursuant to the provisions of the financial assistance policy.\nThe monthly payment under such a plan shall not exceed five percent of\nthe gross monthly income of the patient. The rate of interest charged to\nthe patient on the unpaid balance, if any, shall not exceed two percent\nand no plan shall include an accelerator or similar clause under which a\nhigher rate of interest is triggered upon a missed payment. If such\npolicies and procedures include a requirement of a deposit prior to\nnon-emergent, medically-necessary care, such deposit must be included as\npart of any financial aid consideration. Such policies and procedures\nshall be applied consistently to all eligible patients.\n  (e) Such policies and procedures shall permit patients to apply for\nassistance at any time during the collection process. Such policies and\nprocedures may require that patients seeking payment adjustments provide\nappropriate financial information and documentation in support of their\napplication, provided, however, that such application process shall not\nbe unduly burdensome or complex. General hospitals shall, upon request,\nassist patients in understanding the hospital's policies and procedures\nand in applying for payment adjustments. Application forms shall be\nprinted in the "primary languages" of patients served by the general\nhospital. For the purposes of this paragraph, "primary languages" shall\ninclude any language that is either (i) used to communicate, during at\nleast five percent of patient visits in a year, by patients who cannot\nspeak, read, write or understand the English language at the level of\nproficiency necessary for effective communication with health care\nproviders, or (ii) spoken by non-English speaking individuals comprising\nmore than one percent of the primary hospital service area population,\nas calculated using demographic information available from the United\nStates Bureau of the Census, supplemented by data from school systems.\nDecisions regarding such applications shall be made within thirty days\nof receipt of a completed application. Such policies and procedures\nshall require that the hospital issue any denial/approval of such\napplication in writing with information on how to appeal the denial and\nshall require the hospital to establish an appeals process under which\nit will evaluate the denial of an application. Nothing in this\nsubdivision shall be interpreted as prohibiting a hospital from making\nthe availability of financial assistance contingent upon the patient\nfirst applying for coverage under title XIX of the social security act\n(medicaid) or another publicly subsidized insurance program if, in the\njudgment of the hospital, the patient may be eligible for medicaid or\nanother publicly subsidized insurance program, and upon the patient's\ncooperation in following the financial assistance application\nrequirements, including the provision of information needed to make a\ndetermination on the patient's application in accordance with the\nhospital's financial assistance policy, provided, however, that this\nrequirement shall not apply to any patient that would otherwise not\nqualify for coverage based on their immigration status.\n  (f) Such policies and procedures shall provide that patients with\nincomes below four hundred percent of the federal poverty level are\ndeemed presumptively eligible for payment adjustments and shall conform\nto the requirements set forth in paragraph (b) of this subdivision,\nprovided, however, that nothing in this subdivision shall be interpreted\nas precluding hospitals from extending such payment adjustments to other\npatients, either generally or on a case-by-case basis. Such policies and\nprocedures shall provide financial aid for emergency hospital services,\nincluding emergency transfers pursuant to the federal emergency medical\ntreatment and active labor act (42 USC 1395dd), to patients who reside\nin New York state and for medically necessary hospital services for\npatients who reside in the hospital's primary service area as determined\naccording to criteria established by the commissioner. In developing\nsuch criteria, the commissioner shall consult with representatives of\nthe hospital industry, health care consumer advocates and local public\nhealth officials. Such criteria shall be made available to the public no\nless than thirty days prior to the date of implementation and shall, at\na minimum:\n  (i) prohibit a hospital from developing or altering its primary\nservice area in a manner designed to avoid medically underserved\ncommunities or communities with high percentages of uninsured residents;\n  (ii) ensure that every geographic area of the state is included in at\nleast one general hospital's primary service area so that eligible\npatients may access care and financial assistance; and\n  (iii) require the hospital to notify the commissioner upon making any\nchange to its primary service area, and to include a description of its\nprimary service area in the hospital's annual implementation report\nfiled pursuant to subdivision three of section twenty-eight hundred\nthree-l of this article.\n  (g) Nothing in this subdivision shall be interpreted as precluding\nhospitals from extending payment adjustments for medically necessary\nnon-emergency hospital services to patients outside of the hospital's\nprimary service area. For patients determined to be eligible for\nfinancial aid under the terms of a hospital's financial aid policy, such\npolicies and procedures shall prohibit any limitations on financial aid\nfor services based on the medical condition of the applicant, other than\ntypical limitations or exclusions based on medical necessity or the\nclinical or therapeutic benefit of a procedure or treatment.\n  (h) Such policies and procedures shall prohibit the denial of\nadmission or denial of treatment for services that are reasonably\nanticipated to be medically necessary because the patient has an unpaid\nmedical bill.  Such policies and procedures shall prohibit the forced\nsale or foreclosure of a patient's primary residence in order to collect\nan outstanding medical bill and shall require the hospital to refrain\nfrom sending an account to collection if the patient has submitted a\ncompleted application for financial aid, including any required\nsupporting documentation, while the hospital determines the patient's\neligibility for such aid. Such policies and procedures shall prohibit\nthe sale of medical debt accumulated pursuant to this section to a third\nparty, unless the third party explicitly purchases such medical debt in\norder to relieve the debt of the patient. Such policies and procedures\nshall provide for written notification, which shall include notification\non a patient bill, to a patient not less than thirty days prior to the\nreferral of debts for collection and shall require that the collection\nagency obtain the hospital's written consent prior to commencing a legal\naction. Such policies and procedures shall prohibit a hospital from\ncommencing a legal action related to the recovery of medical debt or\nunpaid bills against patients with incomes below four hundred percent of\nthe federal poverty level. In any legal action related to the recovery\nof medical debt or unpaid bills by or on behalf of a hospital, the\ncomplaint shall be accompanied by an affidavit by the hospital's chief\nfinancial officer stating that based upon the hospital's reasonable\neffort to determine the patient's income, the patient whom they are\ntaking legal action against does not have an income below four hundred\npercent of the federal poverty level. Such policies and procedures shall\nrequire all general hospital staff who interact with patients or have\nresponsibility for billing and collections to be trained in such\npolicies and procedures, and require the implementation of a mechanism\nfor the general hospital to measure its compliance with such policies\nand procedures. Such policies and procedures shall require that any\ncollection agency under contract with a general hospital for the\ncollection of debts follow the hospital's financial assistance policy,\nincluding providing information to patients on how to apply for\nfinancial assistance where appropriate. Such policies and procedures\nshall prohibit collections from a patient who is determined to be\neligible for medical assistance pursuant to title XIX of the federal\nsocial security act at the time services were rendered and for which\nservices medicaid payment is available.\n  (i) Reports required to be submitted to the department by each general\nhospital as a condition for participation in the pools, and which\ncontain, in accordance with applicable regulations, a certification from\nan independent certified public accountant or independent licensed\npublic accountant or an attestation from a senior official of the\nhospital that the hospital is in compliance with conditions of\nparticipation in the pools, shall also contain, for reporting periods on\nand after January first, two thousand seven:\n  (i) a report on hospital costs incurred and uncollected amounts in\nproviding services to eligible patients without insurance during the\nperiod covered by the report;\n  (ii) hospital costs incurred and uncollected amounts for deductibles\nand coinsurance for eligible patients with insurance or other\nthird-party payor coverage;\n  (iii) the number of patients, organized according to United States\npostal service zip code, who applied for financial assistance pursuant\nto the hospital's financial assistance policy, and the number, organized\naccording to United States postal service zip code, whose applications\nwere approved and whose applications were denied;\n  (iv) the number of patients, including their age, race, ethnicity,\ngender and insurance status, who applied for financial assistance under\nthe hospital's financial assistance policy, and the number of patients,\nincluding their age, race, ethnicity, gender and insurance status, whose\napplications were approved and denied;\n  (v) the reimbursement received for indigent care from the pool\nestablished pursuant to this section;\n  (vi) the amount of funds that have been expended on charity care from\ncharitable bequests made or trusts established for the purpose of\nproviding financial assistance to patients who are eligible in\naccordance with the terms of such bequests or trusts;\n  (vii) for hospitals located in social services districts in which the\ndistrict allows hospitals to assist patients with such applications, the\nnumber of applications for eligibility under title XIX of the social\nsecurity act (medicaid) that the hospital assisted patients in\ncompleting and the number denied and approved; and\n  (viii) the hospital's financial losses resulting from services\nprovided under medicaid.\n  (j) Within ninety days of the effective date of this subdivision each\nhospital shall submit to the commissioner a written report on its\npolicies and procedures for financial assistance to patients which are\nused by the hospital on the effective date of this subdivision. Such\nreport shall include copies of its policies and procedures, including\nmaterial which is distributed to patients, and a description of the\nhospital's financial aid policies and procedures. Such description shall\ninclude the income levels of patients on which eligibility is based, the\nfinancial aid eligible patients receive and the means of calculating\nsuch aid, and the service area, if any, used by the hospital to\ndetermine eligibility.\n  (k) Notwithstanding section twelve of this chapter, failure to comply\nwith the provisions of this subdivision by a hospital on and after the\ndate of such determination shall make such hospital liable for a civil\npenalty not to exceed ten thousand dollars for each such violation. The\nimposition of such civil penalties shall be subject to the provisions of\nsection twelve-a of this chapter.\n  (l) A hospital or its collection agent shall not commence a civil\naction against a patient or delegate a collection activity to a debt\ncollector for nonpayment for at least one hundred eighty days after the\nfirst post-service bill is issued and until a hospital has made\nreasonable efforts to determine whether a patient qualifies for\nfinancial assistance.\n  10. In order for a general hospital to be eligible for distribution of\nfunds from the pool, such general hospital if it provides obstetrical\ncare and services must be in compliance with the provisions of paragraph\n(e) of subdivision sixteen of section twenty-eight hundred seven-c of\nthis article.\n  11. Minimum hospital procedures to determine the availability of\ninsurance or other third-party coverage for hospital services shall be\nspecified by the commissioner.\n  12. Each general hospital shall submit reports to the department at\nsuch time and in such form as the commissioner shall require of:\n  (a) hospital costs incurred and uncollected amounts in providing\nservices to the uninsured during the period covered by the report; and\n  (b) hospital costs incurred and uncollected amounts for deductibles\nand coinsurance for patients with insurance or other third-party payor\ncoverage.\n  (c) Such reports shall comply with the reporting requirements\nestablished for receipt of bad debt and charity care pool payments as\nprovided in accordance with section twenty-eight hundred seven-c of this\narticle and regulations promulgated thereunder for periods prior to\nJanuary first, nineteen hundred ninety-seven.\n  13. Distributions to general hospitals pursuant to this section and\nthe adjustments provided in accordance with subdivision fourteen-f of\nsection twenty-eight hundred seven-c of this article shall be considered\ndisproportionate share payments for inpatient hospital services to\ngeneral hospitals serving a disproportionate number of low income\npatients with special needs for purposes of providing assurances to the\nsecretary of health and human services as necessary to meet federal\nrequirements for securing federal financial participation pursuant to\ntitle XIX of the federal social security act.\n  14. Notwithstanding any inconsistent provision of law to the contrary,\nthe availability or payment of funds to a general hospital pursuant to\nthis section shall not be admissible as a defense, offset or reduction\nin any action or proceeding relating to any bill or claim for amounts\ndue for hospital services provided.\n  15. Revenue from distributions pursuant to this section and\nadjustments pursuant to subdivision fourteen-f of section twenty-eight\nhundred seven-c of this article shall not be included in gross revenue\nreceived for purposes of the assessments pursuant to subdivision\neighteen of section twenty-eight hundred seven-c of this article,\nsubject to the provisions of paragraph (e) of subdivision eighteen of\nsection twenty-eight hundred seven-c of this article, and shall not be\nincluded in gross revenue received for purposes of the assessments\npursuant to section twenty-eight hundred seven-d of this article,\nsubject to the provisions of subdivision twelve of section twenty-eight\nhundred seven-d of this article.\n  16. Supplemental indigent care distributions. From available resources\nestablished pursuant to paragraph (a-1) of subdivision four of this\nsection, each hospital shall receive a proportionate share, provided\nthat no hospital shall receive less than the reduction amount calculated\npursuant to paragraph (d) of subdivision three of section twenty-eight\nhundred seven-m of this article, subject to hospital specific\ndisproportionate share payment limits calculated in accordance with\nsubdivision twenty-one of section twenty-eight hundred seven-c of this\narticle.\n  17. Indigent care reductions. For each hospital receiving payments\npursuant to paragraph (i) of subdivision thirty-five of section\ntwenty-eight hundred seven-c of this article, the commissioner shall\nreduce the sum of any amounts paid pursuant to this section and pursuant\nto section twenty-eight hundred seven-w of this article, as computed\nbased on projected facility specific disproportionate share hospital\nceilings, by an amount equal to the lower of such sum or each such\nhospital's payments pursuant to paragraph (i) of subdivision thirty-five\nof section twenty-eight hundred seven-c of this article, provided,\nhowever, that any additional aggregate reductions enacted in a chapter\nof the laws of two thousand ten to the aggregate amounts payable\npursuant to this section and pursuant to section twenty-eight hundred\nseven-w of this article shall be applied subsequent to the adjustments\notherwise provided for in this subdivision.\n